Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Waldron
Toombs
Current Techniques
M. Joseph Bojrab
5th Edition Don Ray Waldron
James P. Toombs
Teton NewMedia
Current Techniques
In Small Animal Surgery
5th Edition
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Current Techniques
In Small Animal Surgery
5th Edition
Editor:
M. Joseph Bojrab, DVM, MS, PhD
Diplomate, American College of Veterinary Surgeons
Private Consulting Practitioner
Las Vegas, Nevada
Associate Editors:
Don Waldron, DVM, DACVS
Chief Veterinary Medical Officer
Western Veterinary Conference
Las Vegas, Nevada
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable
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Preface
This book has been a long time coming and has taken many hours of sweat and tears to finish. It has been anticipated for several
years and has been delayed because of the extensive amount of new and refurbished art work which was required. The book is
designed to be a concise, comprehensive and highly graphic presentation of small animal surgery for the practicing veterinarian. It
represents the viewpoints and surgical approaches of distinguished leaders in the various surgical fields and is therefore a valuable
reference and review of the procedures that the veterinary practitioner is often called upon to perform. I have had innumerable
veterinarians call me and say that they use this book daily and could not do the surgery they do without it. I instructed the authors
to make each procedure accurate and current. Detailed but clear artwork accompanies each procedure and continues to be an
important feature of this book for both students and practitioners. In this day and age the general small animal practitioner is asked
to do more and more complicated procedures since many clients cannot afford a specialist. This book makes it possible for them to
safely and accurately perform a broader range of procedures, and I have had many veterinarians tell me that they consider this the
“bible” and that they could not practice without it. This new edition has been highly anticipated and is finally completed. I must thank
each and every author for their hard work, dedication and patience throughout the revision process. My special thanks go to Drs.
Waldron and Toombs, consulting soft tissue and orthopedic editors. Their untiring dedication made this book finally become a reality.
Harry W. Booth, Jr., DVM, MS, DACVS James L. Cook, DVM, PhD, DACVS
Professor, Department of Clinical Sciences Professor of Orthopedic Surgery and William C. Allen Endowed
Auburn University Scholar for Orthopedic Research
College of Veterinary Medicine University of Missouri
Hoerlein Hall Columbia, MO
Auburn, AL
Stephen W. Crane, DVM, DACVS
Terry D. Braden, DVM, DACVS Colorado Springs, CO
Michigan State University
Veterinary Teaching Hospital James A. Creed, DVM, MS, DACVS
East Lansing, MI Professor Emeritus
University of MO-Columbia
Daniel Brehm, VMD, DACVS Department of Veterinary Medicine and Surgery
Department of Surgery Columbia, MO
South Paws Veterinary Specialists and Emergency Center
Fairfax, VA Dennis T. Crowe, Jr., DVM, DACVS
Veterinary Emergency and Critical Care Consulting
Ronald M. Bright, DVM, MS, DACVS Bogart, GA
Staff Surgeon, VCA-Veterinary Specialists of Northern Colorado
Loveland, CO William T. N. Culp, VMD, DACVS
Assistant Professor
Richard V. Broadstone, DVM, PhD, DACVA University of California - Davis
Hospital Director School of Veterinary Medicine
Iams Pet Imaging Center Department of Veterinary Surgical and Radiological Sciences
Raleigh, NC Davis, CA
William S. Dernell, DVM, MS, DACVS James P. Farese, DVM, Diplomate ACVS
Washington State University Associate Professor of Small Animal Surgery
Department of Veterinary Clinical Sciences University of Florida, College of Veterinary Medicine
Pullman, WA Department of Small Animal Clinical Sciences
Gainesville, FL
Jennifer Devey, DVM, DAVECC
Bozeman, MT Jennifer Fick, DVM, DACVS
Front Range Mobile Surgical Specialists
Chad M. Devitt, DVM, MS, DACVS Englewood, CO
Veterinary Referral Center of Colorado
Engelwood, CO Dean Filipowicz, DVM, DACVS
Bay Area Veterinary Specialists
Mauricio Dujowich, DVM, DACVS San Leandro, CA
Solana Beach, CA
James M. Fingeroth, DVM, DACVS
Dianne Dunning, DVM, MS, DACVS Orchard Park Veterinary Medical Center
Assistant Dean, College Relations Orchard Park, NY
Clinical Associate Professor
North Carolina State University Roger B. Fingland, DVM, MS, DACVS
College of Veterinary Medicine Professor of Surgery
Department of Small Animal Clinical Sciences Director of Veterinary Medical Teaching Hospital
Raleigh, NC University of Kansas, College of Veterinary Medicine
Manhattan, KS
Laura D. Dvorak, DVM, MS, DACVS
Carolina Veterinary Specialists Randall B. Fitch, DVM, DACVS
Mathews, NC VCA Veterinary Specialists of Northern Colorado
Loveland, CO
Nicole Ehrhart, VMD, MS, DACVS
Associate Professor, Colorado State University J. David Fowler, DVM, MVSc. DACVS
Animal Cancer Center Guardian Veterinary Centre
Fort Collins, CO Edmonton, CANADA
Dean R. Gahring, DVM, DACVS H. Phil Hobson, BS, DVM, MS, DACVS
Chief of Surgery Professor of Small Animal Surgery
San Carlos Veterinary Hospital Texas A & M University, College of Veterinary Medicine and
San Diego, CA Biomedical Sciences
Department of Small Animal Clinical Sciences
Dougald R. Gilmore, BVSc, DACVS College Station, TX
International Veterinary Seminars
Santa Cruz, CA David Holt, BVSc, DACVS
Professor of Surgery
Stephen D. Gilson, DVM, DACVS University of Pennsylvania School of Veterinary Medicine
Sonora Veterinary Surgery and Oncology Philadelphia, PA
Phoenix, AZ
Giselle Hosgood, B.V.Sc, M.S, Ph.D., DACVS
Dominique J. Griffon, DMV, MS, PhD, DACVS Murdoch University
Western University of Health Sciences School of Veterinary and Biomedical Sciences
College of Veterinary Medicine Western Australia AUSTRALIA
Pompona, CA
Lisa M. Howe, DVM, PhD, DACVS
Joseph G. Hauptman, DVM, MS, DACVS Professor and Co-Chief, Surgical Sciences Section
Professor of Small Animal Surgery Department of Veterinary Small Animal Clinical Sciences
Michigan State University College of Veterinary Medicine and Biomedical Sciences
College of Veterinary Medicine Texas A & M University
Small Animal Clinical Sciences College Station, TX
G-336 Veterinary Medical Center
East Lansing, MI Donald A. Hulse, DVM, DACVS
Texas A & M University
Robert B. Hancock, DVM, MS, DACVS College of Veterinary Medicine and Biomedical Sciences
South Paws Veterinary Surgical Specialists College Station, TX
Mandeville, LA
Geraldine B. Hunt,B.V.Sc
Joseph Harari, MS, DVM, DACVS Professor of Small Animal Surgery
Veterinary Surgical Specialists University of California-Davis
Spokane, WA Davis, CA
Elizabeth M. Hardie, DVM, PhD, ACVS Brian T. Huss, DVM, MS, DACVS
Professor of Surgery Chief of Staff, Vetcision, LLC
Department of Clinical Sciences Co-Chief of Staff Veterinary Emergency & Specialty Center of
North Carolina State University New England, LLC
Raleigh, NC Waltham, MA
H. Jay Harvey, DVM, DACVS Dennis A. Jackson, DVM, MS, DACVS (deceased)
Associate Professor of Surgery, and Head, Companion Animal Staff Surgeon, Granville Island Veterinary Hospital
Hospital Vancouver, British Columbia, CANADA
Cornell University, New York State College of Veterinary Medicine
Ithaca, NY Ann L. Johnson, DVM, MS, DACVS
Professor of Small Animal Surgery
Cheryl S. Hedlund, DVM, MS, DACVS University of Illinois, College of Veterinary Medicine
Professor of Surgery Department of Veterinary Clinical Medicine
Iowa State University Urbana, IL
Ames, Iowa
Kenneth A. Johnson, MVSc, PhD, FACVSc, DACVS and ECVS
Ian P. Herring, DVM, MS, DACVO Professor of Orthopedics
Associate Professor of Ophthalmology The University of Sydney
Virginia-Maryland Regional College of Veterinary Medicine University Teaching Hospital
Blacksburg, VA Sydney, AUSTRALIA
Contributors xi
Mary Ann Radlinsky, DVM, MS, DACVS Amelia M. Simpson, DVM, DACVS
Associate Professor Veterinary Surgical Center of Portland
University of Georgia Portland, OR
College of Veterinary Medicine
Department of Small Animal Medicine and Surgery Barclay Slocum, DVM (Deceased)
Athens, GA Slocum Veterinary Clinic
Private Practice
Eberhard Rosin, DVM, PhD, DACVS (Deceased) Eugene, OR
John S. Rosmeisl, Jr., DVM, MS. DACIM (Internal Medicine Theresa Devine Slocum
and Neurology) Animal Foundation, Inc.
Associate Professor, Neurology and Neurosurgery Eugene, OR
Virginia-Maryland Regional College of Veterinary Medicine
Department of Small Animal Clinical Sciences Daniel D. Smeak, DVM, DACVS
Blacksburg, VA Professor of Small Animal Surgery
Colorado State University
S. Kathleen Salisbury, DVM, MS, DACVS College of Veterinary Medicine and Biomedical Sciences
Professor, Small Animal Surgery Department of Clinical Sciences
Purdue University Fort Collins, CO
School of Veterinary Medicine
Department of Veterinary Clinical Sciences Julie D. Smith, DVM, CCRT, MBA, DACVS
West Lafayette, IN Sage Centers for Veterinary Specialty and Emergency Care
Campbell, CA
Jill E. Sackman, DVM, PhD, DACVS
Healthcare Consultant, Formerly Director, Preclinical Research Mark M. Smith, DACVS, DAVDC
and Development Center for Veterinary Dentistry and Oral Surgery
Ethicon Endo-Surgery, Inc., a Johnson & Johnson Company Gaithersburg, MD
Saint Louis, MO
Elizabeth Arnold Stone, DVM, MS, DACVS
Susan L. Schaefer, MS, DVM, DACVS Dean, Ontario Veterinary College
Clinical Assistant Professor of Small Animal Orthopedic Surgery Office of the Dean
University of Wisconsin, School of Veterinary Medicine University of Guelph
Madison, WI Ontario Veterinary College
Guelph, CANADA
Jamie J. Schorling, DVM, DACVO
The Eye Clinic for Animals Rod Straw, BVSc, MS, DACVS
San Diego, CA Brisbane Veterinary Specialist Centre
Corner Old Northern Road and Keong Road
Kurt S. Schultz, DVM, MS, DACVS Albany Creek, AUSTRALIA
Peak Veterinary Referrals
Steven F. Swaim, DVM, MS
Williston, VT
Professor, Small Animal Surgery
Department of Small Animal Surgery & Medicine
Peter D. Schwarz, DVM, DACVS
Director, Scott-Ritchey Research Center
Veterinary Surgical Specialists of New Mexico
Auburn University College of Veterinary Medicine
Albuquerque, NM
Auburn, AL
Howard B. Seim, III, DVM, DACVS
Kent Talcott, DVM, Diplomate ACVS
Professor of Small Animal Surgery
PetCare Veterinary Hospital
Colorado State University
Santa Rosa, CA
College of Veterinary Medicine
Fort Collins, CO
Guy B. Tarvin, DVM, Diplomate ACVS
Staff Surgeon Veterinary Surgical Specialists
Colin W. Sereda, DVM, MS, DACVS-SA
San Diego, CA
Guardian Veterinary Center
Edmonton, CANADA Robert Taylor, DVM, MS , DACVS
Director, Bel- Rea Institute of Animal Technology
Kenneth R. Sinibaldi, DVM, DACVS Adjunct Associate Professor, University of Denver
Animal Surgical Clinic of Seattle Staff Surgeon, Alameda East Veterinary Hospital
Seattle, WA Denver, CO
xiv Contributors
Karen M. Tobias, DVM, MS, DACVS Daniel J. Yturraspe, DVM, PhD (Deceased)
Professor, Small Animal Surgery
University of Tennessee, College of Veterinary Medicine Nancy Zimmerman-Pope, DVM, MS, DACVS
Department of Small Animal Clinical Sciences Gentle Hands Veterinary Specialists LLC
C247 Veterinary Teaching Hospital Arena, WI
Knoxville, TN
Surgical Management of Pulmonic Stenosis . . . . . . . . . . . 643 48: Thoracolumbar and Sacral Spine
Jill E. Sackman and D. J. Krahwinkel,Jr. Intervertebral Disc Fenestration . . . . . . . . . . . . . . . . . å°“. . . . . 743
Interventional Catheterization for James A. Creed and Daniel J. Yturraspe
Congenital Heart Disease . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . 649 Prophylactic Thoracolumbar Disc Fenestration . . . . . . . . . 746
Jonathan Abbott M. Joseph Bojrab and Gheorghe M. Constantinescu
Surgical Correction of Persistent Right Aortic Arch . . . . . 661 Hemilaminectomy of the Cranial Thoracic Region . . . . . . . 748
Gary W. Ellison James F. Biggart, III
Surgical Treatment of Pericardial Disease Hemilaminectomy of the Caudal Thoracic and
and Cardiac Neoplasms . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . 664 Lumbar Spine . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . å°“. . . 750
John Berg Karl H. Kraus and John M. Weh
Modified Dorsal Laminectomy . . . . . . . . . . . . . . . . . å°“. . . . . . . 756
43: Lymphatics and Lymph Nodes Eric J. Trotter
Management of Chylothorax . . . . . . . . . . . . . . . . . å°“. . . . . . . . 671 Surgical Treatment of Cauda Equina Syndrome . . . . . . . . . 760
MaryAnn Radlinsky Guy B. Tarvin and Timothy M. Lenehan
Transdiaphragmatic Approach to Thoracic Surgical Treatment of Fractures, Luxations and
Duct Ligation in Cats . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . 677 Subluxations of the Thoracolumbar and Sacral Spine . . . 762
Robert A. Martin Karen L. Kline and Kenneth A. Bruecker
Lymph Node Biopsy . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . 679
MaryAnn Radlinsky
Section L. Fracture Fixation Techniques and
44: Spleen
Surgery of the Spleen . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . 682
Bone Grafting
Dale E. Bjorling 49: Fixation with Pins and Wires
Application of Cerclage and Hemi-cerclage Wires . . . . . . 769
Sharon C. Kerwin
Section J. Exotic Species Intramedullary Pins and Kirschner Wires . . . . . . . . . . . . . . 775
45: Surgical Techniques in Small Exotic Animals Sharon C. Kerwin
Surgery of Pet Ferrets . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . 686 Tension Band Wiring . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . 780
Neal L. Beeber Karl H. Kraus
Anal Sac Resection in the Ferret . . . . . . . . . . . . . . . . . å°“. . . . 691
James E. Creed 50: Interlocking Nailing of Canine and Feline Fractures
Soft Tissue Surgery in Reptiles . . . . . . . . . . . . . . . . . å°“. . . . . . 692 Interlocking Nailing of Canine and Feline Fractures . . . . . 782
Steve J. Mehler and R. Avery Bennett Kenneth A. Johnson
Abdominal Surgery of Pet Rabbits . . . . . . . . . . . . . . . . . å°“. . . 700
Cathy A. Johnson-Delaney 51: Fixation with Screws and Bone Plates
Screw Fixation: Cortical, Cancellous,
Part II: Bones and Joints Lag, and Gliding . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . å°“. 787
Brian Beale
Section K. Axial Skeleton Application of Bone Plates in Compression,
46: Skull and Mandible Neutralization, or Buttress Mode . . . . . . . . . . . . . . . . . å°“. . . . 788
Surgical Repair of Fractures Involving Daniel A. Koch
the Mandible and Maxilla . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . 716 The SOP Locking Plate System . . . . . . . . . . . . . . . . . å°“. . . . . . 792
Mauricio Dujowich Karl H. Kraus and Malcolm G. Ness
Acrylic Pin Splint External Skeletal Fixators for
Mandibular Fractures . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . 725 52: Plate-Rod Fixation
Dennis N. Aron Application of Plate-Rod Constructs for
Fixation of Complex Shaft Fractures . . . . . . . . . . . . . . . . . å°“. . 797
47: Cervical Spine Donald A. Hulse
Cervical Disc Fenestration . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . 728
M. Joseph Bojrab and Gheorghe M. Constantinescu 53: External Skeletal Fixation
Ventral Slot for Decompression of the Basic Principles of External Skeletal Fixation . . . . . . . . . . 800
Herniated Cervical Disk . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . 729 James P. Toombs
Karen L. Kline and Kenneth A. Bruecker Application of the Acrylic and Pin External Fixator
Surgical Treatment of Caudal Cervical (APEF) . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . å°“. . . . . . . . . 811
Spondylomyelopathy in Large Breed Dogs . . . . . . . . . . . . . 732 James P. Toombs and Erik L. Egger
Karen L. Kline and Kenneth A. Bruecker Application of the Securos External Fixator . . . . . . . . . . . . 815
Surgical Treatment of Atlantoaxial Instability . . . . . . . . . . . 737 Karl H. Kraus
K. S. Schultz Application of the IMEX-SK External Fixator . . . . . . . . . . . 819
Surgical Treatment of Fractures of the Cervical Spine . . . 740 James P. Toombs
Karen L. Kline and Kenneth A. Bruecker Circular External Skeletal Fixation . . . . . . . . . . . . . . . . . å°“. . . 828
Daniel D. Lewis and James P. Farese
Contents xix
Application of Hybrid Constructs . . . . . . . . . . . . . . . . . å°“. . . . 843 Surgical Treatment of Injuries to the Antebrachial
Robert M. Radasch Carpal Joint and Carpus . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . 955
Alesandro Piras and Jon F. Dee
54: Bone Grafts and Implants Partial Carpal Arthrodesis . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . 963
Harvesting and Application of Thomas Van Gundy
Cancellous Bone Autografts . . . . . . . . . . . . . . . . . å°“. . . . . . . . 858 Pancarpal Arthrodesis . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . 964
James P. Toombs Arnold S. Lesser
Corticocanceallous Bone Graft Harvested from Repair of Fractures Involving Metabones
the Wing of the Ilium with an Acetabular Reamer . . . . . . . 862 and Phalanges . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . å°“. . 965
Colin W. Sereda and Daniel D. Lewis Alesandro Piras and Jon F. Dee
Harvesting, Storage, and Application
of Cortical Allografts . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . 864 59: Amputation of the Forelimb . . . . . . . . . . . . . . . . . å°“. . . . . . . . . 972
Kenneth R. Sinibaldi William R. Daly
Distraction Osteogenesis as an Alternative to
Bone Grafting . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . å°“. . . 866
Nicole Ehrhart
Section N. Appendicular Skeleton –
Pelvic Limb
Section M. Appendicular Skeleton – 60: Sacroiliac Joint, Pelvis, and Hip Joint
Repair of Sacroiliac Dislocation . . . . . . . . . . . . . . . . . å°“. . . . . 977
Thoracic Limb Charles E. DeCamp
55: Scapula and Shoulder Joint Trans-ilial/Trans-sacral Pinning of Sacral Fractures . . . . . 980
Repair of Scapular Fractures . . . . . . . . . . . . . . . . . å°“. . . . . . . . 871 Randall B. Fitch
Randy Willer and Jennifer Fick Repair of Ilial Fractures . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . 984
Surgical Treatment of Shoulder Luxation . . . . . . . . . . . . . . 876 Charisse D. Davidson, Timothy M. Lenehan, and Guy B. Tarvin
Kent Talcott Surgical Repair of Acetabular Fractures . . . . . . . . . . . . . . . 988
Caudal Approach to the Shoulder Joint for Marvin L. Olmstead
Treatment of Osteochondritis Dissecans . . . . . . . . . . . . . . . 882 Treatment of Coxofemoral Luxations . . . . . . . . . . . . . . . . . å°“. 991
Dean R. Gahring James L. Tomlinson
Surgical Treatment of Biceps Brachii Tendon Injury . . . . . 887 Hip Dysplasia
James L. Cook Algorithms for Treatment . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . 997
Excision Arthroplasty of the Shoulder Joint . . . . . . . . . . . . 891 Barclay Slocum and Theresa Devine Slocum
Donald L. Piermattei and Charles E. Blass Diagnostic Tests . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . 1003
Shoulder Arthrodesis . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . 893 Barclay Slocum and Theresa Devine Slocum
Arnold S. Lesser Radiographic Characteristics of Hip Dysplasia . . . . . . . . 1014
Theresa Devine Slocum and Barclay Slocum
56: Humerus and Elbow Joint Definitions of Hip Terms . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . 1020
Repair of Fractures of the Humerus . . . . . . . . . . . . . . . . . å°“. . 895 Barclay Slocum and Theresa Devine Slocum
Dennis A. Jackson
Treatment of Hip Dysplasia
Treatment of Elbow Luxations . . . . . . . . . . . . . . . . . å°“. . . . . . . 908
Robert A. Taylor Femoral Neck Lengthening . . . . . . . . . . . . . . . . . å°“. . . . . . . . 1022
Barclay Slocum and Theresa Devine Slocum
Surgical Treatment of Ununited Anconeal Process of
Pelvic Osteotomy . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . 1027
the Elbow . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . . å°“. . . . . . . 909
Barclay Slocum and Theresa Devine Slocum
Ursula Krotscheck
Three Plane Intertrochanteric Osteotomy . . . . . . . . . . . . . 1032
Surgical Treatment of Fragmented Coronoid Process . . . 917
Ursula Krotscheck Terry D. Braden and W. Dieter Prieur
Total Elbow Replacement in the Dog . . . . . . . . . . . . . . . . . å°“. 924 DARthroplasty: Another Treatment
Michael G. Conzemius for Hip Dysplasia . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . 1041
Elbow Arthrodesis . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . . . . . 931 Dean R. Gahring and Theresa Devine Slocum
Arnold S. Lesser Total Hip Arthroplasty . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . . 1043
Marvin L. Olmstead
57: Radius and Ulna Excision Arthroplasty of the
Repair of Fractures of the Radius and Ulna . . . . . . . . . . . . 933 Femoral Head and Neck . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . 1048
Curtis W. Probst Joseph M. Prostredny
Correction of Radial and Ulnar Growth Deformities
Resulting from Premature Physeal Closure . . . . . . . . . . . . 943 61: Femur and Stifle Joint
Dominique J. Griffon and Ann L. Johnson Internal Fixation of Femoral Fractures . . . . . . . . . . . . . . . . 1052
Dougald R. Gilmore
58: Carpus, Metacarpus, and Phalanges Repair of Patellar Fractures . . . . . . . . . . . . . . . . . å°“. . . . . . . . 1061
Classification and Treatment of Injuries to the Derek B. Fox
Accessory Carpal Bone . . . . . . . . . . . . . . . . . å°“. . . . . . . . . . . . 952 Surgical Repair of Patellar Luxations . . . . . . . . . . . . . . . . . 1064
Kenneth A. Johnson Guy B. Tarvin and Steven P. Arnoczky
xx Contents
Section A
Suture materials are classified as absorbable or nonabsorbable,
natural or synthetic, monofilament or multifilament, according to
their structure and composition (Table 1-1).
intestine are among the strongest. Tissue strength varies within example, catgut in the presence of infection or gastric secretions,
the same organ and with the age and size of the animal. or when placed in a catabolic patient can be degraded within
days, rendering the wound closure susceptible to dehiscence.
The choice of suture size is based on the tensile strength of the When healing is expected to be delayed, prolonged absorbable
tissue as well as of the suture material. Catgut and synthetic sutures or nonabsorbable sutures are better choices.
suture materials are sized according to either United States
Pharmacopeia (USP) or metric gauge (Table 1-2). A larger numeric
USP value means a larger-diameter suture. Stated numerically,
Healing Considerations
the more zeros (0s) in the number, the smaller the strand. (e.g., Surgeons must consider how the suture alters the biologic
2 polypropylene is larger than 0, and 2-0 is larger than 4-0). The processes in a healing wound environment. Regardless of
metric gauge is the actual suture diameter expressed in milli- its composition, suture material is a foreign body to tissues in
meters multiplied by 10. Stainless steel suture can be sized by which it is implanted, and to a greater or lesser degree will elicit
USP, metric gauge, or Brown and Sharpe wire gauge. Ranges a foreign body reaction. The amount of reaction depends on the
of suture size recommendations for various tissues and surgical nature of the suture implanted (e.g., surgical gut versus inert,
applications are provided in Table 1-3. These guidelines are stainless steel), the amount of surface area and coating of the
general and are based on currently available literature and my suture, the type and location of tissue closed (intestinal viscera
experience. Larger sizes are used in heavier animals, in critical and skin react strongly to silk, whereas fascia reacts minimally
suture lines such as the abdominal fascia, or in tissues closed to silk), the length of implantation (polyglycolic acid, or Dexon II®,
under excessive tension. The surgeon should strive to use the is moderately reactive early but within months is relatively inert),
smallest suture size possible for wound closure since this will and the technique of suture placement (excessive suture tight-
result in less tissue trauma, allow smaller knots to be tied, and ening causes tissue strangulation). Excessive suture-induced
encourage the surgeon to handle the sutures and tissue more tissue reaction increases the likelihood of suture-tissue cutout
carefully. Oversized sutures can actually weaken the wound by softening surrounding tissues, increases the risk of infection,
through excessive tissue reaction and tissue strangulation. To and delays the onset of fibroplasia. Sutures causing excessive
maintain maximum suture strength once the suture is removed tissue reaction are contraindicated in areas in which exuberant
from the packet, certain suture handling rules are suggested scar formation can cause a functional problem (e.g., for vascular
(Table 1-4). repair or ureteral anastomosis) or a cosmetic problem (e.g., in
skin). The surgeon should strive to inflict the least amount of
trauma necessary for the operation, to reduce contamination,
Loss of Suture Strength and Gain and to use sutures that cause the least tissue reaction to avoid
of Wound Strength excessive inflammation and delayed wound healing. Relatively
To use absorbable sutures safely, the loss of suture strength speaking, it is not the suture material but the surgeon that causes
should be proportional to the anticipated gain in wound inflammation within a wound, since most reaction is induced
strength. The relative rates of suture strength loss and simul- during tissue manipulation and the act of suturing.
taneous wound strength gain are important to consider. Fascia,
tendons, and ligaments heal slowly (50% strength gain in 40-50 All suture materials are capable of increasing wound suscep-
days) and are under constant tensile force. For these tissues, tibility to infection. The suture’s filamentous nature, capillarity,
nonabsorbable sutures or the prolonged-degrading, synthetic chemical structure, bioinertness, and ability to adhere to bacteria
absorbable sutures are indicated. Maxon® and PDS II® sutures all play a role in suture related infection. In a classic experiment,
can be used whenever an absorbable suture is needed, but these a single silk suture reduced the total contaminating dose of
should be considered especially in wounds that are expected to Staphylococcus required to induce wound infection 10,000 fold.
require suture support for more than 3 weeks (such as abdominal On the other hand, the byproducts of nylon and polyglycolic
wall fascia). Because visceral wounds heal relatively fast, often acid suture degradation in tissues may have beneficial bacte-
achieving most of their strength in 21 days, rapid to intermediate- ricidal effects. A newer synthetic absorbable suture with an
degrading absorbable sutures (Table 1-1) are good choices. antibacterial coating has been developed specifically for use in
Rapidly-degrading synthetic sutures (Caprosyn®, Monocryl®, contaminated wounds (see discussion under newly developed
Vicryl Rapide®) are indicated in rapidly healing tissues such as sutures). In general, sutures that induce the least foreign body
the mucosal lining of the mouth or urogenital tract where suture reaction in tissues, such as monofilament synthetic absorbable
removal is not possible or undesirable. The more intermediate- and nonabsorbable sutures, produce the lowest incidence of
degrading sutures such as (Vicryl®, Dexon®, and Biosyn®) are infection in contaminated wounds. If possible, suture should not
often chosen to close wounds that are expected to heal within be implanted in highly contaminated wounds or wounds with a
3 weeks, such as the subcutaneous tissue and muscle. Monofil- high risk of infection.
ament nonabsorbable sutures are suggested for skin closure
because they induce little foreign body response and skin Multifilament nonabsorbable suture materials induce chronic
sutures should remain strong since they are subject to chewing sinus formation more often than absorbable or monofilament
and wear. These sutures also provide long-term stability in sutures. Multifilament nonabsorbable sutures harbor bacteria
procedures involving fascia, tendons, and vascular prostheses. within the suture interstices, creating an effective barrier to
Systemic and local factors affecting wound healing must also phagocytosis. These sutures should never be used in contami-
be considered before an appropriate suture is selected. For nated wounds. Wound infection also increases the rate of loss of
4 Soft Tissue
Monocryl copolymer glycolide mono 40-50% loss - 7 days 91- 119 days
(poliglecaprone 25) and epsilon-capro- 100% loss - 21 days
lactone
Absorbable
Intermediate
Coated Vicryl and copolymer of lactide multi 25% loss -14 days 56 - 70 days
Vicryl PlusAntibac- and glycolide 50% loss - 21 days
terial (polyglactin
910, triclosan
coating-Plus)
Dexon S Dexon II homopolymer of multi 35% loss -14 days 60 - 90 days
(coated and uncoated glycolic acid II - 65% loss - 21 days
polyglycolic acid) polycaprolate coating
Polysorb (lactomer) glycolide/lactide multi 20% loss -14 days 56-70 days
copolymer 70% loss - 21 days
Biosyn (glycomer 631) glycolide dioxanone mono 25% loss -14 days 90-110 days
trimethylene carbonate 60% loss - 21 days
Absorbable
Prolonged
PDS II polydioxanene polymer mono 30% loss -14 days 180 - 210 days
(polydioxanone) 50% loss - 28 days
Maxon glycolic acid, polytrim- mono 25% loss - 14 days 180 days
(polyglyconate) ethylene carbonate 50% loss - 28 days
Selection and use of currently available Suture Materials and Needles 5
mild fair to good fair good Provides about 70% of initial strength
of coated Vicryl. Less reactive than gut;
indicated for superficial closure of mucous
membranes.
mild good good good Designed to be an attractive alternative to
chromic gut. Similar suture characteristics
and applications as Monocryl. Excellent
choice for bladder closure.
mild good good to excellent good Minimal tissue drag; handling qualities
are very good for monofilaments. Ideal for
mucosal suturing and subcutaneous tissue
closure.
General soft tissue approximation; use in
visceral tissue where healing is mostly
complete in 21 days. Intermediate absorbing
suture should not be used where extended
approximation of tissue under stress is
required.
mild fair to good good good Plus-Triclosan coating added to provide
antibacterial effect. This suture is not to be
used close to the eye.
mild fair to good good to excellent good Smooth coating allows easier knot formation
without flaking.
mild fair to good excellent good Similar to PDS II; tends to have more memory
and less knot security in larger sizes.
6 Soft Tissue
Nonabsorbable
Multifilament
Sofsilk Permabond silkworm cocoon fibers multi 30% loss - 14 days greater than
50% loss - 365 days 720 days
Selection and use of currently available Suture Materials and Needles 7
minimal fair to good good very good Soft pliable monofilament suture; excellent for
plastic surgery.
minimal good good fair Greater knot security than many monofila-
ments; least thrombogenic. Fluorofil glows
under blacklight for easy location.
minimal good to very excellent good Good alternative to polypropylene. Better
good strength and handling; less fraying.
minimal to none excellent excellent poor Knot ends can cause severe irritation. Tends
to fragment and cut into tissue; must secure
knots.
Do not use multifilament nonabsorbable
suture in contaminated environments.
Use when long term suture strength is
needed. Overall better handling than the
monofilaments.
minimal fair good good Should not be used when permanent
retention of suture strength is required.
minimal to good good to excellent good Inexpensive suture material often supplied in
moderate (if reels. For external use only.
coating breaks)
moderate fair to poor excellent good to excellent Uncoated sutures have excessive tissue drag.
Careful knot tying technique and additional
throws may be needed with coated sutures.
moderate fair to poor fair excellent Best handling multifilament suture.
8 Soft Tissue
Table 1-2. Metric Measures, and U.S.P. Suture Table 1-3. General Suture Size and Usage
Diameter Equivalents Recommendations in Small Animal Surgery
Suture Material Sizes Tissue Suture Size Suture Material:
Actual Size USP Size Brown and Sharpe (USP) Classes
(mm) Catgut Synthetic Wire Gauge Skin 3-0 to 4-0 Monofilament
nonabsorbable
0.02 10-0
Subcutaneous tissue 2-0 to 4-0 Absorbable
0.03 9-0
Fascia 1 to 3-0 Synthetic
0.04 8-0
(prolonged
0.05 8-0 7-0 41 degrading)
0.07 7-0 6-0 38-40 absorbable, or
synthetic nonab-
0.1 6-0 5-0 35
sorbable
0.15 5-0 4-0 32-34
Muscle 0 to 3-0 Skeletal: synthetic
0.2 4-0 3-0 30 (prolonged
0.3 3-0 2-0 28 degrading)
absorbable
0.35 2-0 0 26
Cardiac: synthetic
0.4 0 1 25 nonabsorbable
0.5 I 2 24 Parenchymal organ 2-0 to 4-0 Intermediate
0.6 2 3; 4 22 degrading
0.7 3 5 20 absorbable
0.8 4 6 19 Hollow viscus organ 3-0 to 5-0 Monofilament
absorbable
0.9 7 18
Tendon, ligament 0 to 3-0 Monofilament
To obtain metric gauge, multiply actual size (mm) by 10; for example,
USP 0 catgut 0.4 mm in diameter is metric size 4. nonabsorbable
Nerve 5-0 to 7-0 Monofilament
strength of suture material. If wound contamination is suspected, nonabsorbable
synthetic absorbable sutures should be chosen because these Cornea 8-0 to 10-0 Synthetic
sutures are more stable and have predictable absorption rates absorbable.
in contaminated tissue, when compared to chromic catgut. nonmetallic
If long-term wound support is required of the suture material, nonabsorbable
synthetic monofilament nonabsorbables or synthetic (prolonged-
degrading) absorbable sutures such as PDS II® or Maxon® are Vascular ligation 0 to 4-0 Small vessels-
indicated. absorbable; larger
vessels- prolonged
The presence of any suture material within the lumen of the absorbable or
biliary or urinary tract can act as a nidus and induce calculus nonabsorbable
formation or chronic infection. Thus, more rapidly absorbable Vascular repair 5-0 to 7-0 Monofilament
sutures are recommended in these areas, since they will not nonabsorbable
persist indefinitely in tissue. Silk and nonabsorbable polyester
material, because of their documented calculogenic effects, for joint imbrication. Similarly, inelastic suture material such as
should never be placed in contact with urine or bile. General stainless steel should not be used in tissues that stretch or are
guidelines to avoid suture-related complications in surgery are under constant motion because premature suture-tissue cutout
listed in Table 1-5. or suture breakage could occur.
Table 1-4. Suture Handling and Storage Rules Table 1-5. General Rules to Avoid Most
1. Protect all sutures from heat and moisture. Suture-Related Complications
2. Never autoclave absorbable sutures. 1. Avoid multifilament nonabsorbable suture material use in
3. Refrain from soaking absorbable sutures, particularly in contaminated or infected wounds. Multifilament suture
hot water. harbors bacteria and may cause persistent sinus formation,
4. Use strands directly from the packet; avoid excessive or local infection.
handling of suture strands before use. 2. Avoid nonabsorbable suture exposure within the lumen of
5. Avoid suture kinking, or crushing suture with instruments. hollow organs, such as the urinary bladder or gall bladder, in
which calculus formation at a suture nidus is possible.
6. Suture strands with “memory” may be straightened with
a gentle tug. 3. Avoid burying nonabsorbable suture that has been taken
from a used open cassette. Consider all suture from an open
7. Periodically check suture strands for evidence of fraying or
cassette contaminated.
defects, particularly when using a continuous suture pattern.
4. If continued suture strength is important, avoid chromic gut in
inflamed or infected tissue, and in wounds with delayed
Polyvinylidine Pronova® (Ethicon) healing (catabolic conditions, radiation wounds, etc). Gut in
This unique synthetic nonabsorbable monofilament suture is made contact with proteolytic enzymes such as in the stomach
of two polyvinylidine polymers, with a special extrusion process. lumen or pancreas loses most of its strength within days
This produces an optimal balance between suture strength and of implantation.
handling characteristics throughout the range of suture sizes. 5. Avoid rapidly absorbable suture material use in critical areas
Pronova® suture sizes, 10-0 through 4-0, are composed of an 80/20 such as tendons or ligaments that are known to heal slowly
polymer blend, that emphasizes tensile strength without compro- and are under continual tensile force, or in wounds with
mising handing in smaller sizes. Pronova® suture sizes, 2-0 through delayed healing.
#2, are composed of a 50/50 polymer blend that improves handling
6. Use suture materials that cause less inflammation in wounds
in these larger sizes, without compromising tensile strength. This
that are predisposed to stricture (such as tracheostomies or
suture will remain secure in critical surgical procedures where
urethrostomies) or excessive scar formation (such as skin)
life-long strength is desired, particularly in delicate applica-
tions where fine sutures are used. Tensile and knot strengths of 7. Avoid capillary/multifilament suture material penetration
Pronova® suture meet or exceed those of polypropylene suture in through known contaminated areas such as the bowel
all sizes. The suture has excellent resistance to breakage, fraying, lumen or skin. Bacteria are “wicked” or may be transported
and instrument damage, and has reduced package memory. It to adjacent sterile tissues to form microabscesses around
is an excellent alternate choice when polypropylene suture is sutures.
indicated. The suture is best for general soft tissue approximation
and ligation including cardiovascular, ophthalmic, and neurologic reaction in tissues. Like other synthetic absorbable sutures,
applications. [Ethicon, Product Information; http://jnjgateway. eventual absorption is predictable by means of hydrolysis.
com/home] Biosyn® sutures are available in sizes #1 through 6-0. The suture
maintains 75% strength at two weeks and approximately 40% at
three weeks after implantation. Similar to Dexon® and Vicryl®,
Polyglactin 910 and Triclosan Coated Vicryl Plus this suture should not be used where extended approximation of
Antibacterial® (Ethicon) tissue is required.
This synthetic multifilament absorbable suture has an antiseptic
coating (Triclosan) that creates a zone of inhibition around the Polyglytone 6211 Caprosyn® (Syneture)
suture site that decreases bacterial colonization of the suture
This absorbable monofilament suture is prepared from a synthetic
or tissue. The suture performs and handles similarly to Coated
polyester composed of glycolide, caprolactone, trimethylene
Vicryl® suture. Vicryl Plus® is available in suture sizes, 5-0
carbonate, and lactide. It has very good handling and knot tying
through 0. It elicits a similar tissue reaction as other synthetic
characteristics due to its excellent pliability, and has low tissue
absorbable sutures, and considerably less inflammation than
reactivity. Caprosyn®, similar to Monocryl®, is useful for general
chromic gut sutures, but it should not be used close to the
subcutaneous tissue closure, urogenital surgery particularly in
eye (Triclosan may be irritating to the eye). The manufacturer
the urinary bladder, and where the benefits and rapid absorption
suggests using the suture in procedures that have a higher
may play a role in postoperative success.
risk of infection. Few clinical studies have been conducted to
substantiate the beneficial effects of this suture.
Suture Knots
Glycomer 631 Biosyn (Syneture)
® A knot consists of a minimum of 2 throws (sometimes termed
simple knots). As a knot is created, the material is deformed, and
This absorbable monofilament suture is prepared from a
depending on the properties of the material, this deformation may
synthetic polyester composed of glycolide, dioxanone, and
weaken the suture by as much as 50% of its original strength.
trimethylene carbonate. The advanced extrusion process
Therefore, the knot is the weakest part of a suture. The technical
gives the suture excellent initial strength and knot security and
performance of the knot is critical to the security of the wound
minimal memory. This suture elicits minimal acute inflammatory
10 Soft Tissue
closure as well as the strength of the stitch. A square knot is with high coefficients of friction and minimal tension. When
least likely to untie or loosen so it is the knot of choice for most using monofilament sutures (such as nylon or polydioxanone),
suture lines. Depending on how the throws are placed, three or coated multifilament sutures, four or more throws should be
different knots can be formed (square knot, granny knot, or a half applied. In a continuous suture line, the final knot (consisting of a
hitch shown in Figure 1-1). The latter two knots tend to slip and loop and single strand) should have a minimum of 5 throws to be
are generally avoided. Square knots are produced by reversing secure. General knot tying rules are included in Table 1-6.
direction on each successive throw while maintaining equal
tension on both strands as they are held parallel to the plane Table 1-6. Knot Tying Principles
of the tissue. Failure to reverse direction of successive throws 1. The primary objective in knot tying is to ensure knot security.
will result in granny knots. If one strand is pulled under more The square knot is almost exclusively used since it is the
tension away from the plane of the knot than the other strand, simplest, most secure knot.
with successive throws, a half hitch (or slip knot) is formed.
2. Use appropriate sized suture to keep the knot as small as
Sometimes surgeons using monofilament sutures intentionally
possible. Knots in smaller sized material generally are more
apply half hitch knots (especially if the wound is under tension)
secure.
and this allows precise control of intrinsic suture tension. All
half hitch knots must be completed with several square knots to 3. Avoid friction as the knot throws are tightened. Attempt to
prevent loosening. A surgeon’s knot is similar to the square knot tighten throws by pulling in opposite directions, in a
except one strand is fed through the loop twice on the first throw. horizontal plane, with similar rate and tension.
The additional pass of suture in the loop produces increased 4. Do not crush or kink suture with surgical instruments while
friction. This knot is especially useful when attempting to knot a knot tying. Grasp suture only on the end that will be
stitch when tissues are under tension. Multifilament absorbable discarded.
sutures such as polyglycolic acid or polyglactin 910 may require 5. Avoid excessive intrinsic suture tension to reduce tissue
surgeon’s knots when used to close abdominal fascia. This knot cutting and strangulation.
is avoided when using gut since the increased friction tends to 6. Avoid cutting knot ends too short particularly when using
fray the material and excessively weakens it. Caution should be suture with known knot security problems. If ends are left
exercised with using surgeon’s knots during vessel ligation, since too long, however, irritation from the suture ends may create
the bulk of the first throw may not allow complete occlusion of unwanted tissue inflammation.
the vessel, and the knot is less reliable than the standard square 7. With instrument ties, hold the needle holder parallel to the
knot. Surgeon’s knots have increased bulk and are asymmetric, wound. Move the needle holder back and forth perpendicular
so this knot is used only when necessary. to it.
8. Use a surgeon’s knot only when suture tension is such that
use of a standard square knot would result in poor tissue
apposition. Surgeon’s knots take longer to tie and place
more suture in the wound than does the square knot. It may
not permit proper tension on blood vessel ligations (resulting
in partial occlusion) because of the bulk of suture material
involved in the first throw.
Suture Needles
Surgical needles are manufactured in a variety of sizes, shapes,
and types. Needles are selected to ensure that the tissues being
sutured are altered as little as possible by the needle. The needle
chosen should allow tissue passage without excessive force and
without disruption of tissue architecture. The hole created by
the needle should be just large enough to allow passage of the
Figure 1-1. Surgical Knots. suture material. The needle should be rigid enough to prevent
bending, yet flexible enough to bend before breaking.
Additional factors that influence knot security are the material
coefficient, the length of the suture ends (ears), as well as the Regardless of their intended use, all surgical needles have three
structural configuration of the knot, mentioned previously. Knots basic components: the eye (or suture attachment), the body
that swell (chromic catgut) or knots formed from stiff suture (ones (or shaft), and the point. There are two types of needle eyes
with memory), require longer knot ears in general. Multifilament commonly used in practice, the economical closed eye (suture
sutures possess a higher coefficient of friction, and have better is fed through the eye) and swaged (eyeless). Needles perma-
knot-holding properties than the monofilaments in general; nently connected to suture (swaged needles) produce signifi-
however, coating the strands to reduce friction or chatter in cantly less tissue trauma and are easier to handle compared to
tissue also reduces knot security. Three single reversed throws eyed needles; sutures supplied with needles, expectedly, are
are generally sufficient to secure knots in suture materials more expensive.
Selection and use of currently available Suture Materials and Needles 11
The bodies or shafts of needles vary in shape and size. The body round needles have no edges to cut through tissue. The point
should be as close as possible to the diameter of the suture pierces and spreads tissue without cutting. They are used for
material. The cross-sectional configuration of the body may suturing easily penetrated soft tissues such as muscle, viscera,
be round, side-flattened rectangular, triangular, or trapezoidal. or subcutaneous tissue. Blunt pointed taper needles have a
Some needle bodies are ribbed to prevent rotation and provide rounded point so they are most useful for suturing friable paren-
better stability of the needle in the jaws of needle holders. chymal organs such as the liver or kidney. General principles of
Easily accessible tissues such as the skin may be sutured by needle use are list in Table 1-7.
hand with straight needles but most surgeons prefer curved
needles because they are easier to use with instruments. Curved
needles are supplied in 1/4, 3/8, 1/2, and 5/8 circle configura-
tions (Figure 1-2). Choice of length, width, and curvature of the
needle is dependent on the size and depth of the area to be
sutured. Quarter circle needles have limited use, primarily for
eye surgery. Three-eighths circle needles are most commonly
used in veterinary surgery and are suitable for most superficial
wounds. Half circle needles are preferred for deeper wounds
and in body cavities. Five-eighths circle needles are applicable
for suturing wounds in confined areas such as the oral, nasal,
and pelvic cavities.
Table 1-7. Principles of Suture Needle Use Pineros-Fernandez A, Drake DB, Rodeheaver PA, et al.: CAPROSYN*,
another major advance in synthetic monofilament absorbable suture. J
1. Swaged needles are less traumatic and always preferred.
Long Term Eff Med Implants 14:359, 2004.
2. Curved needles facilitate suturing of deep tissues, and Rosin E, Robinson GM: Knot security of suture materials. Vet Surg
straighter needles are useful in superficial tissues, particu- 18:269, 1989.
larly the skin. Schubert DC, Unger JB, Mukherjee D, et al.: Mechanical performance
3. For general use, needle holders are used to grasp the needle of knots using braided and monofilament absorbable sutures. Am J
1/3 to 1/2 the way down from the suture attachment to the Obstet Gynecol 187:1438; discussion 1441, 2002.
point. Grasp the needle closer to the point if tissue is Smeak DO, Wendelberg KL: Choosing suture materials for use in
especially difficult to penetrate. contaminated or infected wounds. Compend Contin Educ Pract Vet
4. Hold needles in the narrow tips of the jaws of the needle 11:467, 1989.
holders. Stashak TS, Yturraspe OJ: Considerations for selection of suture
5. Use taper needles wherever possible; they should not be materials. Vet Surg 7:48, 1978.
used if it becomes difficult to pass through tissues. Taylor, TL: Suture material: a comprehensive review of the literature. J
Am Podiatr Assoc 65:649, 1975.
6. With increasing tissue density, taper-cut or reverse cutting
Van Winkle W, Hastings JC: Considerations in the choice of suture
needles are required to penetrate tissue without excessive
material for various tissues. Surg Gynecol Obstet 135:113, 1972.
trauma.
7. Needles should be the smallest size to penetrate the tissue
but long enough to penetrate both sides of the incision.
8. Do not grasp the needlepoint with the needle holders or
gloved fingers.
Suggested Readings
Beardsley SL, Smeak DO, et al.: Histologic evaluation of tissue reactivity
and absorption in response to a new synthetic fluorescent-pigmented
polypropylene suture material in rats. Am J Vet Res 56:1246, 1995.
Bellenger CR: Sutures. Part 1. The purpose of sutures and available
suture materials. Compend Contin Educ Pract Vet 4:507, 1982.
Bellenger CR: Sutures. Part 2. The use of sutures and alternative
methods of closure. Compend Contin Educ Pract Vet 4:587, 1982.
Bezwada RS, Jamiolkowski DD, Lee IY, et al.: Monocryl a new ultra-
pliable absorbable monofilament suture. Biomaterials 16:1141, 1995.
Boothe HW: Suture materials and tissue adhesives. In: Slatter DH, ed.
Textbook of Small Animal Surgery. Philadelphia: WB Saunders, 1985, p
334.
Bourne RB: In vivo comparison of four absorbable sutures: Vicryl, Dexon
Plus, Maxon and PDS. Can J Surg 31:43, 1988.
Canarelli JP, Ricard J, Collet LM, et al.: Use of fast absorption material
for skin closure in young children. Int Surg 73: 151, 1988.
Chu CC: Mechanical properties of suture materials: an important
characterization. Ann Surg 193:365, 1981.
Crane SW: Characteristics and selection of currently available suture
materials. In: Bojrab MJ, ed. Current Techniques in Small Animal
Surgery. 2nd ed. Philadelphia: Lea & Febiger. 1983, p 3.
Edlich RF, Panek PH, Rodeheaver GT, et al.: Physical and chemical
configuration of sutures in the development of surgical infection. Ann
Surg 177:679, 1973.
Ford HR, Jones P, Gaines B, et al.: Intraoperative handling and wound
healing: controlled clinical trial comparing coated VICRYL plus antibac-
terial suture (coated polyglactin 910 suture with triclosan) with coated
VICRYL suture (coated polyglactin 910 suture). Surg Infect (Larchmt)
6:313, 2005.
Katz AR, Mukherjee DP, Kaganov AI, et al.: A new synthetic monofil-
ament absorbable suture material from polytrimethylene carbonate.
Surg Gynecol Obstet 161:213, 1985.
Peacock EE: Wound Repair. 3rd ed. Philadelphia: WB Saunders, 1984.
Ray JA. Doddi N, Regula O, et al.: Polydioxanone (PDS), a novel monofil-
ament synthetic absorbable suture. Surg Gynecol Obstet 153:497, 1981.
Bandaging and Drainage Techniques 13
Bandage Components Gauze dressings have several disadvantages. 1.) Both viable
A bandage consists of three layers, each of which has distinctive and nonviable tissue are removed with dressing change. 2.) The
characteristics and functions (Figure 2-1). function of cells and enzymes involved in healing are impaired.
3.) If a gauze is too wet, exogenous bacteria can wick toward
the wound, and a wet bandage favors tissue maceration. 4.)
Bacteria can be dispersed into the air by a dry gauze at bandage
change. 5.) Adherent gauze fibers can remain in a wound to
cause inflammation. 6.) Bandage removal can be painful. 7.)
Cytokines and growth factors essential for optimal healing are
removed with the gauze.
Polyurethane Foam Dressings These film dressings are contraindicated in wounds that are
Polyurethane foam dressings are soft, compressible, nonad- infected and have high exudate levels and wounds with fragile
herent, highly conforming dressings. They are highly absorptive periwound skin. Neither should films be used on wounds with
and indicated for use on moderate to highly exudative wounds. exposed tendon, muscle, bone, or deep burn wounds.
The dressings maintain a moist wound environment which
enhances autolytic debridement. They promote granulation Adherence of the films is poor in areas of skin folds or unshaved
tissue formation and epithelialization. Thus, the dressings can hair, and hair growth on periwound skin can push the adhesive
Bandaging and Drainage Techniques 15
attachment off. However, adherence to periwound skin can be tissue, collagen syntheses, and epithelialization. However,
improved with vapor-permeable film spray. wound contraction may be slowed by the dressing adherence
to periwound skin.
A cloudy white to yellow exudate under the film is just wound
surface exudate and should not be confused with infection. The The dressings should not be used in infected wounds producing
presence of heat, swelling, pain and hyperemia in surrounding large amounts of exudate. The retained exudate can lead to
tissues would indicate infection. maceration and excoriation of periwound skin.
Hydrogel Dressings To apply the dressing, the periwound skin is prepared aseptically.
Hydrogels are water-rich gel dressings in the form of a sheet or The sheet is cut to a size about two centimeters larger than the
amorphorus gel. Some of these dressings contain other medica- wound. The backing is removed from the sheet and it is placed
tions that are beneficial to wound healing, such as acemannan, over the wound. The dressing should be changed in about two or
metronidazole or silver sulfadiazin antimicrobials. three days when it feels like a fluid filled blister over the wound.
Change should take place before this fluid leaks from under the
Because of their high water content, the dressings can be used dressing edge. Lavage and gentle wiping are used to remove the
to rehydrate tissues in wounds with an eschar or dry sloughing gel from the wound and periwound skin.
tissue. A nonadherent semiocclusive dressing or vapor-
permeable polyurethane film can be placed over a hydrogel Nonadherent Semiocclusive Dressings
dressing to assure that its moisture is transferred to the tissue These dressings are porous to allow fluid to move through
and not to the secondary bandage layer. Some hydrogels have them into the secondary bandage layer where it can evaporate.
an impermeable covering as part of the dressing to serve this However, their absorptive capacity is low, and their porosity
purpose. Conversely to wound hydration, some hydrogels can can allow exogenous bacteria to wick toward a wound. The
absorb wound fluid and can be used in exudative wounds. These dressings are generally used when a wound is in the repair
dressings can be used in necrotic wounds to provide a moist stage of healing.
environment to enhance autolytic debridement and promote
granulation tissue formation. The dressing can be either an absorbent material encased
in a perforated nonadherent covering or a wide mesh gauze
Hydrogel dressings are generally changed every three days impregnated with petrolatum. Although they are classified as
in noninfected wounds, but if the dressing contains an antimi- nonadherent, these dressings can adhere to a wound. With the
crobial or wound healing stimulant, daily bandage change may petrolatum impregnated gauze, granulation tissue and epithelium
be necessary to maintain their activity in the wound. Hydrogel can grow into the interstices of the gauze to cause adherence.
dressings can be changed every four to seven days when they With the perforated nonadherent dressings exudate can dry in
are used to treat abrasions that have minimal exudates. Any the perforations to adhere the pad to the wound.
hydrogel remaining on the wound at dressing change can be
removed with gentle saline lavage. Petrolatum impregnated gauze should be used early in the repair
stage of healing and should be changed frequently enough to
Hydrocolloid Dressings prevent granulation tissue from growing into the mesh openings.
These are dressings made of a combination of elastomeric and Because petrolatum may interfere with epithelialization, its early
absorbent components which form a gel when they interact with use may prevent this interference. However, once epithelial-
wound fluid. Some dressings have an outer occlusive polyure- ization starts, a perforated nonadherent material with absorbent
thane film. The hydrocolloid adheres to periwound skin while filler should be used.
the dressing over the wound interacts with the wound fluid to
produce an occlusive gel. This gel may have a yellow purulent If the perforated nonadherent material with absorbent filler is
appearance and have a mild odor; however, this should not be used, its purpose is to retain some moisture over the wound
interpreted as infection it is surface bacterial growth. Infection to promote epithelialization while allowing excess fluid to be
would be manifested as hyperemia, pain, swelling and heat of absorbed into the secondary bandage layer (Figure 2-3). This
the wound and periwound tissues. The gel is more tenacious dressing is indicated for superficial wounds that have low to
than just exudate or the gel from hydrogel dressings. moderate exudate levels. They are often used in the latter part
of the repair stage of healing when exudate levels are low. They
The sheet form of the dressing is the one most frequently used. It are a good primary dressing for sutured wounds.
provides a thermally insulated moist environment that is imper-
meable to gas, bacteria and fluid. Antimicrobial Dressings
Antimicrobial dressings may contain such agents as iodine,
These dressings can be used on partial or full thickness wounds silver, polyhexamethylene biguanide, activated charcoal and
with clean or necrotic bases. Such wounds would include antibiotics. Such dressings are indicated to treat infected
pressure wounds, minor burns, abrasions, or graft donor sites. wounds or wounds at risk for infection. Because these dressings
Hydrocolloids can be used in the inflammatory and repair stages are not moisture retentive, covering them with a polyurethane
of healing. In the inflammatory stage they promote autolytic film dressing may help keep them from drying out.
debridement, and in the repair stage they stimulate granulation
16 Soft Tissue
A properly applied pressure bandage made with elastic material principle is to place the hole of the donut over the prominence
tends to keep some dynamic pressure on the wound as the so the surrounding padding absorbs the pressure, and there
patient moves. Even when an elastic material is used for a is pressure relief over the prominence. Several layers of cast
pressure bandage, excess pressure can impair arterial, venous, padding are folded on each other; thus, making a pad approxi-
and lymphatic flow and can lead to tissue slough as well as nerve mately 3 inches by 3 inches. The pad is folded over on itself and
impingement. Therefore, the area of the limb distal to a pressure a slit is cut in its center with bandage scissors. After opening the
bandage should be carefully inspected for signs of swelling, pad, digital tension is used to enlarge the slit to a round opening
hypothermia, cyanosis, moisture, loss of sensation, or odor; this (“donut” hole). The pad is then placed over the prominence with
duty should be performed at least twice daily by the veterinarian the hole over the prominence. Secondary and tertiary bandage
on hospitalized patients or by the client on outpatients. Many limb wraps hold the pad in place (Figure 2-5A-D). These bandages are
bandages are applied so as to include the entire foot; therefore effective over prominences on the lower limbs, (e.g. lateral/medial
the pad surfaces of the two middle digits should be left exposed malleolus, calcaneal tuberosity, carpal pad). A variant of the
so that they may be examined. An animal will usually not disturb “donut” bandage principle has been employed to relieve pressure
a comfortable, properly applied bandage; if it licks or chews a on the paw pads. This technique uses medium density open-cell
pressure bandage, the bandage should be removed and the area foam of a special type used in aircraft seat padding (Confor™
should be examined. Foam, HiTech Foams, Lincoln NE). Two configurations have proven
effective to relieve pressure on a metacarpal or metatarsal pad:
Pressure caused by an elastic pressure bandage is governed an oblong piece of foam is cut to cover the entire palmar or
by five factors: 1) the elasticity of the material used. Higher plantar paw surface and a hole is cut in it in the area over the
elasticity equates to more pressure, 2) tension applied at the time metatarsal or metacarpal wound; the foam is then incorporated
of application, 3) width of the tape, i.e., the narrower the tape, into the bandage. For pressure relief over digital pad wounds, a
the greater the local pressure, and 4) the number and overlap triangular piece of foam is placed directly over the metacarpal or
of layers. The pressure produced by these factors is additive. metatarsal pad and incorporated into the bandage, thus helping to
Lastly, pressure is inversely proportional to the circumference elevate the digits and relieve pressure. A metal paw pad cup (cup
of the bandaged body part, i.e., the smaller the circumference, end of a mason metasplint) can be placed over the bandage with
the more pressure is applied, and the greater is the chance of either of these configurations for further help with pressure relief.
circulatory compromise. Therefore, care should be taken when This type of pressure relieving bandage is indicated for moderate
moving from an area of small circumference to one of larger pad wounds on small to medium sized dogs.
circumference while bandaging.
Immobilization and extension are important to enhance wound
For example, when bandaging a limb from distal to proximal, the healing over the olecranon. Immobilization allows tissues to heal
distal portion of the bandage should be applied with less tension together and extension prevents elbow flexion to prevent sternal
to prevent excessive constriction of this smaller circumference recumbency and thus keeps pressure off of the wound. Several
area. techniques have been used to bandage elbow wounds.
Practice can help assure that elastic tape is applied with the Pipe insulation bandages can be used for wounds over the
proper tension. As the tape is applied off the roll, it is secured olecranon. They are made by splitting two pieces of foam rubber
near the bandage with one hand while pulling tape off the roll. pipe insulation lengthwise, cutting a hole large enough to go
Thus, the danger of applying it too tightly is reduced. Another around the lesion in each piece, and then stacking and taping the
guideline for tape application is to apply it such that the textured pieces together. The cranial aspect of the humeroradial area is
well padded with cast padding before taping the pipe insulation
pattern of the material is slightly distorted but sill visible. Wraps
bandage in place with the hole over the olecranon. Such padding
should overlap one-third to one-half the tape width.
helps to keep the dog from flexing the joint to position itself in
sternal recumbency to place pressure on the olecranon area. It
Pressure Relieving Bandages may be difficult to secure the bandage to keep it from slipping
Bandages may also be configured to relieve pressure on an distally on the limb, especially on an obese dog that has a short
injured body part. The shape of the bandaged surface has an segment of limb proximal to the elbow to which the bandage
effect on the amount of pressure exerted on the tissue. The can be affixed. Affixing the pipe insulation bandage to a body
more convex the surface, the greater is the pressure exerted by bandage may be necessary to hold the pipe insulation bandage
the dressing on the tissue. Adding more gauze padding over a in place: a body bandage is placed just caudal to the forelimbs.
convex surface makes it even more convex, further increasing A strip of 2 inch adhesive tape is placed, adhesive side down, on
pressure. This can be detrimental when treating an open wound this bandage from the dorsal area well down onto the forelimb.
over a convex surface. Placing more padding over the wound in The roll of tape is left on the strip. The padding and pipe insulation
an attempt to protect it from pressure has the effect of increasing bandage are placed and taped over the elbow area. The previ-
the pressure and impairing healing. Pressure relieving bandages ously placed strip of adhesive tape is twisted 180° at the base
are indicated for bandaging such areas. of this bandage so the adhesive side faces outward. The tape is
then placed adhesive side against the bandage and is taken back
Cast padding material (Specialist Cast Padding, Johnson & onto the body bandage over the animal’s dorsum. This forms a
Johnson Orthopaedics, Raynham, MA) can be used to make a “stirrup” to hold the pipe insulation bandage in place (Figure 2-6).
“donut”-type pad for placement over convex prominences. The No pressure is on the wound, and medications can be applied to
Bandaging and Drainage Techniques 19
A B
C D
Figure 2-5. A.-D. Donut bandage. A. Folding several layers of cast padding to make a pad. B. Scissors cutting a slit in folded-over pad. C. Fingers
enlarging the slit to a round hole. D. Pad placed over the calcaneal tuberosity to be held in place with secondary bandage wrap.
Figure 2-6. A. Steps for putting on a pipe insulation bandage: 1) place a body bandage behind the front limbs; 2) transfer tape from the body ban-
dage onto the limb; 3) split two pieces of pipe insulation; 4) cut holes in the pipe insulation to go over the elbow ulcer and stack the pipe insula-
tion; 5) tape the pipe insulations together and place them over the olecranon wound; 6) put cast padding in front of the elbow area. B. Tape the
pipe insulation and padding in place. Twist the tape (180°) on the limb (arrow) so the adhesive side is back against the bandage. C. Complete the
tape stirrup back onto the body bandage.
20 Soft Tissue
the wound through the holes in the pipe insulation. The bandage plints should extend proximally almost to the elbow or to the
and padding remain in place for several days before adjustment tarsus. The functional effect is to convert the dog’s ambulation
or replacement are necessary. The only daily bandage change to a “tiptoe” gait, like a ballet dancer, thereby relieving pressure
necessary is a small amount over the wound. from the pads. At the end of the splints, a final layer of duct tape
or thick adhesive elastic bandaging material (Elastikon®, Johnson
Splints may also be used on the cranial surface of the forelimb to & Johnson, New Brunswick, NJ) helps protect the splints (and
immobilize the elbow joint in extension and to prevent pressure owners’ flooring!) from abrasion (Figure 2-8).
on wounds over the olecranon. A routine bandage wrap is placed
around the elbow; then a section of aluminum splint rod is used to
fashion a loop type splint, which is incorporated into the cranial
part of the bandage (Figure. 2-7).
The authors have also been able to keep elbows extended and
immobilized by placing a body bandage on the dog with extension
of the bandage down the length of the leg, i.e., a forelimb spica-
type bandage. The leg bandage has some bulk to it. After placing
the bandage, fiberglass casting tape (Delta-Lite “S” Fiberglass
Casting Tape, Johnson & Johnson, Raynham, MA) is used to
create a lateral splint for the limb. The casting tape is layered
along the lateral side of the bandage from the level of the paw to
over the shoulders. Several layers of tape are used, especially
on large dogs. The tape splint is molded by hand to the lateral
surface of the bandage until it hardens. When taken away from
the bandage, it has the shape of a shepherd’s crook or a question
mark. This is taped to the lateral side of the bandage, around the
limb and over the shoulder area. A hole is cut in the bandage over
the olecranon, through which the wound is treated. Usually, the
bandage and splint remain in place 5 to 7 days before adjustment
or replacement are needed, and the wound is treated daily via
the hole with a small bandage covering, following treatment.
The pipe insulation bandage, splint rod loop bandage, and fiber-
glass splint bandages are also effective in keeping pressure off
Figure 2-7. Applying an aluminum rod loop type splint in the front of an wounds on the sternum because they prevent elbow flexion and
elbow bandage. keep the animal out of sternal recumbency. A pressure relief
bandage for wounds (i.e., decubital ulcers) over the ischiatic tuber-
Another application of splints to a special wound healing situation osities is composed of a body bandage with padded aluminum
is the use of “clamshell” technique to relieve pressure from the splints taped to either side of the bandage. These splints extend
palmar or plantar surface of lacerated pads, pad flaps or pad behind the dog and prevent it from attaining a sitting posture to
grafts. This technique is even more effective at relieving pad place pressure on the ischiatic area (Figure 2-9).
pressure than the “donut” technique mentioned above and may
be particularly indicated for protection of pad surgical sites. After Mobilization Versus Immobilization
bandaging the foot in a standard padded bandage, (a “donut” of
The decision whether a wound should be mobilized or immobilized
the Confor™ Foam mentioned previously can also be applied over during healing is often not clear, with advantages and disadvan-
the affected pad or pads), two Mason metasplints are applied, tages to both; wound location and type, and the stage of wound
one on the dorsal and the other on the palmar or plantar aspect healing are important factors to consider in making the decision.
of the limb with the paw cups facing each other and extending
about 2.5 cm beyond the limb. Bandaging tape, applied in a Maintaining mobility of wounds has been considered to minimize
dovetail fashion, secures the splints to the bandage. The metas-
Bandaging and Drainage Techniques 21
Suggested Readings
Anderson DM. Management of open wounds. In Williams J, Moores
A, eds. BSAVA Manual of canine and feline wound management and
reconstruction. 2nd ed. Quedgeley, Glouster, England: British Small
Animal Veterinary Association, 2009: 37.
Figure 2-9. Body bandage with a lateral fiberglass splint to keep pres- Anderson DM, White RAS. Ischemic bandage injuries: A case series
sure off the ischiatic area. and review of the literature. Vet Surg 2000;29:488.
Bojrab MJ. Wound management. Mod Vet Pract 1982;63:867.
negative nitrogen balance of the tissues, to stimulate circulation, Bojrab MJ. A handbook on veterinary wound management. Ashland,
to help combat infection, and to allow movement that loosens OH: KenVet Prof Vet Co, 1994.
adhesions. Mobility can also provide massage for better wound Campbell BG. Dressings, bandages, and splints for wound management
drainage and can prevent joint stiffness and osteoporosis. in dogs and cats. Vet Clin North Am 2006; 36: 759.
Hedlund CS. Surgery of the integumentary system. In: Fossum TW, ed.
Other arguments favor wound immobilization to enhance healing. Small Animal Surgery. 3rd ed. Philadelphia: Saunders Elsevier, 2007:
An immobilizing bandage is needed for wounds with under- 159.
lying orthopedic damage. In addition to providing orthopedic Lee AH, Swaim SF, McGuire JA. The effects of nonadherent bandage
support, wound immobilization may allow better healing over materials on the healing of open wounds in dogs. J Am Vet Med Assoc
the olecranon, and the calcaneal tuber. Immobilization may also 1987;190:416.
increase tissue resistance to bacterial growth and decrease the Lee AH, Swaim SF, Yang ST. The effects of petrolatum, polyethylene
probability of infection and its spread by the lymphatics and tissue glycol, nitrofurazone and a hydroactive dressing on open wound
planes. Other factors favoring immobilization include patient healing. J Am Anim Hosp Assoc 1986;22:443.
comfort and support of the tissues during collagen synthesis. Lee WR, Tobias KM, Bemis DA, et. al. Invitro efficacy of a polyhexam-
Wound immobilization also helps to prevent the dislodgment of ethylene biguanide impregnated gauze dressing against bacterial found
in veterinary patients. Vet Surg 2004;33:404.
fragile clots, rupture of new capillaries, and disruption of new
fibrin. In addition, immobilization prevents tension on repaired Mentz P, Cazzangia A, Serralta V, et. al. The effect of an antimicrobial
gauze dressing impregnated with 0.2% polyhexamethylene biguanide
structures (e.g., muscle, tendons, and ligaments).
as a barrier to prevent Pseudomonas aeruginosa wound invasion.
Mansfield, MA: Kendall, Wound Care Research and Development,
Pressure bandages help to immobilize wounds; casts and splints 2001.
also immobilize wounded limbs. Casts should be applied so that Miller CW. Bandages and drains. In: Slatter DH, ed. Textbook of small
swelling can be accommodated as well as controlled. Applying a animal surgery. 3rd ed. Philadelphia: Saunders Elsevier, 2003: 244.
cast, then splitting the cast longitudinally on both sides, removing Morgan PW, Binnington AG, Miller CW, et al. The effect of occlusive and
and reapplying it (bivalving a cast) allows for swelling and makes semiocclusive dressings on the healing of full thickness skin wounds on
dressing changes possible. Application of a half of the cast to the forelimbs of dogs. Vet Surg 1995;23:494.
the side of the limb opposite the wound can be used for immobi- Pavletic MM. Atlas of small animal reconstructive surgery. 3rd ed.
lization. Such a half cast can act as a point of counterpressure Philadelphia: Saunders Elsevier, 2010.
when a pressure bandage is required. It can be applied so the Ramsey DT, Pope ER, Wagner Mann C, et al. Effects of three occlusive
dressing can be changed without affecting immobilization. dressing materials on healing of full thickness skin wounds in dogs. Am
Incorporating a Mason metasplint into a bandage placed on a J Vet Res 1995;56:7.
lower limb is an example of this type of immobilization. Swaim SF. The effects of dressings and bandages on wound healing.
Semin Vet Med Surg Sm Anim 1989;4:274.
Wounds over extensor and flexor surfaces of joints benefit from Swaim SF. Bandages and topical agents. Vet Clin North Am 1990;20:47.
immobilization during healing. Because flexion of a joint tends Swaim SF. Bandaging techniques. In: Bistner SI, Ford RB, eds. Handbook
to pull wound edges apart on the extensor surface of the joint, of veterinary procedures and emergency treatment. 7th ed. Philadelphia:
immobilization is indicated for such wounds. Large wounds over WB Saunders, 2000.
flexion surfaces of joints can benefit from early reconstructive Swaim SF, Bohling MW. Bandaging and splinting canine elbow wounds.
surgery to help prevent wound contracture leading to deformity NAVC Clinician’s Brief, 3(11):73-76, 2005
and loss of function of the joint. When large wounds over flexion Swaim SF, Henderson RA. Small animal wound management. 2nd ed.
surfaces are to be allowed to heal as open wounds, joint immobi- Baltimore: Williams & Wilkins, 1997.
lization in extension is particularly important to help prevent Swaim SF, Marghitu DB, Rumph PF, et. al. Effects of bandage configu-
contracture deformity. Another specific area where wound ration on paw pad pressure in dogs: A preliminary study. J Am Anim
immobilization is indicated is the axillary region. As the forelimb Hosp Assoc, 2003;39:209-216.
moves, shearing and tension forces in this area interfere with Swaim SF, Renberg WC, Shike KM. Small animal bandaging, casting,
wound healing. Reconstructive surgery and immobilization in a and splinting techniques. Ames, IA: Wiley-Blackwell, (in press).
22 Soft Tissue
Wound Drainage Techniques Because they are soft and flexible, these drains do not exert
undue pressure on adjacent blood vessels or other structures.
Mark W. Bohling and Steven F. Swaim
Single-Exit Drains
Indications Penrose drains can be placed with one end of the drain emerging
Although wounds drain best when left open, often they must be at the distal aspect of the wound. In preparation for placing such
closed before they have drained completely. In general, wounds a drain, the hair around the area where the drain will exit should
must be drained 1) when an abscess cavity exists, 2) when be clipped liberally. The length of drain placed in a wound should
foreign material or tissue of questionable viability that cannot be be recorded for comparison with the length that is removed.
excised is present, 3) when massive contamination is inevitable The dorsal end of the drain should be positioned before wound
(e.g., wounds in the anal area), and 4) when it is necessary to closure, slightly dorsal and lateral to the most dorsal aspect of
obliterate dead space to prevent the accumulation of air, blood, the wound. The preferred technique for fixing the drain in the
serum or exudate, or to permit the egress of air or fluid accumu- dorsal aspect of the wound is to pass a nonabsorbable suture
lations from an existing cavity or wound. Specifically, wound through the skin and the drain and to tie it outside the skin. Only
drainage in veterinary surgery is used in the management of a very small bite is taken in the end of the drain; in the event that
dog bite wounds with separation of the dermis from underlying the patient removes the drain prematurely, a small suture bite
tissue, abcessed cat bite wounds, lacerations with loose skin, in the drain minimizes the chance that a piece of the proximal
radical mastectomy and other large excisional wounds, seromas, portion of the drain will be torn off and remain in the wound. This
auricular hematomas, elbow and ischial hygromas, and certain suture is removed before the drain is removed (Figure 2-10).
instances of orthopedic trauma such as high energy fractures
with extensive soft tissue trauma and swelling.
To prevent drain incorporation in the suture line, the drain is Drains should be covered with sterile absorbent dressings to
placed in the wound via the ventral drain hole. The dorsal end absorb wound fluid and prevent external contamination. Bandages
of the drain is placed at the appropriate location in the wound. also help to prevent molestation of the wound by the patient. The
The point at which the drain exits through the ventral drain hole bandage should be changed frequently to remove fluid from the
is marked on the drain. The drain is then pulled from the dorsal wound area. The area around the exit drain should be cleaned at
end of the wound. This pulls the mark on the ventral part of the bandage change; antiseptic ointments or creams are sometimes
drain into the wound. The subcutaneous tissue is now apposed applied to the skin at the drain exit site to protect the skin from
over the drain. Every 2 or 3 suture bites, both ends of the drain irritation from the draining exudate. In these cases, the ointment
are grasped, and the drain is pulled back and forth to be sure or cream should not be applied too thickly around the drain exit,
no suture bite has incorporated the drain. Lack of free drain or drainage may be obstructed. Inspection of the bandage reveals
movement indicates drain incorporation in a suture, and 2 to 3 the nature and amount of drainage, to determine how long a drain
sutures can be removed and replaced. After all subcutaneous should remain in place.
sutures are placed and the drain moves freely, the ventral end is
pulled so that the dorsal end is now within the wound, and a deep
simple interrupted suture through the skin, drain, and skin again is Double-Exit Drains
used to anchor the dorsal end of the drain. The previously placed Penrose drains can also be placed with one end emerging above
mark on the drain is again at the level of the ventral drain hole. the dorsal aspect of the wound and the other end emerging
The skin can now be closed without concern for incorporating below the ventral end of the wound. Simple interrupted
the drain because it is protected beneath the subcutaneous sutures are placed through the skin and drain at both points of
tissue. The ventral drain anchor suture is then placed. emergence to prevent the drains from retracting into the wound
(Figure 2-13). The use of double exit drains remains somewhat
controversial; many surgeons avoid the use of vertically oriented
double exit drains, asserting that the double exit holes increase
the risk of ascending bacterial infection. However, there is no
support for this hypothesis in the scientific data, whether based
on experimentation or patient statistics. Double exit drains can
be advantageous if the wound is to be flushed with an antibiotic
or antiseptic. They are usually used in heavily contaminated
or infected wounds. Lavaging the wound from the proximal
tube emergence site exposes the wound tract to the solution,
although the lavage solution may merely follow the path of least
resistance, the drain tract, and not reach the crevices of the
wound. Moreover, if pressure is applied to the lavage solution
or if the distal drain opening is occluded, the lavage solution can
spread wound debris and bacteria into surrounding tissue by
hydrostatic pressure.
is removed from the scalp set, leaving the Luer adapter attached
to the tubing, and the tubing is fenestrated. (Figure 2-17A). After
the tubing has been placed in the wound and the wound has
been closed, a plastic syringe is attached to the Luer adapter.
The plunger is withdrawn enough to create the desired negative
pressure without collapsing the drain tubing, and a 16 or 18
gauge needle is driven crosswise through the syringe plunger
just above the syringe barrel to hold the plunger at the desired
level within the barrel (Figure 2-17B). Fixation at different levels
creates different negative pressures. The size of syringe that is
used corresponds to the expected volume of fluid to be drained;
a 6 ml syringe can be used when little drainage is anticipated,
while a 30 mL syringe can be used when large amounts of fluid
are to be removed.
Figure 2-15. Placement of a closed suction drain in a wound. A. The Figure 2-17. Modified closed suction drain. A. The butterfly needle is
fenestrated portion of the drain is inserted into the wound through a removed from the catheter and the catheter tubing is fenestrated. The
small opening near the distal end of the wound. The tube is secured to Luer adapter is left on the catheter. B. A plastic syringe is attached to
the skin with a simple interrupted nonabsorbable suture. B. The wound the Luer adapter of the catheter. A metal pin or hypodermic needle is
is closed. The needle on the tube is inserted into a 5 or 10 mL evacu- driven through the plunger just above the barrel after the plunger is
ated blood collection tube. withdrawn the desired distance. The end of the plunger can be cut off.
26 Soft Tissue
Closed suction drains allow wounds and dressings to be kept dry: give in to the temptation to close and drain areas that would be
they help to prevent bacterial migration through or around the better left open.
drain; they provide continuous drainage to decrease drainage
time; they reduce the need for irrigation; and they have few
complications. When used under skin grafts, these drains help to Suggested Readings
hold the graft in contact with the wound bed, enhancing revas- Fox JW, Golden GT. The use of drains in subcutaneous surgical
cularization and early engraftment. Evacuated blood collection procedures. Am J Surg 1976;132:673.
tubes can be changed as often as necessary, and wound fluid Hak DJ: Retained broken wound drains: A preventable complication. J
can be accurately measured and cytologically examined to Orthop Trauma 2000;14:212.
assess wound infection. Hampel NL. Surgical drains. In: Harari J, ed. Surgical complications and
wound healing in the small animal practice. Philadelphia: WB Saunders,
One disadvantage of closed suction drainage is that high negative 1993.
pressure can injure the tissue. In addition, although the 10 mL Hampel NL, Johnson RG. Principles of surgical drains and drainage. J
evacuated blood tubes are effective and not cumbersome to Am Anim Hosp Assoc 1985;21:21.
incorporate into a bandage, they may need to be changed several Ladlow J. Surgical drains in wound management and reconstructive
times each day in highly productive wounds. surgery. In: Williams J and Moores A, eds. BSAVA Manual of Canine
and Feline Wound Management and Reconstruction, 2nd ed. Quedgeley,
Gloucester, UK, BSAVA, 2009.
Duration of Drainage Lee AH, Swaim SF, Henderson RA. Surgical drainage. Compend Contin
The times for drain removal vary depending on the type of wound Educ Pract Vet 1986;8:94.
drained. A drain should be removed as soon as the need for it no Moss JP. Historical and current perspectives on surgical drainage. Surg
longer exists. The amount and character of drainage fluid are Gynecol Obstet 1981;152:517
the most important factors in determining when a drain should Pope ER, Swaim SF. Wound drainage from under full thickness skin
be removed. In general, it is time to remove the drain when the grafts in dogs. Part 1. Quantitative evaluation of four
amount of drainage is significantly decreased (usually by half or techniques. Vet Surg 1986;15:65.
more) and is remaining relatively constant from day to day, and Roush JK. Use and misuse of drains in surgical practice. Probl Vet Med
the character of drainage fluid becomes less turbid, becoming 1990;2:482.
serous or serosanguinous. Closed suction drains incorporate Swaim SF. Surgery of traumatized skin: management and reconstruction
fluid storage within the system, simplifying evaluation of volume in the dog and cat. Philadelphia: VVB Saunders, 1980:157 160.
and character. When a passive drain is employed, absorbent Swaim SF, Henderson RA. Small animal wound management. 2nd ed.
bandage material should be placed over the drain to protect Baltimore: Williams & Wilkins, 1997.
the wound and the drain, and to capture the drainage for evalu-
ation of volume and character. To give some specific examples
of approximate duration of drainage, a drain placed in a wound
to prevent hematoma formation from capillary oozing can be
removed within 24 hours. A drain used for an infection, such
as an abscess, should be removed in 3 to 5 days or when the
infection is controlled. For hygromas and large seromas, the
drain may need to remain in place for as long as 10 to 14 days, for
severe bite wounds, 4 to 6 days; and for major tumor resection
with creation of extensive dead space, 4 days.
Chapter 3 (Figure 3-2). The destructive effect is heat coagulation, and the
temperature is proportional to the intensity of the current flowing
through the resistance of the tip.
Electrosurgery and Laser Surgery
Electrosurgical Techniques
Robert B. Parker
Electrosurgical units are probably among the most frequently
used and least understood surgical instruments. Little infor-
mation is available in the veterinary literature concerning basic
electronics, proper surgical techniques, and potential hazards.
Judicious use of electrosurgery can be of great benefit to the
veterinarian in maintaining a bloodless surgical field, but indis-
Figure 3-2. Basic circuit diagram for a thermal electrocautery unit.
criminate use can create serious complications. The following
discussion describes available electrosurgical methods and
apparatus and provides a guideline for their proper use. Advantages of this technique are that 1) the degree of tissue
damage is apparent, 2) it coagulates well in a bloody field, and 3)
it is inexpensive and simple. The disadvantages are that 1) tissue
Electrolysis destruction can be extensive and 2) large lesions are slowly
Electrolysis implies a unidirectional, direct current flow that destroyed.
produces strong polarity in the anode and cathode (Figure
3-1). The system is of low voltage and amperage. When the Electrocautery units are generally reserved for minor surgical
electrodes are inserted into the body, hydroxides are produced procedures, such as dewclaw or tail removal in puppies.
at the treatment cathode by the following formula: Disposable electrocautery units, frequently used in ophthalmic
surgery, provide fine hemostasis by pinpoint heat application
2 NaCl + 4 H20 2 NAOH + 2 H2 (cathode) (Figure 3-3).
2 HCI + O2 (anode)
The mode of application can be either uniterminal or biter- Blended currents are possible and produce a combined cutting
minal. Biterminal application, used most frequently with cutting and coagulation mode (Figure 3-8). The more expensive units are
or coagulation, implies the use of an indifferent electrode or capable of varying the “on-to-off” time to accomplish degrees of
“ground plate” (Figure 3-4). The indifferent electrode collects cutting versus coagulation.
the current when it has passed through the body and dissipates
it over a large surface area to produce a low current density.
Because heat production is inversely proportional to the contact
area, the large size of the indifferent electrode evenly distributes Figure 3-6. Undamped, continuous sine (cutting) waves.
the heat to prevent burning. The active electrode concentrates
the same energy at a small point and produces the surgical
effect (Figure 3-5).
Figure 3-5. High current density at the active electrode and low current
density with a properly placed indifferent electrode.
Electrocoagulation
The electrosurgical apparatus is extremely useful for coagulation
of small bleeding vessels. A damped wave pattern provides the
ultimate current for coagulation. Proper technique is required,
and the technique of “frying tissue until it pops” is to be avoided.
This practice is comparable to mass ligation of a bleeding point,
and both lead to unnecessary tissue necrosis.
More expensive units have a 60 cycle monitoring current flowing Radiosurgery is defined as the use of energy created by high
through the “ground plate” system. A break in the ground wire frequency alternating current to perform surgical procedures.
or in its ground plate connection interrupts the monitoring This is in contrast to electrosurgery in which low frequency (.5
current and sounds an alarm. Electrolyte jellies and a large area mhz to 3.7 mhz) alternating current is used. The resistance of the
of contact with the patient are recommended to lower skin resis- tissue to the passage of this current creates heat internally in the
tance and to provide more intimate contact between the skin and tissue resulting in either cutting or coagulation.1 In radiosurgery,
the indifferent electrode. two electrodes (an active electrode and a patient return plate)
of greatly different sizes resulting in increased current density
Explosions and fire are potential hazards when inflammable at the point of the smaller active electrode are utilized. (Figure
anesthetics, such as ether, chloroform, and cyclopropane, and 3-10). While the electrode itself remains cold, the highly concen-
inflammable skin preparations, such as alcohol, are used. trated high frequency energy creates molecular heat inside each
cell. The intercellular water boils and creates a microexplosion,
Electrical channeling occurs when the treatment electrode is thus incising tissue. The key to successful use of radiosurgery
used on tissue that has a thin connection to the body. An example is control of the heat adjacent to the primary incision. By the
is the testicle mobilized out of the scrotum. If electrocoagulation choice of electrodes and selection and adjustment of the current,
is used, electric energy will be channeled or funneled along the the surgeon controls the effect of this energy on the tissues to
spermatic cord and will cause heat damage. achieve the desired results. The ideal frequency for radiosugery
is 3.8 to 4.0 MHz.2 This frequency allows for consistent primary
Cardiac pacemakers are implanted with increasing frequency healing of skin incisions. When low frequency energy is used to
in veterinary medicine, and the veterinary surgeon should be perform a skin incision, the risk of having delayed tissue healing
aware that high frequency electric energy may cause a cardiac increases due to the build up of lateral heat in the tissue.
arrest by interfering with the operation of the pacemaker.
Suggested Readings
Battig CG. Electrosurgical burn injuries and their prevention. JAMA
1968;204:91.
Fucci V, Elkins AD. Electrosurgery: principles and guidelines in veter-
inary medicine. Comp Contin Educ Pract Vet 1991;13:407.
Giddard DW, Jones WR, Wescott JW. Electrosurgical units: particular
attention to tube, spark gap and solid state generated currents–their
differences and similarities. J Urol 1972;107: 1051.
Glover JL, Bendick PJ, Link WJ. The use of thermal knives in surgery:
electrosurgery, lasers, plasma scalpel. Curr Probl Surg 1978; 15:7.
Greene JA, Knecht CD. Electrosurgery: a review. Vet Surg 1980;9:27.
Greene JA, Knecht CD. Healing of sharp incisions and electroincisions
in dogs: a comparative study. Vet Surg 1980;9:42.
Ormrod AN. Electrosurgery: its usefulness and limitations for the small
animal surgeon. Vet Rec 1963;75:1095. Figure 3-10. Active electrode (wire) and indifferent plate.
Swerdlow DB, et al. Electrosurgery: principles and use. Dis Colon
Rectum 1974;17:482. A 4.0 mhz radiosurgery incision, unlike a scalpel blade incision,
Wald AS, Mazzia VDB, Spencer FC. Accidental burns associated with
requires no pressure. The results are technique related (these
electrocautery. JAMA 1971;217:916. techniques will be discussed later). Most of the factors related to
a successful outcome are controlled by the surgeon. The buildup
of lateral heat adjacent to an incision should be avoided. The
Electrosurgery–Radiosurgery following formula expresses the factors involved in the devel-
opment of lateral heat.
A. D. Elkins
Lateral heat =
Introduction Electrode size x electrode contact time with tissue
Electrosurgical units are used to some degree in many veter- X intensity of power x waveform
inary practices. These units are often incorrectly used and in Frequency
most hospitals under-utilized due to a lack of understanding of
proper technique. The use of radiosurgery reduces operative The only factor not in the surgeon’s control is the output frequency
time when used correctly with no delay in healing. The following of the equipment used. As can be seen from the above formula,
discussion describes the difference in low frequency, electro- the lower the frequency, the more lateral heat produced.3
surgery and high frequency (3.8 to 4.0) radiosurgery units and
provides a guideline for their proper use. Radiosurgery can be used for making an incision, excising a
mass, obtaining a biopsy or controlling hemorrhage. The majority
Electrosurgery and Laser Surgery 31
Electrocautery
The term electrocautery denotes the use of a hot iron to stop
bleeding. The use of cautery to control hemorrhage dates back
to the ancient Egyptains.1 Low voltage current is used to heat
an electrode. When this heated electrode is applied to tissue
a thermal burn occurs. The destructive effect on tissue is heat
coagulation and hemorrhage control. Using electrocautery
causes collateral damage to the tissue, resulting in delayed
healing, therefore, electrocautery is not the ideal method of
hemorrhage control. When describing the use of a radiosurgery
unit to stop hemorrhage, the correct term is electrocoagulation.
Since there is no heat build-up at the electrode tip this is not
cautery. The terms electrocautery and electrocoagulation have
been incorrectly used synonymously in the literature.
Electrocoagulation
Electrocoagulation is the use of electrosurgical current to control
hemorrhage. Vessels up to 2 mms in diameter can be coagulated
with electrosurgery units. Vessels larger than 2 mms should Figure 3-11. Thumb forceps on vessel with electrode applied to thumb
be ligated. Utilizing proper technique by touching an electrode forceps.
to a vessel in a relatively dry field or to a hemostat which has
been applied to the vessel will form a coagulum at the end of
a vessel. Excessive heating of the tissue until it snaps or pops
should be avoided as this causes increased tissue necrosis.
The use of electrocoagulation to control hemorrhage results in
better visibility thus allowing the surgeon to be more efficient
and reduce operative time. It also reduces the amount of foreign
material left in a wound from ligatures. The majority of surgical
procedures can benefit from the use of radiosurgical electroco-
agulation. It has been said that a poor surgeon is not made better
by the use of radiosurgery, only more efficient.
Electroincision
An incision with high frequency radiosurgery may replace a
scalpel incision in any tissue. This being said, it is imperative to Figure 3-13. Bipolar forces.
32 Soft Tissue
use proper technique and a frequency of 3.8 to 4.0 MHz when D. Fulguration is a spark-gap wave form (Figure 3-18). Fulguration
making skin incisions. A frequency lower than 3.8 to 4.0 MHz rapidly dehydrates or desiccates tissue. This is ideal for areas
risks the buildup of lateral heat in the tissue. This may result in where the surgeon wants intentional tissue destruction (such
delayed healing and/or dehiscence of the incision.4 as perianal fistula, abscess or draining tracts). This may also
be used with a ball electrode to control diffuse, weeping type
Four wave forms or current types may be selected when using a bleeding. The tissue destruction is self-limiting by the insulating
high frequency radiosurgery unit. These wave forms are: effect of tissue carbonization, therefore only a superficial
A. Fully filtered or continuous wave form is a continuous high layer of tissue is damaged.
frequency waveform that produces a smooth cut (Figure 3-14).
It gives a 90% cut and a 10% coagulation effect. It generates
the least amount of lateral heat. When this waveform is
delivered by a fine wire electrode, it is comparable to a scalpel
blade with excellent healing properties4 (Figure 3-15). A biopsy
obtained with this waveform creates a micro-smooth cut with
no heat artifact at the edges. This allows an accurate reading
by the pathologist on the biopsy specimen. The fully filtered/
continuous waveform should always be used when making
skin incisions. Figure 3-16. Fully recitifed, 50% cut, 50% coagulation waveform on
B. Fully rectified waveform is not as smooth as the continuous oscilloscope.
wave form; thus reducing the efficiency of the cut (Figure 3-16).
It does, however, achieve a significant amount of hemostasis.
When using a unit with 3.8 to 4.0 output frequency, minimal
thermal damage can be expected. This setting produces a
50% cut and 50% coagulation effect. It is ideal for sub-cutaneous
tissue incision, dissection or when working in vascular
tissue such as the oral cavity.
C. Partially rectified waveform is an intermittent transmission
of high frequency waves that increases lateral heat production
(Figure 3-17). This is ideal for electrocagulation of small vessels Figure 3-17. Partially recitifed, 90% coagulation/10% cut waveform on
up to 2 mms. It gives 90% coagulation with a 10% cut effect. oscilloscope.
The following points should be considered when utilizing radio- like alcohol. If alcohol is used in the skin preparation for surgery,
surgery: allow an adequate time for the alcohol to dry.
A. Use a high frequency (3.8 to 4.0 MHz) unit when making skin
incisions. This helps prevent lateral heat damage. In summary, this author has been performing radiosurgery with
B. Chose the smallest wire electrode available to reduce tissue either an Ellman Surgitron (3.8 mhz) or the newer Dual Frequency
resistance and heat build-up. (4.0 mhz) Unit for over 30 years. Excellent clinical results can be
C. Use the full filtered or continuous wave form when making achieved when high frequency, low temperature radiofrequency
skin incisions. devices are used and good radiosurgery principles are followed.
D. Use the lowest power setting possible without producing The modern radiowave units are affordable, durable and become
drag of the electrode through the tissue. The electrode should work horses in surgical practice. Some form of radiosurgery,
pass through tissue effortlessly with minimal sparking or either for making an incision, excision, dissection or hemostasis
plume production. There should be minimal to no charring of is used on each surgery performed.
the tissue.
E. Electrode contact time with the tissue is directly proportional
to the lateral heat transferred to the tissue. The electrode References
should be moved rapidly through the tissue. If you have to 1. Parker RB: Electrosurgery and Laser Surgery in Bojrab MJ, ed; Current
return to the same area, allow an eight second lag period to Techniques in Small Animal Surgery. Philadelphia: Lea & Febiger, P. 41.
occur. This allows heat build-up in the tissue to dissipate. 2. Fucci V, Elkins AD: Electrosurgery: Principles and Guidelines in Veter-
F. Avoid contact of the electrode with cartilage, bone or enamel. inary Medicine. Comp Contin Educ Pract Vet 1991; 13; 407.
The most sensitive tissue is cartilage due to its high water 3. Miller WM: Using High-Frequency Radiowave Technology in Veter-
content. Therefore, when performing a procedure like a feline inary Surgery. Vet Med Sept 2004; 796-802.
onychectomy the distal portion of P2 should be avoided. 4. Olivar AC et al: Transmission Electron Microscopy: Evaluation of
Damage in Human Oviducts Caused by Different Surgical Instrumetns,
Ann Clin Lab Sci. 1999 29 (4): 281-285.
Precautions
Accidental burns to the patient are the most serious observed
complication to electrosurgery.4 Many electrosurgery units Lasers in Veterinary
utilize a metal ground plate. If good contact between the ground
plate and patient is not present, a burn can be created. The
Medicine–An Introduction to
ground plate is designed to be the deferential preferred pathway Surgical Lasers
for current. If a faulty connection exits then a burn can occur.1
Electrolyte jelly and a large area of contact with the patient are
Kenneth E. Bartels
recommended to lower skin resistance and to provide more
intimate contact between the skin and the ground plate.4 Introduction
The principles necessary for the concept of laser development
A safer system is the use of an indifferent plate or an antenna were reported as early as the 19th century with Bohr’s theory
plate found with the the Ellman Surgitron or Dual Frequency of optical resonance. In 1917, Einstein proposed the concept
unita (Figure 3-19). This is a plastic coated plate that requires of stimulated light emission. Finally, in 1960, Theodore Maiman
no conductive gel and does not have to be in contact with the developed the first laser which was a pulsed ruby laser.1 Since
patient. This indifferent plate can be placed under the surgical medical use began in the early 1960’s, the laser has been
drape but it should be in close vicinity to the surgical site. This considered by many to be “a tool in search of an application.”
makes the unit more efficient and allows the surgeon to use a Many of the earlier medical lasers were extremely cumbersome,
lower power setting. expensive, and difficult to maintain. However, as biomedical
laser technology merged with military and industrial efforts,
Explosions or fire are potential hazards if using flammable liquids innovations and improvements in devices and development of
new concepts occurred and continue today. Developmental
requirements to implement these new technologies include
improvements in light delivery systems (robust articulated arms,
small diameter wave-guides, and small-diameter optical fibers),
compatible laser wavelengths, endoscopic visualization, and
more portable, economical, user-friendly biomedical lasers.
invisible and visible light spectrum. The word “LASER” is an is equal to 10-6 meter or 1000 nm. More common medical lasers
acronym that stands for Light Amplification by the Stimulated include ultraviolet (193 nm and 308 nm), visible (532 nm and 630
Emission of Radiation. An extensive discussion in laser physics nm), near-infrared (805 nm, 980 nm, and 1064 nm), mid-infrared
is not consistent with this general overview. In simpler terms, (2100 nm), and far-infrared (10,600 nm) wavelength systems. This
as a bow stores energy and releases it to propel an arrow, a means that many of the common laser wavelengths used for
laser stores energy in atoms, concentrates it, and then releases medical applications (diode/805-980 nm; carbon dioxide/10,600
it in powerful waves of light energy. This process is called stimu- nm) cannot be seen by the human eye and can be extremely
lated emission. The resulting emission of photons resonates dangerous as far as ocular hazards due to this fact.2
between mirrored ends of a laser resonating cavity. These
bouncing photons further excite other atoms in a laser medium.
Momentum builds until a highly concentrated beam of light Types of Laser-Tissue Interaction and Laser
passes through a partially transmissive mirror at one end of the Operational Modes
laser resonating cavity.2 Laser radiation must be converted into another form of energy
to produce a therapeutic effect. Laser-tissue interactions are
Like sound through air or water on a lake, light travels in waves. categorized according to whether laser energy is converted
Moreover, the color of light is governed by its frequency and into heat (photothermal), chemical energy (photochemical), or
wavelength (distance of one peak to the next). Normal white acoustic (photomechanical/photodisruptive) energy. Photo-
light is incoherent and includes many wavelengths radiating thermal interactions occur when laser light is absorbed by
in all directions. The peaks and valleys of the waves do not tissue and converted into thermal energy, which results in a
coincide. A prism illustrates this as it sorts a white light into rise in tissue temperature. When far-infrared laser wavelengths
individual colors of the rainbow. Laser light does differ from (10,600 nm) are used, the water component of tissue plays a
ordinary light much as music does from plain noise. Laser light, predominant role in the absorption of laser energy. Water is
in comparison to ordinary light, is coherent. Each peak and valley heated directly with laser energy, and other molecules may then
of individual light waves align exactly. If laser light waves could be indirectly heated via heat conduction. Other tissue compo-
be heard, their sound would resonate with the clarity of a single nents (hemoglobin, melanin, proteins) may also absorb energy
musical tone. In addition, laser light is of one wavelength (one at specific mid-infrared wavelengths (805, 980, 1064 nm) and play
color), or is monochromatic. Finally, laser light is collimated, an important role in the tissue heating process. The absorption
or non-divergent, and directional. Parallel light waves move of laser energy in any tissue is the sum of the absorptions of
in unison, reinforcing each other as they travel through space each of the tissue components coupled with the absorption
forming a virtual tidal wave of laser energy. coefficient of water. For example, the effective absorption depth
or extinction coefficient of CO2 carbon dioxide laser energy
Today’s technology allows the manufacture of lasers that (10,600 nm), which is heavily absorbed by water, is approxi-
produce wavelengths of light extending from ultraviolet to mately 0.030 mm, but is about 1 to 3 mm for the diode (805/980
far-infrared wavelengths. Devices range in size from minia- nm) or neodymium yttrium aluminum garnet Nd:YAG (1064 nm)
turized diode lasers capable of being passed through the eye of lasers, which are less heavily absorbed by water.3
a needle to a free electron laser which covers the entire length
of a large building. However, each laser is composed of the same Visible laser wavelengths (400 to 700 nm) are poorly absorbed
basic components and functions according to the lasing medium by water and usually rely on blood or other endogenous tissue
stimulated to produce energy emission and light. Please refer to pigments or exogenous photoactive compounds to absorb
Figure 3-20: Laser Components. laser light and convert them to heat or active photochemical
components. Naturally occurring molecules that absorb
Laser wavelength refers to the physical distance between crests visible wavelengths include hemoglobin and melanin. Protein
of successive waves in the laser beam, indicated in units of length molecules, DNA, and RNA absorb ultraviolet wavelengths
expressed as nanometers or microns. By definition, 1 nanometer strongly and usually play a dominant role in converting UV light
(nm) = 10-9 meter, or one-billionth of a meter. One micron (µm) energy into heat. Figure 3-21 illustrates the water absorption
curve, which is an essential component in understanding the
concept of laser-tissue interaction.3
Figure 3-21. Laser tissue optics: water absorption curve. This graph illustrates the varying degrees of absorption of a specific wavelength (color)
of light by water compared to absorption in oxyhemoglobin, melanin, and tissue proteins including amino acids, DNA, and RNA. Ar, argon; KTP,
potassium titanyl phosphate; XeCI, xenon chloride; YAG, yttrium aluminum garnet.
excimer laser energy commonly used in human ophthalmologic the concentration of energy within an area, known as “power
procedures (LASIK).2,3 density” and expressed as watts/cm2. The advantage of a small
spot size is that laser energy is more concentrated and causes
Specific visible wavelengths (630 to 730 nm) can also induce less collateral damage, where fewer cells will be affected and
photobiochemical reactions. This type of reaction can be related destroyed at the margins of an incision. When a rapid, deep
to photodynamic laser interaction. In general, photodynamic incision is required, a small spot size is advantageous in that it
interactions employ light-absorbing molecules (photosensitizers will concentrate a high amount of energy into the tissue leading
such as hematoporphyrin derivatives) to produce a biochemi- to rapid vaporization. A larger spot size will be less precise
cally reactive form of oxygen (singlet oxygen) in tissue when and enhance tissue coagulation rather than vaporization. The
activated by light of a specific wavelength. Photodynamic inter- important term “fluency” takes into account the “time domain” or
actions are considered to be a special type of photochemical laser “on time” and is used to describe the total energy delivered
interaction. The therapeutic process is called photodynamic to the target tissue in joules/cm2. Total energy delivered to the
therapy (PDT).2,4,5 tissue target is extremely important when considering a laser
beam that is set for a pulsed mode delivery.2,7
Biostimulation is a process induced by lower power lasers (5 mW
to 12 W/635 to 1064 nm) that may provide pain relief, stimulate Biomedical lasers can operate in continuous wave (CW) or pulse
wound healing, or alter other biological processes. The entire mode (single pulse, chopped or repeat, and super-pulse). Laser
concept is considered controversial due partly to the fact that output in CW mode remains constant, whereas lasers operating
all of the physical, biochemical, and physiologic mechanisms in pulse mode deliver short bursts of energy. Manipulating pulse
are not well understood. Many of the reported results are mostly duration and pulse frequency allows the surgeon to adapt laser
subjective in nature and are difficult to quantify. However, this output to suit a particular clinical application, as well as ensure
therapeutic modality may gain favor as more objective studies exquisite control. A laser operating in single pulse mode emits
are reported.5,6 a single, user-defined pulse of energy lasting from a few milli-
seconds to several seconds. When operating in chopped or
Laser light focused on tissue may be reflected, absorbed, gated mode, a laser emits energy at selected pulse duration and
scattered throughout, or transmitted through the tissue. The frequency. The primary difference between chopped and CW
application of laser energy is very dependent on wavelength, as emission is that chopped mode has periodic gaps of zero power
mentioned previously. It is also essential to say the effect of a laser in an otherwise CW emission.2,7
on tissue is dependent on power. Power is usually expressed in
watts. When time is figured into the equation of energy delivery, Superpulse is another temporal mode of CO2 laser energy delivery
the term “joule” is used, which is defined as a watt/second. Focal that incorporates high peak power in short, high frequency
spot size (size of the incident beam of the laser light) results in pulses. Lasers operating in a super-pulse mode deliver extremely
36 Soft Tissue
high peak power, often 7-10 times higher than the CW maximum milder thermal injury to the tissue in this region may resolve within
power, short pulse duration, and shorter off time than chopped 48-72 hours. These phenomena are illustrated in figure 3-22. The
mode. The maximum peak power in super-pulse mode is higher generation of smoke, hemorrhage, and char can interfere with
than the maximum CW power by a factor that depends on type the incident laser beam by resulting in scatter, reflection, and
of laser and its specific design. The main advantage of using absorption of the laser energy and may result in uncontrolled
a carbon dioxide laser in superpulse mode is the reduction of effects on the target tissue or adjacent structures.3,7,10
carbon formation or a decrease in char.2,7
Precise control of hemorrhage and inflammation by photothermal
In very simple terms, a volume of tissue cools between rapid sealing of blood vessels, lymphatic vessels, and incised nerve
pulses of targeted energy, a phenomenon known as thermal endings is perceived by most to be distinct advantages of laser
relaxation. When laser exposure (pulse duration) is less than surgery. These benefits relate directly to laser tissue interaction
thermal relaxation time for the targeted structures, maximal depending on wavelength, power, and fluency. However, by inhib-
thermal confinement occurs and vaporization (ablation) occurs iting the early stages of the inflammatory process (lag phase)
without damage to non-targeted collateral structures. This due to cellular constituents and platelets not being immediately
concept along with minimal carbon formation on the target available at the wound site, the healing of laser incisions is
tissue surface provides the laser surgeon with exquisite control minimally delayed. Laser incisions, discounting collateral photo-
and precise vaporization not seen with other means of tissue thermal effects due to poor surgical technique, gain strength as
dissection. For surface ablation, use of computerized micro- quickly as incisions made by a steel scalpel and incisional tensile
processors, accessories for some high power carbon dioxide strengths are comparable within 10 to 14 days.11,12
lasers, utilize superpulse laser energy delivery coupled with
optomechanical hand-pieces to decrease the “dwell time” a Laser vaporization is the process of removing solid tissue by
laser beam interacts with the tissue surface. These scanning converting it into a gaseous vapor or plume. This is usually in
devices decrease surface carbonization and permit rapid and the form of steam or smoke, but laser plume may also contain
precise laser vaporization.3,7,8 noxious substances. Therefore, the use of smoke evacuation
during laser surgery is deemed essential. Safety issues will be
Pulsed laser energy can be converted into photomechanical discussed more specifically in a following section. The term
(photo acoustic) or photothermal energy, depending upon pulse “vaporization” is used as a synonym for tissue ablation.
duration, peak power density, and pulse frequency. Photome-
chanical effects occur when very short (nanosecond – 10-9 sec.),
high-power laser energy pulses are directed at tissue through a
small-diameter optical fiber. The energy plasma-induced shock
waves generated at the tip of the optical fiber mechanically
disrupts the targeted tissue or calculi. Photomechanical inter-
actions are important in many specialized laser applications,
including lithotripsy and ophthalmologic surgery.9,10
in mind, such as dermatologic or endoscopic applications. ization in non-contact mode is possible with a bare non-contact
Overall, the use of laser energy can be an extremely precise fiber, but collateral thermal injury may be substantial. Power
and controlled method for tissue removal or cellular destruction. levels approaching at least 50 watts are usually needed for these
Medical lasers are expensive and require a dedication to proper soft tissue applications.2
use and objective evaluation. Lasers in common use today are
the carbon dioxide (CO2), neodymium yttrium aluminum garnet Continuous wave (CW) Nd: YAG and diode lasers can be used
(Nd: YAG), diode, holmium: YAG (Ho: YAG), and dye lasers. The with “hot-tip” delivery systems to perform vaporization and
following general descriptions are meant to be used as an cutting of soft tissue in a contact mode with surgical precision,
overall guide to medical lasers. In no way should it be considered little collateral thermal injury, and good hemostasis. Hot-tip fibers
complete. Changes in laser types, wavelength preference, and include sculpted quartz fibers, contact-tipped sapphire fibers,
delivery devices are made on a frequent basis, since they are metal-capped fibers, temperature controlled bare fibers, and dual
closely aligned with changes in today’s technologic advance- effect fibers. In principle, contact use of fibers for mechanical
ments in computer hardware and software. coaptation of tissue while it is being heated can be advanta-
geous for hemostasis and controlled excision. Use of contact
tips for endoscopic application is widely accepted, but some tips
Carbon Dioxide Laser (CO2-10,600 nm)
are too large to insert through flexible endoscopes.15,16,17
The carbon dioxide laser was one of the first medical lasers used
for tissue ablation. At 10,600 nm, the wavelength is ideal for cutting
and vaporization because it is highly absorbed by water. It can Diode Laser (635, 805, 980 nm)
cut tissue cleanly when the beam is focused onto tissue and can Advancement of semiconductor diode laser development has
debulk tissue by photovaporization when defocused. Because of progressed tremendously in concert with other aspects of
the high absorption the 10,600 nm wavelength in water, CO2 laser medicine described previously. Engineering and commercial speci-
energy transmission requires energy delivery through a series of fications have allowed development of devices with wavelengths
mirrors in an articulated arm or through a semi-rigid waveguide, varying from approximately 635 to 980 nm. Newer technologies
which makes it awkward for use in an open abdomen or in other may actually allow evolution of diode lasers capable of emitting
localized and confined areas. However, thermal injury from a wavelengths in the mid-infrared range (1.9 to 2.1 µm).2
given amount of energy is relatively superficial (50 to 100 µm in
depth).2 The net surgical result is expressed as “What you see is Therapeutic products that employ semiconductor diode lasers
what you get!” when using the carbon dioxide laser. The learning were first approved for surgical use in this country in 1989.
curve for using a carbon dioxide laser seems to be shorter than Diode lasers (1 to 4 watts) are also used for photocoagulation
with other surgical laser wavelengths (805, 980, 1064 nm) which of retinal and other ocular tissues, and have been employed for
are optically scattered more in tissue. However, since CO2 laser ophthalmologic applications since approximately 1984.18 The
delivery systems (articulated arms, hollow waveguides) must be compact size and high efficiency offer significant ergonomic and
used in a non-contact mode, the tactile appreciation for tissue economic advantages. High power semiconductor diode lasers
is lost. This is a disadvantage which can be overcome quite appropriate for other surgical applications have been recently
easily with practice. Pertinent engineering specifications for introduced for a variety of uses. These lasers currently provide
carbon dioxide lasers include the “excitation” mechanism. That up to 25 to 100 watts at 805 nm or 980 nm, wavelengths that can
is, how the CO2 gas mixture in the resonating cavity is stimu- penetrate deeply into most types of soft tissue, and produce
lated to produce 10,600 nm light. Direct current (DC) devices tissue interactions comparable to the Nd: YAG laser (1064 nm).15
are usually larger machines capable of emitting higher power The theoretical difference between use of a diode laser at 805
(> 20 W). Most of these devices use a water cooling mechanism nm and one emitting a 980 nm wavelength is that a 980 nm device
that is either closed or can be connected to a circulating is absorbed to a greater extent by water than is the 805 nm laser,
cooling water system. Radiofrequency (RF) excited CO2 lasers but in actual clinical practice this difference is negligible. Diode
are usually smaller, more robust devices that are either cooled lasers can be used with bare-fiber delivery accessories in
by convection or by an integral cooling fan. RF excited devices non-contact mode for deep coagulation, or with hot-tip fibers for
usually emit lower power laser energy (< 20 W).10,14 precise cutting or vaporization in contact mode. As mentioned,
diode lasers can be used for many of the same applications as
1064 nm continuous wave Nd: YAG lasers. However, surgical
Nd: YAG Laser (Neodymium Yttrium Aluminum
diode lasers offer considerable advantages compared to Nd:
Garnet-1064 nm) YAG lasers. They are smaller, lighter, require less maintenance,
The Nd: YAG or “YAG” laser differs from the CO2 laser because are extremely user-friendly, and can be more economical. Some
the wavelength allows transmittance though tissue in addition to medical device manufacturers predict prices for diode lasers
surface absorption. High powers up to 100 watts can be delivered will eventually drop to the point where they may be competitive
through small-core optical fibers that can easily be inserted with high-end electrosurgical equipment.
through the accessory channels of standard GI endoscopes.
Since the Nd:YAG laser has less specific absorption by water and Additional applications for diode laser energy have been for
hemoglobin than the carbon dioxide laser, the depth of thermal chromophore enhanced tissue ablation or coagulation, tissue
injury can exceed 3 mm in most tissues, which can be useful for fusion or laser welding, and photodynamic therapy. The use of
coagulation of large volumes of tissue. Fairly rapid tissue vapor- sutureless tissue repair employing laser energy has emerged
38 Soft Tissue
over the last decade. Tissue welding or fusion has the potential 20 Hz) available from most holmium lasers may be considered
to be one of the most important technical developments in as a disadvantage since cutting may be slow or result in jagged
surgery. Used in conjunction with laparoscopic as well as open tissue edges during incisional applications. In addition, at higher
procedures, laser energy used with biological glue or “solder” pulse energies (> 1 Joule), considerable amounts of acoustical
reinforcement can provide a higher leakage pressure for vascular or mechanical energy are generated in tissue. An audible acous-
and alimentary tract structures than sutures alone. Preliminary tical “pop” may be generated and actually heard during laser
investigations involving selective fusion of nerves, urethral application. However, acoustical energy may be considered an
tissue, skin, tracheal mucosa, and even bone fragments have advantage when using holmium energy for photodisruptive proce-
also shown promise. Despite a decade of laboratory success in dures such as lithotripsy of gallstones or urologic calculi.20,21,22
which the superiority of laser tissue welding has been demon-
strated, there is still not much clinical use of this technology.13 Dye Laser (635 to 700 nm)
Diode laser (805 nm) induced photothermolysis of tissue selec- Pulsed and continuous wave dye lasers employ an active laser
tively stained with indocyanine green (ICG) has shown promise medium that consists of an organic dye dissolved in an appro-
for selective coagulation/vaporization of tumors and contami- priate solvent. For the dye laser to work, the dye solution must
nated wounds.4 Diode laser wavelengths of 805 nm have also been be re-circulated at high velocity through the laser resonator.
reported as being used for tissue welding investigations because Dye lasers are useful for medical applications because they can
applications have been centered around the peak absorption generate high output powers and pulse energy at wavelengths
spectrum of indocyanine green (780-820 nm), the selective throughout the visible wavelength spectrum (400 to 700 nm). They
chromophore used in fibrinogen solder. Laser energy required are usually pumped by argon lasers, flashlamps, or a frequency-
for tissue fusion is significantly lower (300 mW to 9.6 W/ cm2) doubled YAG laser. Dye lasers have been used for lithotripsy of
than for incisional/ablative procedures, since minimal thermal biliary and urologic calculi (504 nm-pulsed), activating photosen-
changes are required to produce noncovalent bonding between sitizers for photodynamic therapy (635 to 720 nm CW), ophthal-
denatured collagen strands and produce the weld.9 The small, mologic operations (805 nm pulsed or CW), and dermatologic
convenient size coupled with reliability and user friendliness has applications (577 to 585 nm pulsed) including treatment of birth-
also focused extensive diode laser development for applications marks and removal of tattoos.2,5,13,20,23
in photodynamic therapy, primarily at 635 nm wavelength.19
Laser Delivery Systems
Ho: YAG Laser A delivery system refers to the optical hardware needed to
transfer energy from the laser to the treatment site. Devices
(Holmium Yttrium Aluminum Garnet-2100 nm) for guiding laser beams to the patient include articulated arms
Clinical holmium lasers have appeared in recent years for with internal mirrors, hollow waveguides, and optical fibers.
arthroscopic surgery, general surgery, laser angioplasty, and Articulated arms and hollow waveguides are used with laser
thermal sclerostomy. Additional applications have been imple- wavelengths (2800 nm to 10,600 nm) that cannot be transmitted
mented for laser diskectomy, removal of sessile polyps in the through conventional fiber optics due to their light absorption
gastrointestinal tract, and otorhinolaryngeal procedures. The characteristics. Laser energy delivery through an articulated arm
main attraction of the holmium laser is its ability to cut and has inherent disadvantages due to the size of the arm, durability,
vaporize soft tissue like a carbon dioxide laser, with the added and its inability to be used for minimally invasive (endoscopic)
advantage that holmium energy can be delivered through flexible, procedures. Using carbon dioxide lasers with an articulated
low OH, quartz optical fibers. Good surgical precision and arm allows delivery of a precise collimated (Gaussian) focused
control can be obtained with a bare optical fiber. Unlike visible beam to the incision site. Using a semi-rigid hollow wave-guide
wavelength lasers, and again similar to the carbon dioxide laser, provides a non-collimated beam that is multi-model (top-hat) in
photothermal interactions with the holmium laser do not rely on nature, but still very precise since the laser energy is concen-
hemoglobin or other pigments for efficient heating of tissue. The trated and directed through small, aperture delivery tips (0.2 to
water component of tissue is responsible for absorbing holmium 1.4 mm diameter) that can be used for precise incisional and
laser energy (2100 nm) and converting it to heat. The depth of ablative applications. Hollow waveguides are advantageous in
absorption is quite shallow at approximately 0.3 mm. When permitting greater flexibility for performing laser procedures but
cutting or vaporizing tissue, actual zones of thermal injury vary are not as useful as conventional fiber optic delivery through
from 0.1 to 1 mm, depending on exposure parameters and the quartz fibers. Future advances in laser and optical waveguide
type of tissue. These small thermal necrosis zones provide better technologies will include smaller diameter waveguides that can
surgical precision and adequate hemostasis.2 Current holmium deliver collimated laser energy and be used through endoscopic
instruments are flashlamp-pumped systems. The active laser portals for minimally invasive procedures.2,16
medium consists of a chromium-sensitized yttrium aluminum
garnet host crystal doped with holmium and thulium ions. This The availability of functional and inexpensive optical fibers for
active medium is referred to as Thulium (Tm), Holmium (Ho), laser delivery has played a crucial part in the acceptance of lasers
Chromium (Cr): YAG or THC: YAG, and is common to all holmium for medical applications. The fibers used in laser medical delivery
laser medical devices. Unlike the carbon dioxide laser, higher are made of quartz glass and have diameters ranging from 0.1 to
power holmium lasers cannot operate in a continuous wave 1 mm. Laser energy is transmitted and reflected along the bends
mode at room temperature. The relatively low pulse rates (10 to and curves of the fiber until it reaches the tip where it exits.
Electrosurgery and Laser Surgery 39
The ability to transmit visible and near-infrared laser energy, of laser vaporization must be evacuated with a dedicated smoke
small diameter and flexibility, lower cost, and ruggedness makes evacuator. The filters and tubes on these devices require mainte-
quartz optical fibers essential for endoscopic and other minimally nance and periodic replacement, increasing the cost of laser
invasive applications. Configurations of fiber tips (e.g., flat or surgical procedures.
cleaved, sculpted orb, chisel) and their ability to transmit energy
is a physical science in its own right, but delivery parameters 2. Laser Induced Combustion
are primarily based on two factors, contact mode of delivery or
non-contact mode of delivery. In non-contact mode, a free beam Laser beams can cause fires. The obvious way to prevent
of focused laser energy is delivered to the tissue target surface. laser induced combustion is to make certain the beam is
The power density and fluency of the laser beam determine the always directed towards the surgery site. In addition, the use
degree of photothermal interaction. Non-contact mode usually of moistened sponges surrounding the surgical site decreases
increases the surface area covered by laser energy which the chance for accidental ignition of drapes, etc., especially
can decrease the power density and consequently decreases when using wavelengths highly absorbed by water, such as
vaporization efficiency unless laser power output is increased. the carbon dioxide laser. Polyvinyl chloride endotracheal tubes
In contact mode, a laser optical fiber tip is brought into direct are especially prone to ignition. An endotracheal tube which
contact with the tissue target and the resulting photothermal is carrying oxygen will literally become an airway blowtorch
interaction causes carbonization of the tip, which then becomes instantaneously after impact of the laser beam. In airway and
a focused “hot knife.” The chemical structure of certain optical oral surgery, the endotracheal tube should be of a type that
fibers permits transmission of mid-infrared laser energy (Ho: includes specific laser-safe tubes and less desirably, endotra-
YAG at 2100 nm through a low-OH polyamide fiber) and allows cheal tubes made of red-rubber protected by an application of
minimally invasive laser surgery through small diameter reflective metal tape.
endoscopes and myelographic needles.16,24,25
3. Eye and Skin Burns
Laser Safety Laser energy burns to the eyes or skin on the patient, operator, and
assistants are of extreme importance for consideration. Safety
Even though sci-fi movies and television portray lasers as “death
glasses or goggles, specified for each laser wavelength, must
rays” and “phaser disintegrators,” the instrument is probably
be worn for every laser procedure. Saline moistened surgical
safer to use than a scalpel or scissors in the hands of a trained
sponges or even laser safety eyewear should be considered
operator. However, lasers use by untrained individuals can be
for protecting patient’s eyes. In addition, window barriers, laser
dangerous for both the operating team and the patient. Safety
safety warning lights, ebonized or a dulled, satin-type finish on
standards for medical laser applications have been issued that
surgical instruments to reduce reflection, and laser warning
consider potential hazards and their control measures. The
signs on doors are important safety aspects that should not be
current consensus standard in the United States is through the
ignored. The potential for accidental burns and fires usually is
American National Standards Institute’s (ANSI Z136.3) document
related to accidental depression of the footswitch for the laser.
entitled Safe Use of Lasers in Health Care (Available from Laser
All machines are equipped with a standby mode of operation
Institute of America, 13501 Ingenuity Drive, Suite 128, Orlando,
in which the machine is running but laser energy cannot be
FL 32826). Application of surgical lasers in veterinary medicine
activated. A major responsibility of the laser nurse or technician
should adhere to these regulations and guidelines to ensure
is to evaluate the progress of the laser operation and have the
operator and patient safety. Laser hazards depend on the laser
machine switched to standby when laser energy is not required.
wavelength and power, the environment, and the personnel
The phrase, “laser on,” spoken by the operating laser surgeon
involved with the laser operation. The laser hazard is defined
and required before the laser is activated, becomes as important
by a hazard classification (1 to 4). Surgical lasers are almost all
as safety glasses, smoke evacuators, or the engineering of the
classified as Class 4 laser products because they may represent
machine itself in fostering safety. A team approach with the
a significant fire or skin hazard and also produce hazardous
surgical laser technician, who basically is in charge of the laser,
diffuse reflections. Hazardous diffuse reflections are of concern
and the surgeon is essential.
because the probability of damaging retinal exposure is extreme
without proper eye protection.26,27
Ignition of methane from the rectum or rumen can also be an
With the biomedical application of lasers, the following safety
exciting occurrence; the gas should first be removed by suction
concerns must be considered:
or blocked by tamponade. Vaporization of iodine skin prepa-
rations into irritating fumes, ignition of alcohol, or ignition of
1. Inhalation of Smoke or Laser Plume any pure oxygen environment mentioned previously are also
Laser surgery usually creates more smoke than electrosurgical important concerns.
procedures. Reports have mentioned that smoke products from
lasers are really no different than those created by electro- 4. Miscellaneous Problems
surgery, although the quantity is greater. Some studies have
Other hazards include electrical injury from the high voltage
actually isolated viable tumors cells from smoke evacuation
power supply. Laser operation with newer devices is easy since
tubes, so the concept of uncontrolled viral or bacterial vapor-
they are extremely user-friendly and reliable, BUT machine
ization must also be taken into account. Since even sterile
maintenance including the purchase of maintenance contracts
smoke can be an irritant, all products of combustion as a result
40 Soft Tissue
may be required to maximize use and minimize safety concerns of hemorrhage is important. These procedures have included
for mechanical, electrical, and optical failures. This aspect of liver biopsy, resection of hepatic lobes, splenic biopsy, prostatic
medical laser usage must be recognized because maintenance dissection and ablation, partial nephrectomies and nephro-
contracts and laser repair can both be quite costly. tomies, and excision/resection of a variety of intra abdominal,
intrathoracic, cutaneous, and mammary neoplasms.31 Reports
have reviewed clinical uses of laser energy for ablation/palliation
The use of Biomedical Lasers in of a brain tumor (Nd:YAG), ablation of neoplasms (CO2, Nd:YAG),
Veterinary Medicine and treatment of eosinophilic granulomas (CO2, Nd:YAG),
Early reports concerning the use of lasers for medical applications perianal fistulas (Nd:YAG, CO2), or acral lick dermatitis (Nd:YAG,
involved animals, either as experimental models or as clinical CO2).33,36,38,42,43,46 Upper airway surgery, especially excision of an
veterinary patients. In 1968, the removal of a vocal-cord nodule in elongated soft palate in the dog, is most easily performed using
a dog demonstrated one of the first practical clinical applications laser energy with minimal post-operative complications.41
of the carbon dioxide laser as a precision surgical instrument.28
Since that time, use of biomedical lasers has expanded tremen- With advantages of lower morbidity time for some conditions,
dously in both small and large animal surgery. However, to some less perceived signs of pain, and potential treatment regimes
veterinarians, the laser is still a tool in search of an application. for conditions not amenable to conventional surgical/medical
The rising popularity of the surgical laser has been influenced procedures, employment of biomedical lasers has not only found
most often by their use in private practice and stems from a blend use in the clinical small animal setting, but also in the realm of
of its demonstrated precision and control, improved hemostasis, exotic animal and avian practice, where even minimal blood loss
fewer signs of postoperative pain, increased client satisfaction, can be significant in smaller patients. In addition, clinical use of
and affordability. An objective and practical approach to laser the holmium:YAG laser for percutaneous prophylactic ablation of
surgical procedures in veterinary medicine is essential if the total intervertebral discs and lithotripsy of urologic calculi in dogs have
beneficial potential is to be realized. “Zap and vaporize” techniques been reported and show tremendous potential.24,25,47-49 The use of
coupled with a “burn and learn” philosophy can do potential harm biomedical lasers for veterinary ophthalmologic applications has
to patient and operator and outweigh any beneficial effect. These been firmly established, although use has not become as common
concepts have no place in the objective use of lasers in medicine. as it is in human medicine. The Q-switched or continuous wave
A concerned effort must be made to evaluate the use of a laser for ophthalmic Nd:YAG, argon, and diode lasers have been used as
its potential patient benefit, rather than portraying it as a miracle funduscopic photocoagulators in retinopathies, for treatment of
device of the 21st century that is advertised on an illuminated bill lens-induced pupillary opacification, and for transcleral laser
board in front of a hospital. Although the use of biomedical lasers cyclodestruction of the ciliary body for glaucoma therapy in
has created an entirely new definition for performing surgery, a dogs. The carbon dioxide laser has also been used for soft tissue
surgeon’s knowledge of pathophysiology and technical expertise periocular and scleral surgical procedures. As experience and
must be the primary factors to determine whether a laser should interest increases, and lasers become more available to veter-
be used for a particular surgical procedure in lieu of more conven- inary ophthalmologists, clinical applications will increase as
tional approaches.4 treatment protocols are initiated and proven useful.18,50
to 0.4 mm) which delivers a high power density is ideal. The ablation using fiber optic delivery. It must also be understood
main reason surgical lasers are used for incisional surgery is that a laser fiber used for contact mode delivery for incisional
because of the excellent degree of hemostasis obtained. At the purposes cannot usually be immediately changed from contact
tissue interface, blood vessels less than 0.5 mm in diameter can mode to non-contact mode free-beam energy delivery. Since
be coagulated and sealed so that use of the surgical laser as a contact mode incisional surgery requires the fiberoptic tip to be
light scalpel is relatively hemostatic in most capillary beds and in carbonized so it can absorb adequate energy to incise tissue,
the transection of small venules and veins. Lymphatics are also higher energy levels required for non-contact ablation will
sealed so postoperative edema may be minimized. Subjectively, usually melt the fiberoptic tip. Using a freshly cleaved, a surgeon
there seems to be less pain associated with a laser incision and can go from non-contact, free-beam energy delivery to contact
dissection. This observation could be due to the fact that smaller delivery, but cannot go from contact laser surgery to non-contact
nerves are sealed or even spared at some laser wavelengths.55 delivery without re-cleaving the fiber. In the case of sculptured
Microorganisms are also destroyed in the process of photo- fiber tips (tapered, orb) meant to be used only in contact mode,
thermal ablation, so tissues may be “disinfected” (bacterial high power free-beam delivery should be avoided to prevent
numbers reduced by reduction of numbers due to direct vapor- premature fiber degradation. However, once a sculpted fiber tip
ization) during laser tissue-interaction.57,58 is degraded, the fiber can be cleaved and reused in that configu-
ration for both free-beam and contact delivery.
The depth of the incision made by a surgical laser is both a function
of the irradiance (power density) and the speed with which the
incision is made. With practice, the surgeon can use the laser
Future Innovations
beam as precisely as the scalpel, with the added advantage of The use of lasers in medicine is an exciting treatment modality
less hemorrhage, and less pain, although objective, published that will continue to produce innovative and new methods for
results in veterinary medicine are few.59,60 Laser incisions tend managing diseased tissue. Research focused on basic laser-
to be made more slowly than those made with a scalpel, at least tissue interaction and selective tissue destruction will become
initially. The improved hemostasis and incisional control generally increasingly important. The use of photodynamic therapy (PDT)
makes up for this delay, and in some cases involving highly for treatment of malignant tumors will become an effective part
vascular tissue, a laser incision may actually make it possible of the veterinary oncologist’s armamentarium as more effica-
to perform laser surgery faster than conventional surgery. Care cious photosensitizers become available and expanded use
must be taken not to create excessive collateral photothermal of lower cost lasers or even non-laser light sources occurs.
injury (char formation) during the process. Providing tissue Photothermolysis using appropriate chromophores for selective
counter tension during the incisional procedure aids not only tissue destruction and sterilization/disinfection is currently
tissue separation, as it does with a scalpel, but also decreases proving to be efficacious in both the clinical and laboratory
the amount of char formation. A defocused laser beam (holding settings. Minimally invasive urologic techniques for ablation
the handpiece or cleaved optical fiber an appropriate distance of bladder, urethral, and prostatic pathologic conditions in
from the tissue surface) can be used in some cases to stop small animals will become more common as technologically
bleeding from larger blood vessels that were not sealed by the enhanced and smaller endoscopes are developed, as delivery
focused or contact-mode incisional laser beam. Tissue excised systems are improved, and as new laser wavelengths are inves-
with a surgical laser can still be histopathologically evaluated tigated. Laser lithotripsy is now possible using both visible and
for tumor margins without much difficulty, if proper technique infrared wavelengths. This technology is currently being used
is used that minimizes collateral photothermal damage and the in academic and specialty hospital settings permitting minimally
pathologist is informed that a laser was used for the biopsy.40 As invasive lithotripsy of urinary tract calculi. Tissue fusion/welding
mentioned earlier, healing of laser incisions is minimally delayed of blood vessels, alimentary tract, ureter or urethra, skin, and
due to photothermal collateral tissue interaction.11,12,61 even bone will become clinically available in the near future.
Application of lasers for micromanipulation of gametes and
Tissue ablation or vaporization is most easily accomplished laser energy for improving fertilization and hatching rates during
using a defocused or non-contact, free-beam mode of energy in vitro fertilization in domestic animals are close to becoming
delivery. Defocused beam delivery through an articulated arm or clinical realities. The use of lasers for soft tissue dental proce-
a hollow waveguide can be utilized to ablate tissue efficiently, if dures is already feasible and, as investigations continue, use of
carbonization (char formation) is minimized. To accomplish this, laser energy for hard tissue dental procedures will be possible.
optical and mechanical scanners (described previously) are
ideal accessories for the carbon dioxide laser. In addition, as Low level laser therapy (LLLT), or biostimulation, is now being
char formation occurs, the surgeon should be diligent to remove used commonly in a variety of therapeutic settings in veterinary
any buildup of carbonized tissue by using saline moistened gauze medicine. The efficacious use of this modality to decrease
sponges to mechanically debride the ablated tissue surface. inflammation and pain, as well as enhance wound healing
will continue to be investigated. Well controlled studies are
Tissue ablation can also be performed using fiberoptic delivery underway using reliable LLLT devices. Positive objective results
systems in non-contact mode with compatible laser wavelengths will provide additional therapeutic option for the practitioner and
(diode – 808/980 nm; Nd:YAG to 1064 nm; Ho:YAG – 2100 nm). rehabilitation specialists.63
Laser power and energy delivery levels must be substantially
higher (> 20 W < 100 W) for non-contact, free-beam tissue Development of user-friendly, durable, portable, less expensive
42 Soft Tissue
laser systems is definitely on the near horizon. Semiconductor Saunders, Philadelphia, 1992, 72: 705 - 747.
laser development from ultraviolet to far infrared wavelengths 14. Hecht, J: Carbon dioxide lasers. In The Laser Guidebook, New York,
is feasible. At this point in biomedical laser technology, diode McGraw-Hill, 1992: 159.
laser development and similar technologies seem to hold the 15. Judy, MM, Matthews, JL, Aronoff, BL, Hults, DF. Soft tissue studies
greatest promise. Use of lasers as diagnostic tools and sensors with 805 nm diode laser radiation: Thermal effects with contact tips and
is one of the fastest growing branches of biomedical laser devel- comparison with effects of 1064 nm Nd: YAG laser radiation. Lasers Surg
opment. Clinical applications involving noninvasive recognition of Med, 1993, 13: 528.
malignant cells, abnormal tissue, or abnormal metabolites have 16. Katzir, A: Single optical fibers. In Lasers and Optical Fibers in
tremendous potential. Use of available and future laser diagnostic Medicine, Academic Press, Inc., San Diego, CA, 1993:107.
technology could have a significant impact on the veterinary 17. Tullners, EP: Transendoscopic contact neodymium: yttrium aluminum
profession if a reasonable cost for equipment can be realized. garnet laser correction of epiglottic entrapment in standing horses.
JAVMA, 1990; (144): 1971.
Future use of lasers in medicine depends on the active partici- 18. Gilmour, MA. Lasers in ophthalmology. In: Bartels, KE. ed. Vet Clin NA:
pation of veterinarians in the inception and development of new Laser in medicine surgery. WB Saunders, Philadelphia, 2002, 32(3): 649.
devices that meet the needs of the entire medical profession. 19. Lucroy, MD, Photodynamic therapy for companion animals with
The sensible clinical approach that must be taken every day in cancer, In: Bartels, KE. ed. Vet Clin NA: Laser in medicine surgery. WB
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of biomedical lasers. Veterinary medicine can and should be in K.F., MacAllister, C.G. and Bartels, K.E., Failure of Holmium: yttrium-alu-
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Bladder, JAVMA, 2001, 219:957.
dimension to development of this 21st century technology.
21. Collier, M, Haugland, LM, Bellamy, J, et al: Effects of holmium: YAG
laser on equine articular cartilage and subchondral bone adjacent to
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Tate, LP. Treatment of glaucoma by use of transcleral neodymium: yttrium surgery for the excision of pilonidal cysts: a comparison with traditional
aluminum garnet laser cylcocoagulation in dogs. JAVMA, 1990; 197:350. techniques. Lasers Surg Med. 2000, 26(4):380.
40. Rizzo, L.B., Ritchey, J.W., Higbee, R.G., Bartels, K.E., Lucroy, M.D., 61. Mison, MB, Steicek, B, Lavagino, M, et al. Comparison of the effects
Histologic Comparison of Skin Biopsy Specimens Collected by Use of the CO surgical lasers and conventional surgical techniques on the
of Carbon Dioxide or 810-nm Diode Lasers from Dogs, JAVMA, 2004; healing and wound tensile strength of skin flaps in the dog, Vet Surg
225:1562. 2003; 32(2): 153.
41. Davidson, E.B., Davis, M.S., Campbell, G.A., Williamson, K.K., Payton, 62. Irwin, JR: The economics of surgical laser technology in veterinary
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Brachycephalic Dogs. JAVMA, 2001; 219:776.
63. Aukri, R, Lubort, R, Taitel baum: Estimation of optimal wave lengths
42. Ellison, GW, Bellah, JR, Stubbs, WP, et al: Treatment of perianal fistulas for laser-induced wound healing, Laser Surg Med. 2010, 42(8): 760.
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43. Feder, BM, Fry, TR, Kostolich, et al: Nd:YAG laser cytoreduction of an
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dioxide laser modalities for removal of polymethylmethacrylate cement.
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47. Spindel, ML, Moslem, A, Bhatia, KS, Jassemnejad, B, Bartels, KE,
Powell, RC, et al. Comparison of holmium and flashlamp pumped dye
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482.
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33:56.
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cyclophotocoagulation using a neodymium: yttrium aluminum garnet
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44 Soft Tissue
Chapter 4 The answers to these questions are often difficult since data
regarding specific neoplastic disease is continuously being
collected and changes rapidly. Diagnosis of the disease process
Oncologic Surgery and consultation with referral specialists is recommended to
formulate the most appropriate diagnostic and therapeutic
decisions. It is emphasized that the treatment plan for oncology
The Role of the Surgeon in patients, even those with a similar disease, is not necessarily
Veterinary Oncology standardized. Each patient must be considered individually and
that often requires professional consultation and coordination
Earl F. Calfee, III of efforts.
excisional biopsy) and are covered extensively in chapter 5. It ferred from distant sites through the use of microvascular free
is important to consider the consequences of tissue collection tissue transfer. Most reconstructive techniques are complex
techniques because if not performed appropriately a biopsy can and require appropriate planning and surgical expereince prior
diminish the opportunity for a surgical cure during later, more to the initial surgical procedure.
definitive surgery.
Clean surgical excisions of masses located over appendicular
One of the more common mistakes occurs while performing joints also pose a surgical challenge. This is because of the
marginal tumor excision. There is a tendency to NOT remove lack of a single fascial plane over the joint space. This generally
as much of the mass and surrounding tissues as possible while makes curative surgical excision of masses over the joint space
performing a resection immediately adjacent to the palpable impossible. The surgeon is then left with radical resection (i.e.
mass. There is no benefit to “modified marginal resection”. amputation) or the combination of conservative (i.e. marginal)
The inevitable result is contamination of peripheral and deep surgical excision followed by adjuvant therapies (i.e. external
tissue structures for locally aggressive tumors. The surrounding beam radiation).
tissue contamination with “modified marginal resections” may
eliminate the possibility of a clean surgical excision in the future. Other problematic anatomic areas are the axilla, inguen, and
An incisional biopsy is preferred to a modified marginal resection. perineum. Surgical wounds in the axilla and inguen are predis-
For benign tumors a true marginal resection is adequate. posed to complications. Healing is difficult because of high
motion, dead space and the tendency for seroma formation. The
perineum is a challenge because of its proximity to the anus. Prior
Surgical Therapy to definitive surgery on masses in any of these regions careful
Several tumor types exist where a properly performed surgical consideration must be given to the potential detrimental effects
procedure alone will provide long term survival times or a cure. of incomplete tumor excision. It is often advisable to consider
Examples include complete surgical excision of grade 1 or 2 soft consultation with a board certified surgeon prior to performing
tissue sarcomas and grade 1 or 2 mast cell tumors, noninvasive any surgical procedure for these cases. Incisional biopsy to
canine thyroid carcinomas, canine intramuscular lipomas, obtain a definitive histologic diagnosis is almost always required
canine ceruminous gland carcinomas, canine hepatocellular in these anatomic regions.
carcinomas, and feline thymomas.23-33 With complete surgical
excision of the aforementioned neoplasms extended survival
times are expected. The term “complete excision” is important Surgery as Part of Multimodality Therapy
in reference to tumor excision. Typical recommendations for In some cases of neoplastic disease, surgery as a single mode of
complete excision of a tumor are 2 to 3 cm peripheral margins therapy may provide short-term benefits, but additional modes of
and one deep fascial plane.27 These recommendations are not therapy can significantly extend disease free intervals or prolong
appropriate or applicable to all tumor types. In some cases, life. Animals that have incomplete surgical removal of masses
marginal resection is all that is possible and reliably produces such as mast cell tumors or tumors located adjacent to appen-
extended survival times. Examples include non-invasive thyroid dicular joint spaces may benefit from radiation therapy. Two
carcinoma and feline thymoma. In these two examples, local additional examples where multimodal therapy is of significant
anatomy prevents resection with wide margins, however, benefit are canine appendicular osteosarcoma and feline vaccine
experience has shown that marginal resection is adequate and associated sarcoma. Canine appendicular osteosarcoma has
clearly beneficial with these two tumors.29,33 been extensively studied and is known to have high metastatic
potential. Early in the study of this disease, radical surgery (i.e.
The ability to attain a clean surgical margin is primarily amputation) alone was shown to have no significant benefit on
dependent on the location of the mass and the ability of the survival times and be a purely palliative procedure.38 The benefits
surgeon. Masses located on the distal extremities and the head of chemotherapy combined with surgery have been demon-
and neck are surgical challenges because of a lack of redundant strated in several studies with an extension of survival times from
peripheral and deep soft tissues and the presence of joints in the a median of four months to a median of 11 to 12 months.39,40,41,42
extremities. A lack of soft tissue, particularly on the extremities,
makes primary closure of excision sites impossible. It is empha- Feline vaccine associated sarcomas benefit from a multimodal
sized that complete excision of the mass producing an open approach. This tumor has a relatively low metastatic (approxi-
wound that must be managed or reconstructed is preferable to mately 20% at time of the initial diagnosis) rate but has very
incomplete excision of the tumor and complete wound closure. aggressive local behavior. Conservative surgical excision
In these cases, complete surgical excision is preferred and open (marginal resection) is futile. In many cases because of location
wound management is performed until the formation of healthy (i.e. intrascapular) radical surgery is not possible, therefore
granulation tissue occurs. After a healthy granulation bed has a combination of surgery and radiation therapy is utilized. The
formed, free skin grafting can be performed. Alternatively, in combination of surgery and radiation therapy has been shown to
some cases, closure can be accomplished through the appli- increase survival times to approximately 2 years.43,44,45,46
cation of skin flaps or free tissue transfer. Axial pattern flaps (i.e.
thoracodorsal, caudal superficial epigastric, reverse saphenous In many animals with neoplastic disease, the benefits of adjuvant
conduit flap, etc) or skin fold flaps are especially useful for therapies have not been demonstrated. Canine anal sac apocrine
reconstruction of large defects.34,35,36 Skin can also be trans- gland adenocarcinoma, grade 3 soft tissue sarcoma and feline
46 Soft Tissue
oral squamous cell carcinoma are examples of tumors with and Non-cemented Allografts in Dogs with Osteosarcoma. Veterinary
aggressive behavior where adjuvant therapy has not been Comp Orthop Traumatol. 11:178, 1998.
studied or shown to be beneficial. In some situations (i.e. grade 3 9. Straw RC, Withrow SJ, Powers BE, et al: Partial or Total Hemipel-
soft tissue sarcoma and apocrine gland ACA) appropriate studies vectomy in the Management of Sarcomas in 9 Dogs and 2 Cats. Vet Surg.
do not exist to adequately evaluate the benefit of adjuvant 21:3:183, 1992.
therapies.47,48,49 In other diseases such as feline oral squamous 10. Withrow SJ: Small Animal Clinical Oncology. Philadelphia: Cancer of
cell carcinoma, the benefits of adjuvant therapy have been more the Gastrointestinal Tract (Cancer of the Oral Cavity). 70, 2001.
extensively evaluated and no survival benefit has been attained 11. Garzotto CK, Berg J, Hoffman WE, et al: Prognostic Significance of
with aggressive adjuvant therapy in addition to surgery.50 Serum Alkaline Phosphatase Activity in Canine Appendicular Osteo-
sarcoma. J of Vet Int Med. 2000, 14, 587-592.
12. Ehrhart N, Dernell WS, Hoffmann WE, et al: Prognostic Importance
Conclusion of Alkaline Phosphatase in Serum from Dogs with Appendicular Osteo-
The treatment of cancer is a constantly changing process. The sarcoma: 75 cases (1990-1996). JAVMA. 213:1002, 1998.
veterinary surgeon can influence treatment of the patient with 13. Zekas LJ, Crawford JT, O’Brien RT: Computed tomography-guided
cancer either positively or in some cases negatively. The conse- fine-needle aspirate and tissue-core biopsy of intrathoracic lesions in
quences of any tissue collection must be considered prior to thirty dogs and cats. Vet Radio Ultrasound. 46:3:200, 2005.
biopsy or excisional surgery. Initial diagnostics, tissue sample 14. Prather AB, Berry CR, Thrall DE: Use of Radiography in Combination
collection, and in some cases definitive surgical procedures with Computed Tomography for the Assessment of Noncardiac Thoracic
may be performed by general practitioners following appro- Disease in the Dog and Cat. Vet Radiol Ultrasound. 46;2:114, 2005.
priate principles. To provide the best care for the cancer patient, 15. De Rycke LM, Gielen IM, Simoens PJ, van Bree H: Computed tomog-
knowledge of the current literature and early communication raphy and cross-sectional anatomy of the thorax in clinically normal
with appropriate specialists in oncology is recommended. dogs. Am J Vet Res. 66:3:512, 2005.
16. Garosi LS, Dennis R, Platt SR, et al. Thiamine deficiency in a dog:
Editor’s Note: Adjunctive therapy of anal sac apocrine gland clinical, clinicopathologic, and magnetic resonance imaging findings. J
adenocarcinoma with chemotherapy following surgery has Vet Intern Med. 17:5:719, 2003.
increased median survival times in dogs. Radiation has also 17. Taga A, Taura Y, Nakaichi M, et al: Magnetic resonance imaging of
proved valuable in some cases. An oncologist should be syringomyelia in five dogs. J Small Anim Pract. 41:8:362, 2000.
consulted. 18. M. K. Jankowski, P. F. Stey2, S. E. Lana, et al: Nuclear scanning with
99mTc-HDP for the initial evaluation of osseous metastasis in canine
Turek MM, Forrest LJ, Adams WM, et al: Postoperative radio- osteosarcoma. Veterinary and Comparative Oncology. 1:3:152, 2003.
therapy and mitoxanthrone for anal sac carcinoma in the dog. 19. Liebman NF, Kuntz CA, Steyn PF, et al: Accuracy of Radiography,
Vet Comp Oncol 1:94-104, 2003. Nuclear Scintigraphy, and Histopathology for Determining the Proximal
Extent of Distal Radius Osteosarcoma in Dogs. Vet Surg, 30: 240, 2001.
Turek MM and Withrow SJ. Perianal tumors. In Withrow SJ, 20. Krynyckyi BR, Kim SC, Kim CK: Preoperative Lymphoscintigraphy and
Vail D, and Page R eds: Small animal clinical oncology 5th ed, Triangulated Patient Body Marking are Important Parts of the Sentinel
St.Louis, 2013, Saunders-Elsevier. Node Process in Breast Cancer. World J Surg Oncol. 24:3:1:56, 2005.
21. Payoux P, Dekeister C, Lopez R, et al: Effectiveness of Lymphoscin-
tigraphic Sentinel Node Detection for Cervical Staging of Patients with
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Tumor Biopsy Principles and Techniques 47
29. Klein MK, Powers BE, Withrow SJ, et al. Treatment of Thyroid Carinoma
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30. Thomson MJ, Withrow SJ, Dernell WS, et al: Intramuscular Lipomas
of the Thigh Region in Dogs: 11 Cases. JAAHA. 35:165, 1999.
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31. London CA, Dubilzeig RR, Vail DM, et al: Evaluation of dogs and Cats
with Tumors of the Ear Canal: 145 Cases (1978-1992). JAVMA. 208:9:1413,
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32. Liptak JM, Dernell WS, Withrow SJ: Liver Tumors in Cats and Dogs.
Nicole Ehrhart, Stephen J. Withrow and
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33. Gores BR, Berg J, Carpenter JL, et al: Surgical Treatment of Thymoma
in Cats:12 Cases (1987-1992). JAVMA. 204:11:1782, 1994. The diagnosis of neoplastic and other pathologic conditions
34. Remedios AM, Fowler JD: Axial Pattern Flaps in the Cutaneous Recon- in animals depends on the procurement of an accurate biopsy
struction of Lower Limb Wounds. Compendium for Continuing Education. specimen. Without an appropriate histologic diagnosis, it is
17:11:1356, 1995. impossible to plan appropriate therapy. Histopathologic results
35. Hunt GB, Tisdall PL, Liptak JM, et al: Skin-Fold Advancement Flaps aid the clinician in providing an accurate prognosis and thereby
for Closing Large Proximal Limb and Trunk Defects in Dogs and Cats. Vet guide the owner in the selection of various treatment options.
Surg. 30: 440-448, 2001.
36. Cornell K, Salisburn K, Jakovljevic S, et al: Reverse Saphenous Conduit The ideal biopsy should procure enough tissue for specific
Flap in Cats: An Anatomic Study. Vet Surg. 24:202, 1995. pathologic diagnoses without jeopardizing the patient’s well
37. Fowler JD, Degner DA, Walshaw R, et al: Microvascular Free Tissue being or the surgeon’s ability to achieve local tumor control.
Transfer: Results in 57 Consecutive Cases. Vet Surg. 27:406, 1998. Many biopsy techniques can be used on any given mass. The
38. Spodnick GJ, Berg J, Rand WM, et al: Prognosis for Dogs with Appen- procedure used is determined by 1) the clinician’s goals for
dicular Osteosarcoma Treated by Amputation Alone: 162 Cases (1981988). the patient (i.e., diagnosis with no treatment versus diagnosis
JAVMA. 200:7:995, 1992. with treatment); 2) the skill and preference of the clinician; 3)
39. Watson CL, Lucroy MD: Primary Appendicular Bone Tumors in Dogs. the anatomic site of the mass; and 4) the general health status
Compendium for Continuing Education. 128, 2002. of the patient.1 Cytologic preparations obtained by fine needle
40. Chun R, Kurzman ID, Couto CG, et al: Cisplatin and Doxorubicin Combi- aspirate are often helpful in guiding the selection of the optimal
nation Chemotherapy for the Treatment of Canine Osteosarcoma: A Pilot biopsy technique.
Study. J Vet Intern Med. 14:495, 2000.
41. Bailey D, Erb H, Williams L, et al: Carboplatin and Doxorubicin Combi- General Considerations
nation Chemotherapy for the Treatment of Appendicular Osteosarcoma in
Biopsies can be obtained before the initiation of definitive
the Dog. J Vet Int Med. 17:199, 2003.
therapy (pretreatment biopsy) or histologic specimens may
42. Berg J, Weinstein MJ, Springfield DS, et al: Results of Surgery and
be evaluated after the mass is removed in its entirety. In most
Doxorubicin Chemotherapy in dogs with Osteosarcoma. JAVMA. situations, pretreatment biopsy is the optimum route of action
206:10:1555, 1995. because it provides a diagnosis before the institution of invasive
43. McEntee MC, Page RL: Feline Vaccine Associated Sarcomas. J Vet or aggressive therapeutics.
Int Med. 15:176, 2001.
44. Hershey AE, Sorenmo KU, Hendrick MJ, et al: Prognosis for Presumed Pretreatment biopsy is warranted when the type of treatment
Feline Vaccine-Associated Sarcoma after Excision: 61 Cases (1986 - would be significantly altered by knowing the tumor type. For
1996). JAVMA. 216:1:58, 2000. example, if an animal presents with a mediastinal mass, the
45. Cohen M, Wright JC, Brawner WR, et al: Use of Surgery and Electron distinction between a thymoma (responsive to surgery) and
Beam Irradiation, with and without Chemotherapy, for Treatment of lymphoma (responsive to chemotherapy) would be important to
Vaccine-Associated Sarcomas in Cats: 78 Cases (1996-2000). JAVMA. make before instituting treatment.
219:11:1582, 2001.
46. Bregazzi VS, LaRue SM, McNiel E, et al: Treatment with a Combi- If the extent of treatment would be altered by knowing the tumor
nation of Doxorubicin, Surgery and Radiation Versus Radiation Along for type, pretreatment biopsy should be performed. Certain cancer
Cats with Vaccine-Associated Sarcomas: 25 Cases (1995-2000). JAVMA. types (e.g., mast cell tumors and soft tissue sarcomas) have high
218:4:547, 2001.
local recurrence rates and therefore require removal with wider
47. Ross JT, Scavelli TD, Matthiesen DT, et al: Adenocarcinoma of the margins than benign or lower grade malignant tumors. Many
Apocrine Glands of the Anal Sac in Dogs: A Review of 32 Cases. JAAHA. studies in both animals and human patients have shown that the
27:349, 1991.
best chance for surgical cure is to remove the lesion completely
48. Williams LE, Gliatto JM, Dodge RK, et al: Carcinoma of the Apocrine the first time. Clinicians who are tempted to “peel out” or “shell
Glands of the Anal Sac in Dogs: 113 Cases (1985-1995). JAVMA. 223:825, out” a lesion without knowing the histologic diagnosis are playing
2003.
a dangerous game that may leave microscopic disease in the
49. Bennett PT, DeNicola DB, Bonney P, et al. Canine Anal Sac Adeno- patient. If the lesion is malignant and incompletely excised, it will
carcinomas: Clinical Presentation and Response to Therapy. J of Vet Int often grow back more quickly and invasively than the initial mass,
Med. 16:100, 2002.
thus potentially compromising further attempts at treatment.
50. Withrow SJ: Small Animal Clinical Oncology. Philadelphia: Cancer of
the Gastrointestinal Tract (Cancer of the Oral Cavity). 305, 2001.
48 Soft Tissue
Endoscopic Biopsy
Endoscopic biopsy is used most commonly in the gastrointes-
tinal, respiratory, and urogenital systems. It is convenient, safe,
and cost effective; however, it has several limitations. Visual-
ization may be inadequate, resulting in nonrepresentative
biopsy samples. Full-thickness biopsy specimens are often
impossible to acquire in these organs, and therefore, inflamed
tissue or normal tissue overlying a tumor may undergo biopsy,
not the tumor itself. A histopathologic diagnosis of inflam-
mation in an animal suspected of having neoplasia should be
interpreted with caution.
Figure 5-2. Punch biopsy technique. A. Baker’s punch biopsy instru- Image-Guided Biopsy
ment is applied directly to the mass, and downward pressure is ex-
The use of fluoroscopy, computed tomography, and ultrasonog-
erted while the instrument is twisted. When the metal end is buried up
raphy has greatly expanded the clinician’s ability to stage and
to the plastic hub, the instrument is removed. B. Forceps are used to
lift the biopsy specimen gently, and scissors are used to cut the base. diagnose neoplasia. Image guided biopsy may result in the
avoidance of more invasive diagnostic procedures. A disad-
vantage of image-guided biopsy is that the technique requires
may undergo biopsy without even the use of local anesthetics.
specialized equipment and training. Biopsy in a closed space
The goal is to obtain a composite biopsy of abnormal tissue
with limited visualization of the lesion carries some risk. As
and adjacent normal tissue without compromising subsequent
with laparoscopy and thoracoscopy, image guided biopsy is
resection. The incisional biopsy tract always must be removed
best done when the clinician is fairly certain that an excisional
with a tumor at curative resection. Thus, the surgeon must not
attempt would be unsuccessful or when pretreatment biopsy
open uninvolved tissue planes that can become contaminated
results would change the owners’ willingness to pursue more
with tumor cells. In general, any normal tissue that the scalpel
aggressive medical or surgical therapy.
or surgical instruments have touched during an incisional biopsy
is considered contaminated with tumor cells and is at risk for
eventual tumor growth. Tissue Procurement and Fixation Guidelines
The concept that performing a biopsy releases tumor cells and
Excisional Biopsy leads to early metastasis and decreased survival has proved
Excisional biopsy (See Figure 5-3) can be both diagnostic and false. Although biopsy procedures do release tumor cells into the
therapeutic. Excisional biopsy is best used when the treatment circulation, neoplastic cells are constantly shed into vessels and
would not be altered by knowledge of the tumor type. Benign lymphatics on a day to day basis.1 No evidence in either human
skin tumors and small malignant dermal lesions located in patients or animals indicates that a properly performed biopsy
leads to a decrease in survival or early metastases. On the other
50 Soft Tissue
Figure 5-3. Excisional (top) and incisional (bottom) biopsy. The location of the top tumor would be amenable to wide excisional margins with an
option to pursue a re-resection if needed. The location of the bottom tumor is less amenable to wide excisional margins. Attempts to excise this
tumor with close margins may leave residual disease in this patient and may compromise the optimum surgical course of treatment. The bottom
tumor should undergo biopsy before resection with curative intent. The axis of the biopsy incision is parallel to the long axis of the leg. (Modified
from Withrow Sj, MacEwen EC. Small Animal clinical oncology. 2nd ed. Philadelphia: WB Saunders, 1996.)
hand, a poorly planned or improperly executed biopsy can result for surgical margins. The surgeon should mark any areas
in significant alterations in the optimum treatment plan. of question or submit a margin from the patient in a separate
container. It is good practice to mark all excisional margins
Biopsies should be planned so the tract may subsequently be routinely with ink. The pathologist samples tissue from several
removed with the entire mass. The ideal circumstance is when the areas of the specimen. If tumor cells extend to the inked margin
biopsy is performed by the surgeon who will eventually perform microscopically, the excision should be considered incomplete
the curative intent procedure. Biopsies performed within a body (“dirty”). Lateral and deep margins of an excised mass can be
cavity (either open or closed) should be done so tumor cells are painted with India ink and allowed to dry before placement in
not “spilled” into the cavity. This precaution prevents seeding of formalin. Commercially available colored inks can be used to
peritoneal or pleural cavities. The sample size of the specimen denote different sites on the tumor if desired (Davidson Marking
affects the accuracy of the diagnosis. Because tumors are not System, Bloomington, MN).
homogenous and often contain areas of necrosis and inflam-
mation, larger samples or multiple samples from different areas Ultimately, the surgeon has the responsibility to communicate
in a mass are more likely to yield a diagnosis. The smaller the to the pathologist what is expected when evaluating margins
sample, the less representative it is of the whole tumor. Thus, on an excisional sample. Of course, incisional biopsies, needle
if needle core biopsy specimens are obtained, several samples core biopsies, and punch biopsies have incomplete margins by
should be submitted. Biopsies should not be obtained with definition. Pathologists may not know whether the sample is
electrocautery because this technique will disturb and deform intended to be excisional and do not always evaluate margins
the tissue architecture. Likewise, the clinician should take care unless asked. Good communication between the pathologist and
not to deform the sample with forceps, suction, or other handling the clinician is vital to the care of the patient. Waiting until recur-
methods. Cautery can be used after blade removal of a specimen rence of the tumor to reoperate on a known malignancy that has
to control hemostasis if necessary. been incompletely resected is a disservice to the client and the
animal. Incomplete surgical resection of malignant disease is
The junction of normal and abnormal tissue is frequently the best best dealt with early so further surgery or adjuvant therapy can
area for sampling. This aids the histopathologist in comparing be instituted immediately.
normal and abnormal tissue architecture. It is important to plan
the incision so the normal tissue incised during the biopsy can Tissues should be fixed in 10% neutral buffered formalin in a
easily be removed and is not necessary for reconstruction of the ratio of I part specimen to 10 parts fixative. Proper fixation is
surgical defect. (The exception to the tissue junction rule is bone vital for accurate pathologic diagnosis. Tissue thicker than 1
biopsies, discussed later in this chapter.) Biopsies performed on cm does not fix deeply. Large masses can be sliced like a bread
the legs or the tail should be done using an incision parallel to loaf, leaving one edge intact to allow for orientation. Alterna-
the long axis of the structure. This technique aids in resection of tively, representative samples from the tumors can be sent
the biopsy scar if needed. while the larger portion of tumor is saved in formalin and further
sections submitted if the pathologic diagnosis is in question. It
Excisional specimens submitted for biopsy should be evaluated is possible, especially in some large splenic masses, for only a
Tumor Biopsy Principles and Techniques 51
small portion of the mass to be neoplastic and for the rest to type needle features a pointed stylet that facilitates passage
consist of hematoma, necrosis, or fluid. This possibility empha- through the soft tissues (Figure 5-4). The stylet is secured by a
sizes the need to submit several representative samples or, screw on cap. The tip of the cannula is tapered, allowing the
when possible, the entire mass. Tissue that is prefixed over 2 specimen to be locked into the cannula. This tapering elimi-
to 3 days in formalin can be mailed with a tissue - to - formalin nates the rocking motion necessary to break off and retrieve a
ratio of 1:1. tissue specimen when using a trephine. A small probe is also
provided to assist in removing the specimen from the needle. The
For the pathologist to provide the most accurate diagnosis, each specimen must be pushed out the handle because damage and
sample must be accompanied by a complete history. Whenever compression distortion of the specimen will occur if it is pushed
the histopathologic diagnosis does not concur with the history, out the tapered cannula tip.
clinical signs, or clinician’s impression, a call to the pathologist
is warranted. In some cases, a small but vital piece of infor-
mation left out of the patient’s history can drastically change the
pathologist’s impressions. Pathology is a combination of art and
science, and diagnoses are only as accurate as the information
provided by the clinician.
Frozen Sections
Frozen sections are becoming more common in the perioperative
setting in veterinary medicine. This process provides a rapid
means to a diagnosis at the time of surgery, as well as information
on adequacy of tumor resection and the presence or absence
of metastases. Although the use of this technique in veterinary
medicine is limited to those institutions with specialized personnel
and equipment, it is of potentially great value to the surgeon.
Accuracy rates are high (93%) when results are compared with
those from traditional paraffin embedded tissues.2
Bone Biopsy
Bone biopsy is essential in the diagnosis of proliferative and
lytic bone lesions. Results of a bone biopsy often determine
the course of treatment and may drastically change proposed
operative intervention. As with all biopsies, the clinician must
plan the biopsy with the intended curative treatment in mind. Figure 5-4. Jamshidi type biopsy device. A. Cannula and screw on cap.
The most common instruments used for bone biopsies are the B. Tapered point to “lock in” the biopsy specimen. C. Pointed stylet to
Michelle trephine (Michelle trephine, Kirschner Co., Timonium, advance the cannula through soft tissue structures. D. Probe to expel
MD) and the Jamshidi type bone marrow biopsy needle (Jamshidi the specimen out of the cannula base. (From Powers BE, LaRue SM,
bone marrow/aspirate needle, American Pharmaseal, Valencia, Withrow SJ, et al. Jamshidi needle biopsy for diagnosis of bone lesions
CA 91335; Bone marrow biopsy needle, Sherwood Medical, St. in small animals. J Am Vet Med Assoc [in press].)
Louis, MO 63130). When used properly, both instruments provide
a suitable sample with minimal complications. The small size of Indications and Preoperative Considerations
the Jamshidi biopsy needle cannula is advantageous in that it Bone biopsies are most often performed to confirm the presence
requires a smaller skin approach (1-mm stab incision) and leaves of a neoplasm suspected on radiographic and clinical evaluation.
a small diameter bone defect, making biopsy related fractures Primary malignant tumors of bone in dogs include osteosarcoma,
less likely than with a trephine. Trauma to soft tissue structures chondrosarcoma, fibrosarcoma, and hemangiosarcoma. Plasma
and hemorrhage are minimal with the Jamshidi method. cells, myeloma, and other round cell tumors can also originate
from bone. Metastatic spread to bone from other primary tumors
Jamshidi needles are available in single use and reusable must also be considered. Metastasis to bone can occur with
models.3 The reusable model is “self sharpening” and steam almost any type of tumor. The clinical and radiographic signs
sterilizable. In our experience, the single use model may be of primary and metastatic bone tumors can be similar; they
reused 10 to 15 times after gas sterilization. Jamshidi type include lameness of the affected limb, a warm swelling that is
needles are available in various sizes, but the 8 and 11 gauge sensitive when palpated, and lytic and proliferative changes,
needles (4 inches long), are most commonly used. A Jamshidi- which are apparent on radiographs. Other conditions that can
52 Soft Tissue
mimic bone tumors include fungal and bacterial osteomyelitis. anesthesia is usually necessary for bone biopsy. Selection of
Dogs with fungal infection have generally traveled in fungus- the anesthetic regimen depends on the general condition of the
endemic areas. Dogs with bacterial osteomyelitis usually have animal, on personal preference, and on experience. Because
intermittent drainage from the lesion and a history of penetrating many of these patients are geriatric, complete blood count,
trauma or previous surgery. serum biochemistry, and urinalysis are indicated. In some cases,
particularly in animals with a lytic lesion, heavy sedation and
Although history, clinical signs, and radiographic changes can local anesthesia may suffice.
aid in making a presumptive diagnosis, the definitive diagnosis of
bone lesions can be obtained only through histologic evaluation Surgical Technique
of a tissue specimen. Radiographic evaluation before biopsy
should include two different views (craniocaudal and lateral) of The surgical site should be aseptically prepared and routinely
the lesion. As previously mentioned, biopsies are traditionally draped. Adhesive drapes covering the biopsy site offer excellent
obtained at the junction of tumor and normal tissue. However, protection allowing palpation and manipulation of the limb.
in bone, the center of neoplastic lesions is most likely to yield A 1 - to - 2 mm stab incision in the skin is made at the desired
diagnostic material.4 Bones surrounding almost any insult, location. The Jamshidi cannula, with the stylet locked in place,
including trauma, infection, and tumor, can become reactive. is gently pushed through the soft tissue structures. When bone
Although biopsy specimens obtained at the center of bone tumors is reached, the location of the cannuta should be evaluated
often contain considerable necrotic tissue, tumor identification using the radiographs as reference (Figure 5-5). The cannula
is not impeded.4 Inadequate sampling may result in a report of can be shifted to a different location if desired. The stylet is
reactive bone. In these cases, the clinician should consider removed. With a gentle twisting motion and the application of
rebiopsy, especially if the diagnosis of reactive bone does not fit firm pressure, the cortex is penetrated. The cannula is advanced
the clinical picture. The center of the lesion can be measured on through the medullary cavity, taking care to avoid penetrating
the radiograph with reference to a nearby landmark, generally the opposite cortex (Figure 5-6). After the instrument is removed,
the adjacent joint. The radiograph should be in view and a sterile the specimen is pushed from the tip out through the base of
ruler available at the time of biopsy. the cannula with the probe, not with the stylet (Figure 5-7). The
procedure is repeated, following the soft tissue tract previously
The skin incision and route of the biopsy needle should be made established. The instrument can be angled in different positions
with subsequent surgical procedures in mind (i.e., limb sparing after reaching the bone. Two or three specimens should be
operations). Questions of preferred location of biopsy are obtained. If the center of the lesion is so soft that a core of tissue
best directed to the referral institution that would perform the cannot be obtained, the cannula should be directed toward the
definitive surgery. In any case, a joint should never be entered peripheral aspect of the lesion. Hemostasis is generally not a
and dissection through the planes or neurovascular bundles problem with this technique; however, if bleeding occurs, direct
should be avoided. If evidence points toward primary bone pressure is sufficient to control it. The Jamshidi instrument
tumor and if the clients are interested in pursuing limb sparing bends if excessive pressure is applied.
surgery, referral for biopsy may be the best alternative. General
Figure 5-5. With the stylet locked in place, the cannula is advanced Figure 5-6. After the stylet has been removed, using a twisting motion
through soft tissue structures until bone is reached. The cannula and applying gentle pressure the cortex is penetrated. The cannula is
should point toward the center of the tumor. advanced until the opposite cortex is reached and then is withdrawn.
The procedure is repeated with the cannula pointed toward the periph-
ery of the lesions.
Tumor Biopsy Principles and Techniques 53
References Chapter 6
1. Withrow SJ, MacEwen EC. Small animal clinical oncology. 2nd ed.
Philadelphia: WB Saunders, 1996.
2. Whitebait JG, Griffey SM, Olander HJ, et al. The accuracy of intraoper-
Supplemental Oxygen Delivery
ative diagnoses based on examination of frozen sections: a prospective
comparison with paraffin embedded sections. Vet Surg 1993;22:255 259.
and Feeding Tube Techniques
3. Jamshidi K, Swain WR. Bone marrow biopsy with unaltered archi-
tecture: a new biopsy device. J Lab Clin Med 1971;77:335. Nasal, Nasopharyngeal,
4. Wykes PM, Withrow SJ, Powers BE, et al. Closed biopsy for diagnoses
of long bone tumors: accuracy and results. J Am Anim Hosp Assoc Nasotracheal, Nasoesophageal,
1985;21:489.
5. Withrow SJ, Susaneck SJ, Macy DW, et al. Aspiration and punch
Nasogastric, and Nasoenteric
biopsy techniques for nasal tumors. J Am Anim Hosp Assoc 1985;21:55 1. Tubes: Insertion and Use
Dennis T. Crowe and Jennifer J. Devey
Indwelling tubes that enter the nose and stop in the ventral nasal
meatus (nasal), pharynx (nasopharyngeal), or trachea (nasotra-
cheal) are effective for the delivery of supplemental oxygen (O2).
Those that continue on through the ventral nasal meatus and
pharynx and stop in the caudal thoracic esophagus (nasoesoph-
ageal [NEO]) are useful for the delivery of fluids and nutritional
supplements or for the aspiration of air and fluids to provide
decompression of the esophagus in conditions causing megae-
sophagus. Tubes that continue on into the stomach and either
stop there (nasogastric [NG]) or continue into the duodenum
or jejunum (nasoenteric [NET]) are useful for delivery of fluids
and nutrients or for removal of accumulated air and fluids. All
these tubes are placed initially into the nasal passage and are
passed into the ventral meatus using the same technique. The
type of tube selected depends on its intended use. Placement of
each of the types of tube is simple to perform. In rare instances,
placement under fluoroscopic guidance may be required (i.e.,
placing an NG tube past an esophageal stricture or placing an
NET tube). After insertion, all indwelling tubes are generally well
tolerated by most patients, even patients that are completely
alert. On occasion, an Elizabethan collar is recommended to
prevent the patient from dislodging the tube. Sedation is not
necessary in most patients. The nose generally accommodates
up to three to four types of tubes at the same time. When more
than one type of tube is placed in the nose, the tubes must be
labeled appropriately to avoid complications.
Oxygen Administration
Nasal Tubes
Indications
Supplemental oxygen (O2) should be provided as a first line of
treatment to dogs and cats in shock (septic, traumatic, cardio-
genic) and cardiac failure and those with respiratory compromise.
This supplementation is also a useful treatment in postoperative
critically ill patients during the anesthetic recovery period and in
anemic animals.
the door is opened. Furthermore, once a patient is placed into an Short human nasal cannulas are inserted into the nares and
O2 cage, careful evaluation, continued monitoring, and treatment are secured around the neck using a drawstring. These devices
are difficult in the “forced” isolation that this form of O2 therapy are well tolerated, but they frequently dislodge if the patient is
requires. Much time is also required to generate the higher levels active. Complications with transtracheal catheters have been
of O2 recommended in patients placed in O2 cages. The law of reported. Nasal O2 administration is an efficient and effective
displacement dictates the time required. The cubic volume of means of providing high inhalational concentrations of O2 (up to
commercial O2 cages varies from 300 to 500 L. If O2 is provided at 85 to 95%). The deeper the placement of the end of the tube in
a flow rate of 20 L/minute into the cage, and no leakage occurs, the respiratory tract, the more efficient the device is in elevating
it will take a minimum of 12 minutes to achieve the O2 concen- the concentration of O2. Nasal tubes are not as effective as
tration of near 100% that is recommended in patients suffering nasopharyngeal tubes in raising the inhaled tracheal O2 concen-
from life-threatening conditions. O2 cages are also inefficient tration. The highest concentrations of O2 are achieved with the
at providing sustained concentrations of O2 higher than 50% use of nasotracheal tubes.
because of unavoidable leaks. In investigations with one O2 cage,
the O2 concentration could not be held above 40%. Insertion Technique
The animal’s head is held gently restrained upward, and 1 mL of
Other available means of providing supplemental O2 therapy 2% lidocaine (dogs) (Animal Health Associates, Kansas City, MO)
include the use of face masks, O2 hoods, bilateral human nasal or 5 drops of 0.5% proparacaine ophthalmic Solution (dogs and
cannulas, and transtracheal catheters. Difficulties with the cats) (Ophthaine, ER Squibb & Sons, Princeton, NJ) are admin-
use of a mask in nervous and apprehensive animals are all too istered into either nostril. The right nostril generally is preferred
familiar. O2 hoods are well tolerated and provide up to 80% O2 for right handed operators and the left nostril for left handed
concentrations, but access to the face is restricted, and the operators. The local anesthetic solution is allowed to run down
animal is unable to drink or eat (Figure 6-1). These collars can, the nasal passage. This procedure is repeated after 10 to 20
however, be used in conjunction with nasal catheters or short seconds. After another short waiting period to allow for desensi-
nasal cannulas to increase tracheal O2 concentration. tization, the tip of the selected catheter is lubricated on its outer
surface with a commercial water soluble lubricant (Xylocaine
Jelly 2%, Astra Pharmaceutical Products, Inc., Worcester MA).
The catheter can be a 3.5- to 8-French red rubber (Sovereign,
Sherwood Medical Products, St. Louis, MO) or polyvinyl chloride
(Cook Critical Care, Bloomington, IN) tube, or for extremely small
patients, a long flexible 17-gauge polyethylene intravenous
catheter. The addition of small side holes helps to disperse the
stream of O2 more evenly within the nasal passage; however,
these holes are not usually required.
Figure 6-4. Nasal oxygen tube in place and fixated with a skin suture close to the external nares. The tube is also secured with other skin sutures.
The tube could also be secured ventral to the eye and ear. Elizabethan collars with clear plastic wrap over the front can be used to increase oxy-
gen concentrations if required. This “Crowe collar” can also be used independently to provide a rapid means of increasing inspired oxygen levels.
(Modified from Fitzpatrick RK, Crowe DT. Nasal oxygen administration in dogs and cats: experimental and clinical investigation. J Am Anim Hosp
Assoc 1986;22:293-297.)
Table 6-1. Oxygen Flow Rates and Estimated than 3 to 5 days) may cause rhinitis and sinusitis. When these
Corresponding Inspired Oxygen Concentrations complications do occur, they usually are mild and become evident
as a persistent serous nasal discharge. The discharge usually
Flow Rate Inspiratory O2 Conc. clears within several days after the nasal tube is removed. The
(mL/min/kg) (%) use of nasal O2 in patients with nasal bone fractures may lead
Animals weighing under 25 kg: to subcutaneous emphysema. If blood is present in the nose,
nasal O2 administration is not recommended because bubble
50 30-40
formation and foam may interfere with air exchange. In these
100 40-50 patients, nasotracheal or transtracheal O2 is recommended.
I5O 50-60
Tube dislodgment is an infrequent complication if the catheter is
*200 60-70
placed in the nose for a sufficient distance and if fixation of the
*250 70-80 tube is performed correctly. Persistent sneezing and continued
*300 80-90 irritation are rare and necessitate the use of repeated local
anesthetic instillation, an Elizabethan collar, or light intravenous
Animals weighing 25 kg or more:
chemical sedation (e.g., oxymorphone at 0.02 mg/kg or diazepam
100 30-40 at 0.1 mg/kg). Mild epistaxis caused by misdirection of the tube
150 40-50 into the maxillary or ethmoid turbinates during placement may
occur, but in our experience this occurs rarely and is not severe
200 50-60
enough to warrant discontinuation of a tube’s insertion or use.
*250 60-70
*300 70-75 Contraindications
Patients with severe tracheobronchial froth or fluid accumu-
*350 75-80 lation, as observed in animals with severe pulmonary edema,
*400 80-90 should receive nasotracheal or transtracheal O2 rather than
* Flow rates over 200 mL/min/kg may result in gastric distension. nasal O2. Nasal tubes should be avoided in those patients with
Therefore, at high flow rates, patients should be watched for disten- severe epistaxis or mucopurulent nasal discharge, suspicion of
sion and the condition treated by decompression if it occurs. maxillary or cranial vault fracture after head injury, or head injury
or any condition in which elevation of intracranial pressures
58 Soft Tissue
secondary to sneezing or struggling is contraindicated. just dorsal to the rima glottis (Figure 6-5).
Ineffective ventilation requiring other primary care (intubation
and positive-pressure ventilation) is also a contraindication to High O2 flow rates (greater than 200 mL/kg per minute) should
the placement of nasal O2 tubes. be administered carefully when providing O2 through nasopha-
ryngeal tubes. Rarely, gastric distension occurs if flow rates are
exceedingly high (greater than 200 mL/kg per minute) or if the
Nasopharyngeal Tubes
nasopharyngeal catheter migrates into the esophagus. Brady-
Nasopharyngeal tubes allow delivery of O2 into the nasopharynx. cardia, believed to be vagally mediated, can also occur.
This method can provide high concentrations of O2 and, if flows are
high enough, some level of continuous positive airway pressure
(CPAP). CPAP is even more effective if bilateral nasopharyngeal Nasotracheal Tubes
tubes are placed. As the patient exhales, it exhales against some Nasotracheal tubes provide an effective means of providing O2
force created by the flow of the O2 in a caudal laryngeal direction. to the patient that has laryngeal palsy or a collapsing cervical
The goal is to create an increase in the patient’s functional trachea. These catheters also generate some degree of CPAP
residual volume. This can be done with CPAP. when high flow rates are used. Patient tolerance is usually good,
with little coughing. In animals that do not tolerate the tubes,
A nasopharyngeal tube is placed in a fashion similar to that of mild sedation may be required.
a nasal catheter, but the lubricated tip of the tube is continued
through the ventral meatus past the maxillary turbinate. The tube Before placement of a nasotracheal tube, the tube should be
is held alongside the face and neck and is premeasured from premeasured such that the tip will rest at the level of the tracheal
the external naris to just proximal to the larynx. In dogs, some bifurcation or fifth intercostal space. A 3.5- to 8-French feeding
resistance may be encountered at the maxillary turbinate region tube is generally used. The tube is placed in a fashion similar to
because of a narrowing of the ventral meatus in a dorsoventral that of a nasopharyngeal catheter. The tube is passed blindly into
direction. If the tube cannot be passed farther than the level of the trachea through the larynx by hyperextending the patient’s
the eyes in dogs or cats, the tube is assumed to be in the dorsal head and neck and advancing the tube (Figure 6-6). If coughing
meatus with its tip in the ethmoid turbinate. The tube must be is noted, another 0.33 mL of local anesthetic is infused through
withdrawn and redirected ventrally if this occurs. After the tip is the tubing, with the tubing in the mid distal pharynx. Once the
past the maxillary turbinate in the ventral meatus, resistance to membranes around the larynx are anesthetized, the tube is
the tube’s passage decreases, and the tube can be passed into advanced as inhalation occurs. If the tube does not pass after
the nasal pharynx and pharyngeal isthmus. The ideal location is several attempts, a short-acting neuroleptoanalgesic can be
Figure 6-5. Parasagittal section showing the insertion of a nasopharyngeal oxygen tube through the nasal passage and into the nasopharynx.
Structures identified include the nasal vestibule (NV), cartilaginous septum (CS), maxilia (M), dorsal meatus (DM), middle meatus (MM), ventral
nasal concha (VNC), dorsal nasal concha (DNC), and nasopharynx (NP). (Modified from Crowe DT. Clinical use of an indwelling nasogastric tube
for enteral nutrition and fluid therapy in the dog and cat. J Am Anim Hosp Assoc 1986;22:675 678.)
Supplemental Oxygen Delivery and Feeding Tube Techniques 59
Figure 6-6. Parasagittal section showing the insertion of a nasotracheal oxygen tube through the nasal passage and into the trachea. Structures
identified include the nasal vestibule (NV), cartilaginous septum (CS), maxilla (M), dorsal meatus (DM), middle meatus (MM), ventral nasal concha
(VNC), dorsal nasal concha (DNC), nasopharynx (NP), esophagus (E), and trachea (T). (Modified from Crowe DT. Clinical use of an indwelling naso-
gastric tube for enteral nutrition and fluid therapy in the dog and cat. J Am Anim Hosp Assoc 1986;22:675-678.)
administered to the patient, and the tube can be placed by direct support often is a key component in successful overall patient
visualization using a laryngoscope and something to grasp the tip management. Contraindications to use of NEO or NG fluid and
of the tube and direct it through the rima glottis into the trachea. nutritional therapy support include persistent vomiting and high
gastric residual volumes. The presence of stupor or coma is a
The position of the tube should be confirmed with a radiograph or relative contraindication to NEO and NG feeding, particularly if
by aspiration using a 60-mL syringe. If the tube is in the trachea, bolus feeding is provided. If slow, continuous-rate infusions result
air should continue to be aspirated easily. If the catheter is in the in minimal residual volumes, then the risk of regurgitation and
esophagus, air may be initially aspirated, but it should stop. aspiration is low enough that NEO or NG feeding can be used.
The nasotracheal tube is used in a fashion similar to that of Decompression of a dilated esophagus, stomach, or intestinal
nasal and nasopharyngeal tubes. For nasotracheal catheters, tract can be accomplished by use of large-bore single lumen or
flow rates are decreased by 50% from those recommended for double-lumen (sump) NEO, NG, or NET tubes. Decompression
nasal O2 tubes to provide equivalent O2 concentrations. Humidi- of the esophagus alleviates some of the risk of aspiration in the
fication of the O2 is essential with the use of nasotracheal tubes, patient with megaesophagus and actively decreases the stretch
to prevent mucosal drying and dysfunction of the mucociliary in the skeletal muscle that results in dilatation. In the stuporous
apparatus, which can lead to an inability to clear secretions or comatose patient, or in the patient receiving mechanical venti-
and possible pneumonia. Infusion of saline through the nasotra- lation, active decompression helps to prevent aspiration. In the
cheal tube can be used to help loosen secretions in patients with patient having difficulty ventilating, decompression of the stomach
dysfunction of the mucociliary apparatus or pneumonia. improves ventilation because of reduced impedance to diaphrag-
matic excursions. This is particularly helpful in cats and small dogs
because they breathe primarily using the diaphragm. Clinically, NG
Tubes for Gastrointestinal Access decompression has been helpful in the temporary management of
Indications gastric dilation–volvulus syndrome when the gastric distension
NEO, NG, and NET tubes can be used for decompression and has been due primarily to air and fluid. Decompression of the
feeding. Smaller bore NEO, NG, and NET tubes are useful for the stomach after abdominal surgery helps to decrease the time to
administration of water, electrolytes, and liquid enteral support return to normal gastric motility. After placement, the NG tube is
diets. Because dehydration and protein–energy malnutrition periodically aspirated (e.g., once every 1 to 2 hours). The tube is
frequently are encountered in seriously ill or injured animals, left in place until bowel sounds return or the patient is believed
the use of these indwelling tubes for rehydration and nutritional to be out of danger of postoperative redistension. Antral dilation
60 Soft Tissue
is a strong stimulus for vomiting. The use of NG tubes decreases After selection of the tube and placement of the stylet, the length
the incidence of vomiting in the patient with gastrointestinal or necessary to reach the distal thoracic esophagus (NEO) or the
pancreatic disease and is especially useful in the patient with stomach (NG) is determined by measuring alongside the patient’s
canine parvovirus infection. neck and body from the tip of the nose to the eighth or ninth rib
for NEO tubes or to the thirteenth rib for NG tubes (Figure 6-7). For
Tube Selection and Insertion NET tubes, length is added to ensure that the tip of the proximal
end of the tube will reach the area of the bowel lumen selected.
The techniques for inserting an NEO, NG, or NET tube for
Most often, the tube for enteral feeding is a nasoduodenal tube
decompression or feeding are the same. Polyvinyl chloride
with a tip that ends near the pelvic flexure of the duodenum. The
(Argyle nasogastric feeding tube, Sherwood Medical Products),
tube in these cases is premeasured to extend from the nose to
polyurethane (Cook Critical Care), or red rubber tubes from 3.5
the wing of the ilium (See Figure 6-7).
French (cats and small dogs) to 12 French (medium to large
dogs) are used. Specially designed tubes that are weighted on
The lubricated tip of the tube is introduced into the patient’s nostril
their proximal ends with either tungsten or mercury are useful to
in the same manner as described for nasopharyngeal tubes.
ensure that the tube will stay in the stomach lumen (Travasorb
After the tip is past the maxillary turbinate in the ventral meatus,
dualport feeding tube, Baxter Health Care Corp., Deerfield, IL).
resistance to the tube’s passage decreases, and the tube can be
The smaller the tube, the more difficult it is to use for decom-
passed into the nasal pharynx and pharyngeal isthmus. At this
pression. A nylon stylet that accompanies commercial polyure-
point, the patient’s head must be kept in a neutral position, with
thane tubes provides added stiffness necessary for insertion.
the neck gently flexed to facilitate passage of the tube into the
With smaller polyvinyl chloride tubes, a woven angiographic
esophagus (Figure 6-8). If the neck is hyperextended, the tube
wire stylet (Wire guide, Cook Critical) is used to provide added
may enter the larynx and trachea. With continued advancement
stiffness. One or two milliliters of vegetable or mineral oil is
of the tube, the patient is often observed to swallow several
injected into the lumen of a tube to facilitate ease of insertion
times. Once the tip of the tube has been advanced into the caudal
and withdrawal of the woven wire through the lumen.
thoracic esophagus (NEO tube) or into the proximal portion of
the stomach (NG tube), the lubricated stylet is withdrawn. The
Figure 6-7. Drawing depicting landmarks used to premeasure the various feeding or decompression tubes. The tube should be premeasured from
the tip of the nose of the animal to the eighth rib for nasoesophageal (NE) tubes, to the thirteenth rib for nasogastric (NG) tubes, and at least to the
wing of the ilium for nasoenteric (NET) tubes.
Supplemental Oxygen Delivery and Feeding Tube Techniques 61
Figure 6-8. Parasagittal section showing the insertion of a nasogastric tube through the nasal passage and into the esophagus. The head is bent
to help the tube follow the dorsum of the wall of the pharynx and then course dorsally into the esophagus. Structures identified include the nasal
vestibule (NV), cartilaginous septum (CS), dorsal meatus (DM), middle meatus (MM), ventral nasal concha (VNC), dorsal nasal concha (DNC), alar
fold (AF), nasopharynx (NP), esophagus (E), and trachea (T). (Modified from Crowe DT. Clinical use of an indwelling nasogastric tube for enteral
nutrition and fluid therapy in the dog and cat. J Am Anim Hosp Assoc 1986;22:675-678.)
use of a stylet also helps to facilitate the passage of the tube into degree of gastroparesis. Metoclopramide, 0.4 mg/kg per day
the stomach through the cardia. intravenously, has been used to help stimulate gastric motility to
facilitate the tube’s passage into the duodenum.
Air is injected into the tube while auscultation of the left chest wall
and left paralumbar fossa is performed; the presence of gargling Once the tip of the tube has been placed in the desired location,
sounds during this procedure indicates that the tube is in the the tube is secured with several sutures placed at the base of
distal esophagus or stomach, respectively. In most cases, a lack the nostril and around the tube, or with glue as described previ-
of coughing during injection of 5 to 10 mL of sterile saline down ously for nasal O2 tubes. If the tube demonstrates a tendency to
the tube indicates that the tube is not in the trachea. However, back out of the nose, 1 to 2 cm of coated copper wire (18 gauge
the result of this test may vary with the individual animal, and the telephone wire) can be used to support the bend in the tube
position of all tubes should be radiographically confirmed if they as it exits from the nose. On occasion, the tube may back out
are to be used for infusion of fluids or liquid diets. of the intestine, or the dog or cat may vomit the tubes into the
mouth. In this case, the tube must be removed. A narrow gauge
Special tubes or manipulations are required for placement of NET flexible wire can sometimes be left in the tube to help prevent
tubes into the duodenum or jejunum. The tube can be guided by tube migration. Specially designed catheters are also available
peristaltic action into the duodenum, but this is often difficult to that allow the delivery of nutrients while the wire is left inside the
accomplish. The tubes can be guided through the pylorus using catheter lumen.
endoscopy or fluoroscopy. NET tubes have been most success-
fully placed at the time of abdominal surgery by the surgeon The remaining length of the tube or an attached extension tube
guiding the tip of the tube, which is palpated and guided through (intravenous administration extension set) is secured to the top
the stomach and intestine into the portion of the bowel intended. of the patient’s head or the side of the face. An Elizabethan collar
Weighted tungsten or mercury tubes have been used to help in can be applied if necessary. The end of the tube is capped to
guiding tubes through the stomach into the intestine (Travasorb prevent air from entering the gastrointestinal tract by diaphrag-
dualport feeding tube, Baxter Health Care Corp.). The weighted matic movement until its use is required.
tip also may help to ensure that the tube will stay in the bowel
lumen and not curl or kick back into the stomach. Passage of the
Protocol for Using Tubes for Decompression
tube into the small intestine through the action of peristalsis has
been unreliable, particularly in sick patients with at least some A 60-mL syringe is attached to the end of the tube, and aspiration
is done as often as required to keep a slight amount of negative
62 Soft Tissue
pressure on the hollow viscus aspirated. For prevention of (Peptamen, Clintec Nutrition Co., Deerfield, IL) and require no
recurrence of gastric dilation or for decompression of the small digestion before absorption. The amino acid–based diets tend
intestine, aspiration generally is performed every 1 to 2 hours to be hyperosmotic and may require dilution initially to a 50%
until a negative pressure is reached each time. If the fluid concentration. They usually are more expensive than polymeric
aspirated is viscous, dilution with sterile water or saline may diets, but they may be useful in patients with decreased digestive
be required. The tube should be flushed with a small amount of ability. The dipeptide- and tripeptide- based diets tend to be
saline or water each time the tube is used, and then the tube isosmolar and can generally be given initially at full strength
should be capped. Holding the column of water in the tube helps concentration. Polymeric diets (Impact, Sandoz Nutrition; Jevity,
to prevent clogging. Maintenance of decompression usually is Ross Laboratories) are made of complex carbohydrates and
required only for 24 to 48 hours because most intestinal ileus or proteins and require digestion before absorption, but they are
gastroparesis is resolved by then. usually isosmotic unless they are flavored. Special polymeric
diets designed specifically for cats and dogs (CliniCare and
The efficiency of gastrointestinal decompression achievable with RenalCare, Pet Ag Inc., Hampshire, IL) have been developed and
a simple single lumen tube (Argyle stomach tube (Levine Type), have been clinically effective in providing nutritional support to
Sherwood Medical Products) and intermittent aspiration with a critically ill or injured dogs and cats. Polymeric diets are usually
syringe can be improved by the use of a double lumen sump tube administered either full strength if plasma proteins are normal
(Salem sump tube, Sherwood Medical Products) with continuous and anorexia has not been present for longer than 3 days. If
20- to 30-mm Hg suction or intermittent mechanical 80- to 90-mm plasma protein levels are below normal or anorexia has been
Hg suction. This type of suction requires the use of specially present for longer than 3 days the diets should be initially diluted
designed equipment. Automatic intermittent suction, for example, to a 50% concentration with water. The monomeric diets may
is often best performed with the use of a thermotic drainage pump require dilution to 25% concentration for initial administration.
that is electronically driven (Thermotic drainage pump, GOMCO, After the rate of administration is stabilized at 2 to 3 mL/kg per
Allied Healthcare Inc., Buffalo, NY). Fortunately, in most clinical hour and the diet is found to be tolerable (no abdominal pain,
patients, this type of special equipment is not necessary, and vomiting, or diarrhea), the concentration of the diet can be
simple intermittent syringe decompression is sufficient. gradually increased.
Esophagostomy Tube Placement Esophagostomy tubes were developed and first used in clinical
veterinary medicine by Crowe.2 They were developed and used
and Use for Feeding and to avoid the airway difficulties associated with pharyngostomy
tubes (Figure 6-9).3 With pharyngostomy tubes, a portion of the
Decompression tube can interfere with laryngeal function, even after careful
Dennis T. Crowe and Jennifer J. Devey placement using modified techniques. The surgical approach
for placement of the esophagostomy tube is simpler than that of
the pharyngostomy tube, with less likelihood of damage to vital
Esophagostomy tubes provide a simple and effective means of
vascular and neurologic structures. Percutaneous gastrostomy
administering fluid and nutritional support to the small animal
tubes require special feeding tubes and because of penetration
patient. The tubes can also be used for esophageal or gastric
of the stomach and peritoneal cavity, the risk of leakage and
decompression.1 Esophagostomy tubes can be rapidly placed
subsequent development of peritonitis always exists. From our
(generally within 5 minutes) and require minimal surgical
experience, the patient does not need to be subjected to these
equipment (a scalpel blade, a pair of curved forceps, and nonab-
risks, and, whenever possible, an esophagostomy tube should
sorbable suture material). Simple red rubber feeding tubes
be selected over a gastrostomy tube. Most conditions for which
are most frequently used. Patients have been fed for up to 2
clinicians use percutaneous gastrostomy tubes for feeding can
years using these tubes. No cases of esophageal stricture or
be also managed with esophagostomy tubes. Esophagostomy
permanent esophagocutaneous fistula have been observed.
tubes can be used in patients that have had esophageal surgery;
however, care should be taken to ensure that a smaller bore
Indications flexible feeding tube is used and that the end of the tube is not
Esophagostomy tubes are indicated whenever nutritional rubbing against a wound site or surgical incision.
support is required and the stomach is functional but the patient
is unwilling or unable to ingest food or water. Esophagostomy Contraindications
tubes can also be used to keep the stomach and esophagus
In general, esophagostomy tubes should not be used for feeding
decompressed because aspiration of these tubes helps to
or decompression if the patient 1) is vomiting, 2) has cervical
prevent air or fluid from accumulating. This may be useful in the
or thoracic esophageal disease that will be worsened by the
management of patients with megaesophagus or those that have
placement of a tube passing through the affected area, and 3) has
undergone surgical correction of gastric dilatation–volvulus.
an infection involving the cervical region close to the tube exit Table 6-2. Guidelines for Esophagostomy Tube
site. Because placement of esophagostomy tubes requires light Size Selection*
general anesthesia, the risks of anesthesia should be weighed
against the benefits of the placement of esophagostomy tubes Decompression Feeding
in critically ill animals. Body Weight Gastric or Gruel Liquids
(kg) Esophageal Only
Tube Selection <1 8-10 10 3.5-6
The type and length of tube selected depends on the intended 1-3 10 10 6
use of the tube. Esophagostomy tubes used for feeding or for
3-5 10-12 10-12 6
esophageal decompression (i.e., for long term management of
megaesophagus) should end in the distal thoracic esophagus. 5-10 12-18 12-18 8
Tubes that pass through the lower esophageal sphincter increase 10-20 14-20 14-20 8
the risk of gastroesophageal reflux in some patients. For gastric
20-30 20-26 20-26 10
decompression or feeding, whenever the esophagus needs to be
bypassed, an esophagogastric tube is placed with the tip of the 30-40 26-28 26-28 10
tube resting in the midfundic region of the stomach. An esopha- > 40 28-30 28-30 12
goenteral tube can also be placed at the time of abdominal
* All tube sizes are in French.
surgery if the stomach needs to be bypassed. The proximal end
of the tube should be shortened as required, so only sufficient forceps are inserted into the pharynx and then into the proximal
tubing protrudes from the skin to permit attachment to a syringe cervical esophagus. Curved Kelly forceps are recommended
for feeding or decompression. Excessive tube length protruding
for use in cats and small dogs. In larger dogs, longer curved
from the skin may be annoying to the animal and may catch on
Carmalt, Mixter, or Schnidt forceps are recommended. The tips
objects.
of the forceps are turned laterally, and pressure is applied in an
outward direction, thereby tenting up the tissues so the tips can
Esophagostomy tubes used for feeding or decompression
be seen and palpated (Figure 6-1OA). A small skin incision (just
should be flexible and in general of as large a bore as possible.
large enough to accommodate the tube) is made over the tips of
This provides less chance for kinking and occlusion. The actual
the forceps using a scalpel blade, and the tips of the forceps are
size of each tube selected depends on the size of the animal and
bluntly forced to the outside (Figure 6-1OB). In larger animals,
on the intended purpose for the tube (Table 6-2). Generally, no
as continued pressure is applied, the scalpel blade is used to
tube smaller than 10 French should be used for decompression
cut through the thicker esophagus and to allow passage of the
or if a canned or gruel diet is to be used for feeding. For small
forceps.
cats and dogs, a 10- to 12 French tube is used. For medium sized
dogs, a 12- to 18 French tube is used, and for large to giant breed
The selected tube is premeasured and marked using the
dogs, an 18- to 30 French tube is inserted. When using the tube
landmarks listed in Table 6-3. Esophagostomy tubes are usually
only for the delivery of liquids, smaller-diameter tubes can be
measured to the level of the xiphoid or ninth intercostal space.
used. Tubes should be flexible yet stiff enough to resist kinking.
Esophagogastrostomy tubes are measured to the thirteenth rib.
Commonly, tubes made of red rubber (Sovereign, Sherwood
Medical Products, St. Louis, MO), polyvinyl chloride (Argyle The tip of the tube is grasped by the forceps (Figure 6-1OC)
feeding catheter, Sherwood Medical Products; Cook Critical Care, and is pulled into the esophagus and out through the mouth
Bloomington, IN), polyurethane (Cook Critical Care), Teflon (Cook (Figure 6-1OD). The aboral tip of the tube is turned around and
Critical Care), and silicone (Baxter Health Care Corp., Deerfield, is redirected into the esophagus. The tube is then pushed into
IN) are used. Tubes made of polyurethane or silicone resist the the esophagus with the aid of the forceps (Figure 6-1OE) By
hardening caused by gastric fluids and are recommended if one retracting the external end of the tube 2 to 4 cm, the tube is felt
anticipates that the tube will be used for longer than 1 week. to “straighten,” and then it passes more easily. The tube is then
Commercially available tubes frequently require the addition of passed to the premeasured mark. The oropharynx is visually
three to five side holes. These holes can be made carefully using examined to confirm location of the tube in the esophagus. Ideally,
curved scissors. The diameter of the holes should not exceed the location of the tip should be confirmed with a lateral radio-
approximately 20% of the tube’s circumference. graph in patients with megaesophagus, esophageal stricture, or
any other unusual condition involving the esophagus.
Surgical Technique
An alternative method of confirming appropriate location of the
Tube Esophagostomy tube in the distal esophagus involves passing the tube into the
Light general anesthesia is induced and is maintained throughout stomach. Placement is checked by infusing 30 mL or more of air
the procedure. The airway is protected with a cuffed endotracheal (using a syringe) and ausculting for bubbles over the stomach
tube. The entire lateral cervical region from the ventral midline region. Once bubbles are heard, the tube is retracted to locate
to near the dorsal midline is clipped and is aseptically prepared the tip in the distal esophagus. If bubbles are not ausculted in the
for surgery. Usually, the left side is chosen; however, both sides desired location, a chest radiograph should always be taken to
can be used. The procedure is illustrated in Figure 6-10. Curved confirm appropriate location.
Supplemental Oxygen Delivery and Feeding Tube Techniques 65
Figure 6-10. Drawing illustrating placement of a large bore esophagostomy tube using curved hemostats. A. The hemostats are inserted into the
oral cavity, oropharynx, and proximal esophagus; then the tips are pushed laterally. B. A skin incision is made, and the tips of the hemostats are
pushed through the wall of the esophagus and the subcutaneous tissues. C. The flexible feeding tube is grasped with the tips of the hemostats. D.
The tube is pulled out through the mouth with the hemostats. E. The tube’s tip is regrasped with the hemostats and is guided down the pharynx and
esophagus. F. The tube is pulled gently to straighten the curve in the tube, and after it is advanced so the tip is in the midthoracic esophagus, it is
anchored with a suture that enters the fascia and periosteum around the wing of the atlas.
The tube is secured to the periosteum of the wing of the atlas cheal tube. Curved Kelly forceps are passed into the pharynx
or deep fascia using nonabsorbable suture (Figure 6-1OF). The and proximal esophagus similar to the procedure described
suture is secured to the tube by using several wraps of the for surgical esophagostomy tube placement. The tips of the
suture around the tube. The tube should also be secured to the forceps are then turned outward and are opened slightly so
skin where the tube exits. Care should be taken not to tighten the they can be palpated. The needle is inserted through the skin
suture to the point that it binds the skin to the tube because this into the target location between the tips of the forceps. Once a
may cause irritation and necrosis. popping sensation is felt, indicating puncture of the esophagus,
the catheter, with the stylet backed out slightly, can be passed
through the needle and down to the premeasured location in
Percutaneous Esophagostomy Tube Placement
the distal third of the esophagus. The catheter is sutured to the
An alternative technique for placement of smaller-bore esopha- cervical fascia and skin in a manner similar to that described
gostomy tubes that are only used for administration of water and for surgical esophagostomy tubes. Sterile saline is then injected
other liquids involves percutaneous insertion of a long 10- to through the catheter to ensure good fluid flow. If one has any
14-gauge venous catheter (Intracath, Becton Dickinson, Sandy, question about the location of the catheter, a lateral radiograph
UT) into the esophagus.4 This “needle” esophagostomy tube should be taken.
can be inserted under sedation without passage of an endotra-
66 Soft Tissue
Table 6-3. Premeasured Landmarks Where Distal Triple antibiotic ointment is then applied, and the 4x4 gauze
End of Tube Should Reach dressing is replaced.
of saline or water should be infused into the tube to prevent tube alongside the esophagus instead of in the esophageal lumen.
obstruction. An esophagogastric tube can be used for gastric Because the clinician may not be aware of this situation, the
decompression. If gastric secretions are tenacious, saline can tube must be brought out into the patient’s mouth before being
be infused initially to break up the secretions before aspiration. passed back into the esophagus.
A basic premise “if the gut works, use it” may seem an oversim- Contraindications
plification of the benefits of providing nutritional support by physi-
The major contraindication to the use of a jejunostomy tube is
ologic routes (i.e., the gastrointestinal tract versus parenteral
any disorder causing a nonfunctional gastrointestinal tract (i.e.,
administration). In general, the more orad nutrients are placed in
ileus or neoplastic obstruction of the intestine).2,3
the gastrointestinal tract, the better patients are able to assim-
ilate complex diets into essential nutrients. Conversely, bypassing
a functional segment of the gastrointestinal tract (i.e., stomach) Operative Technique
results in necessary alteration of the dietary composition to From a midline laparotomy incision, a segment of proximal
accommodate for the loss of the portion of gastrointestinal tract. jejunum that is easily approximated to the ventrolateral body wall
is isolated. The direction of ingesta flow (orad to aborad) is deter-
General Considerations mined by tracing the bowel segment from a known anatomic
landmark (i.e., stomach or duodenum). A 2- to 3 cm longitudinal
Whenever a surgeon enters the abdominal cavity, one question
seromuscular incision is made in the antimesenteric border of the
should be answered: Could this patient benefit from a feeding
isolated segment of jejunum. At the aboral end of the seromus-
tube? Surgically placed feeding tubes carry little additional
cular incision, a stab incision is made through the submucosa
operative risk, are economical, and are simple to place and
and mucosa into the lumen of the jejunum (Figure 6-12A). A 5
manage; therefore, they pose little risk to the patient while
French Argyle feeding tube (Sherwood Medical Products, St.
providing a large potential benefit. Special equipment is not
Louis, MO) is directed through the stab incision aborally into
required for placement of enteral feeding tubes. The tubes used
the lumen of the jejunum. Approximately 20 cm of feeding tube
are 3.5- to 5 French infant feeding tubes at least 36 inches in
is threaded aborally into the small intestine (Figure 6-12B). The
length. If intestinal surgery is performed, the catheter is placed
seromuscular incision is closed with 3-0 or 4-0 monofilament
aboral to the site of surgery. Appropriate diets include commer-
synthetic absorbable suture in an interrupted Cushing pattern
cially available polymeric and monomeric diets. The preferred
(Figure 6-12C). The surgeon should close this incision in such
mode of administration is by slow, continuous rate infusion;
a manner that the feeding tube is buried in the submucosa of
however, small frequent boluses can suffice.
the incision, effectively creating a submucosal tunnel (Figure
6-12, inset). The remaining catheter is exteriorized through a
Indications small stab incision in the ventrolateral body wall. Care is taken
Placement of an enterostomy feeding tube may be indicated to select a site that will not result in excessive tension or radial
in any patient undergoing an abdominal operation. The major directional changes of the bowel. The enterostomy site is sutured
criteria are a functional small intestine and the need for nutri- to the peritoneal surface of the adjacent body wall (Figure 6-13).
tional support.2,3 Choosing the appropriate method and deter- Care is taken to create a watertight jejunopexy on all sides of the
mining the need for nutritional support are based on applying the enterostomy. The catheter is secured to the skin of the adjacent
least invasive technique that carries the greatest likelihood of body wall with a Chinese finger trap friction suture. Abdominal
success with the least amount of morbidity. wall closure is routine. A protective bandage is placed on the
patient after the procedure, and an Elizabethan collar is used to
Feeding through an enterostomy tube has induced pancreatic prevent premature removal of the jejunostomy tube.
secretion and therefore was previously contraindicated in
patients with pancreatitis.4,5 Acute pancreatitis induces a hyper- Diet Selection, Dose, and Administration
metabolic state with increased caloric and nitrogen demands
The ideal enteral diet formulation is isotonic, has a caloric density
and at the same time renders the gastrointestinal tract unable
of 1 kcal/mL, a protein content of 4.0 g/100 kcal (16% of total
to meet these increased needs.4,5 Because the exocrine
calories), and approximately 30% of calories as fat. Commer-
function of the pancreas is stimulated by the vagus nerve and
cially available diets designed for humans are the best diets for
by release of gastrointestinal hormones in response to food, one
small animal patients. Liquid enteral diets can be categorized
can reasonably expect that if the diet is administered into the
as polymeric diets or monomeric diets. Polymeric diets contain
jejunum, thereby bypassing the cephalic, gastric, and duodenal
large molecular weight proteins, carbohydrates, and fats. They
source of pancreatic stimulation, no significant increase will
require normal intestinal digestion. Most are relatively isotonic,
occur in the exocrine activity of the pancreas.6 Patients with
contain about 1 kcal/mL, and are readily available. Monomeric
pancreatitis experience modulation of bacterial flora within
diets are composed of crystalline amino acids as the protein
the intestinal tract and increased bacterial translocation, and
source, glucose and oligosaccharides as the carbohydrate
they suffer from a negative energy balance. Early alimentation
source, and safflower oil as the essential fatty acid source. They
through an enterostomy tube in human patients with pancreatitis
are hyperosmolar and expensive. A summary of polymeric and
results in improved immune status and fewer complications.4,6,7 A
monomeric diets is included in Table 6-4.
jejunostomy tube may allow aggressive nutritional support at an
earlier time in the postoperative period. Although these issues are
For patients with impaired digestive or absorptive function
controversial, enteral nutrition is considered an integral part of
(pancreatitis, enteritis, hepatic disease) or suspected food
aggressive treatment of acute pancreatitis in human patients.4,6,7
allergy, a commercial polymeric, enteral liquid diet may be
indicated. Patients should be closely monitored for formula intol-
erance. Jevity (Ross Laboratories, Columbus, OH) is the initial
Supplemental Oxygen Delivery and Feeding Tube Techniques 69
Figure 6-13. The remaining catheter is exteriorized through a small stab incision in the ventrolateral body wall. Care is taken to select a site that
will not result in excessive tension or radial directional changes of the bowel. The enterostomy site is sutured to the peritoneal surface of the
adjacent body wall. The catheter is secured to the skin of the adjacent body wall with a Chinese finger trap friction suture. Abdominal wall closure
is routine. A protective bandage is placed on the patient after the surgical procedure, and an Elizabethan collar is used to prevent premature
removal of the jejunostomy tube.
70 Soft Tissue
Table 6-4. Commercially Available Polymeric and Monomeric Diets and Their Composition
Diet Calorie content Protein Protein Fat Osmolality
(kcal/mL) (g/100 kcal) (g/mL) g/100 kcal (mOsm/kg)
Polymeric
Jevity 1.06 4.20 0.045 3.48 310
Osmolite HN 1.06 4.44 0.047 3.68 310
Impact 1.00 5.50 0.055 2.80 375
Clincare feline 0.92 7.0 0.064 4.60 368
Clincare canine 0.99 5.0 0.050 6.10 340
Monomeric
Vivonex HN 1.00 4.60 0.042 0.90 810
Vital HN 1.00 4.17 .046 1.08 460
formula of choice, owing to the potential benefits of its fiber patients and have significantly lower protein levels. ProMod
content. If the patient becomes intolerant to Jevity, Osmolite HN (Ross Laboratories) is a readily available protein supplement
(Ross Laboratories) should be used. The protein sources of many and contains approximately 75% high quality protein (5 g/6.6 g
human products may not provide adequate arginine and sulfur- scoop). The guideline for dietary protein requirements in dogs
containing amino acids for cats, and additional protein supple- is 5 to 7.5 g/100 kcal, the guideline for cats is 6 to 9 g/100 kcal.
mentation is required for long term use. Patients with renal or hepatic insufficiency should be reduced to
less than 3 g/100 kcal in dogs and less than 4 g/100 kcal in cats.
Monomeric diets are indicated for patients with exocrine
pancreatic insufficiency, short bowel syndrome, or inflam- Feeding can begin immediately in patients with good peristalsis
matory bowel disease or when polymeric diets are not tolerated. noted at surgery, a secure jejunopexy, and an adequate submu-
Monomeric diets promote maximal nutrient absorption and cosal tunnel of the feeding tube. However, if uncertainty exists,
minimal digestive and absorptive work. In addition, monomeric waiting 18 to 24 hours after placement allows a fibrin seal to
diets are less stimulatory for exocrine pancreatic secretion and form at the jejunostomy site and gut motility to normalize. The
may have a role in nutritional support of pancreatitis patients.8 To calculated volume of diet is gradually administered over 4 days
match the caloric density of polymeric formulas, their osmolality (Table 6-5). These are only guidelines, however, and each patient
must be two to three times higher, a feature that can create requires a feeding regimen tailored to fit individual needs.
disorders of gut motility or fluid balance. Their cost is about
seven times more per calorie compared with polymeric formulas. Table 6-5. Recommended Enterostomy Feeding
In most cases, a polymeric diet may be tried first, owing to the Schedule
decreased cost, ease of preparation, and physiologic benefits to
enterocyte function. Day Fraction of Calculated Volume* Dosing Interval
>1 1/4 qid
To determine the dosage of diet to feed, one must first calculate
2 1/2 qid
the basal energy requirement (BER, resting energy requirement)
based on body weight. The BER is calculated from the following 3 3/4 qid
formulas for dogs weighing less than 2 kg: 4 full dose qid
* Calculated dose is diluted to the full volume with tap water
BER (kcal/day) = 70(wtkg0.75)
The following formula is used for dogs weighing more than 2 kg: Complications
Complications of jejunostomy tubes include leakage of intestinal
BER (kcal/day) = 30(wtkg) + 70 contents or diet and are rare; however, they can be devastating.2,3
Therefore, critical placement and monitoring of the tubes in the
After determination of the BER, additional factors can be multi- early postoperative period are imperative. Peritonitis can result
plied depending on the condition of the animal: from leakage of intestinal contents from the jejunostomy site
or from tube displacement into the peritoneal cavity. Clinical
ER (kcal/day) = BER X 1.25 to 1.5 signs of peritonitis include vomiting, tachycardia, pyrexia, and
abdominal pain. Patients in which a leak is suspected should
Protein supplementation should be considered in patients with be evaluated and treated immediately, because progression of
significant negative nitrogen balance. Commercially available clinical signs can be rapid.
polymeric and monomeric enteral diets are designed for human
Minimally Invasive Surgery 71
respiratory difficulties, reduced adhesion formation, earlier insufflation of the thorax. An intimate knowledge of one-lung
ambulation and return to feeding, and rapid return to self-suf- ventilation techniques is necessary for advanced thoracoscopic
ficiency. The veterinary surgeon should investigate all means of techniques. Anesthetic considerations for endosurgery are
pain management for their patients. reviewed in the literature.3
flation needles and trocars. Splenic injuries caused by Veress operating endoscope. Auto-illumination, low-intensity default
needle placement are usually self-limiting. Large vessel injury settings and lamp standby mode can help minimize this risk.
can occur as well, causing severe bleeding, or worse, venous air
embolism through entrainment of insufflation gases. Diagnosis Fiberoptic Light Cable
and treatment of air embolism requires cooperation between the
surgeon and anesthesiologist. Monitoring for a precipitous drop Purpose: Carries light to surgical endoscope.
in end-tidal CO2 can be invaluable in these cases.
Recommendations: Secure connections and connector compat-
ibility with multiple manufacturers (universal clamp). Adequate
Equipment Needed size, durable and flexible construction.
Light, Optics,Video:The multicomponent Explanation: The development of fiberoptics in the 1960s made it
surgical video system possible to present intense light to the endosurgical field without
burning the patient. An incoherent bundle of glass fibers, 10 to
The standard video tower has a light source, light guide cable, rigid
25 μm in diameter, connects the light source to the rigid surgical
operating telescope, video camera, one or two video monitors,
endoscope. Fiberoptic bundles fan around the inner core lens
and often, a video recorder. For laparoscopy, a high-flow insuf-
system of the endoscope, carrying light to the surgical field.
flator, CO2 tank, yoke for the gas supply, and tubing are also used.
Due to air-to-glass interface at connecting points and fiber
The purpose of the system is to provide live, full color images of
mismatching, only approximately one-quarter of the original light
the interior of the body, as well as capture and storage of images
is transmitted, making bright light sources necessary. Secure
for review.
connections are necessary to prevent cable disconnections and
burns. Durable, flexible construction is necessary to limit light
General Considerations fiber fracture and subsequent loss of delivered light.
Image quality is the foremost consideration. The video system
component with the lowest resolution capabilities defines the Surgical Endoscope (Laparoscope)
resolution for the entire system. The final image is affected by
Purpose: Directs light into surgical site and directs reflected
a number of variables, including camera design, signal format,
light back to camera head.
video processor, monitor capabilities, and user settings. The
controls should be easy to identify and activate, providing easily
Recommendations: Hopkins rod-lens system. Autoclave
interpretable feedback. Some degree of automation will further
compatible. Compatible with all common light sources, light
simplify use. Compatibility with existing equipment and hospital
cables and video processors.
sterilization methods is important. Prior experience with the
manufacturer is also invaluable.
Explanation: Reflected light, incident with the operating
endoscope, is captured by a lens system. The diameter of the
Light Source standard lens system ranges from 1 to 5.5 mm, with the large
Purpose: Supplies light to surgical site via the endoscope. lens providing better resolution. Laparoscopes vary in their
depth of focus, magnification, color differentiation, brightness
Recommendations: Xenon or advance LED lamp with a minimum and resolution, as well as their angle of vision and field of view.
500 hour lamp life and backup lamp. Lamp standby mode and Superior light capture is accomplished with the now common-
bulb-life meter. Auto-illumination. place Hopkins glass rod-lens system, and high quality lens
systems. Laparoscopes also vary in their sensitivity to reuse and
Explanation: Adequate illumination of the endosurgical field is sterilization methods.
essential to safely completing the procedure. Light transmitted
from the tip of the endoscope must reflect off anatomic struc- Video Camera
tures and be picked up by the lens system of the endoscope.
Purpose: Generates an electrical signal from reflected light
Light emitted into the body cavity reduces in intensity by the
captured
square of the distance traveled. Changing focal points changes
reflected light intensity. Such changes demand an adjustable
Recommendations: Three-CCD (3-chip) cameras will generally
or automatic light source output control. Automatic brightness
provide superior image quality and color differentiation. Auto-
control helps maintain a constant image brightness regardless
white balance. Camera zoom control. Camera head with
of the target distance. Usually xenon, or more recently advanced
integrated, easy to use, imaging controls. Universal optical
LED light sources, are used over halogen or metal halide bulbs.
coupler will attach to a variety of surgical endoscopes.
Although these modern external light sources may operate
at very high temperatures, little of this heat ever reaches the
Explanation: Light captured by the rigid operating endoscope
patient. However, if a xenon light source is used, burns and fires
can be viewed directly or with greater ease and resolution using
induced by excessive heat production at the interface between
a miniature video camera, also called a charge-coupled device
the fiberoptic light cable and the rigid operating endoscope are
(CCD). The CCD or “chip” is a photosensitive silicone sensor
still quite possible. For this reason, the light source should not be
composed of thousands of photoelectric picture elements
left turned on when the fiberoptic cable is detached from the rigid
74 Soft Tissue
(pixels). Quality cameras use from one to three CCD chips. A Video Monitor
single chip camera uses color-filter overlays or rotating filter Purpose: Displays the live image
wheels to produce color separation. Three chip cameras use
a prism to separate the incoming light into the additive primary Recommendations: HD flat panel LCD with a number of video
colors of red, blue and green (RBG), with each chip dedicated to format inputs (composite, S-video, RBG, and DVI). Consider
one color, thus producing superior color reproduction. However, using more than one LCD for alternate viewing. Horizontal lines
light sensitivity is more important than color separation. A high- of resolution or pixel density, as well as video inputs to match
quality single-chip camera can outperform some three-chip video processor outputs.
systems. Still–in general–three chip systems offer better color
reproduction and image quality than single chip systems. The Explanation: A flat panel LCD will be necessary for HD video
camera head can also have controls for light source control, processor output. However, flat panel screens are also light
image zoom and peripherals like a video recorder. weight and easy to mount even when used with a lower
resolution input. Flat panel screens of various types have essen-
Camera resolution is based on the number of pixels available tially replaced the traditional cathode ray tube monitor.
(called the “native resolution”) and is generally less than that
of the video processor. Resolution is compromised in cameras The US standard, NTSC (National Television System Committee)
with less than 400 horizontal rows of pixels. One-chip cameras format has 525 horizontal scan lines, 4:3 picture aspect ratio and
typically generate signals with a maximum of 400 to 500 lines of runs 30 fields or frames per second (fps). Many surgical monitors
horizontal resolution, whereas three-chip cameras can create in use today have at least 550 to 700 horizontal lines of resolution,
signals with 700 or more. The camera is often the limiting factor a 13-inch diagonal screen, and are medical grade to limit chassis
for the overall resolution. electrical current leakage. However, the introduction of flat panel
fixed-pixel array monitors has changed the game. Resolution of
An optical coupler is used to attach the camera to a surgical these flat panel monitors is determined simply by the physical
endoscope. Video endoscopes have the camera situated at the number of columns and rows of pixels creating the display. The
tip of endoscope (so-called chip-on-the-tip configuration), but monitor must be compatible with the method of communicating
are less commonly used for laparoscopic surgery at this time. the image from the camera (composite, S-video, RBG or digital),
but then uses a digital video processor with memory array, called
Video Processor (Camera Control Unit or CCU) a scaling engine, to match the incoming image format. Again, the
Purpose: Translates the signal from the camera head into video image resolution will be no better than the input from the camera
signal and routes the video signal to the video monitor. regardless of the flat panel pixel density. The digital signal can
be communicated through a standard Bayonet Neill-Concelman
Recommendations: Variety of video format outputs (composite, (BNC) connector using serial digital interface (SDI) or high-defi-
S-video, RBG). Digital output for high definition systems (DVI). nition serial digital interface (HD-SDI). However, the industry has
Matching outputs to display and camera inputs. Brightness and moved to digital communication via Digital Visual Interface (DVI).
color controls. DVI is also compatible with High-Definition Multimedia Interface
(HDMI) with no signal loss using DVI-to-HDMI adapter.
Explanation: The overall resolution is affected by the method of
communicating the image. The standard one-wire, composite Video Image Capture
video signal is simple and familiar. Component video signals Purpose: Document and archive procedures, teaching
(two-wire Y/C or S-video, and three-wire RBG) reproduce more
monochrome and color image detail. High definition (HD) systems Recommendations: Large hard-drive with DVD archiving and
are becoming standardized at this time. To be considered HD, input/output for additional storage attachment (eg. Universal
the system should have a 16:9 picture aspect ratio and either 720 Serial Bus - USB). Digital capture device for instantaneous
horizontal progressive scan lines (720p), 1080 horizontal inter- and continuous capture. Capture resolution should match
laced scan lines (1080i) or 1080 horizontal progressive scan lines image resolution for equivalent replay (with alternative setting
(1080p) digital output formats. Progressive scan shows fewer available).
artifacts with rapid movement, but interlaced is equally effective
in laparoscopy. Since video processors cannot provide greater Explanation: Picture archiving and communication systems
resolution than offered by the video camera, the CCD pixel arrays (PACS) are computer-based systems that can store and retrieve
will also have to be larger or the resolution will not improve. The images in digital format from several different diagnostic imaging
video processor will need to be paired with a flat-panel liquid modalities including endoscopic surgery. Digital-image storage
crystal display (LCD) with a similar aspect ratio, horizontal lines does help organize storage of large volumes of images (such as
and input formats. The monitor resolution should reflect the radiographs) and video, however communication with a PACS
resolution of the camera or image quality may be lost. In general, is likely unnecessary for the average endosurgeon. Temporary
the field is rapidly moving towards HD systems at this time. storage to a large hard-drive and subsequent download to a DVD
for storage will usually suffice, with the understanding that the
average DVD lifespan is limited by the quality of the materials
and manufacturing methods, as well as the storage and handling.
Minimally Invasive Surgery 75
However, in general, manufacturers performing non-stan- Scalpel, can be used for dissection without precise skeleton-
dardized accelerated age testing claim life spans ranging from ization of vessels. The tissue to be coagulated and cut is grasped
30 to 100 years for high quality DVD-R and DVD+R discs and up in the jaws of the instrument and current is applied while the
to 30 years for DVD-RW, DVD+RW and DVD-RAM. Alternatively, tissue impedance is monitored by the instrument. When current
additional portable hard-drives may be connected to the primary flow drops below threshold, an audible alarm sounds to signal
hard-drive for archive download (if connectivity provided). HD complete hemostasis and an internal knife can then be activated
image capture will require larger storage space. to cut the tissue. The LIGASURE is capable of effectively ligating
vessels up to 7 mm in diameter. The Ethicon ENSEAL device also
uses bipolar energy to simultaneously cut and seal tissue up to
Trends and the Future 7 mm in diameter. A unique polymer temperature control feature
Natural orifice “scarless” surgery is being evaluated for is provided within the jaws of the device to precisely heat
surgical access to organs deep inside the body, without external tissue to 100 C and limit the lateral thermal spread outside the
incisions in the abdominal wall. Operating room automation electrode area. Care should be taken to close the device prior
systems designed to control multiple operating-room devices to withdrawal from the trocar to prevent damage to insulation
using a single, common interface are available. Three-dimen- of the wires to the electrodes. The insulation of all monopolar
sional endoscopic surgical techniques have developed more devices should be inspected to ensure that it is intact, as burns
slowly with concerns regarding surgeon’s perception of depth may occur where a defect in insulation contacts tissues.
and scaling. Telepresence including telemedical training and
telerobotic endoscopic surgery are well established. Telero-
botic systems like the da Vinci robotic surgical system (Intuitive Endoscopic Suturing
Surgical, Inc., Sunnyvale, CA, USA) are being used in more and The cost of materials for endoscopic suturing is less than for
more human community hospitals with more and more surgery clips, staplers, and energy devices, but manual suturing is more
going “robotic”. Small, wireless robots about 3 inches in length time-consuming. A description of all aspects of laparoscopic
have been developed which when inserted into a body cavity suturing is beyond the scope of this chapter and the reader is
can be controlled wirelessly by the physician to perform biopsy, referred to recent publications4,5 and the following illustrations of
drug delivery, and control of hemorrhage. extracorporeal ligation with Roeder knot, ligation with a pre-tied
loop ligature, such as ENDOLOOP, and classic intracorporeal
Endosurgical Instrumentation instrument knot tying.
Basic veterinary endosurgical hand-held instrumentation has
not changed dramatically since it was introduced in the late Extracorporeal Knot Tying
1990s. Endoscopic clip appliers, surgical staplers, and automatic
suturing devices were introduced between 1990 and 2000 and are
Equipment
continuing to be refined for use in human surgery. Endoscopic Pretied endoknot or long suture (endosuture) (at least 48 cm)
clips have greatly facilitated endosurgical procedures and Knot Pusher
provide secure hemostasis and sealing of viscus structures. One endoscopic needleholder and one endoscopic grasping
Multiple clip appliers enable rapid and repeated application of forceps
clips. These clips are used to occlude blood vessels and other Endoscopic scissors
small, hollow structures. They are useful in controlling acute
bleeding; however, secure ligation is only accomplished with Technique
complete skeletonization of the vessel. Endosurgical stapling This technique is defined as throws created outside of the
devices place six rows of linear staples that provide closure and body under direct vision which are then transferred to the body
hemostasis, and incision between the middle rows of staples. cavity by a knot pusher. This technique, unlike the pre-tied loop
Staple leg length varies according to anticipated tissue thickness. ligature, can be used on skeletonized structures, and does not
Newer staplers have staggered staple heights with the outer rows require a free end. The structure to be ligated is identified and
forming larger staples and the inner rows forming smaller tighter isolated. The free end of a 48 cm suture is grasped with a needle
staples. Cartridges are available in 30, 45, and 60 mm lengths. driver and passed into the body cavity through a cannula. The
ligature is passed around the structure with assistance of a
Although monopolar and bipolar electrocautery have been used second grasping forceps entering the body from another port.
extensively in MIS, recent major advances have been made in The ligature is then transferred to the original needle driver and
methods for achieving hemostasis and cutting of tissue. The pulled out through the cannula. The remainder of the ligature
Harmonic Scalpel uses ultrasonic energy to coagulate and cut is fed into the cannula while the surgeon simultaneously pulls
tissue, reducing lateral thermal injury and has an advantage the free end of the ligature from the body cavity. The grasping
because no electrical current passes through the patient’s body. forceps is used to prevent pulling and sawing to the tissue being
The vibrating blade creates cavitation in the tissue which opens ligated. The free ends of the ligature are tied in a Roeder knot
up planes of dissection that are not initially apparent. Dissection is (Figure 7-1A-F). The knot is then transferred to the body cavity
facilitated by appropriate tissue tension. Water vapor generated with a knot pusher.
during coagulation must be vented to ensure a clear surgical
field. The LIGASURE bipolar sealing device, like the Harmonic
76 Soft Tissue
Figure 7-1. Extracorporeal Knot Tying. A-C. Produce a simple or surgeon’s throw. D-E. Wrap the free end three times around both limbs of the loop.
Then wrap the free end around the black limb once or twice. F. Tighten by pulling on the free end and advancing the knot with a knot pusher.
Pre-tied Loop (ENDOLOOP) Ligatures is passed through the loop to grasp and elevate the structure to
be ligated. The knot is placed at the level of the intended ligation,
Equipment and the loop is slowly closed with a knot pusher. The commer-
Pretied loop ligature (ENDOLOOP or SURGITIE) cially available products have a nylon cannula with a conical
One endoscopic needleholder and one endoscopic grasping tip that serves as the knot pusher. The cannula is scored near
forceps a red tab. After the grasper is positioned through the loop the
Endoscopic scissors tab is broken from the cannula at the score point. The tab is held
with one hand while the cannula is advanced with the other.
(Figures 7-2A-F) Endoscopic scissors are used to cut the suture
Technique tail (Figures 7-2G-I).
Pretied loop ligatures are commercially available as ENDOLOOP
or SURGITIE ligatures and require a free pedicle for proper use.
The pre-tied loop ligature is passed through one port and a
grasping forceps is passed through a second port. The grasper
Minimally Invasive Surgery 77
Figure 7-2. A. Pre-tied loop ligature. B. The loop folds backwards during insertion through the trocar. Using a trocar with clear housing allows
visualization of the loop during insertion to ensure that it is not caught in the flapper valve mechanism of the trocar. C. The loop is introduced into
the body cavity and a second grasping forceps elevates the desired tissue through the loop. The grasping forceps are passed to an assistant who
holds the tissue firmly. D. Outside the trocar, the break point of the plastic cannula is identified by the red tab. The red tab is held with one hand
while the plastic cannula is advanced with the other. E. As the cannula is advanced the knot is pushed distally, causing the loop to become smaller.
F. The knot is positioned at the desired location and the cannula is firmly advanced while holding the suture taught to tighten the loop. G. The suture
is cut and the tab is removed. The plastic cannula is removed. H. Laparoscopic scissors are introduced beside the suture. This maneuver avoids the
need to place a third trocar for introduction of scissors. I. With the suture guiding the scissors, the suture is cut.
Intracorporeal Instrument Knot Tying be positioned in baseball diamond configuration with the laparo-
scope positioned at home plate, pointing towards the monitor.
Equipment The two working ports are positioned at first and third base, with
Short ligature (10 to 15 cm) with a curved or half-curved (ski) the incision at second base. The incision should be oriented
needle nearly parallel to the shaft of the active needle holder. One simple
Two endoscopic needleholders or one needleholder and one intracorporeal suture technique is illustrated in (Figure 7-3A-H).
grasping forceps
Endoscopic scissors Intracorporeal Suturing
Technique Equipment
ENDOSTITCH Suturing Device with ENDOSTITCH suture material
Endoscopic knot tying is an advanced technique that requires
available in sizes 0 to 4-0 (absorbable, silk, nylon, and polyester)
practice in an endoscopic training box for the surgeon to
10 mm trocar
become proficient before attempting to perform the technqique
on a patient. Proper suture placement requires proper trocar-
cannula placement. The surgeon places two working cannulas
and one cannula for the laparoscope. Ideally, the cannulas will
78 Soft Tissue
Figure 7-3. Intracorporeal Knot Tying. A. For optimal suturing, the incision is oriented at a 30 degree angle to the scope. The needle holder is held in
the dominant (right) hand. Grasping forceps are used with the other hand. The needle is driven through tissue as pressure is applied to the tissue with
grasping forceps. B. The needle tip is grasped and removed. A large C loop is made as the suture attached to the needle is brought to the right side
of the incision. The suture is then wrapped about the grasping forceps, once for a simple throw and twice for a surgeon’s throw. C. The suture tail
is grasped with grasping forceps and brought through the loop. D. Even tension is applied to both the grasping forceps and the needle holder to
complete the first throw of a square knot. E. A reverse C loop is then created with the grasping forceps holding the long end of suture. The needle
holder is placed ventral to the free end of suture and the grasping forceps is used to wrap a single loop around the needle holder. The free end of
suture is grasped and pulled through the loop. F. The square knot is tightened by moving the needle holder to the right and applying even tension
with the needle holder and grasping forceps. G. A large C loop is made with the needle holder and the suture is wrapped around the grasping
forceps. The free end of suture is grasped and pulled through the loop. H. The throw is tightened with even tension applied to the grasping forceps
and needle holders.
Minimally Invasive Surgery 79
Technique the Hasson technique, uses a blunt trocar with an olive plug or a
The suture material is swaged to the center of a needle, oriented screw tipped trocar inserted under direct visualization. The skin
in a T-fashion. Each end of the needle is loaded into the jaws of incision is made and a midline incision is made through the linea
the ENDOSTITCH suturing device. The needle can be toggled from alba. Sutures are placed on each side of the fascia and, after the
one jaw to the other by flipping a switch on the suturing device trocar is inserted, are tied to the olive plug of the trocar (Figure
handle. The needle is loaded on one side, the jaws of the device 7-4A-F). Optical trocars, such as the OPTIVIEW, have a central
are closed on tissue, and the switch is flipped to transfer the channel for the laparoscope that allows continuous visualization
needle to the other jaw of the instrument. Thus, the needle is held of each tissue layer during insertion. They are used both with and
securely and passed through tissue easily, without the difficulty without insufflation of the abdominal cavity. After the primary
of loading the needle into the needle holder each time. After the port is inserted, insufflation of the abdominal cavity with CO2 is
tissue is apposed, it is possible to tie a knot by passing the needle performed to provide a viewing cavity in which to work. Additional
around the suture material to create a loop and then passing ports are placed as needed for each procedure.
the needle through the loop. Alternatively, barbed sutures, such
as the V-LOC suture (Covidien) or STRATAFIX (Ethicon) can be Laparoscopic Liver, Intestinal and Pancreatic
utilized to avoid the need to tie an intracorporeal knot.
Biopsy Procedures
Laparoscopic Endosurgical Indications
If abdominal exploratory and organ biopsy can be obtained with
Procedures MIS, this method is preferred over other techniques. Laparo-
scopic liver biopsy enables the surgeon to obtain more tissue that
Patient Positioning is needed for heavy metal analysis than what can be obtained
Equipment with ultrasound directed fine needle aspirates or ultrasound
Tilt table or other means of tilting the animal by elevating the guided core biopsy procedures. Full thickness intestinal biopsy is
head or feet and rotating the animal side to side preferred over obtaining endoscopic biopsy samples for accurate
diagnosis of diseases of the intestinal tract. Finally, laparoscopy
permits examination of internal organs and visual confirmation of
Technique hemostasis without the invasiveness of open surgery.
The animal may be placed in several different positions, depending
on the procedure. In general, the laparoscope should be inserted
to face the monitor with the target tissue placed between the
Equipment
trocar insertion site and the monitor. Usually, the target tissue 5 mm trocars
will be elevated for optimal visualization. For procedures 5 mm blunt probe
involving the cranial abdomen or thorax, position the monitor 5 mm endoscopic grasping forceps
at the head of the table and elevate the head. For procedures 5 mm endoscopic cup biopsy forceps
involving the caudal abdomen or thorax, position the monitor at Hemostatic agent such as ENDO-AVITENE, SURGICEL, GELFOAM,
the foot of the table and elevate the tail. For ovariectomy proce- or collagen sponge
dures, the animal will need to be rotated to the right and to the Introducer sleeve and plastic push rod from a pre-tied loop
left to identify the left and right ovaries, respectively. ligature system (SURGITIE)
Access Technique
Liver Biopsy. When laparoscopic liver biopsy is the only technique
Equipment being performed, positioning the animal in left lateral recum-
Veress needle or Hasson trocar (blunt trocar with olive plug) bency allows more of the liver surface to be exposed through the
right lateral mid-abdominal approach. In addition, this position
Technique improves visualization because the falciform ligament moves out
of the field. However, performing laparoscopic exploration is more
There are two methods used to create access to the abdominal
difficult, so animals are usually positioned in dorsal recumbency if
cavity. A closed approach uses a Veress needle to insufflate CO2
both techniques are to be performed.
to create a space for primary trocar insertion. The body wall is
grasped and lifted while the Veress needle is passed in the direction
If ascites is present, the open technique for primary port
predicted to be devoid of viscera. Proper needle placement is
placement should be used to allow suctioning of the ascitic
confirmed by aspiration and hanging-drop techniques. The body
fluid before port placement. Pneumoperitoneum is created, the
cavity is insufflated with gas, and the needle is removed. The skin
laparoscope is inserted, and the abdomen is inspected. The liver
incision is made roughly equal to the diameter of the trocar being
is inspected and any lesions are identified. A second 5 mm port
inserted, and the primary sharp trocar is then blindly placed in a
is then placed in the right or left cranial abdominal quadrant,
similar fashion to the needle. In the dog, when the Veress needle is
corresponding to the site of the lesion. A blunt probe is used to
inserted at the umbilicus, it is not uncommon to injure the spleen.
palpate and elevate each of the liver lobes prior to biopsy. Any
For this reason, many veterinarians use the open approach to gain
remaining ascitic fluid is aspirated.
entry to the abdominal cavity. The open approach, also known as
80 Soft Tissue
Figure 7-4. Laparoscopic Access. A. The abdomen is aseptically prepared for abdominal surgery with wide draping to facilitate ovarian suspen-
sion when laparoscopic ovariectomy is being performed. B. A small incision is made on midline near the umbilicus. The incision is extended into
the abdominal cavity through the peritoneum. Two stay sutures are placed through the abdominal fascia. C. A reusable Hasson trocar has an
olive plug that features a blunt obturator and tying posts to secure the sutures placed in the abdominal fascia. D. After the primary port is placed,
the abdomen is insufflated with CO2 to 12 mm Hg and the laparoscope is introduced. E. The working port is placed with direct visualization of its
insertion provided by the laparoscope. F. A second port is placed in the cranial right abdominal quadrant to facilitate procedures in the cranial
abdomen such as liver biopsy or laparoscopic-assisted gastropexy.
Liver biopsy is usually associated with minimal bleeding; forceps are passed through the port, opened, and positioned on
however, placing small sections of Gelfoam into the abdominal tissue. Pressure is held for approximately 30 seconds and then
cavity near the anticipated biopsy site assists in controlling the forceps are rocked or twisted until the tissue is detached.
bleeding if it does occur.6 The Gelfoam sections are back- The Gelfoam samples are then nudged into the defect with the
loaded into the introducer sleeve of the SURGITIE (pre-tied loop forceps to assist in hemostasis. A minimum of five samples are
ligature) system, introduced through the trocar, and pushed taken: one or two for histology, one for culture, and three to
into the abdominal cavity with the plastic rod. If generalized five for heavy metal analysis. If a discrete lesion is identified,
liver disease is present, marginal biopsy samples are obtained the biopsy cup forceps can be used to obtain a sample as just
from the edge of the liver lobe (Figure 7-5A-C). The 5 mm biopsy described, or a needle aspirate or core biopsy can be performed
Minimally Invasive Surgery 81
under direct visualization. For these biopsies, the needle is obtaining multiple biopsy samples of the intestinal tract.
inserted through the abdominal wall, directly above and perpen-
dicular to the lesion. Under direct observation, the needle is The initial 5 mm port is placed on midline just caudal to the
inserted into the core of the lesion and the syringe is aspirated umbilicus. A second 5 mm port is placed in the cranial right
or the barrel of a core biopsy needle is advanced to obtain the quadrant for insertion of biopsy and grasping forceps. Following
specimen. Suspending ventilation during this step helps avoid liver biopsy and aspiration of the gallbladder, the biliary tree is
tearing the hepatic capsule. Aspirates of the gallbladder can examined. If there is dilation of the common bile duct and cystic
be obtained using a spinal needle. To minimize bile leakage, duct, the region where the biliary and pancreatic secretions
the needle is introduced through hepatic parenchyma before enter the duodenum must be seen. Visualization is obtained by
entering the gallbladder. elevating the duodenum and retracting it medially and caudally.
If white, plaque-like discoloration of the pancreas is seen, a
Laparoscopic Intestinal and Pancreatic Biopsy. To reduce biopsy of that area should be obtained, as this can be an early
operative time and the potential for abdominal spillage, intes- sign of pancreatic adenocarcinoma. Biopsy samples can be
tinal biopsy procedures begin with laparoscopic exploration for obtained with the 5 mm cup forceps. Bleeding is minimal. The
assessment of the liver and biliary tract and pancreatic biopsy. remainder of the left and right lobes of the pancreas can be
The procedure is then converted to a mini-laparotomy for visualized by applying traction to the duodenum and elevating
Figure 7-5. A. Laparoscopic Liver Biopsy. A 5 mm laparoscope is placed through the port at the umbilicus. Biopsy forceps are inserted through left
lateral 5 mm port. B. Laparoscopic toothed biopsy forceps are used to obtain a sample from the liver margin. C. Gelfoam is placed in the biopsy
site to assist with hemostasis.
82 Soft Tissue
Figure 7-6. Laparoscopic Ovariectomy. A. A second 5 mm port is placed on midline midway between the umbilicus and pubis. B. The proper liga-
ment of the left ovary is grasped and elevated to the body wall. C. External view showing the animal rotated to the right and the spay hook being
introduced into the abdomen. D. The spay hook is introduced percutaneously and the proper ligament is draped over the hook and secured. E.
External view showing the harmonic scalpel being used through the caudal midline port. Monitors are positioned at the head and foot of the table
and the surgeon is observing the procedure on the monitor at the end of the table. F. The harmonic scalpel is used to transect the suspensory
ligament, ovarian pedicle, and proximal portion of the uterine horn and the round ligament of the left ovary.
84 Soft Tissue
the loop can be positioned on the uterine body. A nylon cannula When the 2-port laparoscopic technique is used for a totally
is broken and advanced to tighten the loop, taking care to avoid laparoscopic procedure, the testicle is lifted suspended from
incorporation of other structures into it. When the loop is tight, the abdominal wall with a percutaneous suture, similar to the
the suture tail is cut with laparoscopic scissors. The uterus is technique used for ovarian suspension in the laparoscopic
then transected and removed from the sub-umbilical port. ovariectomy. The LIGASURE, ENSEAL, or Harmonic Scalpel
are used across the gubernaculums, pampiniform plexus, and
If the tissue is suspected to be malignant or infected, a specimen spermatic cord. Alternatively, clips or sutures can be used. Once
retrieval bag can be utilized to protect the body wall from contam- ligation and transection are complete, the testicle is removed. If
ination. The bag is introduced through one of the ports, tissue is a 10 mm port is placed on midline, the testicle can be removed
placed in it and the mouth of the bag is closed for withdrawal from that port by transferring the laparoscope to the caudal port.
from the body. Final inspection is performed and the port sites Following final inspection, the port sites are closed routinely.
are closed routinely.
Gastropexy
Cryptorchid Castration
Indications
Indication Prophylactic gastropexy is performed to prevent gastric volvulus
This procedure is indicated for animals that have intra- in large breeds of dogs that may be predisposed to developing
abdominal retained testicles, which are susceptible to torsion gastric dilatation-volvulus syndrome. The procedure can be
and neoplasia. A laparoscopic or laparoscopic-assisted combined with laparoscopic ovariectomy in female dogs or
technique can be performed, depending on available equipment. castration in male dogs. In females, the laparoscopic-assisted
If an energy modality such as LIGASURE, ENSEAL, or Harmonic procedure is performed; in males, an endoscopic-assisted
Scalpel is available, the laparoscopic approach is performed. If procedure using a flexible endoscope avoids the need to
not, the laparoscopic-assisted technique is easiest and quickest. use laparoscopic equipment. The technique is an incisional
gastropexy procedure performed by suturing the seromus-
Equipment cular layer of the stomach to the internal fascia and transverse
10 mm blunt-tip trocar-cannula (with reducing cap to be abdominis muscle at a site selected approximately 3 cm caudal
compatible with 5 mm laparoscope) to the costal margin on the right side. Biomechanical studies
5 mm sharp trocar-cannula and clinical experience suggests that the resultant gastropexy
5 mm grasping forceps adhesion is strong and reliable.8
Laparoscopic spay hook or large curved needle
5 mm LIGASURE device, ENSEAL or Harmonic scalpel Equipment
Laparoscopy equipment for the laparoscopic-assisted approach
Technique 10 mm blunt-tip trocar-cannula (with reducing cap to be
With both techniques, the animal is positioned in dorsal recum- compatible with 5 mm laparoscope)
bency and prepared for abdominal surgery. Following the guide- 10 mm sharp trocar-cannula
lines described earlier, a Hasson port is placed on midline caudal 10 mm endoscopic Babcock forceps
to the umbilicus. The abdomen is insufflated and inspection is Flexible endoscope for the endoscopic-assisted approach
performed. Once the testis is identified, a second 5 mm or 10 mm 76-mm long needle with size-2 polypropylene suture
port is placed under direct visualization in the caudal abdominal
quadrant on the side opposite the location of the testicle if Technique
performing a totally laparoscopic procedure (Figure 7-7A-D). If Laparoscopic Approach. Following general anesthesia and
the laparoscopic assisted technique will be utilized, the port is positioning in dorsal recumbency, the abdomen is prepared
placed on the same side as the retained testicle. If both testicles for abdominal surgery. The monitor is placed at the animal’s
are retained, they can usually be retrieved through the same port head and the surgeon stands on the animal’s right side. A 10
with the laparoscopic technique. The port is ideally placed just mm Hasson port placed on midline, just caudal to the umbilicus
lateral to the lateral edge of the rectus abdominis muscle, taking serves as the camera port. The abdomen is insufflated to 12 mm
care to avoid the caudal deep epigastric vessels. Hg and inspected. Particular attention is paid to the location of
the stomach, omentum, and spleen. The pylorus is identified
If the laparoscopic assisted technique is used, the testicle is beneath the right medial liver lobe and gallbladder. A second 10
identified and elevated to the body wall. The trocar is removed mm port is placed 3 to 5 cm caudal to the ribs on the right side at
and the testicle is exteriorized. It may be necessary to enlarge the lateral edge of the rectus abdominis muscle. Babock forceps
the incision, depending on the size of the laparoscopic port. are introducted to elevate the liver lobes and fully expose
Similar to open surgery, ligation of the gubernaculums, pampi- the ventral aspect of the stomach (Figure 7-8A-H). Using the
niform plexus, and spermatic cord is performed. If both testicles aperture of the Babcock forceps as a measuring tool, a site is
are retained, it may be necessary to place a second working port selected in the antral region of the stomach approximately 5 cm
in the opposite caudal abdominal quadrant for removal of the orad to the pylorus and midway between the greater and lesser
second testicle. Following final inspection to ensure hemostasis, curvatures of the stomach. The gastric wall is grasped firmly and
the port sites are closed routinely. elevated to the body wall as the trocar cannula is withdrawn.
Minimally Invasive Surgery 85
Figure 7-7. Laparoscopic Cryptorchid Castration. A. The retained testicle is identified on the right side, lateral to the urinary bladder (arrow). B.
In this case, a port was placed in the right cranial quadrant to enable a gastropexy procedure. Grasping forceps are used to elevate the testicle.
C. The vas deferens and pampiniformplexus are identified as the testicle is elevated. D. The harmonic scalpel is used for obtaining hemostasis
and transection of the vascular structures. The testicle was then removed when the right cranial quadrant incision was enlarged prior to the
gastropexy procedure.
86 Soft Tissue
Figure 7-8. Laparoscopic-Assisted Gastropexy. A. The stomach is elevated to the base of the trocar with Babcock forceps. B. The skin and body
wall incision is enlarged with a scalpel blade. C. With the forceps elevating the stomach, two stay sutures are placed about 5 cm apart in the
gastric wall. D. A Gelpi retractor assists in providing clear visualization of the gastric surface. E. A seromuscular incision is made in the stomach
wall. Pinching the surface of the stomach causes the mucosa to slip away, making the incision less likely to penetrate the mucosa. F. The sero-
muscular layer of the stomach is then sutured to the abdominal wall with a continuous pattern of absorbable sutures. G. Final inspection of the
gastropexy site prior to closure. H. External view of the two incisions for laparoscopic-assisted gastropexy.
Minimally Invasive Surgery 87
When the Babock forceps reach the abdominal wall, the skin Equipment
and abdominal fascial incisions are extended to ~ 5 to 6 cm with 30 degree rigid cystoscope, 1.9 mm for small dogs and cats, 2.7 mm
a scalpel blade under laparoscopic visualization. Pneumoperi- for most other dogs
toneum is lost as the incision is extended and the insufflation Saline irrigation fluids with pressure bag and ingress/egress tubing
gas is turned off. Bleeding is minor. Two stay sutures are placed Stone Basket, compatible with insertion through the working
in the gastric wall about 5 cm apart and the Babcock forceps channel of the cystoscope
are removed. Two Gelpi retractors or the Lone Star Veterinary Arthroscopy or alligator forceps
Retractor system with multiple elastic stays can be helpful to 2 trocars, either 5 mm or 10 mm, depending on the laparoscope
aid in exposure and identification of the layers of the abdominal size
wall. The seromuscular layer of the stomach is then sutured to 5 and/or 10 mm Babcock grasping forceps
the abdominal wall with size 2-0 absorbable suture. The external 5 mm disposable screw tipped trocar (optional)
fascia, subcutaneous tissue, and skin are closed routinely.
Following inspection of the gastropexy site to ensure that there
is no twisting of the gastric wall, the abdomen is desufflated, Technique
the umbilical port is removed, and the fascia, subcutaneous The initial port is placed on midline near the umbilicus for insertion
tissue and skin are closed. An alternative, totally laparoscopic, of the laparoscope. Following insufflation and inspection of
approach is direct laparoscopic suturing of the gastric seromus- the abdomen, a second 5 mm or 10 mm port is placed to exteri-
cular incision to an incision in the peritoneum and transversus orize the bladder. In females, it is placed on midline; in males,
abdominis muscle with traditional needleholders, barbed the second port is placed lateral to the prepuce at the lateral
sutures, or using the ENDOSTITCH device.9 edge of the rectus abdominis muscle. Through the second port,
grasping forceps are introduced to grasp the apex of the bladder
Endoscopic Approach. A flexible endoscope is passed to inspect and elevate it to the body wall as the trocar is removed. Usually,
and dilate the stomach with air. The animal is tilted to the left a 10 mm incision is sufficient unless a very large stone is being
approximately 30 degrees to allow the distended stomach to be removed, but a 5 mm port will need to be enlarged. Stay sutures
in contact with the right lateral body wall caudal to the costal are placed in the bladder wall and a stab incision is made into
margin. With gastric distention, identification of the pylorus, and the bladder with a #11 scalpel blade. The bladder wall can be
indention from forceps applied to the body wall, the correct site sutured to the skin to prevent abdominal contamination during
for gastropexy is identified.10 A large needle is passed percuta- the procedure or a 5 mm disposable screw tipped trocar can be
neously under direct vision with the endoscope into the stomach positioned if repeated insertions of the cystoscope are antici-
and back out through the abdominal wall. A second suture is pated. The insufflator is turned off and the laparoscope is discon-
placed under direct vision from the endoscope 4 to 5 cm from nected from the camera and light guide cable. The camera and
the first suture. Externally, an incision is made through the skin light cable, along with the ingress and egress fluid lines, are then
and abdominal wall between the 2 sutures. The gastric surface attached to the cystoscope. The cystoscope is inserted into the
is identified and a 3 to 5 cm seromuscular gastric incision is bladder, the fluids are turned on, and thorough visual inspection
made, avoiding the mucosa. Similar to the laparoscopic assisted of the bladder is performed. In male dogs, it can be helpful to pass
gastropexy, the seromuscular layer of the stomach is sutured a urinary catheter to assist in occluding the urethral lumen so that
to the body wall and closure proceeds as described previously. stones do not lodge in the urethra during cystoscopy. At the end
The stay sutures are removed and final endoscopic inspection of the procedure, the urethra can be flushed with the catheter
is performed. The surgeon should be alerted to the possibility of to ensure that all stones are retrieved. A flexible endoscope can
trapping of omentum or abdominal contents between the gastric also be used to inspect and/or retrieve urethral calculi.
and abdominal wall so careful identification and palpation should
be performed prior to placing the percutaneous sutures. One of several methods may be used for stone retrieval, depending
on the size and number of cystoliths present. The wire stone basket
is efficient for removal of large numbers of small calculi that stick
Laparoscopic-assisted Cystoscopy together with blood clot. The basket is passed through the working
Indications channel of the cystoscope and, under direct vision, passed past the
This procedure is performed when the surgeon desires to minimize calculi and opened. As the basket is closed, the stones are brought
the approach to bladder biopsy (Figure 7-9A-E) or management of to the end of the cystoscope and the cystoscope is removed from
urinary calculi that are too large or too numerous for other less the bladder to deliver the stones. If calculi are too large for the
invasive treatment modalities.11 Most often, the procedure is stone basket, they can be retrieved with forceps inserted beside
performed in male dogs because stones are more easily retrieved the cystoscope. Numerous small calculi can be removed by using
from the urethra in female dogs. The benefit of this procedure is a suction device in the bladder and flushing the urethral catheter.
that the incisions are very small and there is less likelihood of urine At the end of the procedure, the urethral catheter is withdrawn and
contamination of the abdomen. Preoperative patient management the cystoscope is positioned in the trigone region of the bladder.
practices and preparation are similar to open cystotomy. The urethral catheter is simultaneously flushed and passed, and
any remaining stones are seen as they are flushed back into the
bladder. Bladder polyps or biopsy can be performed with either
cystoscopic technique using a biopsy forceps or externally, if full-
thickness resection is needed.
88 Soft Tissue
Figure 7-9. Laparoscopic Assisted Cystotomy. A. Visual inspection of the urinary bladder revealed scarring on the surface in this case of transi-
tional cell carcinoma. B. Cystoscopyrevealed an irregular mucosal surface in the region of the trigone. C. Babcock forceps are being used to el-
evate the bladder to the abdominal wall. D. External view of the cystotomy showing bulging of the tissue from inside the bladder. E. Laparoscopic
view of the bladder closure with simple interrupted sutures.
Minimally Invasive Surgery 89
The cystotomy is then closed and the bladder is returned to the The minimal invasiveness of the procedure, the rapid patient
abdominal cavity. The caudal incision is closed, the laparoscope recovery, and diagnostic accuracy make thoracoscopy an
is re-attached to the camera and light guide cable, and the ideal technique for selected cases over more invasive proce-
abdomen is re-insufflated. Following final inspection, the camera dures. Small animal thoracoscopy has not only developed into
port is removed, the CO2 is allowed to escape and the port site a diagnostic tool but more recently has progressed to become a
is closed routinely. Although always a concern, seeding of the means for performing minimally invasive surgical procedures.1-4
abdominal wall with tumor cells following biopsy of transitional
cell carcinoma has not occurred. Despite the advent of newer laboratory tests, imaging techniques
and ultrasound directed fine needle biopsy or aspiration, thora-
coscopy remains a valuable tool when appropriately applied
References in a diagnostic plan. Thoracoscopy may also provide accurate
1. Culp WT, Mayhew PD, Brown DC. The effect of laparoscopic versus and definitive diagnostic and staging information that would
open ovariectomy on postsurgical activity in small dogs. Vet Surg 2009; otherwise only be obtained through a surgical thoracotomy.5-6
38:811-817.
2. Nadeau O, Kampmeier O. Endoscopy of the abdomen: abdom-
inoscopy: a preliminary study, including a summary of the literature and Indications and Contraindications
a description of the technique. Surg Gynecol Obstet 1925; 41:259-271. The most common indication for thoracoscopy is to examine
3. Bailey JE, Pablo LS. Anesthetic and physiologic considerations for and biopsy thoracic organs or masses. Thoracoscopy is also a
veterinary endosurgery. In Freeman LJ (ed). Veterinary Endosurgery. St. means of performing various surgical procedures. Thoracoscopy
Louis: Mosby, 1999. may not completely replace an exploratory thoracotomy but can
4. Stoloff DR. Laparoscoic suturing and knot tying techniques. In Freeman provide a minimally invasive means of accomplishing a number
LJ (ed). Veterinary Endosurgery. St. Louis: Mosby, 1999. of diagnostic and surgical procedures in small animals.
5. Freeman L, Rawlings CA, Stoloff DR. Endoscopic knot tying and
suturing. In Tams TR and Rawlings CA (eds), Small Animal Endoscopy, 3rd Diagnostic thoracoscopy is commonly used as a method for
edition. St. Louis: Elsevier-Mosby, 2011. obtaining pleural biopsy, lung biopsy, cranial mediastinal and
6. Freeman LJ. Laparoscopic liver biopsy. Clinician’s Brief, May 2010. lymph node biopsy. Common surgical techniques currently being
7. Hancock RB, Lanz OI, Waldron DR, et al. Comparison of postop- performed in small animals include partial pericardectomy or
erative pain after ovariohysterectomy by harmonic-scalpel-assisted pericardial window, patent ductus arteriosus, lung lobectomy,
laparoscopy compared with median celiotomy and ligation in dogs. Vet resection of cranial mediastinal mass, correction of vascular
Surg 2005; 34:273-282. ring anomalies, thoracic duct ligation, and debridement for the
8. Rawlings CA, Foutz TL, Mahaffey MB, Howerth EW, Bement S, Canalis treatment of pyothorax. The advantages of surgical thoracoscopy
C. A rapid and strong laparoscopic-assisted gastropexy in dogs. Am J Vet over conventional open surgical exploratory thoracotomy include
Res 2001; 62:871-875. improved patient recovery because of smaller surgical sites,
9. Mayhew PD, Brown DC. Prospective evaluation of two intracorporeally lower postoperative morbidity with lower infection rates and
sutured prophylactic laparoscopic gastropexy techniques compared decreased postoperative pain.
with laparoscopic-assisted gastropexy in dogs. Vet Surg 2009; 38:738-746.
10. Dujowich M, Reimer SB. Evaluation of an endoscopically assisted
gastropexy technique in dogs. Am J Vet Res 2008; 69:537-541. Thoracoscopic Equipment
11. Rawlings CA, Mahaffey MB, Barsanti JA, Canalis C. Use of laparo- The basic equipment required for diagnostic thoracoscopy
scopic-assisted cystoscopy for removal of urinary calculi in dogs. J Am includes a telescope, corresponding trocar–cannula units,
Vet Med Assoc 2003; 222:759-761. light source, and various forceps and ancillary instruments.7-9
12. Devitt CM, Cox RE, Hailey JJ. Duration, complications, stress, and pain The telescope most commonly used by the author is a 5 mm
of open ovariohysterectomy versus a simple method of laparoscopic- diameter 0° field of view telescope for routine diagnostic thora-
assisted ovariohysterectomy in dogs. J Am Vet Med Assoc. 2005 Sep coscopy. The 0° designation means that the telescope views
15;227(6):921-7. the visual field directly in front of the telescope. Angled viewing
scopes, the most common being a 30° telescope, views in a 30°
Thoracoscopy downward direction. The angled telescopes enable the operator
to look over the top of organs and view in small areas which
Eric Monnet is very useful during thoracoscopy to look at hilar lymph nodes,
around the base of the heart, the hilus of lungs during lobectomy,
and the mediastinum.
Introduction
Thoracoscopy is a minimally invasive technique for viewing the The telescope is attached to a light source using a light guided
internal structures of the thoracic cavity. The procedure uses a cable. A Xenon light source with a high intensity is considered
rigid telescope placed through a portal positioned in the thoracic to give the truest colors of abdominal organs and is recom-
wall in order to examine the contents of the pleural cavity. Once mended. A high intensity light source provides enough light
the telescope is in place, either biopsy forceps or an assortment for deep chested dogs. The telescope is also attached to an
of surgical instruments can be introduced into the thoracic endoscopic video camera which allows the image to be viewed
cavity through adjacent portals in the thorax to perform various on a monitor.
diagnostic or surgical procedures.
90 Soft Tissue
Open or closed cannulas can be used to perform thoracoscopy. cardiac output but maintains open alveoli in the dependent
With closed cannulas, a controlled pneumothorax can be ventilated lung. One-lung ventilation is mostly used with an inter-
induced and a ventilator is not required. With open cannulas, costal approach when a lung lobectomy is performed. Different
a ventilator is required because the pleural space is open to techniques have been described to achieve one-lung venti-
the environment. Open cannulas are recommended to perform lation in dogs. Selective bronchial intubation with a long small
thoracoscopy because they eliminate the risk of tension diameter endotracheal tube can be used.12 This technique works
pneumothorax especially when advanced surgical procedures most effectively for selective ventilation of the left lung. Since the
are performed. The open cannulas can be either soft or hard. bronchus of the right cranial lung lobe is so cranial, it is difficult
Soft cannulas are less traumatic to the intercostal artery and to perform selective intubation of the right lung. A double-lumen
nerve, and can be cut to a desired length therefore they do not endotracheal tube can be used to intubate the left and right lung
protrude excessively into the thoracic cavity. Rigid cannulas lobes. This approach allows one branch of the tube to be occluded
are required for a transdiaphragmatic sub-xiphoid approach. so that the other lung can be selectively ventilated. Again,
Rigid cannulas protect the telescope better when an inter- because of bronchial anatomy this technique is not very efficient
costal approach is performed. Ribs are very rigid and it is easy in dogs. Introduction of an endobronchial occluder is commonly
to bend or even break a scope if there is no cannula to move used in dogs to induce one-lung ventilation.10,11,13 The occluder
the ribs with. Closed or open cannulas are placed over a blunt is advanced either through or along the endotracheal tube and
trocar into the thoracic cavity. Cannulas exist in a wide variety of is positioned under bronchoscopic guidance. After placement
diameters. Diameter of the cannulas is determined by the instru- of the occluder in the desired position, the balloon at the end of
ments that will be used during the procedure. For example, the the occluder is inflated to occlude the bronchi. It is important to
stapling equipment used for lung lobectomy comes in a 12 mm induce one-lung ventilation with this technique, after the dog has
diameter. Therefore, a 12 mm cannula will have to be placed been positioned for surgery. Manipulation of the patient can easily
for the introducation of the stapling equipment. Thoracoscopy dislodge the ballon and cause complete occlusion of the trachea.
can be performed without cannulas. However, this technique When one-lung ventilation is used it is critical that a capnograph
increases the risk of damaging the intercostal nerve and artery. is used to monitor carbon dioxide production and patency of the
This approach is reserved for small size animals since cannulas airway. Third, carbon dioxide insufflation can be used to collapse
take up excessive space in their thoracic cavity. the lung lobes.14 This technique creates a pneumothorax and the
amount of pressure in the pleural space will control the degree
During diagnostic thoracoscopy, a number of accessory instru- of the pneumothorax. This technique is not currently used in
ments are essential.6,8,9 A palpation probe is required to move veterinary medicine. It can induce severe atelectasis and severe
and palpate the thoracic organs. Most palpation probes have desaturation of oxygen in the arterial blood. This technique has
centimeter markings so one can estimate the relative size of been used to visualize specific areas of the pleural space.
organs or lesions. The palpation probe can also be used to apply
pressure on a biopsy site that is bleeding excessively. Biopsy Thoracoscopy can be performed using either a trans-diaphrag-
forceps are used for biopsy of lymph nodes, and pleura. matic or an intercostal approach.7,12,15 The trans-diaphragmatic
approach allows visualization of both hemi-thoraces. A long
Surgical thoracoscopy often requires a vast array of instruments axis view of the thorax is then obtained. This is the approach of
designed for specific indications. Common instruments include choice for exploration of the thoracic cavity and biopsy. An inter-
grasping forceps, scissors, aspiration tubes and clip applicators. costal approach is indicated for surgical thoracoscopy because
Certain specialized instruments such as stapling devices are it allows very good visualization of specific structures in the
generally 10 to 12 mm in diameter. Many of the surgical instru- affected hemithorax.
ments also have capabilities for monopolar electrosurgery
at their distal tip. Retractors are very important during thora- Transdiaphragmatic Sub-xiphoid Approach
coscopy because they allow retraction of lungs. With retractors,
lung lobes can be removed without using one-lung ventilation. The patient is positioned in a dorsal recumbent position. First,
a screw-in cannula is inserted from a sub-xiphoid position in
a cranial direction. Before insertion of the screw in cannula,
Approaches a small skin incision is performed caudal to the xiphoid. The
Since ribs are supporting the thoracic wall, the chest wall cannot cannula is screwed into the thoracic cavity under thoracoscopic
be distended to create a working space. Different options are visualization. After penetration of the thoracic cavity by the
available to increase working space. First, lung tidal volume cannula, the thoracoscope is advanced into the thoracic cavity.
can be decreased on the ventilator and the frequency of venti- After intial exploration of the thoracic cavity, two other cannulas
lation increased. This will reduce the volume of the lungs without are placed under thoracoscopic visualization to allow utilization
reducing ventilation. This will expand the surgical field enough to of instruments. These cannulas are placed in intercostal spaces
be able to perform diagnostic thoracoscopy. Second, one-lung according to the location of the lesions, which require exploration
ventilation can be instituted to completely collapse the lung on or treatment. Cannulas need to be placed as ventral as possible
one side of the thoracic cavity.10,11 One-lung ventilation induces a to allow maximum mobility of the instruments. Metzenbaum
right to left shunt that results in desaturation of oxygen in arterial scissors with electrocautery and grasping forceps are used to
blood. To further assist patient ventilation, it is recommended to incise the mediastinum. This will allow exploration of both hemi-
use positive end expiratory pressure since it does not reduce thoraces. A 0° telescope is used for initial exploration.
Minimally Invasive Surgery 91
Approach
Surigical Technique To perform minimally invasive PRAA correction the patient
For caudal lung lobes, the pulmonary ligament is incised to free is placed in right lateral recumbency, the telescope portal is
the lung lobe from the diaphragm for manipulation into position placed in the left 4th or 5th intercostal space at the costochodral
for placement of the endoscopic stapling device. Individual junction, and operative portals are placed in the 3rd and 6th or
structures of the hilus are not isolated for minimally invasive 7th intercostal space at the level of the costochondral junction
lung lobectomy and are separated from surrounding structures and at the dorsal end of the 5th intercostal space.
Minimally Invasive Surgery 93
Surgical Technique 8. Freeman LJ. Veterinary Endosurgery. 1st ed. St. Louis: Mosby 1999.
A retractor is placed in the 6th or 7th intercostal portal to 9. McCarthy TC. Veterinary endoscopy. 2005:606.
retract the cranial lung lobe caudally. A stomach tube is placed 10. Kudnig ST, Monnet E, Riquelme M, et al. Cardiopulmonary effect of
in the esophagus to improve visulazation of the ligamentum thoracoscopy in anesthetized normal dogs. Vet Anest Analg 2004;31:121-
arteriosum. A palpation probe is used to further localize the 128.
ligamentum arteriosum. The ligamentum arteriosum is dissected 11. Kudnig ST, Monnet E, Riquelme M, et al. Effect of one-lung venti-
with sharp and blunt dissection to isolate it from the pleura and lation on oxygen delivery in anesthetized dogs with and open thoracic
cavity. Am J Vet Res 2003;64:443-448.
esophagus. Endoscopic 5mm vascular clips are placed on the
isolated ligamentum arteriosum and it is transected between the 12. Potter L, Hendrickson DA. Therapeutic video assisted thoracic
surgery. 1998;169-191.
clips. An ultrasound dissector can be used to seal the edges of
the ductus arteriosus and transect it. Any remaining fibers are 13. Cantwell Sl, Duke T, Walsh PJ, et al. One-lung versus two-lung venti-
lation in the closed-chest anesthetized dog: A comparison of cardiopul-
dissected and divided and the esophagus is dilated by passage
monary parameters. Vet Surg 2000;29:365-373.
of a balloon dilation catheter or esophageal bougies. A chest
tube is placed and the portals are closed. Postoperative dietary 14. Daly CM, Swalec-Tobias K, Tobias AH, et al. Cardiopulmonary effects
of intrathoracic insufflation in dogs. J Am Anim Hosp Assoc 2002;38:515-
management is the same as for open surgical PRAA correction.
520.
15. McCarthy TC, Monnet E. Diagnostic and Operative Thoracoscopy
Mediastinal and Pleural Mass Excision in: McCarthy TC, ed. Veterinary Endoscopy. St. Louis: Elsvier Saunders,
Selected neoplastic, (thymoma) and inflammatory masses can 2005;229-278.
be removed effectively with minimally invasive technique.15 16. Dupré GP, Corlouer JP, Bouvy B. Thoracoscopic pericar-
Masses that are inoperable with minimally invasive technique diectomy performed without pulmonary exclusion in 9 dogs. Vet Surg
can be evaluated for open surgical excision or biopsied and 2001;30:21-27.
staged for appropriate non-surgical treatment. Patient position 17. Jackson J, Richter KP, Launer DP. Thoracoscopic partial pericardi-
and portal placement are defined by location of the mass. Cranial ectomy in 13 dogs. J Vet Intern Med 1999;13:529-533.
mediastinal masses are visualized most effectively in dorsal 18. Walsh PJ, Remedios AM, Ferguson JF, et al. Thoracoscopic versus
recumbency with a para-xiphoid telescope portal. Operative open partial pericardiectomy in dogs: comparison of postoperative pain
and morbidity. Vet Surg 1999;28:472-479.
portals can be placed with both portals on one side or with
bilateral portals. Intercostal space selection for the operative 19. Jackson J, Richter KP, Launer DP. Thoracoscopic partial pericar-
diectomy in 13 dogs. J Vet Intern Med 1999;13:529-533.
portals again depends on the location and size of the cranial
mediastinal mass. Portals are placed as ventrally in the appro- 20. Brissot HN, Dupré GP, Bouvy BM, et al. Thoracoscopic treatment of
priate intercostal spaces as possible without traumatizing the bullous emphysema in 3 dogs. Vet Surg 2003;32:524-529.
internal thoracic artery. Masses are dissected with sharp and 21. Enwiller TM, Radlinsky MG, Mason DE, et al. Popliteal and mesen-
blunt dissection as indicated with ligatures, vascular clip, and teric lymph node injection with methylene blue for coloration of the
thoracic duct in dogs. Vet Surg 2003;32:359-364.
electrosurgical assistance for hemostasis.
22. Isakow K, Fowler D, Walsh P. Video-assisted thoracoscopic division
of the ligamentum arteriosum in two dogs with persistent right aortic
Thoracoscopy is in its infancy in veterinary medicine and surgery.
arch. J Am Vet Med Assoc 2000;217:1333-1336.
The major advantage of thoracoscopy seems to be the reduced
morbidity and pain when compared to thoracotomy.
Small Animal Arthroscopy
References Kurt S. Schultz
1. Borenstein N, Behr L, Chetboul V, et al. Minimally invasive patent
ductus ateriosus occlusion in 5 dogs. Vet Surg 2004; 33:309-313. This topic is written based on the available literature through
2. MacPhail CM, Monnet E, Twedt DC. Thoracoscopic correction of 2010 and does not cover the most current literature on this topic.
persistent right aortic arch in a dog. J Am Anim Hosp Assoc 2001;37:577-
581.
3. Radlinsky MG, Mason DE, Biller DS, et al. Thoracoscopic visualization Introduction
and ligation of the thoracic duct in dogs. Vet Surge 2002;31:138-146. Arthroscopy is the technique of endoscopic examination of a
4. Dupré GP, Corlouer JP, Bouvy B. Thoracoscopic pericardiectomy joint. The use of arthroscopy is growing rapidly in small animal
performed without pulmonary exclusion in 9 dogs. Vet Surge orthopedic practice for several reasons. Arthroscopy is signifi-
2001;30:21-27. cantly less invasive than a traditional arthrotomy and both veter-
5. Kovak JR, Ludwig LL, Bergman PJ, et al. Use of thoacoscopy to inarians and pet owners are seeking to minimize pain associated
determine the etiology of pleural effusion in dogs and cats: 18 cases with surgical trauma. The excellent visualization provided by
(1998-2001). J Am Vet Med Assoc 2002;221:990-994. arthroscopy has led to the discovery of new joint diseases and for
6. McCarthy T. Diagnostic thoracoscopy. Clinical Techniques in Small certain diseases such as ligamentous instability of the shoulder
Animal Practice 1999;14:213-219. or medial compartmental disease of the elbow it may be the only
7. Remedios AM, Ferguson J. Minimally invasive surgery: Laparoscopy practical method of diagnosis. Arthroscopy provides increased
and thoracoscopy in small animals. Compend Cont Ed Pract Vet magnification and visualization of joint structures and this may
1996;18:1191-1199. be its greatest advantage over traditional surgical techniques.
94 Soft Tissue
Magnification has provided new understanding of the devel- Continuing education courses are available for training in small
opment of osteoarthritis in small animals. For example, it is now animal arthroscopy and veterinarians interested in becoming
known that osteoarthritis of the canine elbow affects the medial proficient are encouraged to gain experience in the teaching
compartment much more severely than the lateral compartment laboratory. Iatrogenic damage to the joint and the equipment
(medial compartment disease). Arthroscopy has also demon- is common during the learning process. Initially, performing an
strated that osteoarthritic lesions may occur in sites identical to arthroscopic procedure will require more time than traditional
that of osteochondritis dissecans (OCD) in the shoulder or stifle surgery but with increasing experience arthroscopic procedures
without diagnostic radiographic findings. Finally, arthroscopy become faster than open surgery. Arthroscopy seems likely to
has the ability to diagnose and grade osteoarthritis much earlier become the standard of care for many diagnostic and thera-
and with greater accuracy than radiography in virtually all joints peutic procedures involving the joints of companion animals.
(Table 7-1).
The camera head attaches to the arthroscope eyepiece. been advocated for soft tissue ablation and collagen shrinkage.
Cameras are digital and available as 1 or 3 chip and must be
used with a specific camera box that processes the image for
the video monitor. For general use, 1-chip cameras provide
Arthroscopy of the Shoulder
excellent resolution and recording capabilities and 3 chip Knowledge of diseases of the shoulder and their treatment has
cameras are only necessary for video or still image work that grown recently due to increased experience with shoulder ultra-
is to be published. Medical grade video monitors are recom- sound, arthroscopy, and MRI of the shoulder. The differential
mended to provide a bright, clear, and accurate image. Most diagnosis for shoulder diseases has been expanded, as have
new light sources use xenon lamps, which provide increased the potential methods of treatment. Arthroscopy of the canine
light intensity and higher color temperature than halogen and shoulder should be performed with a 2.7 mm arthroscope. A
therefore provide higher visual clarity and truer color. Xenon cranio-lateral or caudo-lateral arthroscope portal is generally
light sources are more expensive than halogen but are recom- used (Figure 7-10). Recently described portals include a medial
mended for superior image quality. portal using an in to out technique. Arthroscopy on the shoulder
requires less equipment than other joints but can be the most
Fluid flow during arthroscopy helps maintain joint distention, aids difficult to instrument for beginning arthroscopists. The shoulder
in clearing blood and other debris from the joint, and decreases is also the least forgiving when mistakes in technique lead to
the risk of joint contamination. Fluid may be delivered to the joint substantial fluid leakage. Regardless, complications associated
by gravity or from an arthroscopic pump. The use of lactated with arthroscopy of the shoulder are uncommon.
ringers solution as lavage fluid is preferred over saline as the
former is thought to be less destructive to articular cartilage. Thorough examination of the shoulder joint with the arthroscope
Fluid outflow is provided by either a disposable needle or a includes assessment of the cartilage of the humeral head and
specific outflow cannula. glenoid cavity, evaluation of the origin of the biceps tendon and
the remainder of the proximal tendon, evaluation of the subscap-
The majority of arthroscopic therapy is performed with hand ularis tendon, and evaluation of the medial glenohumeral
instrumentation. Both hand instruments and power tools are ligaments. Lesions of the cartilage of the shoulder joint include
inserted into the joint through an instrument portal that may OCD, focal or localized osteoarthritis, and generalized osteoar-
be used with or without a cannula. Hand instruments include thritis. OCD is the most commonly treated disease of the shoulder
probes, knives, curettes, and forceps. The most commonly joint. Arthroscopic treatment of OCD is usually rapid and highly
used probes are right angled and may have calibration marks successful. Although similar clinical results can be obtained
for measurement of lesions. Numerous styles of knives and
curettes are available for manipulations of soft tissue. The most
common forceps used in small animal arthroscopy are graspers
for removal of hard or soft tissues and biters for debridement of
soft tissues.
Figure 8-1. These microsurgical tying forceps are of standard length with miniaturized tips, rounded shanks; this instrument is contoured to fit in
the notch between the base of the thumb and the index figure and is counterbalanced.
This chapter describes instrumentation and suture materials Jeweler’s forceps are inexpensive and have a wide range of
that are most commonly used when performing veterinary styles and usefulness during microvascular surgery; however,
microsurgery. In addition, descriptions of free skin transfer, free they do not have round handles, are not counterbalanced,
muscle tissue transfer and their indications are presented. and are of short length. In contrast, microvascular forceps are
available in a variety of styles and designs but are considerably
more expensive than jeweler’s forceps. Microvascular DeBakey
Jeweler’s Forceps forceps, microring tipped forceps, and a variety of curved or
Jeweler’s forceps consist of two flat, narrow legs connected straight microforceps are available. These forceps are appro-
at the head that narrow to form the jaws of the instruments.1-3 priate in length, have round handles, and are counterbalanced.
The contact surface at the tips is referred to as the bit and the
distance between the jaws is approximately 8 mm. Jeweler’s
forceps are numbered according to the width of the bit and legs Needle Holders
and their overall shape. Five basic jeweler’s forceps are used Number 2 jeweler’s forceps are used as needle holders for their
in microvascular surgery: Nos, 2,3,4,5, and 7 (Figure 8-2A,B,C). simplicity, ease of knot tying, lack of concern about entrapment
The No. 2 forceps have the largest contact surface and are of the suture material in the lock mechanism, and low cost.
advocated for use as needle holders. The No. 3 forceps are used The major disadvantage of jeweler’s forceps is that the needle
for testing vessel patency. The Nos. 4 and 5 forceps are useful is not held securely and may slip at an inopportune moment.
for delicate tissue handling; the No. 4 forceps have a slightly Additionally these forceps do not have rounded handles, lack a
larger bit. The No. 7 forceps have the unique feature of having grooved head, and are not counterbalanced. Rounded shanks
curved tips, which are useful to access obstructed areas or to are particularly important in needle holders because passage
prepare small vessels for anastomosis (Figure 8-2C). of the microneedle through the vessel wall requires that the
instrument be rolled in the fingers.
Special care must be taken to avoid bending the tips of jeweler’s
forceps. The tips should be examined under a microscope before The three basic parts of the needle holder are the jaws, the
the beginning of a surgical procedure to assess the alignment of lock, and the shank. The jaws are usually flat and not grooved.
the tips because bent tips may catch on adventitia, tear vessel Generally, curved needle holders are used because they have
walls, and inhibit proper handling of the microneedle. The tips of less of a tendency to obstruct the surgeon’s view of the operating
some jeweler’s forceps are pointed or rough, leading to tissue field. Ratchetless needle holders are used exclusively in micro-
or vessel damage and inadvertent cutting of suture material. surgery because of the delicate nature of the microneedles.
For these reasons, it is recommended to gently file the tips of Additionally, the locking and unlocking of the ratchet causes
jeweler’s forceps with an emery board or Arkansas stone before motion in the tips that can damage the vessel.
their first use.
Scissors
Microvascular scissors are among the more expensive instru-
ments in the microvascular surgical pack. They should have
rounded shanks, be spring loaded, and have fine, delicate tips.
They are used for delicate dissection, for cutting suture, and for
trimming adventitia during vessel preparation.
Vessel Dilators
Vessel dilators are modified jeweler’s forceps with a narrower,
smoother, nontapering tip (Figure 8-3). The tips of this instrument
are inserted into the vessel lumen and are opened slightly to
dilate the vessel gently as part of vessel preparation. Dilators
may also be used as a counterpressor when suturing vessels.
They should be inspected under high magnification to ensure
alignment of the tips. The tips must be smooth and unbent to
prevent injury to the vascular intima when they are inserted into
the vessel lumen.
Figure 8-4A and B. Vessel clamps are precisely manufactured to
Microvascular Clamps provide adequate pressure to occlude blood flow without damaging
the vessel.
Microvascular clamps are used to occlude the vessel and prevent
intraoperative hemorrhage. These clamps must be atraumatic
The approximating clamp facilitates retraction and reapproxi-
yet have adequate closing pressure to prevent hemorrhage from
mation of vessels for suturing. The purpose of the approximator
the vessel. The blades should be flat to disperse the pressure
clamps is to decrease the amount of tension between two
evenly across the vessel, and they should have a rough surface
vessels being anastomosed, thereby allowing for atraumatic
to hold the vessel securely. Clamps should be easy to apply with
vascular anastomosis. An approximating clamp is composed
finger pressure or applicator forceps (Figure 8-4). Most clamps
of two microvascular clamps joined by a connecting bar. The
are small enough to fit in the operative field but large enough to
clamps may be movable along the connecting bar to allow for
be easily manipulated. Clamps are available in various sizes with
the distance between vessels to be adjusted (Figure 8-5) or fixed
varying closing pressure to accommodate variation in vessel
in position to the connecting bar, a position requiring that the
size. The closing pressure of the clamps should be less than 30
clamps be placed at the appropriate distance along the vessels
gm/mm to avoid endothelial damage. The surfaces of the clamps
because the interclamp distance cannot be adjusted. The entire
are usually dull, to minimize light reflection.
clamp should fit in the operating field, yet be large enough to be
easily maneuvered and turned over for suturing both sides of the
vessels. The Acland framed nonmovable approximator clamps
have two cleats on the frame that facilitate vessel anastomosis,
especially when a surgical assistant is not available (Figure 8-6).
Because they are expensive microvascular instruments, extreme
care should be taken when cleaning and storing microvascular
clamps and approximator clamps to prevent damaging them.
Irrigators
Irrigation of the wound is essential in microvascular surgery
to decrease the amount of desiccation caused by the intense
light source of the operating microscope. Irrigation is also used
to remove clots and to float the vessel edges apart. Standard
irrigation syringes are too bulky and flood the microsurgical
field. A simple irrigator can be made for microsurgery using a
10-ml syringe attached to a 20-gauge needle or catheter using
Figure 8-6A and B. Another vessel approximator clamp in which the either saline or heparinized saline. Irrigation is applied in a gentle
clamps do not move along the bar. With this type of clamp, the vessels stream. The catheter tip is not inserted into the vessel, to avoid
must be positioned precisely to allow the ends of the vessels to be damaging the vascular endothelium.
sutured because the distance between them cannot be adjusted.
The Bishop-Harmon anterior chamber irrigator is used exten-
Coagulators sively in ophthalmic surgery and is applicable to microvascular
Hemostasis is essential for creating a clear field for microvas- surgery. Many cannulas are available and the advantage of this
cular surgery. Because of the magnification required to perform system is that it is easier to operate and to control the flow of the
surgery, even small amounts of blood can obscure the operating fluid with the small bulb than with a syringe.
field making surgery virtually impossible. Unipolar coagulators
damage surrounding tissue because the current passes from the
cautery tip, through surrounding tissues, into the patient, and out
Background Material
to the ground plate. This dissipation of current and associated When performing microvascular surgery, a background is used
heat generation can damage the parent vessel of interest. Bipolar to set the vessels out from surrounding structures. Background
cautery has the advantage that both current and heat are only material is placed behind the structures of interest to improve
produced in the small space between the tips of the coagulating their visualization through the operating microscope. Various
forceps. This restricts the amount of tissue damage, yet it provides colors are advocated to maximize visualization of the structures
for accurate hemostasis. A thin layer of sterile petrolatum applied of interest. Use of dark colors, such as green or blue, enhances
to the tips of bipolar cautery forceps helps to prevent charred visualization of the artery and the vein, as well as the suture
tissue from adhering to the tips of the forceps. If bipolar coagu- material. Background materials are commercially available, but
lation is not available, jeweler’s forceps can serve as cautery a rectangular section of a balloon can be sterilized and used as
forceps. Although this application is monopolar, it is more precise an inexpensive background.
and minimizes the amount of lateral heat and damage to adjacent
tissues compared with the standard cautery pencil. Counterpressor
Counterpressors are used to avoid suturing the opposite wall of
The amount of cautery used in microsurgery should be kept to a
a vessel during a vessel anastomosis. When the surgeon passes
minimum, to avoid damage to vessels or other important struc-
the needle through the vessel wall, counterpressure must be
tures that may be in the vicinity of the operating field. For vessels
applied, or the wall is pushed away. The counterpressor provides
larger than 1.5 mm in diameter, hemostatic clips are effective
resistance for passing the microneedle. The instrument must be
in achieving hemostasis without damaging adjacent structures.
sturdy, small enough to fit in a vessel, and easily maneuverable.
Clips are used judiciously because too many hemostatic clips
The counterpressor has either a circular or a double-pronged
can interfere with the surgical procedure.
tip, so the microneedle can be passed through the circle or
between the tips. A counterpressor can be constructed by
Suction twisting 34-gauge wire onto itself, creating a tiny loop at the end.
Vacuum suction is an optional tool in microvascular surgery. If The free end is connected to a disposable tuberculin syringe or
mechanical suction is used, care must be taken to avoid contact a metal bar to serve as a handle.
with vessels or nerves. Endothelial damage from suction can
lead to complete thrombosis of the vessel and surgical failure. Maintenance of Instruments
Standard suction tips are generally too large for microsurgical
Microvascular instruments are delicate and easily damaged.
application. A 20-gauge catheter may be connected to appropri-
Extreme care is exercised when cleaning and storing instru-
ately sized Silastic tubing and connected to the suction unit to
ments. After use, instruments are soaked in warm water
create a fine tipped suction device. A small fenestration created
containing a commercially available enzymatic cleaner, rinsed
in the Silastic tubing allows the surgeon some control over the
in distilled water, and air dried. Ultrasonic instrument cleaners
strength of the vacuum. The surgeons’ finger is placed over the
offer the best way of cleaning microinstruments. Care should
hole to occlude the fenestration partially or completely, thereby
be taken when instruments are dried with a cloth, because
adjusting the amount of suction at the catheter tip. This control
Microvascular Surgical Instrumentation and Application 101
Vessel Preparation
Vessel preparation is one of the most critical steps in performing
a microvascular anastomosis. Vessel preparation includes
proper alignment of the vessel in the approximator clamp, vessel
irrigation, trimming the adventitia from the end of the vessel, and
vessel dilation. The ends of the vessels must be properly oriented
in the approximator clamp to ensure that the vessels are not
twisted following completion of the anastomosis (Figure 8-7).
Blood should be flushed from the vessel lumen flushed, using Figure 8-8. Irrigation of vessel ends to remove intraluminal blood.
102 Soft Tissue
Figure 8-13. End-to-side anastomosis. A. The adventitia is removed from the vessel. B. A stay suture is placed in the wall of the vessel, and the
arteriotomy is performed. C. The diameter of the arteriotomy site should approximate the diameter of the “end” vessel. D. The first two sutures are
placed 180° apart to position the vessels for the anastomosis. E. The sutures are placed perpendicular to the anastomotic line in a radiating fashion.
damage on thick-walled arteries. Because of the increased risk patency and reduces the chance of thrombosis (Figure 8-14). A
of technical errors associated with performing a suture micro- second major advantage to using a coupling device is shortened
vascular venous anastomosis a coupling device is routinely used overall procedure time which decreases the overall ischemia
and recommended when performing the venous anastomosis. time of tissue when compared to hand suturing.13-15 Anastomotic
Some familiarity with the device is necessary for success, but the couplers come in sizes of 1.0 mm, 1.5 mm, 2.0 mm, 2.5 mm, and 3.0
technique can be quickly learned. The coupling device consists mm diameter.
of a pair of polyethylene rings with six small pins on one side of
each ring. The anastomosis is performed by pulling the end of the
vessel through the ring and impaling the wall of the vessel over the
Free Skin Flaps
six pins. The other end of the vessel is also impaled on the pins of Microvascular free skin flaps can be used to reconstruct wounds
the second ring, and the two rings are precisely joined together in almost any location on the body. Some of the described axial
with an anastomotic instrument. This device provides a secure pattern skin flaps can be used for this purpose.16 The requirements
anastomosis with intima-to-intima contact which in turn improves for an axial pattern tissue flap to be used as a free flap include a
Microvascular Surgical Instrumentation and Application 105
Figure 8-14. Anastomotic coupling devices can be used to anastomose vessels instead of hand suturing. A-C. The vessel is drawn through the
lumen of the anastomotic ring device, and the vessel wall is implanted on alternate pins of the ring. D and E. The ends of the vessels are approxi-
mated by precisely mating the anastomotic rings together with the anastomotic instrument.
1 mm pedicle vessel diameter and a 2 to 4 cm vascular pedicle on the surface of the skin either mapping of the vasculature with
length. Generally, the longer the vascular pedicle, the easier it is Doppler or the use of deep anatomic landmarks are used to define
to perform the vascular anastomosis. As a result, the omocervical, the angiosome of a skin flap. One precautionary note is that the
thoracodorsal, deep circumflex iliac, caudal superficial epigastric, skin of dogs and cats is loose over the torso and may shift during
and the medial saphenous fasciocutaneous flaps could be used in positioning of the patient on the operating table; this will shift
free tissue transfer. The skin flaps that are most commonly used the angiosome relative to deep anatomical landmarks. In order
for this purpose are the medial saphenous fasciocutaneous and to correct for this problem, the skin should be grasped, pulled
omocervical cutaneous free flaps.5-7,17-21 upward, and then allowed to relax back in position. This should
reposition the skin relative to deep anatomical landmarks.
Blood Supply Patterns
The skin has two sources of blood supply. In dogs and cats the
predominant blood supply is from direct cutaneous arteries.
These arteries typically perfuse a very large section of skin. Over
the torso they exit the body wall and lie in the well-developed
panniculus carnosus muscle known as the cutaneous trunci
muscle. In other areas of the body where the panniculus is
absent (extremities), the cutaneous arteries run in the subcuta-
neous fascial layer.22
Blood Supply
The blood supply of the omocervical free skin flap arises from
the cutaneous branch of the superficial cervical artery and vein.
These vessels penetrate the fascia between the omotransver-
sarius and the cervical portion of the trapezius muscles. The
superficial cervical artery and vein have 7 named branches, most
of which supply the adjacent muscles. The prescapular lymph
nodes are intimately associated with the vessels as they traverse
medial to the aforementioned muscles. This is in the region of the
cranial shoulder depression, which is easily palpated cranial to
Figure 8-17. Lateral view of left shoulder depicting the location of the
the scapula. In a large breed dog, the vascular pedicle of the flap is omocervical free flap. Abbreviation key: CT=cervical part of trapezius
about 5 cm long and the diameters of the artery and vein are about muscle; TT= thoracic part of trapezius muscle; SD=spinous head of
1.5 mm and 4 to 5 mm, respectively. The vein is very thin walled deltoid muscle; OT=omotransversarius muscle; BC=brachiocephalicus
which can make it more challenging to work with during microvas- muscle; AD=acromial head of deltoid muscle.
cular anastomosis to a recipient vein. One should be aware that
the vascular pedicle does not always course under the omotrans- the underlying fat should be elevated with the skin. After the
versarius, but may travel superficial to it (Figure 8-16). This variant skin has been incised around the entire circumference of the
was reported in 1 dog and described in another 2 dogs.17 proposed flap, the caudal border of the flap is dissected until
the intermuscular septum between the cervical portion of the
trapezius and the omocervical muscle is identified. The dissection
Anatomic Boundaries then continues along the dorsal border in a ventral direction.
The cutaneous anatomical boundaries of the angiosome of the
superficial cervical artery include the wing of the atlas cranially, The fascia between the cranial border of the cervical part of
dorsal midline, spine of the scapula caudally, and the acromion of the trapezius and omotransversarius is incised to the level of
the scapula ventrally. The axis of the cutaneous vessels is oriented the acromion, which exposes the superficial cervical artery and
in a caudoventral to craniodorsal direction, therefore the outline vein. The cutaneous branches are visualized and the remaining
of the flap should be oriented in this direction (Figure 8-17). portion of the skin flap is dissected free from the muscles. The
muscular branches of the superficial cervical vessels are ligated
Procedure and divided. The fat surrounding the vessels is carefully removed
(skeletonized) in order to decrease pedicle bulk of the pedicle.
The cervical region in some dogs can be laden with fat. This
makes the dissection of this flap very difficult. In order to prevent
Careful removal of adventitia at the proposed site of vein
damage to the vascular supply during the dissection of the flap,
transection when it is distended with blood can make this
Microvascular Surgical Instrumentation and Application 107
process more easily performed, than after the vessel has been There are two cutaneous perforators that perfuse the medial
transected and deflated. After the vessels have been isolated as saphenous fasciocutaneous flap: a cranial branch and a caudal
far down the pedicle as possible, they are occluded with micro- branch (Figure 8-19). Cadavaric studies have confirmed that the
vascular clamps, ligated distal to the clamps, and transected. skin on the entire medial aspect of the femorotibial region from
the level of the inguinal ligament to the distal tibia is perfused
The wound is closed in layers in order to minimize dead space. by segmental fascial perforators of the saphenous artery.
It is advisable to place a closed suction drain in the wound for 3 Two muscular branches are found proximal to the cutaneous
to 5 days, as seroma formation is a common complication in this branches: one to the distal gracilis muscle and the other to the
highly mobile region. The recipient site is protected with a soft distal sartorius muscle. The distal 1/2 of the caudal head of the
padded bandage. The bandage is changed daily as abundant sartorius is consistently perfused by the saphenous artery. The
serosanquinous discharge is expected. gracilis muscle is not well perfused by the saphenous vessels,
as its dominant blood supply is based on the proximal caudal
The flap is transferred to the recipient wound. Care is taken to femoral artery and vein.
ensure that the vascular pedicle is not twisted. The skin flap
is then tacked in place with a few sutures in order to ensure
proper orientation of the hair (if possible) and vascular pedicle.
Microvascular anastomosis of the artery and vein of the flap to
recipient vessels is performed.
Flap Designs Figure 8-19. Medial view of right thigh. Take note of the two cutaneous
• Simple skin flap perforators that perfuse the medial saphenous fasciocutaneous free
• Myocutaneous - skin flap and the distal half of the caudal head flap. Abbreviation key: Cr=cutaneous perforator of the medial saphen-
of the sartorius ous flap; Ca=caudal perforator of the medial saphenous flap; S=cranial
• Osteomyocutaneous - skin flap and distal half of the caudal head of sartorius muscle; CS=caudal head of sartorius muscle;
head of sartorius and medial tibial cortex P=pectineus muscle; G=gracilis muscle.
• Osteocutaneous - skin flap and medial tibial cortex
Anatomic Boundaries
Blood Supply The medial saphenous fasciocutaneous free flap generally is
The blood supply to this flap comes from the saphenous artery and based on the proximal two cutaneous branches. If a smaller
medial saphenous vein (Figure 8-18). Proximally, these vessels flap is needed, it can be based on either the cranial or caudal
lie under the caudal aspect of the caudal head of the sartorius, cutaneous branch. The most proximal cutaneous branch
then enter the superficial fascia at the level of the distal femur. supplies the caudal half of the flap and the second cutaneous
branch supplies the cranial half of the flap. There may be some
variation of the location where the first two cutaneous branches
originate off the medial saphenous vessels, thus care must be
taken when elevating the flap. The flap generally is centered
over the thigh region with the proximal most aspect of the flap
being at the junction of the thigh and abdomen. The flap should
not be centered over the stifle as this may increase the risk for
incisional dehiscence.
Procedure
The proximal, cranial and caudal borders of the flap are incised
and the flap is elevated. A transillumination technique is used to
identify the cutaneous perforators of the flap. The distal border
of the flap should be incised last, as the cutaneous vessels
may extend off the parent vessels in a more distal location than
Figure 8-18. Medial view of vessels of the right hindlimb. Take note expected. Next, the saphenous artery and medial saphenous
of the two muscular branches that penetrate the caudal head of the vein distal to the cutaneous perforators are isolated, ligated and
sartorius and one branch that enters the cranial aspect of the gracilis. divided. The saphenous vessels are dissected from their fascial
108 Soft Tissue
attachments between the gracilis and the sartorius muscles. A number of precautions should be taken in order to decrease
The gracilis muscular branch of the saphenous vessels is ligated the risk of donor site wound dehiscence:
and divided. Two muscular branches of the saphenous vessels • The maximum width of the flap should not be greater then 6 cm
entering the caudal head of the sartorius muscle are ligated and in a large breed dog; if the flap needs to be wider, harvest
divided. The pedicle is then completely isolated to the level of a much longer flap as the length of the flap will translate into
the femoral vessels. greater flap width.
• Attempt to keep the location of the flap as proximal as
The vessels are ligated at the level of the femoral vessels, possible.
occluded with microvascular clamps just distal to this region, • Flex and extend the stifle to determine the isometric points
and sharply divided. The medial saphenous nerve, which is of tension and temporarily appose the skin edges with towel
sacrificed at the time of the vessel dissection, is injected with clamps at the time of wound closure.
bupivacaine (Figure 8-20). The donor site is closed in two layers: • Close the fascia that is attached to the underlying skin edges
subcutaneous fascia and the skin. A drain is usually not placed with a simple interrupted pattern and close the skin with an
in the donor site. interrupted intradermal pattern.
• Protect donor site with a modified Robert-Jones bandage for
10 days after surgery.
The advantage of using a muscle flap over a free skin flap is that superficial cervical artery and vein enter the omotransversarius,
the angiosome is contained within the specific muscle; therefore deltoid, supraspinatus and brachiocephalicus muscles and need
there is no “guess work” as to the location of the blood supply. to be ligated and divided during the dissection. The pedicle has a
If the skin is shifted or skewed off important deep landmarks, the relatively thick cuff of fat that can be safely removed in order to
flap may not be within the primary angiosome. skeletonize the vascular pedicles.
Trapezius Free Muscle Flap23,24 Figure 8-21. Lateral view of the left shoulder region. The dashed line in-
Uses dicates the initial incision that is made between the omotransversarius
and the cervical part of the trapezius. Abbreviation key: CT=cervical
The cervical portion of the trapezius can be used for recon- part of trapezius muscle; TT= thoracic part of trapezius muscle;
struction of distal extremity and facial wounds. It is a fairly SD=spinous head of deltoid muscle; OT=omotransversarius muscle;
sizeable muscle flap and can therefore be used to reconstruct BC=brachiocephalicus muscle; AD=acromial head of deltoid muscle.
moderately large wounds. The muscle may be harvested with
the omocervical skin flap to form a myocutaneous flap. This
composite myocutaneous flap, however, tends to be very bulky
when used for reconstruction of distal extremity wounds.
Blood Supply
The cervical portion of the trapezius muscle is a relatively thin
and broad muscle with the superficial cervical artery and vein
serving as the dominant pedicle. This muscle is useful for recon-
struction of distal extremity and facial wounds.
point the fat and prescapular lymph nodes can be removed from of the muscle, a free rectus muscle flap should be based on this
the pedicle using very gentle dissection and ligation of any side set of vessels.
branches. The attachment of the trapezius muscle to the dorsal
spinous processes and the spine of the scapula are incised. The The caudal epigastric artery and vein enter the caudolateral
trapezius muscle is flipped over which will expose the blood aspect of the rectus abdominis muscle near the inguinal ring. The
supply from the superficial cervical artery and vein (Figure 8-23). pedicle is about 2 to 3 cm long, and the artery and vein diameters
are 1 mm and 2.5 mm, respectively; by harvesting the pudendal
A prominent dorsal venous extension from the superficial vein, artery and vein, the diameters of the vessels are greatly increased.
beyond the branch that enters the trapezius, is ligated and
divided. At this point the entire trapezius should be completely Surgical Procedure
free other than being attached to its vascular pedicle.
A ventral midline skin incision is made from the xiphoid process
to the cranial border of the pubis. In male dogs a parapreputial
incision is made. The initial skin incision is deepened to the level
of the linea alba. Subcutaneous tissues are then dissected off
the superficial rectus sheath.
Figure 8-23. Lateral view of the left shoulder region. Following detach-
The caudal epigastric artery and vein are ligated just proximal to
ment of the origin and insertion of the muscle, the flap is flipped over to the caudal superficial epigastric vessels and divided. The super-
expose the blood supply entering the flap. ficial rectus sheath is closed with 0 PDS in a simple continuous
suture pattern. Subcutaneous tissues and skin are closed
routinely.
Rectus Abdominis Free Muscle Flap25,26
Uses Table 8-2 summarizes important characteristics of the trapezius
The rectus abdominis muscle is very useful for distal extremity, and the rectus abdominis muscle flaps.
facial, and intraoral reconstruction. Because the flap is long, it
can be revascularized to recipient vessels that are distant to the
primary wound bed.
References
1. Daniel RK, Terzis, J.K.: Reconstructive microsurgery Boston: Little,
Brown, 1977.
Blood Supply 2. Zhong-wei C, Dong-yue, Y., De-sheng, C.: Microsurgery. New York,
Shanghai Scientific and Technical Publisher, 1982.
The rectus abdominis muscle is thin and flat and extends from
3. Acland RD: Practice manual for microvascular surgery (ed 2). St.
the first rib to the brim of the pelvis. The abdominal portion of Louis, CV Mosby, 1989.
the rectus abdominis can be used as a free flap. The muscle has
4. Urbaniak JR, Soucacos PN, Adelaar RS, et al: Experimental evalu-
multiple tendinous intersections located along its length. The ation of microsurgical techniques in small artery anastomoses. Orthop
rectus muscle has a type 3 blood supply. The blood supply to the Clin North Am 8:249-263, 1977.
rectus abdominis is from three sources: the cranial epigastric, 5. Degner DA, Walshaw R: Medial saphenous fasciocutaneous and
caudal epigastric, and segmental lateral perforator arteries and myocutaneous free flap transfer in eight dogs. Vet Surg 26:20-25, 1997.
veins. The caudal epigastric vessels join the caudal superficial 6. Degner DA, Walshaw R, Lanz O, et al: The medial saphenous fascio-
epigastric vessels from the mammary chain to form the puden- cutaneous free flap in dogs. Vet Surg 25:105-113, 1996.
doepigastric vessels. In some dogs the pudendoepigastric 7. Fowler JD, Degner DA, Walshaw R, et al: Microvascular free tissue
vessels are absent, leaving the caudal superficial epigastric and transfer: results in 57 consecutive cases. Vet Surg 27:406-412, 1998.
the caudal epigastric vessels to originate directly from the deep 8. Blair WF, Pedersen DR, Joos K, et al: Interrupted and continuous
femoral artery and the external iliac vein. microarteriorrhaphy techniques: a hemodynamic comparison. J Orthop
Res 2:419-424, 1984.
The caudal two-thirds of the abdominal part of the muscle is 9. Chen YX, Chen LE, Seaber AV, et al: Comparison of continuous and
perfused by the caudal epigastric artery and vein. The primary interrupted suture techniques in microvascular anastomosis. J Hand
angiosome based on the caudal vascular pedicle extends Surg [Am] 26:530-539, 2001.
approximately to the third tendinous intersection. Based on the 10. Cordeiro PG, Santamaria E: Experience with the continuous suture
fact that the caudal pedicle is perfusing a much larger portion microvascular anastomosis in 200 consecutive free flaps. Ann Plast
Surg 40:1-6, 1998.
Microvascular Surgical Instrumentation and Application 111
Vocalization 0 No vocalization
1 Vocalization that responds to a calm voice
2 Vocalization that does not respond to a calm
voice
animals for pain should occur frequently, at regular intervals, and chronic pain. Analgesia, anti-inflammatory, and antipyretic
be documented in the medical record. Especially important times effects are brought about by inhibition of the cyclooxygenase
for assessment are if there is onset of new pain, when previously (COX) enzymes resulting in a decrease in the release of
identified pain changes in frequency or pattern, or when there has prostanoids and prostaglandin.16 It is known that NSAIDs act
been a major therapeutic intervention. Changes in the analgesic at the tissue injury site and there is evidence that NSAIDs also
plan should be made in response to these assessments. produce analgesia at the level of the central nervous system.17
NSAIDs are well absorbed after oral administration, or when
given parenterally.18 Most are metabolized in the liver and the
The Analgesic Plan metabolites are then excreted in the urine and feces.19 NSAIDs
Proactive planning and design of analgesic protocols should be are effective, relatively inexpensive, and long lasting analgesics,
performed for all small animals undergoing surgery. These plans however side effects may occur. Gastrointestinal irritation
should be individualized and should consider such factors as ranging from mild gastritis and vomiting to intestinal ulceration,
the type of surgery or procedure to be performed, the expected hemorrhage and death have been reported.20 Nephrotoxicity can
severity of pain, any underlying medical conditions, the risk/ also occur after NSAID administration due to decreases in renal
benefit ratio of available analgesic techniques, and any previous blood flow.21 Hepatotoxicity has been reported (with Labrador
clinical experiences with the animal. After considering these Retrievers over represented) and is generally believed to be
factors, a complete history should be gathered from the owner and idiosyncratic.22 Serious complications have been associated
a plan including preoperative, intraoperative, and postoperative with the use in dogs of NSAIDs intended for humans. NSAIDs
analgesics should be constructed. Once the plan is enacted, the should not be used in animals with existing renal or hepatic
animal’s pain level and behavior should be assessed frequently insufficiency, gastric ulceration, dehydration, hypotension,
and refinements in the treatment protocol should be made. shock, or coagulopathies. Additionally, NSAIDs should not be
administered concurrently with other nephrotoxic drugs, corti-
Preemptive and Multimodal Plans costeroids, or other NSAIDs. Careful monitoring for gastrointes-
Preemptive analgesia refers to the practice of administering tinal, renal, or hepatic toxicity is required when using NSAIDs,
analgesics to a patient before a painful stimulus occurs such especially in animal’s at high risk. Renal and hepatic function
as surgery. The preemptive administration of analgesics has should be evaluated before instituting NSAID therapy in dogs at
been shown to decrease the intensity and duration of postop- risk for complications and during chronic NSAID therapy.
erative pain.13 Additionally, preemptive analgesics have been
shown to decrease both peripheral and central nervous system Opioids
sensitization.14,15 It is important to remember, however, that Opioids are the most consistently effective drugs used for the
administration of analgesic drugs preemptively will not eliminate treatment of moderate to severe pain (Table 9-3). This class
postoperative pain, but can reduce the severity and duration of of drugs produces analgesia by acting on opioid receptors
that pain. without the loss of proprioception or consciousness. Three
opioid receptors (mu, kappa, and delta) have been identified
A simplified explanation of the pain pathway is described here and are found in varying numbers within the brain, dorsal horn
however, it is important to recognize that clinical pain is the result of the spinal cord, and the periphery.23,24 Activation of opioid
of signals transmitted along a multitude of pathways throughout receptors results in inhibition of adenylate cyclase, a decrease
the peripheral and central nervous systems. These pathways in the opening of voltage-sensitive calcium channels, inhibition
involve many mechanisms and neurotransmitters so, it is unlikely of the release of excitatory neurotransmitters, and activation of
that a single analgesic agent or technique will alleviate all pain. potassium channels resulting in membrane hyperpolarization.25
Construction of a multimodal analgesic plan that uses drugs of The overall effect of opioid receptor activation is a decrease in
different classes, each acting at different sites along the pain neurotransmission.26
pathway (e.g. NSAIDS, opioids, local anesthetics), will result in
more effective pain relief. Additionally, the co-administration of Opioid analgesics are classified by their receptor selectivity
drugs in various classes has additive or synergistic effects and and may be active at one or more receptors. Mu agonists
individual drug doses can often be reduced. include morphine, oxymorphone, hydromorphone, fentanyl,
and meperidine. These agonists induce a maximal response,
Analgesic Drugs and can produce increasing levels of analgesia with increasing
The drugs commonly used to treat perioperative pain in dosages. This is in contrast to the partial mu agonist, buprenor-
companion animals consist of nonsteroidal anti-inflammatory phine, which binds tightly to the mu receptor but does not induce
drugs (NSAIDs), opioids, alpha-2 agonists, local anesthetics, a maximal response.27 Butorphanol has agonist activity at the
and adjunctive medications. kappa receptor and antagonist activity at the mu receptor.28
Increasing doses of butorphanol are associated with a ceiling
effect, such that no improvement of analgesia occurs with
NSAIDs increasing doses.
These are commonly used in the canine and less frequently in
the cat for analgesia (Table 9-2). These drugs are used to treat In addition to producing analgesia, the opioids also affect other
pain in a variety of cases ranging from acute surgical pain to organ systems. Opioid administration can result in respiratory
depression due to a decrease in the respiratory center’s response
Pain Management in the Surgical Patient 115
Table 9-2. Nonsteroidal Anti-inflammatory Drugs used in the Treatment of Peri-operative Pain.
Drug Dosage Frequency Notes
Carprofen Dog: 4.4 mg/kg IV, SQ, IM Once at induction Acute hepatoxicity reported,
2.2 mg/kg PO Every 12 hours does not appear to affect platelet
function
Cat: 4.0 mg/kg SQ, IV (67) Once at induction
Deracoxib Dog: 3-4 mg/kg PO Every 24 hours COX – 2 inhibition, GI upset can
occur
Ketoprofen Dog: 2.0 mg/kg IV, IM, SQ, PO Once Preoperative administration
1.0 mg/kg IV, IM, SQ, PO Every 24 hours can result in hemorrhage due
to antithromboxane activity, not
recommended for more than five
Cat: 2.0 mg/kg SQ Once
days, renal damage reported
1.0 mg/kg PO Every 24 hours
Firocoxib Dog: 5 mg/kg PO Every 24 hours Use of doses more than 5 mg/kg
in puppies less than 7 months of
age can result in severe adverse
reactions, including death.
Ketorolac Dog: 0.5 mg/kg IV, IM Every 12 hours for 1 to 2 1 to 2 treatments only to reduce
treatments risk of gastric ulceration
Acetaminophen Dog: 10 - 15 mg/kg PO Every 8 hours Can be combined with opioid for
synergistic effect
Cats: Do not administer to cats Do not administer to cats.
Aspirin Dog: 10 - 25 mg/kg PO Every 12 hours Ulcers and renal damage at higher
doses
Cat: 1 - 25 mg/kg PO67 Every 72 hours
Tolfenamic acid Dog: 4.0 mg/kg IM, SQ, PO Every 24 hours Give for four days, then off for
three days
Cat: 4.0 mg/kg SQ, PO67 Every 24 hours Use for 3 days in cats
Piroxicam (Feldene) Dog: 0.3 mg/kg PO Every 48 hours Use with gastroprotectant
Meperidine Dog: 3-5 mg/kg IM, SC 1-2 hours Significant histamine release
Cat: 3-5 mg/kg IM, SC 1-2 hours if given IV.
Buprenorphine Dog: 10-20 mcg/kg IV, IM, SC 6-8 hours Onset of action may be 30
Cat: 10-20 mcg/kg IV, IM, SC, 6-8 hours minutes or more.
Buccal
Butorphanol Dog: 0.2-0.4 mg/kg IV, IM, SC 1 hour Only use for minor pain
Cat: 0.2-0.4 mg/kg IV, IM, SC 1 hour
Opioid Antagonist Dog: 0.01 mg/kg IV 20-40 minutes Animal should be observed
Naloxone 0.04 mg/kg IM 40-70 minutes for renarcotization or
Cat: Same as dog resedation due to short
duration of action.
Pain Management in the Surgical Patient 117
Mepivacaine Dog: < 6 mg/kg 5 minutes 90-180 minutes Less tissue irritation
Cat: < 3 mg/kg Not effective topically
EMLA cream Apply topically 60 1-2 hours following 1:1 mixture of lidocaine
minutes before removal of cream and prilocaine; do not
procedure. Cover with apply to damaged or
occlusive dressing broken skin, middle ear,
or ocular structures;
Prevent licking and/or
oral ingestion
Alpha-2 Antagonist: Atipamezole Dog: 0.05-0.2 mg/kg IV,IM Or 2-5 times 1-3 hour IV administration
dexmedetomidine dose usually reserved for
Cat: 0.05-0.2 mg/kg IV,IM Or 2-5 times emergencies; can cause
the dexmedetomidine dose excitement, delirium, and
vomiting
Pain Management in the Surgical Patient 119
Tricyclic antidepressants can also play a role in pain management. anesthetics are used on mucosal surfaces, doses should be
Amitriptyline works in the central nervous system to block the calculated carefully, as these drugs are readily absorbed into
reuptake of serotonin and norepinephrine.70 Amitriptyline has the systemic circulation.
been shown in humans to be beneficial in the treatment of
neuropathic and chronic pain states by enhancing the actions of Most commonly, local anesthetics are infused around surgical
opioids.71 There are no controlled studies using Amitryptilline in sites allowing for procedures such as skin mass excision and
veterinary patients however it is thought that the tricyclic antide- repair of lacerations to be performed without general anesthesia
pressants would have similar analgesic effects in animals. although sedation is often required. After aseptically preparing
the surgical site, local anesthetic should be infiltrated into all
Finally, sedatives such as acepromazine and diazepam may of the effected tissue planes. The needle is inserted into the
be useful in potentiating or prolonging the effects of analgesic skin and the plunger aspirated to prevent accidental intra-
agents. If these sedatives are used, careful evaluation of the venous injection. Total doses should be calculated carefully to
patient must continue as the central nervous system depression avoid toxicity. If infiltration of lidocaine is being performed in a
and sedation may mask signs of untreated pain. conscious patient, the lidocaine can be mixed with sodium bicar-
bonate (0.1 ml of 1mEq/ml NaHCO3 to 0.9 ml of 2% lidocaine) to
reduce the discomfort felt by the animal on injection. Infiltration
Multimodal Analgesic Techniques of local anesthetic into more invasive surgical sites can be
Systemic analgesic agents are often combined with local or continued over a period of time by using a fenestrated catheter
regional anesthetic techniques to produce a balanced analgesic attached to a reservoir. The catheter is placed in the surgical site
protocol that may maximize analgesic efficacy. and the reservoir is filled with local anesthetic. The reservoir can
then be set to slowly deliver the local anesthetic to the surgical
Local Anesthetic Techniques site over a period of days.
Local anesthetic agents block transmission in all nerve fibers and
are ideally suited for preemptive administration (Table 9-7). Local Local anesthetic infiltration into a surgical incision site either
nerve block techniques are relatively easy to perform and have before the incision is made or just prior to closure is an effective
few complications. The benefits of performing these techniques analgesic technique. Infiltration of local anesthetic along the
include a significant reduction in inhaled anesthetic requirements muscle of the abdominal wall of a celiotomy incision helps to
and reduction in postoperative pain. Some of the techniques control abdominal wall pain. If the block is performed before
can be performed on conscious animals however most local closure, a sterile syringe, needle, and local anesthetic agent
techniques are easier to perform on sedated or anesthetized are delivered to the surgeon aseptically. The musculature and
patients. The clinician should base their choice of which local subcutaneous tissues along both sides of the incision are then
anesthetic agent to use for a procedure on how quickly the local injected uniformly and wound closure proceeds normally.
anesthetic is needed to work, the route of administration, and the
expected duration of pain (Figure 9-1). Animals recovering from thoracotomy may benefit from blocking
the intercostal nerves prior to incisional closure and/or the instil-
Topical local anesthetics can be used to desensitize cutaneous lation of local anesthetics into the pleural space.74 If the patient
areas for minor, relatively noninvasive procedures. EMLA cream has a thoracostomy tube, a local anesthetic such as 0.5% bupiva-
can be applied to the skin overlying a vessel before venepuncture, caine can be administered through the tube (1.5 mg/kg in the dog,
while 2% lidocaine jelly can be used to desensitize mucosal flushing the tube with saline after administration). The animal is
surfaces such as the urethra before catheterization.72 If local positioned to allow the local anesthetic solution to bathe the
Pain Management in the Surgical Patient 121
incision site (incision side down) for 10 to 20 minutes after instil- advanced through the overlying tissues until it passes through
lation. If the animal does not have a thoracostomy tube in place, the ligamentum flavum. Commonly, a distinctive pop is felt and
the local anesthetic can be instilled by aseptically placing an the saline in the hub of the needle is drawn into the space. If the
over the needle catheter into the pleural space. Complications needle encounters bone before puncturing the ligamentum flavum,
of this procedure include infection and pneumothorax.75 it is withdrawn slightly and redirected. After the needle is directed
into the epidural space, the hub of the needle is observed for the
Local anesthetics can also be infused into the peritoneal cavity presence of blood or cerebral spinal fluid. If neither is present,
using a similar technique. An over the needle catheter is asepti- the epidural injection is preformed. If blood is present, the needle
cally placed into the abdomen at the level of the umbilicus. A is withdrawn and the process repeated. If cerebral spinal fluid is
mixture of local anesthetic and saline (total volume 10-20 mls) is flowing from the needle, a decision to inject the analgesic into
then instilled. This technique may be helpful for those patients the subarachnoid space must be made. If it is decided to proceed
suffering from abdominal pain. Doses are calculated carefully, with the injection, the dose of the analgesic must be reduced by
remembering that local anesthetic drug uptake will occur rapidly, at least 50%.77 After injection, the needle is completely withdrawn.
particularly if the peritoneum is inflamed.76 If injecting a local anesthetic epidurally, the animal is placed with
the affected side down for a period of 5 to 10 minutes.
Epidural Technique Epidural injections can also be performed in lateral recumbency.
Analgesia and/or anesthesia caudal to the diaphragm can be The procedure is the same, with the area over the lumbosacral
achieved with an epidural injection (Figure 9-2). The technique space clipped and aseptically prepared. The anatomic landmarks
is relatively easy to perform and does not require specialized are identified, and the spinal needle is advanced through the
equipment. Injections are performed with the patient chemically skin. In this position, however, the stylet remains in place until the
restrained or anesthetized because the patient must remain still needle is thought to have penetrated the ligamentum flavum. Once
during the procedure. The hanging drop technique is described the needle is in the epidural space, the stylet is removed and the
below. The animal is placed in sternal recumbency with the hind hub of the needle is observed for blood or cerebrospinal fluid.
limbs extending cranially.The hair overlying the lumbosacral
space is clipped and the skin is aseptically prepared. Sterile gloves A test injection of a small amount of air can be performed to
are worn and the lumbosacral space is identified by placing the confirm the needle placement. If the needle is correctly placed,
thumb and middle finger of the non-dominant hand on the cranial there should be little to no resistance to injection of air.78 The
edges of the wings of the ilia. The index finger of the same hand injection of drug is performed, the needle is withdrawn and the
then palpates the spinal process of the seventh lumbar vertebrae. animal is placed with the affected area down if local anesthetic
The lumbosacral space is identified as a depression caudal to drug is administered. It should be noted that, in cats, the spinal
the spinous process. An appropriately sized spinal needle (20-22 cord usually ends at the first sacral vertebra making it more
gauge) is then introduced on midline at an angle that is perpen- likely to puncture the dura during needle placement and obtain
dicular to the skin. Once the needle has passed through the cerebrospinal fluid during epidural injection.77
skin, the stylet is removed and a small amount of sterile saline
is placed into the hub of the needle. The needle is then slowly
L7 L6
SACRUM
Mandibular nerve block91 Bone, teeth, soft tissue, and tongue on infil- Tuberculin syringe; 27 or 25 gauge, 3/4 to 1 inch
trated side needle
Dog: 0.1 to 0.5 ml of 0.5% bupivacaine
Cat: 0.1 to 0.3 ml of bupivacaine
Mental nerve block91 Bone, teeth, and soft tissue rostral to the Tuberculin syringe; 27 or 25 gauge, 3/4 to 1 inch
second premolar on the injected side needle
Dog: 0.1 to 0.5 ml of 0.5% bupivacaine
Cat: 0.1 to 0.3 ml of 0.5% bupivacaine
Auriculotemporal and great External and internal ear Syringe; 22 gauge, 1 inch needle
auricular nerve blocks92
Radial, Ulnar, Median, and Anesthesia distal to the elbow joint Two 20 or 22 gauge 1 inch needles
Musculocutaneous nerve Syringe
block (RUMM)93
Radial, Ulnar, and Median Anesthesia to distal forelimb Three 22 or 25 gauge, 3/4 to 1 inch needles
nerve block (RUM)93 Syringe
Intravenous Regional (IVRA) Anesthesia of limb distal to tourniquet Tourniquet, Esmarch bandage, intravenous
Analgesia/Anesthesia94 catheter, syringe, 20 gauge 1 inch needle
Intercostal nerve block94 Tissues of thorax on side injected 22 gauge 1 inch needle
Syringe
Technique Notes
Palpate infraorbital foramen dorsal to upper third premolar. Complications include damage to nerve and soft tissue (rare),
Needle can be advanced into the foramen in larger dogs. Cardiotoxicity due to inadvertent intravenous administration of
bupivacaine. Calculate doses carefully. Aspirate before injection.
Palpate mandibular foramen intraorally–lingual surface of Complications include damage to nerve and soft tissue (rare).
mandible, 2/3 of distance from last molar to angular process Cardiotoxicity due to inadvertent intravenous administration of
of the mandible. Insert needle intraorally near foramen. bupivacaine. Calculate doses carefully. Aspirate before injection.
Dog: Palpate the middle mental foramen. Insert needle into Complications include damage to nerve and soft tissue (rare),
the submucosa in a rostral to caudal direction. Injection Cardiotoxicity due to inadvertent intravenous administration of
should be ventral to the rostral root of second premolar. bupivacaine. Calculate doses carefully. Aspirate before injection.
Cat: Place needle in submucosa caudal and ventral to lower
canine
Auriculotemporal nerve is located caudal and dorsal to Preoperative performance of block may reduce inhalant require-
masseter muscle and rostral to the ventral ear canal. Great ments during total ear canal ablation and may improve recovery
auricular nerve is ventral to wing of atlas and caudal to postoperatively
vertical ear canal.
Three injection sites: Useful for cats undergoing onychectomy. Calculate dose of local
1. Medial to the accessory carpal pad anesthetic carefully.
2. Lateral and slightly proximal to accessory carpal pad
3. Dorso-medial aspect of proximal carpus
Place intravenous catheter in accessible vein. Desanguinate Do not use bupivacaine due to cardiotoxicity when given IV.
the limb with Esmarch bandage. Place tourniquet immedi- Ischemic injury can occur to limb if tourniquet is not released
ately proximal to bandage. Remove Esmarch bandage. Inject within 90 minutes.
lidocaine through intravenous catheter. Slowly remove
tourniquet within 90 minutes.
Percutaneous injection: Aseptically prepare skin over inter- Due to overlapping innervation, at least three consecutive
costal nerves. Introduce needle caudal to each rib near the intercostal nerves must be blocked. Commonly, at least two
intervertebral foramen. Advance needle to rib, then withdraw intercostal nerves cranial and caudal to the affected area are
slightly into the tissues caudal to rib. Aspirate, then inject. blocked, in addition to the site of incision.
Intraoperative injection: Nerves can be identified and If performed percutaneously, complications include
injected from the pleural side of thorax. pnuemothorax, intrathoracic injection, and pulmonary laceration
Anatomic landmarks depend on joint being injected. Asepti- Can use local anesthetics and/or morphine.
cally prepare skin over joint. Place needle into joint space. Complications include infection if not performed aseptically.
Remove joint fluid if needed.
Inject enough local anesthetic to result in slight distension in
the joint capsule
124 Soft Tissue
If repeated injections or continuous administration of epidural beyond the end of the Tuohy needle, no attempt should be made
analgesics is desired, placement of an epidural catheter should to withdraw it through the needle, as the catheter may be sheered
be considered. A Tuohy or Hustead needle is required to place an off by the sharp edge of the needle. Once the catheter is in place,
epidural catheter. These needles have a curve at the tip that aid the wire stylet is removed if present, and an adapter is attached to
in directing the catheter cranially when placed into the epidural the end of the catheter. A bacterial filter and injection cap primed
space. There are a variety of epidural catheters available that with saline or analgesic are then connected to the catheter. The
are characterized by their size and material used to construct the catheter should then be secured to skin at its exit site. A radio-
catheter. Epidural catheters made of nylon or those with a wire graph can be taken to confirm the placement of the catheter.
spiral within the wall of the catheter are resistant to kinking, while Additionally, catheter placement can be guided by fluoroscopy,
others have a wire guide in the lumen of the catheter and are if available. If cleanliness and sterility are maintained, epidural
more flexible. Polyamide catheters are softer, more flexible and catheters can remain in place for days to weeks.79
kink more easily.77 Prior to beginning the procedure, the clinician
measures the animal to determine how much of the catheter needs Complications of both single epidural injection and epidural
to be inserted, making sure to account for the length of the Tuohy catheter placement include infection, cranial spread of local
needle used for catheter placement. For a hind limb procedure, anesthetic resulting in motor blockade of respiratory muscles,
the catheter may only need to be inserted to the level of the fifth hypotension when using local anesthetics, and urine retention.
or sixth lumbar vertebrae, abdominal procedures require the Muscle spasms of the rear legs, pruritis, epidural hemorrhage,
catheter to be advanced to the second or third lumbar vertebrae, and spinal cord or nerve root trauma have also occurred.
while for a thoracotomy the catheter should be advanced to the Contraindications for epidural injection include pyoderma at the
fifth or sixth thoracic vertebrae. site of injection, coagulopathy, and sepsis.77 Drugs commonly
used in epidural injections and infusions are listed in Table 9-8. It
The animal is clipped and prepped using the anatomic landmarks is emphasized that preservative free formulations of these drugs
for a epidural injection. A keyhole drape is placed over the should be used for epidural injection.
lumbosacral space and the landmarks are palpated with sterile
gloved hands. A small stab incision is made in the skin overlying
the lumbosacral space using a sterile #11 blade to facilitate the
Transdermal Analgesic Administration
passing of the Tuohy needle. The Tuohy needle is placed into the Transdermal administration of analgesics allows for delivery and
stab incision, and advanced through the overlying tissues until the maintenance of sustained concentrations of a drug avoiding the
ligamentum flavum is penetrated. Needle placement in the epidural peaks and troughs associated with intermittent parenteral admin-
space can be confirmed with a test injection of a small amount of istration. Fentanyl and lidocaine are available in transdermal
air. The epidural catheter is then passed through the needle to formulations and their use has been investigated in veterinary
the desired spinal segment. If the catheter has been advanced clinical patients.80-81
To apply a fentanyl patch, the hair of the animal is clipped and any To apply a lidocaine patch, the hair over the area should be
gross debris is removed from the surface of the skin with water or clipped and the skin cleaned if needed. It is believed that the
saline. Alcohol should not be used as it will alter the lipids present lidocaine patch acts by local nervous tissue penetration and
on the epidermis, which will affect drug absorption. Once the area not systemically like the fentanyl patch, thus the lidocaine
is completely dry, the patch is placed firmly onto the skin and patch must be placed close to or directly over the painful area.
held in place for one to two minutes. The patch should be placed Unlike the fentanyl patch, the lidocaine patch can be cut to fit
in an area that will minimize patient removal and/or possible oral the patient or site of application without altering drug delivery.
ingestion, as overdose may occur. Commonly, patches are placed In surgical patients, the patch can be cut to the length of the
on the dorsum of the neck or lateral thorax. A light bandage can incision and cut pieces should be placed on either side of the
then be placed over the patch. Transdermal patches should not incision. Unused, cut portions of the patch can be saved for use
be placed in direct contact with heating pads, as increases in at a later time. Seemingly, lidocaine patches can be left in place
cutaneous blood flow will increase drug absorption.82 for three to five days with minimal side effects.88 Side effects of
lidocaine patches in humans include skin irritation erythema,
Fentanyl patches are available in 25, 50, 75, and 100 mcg/hour hives, and edema associated with the lidocaine patch. These
concentrations. Clinicians should select a patch that will deliver a complications typically resolved within hours of patch removal.89
dose of 3-5 mcg/kg/hour in their patient. Once the patch has been In dogs, skin irritation/inflammation has been noted after patches
placed, steady-state plasma concentrations are obtained in 18 to have been in place for 72 hours.88 Although systemic toxicity is
24 hours in the dog while in the cat, 6 to 12 hours is required for unlikely, animals should be monitored for signs of overdose that
steady plasma concentrations to be reached. Parenteral admin- include bradycardia, hypotension, facial twitching, and seizures.
istration of opioids should be provided to animals when indicated
to provide analgesia during the lag time until effective plasma Fentanyl and lidocaine patches are useful as analgesic adjuncts
concentrations are reached. The patch is designed to deliver but should not be used as the sole method of providing analgesia
fentanyl over a period of 72 hours, but they may be effective for to animals with moderate to severe pain.
longer periods. Studies have shown that there is significant inter
and intra-individual variation in plasma fentanyl concentrations
after patch application.83 For this reason, patients should be
Constant Rate Drug Infusions (CRI)
carefully monitored for signs of pain and/or side effects. Constant rate drug infusions administered intravenously through
an indwelling catheter are used to manage pain effectively while
Complications associated with the use of fentanyl patches limiting the peaks and troughs of intermittent analgesic adminis-
include respiratory depression, sedation, inadequate analgesia, tration. This technique has been found to be particularly effective
skin irritation, failure of the patch to adhere to the skin, and in animals whose pain has been refractory to intermittent admin-
human abuse. In cats, mydriasis, agitation, and dysphoria may be istration of analgesics. Typically, a loading dose of the analgesic
observed.83 If significant respiratory depression is observed, the is administered parenterally followed by a constant rate infusion
patch should be removed and an opioid antagonist administered. of the analgesic. Analgesics may be delivered using a syringe
Once a patch is removed, plasma levels decrease over a period pump, or added to the patient’s maintenance fluids. An example of
of twelve hours. Patches should be disposed of carefully in the the calculations used for constant rate infusions can be found in
same manner as other controlled substances. Table 9-9. Opioids, local anesthetics, and analgesic adjunct drugs
have been used in constant rate infusions to treat pain in animals.
Lidocaine patches have been approved for use in humans for Appropriate doses for these drugs are found in Table 9-10.
the treatment of peripheral neuropathies such as post-herpetic
neuralgia and have generated interest in both human and Table 9-9. Calculations for constant
veterinary pain management.84 It is thought that application Rate Infusions.
of a lidocaine patch produces local tissue concentrations that You are presented with a 15 kg dog. You would like to start a
are high enough to produce local analgesia, without complete lidocaine constant rate infusion.
sensory block, for periods up to 24 hours.85 The lidocaine patch
1. Calculate loading dose
is a 10 by 14 cm patch that contains 700 mg of 5% lidocaine. In
• 15 kg x 2 mg/kg = 30 mg or 1.5 ml of 2% lidocaine.
human studies, once the patch is applied, up to 35 mg of lidocaine
Administer over 20 minutes
is absorbed topically, producing analgesia within 30 minutes,85
with a half-life of 6-8 hours.86 The amount of lidocaine absorbed 2. Calculate maintenance fluid rate
is directly proportional to the area of skin that is covered and the • (15 kg x 60 ml/kg/24 hours)/24 hours = 37.5 ml/hour
length of time the patch is in contact with the area.85 In contrast • Assuming that you have a 1 L bag of fluids, this bag will last
to transdermal fentanyl, transdermally administered lidocaine for 26.6 hours
has a very slow rate of systemic absorption, which makes 3. Calculate how much lidocaine you will need
systemic lidocaine toxicity unlikely.85 The pharmacokinetics of • 50 mcg/kg/min = 3mg/kg/hour
the lidocaine patch in dogs and cats are similar to those observed • 3mg/kg/hour x 15kg x 26.6 hours=1197 mg or 59.85 mls of
in human studies, showing significant tissue levels at the site of 2% lidocaine
patch application, with peak plasma concentrations taking 10-36
4. Prepare the fluid for administration by first removing
hours to be achieved due to slow systemic absorption.87,88 59.85 mls from the fluid bag. Then add the lidocaine to
achieve the exact concentration desired.
126 Soft Tissue
Table 9-10. Drugs used as constant Rate Infusions for the treatment of Peri-operative Pain.
Drug Dosage Notes
Morphine Dog: Loading dose: 0.1-0.25 mg/kg IV (slowly) Histamine release occurs even
CRI: 0.1-0.5 mg/kg/hour IV at low doses,31 48% reduction
Cat: Loading dose: 0.05-0.1 mg/kg IV (slowly) in isoflurane requirement of
dogs95
CRI: 0.05-0.2 mg/kg/hour IV
Morphine is commonly
combined with lidocaine or
lidocaine and ketamine (MLK).
MLK caused a 45% reduction
in the isoflurane requirement
of dogs
Lateral thoracotomy • 0.1 mg/kg oxymorphone • Morphine (0.1 mg/kg/hr) • Continue morphine and
IM-20 minutes before and lidocaine (50 mg/kg/hr) lidocaine CRI for 24 hours
anesthetic induction constant rate infusion • 0.5 mg/kg morphine IM if
• Intercostal nerve blocks needed for rescue analgesia
with 1 mg/kg of bupivacaine • Instill 1 mg/kg of bupivacaine
prior to closure (diluted with saline to volume
of 10-20 ml) into the thorax via
thoracostomy tube every 6
hours
Total ear canal ablation • 0.1 mg/kg oxymorphone • Auriculotemporal and great • Continue fentanyl constant
IM-20 minutes before auricular nerve blocks with rate infusion for first 24 hours
anesthetic induction 2 mg/kg bupivacaine during • 4 mg/kg carprofen SC at
sterile prep recovery
• 5 mcg/kg fentanyl loading
dose IV followed by 5 mcg/kg/
hour constant rate infusion
Radius/Ulna fracture repair • 0.1 mg/kg hydromorphone • RUMM block with 2 mg/kg • 0.1 mg/kg hydromorphone IM
IM-20 minutes before bupivacaine during surgical every 4 hours for first 24 hours
anesthetic induction prep • 2 mg/kg ketoprofen SC at
• 0.05 mg/kg hydromorphone recovery
IV as needed
Dorsal hemilaminectomy • 0.5 mg/kg morphine IM-20 • 0.25 mg/kg morphine IV as • 0.5 mg/kg morphine IM every
minutes before anesthetic needed 4 hours
induction • 0.1 mg/kg preservative free • If pain is not easily con-
morphine placed on the spinal trolled, consider an IV
cord morphine (5 mcg/kg/min),
• Incisional block with 2 mg/kg lidocaine (50 mcg/kg/min), ket-
bupivacaine prior to closure amine (2 mcg/kg/min) constant
rate infusion
Stifle arthroscopy • 0.5 mg/kg morphine IM-20 • Epidural injection with 0.1 • 0.5 mg/kg morphine IM every
minutes before anesthetic mg/kg preservative free 4 hours
induction morphine • 4 mg/kg carprofen SC at
• Intra-articular injection with recovery
2 mg/kg bupivacaine
128 Soft Tissue
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Nervous System 131
Histology/Biologic Activity
Nervous System and Organs Peripheral nerve sheath tumors are histologically heteroge-
neous, comprising cells which are either spindle or oval to round
of Special Sense in shape and arranged in interlacing bundles to10,11 sheets and
cords of pleomorphic cells.2 Divergent differentiation is seen,
with tumors described with fibrous, chondroid, osteoid, myxoid,
and squamous and glandular9,11,12 epithelioid components.2
Malignant cellular criteria are typically present,9,10 including
unknown cause. The lameness is usually initially weight bearing, help rule out primary bone diseases such as proximal humeral
but tends to progress to a non weight bearing status over time. or vertebral osteosarcoma. The most common described radio-
Many dogs react painfully to manipulation of the limb and to graphic abnormality with PNST is widening of an intervertebral
deep axillary palpation, although the exact painful site is difficult foramen when tumors extend into the vertebral canal.18 Survey
to discern. A palpable mass is present in only approximately 37% radiographs are generally of limited use in the diagnosis of
of cases.2 Moderate to severe muscle atrophy of the affected PNST because only a small percentage of cases demonstrate
limb is commonly seen, occurring in approximately 93% of cases detectable abnormalities.
in one study.2 Paresis and neurological deficits of the affected
limb may be seen as the tumor compromises nerve function. Myelography is a more useful radiographic diagnostic tool and is
Additional signs, including paraparesis, loss of the cutaneous essential in cases in which there is suspicion of tumor extension
trunci reflex, and ipsilateral Horner’s syndrome can be seen if the to the vertebral canal (Figure 10-2). In one study, approximately
tumor extends through the intervertebral foramen to involve the 95% of cases with nerve root involvement had abnormal myelo-
spinal cord. Signs of spinal cord involvement may develop after grams.2 Myelography also accurately identified the lack of
a period of forelimb lameness, concurrent with the lameness, or macroscopic vertebral canal or nerve root involvement in 9 of 10
as an initial finding depending on the site of origin of the tumor.9 cases in which the PNST was located within the brachial plexus.
A normal myelogram does not rule out PNST nor does it fully
Peripheral nerve sheath tumors in other locations manifest rule out involvement of the nerve roots, but it can be very useful
with different presenting signs. A smaller population of PNST to better plan the surgical approach or approaches needed for
affects the nerves of the lumbosacral plexus.2,4 These tumors treatment.2
present with a unilateral hind limb lameness which can progress
to unilateral or bilateral hind limb paresis if the tumor invades
the spinal canal. Peripheral nerve sheath tumors have been
described specifically affecting the sciatic nerve and presented
with signs of a hind limb lameness and associated sciatic nerve
deficits.5 Rectal examination of these dogs revealed a palpable
intrapelvic mass not visible on survey radiographs. Peripheral
nerve sheath tumors have also been reported to affect the
trigeminal nerve.7 The main presenting sign of these tumors
was unilateral atrophy of the temporalis and masseter muscles,
seen in all ten described dogs. One case report described a dog
presenting with chronic vomiting, coughing, and signs of respi-
ratory distress and with clinical findings of Horner’s syndrome,
ipsilateral laryngeal hemiplegia, and a ventral cervical mass
identified via ultrasonography.8 At necropsy, a PNST was
identified affecting the vagosympathetic trunk. An intratho-
racic PNST has been described in a dog which presented for
a persistent, productive cough and regurgitation.6 This tumor
was believed to originate from the ventral thoracic spinal nerve
roots.
The differential diagnoses for the most common presenting Figure 10-2. Image of a ventrodorsal projection of a cervical myelogram
sign of PNST is any musculoskeletal disorder which produces demonstrating an intradural-extramedullary pattern due to extension
a forelimb lameness. Many affected dogs have some degree of a peripheral nerve sheath tumor into the spinal canal (arrow). the
of concurrent elbow or shoulder joint disease which can make plexus adjacent to the tumor.
definitive diagnosis of the PNST initially difficult. Because there Photo courtesy of Dr Robert Toal, DACVR
is often a painful reaction on manipulation of the shoulder
Advanced imaging techniques including computed tomography
region, shoulder-area soft tissue injuries, such as biceps
(CT) and magnetic resonance imaging (MR) have become valuable
tendon or infraspinatus or supraspinatus muscle injuries, may
tools in the diagnosis of PNST. These imaging modalities have
be presumed to be the causative problem.17 Although chronic
greater diagnostic sensitivity than conventional radiography and
musculoskeletal injuries can be associated with muscle atrophy,
can provide important pre-treatment information on tumor local-
the atrophy seen with PNST tends to be more severe. Peripheral
ization and the degree of tumor extension.4,5,7,14,15,17 Computed
nerve sheath tumors also must be differentiated from other
tomography was used to identify masses of the brachial plexus
spinal nerve diseases, such as nerve root disease secondary to
in 24 dogs in one study.15 Twenty of the 24 cases (83%) demon-
intervertebral disc compression.
strated either uniform or heterogenous contrast enhancement.
Tumors as small as one cm in diameter were identified; however,
Diagnostics it should be noted not all masses identified on CT are associated
Survey radiographs may provide useful information in the workup with neuronal structures. Magnetic resonance imaging has been
of PNST. It is useful to characterize orthopaedic disease and to used in the diagnosis of PNST’s of the radial nerve, trigeminal
nerve, and in an intrathoracic location.6,7,14 The majority of the
Nervous System 133
lesions were isointense on T1-weighted images and either isoin- margin of grossly normal nerve proximal and distal to the mass.
tense or hyperintense on T2-weighted images (Figure 10-3). This frequently requires resection of multiple nerve branches due
All of the lesions demonstrated contrast enhancement. MR to the highly invasive nature of the tumor. Incomplete excision is
is becoming the preferred advanced diagnostic test due to its common despite aggressive surgical treatment because of the
superior resolution of the tumor boundary and the absence of difficulty of discerning normal from abnormal nerve tissue during
beam-hardening artifacts.7 surgery.2 All resected tissue should be submitted for histopa-
thology with proximal and distal edges marked with ink to assist
Electromyography (EMG) is a useful tool in assisting with the the pathologist in assessing completeness of excision.
diagnosis of PNST. Because of the destructive nature of PNST,
the electrical conductivity through affected nerves is frequently
altered. A primary goal of EMG, used in conjunction with other
Surgical Approaches to the Brachial Plexus
diagnostic tests, is to differentiate between muscle atrophy The main and usually best approach to the brachial plexus is
due to denervation and muscle atrophy due to disuse.18 In the the craniolateral approach.20 This provides a wide exposure to
clinical setting, this applies to differentiation between muscle the plexus nerves and allows exploration and treatment of the
atrophy seen with nerve disease and that seen with orthopaedic peripheral nerves to the level of the spinal canal. Full explo-
disease.2,7,14 It is not specific for PNST since other types of nerve ration of the caudal plexus nerve roots requires transection of
injury (such as brachial plexus avulsion injuries) can produce the scalenus muscle and cranial rotation of the first rib following
EMG changes.19 When used in cases of PNST, EMG can help an osteotomy near the costochondral junction. The craniomedial
determine the extent and severity of the nerve damage caused approach to the plexus provides better exposure of the peripheral
by the tumor, in effect helping to localize the tumor.19 In one study, nerves distal to the plexus.19,20 This approach, though, provides
all twenty nine dogs in which EMG was performed demonstrated limited access to the proximal portions of the plexus nerves,
abnormal, spontaneous electrical activity in muscles of the and it typically involves more muscle dissection than the cranio-
tumor-affected limb.2 In a separate study, EMG studies were used lateral approach.20 Both approaches can be easily modified into
to confirm the diagnosis of sciatic nerve tumors in two dogs.5 a forequarter amputation if the degree of tumor resection will
Changes seen on EMG studies include fibrillation potentials, result in a dysfunctional limb.
positive sharp waves, and bizarre high frequency discharges.7,19
Craniolateral Approach20
The dog is placed in lateral recumbency with the affected limb,
shoulder area, and caudal neck prepared for aseptic surgery.
A skin incision is made at the cranial border of the mid scapula
and extending distal to the greater tubercle of the humerus. The
omotransversarius muscle is transected over the cranial edge
of the scapula. Dissection continues ventrally dorsolateral to
the cleidobrachialis muscle. The omotransversarius and cleido-
brachialis muscles are elevated cranially and cranioventrally,
respectively and the scapula is elevated caudally to expose
the brachial plexus. The plexus nerves are better defined after
separation from the loose subscapular connective tissue. The
scalenus muscle may need to be transected to expose the
Figure 10-3. Transverse view of a T1-weighted, post contrast magnetic seventh and eighth cervical and first thoracic ventral nerve
resonance image of a cervical peripheral nerve sheath tumor. The branches. The first rib can be osteotomized just proximal to the
arrow points to the widened nerve root extending close to the vertebra. costochondral junction and rotated cranially and laterally to
Photo courtesy of Dr Robert Toal, DACVR further expose the first and second thoracic ventral nerve roots
if these need to be treated as well. This will require ligation of
Surgical Treatment the first intercostal artery and vein and transection of the first
intercostal space musculature.
The goals of treatment of PNST include eradication of the
tumor, relief of pain associated with the tumor, and stabilization
of neurological dysfunction caused by the tumor. The primary Craniomedial Approach19
mode of therapy of PNST is aggressive surgical resection of all The dog is placed in lateral recumbency, with the affected
affected nerve tissue.2 The tumor may be approached periph- limb retracted caudally. An incision is made from the caudal
erally if it is located outside of the spinal canal, via a lamine- aspect of the jugular furrow, medial to the greater tubercle of
ctomy if it involves the spinal canal, or from both approaches the humerus, and to the axilla. An incision is made at the medial
if the tumor involves both canal and peripheral locations. If the edge of the cleidobrachialis muscle. The cranial edge of the
tumor has resulted in severe neurological dysfunction of an superficial pectoralis muscle is transected near to its insertion
affected forelimb, or if resection of the tumor will significantly on the humerus. The plexus is exposed by lateral retraction of
compromise forelimb function, amputation of the limb may be the limb and blunt dissection around the nerves.
necessary with resection of the tumor. The basic principle of
tumor removal is to resect all affected nerve tissue with a wide
134 Soft Tissue
Surgical Approach to the Lumbosacral Plexus grow despite radiation therapy will have more profound clinical
consequences than those tumors located distally on a limb or on
The lumbosacral plexus is a comparatively uncommon site for the dog’s trunk, and this will likely lead to shorter disease free
PNST. In one study, only eight of the 51 cases had tumors affecting intervals and survival times.2 At this time, without further data
either the lumbosacral nerve roots or the sciatic nerve.2 Clinical specific to PNSTs affecting the major plexus nerves, radiation
signs associated with tumors affecting the lumbosacral plexus therapy can only be considered as a reasonable, but not proved
nerve roots include hind limb lameness and hind limb paresis adjunct to surgery.
or paraparesis.2,5 Tumors in this area may be more difficult to
locally resect because of the limited access to the lumbosacral
nerve trunk. A lumbosacral nerve sheath tumor was completely Prognosis
excised in one study via a hemipelvectomy.4 The prognosis of PNST is generally guarded to poor.2 The highly
infiltrative nature of PNST and the difficulty of identifying the true
Approach to the Lumbosacral Nerve Trunk21 extent of the tumor make complete surgical excision difficult to
achieve. The proximity of many of these tumors to the spinal
The patient is positioned in ventral recumbency. A dorsal skin
canal also limits complete excision. Prognosis has been linked
incision is made from the craniodorsal iliac spine caudally to
to tumor location. In one study, tumors were divided into three
the ischiatic spine. The gluteal fascia and underlying superficial
anatomical groups: tumors distal to the brachial or lumbosacral
gluteal muscle are incised and the sacrospinalis muscle fibers
plexus (Peripheral Group), tumors involving nerves within the
are separated over the dorsal iliac spine and body. The middle
plexus (Plexus Group), and tumors involving the vertebral canal
gluteal muscle is incised along the dorsal aspect of the ilial
(Root Group).2 The median survival time of dogs in the Root Group
wing and body. Blunt intrapelvic dissection following retraction
was five months. The median survival time of the Plexus group
of the middle gluteal and sacrospinalis muscles exposes the
was 12 months. Although there was no statistical difference, the
lumbosacral nerve trunk.
trend was for dogs in the Plexus Group to survive longer than
dogs in the Root Group. This survival difference is a reflection
Laminectomy of the proximity of the tumor to the spinal cord in the Root Group
A laminectomy is needed in cases in which the PNST extends and the profound clinical effects tumors in this location can have
from a peripheral location into the spinal canal or when the tumor on the patient. Over 82% of all dogs in this study followed to death
originates at the nerve roots within the canal.2,12 A hemilamine- or at least three months following diagnosis had either recur-
ctomy is usually performed to allow exposure of the nerve roots rence of clinical signs or an unaltered, progressive worsening
and the ventrolateral aspect of the spinal cord. The laminectomy of presenting clinical signs. Most of the dogs either died directly
may need to be made over several intervertebral spaces if the from or were euthanized due to the effects of the tumor. In the
tumor involves multiple nerves. After exposure of the spinal cord study describing trigeminal nerve sheath tumors, only three of
and nerve root, a durotomy is performed to allow transection the ten dogs were treated surgically.7 One of these cases was
of the nerve root at the level of the cord. The nerve root is then alive without disease progression 27 months after surgery, one
dissected out from the surrounding epaxial musculature as far was alive four months after surgery, and one was euthanized
as possible. Unless all of the tumor-affected nerve tissue can be from progressive disease five months after surgery. Survival
removed, a second surgery to remove the diseased tissue from times of the non-treated cases ranged from five to 21 months.
a peripheral approach is necessary. It is more typical, though,
that the laminectomy is performed subsequent to a peripheral
approach to remove tumor tissue extending into the spinal canal.
Conclusion
Peripheral nerve sheath tumors are aggressive tumors which can
be difficult to definitively diagnose and successfully treat. Tumor
Adjuvant Therapy recurrence, or unabated progression of presenting clinical signs
Chemotherapy and radiation therapy are of questionable are the most common complications of treatment. The hallmark
benefit in the treatment of PNSTs affecting the major nerves signs of PSNT, which should be an impetus to pursue further
of the brachial and lumbosacral plexes. There is minimal data diagnostics, are a chronic, progressive forelimb lameness and
describing the efficacy of adjuvant therapies for PNST in these marked muscle atrophy. The treatment of choice for these
locations. The majority of information relative to radiation therapy tumors is aggressive surgical excision, which may require
efficacy refers to the peripherally located, soft tissue sarcoma peripheral excision of the mass, limb amputation, laminectomy,
categorization of nerve sheath tumors (hemangiopericytomas). or a combination of these procedures. The efficacy of adjuvant
Radiation therapy as an adjunct to incomplete surgical excision therapies is not clear at this time. The best approach to these
of canine soft tissue sarcomas resulted in a reported disease tumors will likely be early and aggressive intervention, using
free interval of 1082 days with a survival rate of 76% at five diagnostics such as electromyography and MR imaging sooner
years.22 If PNSTs affecting the plexus nerves have a biological rather than later in the diagnostic workup, to hopefully identify
response similar to those placed in the soft tissue sarcoma the tumor before it has had opportunity to invade multiple nerves
category, then adjuvant radiation therapy could be considered or the spinal canal. Because of the aggressive nature of these
an appropriate part of the management of these tumors. The tumors, the overall prognosis of PNST still has to be considered
major problem with plexus-located tumors is their proximity to guarded to poor.
the spinal cord. A recurrent tumor, or a tumor which continues to
Nervous System 135
transient clinical morbidity. Specialized equipment is generally caudal 1/3 of the proximal end of the exposed nerve is isolated
not needed, but operating loupes to improve the surgeon’s using a ligature of 5-0 or 6-0 silk suture. Gentle traction placed
visualization of the operative field are valuable. The fascicular on the proximal ligature allows for the longitudinal division using
biopsy technique will be described here through an approach ophthalmic scissors of a 2- to 4-cm long distal fascicular biopsy
to the common peroneal nerve. Detailed descriptions of the specimen. Fascicular biopsy specimens should not exceed
surgical approaches to several other peripheral nerves have 30% of the diameter of the parent nerve from which they are
been published elsewhere.1,2 harvested. In the event that the underlying disease process
or inherent structure of the nerve complicates visualization of
The animal is placed in lateral recumbency, and an area extending individual nerve fascicles, the exposed nerve segment can be
from the distal third of the femur to the proximal third of the tibia atraumatically spread over a sterile tongue depressor or scalpel
is prepared for aseptic surgery. The common peroneal nerve can handle, which can aid identification of fascicles (Figure 10-5).
be palpated percutaneously as it courses on the lateral aspect of The biceps femoris fascia is closed with absorbable suture, and
the stifle just caudal to the proximal tibia and fibula. A 5- to 7-cm the skin closed routinely. Application of an external protective
oblique skin incision extending from just caudal to the lateral dressing is usually not necessary. Although it was originally
femoral condyle to the proximal fibula will expose the under- reported that neuromas occur frequently following fascicular
lying fascia of the biceps femoris muscle, through which the biopsy, more recent clinical experiences with large numbers of
target nerve can be palpated (Figure 10-4). The biceps femoris patients suggest that biopsy-related complications are rare.2,3 In
fascia is elevated and a 5-cm fascial incision made which will the case of peroneal nerve biopsy, the most commonly reported
allow visualization of the underlying common peroneal nerve as complication consists of transient proprioceptive deficits and
it courses over the lateral head of the gastrocnemius muscle knuckling of the pes, both of which usually resolve within 5 days
(Figure 10-4- inset). Perineural fat and fascia should be carefully of the procedure.
and bluntly dissected off of the visible portion of the nerve. The
Processing of Nerve Biopsy Specimens
Nerve biopsies require special handling to avoid artifact formation
while in fixative. In order to prevent significant contracture of
the biopsy sample, several techniques have been described to
maintain the length of the nerve biopsy prior to fixation. These
techniques include pinning the nerve at both ends to a section
of tongue depressor with 25 to 27 gauge hypodermic needles or
securing the nerve to a length of the stem of a standard wooden
cotton tipped applicator by placing a circumferential suture of
5-0 or 6-0 silk at either end of the biopsy. The nerve may also
be suspended directly in the fixative using a stainless steel Chapter 11
weight attached to the free end of the original silk suture that
was placed in the proximal portion of the nerve during the biopsy
procedure.
Muscle Biopsy
Ideally, the specialized laboratory that will be receiving and Skeletal Muscle Biopsy
processing the nerve sample should be contacted prior to
performance of the biopsy so that laboratory requests for
Techniques
specific fixatives can be followed. Nerve biopsy specimens are John H. Rossmeisl, Jr.,
preferably fixed in both 2.5% glutaraldehyde and 10% formalin.1
If biochemical or specific immunohistochemical studies are The diagnostic approach to a patient with suspected neuro-
desired, snap-freezing of unfixed nerve tissue may be required. muscular disease begins with a thorough history and complete
Formalin-fixed specimens are embedded in plastic and routinely neurologic examination, which will often yield information
stained with hematoxylin and eosin, Luxol fast blue, or Gomori regarding the component of the motor unit affected. Perfor-
trichome stains and evaluated with light microscopy for mance of electrodiagnostic tests in patients with neuromus-
evidence of axonal degeneration, overt demyelination, or inflam- cular disease often provides important information pertaining
matory or neoplastic cellular infiltrates. Fixation of samples in to the specific localization and extent of the disease within the
glutaraldehyde allows for preparation of semithin and ultrathin motor unit, however it is necessary in some cases to perform
sections for more detailed light microscopic and ultrastructural skeletal muscle biopsy, often in conjunction with peripheral
examinations, respectively. Quantitative morphometric analysis nerve biopsy. Morphologic evaluation of biopsy specimens will
of myelinated and unmyelinated axonal numbers and diameters confirm clinical and electrophysiologic findings and is required
and nerve fiber densities may be performed so that disorders to diagnose and classify the underlying disease responsible for
of myelin may be identified. Glutaraldehyde fixation also allows the clinical signs.
for examination of single teased fiber preparations. Evalu-
ation of teased fiber specimens is especially useful for identi- General clinical indications for muscle biopsy include gener-
fication of disorders of myelinated fibers. The technique allows alized or focal muscle weakness, stiffness, contracture, atrophy,
for the quantitative assessment of the lengths and morphology myalgia, or hypertrophy.1,2 Less commonly encountered clinical
of successive myelin internodes in a single nerve fiber. This abnormalities that are suggestive of underlying motor unit
procedure permits characterization of specific demyelinating disease include muscle fasciculations, rippling, myokymia, and
processes such as segmental and paranodal demyelination, as myotonia. Identification of biochemical alterations such as an
well as remyelination.4 In addition, information regarding current elevated serum creatine kinase concentration, lactic acidemia,
nerve fiber degeneration can be obtained from examination of or myoglobinuria, in any animal with clinical signs compatible
teased fiber specimens. with myopathic disease is also an indication to perform muscle
biopsy. It is recommended that at least two muscle samples
References from distant locations, such as the thoracic and pelvic limbs, be
examined when attempting to confirm the presence of a gener-
1. Braund KG: Nerve and muscle biopsy techniques. Prog Vet Neurol 2: alized neuromuscular disorder.1,2
35, 1980.
2. Braund KG, Walker TL, Vandevelde M: Fascicluar nerve biopsy in the
dog. AmJ Vet Res 40: 1025, 1979. Selection of Biopsy Sites
3. Dickinson PJ, LeCouteur RA. Muscle and nerve biopsy. Vet Clin North Several criteria should be considered prior to selection of
America Sm Anim Pract 32: 63, 2002. the specific biopsy site. Primarily, there should be historical,
4. Braund KG. Diagnostic techniques-nerve and muscle biopsy evalu- clinical, and, ideally, electromyographic (EMG) evidence that the
ation. In: Braund KG, ed. Clinical syndromes in veterinary neurology. 2nd specific muscle is affected by the underlying disease.2 Chroni-
ed. St. Louis: Mosby, 1994, p 376. cally affected, severely atrophied muscles are poor candidates
for biopsy, as meaningful interpretation of biopsies sampled
from such sites is often impeded by significant replacement of
myofibers with adipose and fibrous tissues.1 Muscles should also
be evaluated for any previous disease, trauma, intramuscular
injections, or surgery that could result in morphologic artifacts
in the biopsy specimen. It is noteworthy that needle EMG evalu-
ation can also induce focal muscle necrosis in areas of needle
insertion.1 Subsequently, when performing an EMG exami-
nation of a patient with a suspected generalized neuromuscular
disease, it is preferred to electrophysiologically evaluate one
side of the patient’s body, and then utilize the results of the EMG
examination to obtain biopsy samples from affected muscles on
the contralateral side.1,2
138 Soft Tissue
The muscle selected for biopsy should be readily accessible and biopsy needles (Perfectum 11-gauge needle, Popper and Sons,
easily identified through a minimally invasive surgical approach; Inc., New Hyde Park, NY) with minimal morbidity.3,4 The primary
be able to be sampled with minimal resulting morbidity to the limitations of the percutaneous procedure are the small sample
native muscle or surrounding soft-tissues; and ideally have size of tissue obtained using this method, and inability to prevent
previously published normative data regarding myofiber size, contraction of myofibers after sampling.1,4
type, and distribution available for comparison.1,2 Thoracic limb
muscles commonly selected for biopsy include the distal thirds Although open muscle biopsy procedures can also be performed
of the medial or long heads of the triceps brachii, or proximal using local anesthetics, general anesthesia is usually indicated
portion of the superficial digital flexor. In the pelvic limb, the to facilitate completion of electrodiagnostic testing that often
distal third of the biceps femoris or vastus lateralis, and proximal precedes performance of open muscle biopsy. If local anesthesia
third of the lateral head of the gastrocnemius or cranial tibial is considered for open biopsy, care must be taken not to infil-
muscles are frequently sampled. Reference data for both the dog trate the anesthetic agent deep into the muscle that has been
and cat are available for each of these muscles.1 If disease of the selected for biopsy.2 Open muscle biopsy is readily performed
muscles of mastication is suspected, the temporalis muscle is with basic surgical instrumentation.
the preferred biopsy site.
The skin overlying the biopsy site should undergo routine
Additional factors to consider prior to selecting a biopsy site is aseptic preparation, regardless of the type of biopsy procedure
the suspected localization of the disease within the motor unit, performed. When using the open technique, the skin and any
which is based on the differential diagnoses formulated following superficial fascia are incised, carefully dissected, and retracted
completion of the clinical examination. Biopsy of specific muscles to facilitate visualization of the myofiber orientation of the muscle
or certain regions within a muscle may be required to provide selected for biopsy. Manipulation of the muscle biopsy site
the highest diagnostic yield. For example, when ultrastructural, with forceps should be avoided. Following identification of the
immunohistochemical, or in vitro electrophysiological exami- intended biopsy site, there are three similar methods by which
nation of the motor end plate is required, as would be necessary biopsies intended for routine histochemical analysis can be
to confirm a diagnosis of congenital or seronegative, acquired harvested: the stay suture procedure, the muscle clamp method,
myasthenia gravis, it is recommended that biopsy of a muscle, and the free hand technique. It is not necessary to maintain
such as external intercostals, anconeus, or similar muscle that biopsy specimens that will be subjected to routine analyses in
has high concentration of end plates and is able to be harvested a stretched position.1,4
intact from origin to insertion be performed.1 In these circum-
stances, it is generally advised to discuss the proposed site To harvest the muscle biopsy using the stay suture procedure, a
and method of processing of muscle biopsy specimens with the 0.5 cm diameter, 2 cm long strip of muscle is created by placement
laboratory or pathologist that will be charged with interpreting of two stay sutures. The stay sutures should be placed perpen-
the biopsy before the procedure to facilitate collection of a dicular to the longitudinal orientation of the myofibers, and be
diagnostic sample. tied loosely so as not to excessively constrict the myofibers.
After the stay sutures are in place, two 2 cm long incisions are
In situations where the specific location of the disease within the made parallel to the direction of the myofibers and extending
motor unit is unable to be determined following clinical exami- just beyond the proximal stay suture immediately distal to the
nation and adjunctive electrophysiologic testing is unavailable, other stay suture in order to further isolate the muscle (Figure
it is prudent to consider sampling anatomic sites that are 11-1). The two stay sutures can be used to manipulate the biopsy
amenable to simultaneous biopsy of muscle and peripheral specimen atraumatically during the remainder of the procedure.
nerve through a single surgical approach.2 In the pelvic limb, the
biceps femoris and lateral head of the gastrocnemius muscles,
as well as the common peroneal nerve are all accessible through
a single incision placed over the caudolateral aspect of the distal
femur and proximal tibia. In the thoracic limb, performance of
an oblique incision extending from the medial humeral condyle
to the point of the olecranon provides satisfactory exposure to
the distal third of the medial head of the triceps and superficial
digital flexor muscle, as well as the ulnar nerve at the level of
the elbow.
Figure 11-3. Once the muscle has been completely undermined, the The degree of hemorrhage associated with muscle biopsy
biopsy sample is separated from the native muscle belly by cutting procedures is usually minimal, and can often be controlled with
the myofibers adjacent to the sutures with sharp scissors or a scalpel digital pressure after harvesting the biopsy. Suture ligation may
blade in a fashion that allows for removal of both stay sutures with the be required if a larger intramuscular vessel is encountered.
biopsy specimen. The use of electrocautery should be avoided until all muscle
140 Soft Tissue
biopsy samples have been obtained. Closure of the superficial absence of inflammatory cell infiltrates in representative biopsy
muscular fascia and subcutaneous tissues is performed with an specimens, respectively. Morphologically, there are a variety
absorbable suture, and the skin is closed with sutures or staples. of non-specific findings in muscle biopsies that are suggestive
Application of external wound dressings following open muscle of myopathic disease. These include myofiber splitting, degen-
biopsy is rarely necessary. Complications associated with both eration or regeneration, necrosis and phagocytosis, internalized
the open and percutaneous muscle biopsy techniques are nuclei, and vacuolization.1,2 Increased amounts of fibrous or
uncommon, but can include hematoma formation, wound dehis- adipose tissues within muscle biopsy specimens can be a feature
cence, and infection.1,3 of both primary myopathic and neuropathic muscular disease.
A B
Figure 12-1. Applied eyelid anatomy. A. Cross section of canine upper eyelid. B. Frontal view of superficial and deep structures of the eyelid.
142 Soft Tissue
A B
Figure 12-2. Proper placement of temporary tarsorrhaphy sutures over stents. A. Frontal view of placed tarsorrhaphy suture over a stent and
details of placement of suture through eyelid and stent. B. Cross section of tarsorrhaphy suture placement over stent.
days, non-reactive suture such as monofilament or braided nylon an eyelid laceration is recommended. Following surgical prepa-
is preferred to more reactive suture such as silk. Fine suture (5-0 ration of the skin and conjunctival surfaces with povidine iodine
to 6-0) with a small cutting needle allows proper placement of the solution diluted with saline (10% povidine iodine solution diluted
suture. The needle should be passed first through the 4 mm x 6 with saline to 1% final iodine concentration) and saline rinse,
mm stent and then through the eyelid skin 3-6 mm from the eyelid debridement of the wound with a scalpel blade is performed until
margin. By passing the needle into the tarsal plate, the needle the skin edge begins to hemorrhage. Closure of eyelid lacera-
should exit the eyelid margin at the level of the Meibomian gland tions is performed with fine, absorbable suture (6-0 Vicryl) so
openings. The needle should then be passed into the opposite as to appose the edges of the lacerated tarsal plate (Figure
lid margin at the Meibomian gland openings through the tarsal 12-3A-E). The first bite of the needle should enter the tarsal
plate, and then out through the eyelid skin approximately 3-6 mm plate away from the lid margin and exit the tarsal plate close
from the lid margin. The needle should then be passed through the to the lid margin edge of the tarsal plate (Figure 12-3B). The
stent material away from the lid, and then passed back through needle is then passed to the opposite side of the wound and into
the stent material towards the lid. The needle is then passed the tarsal plate in the area closest to the lid margin to exit the
through skin, tarsal plate, and Meibomian gland openings as tarsal plate away from the lid margin. If performed properly, the
previously described, across and through the opposite lid, and suture pattern approximates a horizontal mattress pattern with
finally through the first piece of stent material so that the needle no suture passing through the palpebral conjunctiva (therefore
exits the same side of the stent material where the original suture there will be no possibility of suture rubbing the cornea) with the
bite took place. When finished, the completed suture pattern knot being tied and buried within the eyelid stroma away from
resembles a horizontal mattress pattern through eyelids and the eyelid margin. A simple continuous pattern trailing away
stents. Meticulous exit and entry of the needle at the Meibomian from the eyelid margin completes closure of the palpebral tarsal
gland openings will result in excellent eyelid margin apposition plate/conjunctiva with the final knot being buried within the
with little to no risk of suture abrading the corneal surface. The eyelid stroma (Figure 12-3C). It is important to place suture bites
suture should be tied tightly so that post-operative loosening and so that no suture is passing through the palpebral conjunctiva
corneal abrasion by the suture may not occur. that could abrade the corneal surface. A fine, braided, synthetic
absorbable suture is preferred over larger, monofilament, and/
or catgut suture material, especially in thin-lidded dogs and
Eyelid Laceration Repair
cats. If the eyelid stroma is excessively swollen, or the patient
Full thickness eyelid lacerations that occur perpendicular to the is a large dog, additional simple interrupted sutures to close
eyelid margin are commonly seen secondary to fight wounds the more external orbicularis oculi muscle are indicated. Skin
and other sharp trauma. Proper closure will result in a functional closure must be meticulous at the eyelid margin so as to result
eyelid and a cosmetically acceptable palpebral fissure. The in a smooth, anatomic eyelid margin. Three suture patterns have
technique for eyelid laceration closure described may also be been described to appose the eyelid margin skin. I prefer to use
used to remove a full thickness eyelid tumor or to shorten an a simple horizontal mattress pattern (Figure 12-3D) using fine
eyelid margin for correction of ectropion. (4-0 to 6-0) nonabsorbable (silk or nylon) braided suture followed
by simple interrupted skin sutures. A cruciate or “figure of eight”
The skin, stroma, and conjunctiva of the eyelids are extremely suture (Figure 12-3E) involving the lid margin followed by simple
vascular, and minimal debridement of damaged tissue following
Eye 143
Figure 12-3. Full thickness eyelid laceration repair. A. Frontal/cross sectional view of full thickness eyelid laceration. B. Proper placement of fine,
synthetic, absorbable suture in the tarsal plate to close the tarsal plate/lid stroma. C. The buried suture is tied so the knot is buried within the
eyelid stroma and cannot abrade the corneal surface. A continuous pattern within the eyelid stroma finishes closure of the deep lid layers. It is
important that the suture does not pass through the palpebral conjunctiva, either during the running stitch pattern or when the final knot is tied.
D. Use of a horizontal mattress suture to close the eyelid margin followed by simple interrupted suture to close skin/orbicularis layer. The suture
tags of the first suture may be left long and incorporated into the subsequent simple interrupted suture to prevent suture tag abrasion of the cor-
neal surface. E. Use of a figure of eight or cruciate pattern to oppose the lid margin without suture tag abrasion of the cornea. F. Use of a simple
interrupted suture to close eyelid margin. The suture should be placed very close to the lid margin, the tags left long, and the tags tied back from
the corneal surface in the subsequent simple interrupted skin sutures.
interrupted skin sutures also results in excellent closure. A well Full Thickness Eyelid Wedge Resection for
placed simple interrupted suture at the lid margin (Figure 12-3F)
with the suture tags being tied back by subsequent simple inter- Correction of Ectropion
rupted sutures can result in excellent anatomic closure as well, Ectropion is eversion of the lower eyelid margin resulting in
but it is important to tie the suture tags in a manner that does not spillage of tears onto the face (epiphora) and excessive exposure
allow the suture tags or the knot to come in contact with and of the palpebral and bulbar conjunctiva and cornea. Ectropion
abrade the corneal surface. If eyelid closure is precarious due to is usually seen in those canine breeds with heavy facial skin,
tissue friability and/or swelling, temporary tarsorrhaphy sutures, excessively long palpebral fissures, and/or lax tarsal plates (e.g.
one on either side of the wound closure, can help immobilize the hounds, giant breeds, and sporting breeds). A simple technique
lids and “splint” the lid until healing is complete and sutures are for “tightening” lower lid ectropion involves a full thickness
removed 10 days post-operatively. wedge resection of the lid to shorten the lid margin (Figure 12-4
A-E) with closure of the wound being similar to that described
for eyelid laceration repair.
144 Soft Tissue
A smooth eyelid margin to help stabilize the precorneal tear with the shape of the excised wedge being the same as that
film meniscus is desirable, so the wedge resection to shorten described for scalpel excision using a lid plate. It is important
the lid margin is performed laterally (Figure 12-4B). There should that the initial incisions from the lid margin through the length of
be some tarsal plate left on each side of the wedge to allow for the tarsal plate be parallel to each other so that upon closure,
closure of the wound in two layers. The initial incision is made there will be a straight, non-indented eyelid margin. Closure of
using a scalpel with a Jaeger lid plate inserted into the cul-de- the wound is in 2 (or 3) layers as for an eyelid laceration (Figures
sac to stabilize the eyelid (Figure 12-4B). The incisions should be 12-4 D and E).
made perpendicular to the eyelid margin (parallel to each other)
to the level of the edge of the tarsal plate and then taper to a point Eyelid Tumor Resection
that ends in the deepest recess of the cul-de-sac (Figure 12-4C).
The incisions may also be made using a Metzenbaum scissor, Eyelid margin tumors are commonly seen in dogs. Meibomian
Figure 12-4. Full thickness eyelid resection to correct simple ectropion. A. Lower lid ectropion with exposure of ventral bulbar conjunctiva and
cornea as well as lower lid conjunctiva. B. Use of Jaeger lid plate to excise full thickness wedge of eyelid. The excision should be made laterally
so as to maintain a smooth eyelid margin. The initial cuts from the eyelid margin should be parallel through the tarsal plate and then taper to the
depth of the cul-de-sac. C. With full thickness wedge removed, surgeon should be able to visualize the edges of the cut tarsal plate. D. Closure of
deep eyelid tissue in same manner as described for eyelid laceration repair. E. Skin closure in the same manner as for eyelid laceration repair.
Eye 145
gland adenomas, mast cell tumors, papillomas, melanomas, and is important to excise the eyelid with incisons through the tarsal
squamous cell carcinomas may occur in the lid. In cats, eyelid plate area being made parallel to each other and perpendicular
neoplasia is uncommon and most tumors are malignant. A full to the lid margin to maintain a smooth, anatomic lid margin after
thickness wedge resection as described for ectropion correction healing.
and a two-layer closure as described for eyelid laceration is
used to remove most eyelid tumors. If more than one-third of the lid margin is excised to obtain
tumor free margins, closure may be complicated by inadequate
Depending on the species (cats have tight lid margins compared surrounding tissue. This may result in excessive lid margin
to dogs with more lax margins) and breed (hounds and sporting tension and poor lid function. A lateral canthotomy incision may
breeds have more lax lids than do toy breeds such as miniature enhance lid closure by allowing eyelid tissue to slide medially
poodles), approximately 1/4 to 1/3 of an eyelid may be removed and be advanced to close the defect (Figure 12-5A-C). Following
and closed in the manner listed above for ectropion correction. It excision of the eyelid mass, a Metzenbaum scissor is used to
Figure 12-5. Wedge excision for removal of eyelid mass. A. Excision of 1/3 or more of eyelid margin to remove an eyelid mass. B. Lateral can-
thotomy is performed from canthus to the depth of the cul-de-sac with a Metzenbaum scissor taking care not to sever the orbital ligament. C. The
eyelid margin wound is first closed in two layers. The lateral canthotomy is closed as it lies in two layers. This will result in a wound edge of the
lateral canthotomy becoming the new eyelid margin. This is allowed to heal be second intention.
146 Soft Tissue
cut full thickness from the lateral canthus to the depths of the making the skin incision and during undermining of the flap to not
cul-de-sac laterally being cautious so as to not cut the lateral damage the superficial temporal artery located subcutaneously
orbital ligament. This incision (Figure 12-5B) yields less lateral lateral to the lateral canthus. A two layer closure of the lid mass
tension, which allows for a more effective two-layer closure excision wound is followed by buried absorbable sutures placed
of the lid wound. Closure of the lateral canthotomy using the to reduce dead space beneath the skin flap. The skin flap incision
two layer technique leaves a small wound margin at the lateral is closed in two layers up to the edge of the new lateral canthus.
canthotomy incision to heal by second intention (figure 12-5C). The newly formed eyelid margin created by the skin flap is left to
heal by second intention. Complications may include trichiasis
If one-half or more of the eyelid margin must be excised for tumor from facial hair, a flaccid lower eyelid that permits epiphora,
excison, a semicircular sliding skin flap is constructed to close or a flaccid upper eyelid (ptosis) due to excision of the levator
the resulting defect. Following excision of the lid mass and a palpebrae muscle in the original excision.
releasing lateral canthotomy (Figure 12-6A), the semicircular skin
flap is constructed by making a curved skin incision extending Entropion
laterally from the end of the lateral canthotomy extending approxi-
mately 1.5-2.5 times the width of the void to be filled (Figure 12-6B). Entropion is defined as inward turning/inversion of the eyelid(s).
Excision of a Burow’s triangle of skin at the lateral terminus of the The condition is commonly seen in dogs and occasionally in cats
semicircular flap incision will minimize focal terminal distortion resulting in frictional irritation of the conjunctival and corneal
upon closure of the wound. The surgeon should use caution in surfaces by eyelashes and/or facial hairs of the lid. This frictional
Figure 12-6. Wedge resection of a large eyelid mass with use of a semicircular flap to fill in eyelid margin void. A. Excision of 1/2 or more of eyelid
margin to remove an eyelid mass in conjunction with lateral canthotomy. B. Dotted line indicates the semicircular graft cut and Burow’s triangle.
Cross-hatching indicates skin to be undermined to allow sliding of the graft. C. Eyelid margin excision site is first closed in two layers. Buried
absorbable sutures reduce dead space under semicircular graft. Semicircular graft is closed up to the point of lateral canthus in two layers. The
semicircular flap makes the new lateral aspect of the upper eyelid; the new eyelid margin is allowed to heal by second intention.
Eye 147
irritation is painful and may lead to corneal ulceration, corneal being too tight causing the medial aspect of the upper and
neovascularization and deposition of pigment on the corneal lower eyelids to roll inward. Frictional irritation to the corneal
surface (pigmentary keratitis). In severe cases, vision loss from surface by the medial canthal hairs and lashes leads to medial
corneal scarring and opacification, corneal perforation, and loss corneal neovascularization and subsequent pigment migration
of the globe from deep corneal ulceration are possible. (pigmentary keratitis). This form of entropion seldom appears
to be painful to the patient and usually does not have a spastic
In cats, lower lid entropion may be seen in brachycephalic breeds component similar to other forms of entropion.
(e.g. Persians and Himalayans) as a conformational defect due
to the shortened face. Spastic entropion occurs when an ocular Temporary Everting Suture Technique for
irritant causes severe blepharospasm that leads to rolling in of
the eyelid margin. Since the frictional irritation of the facial hairs Treatment of Spastic Entropion
on the corneal surface causes more pain, spastic entropion Temporarily everting the eyelid margins is an effective method
becomes a cycle of pain, blepharospasm, and corneal irritation of disrupting the cycle of frictional irritation, pain, and blephar-
with continued pain and blepharospasm. Spastic entropion may ospasm caused by spastic entropion. This technique should
be seen in young cats (< 6 months of age) of the brachycepahlic always be used in young animals prior to more permanent skin
breeds and in adult cats with corneal pain due to infectious (e.g. removal entropion repair. It is difficult to evaluate how much
feline herpes virus-1) or irritation induced keratitis conditions. tissue needs to be removed in the young patient with entropion,
and overzealous tissue removal may result in eyelid scarring
In dogs, spastic entropion is seen in young puppies of breeds and/or ectropion in later life. Likewise, in an adult animal with
(e.g. Shar Peis, Chow Chows, and others) with excessive no history of previous entropion, the practitioner should identify
facial skin and laxity of eyelid structures such as the retractor the underlying source of pain, treat that condition, and tempo-
anguli muscle or ligament. In some puppies, when neonatal rarily evert the eyelids for pain relief rather than performing
ankyloblepharon resolves and the eyelids open at 2 weeks of permanent entropion corrective surgery. A simple technique
age, the eyelid margins begin to roll inward due to heavy facial to evaluate for spastic entropion is to apply a drop of topical
skin and eyelid laxity. In adult dogs, spastic entropion may be anesthetic (0.5% proparacaine) to determine if blepharospasm
seen in animals that have a painful ocular condition leading to abates. If topical anesthetic use relaxes the blepharospasm and
excessive blepharospasm similar to that described for cats. resulting entropion, a temporary everting technique maintained
for 7-10 days may result in resolution of the entropion without
Lower eyelid entropion in dogs is commonly seen in younger dogs tissue excision. Topical anesthetic is applied as a diagnostic
(less than one year of age) due to deep-set globes and conforma- test only and is contraindicated as therapy for spastic entropion.
tional defects of the eyelids and facial structures. Lower eyelid Topical anesthetics are epithelial toxic, and by deadening the
entropion may also have a spastic component which should be ocular surface to pain and sensation, further damage to the
considered when surgically correcting the defect. corneal surface may occur.
Upper eyelid entropion occurs in those heavy faced breeds (e.g. Periocular hair is shaved and the skin is prepared with dilute
bloodhounds, Shar Peis, Chow Chows, mastiffs, and others) povidine iodine and saline. Multiple everting sutures of either
where the extreme weight of the forehead skin and upper lids a braided or monofilament synthetic (polypropylene or nylon)
and a lack of connective tissue structures leads to the upper suture material are placed in the skin. Either vertical mattress
eyelid margins rolling over onto the ocular surface with the upper (Figures 12-7A-D) or horizontal mattress (Figure 12-7E) sutures
eyelashes abrading the corneal surface. Upper eyelid entropion are used. I prefer multiple small (5-0 or 6-0) sutures versus fewer
usually has a major spastic component similar to that caused by larger (2-0 or 3-0) sutures. In young patients, thin, friable skin
lower eyelid entropion. may not hold a larger suture, and if the suture pulls through the
skin, entropion resumes, and a noticeable scar may be present
Lateral canthal entropion occurs mostly in heavy faced breeds from the resulting defect. Suture placement depends on how
(e.g. Shar Peis, Chow Chows, mastiffs, St. Bernards, Bernese much entropion is present. If only the lower lid is involved,
mountain dogs, English bulldogs, and others) where there is only everting sutures involving the lower lid are used. It is not
also laxity of the retractor anguli ligament/muscle. This allows uncommon in Shar Peis, Chow Chows, and bulldogs for entropion
the lateral canthal structures to roll inward causing frictional to affect the upper and lower lids and lateral canthus (Figure
irritation to the cornea and conjunctiva. A spastic component may 12-7F), thus everting sutures are placed in all 3 areas (Figure
be seen in cases of lateral canthal entropion. In those breeds (St. 12-7G). For the vertical mattress suture technique, the first bite
Bernard, mastiffs, Bernese mountain dogs, Newfoundlands, and into the skin should be very close to the outside edge of the lid
others) with excessively long palpebral fissures (macropalpebral margin and the needle directed away from the lid margin. The
fissure) and lax tarsal plates, a combination of lateral canthal second bite should be further away from the lid margin so that
entropion and lower lid ectropion with an upward “notching” of when the knot is tied with appropriate tension, the eyelid margin
the upper eyelid margin is seen. is everted from the ocular surface. The suture tag closest to the
globe should be cut close to the knot so as to not abrade the
Medial canthal entropion is seen primarily in brachycephalic cornea while sutures are present. The suture tag directed away
breeds (pugs, Shi Tzus, Lhasa Apsos, and others). The brachy- from the lid margin should be long to allow for suture removal
cephalic conformation results in the medial palpebral ligament in 7-10 days. For the horizontal mattress technique, the first bite
148 Soft Tissue
Figure 12-7. Temporary everting suture correction of spastic entropion. A. Lower eyelid entropion commonly seen with spastic entropion. B.
Placement of multiple fine, synthetic vertical mattress sutures to evert the spastic entropion. Sutures may be placed and tied in sequence, or,
in very small animals, all sutures may be pre-placed and then tied. C. Finished product using vertical mattress temporary everting sutures. Note
how the suture tags closest to the lid margin are cut very short and the suture tags away from the lid margin are left long to aid in suture removal.
D. Cross sectional view of spastic entropion and after temporary everting suture placement. Note that the lid margin is overly everted. This is
preferred to prevent the patient from spasming eyelids and causing frictional irritation of the cornea by the sutures. E. Placement of horizontal
mattress sutures for temporary eversion of lid margins. F. Upper, lower, and lateral canthal spastic entropion commonly seen in Shar Pei and
Chow Chow puppies. G. Suture placement/final product for treatment of upper, lower, and lateral canthal spastic entropion.
Eye 149
should be close to the lid margin and the exit site of the needle man. Skin is excised and wound edges are sutured in a manner
equally close to the lid margin. The second bite will be further that everts the entropic area of the lid margin (Figure 12-8A-D).
from the lid margin with the needle path being parallel to the first Prior to surgery, it is important to estimate how much tissue must
needle tract/lid margin. After tying the suture, the knot is rotated be removed to correct the entropion without causing ectropion.
away from the lid margin and suture tags are cut to avoid corneal This determination is made based on experience, but there are
irritation. Prevention of post-operative self-trauma (or trauma by techniques and surgical landmarks that will aid the surgeon.
the bitch if puppies are still nursing) is important. If the cornea Prior to patient sedation, a drop of topical anesthetic is placed
is ulcerated, symptomatic care with topical antibiotic ointment in the affected eye and the patient placed on an elevated table
with or without use of atropine for cycloplegia and pain relief for examination. The surgeon should examine the patient with
is indicated. Sutures should be left in as long as possible (7-10 magnification without touching the face or periocular struc-
days) to reduce blepharospasm and recurrence of entropion. tures. This will assist the surgeon in accurately estimating the
amount of tissue to be excised. After anesthetic induction, hair
removal, and disinfection of the surgical site, the patient is
Modified Hotz-Celsus Technique for Correction
placed in lateral recumbency for surgery. A Jaeger lid plate is
of Simple Entropion placed to tense the eyelid and an incision is made with a scalpel.
The simplest technique for correction of lower or upper lid The saline moistened Jaeger lid plate is placed in the cul-de-sac
entropion is a modification of the Hotz-Celsus technique used in and an assistant tenses the eyelid by lifting the lid with the lid
Figure 12-8. Modification of simple Hotz-Celsus procedure for entropion correction. A. Lower lid entropion. B. With the Jaeger lid plate in posi-
tion, a smooth tapering skin incision can be made with a scalpel (bold dashed lines). The stippled area represents the area of the lid that was
entropic. C. After excision of the skin, the Jaeger lid plate is removed and the skin is closed without tension. The first suture (1) is placed to halve
the incision line. The next two sutures (2 and 3) are placed so as to quarter the incision line. D. depending on size of suture being used, sutures
are placed 2-4 mm apart. Note that suture tags closest to the globe are cut short, those directed away from the globe are left long to enhance
removal at a later date. Everting vertical mattress sutures are shown (A, B, and C) in this illustration. These are placed in those dogs with a se-
vere spastic component to their entropion to prevent post-operative spasming with suture tag abrasion of the corneal surface. To accomplish this
pattern (see inset), the first pass of the suture is across the wound (1) as with the other simple interrupted sutures to close the wound, and the
second pass is through the skin away from the incision (2). When tied, these vertical mattress sutures evert the lid margins just like the everting
sutures described above under spastic entropion correction.
150 Soft Tissue
plate (Figure 12-8 B). The surgeon uses thumb and index finger (Figure 12-9B). This provides the surgeon additional tissue for
placed at the medial and lateral aspects of the area to be incised closeing the resulting defect. The second incision begins at the
to tense the tissue for a smoother incision. The incision closest medial-most extent of the first incision and gradually diverges
to the lid margin should be made at the level where the eyelid from the first incisions. The point of intersection of the incisions
hair begins (lower eyelid) or about 1-2 mm away from the upper lateral to the lateral canthus is dependent on how much
eyelashes (upper eyelid). The first incision should be made far eversion of the lateral canthus is necessary. In patients with
enough from the lid margin to allow placement of sutures that minimal loose facial skin, closure of the “arrowhead” shaped
will not abrade the cornea during healing. The surgical incisions skin incision may be adequate to correct the lateral entropion.
and resulting wound should only be skin thickness, and no In most dogs undergoing this procedure, however, a prosthetic
attempt should be made to remove orbicularis oculi muscle or lateral canthal ligament must be constructed to retract the
tarsal plate structures. The second incision should be made lateral canthus and correct the defect. Prior to closure of the
distal to the initial incision at the point of greatest entropion and skin, blunt dissection is performed to undermine the skin over
join the ends of the first incision in a smooth tapering fashion. the lateral orbital ligament. Either a 4-0 monofilament nonab-
The amount of tissue to remove is determined in the preoper- sorbable (nylon or polypropylene) or polydioxanone suture is
ative examination prior to sedation and by looking for a line of used to first take a bite in the lateral most tip of the tarsal plate
hair loss or skin discoloration due to the entropion. After the skin followed by passage of the suture through the periosteum over
incisions, the skin is removed with the scalpel or a fine scissors. the orbital ligament. The surgeon may use two sutures (Figure
Following excision of tissue, the Jaeger lid plate should be 12-9C, upper) or a more complex placement of one suture
removed and the skin sutured as it lies without tension (Figure (Figure 12-9C, lower) to pull the lateral canthus laterally and
12-8C). The first nonabsorbable suture (4-0 or 5-0 monofilament anchor it to the orbital ligament. Skin closure should begin at the
or braided nylon or polypropylene) skin suture should approxi- lateral-most “point” of the “arrowhead” followed by a suture of
mately halve the wound defect. The next two sutures should be the upper and then lower lid as for the traditional Hotz-Celsus
placed to divide the suture line into quarters. Since the second technique (Figure 12-9D). In those dogs with upper, lower, and
incision is in the form of an arc, it is longer than the initial skin lateral canthal entropion, a skin incision of approximately 270°
incision that is parallel to and close to the lid margin. By utilizing around the eyelid circumference (Figure 12-9E) may be made
a simple interrupted closure, bunching or “dog-ears” of one end to result in correction of all abnormalities with one surgery.
of the suture line with a continuous suture pattern is prevented. Temporary everting sutures as described for the Hotz-Celsus
The fine sutures should be placed close together (2-4 mm apart, entropion correction are highly recommended in these patients.
depending on the size of the patient and suture size) and the In patients with a macropalpebral fissure, this “arrowhead”
suture tags closest to the eye should be cut close to the knot correction technique corrects the entropion, but the ultimate
with the tags away from the eye being left longer. In animals exaggerated lateral placement of the lateral canthus may be
with excessive preoperative blepharospasm and a spastic cosmetically unacceptable, so the more complex lateral canthal
component to the entropion, intermittent vertical mattress reconstructive surgery described by Bigelbach is indicated.
sutures may be placed along the suture line to “overcorrect”
the entropion until the skin sutures are removed at 10-14 days Modification of Bigelbach’s Combined
post-surgery (Figure 12-8D). In some cases, I “overcorrect”
dogs of certain breeds (Chow Chow and Shar Peis) with vertical Tarsorrhaphy-canthoplasty Technique for
mattress sutures to prevent post-operative spasming with Repair of Lateral Canthal Entropion and Lower
resulting suture contact of the corneal surface. Post-operative
therapy consists of prevention of self-trauma, topical antibiotic Lid Ectropion
ointment for treatment of corneal ulcers, systemic antibiotics, In those dogs where a combination of macropalpebral fissure
and non-steroidal anti-inflammatory drugs for pain. and lateral retractor anguli ligament laxity results in lateral
canthal entropion and lower eyelid ectropion (e.g. St. Bernards,
mastiffs, Newfoundlands, and similar breeds), a technique to
“Arrowhead” Technique for Correction of Lateral shorten the palpebral fissure and retract the lateral canthus has
Canthal Entropion been described (Figure 12-10A-G).
In those breeds with lateral canthal entropion but a normal length
palpebral fissure (e.g. Shar Peis and Chow Chows), a modifi- First, the amount of eyelid to be excised must be determined.
cation of the Hotz-Celsus procedure (termed the “arrowhead” From 20 to 30% of the lateral-most upper and lower lids may
technique) may be used to evert the lateral canthal eyelid skin be removed and still retain normal function and an acceptable
(Figure 12-9A-D). The Jaeger lid plate is used to tense the tissue, cosmetic appearance. The upper and lower eyelid margins are
allowing smooth incision of the eyelid skin with a scalpel. The lid notched with a scissor or scalpel an equal distance from the
plate is placed in the lateral cul-de-sac and tensed upward by an lateral canthus (Figure 12-10B). The distance from these notches
assistant, simultaneously the surgeon tenses the lateral canthal to the lateral canthus (D) is measured. Extending from the lateral
tissue with the thumb and index finger on the upper and lower canthus, sweeping upward and downward from the lateral
lids. The initial skin incisions should be approximately 2 mm from canthus and following the general curvature of the eyelids,
the lid margin along the upper and lower lids. Beginning about 6 two skin incisions are made with a scalpel (Figure 12-10C).
mm from the lateral canthus, the skin incisions start to diverge These incisions are two times D in length. The tips of the two
from the lid margin and meet 5 mm lateral to the lateral canthus. curved incisions are connected by a vertical skin incision, and
Eye 151
Figure 12-9. “Arrowhead” technique for correction of lateral canthal entropion. A. Lateral canthal entropion. B. Placement of Jaeger lid plate to
tense tissue. Scalpel is used to incise skin as depicted by dashed lines. The incisions (1) 2 mm from the lid margins are made first. Approximately
5 mm from the lateral canthus, the incisions gradually diverge so that where the two initial incisions meet is approximately 5 mm lateral to the lat-
eral canthus. The second incisions (2) diverge from the medial-most tips of the first incisions and meet lateral to the lateral canthus. This outlined
skin is excised with a scalpel or small scissors. C. In loose skinned dogs, a prosthetic lateral canthal ligament is constructed prior to skin closure.
Two sutures (1 and 2, upper diagram) of 4-0 monofilament absorbable or nonabsorbable material are placed to retract the lateral tarsal plates
towards the orbital ligament. One continuous suture (lower diagram) may be used instead of two. D. Skin closure of the “arrowhead” begins with
closure of the lateral-most aspect (sutures labeled 1) followed by closure of the middle of the upper lid incision (2), then the lower lid (3). The
remainder of the suture line is then filled in with simple interrupted nonabsorbable sutures like was the case with the Hotz-Celsus procedure de-
scribed above. E. For those patients with complex upper lid, lower lid, and lateral canthal entropion, a continuous upper lid, lower lid, and lateral
canthal skin incision may be made. The lateral canthus is closed first (1), followed by closure of the middle of the upper and lower lid incisions (2
and 3). The remainder of the skin closure is as described above.
full thickness lid incisions are made from the original notches mattress suture of 4-0 braided nylon or silk. The remainder of the
to the tips of the sweeping skin incisions using either a scissor skin incision is closed with simple interrupted sutures.
or a Jaeger lid plate and a scalpel (figure 12-10D). The skin of
the incision triangle is removed with scissor or scalpel, and the
Medial Canthoplasty to Correct Medial Entropion
full thickness eyelid triangles from the upper and lower lids are
removed with scissors (Figure 12-10E). The tarsal plate edges and and to Shorten the Palpebral Fissure (Roberts
ends of the severed orbicularis muscle of the upper and lower and Jensen “pocket-flap” Technique).
lids are tacked to the lateral orbital ligament with absorbable
Reconstruction of the medial canthus in brachycephalic breeds of
suture (5-0 Vicryl or 4-0 PDS) in the same manner as described
dogs may correct medial entropion and reduce frictional irritation
for the “arrowhead” lateral canthal entropion repair (Figure
to the cornea that causes pigmentary keratitis. In addition, the
12-10E). The upper and lower eyelid stroma is sutured to the
shortening of the palpebral fissure reduces exposure of the cornea,
subcuticular fascia of the face in a buried, continuous pattern
enhances total closure of the lids during blinking and during sleep,
with the same absorbable suture (Figure 12-10F). The skin is
reduces frictional irritation from nasal fold trichiasis, and may help
closed to align the lateral canthus with the center of the vertical
to prevent proptosis in predisposed exophthalmic dogs.
connecting incision (Figure 12-10G) using a single horizontal
152 Soft Tissue
Figure 12-10. Correction of lateral canthal entropion, lower lid ectropion, and macropalpebral fissure (modification of Bigelbach’s technique). A.
Combination lateral canthal entropion, lower lid ectropion, and macropalpebral fissure. Many of these patients also have a defined “notch” of the
upper eyelid margin due to tarsal plate malformation. B. Upper and lower eyelids are notched with scissor or scalpel. The distance D from notch
to lateral canthus is noted. C. Sweeping skin incisions that roughly follow the curvature of the lid margins begin at the lateral canthus and extend
a distance of approximately two times distance D. The distal tips of these skin incisions are connected with a skin incision. D. Using a Jaeger lid
plate and scalpel or a scissor, the full thickness of the lids is cut at the previously notched sites extending to the tips of the skin incision. E. After
removal of the full thickness lid pieces and triangular skin excision, the tarsal plate of upper and lower lids are tacked to a common point on the
lateral orbital ligament using absorbable suture. F. The tarsal plate/lid stroma are tacked to the subcuticular tissue of the vertical portion of the
skin incision. G. The points of the skin incisions of the upper and lower lids are sutured to a common point in the center of the vertical skin inci-
sion using a horizontal mattress suture of 4-0 nonabsorbable material. The remainder of the skin is closed with simple interrupted sutures of the
same material.
Eye 153
Figure 12-11. Medial canthoplasty technique (Roberts and Jensen “pocket-flap” technique). A. With the lid tensed laterally, the eyelid is split at
the margin using a scalpel. Both upper and lower lids are split. B. The lid splitting is carried to a depth of approximately one centimeter. C. Using
a small scissor, a strip of lid margin approximately 2 mm wide is excised from the edges of the lid splitting back medially to the medial canthus.
The upper and lower lid excisions join at the medial canthus. D. A scissor is used to cut the innermost tarsal plate/conjunctival tissue of the upper
lid perpendicular to the lid margin to a depth of one centimeter. E. The triangular flap of tissue is scarified on the conjunctival surface to the point
of hemorrhaging. F. To anchor the upper lid flap of tissue into the lower lid pocket, suture is passed through the lower lid skin at the level of the
depth of the pocket, into the pocket, and out the split lid margin. A mosquito hemostat passed into the ventral pocket and partially opened makes
passage of the needle easier. G. The suture is passed through the tip of the flap tissue, and the needle is re-directed back into the ventral pocket
and then out through the skin at the depth of the pocket. H. The suture is tied as the flap is worked into the deepest recess of the pocket. If non-
absorbable silk has been used, the surgeon may choose to place the suture through a stent as described in the temporary tarsorrhaphy proce-
dure. If absorbable suture has been used, the surgeon may choose to bury the suture and knot beneath the skin. I. The skin edges are closed with
fine suture in two layers as described previously for the eyelid laceration closure.
154 Soft Tissue
horizontally and 16 mm vertically. Corneal cross-sectional have protuberant teeth, which aid in grasping and stabilizing
anatomy consists of five layers, with a thickness of approxi- tissues without crushing force. Colibri-style forceps are curved,
mately 400 to 800 µm in the dog and 470 to 830 µm in the cat. which allow manipulation of tissue while keeping the handle of
The outermost layer is the epithelium, comprised of five to seven the instrument out of the magnified surgical field. Bishop-Harmon
stratified squamous cells, which are in a constant state of renewal and similar forceps have teeth at right angles to each other and
every seven to ten days. A basement membrane lies beneath the the handle. These forceps stabilize cut edges, where both sides
epithelium, followed by corneal stroma, which provides approxi- of the tissue may be gently grasped. The third type of forceps
mately 90% of the corneal thickness. Descemet’s membrane is has no teeth, only smooth appositional platforms. These instru-
the acellular basement membrane of the corneal endothelium, ments are indicated for tying fine suture material (eg. 6-0 and
which is a single layer of cells adjacent to the aqueous humor of smaller). They should not be used to grasp tissues, as adequate
the anterior chamber. fixation may only be obtained with crushing force resulting in
possible damage to the tissue and instrument. Some Castroviejo
The cornea functions to protect and support the intraocular and Colibri-style forceps incorporate a tying platform for suture
contents and to transmit and refract light. To accomplish behind the teeth. If the tying platform on these instruments is
these functions, the cornea is avascular, has low cellularity, used, care is taken to avoid grasping and damaging suture with
and maintains a relative state of dehydration by a pumping the forceps teeth.
mechanism in the endothelium and lipophilicity of the epithelial
and endothelial layers. The corneal layers are thus nourished by Ophthalmic surgical scissors that are frequently utilized include
the precorneal tear film, aqueous humor, and perilimbal vascu- blunt and sharp tipped tenotomy scissors. Blunt tips are usually
lature. The corneal stroma is transparent and consists of parallel preferred, as they are less likely to penetrate delicate tissues.
bundles of collagen comprising lamellae that span the entire Stevens tenotomy scissors, with ring finger holds, and Wescott
corneal diameter and lie in layered sheets to provide most of the scissors, with spring handles are our preference.
stromal volume. Low numbers of specialized fibroblasts called
keratocytes, and leukocytes along with extracellular matrix The scalpels and handles that are typically used in corneal
comprise the remainder of the stroma. The corneal curvature surgery are Beaver brand. The handles are rounded and should
and structural composition in the dog allows for approximately be held like a pencil, and the blades are designed in various
40 to 42 diopters of refraction, and represents the most powerful shapes. A #64 Beaver blade has a curved tip and cutting surfaces
refractive surface of the eye. on the tip and on one side of the blade. This blade is used for
performing corneal grooves as well as undermining keratectomy
sites. Another instrument that may be used for keratectomies is
Instrumentation and Surgical Preparation a Martinez corneal dissector, which has a slightly curved semi-
Surgical success improves with the appropriate use of specific sharp blade allowing for dissection between parallel lamellae.
ophthalmic surgical instruments. A comprehensive review of
ophthalmic surgical instrumentation is beyond the scope of Needle holders have fine curved or straight tips, with either
this chapter, however a discussion of required equipment is locking or non-locking handles. Most surgeons use slightly
provided. Most surgical procedures involving the conjunctiva curved locking needle holders for corneal and conjunctival
and cornea are performed more accurately using magnification. procedures. Needles should be positioned in the holders so that
An operating microscope is ideal, although head loupe magni- the shaft of the needle is perpendicular to the tips of the holders.
fication of 2.5 to 4.5x with appropriate lighting is adequate for Spatulated needles with swaged on suture are preferred to
many cases. minimize disruption of corneal layers. Size 6-0 suture or smaller
should be used with ophthalmic needle holders, as larger
Ophthalmic surgical instruments are more delicate and have finer needles may damage the instrument. In general, 7-0 or 8-0 multi-
tips than general surgical instruments, and specialized care is filament absorbable suture material is utilized for conjunctival
required to maintain instruments in the best condition. Surgical and corneal procedures in small animals.
trays that keep instruments separate and protect the tips should
be utilized, and gas sterilization is ideal to maintain instrument Proper patient preparation and positioning are essential for
life. In contrast to instruments used in general surgery, many conjunctival and corneal procedures. Most cases require
ophthalmic instruments have rounded handles and should be general anesthesia, though some may be performed with topical
held like writing instruments. Many instruments also have spring anesthetic and sedation or short acting anesthetic agents.
handles instead of the more traditional finger rings for opening Anesthetic risk and general patient health are vital consider-
and closing blades. These qualities help minimize hand and arm ations, and preoperative evaluation should include a complete
movements, allowing finger movements to predominate, which physical examination as well as appropriate bloodwork. Excess
provides finer surgical control. hair should be carefully trimmed or clipped from the face, and
unless infection is suspected and cultures are desired, any
Instruments required for conjunctival and corneal surgeries discharge or debris should be cleaned from the eye. Surgical
include tissue forceps, scissors, scalpel handles and blades, and scrub solutions should not be applied to the eye, and many
needle holders that accommodate small needles and fine suture. antiseptic solutions are irritating to the conjunctival and corneal
Tissue forceps have three basic designs with regard to the teeth tissues. Dilute povidone solution (1:10 to 1:50 of the 10% stock
and appositional surfaces. Colibri-style and Castroviejo forceps solution) is non-toxic and may be gently applied to the eye by
156 Soft Tissue
lavage and then removed by rinsing with sterile saline. A cotton- Surgical Techniques
tipped applicator soaked in dilute povidone-iodine is used to
clean the cul-de-sacs. In preparation for most conjunctival and Lacerations
corneal procedures, the patient is placed in dorsal recumbency, Conjunctival and corneal lacerations are traumatic injuries that
with the head positioned so that it is stable and the cornea of the often require very different approaches. Preliminary evaluation
eye to be operated is parallel to the table. An eyelid speculum of conjunctival lacerations should allow the surgeon to localize
provides increased exposure of the eye and aids visualization of the wound and assess the extent of the injury. Local swelling,
the surgical field, or alternatively, suture may be passed through hemorrhage, and patient discomfort may obscure the injury
the skin of the eyelid, parallel to the margin, to aid in retraction and general anesthesia may be required to explore the wound.
of the lids. Hemorrhage should be carefully controlled with dilute The sclera, nasolacrimal system, cornea, and intraocular struc-
(approximately 1:10,000) epinephrine and sterile cotton tip appli- tures should be assessed for evidence of trauma. The patient
cators or cellulose sponges. It is essential that the cornea be is positioned in dorsal recumbency and magnification used to
kept moistened throughout the surgical procedure and is accom- accurately assess the injury. An eyelid speculum or stay sutures
plished by dripping saline onto the eye every twenty to thirty are placed to increase exposure. If warranted, the nasolacrimal
seconds. In addition to an eyelid speculum, stay sutures may be ducts should be cannulated and flushed to ensure patency. A
placed to stabilize the globe and expose the areas of surgical 22 to 24-gauge intravenous catheter with the stylette removed
interest. Stay sutures are placed using 5-0 or 6-0 non-absorbable may be used to cannulate the ducts, and the lids may be stabi-
suture, with the needle passed partial thickness through the lized with Bishop-Harmon forceps. Instruments that will assist in
sclera and parallel along the limbus. To avoid penetrating the wound exploration include Colibri or Castroveijo forceps to grasp
globe, the needle should be nearly parallel to the surface of the the tissues and rotate the globe. Gentle and thorough flushing
sclera is it is passed through the tissue. Tags should be tied and should be performed with sterile saline. Necrotic tissue should
left long to allow manipulation without obstructing the visual field be carefully excised and hemorrhage should be controlled. The
(Figure 12-12). Caution is used to avoid traumatizing the cornea wound is systematically explored and evaluated for corneal and
when the stay sutures are manipulated. In general, the globe scleral injury, trauma to the extraocular muscles and perior-
is stabilized by grasping the tissue near the area of interest, bital tissues, and the presence of foreign material. Evidence of
thereby minimizing globe rotation. Tension on the globe caused extensive trauma increases the short and long term chances
by tissue retraction is not appropriate, and tension that causes of vision-threatening complications, such as endophthalmitis,
deformation of the globe is dangerous to the health of the eye. intraocular hemorrhage, or retinal detachment. A description of
surgical repair of extensive globe or orbital trauma is beyond the
scope of this chapter, and referral to a veterinary ophthalmologist
should be considered. If the wound is obviously contaminated,
culture samples should be obtained. A conjunctival wound that
is smaller than one centimeter, or one with copious drainage is
allowed to heal by second intention. If the wound is larger than
one centimeter, closure with 6-0 absorbable suture in a simple
continuous pattern is appropriate. Care is taken to avoid suture
tags or knots contacting the corneal surface.
patient is anesthetized and carefully prepared with minimal neck evaluation. Conjunctival incisions of less than one centimeter in
restraint or manipulation of the globe. The patient is positioned length do not require primary closure and will heal by second
in dorsal recumbency and use of an operating microscope is intention. Defects that are larger than one centimeter should be
preferred. Prolapsed uveal tissue is either replaced with the closed with 6-0 absorbable suture in a continuous pattern. Care
aid of a viscoelastic agent and gentle separation of adhesions should be taken to avoid allowing suture or knots to contact the
or excised if the prolapsed tissue is severely desiccated. Fine corneal surface. Post-operative care is summarized in the final
tipped Colibri forceps are used for corneal and iridal manipula- section of the chapter, and the patient should be rechecked in
tions. Manipulation of iris tissue may cause significant hemor- five to seven days.
rhage, which must be controlled to avoid serious damage to the
eye. Use of 1:10,000 dilute epinephrine will decrease hemorrhage If the tissue of interest is expansive or seems firmly adhered
and careful use of a fine-tipped cautery is sometimes necessary. to the underlying sclera, there should be suspicion of possible
Viscoelastic agents are used to maintain the formation of the intraocular involvement and more extensive disease. Though an
anterior chamber while the corneal wound is assessed and incisional biopsy is still an appropriate initial approach, referral
repaired. Prior to completion of closure of a full thickness lacer- should be considered for ocular ultrasound and additional
ation, most of the viscoelastic agent should be flushed from the surgical options. If the lesion is near the limbus, or if it involves
anterior chamber and replaced with a balanced salt solution. the cornea, a superficial keratectomy may be required, as
described in a later section of this chapter.
Corneal tissue does not stretch, so the edges of corneal lacera-
tions, whether full or partial thickness, should not be debrided or
Keratotomy
excised. Superficial lacerations may heal without surgical repair
by application of prophylactic topical antimicrobial ointment. The primary indications for keratotomies are spontaneous
Many lacerations are deep and irregular, requiring placement chronic corneal epithelial defects (SCCEDs) that occur in
of interrupted sutures to appose the edges. Sutures should middle-aged to older dogs. These lesions are also known as
be placed at approximately 75-90% corneal depth using 7-0 or indolent ulcers, indolent erosions, and boxer ulcers. Ophthalmic
8-0 absorbable braided suture. In placing corneal sutures, the examination typically reveals a chronic (weeks in duration),
needle should be directed perpendicular to the corneal surface, superficial, variably painful, non-infected, and non-progressive
approximately one millimeter from the wound edge, depending erosion or ulceration with a characteristic lip of loose epithelium
on the nature of the laceration. As the needle is advanced, the surrounding the border of the defect. Many patients are reported
needle holders are rotated and repositioned to allow adequate to have sustained an ocular injury, but the lesion does not heal
suture depth and have the needle exit at approximately the same with topical therapy in an appropriate length of time. Diagnosis
distance on the opposite side of the wound. The suture is tied, is made by clinical signs with the aid of fluorescein staining to
using a tying platform, usually with two or three throws on the evaluate for wicking of stain beneath the poorly adherent corneal
first knot, so the wound edges are apposed and not crushed. The epithelium at the edge of the lesion. No specific treatment has
first suture should be placed near the middle of the laceration, been shown to be effective in all cases, but successful therapy
with subsequent sutures placed to divide the remaining length of has included debridement, striate or punctate keratotomies,
the wound until closure is complete. Spacing between sutures corneal gluing, third eyelid flaps, contact lens application, and
is usually one millimeter, but adjustments may be necessary for superficial keratectomies. Most SCCEDs will heal with debri-
irregular lacerations. Post-operative care is described in the dement and keratotomy, but approximately 20 to 30% of animals
final section of the chapter, and the eye should be reevaluated will require additional surgical procedures and referral to a
in five days. veterinary ophthalmologist should be considered. To perform
debridement of the defect, topical anesthesia is applied, and
the patient manually restrained or sedated. Rarely, patients may
Conjunctival and Corneal Biopsy require short-acting general anesthesia. A dry cotton tipped
The most common indication for conjunctival and corneal applicator is swabbed from the center of the lesion peripherally,
biopsies is to identify the cause of abnormal tissue proliferations peeling away loose epithelium in the process. Once the cotton
or chronic inflammatory processes that are not responsive to swab is wet with tears, it is less effective and should be exchanged
medical management. Incisional biopsies for sampling small and for a dry swab. Epithelium that is poorly adhered to the abnormal
freely moveable or pedunculated conjunctival lesions may be underlying stroma is debrided easily with this technique. Debri-
performed with topical anesthetic and sedation or short acting dement is considered complete when a margin of more adherent
anesthesia. Unless culture is desired, the eye should be asepti- corneal epithelium is encountered during swab application. The
cally prepared with dilute povidone iodine solution. Adequate resultant defect will in many cases be considerably larger than
exposure often necessitates placement of an eyelid speculum. A the original lesion. For best results in healing, a punctate or striate
drop of dilute epinephrine or 2.5-10% ophthalmic phenylephrine keratotomy is performed following debridement. Striate (grid)
placed in the eye prior to biopsy will decrease hemorrhage. keratotomy is technically easier to perform, with a lower risk
Incisional biopsies are obtained by stabilizing and placing gentle of globe injury than punctate keratotomy. Patient restraint may
tension on affected tissue with Colibri or Castroveijo forceps. be manual, or sedation or short acting anesthesia may be used.
Stevens or Wescott scissors are used to incise the lesion towards Loupe magnification for the surgeon is ideal. Topical anesthetic
its base, and the excised tissue should be placed in a cassette is applied, and a 25-gauge needle is held at an approximate 45°
in ten percent buffered formalin and submitted for histologic angle to the corneal surface with the bevel directed away from
158 Soft Tissue
the cornea. The surgeon’s hand should rest on the table or on dilute epinephrine (1:10,000) is used to control hemorrhage. A
the patient’s muzzle. The tip of the needle is then used to lightly #64 Beaver blade is used to create a square or circular corneal
scratch the corneal surface, and the pressure applied should be groove surrounding the lesion. The groove should extend into
enough to cause a very faint needle mark in the corneal tissue. slightly deeper corneal stroma than the deepest aspect of the
The scratches extend from normal epithelium across the defect lesion (Figure 12-13A). If the lesion is close to the limbus, the
and back into normal epithelium. The resultant grid consists of groove is made in a semicircular fashion around the lesion and
faint scratches approximately one millimeter apart, crossing in adjacent to the limbal margin. Fine tipped Colibri or Castroviejo
various directions over the lesion. The owner should be warned forceps are used to grasp the grooved edge of the cornea, and
that the animal will show increased ocular discomfort for several either a #64 Beaver blade or a Martinez corneal dissector is
days following the procedure. If successful, complete corneal used to undermine the abnormal tissue. If a blade is used, it is
healing should occur within two to three weeks. These patients held so that the blade is nearly parallel to the corneal surface
should be treated to prevent infection and control inflammation, and small circular motions used to undermine the lesion. A
as described in the Post-Operative Care section, and they Martinez corneal dissector is held so that the dissecting blade
should be rechecked in three to seven days to ensure there is no is parallel to the corneal surface, and a sweeping motion is
evidence of infection or ulcer deepening. used to advance the instrument (Figure 12-13B). If the limbus is
involved, the dissecting instrument is carefully advanced under
the limbal tissue approximately two millimeters, using care to
Superficial Keratectomy
remain parallel to the ocular surface. Diseased conjunctiva that
Corneal and limbal proliferations of abnormal tissue and SCCEDs is adjacent to a limbal lesion is elevated using regular Colibris
are the most common indication for superficial keratectomies. forceps and excised using tenotomy scissors. The conjunctiva
Keratectomy is also indicated in the preparation of the cornea at the margin of the lesion is tented and a small incision is
to receive a conjunctival flap or graft. Ideally, referral to a veter- made. The scissors are then advanced to bluntly undermine the
inary ophthalmologist should be considered, as the benefits of conjunctiva prior to extending the incision, eventually elevating
an operating microscope and advanced microsurgical skills will the entire affected region so that the only remaining conjunctival
increase the success of surgery. The depth of the lesion should tissue attachments are at the limbus. Curved tenotomy scissors
be considered prior to surgery, so that surgical planning may and forceps are then used to incise along the limbus and remove
include a conjunctival flap if the lesion extends deeper than 30% the affected corneal and conjunctival tissue en bloc.
of corneal thickness. If the lesion to be excised is deeper than
approximately 75% of the cornea or if it is full thickness, more The resulting corneal defect if it is less than 30% of corneal thickness
advanced or adjunctive surgical procedures may be required, does not require a conjunctival flap. If the limbus is involved, a
necessitating referral to an ophthalmologist. conjunctival advancement, or hood flap may be performed to
protect the limbal region and close the orbit. Keratectomy beds
The patient is anesthetized, prepared for surgery and positioned > 30% corneal thickness require a graft or flap to re-establish the
in dorsal recumbency. An eyelid speculum and stay sutures structural integrity of the cornea, and some of these techniques
are placed as needed to increase exposure of the eye. Topical
A B
Figure 12-13 A. The cross-sectional view of the cornea demonstrates use of a Beaver blade to groove the cornea to a depth beneath the lesion.
The blade is perpendicular to the corneal surface and is advanced to surround the lesion. B. The cross-sectional view of the cornea shows a
Martinez corneal dissector advanced with a sweeping motion beneath a corneal lesion, with the blade of the dissector aligned with the corneal
curvature.
Eye 159
are described in the following section. Post-operative medications or distal margin of the flap is designated by drawing an imaginary
are described in the final section of the chapter, and these patients horizontal line across the cornea from the ventral aspect of the
should be rechecked in three to five days. corneal lesion to the donor bulbar conjunctiva (Figure 12-14A).
Due to curvature of the globe, the resultant conjunctival flap will
Conjunctival Flaps and Grafts be slightly longer than necessary; however, it is easier to trim
away excess tissue than it is to supplement a flap that is too small.
Conjunctival flaps and grafts differ in that flaps are attached to Hemorrhage is controlled by use of dilute epinephrine (1:10,000)
the tissue of origin with an intact blood supply, whereas grafts cellulose sponges, and cotton tipped applicators. The conjunc-
are completely severed from the donor site and must be revas- tival tissue is tented gently using regular Colibri or Castroviejo
cularized from the recipient site to survive. The most common forceps, and a small incision is made using blunt tipped tenotomy
indication for conjunctival flap construction is to repair a loss of scissors approximately two millimeters posterior to the limbus.
corneal integrity caused by keratomalacia, surgical wounds, and Conjunctival tissue is undermined by blunt dissection with
traumatic injuries. Corneal sequestra are an additional indication tenotomy scissors prior to enlarging the incision, and the elevated
in cats. If corneal tissue is lost, as with keratomalacia, and a tissue should be thin, allowing visualization of the scissor blades
corneal perforation has resulted, tissue replacement with kerato- through the conjunctiva (Figure 12-14B). Care must be taken
plasty procedures may be indicated in addition to conjunctival during dissection to avoid closing the scissor blades until they
flap techniques, necessitating referral to a veterinary ophthal- are completely withdrawn from tissue, as inadvertently cutting
mologist. The inciting cause and severity of corneal disease small holes in the flap will weaken its integrity. The incision is
dictates which of the techniques described here are appro- extended to the predetermined distal point of the flap, staying
priate for use in individual patients. The benefits of conjunctival as close to the limbus as possible. The distal flap margin is then
flaps include provision of physical support to weakened corneal incised by directing the scissors posterior and cutting perpen-
tissue, a direct blood supply to naturally avascular tissue, and a dicular to the initial incision. This incision is approximately one
source of cellular components to accelerate healing. Overall, the millimeter greater than the horizontal width of the corneal lesion.
success rate of conjunctival flap procedures is approximately The third conjunctival incision is parallel to the initial perilimbal
90%, however, failure of adhesion, excessive tension resulting in incision, with the scissors directed toward the base of the flap.
flap dehiscence, flap necrosis, continued leakage of a ruptured This third incision should be parallel to but shorter than the initial
globe, and refractory keratomalacia, are examples of compli- incision to maintain vascular supply to the flap.
cations that may occur following conjunctival flap surgery. In
most cases, referral to a veterinary ophthalmologist should be As the flap is rotated, the surgeon must ensure that the non-epithe-
considered, as surgical experience and technique are factors in lialized surface of the conjunctiva is placed in contact with the
establishing a successful outcome. corneal recipient site. Placement of the flap with the conjunctival
epithelial surface in contact with the corneal defect will result in
Conjunctival Pedicle Flap failure. The donor tissue is positioned over the corneal defect,
Conjunctival rotating pedicle flaps are the most common type and should lie where placed without continued traction or
of flap performed by veterinary ophthalmologists. The patient tension. If there is tension on the flap, the conjunctival tissue
is anesthetized, prepared routinely for ophthalmic surgery and is further undermined to release residual remnants of the white
positioned in dorsal recumbency. Use of an operating microscope connective tissue, Tenon’s capsule. The flap is initially sutured
is recommended for best results. An eyelid speculum and stay with 7-0 to 9-0 multifilament absorbable suture using simple
sutures should be placed to aid in exposure of the surgical field. interrupted sutures placed at the corners of the corneal defect.
The corneal recipient bed is prepared using fine tipped Colibri Needle bites should include approximately one millimeter of flap
forceps for stabilization, and the cornea is grooved around the tissue, and the needle should then enter the cornea at the base
perimeter of the lesion with a #64 Beaver blade. The groove may of the lesion, along the edge of the defect. The needle should
be rounded or squared, depending on surgeon preference, and then exit the normal corneal tissue one to two millimeters from
the affected stroma within the confines of the groove is removed the wound margin. The needle is passed cautiously so as to not
by a superficial keratectomy. If a keratectomy is not performed, penetrate the anterior chamber. If inadvertent penetration into
a surgical blade, cellulose sponges, and fine corneal scissors the anterior chamber occurs, the suture is completely removed
are used to freshen the edges of the corneal defect. The width and placed in a different location. The perforation site will heal
or diameter of the defect is approximated, and a correspond- spontaneously, though some uveitis may occur. Ideally, the
ingly sized or larger piece of conjunctival tissue is obtained for suture should penetrate to a depth that approximates 75-90%
the flap. The donor conjunctival site is typically the dorsolateral of the corneal thickness, though slightly shallower suture bites
bulbar conjunctiva, due to the ease of access and relatively loose are acceptable for conjunctival flaps. Suture should be tied
adhesions to the underlying connective tissue. However, if the with two to three throws on the first knot, and the knot should
lesion is markedly closer to the ventral limbus, a ventrally based be tied so as to appose but not crush tissue. Additional inter-
flap may be more appropriate. The base of the flap, which will rupted sutures are placed by dividing the distance between the
remain attached to the donor tissue, should be located such that initial sutures in half, then in half again, until sutures are spaced
the flap is vertically oriented when positioned over the corneal approximately one millimeter apart around the three exposed
defect; this reduces friction and drag caused by eyelid motion. In sides of the flap. The fourth side of the corneal lesion covered by
designing a flap, the surgeon plans the width of the flap base to be the flap of conjunctival tissue close to the limbus is not sutured,
approximately one millimeter wider than its distal margin. The free as this would compromise vascular supply to the flap. A simple
160 Soft Tissue
continuous suture pattern may be used to suture the three may be severed to improve the cosmetic appearance of the eye.
sides of the flap rather than interrupted sutures. After corneal Ideally, corneal vasculature should reach the surgical site prior
suturing, two anchoring sutures are placed from the base of the to incising the flap. Incising the flap is performed with manual
flap to the limbus on each side. These sutures help to decrease restraint or with a combination of light patient sedation and
flap tension on the corneal recipient site. Closure of the conjunc- ocular topical anesthesia. A drop of dilute epinephrine or 2.5
tival donor site is unnecessary, but may be performed with a to 10% ophthalmic phenylephrine will help to control hemor-
simple continuous pattern of 7-0 to 8-0 multifilament absorbable rhage. The bridge portion of the flap, which is not attached to the
suture. Figure 12-14C demonstrates the appearance of the flap cornea, is gently elevated with Castroviejo forceps, and a blunt
sutured to the corneal surface. The patient should be treated tipped scissor blade is inserted between the flap and the corneal
as described in the Post-Operative Care section, and a recheck surface. As the scissor blades are closed the flap is cut and the
examination should be scheduled in five to seven days. free margin retracts toward the limbus. The remaining tag of
tissue is then trimmed near the limbal attachments. Complica-
Five to eight weeks after surgery and following complete tions of this procedure include necrosis of the remaining island
healing of the corneal wound the vascular supply to the flap graft, iatrogenic corneal ulceration from the scissors, and mild
A C
Figure 12-14. A. In elevation of a conjunctival flap, the conjunctiva is gently tented with Colibri style forceps and tenotomy scissors are used to
incise the conjunctiva and bluntly dissect the thin conjunctival tissue from the underlying Tenon’s capsule. B. Once the thin conjunctival tissue
is elevated and undermined, tenotomy scissors are used to incise along the ventral extent of the flap, perpendicular to the limbus. An incision
is then made parallel to the limbus and towards the flap base resulting in a flap approximately 1mm greater than the width of the corneal lesion.
C. The conjunctival flap has been rotated into place and sutured along the three free margins to the corneal defect. Anchoring sutures are also
placed where the flap traverses the limbus.
Eye 161
Conjunctival Graft
Conjunctival grafts are performed by completely excising a
portion of conjunctival tissue and then suturing the free tissue
graft to a corneal defect. The graft provides structural support
to the cornea, however the benefits of an intact vascular supply
and cell-mediated healing provided by a flap are absent as the
graft has no vascular supply. Indications for performance of a
conjunctival graft are limited to chronic, inactive lesions that
involve greater than 75% of corneal stromal loss. Corneal vascu-
larization should be present at or near the edge of the corneal
defect. Preparation of the corneal recipient bed is described
Figure 12-15. Placement of a conjunctival bridge flap with sutures on earlier with conjunctival pedicle flap construction. The conjunc-
the medial and lateral aspects of the corneal lesion. Anchoring sutures
tival donor graft is usually harvested from the dorsal or lateral
are placed where the flap traverses the limbus dorsally and ventrally.
162 Soft Tissue
area at both ends of the gland that is not incised to allow secre-
tions from the gland to exit onto the ocular surface and not cause
cyst formation.
The incisions are then closed so that the third eyelid conjunctiva
covers the gland. (Figure 12-17C). A knot is tied on the anterior
or palpebral surface of the third eyelid and the needle passed
through the lid to the posterior or bulbar side near one end of the
incision. The incisions are closed in a simple continuous pattern
with 6-0 polyglactin 910 or polyglycolic acid. At the far end of the
incision, the needle is again passed through the third eyelid and
the knot is tied on the palpebral TE surface. This prevents the
suture knots from causing corneal irritation or ulceration.
Postoperative Care
Animals are discharged and owners instructed to apply triple
antibiotic ophthalmic ointment 3 times daily for 5 days. The TE
A gland will likely remain swollen for 2 to 3 days postoperatively,
sometimes up to 7 to 10 days, and then return to more normal
conformation. An Elizabethan collar may be necessary if the
animal shows any tendency to traumatize the eye (s).
B Surgical Procedure
The patient is placed under general anesthesia and positioned
in sternal recumbency. The hair ventral to the eye and over the
zygomatic arch is clipped. The third eyelid surfaces as well
as the clipped site are swabbed three times with dilute (1:50)
povidone-iodine solution. The affected eye is then draped with
either a sterile, disposable drape or with towels. A 5 mm long
skin incision is made with a #11 or #15 Bard Parker blade, parallel
to and just ventral to the periorbital rim (Figure 12-18A). An eyelid
speculum is placed to retract the upper and lower eyelids. A
second incision is made in the center of the ventral conjunctival
fornix with tenotomy scissors on the anterior or palpebral side of
the third eyelid (Figure 12-18B).
Figure 12-18. Orbital Tacking Technique. A. A 5 mm skin incision is made parallel to and just ventral to the periorbital rim. B. A second incision is
made in the center of the ventral conjunctival fornix on the anterior or palpebral side of the third eyelid. C. Suture material anchors the gland to
the periosteum.
Eye 165
Suture material is used to penetrate the gland in multiple direc- small animals include end-stage uncontrolled glaucoma, septic
tions to anchor it to the periosteum. The needle is inserted endophthalmitis, irreparable globe perforation and irreparable
through the gland toward the leading edge of the TE and then globe proptosis. Dogs with chronic glaucomatous eyes are
back through the exit hole to cross horizontally or parallel to the good candidates for implantation of an intrascleral prosthesis,
leading edge (Figure 12-18C). The needle is passed back through a surgical alternative that should be considered. Intraocular
the exit hole and directed towards the ventral fornix so that it neoplasms constitute an additional indication for enucleation.
emerges from the initial conjunctival incision. All suture should However, depending upon the specific neoplasm, age of the
be covered with conjunctiva. The TE is then reflected back to its animal and presence of secondary ocular complications, the
normal position and the suture needle is passed back beneath necessity of and preferred timing for enucleation is variable.
the skin to engage the orbital periosteum a second time. The Many intraocular neoplasms follow a benign course with regard
nylon is tied in a secure knot being careful not to place too much to metastasis (e.g. canine anterior uveal melanoma), whereas
tension on the suture and restrict the movement of the third others commonly metastasize (e.g. feline diffuse iris melanoma).
eyelid. The conjunctival incision may be left open or closed with Additionally, some intraocular neoplasms are amenable to
6-0 polyglactin 910. Similarly, the skin incision may be left open surgical resection or treatment by laser ablation. Consultation
or closed with nylon. with and referral to a veterinary ophthalmologist is encouraged
with cases of ocular neoplasia.
Postoperative Care
The two most commonly utilized methods for enucleation in
Animals are discharged and owners are instructed to apply dogs and cats, transconjunctival and transpalpebral will be
triple antibiotic ophthalmic ointment 3 times daily for 5 days. An described. The tissues removed with both approaches are the
Elizabethan collar should be applied if the animal shows any same and the approach utilized is often a matter of surgeon
tendency to traumatize the eye or surgical site. This technique preference. However, there are specific clinical indications for
may result in some TE immobilization which is usually not clini- utilizing the transpalpebral method. The transpalpebral method
cally significant. is indicated in cases where sepsis or neoplasia involves the
corneoconjunctival surface, as the closed conjunctival sac
Enucleation and Orbital formed with this approach serves to prevent orbital contami-
nation during surgery. I prefer the transconjunctival approach
Exenteration in most cases due to improved visualization and less operative
Ian P. Herring hemorrhage than with the transpalpebral technique. With either
approach, a minimum of traction should be applied to the globe
Some ophthalmic diseases or their consequences necessitate during surgery. Excessive globe traction or orbital pressure may
enucleation or orbital exenteration. Generally, enucleation stimulate an oculocardiac reflex, which causes bradycardia
refers to removal of the globe, whereas exenteration refers to and is occasionally fatal. Additionally, excessive traction may
removal of the globe and all orbital contents. The indications for result in trauma to the optic chiasm or contralateral optic nerve,
enucleation and exenteration are different and are discussed in causing vision loss or blindness in the contralateral eye. The
this chapter. latter complication is a particular concern in cats.
Figure 12-19. Lateral canthotomy improves surgical exposure. Figure 12-21. Extraocular muscles are identified using the scissor
blade in an anterior sweeping motion and are transected at their
scleral insertions.
Figure 12-20. Circumferential conjunctival incision placed 2-3 mm Figure 12-22. The optic nerve bundle is severed, with or without prior
posterior to the limbus exposes the sclera and provides a rim of con- placement of a hemostatic clamp.
junctival tissue attached to the globe to facilitate manipulation.
stop at the muscle’s scleral insertion, at which point the scissors vasculature prior to removing the hemostat. Again, traction on
are closed to transect the muscle tendon. Muscle transection is the optic nerve should be minimized. Some surgeons advocate
performed at the level of scleral insertion rather than mid-body not using a hemostatic clamp at all by simply transecting the
to reduce hemorrhage. The retractor bulbi muscles are then optic nerve and achieving hemostasis with gauze packed into the
severed by sliding curved, blunt-tipped scissors posteriorly along orbit for several minutes following globe removal.
the scleral surface and gently cutting the muscles at their scleral
insertions. After all extraocular muscles have been severed, After the globe is removed, the nictitating membrane (3rd eyelid)
the globe should rotate rather freely. A curved hemostat is used and its associated gland are excised, followed by removal of
to clamp the optic nerve and associated vasculature prior to the remaining conjunctival tissue.(Figures 13-23 and 13-24) The
transecting these structures between the clamp and globe using lacrimal gland can be identified in the dorsolateral region of
curved scissors (Figure 12-22). The clamp may be left in place the orbit and excised, although cyst formation seems rare even
for several minutes during subsequent steps of the surgery to when the gland is left in situ. Finally, the margins of the eyelids
maintain hemostasis. Although seldom necessary, absorbable are removed using Mayo scissors. Excision of the eyelid margins
suture can be used to ligate the optic nerve and associated must incorporate the meibomian glands which requires removal of
Eye 167
Transpalpebral Approach
Presurgical preparation of the surgical site is identical to that
described for the transconjunctival approach. The eyelids are
apposed and sutured shut using 3-0 nylon in a continuous pattern.
An elliptical skin incision is made with a scalpel paralleling and
4-6 mm from the eyelid margins, converging at the medial and
lateral canthus (Figure 12-26). The medial and lateral canthal
tendons must be severed completely before progress can be
made in dissecting down to the sclera. Although not required,
Allis tissue forceps can be placed on the apposed eyelid margins
to aid in subsequent globe manipulations. A combination of blunt
and sharp dissection using Metzenbaum scissors is used to
approach the conjunctiva. Care must be taken not to penetrate ligament, using care not to transect this structure. Ventral
the conjunctival surface or the aseptic advantage of the dissection should avoid trauma to or excision of the zygomatic
transpalpebral technique is lost. If the conjunctiva is inadver- salivary gland, unless it is involved in the disease process, in
tently incised in cases of ocular surface neoplasia or sepsis, the which case it should also be removed. When dissection to the
hole in the conjunctiva should be closed before continuing with orbital apex is complete, a curved hemostat is placed around
dissection. Dissection to the scleral surface just posterior to the optic nerve and extraocular muscle cone near the posterior
the limbus allows identification of the rectus and oblique extra- wall of the orbit and these structures are transected with
ocular muscles, which are transected at their scleral insertions. curved Metzenbaum scissors near the clamp. A ligature using
The retractor bulbi musculature is then transected at or near absorbable suture is placed around the optic nerve and vascu-
their scleral insertions. The optic nerve is then transected after lature posterior to the clamp. The orbit is then irrigated with
liagation of the nerve and its vasculature with absorbable suture. sterile isotonic solution prior to wound closure.
Depending on the extent of dissection in the dorsolateral aspect
of the orbit, the orbital lacrimal gland may or may not be incorpo- Two layer wound closure is performed as described for enucle-
rated in the tissues removed. This can be confirmed by careful ation. Since more extensive orbital tissue removal occurs with
palpation in the dorsolateral region of the orbit. After the orbit is exenteration, the sunken appearance of the orbit will be greater
irrigated copiously with sterile isotonic solution, surgical closure than occurs with enucleation. Post-operative cosmesis can
is performed as described for the transconjunctival approach. be improved by the use of non-absorbable suture material to
bridge the anterior opening to the orbit prior to skin closure, as
Exenteration described under transconjunctival enucleation closure. Silicone
sphere implants can also be used, but the likelihood of dehis-
Exenteration refers to the surgical removal of the eyelids, cence and sphere extrusion may be increased due to the lack
globe and all orbital contents including the conjunctiva, extra- of deep orbital connective tissue to close over the sphere prior
ocular muscles, orbital lacrimal gland, nictitating membrane to skin closure. If exenteration is performed due to uncontrol-
and associated gland, orbital connective tissue and orbital fat. lable orbital infection, both methods for improving cosmesis are
The most common indications for exenteration include extra- contraindicated.
scleral extension of intraocular neoplasms and primary orbital
neoplasms that are not surgically resectable without concurrent
removal of the globe. However, if orbital neoplasms have Post-operative Care
invaded the bony structures of the orbit or extended beyond the Postoperative considerations include provision of analgesia,
confines of the orbit, exenteration would be palliative and more prevention of infection and prevention of self-trauma. The use
aggressive surgical procedures such as orbitectomy should be of opiate analgesics in the early post-operative period followed
considered. Rarely, medically uncontrollable orbital infection by oral non-steroidal anti-inflammatory medications for a period
may necessitate exenteration. of 7 days is recommended. An Elizabethan collar may be used to
prevent self-trauma of skin sutures. Dogs are more likely than
Exenteration is generally performed in a manner similar to cats to require an Elizabethan collar. Owners should be advised
transpalpebral enucleation, with wider excision margins to to keep the incision clean to help prevent localized infection.
incorporate removal of the orbital contents, including the Systemic antibiotics are generally not required beyond the peri-
globe, extraocular muscles, nictitating membrane and gland, operative period, unless pre-existing sepsis is present.
orbital lacrimal gland and orbital fat. Occasionally, removal of
periosteum is indicated, as when neoplastic disease abuts
this tissue. The eyelids are sutured shut with 3-0 monofilament Complications
suture in a continuous pattern. A surgical blade is used to Operative complications of enucleation and exenteration
perform an elliptical skin incision outside of the eyelid margins include hemorrhage and the previously described complica-
as for transpalpebral enucleation. This incision may be carried tions of oculocardiac reflex stimulation and potential damage to
further from the eyelid margins, as necessary, to ensure removal the optic chiasm due to excessive globe or optic nerve traction.
of diseased tissue. However, sufficient skin must be left to Postoperative orbital swelling is common and sometimes severe
allow skin closure without tension on the suture line. Following if related to hemorrhage confined to the orbital space. Although
completion of the skin incision, subcutaneous dissection is not considered a complication, it is also common to note serosa-
continued to the bony margin of the orbit, where the orbital guinous discharge from the ipsilateral nares for a few days
septum is incised. Bands of connective tissue that attach the post-operatively as fluid passes through the severed nasolac-
medial and lateral canthus to the orbital wall, the medial and rimal canaliculus to the nasal ostium. Orbital emphysema is
lateral canthal ligaments, must be sharply incised. The goal of occasionally encountered following enucleation, particularly in
the remainder of the surgery is to continue dissection towards brachycephalic dogs, presumably due to air being forced up the
the orbital apex, staying outside of the extraocular muscle cone. nasolacrimal duct and accumulating in the closed orbit. Orbital
Blunt dissection is continued with Metzenbaum scissors and infection, seroma and cyst formation are rare. Cyst formation is
should follow the bony wall of the orbit dorsally and medially more likely to occur when secretory tissues (e.g. nictitans gland,
proceeding towards the orbital apex. The origin of the ventral lacrimal gland) are left in the orbital space. When orbital silicone
oblique muscle is encountered ventromedially and is incised. spheres are placed to improve post-operative cosmesis, sphere
Dorsolaterally, dissection should proceed underneath the orbital extrusion is a potential complication that can be minimized by
ensuring that adequate deep orbital fascia covers the sphere
Ear 169
Treatment Considerations
Hematomas should be treated immediately after diagnosis.
Untreated hematomas usually cause various cosmetic altera-
tions resulting from fibrous contracture. Some ears have a
cauliflower-like appearance, which is a permanent alteration.
Identification and treatment of the underlying cause are critical
to long-term management of patients with aural hematoma.
Suture Technique
In my experience, incisional drainage combined with suturing
has consistently been the most successful treatment for aural
hematomas. The pinna is surgically prepared on both sides.
Hematomas have been opened using longitudinal, S-shaped,
and cruciate incisions, depending on the surgeon’s preference. I
prefer the longitudinal incision, and it is not necessary to remove
additional skin to widen the incision.
The fibrin clot is removed, and the cavity is curetted and flushed
with saline. Horizontal mattress sutures are placed in rows
parallel to the skin incision (Figure 13-1). The first row of sutures
are placed at the outer edge of the hematoma cavity with each
new row placed toward the skin incision. The spacing of sutures
varies with the size and shape of the pinna and the size and
location of the hematoma.
The sutures penetrate the full thickness of the pinna and are tied
on the convex surface of the ear (Figure 13-3). When placing the
sutures, the surgeon should avoid the three main great auricular
branches, which are visible on the convex surface of the pinna.
Suture tension is subjective. As a guideline, sutures should be
placed with just enough tension to permit insertion of the needle
holder tips to the level of the hinge.
Postoperative Care
A light protective bandage is applied to protect and immobilize
the ear. Pendulous ears are bandaged over the head or neck.
Erect ears are bandaged to maintain a normal erect position. Ear
bandages should not occlude the opening of the vertical canal.
The bandage is changed in 3 days and is removed in 7 days. The
sutures are removed in 3 weeks. An Elizabethan collar is recom-
mended to prevent scratching of the unband-aged ear.
Complications
The most common complications of aural hematomas are
cosmetic alterations and recurrence. Necrosis of the pinna has
been reported from improper suture placement. Cosmetic altera-
tions are usually the result of delayed treatment, improper suture
placement, and excessive suture tension.
Figure 13-1. Correct placement of sutures after removal of an aural
hematoma.
Aural hematomas can recur at the same site, but they are more
likely to recur adjacent to the original hematoma. Recurrence of
a hematoma is likely when inadequate numbers of sutures are
used or inappropriately placed or when the underlying causes
of the hematoma are not identified and treated appropriately.
Necrosis of the pinna can be prevented by avoiding the ascending
branches of the great auricular artery through the use of suture
placement parallel, rather than perpendicular, to the incision.
Client Education
Communication with the animal’s owner regarding all aspects of
aural hematomas and their management will help to avoid misun-
derstandings, especially if complications occur. Owners should
also understand that to treat the underlying causes properly,
further investigation and expense will be required.
Suggested Readings
Figure 13-2. Incorrect placement of sutures after removal of an aural Angarano DW. Diseases of the pinna: Vet Clin North Am 1988; 18:1.
hematoma. Placement of sutures with tranverse orientation may Dubielzig RR, Wilson JW, Seireg AA. Pathogenesis of canine aural
decrease blood supply to the cartilage and skin of the pinna.
Ear 171
hematomas. J Am Vet Med Assoc 1984,185:873. MA 02081) pad is applied to the incision surface and is changed
Harvey CE. Ear canal disease in the dog: medical and surgical as needed. Sutures are not used.
management. J Am Vet Med Assoc 1980:177:136.
Henderson RA, Home RD. The pinna. In: Slatter DH, ed. Textbook of small The ear is left firmly immobilized for 3 weeks. Healing is by second
animal surgery. 2nd ed. Philadelphia: WB Saunders, 1993. intention. The elimination of sutures helps to keep the pinna flat
McKeever PJ. Otitis externa. Compend Contin Educ Pract Vet and prevents thickening, wrinkling, and cauliflowering.
1996:18:759.
McCarthy RJ. Surgery of head and neck. In: Lipowitz AL, Caywood DD,
Newton CD, et al, eds. Complications in small animal surgery. Baltimore:
Williams & Wilkins, 1996.
Figure 13-5. Long pieces of tape are placed on the concave side of
the rostral and caudal borders of the pinna. These tapes also extend
beyond the ear border and contact the tape on the opposite side.
Figure 13-4. Short pieces of tape are placed on the rostral and caudal Figure 13-6. The pinna is then reflected up over a large roll of cast
borders of the convex side of the pinna. The tape extends beyond the padding, and the tape is brought around the neck, to secure the ear in
ear border. The elliptic incision into the hematoma cavity is shown. place.
172 Soft Tissue
External Ear that does not concurrently obstruct the horizontal portion of
the external ear canal, and for exposure and removal of small
Treatment of Otitis Externa tumors or polyps.
M. Joseph Bojrab and The purpose of lateral ear canal resection is to provide environ-
Gheorghe M. Constantinescu mental alteration by means of ventilation so moisture, humidity,
and temperature are decreased. Lateral ear canal resection also
Otitis externa is an inflammation of the epithelium of the provides drainage for exudates and moisture in the ear canal.
external ear canal characterized by an increased production
of ceruminous and sebaceous material, desquamation of Surgical Technique
epithelium, pruritus, and pain. The condition is caused by one or The patient is placed in lateral recumbency and is draped so
more etiologic agents including parasites, bacteria, and fungi. the pinna and external ear canal region are left exposed and
In addition, allergy and trauma may play a role in otitis externa. all anatomic relationships are identifiable (Figure 13-7). The
The conformation of the ear canal and that of the pinna can veterinary surgeon initially is positioned ventral to the patient.
predispose to development of acute and chronic otitis externa. A probe is inserted into the ventral ear canal to determine the
For example, the high incidence of the disease in poodles and canal’s depth. Two skin incisions are extended ventrally, parallel
cocker spaniels indicates that the pendulous pinna and hair-filled to each other, from the intertragic notch and the trago-helicene
external ear canal predispose to otitis externa. The high relative notch. These vertical incisions should be 1.5 times the length of
humidity of the external ear canal, in addition to the warmth, the vertical ear canal. A transverse incision is made joining the
darkness, and enclosed nature of the ear canal of some breeds vertical incisions ventrally (Figure 13-8). The skin is reflected to
of dogs, provides an excellent environment for the growth of its dorsal attachment on the dorsal rim of the vertical ear canal.
infective agents. Chronic otitis externa can permanently change An incision is made through the subcutaneous tissue of the
the size and character of the external ear canal. The epithelium lateral surface of the cartilaginous vertical canal. With scissors,
becomes thickened and fibrous and can become ulcerated. The the subcutaneous tissue is reflected rostrally and caudally off
ear canal can become stenotic if the epithelium becomes exces- the vertical ear canal (Figure 13-9). In similar fashion, the parotid
sively scarred or undergoes metaplastic proliferation. salivary gland is reflected ventrally. The lateral aspect of the
vertical ear canal should be exposed at this point.
Diagnosis and Medical Treatment
The next portion of the surgical procedure is best performed from
A complete otoscopic examination of each ear, including visual-
the dorsal aspect of the head. With scissors, two incisions are
ization of the tympanum, is imperative for proper diagnosis and
made in the cartilaginous vertical canal, one along the rostro-
assessment of otitis externa. The initial treatment of this disease
lateral aspect of the canal and one along its caudolateral aspect.
consists of irrigating and cleansing the external ear canal.
For the incisions to be made properly, the pinna and the skin flap
Additional treatment consists of the use of ceruminolytic agents
must be pulled dorsally and the vertical portion of the ear canal
and, depending on the origin of the otitis, antibiotics (aqueous
visualized. One blade of the scissors is placed into the vertical
solutions) locally or parenterally, antifungal agents or parasiti-
canal (Figure 13-10), which is then incised from the tragohelicene
cides locally, and pH alteration. Bandaging the ears over the top
notch ventrally approximately half the length of the vertical
of the animal’s head allows better ventilation of the ear canal.
ear canal. Both the rostral and caudal ear incisions should be
alternately extended until the floor of the horizontal ear canal
Culture and sensitivity tests in cases of severe or repeated
limits further advancement of the scissors. The lateral wall of
occurrences of acute otitis externa may obviate a future ear
the vertical ear canal is now reflected ventrally (Figure 13-11).
canal operation by identifying the bacterial etiologic agent
and thus the antibiotic that should effectively eliminate that
agent. Chronic otitis externa must be treated more vigorously.
Instillation of “swimmer’s solution” (three parts 70% isopropyl
alcohol and one part white vinegar) is useful for long-term
treatment; it provides a cleaning-drying action and lowers the
pH of the ear canal.
Surgical Treatment
(Lateral Ear Canal Resection)
Indications
When otitis externa becomes unresponsive to medical therapy,
a lateral ear canal operation is indicated. Lateral ear canal
resection is also indicated for frequent recurrence of otitis
externa, for chronic otitis externa resulting from inadequate
treatment or lack of treatment, for external ear canal thickening
Figure 13-7. Anatomic relationships of the ear.
Ear 173
Postoperative Care
Postoperative care includes treatment with appropriate systemic
antibiotics and management of self-trauma and ear movement.
Coping with the prolonged healing time may be difficult. Healing
time averages 10 to 14 days; if the suture line breaks down,
healing may take longer. If lateral ear resection fails to control
otitis externa, ear canal ablation needs to be considered. This
procedure is discussed in the next section of this chapter.
Suggested Readings
Figure 13-11. The lateral wall of the vertical ear canal is reflected Bojrab MJ, Dallman MJ. Lateral ear canal resection. In: Bojrab MJ, ed.
ventrally. The broken line indicates where the lateral cartilage flap is Current techniques in small animal surgery. 2nd ed. Philadelphia: Lea &
incised. Febiger, 1983.
Coffey DJ. Observations on the surgical treatment of otitis externa in the
dog. J Small Anim Pract 1970; 11:265.
Fraser G. Factors predisposing to canine internal otitis. Vet Rec
1961;73:55.
Fraser G, Withers AR, Spruell JSA. Otitis externa in the dog. J Small
Anim Pract 1961;2:32.
Fraser G. et al. Canine ear disease. J Small Anim Pract 1970;10:725.
Grono LR. Studies of the microclimate of the external auditory canal in
the dog. Parts I, II, and III. Res Vet Sci 1970;! 1:307.
Grono LR. Otitis externa. In: Kirk RW, ed. Current veterinary therapy. Vol.
7. Philadelphia: WB Saunders, 1980.
Ott RL. Ears. In: Archibald J, ed. Canine surgery. 2nd ed. Santa Barbara,
CA: American Veterinary Publications, 1974.
Singleton WB. Aural resection in the dog. In: Jones BV, ed. Advances in
small animal practices. Vol. 2. Oxford: Pergamon Press, 1960.
Zepp CP. Surgical correction of diseases of the ear in the dog and cat.
Vet Rec 1949;61:643.
Gregory CR, Vasseur PB. Clinical results of lateral ear resection in dogs.
J Am Vet Med Assoc 182: 1087, 1983.
Figure 13-16. The vertical canal is cut dorsal to the horizontal canal.
Inset, incision of the remaining vertical canal, rostrally and caudally,
Figure 13-13. Skin incisions for this modified ablation technique. down to the horizontal canal.
Total Ear Canal Ablation and pyoderma, hypothyroidism, and atopy.5 When the related
primary skin condition has been thoroughly diagnosed and
Subtotal Bulla Osteotomy appropriately treated but continues to be unresponsive, I prefer
TECA for treatment of persistent otitis externa instead of surgical
Daniel D. Smeak drainage procedures such as lateral ear canal resection. As the
skin disorder progresses, so will the ear disease in most circum-
Introduction stances, and a lateral ear resection or vertical ear canal ablation
will subsequently fail due to progressive inflammatory changes
Otitis externa is an insidious disease that is not usually debili-
in the remaining canal. Similarly, if owners are incapable or
tating, and the associated clinical signs are generally controlled
unwilling to treat the skin or chronic ear disease appropriately,
until medical therapy is withdrawn. When multiple attempts at
TECA may be indicated before irreversible changes exist.
medical treatment fail, ear disease invariably progresses, and
more extensive surgery is indicated to permanently relieve the
Although TECA combined with LBO is indicated for a number
clinical signs. Owners must understand that the frequency and
of conditions in the dog, it is less commonly performed on cats.
severity of intra- and postoperative complications increase in
Irreversible, proliferative inflammatory changes resulting from
proportion to the degree of surgery required. Thus, for the most
long standing otitis externa do not appear to form as readily in
part, early surgical intervention should be strongly advised
cats as they do in dogs. Cats with otic tumors, such as ceruminous
when appropriate medical treatment for otitis externa fails or
adenocarcinoma or basal cell carcinoma, diffuse polypoid
the condition becomes recurrent.1 As the ear tissue damage
disease, or those sustaining severe trauma to the ear canal are
becomes irreversible from chronic infection, drainage proce-
potential candidates for TECA.6 TECA is not usually required for
dures fail and removal of the entire horizontal and vertical ear
cats affected with otitis media or inflammatory middle ear polyps,
canal is required. This salvage procedure is known as total ear
since the external ear canal is usually not severely affected, and
canal ablation (TECA).2
exposure to the source of the clinical problem is best achieved
with a ventral approach (ventral bulla osteotomy).
Secondary middle ear infection frequently develops in dogs with
end-stage otitis externa.3 Consequently, variable results and high
complication rates have been reported when TECA is preformed Owner Education
without a means of middle ear exposure and debridement (bulla The owner must be made fully aware of the purpose of TECA as
osteotomy and curettage). Because TECA eliminates a primary well as the possible sequelae before contemplating surgery. The
pathway for exudate drainage, the external canal, recurrent deep surgeon should remind owners that the principle aim of TECA is
infection occurs unless the middle ear is adequately evacuated. to make their pet more comfortable by removing the source of
Inadequate removal of the secretory epithelium within the bulla pain and chronic infection. Elimination of further ear cleaning
or short osseous ear canal is responsible for such long-standing duties and the malodorous discharge are added benefits. Before
complications as persistent fistulation and abscessation.1,4 For surgery, however, owners seem to be concerned most about the
these reasons, most surgeons routinely combine lateral bulla appearance of their pet and whether their animal will be deaf
osteotomy (LBO) through the same approach used for TECA. after surgery. Generally, the appearance of floppy-eared dogs
These combined procedures are described in this chapter. following TECA is unchanged. In erect-eared dogs, the extent
of auricular and pinna cartilage removed determines whether
Indications the ear will stand following surgery. Removal of extensive
proliferative tissue well up into the pinna will cause the erect
TECA is most often performed for irreversible inflammatory ear
ear to fall owing to lack of support at the ear base. The ear
canal disease in dogs. Other less common indications include
will remain somewhat erect if more than the proximal third of
severe ear canal trauma, neoplasia, and certain congenital
the vertical canal cartilage is preserved in dogs and cats. A
malformations obstructing horizontal ear canal drainage.
simple modification of the TECA skin incision to create a single
Irreversible inflammatory ear canal disease is present when
pedicle advancement flap has been found to maintain normal
one or a combination of the following is observed: hyperplasia
ear carriage in cats.7 The surgeon should not limit the amount
of the epithelium occluding the horizontal ear canal, collapse or
of canal resection because of pressure from owners who want
stenosis of the horizontal ear canal caused by infection within
preservation of ear carriage at all costs. Continued irritation and
the cartilage or bone, or severely calcified periauricular tissue
pain can be expected if proliferative ear canal tissue remains
noted by palpation or observed on skull radiographs.
following TECA.
Many dogs that present to the veterinarian for surgical treatment
Because TECA obliterates the external auditus, most owners
of inflammatory ear disease have one or more irreversible condi-
are skeptical about their pet’s future hearing ability. Although
tions or indications for TECA. If medically unmanageable otitis
the possibility of causing complete deafness remains, TECA
externa is related to an ongoing generalized skin condition such
combined with LBO should not be expected to affect hearing
as atopy or hypothyroidism, treatment of the primary dermato-
appreciably in most cases. Although air conducted sound may
logical disorder often helps control the ear disease. Concurrent
not be detected by brain evoked auditory testing after TECA, the
skin disorders are very common in dogs with otitis externa.
ability to hear bone conducted sound is apparently preserved.8,9 I
Almost 80% of dogs undergoing TECA in one report had one
warn owners that the quality of sound their dog can discern may
or more primary dermatological diseases including seborrhea,
Ear 177
change after surgery, but some hearing ability usually can be If the ear problem is a possible manifestation of a systemic
expected. Most complaints about hearing difficulty after TECA skin disorder, a complete dermatologic examination should be
stem from inadequate owner evaluation or awareness of the pet’s performed and appropriate tests should also be completed.
hearing condition beforehand. The surgeon should try to make Postoperative head shaking and self-inflicted irritation to the
the owner aware of their dog’s hearing deficits before surgery remaining ear tissues may persist if the primary skin condition
to minimize this misunderstanding. Owners must be prepared is neglected or inappropriately treated. This can be seen as a
for serious and potentially long-standing problems resulting failure of the surgical procedure from the owner’s point of view.
from TECA. If nystagmus, circling, or loss of balance are present
before surgery, exacerbation of these signs is common after- The remaining preoperative workup is best performed while
wards in the author’s experience. These signs usually improve if the patient is anesthetized. Thorough ear cleaning must be
middle ear infection is eliminated but they may persist indefinitely. accomplished to allow maximal visualization of the canal during
Transient, or more rarely, permanent facial nerve dysfunction may otoscopic examination. Otoscopic examination of both canals
occur causing drooling from ipsilateral lip paralysis. Hemifacial is indicated, even if one side superficially appears normal or if
spasm or facial nerve deficits that are present before surgery the condition of both ears is severely proliferative. Attention is
may indicate that the facial nerve is invaded by neoplasia or, directed at locating tumors or polyps, as these are not infrequent
more likely, that it is embedded in the horizontal canal or serious in older patients with long standing otitis externa. Otitis media is
secondary middle ear infection is present. More dissection and present if the tympanic membrane is not found and the tympanic
retraction of the nerve may be required to free it up during TECA; bulla is filled with debris. Samples of suspicious tissues are
this greatly increases the risk of iatrogenic facial nerve damage. submitted to help diagnose occult neoplasia, which may drasti-
Ocular problems from a diminished eye-blink response may be cally change the prognosis as well as the owner’s wish to allow
disastrous, particularly in exophthalmic dog breeds or those with surgery on their pet. If neoplasia is suspected, local lymph nodes
inadequate tear production. Unresolved middle ear infection or are examined and fine needle aspirates are evaluated cytologi-
any retained secretory tissue can cause recurrent abscessation cally for tumor staging. Chest radiographs are evaluated for
and fistulation which may create conditions far worse for the evidence of metastatic disease or other occult thoracic problems.
owner and their pet than the presenting otitis externa problem.4 Rather than culturing the exudate at otoscopic examination, a
Proper preparation of owners for these potential problems by more reliable result may be obtained if deep wound tissue and
counseling before surgery is recommended. middle ear exudate are sampled at the time of surgery.
Preoperative Considerations Skull radiographs help confirm the extent and severity of the ear
canal pathology and may alert the clinician that otitis media or
A complete preoperative workup is essential to determine the neoplasia is present. The ventrodorsal skull view may be used to
extent and nature of the disease process and to predict possible help determine the horizontal canal patency and its diameter, and
surgical complications. Following routine physical examination, whether the canal walls have undergone irreversible change.
the external ear is inspected and palpated. A sharp pain response Open mouth plain radiographic views of the bulla are best to
elicited during deep palpation of the ear canal usually indicates evaluate for subtle middle ear change.10 Oblique lateral views
middle ear infection. Thickened and firm (calcified) ear canal may help demonstrate lytic neoplastic changes of the petrous
tissue is a manifestation of irreversible inflammatory change. temporal bone.
Evidence of a head tilt without other signs of inner ear disease
(nystgmus, circling, loss of balance) usually indicates severe Radiography should not be regarded as a highly sensitive tool for
pain in the ear on the lower side. Neoplasia should be highly the diagnosis of otitis media.11 Positive radiographic signs such as
suspected if the ear drainage appears mostly as blood versus thickening and calcification of the bulla indicate the presence of
the more typical thick, foul-smelling exudate of an inflammatory middle ear pathology, but false negative radiographs are common.
otitis externa. The presence of predominately lytic changes in the rostroventral
aspect of the bulla on oblique lateral views most often is a result
A complete neurologic examination should be performed to of chronic inflammation in my experience. Conversely, evidence
evaluate for facial nerve dysfunction (hemifacial spasm, poor of bone lysis in other areas, particularly in the petrous temporal
palpebral reflex, lip droop) and inner ear involvement, especially bone, suggests a neoplastic process. In summary, despite the
in patients with chronic otitis externa. During preoperative lack of sensitivity, radiographic evaluation is recommended to
workup, approximately 15% of patients with end-stage otitis are evaluate for the presence of neoplastic invasion of bone, partic-
found to have partial or total facial nerve deficits.1 It is important ularly when otoscopic examination of deep structures is not
to identify patients with concurrent otitis media because they possible. Normal appearing skull radiographs do not rule out otitis
more often develop complications such as cellulitis, persistent media or neoplasia. CT imaging is a more sensitive modality to
fistulation, or abscessation following TECA.4 In addition, their identify neoplastic and middle ear disease.
postoperative care is more demanding and costly. Any hearing
deficits or other neurologic problems should be clearly noted in
the medical record and brought to the owner’s attention before Surgical Anatomy
TECA; otherwise, the owner may blame the surgeon if these The surgeon must be aware of certain important structures
deficits are noticed after surgery. before surgery (Figures 13-18 and 13-19). Branches of the great
auricular and superficial temporal vessels should be avoided
178 Soft Tissue
when incising through and dissecting medial to the vertical ear emerges from the stylomastoid foramen, located just caudal to
canal cartilage. The V-shaped parotid gland overlays the lateral the ossesous portion of the ear canal, and travels rostroven-
and ventral areas of the ear canal, and it may be damaged if trally directly under the horizontal ear canal. Additionally, the
not retracted during horizontal ear canal exposure. Deep to the terminal branches of the facial nerve and auriculotemporal
parotid gland are the facial nerve, internal maxillary vein, and branch of the mandibular portion of the trigeminal nerve should
branches of the external carotid artery. These structures are be avoided rostral to the ear canal. Careful retraction of tissues
difficult to identify and preserve when dissecting deeply around and hemostasis, meticulous dissection, and staying close to the
the horizontal ear canal and tympanic bulla. The facial nerve external ear canal cartilage and osseous bulla will reduce the
risk of iatrogenic damage to many of the structures.
Figure 13-18. Transverse section of the head showing ear canal, middle
ear, and inner ear structures.
medial aspect of the bulla to preserve the ossicles and sensitive Starting from the caudal aspect, cut through the medial vertical
inner ear structures. The internal carotid artery can be damaged canal wall with serrated Mayo scissors and continue cutting
if the thin bone wall between the carotid canal and tympanic rostrally until the ends of the original horizontal skin incision
cavity has been eroded by chronic infection or neoplasia, or it connect (Figure 14-23C). One must avoid inadvertent damage
may be disturbed by excessive medial pressure during curettage to the branches of the great auricular vessels that travel in a
of the medial bulla wall (Figure 13-22). dorsal direction just deep to the medial canal wall. Damage to
these branches can lead to a vascular necrosis of pinna skin,
particularly in the area of the posterior incisure and cornu of the
Surgical Technique antitragus. Starting at the dorsal and rostral aspect, free the
Total Ear Canal Ablation remaining vertical canal of tissue connections and continue to
The ear canal is difficult to prepare aseptically, and contami- dissect dorsally close to the horizontal canal cartilage down to
nation is inevitable during surgery. Therefore, a broad spectrum, the rim of the boney external auditory meatus. (Figure 13-23D).
bactericidal, intravenous antibiotic is given before and during Damage to the facial nerve and parotid gland is avoided by
surgery so that adequate blood levels are maintained in tissues carefully retracting these structures away from the dissection
during dissection. Alternatively, administration of antibiotics plane at the ventral and caudal aspect of the horizontal canal.
may be delayed until cultures of the osseous bulla are obtained These aforementioned areas are approached last, so that soft
during surgery. In either case, antibiotics are continued until tissues can be retracted sufficiently to allow maximal exposure
the results of the intraoperative culture and susceptibility are during dissection. Occasionally, the facial nerve is entrapped
available. The surgeon should use these susceptibility results to and is hidden from view within extensively thickened and
choose the appropriate drug for long-term therapy. calcified horizontal canal tissue. In such cases, I first search
for peripheral small facial nerve branches (internal auricular
After anesthesia is induced, ample surrounding skin, the ear nerves) that perforate the cartilage on the caudal and more
canal, and pinna are routinely prepared for aseptic surgery. The superficial aspect of the horizontal canal; these branches lead
patient is placed in lateral recumbency with the head elevated to the seventh nerve trunk. Alternately, one may palpate for a
by a towel to a level parallel with the chest wall. Figure 13-23 small sharp protuberance (ridge) which is the rim separating
illustrates the TECA and LBO procedure. A T-shaped skin the caudal osseous ear canal from the stylomastoid foramen
incision is made; the horizontal incision is parallel and just below (origin of the facial nerve). Once this area is located, one follows
the upper edge of the tragus between the tragohelicine and the most proximal portion of the nerve as it courses directly
intertragic notch (Figure 13-23A). The vertical incision is created lateral from the foramen. Entrapment is generally found as the
perpendicular from the midpoint of the horizontal incision to a nerve exits the foramen and begins its rostral course. Carefully
point just ventral to the horizontal canal. The surgeon under- dissect the remaining nerve from the canal. To avoid iatrogenic
mines and retracts the two resulting skin flaps, and exposes the nerve trauma, one should always incise the horizontal canal
lateral aspect of the vertical canal from the surrounding loose attachment to the external auditory meatus away from the course
connective tissue (Figure13-23B). With curved Metzenbaum of the facial nerve. Branches of the superficial temporal vessels
scissors, bluntly dissect around the proximal and medial portion originating from the retroarticular vein (retroarticular foramen)
of the vertical canal staying as close as possible to the cartilage. may be encountered during dissection of the rostral aspect of
A B
Figure 13-22. A. Oblique ventrolateral view of important structures within rostrodorsal compartment of the tympanic cavity. The arch-shaped
malleus is located in the rostrodorsal aspect of the cavity, referred to as the epitympanic recess. The opening of the auditory tube is in the most
rostral aspect of the cavity, an area often lined with ingrown secretory epithelium from the external ear canal. This epithelium must be completely
excised during the LBO. Note the promontory and cochlear window, which house the inner ear structures. A portion of the large fundic compart-
ment of the tympanic cavity is exposed caudally. B. Oblique ventrolateral view of the skull after the lateral wall of the tympanic bulla is removed.
The internal carotid artery, a major blood supply to the brain, is illustrated. The internal carotid artery enters the caudal carotid foramen in the
petro-occipital fissure and transverses in the carotid canal. The medial wall of the tympanic bulla forms the lateral wall of the carotid canal.
180 Soft Tissue
the canal from bone. Electrocoagulation or bone wax may be to the tympanic bulla (Figure 13-23E). Removal of all secretory
required to stop excessive hemorrhage. The entire canal should tissue is critical to the success of the surgery since chronic fistu-
be removed and submitted for histologic examination. Rongeurs lization will occur if secretions form within this enclosed area.
are usually required to excise remaining calcified attachments Grasp the dorsal aspect of the pouch and with traction, “tease
until the entire circumference of the external auditory meatus is out” the pouch in one piece if possible with a Freer elevator. A
seen as a white glistening edge. curette should be used to remove any remaining secretory tissue
that is adherent to the walls of the boney meatus. This tissue is
In severely affected ears, a greenish-brown epithelial pouch submitted for culture and susceptibility testing.
(similar to the shape of a “sock”) is present within the external
auditory meatus and tympanic cavity extending lateral and ventral
Figure 13-23. Summary of surgical technique of TECA and lateral bulla osteotomy. A. T-shaped incision to expose the vertical ear canal. B. Loose
connective tissue is reflected from the vertical ear canal. The parotid gland is ventrally retracted to avoid damage during dissection of the ventral
portion of the vertical ear canal. C. The dorsomedial aspect of the vertical cavity is sharply incised with scissors connecting the ends of the origi-
nal horizontal skin incision. D. The vertical and horizontal ear canals are isolated from surrounding soft tissues by blunt and sharp dissection.
Ear 181
A B
Figure 13-26. Lateral aspect of skull showing epithelial lining of EAM. A. The hatched area denotes the notch created in the ventral floor of the
osseous ear canal described in Figure 13-25. The epithelial tissue lining of the ear canal is shown as the shaded area. B. While grasping the freed
edge, the epithelial “cuff” is elevated both rostrally and caudally from the osseous ear canal beginning in the notched area. The ridge of bone
separating the EAM from the stylomastoid foramen is now well exposed.
Ear 183
Figure 13-27. While protecting the facial nerve with a Freer elevator, Figure 13-28. A Kerrison rongeurs is used to begin removal of the
the ridge of bone between the EAM and foramen has been removed caudolateral aspect of the tympanic bulla while the facial nerve is
with Lempert rongeurs and the facial nerve is isolated and retracted protected with the elevator.
caudally.
A B
Figure 13-29. Lateral views of tympanic bulla after removing the caudal and lateral aspects of the bulla. A. Note the in vivo epithelial remnant
(circled) in the rostral compartment of the cavity, which must be removed entirely without damaging the malleus and promontory areas (labeled).
B. Excellent exposure of the completely evacuated tympanic cavity is achieved with the described subtotal bulla osteotomy technique.
carotid artery) can be penetrated causing profuse hemorrhage. surgical drain (Penrose drain) may be used. If the tissue
If this occurs, the tympanic cavity is tightly packed with gauze surrounding the wound has minimal contamination, inflam-
stripping, and one should wait at least 5 minutes until hemostasis mation or hemorrhage, and the tympanic cavity is thoroughly
is established, and then the packing should be removed slowly to evacuated, there is usually no need for wound drainage.16 Dead
continue the inspection. Daubenspeck or malleable curettes are space is closed in the subcutaneous tissue with 4-0 monofil-
used to scrape the rostral, ventral and caudal tympanic cavity. ament absorbable material. The skin is closed routinely with
Abnormal tissues are submitted for histologic evaluation. The simple interrupted 4-0 monofilament nonabsorbable material to
epitympanic recess and the EAM should be carefully inspected complete the total ear canal ablation.
for remnants of abnormal epithelium or retained tympanum. The
entire tympanic cavity should be irrigated and inspected again
and any remaining suspicious tissue and bony fragments are Postoperative Care
removed. Thorough irrigation of the entire wound, especially the If a drain is used, a loose, padded head bandage is placed to
dead space just medial to the base of the pinna is performed with cover the drain and surgical site until the drain is removed, usually
sterile saline. within 48 to 72 hours. Significant pharyngeal swelling can result
particularly if TECA and bulla osteotomy are performed bilaterally.
Ideally, an active suction drain system (Jackson-Pratt) is In addition, bandages may further reduce pharyngeal airway size
recommended in those patients with heavy contamination and this can cause suffocation in the early postoperative period.
intra-operatively, uncontrolled bleeding, concurrent para-aural These patients should be closely monitored for signs of dyspnea
abscessation, or when the bulla is difficult to clean out properly. especially during the first 24 hours. An Elizabethan collar is used
Alternately, if a closed suction system is not available, a passive when needed to reduce self-trauma until sutures are removed in
184 Soft Tissue
10 to 14 days. During bandage changing, wounds are examined provided normal tear flow is present and the eye is not predis-
for evidence of fluid accumulation or ensuing infection. If signs posed to exposure keratitis from exophthalmia. In summary, most
of acute postoperative infection occur, sutures in the vertical facial nerve damage is iatrogenic and transient and is most often
portion of the wound are removed and the wound is opened fully caused by overzealous retraction during ear canal dissection in
to allow adequate drainage. Systemic antibiotics, based on the my experience. Dissection of an entrapped facial nerve or en
intraoperative culture and susceptibility results, are adminis- bloc resection of neoplasia may cause permanent damage.
tered for a minimum of three weeks. Postoperative treatment for
any underlying systemic skin disorder is continued. Fistulization or skin sinus formation and middle ear infection are
considered the most serious complications from TECA since
Patients undergoing TECA and LBO often show evidence of these problems can cause clinical disability worse than the
extreme postoperative pain due to inflammation and nerve original chronic ear disease. Long-term antibiotic treatment and
stimulation from deep wound dissection and bone removal. The wound drainage rarely eliminate the problem in my experience.
surgeon must be prepared to aggressively manage this pain both Persistent infection usually requires wound exploration for
preemptively and postoperatively. General postoperative guide- successful treatment, a costly and difficult procedure.4 Persistent
lines for management of small animals after TECA and LBO are wound drainage or fistulization forms anytime from one month
beyond the scope of this chapter, and are discussed elsewhere. to over two years after surgery in about 5% to 10% of patients
(See Chapter 9) I prefer to give injectable opioid medications undergoing TECA and LBO for chronic otitis.4 Persistent infection
and NSAIDS in advance of surgery to reduce the amount of is most commonly attributed to a remnant of secretory tissue
postoperative analgesics required to maintain patient comfort. A within the external auditory meatus or tympanic cavity. Isolation
fentanyl patch can be applied 24 hours before surgery as another and removal of retained secretory epithelium with proper
preemptive analgesic option. Postoperatively, injectable opioid drainage of exudates permanently eliminates the problem.
analgesics combined with local anesthetic patches or constant Ventral or LBO may be required depending on the suspected
local anesthetic infusion are also good options. The patient is source of the persistent infection.4,22 CT imaging is useful in
released from the hospital and NSAID treatment is continued for helping the surgeon decide which approach is best. I, and others,
3 to 5 days if indicated. prefer to use the lateral approach through the original incision
site if retained horizontal ear canal tissue is the cause of the
fistulization.22 Ventral bulla osteotomy is the preferred route for
Complications and Treatment exploration if the nidus is believed to be located in the middle ear
Many complications have been reported after TECA.17-21 Most because it avoids dissection through the previous surgery site
complications related to the surgery (wound infections and and allows maximal exposure of the tympanic cavity. Approxi-
seromas) are short-lived and resolve within two weeks if mately 70%-85% of patients explored for persistent infection
treated appropriately. Extensive bacterial numbers are present will be cured.4,22 Despite the expense and potential for serious
in occluded chronically infected ear canals even after proper complications following TECA, most owners are satisfied with
aseptic preparation of the area. Acute postoperative wound the procedure and improvement in their dog’s demeanor.
infection is not uncommon after TECA since wound contamination
is inevitable. Proper intraoperative wound irrigation, antibiotic
administration, and drainage help reduce this problem. Evidence References
of avascular skin slough at the proximal caudal skin margin and 1. Smeak DD, Kerpsack S: Total ear canal ablation and lateral bulla
acute cellulitis are managed with open wound management and osteotomy for management of end-stage otitis externa. Seminars in
debridement until the area heals completely. Animals afflicted Veterinary Medicine 8:30-41, 1993.
with inner ear signs before surgery may deteriorate immediately 2. Smeak DD: Total ear canal ablation and lateral bulla osteotomy. In
after anesthetic recovery and these signs may persist indefi- Bojrab MJ (ed): Current Techniques in Small Animal Surgery. Williams
nitely in my experience. Until proven otherwise, inner ear signs and Wilkens, Baltimore, 1998, pp 102-9.
that first develop in a patient a week or more after surgery are 3. Cole LK, Kwocka KW, Kowalski JJ, Hillier A: Microbial flora and
attributable to a fulminant abscess within the middle ear. Surgi- antimicrobial susceptibility patterns of isolated pathogens from the
cally induced Horner’s syndrome tends to occur from middle ear horizontal ear canal and middle ear in dogs with otitis media. J Am Vet
curettage during TECA only in the cat. This will usually resolve Med Assoc 15:212:534-8, 1998.
within several weeks provided middle ear infection has been 4. Smeak DD, Crocker CB, Birchard SJ: Treatment of recurrent otitis
eradicated. media after total ear canal ablation and lateral bulla osteotomy in dogs:
nine cases (1986-1994). J Am Vet Med Assoc 209:937-942, 1996.
Many dogs experience slow or incomplete eye blink response 5. Mason, LK, Harvey CE, Orsher, RJ: Total ear canal ablation combined
and ear or lip droop immediately after surgery owing to paresis with lateral bulla osteotomy for end-stage otitis in dogs-results in thirty
dogs. Vet Surg 17:263-268, 1988.
of muscles innervated by the facial nerve. Artificial tears or
ointments are used prophylactically until the affected eyes regain 6. Bacon NJ, Gilbert, RL, Bostock DE, et al.: Total ear ablation in the
cat: indications, morbidity, and long-term survival. J Small Anim Pract
full function, usually within five days after surgery. If no evidence
44:430-4, 2003.
of eye blink is appreciable by four weeks following surgery,
7. McNabb AH, Flanders, JA: Cosmetic results of a ventrally based
permanent damage can be expected. Overall, about 10% to 15%
advancement flap for closure of total ear canal ablation in 6 cats:
of dogs have permanent facial nerve damage following TECA.17
2002-2003. Vet Srug 33:435-9, 2004.
This does not cause significant disability in my experience,
8. Krahwinkel DJ, Pardo AD, Sims MH, Bubb WJ: Effects of total ablation
Ear 185
of the external acoustic meatus and bulla osteotomy on auditory function exploring for foreign bodies that have pentrated the caudal
in dogs. J Am Vet Med Assoc 202:949-52, 1993. pharynx or for evaluating neoplasia that may occur in this area
9. McAnulty JF, Hattel A, Harvey CE: Wound healing and brain stem of the head and neck.
audtory evoked potentials after experimental total ear canal ablation
with lateral tympanic bulla osteotomy in dogs. Vet Surg 24:1-8, 1995. Refractory otitis media requiring surgical drainage is less
10. Geary CJ: Radiographic aspects of otitis media. Auburn Vet 21: 71-3, common in cats than in dogs. In cats, the most frequent indication
1965. for ventral bulla osteotomy is exploration to remove the middle
11. Remedios AM, Fowler JD, Pharr JW: A comparison of radiographic ear component of aural or nasopharyngeal polyps. Rarely, the
versus surgical diagnosis of otitis media. J Am Anim Hosp Assoc ventral approach has also been used in cats to treat benign and
27:183-8, 1991. malignant masses involving the middle ear.
12. Garosi LS, Dennis R, Schwarz T: Review of diagnostic imaging of ear
diseases in the dog and cat. Vet Radiol Ultrasound 44: 137-46. 2003.
13. Smeak DD, Inpanbutr: Lateral approach to subtotal bulla osteotomy Bulla Anatomy
in dogs: pertinent anatomy and procedural details. Compend Contin The tympanic bulla in dogs is part of the petrous temporal bone
Educ Pract Vet 27:377-385, 2005. and forms a pear-shaped cavity. The larger main portion of the
14. Lesinskas, E, Lesinskas R, Vainutiene V: Middle ear cholesteatoma: bulla extends ventrally. The smaller epitympanic recess extends
present-day concepts of etiology and pathogenesis. Medicina (Kaunas) dorsally and contains the auditory ossicles, the malleus, incus
38: 1066-71, 2002. and stapes, which extend from the tympanic membrane to the
15. Davidson EB, Brodie Ha, Breznoch EM: Removal of a Cholesteatoma vestibular window (Figure 13-30). Medial to the epitympanic
in a Dog, Using a Caudal Auricular Approach. J Am Vet Med Assoc recess is a bony eminence, the promontory, which contains the
211:1549-1553, 1997. cochlea. The cochlear window is located on the caudolateral
16. Devitt CM, Seim HB, Willer R, McPherro M, Neel, M: Passive aspect of the promontory (Figure 13-31). Curettage of the epitym-
drainage versus primary closure after total ear canal ablation-lateral panic recess and in the area of the promontory should be avoided
bulla osteotomy in dogs: 59 dogs(1985-1995) Vet Surg 26:210-216, 1997. to prevent iatrogenic damage to the vestibular and cochlear
17. Smeak DD, Dehoff WD: Total ear canal ablation-clinical results in the windows. Damage to these structures may cause postoperative
dog and cat. Vet Surg 16:161-170. otitis interna and balance/equilibrium problems for the dog.
18. Mason LK, Harvey CE, Orsher RJ: Total ear canal ablation combined
with lateral bulla osteotomy for end-stage otitis in dogs-results from In the cat, the middle ear is divided by an incomplete boney
thirty dogs. Vet Surg 17: 263-268, 1988. septum into a large ventromedial compartment and a smaller
19. Matthieson DT, Scavelli T: Total ear canal ablation and laeral bulla dorsolateral compartment. During ventral bulla osteotomy in
osteotomy in 38 dogs. J Am Anim Hosp Assoc 26:257-267, 1990. cats, the larger ventromedial compartment is invariably entered
20. Beckman, SL, Henry WB, Cechner P: Toal ear canal ablation first. The septum runs obliquely from craniomedial to caudola-
combining osteotmy and curettage in dogs with chronic otitits externa teral in the rostral one-third of the bulla. Removing this septum
and media. J Am Vet Med Assoc 196:84-90, 1990. and opening the dorsolateral compartment is mandatory during
21. Sharp NJH: Chronic otitis externa and otitis media treated by total bulla osteotomy for polyps as this compartment contains the
ear ablation and ventral bulla osteotomy in thirteen dogs. Vet Surg opening of the Eustachian (auditory) tube. Once the septum is
19:162-166. 1990. removed, the complete extent of the oval promontory can be
22. Holt D, Brockman, DJ, Sylvestre AM, Sadanaga KK: Lateral explo- visualized (Figure 13-32). The cochlear window is located in the
ration of fistuals developing after total ear ablation: 10 cases (1989- caudolateral aspect of the promontory. Postganglionic sympa-
1993). J Am Anim Hosp Assoc 32:527-30. 1996. thetic nerve fibers from the cranial cervical ganglion enter the
bulla caudally and fan out over the promontory where they may
Ventral Bulla Osteotomy be damaged by curettage.
Petrous
temporal bone
Base of stapes
in vestibular window
Cochlear duct
Scala vestibuli
Dura mater
Malleus
External acoustic
meatus
Cochlear
window
Tympanic membrane
Stapes
Incus
Tympanic cavity
Auditory tube
Tympanic bulla
Figure 13-30. The middle ear of the dog illustrating the large ventral bulla cavity and the more dorsal epitympanic recess. The auditory ossicles
extend from the typmpanic membrane to the vetibular window.
facial branch of the jugular vein (Figure 13-33). A small venous from the skull just caudal to the bulla. As an additional means to
branch draining from the salivary gland into the linguofacial vein confirm the bulla’s location, a non-sterile assistant can place an
may require ligation and division. The separation between the index finger into the mouth and palpate the hamular processes
large digastricus muscle laterally and the myelohyoideus muscle of the pterygoid bones. The assistant moves a finger to the bulla,
medially is identified. Correct location of this dissection plane is which lies just caudal and lateral to this process on either side of
crucial for this approach. If this plane is correctly identified and the skull. The surgeon palpates the assistant’s finger to confirm
dissected, the hypoglossal nerve will be visible coursing cranially the location of the bulla.
on the medial aspect of the surgical field. The hypoglossal nerve
is gently retracted and protected from injury throughout the Once the bulla is accurately identified, dissection proceeds
procedure. Surgical exposure is maintained by careful placement dorsally. The bulla lies in a “V” formed by the internal and
of hand-held or Gelpi tissue retractors. external branches of the carotid artery. These branches should
be identified and carefully dissected or protected in the dog. In
At this point, it is important to accurately identify the bulla by dogs, the thin muscular tissue lying immediately ventral to the
palpation. In cats, the large ventral dome of the bulla is easily bulla is bluntly separated parallel with the orientation of its fibers.
palpable. In dogs, especially those with chronic otitis media, the In cats, the loose areolar tissue covering the bulla is bluntly
bulla is not as apparent on palpation, feeling more flat than domed. elevated or dissected. The periosteum of the bulla is incised and
To further localize the bulla, the surgeon should gently palpate elevated from the entire ventral surface of the bulla. The surgeon
for the stylohyoid bone coursing dorsally and laterally from the should take the time to ensure adequate lateral dissection and
remainder of the hyoid apparatus. The hyoid apparatus in both exposure of the bulla in cats before opening the bulla to facil-
species is attached to the caudal and lateral aspect of the bulla itate exposure of the dorsolateral bulla compartment. A sharp
by the tympanohyoid cartilage, a small extension of the stylohyoid Steinman pin in a Jacob’s chuck is used to make the initial
bone. In dogs, the paracondylar process of the occipital bone opening into the bulla. Very little dorsal pressure is applied to the
can often be palpated as a pointed structure protruding ventrally chuck to prevent the pin from lurching into the dorsal aspect of
Ear 187
Retroarticular
process
Malleus
Dorsal boundary of
external acoustic
meatus Promontory
Canal for
facial nerve
Cochlear window
Figure 13-31. The middle ear of the dog with the majority of the tympanic bulla removed. The cochlear window is visible on the caudal aspect of
the promontory.
Eustacian
tube
External
ear canal
Manubrium
Incus
Stapes
Promontory
Round
window
Connecting fissure
Connecting foramen
Tympano-occipital fissure
Figure 13-32. The feline bulla with part of the ventral wall removed. The medial compartment , bony septum and lateral compartment are visible.
The cochlear (round) window is visible on the caudal aspect of the promontory.
188 Soft Tissue
Hyoid
venous arch
Mylohyoid
muscle
Digastric Mandibular
muscle lymph nodes lying
on either side of
the facial vein
Mandibular
salivary gland B
Sternohyoid
muscle Jugular
vein
Sternocephalic
muscle
Figure 13-33. A. Superficial musculature, vessels, and salivary glands visualized during ventral bulla osteotomy dissection. B. Dissection for a
right ventral bulla osteotomy. Once the platysma muscle has been incised, dissection proceeds medial to the submandibular salivary gland,
which is separated from the jugular vein. A small branch of the vein is often ligated. C. Dissection proceeds between the digastricus muscle
laterally and the myelohyoideus muscle laterally. The hypoglossal nerve is visible on the medial aspect of the surgical field. The bulla often lies in
the “Y” formed by the bifurcation of the carotid artery. D. The bulla is identified by palpation and by location of the stylohyoid bone that attaches
to the cranial and lateral surface of the bulla. The overlying tissue is dissected and retracted and the bulla opened using a Steinmann pin.
the bulla when it enters the tympanic cavity. In dogs with chronic and culture and sensitivity testing. The bulla cavity is thoroughly
otitis media and cats with long-standing polyps, the wall of the flushed with warm, balanced electrolyte solution and suctioned
bulla can be quite thick and patience is required whle drilling dry. Often, flushing and suctioning will identify residual tags of
with the Steinman pin. Alternatively, some surgeons prefer epithelial lining that are then removed. A latex drain is loosely
a powered drill for entrance to the bulla. Once an initial bulla placed into the bulla cavity without anchoring sutures. It exits
opening has been made, it is enlarged with rongeurs. through a separate small skin incision. The deeper layers of the
surgical field are closed with a few single interrupted sutures
In cats, the larger ventromedial compartment is opened first. of monofilament absorbable suture, taking care to avoid the
The septum separating this compartment from the dorso- hypoglossal nerve. The subcutaneous tissue and skin are closed
lateral compartment is on the craniolateral aspect of the in a routine manner. The latex drain is anchored to the skin with
medial compartment. In some cats, the septum can be opened two single interrupted sutures.
with a small, fine-tipped, single-action rongeur. In other cats,
the septum must be penetrated by a Steinmen pin and the
opening enlarged with rongeurs. With the bulla fully opened,
Postoperative Care
the promontory is visible in both species as an oval shaped Recovery from anesthesia is routine in most animals. The
bony protuberance in the dorsal aspect of the bulla. Curettage nasopharynx is inspected and suctioned while the animal is still
over the promontory, particularly the caudal aspect, and in under anesthesia as blood or flush solution can travel from the
the epitympanic recess is avoided to prevent damage to the middle ear to the nasopharynx by the Eustachian tube and be
cochlear (round) and vestibular (oval) windows. Diseased or aspirated after extubation if it is not removed. Cats with polyps
infected tissue is removed and samples are taken for biopsy in both middle ears that have undergone bilateral bulla surgery
Ear 189
Complications
Complications following ventral bulla osteotomy in dogs are
uncommon but are usually associated with damage to struc-
tures of the inner ear. Clinical signs include nystagmus, head tilt,
and circling. Neurologic signs are more common after ventral
bulla osteotomy in cats with an 80% incidence of postoperative
Horner’s syndrome due to damage to the sympathetic nerve
fibers in the middle ear. The clinical signs of Horner’s syndrome,
miosis, ptosis, and prolapse of the third eyelid resolve within 4 to
six weeks in the majority of cats. Approximately 40% of cats may
have clinical signs of otitis interna after ventral bulla osteotomy
for polyp removal. These clinical signs are generally transient.
References
Fraser, G., Gregor, W.W., Mackenzie, C.P., et al. Canine ear disease.J
Small anima Pract 1970; 10:725-754.
Getty, R. The ear. In: Evans H.E., Christensen, G.C., ed.: Miller’s Anatomy
of the Dog. Philadelphia: WB Saunders, 1979, pp 1062-1069.
Harvey, C.E.: Diseases of the middle ear. In Slatter, D.H., ed.: Textbook
of Samll Animal Surgery, ed. 1. Philadelphia: WB Saunders, 1985, pp
1919-1923.
Kapatkin, A.S., Mathiesen, D.T., Noone, K.E. et al. Results of surgery and
long-term follow-up in 31 cats with nasophyngeal polyps. J Am Anim
Hosp Assoc 1990; 26:387-392.
Little, C.J.L., Lange J.G. The surgical anatomy of the feline bulla tympanic.
J Small Anim Pract 1986; 27:371-378.
Little, C.J.L; Lane, J.G.; Pearson, G.R. Inflammatory middle ear disease
of the dog: The clinical and pathological features of cholestetoma, a
complication of otitis media. Veterinary Record. 199. 128:14, 319-322.
Lucroy, M.D., Vernau, K.M., Samii, V.F. et al. Middle ear tumours with
brainstem extension treated by ventral bulla osteotomy and craniectomy
in two cats. Vet Comp Oncol 2004; 2:234-242.
Smeak, D.D., Crocker, C.B., Birchard, S.J. Treatment of recurrent otitis
media that developed after total ear canal ablation and lateral bulla
osteotomy in dogs: Nine cases (1986-1994). J Am Vet Med Assoc 1996.
209:5, 937-942.
190 Soft Tissue
Section C so mobile that the clinician considers the tooth or tooth segment
removable with digital manipulation. The extraction forceps
should engage the tooth as far apically as possible in order
to decrease leverage forces on the root which could lead to
Digestive System root fragmentation (Figure 14-1). Generally, these non-surgical
techniques are effective for incisors, first premolars, and third
molars regardless of the health status of the periodontium. Multi-
rooted teeth with periodontal disease and secondary mobility
may be extracted using similar techniques.
Chapter 14
Oral Cavity
Exodontic Therapy
Mark M. Smith
Introduction
Exodontics is the practice of tooth extraction. The most common
indication for exodontic therapy in dogs is severe periodontal
disease. Endodontic therapy is recommended for teeth affected
by crown fracture exposing pulp, and pulpitis. However, it is not
unusual to perform exodontic therapy when there is minimal
crown available for restorative techniques, or when the owner
does not authorize endodontic therapy. Exodontic therapy may
also be used as a component of treatment for malocclusion.
Simple Exodontics
The periodontal ligament attaches the tooth to the bony alveolus
or socket. The goal of exodontic therapy is to disrupt the
periodontal ligament allowing movement of the tooth out of the Figure 14-1. Photograph showing extraction forceps engaging as much
alveolus. This component of the exodontic process is performed of the crown and tooth root as possible while applying gentle force to
with periodontal elevators. There are various size and grip config- complete the extraction of the mesiobuccal crown/root segment of the
urations for periodontal elevators. In dogs, basic periodontal right maxillary fourth premolar tooth.
elevators include instrument numbers 301s, 301, and 401.1
A B
Maxillary Canine a tan color and is readily identified compared with the hemor-
rhagic alveolar bone on the medial and distal sides of the tooth.
The maxillary canine is a large, single-rooted tooth which is
During the alveolectomy process, it is helpful to purposely make
difficult to extract using non-surgical techniques. Canine teeth
gauges or slots in the alveolar bone on both the mesial and distal
affected by severe periodontal disease may be extracted suing
aspects. These focal areas of bone loss provide locations for
non-surgical methods, however if the tooth has a healthy perio-
application of the periodontal elevator (See Figure 14-4).
dontium, it is essential to use surgical exodontic techniques. It
is important to note that the root of the maxillary canine courses
The canine root is elevated with the tooth being displaced in a
in a dorsal and distal direction with its apex directly above the
lateral or buccal direction. If the angle of buccal displacement is
mesial root of the maxillary second premolar. The periodontal
acute, the root apex may fracture through the thin alveolar plate
flap incision begins in the buccal mucosa over the maxillary
of bone separating the alveolus form the nasal cavity. If fracture
second premolar and is directed mesially, sloping towards
leading to perforation occurs, hemorrhage may be noted form
the gingival at the distal line angle of the canine tooth. The
the ipsilateral nares. This problem is treated by primary wound
gingival attachment fibers are incised along the canine tooth in
closure of the periodontal flap over the alveolus. Incising the
a manner described previously. The flap incision is completed
periosteum at the base of the periodontal flap improves flap
with a vertical relief incision form the gingival along the mesial
mobility and decreases wound tension during primary closure
line angle approximately 3/4 the length of the canine tooth root
(Figure 14-5).
(Figure 14-4). Following gingival elevation, the buccal mucosa
is relatively easy to mobilize form the buccal alveolar bone.
An alternate flap design includes a peninsula-shape flap with Mandibular Canine
mesial and distal incisions over the tooth’s line angles (See A buccal (lateral) approach has been recommended for surgical
Figure 14-4). Generally, regardless of flap design, the flap is extraction of the mandibular canine tooth.2-5 This approach
sutured over bone. Therefore, the alveolectomy should be offset requires consideration of anatomic structures including the
when compared with the periodontal flap. Lateral alveolectomy prominent soft tissue attachment (frenulum) of the lip, the neuro-
is performed using methods described previously. The alveo- vascular structures exiting the mental foramen, and the roots
lectomy begins near the cementoenamel junction and continues of the first and second premolar. Considering the orientation of
apically along the canine root (Figure 14-4). The cementum has the root of the mandibular canine tooth is in a lingual (medial)
Oral Cavity 193
A B
C D
Figure 14-4. Photographs showing extraction techniques for the maxillary canine tooth. Flap design includes a peninsula flap with 2 vertical re-
lease incisions A. or a triangular flap with one vertical release incision B. Alveolectomy provides exposure to approximately 1/2 of the root C. while
strategic exaggerated bone/tooth removal provides locations for placement of the periodontal elevator D. with permission. Frost Fitch P. Surgical
extraction of the maxillary canine tooth. J Vet Dent 2003; 20: 55-58.
direction, it would seem appropriate to consider an approach the symphyseal surface near the mandibular symphysis (Figure
that could be performed directly over the root. Such an approach 14-6). The flap apex includes the gingival of the lingual aspect of
would avoid disruption of lip frenulum, potential hemorrhage the mandibular canine tooth. Generally, the flap base is approxi-
from the mandibular artery and vein at the mental foramen, and mately twice the width of the flap apex. A nitrogen-powered
iatrogenic trauma to adjacent tooth roots. A lingual approach dental unit with a high-speed hand piece and round bur are
for for surgical extraction of the mandibular canine tooth has sued to perform lingual alveolectomy (See Figure 14-6). Length
been developed based on anatomic observations of tissues and of alveolectomy ranges form 10 to 20 mm in dogs. Periodontal
structures of the rostral mandible and lingual orientation of the elevators and extraction forceps are used to complete the
mandibular canine tooth root.6 extraction. The remaining alveolus is lavaged with 1.12% chlor-
hexidine and the flap is apposed to the buccal gingival using 3-0
The initial component of the procedure is elevation of a lingually polyglactin 910 in a simple interrupted pattern (See Figure 14-6).
based, full-thickness, mucoperiosteal flap. The flap is based on
A B
References but because these defects are less apparent, some neonates
may die of malnutrition or aspiration pneumonia before other
1. Wiggs RB, Lobprise HB. Oral surgery. In Wiggs RB, Lobprise HB (eds): signs are recognized. Milk or food in the nasal cavity frequently
Veterinary Dentistry: Principles and Practice. Philadelphia, Lippincott- causes sneezing or gagging. Milk may be seen running from the
Raven, 1997, p 233.
nose. The resulting rhinitis causes a serous to mucopurulent
2. Harvey CE, Emily PP. Oral surgery. In: Small Animal Dentistry. Phila- nasal discharge that may be malodorous. Aspiration of milk or
delphia, Mosby, 1993, pp 316-317.
food causes coughing, and aspiration pneumonia is a common
3. Eisenmenger E, Zetner K. Tooth fracture and alveolar fracture. In: sequela. Clefts involving only the distal half of the soft palate are
Eisenmenger E, Zetner K, eds. Veterinary Dentistry. Philadelphia, Lea & unlikely to result in significant clinical signs.
Febiger, 1985, p 105.
4. Holmstrom SE, Frost P, Gammon RL. Exodontics. In: Holmstrom SE,
Frost P, Gammon RL, eds. Veterinary Dental Techniques. Philadelphia, Preoperative Patient Evaluation and Care
WB Saunders, 1992, p 185. Animals with clefts of the primary palate that involve only the
5. Tholen MA. Oral surgery. In: Tholen MA, ed. Concepts in Veterinary lip often need no special care. Except for their being “sloppy
Dentistry. Edwardsville, KS, Veterinary Medicine Publishing, 1983, pp eaters,” the defect is usually well tolerated. Tube feeding can
90-96. be instituted if the defect prevents effective nursing. Repair of
6. Smith MM. Lingual approach for surgical extraction of the mandibular these defects can be delayed until the patient is older (3 months
canine tooth in dogs and cats. J Am Anim Hosp Assoc 32: 359-364, or more), when visualization is improved and tissue manipula-
1996. tions are easier. Animals with clefts involving the premaxilla
are more likely to have difficulty in nursing and require tube
Repair of Cleft Palate feeding. Earlier repair (7 to 9 weeks of age) can be performed in
these animals to reduce the severity of the rhinitis secondary to
Eric R. Pope and Gheorge M. Constantinescu entrance of food into the nasal cavity if oral feeding is begun at
weaning. Tube feeding is recommended for patients with clefts
of the secondary palate to reduce the severity of the rhinitis
Introduction associated with the passage of milk into the nasal cavity and to
Congenital palate defects can affect the primary palate, reduce the potential for aspiration pneumonia. Depending on the
secondary palate, or both. The primary palate extends from the size of the patient, repair of clefts of the secondary palate can
lip to the caudal border of the premaxilla (incisive bone). The be performed between 7 and 9 weeks of age if clinical signs are
secondary palate includes the remainder of the hard palate and severe but I prefer to wait until the patient is 12 to 14 weeks old
the soft palate. Incomplete fusion of these structures results in when access to the oral cavity for tissue manipulation is better
cleft of the primary palate (harelip), cleft of the secondary palate, and the tissues are less friable.
or both. Clefts of the primary palate can involve the lip (cheilo-
schisis), the alveolar process (alveoloschisis), or both (cheiloal- The diagnosis is generally obvious on physical examination. A
veoloschisis). Clefts of the secondary palate include midline complete examination is necessary to rule out other congenital
defects of the hard or soft palate and unilateral or bilateral defects. I routinely take thoracic radiographs of patients with
lateral clefts of the soft palate. clefts of the secondary palate before surgery to document
the presence or absence of aspiration pneumonia. Aerobic
Most clefts are believed to be inherited as either recessive or and anaerobic bacterial cultures are performed on patients
irregularly dominant traits. Nutritional, hormonal, and mechanical with purulent rhinitis, and appropriate antimicrobial therapy
factors have also been incriminated as causes, but these factors is initiated. Patients with minimal rhinitis are given a broad-
are more likely to affect the severity of the cleft in predisposed spectrum antimicrobial perioperatively (administered when the
individuals rather than being a sole cause. Intrauterine infec- intravenous catheter is placed before anesthesia induction and
tions and exposure to toxins at specific periods during gestation continued for up to 24 hours). Food is withheld the morning of
can also result in cleft palate. Cleft palate has been reported in surgery, but the operation should be performed as early in the
many different breeds of dogs, but the brachycephalic breeds day as possible to avoid hypoglycemia. Rhinoscopy should be
appear to be overrepresented. The Abyssinian, Siamese, and considered on patients with purulent rhinitis immediately before
Manx breeds of cats seem to be at increased risk. the surgical procedure because some patients may have foreign
bodies (typically plant material) that might not be dislodged by
Clinical Signs flushing during surgical preparation and result in persistent
rhinitis postoperatively.
The clinical signs vary with the location and severity of the cleft.
Clefts of the primary palate involving only the lip are primarily
a cosmetic defect associated with few clinical signs. Primary Surgical Technique
clefts involving the lip and premaxilla may interfere with the A cuffed endotracheal tube is placed after induction of anesthesia
ability to suckle and may allow milk to enter the nasal cavity and secured to the lower jaw. Access to the pharyngeal area can
resulting in rhinitis. Because the defect is readily apparent, be improved by pharyngotracheal intubation, but it is generally
the inability to nurse properly is likely to be recognized earlier unnecessary. Clefts of the primary palate are repaired with the
by observant owners and hand rearing instituted. Clefts of the patient placed in ventral recumbency and the head elevated on
secondary palate may also interfere with the ability to nurse, a cushion under the mandible. Elevating the head in this manner
196 Soft Tissue
allows the lips to hang in a normal position and provides good are not stiff and it is generally extruded by 14 to 21 days after
surgical access. An oral speculum can be placed if the premaxilla surgery. Some of the new rapidly absorbed monofilament suture
is involved and better access to the oral cavity is needed. The materials are preferred by some veterinary surgeons.
hair on the muzzle is clipped, and the skin is prepared routinely.
The oral cavity is prepared with dilute chlorhexidine or povidone- Cleft of the Primary Palate
iodine solution.
The main objective in repairing a cleft of the primary palate
Clefts of the secondary palate are repaired with the patient is to establish the normal separation between oral and nasal
placed in dorsal recumbency (Figure 14-7). The head is placed cavities. Clefts of the primary palate involving only the lip are
on a soft pad or beanbag, and the maxilIa is immobilized with easy to repair. Although complex flap techniques to reconstruct
1-inch tape placed over the incisors or canine teeth and secured the nostril and columella accurately have been described, they
to the operating table on each side. Access to the oral cavity is are generally unnecessary because of the abundance of labial
obtained by taping the animal’s lower jaw, tongue, and endotra- tissue in animals. The edges of the cleft defect are incised to a
cheal tube to an ether screen. A malleable retractor is also useful depth of 2 to 3 mm along the entire margin of the defect to create
for retracting the tongue and endotracheal tube during repair an inner mucosal layer and outer cutaneous layer (Figures 14-8A
of clefts of the soft palate. Pharyngotracheal intubation can be and B). Beginning at the most dorsal point, the mucosal edges
performed if greater access is needed. The nasal cavity should are apposed with interrupted 4-0 absorbable sutures (Figure
be liberally flushed with saline to remove purulent exudate and 14-8C). Accurate tissue apposition without tension is required.
possible foreign bodies before swabbing the oral cavity with Skin closure should progress from the lip margin to avoid a step
dilute chlorhexidine or povidone–iodine solution. deformity using 3-0 to 4-0 monofilament nonabsorbable suture
material in an interrupted pattern.
Figure 14-8. Repair of a primary cleft palate. A. Incision along the cleft
margin. B. Separation of the oral and nasal mucosa layers. C. The oral
mucosa is closed first. Closure of the skin begins at the mucocutane-
ous junction to avoid step-deformity. (Redrawn from Krahwinkel DJ,
Bone DL. Surgical management of specific skin disorders. In: Slatter
DH, ed. Textbook of small animal surgery. Philadelphia: WB Saunders,
1985.)
Figure 14-10. Two-layer closure using a unilateral hinge flap. A. Incision is made along one side of the cleft separating the nasal and oral mucosa.
A unilateral hinge flap is elevated from the opposite side, “rolled” back over the defect, and sutured to nasal mucosa. A releasing incision is made
along the dental arcade creating a bipedicle mucoperiosteal flap. B. The flap is advanced over the first layer and is sutured to the mucoperiosteum
on the opposite side.
on the first side. The donor site along the dental arcade heals by making it more difficult to achieve an airtight closure. Moreover,
second intention. constant movement of the suture line with respiration and tongue
movements predisposes to dehiscence. Therefore, when wide
When wider defects are present, hinged flaps are elevated defects are present, the following technique is recommended.
bilaterally, rolled back, and sutured together over the middle of
the defect (Figure 14-11A-C). The second layer of the closure Howard Mucoperiosteal Hinge Flap
involves the development of bilateral, bipedicle mucoperiosteal
flaps, which are advanced toward the midline and are sutured The hard palate mucosa is incised parallel to the edge of the
together. The hard palate mucosa is incised just medial (palatal) defect so a mucoperiosteal flap slightly wider than the defect
to the dental arcade, leaving the flap attached rostrally and can be raised (Figure 14-12). The flap is undermined toward the
caudally. The flaps are advanced toward the midline and are midline, with care taken to maintain the blood supply from the
sutured together with 3-0 to 4-0 absorbable suture material. nasal mucosa. The major palatine vessels are identified and
ligated. The edge of the cleft on the opposite side is incised,
The defects along the dental arcade can be allowed to heal by and the oral mucosa is undermined for a depth of 2 to 3 mm.
second intention, or they may be covered by buccal mucosal The mucoperiosteal hinge flap is rolled back over the defect. If
transposition flaps. Potential complications associated with it appears likely that tension will be present, a releasing incision
allowing the defects to heal by second intention are shortening is made along the dental arcade on the side opposite from
and narrowing of the maxilla, but we have not found this to be a the hinge flap. The bipedicle flap is undermined as previously
common clinical entity. Single-pedicle or double-pedicle buccal described and is advanced toward the midline to eliminate the
mucosal flaps can be mobilized to cover the palatal donor sites. tension. The edge of the hinge flap is sutured to the underside of
The buccal mucosa donor sites usually can be easily closed with the mucoperiosteum on the opposite side with preplaced inter-
a simple continuous pattern. Two weeks later, the bases of the rupted sutures using a mayo mattress pattern. Overlapping the
pedicle flaps are incised and sutured. edges in this manner achieves an airtight closure and minimizes
movement along the suture line. The donor site(s) are allowed to
This technique may be difficult to perform without creating heal by second intention.
excessive tension on the suture lines or palatine vessels
when wide defects are present. Although the technique can Closure of Soft Palate Defects
also be performed as a single tissue layer closure by creating Midline soft palate defects commonly accompany hard palate
bilateral, bipedicle mucoperiosteal flaps and advancing them defects (Figure 14-11D-E). If possible, a two-layer overlapping
to the midline, the suture line lies over the center of the defect, technique is used. One flap is based on the nasal mucosa, and
Oral Cavity 199
Figure 14-11. Two-layer reconstruction of a cleft of the hard palate using bilateral hinge flaps. A. Bilateral hinge flaps are elevated and “rolled”
over the defect. The flaps are sutured together on the midline. B. Releasing incisions are made along the dental arcade creating bipedicle muco-
periosteal flaps. C. The bipedicle mucoperiosteal flaps are elevated, advanced over the first-layer closure, and sutured together on the midline. D
and E. Soft palate reconstruction using an overlapping flap technique. D. Partial-thickness incision is made on the nasal surface of the soft palate
on one side and the oral surface on the opposite side (dotted line closest to defect). The flaps are undermined to the midline. E. The oral mucosa-
based flap is sutured to the nasal mucosa on the opposite side. Muscles are apposed if possible. The nasal mucosa-based flap is sutured to the
oral mucosal on the opposite side to complete the repair. Releasing incisions are made along the pharyngeal wall, if necessary, to relieve tension.
(Redrawn from Nelson AW. Upper respiratory system. In: Slatter DH, ed. Textbook of small animal surgery. 2nd ed. Philadelphia: WB Saunders,
1993.)
200 Soft Tissue
Figure 14-12. Howard mucoperiosteal hinge flap. A. Mucoperiosteal flap based on the edge of the cleft is elevated. An incision is made along the
edge of the cleft on the opposite side, and the mucoperiosteum is undermined for several millimeters. B. If the flap is wide enough, mattress-type
sutures are preplaced to pull the edge of the hinge flap under the mucoperiosteum on the opposite side. If tension is present, a releasing incision
is made along the dental arcade and the mucoperisoteum is undermined so it can slide toward the midline and relieve the tension.
the second flap is based on the oral mucosa. The soft palate on Bilateral clefts are much more difficult to close. I have not been
one side is retracted laterally and rostrally to expose the nasal able to re-establish normal length of the soft palate but in the
mucosa. The mucosa is incised the same distance from the edge limited number of cases I have done clinical signs have been
as the width of the defect to create an orally based flap. On the alleviated or markedly improved if more than one-half of the
opposite side, the oral mucosa is incised the same distance from normal length of the soft palate has been achieved. Trying to
the edge as the first flap to create a nasal mucosa-based flap. extend the soft palate much beyond this point has resulted in
The flap based on the nasal side (i.e., side in which incision was excessive tension and postoperative dehiscence. If sufficient
made in the oral mucosa) is rolled back and is sutured to the pharyngeal tissue can be mobilized, the defects are closed as
lateral edge of the incision in the nasal mucosa on the other side described above but generally this type of closure will result in
of the defect. An attempt is made to suture the palatine muscles excessive tension and predispose to dehiscence. A tension-free
along the midline. The oral mucosa-based flap is moved across closure is more likely achieved by making releasing incisions
and is sutured to the oral mucosa incision on the opposite side. in the pharyngeal mucosa which essentially creates bipedicle
If any tension is present, releasing incisions are made in the oral advancement flaps. Alternatively single pedicle flaps can be
mucosa laterally near the wall of the pharynx. elevated bilaterally from the pharyngeal mucosa dorsolateral to
the tonsillar crypt and sutured to the soft palate after incising it
Lateral and bilateral clefts of the soft palate are occasionally along the edge. A one layer closure is performed with 3-0 to 4-0
seen. Lateral clefts can be repaired by direct closure if minimal monofilament suture material using a cruciate suture pattern.
tension is present or with flaps elevated from the dorsolateral The donor site is left to heal by second intention.
pharyngeal wall if excessive tension is present. Direct closure
is performed by incising the edge of the palate defect to create
an oropharyngeal and nasopharyngeal side. The pharyngeal
Postoperative Care
mucosa dorsolateral to the tonsil is incised. A two-layer closure Intravenous fluids are continued until the patient recovers from
is performed beginning with the dorsal (nasopharyngeal) side. I anesthesia. Immature animals are given a liquid meal replacement
prefer to use a monofilament absorbable material (3-0 to 4-0) in diet or gruel after recovery from anesthesia. Placement of an
a continuous pattern on the nasopharyngeal side of the defect. I esophagostomy tube should be considered if tension exists on
prefer to close the oropharyngeal layer with interrupted cruciate the suture line. Tube feeding is continued for at least 1 week until
sutures using the same suture material. healing is confirmed. A soft diet is fed for a minimum of 1 month.
Chew toys and other hard objects should also be withheld for a
minimum of 1 month.
Oral Cavity 201
Dehiscence is the most common complication of cleft palate should also be considered in patients with obvious oronasal
repair. The incidence can be minimized by performing tension- fistula and purulent nasal discharge because foreign bodies
free closures and by gentle tissue handling. Repair of palatal may enter the nasal cavity through the fistula and may contribute
dehiscences\should be delayed for 3 to 4 weeks to allow inflam- to the rhinitis. Bacterial culture and sensitivity testing are
mation from the initial surgery to decrease. Owners should be performed on patients with severe purulent rhinitis or aspiration
cautioned at the initial examination that more than one operation pneumonia. Culture samples are collected by bronchoalveolar or
may be necessary to achieve complete closure of the palatal transtracheal wash in patients with aspiration pneumonia. Alter-
defect. natively, a broad-spectrum antimicrobial with efficacy against
anaerobes can be given empirically. Treatment is continued for
10 to 14 days. In patients with minimal signs of infection, periop-
Suggested Readings erative antimicrobials are administered intravenously when
Griffiths LG, Sullivan M: Bilateral overlapping mucosal single- the catheter is placed before induction of anesthesia and are
pedicle flaps for correction of soft palate defects. J Am Anim Hosp continued for 24 hours only.
Assoc.2001;37:183-6.
Harvey CE: Palate defects in dogs and cats. Compend Contin Educ Pract
Vet 1987; 9:405-4l8. Surgical Techniques
Radlinsky MG: Congenital ornonasal fistula (cleft palate). In: Fossum TW Successful repair of oronasal fistulas requires a well-supported,
(ed). Small animal surgery 4th ed. St Louis: Mosby-Elsevier, 2013. airtight closure that is free of tension. The options for surgical
Howard DR, et al: Mucoperiosteal flap technique for cleft palate repair closure of oronasal fistulas are determined by the size, location,
in dogs. J Am vet Med Assoc 1974; 165:352. and chronicity of the fistula. Although many different techniques
Reiter AM, Holt DE: Palate. In Tobias KM, Johnston SA eds. Veterinary have been described, our preference is to perform a double-
Surgery Small Animal, St. Louis: Elsevier-Saunders,2012. flap closure that reestablishes continuity of the nasal and oral
Salisbury SK. Surgery of the palate. In: Bojrab MJ, ed. Current mucosa whenever possible. Chronic fistulas, in which the nasal
techniques in small animal surgery. 3rd ed. Philadelphia: Lea & Febiger. and oral mucosa have healed together, provide the option of
1990. creating “hinge” flaps based on the edge of the fistula similar
to those described in the discussion of cleft palate repair in an
earlier section of this chapter. These flaps receive their blood
Repair of Oronasal Fistulas supply from vessels in the nasal mucosa that anastomose with
Eric R. Pope and Gheorghe M. Constantinescu vessels in the oral mucosa during the healing process.
based on the edge of the fistula that are rolled back over the
fistula so the mucosal surface is on the nasal side (See Figure
14-14D). If a single flap is used, it is usually raised from the hard
palate. The alternative is to create opposing flaps from the hard
palate and the labial (buccal) gingiva that are rolled back over
the fistula. After the flaps have been created, the rostral and
caudal edges of the fistula are incised to create nasal and oral
sides. The hinge flaps are sutured to the nasal mucosa laterally
or to each other at the center of the defect and to the rostral and
caudal edges with interrupted sutures using 3-0 to 5-0 synthetic
absorbable suture material. The second step is to create a flap
from the buccal mucosa to cover the first layer of closure and
the donor site on the hard palate completely. This step generally
requires a transposition flap, as described earlier.
Figure 14-14. Oronasal fistula repair using a transposition flap. A. Incisions for a rostrally based flap. B. The flap is undermined and transposed
over the defect. C. Closure of the donor and recipient sites. D. When chronic fistulas are present, a hinge flap can be raised from the hard palate
side of the defect and sutured laterally. A transposition flap is used to cover the flap and donor site.
sever the vessel as the rostral incision is made, retraction of the The angularis oris axial pattern flap has been recommended for
vessel rostrally may make grasping it for ligation difficult. The reconstructing difficult or recurrent palate defects. Depending on
flap is elevated from bone with a periosteal elevator, with care head conformation, this flap can be used to reconstruct defects
taken not to injure the major palatine artery. The flap is trans- caudal the canine teeth. Maximum length is achieved when the
posed to cover the defect. In some instances, removing a trian- flap is elevated as an island sized flap leaving only the vessels
gular segment of mucoperiosteum from the caudal aspect of the and a small amount of surrounding soft tissue attached at the
fistula to the base of the flap is necessary to facilitate transpo- donor site. Identification of the vessels can be difficult even with
sition of the flap over the defect. Because no soft tissue secures the use of transillumination and a pencil Doppler probe. Anatomic
the flap on one side of the fistula (the side adjacent to the donor review and practice on cadavers is highly recommended before
site), holes can be drilled in the hard palate bone with a small attempting this procedure on a clinical patient.
K-wire to allow placement of sutures to secure the flap along
the edge of the fistula (Figure 14-15B). These sutures should be
preplaced. The remainder of the flap is sutured in one or two
Postoperative Care
layers with synthetic absorbable suture material. The exposed The pharyngeal area should be examined and any blood
bone of the donor site is allowed to heal by second intention. suctioned before extubation. Most patients are allowed nothing
by mouth overnight. A soft diet is recommended for 3 to 4 weeks.
Fistulas located more caudally can be reconstructed using a Use of chew toys and other hard objects should also be avoided
partial-thickness flap from the soft palate. The transposition flap during this time. An esophagostomy tube can be placed if one
is designed to incorporate the edge of the defect into one side desires to avoid oral feeding. In most instances, problems with
of the flap (Figure 14-15C). The oral mucosa of the soft palate healing become evident within the first week. If dehiscence
is incised, and a partial-thickness flap is elevated by sharp and occurs, the feeding tube can be maintained until another repair
blunt dissection. Again, one must elevate a flap of sufficient is attempted in 3 to 4 weeks. Tube feeding decreases the amount
length to avoid tension on the closure. The flap is moved over the of material that can enter the nose and worsen the inflammatory
defect and is sutured with synthetic absorbable suture material. response. Most complications can be avoided by gentle tissue
The donor site is allowed to heal by second intention. handling, by achieving a tension-free closure, and by accurate
204 Soft Tissue
Figure 14-15. Central palate fistulas can be closed with transposition flaps A and B from the hard palate mucoperiosteum or with partial thickness
flaps from the soft palate C.
oropharyngeal neoplasms in the dog are malignant melanoma, Radiographs alone (of the skull and tumor site) are adequate
squamous cell carcinoma, fibrosarcoma, and epulides or tumors for assessing bone involvement and preoperatively planning
arising from the periodontal ligament.5-8 In the cat, squamous cell margins for smaller tumors rostral to the 3rd premolar tooth and
carcinoma is the most common oropharyngeal cancer, followed showing little involvement with the maxillary or nasal bones.
by fibrosarcoma, undifferentiated sarcoma, hemangiosarcoma, Radiographs should be taken while the patient is under general
lymphoma, and osteogenic sarcoma. Malignant melanoma anesthesia. Lateral, ventrodorsal, and oblique radiographs may
and epulides occur rarely in the cat.8,9 Odontogenic tumors, be helpful, however, the ventrodorsal or dorsoventral intraoral
such as inductive fibroameloblastoma, are the most common view is generally the most useful view. For caudal and more
benign oral tumors in the cat.10 Oropharyngeal tumors tend to extensive tumors (that involve various portions of the orbit,
be locally aggressive and slow to metastasize, except malignant zygoma, and mandibular ramus), computed tomography (CT)
melanoma, caudal tongue tumors,11 and pharyngeal and tonsillar or magnetic resonance imaging (MRI) are important, if not
squamous cell carcinoma.6-8 Morbidity and mortality often result essential. Generally, CT is preferred because of the affinity for
from local disease rather than from distant metastasis; many bone detail as the degree of bone involvement will often dictate
animals die or are euthanized because of signs of local disease, surgical margins and feasibility of the operation. With improve-
such as infection, dysphagia, and aspiration pneumonia, before ments in technique and interpretation of MRI, this modality may
metastases occur. become preferred under certain circumstances.18 The radio-
graphic assessment should include evaluation of cortical bone
Control of local disease is the first goal of most surgical treat- continuity, alterations in bone density, periosteal new bone
ments for oral cancer. Limited soft tissue excisions without formation, and involvement of adjacent soft tissues.
concurrent ostectomy for attempted cure of oral tumors often
fails because of recurrence of the tumor at the primary surgical An incisional biopsy for accurate tissue identification is also
site. Maxillectomy accompanied by en bloc soft tissue resection important before definitive therapy is undertaken. The biopsy
for oral tumors has the potential for prolonged remission or cure site should be selected so complete resection of the mass (See
in certain malignant diseases. Control of local disease improves Chapter 5) and labial flap closure is not compromised. Each
the quality of life even though distant metastasis may ultimately patient can be assigned a World Health Organization staging
occur. Surgical resection should be considered as a first line classification (TNM; tumor, node, metastasis) and clinical stage
of treatment for almost all oral neoplasms. Radiation therapy which are prognostic for disease outcome and can help dictate
can be considered as primary treatment for tumors that show treatment planning.19
consistent responses to radiation, such as lymphoma, other
round cell tumors and acanthomatous epulis. Radiation often
serves in an adjuvant role to surgery for treatment of oral tumors.
General Surgical Considerations
Chemotherapy is indicated for oral neoplasia with a high proba- Boundaries for maxillectomy for oral neoplasms with or without
bility of metastasis; however, highly metastatic oral tumors such cortical bone penetration and destruction are determined by
as malignant melanoma tend to have only a moderate response preoperative imaging and oral examination. Minimally, a 1 cm or
to chemotherapy.12 larger, grossly visible, tumor free margin should be obtained on
all cut surfaces, however, this is dependent on tumor type, site,
Four basic maxillectomy techniques are available to the veter- histologic grade and overall treatment goals.
inary surgeon:2,4 unilateral rostral maxillectomy, bilateral rostral
maxillectomy, total unilateral maxillectomy and caudal maxil- As a rule, an oronasal defect created after resection of tumors
lectomy. The need to perform an incisivectomy, or removal of the that cross the caudal midline is more difficult to close than a
incisive bones (region rostral to the canine teeth) is generally not defect created from resection of tumors that do not cross
encountered. The combination of bilateral rostral maxillectomy the midline. Availability of normal labial and palatal mucosa
and nasal planum resection has also been described for disease generally is the limiting factor. New techniques are continuously
that involves the planum.13,14 Maxillectomy can be combined with being developed and evaluated for closure of more extensive
resections of the ventral orbit, zygoma, dorsal orbit and calvarium oronasal defects which may allow closure of tissue excisions
(orbitectomy procedures) for more extensive, caudal disease.15 which cross midline. Aggressive preoperative imaging and
surgical planning (including closure options) must be done
in cases where aggressive resection is being considered to
Preoperative Evaluation maximize success.20-25 The use of preoperative modeling may
The preoperative workup for maxillectomy is similar to that for assist surgical planning, especially for resections in sensitive
mandibulectomy. The minimum database includes a complete skull sites. Three-dimensional models can be created from CT
blood count, biochemical profile, urinalysis, and thoracic radio- or MRI images which can allow better visualization of disease
graphs for detection of distant metastasis. Regional lymph node extent and involvement of surrounding tissues (Protomed
aspirates should also be examined cytologically to detect nodal Custom Anatomical Models, Arvada, CO). If bone change is
disease. A technique for surgical staging oropharyngeal lymph evident on preoperative imaging, the excised tissue should be
nodes has been described and may be helpful for establishing imaged immediately following resection to determine whether
prognosis and treatment plans for malignant melanoma.16,17 adequate bone disease free surgical margins were obtained,
Evidence of systemic disease or metabolic abnormalities may prior to closure.
preclude or alter the mode of therapy and prognosis.
206 Soft Tissue
The pathologist must ascertain any extension of neoplasia to a days is indicated, usually involving a combination of narcotics and
cut edge. Margins of interest (osteotomy edges and closest soft non-steroidal anti-inflammatory agents. Some dogs may need to
tissue margin) should be identified with India ink or other suitable be treated with additional agents, depending on pain response.
marking system, or tissue margins should be submitted in separate Preoperative or intraoperative nerve blocks using a long acting
containers. This technique aids the pathologist in determining the local anesthetic to the infraorbital nerve ventral to the zygoma
adequacy of mass removal (See Chapter 5). Specimens should be may decrease anesthetic needs and postoperative pain.30,31
placed in 10% buffered formalin and submitted for histopathologic
evaluation. Tumor extension to a cut margin generally implies the After induction, general anesthesia should be maintained with a
need for additional surgery or adjuvant therapy such as chemo- gas inhalant and oxygen. An endotracheal tube with an inflatable
therapy or, more commonly, radiation. cuff is used to prevent aspiration of blood and fluid. Once the
animal is positioned, prior to the start of surgery, the inflation of
Perioperative antibiotics are recommended. Antibiotic therapy the endotracheal tube cuff should be checked again, and upon
for more than 24 hours is not indicated unless dictated by the recovery, extubation with the cuff partially inflated may assist in
situation. Although surgery of the oral cavity is considered removal of blood that has accumulated in the oropharynx. The
contaminated or “dirty,” infection is rarely a postoperative tube should be secured to the animal’s lower jaw to minimize
complication. The antibiotic chosen should be effective against surgical interference. Because intraoperative hemorrhage can
the bacterial flora normally found in the oral cavity, including be significant, a patent intravenous access catheter must be
gram positive cocci (e.g., Staphylococcus sp. and Streptococcus maintained at all times. A balanced electrolyte solution (10 ml/kg
sp.) and gram negative rods (e.g., Proteus and Pasteurella spp.). per hour) is started immediately after induction and is continued
The first generation cephalosporins, penicillins, and synthetic throughout the surgical procedure until the animal has recovered.
penicillins are generally considered effective prophylactic oral Fluid levels may need to be increased, or whole blood, plasma,
antibiotics.26 or colloids may need to be considered, depending on the degree
of blood loss or hypotension. If the planned resection involves
In the authors experience, polydioxanone (PDS, Ethicon, Inc., only intraoral tissues, clipping the patient’s hair is either not
Somerville, NJ), polyglactin 910 (coated Vicryl, Ethicon, Inc.), necessary or minimally required. The exception would be when
polyglycolic acid (Dexon, Davis and Geek, Inc., American using the combined approach for dorsally located maxillary
Cyanamid Co., Manati, PR), and polyglyconate (Maxon, Davis tumors (see total unilateral and caudal maxillectomy section
and Geek, Inc.) sutures (3-0 or 4-0) are prefered for wound below) where the muzzle on the surgical side should be clipped
closure after maxillectomy. These relatively nonreactive sutures and prepped for surgery.32
minimize oral mucosal irritation and maintain adequate tensile
strength during the critical early period of healing. Polydioxanone Temporary unilateral or bilateral carotid artery occlusion has
and polyglyconate have the advantages of being monofilament decreased blood volume loss and has improved visualization of
and absorbable. Their absorption is slower (than polyglactin the surgical field during maxillectomy.33 This procedure can be
910 and polyglycolic acid), however, and food can cling to the considered but is not routine. After removal of the tissue to be
suture, or suture knots can be irritating, resulting in oral mucosal excised, and if carotid artery ligation was performed, blood flow
ulceration if the suture is not removed after healing. Although is reestablished to allow maximum circulation to the surgical site.
polyglactin 910 and polyglycolic acid are absorbable, they are The blood flow to the nasal cavity and palatal mucosa originates
braided suture materials and may increase the possibility of from terminal branches of the maxillary artery, the main continu-
bacterial adherence or may result in a greater inflammatory ation of the external carotid artery. Experimentally and clinically,
response causing oral mucosal irritation. These latter two the common carotid artery has been permanently occluded both
suture materials lose tensile strength sooner than the monofil- unilaterally and bilaterally in dogs without causing neurologic or
ament absorbables, a characteristic that should be considered ischemic deficits.33,34 This situation may not be true, however, in
if adjuvant radiation or chemotherapy may be administered the cat.35
postoperatively or if other patient factors exist that might result
in delayed wound healing. The absorption rate of various suture Positioning of the patient is critical to visualize the entire surgical
materials has been evaluated in vivo for use in the oral cavity in field. In our experience, placement of the animal in dorsal
cats.27 A reverse cutting swaged on needle has been beneficial recumbency with the mouth taped open provides the greatest
in suturing the tough, fibrous soft tissues of the oral cavity. This exposure. The lower jaw, tongue, and endotracheal tube are
type of needle causes less surgical trauma when passed through taped to an anesthesia screen. Movement of the head should
tissues and provides better suture purchase into the soft tissues be restricted by adhesive tape (Figure 14-16). For more dorsally
than other needle types.28 Use of electrocautery should be kept located tumors involving the maxillary and nasal bones, a
to a minimum. Incisions within the oral cavity made with electro- combined intraoral and translabial approach can aid in resection
cautery are more likely to have delayed healing or to become exposure. In these cases, lateral or ipsilateral positioning and
dehiscent than incisions made with a scalpel.2,29 the placement of a mouth gag are preferred. The oral cavity is
prepared by repeated flushing and swabbing with a 10% dilution
The choice of preanesthetic medication and induction agents of povidone iodine solution (Betadine, Purdue Frederick Co.,
is based on preoperative evaluation, personal preference, and Norwalk, CT). The surgical site is draped, with drapes applied
expertise. The use of a narcotic is generally recommended for to the mucocutaneous junction of the upper labia as well as to
its analgesic effects. Adequate postoperative analgesia for 2 to 3 the lower jaw.
Oral Cavity 207
Figure 14-16. The dog is placed in dorsal recumbency with the upper jaw secured to the surgical table with adhesive tape A. The lower jaw,
tongue, and endotracheal tube are suspended by tape from an anesthesia screen B. A gauze sponge has been placed in the caudal oropharynx to
prevent passive aspiration.
Surgical Techniques taneous tissue as possible. The flap is elevated at the level of
the dermis, is left attached at both ends, and is elevated only
Unilateral Rostral Maxillectomy to the point that allows defect coverage without tension. The
Unilateral rostral maxillectomy is indicated for lesions that are surgeon often can establish a tissue plane when undermining
located rostral to the second premolar and do not come up to the labial mucosa and submucosa with Metzenbaum scissors
or cross the midline. The labial and gingival mucosa rostral and (Figure 14-17B). Adequate blood supply and minimal tension are
lateral to the tumor is incised at least 1 cm from the gross margins the critical factors for the survival of the mucosal-submucosal
of the lesion. The incision is continued through the hard palate flap. The base of the pedicle must be of sufficient width to allow
mucosa caudal and medial to the lesion (Figure 14-17A). Hemor- adequate vascularity to reach the tip of the flap.
rhage from the hard palate mucosal incision generally is marked
and requires ligation, electrocoagulation, and pressure to control. The flap is sutured into position with a one layer or two layer
An oscillating bone saw or an osteotome and mallet may be used closure. In a two layer closure, the first or deep layer consists of
to cut the underlying bone following the mucosal incision lines. simple interrupted sutures placed from labial submucosal tissue
The surgeon should try to create curved bone margins, rather to palatal submucosa or through holes predrilled in the bony hard
than square edges, to assist tissue apposition and healing. The palate. This deep layer is especially important for patients that
incised segment of bone is freed of soft tissue attachments and are anticipated to undergo adjuvant radiation or chemotherapy,
is levered en bloc out of the surgical site. Branches of the major because of the effects on wound healing. The second or super-
palatine artery may be visualized and require ligation. Nasal ficial layer consists of simple interrupted or continuous sutures
turbinates should be visible at this time. If tumor has penetrated that appose the palatal mucosa to the labial mucosa (Figure
the bone or if the turbinates are traumatized during the resection, 14-17C). This superficial closure is used alone if a single layer
they should be excised with a scalpel or scissors and submitted closure technique is chosen. Undermining the palatal mucosa
for histologic examination. Before closure, the surgical site is 2 to 3 mm may help in tissue apposition in this closure (Figure
copiously lavaged with sterile physiologic saline. 14-18). If tension is encountered, additional undermining of the
labial flap (toward the mucocutaneous junction) should first be
The oronasal defect created is covered with a labial mucosal attempted. If this does not relieve tension, mattress sutures can
submucosal flap. The flap should be designed so sufficient be placed in addition to the primary sutures.
tissue is obtained to cover the defect without tension. The flap
should consist of mucosa, submucosa, and as much subcu-
208 Soft Tissue
Figure 14-19. Bilateral rostral maxillectomy. A. The dotted line indicates the area to be excised. (Reprinted with permission from Withrow SJ,
Nelson AW, Manley PA, et al. Premaxillectomy in the dog. J Am Anim Hosp Assoc 1985;2 1:50. B. The labial mucosa is incised perpendicular to
the cut edge of the maxilla extending rostrally to the lip margin. C. Both sides of the labial mucosa are undermined deep to the submucosa and
extending to the lip margins. D and E. Two to four bone holes can be placed in the rostral edge of the bony hard palate. F. Submucosa immediately
under the mucosa is attached to the predrilled bone holes using preplaced simple interrupted sutures. G. Mucosal closure is completed by sutur-
ing half of the flap from each side to the mucoperiosteum of the hard palate and the remainder to the opposite side using simple interrupted or
simple continuous sutures.
210 Soft Tissue
Total Unilateral Maxillectomy and between the central incisors and extends along the midline of
the hard palate. The two incisions are joined together just caudal
Caudal Maxillectomy to the last molar tooth at the junction of the hard and soft palate
The most aggressive of the maxillectomy procedures described (Figure 14-21A). Hemorrhage is often marked and is controlled
here, total unilateral maxillectomy, is indicated for tumors that with ligation, electrocautery, and pressure. An ostectomy is then
involve the majority of the hard palate on one side without crossing performed along the incision lines with either an oscillating saw
the midline. It involves removal of the oral mucosa, teeth, and or an osteotome and mallet.
portions of the incisive, maxillary, palatine, and zygomatic bones.
The degree of resection is dictated by the size of the lesion, its The caudal osseous incisions are at the rostral aspect of the
location, the degree of tissue involvement, and the expected zygomatic arch. The terminal branches of the maxillary artery
biologic behavior and grade of the tumor. Any portion of the are in this region and need to be identified and ligated. Once
maxilla can be excised unilaterally and still can result in normal the ostectomy incisions are complete, the tissue to be resected
function and acceptable cosmetics. Caudal maxillary resections is levered loose, soft tissue attachments are excised, and the
can be combined with resections of portions of the inferior orbit, section is removed intact from the surgical site. Exposed or
zygoma, or mandibular ramus, depending on the degree of tissue transected vessels can be identified and ligated at this time.
involvement (Figure 14-20).15 If temporary occlusion of the common carotid artery has been
performed, blood flow should be reestablished to allow identifi-
For the combined dorsolateral and intraoral approach utilized cation of transected vessels. When tumor penetrates the bone
with total unilateral maxillectomy, the dorsal approach involves of the hard palate, the nasal turbinates, which overlie this area,
an incision made through the skin of the lip or muzzle at or above should be excised with scissors or a scalpel and submitted for
the dorsal aspect of the mass; this incision is made parallel to histopathologic examination. Turbinate hemorrhage can be
the lip margin. If there is a biopsy tract in the skin, the incision controlled with a combination of ligation, electrocoagulation,
is carried around this tract to leave it attached to the specimen and pressure. The use of mandibular symphysiotomy to facilitate
(as an island) to be resected. The skin and/or subcutaneous exposure for caudal maxillectomy has been reported.36
tissue are undermined dorsal to the mass, extending to the
mucosal reflection dorsal to the dental arcade. Adequate soft A lip margin-based flap is created by undermining the labial
tissue margins must be maintained around the tumor. The buccal mucosa and submucosa from the maxillectomy site toward the
mucosa is incised at this point to allow communication with the lip margin (Figure 14-21B). The mucosal-submucosal flap must
intraoral dissection (see below). This creates a bipedical skin/ be of adequate size and sufficiently undermined so it can be
mucosal flap over the resection site, facilitating exposure.32 brought into apposition with the mucoperiosteum of the hard
palate without tension. After thorough irrigation of the surgical
The mucosal incision is begun rostrally at the labial-gingival site and confirmation of complete hemostasis, the labial mucosal-
junction dorsal to the incisors and is continued lateral and caudal submucosal flap is sutured to the subperiosteally elevated edge
to the level of the last molar tooth. Medially, the incision begins of the hard palate mucoperiosteum with simple interrupted or
Figure 14-20. Examples of orbitectomy resection options (shaded portions). Reprinted with permission from O’Brien MG, Withrow SJ, Straw RC, et
al. Total and Partial orbitectomy for the treatment of periorbital tumors in 24 dogs and 6 cats: A retrospective study. Vet Surg 1996;25:471-479.
Oral Cavity 211
simple continuous sutures (Figure 14-21C). If indicated, submu- Inflation of the cuff caudal to the site will force the blood loss out
cosal sutures can be placed through predrilled bone holes in the of the nasal cavity and allow better quantitative measurement.
hard palate before closing the mucosal flap. The oropharynx is Without this, large volumes of blood can be swallowed by the
suctioned of blood before the animal is allowed to recover from patient after recovery masking the true volume of loss and
anesthesia. preventing appropriate support. The Foley catheter can then be
removed once hemorrhage has subsided. Another option is to
For cases with persistent, excessive blood loss from the nasal pack the nasal cavity with gauze from a roll, exiting the end of
turbinates, placement of a Foley catheter can aid in control the gauze from the external nares. Once hemorrhage subsides
of hemorrhage. The tip of the catheter is placed through the the gauze can then be carefully pulled. This may require heavy
external nares and passed along the ventral meatus to the site sedation or a short general anesthetic.
of the hemorrhage. The cuff is either inflated at the site of loss,
or, if the site cannot be identified, it is inflated at the very caudal
aspect of the nasal cavity. Inflation of the cuff directly over the
Postoperative Care and Sequelae
site will apply pressure and assist in control of hemorrhage. Because of the aggressiveness of maxillectomy procedures, the
animal should be supported for the first 24 hours postoperatively
212 Soft Tissue
with parenteral fluids and analgesics. Close observation within a In patients that undergo bilateral rostral maxillectomy, removal
critical care unit is preferred, especially following larger resec- of the bony hard palate caudal to the canine teeth may shorten
tions. The use of continuous rate infusion narcotic agents will the nose. In some cases, the upper lip may actually be positioned
often result in smoother recovery and maintenance of pain control. caudal to the lower canines when the mouth is closed, especially
An Elizabethan collar is often necessary to prevent self induced if imbrication or plication sutures are used. Drooping of the nares
trauma to the surgical site. The patient is allowed water after and rostral muzzle also occurs when the mouth is open.
recovery from anesthesia, and soft foods are offered 24 to 48 hours
after surgery. Feeding small meatballs made from canned food for
the first few days can assist the patient in prehending food and
Follow up
decrease messiness associated with eating immediately postop- Initial re-evaluation is recommended 7 days following maxil-
eratively. Pharyngostomy, esophagostomy, and gastrostomy lectomy. This is the time period where dehiscence is most
tubes rarely are necessary in dogs. In the authors’ experience, common, therefore a thorough oral exam is indicated to evaluate
cats undergoing maxillectomy procedures are best supported by for dehiscence or other complications. At the same time, sutures
enteral feeding tubes during the immediate postoperative period. that have loosened and are causing irritation can be removed.
Maxillectomies performed for excision of tumor should then be
The surgical site should be visualized for evidence of dehiscence evaluated at 1 month and then every 3 months during the first
and should be kept free of debris by flushing the mouth with water postoperative year. Evaluations should include both visualization
daily. Wound breakdown is the most significant postoperative and palpation of the oral cavity, muzzle, and regional lymph
complication after maxillectomy. Suture line tension, excessive nodes. Thoracic radiographs, depending on tumor type, may
use of electrocautery, ischemic necrosis of the mucosal submu- also be indicated for detection of distant metastasis. If gross
cosal flap, and tumor recurrence are the major causes of dehis- evidence of local tumor recurrence or suspicious areas can be
cence. Except for tumor recurrence, most problems result from detected, an incisional biopsy should be performed. Skull radio-
technical error by the surgeon and can be eliminated by following graphs or advanced imaging may be beneficial, but they are
proper case selection and technique and by minimizing surgical often difficult to evaluate, especially in the distinction of tumor
trauma. If the sutures holding the flap in place break down and bony reactions resulting from surgical trauma. Complete
after surgery, the animal should be reanesthetized and the flap surgical excision with adequate tumor free margins generally is
resutured. At the time of resuturing, rebiopsy of the surgical site difficult to obtain after documentation of local tumor recurrence.
is always indicated; what appears to be granulation tissue can Chemotherapy and radiation therapy are alternative adjunctive
easily be residual tumor. Up to 33% of maxillectomy patients have therapies to consider in such cases.
some degree of dehiscence during the postoperative period.13,37
Not all cases of dehiscence, however, are of clinical signifi- Table 14-1 lists approximate reported local recurrence and
cance. Dehiscence is most commonly noted after caudal maxil- median survival rates after maxillectomy for the major histo-
lectomy or total unilateral maxillectomy, when tumors cross the pathologic tumor groups found in the dog.1,3,13-16 A lack of reported
midline, and whenever mucosa has been sutured next to a tooth cases in the cat precludes drawing any conclusions concerning
on the occlusal margin of the ostectomy. Tension free closure survival rates.
at the level of the ostectomy can be achieved by extracting an
additional tooth, by elevating the palatal and labial gingiva, and by
suturing the mucosal flaps over the alveolar bone. If dehiscence
results in oronasal fistula formation, secondary closure should Table 14-1. Approximate Reported Local Recur-
be attempted to avoid additional complications. Techniques for rence and Survival Data for Oral Tumors Treated
closure of oronasal fistulas are described in (See Chapter 14 on with Maxillectomy
Repair of Oronasal Fistulas).
Tumor Type Number Local Median
Recurrence (%) Survival
A concave deformity of the muzzle contour can occur after partial
(months)
maxillectomy and repair with a labial mucosal-submucosal flap.
Such indentation generally results from an insufficient amount Acanthomatous
10 10 26
of normal labial tissues. It generally can be corrected by incising epulis
the base of the labial flap 3 weeks after surgery to allow the lip Ameloblastoma 23 13 22
to return to its normal position. This procedure is rarely indicated
Malignant
because function is generally unaffected by the lip indentation. 40 40 8
melanoma
Recently, the development of a salivary mucocele following Squamous cell
16 31 18
a caudal maxillectomy was reported. Initial clinical signs carcinoma
developed 15 days postoperatively, and included swelling of the Fibrosarcoma 35 46 12
left side of the face, exophthalmos, third eyelid protrusion and
Osteosarcoma 17 35 5
pain when the mouth was opened.38 The most common compli-
cations following maxillectomy have been reported.39 (Data from references 2,4,37,40-42)
Oral Cavity 213
References 23. Sager M, Nefen S. Use of buccal mucosal flaps for the correction of
congenital soft palate defects in three dogs. Vet Surg 1998;27:358-363.
1. Fox LE, Geoghegan SL, Davis LH, et al. Owner satisfaction with partial 24. Griffiths LG, Sullivan M. Bilateral overlapping mucosal single-pedicle
mandibulectomy or maxillectomy for treatment of oral tumors in 27 dogs. flaps for correction of soft palate defects. J Am Anim Hosp Assoc
J Am Anim Hosp Assoc 1997;33:25-31. 2001;37:183-186.
2. Withrow SJ, Nelson AW, Manley PA, et al. Premaxillectomy in the 25. Dundas JM, Fowler JD, Shmon CL, et al. Modification of the super-
dog. J Am Anim Hosp Assoc 1985;21:49 55. ficial cervical axial pattern skin flap for oral reconstruction. Vet Surg
3. Salisbury SK, Richardson DC. Partial maxillectomy for oronasal fistula 2005;34:206-213.
repair in the dog. J Am Anim Hosp Assoc 1986;22:185 192. 26. Prescott JF, Baggot JD. Principles of antimicrobial drug selection
4. Salisbury SK, Richardson DC, Lantz GC. Partial maxillectomy and and use. In: Prescott JF and Baggot JD, eds. Antimicrobial Ther¬apy
premaxillectomy in the treatment of oral neoplasia in the dog and cat. in Veterinary Medicine. Boston: Blackwell Scientific Publi¬cations,
Vet Surg l986;15:16 26. 1988:55 70.
5. Dorn CR, Taylor DO, Frye FL, et al. Survey of animal neoplasms in 27. DeNardo GA, Brown NO, Trenka-Benthin S, et al. Comparison of
Alameda and Contra Costa Counties, California. I. Methodology and seven different suture materials in the feline oral cavity. J Am Anim
descrip¬tion of cases. J Natl Cancer Inst 1968;40:295-305. Hosp Assoc 1996;32:164-172.
6. Theilen GH, Madewell BR. Tumors of the digestive tract. In: Theilen 28. Dernell WS, Harari J. Surgical devices and wound healing. In: Harari
GH, Madewell BR, eds. Veterinary Cancer Medicine. Philadelphia: Lea J, ed. Surgical Complications and Wound Healing in Small Animal
& Febiger, 1987:499 534. Practice. Philadelphia: WB Saunders, 1993:249 376.
7. Head KW. Tumors of the alimentary tract. In: Molten JE, ed. Tumors 29. Salisbury SK, Thacker HL, Pantzer EE, et al. Partial maxillectomy:
in Domestic Animals. 3rd ed. Berkeley: University of California Press, comparison of suture materials and closure techniques. Vet Surg
1990:347 428. 1985;14:265 276.
8.Norris AM, Withrow SJ, Dubielzig RR. Oropharyngeal neoplasms. 30. Beckman B, Legendre L. Regional nerve blocks for oral surgery in
In: Harvey CE, ed. Veterinary Dentistry. Philadelphia: WB Saunders, companion animals. Comp Cont Ed Pract Vet 2002;24:439-442.
1985:123 139. 31. Gross ME, Pope ER, O’Brien D, et al. Regional anesthesia of the
9. Cotter SM. Oral pharyngeal neoplasms in the cat. J Am Anim Hosp infraorbital and inferior alveolar nerves during noninvasive tooth pulp
Assoc 1981;17:917 920. stimulation in halothane-anesthetized dogs. J Am Vet Med Assoc
10. Dernell WS, Rullinger GH. Surgical management of ameloblastic 1997;11:1403-1405.
fibroma in the cat. J Small Anim Pract 1994;35:35 38. 32. Lascelles BDX, Thomson MJ, Dernell WS, et al. Combined dorso-
11. Carpenter LG, Withrow SJ, Powers BE, et al. Squamous cell lateral and intraoral approach for the resection of tumors of the maxilla
carcinoma of the tongue in ten dogs. J Am Anim Hosp Assoc 1993;29:17 in dogs. J Am Anim Hosp Assoc 2003;39:294-305.
24. 33. Hedlund CS, Tangner CH, Elkins AD, et al. Temporary bilateral carotid
12. Rassnick KM, Ruslander DM, Cotter SM, et al. Use of carboplatin for artery occlusion during surgical exploration of the nasal cavity of the
treatment of dogs with malignant melanoma: 27 cases (1989-2000). J Am dog. Vet Surg 1983;12:83 85.
Vet Med Assoc 2001;218:1444-1448. 34. Clendenin MA, Conrad MC. Collateral vessel development after
13. Kirpensteijn J, Withrow SJ, Straw RC. Combined resection of the chronic bilateral common carotid artery occlusion in the dog. Am J Vet
nasal planum and premaxilla in three dogs. Vet Surg 1994;23:341 346. Res 1979;40:1244 1248.
14. Lascelles BDX, Henderson RA, Seguin B, et al. Bilateral rostral maxil- 35. Gillian LA. Extra and intracranial blood supply to brains in the dog
lectomy and nasal planectomy for large rostral maxillofacial neoplasms and cat. Am J Anat 1976;146:237-253.
in six dogs and one cat. J Am Anim Hosp Assoc 2004;40:137-146. 36. Mouatt JG, Straw RS. Use of mandibular symphysiotomy to allow
15. O’Brien MG, Withrow SJ, Straw RC, et al. Total and partial orbit- extensive caudal maxillectomy in a dog. Aust Vet J 2002;80:272-276.
ectomy for the treatment of periorbital tumors in 24 dogs and 6 cats: A 37. Schwarz PD, Withrow SJ, Curtis CR, et al. Partial maxillary resection
retrospective study. Vet Surg 1996;25:471-479. as a treatment for oral cancer in 61 dogs. J Am Anim Hosp Assoc
16. Smith MM. Surgical approach for lymph node staging of oral and maxil- 1991;27:617 624.
lofacial neoplasms in dogs. J Am Anim Hosp Assoc 1995;31:514-517. 38. Clarke BS, L’Eplattenier HF. Zygomatic salivary mucocele as a
17. Herring ES, Smith MM, Robertson JL. Lymph node staging of postoperative complication following caudal hemimaxillectomy in a
oral and maxillofacial neoplasms in 31 dogs and cats. J Vet Dent dog. J Small Anim Pract 2010;51:495-498.
2002;19:122-126. 39. Matthiesen DT, Manfra Marretta S. Results and complications
18. Kafka UC, Carstens A, Steenkamp G, et al. Diagnostic value of associated with partial mandibulectomy and maxillectomy techniques.
magnetic resonance imaging and computed tomography for oral Probl Vet Med 1990;2:248-275.
masses in dogs. J S Afr Vet Assoc 2004;75:163-168. 40. Wallace J, Matthiesen DT, Patnaik AK. Hemimaxillectomy for the
19. Owen L, ed. TNM classification of tumors in domestic animals. treatment of oral tumors in 69 dogs. Vet Surg 1992; 21:337 341.
Geneva: World Health organization, 1980. 41. White RAS, Gorman NT, Watkins SB, et al. The surgical man¬agement
20. Beck JA, Strizek AA. Full-thickness resection of the hard palate for of bone involved oral tumours in the dog. J Small Anim Pract 1985;26:693
treatment of osteosarcoma in a dog. Aust Vet J. 1999;77:163-5 708.
21. Smith MM. Island palatal mucoperiosteal flap for repair of oronasal 42. White RAS. Mandibulectomy and maxillectomy in the dog: re¬sults
fistual in a dog. J Vet Dent 2001;18:127-129. of 75 cases. Presented at the 22nd Annual Meeting of the American
College of Veterinary Surgeons, San Antonio, 1987.
22. Bryant KJ, Moore K, McAnulty JF. Angularis oris axial pattern buccal
flap for reconstruction of recurrent fistulae of the palate. Vet Surg
2003;32:113-119.
214 Soft Tissue
Mandibulectomy is also performed for treatment of chronic factors exist that might result in delayed wound healing. The
osteomyelitis or extensive bone or soft tissue injury. Often, these absorption rate of various suture materials has been evaluated in
patients are presented in a debilitated condition. A gastrostomy vivo for use in the oral cavity in cats.18 A reverse cutting swaged
tube can be placed to assist the anorectic preoperative and on needle has been beneficial in suturing the tough, fibrous soft
postoperative patient to maintain proper nutrition and hydration. tissues of the oral cavity. This type of needle causes less surgical
Because most mandibular fractures are open fractures, broad trauma when passed through tissues and provides better suture
spectrum antibiotics are recommended. The duration of antibiotic purchase into the soft tissues than other needle types.19 Use of
therapy depends on the type and severity of infection. electrocautery should be kept to a minimum. Incisions within
the oral cavity made with electrocautery are more likely to have
delayed healing or to become dehiscent than incisions made
General Surgical Considerations with a scalpel.2,20
When mandibulectomy is performed for treatment of an oral
neoplasm, at least a 1 cm, grossly visible, tumor free margin The choice of preanesthetic medication is based on the preoper-
should be obtained on all cut surfaces. If bone change is evident ative evaluation and on personal preference. A narcotic is often
on preoperative imaging, the removed section of mandible should recommended for its analgesic effect. A local nerve block of the
be radiographed to aid in determining whether adequate bony inferior alveolar nerve preoperatively or intraoperatively using
disease-free surgical margins were obtained. Margins of interest a long acting local anesthetic may also decrease postoperative
(osteotomy edges and soft tissue margins) should be identified pain and may lower anesthetic requirements.21,22
with India ink or other suitable marking system, or margins should
be submitted in separate containers. This procedure aids the After induction of anesthesia, an endotracheal tube should
pathologist in determining the adequacy of mass removal (See be inserted, and anesthesia should be maintained with a gas
Chapter 5). The entire specimen is then placed in 10% buffered inhalant and oxygen. A cuffed endotracheal tube is mandatory to
formalin and is submitted for histopathologic evaluation. Tumor prevent passive aspiration of blood and fluid. Once the animal is
extension to the cut margins generally implies the need for positioned, prior to the start of surgery, inflation of the endotra-
additional surgery or adjuvant radiation. cheal tube cuff should be checked again, and upon recovery,
extubation with the cuff partially inflated may assist in removal
Mandibulectomy is considered a contaminated or “dirty” of blood that has accumulated in the oropharynx. The tube is
surgical procedure. Therefore, therapeutic levels of antibiotics anchored to the patient’s muzzle to minimize its interference
are indicated at the time of surgery. Parenteral prophylactic during surgery. Isotonic crystalloid fluid therapy is started
antibiotic therapy begun preoperatively or intraoperatively and immediately after induction at an initial dose of 10 ml/kg per hour.
continued for a maximum of 24 hours is recommended when At times, hemorrhage is brisk, and the dose should be increased
osteomyelitis is not already established. The antibiotic chosen as dictated by the situation. Whole blood, plasma or colloids may
should be effective against the bacterial flora normally found be indicated, depending on the degree of blood loss. The patient
in the oral cavity, including gram positive cocci (e.g., Staphy- is placed on a protected hot water blanket and is monitored at all
lococcus sp. and Streptococcus sp.) and gram negative rods times with a continuous electrocardiogram and preferably with
(e.g., Proteus and Pasteurella spp.). The first generation cepha- either direct or indirect blood pressure measurements. Before
losporins, penicillins, and synthetic penicillins are generally the surgical procedure is begun, the cuffed endotracheal tube
considered effective prophylactic oral antibiotics.17 should be checked again to ensure that an airtight seal has been
created with the trachea to prevent the aspiration of blood.
In the author’s experience, polydioxanone (PDS, Ethicon, Inc.,
Somerville, NJ), polyglactin 910 (coated Vicryl, Ethicon, Inc.), Depending on the type of mandibulectomy performed, the hair
polyglycolic acid (Dexon, Davis and Geek, Inc., American over the dorsal or ventral muzzle may or may not need to be
Cyanamid Co., Manati, PR), and polyglyconate (Maxon, Davis and clipped. Procedures done entirely through an intraoral approach
Geek, Inc.) sutures (3-0 or 4-0) are prefered for wound closure usually do not require clipping. For procedures requiring caudal
after mandibulectomy. These relatively nonreactive sutures approaches, such as total unilateral mandibulectomy and caudal
minimize oral mucosal irritation and maintain adequate tensile mandibulectomy, hair should be clipped in the region of the
strength during the critical early period of healing. Polydioxanone commisure of the lip caudally to the base of the ear. Clipped
and polyglyconate have the advantages of being monofilament regions are routinely prepared for aseptic surgery. The oral
and absorbable. Their absorption is slower than polyglactin 910 cavity should be swabbed with a 10% dilution of povidone iodine
and polyglycolic acid, however, and food can cling to the suture, or solution (Betadine, Purdue Frederick Co., Norwalk, CT). A mouth
suture knots can be irritating, resulting in oral mucosal ulceration speculum is placed between the teeth on the normal side to keep
if the suture is not removed after healing. Although polyglactin the mouth open to assist in exposure. The surgical area is draped
910 and polyglycolic acid are absorbable, they are braided suture as aseptically as possible.
materials and may increase the possibility of bacterial adherence
or may result in a greater inflammatory response causing oral
mucosal irritation. These latter two suture materials lose tensile Surgical Techniques
strength sooner than the monofilament absorbables, a charac- Unilateral Rostral Body Mandibulectomy
teristic that should be considered if adjuvant radiation or chemo-
therapy may be administered postoperatively or if other patient Tumors or injuries involving the incisors, lower canine, or first two
premolars on one side are indications for unilateral rostral body
216 Soft Tissue
mandibulectomy. The soft tissues medial to this region must be free (Figure 14-23A). This procedure is commonly used in cancer
of tumor to obtain a tumor free margin and to allow for adequate patients because of the frequent soft tissue involvement of the
soft tissues for closure (Figure 14-22A). A bilateral rostral body opposite mandible. Even with unilateral disease, some patients
mandibulectomy should be considered if the medial soft tissue function better with a bilateral resection. If the surgeon has any
structures are involved or if an adequate tumor free margin cannot question about the extent of disease (crossing the midline or
be obtained. not), bilateral resection should be performed.
The animal is placed in lateral or dorsal recumbency with the The patient can be placed in lateral, dorsal, or sternal recum-
affected mandible placed upwards. The labial mucosa is incised bency. Dorsal recumbency affords the greatest exposure for
at a minimum of 1 cm outside the visible limits of the tumor dissection and osteotomy, whereas ventral recumbency affords
(Figure 14-22B). The dissection is continued around the body of the greatest exposure of the oral cavity for more difficult closures
the mandible to the sublingual mucosa until the symphysis and (Figure 14-23B). This procedure is similar to unilateral rostral
the caudal limit of the proposed ostectomy are exposed (Figure mandibulectomy, except bilateral resection is performed. No
14-22C). The sublingual and mandibular salivary gland ducts open attempt is made to stabilize the two mandibles together, although
under the body of the tongue on the sublingual caruncle and are an experimental study showed rapid bony union and adequate
generally preserved. If excising this area is necessary, an attempt patient tolerance of a combination of plating and implantation
should be made to ligate these ducts. of bone graft or synthetic graft. Redundant skin may need to be
removed before it is sutured to the sublingual mucosa during
After exposure of the symphysis, the tough fibrous joint is split closure. This is easily accomplished by excising a V shaped
with an osteotome and mallet or oscillating saw to separate the wedge of skin with the apex located ventrally. The excision can
two mandibles (Figure 14-22D). If the tumor has crossed over or is be performed at the most rostral tip of the exposed skin or just
adjacent to the symphysis, the rostral osteotomy should be directed lateral to this point. The location selected should be based first
eccentrically between the incisors or canine tooth on the opposite on location of the tumor and second on cosmetics. Any adherent
hemimandible to excise the symphyseal joint completely. Because skin overlying the tumor should be excised, to ensure a tumor free
the body of the mandible is dense and brittle, an oscillating saw margin. During suturing of the labial mucosa to the sublingual
or Gigli wire is used to make the caudal osteotomy. Tapering the mucosa, the surgeon should attempt to create a soft tissue ridge
osteotomy at the occlusal margin decreases suture line tension on rostrally to help keep saliva in the mouth (Figure 14-23C). The
the mucosal closure (Figure 14-22E). This may require the removal hair of the skin may be partially in the mouth, but care should
of an additional tooth. Hemorrhage from the mandibular medullary be taken to prevent inversion of the suture line. In some cases,
cavity is from the mental artery and vein and may be brisk. Bleeding tumor may adhere to the skin, thus requiring its excision. As with
is best controlled with ligation, however, cautery or bone wax can unilateral rostral mandibulectomy, partial closure and allowing
be used, especially in smaller dogs where the medullary canal is the defect to heal by second intention should result in a cosmeti-
too small to access the vessels for ligation. Remaining portions of cally acceptable appearance. Alternatively, direct closure of
abnormal tooth roots should be removed. No attempt is made to haired skin of the lip to sublingual mucosa can be performed.
stabilize the two mandibles together (Figure 14-22F). Increased salivation can be seen as well as mild dermatitis of
the skin of the chin in these cases due to salivary soiling.
An one layer simple interrupted or continuous suture closure
of the sublingual mucosa to the labial mucosa attached to the Total Unilateral Mandibulectomy
skin is accomplished with 3-0 or 4-0 suture (Figure 14-22G). The
areas with the highest incidence of dehiscence are at each Total unilateral mandibulectomy, the most aggressive form of
end (rostral and caudal) of the incision line. The use of a single mandibulectomy, entails removal of one mandible. The procedure
simple interrupted suture at these points, potentially encircling is indicated for patients with tumors or injuries involving a large
an adjacent tooth (passing the suture subgingivally beneath the segment of the mandible or for those with tumors (e.g., malignant
tooth crown) can aid to decrease the incidence of dehiscence. melanoma, fibrosarcoma, osteosarcoma) that appear to have
These interrupted sutures are in addition to the remaining suture penetrated the medullary cavity.
line. The hair of the skin is partially in the mouth, and care should
be taken to prevent inversion of the suture line. In some cases, The patient is placed in lateral or ipsilateral recumbency, with the
tumor may adhere to the skin, thus requiring its excision. In involved mandible placed upwards. The commissure of the lip is
these patients, partial closure and allowing the defect to heal first incised at its midpoint, full thickness, to the rostral edge of
by second intention should result in a cosmetically acceptable the manibular ramus (Figure 14-24A). A modified incision, directed
appearance. Alternatively, direct closure of haired skin of the from the commissure to the coronoid process has been recently
lip to sublingual mucosa can be performed. Increased salivation described that may improve exposure to deeper tissues.23 The
can be seen as well as mild dermatitis of the skin of the chin in incision is then continued through the skin and the subcutaneous
these cases due to salivary soiling. and fascial tissue to the level of the temporomandibular joint.
Branches of the facial artery and vein are ligated or cauterized as
necessary. The parotid duct is generally dorsal to this incision.
Bilateral Rostral Mandibulectomy
Bilateral rostral mandibulectomy is indicated for tumors or The labial mucosa is then incised, to ensure a visible 1 cm tumor
injuries that cross the midline rostral to the second premolar free margin, beginning at the symphysis and extending caudally
Oral Cavity 217
Figure 14-22. Unilateral rostral mandibulectomy. A. The shaded area represents the region of the mandible to be excised. B. The labial mucosa is
incised and the rostral mandible is undermined to expose the symphysis and caudal limit of the proposed ostectomy. C. The sublingual attach-
ments in the rostral intermandibular space are incised. D. An osteotome is used to split the symphysis. E. The dotted lines indicate the proposed
osteotomy site for removal of the tumor adjacent to the symphysis. Note the eccentric osteotomy of the rostral mandible to include the symphysis
and the tapered caudal osteotomy. F. Ostectomy site after unilateral rostral body mandibulectomy. No attempt is made to stabilize the two hemi-
mandibles together. G. Single layer simple interrupted or simple continuous closure of the ostectomy site. t, tongue. (Reprinted with permission
from Withrow SJ, Holmberg DL. Mandibulectomy in the treatment of oral cancer. J Am Anim Hosp Assoc 1983;19:275 276.)
218 Soft Tissue
Figure 14-24. Total unilateral mandibulectomy. A. The dotted line indicates the skin incision. B. The labial mucosa is dissected free from the
masseter muscle (m) and mandible, respectively, after being incised. The dotted area represents the area on the mandible involved by tumor. C.
The symphysis is split with an osteotome. The dotted line represents the incision level for removal of the intramandibular muscles. D. The dotted
line represents the level of resection for rostrally located tumors that involve the mandibular medullary cavity. The cavity ends at the level of
the rostral attachment of the masseter muscle. E. The dotted line represents the masseter muscle incision. F. The attachment of the digastricus
muscle. G. The pterygoideus muscles are incised medially. Care must be taken to avoid cutting the inferior alveolar artery before it is identified
and ligated. H. The masseter muscle has been incised and elevated to expose the temporomandibular joint. The dotted line represents the joint
capsule incision. (Reprinted with permission from Withrow SJ, Holmberg DL. Mandibulectomy in the treatment of oral cancer. J Am Anim Hosp
Assoc 1983; 19:277 278.)
220 Soft Tissue
Figure 14-25. Cheiloplasty, to prevent lateral drooping of the tongue, and closure after total unilateral mandibulectomy. A. Full thickness incision of
the upper lid margin to the level of the first premolar or canine tooth. B and C. Three layer closure: 1, oral mucosa; 2, subcutaneous tissue; 3, skin
closure. (Reprinted with permission from Withrow SJ, Holmberg DL. Mandibulectomy in the treatment of oral cancer. Am Anim Hosp Assoc 1983;
19:279.)
Caudal Mandibulectomy dibular joint is to be included in the excision, this vessel must
Caudal mandibulectomy (removal of part or all of the mandibular be ligated and the medial pterygoideus muscle incised and
ramus) is indicated for tumors or injuries involving the angle, elevated off the ventromedial aspect of the mandibular angle.
temporomandibular joint, or ramus of the mandible. This The mandible is cut ventral and rostral to the involved bone with
procedure is versatile enough to allow preservation of the an oscillating saw or Gigli wire. Depending on the extent of the
temporomandibular joint or excision of the entire mandible lesion to be removed, one may preserve the temporomandibular
caudal to the last molar. This procedure can be combined with joint or include the joint in the excised bone (Figure 14-26D).
resection of the zygoma or inferior orbit for lesions with more At this point, the ramus can be easily removed by incising any
extensive tissue involvement. loosely attached muscle and fascia; the temporomandibular
joint is dislocated if necessary.
The animal is placed in lateral recumbency with the affected side
placed upwards. A curved skin incision is made over the length After copious lavage with physiologic saline, the muscle groups
of the ventral aspect of the zygomatic arch (Figure 14-26A). at the angle of the mandible are closed together to obliterate
Multiple small vessels are encountered, and several thin super- dead space. Replacing the osteotomized zygomatic arch is not
ficial muscles are incised as they cross lateral to the zygomatic necessary. The fascia of the masseter and temporalis muscles
arch. The periosteum is incised over the lateral surface of the are then reattached to each other. Closure is completed with
zygomatic arch. With a periosteal elevator, the temporalis and placement of subcutaneous and skin sutures.
masseter muscles are subperiosteally elevated off the dorsal
and medial aspect and the ventral aspect, respectively, of the Segmental Mandibulectomy
zygomatic arch (Figure 14-26B). Care should be taken not to Segmental mandibulectomy is indicated for benign disease
injure the infraorbital artery, nerve, and vein as they course just processes and for malignant tumors that do not penetrate
medial to the zygomatic arch. Once the zygomatic arch is free cortical bone and are confined external to the cortex of the body
of soft tissue attachments, it is cut with an oscillating saw or between the first premolar and the last molar.
Gigli wire at its rostral and caudal margins (Figure 14-26C); an
osteotome should not be used because it tends to shatter the The animal is placed in lateral recumbency with the affected
hard, brittle bone of the zygomatic arch. Bleeding at the cut side placed upwards. The labial and lingual mucosa is incised 1
edges of the osteotomy site can be stopped with electrocautery cm outside the visible limits of the tumor. Dissection is continued
or bone wax. completely around the mandibular body until it is exposed for
360°. An oscillating saw or Gigli wire is then used to cut the
The masseter muscle is elevated ventrally off the lateral surface mandibular body 1 cm rostral and caudal to the lesion. The
of the mandibular ramus. The temporalis muscle is similarly dorsal aspect of the osteotomy should be angled away from
elevated off the medial and rostral aspect of the mandibular the lesion (Figure 14-27A). Hemorrhage from the mandibular
ramus. Care should be taken as the medial dissection is medullary cavity may be brisk. Bleeding is best controlled with
continued ventrally to avoid the inferior alveolar vessel. This ligation, however, cautery or bone wax can be used, especially
vessel crosses the lateral surface of the medial pterygoideus in smaller dogs where the medullary canal is too small to access
muscle and enters the mandibular foramen located just rostral vessels for ligation. Normally, no attempt is made to replace the
and ventral to the temporomandibular joint. If the temporoman- bony defect or stabilize the cut bone ends. Healing and eventual
Oral Cavity 221
Figure 14-26. Caudal mandibulectomy. A. The dotted line represents the direction of the skin incision over the zygomatic arch. B. The temporalis
(t) and masseter (m) muscles are elevated subperiosteally from the zygomatic arch. C. The dotted lines represent the rostral and caudal osteot-
omy sites on the zygomatic arch. The shaded area on the ramus represents the proposed mandibular ostectomy. D. The dotted lines represent
various ostectomy sites for tumor removal. The temporomandibular joint is preserved (a) or removed (b) depending on tumor involvement of the
ramus. (Reprinted with permission from Withrow SJ, Holmberg DL Mandibulectomy in the treatment of oral cancer. J Am Anim Hosp Assoc 1983;
19:280 281.)
stabilization is from fibrous tissue bridging the osteotomy gap. segmental mandibulectomy in that the ventral aspect of the
There have been reports of successful grafting or implant stabi- mandible is not removed.27 This procedure may prevent some
lization; additionally, the use of an osteoinductive factor (recom- of the postoperative complications noted in cases of segmental
binant human bone morphogenetic protein-2) to stimulate bone mandibulectomy (see below); however, the indications for this
formation has been described.24,25 However, the vast majority of procedure are limited. Rim excision should only be considered
dogs function well with no effort made to fill the defect intra-op- in patients with very small tumors that are based on the
eratively. There have also been reports of canine experimental occlusal surface and are not invading into the mandibular canal.
models that have been used to assess bone regeneration in Additionally, a preoperative CT scan is mandatory to assess
osteotomy sites using distraction techniques and a membrane these patients for disease that is more extensive than what can
barrier. Short and long term clinical effects and outcome have be palpated or seen grossly.
not been evaluated.26 A one layer closure of sublingual mucosa
to the remaining labial mucosa attached to the skin is accom- In general, patients are placed in sternal recumbency for a
plished with 3 0 or 4 0 suture material, similar to that used in mandibular rim excision procedure and the surgical approach is
unilateral rostral mandibulectomy (Figure 14-27B). similar to the segmental procedure except that 360° dissection
is not necessary.27 The ostectomy can be performed with an
oscillating saw or burr; an attempt should be made to avoid
Mandibular Rim Excision
the mandibular canal. While a right-angled rim excision can be
The mandibular rim excision procedure is a variation of a performed, the curvilinear configuration is preferred.27 At the
222 Soft Tissue
Figure 14-27. Segmental mandibulectomy. A. The dotted line indicates the proposed area to be excised. The osteotomies should be tapered away
from the lesion on the occlusal surface to minimize suture line tension. B. Simple interrupted or simple continuous closure of mucosa.
completion of the ostectomy, the surgical site is flushed, and the excessive use of electrocautery, premature feeding of hard foods
adjacent gingiva is sutured over the bony defect using 3-0 or 4-0 before adequate healing, or excessive tension at the suture line.
monofilament suture material in a simple continuous pattern.27 Overall dehiscence rates are reported to be less than 13%.28,29 Total
unilateral mandibulectomy has the highest potential for dehis-
cence.
Postoperative Care and Complications
Analgesics generally are indicated for the first 24 hours postop- Excess tension is most often noted at the rostral extent of the
eratively, particularly after the more aggressive procedures (i.e., cheiloplasty after total unilateral mandibulectomy or at the
total unilateral mandibulectomy) Narcotic agents are often used occlusal bone margin after unilateral and bilateral rostral mandi-
in combination with non-steroidal anti-inflammatory drugs. A bulectomy and segmental mandibulectomy. Tension free closure
constant rate infusion of fentanyl can be considered. Mainte- of the mucosal suture line at the level of the ostectomy can be
nance parenteral fluids (20 ml/kg three times daily) also are recom- achieved by angling the dorsal (occlusal) bone margin away from
mended during this time. Antibiotics generally are not given for the lesion and by suturing the mucosa over the tapered bone.
longer than 24 hours postoperatively. An Elizabethan collar should This may require extraction of an additional tooth. Drooping of the
be placed on the patient as soon as it is sternally recumbent to tongue to one side of the mouth can occur after total unilateral
prevent self induced trauma to the surgical site. The collar should mandibulectomy if cheiloplasty is not performed or if the wound
be kept on the patient for the first 10-14 days. dehisces. Prehensile function of the tongue generally is normal,
however.
Patients may have water and soft foods on the day after surgery
for all types of mandibulectomy. Feeding small meatballs made If ostectomy is performed caudal to the second premolar bilaterally,
from canned food for the first few days can assist the patient in loss of prehensile function and drooping of the tongue may occur
prehending food and decrease messiness associated with eating after bilateral rostral mandibulectomy. This complication is a result
immediately postoperatively. Most animals are able to maintain of loss of support to the base of the tongue. In our experience,
hydration and caloric intake by 24 to 48 hours postoperatively. most animals regain complete control of tongue function in time.
Pharyngostomy, esophagostomy, or gastrostomy tubes are rarely The owners and veterinarian must be willing to hand feed these
necessary in dogs. The surgical site should be kept free of debris animals during the recovery period. Different types of food should
by flushing the mouth with water daily. After complete healing, be tried (i.e., soft or hard), and a compliant and persistent owner is
return to the animal’s normal diet is encouraged. required. Oral feeding should be encouraged to allow the animal to
adapt and develop a “new” prehensile function of the tongue.
Complications are few after any type of mandibulectomy. Postoper-
ative infection is rare unless a deep-seated infection was present After total unilateral mandibulectomy, edema or a “false” ranula
at the time of surgery. The abundant blood supply to the oral cavity may develop at the lateral base of the tongue on the surgically
is a major reason for the low incidence of infection. treated side. This condition is self limiting and generally disappears
within 7 days. Removal of the sublingual and mandibular salivary
If dehiscence occurs at the surgery site, delaying closure for 7 to glands is not necessary for resolution of this condition. Ligation or
10 days to allow better delineation of necrotic tissue and devel- surgical trauma and inflammation with occlusion of the ducts of
opment of a healthy granulation bed is recommended. Dehis- these glands at the time of surgery lead to atrophy of the glands.
cence generally results from self induced trauma by the animal,
Oral Cavity 223
22. Gross ME, Pope ER, O’Brien D, et al. Regional anesthesia of the
infraorbital and inferior alveolar nerves during noninvasive tooth pulp Tongue, Lip, and Cheek Surgery
stimulation in halothane-anesthetized dogs. J Am Vet Med Assoc
1997;11:1403-1405.
Laura D. Dvorak and Earl F. Calfee, III
23. Felizzola CR, Stopiglia JS, de Arújo VC, et al. Evaluation of a modified
hemimandibulectomy for treatment of oral neoplasms in dogs. J Vent Tongue
Dent 2002;19:127-135. In dogs and cats the tongue is a muscular organ that assists in
24. Bracher KE, Trout NJ. Use of a free cortical ulnar autograft following food prehension, mastication, swallowing, taste, thermoregu-
en bloc resection of a mandibular tumor. J Am Anim Hosp Assoc lation, vocalization, and grooming. Most of the tongue is skeletal
2000;36:76-79. muscle consisting of the genioglossus and geniohyoid muscles.
25. Rubio-Bueno P, Sanroman F, Garcia P, et al. Experimental Indications for partial excision of the tongue include congenital
mandibular regeneration by distraction osteogenesis with submerged anomalies (macroglossia), glossitis, traumatic injuries (lacera-
devices: preliminary results of a canine model. J Craniofac Surg
tions, ulcerations and burns, chronic linear foreign bodies,
2002;13:224-230.
and electrical injuries), hyperplastic lesions, and neoplasia.
26. Peled M, Machtei EE, Rachmiel A. Osseous reconstruction using a Neoplastic lesions of the tongue are rare and account for only
membrane barrier following marginal mandibulectomy: an animal pilot
4% of all oropharyngeal tumors in dogs.1 Glossectomy includes
study. J Periodontol 2002;73:1451-1456.
partial glossectomy (amputation of any portion or all of the free
27. Arzi B, Verstraete FJM. Mandibular rim excision in seven dogs. Vet
tongue rostral to the frenulum), subtotal glossectomy (amputation
Surg 2010;39:226-231.
of all of the free tongue and a portion of the genioglossus muscle,
28. Schwarz PD, Withrow SJ, Curtis CR, et al. Mandibular resection as a
geniohyoid muscle, or both, caudal to the frenulum), near total
treatment for oral cancer in 81 dogs. J Am Anim Hosp Assoc 1991;27:60l
glossectomy (resection of 75% or greater of the entire tongue),
610.
and total glossectomy.2
29. Northrup NC, Selting KA, Rassnick KM, et al. Outcomes of cats with
oral tumors treated with mandibulectomy: 42 cases. J Am Anim Hosp
Assoc 2006;42:350-360. General Surgical Considerations
30. Matthiesen DT, Manfra Marretta S. Results and complications Preoperative evaluation of patients with glossal disease should
associated with partial mandibulectomy and maxillectomy techniques. include a complete physical examination, complete blood count
Probl Vet Med 1990;2:248-275.
(CBC), and serum biochemical profile. Three-view thoracic
31. Salisbury SK, Lantz GC. Long term results of partial mandibulectomy radiographs, skull radiographs, computed tomographic scans,
for the treatment of oral tumors in dogs. J Am Anim Hosp Assoc magnetic resonance imaging, and evaluation of associated
1988;24:285 294.
lymph nodes by fine needle aspiration or surgical biopsy may be
32. Kosovsky JK, Matthiesen DT, Manfra Marretta S, et al. Results of indicated for patients with potential neoplastic lesions. Incisional
partial mandibulectomy for the treatment of oral tumors in 142 dogs. Vet
biopsy of tongue lesions not caused by trauma is strongly recom-
Surg 1991;20:397 401.
mended to obtain an accurate preoperative diagnosis so that a
33. White RAS, Gorman NT. Wide local excision of acanthomatous
therapeutic plan and accurate prognosis may be determined.
epulides in the dog. Vet Surg 1989;18:12 14.
Other diagnostic tests may be indicated to establish the overall
34. White RAS. Mandibulectomy and maxillectomy in the dog: results
general health of the patient, especially geriatric animals prior
of 75 cases. Presented at the 22nd Annual Meeting of the American
to anesthesia.
College of Veterinary Surgeons, San Antonio, 1987.
35. Vernon FF, Helphrey M. Rostral mandibulectomy: 3 case reports in
Food should be withheld for 12 hours prior to the surgical
dogs. Vet Surg 1983;12:26 29.
procedure. Rapid anesthetic induction and intubation are recom-
36. Penwick RC, Nunamaker DM. Rostral mandibulectomy: a treatment for
mended for oral surgery. Intubation by temporary tracheostomy
oral neoplasia in the dog and cat. J Am Anim Hosp Assoc 1987;23:19 25.
or pharyngeal intubation may be required depending upon lesion
37. White RAS, Gorman NT, Watkins SB, et al. The surgical management
location to allow adequate surgical exposure and manipulation
of bone involved oral tumours in the dog. J Small Anim Pract 1985;26:693
of the tongue. The cuff of the endotracheal tube should be
708.
properly inflated to prevent aspiration of blood and lavage fluid
38. Bjorling DE, Chambers IN, Mahaffey EA. Surgical treatment of
during the surgical procedure. The oral cavity should be lavaged
epulides in dogs: 25 cases (1974 1984). J Am Vet Med Assoc 1987;190:1315
1318. to remove any particulate material prior to aseptic preparation.
The head should be positioned appropriately for the procedure
39. Straw RC, Powers BE, Klausner J, et al. Canine mandibular
osteosarcoma: 51 cases (1980-1992). J Am Anim Hosp Assoc
being performed. Sternal or lateral recumbency is preferred for
1996;32:257-262. most glossectomies. Dilute povidine–iodine soap scrub can be
used in a three scrub cycle for preparation of the surgical area.
Chlorohexidine scrub or solution should not be used on the face
to prevent contact with the eyes. The head is draped appropri-
ately for the surgical procedure being performed.
A B
Figure 14-28. A. Preoperative view of a squamous cell carcinoma on the caudolateral aspect of the tongue of an 8-year-old castrated male mixed
breed dog. B. Postoperative view of the tongue identified in Figure 14-29A, after partial glossectomy.
226 Soft Tissue
of hemorrhage control and mucosal apposition described for swallowing. Once the patient has learned how to pick up and
partial glossectomy should be followed for subtotal and near total swallow a meatball on their own, they can be encouraged to
glossectomies. Sutures are preplaced through the body of the drink water by placing the meatball in a bowl of water. This will
tongue and the lingual arteries dissected and ligated to prevent allow them to adapt to having their muzzles under water. Many
excess hemorrhage. Mucosal apposition can be performed with dogs in previous case reports ultimately learned how to suck in
either a simple interrupted or a simple continuous suture pattern water like a vacuum.2 Cats are likely to have greater difficulty
using monofilament absorbable suture. Any remaining frenulum with prehension following glossectomy and will often require
should be reattached ventrally to the tongue with mattress long-term or permanent assisted feeding with a feeding tube.
sutures (Figure 14-29).
The surgical incision closure should be monitored for evidence of
dehiscence and should be kept clean of food and debris by rinsing
the mouth with water daily. Healing of the tongue is generally
rapid due to its extensive vascularity. Lateral deformation of the
tongue can occur with partial glossectomies, especially wedge
recession. Hyperptyalism is a commonly reported complication
in human glossectomy patients and has been reported in canine
glossectomy patients but the incidence remains unknown.2,5,6
Complications related to esophagostomy and PEG tubes are a
potential and are described elsewhere.
defects, reconstructive procedures of the eyelid margins and Lip Margin Reconstruction
surgical repair of primary cleft palates. Several techniques exist for excision of lip neoplastic lesions and
for closure of the resulting defects. In all cases, the mucosa should
Lip avulsion injuries are generally associated with the rostral be anatomically apposed if possible to assure proper cosmetic
mandibular lip and are the result of a shearing injury. Shearing alignment of the lip. This alignment should be achieved without
force causes avulsion of the gingival mucosa from its area of undue tension on the suture line so that normal function of the
insertion on the rostral mandibles just ventral to the incisors. jaw is maintained. Full-thickness triangular or wedge resection
Surgical correction of lip avulsion involves debridement of any of the lip allows realignment of the mucosal and lip edges
devitalized tissue and reattachment of the mandibular skin at the however, the tissue margins obtained with this excision may be
gingival line of the incisors. This can be accomplished by taking inadequate for malignant neoplasms. Full-thickness square or
large bites of tissue from the avulsed lip with polydioxanone rectangular resection can be performed to obtain a wider tissue
suture and subsequent passage of the suture through holes margin. The defect created with this technique can be closed
drilled in the rostral mandible or by encircling the mandibular in a “Y” fashion or with a full-thickness labial advancement flap
incisors. Because of the rich blood supply, tissue healing is (Figures 14-30A-D). Labial advancement or rotational flaps can
generally uncomplicated provided appropriate surgical debri- be mobilized from either the upper or lower lips.
dement is performed prior to reattachment of the lip.
A B
C D
Figure 14-30. A. Preoperative view of a 3-year-old Golden retriever with an incompletely excised grade II mast cell tumor of the cheek. B. Intraop-
erative view of the dog identified in Figure 14-30A with 2 centimeter margins indicated on all sides of the prior incision. C. Intraoperative view of
the dog identified in 14-30A after complete full thickness labial excision of the mast cell tumor. D. Postoperative view of the dog identified in Figure
14-30A after three-layer closure of the surgical defect.
228 Soft Tissue
Figure 14-31C. The incised edges of the lower lip and cheek are ap-
posed with horizontal mattress sutures. The needle is passed split
thickness through the cheek into the incision A. then through the Figure 14-31E. Gross appearance of a patient before and after antidrool
mucosal flap, through the base of the lower lip B, up through the cheiloplasty (ADC). A. Preoperative appearance. B. Appearance after
cutaneous flap, and finally through the opposite side of the cheek C. suture removal 24 days after bilateral ADC was performed. Notice the
The needle is reversed and passed through in an opposite direction to draining wounds around the upper lip incision.
complete the pattern. D. Two or three mattress sutures appose the lip
flaps to the cheek. From Smeak DD: Antidrooling cheiloplasty clinical
results in 6 dogs. J Am Anim Hosp Assoc 25:181, 1989.
In dolicocephalic breeds following unilateral mandibulec- 11. Smeak DD: Lower labial pedicle rotation flap for reconstruction of
tomies, cheiloplasty procedures may be beneficial to maintain large upper lip defects. J Am Anim Hosp Assoc 28: 565, 1992.
the tongue within the oral cavity for cosmetic reasons and to 12. McCoy DE: Surgical treatment of the tight lip syndrome in the
prevent excessive drooling. This is accomplished by performing Shar-Pei dog. J Vet Dent 14: 95, 1997.
a full-thickness lip margin excision along the ventral and dorsal 13. Smeak DD: Anti-drool cheiloplasty: Clinical results in six dogs. J Am
borders of the oral commisure. The mandibular and maxillary Anim Hosp Assoc 25: 181, 1989.
cheek is then apposed in three layers. Absorbable suture 14. Hunt GB: Use of Lip-to-Lid Flap for Replacement of the Lower Eyelid
material is used for the buccal mucosa in a simple continuous or in Five Cats. Vet Surg 35: 284, 2006.
interrupted pattern. The deep muscular layer is closed similarly 15. Pavletic MM, Nafe LA, Confer AW: Mucocutaneous subdermal
to the mucosa and skin sutures are used for skin apposition. plexus flap from the lip for lower eyelid restoration in the dog. J Am Vet
Specific attention must be paid to establishing a balance Med Assoc 180: 921, 1982.
between restriction of the tongue into the oral cavity and inter-
ference with normal eating. (See Figure 14-31).
References
1. Dorn CR, Priester WA: Epidemiologic analysis of oral and pharyngeal
cancer in dogs, cats, horses, and cattle. J Am Vet Med Assoc 169(11):
1202, 1976.
2. Dvorak LD, Beaver DP, Ellison GW, et al.: Major glossectomy in dogs: a
case series and proposed classification system. J Am Anim Hosp Assoc
40(4):331, 2004.
3. Dunning D: Tongue, lips, cheeks, pharynx, and salivary glands. In:
Slatter D, ed.: Textbook of Small Animal Surgery. Philadelphia: WB
Saunders, 2003, 553-561.
4. Harvey CE: Small Animal Denistry. St Louis: Mosby Yearbook, 1993,
301-303.
5. Neverlien PO, Sorumshagen L, Eriksen T, et al.: Glycopyrrolate
treatment of drooling in an adult male patient with cerebral palsy. Clin
Exp Pharmacol Physiol 27(4): 320, 2000.
6. Olsen AK, Sjorgren P: Oral glycopyrrolate alleviates drooling in a
patient with tongue cancer. J Pain Symptom Manage 18(4): 300, 1999.
7. Luskin IR: Reconstruction of Oral Defects using Mucogingival Pedical
Flaps. Clin Tech Small An Prac 15(4):251, 2000.
8. Pavletic MM: Reconstructive surgery of the lips and cheek. Vet Clin
North Am 20: 201, 1990.
9. Grandage J. Functional anatomy of the digestive system. In: Slatter
D, ed.: Textbook of Small Animal Surgery. Philadelphia: WB Saunders,
2003, 499.
10. Pavletic MM: Plastic surgery of the head. Proc Am Anim Hosp Assoc
1987, pp.392397.
Pharynx 231
Chapter 15 the larynx to the thoracic inlet. Exposure of the trachea and
esophagus is by midline dissection of the ventral neck muscu-
lature. Partial incision of the insertion of fibers of the sternohyoid
Pharynx muscle on the basihyoid bone may be necessary. The bisected
sternohyoid muscle is retracted to expose the trachea. Dissection
is continued to the left of the trachea by transection of the
Cricopharyngeal Dysphagia insertion of the left sternothyroid muscle to the lateral surface of
the thyroid lamina. The left thyroid gland is exposed between the
Eberhard Rosin trachea and the sternothyroid muscle. Several small branches of
the cranial thyroid artery that supply the upper aspect of the left
Cricopharyngeal dysphagia, although an uncommon condition, is
thyroid gland are ligated and transected (Figure 15-1). The left
considered in the differential diagnosis of persistent dysphagia
recurrent laryngeal nerve should be preserved.
of young dogs. This condition is characterized by inadequate or
asynchronous relaxation of the cricopharyngeal sphincter that
prevents the normal movement of food from caudal portions of
the pharynx into the cranial esophagus. The etiologic basis of this
failure of reflex relaxation has not been established. Dogs with
cricopharyngeal dysphagia usually have a history of dysphagia
persisting since weaning. Attempts to swallow solid food result
in anxiety, gagging, and expulsion of food from the mouth by
forward movements of the tongue. After repeated ingestion of
the masticated food, the entire meal passes into the stomach.
Diagnosis
Except for slight nasal exudate and occasional coughing, physical
examination reveals no abnormality. Examination of the pharynx
reveals no inflammatory or obstructive lesions. While the patient
is under anesthesia, an esophagoscope can be passed into the
stomach without difficulty. The resting pressure provided by the
closed sphincter, as encountered by passage of the endoscope
and as measured by manometry, is normal.
Closure of the incision is initiated by apposition of the sternohyoid Rosin E, Hanlon GF. Canine cricopharyngeal achalasia. J Am Vet Med
muscle with simple interrupted 3-0 absorbable sutures. Suturing Assoc 1972;160:1496.
the transected insertion of the sternothyroid muscle is not Seaman WB. Functional disorders of the pharyngoesophageal junction.
necessary. The subcutaneous tissue and skin are sutured Radiol Clin North Am 1969,11:113.
routinely. Although other tissue planes that were separated for Sokolovsky V. Cricopharyngeal achalasia in a dog. J Am Vet Med Assoc
exposure are not sutured, seroma formation is uncommon. 1967:150:281.
Suter PF, Watrous BJ. Oropharyngeal dysphagias in the dog: a cine-
fluorographic analysis of experimentally induced and spontaneously
occurring swallowing disorders. I. Oral stage and pharyngeal stage
dysphagias. Vet Radiol 1980:21:24.
Warnock JJ, Marks SL, Pollard R, et al: Surgical management of crico-
pharyngeal dyspahgia in dogs: 14 cases (1989-2001), J Amer Anim Hosp
Assoc 223 (10): 1462-1468,2003.
Otopharyngeal/Otic Polyps
in Cats
Jacqueline R. Davidson
Introduction
Otopharyngeal polyps, also termed nasopharyngeal polyps or
inflammatory polyps, are benign pedunculated growths that arise
from the oropharyngeal mucous membranes. The polyp stalk
may originate from the nasopharynx, the auditory canal, or the
tympanic cavity.1,2 The polyp may grow into the nasopharynx or
tympanic cavity or both. The mucosal lining from the nasopharynx
to the tympanic cavity is continuous and histologically similar, so
it is difficult to identify the origin of polyps. Polyps are composed
of variable amounts of submucosal lymphocytic plasmacytic
cellular infiltration with fibroplasia and the epithelium ranges
from stratified squamous to ciliated columnar cells.2,3
Figure 15-4. A midline incision has been made in the soft palate to
improve exposure of a feline nasopharyngeal polyp.
Stay sutures may be used to retract the palate while the polyp
is being removed. A three-layer closure is performed on the
palate by suturing the nasal mucosa, submucosal tissue and oral
mucosa separately using 4-0 or 5-0 absorbable suture material in
a simple continuous pattern. The polyp should be submitted for
histologic evaluation to confirm the diagnosis.
Zygomatic gland
Parotid gland
Mandibular
gland
Mandibular ducts
Sublingual
gland
Figure 16-1. The four pairs of salivary glands in the dog and cat.
Salivary mucocele is a collection of saliva within tissues glands on the affected side.13 Some authors advocate marsupi-
and is the most commonly diagnosed disease of the canine alization of sublingual and pharyngeal mucoceles in an attempt
salivary glands. Mucoceles are rarely reported in the feline to allow continuous drainage of the accumulated swelling.
and have been associated with trauma.11,12 It is thought that However, without concurrent removal of the affected glands
saliva accumulates due to leakage from a damaged salivary marsupialization alone may lead to recurrence.14,15 Determination
gland or duct although the cause of such leakage is unknown. of which side to operate in cases of cervical mucoceles is usually
Most mucoceles are associated with the sublingual gland/ apparent or made during physical examination. If mucocele
duct complex and occur in the cranial cervical or interman- lateralization is not apparent, displacement of the mucocele may
dibular subcutaneous tissue (cervical mucocele). Intraoral produce a swelling within the oral cavity, adjacent to the tongue
mucoceles associated with sublingual gland/duct defects on the affected side. Alternatively, placing the animal in dorsal
are uncommon and include sublingual mucocele (ranula) and recumbency when the animal is anesthetized usually results in
pharyngeal mucocele. The latter result from saliva accumulating the mucocele shifting laterally towards the affected side. Sialog-
adjacent to pharyngeal and laryngeal structures. Most forms raphy has been recommended by some authors and can demon-
of mucoceles are benign lesions associated with low patient strate a defect in the duct or glands radiographically, allowing
morbidity; however intraoral mucoceles (ranula) may interfere accurate identification of which side is affected however, this
with prehension and pharyngeal mucoceles may cause airway requires cannulation of the sublingual ducts, which is difficult
obstruction and dyspnea. Zygomatic gland mucoceles are rare and time consuming.13,15 Exploratory surgery is performed in
in dogs. These mucoceles cause ophthalmologic signs such as some cases to confirm the affected side. Careful examination of
exophthalmos and periorbital swelling. the mucocele during surgery may allow identification of a small
communication with the affected gland. In rare cases, when no
Diagnosis of a cervical mucocele is usually achieved by side can be identified, removal of the mandibular and sublingual
aspiration of a thick, honey-colored, or blood-tinged mucoid fluid glands bilaterally can be performed with no deleterious effects
with a low cell count from the primary cervical swelling. The to the dog.16
fluid can be confirmed as saliva by using a mucus-specific stain
such as periodic acid-Schiff (PAS). The differential diagnosis for
cervical mucocele includes abscess and neoplasia, especially
Surgical Technique
lymphoma. Thyroglossal duct cysts or branchial cysts are rare Mandibular and Sublingual Salivary
congenital lesions similar to mucoceles.
Gland Excision
The mandibular and sublingual glands and ducts are closely The patient is anesthetized and positioned in lateral recum-
associated anatomically and definitive treatment of cervical, bency with a pad positioned under the neck. The lateral aspect
sublingual or pharyngeal mucoceles involves removal of both of the facial area from mid-mandible to the mid-cervical area
is clipped and prepared for aseptic surgery. A skin incision is
Salivary Glands 237
made extending from the angle of the mandible caudally over saliva from the mucocele and a passive or active drain placed
the jugular vein and its bifircation (Figure 16-2). Subcutaneous in the mucocele prior to closure and maintained for 2 to 3 days.
tissue and platysma muscle are incised and the division of the Subcutaneous tissues and platysma are closed with absorbable
jugular vein to the ventral linguofacial and dorsal maxillary suture, and skin closed routinely. The drain should be covered
veins is identified. Careful hemostasis using electrocautery with a bandage, and removed once there is minimal discharge
and ligation is essential during surgery to maintain visibility from the surgical wound.
within the surgical field. The mandibular gland is located just
medial and cranial to the jugular vein bifurcation. The surgeon Zygomatic Gland Excision
should not confuse the mandibular lymph nodes which are
located ventrally to the linguofacial vein with the salivary gland Zygomatic gland mucoceles are uncommonly diagnosed.
complex. The nodes are smaller and are not lobulated as is the Definitive therapy consists of zygomatic gland excision and
mandibular gland. An incision is made into the fibrous capsule drainage of the mucocele. The patient is anesthetized and
of the mandibular gland and the gland dissected free with a placed in lateral recumbency with the head supported by a
combination of sharp and blunt dissection. Blood supply to the pad. An incision is made along the dorsal rim of the zygomatic
mandibular gland is located medial and dorsally and cauter- arch and the palpebral fascia and retractor anguli muscle are
ization or ligation of the vascular supply is recommended. The incised and reflected dorsally (Figure 16-4A-F). The periosteum
mandibular gland is exteriorized and lateral traction used to allow of the zygomatic arch is incised and reflected ventrally, allowing
dissection of the associated sublingual gland cranially to the visualization of the dorsal aspect of the zygomatic gland. Further
level of the digastricus muscle. The sublingual gland dissection visualization is obtained by partially removing the dorsal half of
is completed with a combination of digital blunt dissection and a the zygomatic arch with an osteotome or rongeurs, and by gentle
Kelly hemostat. Dissection is continued dorsal and cranial to the dorsal retraction of the globe. The zygomatic gland is then bluntly
digastricus muscle, until the lingual nerve is identified rostrally dissected free, with care to avoid a branch of the deep facial
and all glandular tissue is isolated (Figure 16-3). The mandibular vein ventrally. The mucocele is then drained and the surgical site
and sublingual ducts are ligated caudal to the lingual nerve and lavaged with sterile saline. If the section of removed zygomatic
the glandular complex removed. Inadvertent avulsion of the arch is intact, it can be secured in place with suture through
glandular complex sometimes occurs during dissection. If the pre-drilled holes in the bone. The cut ends of the retractor anguli
avulsion occurs rostral to the lingual nerve no further action muscle are apposed, and the palpebral fascia is sutured to the
is necessary. If avulsion occurs caudal to the lingual nerve an zygomatic periosteum with absorbable suture material. Subcu-
effort is made to completely excise glandular tissue to the level taneous tissues and skin are closed routinely.
of the lingual nerve. Suction is used to remove all mucus and
Ramus of mandible
Parotid gland
Maxillary vein
Mandibular
Skin incision salivary gland
Figure 16-2. A skin incision is made from the angle of the mandible extending caudally over the bifurcation of the jugular vein.
238 Soft Tissue
Figure 16-3. The mandibular and sublingual salivary gland complex is dissected and exteriorized after capsular incision. Caudal traction on the
glandular complex assists in exposing the rostral sublingual complex to the level of the lingual nerve.
References Chapter 17
1. Dyce KM, Sack WO, Wensing CJG: The Head and Ventral Neck of
the Carnivores, in Textbook of Veterinary Anatomy (ed 2). Philadelphia,
Pennsylvania, W.B. Saunders, 1996, pp 367-391. Esophagus
2. Evans HE, deLahunta A: The Head, in Miller’s Guide to the Dissection
of the Dog (ed 4). Philadelphia, Pennsylvania, W.B. Saunders, 1996, pp
250-309.
Management of Esophageal
3. Spangler WL, Culbertson MR: Salivary gland disease in dogs and Foreign Bodies
cats: 245 cases (1985-1988). J Am Vet Med Assoc 198:465-469, 1991.
4. Stonehewer J, Mackin AJ, Tasker S, et al: Idiopathic phenobarbital-
Michael S. Leib
responsive hypersialosis in the dog: an unusual form of limbic epilepsy?
J Small Anim Pract 41:416-421, 2000. Introduction
5. Boydell P, Pike R, Crossley D, et al: Sialadenosis in dogs. Journal of Most foreign material ingested by dogs and cats will either pass
the American Veterinary Medical Association 216:872-874, 2000. uneventfully through the gastrointestinal tract, cause mild vomiting
6. Withrow SJ. Cancer of the salivary glands. In Small Animal Clinical and/or diarrhea, or be dissolved by gastric acid.1 However,
Oncology. SJ Withrow (ed).4th ed. Philadelphia, WB Saunders, 2007, foreign bodies that lodge in the esophagus should be considered
476-477. an emergency. The longer entrapped foreign bodies are present,
7. Morrison WB. Cancers of the head and neck. In Cancer in Dogs Cats, the greater the chance of severe esophageal wall damage and
Medical and Surgical Management, Morrison WB ed., Philadelphia, possible perforation.2 Sharp pointed objects can penetrate the
Williams and Wilkins, 1998, 513-514. esophageal wall leading to mediastinitis or occasionally broncho-
8. Hammer A, Getzy D, Ogilvie G, et al: Salivary gland neoplasia in the esophageal fistula.3 The most commonly encountered esophageal
dog and cat: survival times and prognostic factors. J Am Anim Hosp foreign bodies are bones, rawhide chew toys, dental chews such
Assoc 37:478-482, 2001. as Greenies®, fish hooks, and hairballs.4
9. Karbe E, Schiefer B: Primary salivary gland tumors in carnivores. Can
Vet J 8:212215, 1967. Because of indiscriminate eating habits, swallowing of incom-
10. Carberry CA, Flanders JA, Harvey HJ, et al: Salivary gland tumors in pletely masticated food, and exposure to dental cleaners,
dogs and cats: a literature and case review. Journal of the American foreign bodies occur more commonly in dogs than cats.3,5,6,7
Animal Hospital Association 24:561-567, 1988. Hairballs vomited from the stomach can obstruct the esophagus
11. Feinman JM: Pharyngeal mucocele and respiratory distress in a cat. in cats. Foreign bodies can occur in any age animal, but are
J Am Vet Med Assoc 197:1179-1180, 1990. most common in young dogs, or those frequently given bones
12. Martin CL, Kaswan RL, Doran CC: Cystic lesions of the periorbital or rawhide chew toys.8 Foreign body entrapment may be more
region. Compendium on Continuing Education for the Practicing Veteri- common in small dogs and terrier breeds.3,4
narian 9:10221025, 1028-1029, 1987.
13. Smith MM: Surgery of the canine salivary system. Compendium on
Continuing Education for the Practicing Veterinarian 7:457-462, 464-465,
Pathophysiology
1985. The esophagus is very distensible and most ingested foreign
14. Harvey HJ: Pharyngeal mucoceles in dogs. J Am Vet Med Assoc objects are passed into the stomach. Foreign bodies commonly
178:1282-1283, 1981. lodge where the esophagus is restricted from distending: the
15. Hoffer RE: Symposium on surgical techniques in small animal thoracic inlet, base of the heart, or diaphragmatic hiatus. The
practice. Surgical treatment of salivary mucocele. Vet Clin North Am entrapped foreign body stimulates secondary peristalsis, which
5:333-341, 1975 can augment pressure necrosis of the esophageal wall.9,10 Even
16. Waldron DR, Smith MM: Salivary mucoceles. Probl Vet Med though the esophagus is lined by tough stratified squamous
3:270-276, 1991. epithelium, erosion, ulceration, and perforation can develop if
the foreign body is not promptly removed. Fish hooks can lodge
anywhere within the esophagus but the pharyngeal portion of
the esophagus and heart base are most common.6
Clinical Signs
The most common clinical signs associated with esophageal
foreign bodies are regurgitation, excess salivation, anorexia,
odynophagia, and respiratory signs due to aspiration pneumonia.
Foreign body ingestion may be observed or suspected by the
owner. Clinical signs develop acutely. With obstructive lesions
regurgitation of water occurs and dehydration can quickly
develop. Perforation of the esophageal wall may result in pyrexia
and depression. Mediastinitis with extension into the pleural cavity
will lead to pleural effusion and progressive respiratory distress.
240 Soft Tissue
A
Figure 17-1A. Lateral survey thoracic radiograph from a 7 month old male West Highland white terrier showing a bone density cranial to the dia-
phragmatic hiatus. Several other bone fragments are visible in the stomach (arrows).
Diagnosis
Most esophageal foreign bodies are radiodense and clearly
visible on survey radiographs (Figures 17-1A and B). Other
common radiographic findings include a soft tissue density
surrounding the foreign body (fluid in the esophagus, thickened
wall, or localized mediastinitis) and air-filled dilated esophagus
cranial to the foreign body.11 Thin poultry bones can be difficult to
visualize as they silhouette with ribs and vertebrae.
from gastroesophageal reflux. Metoclopramide (0.2-0.4 mg/ 12. Moon M, Myer W. Gastrointestinal contrast radiology in small
kg TID) can help increase gastroesophageal tone and reduce animals. Sem Vet Med Surg 1986;1:121-143.
gastric reflux. Sucralfate suspension can bind to and coat 13. Leib MS. Endoscopic Examination of the Dog and Cat. In: Jensen SL,
eroded or ulcerated esophageal mucosa (1 gm/25 kg TID-QID). If Gregersen H, Moody FG, Shokouh-Amiri MH, eds. Essentials of Experi-
severe mucosal damage is present, broad-spectrum antibiotics mental Surgery: Gastroenterology. Amsterdam: Harwood Academic
should be given for 1-2 weeks. Medical treatments should be Publishers; 1994.
continued for 1 week after normal feeding has been resumed. 14. Tams TR. Esophagoscopy. In: Tams TR, ed. Small Animal Endoscopy.
After the esophagus has healed, oral feeding can be started as St. Louis: C V Mosby; 1990:47-88.
described above. Until oral feeding begins, medications (except 15. Guilford WG. Upper gastrointestinal endoscopy. Vet Clin North Am:
sucralfate) must be given parenterally or via the PEG tube. Sm Anim Pract 1990;20:1209-1227.
16. Guilford W, Jones BD. Gastrointestinal endoscopy of the dog and
cat. Vet Med Rep 1990;2:140-150.
Prognosis
The overall prognosis is good, but is dependent on the type
of foreign body, the duration of time present, the degree and Hiatal Hernia Repair
severity of esophageal damage, and the development of
Ronald M. Bright
perforation.4 The longer a foreign body is impacted within the
esophagus, the harder it is to remove and the greater chance
for perforation. Large perforations warrant a poor prognosis, Introduction
despite aggressive surgical care.3 Most cases with esophagitis, The hiatus of the esophagus is that portion of the diaphragm
that receive appropriate medical care, will heal without compli- that allows the esophagus and vagus nerves to pass between
cations.8,10 Stricture formation following foreign body retrieval of the thoracic and abdominal cavities. A hiatal hernia (HH) can
bones is uncommon and is more likely following perforation or allow the protrusion of an abdominal structure(s) through an
when severe damage to the esophageal wall has occurred, or enlarged hiatus and into the thoracic cavity. The most common
after impaction of a dental chew.7 Animals with severe esopha- HH in the dog and cat is the axial hiatal hernia, which implies a
gitis or ulceration should be endoscopically reevaluated in 7-10 cranial displacement of the gastroesophageal junction through
days to assess stricture formation, which if present can be the hiatus into the caudal mediastinum1 (Figure 17-3A). Various
dilated with balloon catheters. amounts of stomach may reside within the thorax as well as
other viscera that may move cranially. Most of the time this is
References a “sliding” hiatal hernia whereby the viscera is not fixed and
moves back and forth between the thorax and abdomen.
1. Leib M. Diseases of the esophagus. In: Leib M, Monroe W, eds.
Practical Small Animal Internal Medicine. Philadelphia: W B Saunders;
Paraesophageal hernias occur when the esophagaogastric
1997:633-652.
junction remains in its normal position below the diaphragm.
2. Jones BD. Management of Esophageal Foreign Bodies. In: Kirk RW,
(Figure 17-3B). However, the fundus and other parts of the
Bonagura JD, ed. Current Veterinary Therapy XI. Philadelphia: W B
Saunders Company; 1992:577-580.
stomach as well as other abdominal viscera can move through
the hiatus into the mediastinum alongside the esophagus.
3. Parker NR, Walter PA, Gay J. Diagnosis and Surgical management of
esophageal perforation. J Am Anim Hosp Assoc 1989;25:587-594.
Hiatal hernias can be congenital or acquired, although the
4. Moore A. Removal of oesophageal foreign bodies in dogs: use of the
congenital type may not become symptomatic until adulthood.2,3
fluoroscopic method and outcome. J Sm Anim Pract 2001;42:227-230.
There appears to be a congenital predisposition in the Chinese
5. Pearson H. Symposium on Conditions of the Canine Oesophagus - I
Shar Pei breed. This breed has also been shown to have an
Foreign Bodies in the Oesophagus. J Sm Anim Pract 1966;7:107-116.
increased incidence of esophageal motility disorders and esoph-
6. Michels GM, Jones BD, Huss BT, et al. Endoscopic and surgical
ageal redundancy, although these can be incidental radiographic
retrieval of fishhooks from the stomach and esophagus in dogs and
cats: 75 cases (1977-1993). J Am Vet Med Assoc 1995;207:1194-1197.
findings not associated with any clinical signs.4,5 Acquired hiatal
hernias are often associated with some form of trauma although
7. Leib MS, Sartor LL, Esophageal foreign body obstruction caused
by a dental chew treat in 31 dogs (2000-2006). J Am Vet Assoc 2008;
there is some evidence to suggest that they can occur in dogs
232:1021-1025. and cats with no history of trauma but in association with cardio-
pulmonary, neuromuscular, or metabolic disease.6
8. Ryan WW, Greene RW. The Conservative Management of Esophageal
Foreign Bodies and Their Complications: A Review of 66 Cases in Dogs
and Cats. J Am Anim Hosp Assoc 1975;11:243-249. Pathophysiology
9. Spielman BL, Shaker EH, Garvey MS. Esophageal foreign body The terminal esophagus (abdominal portion) incorporates the
in dogs: a retrospective study of 23 cases. J Am Anim Hosp Assoc
lower esophageal sphincter (LES) and extends approximately
1992;28:570-574.
2 cm below the diaphragm. Normally, the LES relaxes to allow
10. Zimmer JF. Canine Esophageal Foreign Bodies: Endoscopic, Surgical,
a bolus of food or liquid to pass into the stomach and quickly
and Medical Management. J Am Anim Hosp Assoc 1984;20:669-677.
closes to prevent excessive gastroesophageal reflux (GER). Any
11. Houlton EF, Herrtage ME, Taylor PM, et al. Thoracic oesophageal change to the normal anatomic relationship between the LES,
foreign bodies in the dog: a review of ninety cases. J Sm Anim Pract
the hiatus, and the phrenicoesophageal ligament can disrupt
1985;26:521-536.
the high pressure zone (unrelated to the cranial displacement
Esophagus 243
A B
Figure 17-3. A. The “sliding” axial hernia allows the distal esophagus, gastroesophageal junction, and a portion of the stomach to protrude into
the thorax. B. The paraesophageal hernia allows the protrusion of viscera through a diaphragmatic defect adjacent to the hiatus. The gastro-
esophageal junction remains fixed in position.
244 Soft Tissue
gastroesophageal reflux and the severity of hypomotility can also A cranial midline celiotomy is performed to access the cranial
be analyzed. If a paraesophageal hernia is present, the gastro- abdomen, diaphragm, and distal esophagus. The stomach and
esophageal junction remains in its normal position while the esophagus are gently retracted caudally while standing on the
stomach and other displaced viscera are displaced cranially into left side of the animal that is placed in dorsal recumbency. An
the thorax along with and adjacent to the distal esophagus. assistant maintains slight caudal traction on the stomach and
esophagus that helps reposition the distal esophagus below the
Endoscopy will assist in identifying not only the HH but secondary diaphragm. The small intestine is packed in warm saline-soaked
inflammatory changes of the distal esophagus as well. Endoscopy laparotomy pads outside the abdominal cavity to the right of
may demonstrate enlargement of the hiatal opening, cranial the midline. The triangular ligament of the liver is incised and
displacement and dilatation of the cardia, and rugal folds of the the liver lobes retracted laterally toward the right side of the
stomach.12 Visualization of the cardia and gastroesopahgeal abdomen to aid in visualization of the esophageal hiatus. The
junction is often easiest with the scope in the retroflex position.12 ventral portion of the esophagus is carefully dissected away
from the phrenicoesophageal ligament to allow the caudal
portion of the esophagus and the LES to be withdrawn into the
Medical Therapy abdomen. During this dissection, the ventral trunk of the vagus
The goal of medical therapy is to alleviate the signs caused by nerve and blood vessels should be avoided. The right and left
reflux esophagitis and any aspiration pneumonia that may be crura of the diaphragm are then approximated (hiatal plication)
present. Animals with minimal symptomatology may benefit from with polypropylene or monofilament synthetic suture to reduce
dietary modification alone. Modification should include a soft diet the hiatus to a diameter of 1-2 cm, or to the size, which would
low in fat, decreasing the volume of food given at each meal while allow the passage of one finger adjacent to the esophagus.7
increasing the frequency of feeding, and feeding from an elevated Polypropylene or a monofilament synthetic suture is preferred
position. Some obese animals will also benefit by losing weight. for the plication (Figure 17-4A).
In those cases that fail to respond to dietary changes, raising the The esophagus is then “fixed” to the diaphragm to maintain the
gastric pH with an H2-receptor antagonist will help neutralize LES in the abdominal cavity caudal to the esophageal hiatus.
the effects of gastric secretions on the esophageal mucosa This esophagopexy is accomplished by placing 2 sutures on
and decrease the esophagitis. The improvement in esophagitis each side of the hiatal opening between the diaphragm and
indirectly helps increase the tone of the LES thereby dimin- the tunica muscularis along the ventrolateral surface of the
ishing the amount of GER. A proton-pump inhibitor (omeprazole, esophagus, again taking care to avoid the vagus nerve (Figure
Prilosec, Astra Zeneca) can be substituted for the H2-receptor 17-4B). Finally, a left-sided incisional gastropexy is performed
antagonist. A prokinetic drug such as metoclopramide (Reglan, while the fundus is under a slight amount of caudal traction.
Wyeth Pharmaceuticals) or cisapride can be used to help The incision on the abdominal wall is made slightly caudal to the
increase the LES tone and hasten gastric emptying resulting in incision on the fundus of the stomach so that when traction is
less GER. Cytoprotective agents such as sucralfate (Carafate, applied to the fundus, the two incisions will be in alignment. In
Hoechst Marion Roussel) has been shown to be effective by cats, the abdominal wall incision for gaqstropexy is placed more
coating the distal esophagus and providing protection against caudally to ensure a moderate amount of traction on the fundus
the effects of gastric acid, pepsin, and bile salts. This is given as when the abdominal wall and gastric incision are aligned.
a slurry or suspension when used for esophagitis.
If the hiatal hernia is small and there is minimal displacement Postoperative Care
of abdominal contents, the reflux esophagitis is not severe and The animal is maintained on medical therapy and special feeding
medical treatment alone is often effective. However, animals techniques as described under medical therapy for 2-3 weeks
that remain symptomatic in spite of aggressive medical therapy postoperatively. If aspiration pneumonia is a concurrent problem,
will require surgical intervention. Some owners may also choose antibiotics, coupage, oxygen therapy, and nebulization may be
surgery initially because of their inability to comply with the necessary. Some degree of regurgitation may continue postop-
rigorous requirements of medical therapy. eratively but usually resolves in 3-7 days. If reflux esophagitis
is severe, a tube gastrostomy can be performed at the time of
hiatal hernia repair and the animal fed in this manner until regur-
Surgical Therapy gitation is absent and esophagitis has decreased. Resolution of
Veterinary surgeons have historically performed plication of the megaesophagus and improved esophageal motility has been
the gastric fundus around the distal esophagus to reverse the documented as early as 7 days after hiatal hernia correction.7
effects on GER caused by a hiatal hernia.3,10 However, Prymak
and colleagues advised against this as a component of surgical In most cases, the prognosis following hiatal hernia correction
therapy for hiatal hernia since a LES disorder is not thought to is good. Some animals may still require feeding from an elevated
be the primary problem associated with an HH.7 Surgical reposi- position and small frequent feedings especially if there is a
tioning of the displaced stomach and gastroesophageal junction generalized gastrointestinal motility disorder.13
to its normal abdominal location, reduction in size of the esoph-
ageal hiatus by plication of the lumbar crus of the diaphragm, In some cases where resolution of clinical signs is not complete,
and esophagopexy/gastropexy are the procedures associated a primary LES disorder may exist. These cases may benefit from
with the greatest degree of success and fewest complications.7
Esophagus 245
References
1. Kelly KA. Physiology of the gastrointestinal tract. New York: Raven
Press, 1981, 281.
2. Lorinson D, Bright RM. Long-term outcome of medical and surgical
treatment of hiatal hernias in dogs and cats: 27 cases (1978-1996). J Am
Vet Med Assoc 213: 381, 1998.
3. Ellison GW, Lewis DD, Phillips L et al: Esophageal hiatal hernia in
small animals: literature review and a modified surgical technique. J
Amer Anim Hosp Assoc 23:391, 1987.
246 Soft Tissue
Therapeutic Intervention
Timing Therapeutic intervention during exploratory celiotomy is directed
When to perform exploratory surgery is one of the most critical toward the lesions identified during the procedure. Specific
decisions to be made. Surgery should be timed to maximize the therapeutic goals of exploratory celiotomy include hemorrhage
potential for success, both diagnostically and therapeutically, control, correction of contaminating sources, correction of
and to minimize patient risk and morbidity. The chronology of causes of pain, removal of mass lesions or obstructions, and elimi-
changing historical and physical findings is usually helpful in nation of abnormal fluid accumulations. By effective decision-
deciding when to perform surgery and minimizing patient risk making and appropriate time management during exploratory
and morbidity.1 Timing is particularly critical when dealing with a celiotomy, there is an opportunity for the veterinary surgeon to
Exploratory Celiotomy 247
Surgical Techniques
Technical considerations when performing a celiotomy include
appropriate patient preparation, proper positioning for surgery,
surgical approach, equipment needs, method of exploration,
biopsy techniques, intra-operative peritoneal lavage, and wound
closure.
examined first by evaluating the caudal surface of the diaphragm and kidney are most commonly performed during exploratory
while carefully retracting the liver lobes caudally. Each liver lobe celiotomy.
should be inspected and gently palpated for mass lesions. The
hepatic hilus, including the gall bladder, hepatic ducts, hepatic Liver
artery, and terminal portal vein branches are examined while
gently retracting the stomach caudally. Bile duct patency can Liver samples for biopsy may be obtained by various
be checked if indicated, by attempting to gently express gall methods.11-13 One of the simplest and most frequently performed
bladder contents into the duodenum. Observe and palpate the is the “guillotine” method.11 A loop of monofilament absorbable
biliary tract including the bile duct as it traverses the hepato- synthetic suture material is placed around a peripheral portion
duodenal ligament. The stomach is thoroughly palpated from the of a liver lobe and the ligature tightened to cut through and crush
gastroesophageal junction and cardia to the pylorus, including the hepatic parenchyma and rest on the hepatic vessels and
all anatomic surfaces and the greater and lesser omentum. biliary ducts. A scalpel blade or scissors is used to excise the
hepatic tissue approximately 5 mm distal to the ligature.
The spleen is exteriorized to thoroughly evaluate the parenchyma
for mass lesions and its vascularity visually and by palpation. Another hepatic biopsy method is the finger or instrument fragmen-
Siderotic plaque is commonly seen and appears as grey to tation technique.12 This method is also limited to sampling the
greenish colored plaques on the splenic edges. These plaques edge of a liver lobe. The proposed biopsy site is isolated from the
are regarded as normal and do not require biopsy. Next, inspect remaining lobe by carefully crushing hepatic parenchyma using
and gently palpate the pancreatic body and left pancreatic limb an instrument (e.g., Crile hemostatic forcepsc) or tips of the thumb
as it extends along the caudal surface of the stomach. Identify and index finger. Parenchymal crushing exposes blood vessels
and grasp the descending colon and use the mesocolon as an and bile ducts to the isolated section. Ligatures of synthetic
anatomic retractor for abdominal contents by positioning the absorbable suture material are placed on exposed blood vessels
colon ventrally and to the right. Colonic retraction exposes and and bile ducts in the isolated lobar section. The exposed vessels
allows examination of the left paravertebral region, including the and ducts are divided distally to the ligatures and the hepatic
left kidney and proximal ureter, left adrenal gland, aorta, and left sample excised.
ovary and uterine horn.
Wedge resection of peripheral hepatic tissue is another biopsy
The spleen is returned to the abdomen or exteriorized and option.12 The proposed biopsy site is isolated by placing and tying
wrapped in a moistened laparotomy pad, which facilitates one or two rows of full-thickness horizontal mattress sutures
evaluation of the intestines. The small intestine is evaluated by of synthetic absorbable suture material in the liver. The biopsy
assessing mesenteric arterial pulsations and peristaltic activity. specimen is excised by sharp dissection distal to the sutures. If
Examination is initiated at the pylorus, and the duodenum is necessary, additional horizontal mattress sutures may be placed
retracted to evaluate the right pancreatic limb. The pancreas near the incised edge of the liver lobe to achieve hemostasis.
should be gently palpated for the presence of mass lesions. Use
the mesoduodenum as a retractor by positioning the duodenum A more versatile hepatic biopsy method involves use of a
ventrally and to the left side of the abdominal cavity. This maneuver cutaneous biopsy punch.d Any portion of the liver may be sampled;
permits examination of the right paravertebral region, including however, smaller, partial thickness samples are obtained.11 The
the portal vein, caudal vena cava, celiac artery, epiploic foramen, biopsy punch is placed into the lesion or hepatic tissue and the
hepatic lymph nodes, right kidney and proximal ureter, and right biopsy obtained by twisting the instrument to free the tissue
ovary and uterine horn. The right adrenal gland can be palpated specimen. Avoid excessive tissue penetration to preserve larger
just dorsal to the caudal vena cava and medial to the right kidney. vessels located in the deeper hepatic parenchyma. Hemostasis
Trace the duodenum distally to the duodenocolic ligament, which is achieved by inserting either a topical hemostatic agent (e.g.,
limits exteriorization of the caudal duodenal flexure and proximal absorbable gelatin spongee) or a vascularized omental tag into
jejunum. The surgeon should carefully visualize and palpate the the biopsy defect.11
distal duodenum and jejunum, ileum, cecum, and colon.
Intestine
Evaluate the mesentery of the intestine and its associated lymph Selected upper and lower intestinal regions are accessible to
nodes, vascularity, and lacteals. Finally, the caudal abdomen, mucosal endoscopic biopsy,14 however full-thickness surgical
including the distal colon and associated lymph nodes, urinary intestinal biopsy samples may be taken from any site. Relative
bladder, distal ureters, proximal urethra, regional lymph nodes advantages of endoscopic, laparoscopic-assisted, and surgical
(medial iliac, sacral, and hypogastric), prostate and ductus biopsies have been described.15-17 Principles of intestinal biopsy
deferens, or uterine body and vagina are visualized and gently collection during exploratory celiotomy include the collection
palpated. of multiple samples along its length, full-thickness sample
collection, and protection of the properly-closed biopsy site.18,19
Technical surgical considerations include closure technique
Biopsy Techniques and incisional protection method.
After a thorough and systematic abdominal examination, appro-
priate tissues are biopsied or specific surgical therapeutic inter- A cutaneous punchd is used to penetrate full-thickness into the
vention is performed. Biopsies of the liver, intestine, lymph node, lumen and obtain the sample.20 The intestinal defect is closed
c
Crile hemostatic forceps, Cardinal Health, McGaw Park, IL 60085. d Baker’s 6 mm biopsy punch, Baker Cummings, Key Pharmaceuticals, Miami, FL 33169. e Gelfoam, Pharmacia &
Upjohn Company, Kalamazoo, MI 49001.
Exploratory Celiotomy 249
Lymph Node
The following abdominal lymph nodes are frequently biopsied
Abdominal Closure
The abdominal wall is closed at the completion of abdominal
during abdominal surgery: medial iliac, mesenteric (jejunal),
exploration and after lavage fluid evacuation. Abdominal wall
pancreaticoduodenal, and colic lymph nodes. Mesenteric
closure technique recommendations are based on biome-
(jejunal) lymph nodes may yield less definitive information.24
chanical information of healing abdominal incisions in the dog.33
While results of fine-needle lymph node aspiration correlate
Sutures should incorporate approximately 8 mm of tissue on
well with those of lymph node histology in small animals with
each side of the wound. Sutures should incorporate the linea
solid tumors, incisional or excisional lymph node biopsy samples
alba and external fascial sheath of the rectus abdominis muscle
are preferred because they provide morphologic information.25
only, not muscle or peritoneum (Figure 18-3).34,35 Incorporating
The blood supply to adjacent tissue (intestine) is carefully
the internal fascial sheath of the rectus abdominis muscle
preserved when excising a lymph node. Divide the blood supply
does not yield additional wound strength and is not recom-
to the lymph node between sutures, and carefully dissect the
mended.34 Suture tightness should be appropriate for wound
lymph node from adjacent tissues.26,27 The lymph node is handled
edge apposition however excessively tight sutures yield lower
gently to avoid creation of tissue artifact.
long-term wound strength.36 Either a continuous or interrupted
suture pattern is performed using appropriate sized synthetic
Kidney absorbable or nonabsorbable suture material.34,37,38 The subcuta-
Biopsy of the kidney is frequently performed to provide both neous tissue and skin are closed in a routine fashion.
diagnostic and prognostic information.27 Surgical biopsy methods
include needle biopsy and wedge resection. The needle biopsy
technique is less traumatic but yields smaller specimens. The
Summary
needlef is placed through the renal capsule at the caudal aspect Exploratory celiotomy is a commonly performed procedure in
of the kidney and directed within the cortex toward the cranial small animals. When properly timed and performed, exploratory
pole. Remove the biopsy needle and apply digital pressure or celiotomy can provide definitive diagnostic, prognostic, and
therapeutic intervention to the patient. Critical decisions to be
f
Coaxial achieve, Cardinal Health, McGaw Park, IL 60085.
250 Soft Tissue
Neoplastic disease
Principles of Gastric and Prophylactic antibiotic Stapling devices
Pyloric Surgery administration
Maria A. Fahie Approach (ventral midline Omental patching
celiotomy)
Figure 19-1. Pertinent gastric arterial anatomy. Reprinted with permission from: Anderson S, Gill P, Lippincott L, Somerville M, Shields S, Balfour
R, Wilson E. Dimensions in Surgery: Partial Gastrectomy. Pulse (an official publication of the Southern California Veterinary Medical Association):
May, 2002.
252 Soft Tissue
Figure 19-3. Anatomy of the bile duct. It is important to avoid damage to the bile duct as it traverses the hepatoduodenal ligament.
abdominal organs and the entire gastrointestinal tract prior to surgical instruments during tissue manipulation. Surgical instru-
gastrotomy or enterotomy to reduce manipulation of these poten- ments that are valuable for gastric surgery include DeBakey
tially contaminated tissues within the abdomen. tissue forceps, Babcock forceps and Doyen intestinal forceps.
As an alternative to Doyen forceps, Allis tissue forceps can be
modified by placing moistened gauze sponges around the arms
Aseptic Technique of the instrument to be applied to tissue. The thickness of the
The surgeon may use several techniques to decrease contami- gauze determines the amount of pressure applied. Bobby pins
nation of the abdominal cavity and incision during gastrointes- can also be sterilized and used as atraumatic intestinal forceps
tinal surgery. Contamination of the abdomen after gastrotomy if an assistant’s fingers are not available.
can be reduced by double-gloving. The surgeon wears an extra
one-half sized larger pair of gloves during gastrointestinal tract
surgery and removes the contaminated outer gloves prior to Palpation of Gastric Foreign Bodies
abdominal lavage and closure. Contamination of the abdomen by Gastric foreign bodies can be difficult to palpate if there is
gastric content is reduced by packing off the stomach from the excessive gastric content and/or if the object is relatively thin,
abdominal cavity with laparotomy pads. The stomach is exteri- flat and lying against the gastric wall. Gastric contents can be
orized as much as possible from the abdomen by placement removed by orogastric tube passage and flushing intraopera-
of stay sutures or Babcock forceps on the serosal surface. tively prior to gastrotomy. Alternatively, contents can be carefully
Stay sutures are positioned around proposed gastrointestinal removed with suction after gastrotomy, using a Yankaeur or
incisions to maintain gentle tissue traction and to aid luminal Poole suction tip. If necessary, the surgeon can manually remove
visualization and prevent spillage of luminal contents. The stay gastric content using care to prevent spillage into the abdomen.
sutures should be placed with a substantial (1cm) full-thickness Gentle and thorough palpation of the entire stomach will permit
inclusion of gastric wall to prevent accidental tissue tearing as foreign body location and removal. Palpation of the dorsal gastric
tissues are manipulated. Frequent reapplication of warm saline surface is aided by digitally creating a fenestration in the greater
to exposed tissues and the laparotomy pads is performed intra- omentum adjacent and caudal to the greater curvature. If a
operatively and prevents dessication of tissues. After closure gastric foreign body is retrieved intraoperatively, the entire intes-
of the gastric wall, contaminated laparotomy pads or sponges tinal tract should be carefully examined and gently palpated to
are removed and replaced. The abdomen is lavaged with ensure that no other foreign material is present that could cause
warm saline to remove blood clots, tissue debris and to reduce an intestinal obstruction. Foreign bodies located in the caudal
bacterial numbers. Contaminated instruments are discarded and esophagus can sometimes be removed safely by a gastrotomy
clean instruments used for abdominal wound closure. incision. Sterile water-soluble lubricant can be used to protect the
esophageal and gastric mucosal surfaces during gentle digital
palpation and retraction to move the object into the stomach.
Atraumatic Tissue Handling
Gastric tissues can be friable and atraumatic tissue forceps
or an assistant’s fingers induce less tissue trauma than some
254 Soft Tissue
reduction in numbers of parietal cells to secrete intrinsic factor, In medium to large patients, with relatively small and smooth
which is crucial for vitamin B12 to complex with and become gastric foreign bodies, removal can occur with induction of
absorbed in the intestine. vomiting. Alternatively, gastric lavage or endoscopy can be
performed with general anesthesia. A recent retrospective study
Suggested Readings of 102 dogs undergoing endoscopic removal of esophageal and
gastric foreign bodies (FB) concluded a low complication rate
Bright RM, Jenkins C, DeNovo RC. Pyloric obstruction in a dog related provided patients were > 10kg and did not have sharp bone FB or
to gastrotomy incision closed with polypropylene. J Small Anim Pract FB present for more than 3 days.
1994; 35 (12): 629-632.
Clark GN. Gastric surgery with surgical stapling instruments. Vet Clin
North Am Small Anim Pract 1994;24:279-304. Surgical Technique
Clark GN, Pavletic MM. Partial gastrectomy with an automatic stapling The optimal location for gastrotomy is the fundus region, avoiding
instrument for treatment of gastric necrosis secondary to gastric dilata- branches of the left and right gastric and gastroepiploic arteries
tion-volvulus. Vet Surg 1991: Jan-Feb; 20(1):61-8. and associated nerves. Babcock forceps or stay sutures are
Coolman BR, Ehrhart N, Marretta SM. Use of skin staples for rapid placed 1-2 cm from each end of the planned gastrotomy site
closure of gastrointestinal incisions in the treatment of canine linear and used to maintain tissue tension to facilitate the incision
foreign bodies. J Am Anim Hosp Assoc. 2000 Nov-Dec;36(6):542-7. (Figure 19-4). A scalpel blade (No. 10, 11, or 15) is used to make a
Radlinsky MG. Digestive System. In: Fossum, TW ed. Small Animal controlled full-thickness stab incision. Alternatively, the scalpel
Surgery, 4th ed. WB Saunders, Philadelphia, 2013, pp 461-497. blade can be used to make a partial-thickness incision through
Khurana RK, Petras JM. Sensory innervation of the canine esophagus, the serosa, muscularis and submucosa, and the mucosal incision
stomach and duodenum. Am J Anat 1991,192: 293-306. performed alone using a similar blade technique. Metzenbaum
Nawrocki MA, McLaughlin R, Hendrix PK. The effects of heated and scissors can be used to extend the stab incision as indicated
room temperature abdominal lavage solution on core body temperature in the individual case. Hemostasis is achieved using hemostats
in dogs undergoing celiotomy. J Am Anim Hosp Assoc, 41, 1, 61-67, or electrocautery. Gastric contents are removed as needed
2005. in order to retrieve the foreign body or identify the lesion that
Qin HL, Su ZD, Hu LG, et al. Effect of early intrajejunal nutrition on prompted the gastrotomy. If a linear foreign body is identified,
pancreatic pathological features and gut barrier function in dogs with the section within the stomach should not be detached until
acute pancreatitis. Clinical Nutrition, 21, 6, 2002 469-473. the distal extent within the small intestine has been identified
Cornell K. Stomach. In: Tobias K, Johnston S eds. Veterinary Surgery via enterotomy. Gastric biopsy is indicated in all cases requiring
Small Animal. WB Saunders, Philadelphia, 2012, pp 1484-1512. gastrotomy, whether or not gross abnormalities are detected. A
Ross WE, Pardo AD. Evaluation of an omental pedicle extension full-thickness strip of tissue can be excised along the gastrotomy
technique in the dog. Vet Surg, 22, 1, 37-43, 1993. incision and submitted for histopathologic analysis.
Seim III HB, Bartges JW. Enteral and Parenteral Nutrition. In, Handbook
of Small Animal Gastroenterology (2nd ed), 2003, 416-462.
Smith MM, Waldron DR. Approach to the Stomach and Approach to the Closure
Pylorus. In: Atlas of Approaches for General Surgery of the Dog and Cat. Prior to closure, all potentially contaminated instruments,
Philadelphia: WB Saunders, 1993, 184-189. suture material, sponges, drapes and gloves are discarded and
Tsukamoto M, Enjoji A, Ura K, Kanematsu T. Preserved extrinsic neural replaced. In general, I prefer a two layer gastric closure with
connection between gall bladder and residual stomach is essential to a simple continuous appositional pattern using monofilament
prevent dysmotility of gall bladder after distal gastrectomy. Neurogas- absorbable suture material usually 2-0 or 3-0 in size. The first
troenterol Mot 2000, 12: 23-31. layer incorporates the mucosa and the second layer incorporates
Ehrhart NP, Kaminskaya K, Miller JA, Zaruby JF. In vivo assessment the submucosa, muscularis and serosa. If there is concern that
of absorbable knotless barbed suture for single layer gastrotomy and suture material exposed within the gastric lumen can wick fluid
enterotomy closure. Vet Surg 42 (2013) 210-216. or contaminants into the gastrotomy incision or peritoneal space,
Ellison GW. Complications of gastrointestinal surgery in companion then another closure pattern should be chosen. A double layer
animals. Vet Clin Small Anim 41 (2011) 915-934. inverting pattern, such as continuous Cushing or Lembert, can be
Smith AL, Wilson AP, Hardie RJ, Krick EL, Schmiedt CW. Perioperative placed incorporating only the submucosa, muscularis and serosa
complications after full-thickness gastrointestinal surgery in cats with (Figure 19-4).
alimentary lymphoma. Vet Surg 40 (2011) 849-852.
Alternatively, stapling devices such as disposable skin staples
Gastrotomy (4.8 mm by 3.4 mm), or a linear stapling device (TA™) can be used.
The primary advantage is reduction in operative time and strength
Maria A. Fahie of tissue apposition compared with hand suturing techniques.
The primary disadvantage is cost and availability of stapling
equipment. Considering these factors, the benefit of staplers is
Indications probably limited to larger gastrotomy incisions. The skin stapling
The most common indication for gastrotomy is for identifi- technique is described as a double-layer closure, with mucosa/
cation and removal of suspected foreign bodies or for gastric submucosa apposed using a simple continuous pattern of
biopsy. Postoperative peritonitis and stricture are rare in simple monofilament, absorbable suture material, and serosa/muscularis
gastrotomy patients. apposed using skin staples placed at 3 mm intervals facilitated by
256 Soft Tissue
A B
Serosa
Muscularis
Submucosa
Mucosa
C
OR
Mucosa
Submucosa
Muscularis
Serosa
Mucosal
Layer
Apposed
D E
F G
Figure 19-4. Gastrotomy. A. Stay sutures allow gentle tissue traction. An inverted #10, 11 or 15 blade is used to make a full-thickness stab incision
into the stomach. A partial thickness initial incision is also acceptable. B. Extension of the incision with Metzenbaum scissors. C. Single-layer
closure using a simple continuous appositional pattern incorporating mucosa, submucosa, muscularis and serosa simultaneously. D. Alternatively,
a double-layer closure can be performed with the initial step of mucosal apposition using a simple continuous pattern. E. The second step is sub-
mucosal, muscularis and serosal apposition using a simple continuous suture pattern. F. Inverting Lembert pattern. G. Inverting Cushing pattern.
Stomach 257
traction on stay sutures at each end of the incision. A TA™ can or lungs by the time of diagnosis. Partial gastric resection can
be applied to the gastrotomy site, providing an everted closure of only be considered palliative in these patients, since long term
all tissue layers at once, with a double staggered row of staples. prognosis is guarded to grave. Up to 75% of the gastric fundus
can be removed without significantly affecting food passage.
Suggested Readings
Gianella P, Pfammatter NS, Burgener IA. Oesophageal and gastric Surgical Technique
endoscopic foreign body removal: complications and follow-up of 102 Abdominal exploration is always indicated prior to partial
dogs. Journal of Small Animal Practice 2009, 50: 649-654. gastrectomy to evaluate the extent or presence of metastatic or
other disease processes. The gastric abnormality to be resected
is identified by visualization and palpation and an appropriate
Partial Gastrectomy surrounding margin of grossly normal tissue is planned. Stay
sutures facilitate exposure and manipulation. The vascular
(Full-Thickness) supply to the region will include branches of the left and right
gastric and gastroepiploic vessels depending on the location of
Maria A. Fahie the lesion. Those branches supplying the area to be resected
are identified and ligated. The stomach has extensive collateral
Indications circulation, therefore ligation of the vascular supply to the
Benign gastric neoplasia, such as adenomatous polyps or region of abnormal tissue can generally be performed without
leiomyoma, can be excised via partial full-thickness gastrectomy. compromise to remaining gastric tissue. Atraumatic intestinal
Gastric ulcers that are not amenable to medical management can forceps, stay sutures, or assistant’s fingers can be used to isolate
be excised via partial gastrectomy. Malignant gastric neoplasia the tissue that will be remaining. Carmalt forceps can be placed
(adenocarcinoma, leiomyosarcoma, lymphosarcoma and fibro- along the margin of the tissue to be resected in order to prevent
sarcoma) has often metastasized to local lymph nodes, liver abdominal contamination with gastric contents. The tissue is
incised, removed and submitted for histopathologic analysis.
stay sutures
Closure
For lesions of the lesser curvature, closure of the remaining defect
can be performed with hand suturing or stapling techniques similar
to those described in the preceding gastrotomy section. Closure
ligated right of U-shaped defects is facilitated by suturing the appropriate
gastric artery
gastrectomy
incision
stay sutures
TA 90 mm
autosuture
device
Autosutures
A B
Figure 19-5. A. Hand suturing for closure of partial gastrectomy of lesser curvature. B. Linear stapling device for closure of partial gastrectomy of
greater curvature.
258 Soft Tissue
C
Figure 19-5C. GIA stapling device for closure of partial gastrectomy on greater curvature. Figures 19-5A-C reprinted with permission from: Ander-
son S, Gill P, Lippincott L, Somerville M, Shields S, Balfour R, Wilson E. Dimensions in Surgery: Partial Gastrectomy. Pulse (an official publication
of the Southern California Veterinary Medical Association): May, 2002.
sequence of tissue layers, beginning with the serosal, muscularis Surgical Technique
and submucosal layers of the dorsal surface of the stomach first
The stomach is exteriorized and isolated from the remainder of the
which is the deepest layer intraoperatively. Next, the mucosal
abdominal contents with moistened laparotomy pads. Stay sutures
layer of the dorsal surface, continued to the mucosal layer of the
are placed 1 to 2 cm from the ends of the planned gastrotomy. The
ventral surface. Finally, the serosal, muscularis and submucosal
gastrotomy incision is made in the body of the fundus, directly
layers of the ventral surface of the stomach. (Figure 19-5A). For
opposite the mass and midway between the greater and lesser
lesions of the greater curvature, closure can be performed by
curvature, avoiding gastric arteries and associated nerves (Figure
hand-suturing similar to as described for gastrotomy. Alterna-
19-6). The mass is located and a stay suture is placed within it to
tively, a linear stapling device can be employed (Figure 19-5B). A
Carmalt forcep should be placed on the tissue to be resected prior
to excision to prevent gastric spillage. An omental patch can be
anchored to the stapling site, simply by mobilizing some omental
adipose tissue and suturing it to the gastric serosa with several
simple interrupted sutures. A GIA™ (USSC, Tyco Healthcare
Group LP, Norwalk, CT) stapling device could also be used (Figure
19-5C). This device incises and applies a double layer staggered
staple line on each side of the incision. The primary advantage is
reduced risk of gastric spillage since the resected tissue also has
a double row of staggered staples.
Suggested Readings
Tobias KM. Surgical stapling devices in veterinary medicine: A review.
Vet Surg 36 (2007) 341-349.
Partial-Thickness Resection via Figure 19-6. Partial thickness submucosal resection of midbody and
Gastrotomy Incision cardia gastric lesions via gastrotomy. A. The gastrotomy incision is
made in the fundic region avoiding gastric arteries and nerves. Stay
Maria A. Fahie sutures are placed to facilitate manipulation of the incision and avoid
spillage of gastric contents. B. A stay suture is placed within the mass
and traction is applied to allow transection of the surrounding mucosa
Indications and submucosa. Closure of the remaining mucosal/submucosal defect
This procedure is indicated for mobile, sessile or pedunculated should begin prior to complete transection of the mass. A simple con-
mucosal masses in the cardia or fundus regions. tinuous appositional or inverting pattern is appropriate.
Stomach 259
allow application of traction and to facilitate transection of the studies, since there is a wide range of gastric emptying times
surrounding mucosa and submucosa. reported in normal dogs (5 to 15 hours). Generally, retention > 8-10
hours is considered prolonged and indicative of gastric outflow
obstruction. Abdominal ultrasound can identify intramural
Closure submucosal/muscularis abnormalities not necessarily visible on
The mucosal closure is initiated prior to completion of transection radiographs or with endoscopy. Gastroduodenoscopy provides
of the mass, and performed in stages as the mass is gradually further detail regarding mucosal causes of pyloric obstruction.
transected. A simple continuous appositional or inverting pattern If pyloroplasty is performed in a patient without diagnosti-
with monofilament absorbable 3-0 or 4-0 suture material is appro- cally confirmed gastric outflow obstruction, the procedure can
priate. The gastrotomy incision is closed as described previously. actually cause delayed gastric emptying by overstimulation of
the enterogastric reflex from the early passage of hyperosmolar
Suggested Readings gastric content into the duodenum. Diagnosis of delayed gastric
emptying provides the greatest challenge to the surgeon. A
Kerpsack SJ, Birchard SJ. Removal of leiomyomas and other nonin-
vasive masses from the cardiac region of the stomach. J Am Anim Hosp review of diagnostic techniques is recommended.
Assoc. 1994: Sept/Oct, 30; 500-504.
Swann HM, Holt DE. Canine gastric adenocarcinoma and leiomyo- Surgical Technique
sarcoma: a retrospective study of 21 cases (1986-1999) and literature
The pylorus and pyloric antrum are identified and isolated
review. J Am Anim Hosp Assoc 2002 Mar-Apr;38(2):157-64.
using a combination of moistened laparotomy sponges and
stay sutures. The pyloric ring is identified by palpation. Using a
Y-U Antral Flap Pyloroplasty #10 scalpel blade, a “Y” shaped incision is made in the serosa
with the base of the “Y” (Figure 19-7A) just oral to the pyloric
Maria A. Fahie ring, and each arm of the “Y” being 3 to 5 cm in length. The
incision is extended into the gastric lumen through an initial stab
incision with the scalpel blade, and extension with scissors. To
Indications facilitate advancement of the antral flap, and alleviate continued
Delayed gastric emptying necessitates medical management obstruction from proliferative pyloric mucosa, a rectangular
with dietary and prokinetic therapy. In some cases, pyloroplasty shaped segment of the exposed hypertrophied pyloric ring
is indicated in patients with gastric outflow obstruction and tissue can be elevated submucosally, from the portion of the
delayed gastric emptying due to congenital or acquired pyloric pylorus that is exposed by your incision, but not from the flap
stenosis from benign proliferative disease of antral and pyloric to avoid disruption of its vascular supply. Excised tissue can be
mucosa (chronic hypertrophic pyloric gastropathy). Breeds submitted for histopathology. The muscularis and serosal layers
with a predisposition to this congenital condition include some (Figure 19-7B) remain intact, and the hypertrophied mucosal/
brachycephalic dogs (English bulldog, Boston terrier, Boxer) submucosal layers (between e & f) are excised.
and the Siamese cat. Patients with acquired disease are usually
middle-aged or geriatric small breeds such as the Lhasa apso,
Shih tzu and Maltese. A study of 45 primarily geriatric patients Closure
demonstrated an 85% good to excellent response to surgical The mucosal/submucosal edges remaining after excision of
management of their hypertrophic disease. proliferative tissue (e and f) are apposed in a simple continuous
suture pattern with monofilament 3-0 or 4-0 absorbable material.
Other intramural causes of acquired lesions affecting gastric The “Y” shaped incision is then sutured closed to form a “U”
outflow include neoplasia, foreign body, hypertrophic or eosino- shaped incision (Figure 19-7C). Care should be taken to contour
philic gastritis and antral polyps. Extramural lesions of the liver the tip of the flap to a “U” shape rather than a pointed “V” shape,
or pancreas can also compress the pyloric region and affect since the vascular supply to the point may not be adequate. The
gastric outflow. Pyloroplasty would not be recommended in those most distal suture should be placed initially, to ensure proper
patients with malignant, inflammatory or extramural disease. flap advancement and placement. The remainder of the tissue
can be closed using simple interrupted or continuous apposi-
Pyloroplasty involves a full-thickness incision and reorientation tional sutures, both incorporating all 4 tissue layers (mucosa,
of the pyloric tissue performed to increase the diameter of the submucosa, muscularis, serosa) simultaneously.
gastric outflow tract. I recommend the Y-U antral flap pyloro-
plasty procedure, instead of pyloromyotomy (Fredet-Ramstedt)
or transverse pyloroplasty (Heineke-Mikulicz), since the Y-U
Postoperative Care
pyloroplasty allows for more resection of hypertrophied pyloric Appropriate postoperative management depends on the patient’s
mucosa while significantly expanding the diameter of the gastric preoperative status. Intravenous fluids should be chosen based
outflow tract and decreasing gastric emptying time. on the patient’s hydration status, electrolyte levels and acid-base
status, and continued postoperatively until adequate oral
Diagnostics to confirm gastric outflow obstruction are crucial alimentation is possible. Medical management of vomiting may
and should include contrast radiographs, abdominal ultrasound be indicated. If there is no vomiting, a low-fat diet can be initiated
and gastroduodenoscopy. Retention of a barium meal in the on the first postoperative day to enhance gastric emptying.
stomach can be difficult to interpret on contrast radiographic
260 Soft Tissue
Billroth I
(Gastroduodenostomy)
Maria A. Fahie
Figure 19-7. Y-U Antral Flap Pyloroplasty. A. The base of the “Y”
Indications
incision extends slightly onto the stomach side of the pyloric ring Patients with gastric outflow obstruction due to malignant or
(1-2). Each limb of the “Y” (1-2, 2-3, 2-4) is approximately 3 to 5 cm in inflammatory disease (such as adenocarcinoma or severe gastric
length. B. a= sub-serosa, b=muscularis, c=submucosa, d=mucosa, ulceration) are candidates for pyloric resection and gastro-
e+f= proliferative tissue located in strip between these two letters; duodenostomy. However, in a review of 24 dogs undergoing
Pyloric submucosal resection of hypertrophied mucosal tissue. C. The pylorectomy with gastroduodenostomy, median survival time
pyloroplasty incision is closed by advancing the antral flap toward with malignant neoplasia was only 33 days. Preoperative weight
the duodenum, suturing tissue in region #2 to that of region #1. Tissue loss and malignant neoplasia are associated with shortened
apposition can be performed using a simple continuous or simple
survival. Hypoalbuminemia and anemia occurred postoperatively
interrupted approximating suture pattern.
in about 62 and 58% of dogs respectively. The goal of gastroduo-
denostomy is removal of the entire pylorus without disruption of
Suggested Readings surrounding structures including the extrahepatic biliary tree, or
Allen FJ, Guilford WG, Robertson IG, Jones BR. Gastric emptying of solid the biliary and pancreatic duct apertures at the major duodenal
radiopaque markers in healthy dogs. Veterinary Radiology and Ultra- papilla. If this is not possible, a gastroduodenostomy procedure
sound 1996: 37;5:336-344. should not be performed. Gastrojejunostomy (Billroth II) with
Arnbjerg J. Gastric emptying time in the dog and cat. J Am Anim Hosp cholecystoduodenostomy and possible pancreatic enzyme
Assoc 1992: Jan-Feb(28):77-81. replacement would be necessary for reconstruction after such
Bright RM, Toal R, Denovo RC, McCracken M, McLauren JB. Effects of an extensive resection. The gastroduodenostomy (Billroth
the Y-U pyloroplasty on gastric emptying and duodenogastric reflux in I) requires less diversion from normal physiologic conditions
the dog. Vet 16 (1987) 392-397. compared with gastrojejunostomy (Billroth II) and as a result,
Burns J, Fox SM. The use of a barium meal to evaluate total gastric there are fewer long term potential complications. In humans,
emptying time in the Dog. Vet Radiol 1986:27(6):169-72. there are fewer problems with gastritis, pancreatic function
Matthiesen DT, Walter MC. Surgical Treatment of chronic hypertrophic impairment and lower esophageal sphincter impairment in
pyloric gastropathy in 45 dogs. J Am Anim Hosp Assoc 1986:Mar/ patients having gastroduodenostomy compared to those having
Apr:22:241-247. gastrojejunostomy. In a study of 21 dogs having gastroduode-
Miyabayashi T, Morgan JP. Gastric emptying in the normal dog. A nostomy for resection of adenocarcinoma and leiomyosarcoma,
contrast radiographic Technique. Vet Radio 1984;25(4):187-91. postoperative survival ranged from 3 days to 10 months due to
Rivers BJ, Walter PA, Johnston GR, Feeney DA, Hardy RM. Canine recurrence of preoperative clinical signs. A recent retrospective
gastric neoplasia: Utility of ultrasonography in diagnosis. J Am Anim study indicated that preoperative weight loss and diagnosis of
Hosp Assoc 1997;33:144-55. malignant neoplasia were significant risk factors that shortened
Stanton ME, Bright RM, Toal R, DeNovo RC, McCracken M, McLauren survival time post pylorectomy and gastroduodenostomy.
JB. Effects of the Y-U pyloroplasty on gastric emptying and duodeno- Hypoalbuminemia and anemia commonly contributed to postop-
gastric reflux in the dog. Vet Surg 1987;16(5):392-7. erative morbidity.
Matthiesen DT, Walter MC. Surgical treatment of chronic hypertrophic
pyloric gastropathy in 45 dogs. J Am Anim Hosp 1986; Mar-Apr (22):
241-247. Approach and Asepsis
Papageorges M, Breton L, Bonneau NH. Gastric Drainage Procedures: In performing gastroduodenostomy, the approach and aseptic
Effects in normal dogs I. Introduction and description of surgical proce- technique are similar to that described in the preceding
Stomach 261
gastrotomy section. It is crucial to identify and avoid the common and palpation. A surrounding margin of grossly normal tissue is
bile duct prior to ligation or transection of any structures (See planned. A minimum of 1 cm of duodenum must be maintained
Figure 19-3). Division of the duodenocolic ligament will enable orad to the major duodenal papilla in order to avoid postoper-
cranial displacement of the caudal duodenal flexure and facil- ative bile and pancreatic duct obstruction. The gastroduodenal
itate approximation of the duodenum and stomach for gastro- artery, biliary tract, hepatic arteries and pancreas must be
duodenostomy post-resection of affected tissues. identified and avoided during manipulations. The vascular supply
to the affected region is ligated in a fashion similar to that for a
partial gastrectomy procedure (Figure 19-5). Atraumatic forceps
Surgical Technique are placed on the gastric and duodenal tissue that will remain.
It is important to perform a complete abdominal exploratory to Carmalt forceps can be placed on the tissue to be resected. The
determine the extent of disease prior to gastric diversion proce- pylorus is resected and submitted for histopathologic analysis.
dures. The affected gastric region is identified by visualization
Figure 19-8. Gastroduodenostomy (Billroth I)- Hand suturing A. Arteries to be ligated are right gastric (A) and right gastroepiploic (B); avoid the
gastroduodenal artery (C). B. Excision of pyloric sphincter and canal. C. Apposition of gastric mucosa in simple continuous or inverting Cushing or
Lembert pattern. D. Apposition of gastric seromuscular layers in simple continuous or inverting Cushing or Lembert suture pattern. E. Completed
anastomosis between stomach and duodenum.
262 Soft Tissue
Figure 19-9. A. Technique for side-to-end gastroduodenostomy (Billroth I) using TA and EEA stapling devices to form a circular anastomosis. After
ligation and division of omental vessels, the gastric pouch is closed using an appropriate size thoracoabdominal instrument. The instrument is
placed proximal (oral) to the mass, leaving appropriate margins of grossly normal tissue and at least 1cm oral to the major duodenal papilla. Tis-
sue forceps are placed adjacent to the mass, and the stomach is transected with a scalpel blade, using the instrument edge as a cutting guide.
B. The pursestring instrument (Furniss clamp) is placed around the duodenum, distal (aboral) to the mass, leaving appropriate margins of grossly
normal tissue. Monofilament 3-0 suture is passed through the superior jaw of the pursestring instrument and returned through the inferior jaw.
Tissue forceps are placed adjacent to the mass, and the duodenum is transected using the pursestring instrument edge as a cutting guide. C.
The pursestring instrument is removed and the appropriately sized end-to-end anastomosis (EEA) cartridge is chosen on the basis of the luminal
diameter of the proximal duodenum. A stab incision is made in an avascular portion of the ventral aspect of the stomach, approximately 3 cm
away from the edge of the TA staple line. Stay sutures aid in the retraction of the stomach. D. The EEA instrument is introduced, without the anvil,
through the stab wound on the ventral surface of the stomach. The center rod of the instrument is exited through a small stab incision in the cen-
ter of a pursestring suture that has been placed on the dorsal surface of the stomach. The pursestring suture is tied on the stomach side, and the
anvil is placed on the central rod. The anvil is introduced into the duodenal lumen and the pursestring suture is tied. The EEA instrument is then
closed and fired. A circular, double-staggered row of staples joins the organs, and the circular blade in the instrument cuts a stoma. E. Comple-
tion of the gastroduodenostomy. The EEA instrument has been gently removed from the entry site on the ventral surface of the stomach and the
staple line inspected for hemostasis. The gastrotomy incision has been closed with a TA instrument. The completed anastomosis consists of two
linear staple closures on the stomach and a circular stapled anastomosis forming the gastroduodenostomy.
Stomach 263
Figure 19-10. A. Normal stomach position when viewed in a ventrodorsal position. B-E. In gastric dilatation-volvulus, the stomach is rotated about
the esophagus in a clockwise direction causing malposition of the pylorus, fundus, and spleen. For illustrative purposes, the gastric dilatation has
not been pictured. Vessels are included for orientation.
cardiac output with decreased systemic blood pressure and acidosis may result. This can exacerbate a metabolic acidosis.
decreased tissue perfusion to major organs. Portal hypertension Aspiration may occur secondary to vomiting, and this may also
also causes interstitial edema, which further compromises the impair respiratory function.
microcirculation of the abdominal viscera and contributes to a
reduced vascular volume. When there is lack of blood flow to Increasing gastric intraluminal pressure impairs perfusion of
the tissues, waste products and toxins may accumulate in the the gastric wall resulting in hemorrhage, edema, ulceration
hypoxic cells. As blood flow is restored, oxygen free radicals may or necrosis, particularly to the gastric mucosa. More severe
form and cause tissue damage, known as reperfusion injury. pressure will compromise perfusion of the seromuscular
layers, and can result in full thickness necrosis with perfo-
Although cardiac arrhythmias commonly occur with GDV, the ration and subsequent peritonitis. Both reduced cardiac output
etiology is unclear.3 Reduced tissue perfusion stimulates the and mechanical kinking or avulsion of vessels can further
release of catecholamines, which cause peripheral vasocon- compromise blood flow to the stomach wall. The short gastric
striction and increased heart rate, thereby increasing myocardial vessels are often affected, but the extensive gastric collateral
oxygen demand. Myocardial ischemia has been implicated as a blood supply makes full-thickness necrosis uncommon.
leading cause of the cardiac arrhythmias.4 Coronary blood flow
may be reduced because of the poor venous return and also Local lymphatic tissue that has suffered ischemic damage
because of the shortened diastole that occurs with tachycardia. is unable to prevent translocation of intestinal pathogens
Other factors that could contribute to arrhythmias include from the gastrointestinal mucosa into the circulatory system.
substances that are released in association with tissue hypop- Translocation of bacteria to the gut-associated lymphatics is
erfusion or systemic inflammation, electrolyte and acid-base believed to stimulate production of numerous cytokines, which
imbalances, and endotoxemia. is a factor in promoting the systemic inflammatory response
syndrome and multiple organ dysfunction syndrome.6 In addition,
Stomach distension prevents normal diaphragmatic excur- impaired return of lymphatic and venous fluid inhibits delivery of
sions, thereby reducing tidal volume. Respiratory rate and effort pathogens to the immune centers. When circulation is restored,
are increased as a compensatory mechanism, but respiratory there is potential for release of pathogens and endotoxins into
Stomach 265
the systemic circulation. Systemic effects include decreased large, uniform gas-filled gastric shadow and possibly excessive
systemic vascular resistance and increased cardiac output, gas in the intestines as well. Gastric dilatation-volvulus is
increased vascular permeability, hepatocellular dysfunction, suspected if a tissue density separates the gas-filled gastric
renal tubular damage, microvascular occlusion, and dissemi- shadow into two regions. The gas-filled pylorus may be identified
nated intravascular coagulation. dorsal to the fundus of the stomach. Gas within the gastric wall
is suggestive of gastric necrosis, but is not a reliable finding.11
Free gas is present in the abdominal cavity in cases where the
Diagnosis stomach has perforated. However, free gas may also be present
A presumptive diagnosis of GDV or gastric dilatation can often in those cases where trocarization for gastric deompression was
be made based on signalment, history and physical examination. performed prior to obtaining radiographs. Gas in the esophagus
Clinical signs include restlessness, hypersalivation, and unpro- may be due to aerophagia and does not necessarily indicate
ductive vomiting or retching. A distended, tympanic abdomen is megaesophagus.
usually obvious, but may not be apparent in some cases. The dog
may be dyspneic due to pain, aspiration, or abdominal distention.
Dogs may present in compensatory shock, with tachycardia, Treatment
tachypnea, pale mucous membranes, prolonged capillary refill The initial therapeutic goals are to relieve the gastric distention
time, normal pulses, and cold extremities with normothermia. and treat the cardiovascular compromise. Treatment should
Endotoxic shock differs from compensatory shock in that the begin immediately, and diagnostic tests may be performed as
membranes may be injected or “muddy”, and fever may be the dog becomes more stable.
present. Severely affected dogs may be recumbent or comatose.
Signs of noncompensatory shock include bradycardia, weak Initial Medical Therapy
respiration, white or muddy mucous membranes, no capillary
refill, poor pulses, cold extremities and hypothermia. Aggressive fluid therapy with isotonic crystalloids should be
instituted immediately. Several large-bore catheters may need
Initial hematology may indicate hemoconcentration (increased to be placed in order to achieve an adequate rate of fluid admin-
packed cell volume and total protein), and a stress or inflam- istration. The catheters should be in the cephalic or jugular
matory leukogram (increased polymorphonuclear leukocytes, veins, since venous return from the hind limbs may be compro-
increased monocytes, decreased lymphocytes). In cases of mised. The administration rate of crystalloid fluids is 90 ml/kg. A
decompensation, polymorphonuclear leukocytes are decreased. quarter of the total shock dose is administered quickly, and the
Thrombocytopenia may be evident on hematology. Changes in dog is reassessed. It is preferable to administer crystalloids (10
activated clotting time, prothrombin time, and partial thrombo- to 40 ml/kg) in conjunction with high molecular weight fluids (10
plastin time may suggest a hypercoagulable state or dissemi- to 20 ml/kg hetastarch or 5 ml/kg of 7% hypertonic saline solution
nated intravascular coagulation. Abnormalities of multiple values in 6% dextran 70 over 5 minutes).12 After initial fluid adminis-
in the coagulation profile are associated with an increased tration, crystalloid fluids are continued at approximately 20 ml/
likelihood of gastric necrosis.7 kg/hr, depending on the dog’s response to therapy. Dopamine or
dobutamine (2 to 5 μug/kg/min) may also be indicated to improve
Initial clinical chemistries may show evidence of liver damage splanchnic blood flow or provide positive inotropic effects. If
(increased alanine transaminase), biliary stasis (increased total disseminated intravascular coagulation is suspected, plasma
bilirubin), and prerenal or renal azotemia (increased blood urea and heparin (100 mg/kg SQ TID) therapy may be instituted.
nitrogen and creatinine). There may also be evidence of blood
loss or transudation (lower than expected total protein and The acid-base status of dogs with GDV is unpredictable, so
albumin) and impaired glucose control. There may be electrolyte specific acid-base therapy should not be administered unless a
abnormalities, particularly hypokalemia. Plasma lactate may be blood gas analysis has been performed. Acid-base imbalances
elevated due to anaerobic metabolism or endotoxins.8 Plasma will generally self-correct as effective circulation is restored.
lactate levels are presumably an indication of the degree of However, if the pH is below 7.2, bicarbonate therapy may be
systemic hypoperfusion, and higher levels are seen in dogs that indicated. Oxygen therapy (40 to 100% inspired) administered by
are more severely affected clinically.8 Increased lactate concen- face mask, nasal catheter, or oxygen cage may be beneficial to
tration may also be associated with gastric necrosis.8 However, offset the effects of impaired ventilation.
change in lactate during the treatment period provides more
useful information regarding prognosis than the plasma lactate Many dogs develop cardiac arrhythmias in association with GDV.13
level at a single point in time.9 The arrhythmias are most commonly ventricular in origin and may
include premature ventricular contractions, ventricular tachy-
Abdominal radiographs are usually not needed to diagnose cardia, or idioventricular tachyarrhythmias. Treatment should
gastric dilatation, but may be used to confirm the clinical be considered if fluid volume has been adequately replaced and
diagnosis or to distinguish between simple gastric dilatation the arrhythmia is life threatening or causing poor perfusion. Pain
and GDV. Emergency medical therapy is initiated to stabilize the control, and correction of potassium and acid-base abnormalities
dog before obtaining radiographs. The right lateral recumbent are important aspects of management prior to specific antiar-
view is the best single view to determine whether the stomach rythmia therapy. Treatment may be indicated in the presence of
is rotated.10 Radiographs of dogs with gastric dilatation reveal a R-on-T phenomenon or ventricular tachycardia. Treatment may
also be considered if PVCs occur at a rate of more than 20 to
266 Soft Tissue
30 per minute, there are runs of PVCs, or PVCs are multifocal is passed slowly through the tape roll and into the esophagus
in origin. Pulse quality and mucous membrane color should be and stomach. The tube should be passed gently to avoid esoph-
evaluated and used to guide therapeutic decisions. The initial ageal or gastric tears. Rotating the tube as it is advanced may
treatment of choice for ventricular arrhythmias is 2% lidocaine facilitate passage. In some cases, elevation of the forequarters
hydrochloride without epinephrine. A slow bolus (1 to 2 mg/kg may decrease pressure on the gastroesophageal junction and
IV) may be administered until a normal sinus rhythm appears. allow the tube to pass. Failure to pass the tube does not neces-
This may be repeated twice within a 30-minute period if needed, sarily indicate gastric volvulus, nor does easy passage indicate
but the entire dose should not exceed 8 mg/kg. If the arrhythmia the presence of a simple dilatation. If the orogastric tube cannot
persists, a continuous intravenous infusion of lidocaine (50 to be passed, or if the dog strongly resists the procedure, needle
100 µug/kg/min) is administered, adjusting the rate based on the trocarization may be performed first.
dog’s response to therapy. Procainamide (10 to 40 µug/kg/min
IV or 6 to 8 mg/kg IM q.i.d.) may be used instead of lidocaine To trocarize the stomach, two to four large-bore (14- to 16- gauge)
in refractory cases. Antiarrhythmic therapy should continue for over-the-needle catheters are inserted percutaneously through
three to five days after the arrhythmias resolve. the abdominal and stomach walls in the region of greatest
abdominal distention. The skin should be clipped and asepti-
Treatment with corticosteroids and antibiotics are not necessary cally prepared prior to catheter insertion. After some gas has
in uncomplicated cases of GDV. There is no confirmed clinical been evacuated from the stomach it may be easier to pass an
benefit from corticosteroids when they are administered after orogastric tube to remove more gas, fluid and ingesta. Complica-
the onset of shock. Risks of corticosteroid use include impaired tions, such as peritonitis, are rare with trocarization.
immune function and possible increased rate of gastrointes-
tinal ulceration. If used, they should be given gradually after If orogastric intubation is unsuccessful and surgery cannot be
adequate volume restoration has been initiated to prevent performed for an extended period, temporary gastrostomy may
further hypotension. be considered to maintain gastric decompression. An inverted
“L” line block of 2% lidocaine is performed in the right paracostal
If gastric ischemia or necrosis is suspected, broad-spectrum region. An incision is made in the anesthetized region. The
antibiotics such as first- or second- generation cephalosporins or abdominal musculature is separated between the fibers. The
ampicillin are used. Drugs such as deferoxamine and allopurinol stomach is identified and sutured to the skin edges circum-
have been used experimentally to prevent reperfusion injury, but ferentially with a continuous suture pattern to provide a good
their use has not been supported by clinical trials.14 seal. An incision is made in the exposed stomach wall to allow
decompression. The temporary gastrostomy has several disad-
During treatment, parameters such as heart rate, pulse character, vantages. It does not correct gastric rotation and it increases the
mucous membrane color, capillary refill time, urine output, risk of peritonitis. In addition it may interfere with the permanent
plasma oncotic pressure, and blood pressure are monitored to gastropexy and must be repaired prior to performing the defin-
assess cardiac function and tissue perfusion. In addition packed itive abdominal surgery. Therefore, this procedure should only
cell volume, total solids, and plasma lactate levels may be useful be performed if absolutely necessary.
measurements to monitor response to fluid therapy. Serum
cardiac troponin I and cardiac troponin T may be useful markers
of myocardial injury.4 Elevated myoglobin can be seen and is not
Client Education
specific to myocardial injury, but may be used as one indicator to The etiology of GDV is not well understood. It is likely that multiple
help estimate prognosis.5 environmental and hereditary factors play a role.16 Anatomic
differences, diet, gastric motility, and gastrointestinal hormones
have been studied. Irish setters with an increased thoracic depth
Gastric Decompression to width ratio are at increased risk. Although overeating, pre- or
Gastric decompression should be performed immediately after postprandial exercise, large water consumption, and temper-
intravenous catheters have been placed and volume support ament of the dog have been implicated, there is little evidence
has been started. Decompression improves venous return, venti- to support any of these factors as the cause.1,17,18 Factors
lation, and gastric wall perfusion. However, it can also result in associated with an increased risk of GDV that were identified in
systemic release of endotoxins and metabolic waste products that a prospective study of large breed dogs include increasing age,
have accumulated in the areas of vascular stasis and ischemia. having a first-degree relative with GDV, faster eating speed (for
This may cause deterioration in clinical signs that necessitate large breed dogs, but not giant breeds), and eating from a raised
further monitoring and treatment. The stomach is decompressed food bowl.17 Feeding a large volume once daily is associated
by orogastric intubation or trocarization. Temporary gastrotomy with an increased risk of GDV compared to feeding a smaller
may be used in rare cases. Esophagostomy or nasogastric volume twice daily.18 Feeding dry foods containing fats or oils
intubation may be used to provide continued decompression. among the first four label ingredients was associated with a
significant increased risk of GDV in one retrospective study.19
Before attempting orogastric intubation, the distance from the Poor body condition and a history of chronic health problems are
dog’s nose to the 13th rib should be measured to estimate the also associated with an increased risk of GDV, although a causal
length of tubing needed. A roll of white tape may be placed in relationship has not been established.18 Therefore, it is recom-
the dog’s mouth as a speculum. A well-lubricated stomach tube mended that large and giant breed dogs be fed more than once
Stomach 267
daily using a food bowl that is not elevated. It can also be recom- Journal of Veterinary Emergency and Critical Care 1995;5:51-60.
mended to avoid breeding dogs that have a first-degree relative 15. Lantz GC, Bottoms GD, Carlton WW, et al. The effect of 360 gastric
that has had GDV. Prophylactic gastropexy may be considered volvulus on the blood supply of the nondistended normal dog stomach.
for breeds that have a high risk of developing GDV.20,21 Veterinary Surgery 1984;13:189-196.
16. Brockman DJ, Holt DE, Washabau RJ. Pathogenesis of acute canine
Dogs that have had one episode of GDV are more likely to have gastric dilatation-volvulus syndrome: Is there a unifying hypothesis?
another, although gastropexy reduces this likelihood. Clients Compendium on Continuing Education 2000;22:1108-1114.
should be educated regarding the potential for recurrence and 17. Glickman LT, Glickman NW, Schellenberg DB, et al. Non-dietary
the clinical signs that should alert them to seek prompt veter- risk factors for gastric dilatation-volvulus in large and giant breed
inary care. Survival rates for dogs that are treated surgically for dogs. Journal of the American Veterinary Medical Association
GDV are about 85%.3,13,22-23 2000;217:1492-1499.
18. Raghavan M, Glickman N, McCabe G, et al. Diet-related risk factors
for gastric dilatation-volvulus in dogs of high-risk breeds. Journal of the
References American Animal Hospital Association 2004;40:192-203.
1. Glickman LT, Glickman NW, Schellenberg DB, et al. Incidence of and 19. Raghavan M, Glickman NW, Glickman LT. The effect of ingredients in
breed-related risk factors for gastric dilatation-volvulus in dogs. Journal dry dog foods on the risk of gastric dilatation-volvulus in dogs. Journal
of the American Veterinary Medical Association 2000;216:40-45. of the American Animal Hospital Association 2006; 42:28-36.
2. Caywood DD, Teague HD, Jackson DA, et al. Gastric gas analysis 20. Ward MP, Patronek GJ, Glickman LT. Benefits of prophylactic
in the canine gastric dilatation-volvulus syndrome. Journal of the gastropexy for dogs at risk of gastric dilatation-volvulus. Preventive
American Animal Hospital Association 1977;13:459-462. Veterinary Medicine 2003;60:319-329.
3. Brourman JD, Schertel ER, Allen DA, et al. Factors associated 21. Rawlings CA, Mahaffey MB, Bement S, et al. Prospective evaluation
with perioperative mortality in dogs with surgically managed gastric of laparoscopic-assisted gastropexy in dogs susceptible to gastric
dilatation-volvulus: 137 cases (1988-1993). Journal of the American dilatation. Journal of the American Veterinary Medical Association
Veterinary Medical Association 1996;208:1855-1858. 2002;221:1576-1581.
4. Schober KE, Cornand C, Kirbach B, et al. Serum cardiac troponin I 22. Glickman LT, Lantz GC, Schellenberg DB, et al. A prospective study of
and cardiac troponin T concentrations in dogs with gastric dilatation- survival and recurrance following the acute gastric dilatation-volvulus
volvulus. Journal of the American Veterinary Medical Association syndrome in 136 dogs. Journal of the American Animal Hospital Associ-
2002;221:381-388. ation 1998;34:253-259.
5. Adamik KN, Burgener IA, Kovacevic A, et al. Myoglobin as a prognostic 23. Mackenzie G, Barnhart M, Kennedy S, et al. A retrospective study
indicator for outcome in dogs with gastric dilatation-volvulus. Journal of of factors influencing survival following surgery for gastric dilatation-
Veterinary Emergency and Clinical Care 2009; 19:247-253. volvulus syndrome in 306 dogs. Journal of the American Animal Hospital
6. Winkler KP, Greenfield CL, Schaeffer DJ. Bacteremia and bacterial Association 2010; 46:97-102.
translocation in the naturally occuring canine gastric dilatation-vol-
vulus patient. Journal of the American Animal Hospital Association
2003;39:361-368. Gastric Dilatation-Volvulus
7. Millis DL, Hauptman JG, Fulton RB. Abnormal hemostatic profiles
and gastric necrosis in canine gastric dilatation-volvulus. Veterinary
(GDV): Surgical Treatment
Surgery 1993;22:93-97. Amelia Simpson
8. de Papp E, Drobatz KJ, Hughes D. Plasma lactate concentration as
a predictor of gastric necrosis and survival among dogs with gastric The goals of surgery for a dog with a GDV are to de-rotate the
dilatation-volvulus: 102 cases (1995-1998). Journal of the American stomach and return other organs to their normal anatomic
Veterinary Medical Association 1999;215:49-52. positions, evaluate the viability of stomach and spleen, perform
9. Zacher LA, Berg J, Shaw SP, et al. Association between outcome and a splenectomy (partial or complete) and/or a partial gastrectomy
changes in plasma lactate concentration during presurgical treatment if indicated, and perform a perform a permanent gastropexy to
in dogs with gastric dilatation-volvulus: 64 cases (2002-2008). Journal of prevent recurrence of volvulus. Surgery should take place as
American Veterinary Medical Association 2010; 236:892-897. soon as the patient is stable enough to undergo anesthesia. If
10. Hathcock JT. Radiographic view of choice for the diagnosis of gastric signs of shock are minimal, surgery may be performed immedi-
volvulus: The right lateral recumbent view. Journal of the American ately after gastric decompression and initiation of fluid therapy.
Animal Hospital Association 1984;20:967-969.
Dogs with moderate or severe signs of shock may be stabilized
11. Fischetti AJ, Saunders HM, Drobatz KJ. Pneumatosis in canine by gastric decompression and fluid therapy for several hours
gastric dilatation-volvulus syndrome. Veterinary Radiology and Ultra- until the vital signs improve. A prolonged period of stabilization,
sound 2004;45:205-209.
however, is undesirable, since the blood supply to the rotated
12. Allen DA, Schertel ER, Muir WW, et al. Hypertonic saline/dextran stomach may remain compromised even after it has been
resuscitation of dogs with experimentally induced gastric dilatation-vol-
decompressed.1
vulus shock. American Journal of Veterinary Research 1991;52:92-96.
13. Brockman DJ, Washabau RJ, Drobatz KJ. Canine gastric dilatation/
volvulus syndrome in a veterinary critical care unit: 295 cases Surgical Technique
(1986-1992). Journal of the American Veterinary Medical Association A ventral midline celiotomy is performed with the incision
1995;207:460-464. extending from the xiphiod process of the sternum to a point
14. Guilford WG, Komtebedde J, Haskins SC, et al. Influence of allopurinol midway between the umbilicus and pubis. The use of Balfour
on the pathophysiology of experimental gastric dilatation-volvulus. The
268 Soft Tissue
retractors is recommended to maintain adequate exposure of be performed. A large bore needle or IV catheter is placed into the
the abdominal cavity. The surgeon should evacuate free blood gastric lumen through an area of the stomach wall that appears.
form the abdomen and any actively bleeding short gastric The needle/catheter can be connected to suction for rapid
vessels should be ligated. Most commonly, with the dog in dorsal removal of accumulated gas and fluid and usually, the orogastric
recumbency, the stomach rotates 180° to 270° clockwise around tube can then be successfully passed into the stomach. Following
the long axis of the esophagus. In this position, the ventral leaf of successful decompression, the needle/catheter is removed and
the omentum covers the ventral aspect of the displaced stomach the stomach is de-rotated as described above. Suturing of the
which is readily apparent to the surgeon after the abdomen is trocharization site is not necessary, unless a tear was created
opened (See Figure 19-10A-E). A clockwise rotation causes the in the gastric wall during needle placement. The surgeon should
pylorus and the gastric antrum to become displaced from the right be certain that the stomach is completely de-rotated and in a
ventral body wall and move ventrally over the gastric fundus and normal anatomic location. This can be achieved by visualizing
body to become positioned adjacent to the esophagus along the the junction of the intra-abdominal esophagus and cardia of
left body wall (See Figure 19-10D and E). The maximum rotation of the stomach and noting a lack of tissue folds in the area. After
the stomach in the clockwise rotation is 360°. Counterclockwise confirming complete de-rotation of the stomach, a complete
rotation, although uncommon, has a maximum rotation of 90°. abdominal exploration is performed.
When counterclockwise rotation occurs, the pylorus and antrum
move dorsally along the right body wall to a position adjacent During the abdominal exploration, particular attention is paid
to the esophagus. Counterclockwise rotation direction, causes to the viability of the gastric wall and spleen. Initially, the
minimal ventral displacement of the gastric fundus and body and spleen is often enlarged and congested and its viability may
the omentum does not cover the ventral aspect of the displaced appear questionable. Often, after return to its normal anatomic
stomach.2 Depending upon the degree of gastric rotation, the rotation the spleen begins to return to its normal size and color
spleen can be found in various positions within the cranial and splenectomy is not required. Thrombosis of the splenic
abdomen. Occasionally the spleen may undergo torsion around artery and/or vein can be detected by careful palpation and,
its vascular pedicle. if identified, requires partial or complete splenectomy. If the
spleen has undergone torsion around its vascular pedicle, it
To de-rotate the stomach for a 180° clockwise rotation, the fundus, should be removed. In order to prevent deleterious toxin release,
which is located near the right abdominal wall, is depressed in splenectomy is performed without de-torsing the splenic vascu-
a dorsal direction and the pylorus, abnormally located on the lature. Splenectomy is required in approximately 25% of cases
dorsal left, abdominal wall is retracted ventrally and from the left of GDV.
to right side of the abdomen. To prevent further trauma to the
gastrosplenic vessels, the spleen is placed in its normal position Partial Gastrectomy
as gastric de-rotation is performed. If significant distension is
present, the stomach may be impossible to de-rotate. In this Approximately 10% of dogs with GDV have necrosis along the
case, gastric decompression is necessary and can be achieved greater curvature of the fundus or body of the stomach.3 Perfo-
by passage of an orogastric tube, trocharization, or by a combi- ration early in the course of disease due to gastric necrosis is
nation of these two methods. If an orogastric tube cannot be rare. Several methods have been described to evaluate viability
advanced into the stomach, trocharization of the stomach should of the gastric wall. These include: clinical assessment of serosal
color and gastric wall texture, the use of intravenous fluroesceine tring suture technique and left to be auto-digested within the
dye, and nuclear scintigraphy. In a study evaluating the use of gastric lumen. I prefer to perform partial gastrectomy and
fluoresceine fluorescence to predict gastric viability, it was found gastric wall closure with staples or suture (Figure 19-11A-C). The
that fluoresceine fluorescence was only 58% accurate.4 Nuclear stomach is packed off with moistened laparotomy pads to prevent
scintigraphy, while accurate in assessing stomach wall viability, contamination of the abdomen from spillage of gastric contents.
is impractical in a clinical setting.5-7 Gastric viability determined Doyen forceps or stay sutures are placed in viable gastric tissue
by clinical assessment of serosal color and gastric wall texture and can be used to help prevent leakage of gastric contents. The
was accurate in 85% of cases of dogs with GDV in one study.4 necrotic portion of the stomach wall is resected with a scalpel to
Since clinical assessment of gastric tissue viability is not always the point where there is active arterial bleeding at the surgical
accurate, it is possible to remove tissue which may survive as margin. A monofilament, absorbable or non-absorbable, suture
well as to leave tissue behind which may subsequently necrose material is used for a two layer closure. A full thickness simple
and lead to gastric perforation hours to days later. General guide- continuous suture pattern followed by an inverting pattern
lines for partial gastric resection include in Table 19-2. such as a Cushing’s oversew is recommended. Alternatively, a
thoraco-abdominal stapler can be used followed by a Cushing’s
Ischemic or necrotic gastric tissue can be excised by partial oversew using a monofilament, absorbable or non-absorbable
gastrectomy, or it can be invaginated by an inverting or purses- suture material. Mortality rates are known to be higher in animals
Figure 19-11. Two variations of partial gastrectomy are shown. In A-C, stay sutures are placed to elevate the stomach and to minimize leakage.
Necrotic tissue is excised with a rim of viable tissue (dotted line). A two-layer inverting closure is used. In D-l, atraumatic clamps are placed
across viable tissue, and the necrotic tissue is excised. The stomach body is subsequently closed with a Parker-Kerr suture line. The first invert-
ing layer of suture is placed over the clamps. The clamps are subsequently removed as the suture line is pulled tight to invertthe suture line. A
second inverting suture line completes the closure. (Redrawn in part from Matthiesen DT. Gastric dilatation-volvulus syndrome. In: Slatter DH, ed.
Textbook of small animal surgery. Philadelphia: WB Saunders, 1995:580-593.)
270 Soft Tissue
where gastric wall excision is required. The owners should be Post-Operative Care and Complications
given a poor prognosis in cases where there is complete gastric Intensive nursing care should be provided during the postoper-
necrosis or necrosis of the cardia and abdominal esophagus. ative period. Pain control, maintenance of vascular volume, and
return to normal alimentation and gastric motility are important.
Gastropexy Pain is controlled with injectable hydromorphone (0.05-0.1 mg/
Mortality rates for dogs with a GDV have been reported to be kg, SC or IV q4-6hrs) or injectable burenorphine (0.02 mg/kg,
as high as 23%.8 Studies have shown that dogs who receive an SC or IV, q6hrs) for 48-72 hours after surgery. Since these dogs
effective permanent gastropexy at the time of surgery have less usually have extended hospitaliztion times, they are comfortable
than a 5% chance of recurrence of GDV, whereas dogs who do by the time of discharge and analgesic medication is not
not receive a gastropexy during surgery have a 54.5-80% rate routinely necessary after discharge. If the dog appears painful,
of recurrence within the first year.8,9 Based on these results, it Tramadol (1-4 mg/kg, PO, q8hrs) can be prescribed to be admin-
is strongly recommended that all dogs with a GDV should have istered at home for 3-5 days. Dogs are routinely maintained on
a permanent gastropexy performed during surgery for gastric intravenous fluids for the first 24-36 hours postoperatively for
repositioning. Several effective gastropexy techniques have maintenance and continuing fluid losses, or until they are eating
been described including: tube gastropexy, incisional gastropexy, and drinking without vomiting. Food and water are withheld for
circumcostal gastropexy, belt-loop gastropexy, fundic gastropexy the first 18-24 hours postoperatively unless the animal is hypoal-
and laparoscopic gastropexy.10-14 Gastrocolopexy and gastroje- buminemic. Ice chips or small quantities of water are offered
junostomy have also been described, but are rarely performed in in small amounts. If there is no vomiting after several hours of
a clinical setting and are no longer recommended.15,16 starting the patient on water, food is offered in small amounts
every 4-6 hours and the patient is gradually returned to normal
I prefer to perform an incisional gastropuexy for prevention of alimentation over 24-48 hours.
GDV. It is simple to perform, can be completed quickly, has minimal
complications, and creates a strong adhesion between the pyloric If vomiting occurs, potassium levels should be assessed as
antrum and the right abdominal wall. The gastropexy is performed hypokalemia is common and may promote ileus. Prokinetic
only after confirming that the stomach is fully de-rotated and in drugs (metoclopramide or cisapride, ranitidine, erythromycin)
normal anatomic rotation. The procedure is easier to perform with and gastric acid-inhibitors (cimetidine, ranitidine, famotidine,
the surgeon standing on the left side of the dog. A 5-6 cm partial omeprazole) are beneficial in animals that have vomiting or
thickness incision is made in the serosal and muscularis layers regurgitation postoperatively.
of the pyloric antrum, midway between the greater and lesser
curvature of the stomach, along the long axis of the stomach Antibiotics administered perioperatively are continued in animals
(Figure 19-12). A corresponding incision is made in the right lateral that have abdominal contamination during surgery secondary
body wall just caudal to the last rib. The body wall incision should to gastric necrosis and in animals that are suspected of having
extend through the peritoneum and transverse abdominal muscle. endotoxic shock initially.
The gastric incision edges are sutured to the corresponding body
wall incision edges using a monofilament absorbable (polydiox- Cardiac Arrhythmias
anone) or non-absorbable suture in a simple continuous pattern After surgery, dogs are observed for cardiac arrhythmias with
(Figure 19-13). The suture should not enter the gastric lumen as continuous ECG monitoring for 48-72 hours. The most common
this may lead to fistula formation and/or sepsis. Routine abdominal arrhythmia seen in these patients is ventricular premature
closure is performed after copious lavage. contractions (VPCs) although supraventricular arrhythmias such
as atrial fibrillation and atrial premature depolarization have also
been observed.17,18 Electrolyte levels should be checked and
corrected if abnormal prior to considering therapy for arrythmias.
Patients with VPCs occurring at a high rate (200-240+ beats per
minute) who appear clinically affected by the arrhythmia (weak
pulse quality, poor mucous membrane color, prolonged capillary
refill time, and weakness/lethargy) should be treated with antiar-
rhythmic medication. Most commonly, lidocaine hydrochloride
at a dose of 2-4 mg/kg, is administered as an intravenous bolus
given slowly to effect. The lidocaine dose can be repeated and,
if necessary, it can be continued at a constant rate infusion of
0.05-0.08 mg/kg/min. If the arrhythmia is refractory to lidocaine,
procainamide can be used. Procainamide should be adminis-
tered at a dose of 6mg/kg as an IV bolus over 5 minutes, followed
by a 10 to 25 ug/kg/min constant rate infusion. The dog should
be placed on oral procainamide at a dose of 10 mg/kg every 8
hours for 15 days. Long-term antiarrhythmic treatment is usually
unnecessary as the arrhythmias usually resolve.
Figure 19-12. The location of the gastropexy site in the area of the
pyloric antrum.
Stomach 271
Sepsis (Gastric Necrosis/Perforation) 11. MacCoy DM, Sykes GP, Hoffer RE, et al: A gastropexy technique for
permanent fixation of the pyloric antrum. J Am Anim Hosp Assoc 18:763-
The risk of dehiscence following partial gastrectomy is greatest
768, 1982.
within the first 72 hours after surgery. Dogs are monitored closely
12. Fallah AM, Lumb WV, Nelson AW, et al: Circumcostal gastropexy in
for signs of peritonitis such as lethargy, abdominal pain and/or
the dog: A preliminary study. Vet Surg 11;9-12, 1982.
distension, vomiting, hypotension, hypoglycemia, and hyper- or
13. Whitney WO, Scavelli TD, Mattheisen DT, et al: Belt-loop gastropexy:
hypothermia. If dehiscence is suspected, a CBC and abdomino-
Technique and surgical results in 20 dogs. J Am Anim Hosp Assoc
centesis should be performed. The abdominal fluid should be 25:75-83m 1989.
evaluated for the presence of intracellular bacteria. A paired
14. Myer-Lindenberg A, Harder A, Fehr M, et al: Treatment of gastric
sample of the abdominal fluid and blood should be measured for dilatation-volvulus and a rapid method for prevention of relapse in dogs:
glucose levels. A glucose level in the abdominal effusion that is 134 cases. J Am Vet Med Assoc 203:1303-1307, 1993.
more than 20 mg/dl lower than the blood glucose is indicative of
15. Christie TR, Smith CW: Gastrocolopexy for prevention of recurrent
septic peritonitis and warrants re-exploration.19 gastric volvulus. J Am Anim Hosp Assoc 12:173-176, 1976.
16. Pritchard D: Prevention of acute gastric dilation by gastroje-
Prophylactic Gastropexy junostomy. Canine Pract 4:51-55, 1977.
Prophylactic gastropexy is currently recommended for dogs who 17. Muir WW, Lipowitz AJ: Cardiac dysrhythmias associated with
have had a spontaneous episode of gastric dilatation, in dogs gastric dilatation-volvulus in the dog. Am J Vet Res 172:683, 1978.
that have a first-degree relative who has had GDV, and in some 18. Muir WW, Bonagura JD: Treatment of cardiac arrhythmias in dogs
breeds that are at high risk for the development of GDV such with gastric distension-volvulus. J Am Vet Med Assoc 184:1366, 1984.
as Great Danes, Irish Setters, and Bloodhounds. Prophylactic 19. Bonczynski JJ, Ludwig LL, Barton LJ, et al: Comparison of peritoneal
gastropexy can be performed at the time of elective neutering in fluid and peripheral blood pH, bicarbonate, glucose, and lactate concen-
susceptible breeds. Any of the previously mentioned gastropexy tration as a diagnostic tool for septic peritonitis in dogs and cats. Vet
techniques can be performed by an open approach. Rawlings Surg 32:161-166,2003.
and colleagues have performed laparoscopic-assisted prophy- 20. Rawlings CA, Mahaffey MB, Bement S, et al: Prospective evaluation
lactic gastropexy in 23 dogs susceptible to GDV and found that of laparoscopic-assisted gastropexy in dogs susceptible to gastric
dilation. J Am Vet Med Assoc 221:1576-1581.
it resulted in a persistent attachment between the stomach and
abdominal wall, few complications and no occurrence of GDV
within one year of the original surgery.20 Clinically, laparoscopic
assisted gastropexy has proven an easy and effective prophy-
Incisional Gastropexy
lactic gastropexy technique.20 Douglas M. MacCoy
Gastric volvulus is a serious, often fatal problem that occurs
References primarily in large, deep-chested dogs. Gastropexy,1,2 gastroplasty,3
1. Lanz GC, Bottoms GD, Carlton WW, et al. The effect of 360 gastric tube gastrostomy,4 and gastrocolopexy5 have all been used
volvulus on the blood supply of the nondistended normal dog stomach. in an attempt to fix the stomach to the body wall permanently
Vet Surg 1984; 13:189-196. and to prevent recurrent volvulus. The incisional gastropexy1
2. Brockman DJ, Holt DE, Washabau RJ. Pathogenesis of acute gastric offers a method of producing a permanent gastropexy without
dilatation-volvulus syndrome: Is there a unifying hypothesis? Compend the potential complications and aftercare associated with
Cont Educ Pract Vet 2000;22:1108-1114. tube gastrostomy. It may be used as an alternative to a tube
3. Matthiesen DT: Partial gastrectomy as treatment of gastric volvulus: gastrostomy when postoperative decompression will be
Results in 30 dogs. Vet Surg 14: 185-193, 1985. provided by pharyngostomy tube or is not thought necessary,
4. Wheaton LG, Thacker HL, Caldwall S: Intravenous fluroescein as an but a permanent gastropexy is still desired.6 The same low
indicator of gastric viability in gastric dilation-volvulus. J Am Anim Hosp potential for complications also makes it suitable as a prophy-
Assoc 22:197-204, 1986. lactic procedure in high-risk patients.
5. Berardi C, Twardock AR, Wheaton LG, et al. Nuclear imaging of the
stomach of healthy dogs. Am J Vet Res 1991;52:1081-8
6. Berardi C, Wheaton L, Twardock AR, et al. Nuclear imaging to
Surgical Technique
The cranial abdomen is approached by a ventral midline laparotomy.
evaluate gastric mucosal viability following surgical correction of
gastric dilatation/volvulus. J Am Anim Hosp Assoc 1993;29:239-46. The pyloric antrum is identified and is held in the surgical field by
thumb forceps, Babcock forceps, or stay sutures. Using a scalpel,
7. Berardi C, Wheaton L, Twardock AR, et al. Use of nuclear
the surgeon makes an incision equal in length to the diameter of
imaging technique to detect gastric wall ischemia. Am J Vet Res
1991;52:1089-96. the duodenum through the gastric serosa and into but not through
the muscularis over the parietal surface of the pyloric antrum
8. Glickman LT, Glickman NW, Schellenberg DB, et al. Non-dietary risk
equidistant from the attachments of the greater and lesser omenta
factors for gastric dilatation-volvulus in large and giant breed dogs. J
Amer Vet Med Assoc 2000;217:1492-1499. (See Figure 19-13A). The incision should be at least one duodenal
diameter away from the pylorus, to avoid distortion of the pylorus. A
9. Wingfield WE, Betts CW, Greene RW. Operative techniques and
second incision of the same length is made through the peritoneum
recurrence rates associated with gastric volvulus in the dog. J Sm Anim
Pract 1975;16:427-32. and internal fascia of the rectus abdominis muscle or transversus
abdominis muscle of the ventrolateral abdominal wall adjacent to
10. Parks JL, Green RW: Tube gastrostomy for the treatment of gastric
the incision on the pyloric antrum (See Figure 19-13B).
volvulus. J Am Anim Hosp Assoc 12:168-172, 1976.
272 Soft Tissue
A
B
C
Figure 19-13. A. Initial pyloric antrum incision. B. Matching incision on body wall. C. Suturing of body wall and pyloric antrum.
The edges of the abdominal wall incision are sutured to the or creation of pneumothorax when the operation is performed
edges of the antral incision using 2-0 or 1-0 monofilament nylon or by surgeons who are inexperienced with the technique.3 This
polypropylene in a simple continuous pattern, creating an imper- procedure is also reported to be more technically demanding and
forate, circular stoma (See Figure 19-13C). The abdominal incision time-consuming to perform than other gastropexy techniques,
is closed in a routine fashion. but I disagree with this statement.
Figure 19-14. After placing stay sutures, two small incisions are made Figure 19-16. After dissecting lateral to the rib, the caudal flap is
through the seromuscular layer of the pyloric antrum and are con- brought around, and the two stay sutures are tied. (From Ellison GW.
nected with scissors. The flaps are undermined for a distance of I cm. Gastric dilatation volvulus: surgical prevention. Vet Clin North Am
(From Ellison GW. Gastric dilatation volvulus: surgical prevention. Vet Small Anim Pract 1993:23:524.)
Clin North Am Small Anim Pract 1993:23:524.)
Figure 19-17. The two flaps are then apposed with simple interrupted
sutures. (From Ellison GW. Gastric dilatation volvulus: surgical preven-
tion. Vet Clin North Am Small Anim Pract 1993:23:524.)
Figure 19-15. The eleventh or twelfth rib is then grasped with towel
clamps from the abdominal surface, and the peritoneum and trans-
verse abdominal muscle are incised with a No. 10 blade. (From Ellison
GW. Gastric dilatation volvulus: surgical prevention. Vet Clin North Am
Small Anim Pract 1993:23:524.)
Laparoscopic Assisted
Gastropexy
Don R. Waldron
Introduction
Creation of a permanent gastropexy is the single most important
factor in preventing gastric-dilatation volvulus (GDV) in suscep-
tible dogs. Gastropexy is performed most commonly as part of
therapeutic surgery following gastric repositioning for animals
with gastric volvulus. Performance of an effective gastropexy
includes fixation of the gastric antrum to the right abdominal wall
or rib area. Many methods of gastropexy have been described
and are effective if performed well technically. Incisional
gastropexy is a simple and effective technique that has been
widely used and is simple to perform.
Figure 19-19. The dog is placed in dorsal recumbency and two ab-
Increased knowledge of GDV among veterinarians and owners dominal incisions are made, midline for the laparoscope and right side
and identification of known risk factors for dogs susceptible to caudal to the last rib for the gastropexy.
the condition has resulted in increased numbers of dogs having
prophylactic gastropexy to prevent gastric volvulus. Risk factors
for development of the disease include first-degree relatives
who have been affected (genetic), stress, breed/confirmation
(Great Danes, St, Bernards, Weimeraners, Irish Setters, Gordon
Setters, Standard Poodles) and diet.1 It is widely accepted that
animals with deep thorax-to-width ratios are especially at risk
for the disease. Because of high mortality rates associated with
GDV, prophylactic gastropexy should be considered in dogs
identified as being at high risk.
Technique
General anesthesia is induced and positive-pressure ventilation
used during laparoscopic surgery. The dog is placed in dorsal
recumbency and the complete abdomen prepared for surgery.
A trocar cannula is placed 2cm caudal to the umbilicus which
accommodates the laparoscope (Figure 19-19). The peritoneal
cavity is distended with carbon dioxide and a 0°, 5°, or 10°
laparoscope connected to a light source and video camera is
inserted through the cannula. A second trocar cannula is placed
3 cm caudal to the last rib and lateral to the rectus abdominis
muscle (See Figure 19-18). A 10mm Babcock forcep is placed
into the abdomen to grasp the gastric antrum midway between
the greater and lesser curvatures approximately 5 to 7 cm
proximal to the pylorus. Allis tissue forceps are more traumatic
but are useful in grasping the antrum if the stomach slips from
the Babcock forceps.
References
1. Glickman LT, Glickman NW, Perez CM, et al. Analysis of risk
factors for gastric dilatation-volvulus in dogs. J Amer Vet Med
Assoc 1994; 204: 1465-1471.
2. Hardie RJ, Flanders JA, Schmidt P, et al. Biomechanical and
histological evaluation of a laparoscopic stapled gastropexy
technique in dogs. Vet Surg 1996;25: 127-133.
3. Rawlings CA, Foutz TL, Mahaffey MB, et al. A rapid and strong
laparoscopic-assisted gastropexy in dogs. Am J Vet Res 2001;
62: 871-875.
4. Rawlings CA. Laparoscopic-assisted gastropexy. J Am Anim
Hosp Assoc 2002; 38: 15-19.
Figure 19-22. Laparoscopic view of the completed gastropexy with no
evidence of antral twisting.
276 Soft Tissue
Intestinal contents are milked 10 cm to either side of the foreign Linear foreign body removal may often be facilitated using a
body and the bowel is held between an assistant’s fingers or urinary catheter technique. With this technique only one or two
with Doyen intestinal forceps. A No. 15 scalpel blade is used to enterotomies are necessary. Once the foreign body is released
make a full-thickness longitudinal incision in the antimesenteric from its proximal anchor point it is tied or sutured to the tip of
border of the intestine in the viable tissue immediately proximal or an eight to 12 French vinyl urinary catheter (Figure 20-3A). The
distal to the foreign body. The length of the enterotomy approxi- catheter tip is then pushed distally along the pleated length of
mates the diameter of the foreign body. Continuous suction is bowel. As the catheter is pushed distally, the imbedded linear
used to reduce spillage, and the surgeon pushes the foreign foreign body disengages from the intestinal wall (Figure 20-3B
body gently through the enterotomy, taking care not to tear the inset) and the bowel unpleats itself (Figure 20-3B). Once the
incision margins (Figure 20-1B). The bowel lumen is examined foreign body is completely disengaged from the bowel wall a
for evidence of perforations or strictures before closure. second short enterotomy is made distally over the distal tip of
the catheter and the remainder of the foreign body is retrieved
Linear foreign bodies such as string, fishing line, meat wrappers, (Figure 20-3C). Alternatively a longer catheter can be used and
and sewing yarn present a difficult surgical problem. The trailing pushed down through the colon. The foreign body can then
end of a linear foreign body usually catches over the base of the be retrieved from the anus (not shown). The author has found
tongue or in the pyloric antrum and acts as an anchor. Intes- catheter facilitated removal to be a very useful method for linear
tinal peristalsis attempts to move the foreign body distally, but foreign body retrieval.
because it remains fixed proximally, the bowel plicates itself
along the length of the foreign body, which often cuts through Closure of the enterotomy incision usually is performed with a
the intestinal wall on the mesenteric surface, resulting in local simple interrupted suture pattern in side-to-side longitudinal
peritonitis. fashion (Figure 20-4). Single-layer closures are recommended
because double-layer closures may cause excessive narrowing
Linear foreign bodies should be managed by identifying the of the lumen diameter. Various suture patterns are acceptable, but
glossal anchor point initially and releasing it before laparotomy. with all techniques, the vascular and collagen-rich submucosa
Commonly, a gastrotomy is also necessary to free wadded string must be incorporated in the sutures. Single-layer appositional
or fishing line from a gastropyloric anchor. The traditional way techniques such as the simple interrupted appositional suture
for linear foreign body removal requires multiple enterotomies pattern is most commonly used. A simple interrupted approxi-
to complete removal of the linear body (Figure 20-2). If too few mating suture can be used (See Figure 20-10A). Sutures are placed
enterotomies are made with too much traction placed on the 3 to 4 mm apart and 2 to 3 mm from the cut edge, taking care
linear body, the mesenteric border may be perforated in an area to incorporate all layers of the intestinal wall. Crushing sutures
that is difficult to explore and suture. Occasionally, the intestinal are tied tightly and cut through the muscularis and engage the
foreign body perforates at several locations before surgery, submucosa. The author feels they should be avoided since they
and local peritonitis is evident. Sometimes, enough fibrosis has cause excessive hemorrhage and tissue ischemia (See Figure
occurred around the foreign body so, even after its removal, the 20-10B). I prefer a modified Gambee suture, which incorporates
bowel retains its plicated conformation. In these patients, intes- the serosa, muscularis and submucosa but excludes the mucosa
tinal resection and anastomosis may be necessary. and is helpful in reducing mucosal eversion (See Figure 20-11).
Figure 20-2. With a linear foreign body (e.g., a piece of string), multiple enterotomies usually are required. Mosquito hemostats are used to grasp a
loop of the string at each enterotomy site. The string is then sequentially cut and withdrawn through the nearest enterotomy site. See text for details.
278 Soft Tissue
Figure 20-3. Fewer enterotomies are needed if A. The linear foreign body is tied or sutured to the tip of a urinary catheter. B. The catheter is
pushed distally and disengages the foreign body from the intestinal mucosa (inset) as the intestine unpleats itself. C. A small enterotomy is made
over the tip of the catheter and the foreign body is retrieved. If the catheter is long enough it can be pushed through the colon and out the anus
(not shown).
Intestines 279
Figure 20-4. An enterotomy usually is closed in side-to-side fashion Figure 20-5. An enterotomy also can be closed with a simple continu-
interrupted suture pattern. Appositional, crushing, or modified Gambee ous appositional pattern.
sutures can be used.
Strangulated loops of bowel associated with diaphragmatic, serosa-to-serosa approximation but they create an internal cuff
ventral, inguinal, perineal, or femoral triangle hernias often of tissue, which may cause luminal stenosis. Inflammation is
require emergency resection and anastomosis. Animals with more severe and healing time is slower than with approximating
intestinal or mesenteric volvulus have peracute mesenteric techniques. Despite these dangers, inverting techniques should
vascular pedicle obstruction and secondary bowel wall ischemia be considered in patients with a high risk of leakage or for use
and may require massive resection and anastomosis. With intus- in colonic resection and anastomosis; in the latter situation, the
susception, the invaginated segment of bowel undergoes early high bacterial content of feces makes leakage of the anasto-
venous congestion and becomes edematous. Intussusceptions mosis extremely dangerous.
then become rapidly irreducible due to outpouring of fibrinous
exudate from the invaginated serosal surface. If arterial throm- Approximating end-to-end intestinal anastomoses can be
bosis occurs, the invaginated bowel will become ischemic and created with various simple interrupted suture patterns or with a
necrotic. Resection and anastomosis of the affected section of simple continuous suture pattern. Interrupted patterns generally
bowel is then necessary. are easier to perform, but the simple continuous pattern
minimizes mucosal eversion and therefore provides better
serosal apposition and primary intestinal healing. Regardless
Determining Intestinal Viability of the suture technique used, proper incorporation of the tough
Non-viable intestine is usually distended, blue, black or grey submucosa and reduction of mucosal eversion are vital in
in appearance and easily discernable from normal bowel. In performing consistently successful intestinal anastomosis.
some cases, determining viability in cyanotic appearing bowel
is difficult. The intestine should be decompressed with a needle A simple interrupted appositional suture incorporates all tissue
and suction apparatus to relieve venous congestion. Standard layers and gently apposes the wound edges (Figure 20-10A). A
clinical criteria for establishing intestinal viability are color, crushing suture is pulled tightly and cuts through the serosa,
arterial pulsations, and the presence of peristalsis. Of these muscularis, and mucosa, and engages only the tough submu-
three parameters, peristalsis is the most dependable criteria of cosal layer of the bowel wall (Figure 20-10B). Crushing sutures
viability. The “pinch test” should be performed on questionable create more microhemorrhage and tissue necrosis directly at
areas of bowel to determine whether smooth muscle contraction the anastomosis and the author feels they should be avoided.
and peristalsis is present. If clinical criteria are inadequate With both the appositional and crushing techniques, mucosal
to determine viability, intravenous fluorescein dye or surface eversion tends to occur between sutures. I prefer a modified
oximetry can be used. A 10% fluorescein solution (Fundescein-10, Gambee suture pattern because it reduces mucosal eversion. In
Cooper Laboratories, San Germain, PR) is given at a dosage of this technique, the need1e is passed through the serosa, muscu-
1 mL/5 kg intravenously through any peripheral vein. After 2 laris, and submucosa, but the mucosal layer is not incorporated
minutes, the tissues are examined using long-wave ultraviolet in the suture (Figure 20-11). The suture is tied snugly enough to
light (Wood’s lamp). Areas of bowel are considered viable if they approximate all layers of the intestinal wall gently. The mucosa
have a bright green glow. Areas of bowel are not viable if they tends to be pushed into the intestinal lumen and does not evert
have a patchy density with areas of nonfluorescence exceeding between sutures.
3 mm, have only perivascular fluorescence, or are completely
nonfluorescent. Oxygen saturation may also be a reliable method
of determining intestinal wall viability. A sterile probe is placed on
the surface of the bowel and an oxygen saturation level reading
will occur. According to published reports in rabbits, saturation
levels of 81% or above typically mean that the bowel is viable.
Values below 76% were consistent with mucosal necrosis and
those below 64% indicated transmural intestinal necrosis.
A taper-cut, narrow-taper, or small reverse-cutting need1e When the anastomosis is closed with a simple interrupted suture
with 3-0 or 4-0 swaged-on suture material is suitable for most technique, the first suture is placed at the mesenteric border
anastomoses. Braided, nonabsorbable materials such as silk because the presence of fat in this area makes suture placement
or braided polyesters should be avoided. Chromic surgical gut most difficult, and this is where leakage is most likely to occur.
rapidly loses tensile strength due to collagenase and phagocy- The second suture is placed on the antimesenteric border, and the
tosis at the wound edge and is not recommended. Synthetic, third and fourth sutures are placed laterally at the 90° quadrants
braided, absorbable suture materials such as polyglactin (Figure 20-15A). Depending on bowel diameter, two to four
910 (Vicryl, Ethicon, Inc., Somerville, NJ) are acceptable, but more sutures are placed between each of the quadrant sutures
they have significant tissue drag. I prefer poliglecaprone 25 (Figure 20-15B). All sutures are placed 3 to 4 mm apart and 2 to
(Monocryl, Ethicon Inc., Somerville, NJ), glycomer 631 (Biosyn, 3 mm from the wound edge. Suture bites on the dilated side of
United States Surgical Corp, Norwalk, CT), polydioxanone (PDS, the anastomosis are placed farther apart than on the contracted
Ethicon, Inc., Somerville, NJ), and polyglyconate (Maxon, United side of the anastomosis to correct for luminal disparity. Once one
States Surgical Corp., Norwalk, CT), which are monofilament side of the anastomosis is sutured, the bowel is flipped over, and
absorbable sutures with little tissue drag and have all been used the opposite side is completed. From 12 to 20 sutures are used
successfully for intestinal anastomoses. Nonabsorbable monofil- to complete the anastomosis. After the anastomosis has been
ament sutures such as nylon (Ethicon, Ethicon, Inc., Somerville, completed, it is checked for leakage by infusing saline under low
NJ) or polypropylene (Prolene, Ethicon, Inc., Somerville, NJ) also pressure into the bowel lumen and massaging the fluid past the
are acceptable for simple interrupted anastomoses, but they anastomosis. The anastomosis can also be checked by gently
should not be used for simple continuous anastomoses because probing the spaces between sutures with mosquito hemostats
they do not allow luminal distension. Newer versions of triclosan for openings. The surgeon then closes the mesenteric defect
impregnated polygalactin 910 (Vicryl plus, Ethicon Inc., Somer- with a simple continuous pattern, taking care not to include any
ville, NJ) and poliglecaprone 25 (Monocryl plus, Ethicon Inc., mesenteric vessels within the suture line (Figure 20-15C).
Somerville, NJ) are undergoing investigation in hopes that this
bacteriostatic compound will reduce wound infection. Occasionally, the small-diameter loop of bowel cannot be
enlarged enough to be anastomosed to the larger one. In this
case, the large-diameter stoma is reduced by initially angling
Surgical Technique the cut at 45°. The anti-mesenteric portion of the incision is
A standard midline laparotomy is performed, as well as a then apposed with simple interrupted sutures in side-to-side
thorough examination of the intestinal tract. The area to be fashion until the remaining opening is an appropriate width to
resected is packed away from the abdomen with moistened anastomose to the smaller-diameter loop of bowel (Figure 20-16).
Intestines 283
Figure 20-12. Proximal A. and distal B. forceps are placed at the area to be resected. Mesenteric and arcadial vessels are double-ligated as
shown. The bowel is transected with a scalpel blade outside of the clamps (dashed lines), and the mesentery is incised with dissecting scissors
(dotted lines). See text for details.
Figure 20-13. Everted mucosa can be trimmed back before the anasto-
mosis is performed.
the intestine with three stay sutures, the skin stapler is used to
place staples every 2-3 mm around the perimeter of the wound
(Figure 20-18). These closures are more rapidly done than
handsewn anastomosis and have similar bursting strengths, but
some mucosal eversion is created.
retention of feces, if chronic or prolonged, can result in severe been used successfully to stimulate colonic motility (0.25 mg/
distention of the colon and motility disorders. It can also result in kg or 2.5 mg every 8-12 hours for smaller cats and 5 to 10 mg
various degrees of mucosal injury that may result in absorption every 8 to 12 hours in larger cats and dogs). This dose can be
of bacterial toxins contributing to more severe clinical signs. safely doubled if lower doses are not effective. Cisapride is no
The duration of obstruction that leads to more severe mucosal longer commercially available but some pharmacies are able
changes is unknown. One study in cats suggests that if colonic to compound this drug on request. I prefer to use cisapride and
distension is present for 6 months or longer as may be seen lactulose (Lactulose generic, Apotex) concurrently to optimize
with pelvic stenosis secondary to pelvic fractures, degenerative the effect of keeping the colon evacuated. Some cats aggres-
intramural myoneural changes in the colon may not allow return sively treated in this manner may never require surgical inter-
to normal function even if the cause of obstruction is relieved. vention. Other cats, however become less responsive to medical
management over time and require surgery.
When constipation progresses to obstipation, excessively hard
feces will prevent defecation. Digital removal of the impaction is
usually necessary in these cases. When the condition progresses Surgical Treatment
to obstipation, medical therapy becomes ineffective. A subtotal colectomy was once considered a “salvage”
procedure. However, a long-term history of success with this
technique makes it a very good alternative to medical therapy.
History and Clinical Signs Surgery is most often performed in those patients who fail to
Regardless of the cause of the constipation, tenesmus with little respond to aggressive medical therapy. However, I have had
or no production of feces is the most common complaint. It is not several owners that opt for surgery on their cat because of their
uncommon to have passage of mucus and/or blood associated unwillingness or inability to be involved in medical management,
with obstipation as a result of inflammation of the colonic mucosa. which becomes cumbersome or causes behavior problems with
Historically, the owner may describe a possible etiology such as the cat. Another group of owners eventually select a surgical
pelvic or lumbosacral trauma or dietary indiscretion. option because of the emotional cost that is associated with
restraining their cat and giving the appropriate medications.
Systemic signs depend on the duration of the obstipation and
degree of injury to the colonic mucosa. These signs can include In cats, a bilateral perineal hernia may be seen concurrently with
anorexia, weight loss, lethargy, dehydration, vomiting, and liquid megacolon. In these cases, performing a subtotal colectomy is
bloody feces. Some cats will eventually become unthrifty and usually sufficient to relieve the signs. If not, a bilateral hernior-
have perineal soiling. Hard concretions within an enlarged colon rhaphy may be necessary at a later time.
will often be palpated and some discomfort may be noted. Rectal
palpation is done to evaluate for any pelvic canal stenosis, the The standard of surgical treatment for megacolon in the cat is a
presence of a perineal hernia, and any intraluminal or extralu- subtotal colectomy that involves removal of approximately 95%
minal masses that can result in a mechanical obstruction. In the of the colon. I prefer preservation of the ileocolic valve (ICV) in
dog, prostatomegaly or severe lymphadenomegaly of the iliac/ most cats and in all dogs, although numerous reports cite good
sublumbar lymph nodes associated with neoplasia should be results when the ICV is removed in cats. I do not remove the
considered and carefully evaluated. ICV except in those cats where a colocolostomy will result in too
much tension across the anastomosis.
Diagnosis Before an animal has colectomy performed, it should be
Tenesmus and decreased fecal production should prompt the
carefully evaluated for concurrent problems that may detract
clinician to consider constipation/obstipation secondary to
from a successful outcome. Loss of anal sphincter tone that is
megacolon. Abdominal and pelvic radiographs will help confirm
not diagnosed prior to a subtotal colectomy will usually result in
megacolon and may identify pelvic abnormalities or lumbosacral
an unsatisfactory outcome. Rectal stricture or neoplasia should
disease, or other abdominal masses that may be causing colonic
be ruled out by performing a digital rectal examination prior to
or rectal obstruction.
surgery.
Careful palpation of the abdomen should be performed after feces
If the megacolon is the result of an acquired pelvic stenosis
has been evacuated. Ultrasound examination or colonoscopy can
that is the result of pelvic fracture malunion and it is less than 6
be used to rule out other disease processes such as neoplasia
months from the time of injury, a hemipelvectomy or corrective
or stricture, especially if there are palpable abnormalites.
osteotomy can be tried. The technical demands of the orthopedic
procedures make the subtotal colectomy a more viable option.
Barium enema contrast studies of the rectum and colon may be
valuable and can be performed especially in dogs after evacu-
Enemas should not be administered within 48 hours of surgery
ation of the feces.
to decrease the risk of contamination from liquid intestinal
contents at the time of surgery. Applying aseptic surgical
Conservative Treatment principles to colonic surgery, carefully isolating segments of
Medical management is indicated prior to any surgical inter- bowel with saline-soaked laparotomy sponges or towels, and
vention. Warm water enemas followed by laxatives and dietary employing meticulous and gentle handling of tissues will help
supplements (canned pumpkin) may be helpful. Cisapride, has ensure success. Perioperative use of an appropriate antimi-
Intestines 287
crobial drug is indicated because the surgery results in a “clean intesine. The urinary bladder is emptied manually or by cysto-
contaminated” or “contaminated” wound. A broad-spectrum centesis to ease isolation from the surgical site. Fecal material
antibiotic such as a second-generation cephalosporin such is massaged toward the middle of the segment of the colon to be
as cefoxitin (Mefoxin, Merck and Co.) is preferred because of removed away from the site of intestinal transection. The colon
its effectiveness against most anaerobes as well as the usual or ileum is transected proximally and again distally 1-2 cm rostral
gram-negative aerobes. It is preferable to give the drug preop- to the pubis. Straight intestinal clamps (Doyen) are used to hold
eratively intravenously. Administering the drug 20 to 30 minutes the segments of the bowel together during the anastomosis. I
prior to surgery at a dose of 20 mg/kg will result in optimum blood prefer to perform a single layer anastomosis using simple inter-
levels of the drug at the operative site. This is repeated 2 to 3 rupted appositional sutures of 4/0 polydioxanone or polypro-
hours later. pylene (Prolene and PDS, Ethicon, Inc., Somerville, NJ). Some
cats have concurrent inflammatory bowel disease and a biopsy
Subtotal colectomy is performed through a ventral midline of the small bowel may be indicated.
abdominal incision extending from the umbilicus to the pubis.
The appropriate colic and caudal mesenteric vessels are ligated When preserving the ICV, a 2-3 cm segment of the proximal
and divided. (Figure 20-20) If the ICV is resected, then additional colon is preserved and anastomosed to the 1 to 2 cm segment
ligatures are necessary for the ileocecocolic artery and vein. I of remaining distal colon just ahead of the pubic bone (Figure
do not find it necessary to ligate the cranial rectal vessels. 20-21). Holding these segments together during the suturing
process requires intestinal forceps. If there is lumen disparity
In order to optimize exposure of the colon and the planned site between the two segments as when the ICV is resected, then the
of anastomosis, it is helpful to exteriorize the small bowel from smaller lumen (ileum) can be spatulated to increase its circum-
the abdomen to the right of the abdominal incision. Moistened ference to match that of the opposite larger colonic segment
laparotomy pads are placed to protect and moisten the small (See Figure 20-14). Alternatively, the larger lumen segment
can be oversewn until it matches the diameter of the smaller
segment and the anastomosis is completed with a simple inter-
rupted approximating suture pattern using 3 or 4-0 suture size
(Figure 20-22). Following the anastomosis, an attempt is made to
remove any remaining feces from the rectum by massaging the
material distally followed by digital removal through the anus at
the conclusion of surgery.
Figure 20-21. The mesenteric sides of the proximal A. and distal B. bowel segments are aligned before proceeding with the anastomosis.
Suggested Readings
Bertoy RW: Megacolon In Bojrab MJ, ed.: Disease mechanisms in small
animal surgery. 2nd ed. Philadelphia: Lea and Febiger, 1993, p 262.
Bright RM: Subtotal colectomy for treatment of acquired megacolon in
the dog and cat. J AM Vet Med Assoc 12: 1412, 1986.
DeNovo RC, Bright RM: Chronic feline constipation/obstipation. In Kirk
RW, Bonagura JD, eds. Current Veterinary Therapy XI. Philadelphia: WB
Saunders, 1992, p 619.
Hoskins JD. Management of feline impaction. Compend Contin Educ
Pract Vet 12: 1579, 1990.
Figure 20-22. When lumen disparity exists between the two segments Kudish M, Pavleteic MM: Subtotal colectomy with surgical stapling
to be anastomosed, the larger lumen can be sutured closed until the instruments via a transcecal approach or treatment of acquired
remaining lumen approximates the size of the opposite segment. megacolon in cats. Vet Surg 22: 457, 1993.
Intestines 289
Matthiesen DT, Scavelli TD, Whitney WO. Subtotal colectomy for the
treatment of obstipation secondary to pelvic fracture malunion in cats.
Vet Surg 20: 113, 1991.
Ryan, S. Comparison of a biogragmentable anastomosis ring and
sutured anastomosis for subtotal colectomy in cats with megacolon.
Proceedings of the 4th Annual Scientific Meeting of the Society for
Veterinary Soft Tissue Surgery. June 2005.
Pozzi A, Smeak DM. Subtotal colectomy in the dog. Personal commu-
nication, 2005.
Introduction
Colorectal surgery in small animals can be performed with the
same surgical success rates as other gastrointestinal surgery
with the use of careful tissue handling techniques and modern
surgical materials.
The large intestine of the dog and cat is shorter than the small
intestine, ranging from approximately 20 to 35 cm in length.1,2 As
a general rule, the large intestine is approximately the length of
Figure 20-23. Surgical anatomy of the feline large intestine, ventral
the trunk in dogs and cats, with the small intestine measuring
view. Legend: A-jejunum, B-ileum, C-cecum, D-ascending colon, E-
about four times the length of the trunk. Because of its shorter
transverse colon, F-descending colon, G-mesentery, H-ileocecal fold,
mesentery, the large intestine does not vary as much in length or
I-mesocolon, J-caudate process of liver, K-right kidney, L-right ureter,
position as the small intestine. The large intestine is, however, M-caudal mesenteric lymph nodes, 1-abdominal aorta, 2-caudal
considerably larger in internal diameter than the small intestine, vena cava, 3-cranial mesenteric a., 4-jejunal a., 5-ileal a., 6-ileocolic
and has neither the tenia (longitudinal bands) nor haustra (saccu- a., 7-colic branch, 8-cecal a., 9-antimesenteric ileal branch, 10-ileal
lations) seen in other species. Classically, the large intestine has mesenteric branch, 11-right colic a., 12-middle colic a., 13-left renal
been divided into the cecum, colon (ascending, transverse, and vessels, 14-testicular a., 15-caudal mesenteric a., 16-left colic a.,
descending), and rectum (Figure 20-23). 17-cranial rectal a., 18-middle colic v.
Microscopically, the colon is composed of five layers. From blood supply to the colon and rectum arises from the cranial
the inner luminal surface outward the layers of the colon are 1) and caudal mesenteric arteries supported in the mesocolon
mucosa, 2) submucosa, 3) circular muscle layer, 4) longitudinal (See Figure 20-23). The cranial mesenteric artery supplies the
muscle layer, and 5) serosa. The mucosa consists of columnar cecum, ascending, transverse, and part of the descending
epithelial lining cells, mucus secreting goblet cells, and colon. The caudal mesenteric artery supplies the remainder
enteroendocrine cells. Intestinal villi are absent in the colonic of the descending colon as well as the rectum.1-4 Numerous
mucosa; however, intestinal crypts (crypts of Lieberk¸hn) remain. perpendicular branches (vasa recta) split from the colic arteries,
Intestinal crypts are elongated and straight, opening onto the anastomosing with each other along the lesser curvature of the
luminal surface of the colon. The submucosa is composed of colon. Most of the large intestine is drained by the portal system
collagen and elastin fibers arranged in an orderly honeycomb through the ileocolic and caudal mesenteric veins.1-4 The caudal
pattern, with submucosal glands and lymphoid tissue dispersed rectal vein drains the anal canal and empties directly into the
throughout this layer. The submucosa’s high collagen and caudal vena cava.1-4
elastin content makes it the important suture holding layer of
the intestine. Tunica muscularis is the term commonly given the
combined smooth muscle layers of the intestine. Contraction of Indications for Surgery
this group of muscles is responsible for intestinal motility. Finally, The need for colonic surgery in small animals is not as common as
the tunica serosa consists of loose connective tissue covered the need for small intestinal surgery. Colonic surgery techniques
with a layer of squamous mesothelial cells. involve primary closure of traumatic defects, resection and
anastomosis, biopsies, and rarely, foreign body removal.
The large intestine is anchored to the sublumbar region by the
mesocolon, which arises from the left side of the mesentery and Trauma to the colon can result from intraluminal or extraluminal
is divided into the same parts as the colon that it suspends. The
sources. Intraluminal causes of injury are rare, but such injury
290 Soft Tissue
can result from ingested sharp foreign bodies or improper use occupying lesions, and they give a rough estimate of intestinal
of transanal instruments. Colonic foreign bodies can often be wall thickness, as well as, plication or intussusceptions of the
gently milked through the colon to a point at which they can intestine. However, abdominal ultrasound provides a better view
be grasped by an assistant using a transanal forceps. Rarely, of the intestinal wall and has become the imaging method of
a colotomy must be performed to retrieve a foreign body. choice for diagnosing intussusceptions. Ultrasonography also
Extraluminal sources of trauma are more common and include allows more detailed imaging of intra-abdominal structures when
gunshot and knife wounds, and less commonly, penetrating bone peritonitis is present and for biopsy and staging of patients with
fragments from pelvic fractures. Indirect or blunt trauma to the neoplasia. Positive-contrast enemas may be helpful diagnostic
colon can also result in contusions, vessel thrombosis, colonic tools in selected cases; however, they are contraindicated when
torsion, or even avulsions of the colon. Penetrating wounds of perforations or weakened intestinal walls are suspected.
the colon require immediate treatment. Primary repair of clean
lacerations, debridement and primary closure of more severe Other diagnostic methods that may be of benefit in large intes-
wounds, or resection and anastomosis of devitalized segments tinal diseases are proctoscopy, computed tomography (CT)
may be required to close colonic defects. In one study of dogs scans and magnetic resonance imaging (MRI). Proctoscopy
with rectal tears resulting from pelvic fractures, only dogs with should be performed with care if weakened intestinal walls are
tears repaired within 24 hours of trauma survived.5 suspected and it is contraindicated when large intestinal perfo-
rations are suspected. Computed tomography scans and MRI
Neoplasia of the colon is less common than in other parts of are most useful when staging patients with cancer to determine
the alimentary system. Benign tumors of the colon commonly the extent and spread of disease.
include leiomyomas, papillary adenomas, and adenomatous
polyps. Malignant transformation of adenomatous polyps has Microscopic analysis of peritoneal fluid can provide a definitive
been reported to occur in 18% of dogs in one study.6 Malignant diagnosis in the case of intestinal perforation. Fluid can be
tumors of the colon commonly include lymphosarcomas, carci- obtained via abdominal paracentesis or, ideally, by peritoneal
nomas, and adenocarcinomas. Metastasis of colonic tumors lavage. A large number of neutrophils with intracellular bacteria
occurs most commonly to the regional lymph nodes and the liver. are diagnostic of bacterial peritonitis. Less definitive are fluid
Intussusception of the large intestine occurs most commonly at samples with large numbers of degenerative neutrophils, free
the ileocecocolic junction. Intussusception of the body of the abdominal bacteria, or debris which would normally be found
colon is rare. Intussusceptions of the large intestine are treated intraluminally. Inadvertent sampling of the intestinal lumen could
in the same manor as those occurring in the small intestine. account for these findings. A peritoneal lavage is recommended
to confirm equivocal results.
Colectomy, either partial or complete, may be the treatment
of choice for patients with unresponsive megacolon, severe
unresponsive inflammatory bowel disease, colonic ulcer-
Preoperative Preparation
ations, colonic strictures, colonic torsion, and pelvic canal Bacterial populations in the normal gastrointestinal tract increase
stenosis resulting from pelvic fracture malunion. Removal of the dramatically from oral to aboral, changing from predominately
cecocolic valve has been advocated in the case of megacolon aerobic to predominately anaerobic. A gram of feces from the
caused by pelvic fracture malunion, to create a soft stool. Most colon contains up to 1011 organisms.7 Aerobic bacteria in the
surgeons, however, recommend leaving the cecocolic valve in large intestine normally include the Gram-positive genera Strep-
the treatment of other colonic diseases. tococcus, Staphylococcus, Bacillus, and Corynebacterium and
Gram-negative members of the enterobacter family, especially
Surgical biopsy of the colon may be the diagnostic method of Escherichia coli, Enterobacter, Klebsiella, Pseudomonas,
choice in some colonic diseases. Direct visualization of the Neisseria, and Moraxella.7 Up to 90% of the bacteria in the large
entire colon, the ability to safely obtain multiple full thickness intestine are anaerobes, including members of the Gram-positive
samples of colonic wall and regional lymph nodes, and commonly genera Clostridium, Lactobacillus, Propionibacterium, and
available surgical instrumentation make open colonic biopsy a Bifidobacterium; the Gram-negative anaerobic bacteria include
viable diagnostic method. Bacteroides, Fusobacterium and Veillonella.7 The importance of
anaerobic bacteria as pathogens in small animals, especially
Bacteroides fragilis, has been demonstrated.8,9
Diagnostic Methods
Diagnosis of colorectal disease is based upon physical exam Mechanical cleansing of the bowel when possible, decreases
findings and various imaging techniques. Colonic masses can the risk of intraoperative bacterial contamination by decreasing
often be palpated in the central to caudal aspect of the abdomen. the quantity of feces in the intestine while the lumen is opened.
Rectal masses can often be felt upon digital rectal examination. Mechanical cleansing, however, does not decrease the concen-
Survey abdominal and pelvic radiographs are recommended tration of bacteria per gram of feces, only the quantity of feces
in all patients with suspected large intestinal disease. Radio- present. The current veterinary regimen of choice for mechanical
graphs can give indications of regional lymph node size, luminal bowel cleansing is the technique used for colonoscopy
contents, including the degree of colonic filling and overall preparation.10,11 The lavage solutions Colyte (Reed & Carnick,
density of the luminal contents. Radiographs can also help to Piscataway, NJ) or GoLytely (Braintree Labs, Inc, Braintree, MA)
diagnose intraluminal or extraluminal foreign bodies, or space at 80 mg/kg are administered orally in two divided doses four
Intestines 291
to six hours apart 18 to 24 hours prior to the procedure. These istration, or administering systemic antibiotics for extended
lavage solutions produce an osmotic diarrhea which cleanses periods prior to surgery, can result in bacterial antibiotic resis-
the entire gastrointestinal tract. Potential problems with using tance and superinfections.
mechanical cleansing are poor cleansing of the proximal colon
when using enemas only, and watery intestinal contents which Systemic antibiotic prophylaxis for colorectal surgery can be
are more difficult to control once the intestinal tract is open. One broken into combination therapy regimens and monotherapy
human study comparing mechanical preparation alone prior regimens. The most commonly used combination antibiotic
to colorectal surgery demonstrated an over-all postoperative regimens for human colorectal surgery are aminoglycosides,
infection rate of up to 45% compared to mechanical prepa- such as gentamicin, kanamycin, amikacin, or tobramycin along
ration with some form of antibiotic solution at 18%.12 To reduce with lincomycin, clindamycin, or metronidazole.14,18 Effective
infection rates to an acceptable level after colorectal surgery, monotherapy drugs used for antimicrobial prophylaxis in
some form of antibiotic prophylaxis is also recommended in colorectal surgery include cefoxitin, several third generation
human colorectal surgery. cephalosporins, and ampicillin/sulbactam.8,14,19 Cefoxitin has
been recommended by several authors as the systemic prophy-
Oral antibiotics used for prophylaxis in colorectal surgery lactic antibiotic of choice for colorectal surgery in veterinary
are generally those that are poorly absorbed from the intes- medicine.20-22 The drug is a single agent intravenous antibiotic
tinal lumen. The purpose of oral antibiotics is to lower the that has a low toxicity, is relatively inexpensive, and has good
concentration of bacteria within the intestine. To be effective, bacteriocidal effects against the primary bacterial pathogens.
oral antibiotics should be active against the organisms most Cefoxitin dosage recommendations in small animals range from
commonly found in the large intestine. Most oral antibiotic 6 to 30 mg/kg IM or IV given every eight hours.21,23 With a half-life
regimens include an aminoglycoside, such as neomycin or of 41 to 59 minutes, cefoxitin should be redosed every 1.5 to 2
kanamycin, in combination with an antibiotic effective against hours as a surgical prophylaxis.
anaerobic bacteria, like metronidazole, erythromycin, tetra-
cycline, lincomycin, or clindamycin.7,12-16 Neomycin used alone The above protocols are predominately based upon research
has actually been incriminated in higher postoperative infection on human colorectal surgery. While controversial, the author
rates.16 When combined with mechanical bowel cleansing, oral only uses first generation cephalosporins as a single agent
antibiotic prophylaxis reduces postoperative infection rates to systemic antibiotic prophylaxes, with no local oral antibiotics or
5% to 18% in human patients undergoing colorectal surgery.12,14,15 mechanical cleansing. The author has not noted any increase in
Oral antibiotic regimens should not be administered earlier than morbidity or mortality in dogs and cats using this minimal bowel
24 hours prior to surgery to prevent possible resistant bacterial preparation.
overgrowth.
Figure 20-25. Approach to the colon and rectum through a pubic osteotomy. See text for details. A. The aponeurosis of the gracili and adductor
muscles are incised on the midline and reflected laterally. Note the obturator nerve and vessels at the cranial lateral edge of the obturator fo-
ramina. B. Osteotomy sites and drill holes for a partial pubic osteotomy. C. After reflecting the pubic floor segment caudally, the rectum is visible
under the urinary tract. D. Reflecting the pubic floor laterally after a complete osteotomy, the entire ventral rectum can be visualized.
The intestinal segment to be resected should be carefully intestinal segment or milk the contents aboral of the planned
isolated with laparotomy sponges moistened with warm isotonic anastomosis site. The blood supply to the affected segment
saline (Figure 20-30A). The exposed tissue should be kept moist should then be double ligated using 3-0 to 4-0 suture material or
at all times to prevent desiccation and trauma. Two to three ligation clips (Figure 20-30B). For short segments, only the vasa
layers of laparotomy sponges or 4x4 sponges allows for removal recta perpendicular to the colon need to be ligated, preserving
of contaminated material with minimal chance for further the vessels running parallel to the colon. Resection of longer
contamination. Contaminated material should be removed from segments necessitates ligation of the main blood supply running
the sterile field as soon as possible to prevent further spread of parallel to the colon. Once the blood supply has been ligated,
contamination. An area for contaminated surgical instruments delineation between vascular and avascular segments of colon
on the sterile field can be made with a dry lap sponge or drape. can be easily observed.
As soon as the instruments are no longer needed, they should be
removed from the instrument table. Carmalt forceps can be placed at the edges of the colonic
segment to be resected. A minimum of 1 to 2 cm of healthy
Once the affected colonic segment is isolated, the luminal vascularized tissue should be included within the segment to be
contents should be milked from the areas that will be incised. The resected. Carmalt forceps can be placed perpendicularly across
author prefers to remove the luminal contents with the resected the colon, or they can be placed to back cut on the antimesen-
294 Soft Tissue
Figure 20-26. Patient positioning for a dorsal approach to the rectum Figure 20-28. After cutting and retracting the rectococcygeus muscles
(See text for details). The curved dotted line indicates the location of the levator ani muscles on either side of the rectum can also be
the incision. partially transected to expose the rectal lesion. The rectum can be
resected with an elliptical incision or circumferentially as needed to
remove the lesion (dotted lines). Make certain to use sufficient stay
sutures in normal rectal tissue to keep the cut edges from retracting
away from the surgery site.
Figure 20-27. The taught thick paired rectococcygeus muscles (under Figure 20-29. Prolapsing caudal rectal mucosa can be done by grasp-
forceps) are easily identified after the incision is made and subcutane- ing the mucosa oral to the lesion with atraumatic forceps or stay
ous fat is dissected. The muscles can be cut anywhere along the belly sutures. Sufficient full thickness stay sutures in normal rectum should
(dotted line) and distracted with stay sutures. be placed to keep the cut edges well defined and prolapsed until the
defect is closed.
Intestines 295
teric side, creating a larger anastomotic diameter. Atraumatic using the outside edge of the Carmalt forceps as a guide. Colonic
clamps (Doyen forceps, vascular forceps, bobby pins, or an mucosa commonly everts over the cut edge of the intestine. It
assistant’s finger tips) are placed 4 to 5 cm to the outside of the is easier to anastomose the colon if the mucosa is resected
Carmalt forceps. The atraumatic forceps keep luminal contents level to the cut edge of the outer colonic wall. This procedure
from leaking from the cut ends of the colon, as well as assisting is easily performed using Metzenbaum scissors. The colonic
in manipulation of the cut ends of the colon. Any remaining segments can then anastomosed using a variety of techniques
mesocolon is then resected as far from any vessels as possible. listed below.
The affected colon segment can then be resected with a scalpel,
Figure 20-30. Preparation for colonic resection and anastomosis. A. Moistened laparotomy sponges are placed under the balfour retractor and
wrapped around the base of the mesentery to isolate the affected colonic segment. B. The blood supply to the affected segment is double ligated.
For short colonic segments, individual vasa recta should be ligated, preserving the longitudinal mesenteric vessels. For longer colonic segments,
the longitudinal mesenteric vessels can be ligated. Carmalt forceps are placed oral and aboral to the segment of colon to be resected, making
certain to include all of the avascular bowel. Atraumatic forceps are then placed outside the carmalt forceps. The affected colonic segment is
now transected using the outside of the carmalt forceps as a guide.
296 Soft Tissue
After performing and pressure leak testing the colonic anasto- everting, or appositional suture techniques. The anastomosis
mosis, the anastomotic site is flushed with saline. Layers of techniques that are the easiest to perform, with the least
laparotomy sponges can be removed in between flushing the leakage, the least adhesion formation, and the best histologic
anastomosis. Surgical gloves, instruments, and other contami- healing, have been the single-layer simple interrupted approxi-
nated equipment should be changed at this time. A sterile fenes- mating techniques. In 1968 Poth and Gold described the crushing
trated drape can be placed over the surgery site. If there is no appositional anastomosis technique in human patients.29 This
obvious contamination of the abdomen, abdominal lavage is technique involved a through-and-through suture, which was
not necessary. Otherwise, the abdomen should be lavaged with then tightened to cut through all the layers of the intestine except
warm isotonic saline until the effluent is clear. The mesocolon the tough submucosa (Figure 20-32A). This technique kept the
should be closed with a continuous suture pattern of 3-0 or 4-0 suture from being exposed to the luminal surface, where it could
absorbable material. Care should be taken so as not to damage become infected, and from exposure to the abdominal lumen
the adjacent blood supply to the colon. The surgical approach is and serosal surface, where adhesions could form. At about the
then closed in a routine manor. same time the crushing technique was developed, DeHoff inves-
tigated the use of a simple interrupted approximating technique
for intestinal anastomosis in dogs (Figure 20-32B).30 Both apposi-
Methods of Colonic Anastomosis
tional techniques maintain luminal diameter, diminish adhesion
After intestinal resection, the continuity of the intestinal tract formation, and allow for rapid primary healing of the intestinal
can be reconstructed using three basic anastomotic techniques: anastomosis. Some eversion commonly occurs with both these
end-to-end, side-to-side, and end-to-side. When hand suturing appositional techniques, resulting in adhesions and some altered
is used, the end-to-end intestinal anastomosis is the easiest healing.28 The Gambee suture pattern helps eliminate the slight
and quickest technique to perform and results in a more physi- eversion caused by the simple appositional suture patterns
ologic reconstruction. Side-to-side and end-to-side anastomosis (Figure 20-32C).
of the intestine have also been incriminated with formation of
blind pouches where bacterial overgrowth and resulting malab- Various suture materials are used successfully for intestinal
sorption can occur. anastomosis, including monofilament and braided sutures of
absorbable and nonabsorbable sutures. The monofilament
When a disparity of luminal diameters is present, especially absorbable sutures polydioxanone, polyglyconate, and poligle-
as seen with ileocolic anastomoses, several techniques are caprone 25 are closest to the ideal suture material available
available to aid in end-to-end anastomoses. A funneled closure for intestinal anastomosis today. Nonabsorbable monofilament
is the simplest anastomosis if minor disparities of luminal suture material such as nylon or polypropylene may be useful
diameters exist. Sutures are placed equidistant around the in patients that are expected to have delayed tissue healing.
circumference of the lumen ends. This results in stretching of The braided absorbable sutures polyglycolic acid and polyg-
the smaller luminal opening and constricts the larger luminal lactin 910 are absorbed in a relatively short period of time. These
opening (Figure 20-31A). With larger luminal disparities, the sutures have a constant absorption rate which is not affected
smaller diameter intestine can be cut at an angle, with more by infection, so infected suture tracts and granulomas are of
tissue removed from the antimesenteric border (Figure 20-31B). little concern. The biggest problem with the absorbable braided
If a luminal disparity still exists, the antimesenteric border of suture is the tissue trauma (drag or chatter) as they are pulled
the smaller-diameter intestine can be further incised 1 to 2 cm. through tissue. The surface characteristics of braided sutures
Two triangular flaps of intestinal wall can then be cut off each have been shown by electron microscopy to increase trauma to
side of the incision, leaving an ovoid stoma that can be anasto- the tissue they have been pulled through, as opposed to smooth
mosed to the larger-diameter intestine (Figure 20-31C). Finally, if surfaced monofilament suture material.31 In small animal colonic
the smaller-diameter intestinal lumen cannot be opened widely surgery, a size 3-0 to 4-0 suture should have sufficient tensile
enough, the larger-diameter intestine can be partially sutured strength to hold intestinal tissue.
closed until the luminal diameters are equal (Figure 20-31D).
A swaged-on reverse cutting or taper-cut suture needle is
Two-layer anastomotic closures of the colon are no longer recommended for colonic surgery. These suture needles facil-
advocated. Several studies have demonstrated there is no itate penetration of the intestine’s tough submucosa with the
increase in intestinal dehiscence and actually an increased least effort and tissue trauma. Taper-point or narrow-taper
healing rate, using a single-layer closure versusa two-layer needles have been suggested by some surgeons, because less
closure.26,27 In fact, two-layer anastomotic closures have been intestinal leakage occurs around the suture tract. The increased
demonstrated to have significantly greater incidences of dehis- trauma of passing the taper needle through the submucosa must
cence and stricture formation in the rectum because of avascular be balanced with this minor benefit.
necrosis of the tissue incorporated in the inner suture pattern.26
Leakage at the anastomosis site is not a problem if the omentum The number of sutures placed to form an anastomosis should
is healthy and intact and the patient is not hypoproteinemic. A be the minimum needed to prevent leakage of the anastomosis.
fibrin seal will form at the anastomosis site within about 3 hours Most intestinal anastomosis techniques describe placing
in most patients.28 sutures 2 to 4 mm from the cut serosal surface and 3 to 4 mm
apart. This averages to approximately 12 to 16 simple interrupted
Numerous intestinal anastomosis studies have been performed sutures evenly spaced around the anastomosis. The first suture
comparing simple continuous, simple interrupted, inverting,
Intestines 297
Figure 20-31. Anastomosis of dissimilar sized lumens. See text for details. A. Funneled closure. B. Oblique transection of the smaller lumen. C.
Spatulated closure. D. Partial over-sew.
298 Soft Tissue
is normally placed at the mesenteric border because this is the hand-sutured inverting anastomosis, that is, luminal strictures.
most difficult to see, and this area has the highest incidence of The circular stapler is a technically demanding stapler to use.
leakage and dehiscence (Figure 20-33A). The second suture is Improper usage of the stapler, or poor surgical technique, may
normally placed at the antimesenteric border, with the remaining result in anastomotic stricture or dehiscence. When performed
sutures filling in the area between the first two sutures (Figure by an experienced surgeon, the stapled anastomosis line has
20-33B). The anastomosis can be tested by filling the segment been demonstrated to leak less, to be better aligned, and to heal
of intestine with saline under slight pressure, or milking luminal better than single-layer hand-sutured anastomoses.32 Ordinary
contents across the anastomosis and looking for leaks. Any skin staplers have also been found to provide safe anasto-
anastomosis will leak if too much pressure is applied. Too moses.33 Skin staplers are especially helpful in repairing multiple
many sutures decrease anastomosis healing by interfering with intestinal perforation caused by gunshot wounds. Various other
blood supply to the intestinal edges. Some authors recommend sutureless intestinal anastomosis techniques have been studied
wrapping or even suturing the omentum around the anasto- through the years, from cyanoacrylate adhesives and fibrin glue,
mosis site. This is normally not necessary because the omentum to laser welding and non-absorbable and absorbable anasto-
naturally moves to cover any leaks in an intestinal anastomosis. mosis rings. For various reasons anastomosis techniques other
than sutures and staples have not met with wide acceptance.
Surgical stapling is another method of intestinal anastomosis
that has become increasingly popular. The device commonly Colonic Healing
used in colonic resection and anastomosis is the circular stapler
manufactured by Ethicon (Proximate ILS, Ethicon, Inc., Somer- The colon follows the same stages of healing as skin and other
ville, NJ) or United States Surgical (CEEA, United States Surgical soft tissue: inflammation, debridement, repair, and maturation.34
Corp., Norwalk, CT). The circular stapler inverts the intes- A unique property of colonic healing, however, involves the
tinal ends and places two circumferential rows of staggered balance of collagen synthesis and degradation. During the first
B-shaped sutures. The device then cuts out a donut-shaped 3 to 5 days after wounding, collagen synthesis is competing
section of the inverted tissue from the ends of the intestine being with collagenolysis.34-36 This is important, because the collagen
joined. The circular stapler can be inserted through the anus or content of a wound has been directly correlated with wound
through an access incision in the intestine. A modified Furness strength.36 There is an especially high turnover rate of collagen
clamp, or purse string stapler, is used to place a purse string in the wounded colon.34-37 Earlier work suggests that as much as
suture around the ends of the intestinal segments to be joined. 40% of the rat colon’s original collagen content, throughout the
One intestinal end is then slipped over the cartridge end, and the entire colon, is lost to collagenolysis during the first 4 to 6 days
other intestinal segment is placed over the anvil. The purse string after wounding.37 However, early studies have over emphasized
sutures are then tied to the movable central shaft between the the drop in collagen content in colonic wounds. With the use of
cartridge head and anvil. The shaft is shortened, compressing more advanced techniques in measuring the collagen content of a
the cartridge to the anvil with the intestinal ends in between. wound, researchers have found that the drop in collagen content
The stapler is then fired, forming the anastomosis and cutting out is not as dramatic as originally thought.38 Rapid gain occurs in
the purse string along with the tissue in the middle of the lumen colonic tensile strength between the third and seventh days after
(Figure 20-34). The circular stapler forms a true inverting anasto- wounding.38 Local factors in the colon can, however, shift a wound
mosis. Occasionally, the result is the same problem caused by a towards increased collagen lysis. Traumatic handling of colonic
Intestines 299
Figure 20-33. Technique for colonic anastomosis. A. The two colonic segments are held together with the aid of the atraumatic forceps as a mes-
enteric and then antimesenteric suture is placed to start the anastomosis. These first 2 sutures can be used as stay sutures to handle the bowel.
B. The anastomosis is completed with a single layer appositional suture pattern filling in the sutures between the stay sutures. The mesentery is
closed with a simple continuous suture pattern.
300 Soft Tissue
Figure 20-34. Distal colorectal anastomosis with a circular stapler. See text for details. A. A modified Furness clamp is used to place a purse string
suture on the aboral intestinal segment (top of figure). The affected orad segment is isolated and resected. B. A transrectal circular stapler is
placed to the level of the aboral purse string suture. The purse string is then tied around the center anvil of the stapler. C. A purse string suture
around the orad intestinal segment is used to secure the segment to the circular stapler anvil cranial to the aboral segment. D. The circular
stapler is then compressed and fired to form the anastomosis.
Biopsy
Full-thickness biopsy techniques of the colon are performed
similar to those in the small intestine. Luminal contents are
milked from the biopsy site, and the site is isolated with a
moistened laparotomy sponge. A full-thickness longitudinal
incision approximately 1 to 2 cm long is made in the antimes-
enteric colonic wall. A full-thickness segment approximately 2
to 3 mm wide is cut from the side of the incision. Care should be
taken not to crush the sample with forceps. The colonic defect
is then closed transversely using simple interrupted sutures
(Figure 20-35). Large diameter round dermal punches have also
been successfully used for full thickness biopsies. Care must be
taken to only cut through one side of the intestine.
mended unless intraoperative signs of established infection and started on an appropriate therapeutic regimen of antibi-
are present. Inappropriate use of antibiotics can mask signs of otics based on culture and sensitivity testing. The surgeon
peritonitis and can result in superinfections. The author routinely should not hesitate to perform a “second-look operation” if
administers injectable narcotics immediately after endotra- indicated. Patients with peritonitis do not generally stabilize
cheal extubation, with a pain protocol for subsequent doses as without adequate abdominal drainage and, if necessary, repair
needed. Oral or transdermal narcotics and anti-inflamatories of leaking intestine. Open abdominal drainage is one successful
are dispensed for 3 to 5 days after surgery. Clinically, patients method of surgical drainage that also allows serial evaluation
appear to be comfortable within 12 to 24 hours after surgery. of the affected colorectal segment. For recurrent dehiscence,
Patients can be offered water once they are fully awake from or areas of questionable vascularity, the use of omental flaps,
anesthesia. A low-residue diet can be offered within 12 to jejunal patch grafts, and peritoneal muscle flaps have been
24 hours after surgery. This diet should be continued for the reported in the veterinary literature. The use of diversional colos-
first 2 to 3 weeks, after which the animal’s normal diet can be tomies have been reported in the human and equine literature.
gradually introduced. Stool consistency, color, and presence of This technique has been reported in dogs, and may be a viable
blood should be carefully monitored. The patient’s first bowel treatment option in selected small animal cases.41,42
movement commonly contains a large amount of soft to liquid,
dark stool whith whole blood. Stool softeners can be adminis- Fecal incontinence, while not in itself fatal, often results in
tered as necessary to maintain a semifirm consistency. Patients euthanasia of house pets. Fecal incontinence can be divided into
that recover without complications are usually discharged on reservoir and sphincter incontinence.43 Patients with reservoir
the second or third postoperative day. incontinence generally have a conscious, but frequent, need
to defecate. This condition is in contrast to unconscious anal
dribbling of feces found in patients with sphincter incontinence.
Early Complications
Reservoir incontinence can be caused by colorectal irritability,
The most serious early postoperative complications of colorectal decreased rectal capacity or compliance, increased propulsive
surgery are infection and fecal incontinence. In a review of motility, and increased fecal volume. One author suggests that
intestinal surgery in dogs and cats, patients with peritonitis fecal continence will be retained if less than 4 cm of rectum is
had a morality rate of 31%.39 Infection after colorectal surgery resected, or greater than 1.5 cm of distal rectum is retained in the
can result from preoperative trauma, interoperative contami- dog.44 Treatment for surgically induced reservoir incontinence
nation of the abdomen, and intestinal dehiscence. While rare, includes anti-inflammatory drugs, drugs that slow intestinal
rectal perforations caused by pelvic fractures can be success- transit time, dietary manipulation to decrease fecal volume, and
fully treated if diagnosed before significant contamination of surgical techniques that increase rectal capacity. Some animals,
surrounding tissue occurs. In one small study of patients with over time, may develop ileoanal continence. This is where the
rectal perforations caused by pelvic fractures, definitive surgical ileum distends, taking over the reservoir function of the colon
treatment performed within 24 hours of occurrence resulted in no and rectum. The causes of sphincter incontinence are not fully
mortality.5 All patients with delayed diagnosis or treatment had understood, but they include neurologic and muscular trauma
fatal outcomes. Postoperative intestinal dehiscence is one of or disease. Along with the external anal sphincter, studies have
the most common causes of infection. In one study, dehiscence demonstrated muscles of the pelvic girdle, especially the levator
resulted in a mortality rate of 80%.39 This same study found no ani, play an important role in fecal continence. Treatment for
significant difference between small and large intestinal dehis- surgically induced sphincter incontinence may include the same
cence rates with an average of 7%. Many factors can result medical treatments used for reservoir incontinence. Surgical
in colorectal dehiscence, including poor surgical technique, treatments for sphincter incontinence include reconstruction of
traumatic tissue handling, disrupted blood supply, poor suture the pelvic girdle and external anal sphincter, sphincteroplasty,
placement, tension on the anastomosis, improper use of drains, replacing muscles of continence with muscle flaps or synthetic
delayed healing, and inappropriate postoperative care. Discrim- material, and ileal J-pouch anal anastomoses.
inant analysis in one study demonstrated a sensitivity of 91% with
a specificity of 83% using a model where dogs having 2 or more
risk factors (preoperative peritonitis, serum albumin concentra- Late Complications
tions less than or equal to 2.5 g/dL, and intestinal foreign bodies) The most common late complication of colorectal surgery is
resulted in intestinal anastomotic leakage.40 lumenal stricture. Most intestinal anastomoses result in some
degree of lumenal stricture. Single-layer and double-layer
The clinical signs of peritonitis have been described previously. inverting suture patterns have been reported to result in 39%
Diagnostic procedures for postoperative peritonitis and dehis- and 54% lumenal stricture respectively. This was compared with
cence may include abdominocentesis or peritoneal lavage, 4% lumenal stricture using an approximating Gambee pattern
gentle rectal palpation, complete blood count, plain abdominal closure.45 In another study, colonic anastomoses created with a
and pelvic radiographs, and abdominal ultrasonography. Contrast 25 mm circular stapler where found to result in an average 32%
radiographs or proctoscopy are contraindicated and may result decrease in lumenal diameter at the anastomosis.46 Too much
in further abdominal contamination. tissue inversion, suture patterns that restrict the luminal diameter,
tension at the anastomosis, and extra lumenal adhesions can
If signs of peritonitis or intestinal dehiscence are present, the result in excessive lumenal stricture. Diagnosis of colorectal
animal should be supported with appropriate intravenous fluids stricture include clinical signs, rectal or abdominal palpation,
302 Soft Tissue
contrast radiographs, abdominal ultrasound, and proctoscopy. 17. Baum, M.L., Anish, D.S., Chalmers, T.C., et al.: A survey of clinical
Most commonly, colorectal strictures are treated medically with trials of antibiotic prophylaxis in colon surgery: Evidence against further
diet change and stool softeners. Treatment of severe colorectal use of no-treatment controls. N. Eng. J. Med., 305:795-799, 1981.
strictures may require resection and anastomosis of the stric- 18. Onderdonk, A.B., Bartlett, J.G., Louie, T., et al.: Microbial synergy in
tured segment, or, less commonly, mechanical dilation may be experimental intraabdominal abscess. Infect. Immun., 13:22-26, 1976.
attempted. Mechanical dilation can be achieved digitally, by 19. De La Hunt, M.N., Karran, S.J., Chir, M.: Sulbactam/ampicillin
bougienage, or with balloon catheters. Care should be taken not compared with cefoxitin for chemoprophylaxis in elective colorectal
to perforate the intestinal lumen using dilation techniques. surgery. Dis. Colon Rectum, 29:157-159, 1986.
20. Bright, R.M.: Treatment of feline colonic obstruction (megacolon).
A less common long term complication is associated with the use In: Current Techniques in Small Animal Surgery, 3rd Ed.. Edited by M.J.
of nonabsorbable suture material when it is used in a continuous Bojrab. Philadelphia, Lea & Febiger, 263-265, 1990.
suture pattern.47 The nonabsorbable suture can be extruded 21. Rosin, E., Dow, S., Daly, W.R., et al.: Surgical wound infection and use
partially into the intestinal lumen where foreign bodies have of antibiotics. In: Textbook of Small Animal Surgery, 2nd Ed.. Edited by D.
Slatter. Philadelphia, W.B. Saunders Co.84-95, 1993.
been reported to attach causing intestinal obstructions. The use
of absorbable suture is recommended when making intestinal 22. Huss, B.T., Payne, J.T., Wagner-Mann, C.C., et al.: Pharmacokinetic
disposition of cefoxitin in serum and tissue during colorectal surgery in
anastomoses with a continuous suture pattern.
cats. In preparation, 1996.
23. Plumb, D.C.: Veterinary Drug Handbook, 3rd Ed.. White Bear Lake,
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Philadelphia, W.B. Saunders Co., 1979. 25. Allen, S.W., Crowell, W.A.: Ventral Approach to the pelvic canal in
3. Schaller, O., Constantinescue, G.M.: Illustrated Veterinary Anatomical the female dog. Vet. Surg., 20:118-121, 1991.
Nomenclature. 1992. 26. Everett, W.G.: A comparison of one layer and two layer techniques
4. Goldsmid, S.E., Bellenger, C.R., Hopwood, P.R., et al: Colorectal blood for colorectal anastomosis. Br. J. Surg., 62:135-140, 1975.
supply in dogs. Am. J. Vet. Res., 54:1948-1953, 1993. 27. Ballantyne, G.H.: The experimental basis of intestinal suturing: Effect
5. Lewis, D.D., Beale, B.S., Pechman, R.D., et al: Rectal perforations of surgical technique, inflammation, and infection on enteric wound
associated with pelvic fractures and sacroiliac fracture-separations in healing. Dis. Colon Rectum, 27:61-71, 1984.
four dogs. J. Am. Anim. Hosp. Assoc., 28:175-181, 1992. 28. Ellison, G.W.: End-to-end anastomosis in the dog: A comparison of
6. Valerius, K.D., et al: Adenomatous polyps and carcinoma in situ of techniques. Compend. Contin. Ed. Pract. Vet., 3:486-494, 1981.
the canine colon and rectum: 34 cases (1982-1994). J. Am. Anim. Hosp. 29. Poth, E.J., Gold, D.: Intestinal anastomosis: A unique technic. Am. J.
Assoc., 33:156, 1997. Surg., 116:643-647, 1968.
7. Greene, C.E.: Infectious Diseases of the Dog and Cat. Philadelphia, 30. DeHoff, W.D., Nelson, W., Lumb, W.V.: Simple interrupted approxi-
W.B. Saunders Co., 1990. mating technique for intestinal anastomosis. J. Am. Anim. Hosp. Assoc.,
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Pract., 18:1167-1182, 1988. 31. Lord, M.G., Broughton, A.C., Williams, H.T.G.: A morphologic study
9. Boothe, D.M.: Anaerobic infections in small animals. Prob. Vet. Med., on the effect of suturing the submucosa of the large intestine. Surg.
2:330-347, 1990. Gynecol. Obstet., 146:211-216, 1978.
10. Richter, K.P., Cleveland, M.vB.: Comparison of an orally adminis- 32. Stoloff, D., Snider, III T.G., Crawford, M.P., et al.: End-to-end colonic
tered gastrointestinal lavage solution with traditional enema adminis- anastomosis: A comparison of techniques in normal dogs. Vet. Surg.,
tration as preparation for colonoscopy in dogs. J. Am. Vet. Med. Assoc., 13:76-82, 1984.
195:17271731, 1989. 33. Coolman, B.R., Erhart, N., Pijanowsk, G., et al: Comparison of skin
11. Burrows, C.F.: Evaluation of a colonic lavage solution to prepare the staples with sutures for anastomosis of the small intestine in dogs. Vet.
colon of the dog for colonoscopy. J. Am. Vet. Med. Assoc., 195:1719- Surg., 29:293-302, 2000.
1721, 1989. 34. Ravo, B.: Colorectal anastomotic healing and intracolonic bypass
12. Peck, J.J., Fuchs, P.C., Gustafson, M.E.: Antimicrobial prophylaxis in procedure. Surg. Clin. N. Am. S. A., 68:12671294, 1988.
elective colon surgery: Experience of 1,035 operations in a community 35. Ellison, G.W.: Wound healing in the gastrointestinal tract. Sem. Vet.
hospital. Am. J. Surg., 147:633-637, 1984. Med. Surg. S.A., 4:287-293, 1989.
13. Penwick, R.C.: Perioperative antimicrobial chemoprophylaxis in 36. Ballantyne, G.H.: Intestinal suturing: Review of the experimental
gastrointestinal surgery. J. Am. Anim. Hosp. Assoc., 24:133-145, 1988. foundations for traditional doctrines. Dis. Colon Rectum, 26:836-843,
14. Burnakis, T.G.: Surgical antimicrobial prophylaxis: Principles and 1983.
guidelines. Pharmacotherapy., 4:248-271, 1984. 37. Cronin, K., Jackson, D.S., Dunphy, J.E.: Changing bursting strength
15. Condon, R.E., Bartlett, J.G., Greenlee, H., et al.: Efficacy of oral and and collagen content of the healing colon. Surg. Gynecol. Obstet.,
systemic antibiotic prophylaxis in colorectal operations. Arch. Surg., 126:747-753, 1968.
118:496-502, 1983. 38. Irvin, T.T., Hunt, T.K.: Reappraisal of the healing process of anasto-
16. Washington, II J.A., Dearing, W.H., Judd, E.S., et al.: Effect of preop- mosis of the colon. Surg. Gynecol. Obstet., 138:741-746, 1974.
erative antibiotic regimen on development of infection after intestinal 39. Wylie, K.B., Hosgood, G.: Mortality and morbidity of small and large
surgery: Prospective, randomized, double-blind study. Ann. Surg., intestinal surgery in dogs and cats: 74 cases (1980-1992). J. Am. Anim.
180:567-572, 1974. Hosp. Assoc., 30:469-474, 1994.
Intestines 303
40. Ralphs, S.C., Jessen, C.R., Lipowitz, A.J.: Risk factors for leakage
following intestinal anastomosis in dogs and cats: 115 cases (1991-
2000). J. Am. Vet. Med. Assoc., 223:73-77, 2003.
41. Swalec-Tobias, K.M.: Rectal perforation, rectocutaneous fistula
formation, and enterocutaneous fistula formation after pelvic trauma in
a dog. J. Am. Vet. Med. Assoc., 205:1292-1296, 1994.
42. Chandler, J.C., Kudnig, S.T., Monnet, E.: Use of laparoscopic-assisted
jejunostomy for fecal diversion in the management of a rectocutaneous
fistula in a dog. J. Am. Vet. Med. Assoc., 226:746-751, 2005.
43. Guilford, W.G.: Fecal incontinence in dogs and cats. Compend.
Contin. Ed. Pract. Vet., 12:313-326, 1990.
44. Holt, D., Johnston, D.E., Orsher, R., et al.: Clinical use of a dorsal
surgical approachto the rectum. Compend. Contin. Ed. Pract. Vet.,
13:1519-1528, 1991.
45. Hamilton, J.E.: Reappraisal of open intestinal anastomoses, Ann.
Surg., 165:917, 1967.
46. Yamane, T., Takahashi, T., Okuzumi, J., et al.: Anastomotic stricture
with the EEA stapler after colorectal operation in the dog. Surg. Gynecol. Figure 20-36. Placement of anal pursestring suture after reduction of
Obstet., 174:41-45, 1992. rectal prolapse by manipulation.
47. Milovancev, M., Weisman, D.L., Palmisano, M.P.: Foreign body
attachment to polypropylene suture material extruded into the sm all relieving edema, so the prolapse can be reduced more easily. When
intestinal lumen after enteric closure in three dogs. J. Am. Vet. Med. the prolapse has been reduced, an anal pursestring suture is used
Assoc., 225:17131715, 2004. to prevent recurrence. General anesthesia or epidural analgesia
is used in some patients to facilitate reduction of the prolapse and
placement of the anal pursestring suture (Figure 20-36).
Management of Rectal Prolapse
Mark H. Engen After reduction of the prolapse, epidural analgesia prevents
straining for several hours. Periodic rectal application of a local
Although rectal prolapse can occur with any condition that causes anesthetic ointment (1% dibucaine [Nupercainal ointment, Ciba
prolonged tenesmus, it is most common in heavily parasitized Pharmaceutical, Ciba-Geigy, Summit, NJ]) may be done initially
animals that have severe diarrhea and tenesmus. Other causes and after removal of the anal pursestring suture to prevent
of straining resulting in rectal prolapse are dystocia, urolithiasis, further straining. The anal pursestring suture is left in place for
intestinal neoplasms and foreign bodies, prostatic disease, a minimum of 24 to 48 hours, and the animal is given only fluids
perineal hernia, constipation congenital defects, and postop- orally during this time.
erative tenesmus after anal or perineal surgery.
Surgical Treatment
Diagnosis When a rectal prolapse cannot be reduced by manipulation
The diagnosis of rectal prolapse is made by visual observation and the lack of tissue viability contraindicates reduction, rectal
of a tubelike mass, of varying length, protruding from the anus. resection and anastomosis are performed. This procedure is
If rectal prolapse is diagnosed early, the protruding tissue may performed under general anesthesia or epidural analgesia.
be short, and the prolapsed mucosa will appear bright red and The patient is positioned and draped (Figure 20-37A and B). A
nonulcerated. In patients with rectal prolapse of long duration, test tube or a saline-soaked sponge is placed into the lumen of
the protrusion is longer, and the mucosa appears red or black the bowel to prevent fecal contamination. Three stay sutures
and is either ulcerated or necrotic. are placed through the full thickness of both layers of the
prolapse to form a triangle (Figure 20-37C and D). The prolapse
True rectal prolapse must be differentiated from prolapsed is then resected 1 to 2 cm from the anus. The anastomosis is
intussusception of the intestine or colon. These conditions can performed with a single-layer closure using a simple inter-
be differentiated by passing a probe between the anus and the rupted suture pattern (Figure 20-37E). Synthetic absorbable
prolapsed mass. The probe can be passed if an intussusception suture (3-0 or 4-0) is preferred. The sutures are placed through
is present, but it cannot be passed if a rectal prolapse has the full thickness of the incised ends of the bowel. The sutures
occurred. To achieve a permanent cure for rectal prolapse, the must pass through the submucosa to ensure proper holding
underlying cause of tenesmus must be diagnosed and treated. strength. The stay sutures are then removed, and the anasto-
mosis is reduced manually inside the anus.
Nonsurgical Treatment
Treatment to correct a rectal prolapse depends on the viability of When the rectal prolapse cannot be reduced by external
the exposed tissue and the size of the prolapse. A small prolapse manipulation, but the rectal tissue is still viable, a celiotomy
with viable-appearing mucosa usually can be replaced by using is performed, and the prolapse is manually reduced by gentle
a finger or bougie to reposition the bowel. Topical application of traction on the colon (Figure 30-38A). A colopexy is performed
hypertonic sugar solution for 20 to 30 minutes may be helpful in after reduction of the prolapse to prevent recurrence using
304 Soft Tissue
Figure 20-37. Rectal resection and anastomosis to correct prolapse. A. Positioning of patient on a perineal stand. B. Sterile draping of the pro-
lapse. C. Insertion of test tube into rectum and placement of stay sutures. D. Excision of the prolapsed mass. E. Full-thickness anastomosis of the
rectal lumen.
Intestines 305
Figure 20-38. Celiotomy and colopexy for treatment of rectal prolapse. A. Abdominal incision and digital replacement of the prolapsed tissue. B.
Placement of colopexy mattress sutures. C. Six to eight mattress sutures are placed to complete the colopexy.
306 Soft Tissue
synthetic absorbable suture (2-0 or 3-0) (Figure 30-38B and C). The blood supply to the anal sac arises from the caudal hemor-
A colopexy may also be performed in cases of recurrent rectal rodial, perineal and caudal gluteal arteries and veins. The inner-
prolapse that can be reduced by external manipulation. Such a vation to the anal sac and external anal sphincter is via the
colopexy is rarely needed, however, if the cause of straining has pudendal nerve.
been diagnosed and eliminated.
Preoperative Care
Postoperative Care Prior to anal sacculectomy, patients with anal sac impaction or
Topical anesthetic (1% dibucaine) ointment is instilled rectally infection should undergo medical therapy. Failure to resolve any
after correction of any rectal prolapse to prevent further inflammation associated with the anal sac disease prior to surgery
tenesmus. The patient may be fed on the day after the operation. may increase the potential for postoperative complications.
A diet of soft food and a fecal softener (dioctyl sodium sulfos-
uccinate) also may be administered for 1 week postoperatively. Medical therapy consists of expression of the anal sacs and the
Diarrhea should be treated with neomycin, intestinal coating concurrent instillation of an oil-based antibiotic and corticos-
agents, and anticholinergic drugs. Feces should be examined, teroid-containing ointment into the anal sac. Broad spectrum
and antihelminthic agents should be administered, based on antibiotics are utilized in animals with severe infection or absces-
results of fecal examinations for parasitic ova. sation of the anal sac. Warm compresses and hydrotherapy are
applied to the perineum to improve lymphatic drainage, and
In conclusion, once a rectal prolapse has been corrected by cleanse the region. All animals with a suspected neoplasm of
surgical or nonsurgical means, recurrence is rare if the cause of the anal sac should undergo appropriate clinical staging with
the tenesmus has been diagnosed and resolved (e.g., removal of emphasis on determining the potential for local and distant
intestinal parasites by worming). metastasis. Hypercalcemia, if present, should be treated with
appropriate medical therapy prior to the induction of general
anesthesia. Consideration should also be given to the possibility
Suggested Readings of postoperative hypocalcemia.
Aronson L. Rectum and anus. In: Slatter D, ed. Textbook of small animal
Surgery. Philadelphia: Saunders, 2003.
Popovitch CA, Holt D, Bright R. Colopexy as a teatment for rectal Surgical Technique
prolapse in dogs and cats; a retrospective study of 14 cases. Vet Surg Several surgical techniques have been described in the veterinary
1994:23:115. literature for removal of the anal sacs. Surgeries are divided into
open, modified open or closed techniques. The major difference
between the techniques is whether or not the anal sac and its
Anal Sac Disease and Removal duct are incised, thus exposing the lumen. The closed technique
Roy F. Barnes and Sandra Manfra Marretta is described here. It is imperative that a closed anal sacculectomy
be performed for the treatment of apocrine gland anal sac adeno-
carcinoma or any other malignancy of the anal sac or duct.
Introduction
Anal sac disease occurs with an approximate incidence of Regardless of which surgical technique is performed, the
12% in the canine, with small breeds being overrepresented protocol for surgical preparation is similar. The diseased anal sac
compared to large breeds. Cats are infrequently afflicted with is expressed to expel its contents with subsequent instillation
anal sac disorders. Conditions which require anal sacculectomy of a dilute antiseptic, such as chlorhexidine or povidone-iodine
include relief from chronic and recurrent episodes of anal sac solution. Neoplastic conditions of the anal sac may not allow anal
impaction or infection, adjunctive treatment of perianal fistulas sac expression and the instillation of antiseptic solutions. The
and local treatment of apocrine gland anal sac adenocarcinoma patient is placed in a padded perineal stand (Figure 20-39). Proper
and other malignant neoplasms. position on the stand will help prevent circulatory compromise,
neuropraxia and exacerbation of chronic osteoarthritis of the
rear limbs. Several gauze sponges are placed into the patient’s
Anatomy rectum. The perineum is clipped and scrubbed according to
The anal sacs are cutaneous diverticula ventral and lateral to the acceptable standard aseptic techniques. The surgical site is
anus, between the internal and external anal sphincters. Anal draped routinely to protect the surgical wound.
sacs of the dog and cat are composed of large coiled apocrine
glands. In addition, the feline anal sac includes a complex In preparation for a closed anal sacculectomy some surgeons may
series of sebaceous glands. Despite the species difference, all elect to fill the anal sac with a groove director, self-hardening gel
glands will coalesce to form a sac and from the sac, a kerati- or resin, string, umbilical tape, plaster of Paris or dental acrylic
nized epithelial duct arises to carry material to the external to assist in the dissection of the anal sac and associated duct
environment. In the dog, the anal ducts open into the inner (Figure 20-40A). In larger dogs, a #6 Foley urinary catheter can
cutaneous zone of the anus while in the cat, the ducts open into be inserted into the anal sac and the balloon inflated. It should
a pyramidal prominence 2.5 mm lateral to the anus. Regardless be noted that filling of the anal sac with material can only be
of the duct opening, the anal sacs are typically located at the 4 performed in non-neoplastic diseases.
and 8 o’clock positions with reference to the anus proper.
Intestines 307
Based upon the described anatomy, a vertical skin incision equidistant with the skin. Blunt dissection and digital palpation
is made over the anal sac, approximately 3 to 4 cm in length is used to locate the anal sac. Blunt and sharp dissection using
and 5 to 10 mm lateral to the mucocutaneous junction (Figure Steven’s tenotomy scissors, metzenbaum scissors and cotton-
20-40B and Figure 20-41). The subcutaneous tissue is incised tipped applicators can be used to isolate the anal sac and duct
(Figure 20-40C and Figure 20-42). Dissection of the anal sac from
the internal and external anal sphincter can be difficult. The
caudal rectal branch of the pudendal nerve should be avoided.
Hemorrhage can be controlled using judicious use of electro-
cautery, ligatures and direct digital pressure. Once the anal sac
and duct is dissected, the anal duct is ligated close to its termi-
nation at the anus and transected (Figure 20-40D). Alternatively,
the anal duct can be transected at its termination at the anus
(Figure 20-43). The anal mucosa is everted and subsequently
closed using absorbable suture material (Figure 20-44).
Anal sac
A B C
D E
Figure 20-40. Closed technique tor anal sac removal, A. A groove director is used to identify the anal sac. The anal sac can be filled to delineate
it from surrounding tissues. B. An incision is made over the anal sac. C. The anal sac is dissected out from surrounding tissues, D. The duct is
ligated, and the sac is removed, E. Routine closure. (Courtesy of Dr. Pamela Whiting.)
308 Soft Tissue
Postoperative Care
An Elizabethan collar is recommended to prevent self-mutilation
of the surgical site. Broad spectrum antibiotics should be admin-
istered immediately preoperatively and for the next 7 to 10 days
due to the classification and location of the surgical wound. Cold
compresses should be applied three to four times daily to the
wound for the first 36 to 48 hours. After discontinuation of cold
compresses, warm compresses should be applied two to three
times daily until suture removal. Alternatively, hydrotherapy can
be administered during the period of warm compresses. Hydro-
therapy will not only help with any post-operative swelling, but
will help keep the surgical site clean. Skin sutures, if present, are
Figure 20-41. Initial skin incision, just lateral to the anus. removed in 10 to 14 days.
Figure 20-42. Dissection of the anal duct. Forceps are pointing to the
anal duct. Note the presence of retractors in the surgical field. Figure 20-44. Apposition of the anal mucosa after transection of the
anal duct.
Figure 20-43. Forceps are depicting the opening of the anal duct at the Figure 20-45. Apposed skin and anal mucosa. Note the short sutures
level of the inner cutaneous zone. along both apposed incisions.
Intestines 309
agonist opioid, such as hydromorphone or oxymorphone, should of fistula formation is incomplete removal of the anal sac or
be utilized for the first 24 to 36 hours. If medically appropriate, duct. Treatment of the fistula includes surgical exploration of
a non-steroidal anti-inflammatory drug, such as carprofen or the draining tract and subsequent removal of any remaining
etodolac, can be administered for additional analgesia. A high- secretory tissue. Anal stricture is an infrequent complication of
fiber diet or stool softeners may be utilized to provide a soft, but closed anal sacculectomy due to the surgical approach. Clini-
formed stool. Either therapy can be useful in the post-operative cally, anal strictures will appear weeks to months after surgery
period to help limit constipation associated with the adminis- and clinical signs usually reveals tenesmus. Treatment of anal
tration of opioids or to help offset any potential tenesmus. strictures includes stool softeners, balloon dilation, and if severe,
surgical resection of the stricture. Local disease reoccurrence
Preoperative conditions, such as hypercalcemia, should be may occur in the case of anal sac neoplasms. Ancillary therapy,
monitored closely. If the hypercalcemia is secondary to a such as radiation therapy for local disease or chemotherapy for
malignant neoplasm, such as an apocrine gland anal sac adeno- distant metastasis may be necessary for neoplasms. Complete
carcinoma, the hypercalcemia should resolve if there is no staging of the neoplasm coupled with consultation with a medical
local or distant tumor burden. However, if the hypercalcemia oncologist is recommended.
persists in the post-operative period, then either the tumor
has metastasized or there is another disease process present.
If the persistent hypercalcemia is secondary to a malignant
Selected Readings
neoplasm, consultation with a medical oncologist is recom- Aronson L. Rectum and anus. In: Slatter DH, ed. Textbook of small
mended. Regardless of the presence of hypercalcemia, any animal surgery. 3rd ed. Philadelphia: WB Saunders, 2002: 682-708.
patient suffering from a neoplasm of the anal sac or duct should Lipowitz A. Perineal Surgery. In: Lipowitz AJ, Caywood DD, Newton CD,
be evaluated by a medical oncologist to determine if ancillary et al, eds. Complications in small animal surgery. Baltimore: Williams &
therapy is warranted. Wilkens, 1996: 527-540.
Van Sluijis FJ. Anal sacculectomy. In: van Sluijis FJ, ed. Atlas of small
animal surgery. New York: Churchill Livingstone, 1992: 114-115.
Postoperative Complications Hill LN, Smeak D. Open versus closed bilateral anal sacculectomy
Short-term complications (< 14 days) after a closed anal for treatment of non-neoplastic anal sac disease in dogs: 95 cases
sacculectomy include drainage, seroma formation, inflammation, (1969-1994). JAVMA 2002; 221: 662-665.
hemorrhage, infection, and tenesmus or dyschezia. Drainage Van Duijkeren E. Disease conditions of canine anal sacs. JSAP 1995;
and seroma can be minimized by meticulous and delicate tissue 36: 12-16.
handling and apposition of incised tissues. Inflammation can
be minimized by avoidance of traumatic tissue handling, desic-
cation of exposed tissues, judicious use of electrocautery and Nonsurgical Management of
proper identification of anatomy. Hemorrhage can be avoided if
subcutaneous, muscular and parenchymal vessels are ligated Perianal Fistulae
using appropriate techniques and the use of electrocautery. If Dean Fillipowicz
mild postoperative hemorrhage is present, a cold compress and
sedation with acepromazine may provide relief. If hemorrhage is
severe, immediate exploration of the surgical wound is indicated. Introduction
Infection rates associated with a closed anal sacculectomy are Dogs afflicted with anal furunculosis (perianal fistula, fistulae or
low. However, if infection occurs, it will become apparent within fistulas; perianal hidradenitis) suffer from painful, malodorous
the first 48 to 72 hours after surgery. The treatment of infection and suppurative ulceration and sinus tract formation of the skin
consists of removing the ventral sutures in the surgical wound to and subcutaneous tissues of the perineum. The etiology of this
allow drainage and the application of dilute antiseptic solutions chronic and progressive inflammatory condition is unknown, but
(chlorhexidine or povidone-iodine). Hydrotherapy performed an immune mediated cause is likely. Previously regarded as a
twice daily and the administration of broad spectrum antibiotics surgical disease, medical management is now the primary mode
(based on proper pharmacokinetics and suspected pathogen) of treatment, with surgery reserved for recalcitrant cases and
pending results of bacterial culture and sensitivity testing is animals whose lesions are no longer responsive to immuno-
recommended. suppressive therapy. Goals of therapy include eliminating
discomfort, ameliorating other associated clinical signs, and
Long-term complications of a closed anal sacculectomy can preventing recurrence.
include fecal incontinence, chronic fistula formation, anal
stricture and reoccurrence of local disease. The first three
complications can be minimized with careful intraoperative Signalment and Clinical Signs
technique and attention to anatomical structures. Fecal inconti- German Shepherd dogs are most commonly affected making
nence may result from excessive surgical trauma to the external up 89%,1 85%,2 81%,3 79%,4 96%,5 75%,6 and 100%7 of recent
anal sphincter (> 50% of its diameter) or direct damage to the studies. Other breeds that have been reported include Labrador
caudal rectal branch of the pudendal nerve. Treatment of fecal Retrievers, Irish Setters, Old English Sheep Dogs, Border collies,
incontinence includes dietary changes and the potential for Bulldogs, Bouvier des Flandres, beagles, various spaniels, and
muscle pedicle transpositions. Chronic fistula formation usually mixed breeds.5,8-13 The mean age of presentation is between four
appears a few weeks to months after surgery. The cause and seven years old, but reports exist of patients aged between
310 Soft Tissue
one and fourteen years old.12,13 A sex predisposition has not diagnoses. Severe local pain makes a thorough examination of
been substantiated; reports exist of increased male preva- the perineum difficult in affected animals and can seldom be done
lence,4,7,14-18 increased female prevalence,19 and an equal sex without general anesthesia. Prior to anesthesia, it is important to
distribution.3,6,20,21 assess anal tone, as incontinence can be seen with advanced
disease and as a post-operative complication. Once the patient
Clinical signs most commonly reported include tenesmus, pain, is anesthetized, the perineal area should be liberally clipped to
dyschezia, excessive licking of the perineum, and a malodorous, aid in assessment and subsequent cleaning of diseased tissue.
purulent discharge, but self-mutilation, hematochezia, fecal Tracts should be gently probed with a sterile, blunt instrument
incontinence, constipation or diarrhea, flatulence, and weight to assess size, depth, and possible communication with nearby
loss may also be seen.1-8,10,15,21 structures. At least one of the anal sacs is often secondarily
involved or may become so before a response to therapy is seen.
Patients present with varying degrees of ulceration and sinus Both structures should be evaluated for involvement, rupture, or
tract formation radiating around the anus. In mild cases, the abscessation. Palpation, expression of the sacs if un-involved,
affected region may encompass an arc of 90° or less with and flushing with sterile saline to identify previously unobserved
focal, erythematous, superficial lesions. More advanced cases tracts is important. If occluded, the anal sac ducts should first
may have diffuse, deep, epithelial lined, communicating tracts be cannulated with a lacrimal duct cannula or small urinary
extending 360° circumferentially with possible involvement catheter. Fine needle aspiration of grossly enlarged anal sacs
of the anal sacs. True anocutaneous and rectocutaneous may help identify abscessation or neoplasia.
fistulae have been reported. Fortunately, they are uncommon
in the canine species, with most dogs being presented with A thorough rectal examination is necessary. The concurrent
moderate to severe ulceration and multiple sinuses.5,10-13 Many presence of a perineal hernia, or rectal dilation, or sacculation
dogs have advanced forms of the disease before initial presen- affects prognosis for both disease processes. Gently probing
tation, possibly because the wide tail base and dense, thick hair the fistulous tracts while performing the rectal examination may
coverage of many afflicted dogs prevents frequent observation identify rectocutaneous fistulae. Care should be taken to identify
of affected areas by owners. thickening of the external anal sphincter and rectal and anocu-
taneous tissues, particularly in those patients suffering from
tenesmus. Anorectal stenosis or stricture caused by chronic
Pathogenesis disease will also adversely affect prognosis.
Though the etiology of anal furunculosis is uncertain, several
factors have been proposed as contributing to development of Superficial cytology and culture gives little useful information,
the disease: low tail carriage, broad tail base, and dense tail fur though culture and sensitivity of deep sinus tracts will aid in
resulting in increased perianal humidity and contamination, anal antibiotic selection for those cases responsive to medical
sacculitis with concomitant spread of infection, anal crypt or management. Sinus tract biopsies can give histological support
gland fecalith impaction with subsequent abscessation, perianal of a diagnosis of anal furunculosis, but more importantly, may
trauma, and foreign body reaction. Though it is likely that these identify neoplastic disease.
conditions may exacerbate inflammation and lesion formation,
no strong evidence exists supporting any of these as a primary An association has been suggested between colitis and perianal
cause of the disease.2,9,10,13 Involvement of the anal sacs and fistulae.16,20 It is therefore further recommended to obtain colonic
subsequent infection, abscessation, and ulceration is common biopsies as the two disease entities present similarly, and
in advanced cases, but appears to be a secondary development treatment of fistulae is complicated by concurrent large bowel
rather than a primary cause of the disease.9,12 A correlation with disease.
hypothyroidism has been proposed, but remains unsubstan-
tiated.17 In the same study, no immunologic abnormalities were Additional diagnostics may include complete blood count,
found between affected and normal dogs.17 chemistry panel, and urinalysis for overall health assessment,
fecal floatation to help identify endoparasites, and thoracic radio-
A failure in immune modulation is accepted to be the most likely graphs if neoplasia or fungal infection is suspected as contrib-
cause of perianal fistulae, and evidence exists supporting this uting to the perianal ulceration. Other perineal disease entities to
hypothesis. Most notably, anal furunculosis and Crohn’s disease rule out include anal sac abscessation, fungal infection, pythiosis,
in humans have similar clinical appearances and demonstrate lagenidiosis, perianal adenoma, apocrine gland adenocarcinoma,
similar positive responses to immunomodulatory medica- squamous cell carcinoma, caustic injury, and trauma.10,25
tions.2-7,10,12,15,19,20,22 In addition, it has been shown that mRNA
expression of those cyctokines associated with TH-1 T-cells is
heightened in perianal tissue taken from dogs with anal furun- Medical Management-Systemic
culosis.23 However, a simple immunological defect, at least in It is important for owners to be aware that therapy is directed
German Shepherds, has not been found.24 at control of the disease and its clinical signs and that a cure
is seldom attained. In addition, owners must be well informed
about the potential complications of management and should be
Diagnosis and Evaluation committed to long-term aftercare.
The diagnosis of anal furunculosis is based on signalment, history,
physical examination findings, and exclusion of differential
Intestines 311
Previously an exclusively surgically-managed disease, medical and can be used concurrently with systemic antibiotics. Lesion
management is now the cornerstone of therapy for anal furuncu- resolution negates the need for continued antibiotic therapy.
losis. The goals of treatment are initially to eliminate discomfort Hygiene and antibiotic therapy alone are unsuccessful in the
and pain followed by reduction in lesion volume. Long term management of this disease, and are considered to be palliative
therapy is directed at prevention of disease recurrence. Four at best.9
components make up medical management: regional hygiene,
elimination/reduction of secondary infection, immunomodulatory Immunomodulatory therapy is the primary and most important
therapy, and dietary modification. Surgery is indicated in recal- aspect of the medical management of anal furunculosis, and
citrant cases and in those cases where no further improvement several regimens are available. As discussed later, systemic
from medical management is noted. However, medical therapy cyclosporine coupled with ketoconazole followed by topical
should be be attempted first to reduce lesion severity; subse- tacrolimus is the currently preferred method of management.
quent surgery may then be associated with fewer complications However, reasonable success has been attained with cheaper,
such as incontinence, stricture, and disease recurrence.13,19 more commonplace immunosuppressives such as glucocorti-
coids, azathioprine, and metronidazole. Table (20-1) summarizes
As therapy is initiated, attention to perianal hygiene should drug regimens recently as offering some success with less
only be attempted with the aid of chemical restraint. As lesions expensive drug combinations.
and pain diminish, the patient may learn to tolerate disease
care without sedation. Frequent clipping is initially necessary The advantages of glucocorticoid administration are ease and
to remove debris and allow cleaning and monitoring of the low cost. Unfortunately, side effects with this medication can be
affected area. Later in the course of management, the area severe and include polydypsia, polyuria, polyphagia, decreased
should remain clipped and clean to prevent recurrence and resistance to infection, slower wound healing, muscle wasting,
allow application of topical medication. and insulin antagonism. In addition, glucocorticoid administration
for perianal fistulae may show no, poor, or transient response.
Systemic antibiotics are indicated as most cases have some Advantages of the metronidazole/azathioprine regimen include
degree of secondary infection. Bacterial culture and sensitivity low cost, absence of untoward side effects, and reduced risk
results should dictate the antibiotic of choice. However while of post-operative complications previously reported.19 Though
results are pending, empiric therapy with an antibiotic that side effects were not seen in the cases of this report, this
affords gram negative and anaerobic coverage such as amoxi- drug regimen is not innocuous. Azathioprine suppresses both
cillin-clavulanic acid is appropriate. Systemic therapy should humoral and cell mediated immunity and can result in gastro-
continue for five days past the disappearance of gross evidence intestinal upset, pancreatitis, hepatotoxicity, and bone marrow
of infection. Topical antibiotic therapy such as mupirocin suppression.26 Metronidazole is an antiprotozoal with immuno-
ointment (Bactoderm, Pfizer) once every twelve to twenty-four modulatory effects but can result in vomiting, anorexia, hepato-
hours can be used once patient compliance allows application. toxicity, and central vestibular signs.27
This can be used to prevent and reduce bacterial colonization,
16 27 GS w/PF Pred: 2 mg/kg SID x 2 wks→1 mg/ Complete in 1/3 11/16 regardless Caution as to GC
& colitis kg SID x 4 wks→1 mg/kg EOD x 8-16 Partial in 1/3 of lesion usage
wks resolution
10 Pred: 3-4 mg/kg SID-BID x 3-6 wks Reasonable GCs tapered over
PLUS success in weeks to months.
Azathioprine: 1.5-2.2 mg/kg SID x reducing lesion Azathioprine
2-4 wks size and associated tapered to EOD x 4
pain and inflam- wks.
OR
mation though data Caution as to
Metronidazole: 10-15 mg/kg BID is lacking GC and Azath or
Metronid usage
19 5 dogs Metronidazole: 400 mg/dog SID Significant Significant Sx at end of
AND improvement improvement in regimen followed
Azathioprine: 50 mg/dog SID with no additional all w/in 2 weeks by addl. 3-6 weeks
progress after 4-6 immunomodu-
wks latories. 5/5 dz
free 7-10 months
post-op
312 Soft Tissue
The similarities in clinical appearance between Crohn’s disease case reports in the veterinary literature (one cat after renal trans-
in humans and canine anal furunculosis led to the discovery that plant surgery and one dog with anal furunculosis) that suggest
encouraging treatment results can be achieved when affected lymphomagenesis may be associated with cyclosporine adminis-
dogs are treated with the same immunomodulating drug used tration.30 There is no evidence that administration of cyclosporine
in human medicine.2-7,10,14,15,22,28 Cyclosporine acts by reversible in dogs, or in humans with dermatologic conditions, has been
inhibition of calcineurin, an enzyme normally partially responsible associated with an increased risk of infection.22
for cytokine synthesis, among other functions. The end result
is inhibition of cell mediated immunity and T-cell (T-helper and Unfortunately, cyclosporine is expensive, particularly when
T-cytotoxic) activation and proliferation.10,22 The microemulsion treating the large breeds affected by anal furunculosis. By inhib-
(ME) formulation of this drug (Atopica, Novartis) is given because iting the cytochrome P450 system, ketoconazole has been used
of improved bioavailability and decreased inter-individual serum to decrease the hepatic clearance of cyclosporine resulting in
levels. Because of delayed absorption when given with food (even increased serum levels. Lesser amounts of cyclosporine are then
with the ME formulation), it is recommended that cyclosporine be needed at a significant cost advantage to the owner. Increases in
administered two hours before or after a meal.22 serum cyclosporine levels are proportional to ketoconazole doses
when the latter is dosed between two and twelve mg/kg.31 Unfor-
Several reports have shown the benefits of the sole use of tunately, the amount of increase in cyclosporine blood concen-
cyclosporine in the treatment of anal furunculosis, and several tration due to hepatic inhibition from ketoconazole is individually
conclusions have been reached: faster remission and higher variable, necessitating dose adjustments for most patients. This
recovery rates are seen with higher dosages, clinical signs may is an indication for measuring cyclosporine serum trough levels.
be more likely to return after cessation of high dose treatment, Trough levels can be evaluated by high pressure liquid chroma-
and longer administration (thirteen weeks) decreases the rate of tography (HPLC), fluorescent polarization immunoassay (FPIA) or
relapse.2,4-7,11,14,15,29 Unfortunately, a definitive dosing regimen has radioimmunoassay (RIA). These last two assays, though faster
not been found. A recent review recommends initially treating at and cheaper, use antibodies that cross react with cyclosporine
4 to 8 mg/kg PO q 24h for eight to sixteen weeks until a marked metabolites, and can overestimate the cyclosporine blood
resolution of clinical signs has occurred. At that point, it has been concentration. In fact, cyclosporine blood concentrations when
suggested to decrease the dose by 20 to-40% or decrease the measured with FPIA are nearly twice those measured with HPLC.
frequency of administration to every forty-eight hours with further This latter assay is more expensive and less widely available, but
tapering based on clinical response and lack of recurrence.10 more accurate.22
Though encouraging results have been obtained with the use of A previous review suggests an initial starting dose of ketocon-
cyclosporine, difficulties still exist as to the appropriate dosage, azole at 5-10 mg/kg PO q 24h in conjunction with a moderate
schedule, and duration of therapy. Initial dose schedules were starting dose of cyclosporine at 5mg/kg PO q 24h.10 With resolution
extrapolated from human medicine where cyclosporine was used of lesions and other clinical signs, the cyclosporine dose is
to prevent renal allograft rejection. Because of the high doses tapered starting six to ten weeks after initiation of therapy. Higher
required to prevent organ rejection and the relatively small margin doses may be required in some recalcitrant cases or in more
of safety this drug has in humans (hypertension and nephrotoxicity severe, chronic cases. The goal of therapy is the lowest dose and
are not uncommon side effects), dosing adjustments in transplant frequency of both drugs that will prevent recurrence of lesions or
patients are necessary and are made based on serum trough levels. clinical signs. Some animals may only require topical medication
The treatment of canine anal furunculosis requires lower doses (described below) as maintenance therapy, while others will
of cyclosporine than is required to prevent organ rejection. In require life long cyclosporine treatment with or without topical
addition, recent studies in dogs with anal furunculosis treated with therapy. Trough cyclosporine levels, measured ideally with HPLC,
cyclosporine failed to find a relationship between trough concen- should be assessed if the patient is not or is no longer responding
trations and treatment efficacy.5,7 Therefore, though monitoring to treatment. Dosing should be increased in these cases if trough
trough levels in transplant patients assists in fine tuning those levels below 400 ng/ml are found. Serum trough levels to monitor
treatment regimens, the practice provides no additional infor- dose reductions are also necessary when signs of cyclosporine
mation in the treatment of most cases of anal furunculosis in which toxicosis are noted.
a favorable clinical response is seen to cyclosporine alone.
Because large variations (10 to 60%)4,7 in blood cyclosporine
concentrations exist between dogs on the same dose of
Serious side effects are rare with cyclosporine administration in
cyclosporine given both cyclosporine and ketoconazole for the
dogs, but long term studies are needed to assess its full effects.22
treatment of anal furunculosis, definitive dosing regimens are
Side effects noted in recent clinical reports include hair shedding
unavailable, and the above is given as a starting point. However,
that may be followed by increased hair growth, gastrointes-
encouraging results have been reported with the use of this drug
tinal effects (vomiting and diarrhea, inappetance), lethary, and
combination (Table 20-2).
lameness.2-5,15 The most common side effects, hypertrichosis
and vomitting/diarrhea, were mild and resolved spontane-
Side effects noted in clinical reports of combination therapy
ously during treatment or after cyclosporine administration had
included vomiting, diarrhea, inappetance, weight loss, hypertri-
stopped. Gingival hyperplasia and papillomatosis have also been
chiasis, hypoalbuminemia, lameness, and gingival hyperplasia.
reported.28 Though there is an increased risk in humans of devel-
Most effects were transient during initial treatment and resolved
oping lymphoma after cyclosporine usage, there are only two
spontaneously or with minimal intervention. Those side effects
Intestines 313
TABLE 20-2. Results using Cyclosporinte and Ketoconazole for Treatment of Perianal Fistulae
Ref # Sample Size Medication Regimen Response Long Term Notes
7 16 CSA 1mg/kg BID 50% sinus depth 93% in full remission @ 14 Dosages decreased to
Ketoconazole 10mg/kg reduction and area weeks maintain 200 ng/ml trough
SID of ulceration w/in 50% disease free @ 1 levels by HPLC. Suggested
2 weeks year that starting CSA @ 0.5 mg/
kg BID may allow fewer
dosage adjustments but still
therapeutic serum levels
and steady maintenance
level
6 12 8K9: CSA 2.5 mg/kg BID 100% full Full remission in 8/12. CSA dosages adjusted to
Keto 8 mg/kg SID resolution of 5/8 suffered recurrence maintain 400-600 ng/mL
4K9: CSA 4 mg/kg SID clinical signs in 9 @ mean of 12.4 weeks (checked monthly). B/c
weeks past cessation of tx. of keto involvement, CSA
Keto 8 mg/kg SID
5/5 complete resolution dose reductions of 50-75%
of clinical signs with appreciated resulting in
same tx. Significant savings of 36-71%. Those
improvement in severity w/ relapse more likely to
of lesions in 4/12 but have suffered clinical signs
persistent lesions longer hinting @ more
severe dysregulation of
immune system.
4 19 CSA @ 0.5, 0.75, 1, or 2 Resolution in all 12/19 remained in Radioimmune assays
mg/kg within 3-10 weeks remission. 4/4 of those weekly w/adjustments to
Keto 5.3-8.9 mg/kg BID with recurrence achieved achieve 400-600 ng/mL.
full resolution after 2 nd Dogs on higher 2 dosages
course of therapy. had trough levels persis-
tently above target range
indicating that dosages of
0.5-0.75 mg/kg BID may be
sufficient. Savings of up to
70% realized compared to
earlier study.
which were more recalcitrant resolved with cessation or reduction mild to moderate cases of anal furunculosis or as maintenance
of administration and were not intolerable.4,6,7,32 Hepatotoxicity is therapy after cyclosporine induced remission of disease.
a suggested side effect of ketoconazole and may be idiosyncratic
or dose dependent, though none of the previous reports describe There is little in the literature that describes the concurrent use
this complication.33 of both calcineurin inhibitors, but combination therapy should
have a role in treatment. One group has reported good results in
Medical Management-Topical “normal” cases of anal furunculosis with twice daily application
of tacrolimus that was started once tapering of cyclosporine
In 2000, Misseghers et al.reported on once to twice daily topical
has begun.10 Anecdotally, the tacrolimus seems to speed
application of tacrolimus (0.1%) to treat canine anal furunculosis
cyclosporine tapering. This paper suggests that some patients
in ten dogs.34 Like cyclosporine, this drug is used to inhibit T-cell
can be weaned entirely off systemic cyclosporine/ketoconazole
activation through inhibition of calcineurin. Tacrolimus is ten to
and be managed with tacrolimus applied topically every 24 to-72
one hundred times more potent than cyclosporine, is absorbed
hours. In very mild cases of disease, tacrolimus alone may be
topically better than cyclosporine, and doesn’t require systemic
sufficient. Whether topical medication may be required for life
levels to be effective. Side effects are typically reported at the
long management10 or should only be continued for four weeks
same frequency as those of cyclosporine. However none of
past resolution of clinical signs34 in these cases is uncertain. If
the animals described in the initial study showed untoward
tacrolimus is not used because of client or patient concerns, the
side effects. Five of the ten dogs (50%) achieved full remission
lowest dose and frequency of cyclosporine and ketoconazole (or
of between one and eight months duration after cessation of
other immunomodulator combination) that controls clinical signs
treatment, and nine of ten (90%) dogs showed complete resolution
is recommended.
of clinical signs with at least a 50% reduction in lesion volume.
This report suggested that once daily administration of tacrolimus
should be considered a low cost alternative to cyclosporine in
314 Soft Tissue
cyclosporine dose in healthy dogs. Veterinary Surgery, 1998. 27(1): p. the fistulas, or if extensive fibrosis has occurred, then incision or
64-68. excision of the areas of fibrosis is usually necessary for release
33. Plumb, D.C., Veterinary Drug Handbook. 4 ed, ed. D.C. Plumb. 2002, of the constriction and for relief of painful defecation.
Ames: Iowa State University Press. 465-470.
34. Misseghers, B.S., A.G. Binnington, and K.A. Mathews, Clinical
observations of the treatment of canine perianal fistulas with topical Preoperative Medical Treatment
tacrolimus in 10 dogs. Can Vet J, 2000. 41(8): p. 623-7. For recurrent fistulas I prefer to treat the patient for two to
four weeks preoperatively with 2 to 3 mg/kg of cyclosporine
(Neoral, Novartis NA, East Hanover, NJ) PO every 12 hours or
Excisional Techniques for with a combination of 0.25 to 0.5 mg/kg cyclosporine and 10
Perianal Fistulas mg/kg of ketaconazole (Nizoral, Janssen, Titusville, NJ) PO
once daily. Pre-treatment CBC and blood chemistries should be
Gary W. Ellison drawn to establish baseline values for liver and renal function.
Cyclosporine dosages often need to be adjusted to achieve a
target range concentration of 200 ng/L on a 12 hour trough serum
Introduction sample. The goal of presurgical therapy is to reduce existing
Since the last edition of this text was published, dramatic improve- fistulas to a negligible size and therefore reduce the volume of
ments have been made in the medical management of perianal diseased tissue that needs to be excised. Reduction in diseased
fistulas to the point that surgical therapy is currently considered tissue will also allow the surgeon to better visualize the involved
a secondary treatment for this confounding disease. Current anal sacs and aid in their complete removal. If perianal fistula
theory is that the disease may be immune mediated resembling disease is chronic in a dog, abdominal radiographs should be
Crohns disease in people. The term “immune mediated proctitis” taken to rule out the presence of secondary megacolon. Biopsies
may be a better term for this syndrome than perianal fistulas. may be indicated in some cases to rule out neoplastic disease
The presence of concomitant inflammatory bowel disease and before extensive surgical therapy is performed.
recent reported success of immunosuppressive therapy with
drugs such as oral prednisone, oral cyclosporine, combination
oral cyclosporine and ketoconizole, combination oral azathio- Surgical Technique
prine with metronidazole and topical tacrolimus lend further The perianal area and tail base are clipped extensively after the
support to this hypothesis. Early infiltration of the circumanal animal has been placed under general anesthesia. A thorough
glands with lymphocytes and plasma cells may occur prior to the digital rectal examination should be performed to determine
more traditional secondary histologic changes which include how much of the rectal circumference is diseased, to identify
inflammation and necrosis of the apocrine glands, infection of the severity of anal sphincter stenosis and to determine how far
circumanal glands or hair follicles, impaction and infection of the the fistulas extend peripherally. The fecal contents of the rectum
anal sinuses or anal crypts and anal sac infection or absces- are evacuated digitally. Enemas are usually not administered
sation. Ultimately the normal regional anatomy is permanently prior to surgery unless significant fecal impaction is present.
disrupted and gross lesions include fistulas of the anal sinuses, Culture of the fistulous tracts usually is not warranted since a
submucosal fistulas and ruptured anal sacs in addition to mixed culture of gram positive cocci and gram negative coliform
cutaneous perianal fistulas. In these advanced cases medical bacteria are usually isolated. The animal can be positioned in
therapy is more likely to fail and surgery is indicated. ventral or dorsal recumbency with the tail pulled over the back
or below the table, respectively. The rectum is packed with
chlorhexidine soaked tampons and routine surgical preparation
Indications for Surgery of the perianal region is performed.
Although an estimated 85% to 90% of perianal fistulas show
improvement or complete resolution after eight to twelve weeks The fistulas and anal sacs are carefully probed with a groove
of immunosuppressive therapy, those lesions associated with director to determine their extent and depth. When the anal
anal sac rupture or disruption of the anal sac ducts often will not sacs are not diseased, they are removed prior to fistulectomy.
completely respond, or are subject to recurrence after cessation More commonly, the anal sacs are ruptured or abscessed,
of appropriate medical therapy. Recurrence rates of 40 to 60% and are best excised concurrently with the fistulous tracts. A
are reported especially in those cases where anal sac drainage circular incision is made around the periphery of the fistulas
is impaired. In the authors experience, residual or recurrent using a #10 blade, needle tipped electrosurgical unit or surgical
lesions are most often located ventral and lateral to the anus. laser (Figure 20-46). A plane is established deep to the fistulas
Surgical excision of fistulas with concurrent anal sacculectomy and dissection is carried medially toward the anal canal. The
is indicated in these cases as well as those where large areas dissection plane must stay as close to the fistulas as possible
of the anal circumference are involved and continued tenesmus to preserve the external anal sphincter but it is important to
or dyschezia with obstipation is caused by anal stenosis. dissect deep to the fibrous tracts (Figure 20-47). Hemorrhage
Potential limitations of excision include the inability to remove is moderate and is controlled with electrocoagulation or laser
all of the tracts if they extend too far peripherally and the danger ablation. Any remaining anal sac lining is carefully dissected
of creating fecal incontinence if the tracts deeply invade the from the surrounding fibers of the external anal sphincter with
external anal sphincter. However, if an anal stricture is present mosquito hemostats or fine dissection scissors (See Figure
due to a deep-seated invasion of the external anal sphincter by 20-47 inset). The entire secretory lining of the anal sac must
316 Soft Tissue
Figure 20-47. The dissection is continued deep to the tracts with efforts
at preserving as much of the anal sphincter. Residual anal sacs lining
should be removed by blunt dissection using mosquito hemostats or
fine tipped scissors (inset). Figure 20-48. Cross section of the anus and rectum showing excision of
the fistulas with preservation of the external anal sphincter. The fistulas
are transected through the rectal mucosa cranial to the anocutaneous
junction.
Intestines 317
Suggested Readings
Day MJ, Weaver BMQ: Pathology of surgically resected tissue from 305
cases of anal furunculosis in the dog. J Sm Anim Pract 33:583, 1992.
Ellison GW: Treatment of perianal fistulas in dogs. J Am Vet Med Assoc
206:1680, 1995.
Ellison GW, Bellah JR, Stubbs WP: Treatment of perianal fistulas with
ND/YAG laser-results of 20 cases. Vet Surg 24:140, 1995.
Harkin KR, Walshaw RW, Mullaney TP: Association of perianal fistula
and colitis in the German Shepherd dog: Response to high dose
prednisone and dietary therapy. J Am Anim Hosp Assoc 35:515, 1996.
Mathews KA, Sukiana HR: Randomized controlled trial of cyclosporine
for treatment of perianal fistulas in dogs. J Am Vet Med Assoc 211:1249,
1997.
Misseghers BS, Binnington AG, Matthews KA: Clinical observations in
the treatment of perianal fistulas with topical tacrolimus in 10 dogs. Can
Vet J 41:623, 2000.
Mouatt JG: Cyclosporin and ketaconazole interaction for treatment of
perianal fistulas in the dog. Aust Vet J 80:207, 2002.
Shelley BA: Use of the carbon dioxide laser for perianal and rectal
surgery. Vet Clin North Am Small Anim Pract 32:621, 2002.
Tisdale PL, Hunt GB, Beck JA, et al: Management of perianal fistulae in
five dogs using azathioprine and metronidazole prior to surgery. Aust
Vet J 77:374, 1999.
Figure 20-49. After apposing the deep subcutaneous tissues with simple
interrupted sutures the rectal mucosa is apposed to the skin with simple Vasseur PB: Results of surgical excision of perianal fistulas in dogs. J
interrupted sutures. It is important to closely approximate the rectal Am Vet Med Assoc 185:60, 1984.
mucosa with the skin (inset).
Chapter 21 caudolateral to the vena cava. The right and left triangular
ligaments extend from their respective crus of the diaphragm,
attaching to the adjacent lateral lobes. The visceral surface
Liver, Biliary System, Pancreas consists of several visceral impressions; the most prominent is
to the left of midline, formed by the stomach. The dorsal border
extends more caudally than the ventral border, with the cranial
Hepatobiliary Surgery pole of the right kidney located within a renal impression formed
on the caudate process of the caudate lobe. The normal liver
Robert Martin and Mike King does not usually extend caudal to the costal arch.1,2
Liver Surgery Blood supply to the liver arises from both the hepatic artery (a
branch of the celiac), and the portal vein (formed from tributaries
Anatomy that drain the gastrointestinal tract, pancreas, and spleen).
The liver is the largest glandular organ in the body, consisting Branches of both these vessels supply the connective tissue
of between 3% and 5% of bodyweight in dogs and cats. Blood of the liver as they divide and course through the parenchyma
draining from the gastrointestinal tract passes through hepatic ending at the hepatic sinusoids. Blood is carried away from the
cells prior to returning to the general circulation of the body. liver first via central veins of the hepatic lobules which then form
hepatic veins that finally empty into the vena cava. Innervation
Positioned in the cranial abdomen, the canine liver is bound by of the liver is maintained by both periarterial plexuses (sympa-
the diaphragm cranially, and the stomach, intestines and spleen thetic) and the vagal trunks (parasympathetic).
caudally, and lies transversely within the abdomen, with a slight
majority of its mass located on the right of midline. The organ is Bile is secreted by the hepatocytes into canaliculi within hepatic
divided into 6 lobes: left lateral, left medial, quadrate, caudate, lobules. Canaliculi drain into interlobular ducts which unite to
right medial and right lateral (Figure 21-1A). The caudate lobe form lobar ducts that exit from each liver lobe as extrahepatic
is further divided into caudate and papillary processes and is bile passages termed hepatic ducts. Hepatic ducts may vary in
positioned transversely across the abdomen. The papillary number and terminate in the bile duct (Figure 21-1B).
process extends to the left where it lies in the lesser curvature
of the stomach and the caudate process to the right where it In addition to the production of bile the liver has other functions,
contacts the cranial aspect of the right kidney. The portal vein including metabolism of protein, fat, carbohydrates, as well as
lies ventrally and the vena cava dorsally to the caudate lobe. many drugs. Patients with liver disease may suffer from hypopro-
The quadrate lobe is situated between the right medial and left teinemia, hypoglycemia, and decreased levels of clotting factors.
medial lobes, with the gallbladder located in a fossa formed Patients with liver disease to be treated surgically are less than
between the quadrate and right medial lobes.1,2 ideal anesthetic candidates, as hypotension, increased risk of
hemorrhage, and more profound reaction to many anesthetic
The cranial surface of the liver follows the curve of the diaphragm, agents may be seen. Preoperative hemogram, serum chemis-
and the right and left coronary ligaments attach it to the diaphragm tries, strict attention to intravenous fluid support (often with
Figure 21-1. Anatomic relationship of the lobes of the liver (C, caudate; LL, left lateral; and LM, left medial; Q, quadrate; RL, right lateral; RM, right
medial) and gallbladder (G) as viewed from the caudoventral perspective. A. Afferent vascular supply of the liver (CHA, common hepatic artery; CVC,
caudal vena cava; PV, portal vein). B. Biliary system (CBD, common bile duct).
Liver, Biliary System, Pancreas 319
Biopsy Techniques
Cytological evaluation of samples obtained by fine needle
aspiration can be useful in diagnosis of some diffuse diseases.
Care should be taken in the interpretation of such samples
because the accuracy of liver cytology is markedly less than
that of histopathological evaluation, especially in inflammatory
hepatic disease.3-5
vascular inflow occlusion using the Pringle maneuver.12 A finger and the stapler removed, the hilus should be assessed for any
is passed around the free edge of the lesser omentum into the persistent hemorrhage which may require additional attention
epiploic foramen where the hepatic artery, portal vein, and bile with suture or large vascular clips.7,13,14
duct can be compressed between the thumb and forefinger.
Occlusion of the hepatic artery and portal vein can be maintained
safely in this manner for up to 15 minutes while the hemor-
Extrahepatic Biliary Tract Surgery
rhage is controlled.12 A bulldog vascular clamp can be used to Anatomy of the Extrahepatic Biliary System
occlude these vessels, providing less interference to surgical The gallbladder, a pear-shaped structure located between the
exposure of the liver. Upon completion of a partial lobectomy the quadrate and right medial liver lobes, varies in size depending on
exposed parenchyma should be free of hemorrhage. Omentum the size of the dog. Cats have a relatively consistent gallbladder
can be sutured over the raw hepatic surface, though this is not size but are more prone to anatomic variations. In a beagle-
necessary as omental adhesions will form spontaneously.7 sized dog, the gallbladder measures 5 cm long and 1.5 cm wide
at its widest area with an approximate 15 ml volume storage
Partial liver lobectomy can also be performed with specialized capacity of bile.15 Anatomic regions of the gall bladder include a
surgical stapling equipment, though this is dependent on lobe fundus, body, and a neck that continues as a cystic duct, the first
thickness and width.7,13,14 The Thoracoabdominal (TA™) series structure of the biliary duct system (Figure 21-3).15 The bile duct is
of stapling instruments were designed for use in pulmonary the main excretory channel to the duodenum that begins where
and gastrointestinal surgery and are also effective for hepatic the cystic duct joins with the first biliary tributary (hepatic duct)
surgery.7,13 Stapling devices are faster, provide more complete from the liver.15 Four hepatic ducts drain functional divisions of
hemostasis, and are thought to cause less tissue inflammation the liver and empty into the bile duct along its free portion (5 or
than dissection and ligation techniques.13 The TA stapling more cm) as it courses to the duodenum through the hepatoduo-
instruments use preloaded disposable cartridges that produce denal ligament and lesser omentum (Figure 21-4).7,15 The central
a staggered double row of staples 30, 55, or 90 mm in length.14 liver division (right medial and quadrate lobes) usually contribute
The appropriate size instrument is selected based on lobe width 2 hepatic ducts that empty into the origin of the bile duct along
at the desired point of transection. The liver capsule is incised, with the cystic duct. The left division (left lateral and medial lobes,
and the stapler is used to crush the parenchyma, compressing papillary process of the caudate lobe) usually gives rise to a single
vessels and bile ducts between the jaws of the instrument. The hepatic duct that enters midway along the free portion of the bile
staples are discharged and the parenchyma excised distal to duct. The right division (right lateral and caudate lobes) usually
the staple line.7,14 Application of the TA stapler can be simplified gives rise to a single duct that is the last hepatic duct to enter
by crushing the liver parenchyma digitally or with a crushing the bile duct before it enters the duodenal wall where it courses
instrument (Carmalt or Doyen intestinal forceps), leaving the for about 2 cm through the duodenal wall as the intramural
vascular pedicle intact for stapling. portion of the bile duct. The intramural bile duct is surrounded
by a double layer of smooth muscle as it passes terminally into
Complete liver lobectomy can be a challenging procedure. For the major duodenal papilla through a smooth muscle funnel. Bile
complete lobectomy of the left liver lobes, the triangular ligament is discharged into the duodenal lumen primarily as a result of
is transected, allowing surgical access to the hilus. In small duodenal motility with digestion but also by a coordinated active
dogs and cats the tissue around the hilum can be crushed using gallbladder contractile process.7,15 Variations in hepatic duct
digital pressure, and a single encircling ligature placed, prior to number (usually 3 to 5), liver division drainage, and hepatic duct
transection of the lobe distal to the suture.6,7 Mass ligatures are entry into the bile duct can occur.
not recommended for use in central or right division lobectomy
or in larger dogs for left liver lobectomy as severe hemorrhage The frequent use of abdominal ultrasound (U/S) examination in
can occur should the ligature become dislodged.6,7 Complete dogs and cats has led to identification of asymptomatic biliary
lobectomy of central or right division lobes requires dissection conditions such as gallbladder sludge (up to 50%), choleliths
of hepatic parenchyma from the caudal vena cava. Care must be (about 5%), mucocoele (1 to 2%), and gallbladder wall thickening
taken to not damage this structure. The lobe must be freed from (1 to 2%) as incidental findings in dogs that do not have clinical
attachments to surrounding tissues or organs, and any paren- signs of biliary tract disease.a Abnormal ultrasound findings can
chyma remaining at the hilus is crushed. If the right medial and/ be significant if accompanying clinical signs and laboratory
or quadrate lobes are to be removed, the gallbladder has to be abnormalities (hemogram, serum chemistries) support a
preserved.7,14 Once the vascular supply and biliary duct(s) of the diagnosis of biliary tract obstruction. Only when ultrasono-
lobe to be removed have been identified, they should be isolated graphic evidence of biliary obstruction (dilatation of the extrahe-
and individually ligated. The lobe is then transected distal to patic biliary system) is seen in a clinically ill patient does the role
these ligatures and removed. The hilus is examined for any signs of infection become a likely contributor to biliary tract disease.
of persistent hemorrhage and additional ligatures placed, if
necessary. Surgical manipulation of the extrahepatic biliary tract is only part
of the overall management of patients with clinical evidence of
Use of surgical stapling devices can avoid the need for individual an extrahepatic biliary tract disease. The decision for surgical
dissection and ligation of hilar vessels. Once the lobe has been exploration should be made cautiously in clinically ill patients
freed from its attachments the instrument can be applied at the where morbidity has been induced by a biliary obstructive
hilus and the staples deployed. After the lobe has been excised process (cholecystitis, inspissated bile, cholelithiasis, mucocoele,
a.
Personal Communication, Dr. Martha M. Larson and Dr. Colin C. Carrig
Liver, Biliary System, Pancreas 321
Figure 21-3. Palpation of the hepaticoduodenal ligament and intimate portal vein, common bile duct, and proper hepatic arteries. (Redrawn from Nora
PF, ed. Operative surgery. Philadelphia: Lea & Febiger, 1972.)
effusion is at least twice that of peripheral blood, a diagnosis of used for both palliative and curative intent. A bile sample is always
biliary disruption is confirmed.7 Surgical exploration is indicated taken for routine culture and antibiotic sensitivity testing and a
either immediately in a stable patient or should be delayed (hours) liver biopsy is standard for biliary tract surgery. Moist laparotomy
while steps are taken to improve the unstable patient’s surgical sponges are routinely used to pack around the surgical site to
status. Most frequently, omentum will have formed adhesions contain bile spillage. Gauze sponges with a radiopaque marker
in the vicinity of the biliary rupture that must be broken down to (Vistec X-ray Detectable Sponges, Tyco Healthcare/Kendall,
identify the site of rupture to determine what appropriate surgical Mansfield, MA) are counted immediately prior to a celiotomy
steps should be taken.16 and immediately prior to closure to prevent leaving a sponge in
the abdomen. Abdominal lavage with warm physiologic fluid is
Bile peritonitis can also occur following gallbladder rupture from a standard part of surgical management of extrahepatic biliary
obstruction or infarction.7,18 These patients are often very ill and tract disease prior to celiotomy closure. The surgeon should
have a high mortality rate as a result. Surgical timing should consider use of supplemental feeding techniques postopera-
coincide with an initial delay while attempts are made to improve tively (esophageal feeding tube, gastrostomy tube, jejunostomy
patient stability over a period of hours, not days. A delay in owner tube; jugular catheter for total parenteral nutrition) to promote
recognition and subsequent presentation of a pet becoming ill nutritional health. Laparoscopic equipment, if available, can be
from a biliary obstruction with bile peritonitis usually exists and used efficiently to visualize the extrahepatic biliary system and
time becomes a critical factor for patient survival in making the assist in performing temporary decompression procedures, liver
diagnosis and electing surgical intervention.18 biopsy, or cholecystectomy.
Hepatic Duct Ligation guidewire; Cook, Inc., Bloomington, IN) and a 6.5-Fr polytetra-
Avulsion of a single hepatic duct can occur following blunt fluoroethylene self-retaining accordion catheter with side holes
abdominal trauma. Bile peritonitis results and a significant delay has been described for percutaneous placement through the
(10 to 20 days) between the time of trauma and onset of clinical right abdominal wall caudal to the costal arch.17 The catheter is
signs is common.7,16 Surgical management usually involves secured to a Tuohy-Borst fitting and functions as a self-retaining
ligation of the avulsed duct.7 Marked elevation in serum alkaline catheter.17
phosphatase will result (usually present with bile peritonitis),
peaking at 10 to 14 days, and declining subsequently.20 In some A right paracostal celiotomy provides direct access to the
cases, an auxiliary retroportal network of bile ducts will develop gallbladder but ventral midline celiotomy is the more common
to drain bile from the affected liver lobe (s) whereas, in other approach for biliary surgery. Following creation of a cranial
cases, diffuse microscopic biliary cirrhosis results.7,16,20 If the midline celiotomy, the falciform ligament is separated but not
avulsion is directly off the bile duct (often), either the bile duct removed to minimize surgical time and blood loss. A self-retaining
tear is oversewn with 6/0 monofilament suture with or without a retractor (Gelpi for small dogs and cats; Balfour [pediatric
stent or the bile duct is ligated and a bile flow diversion procedure and standard]) is used most efficiently to maintain body wall
is performed.7,16 retraction for access to the gallbladder. A cutaneous incision is
made ventral to the tip of the 13th rib on the right lateral body
wall and a hemostatic forceps (Crile, Kelly, mosquito) is pushed
Tube Cholecystostomy with its tip from intraabdominal toward the skin incision. A Bard
In situations where the clinician does not have the capability of scalpel blade is used to sharply incise over only the tip of the
providing frequent cholecystocentesis, tube cholecystostomy forceps until its jaws pass completely through the body wall at
can be employed as a percutaneous placement or by relatively that site. The tip of a 7- to 14-Fr balloon catheter (Foley catheter,
quick surgical intervention to achieve biliary decompression Tyco Healthcare/Kendall, Mansfield, MA) or mushroom-tipped
without performing a prolonged definitive corrective procedure catheter (Bard Urological Catheter, CR Bard, Inc, Covington, GA;
(Figure 21-5).16,17,20 Because surgical time can be a critical excise the tip of the mushroom catheter to improve bile drainage)
factor in a patient’s survival, tube cholecystostomy should be is grasped with the forceps and pulled through the body wall and
selected only as a temporary procedure for rapid surgical biliary into the abdomen. The catheter is then passed through a layer
decompression until patient stabilization permits a definitive of omentum.7,16,17 Avoid bunching omentum such that it impairs
correction of extrahepatic biliary tract obstruction. The Hawkins surgical manipulation of the gallbladder. Using 3/0 monofilament
needle-guide system (22-ga cannulated needle with stylet and absorbable suture material, a pursestring suture is placed in the
Figure 21-5. A cholecystostomy tube is maintained in the gallbladder with a pursestring suture. Two (of five or six) chromic catgut sutures are placed
through the serosa of the gallbladder and peritoneum at the place of exit through the skin.
324 Soft Tissue
fundus of the gallbladder. The gallbladder is not dissected from its Choledochal Tube Stenting
hepatic fossa7,16 nor is it necessary to pexy the gallbladder fundus Use of a choledochal tube stent has been previously described in
to the body wall at the site of tube entry into the abdomen.7 Once individual case reports in the veterinary literature and in experi-
the pursestring suture is placed, a stab incision (caution to avoid mental studies however only recently has its use in a series
cutting the pursestring suture) is made with an 11 Bard blade of dogs with clinical biliary tract obstruction been reported,
into the center of the pursestring suture and bile is aspirated including long-term outcome.7,21 Indications include short-term
using suction. Alternatively, a large bore needle (14 gauge or teat stenting for reversible disease processes (acute pancreatitis
cannula) connected to a 35 ml syringe can be introduced into with temporary obstruction), internal support after primary
the gallbladder from inside the pursestring suture to aspirate bile repair of bile duct trauma, palliation of bile duct obstructing
sufficiently to avoid leakage when the cholecystotomy is made malignancy, and drainage of an obstructed bile duct prior to
for catheter tip introduction. Insert the catheter tip, inflate the definitive surgical management in the severely compromised
balloon with sterile saline if a Foley® catheter is used, and tie patient.21 We prefer tube cholecystostomy over choledochal
the pursestring suture securely. Using a 4mm skin biopsy punch, tube stenting for temporary decompression of biliary obstruction
take a liver biopsy from the ventral surface of a liver lobe, place in the severely compromised patient because tube cholecys-
a gelatin foam hemostatic sponge (Gelfoam®, Upjohn Company, tostomy is a more rapid surgical technique that does not require
Kalamazoo, MI; VETSPON®, Ferrosan A/S, Soeborg, Denmark) an enterotomy. Advantages of choledochal tube stenting include
plug in the biopsy site to control hemorrhage, and close the decompression for temporary obstructive diseases (pancreatic
celiotomy wound with an appropriate size absorbable monofil- inflammation, edema, or abscesses) without altering the normal
ament suture material in a simple continuous pattern. The tube anatomic features of the biliary tract, support for primary repair
is secured to the skin at the exit site using 2/0 nylon in a finger- of a bile duct tear, and possibly preventing stricture during the
trap suture pattern. Avoid placing excessive external tension on early phases of healing (controversial).7,21
the tube. The tube is occluded (use a 3 ml syringe placed into
the tube end) and bandaged to the dorsal aspect of the patient An antimesenteric duodenotomy is made 3 to 6 cm distal (aborad)
for easy access for intermittent drainage multiple times daily. to the pylorus over the major duodenal papilla. A red rubber
Gravity flow into a sterile collection system can also be used. catheter (Feeding tube, Tyco Healthcare/Kendall, Mansfield, MA)
The wound at the tube exit site is cleaned daily. The procedure is used because of its availability in a variety of sizes to accom-
should be accomplished in about 15 minutes in an attempt to modate variable diameters of a bile duct opening.21 An appro-
minimize patient morbidity. priate diameter catheter is selected and passed retrograde from
the bile duct opening at the major duodenal papilla. The biliary
If the bile is not septic and the patient is eating or being fed tract is flushed with a balanced electrolyte solution or sterile
through a tube (esophagostomy, gastrostomy), collected bile saline (0.9% NaCl) solution. If patency can be established, either
can be returned to the patient in gelatin capsules or directly into by flushing through the stent only or by concurrent removal of
the tube to support digestion of dietary fats if prolonged drainage choledocholiths/cholecystoliths through a choledochotomy,
is anticipated.7,16,20 In cases of temporary bile duct obstruction, cholecystotomy or cholecystectomy, the stent is left with its tip
biliary tract patency can be determined with cholangiography midway in the free portion of the bile duct. The remaining tube
by injecting radiographic contrast media (Conray® 400) through is cut to leave 3 to 5 cm of stent extending through the major
the tube and into the gallbladder, taking a radiograph immedi- duodenal papilla and into the duodenal lumen. The stent is
ately after injection. If biliary patency is confirmed, the patient secured in place by passing a monofilament absorbable suture
is sedated and the tube removed by firm traction five or more through the stent wall and through the submucosa of the duodenal
days postoperative without concern for bile leakage into the wall just distal (aborad) to the major duodenal papilla and tying
abdomen.7,16 If at the time of tube placement the surgeon antici- the suture routinely.21 A monofilament nonabsorbable suture
pates tube removal without further definitive biliary tract surgery, material should be used when a stent is placed for palliation of
a balloon-tipped catheter (Foley catheter, Tyco Healthcare/ malignancy. Because of likelihood for stent occlusion to occur
Kendall, Mansfield, MA) is preferred since it can be deflated postoperatively, removal of the tip of the red rubber catheter
and more easily removed by traction than a mushroom-tipped while preserving the side openings should be considered even
catheter. The omentum forms a fibrous tract around the tube that though bile can be expected to flow freely around the stent and
collapses and seals off the gallbladder stoma after the tube is into the duodenum.21 The duodenotomy is closed routinely. The
extracted. The cutaneous stoma is cleaned daily and allowed to stent can be expected to pass through the feces months later
heal by second intention. or it can be electively removed by endoscopic retrieval 3 to 6
months later after clinical and biochemical evidence of biliary
After stabilization of a patient requiring definitive biliary surgery, tract obstruction has resolved.
the tube is removed under direct visualization following a second
celiotomy. Tube cholecystostomy does not hinder subsequent An alternate placement of a red rubber catheter stent is by direct
cholecystectomy or biliary diversion using the gallbladder for a introduction through the body wall and duodenum and through
cholecystoenterostomy. In either procedure the tube should be the major duodenal papilla into the bile duct. A large bore needle
cut several cm distal to the pursestring suture site to extract it is passed from within the abdominal cavity through the right
externally from the body wall. The tube stump can be used to body wall at a point equidistant between the tip of the last rib
apply traction while the surgeon dissects the gallbladder from and ventral midline. The tip of an appropriate size red rubber
its hepatic fossa. catheter is passed from outside into the needle lumen and into
Liver, Biliary System, Pancreas 325
the abdomen. The needle is removed from the body wall and cholecystoliths/choledocholiths, and possibly to cannulate the
catheter and it is next passed from the lumen of the duodenum 5 bile duct to confirm its patency).7,16 A bile sample for culture
to 10 centimeters distal (aborad) to the major duodenal papilla (at analysis can be obtained as an attempt is made to aspirate bile
a point in the descending duodenum that can be easily approxi- (20 to 35 ml syringe, 14- or 16-ga needle) before cholecystotomy
mated to the right body wall) through the bowel wall on the is performed.7 The bile duct is difficult to catheterize through
antimesenteric surface of the duodenum. The tip of the red rubber a cholecystotomy because of the acute angle formed by the
catheter is again passed through the needle lumen and into the cystic duct as it joins the bile duct. An angiographic flexible-
duodenal lumen. The needle is withdrawn and the catheter is tipped guidewire is usually necessary to first pass around the
passed into the bile duct through the major duodenal papilla to sharp angle, followed by catheter passage over the guidewire
the midpoint in the free portion of the bile duct proximal to the to explore and flush the bile duct and its branches from this
level of obstruction or tear. The duodenotomy is closed routinely. approach.16 Diseases of the gallbladder are usually best managed
The descending duodenum is sutured to the right body wall to fix by cholecystectomy and not just evacuation of gallbladder
the points of tube entry and prevent potential leakage. The red contents (stones, mucocoele, and sludge) although stones can
rubber feeding tube (Tyco Healthcare/Kendall, Mansfield, MA) be successfully removed via cholecystotomy.7 It is imperative to
is fixed to the skin by a finger-trap suture pattern with 3/0 nylon insure that the bile duct is patent and a biopsy of the gallbladder
suture material. Bile can be drained passively from the tube wall is taken before a cholecystotomy is closed.7 Closure is best
externally or aspirated intermittently and returned to the animal achieved by using small-gauge monofilament absorbable sutures
through feeding as described above, if appropriate. Once serum in a simple interrupted or continuous, inverting suture pattern
bilirubin concentrations return to a normal level, a cholang- (Lembert or Cushing). A two-layer closure is not necessary or
iogram is performed by injecting contrast material (Conray 400®) recommended.7 The primary indication for a controlled surgical
through the stent and into the biliary system. If contrast can be opening of the gallbladder is in preparation for tube cholecys-
seen flowing around the stent and into the duodenum, then the tostomy or cholecystoenterostomy.
tube can be removed by cutting the fingertrap suture and placing
gentle traction on the catheter. Cholecystectomy
Choledochal stenting may provide a less invasive and less time- Gallbladder removal is the treatment of choice for diseases of
consuming option for palliation of malignancies, compared with the gallbladder.7 Secondary changes of inflammation, fibrosis
rerouting procedures.21 Duodenobiliary reflux with subsequent or necrosis of the gallbladder wall are common. Removing
cholangiohepatitis does not seem to be a consequence of the gallbladder eliminates a potential source of disease and a
stenting.21 reservoir for subsequent stone formation.7 An intact distended
gallbladder is more easily dissected from its hepatic fossa than
a flaccid one and stay sutures or tissue clamp become useful
Cholecystotomy in manipulating the structure (Figure 21-6).16 With gallbladder
Cholecystotomy has limited indications in biliary surgery necrosis and/or rupture, cholecystectomy becomes more
(removal of inspissated bile or biliary sludge, gelatinous bile, difficult to perform because stay sutures are no longer useful.
Figure 21-6. Tissue clamp is placed on the fundus of the gallbladder, and dissection from fundus to neck begins. (Redrawn from Nora PF, ed. Opera-
tive surgery. Philadelphia: Lea & Febiger, 1972.)
326 Soft Tissue
Omental, liver lobe, and diaphragmatic adhesions often require is controlled with pressure by packing with a moist laparotomy
dissection to expose the gallbladder.7 Traumatic rupture of the sponge.7 In the normal dog, the cystic artery can be identified
gallbladder is uncommon, and by the time of diagnosis, omental and ligated or coagulated directly. In clinical obstructive disease
adhesions have usually formed so that primary closure is a less this structure can be ligated or coagulated when it is encoun-
likely consideration, necessitating cholecystectomy.7 tered. After gallbladder dissection is complete, the cystic duct
can be cross-clamped and severed between the clamps (Figure
The gallbladder is covered by a layer of visceral peritoneum 21-8). Our preference is to place a single clamp midway on the
over its free (abdominal) surface that is confluent with the liver cystic duct to prevent spillage of gallbladder contents while
surface (tunica serosa or Glisson’s capsule). This layer requires leaving a sufficient stump (5 to 10 mm) attached to the bile duct
sharp dissection along the complete margin of the gallbladder to manipulate with Debakey tissue forceps for cannulation with
and hepatic fossa. Some surgeons inject fluid beneath this an appropriate size catheter (5- to 8-Fr red rubber feeding tube,
layer to make it more distinct and to improve ease of dissection Tyco Healthcare/Kendall, Mansfield, MA). Once patency of the
(Figure 21-7).7,16 Once this layer of peritoneal reflection is partially bile duct is confirmed by flushing and passing a catheter through
disrupted, the gallbladder can be sequentially removed from its the bile duct, a circumferential ligature is placed on the stump
intimate attachment with hepatic parenchyma in the hepatic with 3/0 monofilament absorbable suture material or a hemoclip
fossa, either by precise blunt scissor dissection or by more crude is applied. Double ligation or transfixation is not necessary when
but rapid finger dissection. As this separation progresses, the an adequate cystic duct stump is preserved although either
peritoneal reflection can be continued sharply until the gallbladder can be employed, based on a surgeons’ discretion. With a very
is completely freed from its hepatic fossa, down to the junction short stump or with friable tissue, transfixation becomes more
of the cystic duct and the bile duct. With precise dissection, the important to avoid suture slippage or tissue tearing and subse-
hepatic fossa is minimally disturbed so that hemorrhage from a quent bile leakage. Because bile is soluble in saline or balanced
raw liver surface is minimal. With finger dissection, increased electrolyte solutions, any spillage not contained by laparotomy
hepatic hemorrhage can be expected.7 Because hemorrhage sponges during the cholecystectomy can be removed during
is not usually a major concern, blunt finger dissection of the abdominal lavage. Sponges are removed from the hepatic fossa
gallbladder from the liver after peritoneal incision is a rapid at completion of the procedure. Omentum can be placed in
method of mobilizing the gallbladder.7 Any hepatic hemorrhage contact with the raw liver surface if leakage is a concern.
Figure 21-7. Saline solution injected subserosally, where the gallbladder adheres to the liver, aids in dissection during cholecystectomy. (Redrawn
from Nora PF, ed. Operative surgery. Philadelphia: Lea & Febiger, 1972.)
Liver, Biliary System, Pancreas 327
Figure 21-8. Sharp and blunt dissection isolates the cystic duct with traction sutures; the cystic artery is doubly ligated and transected between
ligatures. (Redrawn from Nora PF, ed. Operative surgery. Philadelphia: Lea & Febiger, 1972.)
Drainage of the area is unnecessary. The bile duct will dilate 2 toenterostomy can be performed after ligation of the bile duct
to 3 times its normal diameter and remain dilated after chole- proximal to the tear. Primary closure of a choledochotomy or
cystectomy.7 Cholecystectomy performed by beginning the laceration by application of collagen biomaterial (fibrin-glued,
dissection at the cystic duct has been described.16 sutured collagen patch) has been described; fibrin sealant alone
was not reported to be effective.7
Choledochotomy
The bile duct is used in humans to bypass distal benign obstruc-
The normal bile duct in dogs and cats is usually too small (2.5 mm tions, usually stones, by creating a choledochoenterostomy
in diameter15) to consider an elective choledochotomy because (duodenal or jejunal). The procedure is described as a viable
of risk of either stricture and/or leakage after closure. However, option in dogs and cats (Figure 21-9) when the duct is of suffi-
in cases of bile duct obstruction in the distal free portion or in cient size and the obstruction is distal.16 There is little indication
the intramural portion, dilation can result in a duct of sufficient for this procedure electively in dogs and cats. Choledochoduo-
size to make choledochotomy practical if needed to remove denostomy is not recommended unless the gallbladder must be
an intraluminal obstruction such as a choledocholith.7 Biliary removed, the bile duct is dilated to at least 1 cm in diameter, and
flushing and tube exploration in both directions is achieved a stoma of at least 2.5 cm can be created.7
through the choledochotomy.
Figure 21-9. The dilated common bile duct is united by a simple interrupted serosal suture line to the intestine, and a gallbladder incision and entero-
tomy are made close to the serosal suture line. (Redrawn from Nora PF, ed. Operative surgery. Philadelphia: Lea & Febiger, 1972.)
Figure 21-10. A. The duodenal incision is maintained open with four traction sutures. Three additional traction sutures elevate the bile duct hillock
containing a choledochal tube in the bile duct orifice. Dashed lines on the hillock and tube indicate incision lines. B. The choledochal tube is split and
retracted into the common bile duct. Mosquito forceps spread the split tube in and out of the common duct. Sphincterotomy can be easily performed
along the split tube (dashed line). C. Sphincterotomy is complete. The ventral pancreatic duct may be present within the common bile duct hillock.
Liver, Biliary System, Pancreas 329
Cholecystojejunostomy
This technique is employed when a surgeon either elects to
perform the procedure or circumstances (gastric, duodenal,
pancreatic, or biliary masses) require its performance. When
bile is diverted from the proximal duodenum, normal physi-
ology of gastric acid production and fat digestion is altered.
Bile is required in the proximal duodenum to activate duodenal
mechanisms responsible for inhibition of gastric acid secretion.
Excessive gastric acid production can lead to peptic ulceration
of the pyloric antrum and/or, more commonly, the proximal
duodenum.7 Fat digestion is also disrupted since bile salts
enhance both the hydrolysis and absorption of fats. Weight loss
can result. No long-term reports exist on outcomes of chole-
cystojejunostomy in a series of dogs or cats to recommend the
procedure.
References
1. Dyce KM, Sack WO, Wensing CJG: In Dyce KM, ed.: Textbook of
Veterinary Anatomy. 2nd ed. Philadelphia: WB Saunders, 1996, p
2. Evans HE, deLahunta A: Millers’ Guide to the Dissection of the Dog.
Liver, Biliary System, Pancreas 331
Diagnostic Tests
The most common abnormality found on hemograms of animals
with PSS is microcytosis.1,11 Up to half of dogs with congenital
PSS have prolonged PTTs;12 however, this does not usually result
in clinically significant hemorrhage. Biochemical abnormalities
in dogs with PSS include decreases in blood urea nitrogen,
protein, albumin, glucose, and cholesterol; and increases in
serum alanine aminotransferase and alkaline phosphatase.1 An
increase in alkaline phosphatase is most likely from bone growth,
since cholestasis is not usually a problem in animals with PSS.
Cats with PSS often have increased liver enzymes but may have
normal albumin and cholesterol concentrations.7,8 Urine abnor-
malities may include low urine specific gravity and ammonium
biurate crystalluria, and inflammatory urine sediment in animals
Figure 21-12. A transplenic through-the-needle catheter has been
with cystitis or urolithiasis. placed through the parenchyma and into splenic vein. The catheter
may be used for portography or portal pressure measurements. (From
Animals with portosystemic shunting will have decreased protein Schultz KS, Marin RA, Henderson RA. Transsplenic portal catheter-
C activity and increases in fasting and 2-hour postprandial bile ization: surgical technique and use in two dogs with portosystemic
acids and in ammonia after an ammonia challenge (ammonia shunts. Vet Surg 1993;22:365)
tolerance test). These tests are not specific for shunting, since
they can occur with many liver diseases. with PVH display biochemical, hematologic, and clinical changes
consistent with portosystemic shunting but lack a macroscopic
Hepatic histologic changes in animals with PSS include portosystemic shunt. Therefore, in dogs with PVH, portograms
generalized congestion of central veins and sinusoids, lobular and scintigrams are normal. Signs of PVH are managed with a
collapse, bile duct proliferation, hypoplasia of intrahepatic protein restricted diet. Lactulose is added if clinical signs are
portal tributaries, proliferation of small vessels and lymphatics, not controlled with diet alone. Some clinicians may administer
diffuse fatty infiltration, hepatocellular atrophy, and cytoplasmic nutriceuticals (milk thistle, denosyl) to improve hepatic function.
vacuolization.1,11,13 These pathologic changes are often termed
“hepatic microvascular dysplasia” and can also be seen in
dogs with congenital portal vein hypoplasia (without macro-
Medical Management of PSS
scopic shunting) or noncirrhotic portal hypertension. Patho- Medical management of animals with PSS includes correction
logic changes may be present in the central nervous system, of fluid, electrolyte, and glucose imbalances and prevention of
especially in encephalopathic animals with shunts. hepatic encephalopathy by controlling precipitating factors.1
Dietary protein is restricted (protein content 18-22% in dogs;
On plain radiographs, microhepatica and renomegaly may be 30-35% in cats) to reduce substrates for ammonia formation by
present. Urate calculi normally are radiolucent but occasionally colonic bacteria, and any sources of gastrointestinal bleeding
will be seen in the renal pelvis, ureter, or bladder on survey films must be treated. Antibiotics that are effective against urease
when combined with struvite or other radioopaque material. producing bacteria, such as neomycin or metronidazole, can
Portosystemic shunts may be definitive diagnosed with angiog- be administered to decrease intestinal bacterial populations.
raphy, ultrasonography, scintigraphy, computed tomography, Enemas and cathartics may be used to reduce colonic bacteria
or magnetic resonance angiography.1 Mesenteric portography and substrates and are especially important in animals with
provides excellent visualization of the portal system but usually hepatic encephalopathy. Lactulose is administered to reduce
requires an abdominal incision. Water-soluble,sterile, iodinated ammonia absorption and production. Cystitis is treated with an
contrast medium is injected into a catheterized jejunal or splenic appropriate antibiotic based on urine culture and sensitivity;
vein (Figure 21-12), and one or more radiographs are taken during response may be poor if uroliths are present. Urate uroliths
completion of the injection. Sensitivity of the test is greatest may respond to low protein diets; renal calculi have reportedly
when performed with the animal in left lateral recumbancy.14 dissolved after shunt ligation.
When a shunt is not found, the surgeon should obtain a liver that you wish to achieve during shunt occlusion.22 Place the
biopsy to rule out other hepatic diseases such as PVH and cylinder next to the shunt and wrap the ligature around the shunt
perform intraoperative mesenteric or splenic portography to and the cylinder. Tie the ligature and remove the cylinder, then
definitively rule out a PSS. recheck portal pressures and evaluate the color of the viscera.
ization. Surgical technique and use in two dogs with portosystemic mentally, including cellophane bands, ameroid constrictors,4-9
1-3
Initially, the abdominal viscera is retracted to the right using dissection is easiest when performed through the epiploic
the mesocolon and the paravertebral gutter and left kidney are foramen. For portoazygous shunts, dissection is usually easiest
examined to rule out the presence of multiple acquired shunts from a left approach with the viscera retracted to the right.
that result from portal hypertension. The crura of the diaphragm is Attenuation of any shunt should take place as close as possible
examined to determine whether a portoazygous shunt is present. to the systemic vascular system so as to ensure that small portal
branches do not enter distal to the attenuation point.
The abdominal viscera is then retracted to the left using the
mesoduodenum and the caudal vena cava examined for the
presence of abnormal veins emptying into it. The cava should
Determining Cellophane Band Diameter
be visualized from its origin at the confluence of the common The shunt vessel should be dissected free from surrounding
iliac veins to the area cranially where it deviates to pass dorsad fat and connective tissue. A suture of 2-0 or 0 polypropylene is
to the liver. The right and left renal veins, gonadal veins and passed around the vessel to facilitate further attenuation at a
phrenicoabdominal veins should be the only vessels entering later date should the cellophane band not promote complete
the caudal vena cava within the cranial abdominal cavity. Any shunt occlusion. Baseline physiologic parameters are measured
vessel terminating in the vena cava cranial to the phrenicoab- including heart rate, direct or indirect systolic arterial pressure
dominal veins is abnormal. Dilation and obvious turbulence and central venous pressure. The color of the pancreas and
visualized through the thin wall of the cava may be indicative of intestines, and intestinal motility are assessed prior to placement
an abnormal vessel. However, turbulence can occur as a normal of the cellophane band. In dogs heavier than 10 kg, and those
finding at the point of entry of the renal veins in some animals. with intrahepatic shunts, a jejunal vein is catheterized to permit
The caudal vena cava should be inspected as it crosses the liver measurement of portal pressure using a water manometer during
to ensure that it does not continue forward as the azygous vein. band placement and tightening.
Particular attention is directed to the area of the epiploic The polypropylene suture is tightened so as to occlude the shunt
foramen. The epiploic foramen is dorsal to the duodenum and completely and measurement of the previously described physi-
is created by the fold of tissue containing the hepatic artery and ologic parameters repeated. Elevation of the heart rate by more
portal vein ventrally and bounded by the vena cava dorsally. A than 20 beats per minute, a fall in systolic arterial pressure of
small, flat-bladed retractor is placed dorsal to the hepatic artery more than 10 mm Hg, a fall in central venous pressure of more
into the foramen and elevated to visualize the left side of the than 1 mm Hg, or a rise in portal pressure of more than 10 cm
vena cava. Extrahepatic portosystemic shunts are commonly H20 (to a maximum of 20 cm H20) all signify inability to completely
detected entering the vena cava in this location. occlude the shunt.
The hepatic portal vein should be examined as it courses Congestion and cyanosis of the pancreas and intestines, and
adjacent and ventral to the hepatic artery to arborize at the porta a substantial increase in intestinal motility are also considered
hepatis of the liver. Portal vein branches can be identified that indications of unacceptable portal hypertension.
supply the right lateral, right medial and left liver lobes. Dilation
of one of these branches may indicate the presence of an intra- In animals weighing 10 kg or less, cellophane bands between 2
hepatic shunt. Dilatation of all portal vessels simultaneously may and 3 mm diameter are usually placed around the shunt. A 3 mm
signify portal hypertension, rather than increased portal flow. band is placed if the shunt is not amenable to total occlusion. If
mild to moderate changes in baseline hemodynamic parameters
If a shunt has not been identified within the epiploic foramen, the and intestinal color and motility are observed, a 2.5 mm band is
abdominal viscera are returned to their normal position and an placed. If no change is observed, a 2 mm band is applied. In dogs
opening created in the ventral leaf of the omentum to visualize weighing 10 kg or more, the band diameter is dictated by changes
the omental bursa. The stomach is retracted cranially to inspect in portal pressure, as for other forms of attenuation. Cellophane
the left gastric, splenic and pancreaticoduodenal veins. Dilation bands between 2 and 3 mm diameter result in substantial shunt
of one of these vessels usually indicates the presence of an attenuation, however, life-threatening portal hypertension
extrahepatic shunt. Identify the portal branch giving rise to the necessitating removal of the cellophane band has only been
dilated vessel and follow it to its point of entry into the systemic seen in one small dog (a Bichon Frise in which a small thrombus
circulation. embolized to the attenuation site 3 days after surgery). Wider
cellophane bands may also cause complete eventual occlusion,
If it is not possible to confidently identify an extrahepatic shunt, but this has not been proven in an experimental setting.
consider the likelihood of an intrahepatic shunt, or microvascular
dysplasia. If a portoazygous shunt is suspected, the crura of the Preparation and Placement of the
diaphragm may be divided to allow visualization of the caudal
mediastinum. Cellophane Band
Following identification and mobilization of the shunt, a strip of
Once the shunt has been identified, the viscera should be cellophane 1.2 cm wide and about 15 cm long is folded lengthwise
retracted so as to provide maximum access for dissection and to produce a 3-layered band 4 mm in width and 15 cm in length.
attenuation of the vessel. Exposure of the shunt varies according The end of the cellophane is cut obliquely to facilitate passage
to specific shunt anatomy but in most cases, portocaval shunt around the shunt.
Liver, Biliary System, Pancreas 339
The cellophane band is passed gently around the shunt, incor- 21-16C). Recent work has shown that the resistance to tensile
porating as little perivascular tissue as possible (Figure 21-16A). forces of the clip-cellophane configuration increases when
The cellophane is easily torn when wet, so manipulation of the multiple clips are alternately applied from opposing directions.19
band should be minimized once it is in place around the vessel. In practice, the forces applied to the cellophane band following
implantation are low, and placement of two clips with opposing
The surgeon should hold both ends of the band between thumb orientations should be sufficient. This results in creation of a
and forefinger and insert a stainless steel pin of appropriate cellophane band of the required diameter. The stainless steel pin
diameter inside the band, next to the shunt vessel (Figure is withdrawn, allowing the shunt to expand inside the cellophane
21-16B). Hemostatic clips are then applied while the cellophane band to the predetermined diameter (Figure 21-16D). One of the
band is held tight around both the pin and the shunt (Figure original research studies4 showed that the diameter tended not
6 mm
3 mm
A B
C D
3 mm
to decrease by more than 3 mm following cellophane band appli- and 60% of cats. Reasons for continued liver dysfunction include
cation, and hence it is recommended that this diameter not be failure of the shunt to close, inappropriate placement of the cello-
exceeded in smaller patients. However, other researchers6 have phane band, and development of acquired shunts.7,9 This was
shown that placement of loose bands that do not constrict the similar to reported results for a series of 127 dogs that underwent
shunt may be preferable in larger patients. It should be noted, placement of ameroid constrictors in dogs7 and cats.10,11 The
however, that the clear film used in these other reports was not survival rate and resolution of hepatic dysfunction were lower
cellophane, and may therefore behave differently to cellophane in dogs with intrahepatic shunts versus those with extrahepatic
in clinical patients. shunts. Follow up of an additional 33 dogs subsequent to the
cases reported above3 confirms the low mortality rate (1 dog,
Haemodynamic measurements are repeated and the intestine 3%). This dog (a Bichon Frise) was the only animal that experi-
and pancreas inspected to ensure that safe portal pressures enced post ligation neurological disorder and was euthanatized
have not been exceeded. The ends of the cellophane are cut, so as a result of uncontrollable seizures that commenced 70 hours
as to leave 1 mm protruding beyond the surgical clip. The cello- after shunt attenuation. No instances of life-threatening portal
phane band is gently rotated to ensure it does not kink the shunt hypertension were encountered. Cellophane banding continues
or adjacent vessels. The polypropylene suture is tied loosely to yield poorer results in cats than in dogs, for reasons that are
and cut to leave 4 cm ends. This enables identification of the not entirely clear.8
shunt if subsequent surgery is required due to persistent signs
of hepatic dysfunction or portosystemic shunting. The polypro-
pylene suture may be pulled tight during later surgery to check References
whether the original shunt is closed or patent, thus avoiding 1. Harari J, Lincoln J, Alexander J, et al. Lateral thoracotomy and cello-
the necessity of dissecting through fibrous tissue. The polypro- phane banding of a congenital portoazygous shunt in a dog. J Sm Anim
Pract 31: 571, 1990.
pylene suture may be tightened if necessary without having to
disturb the shunt itself. The need for a second surgery is rare 2. Connery NA, McAllister H, Skelly C, Pawson P, Bellenger CR: Cello-
following cellophane banding of portosystemic shunts. phane banding of congenital intrahepatic portosystemic shunts in two
Irish wolfhounds. Journal of Sm Anim Pract 43: 345-349, 2002.
3. Youmans KR, Hunt GB: Cellophane banding for the gradual attenuation
Postoperative Care of single extrahepatic portosystemic shunts in eleven dogs. Aust Vet J
The abdomen is lavaged with warm saline and the celiotomy 76: 1998.
wound closed routinely. Animals are monitored intensively for 4. Youmans KR, Hunt GB: Experimental evaluation of four methods of
the first 72 hours after surgery, which is considered the high risk progressive venous attenuation in dogs. Vet Surg 28: 531, 1999.
period for seizures and portal hypertension. A broad spectrum 5. Hunt GB, Kummeling A, Tisdall PLC, et al.: Outcomes of cellophane
antibiotic is administered perioperatively. Phenobarbital is given banding for congenital portosystemic shunts in 106 dogs and 5 cats. Vet
as a premedication 30 minutes before surgery (10 mg/kg intra- Surg 33: 25, 2004.
muscularly) and continued for 72 hours postoperatively (2 to 5 mg/ 6. Frankel D, Seim H, Macphail C, et al: Evaluation of cellophane banding
kg twice daily by injection or per os). If the animal experienced with and without intraoperative attenuation for treatment of congenital
generalized motor seizures before surgery, phenobarbital is extrahepatic portosystemic shunts in dogs. J Am Vet Med Assoc 228:
1355, 2006.
continued for approximately four weeks postoperatively and the
dose then tapered. Animals are maintained on a commercially 7. Landon BP, Abraham LA, Charles JA: Use of transcolonic portal
scintigraphy to evaluate efficacy of cellophane banding of congenital
available restricted protein diet (Hills L/D) for the first 4 weeks after
extrahepatic shunts in 16 dogs. Aust Vet J 86: 169, 2008.
surgery. No other medical management is used unless animals
show signs of hepatic encephalopathy (rare). If the patient is clini- 8. Cabassu J, Seim HB III, MacPhail C, et al: Outcomes of cats under-
going surgical attenuation of congenital extrahepatic portosystemic
cally normal four weeks after surgery, the owners are instructed
shunts through cellophane banding: 9 cases (2000-2007). J Am Vet Med
to gradually return them to the original diet they were eating Assoc 238: 89, 2011.
before they experienced clinical signs. If the patient shows signs
9. Nelson NC, Neslon LL: Anatomy of extrahepatic portosystemic shunts
of hepatic encephalopathy, medical management with restricted in dogs as determined by computed tomography angiography. Vet Rad
protein diet, lactulose syrup (0.5 ml/kg twice daily) and antibiotics Ultrasound, 52, 498, 2011.
is resumed. Analysis of liver function using ammonia tolerance
10. Vogt J, Krahwinkel DJ, Bright RM, et al.: Gradual occlusion of
testing, serum bile acid determination or scintigraphy is recom- extrahepatic portosystemic shunts in dogs and cats using the ameroid
mended two months after surgical attenuation of the shunt. constrictor. Vet Surg 25: 495, 1996.
Follow up of patients demonstrating continued liver dysfunction 11. Havig M TK: Outcome of ameroid constrictor occlusion of single
should include some form of imaging (ideally contrast-enhanced extrahepatic portosystemic shunts in cats: 12 cases (1993-2000). J Am
computer tomography) to differentiate the cause of persistent Vet Med Assoc 220: 337, 2002.
shunting and determine the best management plan. 12. Kyles AE HE, Mehl M, Gregory CR: Evaluation of ameroid ring
constrictors for the management of single extrahepatic portosystemic
Summary shunts in cats: 23 cases (1996-2001). J Am Vet Med Assoc 220: 1341, 2002.
13. Mehl ML , Kyles AE, Hardie EM, ety al: Evaluation of ameroid ring
Results of cellophane banding have been reported by several
constrictors for treatment of single extrahepatic portosystemic shunts in
authors.5-8 The mortality rate is up to 5.5%, largely resulting from dogs: 168 cases (1995-2001). J Amer Vet Med Assoc 226, 2020-2030, 2002.
portal hypertension and post ligation neurological dysfunction.
14. Falls EL, Milovancev M, Hunt GB et al: Long term outcome after
Liver function returned to normal postoperatively in 85% of dogs
Liver, Biliary System, Pancreas 341
Pancreatic Surgery
Elizabeth Hardie
Figure 21-17. The pancreatic excretory ducts.
Introduction
In general, surgeons prefer to avoid the pancreas, because manip- There is significant anatomic variation between individuals and
ulation may incite inflammation and pancreatitis. The blood supply between species in the number and location of the principal
of the pancreas is intimately connected to that of the duodenum, pancreatic ducts that carry pancreatic secretions to the
which makes pancreatic resection technically challenging. duodenum.1,3 In most dogs, there are two ducts entering the
However, there are some indications for surgery on the pancreas.1,2 duodenum. The pancreatic duct is in the body of the pancreas
Pancreatic biopsy is used to confirm pancreatic disease. Nodule and enters the duodenum, along with the bile duct, at the major
removal or partial pancreatectomy is used to treat insulinoma, duodenal papilla. The second duct, the accessory pancreatic
other endocrine tumors, and pancreatic carcinoma. Complete duct, is further distal in the right pancreatic lobe and enters
pancreatectomy has been used mainly as a research surgery to the duodenum at the minor duodenal papilla. In most dogs, the
create diabetic models, but may be performed in animals with accessory pancreatic duct is the larger duct and drains both
intractable chronic pancreatitis. Acute pancreatitis is not treated lobes of the pancreas, while the pancreatic duct is small and
surgically, but may require placement of a jejunostomy tube for only carries a small amount of secretions. Variations include the
enteral feeding. The intimate relationship of the pancreatic duct presence of three ducts (two opening at the minor papilla and
and the bile duct as they enter the duodenum means that inflam- one at the major papilla) and completely separate ducts for the
mation or scarring of pancreatic tissue may compress the bile right and left lobes. In the cat, the pancreatic duct is the larger
duct, and stenting or diversion of the biliary tract may be needed duct, joining the bile duct and entering the duodenum at the
in animals with pancreatitis. The pancreas can develop cysts or major duodenal papilla. Eighty percent of cats do not have an
abscesses, and drainage or resection may be needed to resolve accessory pancreatic duct or a minor duodenal papilla. Ferrets
clinical signs related to these fluid accumulations. are similar to cats, but the accessory pancreatic duct is present
more often.4 Pancreatic bladders, which are dilations off the
pancreatic duct, have been reported in cats.3
Pancreatic Anatomy
The pancreas is a bilobed organ that sits in the angle between The blood supply to the right lobe of the pancreas comes from
the duodenum and the greater curvature of the stomach. The the cranial and caudal pancreaticoduodenal arteries, which
portion of the gland lying along the duodenum is termed the right anastomose in the right lobe (Figure 21-18). The cranial pancreati-
lobe, while the portion lying adjacent to the stomach is the left coduodenal artery is a branch of the gastroduodenal artery, while
lobe. The portion where the two lobes join is the body. The right the caudal pancreaticoduodenal artery is a branch of the cranial
lobe lies within the duodenal mesentery. The more distal aspect mesenteric artery. The left lobe of the pancreas is supplied by the
of the right lobe can be separated from the duodenum, but the splenic artery and small branches off the hepatic artery. Venous
gland is tightly adherent to the duodenum in the region of the blood drains to the portal vein through the pancreaticoduo-
body. The left lobe lies within the dorsal sheet of the greater denal veins and the splenic vein. Lymphatic drainage goes to the
omentum. Accessory pancreatic tissue may occur in the region pancreaticoduodenal, hepatic, jejunal and splenic lymph nodes.3
of the gall bladder or mesentery in the dog.3
Exocrine secretions from pancreatic tissue are carried by ducts Pancreatic Biopsy
that run along the center of each pancreatic lobe (Figure 21-17). Pancreatic biopsy is performed to diagnose or confirm pancreatic
disease.1,5 Chronic low-grade pancreatitis must be differentiated
342 Soft Tissue
from other causes of chronic gastrointestinal disease. Chronic The mesentery or omentum overlying the portion of the pancreas
pancreatitis may only be apparent microscopically and may be to be biopsied must be incised to expose the tissue.
multifocal rather than diffuse, requiring several small biopsies
to confirm or deny a diagnosis.6 In animals with macroscopic
disease of the pancreas, biopsy is used to differentiate between
Partial Pancreatectomy and Nodule Removal
diseases such as chronic pancreatitis, pancreatic carcinoma, Partial pancreatectomy is most commonly used to treat insulin
and pythiosis. Leiomyosarcoma of the duodenal wall may invade secreting beta cell tumor (insulinoma), but there is confusion in
the pancreas through the shared blood supply. the veterinary literature over the term partial pancreatectomy.2,8
The term has been used to describe neoplastic nodule removal
If the biopsy is being obtained from a grossly normal pancreas, it is (enucleation), nodule removal with removal of a border of
usually taken at the distal aspect of the right lobe of the pancreas normal pancreatic tissue, and removal of most of one lobe of
because of the ease of exposure and low risk of inciting pancre- the pancreas. The term should probably be reserved for removal
atitis. If the biopsy is obtained laparoscopically, a small piece of of most of one lobe. In general, pancreatic neoplastic nodules
tissue is removed using cup biopsy forceps.7 If needed, hemor- should be removed with a border of normal tissue, which is most
rhage is controlled with gentle pressure or a piece of Gelfoam. easily accomplished by removing the nodule and the lobe of
When the biopsy is taken as part of an exploratory laparotomy, the pancreas distal to the nodule. In ferrets, it has been shown
an encircling ligature of a monofilament suture is placed around that animals with beta-cell tumors treated with partial pancre-
a portion of the distal lobe. The ligature is tightened and the atectomy survive longer than animals treated with enucleation.8
tissue is removed. If multiple small samples of pancreatic tissue Enucleation should be reserved for animals with nodules in the
are needed, hemostatic clips can be used to occlude the vessels body of the pancreas. If the nodule in the body is large or is in a
supplying the tissue which is then excised distal to the clip. The difficult location, it may be preferable to biopsy the nodule using
mutilobular nature of pancreatic tissue makes this a relatively a needle biopsy technique and forego nodule removal in favor
easy procedure, but small delicate instruments and magnifi- of medical therapy (frequent feeding, corticosteroids, diazoxide,
cation are helpful when isolating a lobule. The major ducts and octreotide, streptozocin).2,9,10 The risk of pancreatitis is higher
vessels should be avoided, thus biopsies are most safely taken at when extensive or prolonged dissection of the body is performed.
the edges of the gland opposite the duodenum and the stomach.
The technique for partial pancreatectomy differs for the two
Liver, Biliary System, Pancreas 343
lobes of the pancreas. For the right lobe, dissection is begun at vessels is identified. The pancreatic arteries supplying the distal
the distal aspect of the lobe, where the pancreaticoduodenal left lobe are branches off the splenic artery. The venous drainage
vessels are most easily visualized. The mesentery is incised and of the left lobe of the pancreas is through two branches that enter
the distal pancreas is grasped. The dissection proceeds towards the splenic vein. The various pancreatic vascular branches are
the pylorus, and care is taken to protect the pancreaticoduo- occluded with vascular clips or ligated, while preserving the
denal vessels. Hemoclips or bipolar cautery are used to control splenic vessels. If there is doubt about the integrity of the splenic
bleeding from small branches of the pancreaticoduodenal vessels, splenectomy is performed. As the dissection proceeds
vessels entering the pancreas. The pancreas becomes more towards the body, the branches of the hepatic artery that supply
tightly associated with the duodenum as the dissection proceeds the pancreas must be ligated. Care is taken to preserve the
proximally, making isolation of the pancreaticoduodenal vessels celiac, left gastric, hepatic and gastroduodenal arteries. Once
more difficult. Blunt dissection using moistened cotton swabs or the vasculature is clipped or ligated, the pancreatic tissue is
fine hemostats is used to separate the lobules from the vessels removed in a similar fashion to the right lobe.
(Figure 21-19). In the dog, the right lobe can only be removed to
the level of the accessory pancreatic duct, while in the ferret or Nodule removal is performed by bluntly dissecting the nodule from
the cat, the lobe can be removed to the level of the pancreatic the surrounding tissue using cotton swabs or a fine hemostat.
duct. Once the desired portion of the pancreas is dissected free Hemorrhage from small vessels may be controlled using pressure
from its attachments, one of several techniques may be used to or small vascular clips. Care is taken to preserve the major intes-
occlude the ducts. An encircling ligature can be placed around tinal and pancreatic vessels and ducts. Ideally, a border of normal
the organ, a stapling device can be used to compress the tissue, pancreatic tissue should be removed with the nodule.
or fine hemostats can be used to bluntly remove glandular tissue
from the vessels and ducts, which are then individually occluded If multiple pancreatic nodules are found, it may be necessary
with vascular clips or ligated. The distal portion of the gland is to use a combination of techniques to remove the nodules. If no
then removed. Any complete rent in the mesentery created by nodules are found, intraoperative ultrasound may aid in identifi-
removal of the gland is directly repaired or is covered with an cation. In dogs, injection of methylene blue has been used to help
omental patch. identify nodules, but the technique carries the risk of causing
acute renal failure and is falling out of favor. Finally, if no nodules
To gain exposure to the left lobe, the ventral leaf of the omentum can be identified , pancreatic biopsy should be performed to rule
is opened. The distal portion of the lobe is grasped and the out diffuse pancreatic beta cell tumor, a condition that occurs in
relationship of the pancreas to the splenic and left gastroepiploic < 5% of dogs with insulinoma.2
Figure 21-19. Pancreatectomy technique: separation of the pancreas from the duodenum.5
344 Soft Tissue
Most animals with insulinoma have microscopic or gross with chronic pancreatitis can have obstruction of the bile duct
metastatic lesions present at the time of initial diagnosis. Metas- secondary to scar formation and may need to be treated with a
tasis is seen most commonly in regional lymph nodes and the biliary diversion procedure.
liver. Since metastases are functional tumors it is important to
identify and remove as many of the lesions as possible. It would
be ideal if metatstatic lesions were identified before surgery, but
Surgical Treatment of Pancreatic Cysts
surgical exploration is currently the most accurate method for and Abscesses
identifying these lesions. Ultrasound, computed tomography and Cystic fluid accumulations and abscesses can occur in pancreatic
single photon emission computed tomography have all been used tissue, mainly in association with pancreatitis. Sterile abscesses
to identify primary and metastatic lesions, but no technique is may be the result of tissue necrosis. When a pancreatic fluid
superior to surgery.11 The pancreaticoduodenal, hepatic, jejunal accumulation is observed on ultrasonic examination, needle
and splenic lymph nodes are carefully examined for enlargement. aspiration is used to identify the fluid and may also be used to
Precise, careful dissection using fine vascular instruments and drain the accumulation. Cysts and sterile abscesses are not
magnification is often needed to remove an enlarged lymph node usually treated surgically, unless they are causing obstruction.
while preserving the vasculature to the intestines. Nodules within Infected abscesses require surgical debridement and drainage.
the liver can be removed with partial hepatectomy. If removal of
the metastatic lesions is likely to endanger the life of the animal, The pancreatic region is carefully explored and the fluid accumu-
it may be preferable to treat with medical therapy. lation is located. The wall of the cyst or abscess is removed. The
region is flushed and debrided, if indicated. If available, omentum
Pancreatic tumors other than insulinomas are rare. Endocrine can be placed in the cavity to aid in drainage.16 A silicone closed
tumors include gastrinomas, glucagonomas and other neuroen- suction wound drain or a sump drain is placed to further drain
docrine cell tumors. Surgical treatment of these tumors is similar the region.
to that of insulinoma. Pancreatic carcinomas are often extensive
at the time of diagnosis and are highly metastatic. Partial pancre-
atectomy can provide a period of remission from clinical signs if Perioperative Care
the primary tumor is localized to one lobe.12 Glucose control is an important part of perioperative management
of an insulinoma patient. At the time of food withdrawal, an intra-
venous infusion of a balanced electrolyte solution containing
Complete Pancreatectomy 2.5-5% dextrose is begun. Infusion is continued through surgery
Complete pancreatectomy is a formidable procedure and is and into the postoperative period. Large doses of dextrose may
rarely indicated. Removal of the entire pancreas produces an cause an exaggerated insulin response and should be avoided.
animal that is diabetic and has pancreatic exocrine insuffi- After surgery, glucose must be monitored closely because hyper-
ciency. Management of these patients requires an intelligent, glycemia (8-35% of canine patients) and hypoglycemia (15-26%
dedicated owner, who can follow a detailed feeding, medication of canine patients) have been reported. The goal is to maintain a
and glucose monitoring regime. The technique is similar to the blood glucose between 40-200 mg/dL. If hyperglycemia persists
technique for partial pancreatectomy, except that the dissection after 48-72 hrs, insulin therapy may be needed.2
is carried around the body of the pancreas. The dissection is
most commonly performed from the left to the right side. The Animals should be kept well hydrated to help prevent the devel-
pancreatic branches from the hepatic and gastroduodenal opment of pancreatitis. Oral feeding may be delayed for 24-72
arteries are ligated. Blunt dissection is used to expose and hours after surgery, depending on the extent of pancreatic
preserve the pancreaticoduodenal vessels and the branches manipulation. When food is reintroduced, small bland meals
entering the pancreas are clipped or ligated. The pancreatic are fed. The animal is monitored closely for the development of
ducts are transected without ligation. After removal of the nausea, vomiting, cranial abdominal pain or systemic inflam-
pancreas, the rent in the duodenal mesentery is closed. matory syndrome. Postoperative pancreatitis has been reported
in 10-43% of canine patients undergoing nodule removal or partial
Surgical Treatment of Pancreatitis pancreatectomy.2 It is rare in ferrets.8 If extensive dissection in
the body of the pancreas is performed, a jejeunostomy tube
A recent consensus conference on the treatment of acute
should be placed prophylactically to allow early enteral feeding
pancreatitis in people confirmed that surgical treatment of acute
after surgery. Placement of a closed silicone abdominal drain in
pancreatitis is not indicated unless confirmed bacterial abscess
the region of the pancreas at the conclusion of surgery allows
formation is present.13 Studies in dogs have shown that animals
for rapid diagnosis of postoperative pancreatitis and aids in the
treated with early enteral feeding rather than intravenous
management of abdominal effusion associated with pancreatitis.
feeding during pancreatitis have reduced plasma endotoxin
levels, decreased bacterial translocation to the portal and
systemic blood, and improved measures of bowel wall health.14 References
Jejunal feeding tubes can be placed during celiotomy or using 1. Cornell KF, J. Surgery of the exocrine pancreas In: Slatter D, ed.
minimally invasive surgery techniques. Acute pancreatitis can Textbook of Small Animal Surgery, third edition. Philadelphia, PA: W.B.
also lead to obstruction of the bile duct secondary to inflam- Saunders, 2003;p 752.
mation. Temporary choledochal stenting (See Hepatobiliary 2. Kyles A. Endocrine Pancreas In: Slatter D, ed. Textbook of Small Animal
Surgery) is used to maintain biliary tract patency.15 Animals Surgery, third edition. Philadelphia, PA: W. B. Saunders, 2003; p1724.
Liver, Biliary System, Pancreas 345
3. Miller ME CG, Evans HE. Anatomy of the Dog. Philadelphia: W. B. toward the ventral midline from right to left during ventral midline
Saunders, 1964. p. 706. celiotomy. The left limb can then be identified by tracing the right
4. Poddar S. Gross and microscopic anatomy of the biliary tract of the limb towards the angle (body), and retraction of the spleen. It can
ferret. Acta Anat (Basel);97:121, 1977. be helpful to perforate the greater omentum to better visualize
5. Caywood D. Surgery of the Pancreas In: Bojrab M, ed. Current and palpate the left limb of the pancreas as it courses dorsally
Techniques in Small Animal Surgery 2nd edition. Philadelphia: Lea & along the greater curvature of the stomach. In the area of the
Febiger, 1983; p 232. angle and left limb of the pancreas the surgeon should also
6. Newman S, Steiner J, Woosley K, et al. Localization of pancreatic examine the regional lymph nodes since these may be affected
inflammation and necrosis in dogs. J Vet Intern Med 18:488, 2004. by metastasis in cases of pancreatic neoplasia (Figure 21-20).
7. Harmoinen J, Saari S, Rinkinen M, et al. Evaluation of pancreatic
forceps biopsy by laparoscopy in healthy beagles. Vet Ther;3:31, 2002. Because of the lobulated nature of the pancreatic parenchyma,
8. Weiss CA, Williams BH, Scott MV. Insulinoma in the ferret: clinical and the tendency for the organ to sometimes fold on itself,
findings and treatment comparison of 66 cases. J Am Anim Hosp examination of the pancreas should be both visual and tactile
Assoc;34:471, 1998. (See Figure 21-20). The latter requires the surgeon to gently
9. Moore AS, Nelson RW, Henry CJ, et al. Streptozocin for treatment of palpate the organ between his or her fingers along its entire
pancreatic islet cell tumors in dogs: 17 cases (1989-1999). J Am Vet Med course. Small, but potentially significant lesions (e.g., islet cell
Assoc;221:811, 2002. tumors) may be missed if the pancreas is not palpated in addition
10. Robben JH, van den Brom WE, Mol JA, et al. Effect of octreotide on to visual inspection.
plasma concentrations of glucose, insulin, glucagon, growth hormone,
and cortisol in healthy dogs and dogs with insulinoma. Res Vet Sci 2005, On occasion the pancreas will be explored because a large
in press.
mass has been identified on pre-operative imaging, or because
11. Robben JH, Pollak YW, Kirpensteijn J, et al. Comparison of ultraso- of medically unresponsive pancreatitis. Surgeons should be
nography, computed tomography, and single-photon emission computed
familiar with the appearance of such lesions as pancreatic
tomography for the detection and localization of canine insulinoma. J
pseudocysts and abscesses when examining the pancreas at
Vet Intern Med;19:15, 2005.
the operating table. Surgeons should especially be aware that
12. Tasker S, Griffon DJ, Nuttall TJ, et al. Resolution of paraneoplastic
inflammatory disease of the pancreas may appear aggressive
alopecia following surgical removal of a pancreatic carcinoma in a cat.
J Small Anim Pract;40:16, 1999. and invasive. The organ may be diffusely enlarged, irregular, have
varying color, and appear to invade into surrounding omental fat.
13. Nathens AB, Curtis JR, Beale RJ, et al. Management of the critically
ill patient with severe acute pancreatitis. Crit Care Med;32:2524, 2004.
This appearance may suggest a gross diagnosis of “extensive
and unresectable malignant neoplasia”, and may even prompt
14. Qin HL, Su ZD, Gao Q, et al. Early intrajejunal nutrition: bacterial trans-
location and gut barrier function of severe acute pancreatitis in dogs.
the surgeon to recommend immediate euthanasia. However, it is
Hepatobiliary Pancreat Dis Int;1:150, 2002. not uncommon for biopsies of aggressive appearing pancreatic
lesions to reveal no evidence of neoplasia, and instead necro-
15. Mayhew PD RR, Mehler SJ, Holt DE, Weisse. Choledochal tube
stenting for decompression of extrahepatic biliary obstruction in dogs. tizing/hemorrhagic inflammation along with local steatitis,
Proceedings of the American College of Veterinary Surgeons Veterinary adhesions, and fat saponification. While the diagnosis of necro-
Symposium 2004:14. tizing/hemorrhagic pancreatitis may prove to be a serious and
16. Jerram RM, Warman CG, Davies ES, et al. Successful treatment of a potentially fatal diagnosis, it may still be manageable with appro-
pancreatic pseudocyst by omentalisation in a dog. N Z Vet J 2004;52:197, priate therapy. The surgeon should not conclude that neoplasia
2004. is the diagnosis on the basis of appearance alone.
Figure 21-20. Pertinent anatomy for exploration of the pancreas. Arrows depict the right limb, left limb, angle, and approximate location of the
pyloric lymph nodes. The pancreas may be gently palpated as shown to detect small masses that may be otherwise visually obscured. The entire
organ should be examined, including the left limb which is located in the omental tissues caudal to the stomach and cranial to the spleen. Note
the relationship between the right limb and the duodenum, including their shared blood supply.
the two organs, but even then they usually become more closely the surgeon when examining or operating on the pancreas.
apposed at the cranial aspect of the right limb near the angle. The
arteries course longitudinally between the two organs and are The pancreas has lymphatics that drain into the mesenteric,
almost completely obscured by pancreatic parenchyma on both hepatic, and splenic lymph nodes, and these nodes (along with
sides. The cranial and caudal pancreaticoduodenal arteries (the the pyloric nodes) should be examined for metastatic disease
former a branch of the celiac via the hepatic; the latter a branch when pancreatic neoplasia is suspected. The pancreas receives
from the cranial mesenteric) anastomose within the organ. The some sympathetic innervation from the nerves that emerge from
left limb of the pancreas is contained within the deep leaf of the the celiac plexus, while parasympathetic nerve fibers from the
greater omentum. Its main blood supply is from the pancreatic vagus course to the gland with the celiac and cranial mesenteric
branches of the splenic and hepatic arteries (branches of the vessels. Venous drainage from the pancreas (caudal pancreati-
celiac), with some contribution by the gastroduodenal artery. coduodenal vein from the right limb and splenic vein from the
Thus, the blood supply to the left limb is more segmental than left) empties into the portal vein.
the right. The left and right limbs are joined at a V-shaped angle
called the body. This portion of the pancreas resides caudal to The exocrine ducts were named based on the description in
the pylorus and antral region of the stomach, and is where the humans (pancreatic vs. accessory pancreatic) and this leads to
exocrine ducts of the pancreas enter into the duodenum. some confusion. Although variation in ductal anatomy has been
well described in dogs, the vast majority of dogs have most of their
The location of the right limb of the pancreas brings it into pancreatic exocrine flow into the duodenum via the accessory
proximity with other abdominal structures including the right duct and the minor duodenal papilla. Since, with few exceptions,
body wall/flank, sublumbar fat containing the right ureter and the left and right ducts anastomose within the body, the accessory
kidney, the caudate process of the liver, the ascending colon duct carries secretion from both limbs. The smaller (in dogs)
and cecum, and loops of jejunum. The left limb may be in contact pancreatic duct enters the duodenum at the major papilla directly,
with the caudate process of the liver, the portal vein, caudal vena or by opening into the bile duct as it joins the intestine. In cats, the
cava, aorta, left adrenal gland, transverse colon, and cranial pole ducts from left and right join to empty almost exclusively via the
of the left kidney.2 These relationships may have implications for pancreatic duct into the bile duct at the major duodenal papilla.3
Liver, Biliary System, Pancreas 347
Indications for Pancreatic Surgery the absence of specific clinical signs usually results in a delay in
diagnosis until late in the biological course of disease.
Exocrine Pancreatic Disease
The pancreas may be explored because of a clinical diagnosis Endocrine Pancreatic Disease
of exocrine pancreatic insufficiency (EPI). Dogs with EPI are
The most common endocrine disease of the pancreas is diabetes
expected to have a significantly reduced volume of pancreatic
mellitus. This disease is usually not an indication for pancreatic
parenchyma compared with normal individuals. A confirmatory
surgery. There are important considerations with respect to
biopsy may be performed as described below. Assuming the
properly managing diabetic patients undergoing anesthesia
entire organ is diffusely affected, the easiest and safest location
and surgery for other disease processes that are addressed
to biopsy is the distal aspect of the right limb. Dogs with EPI,
elsewhere.18
especially German shepherds, have a reported higher risk for
mesenteric volvulus, and may also be at higher risk for gastric
The most common indication for pancreatic surgery due
volvulus.4 Therefore, a dog with suspected EPI should have
to endocrine disease is the suspicion that the patient has
a prophylactic gastropexy performed as part of the surgical
a functional endocrine tumor. Several types of endocrine
procedure (See Chapter 19).
pancreatic neoplasia have been documented in small animals.
The endocrine functions of the pancreas are located in the islet
Pancreatitis is treated with intense medical management and is
cells (of Langerhans), which are distributed randomly throughout
rarely an indication for exploration of the pancreas surgically.
all portions of the pancreas. These mostly neural crest-derived
However, if imaging studies suggest the presence of an abscess
APUD (Amine Precursor Uptake and Decarboxylation) cells
or pseudocyst then there may be benefit to surgical inter-
migrate into the pancreas during embryonic development. This
vention. The goal should be to obtain appropriate samples for
migration can be imperfect, and as a result functional neuroen-
histopathology and culture, and to establish drainage. Drainage
docrine cells normally associated with the pancreatic islets
techniques will be dependent on the location, size, and mobility
may be located in extra-pancreatic locations, including the
of any cavitary lesion identified. Marsupialization is probably the
gastric wall, duodenum, and elsewhere. This in turn implies that
least practical or desirable technique. Drainage tubes may be
functional “pancreatic” tumors may arise ectopically, and this
chosen, and of these a fenestrated silastic drain attached to a
must be borne in mind when exploring a patient’s abdomen for a
closed-suction type device exited through the body wall would
suspected endocrine tumor, especially if a primary lesion is not
be best. Another excellent option to consider is omentalization.
found in the pancreas itself.
This has been described for use with a variety of intra-abdominal
abscesses and involves placing a pedicle of vascularized
Endocrine pancreatic neoplasia is usually named based on the
omentum into and/or through the abscess or cystic cavity and
predominant hormone produced by the tumor. The most common
securing it with sutures. The omentum brings a blood supply as
of these tumors is the insulinoma, derived chiefly from a clone
well as lymphaticovenous drainage to the site of disease.5-12
of neoplastic beta cells in an islet. In older veterinary literature
and in the parlance of the human literature a distinction is made
Pancreatitis may be associated causally with or as a result of
between “insulinoma” (a benign proliferation of beta cells) and
biliary disease.13,14 Because of the close anatomic association
“functional islet cell adenocarcinoma” (the malignant variety
of the pancreatic and accessory pancreatic ducts with the bile
most commonly diagnosed in dogs). However, in current veter-
duct in the proximal duodenum it is possible for disease in one
inary clinical and pathology literature the two terms tend to be
system to spread to the other. Sludging of bile with extrahepatic
used interchangeably, so that the term “insulinoma” can describe
biliary obstruction has been reported in dogs with previous
either benign or malignant neoplasia. Other reported neuroendo-
episodes of acute pancreatitis.13,14 Similarly, but less commonly,
crine tumors include gastrinomas (Zollinger-Ellison syndrome)
a primary cholangitis/cholangiohepatitis might result in spread
arising mostly from non-pancreatic sites, but occasionally in the
of micro-organisms from the biliary tree into the pancreatic
pancreas (putatively from delta cells), glucagonomas (alpha cells),
ducts, inducing pancreatitis. Thus, whenever examining the
non-specific polypeptidinomas, and somatostatinomas (delta
pancreas in instances of exocrine disease the surgeon should
cells). In dogs these tumors are usually malignant, and spread to
also evaluate the biliary tree and liver.
local lymph nodes (Stage II disease) or liver (Stage III disease)
is commonly found at the time of initial surgery. The implications
Exocrine tumors of the pancreas (pancreatic adenocarcinoma)
for prognosis (disease-free interval and survival time) have been
are infrequently diagnosed in the canine and feline. Clinical
reported as has the use of adjuvant medical therapy.18-23 This
signs of vomiting and anorexia are non-specific, however cats
discussion will be limited to patient management during surgery
may develop a cutaneous syndrome that includes lameness
and the immediate postoperative period. The reader is directed
due to foot pad ulceration and sloughing.15-17 Clinical signs of
elsewhere for a review of criteria for confirming the diagnosis of
exocrine pancreatic neoplasia may be due to the mass effect
specific endocrine tumors of the pancreas.18
on neighboring organs if the tumor is large enough, or due to the
effects of metastatic disease and/or carcinomatosis. Dogs with
pancreatic adenocarcinoma usually do not have signs of either Pancreatic Biopsy and Partial Pancreatectomy
EPI or of pancreatitis. Surgical resection may be attempted Incisions into the pancreas have the potential for inducing pancre-
depending on the extent of disease, but the prognosis is usually atitis as a consequence of enzymatic leakage and activation of
grim. Malignant pancreatic tumors are aggressive cancers and zymogens. Even gentle tissue handling may cause enzymatic
348 Soft Tissue
activation. The safest course of action, in my opinion, is to assume of the mass, or incisional or needle biopsy. The latter may be
that some leakage has occurred. I recommend withholding food performed with a Tru-cut device or other biopsy needle such as
and water for a minimum of 36 hours after pancreatic incision. Vim-Silverman needle. Enucleation refers to a local dissection
Serum enzymes such as lipase and amylase may be monitored of pancreatic lobules while leaving the pancreas distal to the
as desired, but these enzymes are notoriously insensitive and biopsy site intact. Lobules of parenchyma are teased away from
non-specific markers for acute pancreatitis. A better indication the tissue to be removed using fine hemostats and sterile cotton
of when to resume oral intake is the clinical appearance of the swabs. Hemostasis can be achieved with gentle direct pressure,
patient, including such signs as rectal temperature and emesis. fine suture (4-0 or 5-0) or fine-tipped bipolar electrocautery.
If the patient has not vomited for 36 hours or more, there is no However, if extensive damage to the ducts or vessels is required
fever, and there is no unusual abdominal tenderness on palpation, (depending on the size and location of the lesion), partial pancre-
oral consumption of small amounts of water, followed by small atectomy is considered and is preferred rather than enucleation.
amounts of bland food every few hours can be attempted, with a Incisional biopsy is performed using a #15 scalpel blade to take
gradual return to normal alimentation. Oral consumption should a small wedge of tissue and a single absorbable suture is used
be discontinued or delayed if the animal has signs suggestive of to close the defect.
pancreatitis. If extensive pancreatic manipulation is required a
jejunostomy feeding tube should be placed at the time of surgery When pancreatic disease is identified during surgery, the surgeon
(See Chapter 6). The jejunostomy tube will permit feeding the must determine whether and how to employ the above techniques
animal without stimulation of pancreatic exocrine secretion. for successful excision if possible. The most difficult anatomic
location to excise a lesion is in the body of the pancreas since
A generous cranial ventral midline incision is made to expose there is a risk of disrupting both the pancreatic and accessory
the cranial abdomen. Exposure of the pancreas is facilitated pancreatic ducts. There are techniques for attempting to directly
by appropriate use of retractors and moistened laparotomy anastomose the remaining pancreas and duct to the intestine,
pads. Self-retaining retractors such as Balfours placed on the but this is technically difficult and rarely performed in veterinary
abdominal wall and a surgical assistant using malleable ribbon clinical cases.25 In this situation, or in other situations that might
retractors to retract viscera are beneficial for exposure. Warmed call for total pancreatectomy (such as lesions causing complete
irrigation solution is indicated for local lavage after pancreatic obstruction to exocrine flow already, as might be seen with
surgery is completed, and suction is helpful to aspirate blood chronic pancreatitis or neoplasia), the surgeon must give careful
and lavage fluid. consideration to the merits of attempting to resect all disease
relative to the impact on the animal’s (and client’s) quality of life
When lesions are confined to the caudal aspect of the right limb of following surgery.
the pancreas, or a random biopsy is intended, the easiest method
is excision of the caudal aspect of the right pancreatic limb. This
can be performed with sutures, surgical stapling equipment,
Total Pancreatectomy
or the use of a hemostatic sealing device (eg. Liga Sure™). For There are no indications for total removal of the pancreas
those animals with a small pancreas it may be suitable to mass in dogs other than in the research laboratory. The clinical
ligate the isolated portion with suture (suture-fracture technique) diagnosis where total pancreatectomy might be indicated is
after dissection of the pancreas from the mesoduodenum. I extensive pancreatic neoplasia, but it would be unlikely to have
recommend the use of 2-0 or 3-0 monofilament non-absorbable disease confined to the pancreas in such a case. The presence
suture such as polypropylene. Alternatively, the duodenal of local infiltration and distant metastasis make such surgical
serosa can be gently grasped and dissected off the pancreatic treatment a short term palliative procedure at best. Because
lobules; the lobules are then separated (sterile cotton swabs of the shared blood supply between duodenum and pancreas,
are useful) from the midline of the gland to expose the vessels total pancreatectomy will require duodenectomy, splenectomy,
and ducts. The vasculature and ducts can then be ligated with and biliary diversion. As a result of surgery the patient will be
suture (3-0 or 4-0) or hemostatic clips and the pancreas resected diabetic and have EPI post-operatively. To my knowledge, there
distal to the ligations. Thoracoabdominal staplers are effective are, at present, no reports of total pancreatectomy for treatment
for single-stage ligation and resection. In most dogs the TA-30 of naturally-occurring disease in dogs or cats.
size will be suitable, and small vascular staple cartridges (V3)
are most effective (Figure 21-21) Stapling can also be performed Surgical Technique for Treating Pancreatic
by laparoscopy. Although the suture-fracture and stapling
techniques induce some parenchymal crushing as the suture Endocrine Neoplasia
is tightened or staples are fired, no differences in complication The most common indication for pancreatic exploration and
rates have been found.24 Ligation of a pancreatic duct does not partial pancreatectomy is the suspicion of a functional beta-cell
induce pancreatitis but will induce acinar atrophy in any residual tumor (insulinoma). In most cases the veterinarian should have
pancreas distal to the ligation. make a diagnosis of insulinoma by demonstrating that the patient
has persistent hypoglycemia not due to laboratory error, and a
If biopsy or excision of a lesion nearer the body or in the left high level of serum insulin when the serum glucose is well below
limb is required, surgical options include partial pancreatectomy normal ranges. These findings are not exclusive to insulinoma
as described above (for the left side this requires dissection however. There may be other causes for hyperinsulinism such
of the deep leaf of the omentum for exposure), enucleation as hepatic disease (usually neoplasia) that disrupts normal
Liver, Biliary System, Pancreas 349
Figure 21-21. Partial pancreatectomy. Depending on patient size, it may be possible to mass ligate the distal aspect of the pancreas for excision
of a tumor. For most patients, however, surgical tools designed for achieving hemostasis without inducing pancreatic injury that might activate
zymogens (and cause pancreatitis) are preferred. Two of these instruments are depicted here. A. is application of a thoracoabdominal (TA) sta-
pling device. For most patients a 30 mm instrument is appropriate, and a cartridge with small vascular staples in a triple staggered row achieves
both hemostasis and closure of the ducts. (Aa) The specimen distal to the stapler, containing the tumor, is then sharply incised using the stapler
as a cutting guide, and the specimen is removed. Alternatively, a vessel sealing device may be used as depicted in B. The jaws of the instrument
are closed around the pancreas and the instrument activated to seal the vessels and ducts. An audible feedback is provided by the instrument
to alert the surgeon whether successful sealing has occurred. (Bb) The device contains a cutting blade that then divides the tissues contained
in the jaws, and the instrument is then advanced sequentially until the entire specimen has been dissected and can be removed. With the vessel
sealing device, a portion of the pancreas distal to the area containing the tumor may be preserved. However, the ducts may not be patent and
acinar atrophy might result.
350 Bones and Joints
insulin degradative metabolism and which may also consume visually and thoroughly palpated. Most islet cell tumors will
glucose prodigiously. Appropriate imaging studies (ultrasound, appear as discrete, raised, firm, lobulated nodules. They range
computed tomography, magnetic resonance imaging) should be from light brown to almost violet in color. Size can range from
able to distinguish those patients with a primary hepatic lesion. a few millimeters in diameter to several centimeters. There is
With the possible exception of CT or MRI, however, imaging no proven site predilection within the pancreas and tumors have
studies (particularly ultrasound) are often not able to confirm the been reported with equal distribution in both limbs and the body
presence of a primary insulinoma in the pancreas. Thus, in most of the organ. There is also no correlation between the severity/
cases animals undergo celiotomy for diagnostic confirmation as refractoriness of pre-operative hypoglycemia and the size of
well as for disease staging and treatment. the primary tumor. Tumors are usually solitary but the entire
pancreas should be examined to ensure that no additional tumors
The goal of pre-operative and intra-operative patient are present. Once the tumor is identified the surgeon will need to
management should be to stabilize the blood glucose in an determine which of the techniques for partial pancreatectomy
acceptable range, ideally in the low normal range if possible. is appropriate. In all cases, whether there are gross lesions or
Anesthetized patients and those with a history of hypoglycemia- not, one or more regional lymph nodes should be resected and
induced seizures are particularly vulnerable to the effects of at least one liver biopsy obtained for staging purposes. Partial
neuroglycopenia which can cause cortical laminar necrosis and pancreatectomy is desirable when possible since recurrence
permanent brain damage. To some degree, the central nervous rates may be lower with this technique compared to enucleation
system (CNS) has adaptive mechanisms that permit function even of the mass. All apparent neoplastic tissue including metastatic
at low levels of blood glucose, but the neurons are at a threshold disease is resected when possible. Persisitent hypoglycemia
and are intolerant of any further (especially sudden) decrease in may result if gross neoplastic disease cannot be resected.27
glucose levels. Achieving and keeping blood glucose normalized The local area should be lavaged with warm saline to remove
and stabilized is challenging since insulinomas, although not bacterial contamination or pancreatic enzymes that might have
responsive to normal negative feedback mechanisms, may leaked, and the abdominal incision closed routinely.
still have intact positive feedback. Administering exogenous
dextrose especially in high concentrations may stimulate further In rare instances, examination of the pancreas will fail to identify
secretion of insulin. This may fail to raise the blood glucose the tumor. This could be the consequence of missing a tumor
level by stimulating excess insulin secretion and may cause that’s present (eg., a small tumor enveloped within surrounding
wide variations in glucose levels. These variations, especially exocrine parenchyma), an ectopic (extra-pancreatic) tumor, or a
sudden decreases in glucose may induce more severe signs of misdiagnosis. The first two are most likely. In this case, it can
CNS dysfunction than persistently low blood glucose, at least be helpful to utilize intra-operative vital staining with methylene
in conscious patients. The use of 10% to 20% glucose solutions blue, USP. Methylene blue concentrates in specific endocrine
is indicated for management of patients with persistent hypol- cells, notably pancreatic islet cells and parathyroid chief cells.
glycemia. Hypertonic dextrose solutions are best adminstereed The degree of cellular uptake (and therefore intensity of tissue
through a jugular catheter. A second peripheral catheter can be staining) is correlated with the degree of function (secretion) of
used for blood sampling and monitoring. In addition to dextrose, these cells. Thus islet cell tumors and parathyroid gland tumors
other techniques for raising and stabilizing blood glucose include will selectively stain more intensively than normal cells.28,29
constant rate infusions of glucagon,26 administration of cortico-
steroids, beta-blockers, and specific drugs that inhibit secretion Methylene blue, USP (MB) is provided in 10 ml ampules as a 1%
of insulin from beta cells such as diazoxide.18-23 Blood glucose solution. It is approved for in vivo, intravenous administration. IT IS
should be monitored regularly during anesthesia and modifica- NOT THE SAME AS NEW METHYLENE BLUE (NMB)! The latter is
tions in treatment made as necessary to stabilize levels in the a laboratory reagent, and other than for the unfortunate similarity
appropriate range. in common names, the two products are entirely different chemi-
cally. If you choose to use this technique be certain you use the
Anesthetic protocols, other than for glucose homeostasis, correct product. Do not use New Methylene Blue!
are routine and at the discretion of the surgeon or anesthesi-
ologist. I administer prophylactic antibiotics, typically cefazolin The recommended protocol is to calculate a dose of 3mg/kg
(22mg/kg IV, q2h) starting at induction, and pre-emptive use of methylene blue and dissolve this quantity in 250 to 500 ml of 0.9%
analgesics should be standard. Drugs that cause blood pooling saline. This fluid can then be infused intravenously at a mainte-
in the spleen (barbiturates, phenothiazines, certain opioids) nance fluid rate of 10ml/kg/hr. Visualization of tissue staining will
should be avoided since retraction of an enlarged spleen may usually occur 15 to 20 minutes after starting the infusion, with
make surgical visualization and manipulation of the left limb of the pancreas taking on a dusky pale blue hue. An islet cell tumor
the pancreas more difficult. will stain a more intense blue or purplish color. Once the tumor is
visualized the MB infusion can be discontinued.28,29
Exploratory surgery of the pancreas for an insulinoma is preceded
by complete abdominal exploration to identify related or unrelated In addition to identifying an occult primary tumor or ectopic
disease. Special attention and examination for metastasis is disease MB infusion can help determine if a lesion seen beyond
focused on the liver and local lymph nodes. I usually reserve the pancreas is a metastatic nodule, and help determine if it
examination of the pancreas for last so as to not miss other should be resected.30
lesions. The entire pancreas should be exposed, then examined
Diaphragm 351
Using MB infusion routinely during pancreatic exploration for for insulinomas. Management of the medical syndrome induced
endocrine tumors is not recommended because of potential by the specific hormome excess is dictated by the effects of
negative effects. The patient may develop a pseudocyanosis that that syndrome. Gastrinomas are usually associated with the
has the potential for interfering with monitoring of patient oxygen- Zollinger-Ellison syndrome. These tumors produce hypergas-
ation during anesthesia. More significantly, MB can induce a trinemia that cause pyloric mucosal hypertrophy and possible
Heinz-body anemia that will cause the hematocrit to decrease 1 to gastric outflow obstruction. Gastrin also acts synergistically
2 days after MB administration. In experimental cases and limited with histamine and acetylcholine to increase production of
clinical use the anemia has not required transfusion however hydrochloric acid by parietal cells in the stomach, this may
the potential exists, especially if the patient has sustained acute cause gastric ulceration. Antacids such as proton-pump inhib-
blood loss from the operation. There have been reports of acute itors, as well as H2-receptor antagonists are part of the medical
renal failure after MB infusion. I am not convinced this was a management for this neuroendocrine tumor. Definitive therapy
toxic effect of MB as the reported cases did not provide adequate is removal of the primary tumor, however gastrinomas may be
descriptions of either the pre-operative renal status or of the use occult, ectopic, or diffuse, making identification and complete
of intra-operative fluid therapy. However, caution dictates that this removal difficult. Although gastrin is produced by fetal islet
potentially serious adverse effect should be considered especially cells (some gastrinomas have a primary pancreatic location), in
if the animal has preexisting renal disease. Finally, MB is excreted adults most gastrin is derived from extra-pancreatic sites. One of
in the urine. This will make the urine green, and has the potential the treatments for this disease is to remove the target for gastrin,
of staining flooring surfaces that urine may come in contact with.28 ie, to perform a partial gastrectomy with gastroduodenostomy
(Bilroth I) or gastrojejunostomy (Bilroth II).
After the primary insulinoma has been resected the surgeon
can expect a rapid rise in blood glucose levels. Fluid therapy Too few glucagonomas, VIPomas, pancreatic polypeptidomas
should be modified as glucose levels change. In most dogs, the or somatostatinomas have been reported in animals to reach
blood glucose will return to and remain in the normal range after meaningful conclusions about their biological behavior or
administration of dextrose and other pro-glycemic agents has treatment, but the principles with respect to pancreatic surgery
been stopped. However, in some instances the dog will become should be similar. Glucagonomas in dogs have been associated
hyperglycemic and have at least a transient diabetes mellitus. with superficial necrolytic dermatitis and diabetes mellitus, but
This is largely explained by down-regulation of receptors on these conditions can arise independently of a glucagonoma, and
the normal beta cells. Persistent hyperglycemia may require need not occur in confirmed cases of glucagonoma.32-34
exogenous insulin for treatment. Less commonly, but especially
if incompletely excised metastatic disease in lymph nodes or
liver is present, hypoglycemia may persist after removal of the References
primary tumor. Further surgical resection of gross disease is 1. Nickel R, Schummer A, Seiferle E, Sack WO: The Viscera of the
possible however most animals are managed with combinations Domestic Mammals. Berlin, Verlag Paul Parey, 1973, p119-122.
of euglycemic agents such as corticosteroids, diazoxide, and 2. DeHoff W, Archibald J: Pancreas. In: Archibald J (ed) Canine Surgery,
dietary modification. Because almost all insulinomas in dogs are 2nd. Santa Barbara, American Veterinary Publications, 1974, p827-842.
malignant, metastatic disease, even if not grossly apparent at the 3. Nielsen SW, Bishop EJ: The duct system of the canine pancreas. Am
time of surgery, is likely to develop. Development of metastatic J Vet Res 15:266, 1954.
disease may result in illness caused by the effects of the tumor in 4. Westermarck E, Rimmaila-Parnanen E: Mesenteric torsion in dogs
the organ involved, or more likely, due to the recurrence of hyper- with exocrine pancreatic insufficiency: 21 cases (1978-1987). J Am Vet
Med Assoc 195:1404-1406, 1989.
insulinism and resultant hypoglycemia. In some cases a second
(or more) operation can be used to effectively debulk metastatic 5. Whittemore JC, Campbell VL: Canine and feline pancreatitis. Compend
Contin Ed Pract Vet 27:766-776, 2005.
disease and prolong the disease-free interval and survival time.
6. Salisbury SK, Lantz GC, Nelson RW, et al: Pancreatic abscess in dogs:
Six cases (1978-1986) J Am Vet Med Assoc 193:1104-1108, 1988.
In addition to medical therapy that specifically promotes eugly-
cemia, cytotoxic chemotherapy can be used as adjunctive 7. Bailiff NL, Norris CR, Seguin B, et al: Pancreatolitihiasis and pancreatic
pseudobladder associated with pancreatitis in a cat. J Am Anim Hosp
treatment. The current drug of choice is streptozotocin. This
Assoc 40:69-74, 2004.
drug acts specifically to cause death of islet cells, but is also
8. Coleman M, Robson M: Pancreatic masses following pancreatitis:
extremely nephrotoxic. Historically, the drug was not used clini-
Pancreatic psedocysts, necrosis, and abscesses. Compend Contin Ed
cally because of its nephrotoxic effects which were reported to Vet Med 27:147-154, 2005.
be lethal. Interestingly, this conclusion was reached based on
9. Bray JP, White RAS, Williams JM: Partial resection and omental-
a report of four dogs in the literature. More recently, strepto- ization: A new technique for management of prostatic retention cysts in
zotocin has been used with success in treating islet cell tumors dogs. Vet Surg 26:202-209, 1997.
when administered with an intensive diuresis protocol.31 10. Campbell BG: Omentalization of a non-resectable uterine stump
abscess in a dog. J Am Vet Med Assoc 224:1799-1803, 2004.
Other Pancreatic Islet Cell Tumors 11. Johnson MD, Mann FA: Treatment for pancreatic abscesses via
omentalization with abdominal closure versus open peritoneal drainage
Less common than insulinoma are the other islet cell tumors of
in dogs: 15 cases (1994-2004) J Am Vet Med Assoc 228: 397-402, 2006.
the pancreas. The principles of surgical exploration, disease
12. Hosgood G: The omentum – the forgotten organ. Physiology and
staging, and partial pancreatectomy are similar to that described
potential surgical applications in dogs and cats. Compend Contin Educ
352 Soft Tissue
arrhythmias are present in 12% of small animals with diaphrag- a herniated stomach and strangulated bowel are situations in
matic hernia.8 Other common clinical signs include muffled which emergency surgery may be indicated.9 Gastric outflow
heart and lung sounds, thoracic borborygmi, a strong apex beat obstruction, metabolic alkalosis, and hypokalemia have been
ausculted on one side of the chest because of shifting of the reported in a dog with diaphragmatic hernia.24
apex to one side, and an asymmetric decreased caudoventral
resonance when the thoracic cavity is percussed.5 A “tucked A herniated stomach can rapidly distend from aerophagia,
up” abdomen is a rare finding.5,14 decreasing pulmonary compliance and can compress the caudal
vena cava, decreasing venous return resulting in a vicious cycle
Lateral radiographs of the thorax show an incomplete diaphrag- that can be rapidly fatal.5
matic silhouette in 97% of animals with a diaphragm tear.15 In 61%
of these animals, airfilled small intestinal loops are identified on A herniated parenchymal organ such as the spleen may tear
the thoracic side of the diaphragm.15 Hydrothorax, which may be as it passes through the diaphragm; the result may be acute
pleural effusion or hemothorax depending on the chronicity of hemothorax and a patient that may deteriorate rapidly after
the hernia, may be identified and may obscure the diaphragm. an initial response to shock therapy. Most small animals with
Repeated radiography after thoracocentesis is advisable, but it diaphragmatic hernia can be stabilized over 24 to 72 hours
may not show a diaphragmatic hernia definitively.15 Ultrasono- because the mere presence of a diaphragmatic hernia is not an
graphic evaluation is useful to identify abdominal viscera on indication for emergency surgery.8 For example, thoracic injuries
the thoracic side of the diaphragm, especially in the presence such as pulmonary contusion improve dramatically in 24 to 48
of pleural fluid because it enhances sonographic evaluation.16 hours, and pneumothorax may be managed by thoracostomy tube
Ultrasound can show abdominal organs, can differentiate insertion. The goal of initial management is to improve the cardio-
organs such as the spleen or liver from pleural fluid, and can respiratory status of the patient, thus improving the patient’s
sometimes demonstrate the defect in the diaphragm.16 Cytologic capability of tolerating the stress of anesthesia and surgery.
evaluation of pleural fluid in patients with acute hernias usually
reveals hemorrhage, whereas in a chronic diaphragmatic hernia,
a modified serosanguinous transudate is identified.5
Anesthesia
Anesthesia in the patient with diaphragmatic hernia is induced
Alternative techniques to attempt to confirm the presence or with as little stress as possible. Intravenous catheterization,
absence of a diaphragmatic hernia include barium adminis- appropriate intravenous fluid adminstration (crystalloid or
tration (1.0 mL 1kg) to verify herniation of a portion of the gastro- colloid), and cardiorespiratory monitoring are important.
intestinal tract, pneumoperitoneography, and positive contrast Premedication with a phenothiazine or a narcoleptic combi-
peritoneography (using 1 to 2 mL/kg of an aqueous tri iodidinated nation may relieve apprehension, but care is taken not to use
contrast agent).17,18 These techniques are done only if, in the cardiorespiratory depressing drugs when possible if decompen-
clinician’s judgment, the patient can tolerate the stress of such sation of the patient’s status is predictable.8 Mask induction of
a procedure and if plain radiographs and ultrasonography are anesthesia is avoided because it’s stressful and does not allow
nondiagnostic.15 Moreover, when viscera or omentum plugs the control of respiration or provide the ability to assist ventilation.8
diaphragm defect, a false negative evaluation is made.19,20 An ultra short acting barbiturate or propofol is used because
it allows rapid induction of anesthesia, quick intubation and
Ventilation can be evaluated by arterial blood gas analysis and near immediate control of ventilation with assitance or by a
noninvasive pulse oximetry.21,22 These techniques may identify mechanical ventilator.25 Isoflurane is preferred for maintenance
ventilation perfusion inequalities (alveolar arterial oxygen of anesthesia because a surgical plane of anesthesia is attained
difference)14 and physiologic shunting (estimated shunt equation).14 more quickly, it is associated with decreased recovery time, it
Impaired ventilation (hemoglobin saturation) can be determined subjects the patient to less cardiac depression, and it does not
using pulse oximeter probes attached to the lip in the awake dog.23 sensitize the myocardium to arrhythmias.8
The ear, tail, and toe may also be used effectively in awake dogs if
good contact is maintained across the vascular beds.23 Ventilation assistance is important as soon as anesthesia
is induced because of decreased pulmonary compliance
secondary to the presence of air, fluid, or abdominal viscera
Timing of Surgical Intervention within the pleural space.5,14 Assisted ventilation should not
The timing of anesthesia and surgical correction of diaphrag- exceed 20 cm H2O, to limit potential barotrauma from pulmonary
matic injury has a profound effect on the outcome of treatment.5,14 hyperinflation.8 Overinflation of the lungs during surgery may
Approximately 15% of small animals with diaphragmatic hernia result in rupture of pulmonary parenchyma, intrapulmonary
die before surgery.5 Animals with diaphragmatic herniorrhaphy hemorrhage, plumonary edema, and, rarely, pneumothorax.26
performed within the first 24 hours after injury have the highest Intraoperative elimination of atelectic areas subjects chroni-
mortality rate (33%).8 When surgery must be done depends on the cally atelectic lungs to mechanical and reperfusion injury.8,26 In
extent of the initial cardiopulmonary dysfunction, the presence this situation, reperfusion of these collapsed vascular channels
or absence of organ entrapment, and the degree of compro- disrupts capillary integrity and causes fluid to leak into the
mised pulmonary function.14 Diaphragmatic herniorrhaphy may interstitium; reexpansion pulmonary edema may result within
become an emergency procedure if aggressive supportive several hours after surgery.5,8,27 Atelectic areas that do not inflate
care cannot stabilize respiratory function.9 Acute dilatation of with 20 cm H2O gradually reexpand over several hours with a
354 Soft Tissue
continual negative pleural pressure of 10 cm H2O.28 Preoperative Strangulated viscera found within the thoracic cavity should be
treatment with glucocorticoids and antihistamines has been resected in situ without reestablishing circulation if possible.8 By
recommended (based on experimental evidence) to inhibit the doing so, prevention of toxemia from bacterial endotoxins and
effects of mediators of pulmonary vascular permeability that are exotoxins and the by products of tissue autolysis is possible.8
activated by lung injury in patients with chronic diaphragmatic Viscera may be incarcerated, strangulated, or obstructed after
hernia, but care is advised because antihistamines may poten- passing through a diaphragmatic hernia and the systemic
tiate hypotension.6,8 effects such as gastrointestinal obstruction or extrahepatic bile
duct obstruction may occur acutely or chronically.5,14,30 Chronic
strangulation of a liver lobe results in a modified serosanguinous
Surgical Approach transudate approximately 30% of the time.5 Before closing the
A ventral midline celiotomy extending from the xiphoid process to diaphragm defect, a chest drain is placed from a paramedian
a point caudal to the umbilicus is used to provide initial exposure stab incision, it is tunneled subcutaneously, and it is inserted
for diaphragmatic herniorrhaphy. The incision should be large intercostally into the pleural space (Figure 22-2). The advan-
enough to allow exploration of the abdominal cavity. This exposure tages of placing the chest drain early are that the drain can be
allows access to all regions of the diaphragm. Most diaphragmatic placed accurately with direct visualization and, after hernior-
tears are muscular and are located ventrally and may favor either rhaphy, control of the pleural space is obtained for the duration
the right12 or left side.10,29 The liver, small intestine, and pancreas necessary. The diaphragm closure need not be airtight because
are most commonly prolapsed into the thoracic cavity when the the chest drain provides control. Should an inadvertent tear in
diaphragm defect is on the right side, whereas the stomach, the lung parenchyma occur during herniorrhaphy, the presence
spleen, and small intestine prolapse on the left side.5 The surgeon of the tube will detect it and allow simple management. The
must examine the entire diaphragm because more than one tear chest drain is managed for a short time, usually 8 to 12 hours, or
may occur.14 Exploration of the abdominal cavity is indicated until the volume of air or fluid is 2 to 3 mL/kg per day or less. Air
because injury to other abdominal organs may be present and can be aspirated from the pleural space as the last suture is tied,
are potentially treated concomitantly. Should additional exposure but if a parenchymal tear is leaking air or if the herniorrhaphy is
be required to retrieve abdominal viscera adhered to structures not airtight, hypoventilation may result.
within the thoracic cavity, surgical exposure can be improved by
enlargement of the rent in the diaphragm, by paracostal extension
of the celiotomy, or by caudal midline sternotomy (Figure 22-1).
Lateral thoracotomy is not a practical or appropriate method to
expose a diaphragmatic tear because it requires preoperative
knowledge of the extent and side of the hernia, and the approach
does not allow exploration of the abdomen.8,14 Lateral thora-
costomy also decreases thoracic compliance from pain and thus
may contribute to hypoventilation.8
Figure 22-2. In this view, a chest drain has been inserted from a
paramedian incision, tunneled over the costal arch, and placed
within the pleural space under direct visualization before closing the
diaphragmatic hernia.
The suture material and pattern used to appose the diaphragm puppies, result in significant hemorrhage. and can jeopardize
depend largely on the surgeon’s preference. Radial tears are the life of the patient. Prosthetic materials may be a better option
apposed with simple continuous patterns or a combination of a if the potential to use autologous tissue may injure the patient.
horizontal mattress pattern oversewn with a simple continuous
pattern. A single layer simple continuous pattern is quickly Abdominal closure is accomplished routinely in patients with
completed, but it is susceptible to reherniation should the implant acute hernias. In those with chronic hernias, accommodation of
break. The surgeon should suture from the deepest portion of the viscera within the peritoneal cavity may be difficult because
the tear toward the more superficial regions. Large tears or of the contracted abdominal musculature. The abdominal
combined radial and paracostal tears may be apposed with musculature relaxes over time.14 Increased intraperitoneal
several interrupted sutures to arrange apposition of the wound pressure may occur. If intra abdominal pressure increases over
margins to minimize tension. Closure follows, using a simple 13 cm H2O, hepatic and portal venous flow may decrease.39 Intra
continuous pattern (Figure 22-3). Polypropylene, monofilament abdominal pressure (30 cm H2O) in one dog necessitated surgical
nylon, poliglecaprone, (Monocryl, Ethicon, Inc., Somerville, decompression.39
NJ), polydioxanone, and polyglyconate are sutures materials
acceptable for herniorrhaphy. Paracostal tears are sutured
using simple continuous patterns by suturing the diaphragmatic
Postoperative Care
wound edge to paracostal fascia or encircling the ribs. Mattress Evacuation of air from the pleural space should be done carefully
patterns that encircle the costal arch or paracostal muscle in patients with atelectasis that does not reinflate with inflation
fascia may also be used. Preplacing sutures sometimes facili- pressures of 20 cm H2O, such as may occur with chronic hernias.
tates closure of chronic diaphragmatic defects. Use of 3-0 and 2 Air may be evacuated in these patients slowly over a 12 hour
0 suture for small cats and dogs and 2 O and 1 0 for larger dogs is period by using periodic evacuations or by using a Pleurivac
recommended. Larger sizes are appropriate for giant breeds. (water seal) with no greater than a negative pleural pressure of
10 cm H2O.
Figure 22-4. A. A large defect in the diaphragm is shown. B. Paracostal incisions are made to release the diaphragm from restrictive scar. C. The
margins of the diaphragm are apposed using a simple continuous pattern. The paracostal margins may be apposed using interrupted mattress
sutures or sutures that encircle the costal arch.
Diaphragm 357
may reveal electrical alternans or may be normal.21 Radiographs defect) and caudoventral pericardial defect may commonly
of the thorax usually reveal an ovoid cardiac silhouette that accompany a congenital diaphragmatic hernia.12,13 These defects
joins the ventral diaphragm ventrally. Gas-filled loops of bowel may occur in varying degrees, depending on the individual dog
may be seen over the cardiac silhouette.14,21 Congenital perito- and they do not always appear together. Commonly, the heart
neopericardial hernias are often symmetrical in appearance on has no apparent abnormality. This pentalogy of defects has been
radiographs whereas thoracic abnormalities in pleuroperitoneal noted in several breeds, including cocker spaniels, Weima-
hernias may be assymetrical.8 Pectus excavatum and sternal raners dachshunds, and collies, and I have seen it in two kittens.
abnormalities may be seen with congenital diaphragmatic This syndrome is similar in some respects to thoracoabdominal
hernias in cats.20 Other diagnostic procedures that may be used ectopia cordis in human infants and has been termed peritoneo-
include administration of contrast material into the upper gastro- pericardial diaphragmatic hernia in small animals.14,18 A recent
intestinal tract, pneumoperitoneography or contrast peritoneog- report did not find abnormalities identical to the pentalogy found
raphy, and ultrasonography.10 Pneumoperitoneogrpahy may in puppies but skeletal and nonskeletal abnormalities did occur
induce pneumothorax and therefore may risk decompensation in 8 of 67 cats.20 Peritoneopericardial diaphragmatic hernias
so use of aqueous contrast is preferred.8 Ultrasonography from are not always associated with cranioventral abdominal wall
the right fifth intercostal space may reveal cardiac tamponade defects or intracardiac defects, and they are often difficult to
if liver lobes herniate into the pericardial sac and produce an detect unless clinical signs are obvious (usually exercise intol-
effusion.10,21 In general, ultrasonagraphic diagnosis of diaphrag- erance or a restrictive breathing pattern).
matic hernia is difficult.22 Thoracoscopy can be used to directly
observe the abdominal structure but careful inflation pressures The sternum normally fuses from cranial to caudal in dogs, and
are necessary to avoid compromising ventilation.22 the abdominal wall fuses from caudal to cranial. The ventral
portion of the diaphragm is thought to originate from the septum
transversum, which develops at the same time as cardiac
Congenital Diaphragmatic Hernia with septation; therefore, it seems reasonable that disruption of
Cranioventral Abdominal Defects fetal development at this particular time could cause defects
Congenital cranioventral abdominal wall defects in puppies in both regions. Dogs do not have a communication between
occur cranial to the umbilicus, but they may extend caudally the pericardial cavity and the peritoneal cavity so if such a
toward and to the umbilicus. (Figure 22-6). The cranial extent of communication is present congenitally, it is due to a defect in
the defect is often in the area of the commonly absent xiphoid development. The pericardium normally attaches to the ventral
process. Although cranioventral abdominal hernias are not diaphragm by the sternopericardial ligament and visceral
frequently encountered in small animal practice, the clinician mediastinum. Communication of the peritoneal and pericardial
must recognize that the abnormality differs from the much more cavities is not always obvious in this defect.
common umbilical hernia. Cranioventral abdominal hernias are
commonly associated with four other defects, which are recog- In human beings, these defects are attributed to a uterine
nized as a syndrome in humans and which have been reported in accident and are not considered heritable. Parents with children
dogs.12,13 Cranioventral abdominal hernia, failure of caudal sternal affected with thoracoabdominal ectopia cordis have gone on to
fusion, intracardiac defects (most commonly ventricular septal have anatomically normal children thereafter. No data support
heritability of the pentalogy of defects in dogs or cats.
Surgical Correction
Surgical repair of the cranioventral abdominal defect and the
diaphragmatic defect can be done early (I have performed such
operations on animals as young as 7 weeks of age), usually
between 8 and 12 weeks of age. The puppies are usually masked
with isoflurane to induce and maintain general anesthesia unless
they have significant respiratory restriction. In the latter example,
anesthesia may be induced with propofol with prompt intubation,
so ventilation may be carefully assisted. All puppies with these
defects benefit from assisted ventilation because of the space-
occupying abdominal viscera within their caudal mediastinum
and/or pericardial sac.13,23 Liver lobes, gall bladder, omentum and
small intestine are commonly found in the caudal mediastinum
or pericardial sac, and this appears to be similar in cats with
congenital diaphragmatic hernias.20
Figure 22-8. After incising the fascia on the abdominal side of the
diaphragmatic defect, a simple continuous suture pattern of 3-0 poly-
propylene is used to appose the crura of the diaphragm. (From Bellah
JR, Whitton DL, Ellison GW, et al. Surgical correction of concomitant
cranioventral abdominal wall, caudal sternal, diaphragmatic, and
pericardial defects in young dogs. J Am Vet Med.
Figure 22-7. Drawing of the surgeon’s view of a congenital diaphrag- tension on the closure. The pliability of the unfused costal arch
matic hernia before surgical correction. Notice the flared costal
in the young puppies and kittens makes this maneuver possible.
arches, absence of a xiphoid process, and a smooth-bordered V-
shaped diaphragmatic defect. (From Bellah JR, Whitton DL, Ellison GW,
If caudal sternal apposition does not narrow the defect to a
et at. Surgical correction of concomitant cranioventral abdominal wall, size that can be apposed without tension, the pericardium can
caudal sternal, diaphragmatic, and pericardial defects in young dogs. be incised cranial to the diaphragm and flaps can be created to
Am Vet Med Assoc 1989; 195:1722. close the defect.24 A free graft of pericardium may also be used to
close the defect.24 The third method is insertion of polypropylene
defect can be closed by using a simple continuous pattern from mesh to separate the body cavities. Omentum can be mobilized
the dorsalmost aspect of the defect and continuing in a ventral and sutured to each side of the implant to cover its surface. Other
direction (toward the sternal defect). When the diaphragm synthetic implants, such as lyophilized collagen sheeting (derived
apposition becomes tense, the suture can be tied, and mattress from porcine submucosa) have been used successfully.17
sutures can be preplaced from the diaphragm to the costal arch to
complete the separation of the thoracic and abdominal cavities. Congenital diaphragmatic hernias that are not associated with
The pleural cavity does not have to be invaded or opened when ventral abdominal wall defects and that lack obvious clinical
this defect is closed. Accidental opening of the pleural cavity by signs may not be diagnosed until much later in the pet’s life,
dissection or by needle penetration is possible while suturing. often when the animal is radiographed for another reason.
After the mattress sutures are tied, the abdominal defect can Correction of all congenital diaphragmatic hernias may not be
usually be apposed with simple interrupted nonabsorbable necessary, especially hernias diagnosed in old animals with
suture, followed by routine subcutaneous and skin apposition. no clinical signs of abdominal viscera (usually omentum) in the
When closure of the defects as described is routine, young caudal mediastinum or the pericardial sac. However, dogs or
puppies and kittens recover quickly and often do not require cats with clinical signs of congenital diaphragmatic hernia that
specialized postoperative care, other than that appropriate for are adults when the diagnosis is made are much more likely to
pediatric patients. Sometimes, the diaphragmatic defect is too have intrathoracic adhesions that prevent simple replacement
wide to appose without excessive tension. Three methods can of abdominal viscera into the abdominal cavity. These adhesions
be used to alleviate this problem. First, the caudal sternal costal may require extension of the diaphragmatic defect or a caudal
arch can be apposed by encircling with nonabsorbable suture. midline sternotomy to provide enough exposure for safe
This can effectively decrease the distance between the right dissection within the caudal thorax. Closure of the diaphragmatic
and left edges of the diaphragm and therefore can reduce the defect often requires releasing incisions from the paracostal
360 Soft Tissue
References
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Figure 22-9. When placement of the continuous suture is complete, 7. Keep JM. Congenital diaphragmatic hernia in a cat. Aust VetJ
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ventral abdominal wall, caudal sternal, diaphragmatic, pericardial, and
intracardiac defects in Cocker Spaniel littermates. J Am Vet Med Assoc
1989; 194:1741-1746.
13. Bellah JR, Whitton DL, Ellison GW, Phillips L. Surgical correction of
concomitant cranial ventral abdominal wall, caudal sternal, diaphrag-
matic, and pericardial defects in young dogs. J Am Vet Med Assoc 1989;
195:1722-1726.
14. Evans SM, Beiry DN. Congenital peritoneopericardial diaphragmatic
hernia in the dog and cat: a literature review and 17 additional case
histories. Vet Radiol 1980;21:108.
15. Eyster GJ, et al. Congenital pericardial diaphragmiatic hernia and
multiple cardiac defects in a litter of collies. J Am Vet Med Assoc
1977;170:516.
16. Valentine BA, et al. Canine congenital diaphragmatic hernia. J Vet
Figure 22-10. Closure of the diaphragmatic defect is complete after the
Intern Med 1988;2:109.
mattress sutures are tied. (From BelIah JR, Whitton DL, Ellison GW, et
al. Surgical correction of concomitant cranioventral abdominal wall, 17. Hunt GB, Johnson KA. Diaphragmatic, Pericardial, and Hiatal Hernia.
caudal sternal, diaphragmatic, and pericardial defects in young dogs. In Slatter D (Ed.), 3rd Edition, Saunders, Philadelphia, 2003; 471-487.
J Am Vet Med Assoc 1989; 195:1722.) 18. Kaplan LC, et al. Ectopia Cordis and cleft sternum: evidence for
Peritoneum and Abdominal Wall 361
Figure 23-1. Cross sections showing the anatomy of the sheath of the rectus abdominis muscle in the cranial and caudal portions of the
abdominal wall.
peritoneal fluid bathing the wound surface. The wound also is the admonition that closing only the external leaf of the rectus
invaded by monocytes and histiocytes from blood and underlying sheath provides insufficient strength to the incision. In a biome-
exposed tissues. Cells from peritoneal fluid, blood, or underlying chanical study of healing abdominal incisions in the dog, the
tissues differentiate to form fibroblasts, and the superficially strength of incisions closed by suturing the internal and external
located cells undergo metaplasia, gradually forming mesothelial leaves of the rectus sheath and the strength of incisions closed
cells. At the same time, intact mesothelial cells at the perimeter by suturing the external leaf only were similar.8
of the wound help in the repair by proliferation and migration.
Small defects in the peritoneum are healed by proliferation of Simple Interrupted Versus Simple Continuous
adjacent mesothelial cells, whereas large defects are covered
by undifferentiated cells that then become mesothelial cells.2-4 Suture Pattern
The traditional method to close an abdominal incision is simple
Peritoneal defects that are sutured have a higher incidence of interrupted sutures. The same incision can be closed more
adhesions than defects that are left open to heal. The stimulus quickly using a simple continuous pattern, with no difference in
for adhesion formation is not the peritoneal defect itself, but wound healing. In a randomized prospective trial of 3135 human
rather the ischemic tissue that results when edges of the defect patients comparing continuous and interrupted abdominal midline
are brought together by sutures. incision closure, no difference was found in the incidence of
wound dehiscence.9 In clinical use of simple continuous closure
No evidence, experimental or clinical, supports the contention of abdominal incisions in over 5000 dogs and cats, the incidence
that closure of the peritoneum is necessary for wound strength, of dehiscence is negligible.
to minimize postoperative dehiscence or hernia formation, or
to minimize the development of adhesions. On the contrary,
experimental and clinical studies in dogs, horses, and human
Closure Techniques
patients indicate that suturing the peritoneum should be avoided Midline Incision
to minimize the incidence of postoperative intra-abdominal With an incision through the linea alba in the cranial two-thirds
adhesions.3-7 of the abdominal hall, fibers of the rectus abdominis muscle are
not exposed, and the linea alba, including the peritoneum, can
Closure Alternatives be apposed accurately by full-thickness sutures. An adequate
portion of fascia must be included with each suture, and the
Closure of the Internal and External Leaves falciform ligament must not be interspersed between the edges
of the Rectus Sheath Versus Closure of the of the linea alba (Figure 23-2). Although the traditional suture
pattern is simple interrupted, a simple continuous pattern is a
External Leaf Only safe and faster alternative.
Closure of the paramedian abdominal incision by apposition of
the internal and external leaves of the rectus sheath is tradi- In the caudal third of the abdominal wall, the width of the linea
tional and has proved successful for years of clinical experience. alba decreases. An incision here frequently exposes the rectus
However, closure of the internal leaf takes time and requires that abdominis muscle. Because fibers of the rectus abdominis
the abdominal wall be manipulated to expose the internal leaf, muscle have little holding power, sutures are not full thickness.
which frequently retracts after incision. Studies have refuted Instead, sutures are placed to include an adequate portion of the
Peritoneum and Abdominal Wall 363
external leaf of the rectus sheath on each side of the incision and A paramedian incision in the caudal third of the abdominal cavity
to appose this fascia accurately without interspersion of rectus is closed by suturing the rectus fascia in a simple interrupted
abdominis muscle (Figure 23-3). The transversalis fascia and the or continuous pattern. The transversalis fascia and peritoneum
peritoneum are not included in the sutures. Sutures traditionally have little strength and are not sutured.
are simple interrupted, but a simple continuous pattern is a satis-
factory alternative. Simple Continuous Suture Technique
Acceptable suture materials include polyglycolic acid, polyg-
lactin 910, polydioxanone, polyglyconate, polypropylene, and
nylon. Surgical gut, stainless wire, and multifilament nonab-
sorbable suture materials should not be used. Suture size is
based on patient size: 3-0 suture material should be used for
cats and small breed dogs, 2-0 for medium-sized dogs, 0 for large
dogs, and 1 for giant breed dogs.
All knots are placed with care. The first throw is tied with apposi-
tional tension only to ensure that tissue is not strangulated. Five
additional square, flat throws are placed.10 After each throw is
made, the ends of the suture are pulled tight to make the knot
secure. The ends of the suture are cut 4 mm from the knot. As the
Figure 23-3. Midline incision in the caudal third of the abdominal wall continuous suture is placed, the rectus fascia must be loosely
closed by a suture placed to appose the external leaf of the rectus approximated, not apposed with tension. Wound strength is
sheath accurately. adversely affected if fascia is closed tightly.11
Paramedian Incision Subcutaneous tissues are closed with the same suture materials,
If the incision is paramedian in the cranial two-thirds of the usually a smaller size, placed in simple continuous pattern. Care
abdominal wall, the linea alba will be on one side and the is taken to avoid cutting the rectus fascia suture during closure of
external and internal leaves of the rectus sheath and rectus the subcutaneous tissue. Skin is closed with 3-0 nonabsorbable
abdominis muscle will be exposed on the other side, or on both suture placed in a simple interrupted or cruciate pattern, or skin
sides of the incision, the internal and external leaves of the staples are used.
rectus sheath and rectus abdominis muscle will be exposed. The
external leaf of rectus sheath is closed with a simple interrupted
or continuous pattern. The internal leaf of the rectus sheath and
References
1. Evans HE, Christensen GC. Miller’s anatomy of the dog. 2nd ed. Phila-
the peritoneum are left unsutured (Figure 23-4). delphia: WB Saunders, 1979.
2. Ellis H, Ashby EC, Mott TJ. Studies in peritoneal healing: a review. J
Abdom Surg 1969,11:110.
3. Hubbard TB, et al. The pathology of peritoneal repair: its relation to
the formation of adhesions. Ann Surg 1967; 165: 908.
4. Ellis H. The cause and prevention of postoperative intraperitoneal
adhesions. Surg Gynecol Obstet 1971;133:497.
5. Karipineni RC, Wilk PJ, Danese CA. The role of the peritoneum in the
healing of abdominal incisions. Surg Gynecol Obstet 1976:142:729.
6. Swanwick RA, Milne FJ. The non-suturing of parietal peritoneum in
abdominal surgery of the horse. Vet Rec 1973:93:328.
7. Ellis H, Heddle R. Does the peritoneum need to be closed at
laparotomy? Br J Surg 1977;64:733.
Figure 23-4. Single-layer closure of only the external leaf of the rectus
8. Rosin E, Richardson S. Effect of fascial closure technique on strength
sheath. Care is taken to avoid interspersing rectus muscle between the
of healing abdominal incisions in the dog: a biomechanical study. Vet
edges of the rectus sheath.
Surg 1987; 16:269.
364 Soft Tissue
9. Fagniez P, Hay JM, Lacaine F, et al. Abdominal midline incision vacuum and to create a positive atmospheric pressure within
closure: a multicentric randomized prospective trial of 3,135 patients, the peritoneal cavity.8 Positive pressure occurs after celiotomy
comparing continuous vs interrupted polyglycolic acid sutures. Arch or after a stab incision into the abdomen for drain placement.
Surg 1985:120:1351. Passive peritoneal drainage relies on a pressure differential
10. Rosin E, Robinson GM. Knot security of suture materials. Vet Surg between the peritoneal cavity and the environment and functions
1989:18:269. primarily by overflow. Passive drainage is gravity dependent, and
11. Stone KI, vonFraunhofer JA, Masterson BJ. The biochemical effects the drain provides a tract of least resistance along which excess
of tight suture closure upon fascia. Surg Gynecol Obstet 1986,163:448. fluid flows.2,8 An inexpensive and easily accessible passive
collection system is through a sterile intravenous administration
Closed Peritoneal Drainage set into a sterile bag. Sterile urine collection systems can also
be used. Although passive drains are gravity dependent,1 the
Giselle Hosgood resting level of the drain and the collection bag proportionally
affect the gravitational force and the rate of drainage. Increasing
this distance excessively may promote obstruction of the drain
Indications by omentum or intestinal loops; for instance, having a dog in a
The use of drains to remove fluid, pus, or contaminated material high cage with the collection bag on the floor.
from the closed peritoneal cavity is hereby referred to as closed
peritoneal drainage. The use of drains in the peritoneal cavity
is primarily indicated in the management of peritonitis although Active Drainage
there is some evidence to show that appropriate surgical and Active drainage requires an external vacuum to create negative
medical management without drainage is equally effective.1-4 pressure within the peritoneal cavity. This allows drainage
Other indications for peritoneal drainage include diagnostic to occur independent of gravity. The vacuum is achieved
peritoneal lavage, peritoneal dialysis and administration of by connection of the drain to a compressible container or a
peritoneal chemotherapy.5 Placement of drains after routine constant, low-pressure, suction device (Figure 23-5).1,2 Some
abdominal procedures is discouraged, and the use of drains commercial collection systems have one-way valves to prevent
should not replace meticulous surgical technique. The use fluid reflux from the collection system into the peritoneal
of drains can be associated with multiple complications, and cavity. Suction should be applied to the drain before complete
peritoneal drainage is not a reliable indicator of wound or body abdominal closure to prevent occlusion of the drain by intralu-
cavity events; the absence of drainage does not always imply minal blood clot formation or tissue debris. The optimal level
the absence of fluid and fluid production can be induced by the of suction is unclear. Low-level suction is effective, but higher
presence of the drain alone.1 levels are not always harmful and may remove more fluid.
Suction levels between -9 mm Hg (-12 cm water)9 and -15 mm Hg
(-20 cm water)10 are typically used in wound drainage in people,
Closed-collection systems although higher levels of suction, -80 mm Hg ( -112 cm water)11
Connecting a drain to a collection system has several advantages, and -150 mm Hg (-200 cm water),12 have been used successfully.
and is strongly recommended. A collection system, whether Closed active drains are effective in removing large volumes of
by passive or active drainage, reduces the risk of ascending fluid; however, as the volume of intraperitoneal fluid decreases,
infection through the lumen of the drain. Ascending infection is active drainage causes suction of tissue, viscera, omentum, or
one of the most common complications of peritoneal drainage, abdominal wall toward the drain, resulting in occlusion.1,13 Tissue
a function of both bacterial load migrating up the drain and debris may also occlude the lumen. High-level suction may
decreased local tissue resistance because of the presence of promote obstruction.
the drain.6 Although bacteria can also migrate along the outside
of the drain,7 a closed system greatly reduces the bacterial load.
Protection of the drain by a sterile bandage can reduce bacterial
migration along the outside of the wound. Collection systems
also eliminate the chance of saturating the bandage covering an
open drain. A wet bandage over a freely draining passive drain
provides an additional source of contamination by bacterial
strike-through from the environment. Collection systems also
allow accurate assessment of fluid character and volume.
Passive Drainage
The abdomen can be compared with a fluid-filled, flexible
container with two separate pressure zones. Positive atmospheric Figure 23-5. A silicone wound drain and compressible collection
pressure exists within the gastrointestinal tract, whereas the canister that can be connected together and used for active peritoneal
peritoneal cavity has an extraluminal subatmospheric pressure drainage. Note the one-way valve on the canister. Alternately, the
between -5 and -8 cm water; the pressure is most negative in drain can be connected to a passive collection system.
the cranial abdomen near the diaphragm.8 Passive drainage of
fluid from the peritoneal cavity requires an air vent to break the
Peritoneum and Abdominal Wall 365
A small exit incision reduces subcutaneous fluid leakage and for 1 to 2 days after drain removal, and a bandage should remain
subsequent cellulitis and possible incisional herniation. The in place over the exit point to collect drainage and to prevent
exit incision should not be so small as to obstruct the drain. The contamination of the exit site until it is sealed.
epigastric vessels, which run through the middle of the mammary
chains, should be avoided. If the exit incision is small, it can be
made between the epigastric vessel and the midline (incision)
Complications
without weakening the midline celiotomy incision. Exiting lateral The most common complications of abdominal drains are
to the epigastric vessels moves away from a dependent exit site obstruction and ascending infection. Nosocomial bacterial
and may promote subcutaneous fluid leakage and cellulitis. If contamination of the drain and drainage site is a common compli-
celiotomy is performed, tacking the omentum to the stomach cation of any drain placement. Retraction of the drain may occur
may help to prevent it from enveloping the drains. The omentum once the animal begins to move and stand. This tends to occur
can be excised if it is obviously compromised or heavily contam- with drains that are not connected to a collection system and
inated. Excising the falciform fat may help to reduce tissue that are cut short at the exit site. Suturing the drain securely, at
obstruction of the drains. several sites, is also important. Exit site and drain tract cellulitis
is not uncommon. This complication is not serious and usually
The exit tubing can be connected to a collection system, to resolves once the drain is removed.
function by passive drainage or low-pressure suction (40 to 60
mm Hg). All drains should be sutured to the skin using a secure Subcutaneous fluid leakage is more common when peritoneal
suture such as the Chinese finger trap suture.18 Suction is lavage is used and is particularly noted in the first few hours
applied as soon as the drain is placed, to prevent intraoperative after surgery. Subcutaneous fluid leakage and cellulitis can
obstruction of the drain with blood clots or tissue debris. All be reduced by using a short subcutaneous tunnel between
drain exit points should be covered with a sterile bandage on the skin and the abdominal wall exit site for the drain and by
completion of the surgical procedure. If for some reason a closed having the exit site in a dependent position. The Dacron cuffs
system is not used, multilayered, thick, absorbent bandage on the peritoneal dialysis catheter and disc catheter also help
material is indicated to cover the drain, noting that the contact to reduce this complication. Applying a water-repellent ointment
layer must be sterile. Sterile cloth towels and sterile disposable to the skin around the exit site (petroleum jelly) may help to
diapers (sterilized with ethylene oxide) make useful absorbent prevent skin irritation from drainage fluid. Hypoproteinemia and
bandage layers. hypoalbuminemia are significant complications of peritonitis
and drainage, but are not complications of drainage per se.
Close monitoring of plasma protein concentrations in animals
Postoperative Management with peritonitis is imperative, and intravenous plasma or colloid
The bandage should be changed as often as required to prevent infusion may be required.
complete soaking by exudate and possible strikethrough of
bacteria from the environment. The frequency of bandage
changes is considerably reduced for drains using a collection
Negative Pressure Wound Therapy – Modified
system, but some leakage can occur through the exit site around Closed Drainage
the drain. Contamination of the bandage from the environment A modified application of suction drainage for septic peritonitis
(urine, feces) can also occur. Use of an indwelling urinary is the use of negative pressure wound therapy.19,20 The septic
catheter, particularly in male dogs, may help to prevent urine abdomen is essentially treated as an open wound with removal
contamination. This is especially useful if the animal is recumbent. of exudate through the application of a sealed, absorbant
Bandaging also helps to prevent self-mutilation of the drainage dressing over the open abdomen which is connected to a
area and premature removal or damage to the drain by the animal. commercial, portable suction apparatus. The suction apparatus
The volume and nature of the fluid should be monitored closely, at provides continuous subatmospheric pressure at -80 mmHg to
least three to four times a day or more if profuse. The collection -125mmHg. While the abdomen is open, the drainage system is a
system should be changed using sterile technique when it is full closed system, isolated from the environment. Once infection is
or the vacuum has been lost. The vacuum may be lost before the controlled, delayed abdominal closure is then performed.
collection system is completely full. Without vacuum and fluid
flow, the risk of obstruction of the drain by tissue debris or fibrin
and blood clots is increased. In addition, fluid that remains in the References
collection system for a prolonged period may promote bacterial 1. Donner GS, Ellison GW. The use and misuse of abdominal drains in
growth. The drain is removed once the volume of fluid becomes small animal surgery. Compend Contin Educ Pract Vet 1986;8:705-715.
significantly reduced and the fluid becomes serosanguineous. 2. Hosgood G. Drainage of the peritoneal cavity. Compend Contin Educ
Drainage beyond 2 to 3 days is rarely necessary and persistent Pract Vet 1993;15:1605-1617.
fluid production may indicate non-resolving peritonitis or other 3. Staatz AJ, Monnet E, Seim HB 3rd. Open peritoneal drainage versus
problems with response to management. The presence of a drain primary closure for the treatment of septic peritonitis in dogs and cats:
incites an inflammatory reaction and some fluid production (2 to 4 42 cases (1993-1999). Vet Surg 2002;31(2):174-80.
mls/kg/day), hence drainage usually does not cease completely. 4. Lanz OI, Ellison GW, Bellah JR, Weichman G, VanGilder J. Surgical
If drainage ceases suddenly, it may represent drain obstruction treatment of septic peritonitis without abdominal drainage in 28 dogs. J
rather than resolution of the disease. Fluid may continue to drain Am Anim Hosp Assoc 2001;37(1):87-92.
Peritoneum and Abdominal Wall 367
5. Hunt CA. Diagnostic peritoneal paracentesis and lavage. Compend leaf that is transparent, except for the lacey appearance of fat
Contin Ed Pract Vet 1980;11:449-453. around the blood vessels that run through it.
6. Hampel NL, Johnson RG. Principles of surgical drains and drainage. J
Am Anim Hosp Assoc 1985;21:21-28. The bursal portion of the greater omentum is of most clinical and
7. Raves JJ, Slitkin M, Diamond DL. A bacteriologic study comparing surgical significance and is hereafter referred to as the omentum.
closed suction and simple conduit drainage. Am J Surg 1984;148:618-620. The bursal portion is attached cranioventrally to the greater
8. Gold E. The physics of the abdominal cavity and the problem of curvature of the stomach and extends caudally to the urinary
peritoneal drainage. Am J Surg 1956;91:415-416. bladder. The omentum reflects on itself forming a double layer
9. Tenta LT, Maddalozzo, Friedman CD, et al. Suction drainage of wounds (visceral and parietal layer) that covers the intestines (Figure
of the head and neck. Surg Gynecol Obstet 1989;169:558. 23-8). The potential cavity between the layers is the omental bursa
10. Kern KA. Technique for high volume drainage beneath large tissue (lesser peritoneal cavity). The only natural opening of the omental
flaps. Surg Gynecol Obstet 1990;170:70. bursa is the epiploic foramen.
11. Garcia-Rinaldi R, Defore WW, Green ZD, et al. Improving the efficiency
of wound drainage catheters. Am J Surg 1975;130: 372-373. Important anatomical features of the omentum in the dog, which
12. Moss JP. Historical and current perspectives on surgical drainage. differ from that of people, may affect the surgical extension proce-
Surg Gynecol Obstet 1981;152:517-527. dures that are sometimes performed depending upon its surgical
13. Formeister JF, Elias EG. Safe intra-abdominal and efficient wound use. In the dog, the spleen is attached to the parietal layer of the
drainage. Surg Gynecol Obstet 1976;142;415-416. omentum. There is no colonic attachment of the omentum in the
14. Hanna EA. Efficiency of peritoneal drainage. Surg Gynecol Obstet dog.1 The primary omental blood supply comes from right and left
1970,131:983-985. border vessels that arise from the right gastroepiploic and splenic
15. Paton RW, Powell ES. Which drain? A comparison of the tensile arteries, respectively.3 Approximately nine smaller vessels originate
strengths of vacuum drainage tubes. J R Coll Surg Edinb 1988;33:127-129. from the gastroepiploic arcade along the greater curvature of the
16. Arnstein PM. Custom tube drains. Lancet 1988;1:215. stomach.1 The gastroepiploic arcade does not require mobilization
17. Hosgood G, Salisbury SK, Cantwell HD, et al. Intraperitoneal circu- in the dog.1 The omentum is one of the major fat repositories in
lation and drainage in the dog. Vet Surg 1989;18:261-268. obese animals. Lymphatic drainage occurs by blind, bulbous capil-
18. Smeak DD. The Chinese finger trap suture technique for fastening laries present in the milk spots on the surface of the omentum.
tubes and catheters. J Am Anim Hosp Assoc 1990;26:215-218. The mesothelial membrane is discontinuous over the milk spots,
19. Cioffi KM, Schmiedt CW, Cornell KK, Radlinsky MG. Retrospective allowing material access to the lymphatics.4 Lymphatics follow the
evaluation of vacuum-assisted peritoneal drainage for the treatment of vascular paths and anastomose with lymphatics of the stomach
septic peritonitis in dogs and cats: 8 cases (2003-2010). J Vet Emerg Crit and spleen which drain by regional and celiac lymph nodes into
Care 2012: 22: 601-609. the thoracic duct.4 Drainage into the lacunae on the visceral
20. Buote NJ, Havig ME. The use of vacuum-assisted closure in the surface of the diaphragm also occurs.2 Milk spots are collections
management of septic peritonitis in six dogs. J Am Anim Hosp Assoc of cells of lymphoid and myeloid origin, mainly T and B lymphoctes,
2012;48:164-171. monocytes and macrophages. These sites may provide cells that
have roles in inflammation, angiogenesis and immune responses.
Introduction Bladder
Diaphragm
Vagina
The omentum is a mesothelial membrane with a unique vascular Falciform ligament
and lymphatic network that supports its use in various abdominal Small
intestine Coronary ligament
and extraabdominal surgical procedures. In any surgical
procedure where there is a need for increased vasculature, Rectum Pancreas
Colon
lymphatics, or tissue bulk, the omentum may prove useful.1 Mesentery Lesser omentum
double layer after freeing the dorsal layer.1 The omentum and
spleen are exteriorized and the dorsal omental layer is reflected
ventrally and cranially to identify the pancreatic attachments
(Figure 23-9). The dorsal layer is freed from the pancreas using
sharp dissection proceeding from right to left. As the dissection
approaches the tail of the left lobe of the pancreas, vessels
entering the spleen are encountered. Several omental vessels
originating from the splenic artery may be encountered and
are ligated close to the spleen. Hemorrhage is controlled with
ligation, radiosurgery or ligature clips. Care must be taken to avoid
hematoma formation which will compromise the vascularity of the
omentum.1 The omentum is now unfolded and extended caudally
(Figure 23-10). The extension procedure provides considerable
mobility and length with the free edge of the omentum reaching
as far as the thoracic inlet cranially and the stifle caudally.1
A B
Figure 23-11. Creation of the omental pedicle. The inverted L-shaped incision is begun just caudal to the gastrosplenic ligament (A) and extended
caudally for full extension (B). (From Ross WE, Pardo AD. Evaluation of an omental pedicle extension technique in the dog. Vet Surg 1993;22:37-43.)
Specific Applications using the Omentum chylothorax have been reported. The omentum was brought
through an incision in the muscle of the diaphragm, spread out in
Omentalization of Cystic Organs and Abscesses the thorax and sutured in the region of the mediastinum. The basis
The technique for using the omentum in the management of cysts for the use of the omentum in the treatment of chylothorax is to
and abscesses of abdominal organs is the same, regardless of the take advantage of the considerable lymphatic drainage provided
organ affected by disease. Extension of the omentum is usually by the omentum. Both animals were free of disease 16 and 13
not necessary for intraabdominal use. Omentalization of prostatic months after surgery, respectively. Since the omental lymphatics
abscesses and cysts, pancreatic cysts and abscesses, uterine drain into the cysterna chyli, the rationale for treatment of chylo-
stump abscess, perinephric cysts, liver cysts and sublumbar thorax with omental transposition has been questioned.17
lymph nodes has been reported.6-12 The technique requires the
cyst to be partially or almost completely removed. The omentum In theory, non-chylous effusion that may occur following correction
is then packed into the remaining shell of the cyst and loosely of chylothorax may be reduced following omentalization.
sutured in place with monofilament, absorbable suture material.
Abscess cavities are first cultured and drained and as much Chronic Wounds
of the outer surface wall is removed as possible. Omentum is
Extraabdominal translocation of the omentum to sites of
packed into the remaining abscess cavity and sutured in place.
non-healing wounds has been reported in the dog and the cat.15-17
The omentum provides a vascular bed for free skin grafting or for
Chylothorax random cutaneous or axial pattern skin flap reconstruction. The
Translocation of the omentum into the thorax of a 6 year-old omentum is first extended and an omental pedicle is created if
Rhodesian ridgeback15 and a 6-year-old Himalayan cat16 with necessary. The omentum is then passed through a paracostal
incision in the abdominal wall and tunneled subcutaneously to
370 Soft Tissue
the wound bed. The skin is reconstructed over the omentum. 6. Bray JP, White RAS, Williams JM. Resection and omentalization: A
Wound drainage with a closed, active drain may be required. new technique for management of prostatic retention cysts in dogs. Vet
Surg 1997;26:202-209.
7. Campbell BG. Omentalization of a nonresectabe uterine stump
Thoracic and Abdominal Wall and abscess in a dog. J Am Vet Med Assoc 2004;224:1799-1803.
Diaphragm Reconstruction 8. Friend EJ, Niles JD, Williams JM. Omentalisation of congenital liver
The omentum has been used in conjunction with mesh recon- cysts in a cat. Vet Rec 2001:149:275-276.
struction of thoracic and abdominal wall defects.23,24 The 9. Hill TP, Odesnik BJ. Omentalisation of perinephric pseudocysts in a
omentum is first extended and an omental pedicle is created if cat. J Sm Anim Pract 2000;41:115.
necessary. The omentum is then passed through a paracostal 10. White RAS, Williams JM. Intracapsular prostatic omentalization:
incision in the abdominal wall and tunneled subcutaneously to A new techinque for management of prostatic abscesses in dogs. Vet
the defect and placed on top of the mesh. Surg 1995;24:390-395.
11. Hoelzler MG, Bellah JR. Omentalization of cystic sublumbar lymph
The omentum fills the soft tissue defect and also brings vascu- node metstases for long-term palliation of tenesmus and dysuria in
larity and lymphatic drainage to the wound site. The skin is adog with anal sac carcinoma. J Am Vet Med Assoc 2001;219:1729-1731.
reconstructed over the omentum. Wound drainage with a closed, 12. Johnson MD, Mann FA. Treatment for pancreatic abscesses via
active drain may be required. omentalization with abdominal closure versus open peritoneal drainage
in dogs: 15 cases (1994-2004). J Am Vet Med Assoc 2006;228:397-402.
The omentum has been used to cover experimentally created 13. Jerram RM, Warman CG, Davies ES, Robson MC, Walker AM.
defects in the diaphragm in the dog. The omentum was folded Successful treatment of a pancreatic pseudocyst by omentalisation in a
dog. N Z Vet J. 2004;52:197-201.
over on itself and sutured to the edges of defect. After three
weeks, the omentum remained viable with evidence of fibro- 14. Franklin AD, Fearnside SM, Brain PH. Omentalisation of a caudal
mediastinal abscess in a dog. Aust Vet J 2011;89:217-220.
metaplaisa with fibrosis to the diaphragm edges. Despite
promising experimental results, reconstruction of the diaphragm 15. Williams JM, Niles JD. Use of omentum as a physiologic drain for
treatment of chylothorax in a dog. Vet Surg 1999;28:61-65.
is rarely required in dogs and cats. Primary closure of tears in
the diaphragm is usually possible, even in chronic cases. 16. LaFond E, Weirich WE, Salisbury SK. Omentalization of the thorax for
treamment of idiopathic chylothorax with constrictive pleuritis in a cat.
J Am An Hosp Assoc 2002;38:74-78.
Other Applications 17. Sicard GK, Waller KR, McAnulty JF. The effect of cisterna chyli
Application of the omentum to other surgical situations is possible, ablation combined with thoracic duct ligation on abdominal lymphatic
based on the ability of the omentum to enhance vascularity, drainage. Vet Surg 2005;34:64-70.
lymphatic drainage and immune response at a recipient site. Use 18. Brockman DJ, Pardo AD, Conzemius MG, Cabell LM, Trout NJ.
of the omentum to pack traumatic fractures in parenchymatous Omentum-enhanced reconstruction of chronic nonhealing wounds in
organs such as the liver, kidney and spleen is reported in humans. cats: Techniques and clinical use. Vet Surg 1996;25:99-104.
Support of gastrointestinal anastomotic sites is possible and 19. Lascelles BDX, White RAS. Combined omental pedicle grafts and
widely used. Autgenous omental grafts, as free non-vascularized thoracodorsal axial pattern flaps for the reconstruction of chronic,
grafts, have been used to enhance bone healing in experimental nonhealing axillary wounds in cats. Vet Surg 2001;30:380-385.
non-union models in dogs.25,26 Radial osteotomies treated with 20. Smith BA, Hosgood G, Hedland CS. Omental pedicle used to manage
free autogenous omentum had union by 16 weeks while untreated a large dorsal wound in a dog. J Sm Anim Pract 1995;36:267-270.
osteotomies remained as a non-union.25 In a second study using 21. Gray MJ. Chronic axillary wound repair in a cat with omentalisation
a similar non-union model in dogs, the effect of the omental graft and omocervical skin flap. J Small Anim Pract. 2005;46:499-503.
was potentiated by the inclusion of adipose-derived stem cells.26 22. Roa DM, Bright RM, Daniel GB, McEntee MF, Sackman JE, Moyers
The surgical applications for use of the omentum are numerous TD. Microvascular transplantation of a free omental graft to the distal
and varied however, the use of omentum should be viewed as extremity in dogs. J Small Anim Pract. 1998;39:475-480.
an adjunct to sound surgical practice and not as a substitute for 23. Bright RM, Thacker LH. The formation of an omental pedicle flap and
good surgical technique. its experimental use in the repair of a diaphragmatic rent in the dog. J
Am An Hosp Assoc 1982;18:283-289.
24. Liptak JM, Dernell WS, Rizzo SA, Monteith GJ, Kamstock DA,
References Withrow SJ. Reconstruction of chest wall defects after rib tumor
1. Ross WE, Pardo AD. Evaluation of an omental pedicle extension resection: a comparison of autogenous, prosthetic, and composite
techinque in the dog. Vet Surg 1993;22:37-43. techniques in 44 dogs. Vet Surg 2008;37:479-487.
2. Evans HE. The abdomen. Millers Anatomy of the Dog. Philadelphia: 25. Saifzadeh S, Pourreza B, Hobbenaghi R, Naghadeh BD, Kazemi
W.B. Saunders Co; 1993:425. S. Autogenous greater omentum, as a free nonvascularized graft,
3. Gravenstein H. Uber die arterien des grossen netzes beim hunde. enhances bone healing: an experimental nonunion model. J Invest
Morph Jahrb 1938;82:1-26. Surg. 2009;22:129-137.
4. Nylander G, Tjernberg B. The lymphatics of the greater omentum: An 26. Bigham-Sadegh A, Mirshokraei P, Karimi I, Oryan A, Aparviz A,
experiemental study in the dog. Lymphology 1969;1:3-7. Shafiei-Sarvestani Z. Effects of adipose tissue stem cell concurrent with
greater omentum on experimental long-bone healing in dog. Connect
5. Roa DM, Bright RM, Daniel GB, McEntee MF, Sackman JE, Moyers
Tissue Res. 2012;53:334-342.
TD. Microvascular transplantation of a free omental graft to the distal
extremity in dogs. Vet Surg 1999;28:456-465.
Nasal Cavity 371
Section D and cats. Although the cosmetic results in cats are generally
good and acceptable to most owners, dogs are more noticeably
deformed by the surgery. Function is usually excellent.
Indications
Various methods have been described to treat cats with
squamous cell carcinoma of the nasal planum including radiation
therapy, hyperthermia, intratumoral administration of carbo-
platin, cryosurgery, conservative (marginal or intralesional)
surgery, and photodynamic therapy.8-13 Unfortunately, with most
of these treatments, the tumor margins cannot be evaluated to
ensure that an adequate volume of tissue is treated. Each of
these modes of therapy has other disadvantages, including the
need for special equipment and facilities for some techniques,
high rates of tumor recurrence, and reported control rates for
deeply infiltrating lesions of up to 55% at 1 year. Most of these
techniques may work for early, small lesions or carcinoma in Figure 24-1. The 360° incision around the nasal planum is indicated by
situ, but the most cost-effective, reliable treatment for selected the dotted line. If possible, a strip of skin is left ventrally so the lips are
patients with invasive squamous cell carcinoma is nasal planum left attached at the midline. (From Withrow SJ, Straw RC. Resection of
resection. Fifteen of 20 cats with invasive squamous cell the nasal planum in nine cats and five dogs. J Am Anim Hosp Assoc
carcinoma treated with nasal planum resection were free of 1990;26:219-222.)
372 Soft Tissue
Figure 24-3. A continuous pursestring suture is used to reduce the nasal Figure 24-4. A. The dog is placed in sternal recumbency and is draped
orifice to about I cm diameter. No sutures are placed in cartilage. (From after preparation for aseptic surgery. The mouth is open, and the lower
Withrow SJ, Straw RC. Resection of the nasal planum in nine cats and drape is within the mouth. B. The upper lip is incised full thickness on
five dogs. J Am Anim Hosp Assoc 1990;26:219-222.) each side of the nasal planum. C. The two incisions are united on the
dorsal midline of the nose caudal to the nasal planum. (From Kirpen-
steijn J, Withrow SJ, Straw RC. Combined resection of the nasal planum
and premaxilla in three dogs. Vet Surg 1994;23:341-346.)
Nasal Cavity 373
the need for adjuvant or primary radiation therapy. Cosmetic material in a continuous or interrupted pattern. This technique
results are considered acceptable by most owners. results in closure of the oral cavity in the form of a “T” (Figure
24-6B). The skin of the lips is closed on the midline with 2-0 or 3-0
The dog, maintained under general anesthesia and intubated with monofilament nonabsorbable suture material. As with closure
a cuffed endotracheal tube, is positioned in sternal recumbency after nasal planum resection alone, the diameter of the nasal
with the mouth slightly open. The skin overlying the maxilla and opening is reduced using a pursestring suture of monofilament
upper lip is clipped and prepared for aseptic surgery. The oral nonabsorbable suture material (Figure 24-6C). The nasal opening
mucosa of the lips and hard palate is prepared with a disinfectant
such as a dilute povidone-iodine solution. The area is draped,
allowing access to the oral cavity (Figure 24-4A). The upper lip
is incised from the skin through the mucosa on each side of the
nasal planum (Figure 24-4B). The two incisions are connected at
the dorsal midline of the nose caudal to the nasal planum (Figure
24-4C). The nasal cartilages are incised to the palatal region of
the maxillary bone. At the level just either rostral to or caudal
to the canine teeth, depending on the extent of invasion of the
tumor, the mucosa of the hard palate is incised transversely
with a scalpel blade down to bone. An oscillating saw is used to
cut the palatal and maxillary or incisive bone (Figure 24-5). The
excised specimen is submitted for histopathologic examination,
with emphasis on evaluation of margins for completeness of
resection. Hemorrhage is controlled by a combination of direct
pressure, electrocautery, and vessel ligation. Four or five small
holes are drilled 2 to 3 mm from the cut edge of the hard palate. Figure 24-5. The nasal cartilages are incised perpendicular to the long
The submucosa of the incised lip is sutured through the holes axis of the skull down to the floor of the nasal cavity. The mucosa of the
in the hard palate with 2-0 monofilament absorbable suture hard palate is transversely incised at a level just rostral to the canine
material. The lip is joined on the midline of the palate with sutures teeth (or caudal to the canine teeth, depending on the extent of tumor
that are placed approximately in the middle of each lip incision invasion) down to bone. An oscillating saw is used to cut the bone of
(Figure 24-6A). The mucous membrane of the lip is sutured to the hard palate and lateral bodies of the maxilla. (From Kirpensteijn J,
the mucous membrane of the hard palate, and the contral- Withrow SJ, Straw RC. Combined resection of the nasal planum and
premaxilla in three dogs. Vet Surg 1994;23:341-346.)
ateral lip is sutured with 3-0 monofilament absorbable suture
Figure 24-6. A. The submucosa and mucosa of the lip is sutured through drill holes in the hard palate and to the contralateral lip. B. This results in
closure of the oral cavity from the nasal cavity in the form of a “T.” C. The nasal orifice is reduced in diameter by placing a simple continuous purs-
estring suture. D. View from the front of the dog after surgery. The new nasal orifice is approximately the diameter of the resected nasal planum.
(From Kirpensteijn J, Withrow SJ, Straw RC. Combined resection of the nasal planum and premaxilla in three dogs. Vet Surg 1994;23:341-346.)
374 Soft Tissue
is reduced to a size corresponding to the diameter of the nasal will need to be divided between ligatures. If this is near the
planum removed (Figure 24-6D). canine tooth the skin, subcutis, nasolabial muscle, and labium
are reflected while preserving their vascular support from the
Analgesia is provided using narcotics as necessary. An Eliza- infraorbital neurovascular bundle. These soft tissues and labium
bethan collar may be needed to prevent mutilation of the wounds. are reflected to the rostral zygomatic arch, exposing the maxilla.
Dogs are allowed to drink water on recovery and are offered Once exposed, the rostral maxilla, nasal turbinates, and bony
food 24 hours after surgery. Antibiotics can be given during palate are amputated with a reciprocating saw. The transection
the immediate perioperative period, but they are usually not is perpendicular to the maxillary axis. The rostral maxilla can
necessary. Dogs are sent home within 2 to 3 days, and sutures then be removed following transection of the palatine mucosa
are removed 10 days postoperatively. parallel to and at the level of the hard palate. The palatine and
sphenopalatine arteries are ligated.
Mild postoperative bleeding may occur and resolves within a
day or so. Lip dehiscence can be avoided if the closure is tension Labial reconstruction is performed by transposing either a
free. Stenosis of the new nares can occur if the pursestring unilateral labial flap or bilateral labial flaps depending on the
suture is too tight. Crusting of the nasal orifice is possible and amount resected and the conformation of the animal. Regardless
resolves after suture removal; however, serous nasal discharge of whether a unilateral or bilateral flap is used, the lip and palate
can persist. are united first. Dehiscence may be less likely when bilateral
flaps are used. It may be necessary to relieve tension by incising
the labiogingival reflection to mobilize the labial flap. The mucosa
Combined Resection of the Nasal Planum of the labial flap is removed except for a 0.5- to 1.0-cm width
and Rostral Maxilla adjacent to the labial margin. This distance is determined by
For animals with malignant rostral maxillary tumors a technique bringing the tissues together and identifying the contact point of
has been described where the maxilla and nasal planum can the palatine mucosa and labium, and then assessing how much
be resected between PM2 and PM3.14 The postoperative “new lip” there would be projecting ventrally from the palatine
appearance was acceptable to owners and there was a low mucosa. Avoid making this margin overly large which may
risk of local recurrence which can produce long term survival result in prehension problems after surgery. Once the mucosa is
for animals with certain malignancies. A preoperative biopsy excised, the remaining mucosal margin is sutured to the palatine
is performed with appropriate tumor staging before definitive mucosa with interrupted 4-0 absorbable sutures, thus providing
resection with this aggressive rostral maxillectomy procedure. strong support and preventing mucosal inversion.
Computed tomography (CT) is excellent for tumor staging and
surgical planning. Bilateral advancement flaps are also prepared by incision of
the labiogingival borders as necessary to permit tension-free
The animal is positioned in ventral recumbency and anesthesia, advancement of the flaps on the approximate midline. The labial
analgesia and surgical preparation are similar to previously mucosa is once again débrided leaving only a 0.75- to 1.0-cm
described procedures in this chapter. The mouth is held slightly margin of labial mucosa to be sutured to the palatal incision as
open with a mouth gag or similar device and care is taken to pack a palatobuccal recess. This length of recess is chosen to ensure
the pharynx with moistened gauze swabs adjacent to a cuffed or the margin will not be trapped between the teeth during chewing
snug fitting endotracheal tube to avoid aspiration of blood and or interfere with food transfer into the mouth. Prior to suturing,
fluid during surgery. The commissures of the lips need to remain the left and right lips are aligned toward the midline using
mobile after draping to allow for labial advancement during temporary sutures. As the palatolabial suturing progresses from
reconstruction. The preoperative CT scan defines the extent of lateral to medial, the labial margins are drawn into apposition. As
tissue infiltrated with tumor, and its relation to the dentition. The with the unilateral flap the labial submucosa can be first sutured
teeth are used as landmarks to allow the approximate edges of to the edge of the incised palatine bone using small holes drilled
the tumor to be marked using a sterile marker pen. A sterile ruler in the palatine bone with a 0.0625-inch Kirschner wire. The
is used to mark 1 or 1.5 cm beyond the borders of the tumor so remaining lip union is reconstructed beginning along the ventral
that a line of “planned complete resection” can be drawn. The aspect, aligning the labial margin with a nonrolling figure-of-
line of bone excision is level with or slightly caudal to the caudal- eight suture. Suturing progresses using the same suture pattern
most aspect of the soft-tissue resection. This results in sufficient in the submucosa, muscle, subcutaneous, and dermal layers.
soft tissues to reconstruct a lip rostrally and cover the exposed
maxilla. Full-thickness, labial incisions are made perpendicular The dorsal and rostral portions of the incision are left open
to the labial margin. The incisions are continued perpendicular forming the nasal orifice. And it is advisable to create an orifice
from the labial margin for a minimum of 1 to 2 cm and then curved approximately twice the desired final size to compensate for the
to meet on the midline of the maxilla. Once the skin is scribed with expected contraction during healing. The nasal orifice size can
a scalpel, electrocautery is used for most of the tissue division, be controlled using a purse-string type pattern of suture as with
and hemostasis is maintained by a combination of cautery and simple nasal planectomy.
vascular clips or ligatures. The incisions are continued deeper
through the subcutis and nasolabial muscles and fascia to the Analgesic protocols are aggressive and include premedication
maxillary bone at predetermined resection levels. If this is the with an opioid (i.e., oxymorphone at 0.2 to 0.5 mg/kg intramuscu-
rostral zygomatic arch, the infraorbital neurovascular bundles larly [IM] or morphine at 0.2 to 0.6 mg/kg IM) and infraorbital nerve
Nasal Cavity 375
blocks performed bilaterally prior to surgery using bupivacaine 5. Miller MA, Ramos JA, Kreeger JM. Cutaneous vascular neoplasia in
(0.5 to 1.0 mL of a 0.75% solution used per site). During general 15 cats: clinical, morphologic, and immunohistochemical studies. Vet
anesthesia, constant-rate infusions of fentanyl (0.01 mg/kg per Pathol 1992: 29: 329-336.
hour) may be administered. At the time of extubation, the opioid 6. Withrow SJ, Straw RC. Resection of the nasal planum in nine cats and
administered preoperatively is repeated, and a postoperative five dogs. J Amer Anim Hospt Assoc 1990; 26: 219-222.
analgesic opioid protocol is instituted. This can be buprenor- 7. Kirpensteijn J, Withrow SJ, Straw RC. Combined resection of the
phine (0.07 mg IM q 6 hours) which can be continued for up to nasal planum and premaxilla in three dogs. Vet Surg 1994; 23: 341-346.
60 hours. Following a loading dose of the appropriate opioid (i.e., 8. Carlisle CH, Gould S. Response of squamous cell carcinoma of the
morphine 0.5 mg/kg intravenously [IV]; oxymorphone 0.2 mg/kg nose of the cat to treatment with X rays. Vet Radio 1982; 5: 186-192.
IV; or fentanyl 0.002 mg/kg IV), dogs can receive constant-rate 9. VanVechten MK, Theon AP. Strontium-90 plesiothcrapy for treatment
infusions of morphine (0.05 mg/kg per hour), oxymorphone (0.13 of early squamous cell carcinomas of the nasal planum in 30 cats. In:
mg/kg per hour), or fentanyl (0.002 to 0.006 mg/kg per hour) for 24 Proceedings of the 13th Annual Conference of the Veterinary Cancer
hours to provide a constant level of analgesic drug. Carprofen Society. Columbus, OH 1993: 107-108.
(2.0 mg/kg per os [PO] q 12 hours) may be initiated 12 hours after 10. Theon AP, Madewell BR, Shearn VI, et al. Prognostic factors
surgery and continued postoperatively as necessary. associated with radiotherapy of squamous cell carcinomas of the nasal
plane in cats. Am J Vet Assoc 1995; 206: 991 – 996.
An Elizabethan collar is often used until healing is complete 11. Theon AP, VanVechten MK, Madewell BR. Intratumoral adminis-
and it may be necessary for oronasal suction to be instituted tration of carboplatin for treatment of squamous cell carcinomas of the
nasal plane in cats. Am J Vet Res 1996; 57: 205-210.
as needed to keep the nasal passages clear, using a pediatric
suction device. Some animals do not eat readily, and feeding 12. Peaston AE, Leach MW, Higgins RJ. Photodynamic therapy for nasal
and aural squamous cell carcinoma in cats. J Am Vet Med Assoc 1993;
can be supplemented with a food gruel administered through
202: 1261-1265.
a pharyngostomy tube for a short term up to 7 days. Topical
13. Fidel JL, Egger E, Blattmann H, et al: Proton irradiation for feline
petrolatum-based antibiotic ointment can be placed around
nasal planum squamous cell carcinoma using an accelerated protocol.
the nasal orifice wounds to reduce wound crusting and debris.
Vet Radiol and Ultrasound, 42: 569-575, 2001.
Additionally, topical misting of physiological saline can be
14. Lascelles BDX, Henderson RA, Sequin B, Liptak JM, Withrow SJ.
delivered via a conventional spray bottle to humidify and cleanse
Bilateral rostral maxillectomy and nasal planectomy for large rostral
the nasal turbinates. Some animals are able to eat soft food maxillofacial neoplasms in six dogs and one cat. J Amer Anim Hospt
offered on a plate between 12 and 30 hours after surgery and Assoc 2004; 40: 137-146.
may be discharged to their owners once eating on their own.
Owners may be advised to keep the new rostral orifice patent
and clean using saline-soaked cotton balls for 1 month postop- Rhinotomy Techniques
eratively. Antibiotics such as cefazolin 20 mg/kg IV are given
immediately preoperatively and every 90 minutes during surgery Cheryl S. Hedlund
and postoperative antibiotics are generally not necessary.
Introduction
Although this technique is very similar to the combined resection
Dogs and cats with chronic nasal and paranasal sinus disease
of the nasal planum and premaxilla it is more extensive allowing
are usually diagnosed and treated without the need for rhinotomy
wide resection of larger tumors. The advantage of such a
(surgical exploration of the nasal cavity). Rhinotomy is only
technique is that it has the potential to increase the number
indicated if other diagnostic techniques fail to provide a defin-
of animals in which “complete” resections can be performed.
itive diagnosis or if required as part of a therapeutic protocol.
However, the disadvantage of such a surgery is the possibility
Potential candidates for rhinotomy have symptoms that may
of interfering with the animal’s ability to eat and drink making
include: nasal discharge, epistaxis, sneezing, gagging, stertorous
oral spillage of both food and water possible. The technique
breathing, dyspnea, fetid breath, nasal discomfort, or nasal
does offer the opportunity for prolonged tumor-free remission
deformity. Causes of diseases of the nasal cavity and paranasal
times for animals with certain neoplasms that involve the rostral
sinus can be difficult to identify, but are commonly of infectious
maxilla, if tumor-free margins can be obtained.
(fungal, bacterial, or viral) or neoplastic origin. Other inciting
causes include foreign bodies, trauma, parasites (Pneumo-
References nyssus caninum, Linguatula serrata), dental disease, congenital
1. Hargis AM. A review of solar-induced lesions in domestic animals. anomalies, and lymphocytic plasmacytic inflammation.1
Compend Contin Educ Pract Vet 1981: 3: 287-293.
2. Munday JS, Dunowska M, DeGrey S: Detection of two different papil- Diagnostic Procedures
lomaviruses within a feline squamous cell carcinoma: case report and
A standard protocol for evaluation should be used for all dogs
review of the literature, NZ Vet J 57: 248-251, 2009.
and cats presenting with chronic nasal disease. The protocol
3. Withrow SJ. Tumors of the respiratory system. In: Withrow SJ,
should include a thorough history and physical examination.
MacEwen EG, eds. Veterinary oncology 2nd ed. Philadelphia: WB
Saunders, 1996: 268-286.
In addition, a complete blood count, serum chemistry profile,
coagulation profile, radiographs, computed tomography (CT
4. Hargis AM, Ihrke PJ, Spangler WL, et al. A retrospective clinic-patho-
scan), magnetic resonance imaging (MRI), serology, cytology,
logical study of 212 dogs with cutaneous hemangiomas and hemangio-
sarcomas. Vet Pathol 1992: 29: 316-328. culture, rhinoscopy, and nasal biopsy may be required for
376 Soft Tissue
accurate diagnosis and prognosis.2-6 The clinical history provides or lateral recumbency following skull imaging and sample
important diagnostic clues. A destructive process is suspected collection for cultures. Violent sneezing with possible damage
if the discharge changes from unilateral to bilateral. Sneezing to instruments and mucosa resulting in hemorrhage may occur
suggests involvement of the rostral or middle nasal chambers if anesthetic depth is inadequate. The nasal mucosa is sensitive
and gagging suggests nasopharyngeal involvement. A history of to manipulation; it bleeds easily, and this may obscure visual-
trauma or dental disease might suggest an oronasal fistula. ization. Therefore, patience, gentleness, suction, and lavage are
advantageous during this procedure. The least affected side
Physical examination findings are as follows: Epistaxis may of the nasal cavity is examined first. The rostral aspect of the
indicate a systemic disease, an acute nasal disease, or an nasal cavity may be visualized with an otoscope and appropriate
ulcerative, destructive disease. A mucopurulent discharge with speculum. The caudal choanae and nasopharynx can be viewed
or without epistaxis suggests chronic rhinitis. Obstruction of with a dental mirror or rigid scope with a 120° lens when the
nasal airflow through one or both nostrils suggests a unilateral soft palate is retractated rostrally. Visualization of the entire
or bilateral condition. Facial or palatal deformity suggests cavity is achieved with a flexible pediatric bronchoscope (< 1
neoplasia. Mouth breathing may indicate nasopharyngeal cm diameter) or a rigid scope (bronchoscope or arthroscope, 2
obstruction. Labored breathing suggests possible pulmonary to 5 mm diameter) with a working piece (outer sheath) to allow
involvement with a fungal or neoplastic condition. An ocular suction, lavage, and biopsy. Both normograde and retrograde
discharge may indicate nasolacrimal duct erosion. General rhinoscopy is performed to completely visualize the nasal cavity
debility suggests systemic disease. and nasopharynx. After complete rhinoscopic examination,
suitable biopsy forceps are used to collect tissue for culture and
A complete blood count, serum chemistry panel, and urinalysis histologic evaluation.
should be obtained to assess overall patient status. A coagu-
lation profile is indicated if exploratory rhinotomy is planned or Lesions that are not accessible to biopsy during rhinoscopy
if epistaxis is a major clinical sign. In addition, serologic evalu- may be sampled by nasal flushing or coring procedures.
ation for Ehrlichia canis may be beneficial when epistaxis is the These procedures are performed in the anesthetized patient.
predominant clinical sign. Serologic evaluation for Aspergillus Gentle flushing of the nasal cavity with saline does not usually
and Penicillium species can be beneficial when fungal disease dislodge tissue for evaluation. Nasal coring, pinch, punch, or
is suspected. Serologic tests for Crytptococcus, FeLV, FIV and needle biopsy are more effective biopsy techniques.6 To prevent
heartworms may also be indicated. Nasal swabs for culture or aspiration, the endotracheal tube cuff is inflated, gauze sponges
cytologic evaluation are of limited value but may be helpful in are placed in the nasopharynx and the nose is tilted ventrally
identifying parasites, cryptococcoses organisms and single during sampling. To prevent penetration of the cribriform plate,
bacterial infections. Positive fungal cultures can be obtained in biopsy instruments should be marked and not advanced further
40% of normal dogs. than the distance from the external nares to the medial canthus
of the eyes. One technique for nasal coring uses a stiff plastic
Radiographs of the thorax and skull are taken to demonstrate tube inserted through the nares and vigorously moved in and out
the extent of disease involvement. Radiographs of the thorax are of the nasal passages while flushing saline and aspirating tissue.
taken in the awake patient to evaluate for evidence of cardiac or The collected lavage fluid, debris and tubing are examined for
pulmonary disease (metastasis or infection). Skull radiographs tissue fragments. Repeating biopsies when samples are nondi-
require general anesthesia to allow accurate evaluation of the agnostic is preferred to rhinotomy in most cases.
nasal cavity and paranasal sinuses. Skull images are performed
prior to rhinoscopic, flush, or biopsy procedures to avoid iatro- Patients whose disease has not been diagnosed by the foregoing
genic fluid densities within the cavities. Skull radiographs procedures are candidates for exploratory surgery. Rhinotomy
should include lateral, ventrodorsal, rostrocaudal, and rostro- may also be included in treatment protocols for fungal diseases,
ventral caudodorsal open mouth or occlusal views. The two tumors, and foreign bodies. Rhinotomy can be performed using
most useful radiographic views are the ventrodorsal view of the dorsal, ventral, or lateral approaches. The approach chosen
maxilla made using intraoral radiographic film and the rostro- depends on the location and extent of the lesion. The objec-
caudal projection highlighting the frontal sinuses. Skull radio- tives of rhinotomy include the following: 1) To obtain sufficient
graphs are examined for evidence of increased or decreased samples from the nasal cavity or sinuses to achieve a definitive
tissue densities, distortion or loss of turbinates and bone, and diagnosis. 2) To completely remove or debulk a lesion. 3) To
symmetry between right and left sides of the nasal cavity and facilitate administration or effectiveness of adjuvant therapy.
sinuses. The same changes are evident on CT and MRI images 4) To minimize patient morbidity. 5) To maintain a cosmetically
but they localize lesions better than radiographs. CT images acceptable appearance.
provide good anatomic detail of bony tissues while MRI images
are superior for evaluating soft-tissue structures.3 In addition to a standard surgical pack, equipment which may
be needed for rhinotomy includes a periosteal elevator, Gelpi
Rhinoscopy is useful because it allows visual assesment of retractor, oscillating saw, air drill, pins and pin chuck, osteotome
lesions and acquisition of specimens for further evaluation.4-6 and mallet, bone curette, rasp, bur, rongeur, trephine, fenestrated
The diagnostic success of rhinoscopy-assisted biopsy is 83% tubes, and synthetic mesh. If temporary carotid artery occlusion
(78 of 94 dogs) when performed by an experienced clinician.6 is performed in conjunction with rhinotomy, vascular occlusion
Rhinoscopy is performed on an anesthetized patient in sternal
Nasal Cavity 377
Preoperative Preparation
Analgesics are administered in the preoperative period. After the
anesthetized animal is intubated, the endotracheal tube cuff is
inflated, and the pharynx is packed with gauze sponges to prevent
drainage of fluids into the distal trachea. Hair is clipped and the
surgical site is aseptically prepared for the selected approach. Figure 24-8. The common carotid artery is occluded with a bulldog
clamp after being separated from the vagosympathetic trunk and
internal jugular vein.
378 Soft Tissue
Dorsal Rhinotomy
Dorsal rhinotomy allows access to the entire nasal cavity and
the frontal sinuses.8 After the anesthetized animal is intubated,
the endotracheal tube cuff is inflated, and the pharynx is packed
with gauze sponges to prevent drainage of fluids into the
trachea. The patient is positioned in ventral recumbency, then
the dorsum of the head is clipped and prepared for surgery. The
surgeon begins the rhinotomy by making a midline skin incision
over the nasal cavity and frontal sinus which extends caudal
to the orbits (Figure 24-9). The dense fascia and periosteum
overlying the bone are incised, elevated and retracted laterally.
The bone is scored with a scalpel blade to outline a unilateral or
bilateral bone flap depending on the extent of the disease and
the exposure necessary (Figure 24-10). The flap is made using Figure 24-10. The dashed line represents bone scoring for a bilateral
an oscillating saw, drill, osteotome and mallet, or trephine and bone flap. The dotted line represents the location of the nasal septum,
rongeurs. The margins of the bone are beveled inward if bone which divides the nasal cavity into two fossae.
flap replacement is anticipated. In addition, pre-drilling holes in
the flap and adjacent bone margin for suture placement aids in
easier bone flap reattachment. The bone flap is elevated from the
underlying turbinates with an osteotome or periosteal elevator.
The bone flap is reflected rostrally leaving it attached to the
dorsal parietal cartilage of the rhinarium by the nasal ligaments
if flap replacement is planned (Figure 24-11). After exposing the
nasal cavity and frontal sinus, the surgeon suctions secretions or
exudate and explores the area. The lesion and involved turbinates
are removed or sampled for biopsy with forceps, a bone curette
and Metzenbaum scissors. (Figure 24-12). Total turbinectomy is
often necessary to eliminate extensive areas of nasal mucosa
with chronic irreversible hyperplasia. One should avoid trauma-
tizing or perforating the cribriform plate during turbinectomy.
Identifiable bleeding vessels are ligated. When external carotids
are not occluded it may be necessary to control hemorrhage
with cautery, iced saline, or pressure. Tissues are submitted for
histologic and culture evaluation . During a unilateral rhinotomy,
Figure 24-11. The bone flap is reflected rostrally and remains attached
to the dorsal parietal cartilages.
Figure 24-9. The outer dotted line outlines the approximate extent of
The bone flap is replaced or discarded depending on the extent
the nasal cavity and frontal sinus. The inner dashed lines outline the of disease and the surgeon’s preference. The flap is discarded
bone flap for a unilateral or bilateral rhinotomy. The X’s over the frontal if it is involved in the disease process or if fragmentation occurs
sinuses indicate the site for insertion of a drain(s). during removal. If the flap is being replaced, drill three or
Nasal Cavity 379
Figure 24-14. A drain can be positioned in the frontal sinus for adjuvant
therapy or to reduce subcutaneous emphysema.
Ventral Rhinotomy
Figure 24-13. The bone flap is replaced by placing sutures through
Ventral rhinotomy allows exploration of the nasal cavity and
holes drilled in the flap and margins of the defect.
nasopharynx.8 Evaluation and evacuation of the frontal sinuses
four holes in the flap and the adjacent margins of the defect. is limited to the rostral half with ventral rhinotomy. Concurrent
The surgeon then preplaces nonabsorbable sutures (nylon, mandibulotomy may be performed to improve access to the
polypropylene) through the holes, positions the flap, and ties caudal nasal cavity and nasopharynx. Although most surgeons
the sutures to secure the flap. (Figure 24-13). One should not prefer dorsal rhinotomy, advantages of ventral rhinotomy include
use wire to secure the bone flap if radiation therapy is being improved cosmesis and less risk of subcutaneous emphysema.
planned. Occasionally, when the defect is large, if the flap is Disadvantages include incomplete access to the frontal sinuses
discarded and cosmetics are critical, a bone graft or synthetic and the potential for oronasal fistula formation.9
mesh is stretched across the bony defect and secured. Potential
risks with the use of such implants include sequestration and The patient is positioned in dorsal recumbency with the oral
infection. Soft tissues are apposed in three layers (fascial/ cavity maximally exposed by hanging and securing the mandible
periosteal layer, subcutaneous tissues, and the skin) using in a wide, open-mouth position. One should use mild antiseptic
continuous suture patterns. Air leakage from the rhinotomy site solutions (0.05% chlorhexidine or 0.1% or 1% povidone-iodine) to
and subcutaneous emphysema may be controlled by suturing a cleanse the oral cavity prior to incising tissue.
stent over the surgical site, placing a drain in the frontal sinus
and nasal cavity or leaving a small gap between tissue edges
during closure.
380 Soft Tissue
Figure 24-15. Ventral Rhinotomy: A. The dashed line represents a U-shaped mucoperiosteal incision made just medial to the major palatine artery
when performing a ventral approach to the rostral aspect of the nasal cavity. B. A rectangular palatine bone flap of similar size is created and
removed to expose the nasal turbinates.
Figure 24-17. The caudal aspect of the nasal cavity and nasopharynx is
Figure 24-16. The palatine bone flap is replaced by sutures secured approached ventrally by incising the soft and hard palates for varying
through holes drilled in the flap and bone margins. distances.
Nasal Cavity 381
Figure 24-18. The soft palate incision is closed with two or three layers Figure 24-20. The lateral rhinotomy incision is directed between the dor-
of sutures to allow good apposition of the nasal and oral mucosae. sal and ventral parietal cartilages but transects the accessory cartilage.
Complications
Complications of rhinotomy include hemorrhage, entrance
into the cranium, pain, subcutaneous emphysema, airway
obstruction, nasal discharge, fistula and disease recurrence.
Intraoperative hemorrhage is minimized by temporary occlusion
of the external carotid arteries and good hemostasis during
surgery. Packing the nasal cavity is discouraged as it may lead
to hyperventilation and subcutaneous emphysema; in addition
removal of the packing material 2 to 3 days after surgery is
painful. Postoperative hemorrhage is rare however blood trans-
fusions are sometimes necessary to replace lost volume.
Figure 25-1. The dorsal dashed line represents the position of an elon-
gated soft palate obstructing the dorsal aspect of the larynx. Everted
laryngeal saccules (ventral dashed line) protrude from their crypts Figure 25-2. Severe collapse of the arytenoid cartilages in conjunction
cranial to and partially obscure the vocal folds. with an elongated soft palate (dorsal dashed line) and eversion of the
laryngeal saccules (ventral dashed lines). The aryepiglottic folds and
cuneiform cartilage collapse medially obstructing the ventral aspect of
In their normal position between the vocal cords and the
the glottis in stage two laryngeal collapse. The corniculate processes
ventricular bands (false vocal cords), the laryngeal saccules of the arytenoid cartilages collapse medially narrowing the dorsal glot-
are not visualized. Increased airflow resistance and increased tis with stage three laryngeal collapse.
negative pressure generated to move air past obstructed
areas due to stenotic nares and soft palate elongation pulls the obstructing the dorsal aspect of the glottis (See Figure 25-2). The
saccules from their crypts and causes them to swell. Everted normal glottic diameter at rest is narrowed and widening of the
and edematous saccules obstruct the ventral aspect of the glottis during inspiratory abduction of the corniculate processes
glottis further restricting airflow (See Figure 25-1). Diagnosis is reduced.
of laryngeal saccule eversion is made during laryngoscopic or
endoscopic examination. The everted saccules are recognized
as edematous or fleshy soft tissue masses immediately rostral Associated Abnormalities
to and often obscuring the vocal folds. Acutely everted saccules During laryngoscopic and endoscopic examination of the airway
are whitish and glistening in appearance. Chronically everted the pharynx should be assessed for degree of inflammation and
saccules are pink and fleshy. It is difficult to visualize and edema, evidence of redundant dorsal pharyngeal mucosa, and
thoroughly evaluate the laryngeal saccules and larynx prior to tonsil eversion. Tonsil eversion, inflammation and edema are
soft palate resection as the soft palate obscures the other struc- secondary to air turbulence and increased breathing effort.
tures, and the severely affected patient may become cyanotic. Aberrant nasal turbinates and gastrointestinal lesions have
For these reasons, laryngeal saccule eversion is diagnosed also been described. Tracheoscopy is performed to assess the
less often than elongated soft palate or stenotic nares. Saccule tracheal conformation and degree of inflammation. Many brachy-
eversion may also be suspected during ultrasonographic exami- cephalics have concurrent tracheal hypoplasia and a few have
nation of the larynx when there is a narrowed air shadow within tracheal collapse. Hypoplasia results in a narrow lumen due to
the rima glottis.2 the cartilages meeting or overlapping. These cartilages are often
abnormally rigid and the trachealis muscle is often obscured or
rolled into the lumen. Tracheal collapse is usually a dorsoventral
Advanced Laryngeal Collapse narrowing of the trachea with cartilages being more flaccid than
Advanced laryngeal collapse is caused by chronic upper airway normal and the trachealis muscle is stretched and droops into
obstruction which results in increased inspiratory efforts and the lumen. These abnormalities further restrict airflow.
causes the cartilages to fatigue and lose their rigidity. Stage
two and three laryngeal collapse may be recognized during
laryngoscopic or endoscopic evaluation of animals with the Treatment
brachycephalic syndrome. In stage two collapse or collapse of After definitive diagnosis, the syndrome is treated with the
the aryepiglottic fold, the cuneiform process of the arytenoid goal of achieving long-term relief from respiratory distress and
cartilage and the fold of tissue connecting it to the epiglottis preventing progression of the disease. Partial resection of the
weaken and deviate medially (Figure 25-2). Medial deviation of nares, soft palate and laryngeal saccules is recommended for all
this aryepiglottic fold causes further obstruction of the ventral patients with these brachycephalic abnormalities. Patients with
aspect of the glottis. In stage three collapse or collapse of advanced laryngeal collapse who do not improve adequately
the corniculate processes of the arytenoid cartilages, the following palate and saccule resection or those who improve
corniculate processes loose their rigidity and deviate medially and then later relapse with severe signs of respiratory distress
Larynx 385
Figure 25-4. A. The tip of the soft palate is grasped with Allis tissue forceps. After noting the length of soft palate to be amputated, stay sutures are
placed just cranial to the proposed line of resection. B. The full thickness of the soft palate is incised with a surgical blade approximately half the
width of the soft palate. A length of the “stay” suture with the needle attached is used to appose the edges of the cut surface while one takes care
to incorporate both the pharyngeal and nasal mucosa. C. After completing mucosal apposition, the suture is tied to a length of suture being used as
a “stay” suture on the opposite side.
Figure 25-6. Stenotic nares resection. A. Resection of the nares begins by grasping the moveable margin of the nares to outline the wedge to be
removed and to stabilize the tissue. B. Using a #11 scalpel blade a medial and the lateral incision are made adjacent to the tips of the forceps. C.
The wedge is removed and discarded. D. The external nares are then widened by placing appositional sutures to appose the incised edges.
Aryepiglottic fold resection is occasionally performed in withdraw any blood clots that may have entered the trachea.
patients with aryepiglottic fold collapse. It is performed when Begin supplemental oxygen through the nasal catheter (50 ml/
other resection techniques have not adequately alleviated the kg/min) just before or after the endotracheal tube is removed.
patient’s respiratory distress or concurrently with resection of Continue nasal oxygen administration until the patient is fully
palate, nares and saccules if respiratory distress is extreme and recovered from anesthesia and breathing with minimal or no
permanent tracheostomy is not acceptable to the client. Aryepi- distress, usually 2 to 3 hours. Provide continuous monitoring
glottic fold resection is performed unilaterally through an oral during recovery and postoperatively for 24 to 72 hours as
approach. The fold is grasped and stabilized with thumb forceps inflammation and edema may result in airway obstruction. The
and the fold and cuneiform process excised with Mayo scissors clinician should be prepared to reanesthetize and re-intubate
or uterine biopsy forceps. The tissue defect is allowed to heal by or perform a tube tracheostomy in patients which experience
second intention. severe dyspnea. Additional doses of corticosteroids may also be
necessary and gastroprotectants are continued. Analgesics are
continued for 48 to 72 hours. A weight reduction program should
Postoperative Management be instituted for obese animals.
The nasopharynx and larynx are aspirated and a nasal catheter
placed for oxygen administration during recovery. Advance the Serious surgical complications include death due to glottic
catheter to the end of the soft palate if possible. Suture or glue obstruction from inflammation and edema, and nasal regurgi-
the catheter to the skin and fit the animal with an appropriately tation and rhinitis/sinusitis due to excessive soft palate resection.
sized Elizabethan collar to prevent the patient from removing Inadequate resection of tissue results in persistent signs of upper
the catheter. Keep the animal quiet and sedated to allow a slow airway obstruction. Excessive glottic manipulation may cause
quiet recovery with the endotracheal tube in place for as long vagal induced bradycardia. Hemorrhage, gagging and coughing
as possible. Remove the tube with the cuff slightly inflated to and aspiration may also occur in the early postoperative period.
388 Soft Tissue
Neurogenic atrophy of intrinsic laryngeal muscles, particu- Definitive diagnosis of laryngeal paralysis is made with laryn-
larly the cricoarytenoideus dorsalis muscle, causes failure of goscopy under very light anesthesia. In lightly anesthetized
arytenoid cartilages and vocal folds to abduct, resulting in upper dogs with laryngeal paralysis, there is a failure of the arytenoid
airway obstruction. The obstruction can worsen with exercise, cartilages to abduct during inspiration. The arytenoid cartilages
excitement, or hot weather as increased oxygen demand causes can also fail to abduct if the level of anesthesia is too deep. In
greater inspiratory effort (greater negative pressure), which order to make an accurate diagnosis, the patient must be under
draws the arytenoid cartilages and vocal folds medially. This can as light a plane of anesthesia as possible and the evaluation
become a vicious cycle, leading to cyanosis and collapse. must be of adequate duration to be sure there is no effective
arytenoid abduction during inspiration (at least 5 to 10 minutes).
In some cases, paradoxical movement of the arytenoid carti-
Diagnosis lages may occur where the arytenoids are drawn medially due
The importance of an accurate diagnosis cannot be overem- to the negative pressure created at inspiration.8 Similarly, the
phasized. Laryngeal paralysis occurs primarily in older, larger arytenoids may appear to abduct weakly on expiration; this is
breed dogs. It is rare in toy and small breed dogs. Other causes caused by the arytenoids being moved from their paramedian
of respiratory distress such as upper airway obstruction caused position by passive expiratory efforts. It is extremely important
by intraluminal or extraluminal (thyroid) neoplasia should be to correlate any laryngeal movement with the phase of respi-
considered and ruled out before laryngeal paralysis is considered ration. Various anesthetic protocols have been used effectively
the primary cause. The most common clinical signs are respi- to assess arytenoids function. I currently use propofol (2 to 6 mg/
ratory distress, stridor, and exercise intolerance, often with a kg, IV). After initial induction and arytenoid evaluation, I admin-
slow, insidious onset over a period of months to years. Other ister doxapram (1.0 to 2.2 mg/kg) and continue laryngoscopy. Use
clinical signs observed less commonly include voice change and of doxapram is very useful in more clearly differentiating normal
coughing or gagging. Although the onset of signs is gradual, it dogs from those with laryngeal paralysis. It increases respiratory
is not uncommon for patients to have acute, severe, life threat- effort and increases any intrinsic laryngeal motion (if present).21
ening episodes of upper airway obstruction, particularly during In dogs with bilateral laryngeal paralysis, use of doxapram
hot weather and when the dog is excited or exercising. may increase paradoxical arytenoid motion. Close monitoring
of the patient’s ventilatory status during laryngeal examination
Physical examination of patients with suspected laryngeal is important and the examiner should be prepared for patient
paralysis should include auscultation of the laryngeal region intubation with the appropriate sized endotracheal tube. Laryn-
with and without mild laryngeal compression both before and goscopy often reveals laryngeal (arytenoid) edema and inflam-
after exercise.6 In dogs with laryngeal paralysis, auscultation mation, which may worsen the signs of laryngeal paralysis, and
usually reveals increased respiratory noise (stridor) over the may change the character of dyspnea from primarily inspiratory
laryngeal region, especially during inspiration. Dogs with normal to both inspiratory and expiratory.8 If laryngeal paralysis is
laryngeal function should not have an appreciable change in strongly suspected in patients with moderate to severe clinical
upper airway noise with mild laryngeal compression. Dogs with signs, based upon history and physical examination, it is advan-
laryngeal paralysis will exhibit a distinct worsening of the stridor tageous to schedule laryngoscopy so that surgery can be
as laryngeal compression is applied because they already have performed immediately following laryngoscopy if the diagnosis
a fairly narrow, relatively fixed laryngeal glottis. This may be is confirmed.
noted while listening as the dog is panting or upon auscultation
of the laryngeal region. Thoracic auscultation will often only
demonstrate referred upper airway sounds, but it is extremely Treatment
important in order to evaluate the patient for possible concurrent The recommended emergency medical treatment for an acute
disease. Aspiration pneumonia and/or bronchial disease can respiratory crisis due to laryngeal paralysis is sedation and
occur in patients with laryngeal paralysis because these patients endotracheal intubation, followed by gradual wakening of the
are unable to fully close the glottis during swallowing. animal.6 These severely affected patients should be observed
continuously and may need emergency surgery to relieve
Thoracic and cervical radiographs should be obtained to rule the upper airway obstruction. It is best to perform a definitive
out other causes of respiratory compromise and to document corrective procedure if possible rather than a temporary
concurrent disease. In addition to a CBC and chemistry profile, tracheostomy.
thyroid status is evaluated (T4 or TSH stimulation). There is an
increased incidence of hypothyroidism in dogs with laryngeal Alleviation of upper airway obstruction caused by laryngeal
paralysis, although there is not a proven cause and effect paralysis can be best achieved with surgery.2 Medical therapy,
relationship. Hypothyroidism, like acquired laryngeal paralysis, including the use of tranquilizers, oxygen, and corticosteroids
tends to be a disease of older dogs. Hypothyroidism has may be helpful in management of severely affected patients prior
been reported as a cause of generalized polyneuropathies.7 to surgery. Patients with preexisting aspiration pneumonia should
Supplementation with thyroxine will not reverse the laryngeal be treated prior to surgery and may be more likely to develop
390 Soft Tissue
postoperative aspiration pneumonia. Patients with laryngeal anatomy of the cervical and laryngeal region and the specific
paralysis and megaesophagus (or any cause of regurgitation) surgical procedure. The surgical technique should be observed
have a poor prognosis due to the extremely high likelihood of prior to performing it and practiced on cadavers, or performed
developing severe aspiration pneumonia after surgery. with an experienced surgeon present if possible.
The goal of surgery is to provide complete relief of upper airway Routine endotracheal intubation is performed following laryn-
obstruction while minimizing discomfort and postoperative goscopy. The unilateral cricoarytenoid laryngoplasty can be
complications. After surgery, patients should be able to breathe performed on either side. I perform the procedure on the left
comfortably and have a normal activity level for their age. side for consistency only. Right handed surgeons usually prefer
to perform left side lateralization because needle advancement
Unilateral arytenoid lateralization in some form (cricoarytenoid through the cricoid is easier and less awkward. The patient is
laryngoplasty is described here) has been used successfully to placed in right lateral recumbency with a slight rotation towards
achieve these goals in treating laryngeal paralysis and is the dorsal recumbency. It is helpful to place a small rolled towel under
procedure of choice of many surgeons.1,2,6,8-16 Other reported the neck at the level of the larynx. A ventrolateral approach to the
surgical techniques for treatment of laryngeal paralysis include larynx is made, beginning with a 5 to 8 cm long skin incision over
partial laryngectomy (partial arytenoidectomy with vocal the larynx, just ventral to the external jugular vein (Figure 25-7).
fold resection) using either an oral or ventral laryngotomy It is helpful to palpate the caudal border of the cricoid cartilage
approach17,18 and modified castellated laryngofissure with vocal and the wing of the thyroid cartilage as anatomic landmarks
fold resection.19,20 during the approach. Dissection is continued to the lateral and
dorsal aspects of the larynx through the subcutaneous tissue
and the superficial muscles of the neck, being careful to avoid
Surgical Technique the external jugular, linguofacial and maxillary veins.
There are several variations of unilateral arytenoid lateralization.
The procedure described here has been called cricoarytenoid The dorsal margin of the wing of the thyroid cartilage is palpated
laryngoplasty.6,8 The procedure involves the placement of two and retracted laterally by use of a “stay” suture or a hand-held
sutures in the same location as the cricoarytenoideus dorsalis retractor. The thyropharyngeus muscle is incised along the dorsal
muscle, from the caudal dorsolateral aspect of the cricoid rim of the thyroid cartilage (Figure 25-8). Lateral retraction of the
cartilage to the muscular process of the arytenoid cartilage thyroid cartilage is important in order to avoid the esophagus. A
(through the articular surface). Arytenoid lateralization has been layer of connective tissue is incised just medial and parallel to the
used as a general term or to describe the procedure where sutures rim of the thyroid cartilage and separated bluntly. The cricothyroid
are placed from the caudal border of the thyroid cartilage to the articulation at the caudal edge of the thyroid cartilage is separated
muscular process of the arytenoid cartilage.2,9,10,15,16 Regardless with scissors and/or a Freer septum elevator (Figure 25-9A). This
of the technique used, it is advisable to become familiar with the
Figure 25-7. The site of the skin incision is shown by the dotted line. A ventrolateral approach to the larynx is made, beginning with an 8 to 10 cm
long skin incision starting near the angle of the mandible and extending caudally just ventral to the external jugular vein. It is helpful to palpate
the caudal border of the cricoid cartilage as a landmark during the approach.
Larynx 391
Postoperative Management
Postoperative care includes continuous (24 hour) monitoring
for dyspnea, intravenous fluid therapy, and withholding of food
and water for 12 to 24 hours. Cefazolin (20 mg/kg, IV) is given at
the time of anesthetic induction and repeated two hours later.
Antibiotic therapy (ampicillin 20 mg/kg, PO, TID) is only continued
if the laryngeal mucosa is penetrated. Patients most often do
well postoperatively and are discharged from the hospital within
1 to 2 days of surgery. The most common serious complication
that can occur postoperatively is aspiration and development of
aspiration pneumonia. Depression, fever or coughing postoper-
atively should prompt the surgeon to take thoracic radiographs
Figure 25-9. A. The cricothryroid articulation at the caudal edge of the
to rule out aspiration pneumonia. A soft, canned food consis-
thyroid cartilage is separated with scissors and/or a Freer septum
elevator. B. The cricoarytenoideus muscle and muscular process of
tency diet with no excess gravy or crumbs is recommended to
the arytenoid cartilage are identified. The muscle is undermined and minimize the risk of aspiration pneumonia. I also counsel owners
incised close to the muscular process, leaving enough muscle on the to avoid any food that might result in vomiting, as that increases
muscular process to attach mosquito forceps for use in gentle ma- the risk of aspiration pneumonia. A voice change (similar to a
nipulation. C. The cricoarytenoid articulation is separated using blunt debarked dog) is expected after cricoarytenoid laryngoplasty
dissection with fine scissors or a Freer elevator (preferred), being and other laryngoplasty techniques. Occasional coughing after
careful not to damage the muscular process or penetrate the laryn- drinking water occurs commonly in the postoperative period, but
geal mucosa. The rostral aspect of the cricoarytenoid joint capsule is usually decreases after a short period of adaptation.9
left intact as long as this allows mobility of the arytenoid cartilage to
be attained. Thyroid cartilage is not pictured in B and C. It would be
retracted laterally during these stages of the procedure.
392 Soft Tissue
Figure 25-10. A. The first of two sutures is passed over the caudal edge of the cricoid cartilage and directed cranially to penetrate through
the cartilage on the dorsolateral aspect (approximately 5 to 8 mm from the caudal edge), being careful not to penetrate laryngeal mucosa. B.
Suture is then passed from medial to lateral through the articular surface and/or muscular process of the arytenoid cartilage at least 2 to 3 mm
from the cartilage edge. C. The second suture is passed in a similar manner. D. Each suture is tied separately. The intact rostral portion of the
cricoarytenoid joint capsule helps to prevent over-abduction of the arytenoid cartilage. Thyroid cartilage is not pictured. It would be retracted
laterally during these stages of the procedure.
Arytenoid Lateralization/Cricoarytenoid
Modified Castellated Laryngofissure
Laryngoplasty Modified castellated laryngofissure widens the glottic lumen
Unilateral cricoarytenoid laryngoplasty or some form of by performing a stepped incision in the thyroid cartilage. The
unilateral arytenoid lateralization has been shown to relieve procedure also includes vocal fold resection and placement of
signs of upper airway obstruction such as stridor, dyspnea mattress sutures through the arytenoid and thyroid cartilages to
and exercise intolerance in 82% to 100% of patients.1,8,10-12,15,16,23 stabilize the arytenoid cartilages. In a report of four dogs treated
Lane reported a 97% overall success rate in surgical treatment with castellated laryngofissure,19 two (50%) had no clinical
of 167 cases of laryngeal paralysis using several modifications signs of upper airway obstruction at 7 and 12 months postop-
of arytenoid cartilage lateralization.10 My success rate with eratively, and two (50%) had no clinical signs of upper airway
unilateral cricoarytenoid laryngoplasty in over 500 dogs has obstruction at 10 and 12 months postoperatively. Another study
been consistent with these results. White reported alleviation evaluated a modified castellated laryngofissure in 12 dogs with
of exercise intolerance or stridor after arytenoid lateralization laryngeal paralysis.20 Signs of upper airway obstruction had
(with attachment of arytenoid cartilage to cricoid and/or thyroid either decreased in severity or disappeared in 11 of these dogs
cartilage) in 82% of dogs with laryngeal paralysis.15 Greenfield 15 to 452 days after surgery. One dog died immediately after
and Venker-van Haagen reported alleviation of clinical signs surgery from hyperthermia, and three dogs died 1, 9, and 11
of upper airway obstruction in 89% and 95% respectively with months postoperatively from non-related or unknown causes.
unilateral arytenoid lateralization.2,11 Payne, et al reported results Tracheotomy tubes were used during the operation and were
of abductor muscle prosthesis in 11 dogs, where placement of maintained for a minimum of three days postoperatively in both
the sutures from cricoid cartilage to muscular process of the
Larynx 393
studies. Duration of postoperative hospitalization noted in only laryngeal webbing occurred in nine of the 24 dogs (37.5%),
one case was eight days. requiring further surgery. The authors of this report recom-
mended unilateral cricoarytenoid laryngoplasty for treatment of
Modified castellated laryngofissure and arytenoid abduction laryngeal paralysis in dogs.
techniques were evaluated using 30 canine postmortem
specimens.14 There was a greater change in cross-sectional
area of the rima glottidis with modified castellated laryng-
Summary/Prognosis
ofissure than with unilateral arytenoid lateralization techniques. It is important to recognize that while bilateral laryngeal paralysis
The authors of this study suggested using modified castellated is a significant cause of upper airway obstruction in older dogs,
laryngofissure when subglottic luminal compromise, such as it is surgically treatable, with a good prognosis. Consistently
traumatic fibrosis, is present. They felt the procedure was good results have been obtained by many different surgeons
technically more demanding, more time consuming, and more with unilateral cricoarytenoid laryngoplasty or other forms of
traumatic than arytenoid abduction (lateralization) techniques. unilateral arytenoid lateralization. Familiarity with the laryngeal
anatomy and the procedure is essential to a successful surgery.
I recommend the unilateral cricoarytenoid laryngoplasty or other
Partial Laryngectomy/Bilateral form of arytenoid lateralization because it achieves the goals of
Ventriculocordectomy surgery in treating laryngeal paralysis, by relieving the respi-
Several studies have shown a high incidence of postoperative ratory distress, stridor, and exercise intolerance with a minimum
complications associated with partial laryngectomy for the of complications.
treatment of laryngeal paralysis. Long term results of partial
laryngectomy (oral approach) in 25 dogs with idiopathic laryngeal Editor’s Note: Recent studies seem to confirm that dogs with
paralysis were as follows:13 (52%) could breathe, eat and drink laryngeal paralysis likely have a polyneuropathy. See references
normally; four (16%) were considerably improved but still were 24 and 25.
noisy or had a cough, gag, or retch; six (24%) died of airway
disease postoperatively; and two (8%) had initial improvement
but were lost to follow-up.17 Aspiration was the cause of death in
References
three dogs. Tracheotomy tubes were placed prior to performing 1. Gaber CE, Amis TC, LeCouteur RA: Laryngeal paralysis in dogs: A
surgery in all cases. Duration of maintenance of the trache- review of 23 cases. J Am Vet Med Assoc 186:377-380, 1985.
otomy tube and length of postoperative hospitalization were not 2. Harvey CE, Venker van Haagen AJ: Surgical management of
described. Granulation tissue or web formation across the glottic pharyngeal and laryngeal airway obstruction in the dog. Vet Clin North
Am (Small Anim Pract) 5:515-535, 1975.
region causing airway obstruction has been reported after partial
laryngectomy, particularly when a ventral laryngotomy approach 3. Braund KG, Shores A, Cochrane S, et al: Laryngeal paralysis-polyneu-
was used. ropathy complex in young dalmatians. Am J Vet Res 55:534-542, 1994.
4. Smith MM, Child G, Cardinet GH, et al: Muscle and nerve abnormalities
Complications and long term results after partial laryngectomy for associated with canine laryngeal paralysis. Vet Surg 21:239, 1992 (abstr).
the treatment of idiopathic laryngeal paralysis were reported in 45 5. Braund KG, Steinberg HS, Shores A, et al: Laryngeal paralysis in
dogs.18 Good or excellent results were obtained in 29 dogs (65%). immature and mature dogs as one sign of a more diffuse polyneuropathy.
Six dogs (13%) had some improvement, but residual respiratory J Am Vet Med Assoc 194:1735-1740, 1989.
compromise, exercise intolerance and consistent coughing. Ten 6. LaHue TR: Laryngeal surgery: Lateralization techniques: 1994 Scientific
dogs (22%) either showed no improvement over preoperative Proceedings, 22nd Annual Surgical Forum, Washington, D.C., American
condition or developed fatal postoperative complications related College of Veterinary Surgeons, 1994, pp 255-257.
to the partial laryngectomy. Death occurred in the immediate 7. Harvey HJ, Irby NL, Watrous BJ: Laryngeal paralysis in hypothyroid
postoperative period (3 to 11 days) either because of pneumonia dogs,in Kirk RW, (ed): Current Veterinary therapy VIII, Small Animal
Practice. Philadelphia, PA, Saunders, 1983, pp 694-697.
(8 dogs) or complete upper airway obstruction (1 dog). Nine dogs
died of respiratory disease. Three dogs developed web stenosis 8. LaHue, TR: Treatment of laryngeal paralysis in dogs by unilateral crico-
across the glottis. The authors of this study did not recommend arytenoid laryngoplasty. JAAHA 25:317-324, 1989.
partial laryngectomy for the treatment of laryngeal paralysis 9. Lane JG: ENT and Oral Surgery of the Dog and Cat. Bristol, England,
because of the high incidence of postoperative complications. Wright, 1982, pp 113-118.
They felt that unilateral arytenoid lateralization may be a superior 10. Lane JG: Diseases and surgery of the larynx, in: 1986 Scientific
technique because unilateral lateralization provides relief from Proceedings, 53rd Annual Meeting of the American Animal Hospital
respiratory distress with a low complication rate. Association, Denver CO, American Animal Hospital Association, 1986,
pp 620-623.
Twenty four dogs with laryngeal paralysis treated with bilateral 11. Greenfield CL: Canine laryngeal paralysis. Comp Cont Ed 9:1011-1020,
ventriculocordectomy through an oral approach at the 1987.
University of Wisconsin-Madison were evaluated.12 There was 12. Peterson SW, Rosin E, Bjorling DE: Surgical options for laryngeal
an unacceptably high incidence of postoperative complications paralysis in dogs: a consideration of partial laryngectomy. Comp Cont
Ed 13:1531-1540, 1991.
after the bilateral ventriculocordectomy procedure. Compli-
cations occurred in 58% (14 of 24) of the dogs. The reported 13. Payne JT, Martin RA, Rigg DL: Abductor muscle prosthesis for
complications included increased respiratory stridor, exercise correction of laryngeal paralysis in 10 dogs and one cat. JAAHA 26:599-
604, 1990 .
intolerance, and difficulty cooling off after exercise. Transverse
394 Soft Tissue
Lateral collapse of the trachea or ventral collapse with minimal Periodic reevaluation is considered the best approach for these
widening of the dorsal membrane associated with loss of patients. Patients with a 50% or greater collapse of the trachea
cartilage rigidity is seen infrequently. Collapse caused by are likely to experience respiratory distress, especially during
pressure from external masses is rare. Laryngeal function may times of excitement, when oxygen demands are high or when
be less than optimal. respiratory infections are present. These patients are considered
far less likely to respond to, or already have not responded to,
Recently, the not infrequent occurrence of collapsed tracheas conservative therapy, and thus surgery should be considered.
in miniature horses suggests to the author that there may be an
association with the gene/s responsible for “dwarfism”/minia- Postoperative infection with swelling of the mucosal lining,
turization, and bears further study. dorsal membrane, and surrounding tissue is always of concern,
because the sutures used in prosthetic implant placement are
likely to penetrate the unsterile lumen of the trachea. If infec-
Diagnosis tions are to occur, they are most likely during the first 2 weeks
A presumptive diagnosis is often made on the presentation of after the operation. Abscessation around a prosthetic ring
a toy breed dog exhibiting a honking cough, with a history of when antibiotics are administered is rare. The mortality rate
chronic respiratory infections. Yorkshire Terriers, toy poodles, associated with surgery is in the range of 3% to 5% and is likely
Pomeranians, Chihuahuas, and Maltese are most commonly to be associated with impairment of air movement during the
affected. The condition has been seen rarely in mixed or larger postsurgical recovery period.
breeds of dogs, cats, and miniature horses. The disorder has no
sex predilection. The greatest concern during the surgery is injury to the recurrent
laryngeal nerves with resulting laryngeal paralysis. The nerves lie
Most patients, probably those with a grade I collapse, respond in close approximation to the dorsal lateral aspect of the trachea
to medical therapy consisting of antibiotics, cough suppres- just caudal to the larynx, to a more ventral medial position at the
396 Soft Tissue
thoracic inlet. The nerves are 1 mm or less in diameter in the toy primarily within the thorax and for collapsing principal bronchi.
breeds of dogs and are subject to injury during dissection of the Problems experienced with intraluminal stents include collapse
trachea, tissue handling, prosthetic ring placement, or possibly when subjected to too much flexion, failure to anchor well
even from the prosthetic ring itself if not placed properly. resulting in expulsion when coughing occurs, pulmonary edema,
availability of inappropriate sizes, and uneven contact between
Owners should be alerted to the potential need to perform a the stent and the airway wall. Granulation tissue proliferation
tracheostomy or laryngoplasty should laryngeal paralysis result. caused by stents may result in intraluminal obstruction.
The patient’s laryngeal function should be checked before leaving
the operating room, and a tracheostomy should be performed if Currently, the surgical techniques most universally accepted
needed. A permanent tracheostomy is considered preferable by are those that support the trachea, including the dorsal tracheal
the author to laryngeal tie-backs or arytenoid cartilage resection membrane, with extraluminal prosthetic devices to which the
in toy breeds of dogs with laryngeal paralysis. trachea is sutured. Earlier use of long sections of extraluminal
prosthetic devices restricted needed flexion of the trachea,
Laryngeal function should be evaluated while the patient is and shorter sections applied only to the ventral aspect of the
under a light plane of anesthesia as part of the preoperative trachea failed to support the sagging dorsal membrane. Current
examination. Drugs with analgesic properties administered as prosthetic devices provide that support. Support is reinforced by
preanesthetic agents make evaluation of laryngeal function on connective tissue proliferation around the prosthesis and through
stimulation of the larynx more difficult and should be avoided the holes in the prosthesis when individual ring prostheses are
when possible. Respiratory stimulants such as doxapram (0.5 to used. The individual ring technique consists of the placement
1.0 mg/kg IV) may be of value in assessing the larynx for normal of four to seven individual prosthetic rings around the trachea
function. Aerobic cultures should be taken directly from the with spacing between the rings, whereas the spiral technique is
trachea, avoiding the pharyngeal area. Tracheoscopy should essentially a continuous spiral prosthesis.
follow, with the patient under a surgical plane of anesthesia.
Oxygen can be administered directly through the bronchoscope.
Total Ring Prosthesis
Brush biopsies for cytologic evaluation should be taken of the
caudal trachea at the completion of the visual examination. With Prosthetic rings are made from 3-mL polypropylene syringe cases
proper preparation, the examination, culture, and biopsy can be by cutting the syringe case into 7-to 10-mm sections with a pipe
completed expeditiously, thus keeping the use of intravenous cutter over a wood dowel rod or by sawing the syringe case into
anesthetic induction agents to a minimum. sections and drilling approximately 3-mm diameter holes with
either a hand drill or with a No. 11 Bard-Parker scalpel blade, or a
Radiographs of the lungs should follow, with the intubated leather punch can be used. Five holes are usually drilled, with the
patient under general gaseous anesthesia. Compression of the syringe case ring cut at the location of the sixth equally spaced
rebreathing bag provides for deep inspiratory radiographs to be hole. Angled serrated wire-cutting scissors work well for cutting
made and thus for optimal evaluation of the lungs by the radiol- the ring to decrease its size if necessary and facilitate placement
ogist. Most concurrent lung disease can be ruled in or out by of the ring around the trachea. The ends of the ring are rounded
these techniques. The final decision whether or not to proceed and smoothed, as are the edges of the ring and the edges of the
with surgery is made at this time. holes, to minimize irritation after placement. The polypropylene
rings can be autoclaved or sterilized by other methods. The rings
When surgical treatment is to follow, antibiotics should be admin- can be made larger if necessary by simply spreading the ends of
istered parenterally A broad-spectrum bactericidal antibiotic the rings before suturing them to the trachea. Conversely, they
such as enrofloxacin that is effective against gram-negative can be made smaller by trimming the ends of the rings, squeezing
organisms, should be used until the results of tracheal culture the rings, and placing a figure-of-eight suture across the cut
and sensitivity testing are available. The appropriate antibiotic ends of the rings through the adjacent holes after placement, but
should be continued for 2 weeks postoperatively. before suturing to the trachea. Polypropylene rings may break if
too much pressure is applied in either expansion or compression
during alteration for size and contour at the time of surgery.
Surgical Management
Various, surgical techniques have been proposed to treat The patient is positioned in dorsal recumbency with the forelegs
tracheal collapse. Everting plication of the dorsal tracheal secured caudally. A towel roll is positioned under the neck near
membrane has been effective in moderately affected animals the shoulders. A ventral midline incision is made from the larynx
with rigid cartilage rings. Chondrotomy of the ventral aspect of to just caudal to the manubrium (Figure 26-2). The sternohyoideus
every other tracheal ring has also been effective in some moder- and sternocephalicus muscles are separated to expose the
ately affected patients with rigid cartilage rings. Resection and trachea; the surgeon should avoid the thyroid vein as much as
anastomosis are effective when few rings are collapsed, usually possible. The thyroid vein lies between the sternocephalicus
by trauma. Intraluminal prosthetic dilators have been useful for muscles in fascia on the ventral surface of the trachea. The
the short term, but they can erode the tracheal wall, stimulate trachea is surrounded by loose areolar tissue and receives its
granuloma formation, or interfere with mucus clearance over the primary blood supply segmentally from the thyroid arteries and
longer term. Intraluminal stents have been used and may prove its nerve supply segmentally from the recurrent laryngeal nerves.
very effective in the future, especially when tracheal collapse is Preservation of as much of the blood supply and innervation to
the trachea as possible is desirable. The recurrent laryngeal
Trachea 397
Figure 26-2. Ventral cervical midline approach to the cervical trachea. Placement of the rings is begun just caudal to the larynx and is
The skin incision extends from the larynx to the manubrium. continued caudally with approximately the width of the prosthetic
ring left between each ring placed. The neurovascular supply to
nerves lie in close approximation to the dorsal lateral aspect of the trachea is carefully left intact between the rings. Movement
the trachea near the larynx coursing more ventral medially as of the endotracheal tube during surgery is essential to prevent
the thoracic inlet is approached. These nerves must be handled suture from passing through the cuff of the endotracheal tube. In
carefully during dissection and ring placement. No tissue should addition, movement of the endotracheal tube is performed after
be cut without knowing that the nerves are protected. The nerves each prosthetic ring is sutured into place to prevent inadvertent
should be retracted gently by grasping adjacent tissue, not the suturing of the endotracheal tube to the trachea.
nerve itself, during dissection.
Rings can be placed around the trachea deep within the thoracic
Curved hemostats are used to bluntly dissect a tunnel dorsally inlet by gentle but strong rostral traction on the trachea. This
around the trachea (Figure 26-3). Care is taken to dissect is facilitated by grasping a distal prosthetic ring that has been
Figure 26-3. Implantation of total ring prosthesis. A. A small section of trachea is isolated by blunt dissection with a curved hemostat. The hemostat
is then used to direct the prosthesis around the trachea. The recurrent laryngeal nerves are carefully retracted. B. Suture placement. C. Cranial
retraction on the cervical trachea facilitates placement of total ring prostheses to the thoracic inlet portion of the trachea. (From Walker TL, Hobson
HP. Tracheal collapse. In: Bojrab MJ, ed. Current techniques in small animal surgery. 2nd ed. Philadelphia: Lea & Febiger, 1983.)
398 Soft Tissue
with both procedures. In these cases, the author is currently rate of approximately 10% in one report.3,4 Late complications
placing a single, long stent to span both the intra- and extra- can include stent shortening, excessive granulation tissue,
thoracic trachea. Others are placing stents intra-thoracically progressive tracheal collapse, and stent fracture. Continued
and surgical rings on the cervical trachea.5 coughing should be anticipated in patients with concurrent
bronchial collapse and these patients may have a worse
prognosis. In addition, the vast majority of patients will require
Bronchial Collapse continued medical therapy.
There remains much debate concerning the use of intra-luminal
stents in patients with mainstem bronchial collapse. Unfortu-
nately, there is currently no data available to recommend or Stent Selection
oppose the routine use of intra-luminal stents in these patients, A general review of stents is beyond the scope of this chapter, but
and therefore, regrettably, the author can only offer an opinion. a brief discussion of certain stent characteristics is necessary to
The questions raised are two-fold: understand how one selects an appropriate stent type and size.
This discussion will not include balloon-expandable metallic
(1) Should stents be placed within collapsing mainstem bronchi? stents (BEMS) as SEMS are exclusively being used to treat
I do not recommend stenting of collapsing mainstem bronchi. tracheal collapse in animals. In their resting state (deployed,
Not only will bronchial stents “cage-off” other bronchi and or outside of the delivery system), SEMS are expanded to their
consequently prevent drainage from affected lung lobes, stated, pre-determined dimensions. For example, a 10 mm
but secondary and tertiary bronchi will continue to collapse diameter x 70 mm long SEMS will be 10 mm wide and 70 mm long
and therefore the benefit achieved will likely be minimal, and if deployed from the delivery system. Following manufacturing,
temporary, when compared to the risks. Theoretically, there may an SEMS is compressed and mounted onto a delivery system
be animals in which focal mainstem bronchial collapse has been using a number of different techniques. The relatively small
diagnosed in which placement of short bronchial stents could delivery system (compared to the expanded stent diameter)
provide some benefit. allows introduction through very small holes (vascular sheath
or endotracheal tubes, for instance). During placement, as the
(2) Should tracheal stents be placed in patients with concurrent delivery system sheath is retracted, the stent expands back to
tracheal and mainstem bronchial collapse? Certain patients will its original dimensions.
benefit from tracheal stenting, even when concurrent mainstem
bronchial collapse is present. The patient should be carefully
Stent Material
evaluated to determine the animal’s primary clinical signs.
Tracheal collapse can lead to dyspnea, coughing/honking, The majority of stents being manufactured today are made of
or both. Bronchial collapse will usually manifest as a cough, nitinol, a nickel (“Ni”)-titanium (“Ti”) alloy developed by the
expiratory dyspnea, or both. When both tracheal and bronchial Naval Ordinance Laboratory (“NOL”) which is classified as a
collapse are present, the results following tracheal stent shape-memory metal. This characteristic means that nitinol
placement become less predictable. If dyspnea is the major assumes a weakened, deformable state (Martensite phase) at
clinical sign and intra-thoracic tracheal collapse is present, a low temperatures but it will return to, and maintain, its original
tracheal stent can help relieve the dynamic obstruction. If the shape at body temperature (Austenite phase). Laser-cut nitinol
patient’s primary problem is coughing, then it becomes difficult to stents are cut from hollow tubes of nitinol and at cooled temper-
determine if the coughing is secondary to the tracheal collapse atures, the metal’s properties change allowing compression
or bronchial collapse. In these patients, the author always warns of the stent onto a delivery system. Upon returning to ambient
the owner that continued coughing will likely be present as the temperature, the stent favors its original design which is
bronchial collapse will continue. In addition, in the author’s achieved upon deployment from the delivery system. Laser-cut
experience, it appears that continued, intractable coughing will nitinol SEMS are currently not recommended by the author for
cause repeated cycling of the stent and may increase the risk of the treatment of diffuse cervical and intra-thoracic tracheal
subsequent fracture, or predispose to the formation of excessive collapse in veterinary patients due to an unacceptably high
granulation tissue. Persistent coughing must be treated aggres- occurrence of stent fracture (personal experience). However,
sively to minimize the risk of these complications. others have had success placing shorter laser-cut nitinol stents
in the intra-thoracic trachea only.5 Woven, knitted, or mesh stents
are designed to be compressed onto a delivery system at normal
Expectations/Risks/Discussion temperatures through specific design modifications. While the
with the Owner design of these stents facilitates placement onto a delivery
system, there is a wide range of foreshortening that occurs from
An in-depth discussion with the owner concerning the risks the design changes as well. Examples of more commonly used
and expectations should take place once the decision has been nitinol stents in veterinary patients currently include mesh stents
made to consider tracheal stenting. Neither surgery nor stenting (Vet Stent-Trachea, Infiniti Medical) or knitted stents (Ultraflex,
has been demonstrated to slow the progression of tracheal Boston Scientific). Other commercially available stents used for
collapse and both techniques are considered palliative. Clinical tracheal collapse are made of stainless steel or similar alloys
improvement rates in 75% to 90% of animals treated with intra- (Wallstent, Boston Scientific) (Figure 26-4).
luminal SEMS have been reported, and immediate complications
were mostly minor although there was a peri-operative mortality
Trachea 401
Reconstrainability
While foreshortening can complicate the process of choosing the
appropriate SEMS for tracheal collapse, another characteristic of
some of these stents is “reconstrainability”. This feature allows
the operator to re-sheath a partially deployed stent in order to
reposition the stent and deploy it elsewhere or remove it completely
if necessary. Generally, the mesh stents (Vet Stents-Trachea™
[nitinol], Wallstents™ [Stainless steel]) are reconstrainable to
varying degrees, while the knitted stents (Ultraflex™ [nitinol]) are
not reconstrainable. Obviously, it is important to know beforehand
whether the stent is reconstrainable. In addition, although a stent
may be considered “reconstrainable”, that does not mean that
Figure 26-4. A. Mesh nitinol stent; Vet Stent – Trachea™ (Infiniti Medical). the stent can be removed once fully deployed. While some stents
Note the rounded edges of this stent chosen to reduce potential gran- can be removed following placement, most stents currently used
ulation tissue development. B. Mesh stainless steel stent; Wallstent™ for tracheal collapse in veterinary patients are designed to remain
(Boston Scientific). in place, and as such removal would be very difficult.
in order to account for radiographic magnification. Alterna- than the maximal tracheal diameter to minimize chances of
tively, some other measuring device can be placed externally subsequent stent migration. The author generally inventories
and included in the radiograph, although placement within stents in 2 mm diameter increments (i.e., 8 mm, 10 mm, 12 mm,
the esophagus is ideally located directly beside the trachea. and 14 mm diameter) and in the most commonly used lengths.
With the esophageal marker catheter technique, the patient is The cervical trachea is routinely larger in diameter than the
placed in lateral recumbency following intubation. A wet hydro- intra-thoracic trachea. Stent sizing can be complicated when
philic guidewirea and flushed marker catheterb combination the difference in these two measurements varies dramatically.
are advanced into the mouth. Using fluoroscopic guidance, When the two diameters are similar (within 2 mm), the stent
the guidewire is gently advanced down the esophagus and the diameter chosen is at a minimum equal to the maximal tracheal
marker catheter is advanced over-the-wire. The soft guidewire is diameter and typically no more than 10% to 20% larger than the
always advanced first to avoid damage to the esophagus by the maximal diameter.
relatively stiffer marker catheter. The marker catheter is placed
within the esophagus such that the radio-opaque marks extend Example 1: A dog with maximal intra-thoracic tracheal diameter
along the location of the tracheal collapse. The guidewire can of 8mm and maximal cervical tracheal diameter of 10mm would
then be withdrawn. Under fluoroscopic guidance, the endotra- likely receive a 12 mm diameter stent. When the discrepancy
cheal (ET) tube is withdrawn until the distal-most aspect is just between the cervical and intra-thoracic trachea is 3 mm or
beyond the larynx and the cuff is gently re-inflated. Positive greater, a stent diameter that is at least 10% to 20% larger than
pressure ventilation of 20 cm H2O is temporarily performed to the intra-thoracic tracheal diameter or the average of the two
achieve maximal tracheal expansion as a radiograph is taken. measurements is chosen as long as the stent will be well seated
The radio-opaque marks on the marker catheter are 10 mm within the intra-thoracic trachea to prevent cranial migration.
apart; this distance is measured on the radiograph and used
to determine the radiographic magnification that is then used Example 2: A dog with a maximal intra-thoracic tracheal diameter
to extrapolate the actual maximal diameters of both the intra- of 8 mm and maximal cervical tracheal diameter of 12 mm would
thoracic and cervical trachea (Figure 26-9A). It is important to likely receive a 12 mm (or 10 mm) diameter stent. However, one
take maximal measurements of BOTH the cervical and intra- must also consider the relative length of the stent that will be
thoracic trachea as these measurements can vary dramatically. located in the smaller diameter trachea. If only about 20% of the
stent will be located in the 8 mm diameter portion of the trachea,
The stent diameter is usually chosen to be 10% to 20% greater adequate tracheal wall contact may not be achieved with the
10 mm stent. Alternatively, if 80% of the stent will be within the 8
mm diameter portion of the trachea, a 10 mm diameter stent may
be sufficiently seated within this location to prevent migration.
The advantage of the 10 mm diameter stent is that the length
will be easier to determine as it will more closely achieve full
expansion and therefore the length will be closer to its prede-
termined length.
a combination of intravenous propofol and diazepam are used some have performed these techniques using endoscopic
with minimal inhalant anesthesia concentrations. Propofol CRIs assistance alone. In addition, passage of the delivery system
are occasionally used. The use of peri-operative antibiotics and stent placement can induce a coughing reflex. The animal
is debatable and chosen on an individual case basis. Unless should be sufficiently anesthetized to avoid a coughing episode
contraindicated, these patients typically receive one perioper- during stent deployment.
ative dose of dexamethasone SP (0.1 to 0.25 mg/kg IV).
The radio-opaque stent is easily visualized under fluoroscopy,
The largest diameter ET tube possible should be selected (at least even when constrained within the delivery system. Once the
4 mm inner diameter) to facilitate unrestricted passage of the distal end of the stent has been positioned appropriately, stent
stent delivery system through the tube while permitting simulta- deployment can proceed. During deployment, the entire stent
neous oxygen delivery and ventilation during the procedure. An and delivery system combination can be gently pulled craniad
ET tube with a radio-opaque line or markers should always be if the stent is initially placed too caudally, however the entire
used when possible to help avoid inadvertent deployment of the system cannot be advanced caudally if placement is inappro-
stent within the tube. The use of sterile ET tubes is debatable and priately cranial. For this reason, some prefer initially to place
not routinely required by the author. Following intubation, the the distal aspect of the stent slightly (~0.5 to 1cm) caudal to the
patient is placed in lateral recumbency. Subsequent measure- desired final location. To initiate stent deployment, with one hand
ments are used to determine the tracheal stent diameter as on the hub (or the cannula), and the other hand on the Y-piece
described above. The radiographic landmarks previously (sheath), gently withdraw the Y-piece (sheath) while simultane-
obtained during awake fluoroscopy identifying the length of the ously advancing the hub (cannula) in equal proportions (Figure
collapse are compared with those of the esophageal marker 26-11). If done appropriately, as stent deployment proceeds, the
catheter to determine the length of stent necessary. distal end of the stent will remain in the same location throughout
deployment. Under no circumstances should the cannula (hub)
Stent Placement
Once the appropriately sized stent is chosen, it is removed from
its packaging using sterile technique. The stent is prepared and
saline flushed according to manufacturer recommendations. The
operator is encouraged to practice these techniques outside of
the patient before introducing the delivery system into the ET tube.
ALL MANIPULATIONS SHOULD BE PERFORMED UNDER DIRECT
FLUORSCOPIC GUIDANCE. A right-angle bronchoscope adapter
(Figure 26-10) is attached to the ET tube to facilitate passage of
the stent delivery system through the tube while maintaining the
anesthesia circuit system. The delivery system must pass easily Figure 26-11. Tracheal stent mounted on delivery system within pack-
and without friction. Occasionally it is necessary to remove the aging.
diaphragm on the bronchoscope adapter to permit unrestricted
passage of the delivery system. Before passing the stent, the be advanced while the sheath remains stationary. This will
patient should be positioned such that the cervical and intra- force the stent caudally and traumatize the tracheal mucosa.
thoracic trachea lie in a straight line to facilitate unrestricted These same circumstances apply to the process of stent recon-
passage of the relatively inflexible delivery system (Figure strainment. If the operator is unhappy with the location of the
26-9B). This position will minimize trauma to the tracheal wall partially deployed stent, reconstrainment should be performed
during advancement of the delivery system. The author always via simultaneous withdrawal of the cannula and advancement
places tracheal stents under fluoroscopic guidance although of the sheath in order to avoid dragging the stent across the
tracheal mucosa. The operator should read the manufacturer’s
instructions to determine the degree to which stent deployment
can occur before stent reconstrainment is no longer possible.
Post-Operative Care and Follow-Up malignant lesions, evaluation of the animal for distant metas-
tases. Plain film radiography, tracheoscopy, and computed
Patients are routinely discharged one or two days post-stenting
tomography are helpful in localization of tracheal lesions.
with a 3 to 6 week tapering dose of prednisone (initial dose of 1 to
2 mg/kg/day PO), continued anti-tussive therapy (Hydrocodone
Tracheal anastomosis in veterinary patients typically is accom-
0.25 mg/kg PO q6 to 12 hours or higher doses if tolerated), and
plished by apposition of circumferentially divided tracheal carti-
10 to 14 days of broad-spectrum oral antibiotics. Patients with
lages with sutures placed in simple interrupted fashion (split-ring
bronchial collapse and/or an observed “expiratory push” during
technique).1 Alternative techniques such as overriding segments,
exhalation may benefit from bronchodilator therapy as well. creation of mucosal flaps, and apposition of annular ligaments are
less desirable because these techniques are technically more
Owners should be warned to anticipate an initial dry cough difficult or result in critical anastomotic stenosis.1,2 In one study,
that should improve over the following 3 to 4 weeks. If the simple continuous and simple interrupted suture techniques for
patient has documented bronchial collapse, the owners should tracheal anastomosis after large-segment tracheal resection
expect continued coughing in the future. Aggressive medical were compared in dogs. Differences in surgical time and anasto-
management of coughing is imperative for a good long-term motic stenosis were not clinically significant.3
outcome. It is the author’s anecdotal experience that continued
coughing increases the risk of both granulation tissue formation Tension has a profound effect on anastomotic healing and is the
and stent fatigue/fracture. High doses of anti-tussive medications major factor limiting the extent of tracheal resection. Tracheal
and inhalation steroids have been useful when routine therapy
anastomoses consistently are successful in mature dogs when
is inadequate. The majority of patients will require life-long
tension on the anastomosis is less than 1750 g.4 Unfortunately,
medication following tracheal stenting. The initial recheck
attempts to correlate grams of tension with number of tracheal
examination is approximately two weeks post-stenting or sooner
cartilages have produced widely disparate results.5 In general,
if problems arise. Repeat examinations are performed regularly
25% of the trachea (8 to 10 tracheal cartilages) can be resected
(every 3 to 6 months if possible) or sooner if the patient’s clinical
in a mature dog with consistently satisfactory results. In young
signs worsen.
animals and in animals with primary tracheal disease, this
number may be significantly lower.6
Disclosure: The author is a consultant for Infiniti Medical,
LLC and has been involved in the specifications chosen for the
Vet Stent-TracheaTM and Delivery System.
Surgical Techniques
Cervical Trachea
References Preoperative planning is imperative. An endotracheal tube with
a high-volume, low-pressure cuff should be used. Ideally, the
1. Buback JL, Boothe HW, and Hobson HP. Surgical treatment of endotracheal tube should be positioned proximal to the affected
tracheal collapse in dogs: 90 cases (1983-1993) Journal of the American
tracheal segment, and the entire procedure should be performed
Veterinary Medical Association 1996; 208(3):380-384.
“over” the endotracheal tube. In patients with significant luminal
2. Radlinsky MG, Fossum TW, Waler MA, et al. Evaluation of the palmaz
compromise, the endotracheal tube should be positioned distal
stent in the trachea and mainstem bronchi of normal dogs. Veterinary
(orad) to the lesion for the surgical approach and the initial tracheal
Surgery 1997; 26(2):99-107.
dissection. Tracheal anastomosis necessitates intraoperative
3. Norris JL, Boulay JP, Beck KA, et al. Intraluminal self-expanding
manipulation of the endotracheal tube and, on occasion, direct
stent placement for the treatment of tracheal collapse in dogs (abstr),
in Proceedings, 10th Annual Meeting of the American College of Veter- intubation of the distal segment of the trachea. A sterile endotra-
inary Surgeons 2000. cheal tube should be available for intraoperative intubation of the
4. Moritz A, Schneider M, and Bauer N. Management of advanced
distal segment of the trachea. The endotracheal tube cuff must
tracheal collapse in dogs using intraluminal self-expanding biliary be deflated when the tube is repositioned within the trachea and
wallstents. Journal of Veterinary Internal Medicine 2004; 18:31-42. then reinflated before the procedure continues. Prophylactic
5. Krahwinkel DJ. Tracheal collapse: Is surgery an option?, in administration of a broad-spectrum antibiotic is recommended.
Proceedings, 15th Annual Meeting of the American College of Veter-
inary Surgeons, San Diego, CA, 2005. The patient is positioned in dorsal recumbency, and the
ventral cervical region is prepared for aseptic surgery. The
skin and subcutaneous tissues are incised from the larynx to
Tracheal Resection the manubrium. The trachea is exposed by midline separation
and Anastomosis of the paired sternocephalicus and sternohyoideus muscles.
The segment of trachea to be resected is determined based
Roger B. Fingland on preoperative evaluation and intraoperative inspection and
palpation. The lateral pedicles are dissected from the trachea
Tracheal anastomosis is indicated for management of benign along a segment that includes two cartilage rings proximal and
and malignant tracheal stenoses, traumatic tracheal disruption, two cartilage rings distal to the proposed margins of the excision.
and segmental tracheomalacia. Important preoperative consid- Carrying the lateral pedicle dissection beyond the proposed
erations include localization of the lesion, determination of the margins of excision facilitates manipulation of the proximal and
proximal and distal margins of the lesion, and, in the case of distal tracheal segments and placement of primary anastomotic
406 Soft Tissue
and tension sutures. Traction sutures (3-0 polydioxanone, SH-1 rates the split proximal and distal tracheal cartilages. All sutures
taper needle, 70 cm) are placed around the right and left lateral enter the lumen of the trachea.
aspects of the second tracheal cartilage proximal to the cartilage
to be incised. The swaged-on needle is left in place, and the The dorsal tracheal membrane is exposed by rotating the trachea
suture is looped but not tied. These traction sutures facilitate with the preplaced lateral tension sutures (Figure 26-16). Anasto-
manipulation of the proximal tracheal segment and are used as motic sutures are placed in the dorsal tracheal membrane in a
tension sutures after the primary anastomosis is completed. manner that ensures accurate apposition and an airtight seal.
The segment of trachea is excised by circumferentially incising The lateral tension sutures are tied after the primary anasto-
one tracheal cartilage at each end of the segment (Figure 26-12). mosis is complete (Figure 26-17). A third tension suture is placed
Care is taken to incise the tracheal cartilages circumferen- on the ventral aspect of the trachea. The tension sutures should
tially in two equal halves. If the endotracheal tube was initially be tight enough to relieve tension from the primary anastomotic
positioned distal to the lesion, the cuff is deflated, the endotra- sutures, but they should not cause deviation or overlapping of
cheal tube is directed into the proximal tracheal segment, and the apposed ends of the proximal and distal segments of the
the endotracheal tube cuff is reinflated. On both sides of the trachea.
trachea, the swaged-on arm of the lateral traction suture is
passed around the second complete tracheal cartilage distal
to the incised tracheal cartilage. These sutures are used to
Thoracic Trachea
approximate and maintain apposition of tracheal segments and The thoracic segment of the trachea is approached through a
to facilitate rotation of the trachea for placement of primary right third intercostal thoracotomy. The technique for resection
anastomotic sutures (Figure 26-13). and anastomosis of the thoracic segment is similar to the
technique described for the cervical segment of the trachea.
The proximal and distal circumferentially incised tracheal carti- Direct intubation of the proximal segment of the trachea intra-
lages are approximated using the pre-placed lateral tension operatively usually is necessary. Direct intubation of an isolated
sutures (Figure 26-14). Accurate alignment of the two split carti- primary bronchus may be necessary to maintain ventilation.
lages is important. The primary anastomosis is created using 4-0 Preoperative planning and technical expertise are necessary to
polydioxa-none suture placed in a simple interrupted pattern ensure success.
approximately 3 mm apart (Figure 26-15). Each suture incorpo-
Figure 26-12. Ventral view of the exposed cervical trachea showing placement of traction sutures. The segment to be removed has been excised by
circumferentially incising (inset) the proximal and distal tracheal cartilages.
Trachea 407
Figure 26-13. The tracheal segment has been excised. A. The proximal and distal segments of the trachea are joined by tension sutures. The tension
sutures are drawn through the tracheal wall B. and are tagged to facilitate manipulation of the trachea for primary anastomosis.
Figure 26-14. The tagged tension sutures are used to approximate the Figure 26-15. The primary anastomosis begins on the ventral aspect
proximal and distal segments of the trachea for primary anastomosis. of the trachea by placing simple interrupted sutures around the split
proximal and distal tracheal cartilages.
408 Soft Tissue
References
1. Hedlund CS. Tracheal anastomosis in the dog: comparison of two
end-to-end techniques. Vet Surg 1984;13:135.
2. Lau RE, Schwartz A, Buergelt CD. Tracheal resection and anastomosis
in dogs. J Am Vet Med Assoc 1980; 176:134.
3. Fingland RB, Layton CE, Kennedy GA, et al. A comparison of simple
continuous versus simple interrupted suture patterns for tracheal
anastomosis after large-segment tracheal resection in dogs. Vet Surg
1995,24:320.
Figure 26-16. A tagged tension suture is used to rotate the trachea for
exposure of the left lateral and dorsal aspects. Simple interrupted anas- 4. Cantrell JR, Folse JR. The repair of circumferential defects of the
tomotic sutures are placed approximately 3 mm apart. trachea by direct anastomosis: experimental evaluation. J Thorac
Cardiovasc Surg 1961,42:589.
5. Vasseur PB, Morgan JP. The trachea. In: Gourley IM, Vasseur PB, eds.
General small animal surgery. Philadelphia: JB Lippin-cott, 1985.
6. Maeda M, Grillo HC. Effects of tension on tracheal growth after
resection and anastomosis in puppies. J Thorac Cardiovasc Surg
1973;65:658.
7. McKeown PP, Tsuboi H, Togo T, et al. Growth of tracheal anasto-
moses: advantages of absorbable interrupted sutures. Ann Thorac Surg
1991;51:636.
Permanent Tracheostomy
Cheryl S. Hedlund
Introduction
A permanent tracheostomy is a stoma in the ventral tracheal
wall created by suturing tracheal mucosa to skin. Tracheostomy
tubes are not needed to maintain lumen patency following
this procedure. Tracheostomas are maintained for life or until
the stoma is surgically closed. Permanent tracheostomies are
Figure 26-17. The primary anastomosis is completed, and the tension recommended for animals with upper respiratory obstructions
sutures are knotted. A third tension suture is placed on the ventral causing moderate to severe respiratory distress that cannot be
aspect of the trachea. The tension sutures should relieve tension from successfully managed by other methods. Dogs and cats with
the primary anastomosis, but they should not result in deviation or cyanosis or severe dyspnea at rest or with minimal exertion
overlapping of the tracheal segments. are candidates. Respiratory distress is commonly associated
with laryngeal dysfunction secondary to laryngeal collapse or
Postoperative Considerations neoplasia, and sometimes nasopharyngeal or proximal tracheal
obstruction. Before creating a tracheostoma, it is important to
Brief, atraumatic tracheal suctioning after extubation is helpful establish the clients willingness and ability to provide postop-
to remove clotted blood from the lumen of the trachea. The erative care. Although most patients requiring a permanent
patient should be observed closely for respiratory distress for tracheostomy function much better after surgery, some clients
12 to 24 hours after surgery. Postoperative respiratory distress will refuse the procedure and elect less beneficial surgical
can result from laryngeal or pharyngeal edema, occlusion of the procedures or euthanasia.
tracheal lumen at the anastomotic site, or iatrogenic laryngeal
paralysis from intraoperative recurrent laryngeal nerve injury.
Antitussives and glucocorticoids are administered as needed to
Trachea 409
Surgical Technique absorbable) (Figure 26-19). Simple interrupted sutures are placed
at the corners and a simple continuous pattern is used along the
A permanent tracheostomy is performed with the anesthetized
sides of the stoma. Sutures are spaced approximately 2 mm apart.
patient in dorsal recumbency.1-3 The skin of the ventral and
Precise apposition is important to minimize tracheostomal stenosis
lateral neck is clipped and aseptically prepared for surgery. On
but is not always possible. Precise apposition is not possible if the
the operating table, the patient’s forelegs are positioned caudally
tracheal mucosa is disrupted during dissection or previous tube
along the chest, and then the animal’s neck is elevated and
tracheostomy, or of poor quality due to disease. If the patient does
extended with a dorsal cervical pad. The proximal cervical trachea
not have enough mucosa to cover the incised cartilage edges and
is exposed with a ventral cervical midline incision beginning at
annular ligaments, the surgeon should appose as much mucosa
the distal larynx and extending caudally 8 to 10 cm. The paired
to the skin as possible and allow the exposed areas to heal by
sternohyoid muscles are separated and are retracted laterally
second intention. If necessary, sutures are passed around or
to visualize the trachea. The endotracheal tube cuff is advanced
through adjacent cartilages or annular ligaments. Skin edges are
distal to the proposed tracheostomy site. The surgeon creates a
apposed proximal and distal to the stoma with simple interrupted
tunnel dorsal to the trachea from the third to sixth tracheal carti-
or cruciate sutures. Blood and mucus are suctioned from the
lages and, using this tunnel, apposes the sternohyoid muscles
stoma before the animal recovers from anesthesia.
dorsal to the trachea with horizontal mattress sutures to create
a muscle sling (Figure 26-18). The muscle sling serves to deviate Permanent tracheostomy following total laryngectomy requires
the trachea ventrally reducing tension on the mucosa-to-skin the creation of a tracheostoma after the transected end of
sutures. Beginning with the second or third tracheal cartilages, the trachea is closed or deviated to the skin.3,5 Closure of the
a rectangular segment of tracheal wall three to four cartilage
transected trachea is accomplished by preserving a flap of dorsal
widths long and one-third the circumference of the trachea in
tracheal membrane from the more proximal trachea that can be
width is outlined. (See Figure 26-18) Using a #11 scalpel blade,
folded over the exposed lumen of the distal trachea and then
the cartilage and annular ligaments are incised to the depth of
sutured. Alternatively, the transected distal trachea is closed
the tracheal mucosa. The surgeon elevates a cartilage edge
by placing a series of interrupted horizontal mattress sutures
with thumb forceps and dissects the cartilage segment from the
to appose the dorsal tracheal membrane to the cartilage. After
mucosa using the blunt edge of the scalpel blade. If tracheal carti-
using either of these closure techniques a permanent trache-
lages show any weakness or tendency to collapse, place one or
ostomy is performed as described previously.
two prosthetic tracheal rings cranial and caudal to the stoma. A
similar segment of skin is excised adjacent to the stoma. If the
Another option after total laryngectomy is to incorporate the
patient has loose skin folds or abundant subcutaneous fat, larger
distal tracheal end into the tracheostoma. This is accomplished
segments of skin are excised to help prevent skin fold occlusion
by apposing the sternohyoid muscles dorsal to the distal tracheal
of the stoma. Excess fat is excised in obese patients to allow
end. Then, beginning at the distal tracheal transection site, the
direct contact of the skin and peritracheal fascia. The surgeon surgeon removes segments of four to six tracheal cartilages
sutures the skin directly to the peritracheal fascia laterally and from the ventral aspect of the tracheal wall, while preserving as
the annular ligaments proximal and distal to the stoma with a much mucosa as possible (Figure 26-20). At the most proximal
series of interrupted intradermal sutures (3-0 or 4-0 polydiox- aspect of the proposed stoma, the dorsal tracheal membrane
anone or poliglicaprone 25) without entering the tracheal lumen. is apposed directly to the skin with simple interrupted sutures.
These skin-peritracheal sutures promote adhesion of the skin to Excess skin is excised as necessary to prevent skinfolds at the
the trachea and are important in reducing postoperative skin fold site, and then the skin is sutured directly to the peritracheal
problems, seroma formation, and tension on the stomal sutures. An fascia and annular ligaments with intradermal sutures. The
“I” or “H” shaped incision is made through through the mucosa. tracheostoma is completed by apposing the tracheal mucosa at
The mucosa is folded over the cartilage edges and sutured to the the lateral and distal cartilage margins to the skin with simple
edges of the skin with approximating sutures (4-0 monofilament continuous sutures (Figure 26-21).
Chapter 27
Lung and Thoracic Cavity
Thoracic Approaches
Dianne Dunning
Introduction
Intercostal thoracotomy and median sternotomy are the most
commonly used thoracic approaches in small animals. The
choice of a thoracic approach depends upon the type of access
to the thoracic cavity that is needed. Intercostal thoracotomy is
easy to perform and does not require special surgical instrumen-
tation, but it permits only limited access within the thoracic cavity.
Median sternotomy allows wide access to the thoracic cavity,
except for the structures in the dorsal mediastinum such as the
esophagus and bronchial hilus. However, median sternotomy
requires access to an oscillating saw or sternal splitter. Never-
theless, median sternotomy is the thoracic approach that allows
the most complete exploration of the thoracic cavity.
Table 27-1. General Recommendations for Figure 27-1. Intercostal thoracotomy. Incision of the latissimus dorsi
Intercostal Thoracic Approaches muscle. The fifth rib is identified by the caudal insertion of the scale-
nus muscle and the cranial origin of the external abdominal oblique
Anatomic Structure Intercostal Space muscle. (From Orton EC. Small animal thoracic surgery. Baltimore:
Williams & Wilkins, 1995:57.)
Heart
Patent Ductus Arteriosus Left 4th or 5th
Persistent Right Aortic Arch Right 4th
Pulmonic Valve Right 4th
Pericardium Left or Right 5th
(pericardectomy)
Thoracic Duct
Dog Right 8th, 9th, or 10th
Cat Left 8th, 9th, or 10th
Lung Lobes
Left Cranial Left 4th, 5th, or 6th
Left Caudal Left 5th or 6th
Right Cranial Right 4th, 5th, or 6th
Right Middle Right 5th
Right Caudal Right 5th or 6th
Esophagus
Cranial Left 3rd or 4th
Heartbase Right 5th
Caudal Left or Right 7th, 8th, or 9th
Vena cava
Cranial Right 4th Figure 27-2. Intercostal thoracotomy. Incision of the scalenus muscle
and the serratus ventralis muscle. (From Orton EC. Small animal tho-
Caudal Right 6th, 7th, or 8th racic surgery. Baltimore: Williams & Wilkins, 1995:57.)
Lung and Thoracic Cavity 413
been suggested as a less painful method of closure. The serratus Before closure, a thoracostomy tube is placed subcostally and
ventralis or external abdominal oblique and scalenus muscles are lateral to the midline (Figure 27-10). The sternotomy is closed with
closed in a single layer with a simple continuous suture pattern. alternating figure-of-eight 20 to 22gauge orthopedic wires (Figure
The latissimus dorsi muscle, cutaneus trunci muscle, subcuta- 27-11). The pectoralis muscles, subcutaneous tissues, and skin are
neous tissues, and skin are closed in separate layers with a simple closed in separate layers with a simple continuous suture pattern.
continuous suture pattern (Figure 27-6).
Median Sternotomy
Postoperative Care
Hypoventilation, hypoxemia, hypothermia, acid-base imbalance,
Median sternotomy is indicated when exploratory surgery of hypotension, pain and hemorrhage are among the problems that
the thoracic cavity is necessary. Median sternotomy should not may arise in the first 12 to 24 hours after thoracotomy. Median
be avoided because of a belief that it is associated with higher sternotomy and intercostal thoracotomy are both associated
postoperative pain and complication rates than intercostal thora- with alterations in normal pulmonary function that may be
cotomy. Complication rates associated with median sternotomy attributed to several factors including pain. These changes may
are no higher than those associated with thoracotomy. inhibit deep inspiration and may promote small airway collapse,
resulting in ventilation-perfusion mismatch. Measurement of
Median sternotomy is performed with the animal in dorsal recum- arterial blood gases after surgery provides information about
bency. The skin and subcutaneous tissues are incised with a ventilation and pulmonary gas exchange. Additional postoper-
scalpel over the midline on the sternum (Figure 27-7). The pectoral ative monitoring should include frequent assessment of drainage
musculature is incised and is elevated from the sternebrae with from the thoracic cavity, temperature, pulse rate, respiratory
electrocautery. The sternum is then cut on its midline with an rate, and mucous membrane color.
oscillating saw or sternal splitter (Figure 27-8). Care is taken
to limit the penetration of the saw or osteotome to avoid injury Analgesia is indicated in all animals after thoracotomy. Paren-
to internal thoracic structures. Either the manubrium or the teral opioids, epidural morphine, intrapleural anesthetics, and
xiphoid is left intact to achieve a stable closure of the sternum. selective intercostal nerve blocks using 0.75% bupivacaine
Finochietto retractors are used to expose thoracic structures. may be used alone or in combination to provide postoperative
A caudal median sternotomy can be combined with a ventral analgesia (Table 27-2).
414 Soft Tissue
Figure 27-5A. Intercostal thoracotomy closure. Approximation of the ribs by an assistant using the preplaced circumcostal sutures while the
surgeon ties each suture. (From Orton EC. Small animal thoracic surgery. Baltimore: Williams & Wilkins, 1995:60.)
Suggested Readings
Burton CA, White RN. Review of the technique and complications of
median sternotomy in the dog and cat. J Small Anim Pract 1996;37:516-
522.
Pelsue DH, Monnet E, Gaynor JS, et al. Closure of median sternotomy in
Suture dogs: suture versus wire. J Am Anim Hosp Assoc 2002;38:569-576.
(A) Transcostal Suture (B) Circumcostal Suture Rooney MB, Mehl M, Monnet E. Intercostal thoracotomy closure:
transcostal sutures as a less painful alternative to circumcostal suture
Intercostal nerve placement. Vet Surg 2004;33:209-213.
Intercostal vein
Berg RJ, Orton EC. Pulmonary function in dogs after intercostal thora-
Intercostal artery
cotomy: comparison of morphine, oxymorphone, and selective inter-
Rib costal nerve block. Am J Vet Res 1986;47:471-474.
Rib with 0.062 in. hole Conzemius MG, Brockman DJ, King LG, et al. Analgesia in dogs
after intercostal thoracotomy: a clinical trial comparing intravenous
buprenorphine and interpleural bupivacaine. Vet Surg 1994;23:291-298.
Figure 27-5B. Schematic of transcostal suture placement. A 0.062 Orton EC. Small animal thoracic surgery. Baltimore: Williams & Wilkins,
Steiman pin is used to drill the holes in the 5th rib. The suture is passed 1995:33-40, 55-72.
around the cranial aspect of the cranial rib and through the caudal Pascoe PJ, Dyson DH. Analgesia after lateral thoracotomy in dogs:
rib and tied securely, thus avoiding the neurovascular bundle. (From epidural morphine vs. intercostal bupivacaine. Vet Surg 1993;22:141-147.
Rooney MB, Mehl M, Monnet E. Intercostal thoracotomy closure:
Stobie D, Caywood DD, Rozanski EA, et al. Evaluation of pulmonary
transcostal sutures as a less painful alternative to circumcostal suture
function and analgesia in dogs after intercostal thoracotomy and use
placement. Vet Surg 2004;33:209-213.)
of morphine administered intramuscularly or intrapleurally and bupiva-
caine administered intrapleurally. Am J Vet Res 1995;56:1098-1109.
Thompson SE, Johnson JM. Analgesia in dogs after intercostal
thoracotomy: a comparison of morphine, selective intercostal nerve
block, and interpleural regional analgesia with bupivacaine. Vet Surg
1991;20:73-77.
Walsh PJ, Remedios AM, Ferguson JF, et al. Thoracoscopic versus
open partial pericardectomy in dogs: comparison of postoperative pain
and morbidity. Vet Surg 1999;28:472-479.
Lung and Thoracic Cavity 415
Figure 27-6. Intercostal thoracotomy closure. Closure of the muscle Figure 27-8. Median sternotomy. The sternum is cut on midline with
and skin in separate layers with a simple continuous suture pattern. an oscillating saw. (From Orton EC. Small animal thoracic surgery.
(From Orton EC. Small animal thoracic surgery. Baltimore: Williams & Baltimore: Williams & Wilkins, 1995:66.)
Wilkins, 1995:62.)
Table 27-2. Commonly Used Drugs for Postoperative Calming and Alleviation of Postoperative Pain.
Key Drug Route Dose Range (dog) (mg/kg) Frequency (hr)
Morphine IV 0.5-1.0 Q 1-2
Morphine IM, SQ 0.2-2.0 Q 2-6
Morphine IV 0.3-0.5 IV loading dose CRI
followed by 0.10.3
Fentanyl IV 0.002-0.003 IV loading dose CRI
followed by 0.001-0.005
Hydromorphone IV, SQ, IM 0.05-0.2 Q 4-6
Oxymorphone IV 0.02-0.1 q 1-2
Oxymorphone IM, SQ 0.05-0.2 q 2-4
Carprofen SQ 4.4 followed by 2.4/4.4 Pre-emptive injectable BID/qd
PO
Deracoxib PO 3-4 qd for 7 days
Ketoprofen IV, SC, IM 2.0 One time dose
Meloxicam IV, SQ 0.2 qd
Tepoxalin PO 10 qd
Lung and Thoracic Cavity 417
Figure 27-12. Lung lobe anatomy. A. Left. B. Right. (From Orton Figure 27-13. Partial lung lobectomy. The lung is clamped proximal to
EC. Small animal thoracic surgery. Baltimore: Williams & Wilkins, the isolated lesion. (From Orton EC. Small animal thoracic surgery.
1995:162.) Baltimore: Williams & Wilkins, 1995:165.)
418 Soft Tissue
Figure 27-16. Partial lung lobectomy with staples. The stapler is placed
across the lung and is clamped proximal to the lesion. (From Orton
EC. Small animal thoracic surgery. Baltimore: Williams & Wilkins,
1995:166.)
Figure 27-15. Partial lung lobectomy. The clamps are removed, and the Lung lobectomy should follow the anatomic distribution of the
incision is oversewn with a simple continuous pattern. (From Orton bronchi. The left cranial and caudal lung lobes may be removed
EC. Small animal thoracic surgery. Baltimore: Williams & Wilkins, individually. The cranial, middle, and caudal right lobes may be
1995:165.) removed individually because they each have separate bronchi.
The accessory lung lobe usually is removed with the left caudal
or the 2.5 mm (white, V or V3) staple cartridges may be used for lung lobe. Before removal of the caudal and accessory lobes, the
pulmonary procedures. A gastrointestinal anastomosis stapler pulmonary ligaments must be divided from the mediastinum with
also may be used for longer staple lines. The stapler is placed Metzenbaum scissors.
across the lung and is clamped proximal to the lesion (Figure
27-16). The staple device is fired and the lung is transected The pulmonary artery is accessed first by ventral and caudal
utilizing the edge of the TA stapling device as a cutting edge. retraction of the lung lobe. The lobe may be grasped gently with
After the removal of the stapling device, the lung is checked for a dry gauze sponge. The artery is isolated by blunt dissection
air leaks in the manner described previously. with right-angle forceps parallel to the long axis of the vessel
(Figure 27-17). The artery is triple ligated and is divided between
the middle and distal ligature. The pulmonary vein is accessed by
Complete Lung Lobectomy
dorsal and cranial retraction of the lung lobe. The vein is isolated,
Excision of an entire lung lobe is indicated for severe trauma, ligated, and divided in a similar manner to the artery. The lobar
neoplasia, lobe torsion, abscesses, or refractory infections. The bronchus is then clamped with a noncrushing tangential clamp
affected lung lobes should be manipulated gently to minimize and is divided 3 mm distal to the clamp. The bronchial stump is
Lung and Thoracic Cavity 419
Postoperative Care
Placement of a thoracostomy tube is always recommended before
closure of the thoracotomy. If the thoracostomy tube is nonpro-
ductive, it may be removed soon after the surgical procedure
(see the earlier section of this chapter on thoracic approaches).
Figure 27-17. Complete lung lobectomy. Dissection of the ligatures
Animals should be monitored frequently for pneumothorax or
around the pulmonary vessels is accomplished with right-angle
hemorrhage after pulmonary surgery. Pneumothorax usually
forceps parallel to the long axis of the vessel. (From Orton EC. Small
animal thoracic surgery. Baltimore: Williams & Wilkins, 1995:164.) resolves spontaneously after pulmonary surgery. High-volume air
leaks can be managed by continuous suction until they resolve.
closed with 4-0 suture in a continuous mattress pattern (Figure
27-18). The tangential clamp is removed, and the bronchial
stump is oversewn with a continuous pattern (Figure 27-19). The
Suggested Readings
Garcia F, Prandi D, Pena T, et al. Examination of the thoracic cavity
bronchus is then checked for air leaks by saline immersion. and lung lobectomy by means of thoracoscopy in dogs. Can Vet J
1998;39:285-291.
En bloc stapling of the hilus may be used to remove large lung Lansdowne JL, Monnet E, Twedt DC, et al. Thoracoscopic lung lobectomy
lobe abscesses or tumors when minimal handling of the affected for treatment of lung tumors in dogs. Vet Surg 2005;34:530-535.
lung is desired. When using 2.5-mm staples (TA 30 V or V3, Lipscomb VJ, Hardie RJ, Dubielzig RR. Spontaneous pneumothorax
white), it is rarely necessary to separately ligate and divide the caused by pulmonary blebs and bullae in 12 dogs. J Am Anim Hosp
pulmonary vessels. Dissection of the lung lobe from the medias- Assoc 2003;39:435-445.
tinum is performed if needed to exteriorize the lobe. The stapler McNiel EA, Ogilvie GK, Powers BE, et al. Evaluation of prognostic factors
is placed across the hilus of the lobe and is clamped. A clamp is for dogs with primary lung tumors: 67 cases (1985-1992). J Am Vet Med
placed distal to the TA stapler across the lobe to prevent spillage Assoc 1997;211:1422-1427.
of material from the lobe. The staple device is fired, and the Murphy ST, Ellison GW, McKiernan BC, et al. Pulmonary lobectomy in
lobe is transected, using the edge of the TA stapling device as a the management of pneumonia in dogs: 59 cases (1972-1994). J Am Vet
cutting edge. After the removal of the stapling device, the hilus is Med Assoc 1997;210:235-239.
inspected for leaks in the same manner as described previously. Orton EC. Small animal thoracic surgery Baltimore: Williams & Wilkins,
1995:161-167. Walshaw R. Stapling techniques in pulmonary surgery.
Vet Clin North Am Small Anim Pract 1994;24:335-366.
Thoracic Drainage
Dennis T. Crowe and Jennifer J. Devey
The ability to recognize and manage the dog or cat with various
types of fluid (blood, chylous effusion, suppurative effusion,
transudate) or air accumulation in the pleural cavity is vital.
Although small accumulations of fluid or air in the pleural
space may be easily tolerated and hence go undetected, larger
amounts prevent normal lung expansion during the inspiratory
phase of the ventilatory cycle and can cause a significant
increase in ventilatory effort. If significant air or fluid accumu-
lations are present, the animal may display signs of respiratory
distress, orthopnea, polypnea, and poor tolerance for exercise
Figure 27-18. Complete lung lobectomy. The lobar bronchus is clamped or stress. Immediate thoracentesis of fluid or air can be accom-
and divided, and the bronchial stump is closed in a continuous mattress plished with a minimal stress to the patient and may provide
pattern. (From Orton EC. Small animal thoracic surgery. Baltimore: enough drainage to be lifesaving. Although mild conditions may
Williams & Wilkins, 1995:164.)
420 Soft Tissue
require treatment only by thoracentesis, more severe conditions either directly or by a 20-inch section of intravenous extension
require the placement of a chest tube (tube thoracostomy) and tubing. The intravenous tubing, three-way stopcock, syringe
either intermittent or continuous pleural evacuation. If suppu- should be assembled and capped to maintain sterility and stored in
rative or infected fluids are retained in the pleural space, the a crash cart for emergencies. A second section of tubing, attached
patient is at an increased risk of systemic infection or sepsis. to the sidearm of the stopcock, is useful in directing aspirated fluids
Retention of chylous effusions can lead to fibrosing pleuritis and into a collection jar. This assembled apparatus can be operated by
atelectasis. This discussion reviews the common methods of one person.
pleural drainage used in small animal practice.
Thoracentesis is usually performed at the seventh or eighth inter-
Needle Thoracentesis costal space (Figure 27-21). The animal should be allowed to rest
in the position providing the least stress. Usually, this is standing,
Procedure sitting, or in sternal recumbency. The lateral recumbent position
If the patient has any evidence of respiratory distress, oxygen is only acceptable if the patient is unconscious, intubated, and
should be provided immediately. This can be administered by being ventilated. The dorsoventral location of the puncture site
flow-by oxygen at high flow rates (10 to 15 L/minute), oxygen mask, within the intercostal space is influenced by whether air or fluid
human nasal cannulas, nasal oxygen tubes, or oxygen hoods. is to be aspirated. If air is to be aspirated, the midthoracic region
Oxygen cages are not recommended because of the inability to is preferred, with the animal in lateral recumbency. If the animal
monitor and treat the patient (See Chapter 6). is standing or is in sternal recumbency, air is aspirated at the
junction of the dorsal and middle thirds. Fluid is best removed from
Before performing needle thoracentesis in the conscious and the middle third of the seventh intercostal space, when the animal
aware patient, a local anesthetic block is recommended. Using is standing or is in sternal recumbency. More caudal placement
a 22- to 25-gauge needle 1% lidocaine is infiltrated into all layers of a needle may lead to penetration of the dome of the diaphragm
from the skin down to and including the pleura, with a small amount and or liver injury.
of anesthetic deposited into the pleural space. The lidocaine
should be buffered with sodium bicarbonate. A suggested ratio Inadvertent injury to the lung parenchyma with the tip of the needle
is two-thirds 1% lidocaine to one-third sodium bicarbonate. may lead to pneumothorax, particularly if the lung is lacerated in
Systemic analgesia is not generally required for needle thoracen- the process. This complication can be avoided by the use of the
tesis; however, when the patient is in pain, parenteral analgesics following technique: An 18- or 20-gauge needle is placed through
may also be used. the skin with the bevel facing caudally. A drop of saline is placed
on the needle hub, and the needle is then slowly advanced into the
Emergency and diagnostic needle thoracentesis can be performed pleural space (Figure 27-22A). Once the pleural space is entered,
with various needles and catheters, including an 18- to 20-gauge the negative pressure within the thorax causes the fluid in the
hypodermic needle, a short plastic intravenous catheter, or a hub to be pulled into the chest. In cases of tension pneumothorax,
bovine teat cannula (Figure 27-20). In extremely small patients, an the pressure causes the fluid to be pushed out of the needle hub
18- to 20-gauge butterfly catheter can also be used. A three-way (Figure 27-22B). The surgeon must stop advancing the needle at
stopcock and a 35- or 60-mL syringe are attached to the needle this point, to avoid lung injury. The needle is then tilted in a caudal
direction. At this time, the bevel of the needle should be directed
parallel to the chest wall, with the opening directed away from the
chest wall (Figure 27-22C).
Indications
Thoracentesis used as a diagnostic procedure can provide a
fluid sample for laboratory evaluation. Thoracentesis is ideal for
the initial treatment of acute pneumothorax and pleural effusions
and as a method of intermittent drainage of the pleural cavity
for treatment of slow accumulations of fluid or air. The surgical
placement of a chest drainage tube (tube thoracostomy),
however, is preferred for the removal of large volumes of fluid
or continuing accumulation of air in the pleural space. Clinical
experience has also suggested that it is impossible to drain
the pleural space adequately with simple thoracenteses when
accumulations of blood, chylous effusion, or pus are present.
Figure 27-20. Apparatus for thoracentesis: an indwelling intravenous
catheter or a bovine teat cannula, a three-way stopcock, a large Complications
syringe, and tubing from an intravenous administration set. Plastic cath-
Inadvertent trauma to the lung from overpenetration and
eters and blunt teat cannulas can remain perpendicular to the chest
wall because of the low likelihood of causing lung injury. (From Bojrab movement of the needle leading to lung laceration is the most
MJ, ed. Current techniques in small animal surgery. 2nd ed. Philadel- common complication. This is best prevented using the foregoing
phia: Lea & Febiger, 1983.) technique. The intercostal vessels can be lacerated during the
Lung and Thoracic Cavity 421
Figure 27-21. The seventh intercostal space is the ideal location for thoracentesis and chest tube insertion in most patients because of safety.
Here at the junction of the dorsal third and ventral third of the space is the least danger of causing injury to vascular structures, the large airway,
and the diaphragm.
procedure if the needle is introduced immediately adjacent to to effect, and ventilation should be monitored. A small skin incision
the ribs. A minor laceration is likely to be self-limiting; however, (large enough to allow passage of the thoracostomy tube) is made.
if an expanding hematoma is noted over the thoracentesis site, The needle and catheter system are slowly introduced into the
this area should be surgically explored and the vessel ligated or pleural space, and suction is applied. If an indwelling system is
cauterized. Rarely, tangential laceration of an intercostal artery required, the catheter assembly is advanced, the needle assembly
can cause serious hemothorax. is removed, and the tube is secured. Some systems (Argyle Turkel
Safety Thoracentesis System, Sherwood Medical Products)
have color indicators to detect when the pleural space has been
Minithoracostomy entered. After placement, the catheter is fixed in place by suturing
Indications and Tube Selection the tube to the fascia, and a bandage is applied. A radiograph is
Various commercial thoracentesis and minithoracostomy tube taken to assess tube location.
kits are available (Argyle Turkel Safety Thoracentesis System,
Sherwood Medical Products, St. Louis, MO; Pneumothorax Complications
Sets, Cook Critical Care, Bloomington, IN). These kits contain The short length of these minithoracostomy catheters may lead
a medium-bore multiholed catheter (8 to 10 French) for pleural to dislodgment, particularly in larger dogs (A Mann, unpublished
drainage. These catheters can be used for temporary drainage data). The catheter may also be too small to achieve adequate
and may be valuable for short-term indwelling chest tubes for pleural drainage in big dogs or in those animals with rapid
cats and small dogs. reaccumulations of fluid or air. Kinking can also be a problem
with these catheters.
Procedure
If a minithoracostomy tube is selected for insertion, the lateral Tube Thoracostomy
chest wall at the level of the seventh to ninth intercostal spaces
is aseptically prepared. A local anesthetic block using 1 to 2% Tube Selection
lidocaine is placed. On rare occasions, the animal may require Tube thoracostomy involves the surgical placement of flexible
minor sedation or short-acting neuroleptanalgesia. If sedation or sterile red rubber (Sovereign, Sherwood Medical Products),
neuroleptanalgesia is required, it should be provided intravenously polyvinyl chloride (Argyle Straight Thoracic Catheter, Sherwood
422 Soft Tissue
Figure 27-22. A-C. A hypodermic needle is used to evacuate air or fluid from the pleural space. A drop of saline added to the hub of the needle
is used to indicate when the tip of the needle is in the pleural space. The drop of fluid is aspirated into the pleural space if the fluid is still under
negative pressure. If it is under positive pressure, the fluid moves outward; if it moves outward under force, a tension pneumothorax is present. The
needle is then angled to allow the bevel of the needle to face the open pleural space and is held there while aspiration is performed. (The syringe
depicted in the drawing is too small for the job.)
Lung and Thoracic Cavity 423
Medical Products; Cook Critical Care), or silicone (Cook Critical Chest Tube Placement During Thoracotomy
Care) tube into the pleural space. Sterile endotracheal tubes can To place a chest tube at the time of a thoracotomy, the tip of
also be used if they are modified by knotting the cuff inflation a curved hemostat is bluntly forced through intercostal muscle
mechanism, cutting the valve off, and removing the cuff. The and parietal pleura at the seventh or eighth intercostal space or
tubing should be flexible, but not collapsible. The internal two spaces caudal to the thoracotomy incision. A subcutaneous
diameter of the tube should be at least one-half to two-thirds tunnel is made in a caudal direction from the inside of the thorax
the width of one of the larger intercostal spaces (approximate to the outside for a distance of two to three intercostal spaces.
diameter of a mainstem bronchus). This is important if tension A small skin incision is made at the ninth or tenth intercostal
pneumothorax is being treated and to help prevent occlusion by space over the tips of the hemostats. The proximal part of the
clots or viscous fluids. chest tube is grasped, and the tube is pulled into the thoracic
cavity and positioned. The tube can also be placed by advancing
The number and size of the holes placed in the catheter also a curved hemostat through the incision into the pleural cavity, by
influence the flow rate and effectiveness of the tube. Experi- grasping the distal part of the tube and pulling the tube out of the
mental flow studies on catheters indicate that, when three side chest cavity in a reverse fashion (Figure 27-24). Cutting the distal
holes are present, each additional hole increases the flow rate part of the tube on an oblique angle creates a pointed end that
by only 6%. Most commercially available chest tubes contain an facilitates its movement through the thoracic wall if it is placed
end hole and five or six side holes. If a noncommercial tube is in a reverse fashion. The tip of the tube is positioned cranial and
used, side holes can be created using a pair of scissors or a No. ventral. In all cases, radiographs should be taken after the tube
15 scalpel blade. The recommended size of the hole is approxi- is placed to ensure that the tube is in a proper location and is not
mately one-fourth the circumference of the tube. Diameters kinked or twisted (Figure 27-25).
exceeding one-third the circumference of the tube cause
considerable weakness and predispose the tube to kinking.
Anchoring the Chest Tube
Commercially available chest tubes contain a marker strip The tube is secured by passing a heavy suture on a taper needle
throughout their length to allow radiographic confirmation of through the skin next to the tube and into the periosteum of the
placement. The end of a chest tube should be placed on the rib adjacent to the tube. A hinge is created by tying 6 to 10 knots
ventral floor of the patient’s thorax and cranial to or adjacent and then the suture is passed around the tube in a simple criss-
to the heart. In this location, both air and fluid can be drained cross fashion and tied with 2 knots. This criss-cross “friction
efficiently from the pleural cavity where the tube is located. All knot” is repeated 2 to 3 times, and then 3 to 5 more knots are tied
holes must be located within the chest cavity. This placement (Figure 27-26). The use of this friction knot avoids the need for
can be verified radiographically with tubes that have a “sentinel tape, which is not sterile and can slip. A second hinge is created
eye,” that is, an interruption in the radiopaque marker where the on the other side of the tube with the same suture, and the suture
last hole is located. For best function, the tube should be placed is anchored again through the skin and into the periosteum. In
no farther cranially than the level of the second rib; more cranial small patients, the suture can be passed around the rib. If this is
placement may obstruct the flow of air or fluid and may cause done, care is taken to ensure that the needle does not lacerate
phrenic nerve irritation and dysfunction (Figure 27-23). In tubes the lung. If the suture is not anchored to the periosteum, the tube
where holes have been created, the last hole should be placed may migrate as the patient breathes and moves, and the tip may
through the radiopaque marker for identification purposes. In exit the pleural space. The thoracotomy is then closed.
some cases, because the mediastinum is intact, two chest tubes
are required, one for each side of the pleural space.
Figure 27-23. Drawings from lateral A. and ventrodorsal B. radiographs demonstrate proper intrathoracic location of the chest drain. The arrow-
head in A indicates the location of the last side hole in the catheter as seen on the radiograph (where the radiopaque line is interrupted). (For best
function, the tube should be placed no farther cranially than the level of the second rib; more cranial placement may obstruct the flow of air or fluid.)
(From Bojrab MJ, ed. Current techniques in small animal surgery. 2nd ed. Philadelphia: Lea & Febiger, 1983.)
424 Soft Tissue
Figure 27-24. In pulling the chest drain out through the seventh or eighth intercostal space, cutting the end of the tube on an oblique angle facilitates
its movement through the thoracic wall. (From Bojrab MJ, ed. Current techniques in small animal surgery. 2nd ed. Philadelphia: Lea & Febiger, 1983.)
Kelly forceps are then used to separate the intercostal muscles Methods of Pleural Space Evacuation
in a controlled fashion (Figure 27-27C). The tips of the forceps
The open end of the tube must be attached to one of the following:
are inserted into the incision, and mild pressure is exerted in a
1) a Heimlich valve (Bard-Parker, Rutherford, NJ) or another
medial direction; the tips are then opened to spread the tissues,
one-way egress valve; 2) a three-way stopcock; 3) an under-
and then the forceps are removed (Figure 27-27D). This dissecting
water seal; 4) an underwater seal with controlled continuous,
action is used to create a small defect in the pleural space
low-vacuum suction drainage (high-volume or low-volume
(Figure 27-27E). A small amount of air is intentionally allowed to
types depend on the rate of air or fluid-blood accumulation); 5)
move into the pleural space, to cause the lung to retract away
an underwater seal with controlled, intermittent low-vacuum
from the parietal pleura as the tips of the forceps penetrate
suction drainage; or 6) under emergency conditions, a regular
the pleural space. This maneuver permits the chest tube to be
suction unit with a side hole cut into the connective tubing to
inserted without injuring the lung. The hemostat is left in place
control the suction pressure. The choice of device depends on
to allow continued identification of the thoracotomy site. A stylet
the size of the patient, the size of the air leak, the nature of the
is used in the tube to help guide it into the appropriate position.
pleural fluid, and the patient’s tractability. All attachments to the
The tip of the stylet should not protrude beyond the end of the
chest tube should be secured with tape placed in a criss-cross
tube. The tube tip is then passed into the chest cavity through
fashion. This allows the inside of the tubing or attachment to be
intercostal musculature previously separated by the tip of the
hemostat and is gently guided (without undue force) into the visualized. If the attachment is inadvertently pulled, the tape will
cranioventral thorax (Figure 27-27F). The stylet is removed, and tighten and prevent loosening or detachment.
the tube is rotated to ensure that it is not kinked. The assistant
releases the skin so the skin returns to its original position, thus Heimlich Valve
creating a subcutaneous tunnel for the tube (Figure 27-28). The The Heimlich valve consists of a rubber one-way flutter valve
tube is then anchored as described previously. If an assistant that is enclosed in a clear plastic tube open at each end (Figure
is not available, the skin incision should be made over the tenth 27-29). The end of the chest tube is attached to the wide end of
or eleventh intercostal space, and a curved hemostat should be the flutter valve and is an excellent device for evacuating air.
used bluntly to create a tunnel cranial to the seventh or eighth It is a good temporary device for evacuating blood and other
intercostal space. The catheter tip is then grasped in the jaws fluids; however, the valve should be replaced frequently during
of stout hemostatic clamps, is passed down the subcutaneous drainage of blood or other tenacious fluids because the rubber
tunnel, and is forced into the chest cavity through intercostal valve becomes sticky and does not open freely. The end of a
musculature previously separated by the tip of the hemostat. This Heimlich valve has a fitting that accommodates a syringe in
maneuver is difficult and must be closely controlled to prevent case manual suction is required. Although the valve has been
overpenetration. Practice with a cadaver is recommended. used with success in animals weighing less than 15 kg, some
Placing a tube using local anesthetic alone can be more easily smaller patients may not be able to generate sufficient increases
accomplished using the former technique. in intrapleural pressure during expiration to open the valve and
to allow evacuation. One-way valves are especially useful in the
Placement of a thoracostomy tube can also be accomplished initial management of tension pneumothorax in patients weighing
using a commercially available tube and trocar stylet unit, which more than 15 kg if an underwater seal and suction system is not
is pushed through the chest wall. This procedure is strongly immediately available.
discouraged because of the high likelihood of iatrogenic injury
to intrathoracic structures and the high degree of tolerance of
the first procedure described earlier. The skin over the tenth to Stopcock
eleventh intercostal space is pulled cranially by an assistant A stopcock attached to the end of a catheter prevents air or
to overlie the eighth to ninth intercostal space. The trocar- fluid from moving either in or out without manual operation. Its
pointed stylet is then forced through the intercostal space with a use is recommended in animals weighing less than 15 kg and
controlled thrust. As soon as the tip of the tube enters the chest, in animals that are not accumulating air or fluid rapidly in their
the metal stylet is retracted to just inside the cannula. The rigidity pleural cavity. The rate of fluid or air evacuation is determined
of the stylet aids in manipulating the tube into the correct cranio- by the size of the stopcock because the stopcock is of a smaller
ventral position. The assistant then allows the patient’s skin to diameter than the chest tube. A large syringe is used for periodic
retract caudally to its normal position. Once released, the skin aspiration by opening and closing the valve as needed to accom-
and subcutaneous tissue form a seal over the hole. plish thoracentesis. The syringe plunger should be pulled back
gently with only sufficient pressure applied to evacuate the
fluid. Excessive pressure (greater than 30 cm H2O) can lead to
Bandaging the Chest Tube lung injury or ineffective evacuation caused by the aspiration of
An occlusive dressing is placed using sterile antibiotic ointment mediastinal tissue.
or petrolatum over the ostomy site. The exiting catheter and torso
are then wrapped gently but securely with gauze and tape for
further protection. A stockinette can also be used to cover the Temporary Emergency Underwater Seal
entire area. The end of the catheter should be exposed near the and Suction System
dorsum of the animal’s back, and the rest of the catheter should A disposable plastic intravenous administration set can be used
be covered to prevent its being damaged or dislodged. to facilitate emergency drainage of large quantities of pleural
426 Soft Tissue
Figure 27-27. A-F. Placement of a chest tube with the skin pulled as far forward as possible that creates a flap when the tube is inserted and the skin
is released.
Lung and Thoracic Cavity 427
Figure 27-28. When the skin is allowed to return to normal position, a tunnel is created that helps to prevent air from migrating into the pleural space.
Note the position of some of the side holes in the tube that allow air and fluid to drain from the pleural space as the lung reexpands (1 to 4).
428 Soft Tissue
Figure 27-31. Three-bottle suction drainage: A, Distal end of the chest tube exiting from the bandaged thorax; B, gum-rubber tubing (approximately
half an inch in diameter) to allow “stripping” of the tube, about 3 feet in length (see text); C, polyvinyl chloride “bubble” tubing. (From Bojrab MJ, ed.
Current techniques in small animal surgery. 2nd ed. Philadelphia: Lea& Febiger, 1983.)
may be considered from this vessel. In this case, approximately underwater seal system that is in essence a three-bottle system.
50 to 75 mL anticoagulant solution is initially added to the bottle. This also has an autotransfusion system that can be attached for
When 500 to 1000 mL blood has been aspirated, a second fluid- collecting blood for autotransfusion. The Pleur-evac does require
trap bottle containing anticoagulant is substituted for the first the use of a suction unit to generate the vacuum powering the
bottle, and autotransfusion is begun. The second bottle of the system. The AN50 Thorovac (H. W. Andersen Products, Inc., Haw
three-bottle system is connected to the first bottle and acts as River, NC) is a commercial example of a two-bottle system. This
the underwater seal. Its function and filling are similar to those is an electrically driven underwater seal suction system. Up to
of the first bottle of a two-bottle system. The third bottle is 20 cm of water pressure can be generated; however, in patients
connected to the second and again acts as suction regulator. with large leaks, the unit may not be able to evacuate rapidly
enough. It is generally useful if the air leak from a pneumothorax
For the underwater seal and suction drainage system, at least is less than 500 mL per hour.
the first 3 feet of the tubing leading from the chest catheter to
the underwater seal should be made of gum rubber (Tomac
Troubleshooting and Tube Stripping
amber latex intravenous tubing, American Hospital Supply Corp.,
McGaw Park, IL). Any animal whose chest catheter is connected When using any form of continuous underwater suction system,
to an underwater seal device by a tube must be watched the chest tube should be intermittently stripped and, in some
carefully because knocking over of the bottles and detachment cases, hand suctioned using a stopcock and syringe to ensure
or chewing of the tubing can lead to massive pneumothorax. that the system is working adequately. The best way to hand
This possibility is the major drawback of the use of bottle suction suction using a stopcock is to attach a “Y” connector (Abbott
systems in many small animal practices in which staff coverage Laboratories, Chicago) to the chest tube. A red rubber tube
is not available on a 24-hour basis. If an intensive care unit, (Sovereign, Sherwood Medical Products) is used to connect the
hospital with 24-hour staff coverage, or emergency practice is stopcock to the Y connector. The other end of the Y connector is
available, however, continuous suction and drainage may be attached to the suction tubing (Figure 27-32). A clamp is placed
accomplished and continued for as long as necessary. across the section of tubing not being used. This method allows
either continuous suctioning or syringe aspiration without
With several alternatives available, selection of a drainage disruption of the connections.
system depends on the following criteria: 1) the patient’s size;
2) the type of material drained and its rate of accumulation With continuous-suction systems, leaks and generation of inade-
within the pleural space; 3) the facilities and staff available for quate suction pressure are the two most common complications.
monitoring; and 4) economic considerations. Without question, Leaks can occur anywhere along the system from the ostomy
the underwater seal and suction drainage system is the most site to the suction unit. If the tube was not tunneled at least two
effective. A three-bottle system is no longer available, but one spaces, the tube may start to leak at the ostomy site. This is more
may buy a two-bottle and a one-bottle system and combine them likely to occur the longer the tube is in place because the skin
(American Hospital Supply Corp.). The Pleur-evac chest drainage edges retract around the ostomy site, thereby creating a larger
unit (Deknatel, Inc., Fall River, MA) is a commercially available hole. If the tube backs out of the chest, holes in the tube may
communicate with the environment.
430 Soft Tissue
Figure 27-32. Y connecter attached to a chest tube to allow a continuous-suction system to be connected as well as a stopcock to aspirate
intermittently, to ensure function of the continuous system and to act as a “fail safe” for evacuation of the pleural space if the system stops
working properly.
The pressure generated at the chest tube should be checked Special Considerations for the Rapid
periodically. This can be done by placing a manometer near the
chest tube and monitoring the pressure as the suction is applied. Accumulation of Fluid or Air
A commercial manometer (Vital Signs Inc., Totawa, NJ) can Currently, an underwater seal and suction drainage system
be used for this purpose, or tubing can be placed in a bottle of attached to the chest tube is the recommended method of
sterile saline. A column of saline pulled upward into the tubing treatment for trauma or disease conditions involving the
should be between 15 and 20 cm above the surface of the saline. continuous or rapid accumulation of air or fluid in the pleural
The pressure indicated at the suction unit itself is always less space. In these situations, a Heimlich valve should only be used
than the pressure generated at the chest tube because of resis- as a temporary means of evacuating the chest if the patient’s
tance within the tubing. This problem worsens in proportion to weight exceeds 15 kg, such as when transporting the patient
the length and collapsibility of the tubing. from the emergency treatment area to the intensive care unit.
For patients under 15 kg, use of a three-way stopcock and
Fluid accumulations within the suction tubing also interfere syringe is the only method recommended for the drainage of
with operation of the system. Stripping is required to keep the rapid accumulation of air or fluid other than underwater seal and
fluid from accumulating. By grasping the tubing as near to the suction systems.
patient as possible and by pinching it closed, a stripping motion
(a sliding motion, with the tube pinched off) is applied along the Under emergency conditions, if an underwater seal and suction
length of the tube for 20 to 40 cm (Figure 27-33). The stripping system is not immediately available, a regular suction unit can
action creates a sudden, high negative pressure inside the tube be used. The vacuum is reduced to 20 to 30 cm H2O by one of
past the area where the tube has been pinched closed. At the three methods: 1) cutting a small hole in the side of the tubing; 2)
end of each stripping action, the pinch is released, and a surge partially clamping the tubing; and, 3) opening the “escape” valve
of negative pressure is transferred to the thoracic catheter. The or using the control valve on the suction unit.
high negative pressure generated also loosens and evacuates
fibrin clots and debris inside the catheter. This stripping should
be done every hour when a significant amount of blood or other
Analgesia
viscous or sticky fluid is encountered. The frequency of stripping The presence of chest tubes can be painful for the patient, and
may be decreased as the amount of fluid removed decreases. analgesia should be administered on a regular basis as required.
Generally, by the second day, stripping is only necessary every Intercostal nerve blocks can be provided with 0.25 to 1.0 mL of
4 to 8 hours. 0.25% bupivacaine through intermittent injections or with the use
of an indwelling catheter. Intrapleural analgesia is best provided
with 0.25 to 0.5% bupivacaine (up to 2 mg/kg) administered into
Lung and Thoracic Cavity 431
Figure 27-33. Chest tube stripping done by a nurse every 6 to 8 hours to keep the tubing and the tube patent. The left hand pinches the tubing (made
of gum rubber) shut, and the right hand is used to strip the tube, by pinching and then sliding using the thumb and index finger, which are lubricated
with water or petroleum jelly. When the right hand meets the left, the tube in the left hand is allowed to snap open, creating a sudden popping of air.
the chest tube. The addition of sodium bicarbonate (one-third in the patient with a large-bore chest tube, death can occur
sodium bicarbonate to two-thirds bupivacaine) to the local within 5 to 10 minutes because of the effects of a progressive
anesthetic helps to decrease the irritation from the acidity of the pneumothorax.
drug. Warming the medication to body temperature and admin-
istering the drugs slowly also provide less discomfort. Systemic An occasional problem is the accumulation of fibrin clots,
administration of a neuroleptanalgesic is also recommended in especially when a small-lumen-diameter catheter (smaller than
combination with local analgesia. 20 French) is used or when a large amount of fibrin, blood, or
other proteinaceous material is drained. Blockage is prevented
by frequent stripping of the tubing. When using a three-way
Tube Removal stopcock on the end of the chest catheter, a small amount of
The chest drain should be removed whenever it is no longer sterile heparinized saline solution can be infused every few
needed. This time may range from the immediate postoperative hours; when using the Heimlich valve or other one-way rubber
period to more than a week. Suction should be continued until no valve, it may be necessary to change the valve frequently.
air has been removed for 12 to 24 hours or until fluid accumula-
tions are less than 1 to 2 mL/kg per day. If any question exists Reexpansion pulmonary edema has been occasionally reported
concerning the safe removal of the chest tube, it should be in patients with chronic cases of atelectasis when the lung is
clamped for 24 hours. The patient should be closely monitored reinflated rapidly after rapid removal of pleural fluid or air. In
during this time, and the tube should be suctioned if the patient general, this complication is not seen until the lungs have been
has any evidence of respiratory compromise. The tube is atelectatic for longer than 3 days.
aspirated after the 24-hour period, and radiographs are then
taken to determine whether any intrapleural accumulation of air Another reported complication is subcutaneous emphysema as
or fluid is present. If no accumulation is present, the tube may be the result of a large hole in the chest wall that is not completely
safely removed. occluded by the presence of the drainage tube. An occlusive
dressing applied around the exit site helps to minimize this
When the surgeon determines that the tube is no longer needed, problem. Lung tissue entrapment and subsequent infarction by
the bandage and sutures are removed, and the tube is quickly vigorous chest suction have been reported. This complication
removed using traction. The hole is covered with a gauze may be considered whenever a radiographic pulmonary infil-
dressing impregnated with an antibiotic ointment. The gauze trate appears near a side or end hole of the chest tube. Unreg-
is held in place with a torso bandage. Complete sealing of the ulated, high vacuum levels, as in operating room or portable
wound generally occurs in 2 or 3 days. Until then, the dressing suction units (80 to 120 mm Hg), should not be used. All active
is changed as required to maintain a clean, dry, and occlusive suction must be regulated by a two- or three-bottle system, the
(with ointment) environment. emergency system mentioned earlier, or, if one is aspirating with
a syringe, it should be done gently.
Complications
As previously mentioned, whenever the patient must be left Although infection can occur whenever any indwelling catheter
unattended, the entire chest catheter and attached apparatus is used, this problem is minimized by careful tube placement and
must be covered completely under a well-secured dressing to care. In a randomized study of 120 human patients with indwelling
prevent disturbance or dis-lodgment. If disconnection occurs chest drains, half were treated with prophylactic antibiotics,
432 Soft Tissue
and the other half were given a placebo. Those patients given
antibiotics had the higher infection rate. Our clinical results with
Suggested Readings
the use of chest drains in dogs and cats also seem to indicate Brandstetter RD, Cohen RP. Hypoxemia after thoracentesis. JAMA
similar conclusions. Proper wound care at the site where the 1979;242:1060.
drainage catheter enters the chest and strict attention to aseptic Butler WB. Use of a flutter valve in treatment of pneumothorax dogs and
technique and suction drainage remain the most important cats. J Am Vet Med Assoc 1969;155:1997.
factors in preventing serious infection of the pleural cavity and Crowe DT. Help for the patient with thoracic hemorrhage. Vet Med
subcutaneous tissue. If any concerns exists, the evacuated 1988:83:578-588.
fluid should undergo periodic cytologic assessment, and Gram Graham JM, Mattox KL, Beall AC. Penetrating trauma of the lung. J.
staining and culture should be performed as indicated. Culture Trauma 1979; 19:665.
of tips of the tubes on removal should be considered in any tubes Griffith GL, et al. Acute traumatic hemothorax. Ann Thorac Surg
that have been in place for an extended period. 1978:26:204.
Harrah JD, Wangensteen SL. A simple emergency closed thoracostomy
A rare complication of chest tubes is phrenic nerve irritation and set. Surgery 1970:68:583.
palsy. This problem may be severe enough to cause diaphrag- Holtsinger RH, Beale BS, Bellah JR. et al. Spontaneous pneumothorax in
matic paresis. If the tube rubs the pericardium or the heart after the dog: a retrospective analysis of 21 cases 1993; 29:195-210.
pericardi-ectomy, arrhythmias may occur. These are generally Richards W. Tube thoracostomy. J Fam Pract 1978;6:629.
self-limiting. Sauer BW. Valve drainage of the pleural cavity of the dog. J Am Vet Med
Assoc 1969;155:1977.
If the tube has been in place for several days, adhesions may Turner WD, Breznock EM. Continuous suction drainage for management
have formed, and mild intrathoracic bleeding may occur when of canine pyothorax: a retrospective study. J Am Anim Hosp Assoc
the tube is removed. Rarely, bleeding may persist to the point 1988;24:485-494.
that surgical exploration and vessel ligation are required. Withrow SJ, Fenner WR, Wilkins RJ. Closed chest drainage and
lavage for treatment of pyothorax in the cat. J Am Anim Hosp Assoc
1975:11:90.
Comments Zimmerman JE, Dunbar BS, Klingenmaier CH. Management of subcu-
Often, animals suffering from multiple injuries, including fractures, taneous emphysema, pneumomediastinum, and pneumothorax during
have a pneumothorax. Mild pneumothoraces do not cause respi- respirator therapy. Crit Care Med 1975:3:69.
ratory distress, but they are readily diagnosed by chest radio-
graphs. If anesthesia is necessary for fracture repair, a chest
tube should be inserted to aid resolution of the pneumothorax,
to help in lung healing, and to allow earlier and safer use of
anesthesia. Positive-pressure ventilation during anesthesia may
predispose the healing lung or bronchus to rupture. Without a
chest tube in place, a tension pneumothorax can rapidly develop
and can prove fatal. The placement of prophylactic chest tubes
is also indicated in patients with lung injury that require positive-
pressure ventilation.
Chapter 28 tively. The poor prognosis emphasizes the need for accurate
9,11,12
Thoracic Wall Chondrosarcoma has a predilection for flat bones where it occurs
61% of the time.10 In the canine, occurrence of chondrosarcoma
on the ribs ranges from 6% to as high as 33%.7 In cats common
Thoracic Wall Neoplasia locations near the thorax are the scapula and vertebrae and
rarely the ribs or sternum.7 Biologically, chondrosarcomas are
Dennis Olsen less malignant than osteosarcoma, however this tumor may attain
large dimensions prior to diagnosis. It invades local tissues, the
Biology of Thoracic Wall Neoplasia pleural space, and may cause pleural effusion.7 Metastasis is
Tumors of the thoracic wall are considered uncommon and can reported to be slower than with osteosarcoma and the prognosis
originate from skeletal or soft tissues structures. The tissue of is somewhat better if early diagnosis and aggressive surgical
origin and tumor type determine biologic behavior and behavior resection is performed.7,9 The reported median survival times
dictates the degree of surgical intervention. Benign soft tissue for dogs with chondrosarcoma of the ribs are quite variable but
tumors (e.g. lipoma) can often be removed without wide margins are considerably longer than osteosarcoma with some authors
or aggressive excision. However, malignant tumors, regardless reporting up to1080 days.9,12 Therapy for chondrosarcoma is also
of tissue of origin, should be removed with a variable margin of en bloc resection of the tumor with reconstruction of the thoracic
normal tissue dictated by the type of tumor. Those tumors that wall if needed.
have a high probability of recurrence should have large borders
of normal tissue removed three dimensionally around the tumor.1 Metastatic neoplasms of the thoracic wall have been described
This degree of surgical excision often comprises the full thickness and the ribs are considered a common site while the sternum is
of the thoracic wall which, may affect function as well as dictate rarely affected.2,9 When metastasis to the ribs occurs, the diaph-
the type of closure or reconstruction required to restore integrity yseal area near the nutrient foramen is the common location.7,9
of the thoracic wall. Variations in surgical therapy recommenda- The incidence of metastasis of appendicular osteosarcoma to
tions emphasize the need for accurate differentiation between other bones such as the ribs may be increased following chemo-
benign and malignant tumors before appropriate therapy can be therapy regimens.10
planned and initiated.
Primary tumors of thoracic soft tissues include various sarcomas
Primary tumors affecting the skeletal structures of the thoracic (e.g. fibrosarcoma, hemangiosarcoma, hemangiopericytoma,
wall are malignant more often than they are benign.2-7 Most and malignant fibrous histiocytoma) and occasional discrete
authors report that osteosarcoma is the most common type of cell tumors (i.e. mast cell tumor).3,6,12,15 Wide three dimensional
malignant rib tumor followed by chondrosarcoma1,3-7 however, at surgical excision is recommended for these tumors. If removal
least one report has this order reversed.7 Skeletal tumors often requires en bloc excision of the thoracic wall, reconstruction may
occur at the costochondral junction of the ribs and more rarely the be required.
sternum.2,3,5,7 These tumors are often firmly attached to soft tissues
of the thorax making them relatively immobile. This characteristic En Bloc Resection Technique
may be an indication of malignancy.6 Young to middle aged dogs Prior to considering en bloc excision, the patient should be
are most commonly diagnosed with these tumors.2,5,7,8 The occur- evaluated for the presence of distant metastasis. If regional lymph
rence of skeletal tumors in this location in the cat is very rare.7 nodes are accessible, palpation followed by fine needle aspiration
of the nodes should be performed. Three-view radiographs of
Clinically, dogs with osteosarcoma of the thorax are presented the thorax should be obtained to evaluate for the presence of
with a palpable mass of the ribs or sternum that may be painful,9,10 pulmonary metastasis.10 Right and left laterally recumbent and
although some authors describe them as nonpainful.5,7 Dyspnea either a dorsoventral or ventrodorsal views should be obtained.
due to pulmonary impingment from intrathoracic extension of Ultrasound examination of the abdomen can be performed to
the tumor, pleural effusion, and pulmonary metastasis has been check for metastasis or other concurrent disease that may be
reported2,5,7,9 but another source states that respiratory signs due important prognostically. The presence of distant metastasis
to these conditions are not commonly seen.10 One character- should be carefully considered prior to surgical therapy.
istic that is generally agreed upon is that the biologic behavior
of osteosarcoma in the rib is similar to other locations. Locally, A plan for surgical treatment of thoracic tumors is developed
osteosarcoma is aggressive with lysis and production of bone by recognizing the extent of the neoplasm. While the external
and replacement with neoplastic tissue.10 Early metastasis is a extent may be apparent, the internal extent may be more difficult
trait of osteosarcoma with the lungs as the primary location for to define. Diagnostic imaging studies that may include radiog-
tumor spread and this characteristic is responsible for the poor raphy, ultrasonography, computed tomography, and/or magnetic
prognosis for animals with osteosarcoma.4,7,10 En bloc resection of resonance imaging, should be performed to further define the
the tumor including wide margins of normal tissue with adjunctive extent of the disease. Once the extent of disease is determined,
radiation and or chemotherapy are recommended. The median the excisional boundaries can be planned. It is generally accepted
survival times for cases treated by en bloc excision and excision that wide excision is the method of choice for thoracic wall malig-
plus adjunctive chemotherapy are three and eight months respec- nancies. Wide excision is defined as removing normal tissue
434 Soft Tissue
margins in excess of one centimeter. Two to three centimeters larger vessels. Positive pressure ventilation should be initiated
are regarded as standard margins in a wide excision.1 When en prior to the thoracic cavity being entered. As the external inter-
bloc excision of thoracic wall malignancies is performed, one costal muscles and ribs are encountered, the ribs are cut dorsal
extra rib on each side of the mass is often taken in an attempt and ventral to the mass. Circumcostal sutures that incorporate
to obtain adequate margins.4 Using this as a guideline along with the intercostal vasculature caudal to each rib can be preplaced
knowledge of tumor extent allows estimation of surgical bound- around each rib involved in the resection to decrease hemor-
aries. This will allow the surgeon to determine the potential rhage. Sutures should be placed dorsal and ventral to planned
closure or reconstructive techniques that may be necessary after transection sites. The intercostal musculature is incised at the
thoracic wall excision. When the excisional area involves only same level and the mass and surrounding tissues are removed
one rib and the surrounding tissues, standard soft tissue closure (Figure 28-2). Following mass removal, surrounding soft tissues
techniques can be utilized. When two or more ribs are excised are evaluated for hemorrhage and the adjacent pleural cavity
with surrounding tissues, thoracic wall reconstruction techniques and pulmonary surfaces are inspected for evidence of damage
are required. Boundaries involving six ribs is considered the or neoplastic invasion and these are treated as needed. A thora-
upper limit of surgical excision.4-6 Reconstruction is also indicated costomy tube should now be placed under direct visualization to
when a part of or the entire sternum is removed.5,6 It should be provide optimal positioning for restoration of negative pressure
noted that altering the planned surgical boundaries in an effort to within the pleural space.
simplify closure of the thoracic defect may increase the potential
for incomplete removal of the tumor. The planned closure of the
defect should not influence the surgical excision plan. Rather, the
excision should dictate the closure technique.
Figure 28-2. En bloc resection of thoracic wall tumor. All ribs involved
with the tumor and one rib cranial and caudal are cut dorsally and
ventrally. The intercostal musculature has been cut at the same level
and the section of thoracic wall has been removed.
to cover the defect and this is followed by closure of the subcuta- placed. The final border is now sutured in a similar manner as
neous tissues and skin. When the defect is considered too large the initial border again stretching and maintaining tension on the
for simple closure or muscle flaps, the greater omentum can be mesh. At this point the superficial thoracic muscles are sutured
isolated and utilized to augment wound coverage.5,6 The greater using a four corner simple interrupted pattern to decrease the size
omentum can be retrieved through a paracostal or transdiaphrag- of the defect.4 (Figure 28-4) If the defect cannot be entirely closed
matic approach to the abdominal cavity. If the omentum can be using this technique the latissimus dorsi muscle can be under-
exteriorized through the paracostal incision and manipulated mined and sutured over the remaining area. If simple undermining
through a subcutaneous tunnel to reach the defect, it is sutured and suturing is not sufficient then the origin of the muscle can
over the defect and the remaining tissues are closed. When the be incised and then rotated into the defect for coverage. (Figure
defect cannot be reached, an omental pedicle extension flap can 28-5) Direct cutaneous vessels that perforate the caudal aspect
be prepared by previously described techniques.13,14 The omental of the muscle should be ligated and transected prior to rotation of
flap is then passed through the paracostal incision and a subcuta- the muscle.4 Alternatively, other muscle flaps such as the rectus
neous tunnel and sutured to the thoracic defect. abdominus muscle can be used. The greater omentum can also be
used as previously described to cover the mesh prior to muscular
Larger thoracic defects may require the use of synthetic materials. and/or subcutaneous and cutaneous closure.4,13,14
Various materials are available for reconstruction such as polypro-
pylene mesh, polymer composite struts, and combinations of If more than four ribs have been excised, closure with mesh may
synthetic materials.4,6,10,11,16-22 When the defect is four ribs or fewer, not provide a stable repair and paradoxic thoracic motion may be
mesh may be all that is required to cover the defect and available seen. In order to prevent abnormal motion and provide protection,
soft tissues are then used to cover the mesh. After the mass is various devices such as synthetic, metal, or bioabsorbable plates
excised and a thoracostomy tube is placed, a piece of mesh is or rib allografts have been attached to the osteotomized rib ends
cut such that it is approximately one centimeter larger than the across the defect, over the mesh and secured with interrupted
thoracic wall defect on all sides. The edges of the mesh are folded wire sutures4,6,10,18,19 (Figure 28-6).
away from the pulmonary surface and placed within the pleural
cavity. This provides a double mesh layer for suturing. Along either Bioprosthetic materials such as small intestinal submucosa
the cranial or caudal border of the defect, non-absorbable monofil- may be considered for use in thoracic wall reconstruction as an
ament sutures are placed around a rib and through the folded edge adjunct to or an alternative to synthetic mesh materials. These
of the mesh implant. After the entire edge is secured, the dorsal have been used successfully in humans to reconstruct en bloc
and ventral borders are alternately sutured from the secured resections of the thoracic wall.23,24 Reports of its use in veterinary
towards the unsecured side, engaging soft tissues and encircling surgery for thoracic wall reconstruction are lacking. The physio-
the ribs or being passed through predrilled holes through the cut logic properties of these bioprosthetic materials have been shown
ends of ribs (Figure 28-3). It is important to stretch the mesh tightly to be acceptable for soft tissue augmentation and it is reasonable
and maintain even tension as the dorsal and ventral sutures are that this would be true for animals as well.25
Figure 28-3. Synthetic mesh placement for thoracic wall reconstruc- Figure 28-4. Synthetic mesh placement for thoracic wall reconstruc-
tion. The caudal edge of the mesh has been folded and sutured in tion. Thoracic musculature is sutured in a four corner simple inter-
place. The dorsal and ventral edges are likewise folded away from the rupted pattern to decrease the size of the thoracic wall defect.
lung and alternately sutured towards the unsecured edge.
436 Soft Tissue
Figure 28-5. Coverage of a thoracic wall defect with a latissimus dorsi flap. The origin of the latissimus dorsi is identified and elevated and rotated
to cover the thoracic wall defect and secured.
Figure 28-6. Placement of plate struts to stabilize large thoracic wall Figure 28-7. Diaphragmatic advancement for caudal thoracic wall
defects of 4 or more ribs. Plates have been attached to transected rib reconstruction. The caudal diaphragm attachment is transposed crani-
ends and secured to the underlying mesh. ally and sutured to the intercostal musculature, osteotomized ribs, and
around the remaining caudal rib if necessary.
Thoracic Wall 437
References 23. Cothren CC, Gallego K, Anderson ED, et al.: Chest wall reconstruction
with acellular dermal matrix (Alloderm) and a latissimus dorsi flap. Plast
1. Withrow SJ: Surgical Oncology In Withrow SJ, MacEwen EG, eds: Reconstr Surg 114:1015, 2004.
Small Animal Clinical Oncology, 3rd ed. Philadelphia: WB Saunders, 24. Berberoglu U, Alogol H: Reconstruction of a chest wall defect with
2001, p 70. dehydrated human dura mater graft. Thorac Cardiovasc Surg 41:133,
2. Fossum TW: Thoracic Wall and Sternum: Diseases, Disruptions, and 1993.
Deformities In Bojrab MJ, ed.: Disease Mechanisms in Small Animal 25. Spiegel JH, Egan TJ: Porcine intestine submucosa for soft tissue
Surgery, 2nd ed. Philadelphia: Lea & Febiger, 1993, p 411. augmentation. Dermatol Surg 30:1486, 2004.
3. Sweet DC, Waters DJ: Role of surgery in the management of dogs 26. Aronsohn MG: Diaphragmatic advancement for reconstruction of
with pathologic conditions of the thorax. Compend Contin Educ Pract the caudal thoracic wall. In Bojrab MJ, Ellison GW, Slocum B, eds. In
Vet 13:1671, 1991. Current Techniques in Small Animal Surgery, 4th ed. Baltimore: Williams
4. Orton EC: Small Animal Thoracic Surgery. Philadelphia: Williams & & Wilkins, 1998, p 419.
Wilkins, 1995, p 73.
5. Fossum TW: Surgery of the lower respiratory system: lungs and
thoracic wall In Fossum TW, ed.: Small Animal Surgery, 3rd ed. St. Louis: Management of Flail Chest
Mosby, Inc., 2007, p 867.
6. Orton EC: Thoracic wall In Slatter D, ed: Textbook of Small Animal
Dennis Olsen
Surgery, 3rd ed. Philadelphia: Elsevier Science, 2003, p 373.
7. Bell FW: Neoplastic diseases of the thorax. Vet Clin North Am Small Pathophysiology
Anim Pract 17:387, 1987. Flail chest exists when costal support of a section of the thoracic
8. Bauer T, Woodfield JA: Mediastinal, pleural and extrapleural wall has been lost due to segmental (minimum of two) fractures,
diseases. In Ettinger SJ, Feldman EC, eds.: Textbook of Veterinary dorsal and ventral, of at least two adjacent ribs. It is also
Internal Medicine, 4th ed. Philadelphia: WB Saunders, 1995, p 815. reported to occur in young animals with only dorsal fractures
9. Feeney DA, Johnston GR, Grindem, et al.: Malignant neoplasia of of adjacent ribs and pliable costal cartilages that cannot resist
canine ribs: clinical, radiographic and pathologic findings. J Am Vet the interpleural pressure changes that accompany respiration.1,2
Med Assoc 180:927, 1982.
The fractures create a section of thoracic wall that has lost not
10. Dernell WS, Straw RC, Withrow SJ: Tumors of the skeletal system In only structural but functional continuity with adjacent normal
Withrow SJ, MacEwen EG, eds: Small Animal Clinical Oncology, 3rd ed.
thoracic wall. The section “flails” asynchronously with normal
Philadelphia: WB Saunders, 2001, p 378.
motion of the thorax during respiration and is characterized by
11. Matthiesen DT, Clark GN, Orsher RJ, et al.: En bloc resection of
paradoxic inward displacement during inhalation and outward
primary rib tumors in 40 dogs. Vet Surg 21:201, 1992.
displacement during exhalation. For many years the clinical
12. Pirkey-Ehrhart N, Withrow SJ, Straw RC, et al.: Primary rib tumors in signs associated with flail chest were thought to be due, in large
54 dogs. J Am Anim Hosp Assoc 31:65, 1995.
part, to the paradoxic movement of the flailing section.2-8 It was
13. Ross WE, Pardo AD: Evaluation of an omental pedicle extension thought that pendulous airflow which occurs between opposite
technique in the dog. Vet Surg 22:37, 1993.
lungs resulted from the loss of thoracic wall integrity (Pendelluft
14. Hedlund CS: Surgery of the integumentary system In Fossum TW, theory).3,4,7,8 Simply stated, the air in the lung beneath the flail
ed.: Small Animal Surgery, 3rd ed. St. Louis: Mosby, Inc., 2007, p 222.
section would flow across to the lung in the opposite hemithorax
15. MacEwen EG, Powers BE, Macy D, et al.: Soft tissue sarcoma In upon inhalation and then back again during exhalation. This
Withrow SJ, MacEwen EG, eds: Small Animal Clinical Oncology, 3rd ed.
abnormal airflow would result in increased physiologic “dead
Philadelphia: WB Saunders, 2001, p 283.
space” and contribute to decreased vital and functional residual
16. Lampl LH, Loeprecht H: Chest wall reconstruction: alloplastic capacities, increased airway resistance, and hypoxemia. The
replacement. Thorac Cardiovasc Surg 36:157, 1988.
end result was severe respiratory distress attributed to the
17. Akiba T, Takagi M, Shioya H: Reconstruction of thoracic wall defects erratic thoracic wall motion. Therapeutic efforts were primarily
438 Soft Tissue
directed at stabilizing the unstable section as soon as possible Pain is another recognized component in the pathophysiology
and this treatment is still recommended by some authors.5,6,9,10 of respiratory distress that accompanies flail chest.2,3,7,9,25 Pain
Consequently, there are many published techniques for thoracic contributes to hypoventilation due to patient reluctance to fully
wall stabilization, from procedures that place and maintain expand the thoracic wall, which results in hypoxemia, pulmonary
traction on ribs in the unstable section with braces or external atelectasis, and also in a diminished cough reflex which leads to
fixation devices to internal fixation of the fractures in an effort to the accumulation of pulmonary secretions.3,7,26,27
restore synchronous motion of the thoracic wall.2,3,5,8-10
the opioid can be easily reversed.14 The site for epidural admin- promise in laboratory models and initial clinical trials but there
istration of analgesics is the lumbosacral space. The landmarks are many that do not.14,31,42,43 Further research is needed before
for locating the space are the ilial wings and the dorsal spinous general recommendations regarding anti-inflammatory therapy
process of L7. The site for injection is a depression on the dorsal can be made.
midline caudal to the L7 dorsal spinous process on an imaginary
line between the iliac crests. Once located, the area is clipped
and prepared aseptically and an appropriate spinal needle is
Surgical Therapy
used to penetrate the skin, subcutaneous tissues, supraspinous Therapeutic recommendations in veterinary medicine for
and interspinous ligaments, and ligamentum flavum. Because the many years have largely involved surgical stabilization of the
ligamentum flavum offers increased resistance to the passage of flail segment but it is emphasized that surgery should only be
the needle a distinct “pop” may be felt indicating entry into the performed when the patient has been clinically stabilized or if
epidural space. Accurate placement can be verified by injecting there is imminent risk of further trauma to thoracic organs due to
a small amount of sterile saline or air in a separate syringe and motion of the flail section. Because of previous concerns relative
encountering little to no resistance. When there is no resis- to chest wall instability there are many methods described for
tance, the syringe containing the anesthetic agent is placed on stabilization.2,3,5,6,8-10
the needle and the drug is injected. For appropriate drugs and
doses to administer epidurally an appropriate anesthesia text or If flail chest has resulted in severe tissue disruption, open
formulary should be consulted (See Chapter 9). Complications pneumothorax, or fracture fragments that have, or may lacerate
from epidurals are relatively uncommon and may be related to the thoracic organs, then open reduction of the fractured ribs and
drug and amount used. restoration of thoracic wall continuity is indicated as soon as the
patient’s condition permits. Repair of rib fractures, depending
Fluid therapy is often necessary in the initial management of on the size of the patient, can be undertaken with appropriately
flail chest cases because patients may be in shock. However, sized orthopedic pins and wire or plates and screws. In addition
the presence of pulmonary contusions that accompany flail to orthopedic repair, it is equally important to re-establish soft
chest can complicate fluid therapy. It is important to maintain tissue integrity such that negative pleural space pressure can
adequate tissue perfusion and hydration without contributing be restored. Repair of soft tissues when one intercostal space
to fluid overload and pulmonary edema that could occur with has been disrupted can be accomplished in a manner similar
high fluid rates that may be required in cases of shock.14,22,31,40 to closure of an intercostal thoracotomy following adequate
The type of fluid, crystalloid (isotonic or hypertonic) or colloid, debridement of devitalized tissues.10 If the soft tissue integrity
that should be used is a point of debate and controversy.14,28,31 of multiple intercostal spaces has been disrupted it may be
There is agreement, however, that regardless of the fluid type, necessary to place a series of staggered overlapping circum-
the therapy should maintain cardiac performance and tissue costal sutures incorporating all of the affected ribs and one
perfusion. This can be accomplished with various fluid types but rib cranial and caudal to the effected section. This creates a
requires careful monitoring of physiologic parameters such as “basket weave” pattern and can act as a support for soft tissues
indicators of perfusion, arterial blood pressure, central venous mobilized to cover the defect such as the latissimus dorsi or
pressure, urine output, and respiratory function. Therefore, external abdominal oblique muscles or a flap created from the
whether delivering isotonic crystalloids for shock (90 ml/kg/hr in greater omentum.10 Placement of a thoracostomy tube will facil-
dogs, 45 to 50 ml/kg/hr in cats), hypertonic saline (4 to 5 ml/kg) itate reestablishment of negative interpleural pressure and aid in
followed by isotonic crystalloids, or hypertonic saline and colloid postoperative management.
combinations, the primary aim is to maintain tissue perfusion.14,41
The use of diuretics to decrease pulmonary edema should only The more common methods of flail section stabilization involve
be considered if generalized fluid overload occurs because the the percutaneous placement of sutures that encircle the ribs
increased vascular permeability that often attends pulmonary of the flail section, applying traction with those sutures and
contusions renders diuretics such as furosemide ineffective.14,28 attaching them to an external brace that uses the adjacent intact
thoracic wall to provide counter traction for stabilization of the
Antibiotics should be administered when cases of flail chest flail segment. Prior intercostal nerve blocks with long acting
have been caused by penetrating injury such as bite wounds. local anesthesia will facilitate placement of the external brace.
However, antibiotics are not indicated when pulmonary contu- One such method utilizes heat sensitive plastic or fiberglass
sions are the primary concern because of the low incidence of casting material that has been molded to fit the thoracic wall
bacterial pneumonia.14,28,41 Inflammatory mediators released in over the area of the flail section. It is important that the prosthetic
trauma cases are known to exacerbate clinical signs that can material extend beyond the borders of the flail section so that it
accompany flail chest and one key to minimizing pulmonary rests across non-fractured ribs. Once molded and set, two holes
injury may be to control the inflammatory cascade. The use of are placed through the material in locations that will correspond
corticosteroids is controversial in that some studies have shown to each fractured rib in the flail section. It is important to place
benefit while others suggest no effect or potential adverse conse- holes sufficient for passage of two sutures per fractured rib,
quences. A high dose of methylprednisolone (30 mg/kg) given dorsally and ventrally positioned. This will prevent pivoting of
within a short time of the trauma (~30 minutes) may have benefit the ribs that may occur with only one point of fixation.3,33 The
but studies do not agree on this point.3,14,28 Other approaches to area for suture placement should be prepared aseptically and
mitigate the effects of anti-inflammatory mediators have shown monofilament non-absorbable sutures should be passed around
Thoracic Wall 441
each rib, dorsally and ventrally, so that the suture ends can be the placement of one circumcostal suture (Figure 28-12). The
2,9
passed through the holes placed through the bracing material. bracing should be protected from becoming entangled in bedding
In order to avoid interference of the brace with proper suture or being dislodged by covering it with a padded bandage. The
placement it is important to preplace all of the sutures prior to brace is left in place for 3 to 4 weeks to allow osseous callus
securing the brace. When passing the suture it is prudent that as formation and soft tissue healing.
the needle passes around the rib it remains immediately adjacent
to the bone especially along the caudal and medial borders.
This will minimize the potential of encircling the neurovascular
bundle caudally and lacerating pulmonary parenchyma (Figure
28-10). It has been reported that placement of circumcostal
sutures does not usually damage the underlying lung because
the existing pneumothorax results in a gap between the visceral
and parietal pleura, caution should none-the-less be exercised
during placement.2 After suture placement, light padding can be
interposed between the thoracic wall and the bracing material.
The suture ends are passed medial to lateral through the holes
in the brace and secured (Figure 28-11). A light thoracic bandage
can then be placed to help secure and protect the brace. The
brace should be left in place for 3 to 4 weeks to allow for soft
tissue healing and callus formation around the fractured ribs.
The bandage should be checked on a periodic basis to assure
proper position and evaluate the skin under the edges of the
Figure 28-11. Schematic drawing of an external moldable splint for
brace. If cutaneous lesions become evident, the padding may stabilization of a flail section. Two circumcostal sutures are pre-placed
need to be increased around the edges of the brace. at the dorsal and ventral extents of each rib of the flail section and
then secured to the moldable splint through appropriately placed per-
forations. The splint extends beyond the flail section to rest on stable
thoracic wall.
rib
Pleural space
lung
4. Trinkle JK, Richardson JD, Franz JL, et al.: Management of flail chest 28. Beal MW: Thoracic trauma In Ettinger SJ, Feldman EC, eds.: Textbook
without mechanical ventilation. Ann Thor Surg 19:355, 1975. of Veterinary Internal Medicine, 6th ed. St. Louis: Elsevier Inc., 2005, p
5. Kagen KG: Thoracic Trauma. Vet Clin N Am Sm Anim Pract 10:641, 461.
1980. 29. Nelson OL, Sellon RK: Pulmonary parenchymal disease In Ettinger
6. Dixon JS: Use of a slab traction splint to stabilize canine flail chest. SJ, Feldman EC, eds.: Textbook of Veterinary Internal Medicine, 6th ed.
Vet Med Sm Anim Clin 77:601, 1982. St. Louis: Elsevier Inc., 2005, p1239.
7. Shackford SR, Smith DE, Zarins CK, et al.: The management of flail 30. Campbell VL, King LG: Pulmonary function, ventilator management ,
chest: A comparison of ventilatory and nonventilatory treatment. Am J and outcome of dogs with thoracic trauma and pulmonary contusions:
Surg 132:759, 1976. 10 cases (1994-1998). JAVMA 217:1505, 2000.
8. Bjorling DE, Kolata RJ, DeNovo RC: Flail chest: Review, clinical 31. Bateman SW: Managing the acutely lung injured patient In
experience and new method of stabilization. J Am Anim Hosp Assoc Proceedings of the 11th Annual ACVS Symposium, Chicago, American
18:269, 1982. College of Veterinary Surgeons, 2001, p 559.
9. McAnulty JF: A simplified method for stabilization of flail chest injuries 32. McCool FD, Rochester DF: Lung and chest wall diseases. In Murray
in small animals. J Am Anim Hosp Assoc 31:137, 1995. JF, Nadel JA, eds.: Textbook of Respiratory Medicine. Philadelphia: WB
Saunders 1994, p 2524.
10. Orton EC: Thoracic wall. In Slatter D, ed.: Textbook of Small Animal
Surgery (ed 3). Philadelphia: WB Saunders, 1993, p 373. 33. Spackman CJA, Caywood DD: Management of thoracic trauma and
chest wall reconstruction. Vet Clin North Am Sm Anim Pract 17:431,
11. Harada K, Saoyama N, Izumi K, et al.: Experimental pendulum air in
1987.
the flail chest. Jpn J Surg 13:219, 1983.
34. Knottenbelt JD, James MF, Bloomfield M: Intrapleural bupivacaine
12. Craven KD, Oppenheimer L, Wood LDH: Effects of contusion and flail
analgesia in chest trauma: a randomized double-blind controlled trial.
chest on pulmonary perfusion and oxygen exchange. J Appl Physiol
Injury 22:114, 1991.
47:729, 1979.
35. Thompson SE, Johnson JM: Analgesia in dogs after intercostals
13. Parham AM, Yarbrough DR, Redding JS: Flail chest syndrome and
thoracotomy. A comparison of morphine, selective intercostals nerve
pulmonary contusion. Arch Surg 113:900, 1978.
block, and interpleural regional analgesia with bupivacaine. Vet Surg
14. Hackner SG: Emergency management of traumatic pulmonary contu- 20:73, 1991.
sions. Comp Cont Ed Pract Vet 17:677, 1995.
36. Conzemius MG Brockman DJ, King LG, et al.: Analgesia in dogs
15. Cappello M, Yuehua C, DeTroyer A: Rib cage distortion in a canine after intercostals thoracotomy: a clinical trial comparing intravenous
model of flail chest. Am J Respir Crit Care Med 151:1481, 1995. buprenorphine and interpleural bupivacaine. Vet Surg 23:291, 1994.
16. Melton SM, Davis KA, Moomey CB, et al.: Mediator-dependent 37. Grabinsky A: Mechanisms of Neural Blockade. Pain Physician 8:411,
secondary injury after unilateral blunt thoracic trauma. Shock 11:396, 2005.
1999.
38. Wetmore LA, Glowaski MM: Epidural analgesia in veterinary critical
17. Spackman CJA, Caywood DD, Feeney DA, et al.: Thoracic wall and care. Clin Tech Small Anim Pract 15:177, 2000.
pulmonary trauma in dogs sustaining fractures as a result of motor
39. Gallivan ST, Johnston SA, Broadstone RV, et al.: The clinical, cerebro-
vehicle accidents. J Am Vet Med Assoc 185:975, 1984.
spinal fluid, and histopathologic effects of epidural ketorolac in dogs.
18. Crowe DT: Traumatic pulmonary contusions, hematomas, pseudo- Vet Surg 29:436, 2000.
cysts, and acute respiratory distress syndrome: An update-Part I. Comp
40. Van Pelt DR: Respiratory emergencies In Wingfield WE, ed.: Veter-
Cont Ed Pract Vet 5:396, 1983.
inary Emergency Medicine Secrets. Philadelphia, Hanley and Belfus
19. Sweet DC, Waters DJ: Role of surgery in the management of dogs 1997, p 50.
with pathologic conditions of the thorax-Part II. Comp Cont Ed Pract Vet
13:1671, 1991. 41. Mann FA: Pulmonary emergencies In Ettinger SJ, Feldman EC, eds.:
Textbook of Veterinary Internal Medicine, 6th ed. St. Louis: Elsevier Inc.,
20. Tamas PM, Paddleford RR, Krahwinkel DJ: Thoracic trauma in dogs 2005, p 443.
and cats presented for limb fractures. J Am Anim Hosp Assoc 21:161,
1985. 42. Dahelm P, van Aalderen, de Neef M, et al.: Randomized controlled
trial of aerosolized prostacyclin therapy in children with acute lung
21. Griffon DJ, Walter PA, Wallace LJ: Thoracic injuries in cats with injury. Crit Care Med 32:1089, 2004.
traumatic fractures. Vet Comp Orthop Traum 7:98, 1994.
43. Kelly ME, Miller PR, Greenhaw JJ, et al.: Novel resuscitation strategy
22. Cockshutt JR: Management of fracture-associated thoracic trauma. for pulmonary contusion after severe chest trauma. J Trauma 55:94,
Vet Clin N Anim Clin 25: 1031, 1995. 2003.
23. Fossum TW: Thoracic wall and sternum: Diseases, disruptions, and
deformities In Bojrab MJ, ed.: Disease Mechanisms in Small Animal
Surgery. Philadelphia: Lea & Febiger, 1993, p 411.
24. Fossum TW: Surgery of the lower respiratory system: Lungs and
thoracic wall in Fossum TW, ed.: Small Animal Surgery. 3rd ed. St. Louis:
Mosby, 2007, p 867.
25. Rich W, Reichenberger M: Managing flail chest. Nursing 11:26, 1981.
26. MacKersie RC, Shackford SR, Hoyt DB, et al.: Continuous epidural
fentanyl analgesia: Ventilatory function improvement with routine use
in treatment of blunt chest injury. J Trauma 27:1207, 1987.
27. Cullen P, Modell JH, Kirby RR, et al.: Treatment of Flail Chest: Use of
intermittent mandatory ventilation and positive end expiratory pressure.
Arch Surg 110:1099, 1975.
Kidney and Utreter 443
Surgical Technique
Section E
The patient is anesthetized and is placed in dorsal recumbency.
The abdomen is prepared for an aseptic surgical procedure. A
midline abdominal incision is made from the xiphoid process
through the umbilicus. The edges of the incision are protected
Urogenital System with moist laparotomy pack, and a Balfour retractor is inserted.
Figure 29-1. The left kidney is exposed by using the mesentery of the descending colon as a retractor for the small intestine.
444 Soft Tissue
Reference
1. Osborne CA, Finco DR, eds. Canine and feline nephrology and urology.
Baltimore: Williams & Wilkins, 1995.
Nephrotomy
Nancy Zimmerman-Pope and Michael King
Figure 29-2. Reflection of the perirenal fat on the dorsal lateral surface
Surgical Anatomy
of the renal hilus exposes the renal artery. Kidneys and ureters lie against the sublumbar muscles of the
dorsolateral abdomen within the retroperitoneal space. The
cranial pole of the right kidney is nestled in the renal fossa of the
caudate liver lobe at the approximate level of the 13th rib (slightly
cranial to the left kidney). A thin fibrous capsule envelopes each
kidney. Gross appearance of the feline kidney is distinctive due
to a radial network of subcapsular veins that course over the
surface of the kidney toward the hilus.
The renal artery, vein, and ureter enter the concave surface of
the kidney at the hilus (Figure 29-5). The primary renal artery may
arborize into several branches after leaving the aorta and before
entering the hilus. Arterial branching is present in 5 to 10% of
dogs and cats and is most common in the left kidney. Cats may
also have multiple renal veins. The left testicular or ovarian vein
drains into the left renal vein rather than the caudal vena cava.
Care must be taken to preserve these vessels when performing
renal surgery in an intact dog or cat. The ureter is a firm tubular
structure that exits the caudodorsal surface of each kidney at
Figure 29-3. The renal artery and vein are separated, ligated individually, the hilus and courses in a caudal direction in the retroperitoneal
and transected. space. The left ureter courses lateral to the aorta, but the right
may be dorsal or lateral to the vena cava. In male dogs and
cats, the ureter crosses dorsal to the ductus deferens and in the
female it courses in the dorsal aspect of the broad ligament.17
Each ureter traverses the respective right or left lateral ligament
of the urinary bladder and enters the bladder on the dorsolateral are the simplest methods of evaluating renal function in the
mucosal surface at the trigone. clinical patient however elevation of values beyond the normal
range does not occur until severe kidney disease is present (less
Traditional surgical approach to the kidneys and ureters is via a than 30% functional nephrons remaining). An additional limiting
ventral midline celiotomy. The left kidney is exposed by grasping factor is that biochemical markers only provide information
and retracting the colon and associated mesocolon across regarding total renal function and do not provide specific quanti-
midline toward the right side (Figure 29-6). The right kidney is fication of individual kidney function. Assessment of individual
similarly exposed by grasping and retracting the duodenum and kidney function is important when trying to determine whether
associated mesoduodenum toward the left side (Figure 29-7). efforts to preserve a kidney via nephrotomy or pyelolithotomy
Gentle retraction of the duodenum is recommended to minimize should be considered or if nephrectomy is indicated. Determi-
trauma to the pancreas. nation of glomerular filtration rate (GFR) is essential in dogs and
cats with underlying renal disease to guid specific treatment
recommendations and provide prognostic information.
Surgical Technique
Indications for renal surgery include neoplasia, obstructive renal
calculi, trauma, persistent renal hemorrhage, chronic inflam-
mation or infection, severe hydronephrosis, renal cystic disease
and in some cases, treatment of ectopic ureters.4 Appropriate
preoperative diagnostics and careful assessment of the patient
will guide the clinician in formulating an overall treatment plan.
Figure 29-8. Appearance of the right canine kidney in situ, with renal
vessels and ureter identified. The peritoneal attachments and renal
Nephrotomy capsule have been incised to aid in mobilization of the kidney. Isolation
Nephrotomy is most commonly performed to remove obstructive of the renal vessels is by blunt dissection.
or infected calculi but is also indicated to evaluate the renal
pelvis for causes of hematuria or chronic infection, or to
biopsy tumors. It is important to recognize that not all nephro-
liths require surgical removal. Nephrotomy or pyelolithotomy
for urinary calculi is indicated when there is evidence of
urinary obstruction or chronic infection. Historically, bisection
nephrotomy was thought to decrease renal function by 20 to 50%
in normal dogs however, more recent studies have reported that
nephrotomy has no significant adverse effect on renal function
in the normal dog or cat.5-9 The effect of nephrotomy on renal
function in patients with kidney disease has not been reported.
Pyelolithotomy
Pyelolithotomy is an alternative to nephrotomy and can be used
to remove calculi from the renal pelvis if the proximal ureter is
sufficiently dilated. Extracorporeal shock wave lithotripsy may
also be considered to treat dogs with small nehroliths (< 1-2 cm).16
Excretory urography, ultrasonography and scintigraphy can be
used to confirm and estimate the severity of obstruction of the
renal pelvis or ureter. In cases of ureteral obstruction, placement Figure 29-13. A catheter is placed to gently flush any remaining frag-
ments from the renal pelvis and ureter.
448 Soft Tissue
Introduction
The location and composition of uroliths in cats has changed
dramatically over the past three decades. Between 1981 and
Figure 29-14. The catheter can be used to facilitate closure of the 1999 there was a dramatic increase in the number of upper tract
pyelolithotomy. uroliths submitted to the Minnesota Urolith Center.1 Approxi-
mately 75% of upper tract uroliths are composed of calcium
References oxalate.1 During this 20-year period there was a 10-fold increase
in the frequency of upper tract uroliths in cats at nine veterinary
1. Daniel GB, Mitchell SK, Mawby D, et al.: Renal Nuclear Medicine: A
teaching hospitals.1 A more recent case series of cats treated
Review. Vet Radiol Ultrasound 401: 572, 1999.
for ureterolithiasis found that approximately 98% of ureteroliths
2. Uribe D, Krawiec D, Twardock A, et al.: Quantitative renal scintigraphic
contain calcium oxalate.2 Veterinary surgeons are increasingly
determination of the glomerular filtration rate in cats with normal and
abnormal kidney function, using 99mTc-diethylenetriaminepentaacetic faced with the challenge of surgical management of upper tract
acid. Am J Vet Res 53: 1101, 1992. uroliths in cats.
3. Krawiec DR, Badertscher RR, Twardock AR, et al.: Evaluation of
99mTc-diethylenetriaminepentaacetic acid nuclear imaging for quanti- Clinical Signs
tative determinationof the glomerular filtration rate of dogs. Am J Vet
Clinical signs of cats with ureteroliths or nephroliths tend to
Res 47: 2175, 1986.
be nonspecific and include anorexia, vomiting, lethargy, and
4. Rosin, E: Kidney – Nephrectomy In Bojrab MJ, 4th ed: Current
weight loss.2 Polydipsia and polyuria, stranguria or pollakiuria,
Techniques in Small Animal Surgery. Maryland: Williams and Wilkins,
1998, p 429.
hematuria, and inappropriate urination may be seen. Pain may
be evident if the ureter becomes acutely obstructed, however,
5. Gahring DR, Crowe DT, Powers TE, et al.: Comparative renal function
studies of nephrotomy closure with and without sutures in dogs. JAVMA
pain appears to be much less common than in humans with
171: 537, 1977. ureteroliths. Affected cats may be asymptomatic and the calculi
are detected during a work-up for other problems. Many cats
6. Fitzpatrick JM, Sleight MW, Braack A, et al.: Intrarenal access; Effects
on renal function and morphology. British J of Urology 52: 409, 1980. with ureteroliths and nephroliths also have chronic kidney
disease, therefore, unilateral ureteral obstruction may result in
7. Stone EA, Robertson JL, and Metcalf MR: The effect of nephrotomy
on renal function and morphology in dogs. Vet Surgery 31: 391, 2002. signs of renal failure. Physical examination findings are usually
non-specific, but some cats will have small, irregularly shaped
8. Zimmerman-Pope N, Waldron DR, Barber DL, et al: Effect of
fenoldopam on renal function after nephrotomy in normal dogs. Vet Sug
kidneys. Acute ureteral obstruction may result in the affected
36: 566, 2003. kidney being enlarged, firm, and painful.
9. King M, Waldron DR, Barber DL, et al.: The effect of nephrotomy on
renal function and morphology in normal cats. Ver Surg 35: 749-758, Diagnosis and Preoperative Evaluation
2006.
Nephroliths and ureteroliths should be suspected in cats with
10. Selkurt EE: The changes in renal clearance following complete chronic kidney disease, renomegaly, abdominal or lumbar
ischemia of the kidney. AM J Physiol 144: 395-403, 1945.
pain, vomiting, or recurrent urinary tract infection. Cats that
11. Maddern JP: Surgery of the Staghorn Calculus. Brit J Urol 39: 237, are presented with vague signs of illness or signs of renal
1967.
disease should be evaluated for the presence of uroliths by
12. Rawlings CA, Bjorling DE, Christie BA: Kidneys In Slatter D, 3rd ed.: survey abdominal radiographs and abdominal ultrasonography.
Textbook of Small Animal Surgery, Philadelphia, 2002, p 1606.
Most uroliths of the upper urinary tract in cats are radiodense
13. Alexander K, Dunn, M, Carmel EN, et al: Clinical application of and can be seen on survey radiographs. However, calculi can
Patlak Ploty CT-GFR in animals with upper urinary tract disease. be quite small and may be obscured by fecal material or other
Ver Radiol Ultrasound 47 (2), 127-135,2006. structures. It is common to find that one kidney is small and
14. Anderson KJ,Twardock R, Grimm JB, et al: Determination irregular in contour while the other kidney may be of normal
of glomrular filtration rate in dogs using contrast-enhanced size or enlarged. Ultrasonography is very helpful in confirming
computed tomgraphy. Vet Radiol Ultrasound 47 (2), 86-103,2011. the presence of calculi and in assessing the degree of dilation
15. Berent AB: Ureteral obstructions in dogs and cats: a review of the renal pelvis and ureter. However, ultrasonography
of traditional and new interventional diagnostic and therapeuitc failed to identify ureteroliths in 23% of cats in one report.2 The
options. J Vet Emerg Crit Care 21 (2), 86-103,2011. combination of abdominal radiographs and ultrasonography is
16. Lane IF: Lithotripsy: an update on urologic applications in small reported to have a sensitivity of 90% for detection of uretero-
animals. Vet Clin NA Small Animal Pract 34 (4): 1011-1025,2004. liths in cats.2 Excretory urography can be helpful in identifying
ureteral obstruction, assessing the degree of dilation of the renal
pelvis and ureter, and determining the tortuosity of the ureters
Kidney and Utreter 449
in preparation for surgery. However, many cats with ureteral ureteroliths are azotemic and have chronic kidney disease.
obstruction do not concentrate the intravenously administered Assessment of individual kidney function by nuclear scintig-
contrast medium adequately to delineate the ureters. In these raphy is useful in cats with upper urinary calculi however this
cats, a percutaneous antegrade pyelogram can be performed. diagnostic aid is not widely available. If a cat has a ureterolith
Contrast medium is injected directly into the renal pelvis using in one ureter and the other kidney has end-stage renal disease,
ultrasound guidance and radiographs are made of its passage surgical removal of the ureterolith is recommended to preserve
down the ureter.3,4 The technique also allows a urine sample to the function of the obstructed kidney. If the cat is very ill due to
be obtained directly from the renal pelvis for bacterial culture. ureteral obstruction by a ureterolith, it may not be appropriate
to wait for the ureterolith to pass. As I have gained experience
A complete blood count (CBC), serum chemistry profile, and with ureteral surgery in cats, I have become more aggressive
urinalysis should be performed to evaluate renal function and in pursuing surgery sooner rather than later. This is consistent
the cat’s general health. A CBC may show a nonregenerative with another report.10 Aggressive fluid therapy is administered
anemia if the cat has chronic renal failure; a leukocytosis and to stabilize the cat while monitoring the cat carefully for fluid
left shift may be present in cats with pyelonephritis. A serum overload. If the ureteral obstruction persists, surgical inter-
chemistry profile may be normal or may show azotemia, hyper- vention is usually performed in 2-4 days. If bilateral ureterotomies
phosphatemia, and hyperkalemia. An idiopathic hypercal- are necessary, they can be performed in the same surgery.
cemia is reported to occur in approximately 35% of cats with
calcium oxalate uroliths.5 A urinalysis and urine culture should Many cats with ureteroliths have concurrent nephroliths.
be performed to determine if there is a urinary tract infection. Following ureterotomy, these cats are at risk for recurrent
If surgery is planned, a cross-match or blood typing should be ureteral obstruction by nephroliths that may pass into the
performed in case administration of blood is needed during or ureter. Because of this, ureterotomy is now generally reserved
after surgery. Compatible whole blood or packed red cells should for cats with a single ureterolith and no nephroliths. Cats with
be available. multiple ureteroliths and nephroliths are generally being treated
with ureteral stenting or subcutaneous ureteral bypass (SUB)
placement.6 Ureteral stenting results in dilation of the ureter so
Indications for Surgery that urine can pass around and through the stent thus relieving
Indications for surgical removal of nephroliths and ureteroliths the obstruction and preserving renal function. SUB placement
in cats are controversial. In general, nephroliths that are not allows urine to be diverted from the renal pelvis to the urinary
associated with a urinary tract infection and that are not causing bladder through a combination of a locking-loop nephrostomy
ureteral obstruction do not require surgical removal. However, if catheter and a locking-loop cystostomy catheter.6
a cat with nephroliths has a urinary tract infection that cannot
be cleared with appropriate antimicrobial therapy, then surgical
removal of the nephroliths is recommended to allow clearance Surgical Treatment
of the bacteria. If a nephrolith is causing complete or partial Nephroliths
obstruction of urine flow, removal is indicated. Nephroliths that
appear quiescent are generally not removed because the conse- Nephroliths can be removed by either nephrotomy or pyelo-
quences of surgical removal are renal scarring and possible lithotomy. With either technique, however, it is not always
reduced renal function. In addition, it can be quite difficult to possible to retrieve all the calculi. Nephrotomy should be avoided
locate small nephroliths by nephrotomy or pyelolithotomy. If when possible because it can cause renal scarring and loss
bilateral nephrotomies are required, the procedures should of function. Many cats with nephroliths already have reduced
be staged with the nephrotomies separated by approximately renal function and further loss of function should be avoided.
4 weeks. In general, the kidney that appears to have the most Pyelolithotomy is the preferred technique for surgical removal
functional capacity should be operated first. Pyelolithotomies of nephroliths because it does not require interruption of renal
can be performed bilaterally at the same surgery. blood flow or incision into the renal parenchyma and the resulting
loss of function. However, pyelolithotomy cannot be performed
There are no clear recommendations regarding surgical removal unless the renal pelvis is dilated beyond the renal parenchyma. If
of ureteroliths in cats. Most ureteroliths cause some degree of a kidney is severely hydronephrotic and non-functional, nephre-
obstruction of the ureter. Prolonged ureteral obstruction can lead ctomy and ureterectomy are indicated.
to renal damage and loss of function. If a cat with a ureterolith
is treated conservatively to allow the calculus to pass spontane- All retrieved nephroliths and ureteroliths should be submitted for
ously, there is a chance of further loss of renal function during quantitative analysis so that appropriate preventative strategies
the weeks or months that it may take for passage, if passage can be implemented. Bacterial culture should also be performed
of the calculus ever occurs. One study showed that resolution on any calculi that are available.
of ureteral obstruction occurred in very few cats treated with
medical therapy alone.10 It has not been determined if there is Nephrotomy
a “safe” waiting time for conservative management of uretero- After performing a complete abdominal exploratory, the kidney
liths in cats. The overall status of the cat’s renal function should is packed off from the rest of the abdomen. The peritoneum is
be considered in determining whether conservative or surgical incised along the greater curvature of the kidney and the kidney
therapy will be pursued. Many cats with nephroliths and/or is reflected medially. The renal artery is located on the dorsal
450 Soft Tissue
aspect of the renal hilus, the renal vein is ventral and the ureter to the bladder to remove the calculus and reimplantation of the
is caudal. The renal artery is isolated by careful dissection and a proximal ureter into the urinary bladder. I prefer to perform
bulldog vascular clamp is applied. It is not necessary to occlude ureterotomies for all ureteroliths regardless of location. I reserve
the renal vein. The kidney should become soft and dark-colored partial ureterectomy and ureteroneocystostomy for treatment of
if the entire arterial supply has been occluded. If the kidney complications that could occur secondary to ureterotomy, such as
does not become soft, the clamp should be removed and further ureteral stricture. Abdominal radiographs should be made immedi-
dissection performed to identify additional branches of the renal ately before surgery to confirm the current location of the calculi.
artery. After occluding the renal arterial supply, a longitudinal
incision is made through the renal capsule along the greater Ureterotomy
curvature for approximately two-thirds the length of the kidney.
The renal parenchyma is separated by pushing the blunt handle The ureter is examined visually using the preoperative radiographs
of a scalpel through the tissue toward the renal pelvis. Once the to help locate the ureterolith. In many cases the calculus can be
renal pelvis is reached, the parenchyma is spread so that calculi seen through the wall of the ureter. The ureter can be palpated
in the pelvis can be visualized. Calculi are removed, the diver- gently to identify the ureterolith. If the calculus is located in the
ticula are explored for additional calculi, and the renal pelvis proximal ureter, care should be taken not to push the calculus
is flushed with saline. The ureter is catheterized and flushed to back into the renal pelvis. To prevent the calculus from moving
the bladder if possible to confirm its patency. The edges of the retrograde into the renal pelvis, a loop of moistened umbilical tape
kidney are pressed together and the renal capsule is carefully or a vascular tie can be placed around the most proximal aspect
closed with a simple continuous suture of 4-0 polydioxanone. of the ureter immediately distal to the renal pelvis and the ureter
The vascular clamp is removed from the renal artery and direct can be gently occluded by applying pressure to the vascular tie.
pressure is applied to the suture line to control hemorrhage as After the ureterolith is identified, the peritoneum is incised over
necessary. The warm ischemia time of the kidney should not the affected area of the ureter and the periureteral fat is dissected
exceed 20 minutes.6 The kidney is tacked in place with a few to expose the ventral aspect of the ureteral wall. The operating
capsular sutures to the surrounding psoas musculature to microscope is positioned over the ureter and a stay suture of 8-0
prevent the kidney from twisting on its blood supply and causing suture material is placed in the ureter at one end of the planned
renal ischemia. ureterotomy. A #11 blade is used to make a longitudinal incision into
the ureter directly over the calculus and the incision is extended
with microsurgical dissecting scissors. The calculus is removed
Pyelolithotomy and the ureter is flushed proximally and distally (if possible). If the
Magnification is helpful for performing pyelolithotomy in cats. ureter is very dilated, it can be flushed proximally with a 3.5 French
I prefer to use an operating microscope unless the renal tom cat catheter. If the ureter is not very dilated, a 27-gauge intra-
pelvis and proximal ureter are extremely dilated. The kidney venous catheter can be used for flushing. It is often difficult to
is reflected medially and the dilated renal pelvis and proximal flush the distal segment of the ureter due to its small diameter.
ureter are exposed by dissecting the perirenal fat away from the Some surgeons confirm patency of the ureter by passing a piece
ureter at the caudal aspect of the renal hilus. A stay suture of of suture material (size 2 polybutester7) down the ureter. I usually
5-0 to 7-0 suture is placed in the dilated pelvis and a #11 blade try to flush the distal ureter gently and palpate it carefully to
is used to make a stab incision into the exposed pelvis. The be sure there is not another calculus more distally, but I do not
incision is extended longitudinally with iris scissors. Calculi are usually pass anything down the ureter to avoid further trauma. A
retrieved from the renal pelvis and proximal ureter and the renal swab is taken from the ureter and/or calculus for aerobic bacterial
pelvis is flushed by passing a catheter through the ureteral/ culture and susceptibility testing. The ureterotomy is closed with
pelvic incision and up into the renal pelvis. If possible, the ureter full-thickness simple interrupted sutures of 8-0 polyglactin 910
should be flushed distally to the bladder to assure patency, with a BV130-4 taper needle (8-0 Coated VICRYL, Ethicon Inc,
however, this is not always possible due to the small diameter Somerville, NJ). In some cases the ureter is very thickened and
of the normal feline ureter. The pyelolithotomy is closed with full- fibrotic and it is difficult to pass the needle of the 8-0 polyglactin
thickness simple interrupted sutures of 5-0 to 7-0 polyglactin 910 910 through the wall. In those cases, 7-0 polydioxanone on a BV1
or polydioxanone. The kidney is tacked in place to surrounding taper needle (PDS II, Ethicon Inc, Somerville, NJ) can be used. It is
psoas musculature with a few capsular sutures. helpful to preplace the last two or three sutures to ensure proper
suture placement. The final sutures are then tied. The suture line
should be examined carefully under the operating microscope
Ureteroliths
for urine leakage between sutures or through the needle holes. If
Ureteral calculi can be removed by ureterotomy or partial urine leakage occurs between sutures, additional sutures should
ureterectomy and ureteroneocystostomy. Both procedures are be placed. If urine leakage occurs through the needle holes, a
technically demanding because of the small size of the feline small piece of absorbable gelatin sponge (Gelfoam®, Pharmacia
ureter and should be performed using an operating microscope. and Upjohn Company, Kalamazoo, MI) soaked with the patient’s
Surgeons should have experience with microsurgical techniques blood can be placed over the suture line. After the ureterotomy
and microsurgical instrumentation should be used to avoid unnec- is closed, the peritoneum can be closed over the site. However,
essary trauma to the ureter. Because of the difficulties associated if closure of the peritoneum compresses the distal ureter so that
with ureteral surgery in cats, some surgeons recommend that it causes a partial obstruction, the peritoneum can be left open.
ureteroliths located in the middle or distal thirds of the ureter be If calculi are present in more than one location in the ureter,
treated by resection of the portion of the ureter from the calculus
Kidney and Utreter 451
multiple ureterotomies can be performed at the same surgery. It Nephrostomy Tube Placement
is not usually possible to flush or milk calculi to a ureterotomy site Nephrostomy tube placement is indicated as an emergency
that is more than a couple millimeters from the calculus unless the procedure in cats with acute ureteral obstruction that are
ureter is very dilated. severely hyperkalemic and are poor candidates for a long
surgical procedure. After instituting intravenous fluid therapy
Partial Ureterectomy and Ureteroneocystostomy and attempting to lower the serum potassium concentration, the
Ureteroliths in the distal two-thirds of the ureter may be managed cat is anesthetized for nephrostomy tube placement. Although
by resecting the ureter from the site of the calculus to the urinary nephrostomy tubes can be placed percutaneously, it is recom-
bladder and then reimplanting the ureter into the bladder.7 The mended in cats they be placed via an open approach because
ureter is ligated and transected proximal to the obstructing feline kidneys are so mobile. A ventral midline celiotomy is
ureterolith and at its entry into the urinary bladder and the excised performed to allow the kidney to be sutured to the body wall.
portion is removed with the calculus. The proximal portion of the Four sutures of 4-0 polydioxanone are placed from the greater
ureter is implanted into the urinary bladder. Multiple techniques curvature of the kidney to the dorsolateral body wall. The sutures
have been attempted for ureteroneocystostomy in cats but the are placed through the renal capsule and a small amount of renal
best results occur with an extravesicular mucosal apposition parenchyma and through the transversus abdominus muscle
technique (modified Lich Gregoir technique) using simple inter- and tied so that the kidney is secured to the body wall. The four
rupted sutures.8 This technique is performed by making a partial sutures are placed to form a square (sutures are placed cranially,
thickness incision through the serosa, muscularis, and submucosa caudally, dorsally, and ventrally) so that the nephrostomy tube can
of the ventral aspect of the apex of the urinary bladder to expose be placed in the center of the square. A 5 French locking-loop
the mucosa. The distal end of the ureter is spatulated. An incision pigtail nephrostomy catheter is preferred because it is less likely
equal in length to the spatulated ureteral incision is made through to become dislodged than a straight catheter.12 A stab incision is
the bladder mucosa at the caudal end of the muscularis incision. made through the skin over the nephropexy site. Using ultrasound
One suture is placed between the cranial end of the spatulation guidance, a 22-gauge intravenous catheter is inserted through
and the cranial end of the bladder mucosal incision. A second the skin incision, body wall and greater curvature of the kidney
suture is placed between the distal end of the ureter and the into the renal pelvis at the site of the nephropexy. When urine
caudal end of the mucosal incision. These sutures are placed backflows through the catheter, the stylette is removed. A urine
full-thickness through the ureter and the bladder mucosa and sample is obtained from the renal pelvis for bacterial culture. At
tied. Then a stent of 4-0 polypropylene is placed in the ureteral this point a pyelogram can be performed if desired. An angle-
lumen to aid in the placement of additional sutures. Two simple tipped hydrophilic 0.018-inch guidewire (Weasel Wire, Infiniti
interrupted sutures are preplaced between the ureter and the Medical LLC, Malibu, CA) is passed through the catheter and
bladder mucosa on one side of the stoma and then two similar coiled in the renal pelvis. The catheter is removed over the wire.
sutures are preplaced on the other side of the stoma. If the ureter The pigtail nephrostomy catheter (5F Dawson-Meuller locking-
is very dilated, additional sutures may be needed on each side loop pigtail catheter, Cook Medical, Bloomington, IN) is passed
of the stoma. The sutures on one side of the stoma are tied and over the wire through the body wall and renal parenchyma and
the polypropylene stent is removed. Then the remaining sutures into the renal pelvis with the hollow cannula inside the pigtail
are tied. The standard description of this technique recommends catheter remaining secure to keep the catheter rigid during renal
the use of 8-0 nylon swaged on a BV 130-5 taper needle (Ethicon penetration. Once the tip of the pigtail catheter is confirmed to
Inc, Somerville, NJ) for the mucosal sutures. I prefer to use 8-0 be in the renal pelvis, the cannula is immobilized as the catheter
polyglactin 910 swaged on a BV 130-4 taper needle (Ethicon Inc, is advanced over the guidewire to form its loop. Once the loop of
Somerville, NJ) so that nonabsorbable suture material does not the pigtail is completely within the renal pelvis, the loop is locked
remain in the lumen of the urinary tract. After the mucosal sutures in place by pulling on the string at the hub of the catheter. The
are completed, the bladder serosa and muscularis are apposed string is secured and the cannula is removed from the catheter.
using simple interrupted sutures of 4-0 polydioxanone or polyg- The catheter is sutured securely to the skin and body wall with at
lactin 910 to create a water-tight seal. The bladder is checked for least two friction sutures of 3-0 nylon. Each suture is tied tightly
leaks by injecting sterile saline into its lumen. around the nephrostomy catheter being careful not to occlude
the catheter lumen. The suture is then passed through the skin
If there is tension on the anastomosis site between the ureter and body wall adjacent to the catheter. It is essential that the
and the bladder, the kidney can be moved caudally (renal friction sutures are secured to the body wall and not just the skin
descensus) and the urinary bladder can be advanced cranially because the mobility of the skin can cause dislodgment of the
(psoas cystopexy).7,9 The kidney is freed from its peritoneal and catheter. Alternatively, a Chinese finger trap suture may be used
fascial attachments and moved to a more caudal and medial to secure the nephrostomy catheter. The nephrostomy catheter
location taking care not to kink the renal vasculature. The renal is attached to a sterile closed urine collection system. Following
capsule and a small amount of parenchyma is sutured to the closure of the abdomen, a body bandage is applied to protect the
body wall with 3 or 4 simple interrupted sutures of 4-0 nylon or nephrostomy tube.
polypropylene. To perform the cystopexy, the bladder is stretched
cranially and the seromuscular layer of the dorsolateral bladder If a locking-loop pigtail nephrostomy catheter is not available,
wall is sutured to the iliopsoas muscle with two or three simple a 16-gauge, 8-inch central venous catheter (Arrow Interna-
interrupted nonabsorbable sutures. tional, Inc., Reading, PA) may be used for the nephrostomy tube.
Additional side holes can be made near the tip of the catheter
452 Soft Tissue
before catheter placement. A nephropexy is performed as previ- the first couple of days after surgery. This is most likely due to
ously described. partial ureteral obstruction from swelling at the ureterotomy site.
Intravenous fluid therapy is continued and after three to four
A small stab incision is made with a #11 blade through the skin days the creatinine usually begins to decrease. Fluid therapy is
at the site of the nephropexy. The intravenous catheter is passed discontinued when the creatinine is within the reference range
through the stab incision and body wall and then through the or has remained stable for several days. Postoperative antibiotic
greater curvature of the kidney and into the renal pelvis. When therapy is indicated only if a urinary tract infection is present.
urine backflows through the catheter, the catheter is advanced
off the stylette into the renal pelvis and the stylette is withdrawn.
A guide wire is threaded through the catheter into the renal pelvis
Outcomes and Postoperative Complications
and the catheter is withdrawn over the wire. A dilator is passed Prevention
over the wire and into the renal pelvis. The dilator is withdrawn Dietary therapy should be based upon quantitative analysis
and the single lumen catheter is threaded onto the guide wire. The of the calculus. Most nephroliths and ureteroliths in cats are
catheter is advanced up the guide wire until the distal two centi- composed of calcium oxalate. There are commercially available
meters of the catheter (including any side holes) are in the renal diets for prevention of calcium oxalate uroliths. Ideally, a canned
pelvis. The guidewire is withdrawn while holding the catheter in diet should be fed so that the cat consumes more water. The
place. The catheter is secured in place as previously described. urine pH can be monitored. If it remains acidic in spite of the
use of a non-acidifying diet, potassium citrate can be adminis-
Once the cat is stable medically, the nephrostomy tube can be tered to alkalinize the urine. The cat should be monitored every
used to perform antegrade pyelography to document persistence three to six months for recurrence of calculi by abdominal radio-
of the ureteral obstruction. If the ureter remains obstructed, graphs, ultrasonography, urinalysis and urine culture. If the cat
definitive ureteral surgery can be performed. One disadvantage has chronic kidney disease, a CBC and serum biochemistries
of performing a ureterotomy after a nephrostomy tube has should also be evaluated.
been placed is that the decompressed ureter is less dilated so
performing the ureterotomy is more challenging than it would
have been during the acute obstruction. Complications
Postoperative complications are common following surgical
Nephrostomy tubes can be useful in some cats following ureter- removal of ureteral calculi in cats. In a series of 88 cats that
otomy when there is concern that the ureterotomy site may leak survived surgical removal of ureteroliths, 31% developed major
or develop an obstruction due to severe postoperative inflam- postoperative complications and 18% of these cats died.10
mation. Antegrade pyelography is performed four to six days Another report of 47 cats that underwent ureterotomy for urolith
postoperatively to evaluate the patency and integrity of the removal had a mortality rate of 21%.13 The most common compli-
ureter. If the ureter is patent and there is no evidence of leakage cations following removal of ureteral calculi are urine leakage
at the ureterotomy site, the nephrostomy tube is removed. and persistent ureteral obstruction. Urine leakage is usually
Nephrostomy tubes have also been used to treat ureteral urine apparent within two to four days. The blood urea nitrogen and
leakage that may occur as a complication in the postoperative serum creatinine concentrations will increase and the cat may
period. Nephrostomy tubes can become dislodged or obstructed. show abdominal pain. If uroabdomen does not resolve spontane-
In addition, they can allow urine leakage from the kidney into the ously and requires a second surgical procedure, the prognosis
peritoneal cavity or the subcutaneous tissues.10,12 Nephrostomy is guarded. In the previously cited case series, the mortality rate
tubes that are maintained for several days or weeks can be of cats that underwent a second surgical procedure because
associated with chronic, antibiotic-resistant urinary tract infec- of uroabdomen was 27% (3/11).10 Three cats that developed
tions. Because of their potential complications and the increased uroabdomen were euthanized without additional surgery.10
nursing care required, I prefer not to place nephrostomy tubes Partial or complete obstruction of the ureter following ureter-
unless there is a high likelihood of urine leakage or urethral otomy may be transient due to swelling at the surgery site. If
obstruction postoperatively. the cat is becoming progressively more azotemic two to four
days following surgery, an excretory urogram or percutaneous
antegrade pyelography should be performed to determine if
Postoperative Care there is urine leakage or ureteral obstruction. Stricture at the
Many cats with ureteroliths and nephroliths are anorectic, so a ureterotomy site could occur as a long-term complication but
gastrostomy or esophagostomy tube is usually placed at the time this is not detected often.14 Ureteral stricture can also be present
of surgery for postoperative nutritional support. Intravenous at the time of initial surgery due to chronic ureterolithiasis and
fluids are administered for three to five days after surgery to ureteral fibrosis. Approximately half of cats that recover from
promote diuresis. Many affected cats are anemic at the time surgical removal of ureteroliths can be expected to have chronic
of surgery and the anemia may worsen postoperatively. If the kidney disease and maintain serum creatinine concentrations
anemia is moderate to severe, whole blood or packed red cells above the reference range.10 Recurrence of ureterolithiasis has
should be administered. Serum creatinine concentration is been reported in 40% of cats in which serial abdominal imaging
measured daily for the first few days after ureterotomy. Although was performed after medical or surgical management.10 The
the serum creatinine in some cats decreases immediately after second episode of ureterolithiasis occurred a median of 12.5
surgery, it is common for it to remain high or even increase during months (range 2 to 88 months) after the initial diagnosis.10
Kidney and Utreter 453
Editors Note: Minimally invasive therapy by interventional the 1980s, and since that time, the addition of endosurgical and
1
radiology has advantages when considering therapy for ureteral percutaneous techniques to ESWL have made open surgery of
obstruction. Consultation with a specialist is recommended. the urinary tract uncommon. As shock wave lithotripsy and laser
lithotripsy have become more available in human medicine,
a similar transformation is occurring in veterinary medicine;
References however, limited availability and cost of these procedures
1. Lekcharoensuk C, Osborne CA, Lulich JP, et al: Trends in the frequency limits the number of patients who can be treated in this fashion.
of calcium oxalate uroliths in the upper urinary tract of cats. J Am Anim Additionally, variability in lithotriptors makes treatment protocols
Hosp Assoc 41:39, 2005.
and responses difficult to compare; effectiveness will vary with
2. Kyles AE, Hardie EM, Wooden BG, et al: Clinical, clinicopathologic, machine type as well. Currently, the most common applications
radiographic, and ultrasonographic abnormalities in cats with ureteral of ESWL include the treatment of nephroliths and ureteroliths
calculi: 163 cases (1984-2002). J Am Vet Med.Assoc 226:932, 2005.
in dogs, and treatment of ureteroliths in cats. In specific cases,
3. Rivers BJ, Walter PA, Polzin DJ: Ultrasonographic-guided, percuta- ESWL can be applied to fragment urocystoliths as well.
neous antegrade pyelography: technique and clinical application in the
dog and cat. J Am Anim Hosp Assoc 33:61, 1997.
4. Adin CA, Herrgesell EJ, Nyland TG, et al: Antegrade pyelography for Methods and Equipment Required
suspected ureteral obstruction in cats: 11 cases (1995-2001). J Am Vet Application of shock-wave lithotripsy requires a source to
Med Assoc 222:1576, 2003. generate shock waves, a method for focusing the shock waves
5. McClain HM, Barsanti JA, Bartges JW: Hypercalcemia and calcium (SW) to a solitary point, and a method for transmitting (or
oxalate urolithiasis in cats: a report of five cases. J Am Anim Hosp “coupling”) the SW to the patient. Shock waves are generated
Assoc 35:297, 1999. by electrohydraulic, electromagnetic, or piezoelectrical energy
6. Berent AC: Ureteral obstructions in dogs and cats: a review of tradi- sources. With extracorporeal methods, the shock waves are
tional and new interventional diagnostic and therapeutic options. J Vet generated outside the body, then reflected to converge on a
Emerg Crit Care 21:86, 2011.
target (the urolith) in the patient (Figure 29-15A,B). Like ultra-
7. Kyles AE, Stone EA: Removal of nephroliths. In Bojrab MJ, Ellison GW, sound waves, shock waves readily travel through fluid or soft
Slocum B, eds: Current Techniques in Small Animal Surgery, fourth ed.
tissue until they reach the “hard” acoustic surface of the urolith.
Baltimore: Williams & Wilkins, 1998, p 431.
Energy reflection, creation of tensile stresses along the surface
8. Kyles AE, Stone EA, Gookin J, et al: Diagnosis and surgical of the stone, generation of cavitation bubbles, and dynamic
management of obstructive ureteral calculi in cats: 11 cases (1993-
fatigue lead to fragmentation with repeated shock waves.2,3 Early
1996). J Am Vet Med Assoc 213:1150, 1998.
lithotripsy treatments using the Dornier HM3 (Dornier, Marietta,
9. Mehl ML, Kyles AE, Pollard R, et al: Comparison of 3 techniques for
ureteroneocystostomy in cats. Vet Surg 34:114, 2005.
10. Stone EA: Surgical management of urinary tract disease: ureteral
calculi in cats and urinary bladder neoplasia in dogs. Compendium on
Continuing Education for the Practicing Veterinarian 19:62, 1997.
11. Kyles AE, Hardie EM, Wooden BG, et al: Management and outcome
of cats with ureteral calculi: 153 cases (1984-2002). J Am Vet Med Assoc
226:937, 2005.
12. Berent AC, Weisse CW, Todd KL, Bagley DH: Use of locking-loop
pigtail nephrostomy catheters in dogs and cats: 20 cases (2004-2009). J
Am Vet Med Assoc 241:348, 2012.
13. Roberts SF, Aronson LR, Brown DC: Postoperative mortality in cats
after ureterolithotomy. Vet Surg 40:438, 2011.
14. Zaid MS, Berent AC, Weisse C, Caceres A: Feline ureteral strictures:
10 cases (2007-2009). J Vet Intern Med 25:222, 2011.
Extracorporeal Shock-Wave
Lithotripsy
India F. Lane
Introduction
Extracorporeal shock-wave lithotripsy (ESWL), in which high
amplitude sound waves are generated outside the body and
focused on a hard surface to create fissure and fragmentation,
has been applied primarily to nephroliths and ureteroliths in
dogs and people. In human medicine, adaptation of shock- Figure 29-15. A. and B. Schematic depicting the extracorporeal shock-
wave method. Shockwaves are generated outside the body, then
wave treatment revolutionized the treatment of urolithiasis in
reflected to converge on a target (urolith) in the patient.
454 Soft Tissue
GA), relied upon pulsatile sparks created by an electrohydraulic very difficult in small animals and has not proven useful in our
electrode and transmitted through a water bath medium (“wet” practice. Radiographic contrast media can be injected intrave-
lithotripsy).1,4,5 Newer lithotripters utilize other SW generators and nously during treatment to enhance visualization of a ureterolith
“dry” methods, in which SW are coupled to the patient through a or radiolucent nephrolith; contrast nephropathy is possible, but
fluid filled cushion.3,6-9 While these lithotriptors are easier to use rare.11 Regardless of imaging capability, the degree of urolith
and maintain, the efficacy of dry lithotriptors is lower than the fragmentation can be difficult to assess during treatment, since
“gold standard” water bath model, because of a smaller focal fragments may overly each other until they begin to move into
zone and in some cases, lower peak pressure. An advantage of the ureter.
this narrow focal zone is less damage to surrounding tissues;
however, re-treatments are more common. The most recently Following lithotripsy treatment, a 2 to 4 day period of diuresis
produced lithotriptors are designed to increase portability and is continued to promote passage of stone fragments. Follow
flexibility for various urologic procedures, as well as reduce up radiographs and ultrasound are generally performed one or
cost of the equipment. Machines with mobile, handheld SW two days following treatment and every 3 to 4 weeks thereafter.
application sources may be useful for reaching uroliths in Urolith passage may be rapid in some animals, or may take several
difficult locations and may allow for non-urologic applications months to completely clear from the urinary tract. Fragmentation
(e.g. orthopedic) to be delivered by the same unit. However, has been considered complete in human beings when only clini-
these lithotriptors usually sacrifice efficiency and depth of cally insignificant (< 2 mm) fragments remain visible.13 Based on
penetration, which limits their effectiveness for nephroliths in veterinary experience, even smaller fragments are desired in
larger human patients. While this would seem inconsequential in small animal patients in order to facilitate passage of all debris
small animals, initial experience with the handheld units in dogs along the ureter. Small residual fragments also can serve as a
and cats suggests that efficiency is indeed sacrificed; a higher nidus for urolith recurrence in stone-forming individuals.12,13
number of repetitive shocks and a higher retreatment rate are
likely.10 The cost of equipment varies widely; reconditioned dry ESWL is contraindicated in animals with uncontrolled coagul-
ESWL lithotripters require at least a several-hundred-thousand opathy, hypertension, or other intra-abdominal disease such
dollar investment. as chronic pancreatic or hepatic disease. Concurrent pyelo-
nephritis or renal failure, while considered an indication for
In general, ESWL treatment includes general anesthesia of the pursuing treatment of nephroliths, may increase the risk of
animal, localization of the urolith in the lithotriptor’s focal zone, SW induced renal injury in dogs and cats. I generally perform
and application of sets of shock waves until sufficient fragmen- a more conservative lithotripsy regimen using less energy if
tation is observed on subsequent imaging. Shock-wave dose measured glomerular filtration is subnormal, even if the animal
(power and number of shocks) and frequency varies depending is nonazotemic. Urinary tract infection should be managed and
on the patient and the machine settings. Usually, 1400-1500 SW sterile urine obtained before performing ESWL. While small
are administered per kidney per treatment. Shock-waves are body size is not a contraindication, a greater percentage of the
usually initiated at low power settings, then the power may kidney is exposed to SW injury in patients or species with small
be increased slowly to the effective level (usually 13 to 18 kV). kidneys.14,15 The risk of damage to surrounding tissues, including
Although this protocol was primarily created to improve patient lungs and bone, is also greater in very small animals.
comfort and procedure tolerance, it also affects urolith fragmen-
tation by slowly creating small dust-like particles. Fluoroscopic
or sonographic imaging is available for monitoring stone
Lithotripsy for Canine Nephroliths
fragmentation. In-line sonographic visualization, such as that If removal of nephroliths is indicated (progression in nephrolith
available with the Storz Modulith SL20 (Figure 29-16), can be growth, persistent urinary tract infection, presence of
symptomatic or obstructive disease), lithotripsy is an option
for treatment of the most common types of nephroliths in dogs
(Table 29-1). Fragmentation of calcium oxalate nephroliths is
reasonably effective in this species (Figure 29-17). In several
reports, Adams has reported overall success in approximately
85% of dogs treated with the HM-3 lithotriptor.4,11 We reported a
similar overall response after our early experience with a Storz
Modulith 20 dry lithotriptor,16 and have since found fragmentation
of canine nephroliths highly variable. Treatment of nephroliths
up to 2 or 3 cm in their largest dimension can be treated using
this technology; however, smaller nephroliths (< 1.5 cm) are
generally more amenable to treatment in our experience.
Table 29-1. Referral Considerations regarding staged, due to high shock wave dose and anesthetic time
ESWL for Canine Uroliths needed to create fragmentation. Additionally, large fragments
may be expected, leading to the increased likelihood or ureteral
• Do the uroliths require direct treatment or can they be
obstruction by stone fragmentation post-ESWL.11
monitored for progression or movement?
• Are uroliths clearly identifiable on survey radiographs so that
they can be located readily during ESWL? Potential Complications
• Are nephroliths less than 1.5-2 cm in their largest diameter? Extracorporeal shock-wave lithotripsy, while considered safer
than surgical approaches, is not without risk. Potential compli-
• Is the overall urolith burden reasonable for ESWL treatment?
cations of lithotripsy for nephroliths include pain, the creation
• Does the risk posed by the urolith outweigh the risk of of obstructive ureteral fragments, damage to the kidney (paren-
potential damage created by ESWL? chymal hemorrhage or subcapsular hematoma), or damage
• Can the dog tolerate general anesthesia and fluid diuresis? to other organs secondary to shock wave application. Adams
• Are concurrent problems such as chronic renal failure, (2013) estimates that 10% of ESWL treated dogs have transient
hyperadrenocorticim, urinary tract infection and ureteral obstruction. Stent placement or additional lithotripsy
hypertension well controlled? are indicated to alleviate persistent obstruction.17a Transient
• Are the clients prepared for the costs and requirements for hematuria, transient or progressive decrease in renal function,
retroperitoneal fluid accumulation, ureterectasia, pain, diarrhea
post-treatment monitoring?
and ureteral obstruction by urolith fragments have been observed
• Is surgical intervention or repeat ESWL treatment readily in dogs.7,18 I routinely treat with analgesics for 24 hours post
available for an obstructive fragment? treatment, and extend the treatment if fragments are actively
• Is there a significant advantage of ESWL over surgical or moving along the ureter, or if clinical signs of pain are observed.
laser lithotripy methods (urocystoliths)? Acute pancreatitis has been described as a consequence of
right kidney ESWL treatment in two small (< 5 kg) dogs, with fatal
stones are more resistant to fragmentation. In 5 dogs with urate complications in one dog.19 Pancreatic injury may affect many
or xanthine stones, lithotripsy was effective in only 2.11 For ESWL treated dogs but clinical pancreatitis is seen in less than
large or refractory uroliths, multiple treatments (separated by 2%.17a Fatal arrhythmia, possibly secondary to shock waves, was
at least 4 weeks) may be considered. Ideally a ureteral stent is recently described in one dog treated with the HM-3.11 We have
placed concurrently to facilitate fragment passage and prevent observed a transient ventricular arrhythmia in one cat during
obstruction of the ureter. Transurethral, endoscopic ureteral ESWL application. Residual fragments are common, and may
stent placement may be feasible in some dogs using fluoro- provide a nidus for harboring infection or for formation of recurrent
scopic guidance.17 The reported re-treatment rate for nephro- uroliths. Complications can be minimized by ensuring the health
liths varies with machines, ranging from 30%11 to 50%.16 and suitability of the patient for anesthesia and shock wave
treatment, ensuring appropriate shock wave dosage and appli-
Bilateral nephroliths may be treated at the same time or staged, cation, shielding other organs from shock waves during treatment,
depending on the size of the nephrolith and renal function. ensuring adequate diuresis and monitoring post treatment, and
Bilateral uroliths can be treated during the same anesthetic providing prompt treatment of obstructive fragments.
episode unless concern about individual renal function dictates
staged treatments. Treatment of large stones may also be
A B
Figure 29-17. A. and B. Fragmentation of Calcium Oxalate Nephroliths in a canine patient using lithotripsy.
456 Soft Tissue
Lithotripsy (ESWL) for Canine Ureteroliths dosage (especially shock-wave number, while still limiting
power and frequency) may help minimize the size of fragments,
Ureteroliths can also be fragmented using ESWL. The method
but can only be effectively applied to one or two small stones
is similar to that for nephroliths, although their treatment can be
during a treatment session. The number and size of nephroliths
more difficult for several reasons. Ureteroliths are more difficult
(or the finding of multiple, concurrent nephroliths, ureteroliths
to image and focus, are not in contact with as much fluid as
and cystoliths) makes lithotripsy impractical for stone removal in
stones in the renal pelvis, have less room for fragments to fall
many cats. Renoprotective agents may help minimize renal injury
away, and may be imbedded in the ureteral wall.3 A higher shock
during aggressive shock wave treatment. Logical protective
wave dose may be required to sufficiently fragment uretero-
measures also might include pre-treatment with mannitol or
liths. Using an aggressive treatment approach (mean 2600 SW
calcium channel blockers.
at 14-19 kV) and a lithotripter with a small, high pressure focal
zone, we have had very good success (> 90%) in fragmenting
ureteroliths in dogs.6,7 So far, only one ureterolith, lodged in the Lithotripsy for Feline Ureteroliths
mid-ureter in a small dog (body weight < 3 kg), was insufficiently Lithotripsy of ureteroliths in cats poses similar, but magnified,
fragmented to pass after initial treatment. By comparison, challenges when compared to those encountered in dogs.
retreatment rates for ureteroliths are approximately 50% using Imaging of very small ureteroliths in cats can be extremely
the HM3 lithotriptor.11 Factors limiting successful fragmentation difficult using the available fluoroscopic monitors (Figure
in human patients, that have led to an increase in ureteroscopic 29-18A-C). Distal ureteroliths, in particular, can be obscured
techniques, have included larger stone size (> 10 to 12 mm), distal by pelvic structures, whereas other small ureteroliths can be
(pelvic) location,20,21 degree of obstruction and patient obesity.20 difficult to place precisely in the focal zone. Movement of the
ureterolith during ESWL appears much more common in cats as
The primary complication of ureterolith fragmentation is further well, either with respiration or due to mobility of the ureter or
ureteral obstruction. Fragmentation or movement of a ureterolith urolith. Frequent repositioning and coordination with ventilation
can create a more lodged stone, even if the ureterolith was is imperative for effective fragmentation. We have reported
nonobstructive initially. In our experience, ESWL treatment of progressively improving results in several feline ureteroliths
ureteroliths can be more painful postoperatively than treatment treated with ESWL6 and have experienced an approximately 50%
of nephroliths. Dogs appear to tolerate passage of ureteral success rate (complete fragmentation and passage) after one or
fragments well, presumably due to the size and distensibility of two treatments. Short term interim complications (retreatment,
the canine ureter. Breakthrough pain is an uncommon finding in slow passage of fragments or debris) pose challenges; however
ESWL treated dogs, whereas pain can be excruciating during most cats have had a favorable long term outcome. Unfortu-
stone passage in people. nately, further urinary tract compromise may occur in between
treatments if the ureterolith remains obstructive. Surgical inter-
Limitations of ESWL for Feline Uroliths vention is likely to alleviate obstruction more rapidly than litho-
tripsy in some cats, but is associated with significant morbidity.
ESWL treatment of uroliths in cats has been limited by disap-
pointing early results. Adams observed significant renal trauma
Despite good fragmentation of a nephrolith, residual fragments
(renal hemorrhage and functional impairment) in a small number
still must be small enough to traverse the feline ureter (internal
of healthy cat kidneys treated with the HM-3, as well as insuffi-
diameter < 0.4mm). Fluid and diuretic treatment to promote
cient fragmentation of upper tract uroliths in 5 clinically affected
ureteral urine flow, or treatment with agents that may relax
cats.4 Using the HM-3 lithotriptor, Adams found that uretero-
ureteral smooth muscle, are strategies that may improve the
liths could be fragmented successfully in only 1 of 5 cats, and
success of lithotripsy in cats. Based on experience with human
that fragmentation of nephroliths was incomplete. In addition,
beings, alpha antagonist and anti-inflammatory treatment may
transient or permanent worsening of renal function occurred in
be the most promising adjunct treatments.24 Amitriptyline also
several cats. Based on this experience, cat kidneys have been
may relax urinary smooth muscle in cats.25 Treated cats must be
considered more sensitive to damage from ESWL.
able to tolerate fluid diuresis, and should be screened for occult
cardiac disease prior to treatment.
Although promising results were obtained in a small group
of healthy cats treated with a dry lithotriptor (no change in
Although the primary risks of ESWL in cats have been viewed as
sonographic renal structure or function as assessed by renal
damage to the kidney or worsening obstruction, other complica-
scintigraphy)22 fragmentation of nephroliths or ureteroliths to the
tions of ureteral treatments are possible. Ureteral rupture has
size needed to pass through the extremely small ureteral lumen
been observed in one cat in our hospital. Pancreatic or bowel
still poses a considerable challenge.10,11 Feline uroliths also are
damage is also possible, given the size of the patient. Long-term
more difficult to fragment in vitro,23 a finding that correlates with
effects on ureteral function or structure in small animals are
clinical experience. Using a research electrohydraulic litho-
currently unknown, but do not appear to be a major concern of
triptor that simulates the function of the Dornier HM-3, breakage
ESWL in human patients.
of intact calcium oxalate uroliths retrieved from dogs and cats
was evaluated using digital image size.23 In this study from
the Minnesota Urolith Center, significantly less breakage was Current Recommendations for Cats
observed in feline stones than in canine uroliths following the At the current time, ESWL is most suited for treatment of a single
same SW dosage (100 SW at 20 kV).23 Increased shock-wave (unilateral) obstructive ureterolith separated by some distance
Kidney and Utreter 457
A B
from the kidney. At this time, approximately one-half of cats with within the bladder limits the effect of the carefully targeted, repet-
a single stone will have successful fragmentation of the stone itive shock waves, and may result in failure of fragmentation, or
(such that all fragments pass into the lower urinary tract) with one larger fragments than desired. In some cases, however, urocys-
or two lithotripsy treatments. Obstructive nephroliths of small size toliths can be fragmented fairly easily. Most commonly, urocys-
(< 1 cm) also may be good candidates for ESWL, although the risk toliths are treated concurrently when nephroliths are treated.4
of renal injury increases with treatment of nephroliths. Owners Extracorporeal lithotripsy can also be used to reduce the size of
of cats referred for lithotripsy should be prepared for multiple cystoliths for medical dissolution, removal by hydropropulsion, or
treatments, possible worsening of renal function, or progressive prior to laser lithotripsy.11 I have been pleased with the ability of the
ureteral obstruction after ESWL (Table 29-2).10 Surgical inter- dry lithotriptor to fragment bladder stones for sufficient passage in
vention or dialysis support may be necessary if these complica- several female dogs and one cat, but have avoided this treatment
tions are severe. For these reasons, surgery or ureteral stenting26 in male dogs due to the increased risk of urethral obstruction by
may be a preferred option for metabolically unstable, patients small uroliths and stone fragments. Other clinicians have success-
with completely obstructive ureteroliths, where the immediate fully applied the technique to small male dogs and removed the
relief of obstruction is of primary concern. Potential modifications fragments by voiding urohydropropulsion.11 A higher shock-wave
of lithotripsy protocols, including slow rate of energy delivery, dose may be required to create sufficiently small fragments; at this
lower power regiments, newer lithotriptors, and use of ureteral time it appears that urinary bladder tissue can tolerate this modifi-
stents may minimize renal damage in cats. cation. For female dogs and cats, and male dogs large enough to
undergo transurethral procedures, intracorporeal laser lithotripsy
is preferred for optimal fragmentation of cystoliths.
Lithotripsy for Urocystoliths in Dogs or Cats
Extracorporeal shock wave lithotripsy has not been widely recom-
mended for treatment of bladder stones. Free movement of uroliths
458 Soft Tissue
14. Blomgren P, Connors B, Lingeman J, et al: Quantitation of shock wave perioperative hemorrhage, urethral or ureteral stricture, intra-
lithotripsy-induced lesion in small and large pig kidneys. Anatomical abdominal adhesions, and urolith recurrence are common.
Record 249:341, 1997.
15. Willis L, al e: Relationship between kidney size, renal injury and Nephrotomy may cause a temporary decrease in renal function
renal impairment induced by shock wave lithottripsy. J Am Soc Nephrol and nephron loss in those animals with preexisting renal disease.
10:1753, 1999. Recurrence of calculi formation, adhesions, and urine leakage
16. Lane I: Dry extracorporeal shock-wave lithotripsy, in 21st American may occur after cystotomy.5,6 Leakage of urine from the kidney,
College of Veterinary Internal Medicine Forum, Charlotte, NC, June ureter or bladder causes uroperitoneum and metabolic, fluid,
2003. electrolyte, and acid-base abnormalities. Incomplete removal of
17. Weisse CW, Berent AC. Interventional radiology in urinary diseases. calculi especially from the bladder is not uncommon. Because of
In Bonagura J and Twedt D, Current Veterinary Therapy XIV, Saunders the small size and irregular contour of some uroliths, complete
Elsevier 2009, pp 965-971.
removal of all stones can be difficult.7,8 Flushing the bladder and
17a. Adams LG: Nephroliths and ureteroliths: a new stone age. N Zeal urethra is not a reliable method to ensure complete removal of
Vet J 61:212,2013.
all calculi; in one study, uroliths were incompletely removed in 1
18. Siems J, Adams, LG, et al.: Ultrasound findings in 14 dogs following of 7 dogs and 1 of 5 cats following cystotomy.9
extracorporeal shock-wave lithotripsy for treatment of nephrolithiasis
[abstr]. In: in Proceedings of the American College of Veterinary
Complications following urethrotomy include hemorrhage, urine
Radiology Chicago, p 11.
leakage, and possible urethral stricture; and is indicated only if
19. Daugherty M, Adams LG, al e: Acute pancreatitis in two dogs
obstructive uroliths cannot be hydropropulsed retrograde into
associated with shock wave lithotripsy (abstr). Journal of Veterinary
Internal Medicine 18:441, 2004.
the bladder for dissolution or removal.5,7,10 The urethrotomy site
may be closed or left to heal by 2nd intention, in which case
20. Delakas D, Karyotis I, Daskalopoulos G, et al: Independent predictors
hemorrhage occurs for 7 to 10 days. Chronic stricture formation
of failure of shcokwave lithotripsy for ureteral stones employing a
second-generation lithotripter. Journal of Endourology 16:201, 2003. following urethrotomy increases the risk of blockage during
voiding of calculi. Other potential complications include scarring
21. Shiroyanagi Y, Yagisawa T, Nanri M, et al: factors associated with
failure of extracorporeal shock wave lithotripsy for ureteral stones of the incision site, tissue irritation, urethrocutaneous fistulae,
using Dronier lithotriptor U/50. International Journal of Urology 9:304, and diverticula formation. Permanent urethrostomy may be
2002. necessary if stricture occurs. Complications of urethrostomy
22. Gonzales A, Labato M, Solano M, et al: Evaluation of the safety of include hemorrhage, recurrent urinary tract infections, and
extracorporeal shock-wave lithotripsy in cats (abstr). Journal of Veter- inguinal and scrotal scalding.5
inary Internal Medicine, 2002.
23. Adams LG, JC W, JA M, et al: In vitro evaluation of canine and feline
urolith fragility by shock wave lithotripsy (abstr). Journal of Veterinary
Lithotripsy
In human urology, surgical removal of uroliths has been largely
Internal Medicine 17:406, 2003.
replaced by lithotripsy.1,11 Lithotripsy, the act of breaking or
24. Porpiglia F, Ghignone G, C F, et al: Nifedipine versus tamsulosin for fragmenting stones, uses the generation of shock waves or laser
the management of lower ureteral stones. Journal of Urology 172:568,
energy to fragment uroliths. There are two forms of lithotripsy
2004.
that use shock waves to fragment the stone; electrohydraulic
25. Achar E, Achar R, Paiva T, et al: Amitriptyline eliminates calculi
shock-wave lithotripsy (EHL) and extracorporeal shock wave
through urinary tract smooth muscle relaxation. Kidney International
lithotripsy (ESWL). All shock waves, when focused, fragment
64:1356, 2003.
urinary stones by erosion and shattering.12,13
26. Berent AC,Weisse CW,Todd KL, et al: Use of locking-loop pigtail
nephrostomy catheters in dogs and cats: 20 cases (2004-2009). J Am Vet
Med Assoc 241:348, 2012.
EHL uses the generation of sparks in a fluid medium to develop
shock waves. The shock wave is generated at the tip of an
insulated wire that is placed immediately adjacent to uroliths
Laser Lithotripsy for Treatment within the urinary tract. The shock wave passes through the
body of a urolith and reflects back from its edge to pass back
of Canine Urolithiasis through the body of the stone. Many 1° and 2° shock waves are
Ellen B. Davidson Domnick created, causing shearing forces that destroy the lattice of the
urolith.11,13 EHL has been used successfully in horses; successful
ureteroscopic EHL was performed by perineal urethrostomy in a
Introduction 3 yr. thoroughbred colt.14 In an 18-year old thoroughbred gelding,
Uroliths are a common cause of hematuria, stranguria, and a ballistic shock wave lithotriptor was used to break up an 8 cm.
dysuria in dogs.1,2 Obstructive uroliths, if left untreated, may bladder calculus and by flushing out the sand-like residue under
cause azotemia, recurrent urinary tract infections, loss of kidney epidural anesthesia.15
function, or death.1-3 Surgical removal is the traditional treatment
for removal of recurrent stones or obstructive stones in veter- In ESWL, shock waves are generated outside the body and
inary medicine.2,4-6 Surgery in the carefully selected patient is directed or focused toward the urolith. The stone is localized
relatively quick, relieves obstruction, and decreases or reverses during lithotripsy with ultrasonographic or fluoroscopic
loss of glomerular function. However, surgery is invasive and guidance. ESWL is standard therapy for renal and upper urinary
complications, including damage to healthy functioning tissue, tract calculi in humans, with over 75 to 90% of stones resolved
460 Soft Tissue
with lithotripsy.12,13 Because of the relative immobility of the renal are accessible at the distal urethra via a perineal urethrotomy
pelvis, ESWL is most applicable to renoliths that are relatively or via a transurethroscopic approach. Transendoscopic pulsed
fixed as shock waves move through them. The relative mobility dye laser lithotripsy was effective in the treatment of calcium
of the bladder and bladder stones makes ESWL less ideal for carbonate urolithiasis in 2 adult geldings.27 The principle disad-
treatment of stones in the lower urinary tract.16 Nephroliths and vantages included cost of the procedure and the time delay
ureteroliths have been successfully treated in dogs with 1st and required for use of the pulsed dye laser lithotriptor.
2nd generation lithotriptors.1,17 Expense, purchase, upkeep, and
availability of ESWL have limited its use in small animals.13,17 (See Success in fragmenting calcium carbonate uroliths in horses
ESWL by Dr. I. Lane). with Ho:YAG has been mixed; successful removal of calculi
was reported in 5 horses with a combination of laser lithotripsy,
Laser lithotripsy, an alternative to other forms of shock wave litho- lavage, basket snare removal, and digital manipulation.39 In
tripsy, effectively eliminates uroliths in humans, horses, ruminants, another report, the Ho:YAG failed to adequately fragment calculi,
pigs, and dogs.18-32 Laser-induced shock wave lithotripsy trans- and pulsed dye lithotripsy or digital manipulation was necessary
forms light energy into acoustic energy (photoacoustic) or thermal to remove the uroliths.40
(photothermal) energy, depending on pulse duration.21 The shock
wave generated is large enough to fragment uroliths by photoa- Initial experience in human urology with the Ho:YAG laser has
coustic or photothermal ablation.21 During lithotripsy, laser energy demonstrated its safety and that no excess hemorrhage, renal
is transmitted and directed to the urolith surface through a small deterioration or trauma occurs.25 Reported stone-free rates are 67
diameter flexible optical fiber that allows the operator to directly to 84% for renal calculi, with complications rates of < 1%.25 Ho:YAG
visualize the urolith under endoscopic guidance. The devel- lithotripsy is effective for ureteral and renal calculi in morbidly
opment of fiberoptic cables has greatly increased therapeutic obese patients.26 Additionally, the photothermal effects of the
applications of the laser, as fiberoptics allow the laser delivery Ho:YAG laser use are minimal; lesions are consistently < 1 mm.25,26
beam to be brought in contact with the stone.26 The small fiber size
of a laser generally between 300 to 600 microns in diameter (0.3 Advantages of the Ho:YAG laser for lithotripsy. The Ho:YAG laser
to 0.6 mm), allows it to be passed through instrument channels in is portable and rugged. The Ho:YAG laser precisely cuts with
newer generation flexible and rigid endoscopes, and limits retro- minimal damage to adjacent mucosal tissue. It offers fiber optic
pulsion. Fiberoptics allow the operator to safely, effectively, and delivery, which is ideal for endoscopic use, and can treat tissue
accurately deliver laser energy and fragment a stone with little in a liquid environment such as the urinary tract. Protective
damage to surrounding tissue damage.31-33 In humans, laser litho- eyewear is available for its infrared wavelength (2100 nm).
tripsy is the 2nd most preferred method for urinary calculi removal Its laser wavelength is poorly absorbed in tissue, resulting in
after shock wave lithotripsy.18,34-35 minimal damage to the adjacent urethral mucosa.30-32 Its effect
is independent of stone color.38 Of all lasers, Ho:YAG produces
A pulsed laser that can be delivered through fiberoptic cables is the smallest fragments in all stone types. The reported efficacy
required. Pulsed laser energy is absorbed by water in the urolith, of the Ho:YAG laser in fragmenting uroliths is 100% vs. 78 to 89%,
the resulting photothermal effect fragments the urolith, and for the pulsed dye laser.38
fragments are actively flushed out with a flushing system attached
to the endoscope’s biopsy port. Any remaining stone fragments
are left to be passed normograde during urination.31 Because
Laser Lithotripsy in Veterinary Medicine
stones can be visualized endoscopically and the fiber is placed The Ho:YAG laser effectively fragments urinary stones
directly on the surface of the stone, the stone is consistently independent of composition, water content, or size.32,41 Pulsed
fragmented.18,31 Laser lithotripsy is useful for patients at risk for Ho:YAG laser energy fragments canine uroliths in-vitro without
hypertension or renal dysfunction, is non-invasive, protects renal optical fiber damage. In an initial in vitro study all stones were
function, and rapidly resolves clinical signs of obstruction.26,36 successfully fragmented in less than 30 seconds.30 This and
other studies have shown that that higher pulse frequencies (10
to 40 Hertz [Hz]) and lower pulse energies (< 1 joule[J]) were
Lasers used in Lithotripsy safer and more efficient for urolith fragmentation using Ho:YAG
Both the Holmium: Yttrium Aluminum Garnet (Ho:YAG) and laser energy.30,32,42
pulsed dye lasers can effectively fragment biliary and urinary
stones.22,26,37 but the dye laser energy required for urolith In a subsequent in vivo experimental study, laser lithotripsy with
fragmentation may damage the optical fibers and fragmentation the Ho:YAG laser successfully fragmented obstructive uroliths in
efficiency is dependent on urolith composition and color.19 The the urethra of male dogs.31 Mean time for adequate fragmentation
pulsed dye laser has a wavelength of 504 nm, which is selectively was rapid, 166.7 seconds (range, 47 to 494.5 seconds). Minimal (<
absorbed by black or brown, the color of many uroliths. This is 30 mg) or no urolith material was evident within the urethra after
a disadvantage when treating “pale” uroliths such as cystine, lithotripsy. Urinary clinical signs related to lithotripsy resolved
because fragmentation may be ineffective for relatively colorless without further treatment in all dogs by day 5. Endoscopic evalu-
stones.38 Pulsed dye laser lithotripsy is effective in fragmenting ation of the urinary tract on day 10 revealed no mucosal lesions,
the most common uroliths of horses, calcium carbonate, and may stricture or narrowing of the urethra, or urolith remnants. No dog
be performed in standing horses with less surgical invasiveness became obstructed during 30 days of observation.
and trauma to the urinary tract.27 In male horses urethroliths
Kidney and Utreter 461
A B
Figure 29-19. A. (lateral) and B. (Ventro Dorsal) radiogrpahic views of a dog with obstructive urethrolith formation (arrows).
A B
Figure 29-21. A. Post-lithrotripsy positive contrast cystourethrogram of the same dog. No filling defects are evident. There is mild narrowing of
the distal urethra at the site where the stone was treated. This is likely due to mild spasming of the urethra from the lithotripsy procedure. B. Post.
lithrotripsy positive contrast cystourethrogram of the same dog. No filling defects are evident. There is mild narrowing of the distal urethra at the
site where the stone was treated (arrow) which is likely due to mild spasming of the urethra from the lithotripsy procedure.
462 Soft Tissue
A 2.5 mm (7.5 French) (Karl Storz, Inc., Goleta, CA) or 2.8 mm (8.4 In my clinical experience, all canine urolith types fragment consis-
French) (Mitsubishi Endoscopy, Irvine, CA) flexible endoscope with tently independent of composition, but continual readjustment
an intraluminal channel is passed retrograde through the urethra and attention to the aiming beam position on the stone as it
to the level of the most distal urolith. A 320 um low-OH optical fragments is critical. Experience with use of the Ho:YAG laser is
laser fiber (Sunrise Technologies, Fremont, CA) is passed through important to minimize potential complications including collateral
the operating channel until the aiming beam is visible extending tissue damage from reflected photoacoustic energy and risk of
from the tip of the endoscope. The fiber is directed onto the urolith retropulsing a large fragment into the urinary bladder. Continual
surface and laser energy (sLase210 Ho:YAG laser, New Star Lasers, readjustment and attention to the aiming beam position on the
Auburn, CA) is applied in contact mode to the urolith surface until stone as it fragments is critical. Continual flushing of the urethra
complete fragmentation occurs. Power settings are 5 Watt (W) or bladder to clear debris and fragments, and dilate the urethra
power at 15 Hertz (Hz). Experience has shown that the total laser during laser lithotripsy is helpful. Even when flushing is performed
energy applied should be less than 1 J/pulse.31 Continuous flushing gently and overfill of the bladder is not permitted, iatrogenic
with normal saline (0.9% NaCl) solution delivered through the bladder rupture can occur.43
biopsy/irrigation port of the endoscope is performed during litho-
tripsy. This provides excellent visualization and allows normograde
and retrograde flushing of the stones.
Lithotripsy Technique for Cystic Calculi
Despite advances in nutrition and antibiotic treatment, cystic
Fragmentation of the stone is considered complete when the calculi remain a common problem in dogs and cats.7,8 Approxi-
fragments are easily flushed out through the urethra and the mately 79 to 93% of all urinary calculi in dogs occur in the
fragments are visually smaller than the urethral lumen at the level bladder.44 Cystic calculi may cause recurrent urinary tract
of the obstruction. Urethral obstruction occurs consistently at infections and obstruction. Traditionally, stones are removed by
the level of the proximal or mid-os penis. The urethral mucosa is cystotomy, but surgical morbidity and cost of surgical removal
examined endoscopically before scope removal to determine that are concerns especially when stones recur.5 There is not a
there is no immediately discernable gross damage to the mucosa. widespread useful alternative to surgical removal of calculi in
dogs.4,5 Minimally invasive alternatives, such as laparoscopic
Kidney and Utreter 463
cystotomy have been described, but are available on a limited postoperatively. Temporary urethral catheters in dogs are placed
5
basis.45 ESWL has a high rate of residual stone fragments and if moderate stranguria persists following lithotripsy. Catheter-
is used primarily for ablation of ureteroliths or nephroliths ization is unnecessary in most cases, unless urethritis develops.
because the relative mobility of the urinary bladder decreases In my experience, stranguria secondary to post-lithotripsy edema
its efficiency in fragmenting cystic calculi.13 is more likely in dogs with chronic, multiple urethroliths.
Several recent studies have documented the efficacy of laser Pronounced, prolonged stranguria or hematuria may indicate
lithotripsy for the treatment of urethral and cystic calculi in the presence of residual stones or more severe urethral mucosal
dogs.46,47,48 Lithotripsy using this technique is a minimally invasive damage. In those cases, additional imaging such as urethrog-
procedure that appears to be a safe procedure with minimal raphy/cystography, endoscopic examination and retreatment may
complications. Depending upon the operator, anesthesia time can be necessary if the dog has evidence of obstructive urolithiasis
be longer than traditional surgical techniques such as cystotomy. (acute dysuria).
Results of all three studies suggest that the use of laser litho-
tripsy is a safe and effective alternative to surgical removal of Remaining urolith fragments that are too small for further fragmen-
cystoliths and urethroliths in dogs (Table 29-3). At this time, laser tation or that retropulse proximally generally are voided normally
lithotripsy is most available in academic or referral practices. within 24 hours.31 Small (< 30 mg) fragments should pass easily
during urination after lithotripsy. Large (> 100 mg) fragments may
A brief description of cystic lithotripsy follows. A contrast ureth- result in reobstruction from incomplete fragmentation. A fragment
rocystogram is performed prior to lithotripsy. In males, the dog that retropulses into the bladder during urethral lithotripsy or is
is placed in dorsal recumbency and the prepuce and ventral not located during bladder lithotripsy may later move distally
abdomen are prepared aseptically. A 2.5 mm (7.5 Fr.) (Karl Storz, and lodge in the urethra at the level of the os penis. In human
Inc., Goleta, CA) or 2.8 mm (8.4 Fr.) (Mitsubishi Endoscopy, Irvine, lithotripsy procedures, intraoperative contrast fluoroscopy is
CA) flexible ureteroscope with an intraluminal channel is passed routinely performed to confirm that no large fragments remain.12
retrograde through the urethra to the bladder. In females, the Retropulsion increases as fiber diameter and pulse energy
dog is placed in dorsal recumbency with the hindquarters placed increases therefore small fibers should be used.50 Alternatively,
slightly beyond the edge of the table and elevated slightly. This stones that are fragmented and photomechanically retropulsed
allows the tail and hind limbs to remain out of the way and puts the into the urinary bladder may be removed laparoscopically.45 This
dogs at a comfortable angle for the examiner.49 A rigid 1.9 mm, 2.7 would avoid laparotomy, but requires an additional procedure.
mm, or 4.0 mm cystoscope (Karl Storz Veterinary Endoscopy, Inc,
Galeta, CA) is used for dogs < 10 kg, 10 to 20 kg, and 15 to 20 kg and In dogs with large fragments, repeat lithotripsy to treat recurrent
above, respectively. The calculi are visualized and immobilized obstruction is an option, but waiting for reobstruction to occur
with an endoscopic basket (Securos endoscopic basket, Boston may not be satisfactory and could result in complications from
Scientific Inc., Boston MA) to grasp and immobilize each stone obstructive urolithiasis. Regardless, dogs with clinical signs of
in preparation for fragmentation. Some stones do not need to be reobstruction may have urethral endoscopy and repeat litho-
mobilized inside the basket; instead, lithotripsy is performed by tripsy if necessary. The effect of multiple lithotripsy sessions on
immobilizing stones between the laser fiber and the bladder wall. the lower urinary tract of dogs is unknown. Repeat lithotripsy
has not been reported in the veterinary literature. Confirmation
The remainder of the procedure is performed as for urethral of complete fragmentation with post-lithotripsy contrast studies
lithotripsy. The entire bladder, with particular attention to the and observation of normal urination is advised.
mucosa, should be examined endoscopically before scope
removal to determine that there is no immediately discernable Histologic mucosal changes following lithotripsy in humans
gross damage or large stone remnants. Random bladder biopsies and dogs include temporary erythema, erosion, hemorrhage, or
may be performed after lithotripsy using a 3.5 mm endoscopic ulceration.30,31,38,51 Depending upon the location and microscopic
biopsy cup (apposing cup biopsy forceps, Karl Storz Veterinary character of the lesions, causes include damage from the urolith
Endoscopy, Goleta, CA). as it was placed or lodged into the urethra, mechanical damage
from the endoscope or grasper as it is directed into the urethra,
or damage associated with the fragmentation and flushing of
Post Lithotripsy Recovery stone fragments.38 Long-term deleterious effects on the urethral
Vital signs (temperature, pulse, respiration, and pain) are mucosa from repeated laser lithotripsy are unlikely.52
monitored routinely and patients generally are permitted water
and food within 12 hours of the procedure. Dogs are monitored
daily for gross hematuria, stranguria, and poilakiuria. Dogs Lithotripsy for Treatment of Nephroliths
frequently are poilakiuric initially. Mild to moderate hematuria Surgical morbidity, effect on glomerular filtration rate, and cost
and poilakiuria, if they occur, generally are self-limiting and of surgical removal of renoliths are important concerns in veter-
resolve within 24 to 48 hours in affected dogs.31 Similar clinical inary surgery.4,5 To date, there is not a widespread alternative to
signs routinely occur in humans after laser or extracorporeal nephrotomy or pyelolithotomy for removal of nephroliths in dogs.
shock wave lithotripsy.12,13,36,50 Concurrent cystotomies to retrieve In human urology, surgical removal for renoliths and uteroliths
bladder uroliths that are not accessible with the laser result has been superseded by minimally invasive procedures. Options
in clinical signs of hematuria and stranguria for several days for removal of stones in the renal pelvis include ESWL, percuta-
464 Soft Tissue
neous nephrolithotripsy (PCNL), intracorporeal or transureteral This is especially important for breeds (or individual dogs) that are
endoscopic retrieval, or laser lithotripsy.12,22,25,26,51 predisposed to recurrent urolith formation. Techniques for laser
fragmentation of obstructive uroliths in the urethra and bladder
ESWL is the most common technique for removal of kidney have been established. Further advancements in lithotripsy in
stones in humans, but has a higher rate of resistant residual veterinary patients may obviate the need for traditional surgery.
stone fragments.25,50 In addition, some stones located in the lower
pole of the pelvis are not amenable to ESWL.47 ESWL has been Until the complex and multifactorial causes of stone formation
reported on a limited basis in veterinary medicine and is available in dogs are elucidated and stone formation is preventable, the
at some referral practices.1,13,17 Future advancements in ESWL further development of minimally invasive treatment protocols
therapy in veterinary medicine may occur as lithotriptors become that prevent the need for multiple surgical procedures has many
more available. advantages. Laser lithotripsy appears to have applications for
treatment of urolithiasis, a common and potentially dangerous
PCNL In humans, allows a minimally invasive approach to the renal health problem in dogs. In particular, successful laser lithotripsy
pelvis and renolith fragmentation with fluoroscopic or ultrasound may reduce or prevent associated problems that affect animal
guidance.54 Renoliths larger than 3 cm in diameter, staghorn-shaped urinary health such as urinary tract infections, acute dysuric
stones, calcium oxalate monohydrate stones, and cystine stones obstruction, and hydroureter/hydronephrosis. Potential disad-
that are relatively resistant to ESWL are indications for PCNL.26,38 vantages of laser lithotripsy include patient and operator safety
Prior to lithotripsy, a percutaneous pyelogram may be performed to issues, cost,laser maintenance, and the training and experience
locate the exact stone position and size. The intrarenal collecting required for successful stone fragmentation.
system is accessed through a percutaneous nephrostomy tract. In
this procedure, a hollow needle is passed into the renal pelvis under
fluoroscopic or ultrasonographic visualization. A flexible guide References
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a non-invasive, cost-effective, rapid treatment option for dogs Cur Opin Urol 12:287, 2002.
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Laser lithotripsy is a non-invasive, cost-effective, rapid treatment
14. Rodger LD, Carlson GP, Moran ME, et al: Resolution of a left ureteral
option for dogs with urinary calculi in the bladder and/or urethra.
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Intern Med. 9:280, 1995. 39. Judy CE, Galuppo LD: Endoscopic assisted disruption of urinary calculi
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J Urol 141:275, 1988. 43. McCarthy TC, McDermaid SL: Cystoscopy. Vet Clin North Am: Small
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24. Zorcher T, Hochberger J, Schrott KM, et al: In vitro study concerning lithotripsy in fragmentation of urocystoliths and urethroliths for removal
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32. Wynn VM, Davidson EB, Higbee RG, et al: In vitro effects of pulsed
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33. Grasso M, Bagley D: Small diameter, actively deflectable, flexible
Companion Animals
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34. Psihramis KE, Buckspan MB: Laser lithotripsy in the treatment of
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35. Bagley DH: Expanding role of ureteroscopy and laser lithotripsy for
Introduction
treatment of proximal ureteral and intrarenal calculi. Curr Opin Urol Clinical renal transplantation in cats was performed successfully
12:270, 2002. in 1984 by Dr. Clare Gregory and Dr. Ira Gourley at the University
36. Bataille P, Pruna A, Cardon G, et al: Renal and hypertensive complica- of California-Davis, School of Veterinary Medicine. The ability to
tions of extracorporeal lithotripsy. Presse Med. 29:34, 2000. successfully perform renal transplantation as treatment for renal
37. Kopecky KK, Hawes RH, Bogan ML, et al: Percutaneous pulsed-dye failure in companion animals was due to a number of factors
laser lithotripsy of gallbladder stones in swine. Investig Radiol 25: 627, including the development of microsurgical techniques and the
1990. availability of microsurgical equipment in veterinary practice,
38. Matsuoka K, Iida S, Inoue M, et al: Endoscopic lithotripsy with the the ability to use an allograft from an unrelated donor and the
466 Soft Tissue
administration of cyclosporine for immunosuppressive therapy hour care and a veterinarian who is willing to care for a renal
in the dog and cat.1-3 transplant recipient. Finally, a critical aspect of any transplant
program is donor adoption. The client must be willing to provide
Results published in 1992 evaluating the first 23 cases of feline a lifelong home for the donor animal regardless of the outcome
renal transplantation, supported transplantation as a treatment of the transplant procedure.
option for cats in end stage renal failure. In that study, 70% of
the cats were discharged from the transplant facility and the
mean survival period was 12 months for all cats with the longest
Evaluation of a Potential Recipient
surviving for 31 months.4 In 1996, a retrospective study evaluating Thorough screening, which is often performed by the referring
66 cases of feline renal transplantation (including the 23 cases veterinarian working with the transplant surgeon, is essential
that had been previously described) was published.5 In that study, for a potential feline renal transplant recipient to decrease the
although the percentage of cats surviving to discharge was incidence of morbidity and mortality that can occur following
similar to the first report during the 9 year study period, there was the surgical procedure. Although the ideal time to perform
an improvement in perioperative survival. Perioperative survival transplantation is not known, experienced clinicians suggest
rate improved from 64% in the first 33 cats to 79% for the last 33 that the best candidate for renal transplantation is a cat in early
cats.5 It is estimated that over 400 feline renal transplants have decompensated renal failure.6,7 Indications of decompensation
been performed since the procedure was first introduced in 1984. include continued weight loss and worsening of anemia and
Although a retrospective study describing all cases that have azotemia in the face of medical management. Although attempts
been performed to date is not available, recent information from to alter the physical deterioration of animals with chronic renal
veterinary surgical centers active in tranplantation suggests that failure have been reported to be unsuccessful, the placement
survival times are continuing to improve (Table 29-4). Improved of either an esophagostomy tube or percutaneous endoscopic
survival may be related to more stringent case selection, as well gastrostomy (PEG) tube has been used successfully for up to 2
as the clinician’s ability to better recognize and treat complica- years for the medical management of some potential renal trans-
tions both in the immediate postoperative period and long term. plant candidates6,7 (Personal communication, Mathews, KG). It is
Cats are the predominant species to undergo transplantation noted that the degree of azotemia, anemia, urine specific gravity
and will be the focus of this chapter, however information will and age, do not determine a suitable patient for transplantation.
also be presented on canine transplantation since it is becoming In one report, cats greater than 10 yrs of age had an increase in
more common at selected university hospitals. mortality, particularly during the first 6 months following surgery.8
To date, the oldest cat that has had successful transplantation at
our hospital was 18 years of age.
Table 29-4. Feline Renal Transplant (University)
Centers in the United States Both physical and biochemical parameters should be carefully
University of Pennsylvania, School of Veterinary Medicine evaluated to determine if a cat is suitable for transplantation.
Contact: Dr. Lillian R. Aronson Current evaluation in our hospital includes laboratory testing
(complete blood count/chemistry/blood type and crossmatch/
University of Wisconsin, School of Veterinary Medicine thyroid evaluation), evaluation of the urinary tract (urinalysis,
Contact: Dr. John F. McAnulty urine culture, urine protein:Cr ratio, abdominal radiographs,
abdominal ultrasound), evaluation for cardiovascular disease
University of Georgia, School of Veterinary Medicine (thoracic radiography, blood pressure electrocardiography,
Contact: Chad Schmeidt echocardiography, and infectious disease screening (FeLV/FIV,
Toxoplasma titer, IgG and IgM) (Table 29-5).
Client Education
It is important for clients to realize that renal transplantation is a
Table 29-5. Pre-operative screening for a
treatment option for animals in chronic renal failure, but is not a Potential Feline Renal Transplant Recipient
cure. Medical therapy including subcutaneous fluid therapy, low • Complete blood count
protein diets, phosphate binders, hormonal therapy including • Serum chemistry profile
Erythropoietin and Darbopoietin, gastrointestinal protectants,
and antihypertensive medication can often be discontinued • Blood type and cross-match
following surgery however the pet will still need immunosup- • Thyroid hormone evaluation (T4)
pressive therapy for life. Selection criteria for transplantation
• Urinalysis, urine culture, urine protein:Cr ratio
are rigorous and the owner needs to understand the risks of the
procedure and that their cat may be turned down as a potential • Abdominal radiography
candidate if the cat fails any aspect of the medical screening • Abdominal ultrasonography
process or if the cat has a fractious temperament. The cost of
• Thoracic radiography
renal transplantation is high and additional veterinary visits
postoperatively for monitoring of renal function and determining • Electrocardiography, echocardiography, blood pressure
serum levels of cyclosporine are required. It is necessary for • Feline leukemia virus, Feline immunodeficiency virus
the owner to identify a veterinary hospital that can provide 24
• Toxoplasmosis titer, IgG and IgM
Kidney and Utreter 467
Evaluation of the Urinary Tract transplant recipients, only 22% were found to have a normal heart
on echocardiographic examination. The most common abnormal-
Evaluation of the urinary tract to rule out underlying infection or ities identified included both papillary muscle and septal muscle
neoplastic disease is essential prior to transplantation. Based on hypertrophy and it was suggested that these changes may be
biopsy reports from cats that have been transplanted, the most related to chronic uremia, hypertension, age or early changes
common diagnosis of renal disease is chronic tubulointerstitial of hypertrophic cardiomyopathy.10 We have identified patients
nephritis. Other diseases successfully treated by transplan- with similar changes on echocardiography that were unable
tation include polycystic kidney disease, membranous glomeru- to tolerate fluid therapy prior to transplantation. Four patients
lonephropathy, calcium oxalate urolithiasis and ethylene glycol developed varying degrees of pulmonary edema and pleural and
toxicity.6 If on abdominal ultrasound, renomegaly is identified pericardial effusion. Following transplantation, fluid therapy was
and the cause is not polycystic kidneys or perinephric pseudo- reinitiated without complication. In 2 cats, echocardiographic
cysts, then a fine needle aspirate or a biopsy is recommended to evaluation performed within 3 months following surgery revealed
rule out Feline Infectious Peritonitis (FIP) or neoplasia. Animals resolution of echocardiographic abnormalities. Potential candi-
diagnosed with a urinary tract infection should be treated with dates with diffuse hypertrophic cardiomyopathy or those with
the appropriate antibiotic therapy based on culture and sensi- congestive heart failure are declined as candidates for renal
tivity prior to presentation. In patients with recurrent urinary transplantation in our hospital. In cats with less severe cardiac
tract infections or those that have recently been treated, but at disease, a decision is made on a case to case basis.
the time of presentation have a negative urine culture, a Cyclo-
sporine (CsA; Neoral, Sandoz Pharmaceuticals) challenge is
indicated. The patient is administered Cyclosporine for approxi- Infectious Disease
mately two weeks at the recommended dose for transplantation If a cat has an active FIV infection or is FeLV positive, they are
immunosupression. The urine is evaluated for the presence of declined as candidates for transplantation. All potential trans-
an infection on at least 2 occasions; after therapeutic CsA blood plant donors and recipients currently undergo serologic testing
levels have been obtained and at the end of the 2 week period. (IgG and IgM) for Toxoplasmosis. Toxoplasma gondii can cause
Although negative urine culture results will not guarantee that significant morbidity and mortality in both human and veterinary
a patient will remain infection free after transplantation and immunocompromised patients. Most human transplant patients
chronic immunosupression, it can eliminate some cats with will display clinical signs within the first 3 months following
occult infections. Alternatively, all potential transplant candi- surgery since this is the period of maximum immunosupres-
dates can be treated with CsA for 2 weeks prior to surgery to sion.11 In a report describing 3 cats and 1 dog, disseminated
attempt to identify occult infection prior to transplantation.7 toxoplasmosis occurred within 3 weeks to 6 months following
transplantation.12 As a matter of policy at our facility, we do not
The incidence of cats with calcium oxalate (CaOx) urolithiasis and use seropositive donors for seronegative recipients, but we
concurrent renal failure and subsequent presentation of the cat have successfully used a seropositive donor for a seropositive
for renal transplantation, has been increasing. In a recent retro- recipient. Seropositive recipients are placed on lifelong prophy-
spective study, renal transplantation was a successful treatment lactic Clindamycin (25 mg PO q12h) which is started in conjunction
option for cats whose underlying cause of renal failure was with immunosupression. Tribrissen has also been used in cats
associated with CaOx urolithiasis.9 No difference in long term that did not tolerate Clindamycin. To date, 10 recipients with a
outcome was found between a group of 13 stone formers and a positive IgG and/ or a positive IgM titer have been placed on
control group of 49 cats whose underlying cause of renal failure prophylactic Clindamycin therapy. Two cats are currently alive
was not related to stone disease. If hydronephrosis is present on 105 and 545 days following transplantation. Eight cats have died
abdominal ultrasound during the recipient screening process, a a median of 379 days following transplantation. Cause of death
pyelocentesis and urine culture is recommended prior to trans- included, lymphosarcoma (3 cats), presumed antibiotic toxicity (1
plantation to identify patients that may be harboring an infection. cat), cardiomyopathy (1 cat), accidental avulsion of the allograft
The author has identified five cats with obstructive CaOx uroli- (1 cat), chronic pyelonephritis (1 cat) and allograft failure (1 cat).
thiasis that have had a negative urine culture from urine collected None of the cats died from an active Toxoplasma gondii infection
from the urinary bladder and a positive urine culture from urine (L.R. Aronson unpublished data 2005).
collected by pyelocentesis (L.R. Aronson unpublished data 2005).
Allograft rejection as well as an increase in morbidity and mortality Although we have become more selective in case selection
can occur in an immunosupressed patient harboring an infection. in recent years, with the availability of hemodialysis and the
increasing experience of clinicians who manage these cases
Cardiovascular Disease we have “pushed the envelope” by performing transplants on
cases that may be considered questionable recipients. Definitive
Many cats presented for transplantation have systolic murmurs
findings that preclude renal transplantation include cats with
identified on physical examination. These murmurs may be
neoplastic disease, severe cardiac disease, FeLV positive status,
secondary to the anemia of chronic renal failure and not represent
active FIV infection, recurrent or existing urinary tract infection
significant heart disease.6 Historically, because of complications
that fails medical therapy and/or a CsA challenge, uncontrolled
associated with transplanting cats with hypertrophic cardiomy-
hyperthyroidism and a fractious temperament. (Table 29-6).
opathy, cats with underlying cardiac disease were not accepted
Although objective information associated with survival has
into the program. In a recent study performed at the University of
been identified with regard to some aspects of the screening
California-Davis evaluating cardiac abnormalities in 84 potential
468 Soft Tissue
Table 29-6. Tests results or conditions that rule nance requirements. In some cases, underlying cardiac disease
out Tranplantation in the Cat may preclude this rate of fluid administration because of the
risk of development of pulmonary edema and pleural effusion.
• Primary or metastatic neoplasia
Additionally, the calcium channel blocker amlodipine (Norvasc,
• Severe cardiac disease Pfizer labs, 0.625 mg/cat PO q24h) may be indicated prior to
• FeLV positive status surgery if the cat is hypertensive. Anemia is typically corrected
• Active FIV infection with either whole blood transfusions or packed red cells with the
• Recurrent or existing urinary tract infection that fails medical goal of obtaining an endpoint packed cell volume of 30% prior to
therapy and/or a CsA challenge surgery. If the cat is stable on admission with respect to anemia,
blood transfusions are administered at the time of surgery. The
• Uncontrolled hyperthyroidism
first unit that is administered is a unit previously collected from
• Fractious temperament the cross-match compatible donor cat. It is important to note
that some cats in chronic renal failure are not transfusable
Test results or conditions that May rule out because of incompatabilities despite the fact that the cats are
of the same blood type and have had no known exposure to
Tranplantation in the Cat
blood products. If the patient is traveling a great distance to the
• Inflammatory bowel disease transplant hospital, blood crossmatching should be performed
• Diabetic patients prior to admission. A blood sample can be sent to the transplant
• Patients with echocardiographic abnormalities that suggest hospital for cross-matching in order to identify a compatible
they are unable to receive fluid therapy kidney donor as well as identify 2 to 3 potential blood donors.
Hormonal therapy including Erythropoietin or Darbopoietin can
process in recipients, some clinical uncertainties continue to be administered if a delay is expected and can greatly reduce
pose challenges including animals with inflammatory bowel the need for blood products at the time of surgery. Although
disease, diabetes mellitus, and those cats with echocardio- uncommon, the owner should be cautioned regarding the possi-
graphic abnormalities that are not able to receive fluid therapy bility of the development of antibodies to these drugs which can
without causing fluid overload (See Table 29-6). result in significant morbidity and potentially mortality in the
postoperative period. If deemed necessary, phosphate binders
and gastrointestinal protectants can be given and if the cat is
Evaluation of a Potential Donor anorectic, a nasogastric, esophagostomy or PEG tube may be
Cats selected as kidney donors are in excellent health and placed prior to surgery to administer nutritional support.
are typically between 1 to 3 years of age. Standard evaluation
includes a serum chemistry profile, complete blood count,
urinalysis and culture, FeLV and FIV testing and a Toxoplasmosis
Feline Immunosupression
titer (IgG and IgM). The feline kidney donor must also be blood- Two protocols are currently being used for the feline renal
cross match compatible to the recipient and of a similar size. transplant recipient. In the first protocol, a combination of the
Additionally, CT angiography is performed on all of the potential Calcineurin inhibitor, CsA and the glucocorticoid, prednisolone
donors to evaluate the renal vasculature as well as evaluate are used together for their synergistic effects. Because the dose
the renal parenchyma for any abnormalities (Table 29-6).13 This of cyclosporine that cats often require for immunosupression is
screening technique has allowed us to identify potential donors small, an oral liquid formulation is used so that the dose can be
unsuitable for donation including those with renal infarcts as well titrated accordingly for each individual cat. Currently, the oral
as the presence of multiple arteries. A suitable home is found for liquid formulation, Neoral (100 mg/ml), is recommended. Neoral
any donor that fails the screening process. In a study evaluating is a microemulsified formulation and is preferred over the other
the long term effects of performing a unilateral nephrectomy in a oral liquid formulation, Sandimmune (Novartis Pharmaceuticals),
healthy cat, 16 donors were followed between 24 and 67 months because of better gastrointestinal absorption allowing for more
postoperatively.14 Fifteen of the 16 cats were clinically normal predictable and sustained blood concentrations of the drug.6
and serum creatinine concentrations for these cats remained Additionally, the dose of Neoral necessary to maintain thera-
within the reference range. One cat was diagnosed with chronic peutic blood concentrations compared to Sandimmune is less,
renal insufficiency 52 months following surgery. Although renal making the drug more economical for clients.
donation does not appear to affect normal life expectancy, long
term monitoring is recommended in these animals. Depending on the transplant facility performing the procedure,
CsA is typically begun 24 to 96h prior to transplantation.
Depending on the cat’s appetite, Neoral is administered at a
Preoperative Recipient Treatment dose of 1 to 4 mg/kg PO q12h. In the author’s experience, cats
Preoperative care for the recipient varies depending on the that are anorexic or that are eating a minimal amount prior to
stability of the animal. At some centers, hemodialysis is performed surgery have a much lower drug requirement to obtain appro-
prior to surgery in cats with severe azotemia (BUN > 100 mg/ priate drug levels prior to surgery. A 12-hour whole-blood trough
dL, Cr > 8mg/dL).8 In cases that do not require hemodialysis, the concentration is obtained one day prior to surgery to adjust the
recipient is typically placed on intravenous fluid therapy of a oral dose for the surgical procedure. A target 12-hour whole-
balanced electrolyte solution at 1.5 to 2 times the daily mainte- blood trough concentration of 300 to 500 ng/ml prior to surgery
Kidney and Utreter 469
using the technique of high-pressure liquid chromatography concentration. More work in this area is necessary prior to
20
(HPLC) is recommended.15 This level is maintained for approxi- changing current drug monitoring protocols. Since CsA has a
mately 1 to 3 months following surgery and is then tapered to bitter taste, the medication is placed into a gelatin capsule prior
approximately 250 ng/ml for long term maintenance therapy. to administration. If the owner is unable to medicate the cat, they
Prednisolone is administered beginning the morning of surgery. should be given empty gelatin capsules to practice with until
At our facility, prednisolone is started at a dose range of 0.5-1 they feel comfortable with the technique. The capsule sizes that
mg/kg q12h orally for the first 3 months and then tapered over we most commonly use range from #1 to #3 depending on the
several weeks to q24h. Protocols for both CsA and prednisolone dosage. The prednisolone, as well as other medication that the
vary between transplantation facilities. Doses have ranged from cat is taking, can be added to the gelatin capsule.
0.25 to 2.5 mg/kg PO q12h orally starting the morning of surgery
and then tapering to 0.25 mg/kg PO q24h by 1 month following Both in vitro and in vivo studies have been performed evalu-
surgery.2,3,15 Prednisolone is preferred over prednisone for ating the effects of various novel immunosuppressants such as
immunosupression in the these patients. In an abstract evalu- tacrolimus, sirolimus, mycophenolate mofetil and leflunomide
ating the bioavailability and activity of these two drugs in cats, in cats, they have not been evaluated in the clinical patient.21,22
serum prednisolone levels were significantly greater for oral Although these drugs may be effective for renal transplantation
prednisolone than oral prednisone.16 It was suggested that these in cats, they are not without complication in the human trans-
differences may be related to a decreased hepatic conversion of plant patient. Currently no other alternative immunosuppressive
prednisone to prednisolone in some cats or decreased gastroin- protocols exist for cats that cannot take CsA and prednisolone.
testinal absorption of prednisone.
Table 29-7. University of Pennsylvania products as needed. The donor cat is administered mannitol on
Anesthetic Protocol for Feline donor 2 occasions during the surgical procedure; 0.25 g/kg IV at the
time of the abdominal incision and 1 g/kg 20 minutes prior to
and recipient nephrectomy. Mannitol (0.5-0.1 g/kg IV) is occasionally admin-
IM Pre-op istered to the recipient if there is concern regarding allograft
Butorphanol: 0.5 mg/kg perfusion following vascular anastomosis. Systemic arterial blood
Telazol: 3-4 mg/kg pressure is monitored regularly in both cats non-invasively via a
Doppler technique and hypotension corrected by decreasing
Epidural the concentration of inhalant anesthetic, or by the adminis-
Bupivicaine: 0.1 mg/kg tration of fluid boluses, blood products or a continuous infusion
Morphine: 0.15 mg/kg of dopamine (5 ug/kg/min). Intraoperative hypertension can be
treated successfully with the SQ administration of hydralazine (2.5
Induction mg SQ for a 4 kg cat).
Oxymorphone: 0.1 mg/kg
Midazalam: 0.5 mg/kg
Lidocaine: 1 mg/kg
Renal Transplantation Surgery
Successful renal transplantation in the cat requires an operating
Etomidate: 0.2 mg/kg +/- Glycopyrrolate/Atropine
microscope and surgical experience with microsurgical vascular
Intra-operative and ureteral surgical procedures.
Mannitol; 0.25 g/kg at time of incision and 1 g/kg before
nephrectomy Feline Surgical Technique
In our hospital, 3 surgeons are required for each transplant
Post-operative
procedure; 2 surgeons to operate on the donor and recipient and
Buprenorphine 8 hours post induction: 0.02 mg/kg a third surgeon to close the donor following the nephrectomy.
The donor cat is brought into the surgical suite approximately
Recipient
45 minutes prior to the recipient and the donor kidney prepared
Epidural for nephrectomy. At the time of initial incision, the donor is given
Bupivicaine: 0.1mg/kg a dose of mannitol (0.25 g/kg IV over 15 minutes). The alpha
Morphine: 0.15 mg/kg adrenergic agonist acepromazine (0.1 mg/kg IV) has also been
recommended by some surgeons.17 These drugs are used to
Induction minimize renal arterial spasms, improve renal blood flow and
Oxymorphone: 0.1 mg/kg protect against renal tissue injury that can occur during the
Midazolam: 0.5 mg/kg warm ischemia period. It is essential to harvest a donor kidney
Lidocaine: 1 mg/kg with a single renal artery. Many renal arteries bifurcate close
Etomidate: 0.2 mg/kg +/- glycopyrrolate/atropine to the kidney. A minimal length of 0.5 cm of a single renal artery
is necessary for the arterial anastomosis.6 The CT angiography
Intra-operative Fentanyl infusion that was performed on the donor prior to anesthesia not only
Post-operative provides important information regarding the renal vasculature,
Buprenorphine 8 hours post induction: 0.02 mg/kg but also prevents delays between the donor nephrectomy and
Hydralazine if needed for hypertension: 2.5 mg/4 kg cat SQ recipient anesthesia induction. The left kidney is preferred as
a donor because it provides a longer renal vein than the right
kidney. In most situations, if two renal veins are present, the
transplantation.26 At the time of anesthetic induction, both the
smaller vein can be sacrificed. Prior to sacrificing a small vein,
donor and recipient cats are given cephalexin (22 mg/kg IV
however, it is important for the surgeon to identify the ureteral
q2h). Additionally, an epidural injection is performed on both
vein and determine that it is not draining into the renal vein that
cats (Bupivicaine [0.1 mg/kg] and Morphine [0.15 mg/kg]) for
is being sacrificed. The renal artery and vein are cleared of as
analgesia. Both cats may be under anesthesia for as long as 4
much fat and adventitia as possible and the ureter is dissected
to 6 hours and hypothermia is of serious concern and can be
free to the point where it enters the bladder serosa. Using sterile
detrimental to these patients. A circulating warm air blanket is
paper, templates are made of both the donor renal artery and
used throughout the procedure and continuous monitoring of
vein to determine the size of the venotomy and aortotomy to
esophageal temperatures is performed. In addition to cephalic
be performed in the recipient. Harvesting the donor kidney is
catheters, an indwelling double lumen jugular catheter is placed
performed when the recipient is fully prepared to receive the
into the recipient right jugular vein so that venous blood gases,
kidney. Fifteen minutes prior to nephrectomy, a 2nd dose of
the PCV and TP as well as the electrolytes can be monitored
mannitol (1.0 g/kg IV) is given to the donor cat.
throughout surgery. The left side of the neck is preserved
in animals where an esophagostomy tube may be placed.
An operating microscope is used for the majority of the recipient
Additionally, at the time of anesthetic induction, the recipient
surgery. Following a full abdominal exploratory, the colon and
is given a unit of cross-match compatible whole blood from the
ileum are tacked to the body wall using 3-0 chromic gut to aid
kidney donor followed by other cross-match compatible blood
in surgical exposure. Two surgical methods of renal trans-
Kidney and Utreter 471
plantation have been described. The first technique described aorta and adventitial scissors are used to create an oval defect
transfers the transplanted kidney to the recipient’s iliac vessels. in the vena cava. The aorta and vena cava are flushed with a
In this technique, an end-to-end arterial anastomosis of the heparinized saline solution. Two sutures of 8-0 nylon are placed
external iliac and renal artery and an end-to-side anastomosis at the cranial and caudal aspect of the aortotomy site. Sutures
of the external iliac vein and renal vein are performed.2 Approxi- are not pre-placed in the venotomy.
mately 12% of cats having this procedure developed pelvic limb
complications including pain, hypothermia, edema, paresis Following the second mannitol infusion in the donor, the graft
and paralysis.5 These complications have been successfully is harvested and flushed with a phosphate-buffered sucrose
prevented by changing the vascular surgical technique. In the preservation solution. Excess adventitia on the end of the renal
revised procedure, the renal artery is anastomosed end-to-side artery is excised and the artery dilated. The renal artery is
to the caudal aorta (proximal to the caudal mesenteric artery), anastomosed to the aorta using 8-0 nylon in 2 rows of simple
and the renal vein is anastomosed end-to-side to the caudal continuous sutures; one on the medial aspect and one on the
vena cava (Figure 29-22A and B).27 Partial occlusion vascular lateral aspect of the artery. The renal vein is anastomosed to
clamps are used to obstruct blood flow in both the aorta and the the vena cava using 7-0 silk. A back wall technique is used first
caudal vena cava. Using the previously made templates from the to suture the portion of the renal vein closest to the renal artery.
donor vessels, windows are created in both the aorta and vena The anastomosis is completed once the second side of the
cava that match the size of the renal artery and vein, respec- vein is sutured using a continuous pattern. The venous clamp
tively. An aortotomy clamp is used to create the stoma in the is removed first and then the arterial clamp. Some hemorrhage
may occur but typically can be controlled with direct pressure.
Significant leaks are repaired with the placement of additional
single interrupted sutures. Occasionally, renal arterial spasm
can occur following release of the vascular clamps. The appli-
cation of topical lidocaine or acepromazine has been effective
in some cases in eliminating this problem. Others recommend
the systemic use of chlorpromazine or acepromazine for treating
the vascular spasms that can occur and have found these drugs
to be more effective than lidocaine.17 In a comparison of the
two surgical techniques, although not statistically significant,
the graft warm ischemia and total surgical times were shorter
using the arterial end-to-side technique compared to the iliac
vessel technique. Additionally, pelvic limb complications were
not identified using the revised technique.27
Figure 29-26. Extravesicular technique for ureteroneocystostomy. A 1 cm incision is made on the ventral surface of the bladder through the
seromuscular layer allowing the mucosa to bulge through the incision. A smaller incision (3 to 4 mm) is made through the mucosal layer of the
bladder at the caudal aspect of the seromuscular incision. The distal end of the ureter is spatulated and the ureteral mucosa is sutured to bladder
mucosa using 8-0 nylon. The proximal and distal sutures are placed first. The seromuscular layer is closed over the ureter in a simple interrupted
suture pattern.
aspect of the seromuscular incision. The distal end of the ureter the native kidneys is taken (if not previously performed) and an
is prepared as previously described. Ureteral mucosa is sutured esophagostomy tube placed if nutritional support is deemed
to bladder mucosa using 8-0 vicryl or nylon. The proximal and necessary. Finally, the allograft is pexied to the abdominal wall.
distal sutures are placed first. Similar to the previous technique, If the kidney is transplanted onto the aorta and vena cava, the
5-0 polypropylene suture can be used to check for ureteral adjacent body wall is incised and the incised edge sutured to the
patency. Once the ureteral anastomosis is complete, the renal capsule using 6 interrupted sutures of 4-0 polypropylene.
seromuscular layer is apposed in a simple interrupted pattern Another procedure involves the creation of a musculoperitoneal
over the ureter using 4-0 absorbable suture such as PDS. In flap (based ventrally) which is elevated from the adjacent body
the second technique, the entire ureter and ureteral papilla are wall and sutured to the renal capsule using 4-6 interrupted
harvested and sutured using an extravesicular technique.30 A 2 sutures of 5-0 polypropylene.6 The pexy is critical to prevent
mm cuff of bladder wall is isolated along with the distal end of allograft torsion on its vascular pedicle causing ischemia and
the ureter. A 4 mm defect is made at the apex of the bladder and subsequent graft loss. The native kidneys are usually left in situ
the ureteral papilla sutured in place using 8-0 Vicryl in a 2 layer to act as a reserve if graft function is delayed. If warranted, the
pattern; mucosa to mucosa and seromuscular layer to seromus- kidneys can be removed at a later time. In cases of polycystic
cular layer. kidney disease, often one of the native kidneys needs to be
removed at the time of the transplantation procedure in order to
Prior to abdominal closure of the recipient, a biopsy of one of make room in the abdomen for the allograft.
474 Soft Tissue
Canine Surgical Technique oral CsA dose is adjusted accordingly depending on postoperative
blood levels. It has been the author’s experience that CsA require-
The surgical techniques described for renal transplantation in ments typically decrease in the early postoperative period, likely
the dog are similar to those described for the cat with minor associated with preoperative fasting of the patient and postop-
differences. Both the iliac vessel technique as well as anasto-
erative anorexia. The prednisolone dose is continued as previ-
mosing the renal vasculature to the caudal aorta and vena cava
ously described (0.5 to 1 mg/kg PO q12h). Voided urine is collected
have been performed successfully in the dog and unlike the cat,
daily to assess urine specific gravity. Typically with appropriate
magnification may not be necessary depending on the size of
pain control and improvement in azotemia, most cats start eating
the patient.6 Unlike cats, the iliac vessel technique is still being
within 24 to 48 hours following the surgical procedure. In some
used both experimentally and clinically in the dog. The selected
cases in which continued anorexia is thought to be associated
iliac artery is prepared for an end-to-end anastomosis to the
with altered gastric motility following surgery, metoclopramide
renal artery and the external iliac vein is prepared for an end-to-
administration (0.2 mg/kg SQ q6-8h) has been successful in
side anastomosis to the renal vein. A bulldog vascular clamp is
improving a cat’s appetite. If the cat remains anorexic, feeding is
placed near the aortic bifurcation to occlude the iliac artery. The
begun using the esophagostomy tube. Feeding is continued until
artery is subsequently ligated distally, severed and then flushed
the cat is eating and drinking and then tapered accordingly.
with heparinized saline solution. The end of the artery is dilated
slightly and cleaned of any excess adventitia. The external iliac Patients are monitored for postoperative seizure activity every
vein is isolated in the same region, tributary veins ligated and 1 to 2 hours for the first 3 days. During the 1990’s, the most
then 2 bulldog vascular clamps placed as far apart as possible common complication reported in cats during the perioperative
(first distally and then proximally). A partial occlusion clamp can period was central nervous system (CNS) disorders including
also be used. A venotomy in the external iliac vein is performed disorientation and seizures which occasionally progressed to a
and then 2 rows of simple continuous sutures are used on the comatose state as well as respiratory and cardiac arrest.31 In
medial and lateral aspect of the renal vein and iliac vein as one report, the median time until onset of seizure activity was
previously described for the cat. The renal artery and iliac artery 24 hours following surgery.5 Many variables were evaluated and
are anastomosed using a simple interrupted pattern. Suture
showed no difference between affected and unaffected cats
material used for the vascular anastomoses is 4-0 to 6-0 silk for
with respect to the degree of azotemia, magnesium and choles-
the venous anastomosis and 5-0 to 8-0 nylon or polypropylene
terol levels, intraoperative blood pressure, osmolality, serum
for the arterial anastomosis. Both intravesicular and extrave-
electrolyte and blood glucose concentration, erythropoietin
sicular techniques for ureteroneocystostomy have been used
and CsA administration.7,31 In one study, postoperative hyper-
successfully in canine transplantation. The renal capsule of the
tension was identified as a major contributing factor to postop-
allograft is sutured to the abdominal body wall with simple inter-
erative seizure activity in the feline renal transplant recipient.32
rupted sutures of 3-0 polypropylene, with a musculoperitoneal
Additionally, the administration of antihypertensive therapy
flap (based ventrally) using 3-0 polypropylene or by suturing the
significantly reduced the seizure frequency and the morbidity
allograft capsule to the adjacent mesocolon with simple inter-
and mortality associated with neurologic complications.
rupted sutures of 3-0 polypropylene.6,24
Because of these findings, during the first 48 to 72 hours, indirect
blood pressure is monitored every 1 to 2 hours for the devel-
Postoperative Care and opment of hypertension. If the systolic blood pressure is equal
to or exceeds 170 mmHg, hydralazine (Sidmack Laboratories, 2.5
Perioperative Complications mg SQ) is administered. The hydralazine dose can be repeated
Important points of postoperative care in the transplant patient if the systolic pressure hasn’t decreased within 15 minutes. If
include minimizing stress and handling of the patient and treatment the cat is refractory to hydralazine, acepromazine (0.005-0.01
of hypothermia. The recipient is administered a balanced mg/kg IV) has been used successfully. It is important to note
electrolyte solution with the volume adjusted depending on the that the cause of CNS disorders in human transplant patients
cat’s hydration status and oral intake of water. Blood transfusions is thought to be multifactorial, and since there appears to be a
should be given as needed. The cat is maintained on IV antibiotic difference between transplant centers in the incidence of hyper-
therapy (cefazolin, 22 mg/kg IV q8h) until the intravenous catheter tension and CNS disorders, the occurrence of CNS disorders
is removed and then the cat is maintained on oral amoxicillin in cats following renal transplantation remains a challenge.17
combined with clavulenic acid (Clavamox, 62.5 mg PO q12h) until Postoperative hypotension may also produce complications.
the feeding tube is removed. If the cat is Toxoplasma positive, Systolic blood pressure should be maintained at equal to or
Clindamycin (25 mg PO q12hr) is administered and continued for greater than 100 mmHg. Sustained hypotension can be a serious
the lifetime of the cat. Postoperative pain has been controlled problem leading to poor graft perfusion. These patients need to
successfully using either hydromorphone (0.1-0.2 mg/kg IM or SQ be treated aggressively to prevent acute tubular necrosis and
q4-6h), buprenorphine (0.005-0.02 mg/kg IV q4-6h) or a constant delayed graft function.
rate infusion of butorphanol (0.1-0.5 mg/kg/h). An extended data
base evaluating the packed cell volume, total protein, electro- If transplant surgery is technically successful, azotemia typically
lytes, blood glucose and acid base status is initially evaluated 2 resolves and the cat improves clinically within the first few days
to 3 times daily and then tapered accordingly depending on the following surgery. If improvement is not identified during this
patient’s stability. A renal chemistry panel is checked every 24 to time or if improvement in renal function as well as the clinical
48 hours and a blood CsA level is checked every 3 to 4 days. The status of the patient is initially identified, but then worsens, an
Kidney and Utreter 475
ultrasonographic examination of the allograft is warranted. If renal function remains normal following transplantation, the
The allograft should be evaluated for any signs of hydroneph- anemia associated with renal failure should resolve within 3-4
rosis and hydroureter as well as renal blood flow. If ureteral weeks after surgery.34 If graft function remains adequate, but the
obstruction is suspected, the cat is anesthetized and the anemia persists, iron supplementation should be considered.
allograft ureter evaluated. In some cases, the ureter may need
to be re-implanted into the urinary bladder. If graft perfusion is Renal complications following transplantation have included
adequate and no hydronephrosis/hydroureter exists, delayed renal rejection, hemolytic uremic syndrome, oxalate nephrosis
graft function may be occurring. Typically, if perfusion remains and renal failure. Both acute and chronic rejection have been
adequate, improvement in graft function often occurs within the described in the cat. Acute rejection with loss of function of
first few weeks following surgery. The author suspected delayed the affected organ can occur at any time, but is most common
graft function in one cat and significant improvement didn’t within the first 1 to 2 months following surgery. Acute rejection
occur for approximately 6 to 8 weeks postoperatively. This cat is often associated with poor owner compliance in adminis-
experienced prolonged episodes of hypotension during surgery tration of required medication. Some cats that are experiencing
as well as in the immediate postoperative period. a rejection episode may be lethargic, depressed, anorexic and
PU/PD and thus prompt a visit to a veterinarian while in other
Normally, without major complication, the recipient is transferred cats, clinical signs may be minimal. For this reason, weekly blood
from the intensive care unit to the renal transplantation ward sampling is critical during this time period to detect any changes
within a few days following surgery. Patients are discharged when in serum creatinine concentration. Histopathologic, sonographic,
graft function appears adequate and CsA blood levels are stable. and scintigraphic examination of allograft rejection in cats has
If otherwise stable, cats with a delay in function of their graft recently been described.35,36 In one study, allograft histopa-
can also be discharged. Medical management can be continued thology revealed significant interstitial inflammation and tubulitis
in this subset of patients until graft function returns to normal. with varying degrees of intimal arteritis.35 A significant increase
If the transplanted kidney fails to function, the kidney should be in cross sectional area of the kidney on ultrasound examination
biopsied prior to attempting retransplantation of the patient. has been identified in cats during a rejection episode.36 Although
normal allograft enlargement is expected during the first week
postoperatively, a gradual decline in size should then occur.
Long-Term Management and Complications Allograft rejection should be suspected if renal enlargement
Following discharge, both cats should be evaluated by the persists or progresses beyond 7 days. Additionally, a subjective
primary care veterinarian once a week for the first 4 to 6 weeks increase in echogenicity and a decrease in corticomedullary
initially and then extended to monthly intervals if the cat is clini- demarcation may be identified in allografts undergoing rejec-
cally stable. During each exam, a renal panel, packed cell volume, tion.36 Neither resistive index nor glomerular filtration rate were
total protein, a cyclosporine level and a urinalysis of a free-catch sensitive indicators in normal grafts and those undergoing
urine sample is performed. Body weight should be monitored allograft rejection.36-38 Prior to initiating treatment for rejection, a
regularly. It is recommended that a complete blood count and urine sediment should be evaluated to rule out obvious infection
serum chemistry panel be performed every 3 to 4 months and an and an abdominal ultrasound performed of the allograft to rule
echocardiography performed every 6 to 12 months if the cat had out ureteral obstruction.
been diagnosed with underlying cardiac disease prior to trans-
plantation. The feeding tube can be removed at suture removal if Treatment for a possible rejection episode should not be delayed
oral intake of food and water is appropriate. and these tests should only be performed prior to initiating therapy
if in house capabilities are available. Acute rejection episodes are
There is seemingly little correlation between the oral dose of treated with intravenous administration of cyclosporine (6.6 mg/
cyclosporine and the blood level that will be achieved in an kg q24h given over 4 to 6h) and prednisolone sodium succinate
individual animal. Cats of similar weight on identical doses of (Solu Delta Cortef, Upjohn, 10 mg/kg IV q12h). Each milliliter of
CsA may vary markedly in blood levels achieved. Because of the IV cyclosporine is diluted with 20 to 100 ml of either 0.9% NaCl
individual patient variability in the absorption of oral cyclosporine or 5% Dextrose (not Lactated Ringer’s solution). Because CsA
and its metabolism, it is essential that blood levels are monitored is light sensitive, the IV fluid lines should be covered. Following
regularly to maintain therapeutic concentrations and minimize the completion of the CsA infusion, the cat is continued on IV
side effects from toxicity. As previously described, CsA trough fluid therapy. The infusion of CsA can be repeated, however if
levels are maintained for approximately 1 to 3 months following the creatinine concentration does not improve within 24 to 48
surgery at 300 to 500 ng/ml and then tapered to approximately hours, other causes for the azotemia should be investigated.
250 ng/ml for maintenance therapy. Although rare, a fatal side Chronic rejection is characterized by a gradual loss of organ
effect of CsA therapy, hemolytic uremic syndrome (HUS), has function over months to years, often without a known episode
been identified in the cat.33 Patients develop hemolytic anemia, of rejection. Kidneys undergoing chronic rejection show severe
thrombocytopenia with rapid deterioration of renal function narrowing of numerous arteries and thickening of the glomerular
secondary to glomerular and renal arteriolar platelet and fibrin capillary basement membrane. Unfortunately, the cause of
thrombi. Unfortunately, the disease typically has not manifested chronic rejection is undetermined. As described previously, HUS
itself until after the transplant procedure and the mortality rate is a rare, but fatal complication in the feline renal transplant
has been 100%. recipient. Three feline transplant recipients were dignosed with
HUS secondary to cyclosporine therapy.33
476 Soft Tissue
Results of a recent study suggest that transplantation is a pet need to understand the risks of surgery and recovery and that
treatment option for cats with calcium oxalate (CaOx) urolithiasis. substantial ongoing care is necessary for the life of the animal.
No difference in long term outcome was found between a group
of 13 cats with CaOx calculi and a control group of 49 cats whose
underlying cause of renal failure was not related to calculi References
formation.9 Although formation of calculi in the allograft did not 1. Gregory CR, Gourley IM, Taylor NJ, et al. Preliminary results of clinical
significantly reduce survival, the power of the study was low renal allograft transplantation in the dog and cat. J Vet Intern Med 1:53,
1987.
and there was a trend towards lower survival rates in cats that
formed calculi. Four of the 5 cats that formed calculi following 2. Gregory CR, Gourley IM. Organ transplantation in clinical veterinary
surgery had calculi attached to the nylon suture used to perform practice. In:Slatter DH, ed. Textbook of small animal surgery. Phila-
delphia: WB Saunders, 1993, 95.
the ureteroneocystostomy and two cats that formed calculi
after surgery were diagnosed with a urinary tract infection. We 3. Gregory CR. Renal transplantation. In: Bojrab MJ, 4th ed. Current
techniques in small animal surgery. Williams and Wilkins, 1998,434.
speculate and recommend that the use of absorbable suture
material for performing the ureteroneocystostomy and a more 4. Gregory CR, Gourley IM, Kochin EJ, et al. Renal transplantation
for treatment of end-stage renal failure in cats. J Am Vet Med Assoc
thorough screening for urinary tract infection be performed in
201:285,1992.
these cats.
5. Mathews KG, Gregory CR. Renal transplants in cats : 66 cases (1987-
1996). J Am Vet Med Assoc 211:1432, 1997.
Another potential cause for the recurrence of azotemia in the first
few months postoperatively in the feline renal transplant recipient 6. Gregory CR, Bernsteen L. Organ transplantation in clinical veterinary
practice. In:Slatter DH, ed. Textbook of small animal surgery. Phila-
is the development of retroperitoneal fibrosis.39 The cause is
delphia: WB Saunders, 2000,p 122.
unknown but may be associated with operative trauma, infection,
7. Mathews KG. Renal transplantation in the management of chronic
the presence of foreign material, inadequate immunosupression,
renal failure. In: August J, ed. Consultation in feline internal medicine 4.
hemorrhage or urine leakage during the transplant procedure. Philadelphia: WB Saunders, 2001, p 319.
Ultrasound examination of the kidney reveals hydronephrosis
8. Adin CA, Gregory CR, Kyles AE, et al. Diagnostic predictors and
with or without hydroureter and occasionally, a capsule can be
survival after renal transplantation in cats. Vet Surg 30:515, 2001.
identified surrounding the allograft. Surgery has been successful
9. Aronson LR, Kyles AE, Preston A, Drobatz K, Gregory CR. Renal trans-
in relieving the obstruction and restoring normal renal function.
plantation in cats diagnosed with calcium oxalate urolithiasis:19 cases
(1997-2004). J Am Vet Med Assoc. Accepted with revisions.
Finally, similar to humans following transplantation, complica-
10. Adin DB, Thomas WP, Adin CA, et al. Echoardiographic evaluation
tions occur secondary to chronic immunosuppressive therapy. of cats with chronic renal filure. Absrtact, ACVIM Proceedings, May
Cats and dogs are more susceptible to bacterial and fungal 25, 2000, p714.
infections as well as opportunistic infections such as the reacti- 11. Renoult E, Georges E, Biava MF, et al. Toxoplasmosis in kidney
vation of latent Toxoplasma gondii infection.12 Bacterial urinary transplant recipients:report of six cases and review. Clin Infect Dis
tract infections in the transplant patient cause direct morbidity 24:625,1997.
and mortality due to the infection itself, and may also activate 12. Bernsteen L, Gregory CR, Aronson LR, et al. Acute toxoplasmosis
the rejection process. Two cats have developed fatal Mycobac- following renal transplantation in three cats and a dog. J Am Vet Med
terium infections following chronic immunosuppressive therapy; Assoc 215:1123, 1999.
one cat had systemic disease and the other cat had septic 13. Bouma JL, Aronson LR, Keith DM, et al. Use of computed tomog-
arthritis.40,(personal communication, Aronson 2005) Transplant recipients are also raphy renal angiography for screening feline renal transplant donors.
more susceptible to various forms of neoplasia and diabetes. Vet Radiol & Ultrasound 44:636, 2003.
Decreased immune surveillance, activation of latent oncogenic 14. Lirtzman RA, Gregory CR. Long-term renal and hematological effects
viruses such as the Epstein Barr virus and chronic antigenic of uninephrectomy in healthy feline kidney donors. J Am Vet Med Assoc
stimulation are thought to put human patients at increased risk 207:1044,1995.
for various forms of neoplasia.7 The prevalence of neoplasia in 15. Bernsteen L, Gregory CR, Kyles AE, et al. Renal transplantation in
cats following renal transplantation has been reported from 9.5 to cats. Clin Tech in Sm Anim Prac 15:40, 2000.
14% with lymphoma being the most common type reported.41 16. Graham-Mize CA, Rosser EJ. Bioavailability and activity of prednisone
and prednisolone in the feline patient. Dermatology Abstracts 2004;15:9.
Conclusion 17. Katayama M, McAnulty JF. Renal transplantation in cats: Techniques,
complications, and immunosupression. Comp Cont Educ Pract Vet
Renal transplantation offers a unique method of treatment for 24:874, 2002.
renal failure in cats. Currently, approximately 90 to 95% of cats
18. McAnulty JF, Lensmeyer GL. The effects of ketoconazole on the
recover from surgery sufficiently to be discharged to the owner pharmacokinetics of cyclosporine A in cats. Vet Surg 28:448,1999.
and approximately 70% of these cases are alive and clinically
19. McAnulty JF, Lensmeyer GL. Comparison of high performance liquid
doing well 1 year after transplant. Transplant success in the canine chromatography and immunoassay methods for measurement of cyclo-
is considerably less than the feline unless matched donors and sporine A blood concentrations after feline kidney transplantation. Vet
recipients are used. Survival times have steadily improved as more Surg 27:589,1998.
animals have been treated and careful screening of recipients is 20. Mehl ML, Kyles AE, Craigmill AL, et al. Disposition of cyclosporine
performed, and early recognition of problems and complications after intravenous and multi-dose oral administration in cats. J Vet
has improved. Clients interested in renal transplantation for their Pharmacol 26:349, 2003.
Kidney and Utreter 477
21. Kyles AE, Gregory CR, Craigmill AL. Comparison of thee in vitro antip-
roliferative effects of five immunosuppressive drugs on lymphocytes in Management of
whole blood from cats. Am J Vet Res 61:906,2000.
22. Kyles AE, Gregory CR, Craigmill AL. Pharmacokinetics of tacro-
Ureteral Ectopia
limus after multidose oral administration and efficacy in the prevention Mary A. McLoughlin
of allograft rejection in cats with renal transplants. Am J Vet Res
64:926,2003.
23. Bernsteen L, Gregory CR, Kyles AE, et al. Microemulsified cyclo-
Introduction
sporine based immunosupression for the prevention of acute renal Ureteral ectopia is a complex congenital abnormality of the
allograft rejection in unrelated dogs: preliminary experimental study. urinary system frequently resulting in urinary incontinence. Distal
Vet Surg 32:219,2003. displacement of one or both ureteral orifice(s) to sites within the
24. Mathews KA, Holmberg DL, Miller CW. Kidney transplantation in bladder neck, urethra, vagina or vestibule has been described in
dogs with naturally occurring end stage renal disease. J Am An Hosp small animal patients. Intermittent, continual or positional urinary
Assoc 36:294,2000. incontinence is the most common clinical symptom reported
25. Kyles AE, Gregory CR, Griffey SM, et al. An evaluation of combined in both juvenile and adult patients diagnosed with ureteral
immunosupression with MNA 715 and microemulsified cyclosporine on ectopia. Ureteral ectopia is diagnosed with significantly greater
renal allograft rejection in mismatched mongrel dogs. Vet Surg 31:358, frequency in females compared to males in all affected species.
2002. Ureteral ectopia is reported in both purebred and mix-breed
26. Valverde CR, Gregory CR, Ilkew JE. Anesthetic management in feline dogs. It has been documented with greater frequency in specific
renal transplantation. Vet Anaes & Analgesia 29:117,2002. breeds including Labrador retriever, Golden retriever, Siberian
27. Bernsteen L, Gregory CR, Pollard RE, et al. Comparison of two husky, Newfoundland, Skye terrier, West Highland white terrier,
surgical techniques for renal transplantation in cats. Vet Surg 28:417, Wire-haired fox terrier, Soft-Coated Wheaten terrier as well as
1999. Standard and Miniature poodles. The specific etiology of this
28. McAnulty JF. Hypothermic storage of feline kidneys for transplan- developmental anomaly remains unclear and a genetic basis
tation. Vet Surg 27:312, 1998. has not yet been established.
29. Mehl ML, Kyles AE, Pollard R, et al. Comparison of 3 techniques for
ureteroneocystostomy in cats. Vet Surg 34:114, 2005. Two types of ectopic ureters are recognized in veterinary
30. Hardie RJ, Schmiedt CW, Phillips L. Ureteral papilla implantation for patients based on the anatomic structure and pathway of the
neoureterocystostomy in cats. 14th annual ACVS Symposium, October distal ureter. Extramural ureters exit the kidney and completely
7-9, 2004. bypass the bladder opening directly into the proximal, middle
31. Gregory CR, Mathews KG, Aronson LR, et al.Central nervous system or distal urethra, uterus, vagina or vestibule. The incidence of
disorders following renal transplantation in cats. Vet Surg 26:386, 1997. extramural ectopic ureters is rare. Intramural ectopic ureters
32. Kyles AE, Gregory CR, Wooldridge JD, et al. Management of hyper- attach to the serosal surface of the bladder in the expected
tension controls postoperative neurological disorders after renal trans- dorsolateral anatomical position, yet fail to open into the bladder
plantation in cats. Vet Surg 28:436, 1999. lumen at the tip of the trigone. Intramural ectopic ureters tunnel
33. Aronson LR, Gregory CR. Possible hemolytic uremic syndrome in submucosally through the trigonal region to open at sites within
three cats after renal transplantation and cyclosporine therapy. Vet or distal to the bladder neck. Intramural ectopic ureters are the
Surg 28:135, 1999. most common type of ectopic ureters identified in both male and
34. Aronson LR, Preston A, Bhalereo DP, et al. Evaluation of erythro- female dogs. Additional anatomic variations of the distal ureteral
poiesis and changes in serum erythropoietin concentration in cats after segment include multiple fenestrations, ureteral troughs,
renal transplantation. Am J Vet Res 64:1248, 2003.
dilation, branched ureters and associated ureteroceles. Urinary
35. Kyles AE, Gregory CR, Griffey SM, et al.Evaluation of the clinical and incontinence since birth or following ovariohysterectomy is the
histological features of renal allograft rejection in cats. Vet Surg 31:49,
most frequently reported clinical symptom in patients diagnosed
2002.
with ureteral ectopia. Normal voiding patterns may also be
36. Halling KB, Graham JP, Newell SP, et al. Sonographic and scinti-
observed in these patients. The cause of urinary incontinence
graphic evaluation of acute renal allograft rejection in cats. Vet Rad and
is considered multifactorial. It can result from urine outflow
Ultrasound 44:707, 2003.
distal to the bladder neck and urethral sphincter mechanism,or
37. Newell SM, Ellison GW, Graham JP, et al. Scintigraphic, sonographic,
functional and/or structural abnormalities of the vesicourethral
and histologic evaluation of renal autotransplantation in cats. Am J Vet
Res 60:775, 1999.
junction and urethra resulting in primary sphincter mechanism
incompetence. The degree of urinary incontinence and patterns
38. Pollard R, Nyland TG, Bernsteen L, et al. Ultrasonagraphic evaluation
of renal autograpfts in normal cats. Vet Rad and Ultrasound 40:380, 1999.
of urination cannot be used to confirm the diagnosis of ureteral
ectopia nor determine if unilateral or bilateral disease exists.
39. Aronson LR. Retroperitoneal fibrosis in four cats following renal
transplantation. J Am Vet Med Assoc 221: 984, 2002.
40. Griffin A, Newton AL, Aronson LR, et al. Disseminated Mycobac- Diagnosis
terium avium complex infection following renal transplantation in a cat. Ureteral ectopia is the most common cause of urinary incontinence
J Am Vet Med Assoc 222:1097, 2003. in young female dogs. However, it should also be considered as a
41. Wooldridge J, Gregory CR, Mathews KG, et al. The prevalence of rule-out for patients with history of incontinence after ovariohys-
malignant neoplasia in feline renal transplant recipients. Vet Surg 31: terectomy. Physical examination is often normal with the exception
94, 20002.
of moist or urine stained hair in the perivulvar or prepucial region.
478 Soft Tissue
using 4-0 absorbable monofilament suture in a single or double with unrelenting urinary incontinence after appropriate surgical
layer continuous or interrupted pattern. correction of the ureteral ectopia, is the use of endoscopically
placed urethral submucosal bulking agents such as bovine
The urinary catheter and a closed urine collection system should collagen to treat the sphincter mechanism incompetence.
be maintained for 24 to 48 hours after surgery. Following removal
of the urethral catheter, stranguria may be noted. Administration Editor’s Note: Until recently, surgical correction has been the
of NSAID therapy can be considered if renal function is normal. primary treatment for ectopic ureter. Surgical correction is
challenging and a high degree of technical skill is required.
Surgical time, patient pain, and required hospitalization are
Nephroureterectomy potential disadvantages. Cystoscopic laser ablation performed
Removal of a nonfunctional, dysplastic or hydronephrotic kidney by minimally invasive techniques has shown promising results.
with a severely dilated ectopic ureter is indicated as a salvage Cystoscopic capability and laser access are required. Consul-
procedure provided renal function in the contralateral kidney tation with an internist at a referral center is recommended.
is normal. Aerobic bacteriologic cultures from the renal pelvis
should be obtained if a urinary tract infection is diagnosed prior
to surgery or pyelonephritis is suspected. Perform a ventral Suggested Readings
midline celiotomy from xyphoid to pubis. Gently free the kidney Cannizzo K.A., McLoughlin M.A., Mattoon J., Chew D.J., Samii V.F.,
from its retroperitoneal attachments and reflect it medially to DiBartola S.P.; Transurethral cystoscopy and intravenous pyelography
expose the vascular pedicle and ureter at the dorsal aspect of for the diagnosis of ectopic ureters in 25 female dogs. (1992-2000). J
the renal hilus. Bluntly dissect the perirenal fat from the renal Amer Vet Med Assoc 223:475, 2003.
hilus to expose the vascular pedicle. Isolate and doubly ligate Dean P.W., Bjorab M.J., Constantinescu G.M.: Canine ectopic ureter.
the renal artery and vein individually with an appropriate sized Compend Contin Educ Pract Vet 10(2):146, 1988.
silk suture. An additional transfixation suture is placed through Lane I.F., Lappin M.R., Seim H.B.: Evaluation of results of preoperative
the renal artery and the renal artery and vein transected. Sharply urodynamic measurements in nine dogs with ectopic ureters. J Am Vet
dissect the ureter from the ureteral fascia and retroperitoneal Med Assoc 206:1348, 1995.
space to its termination. The ureter is ligated at its most distal Leveille R., Atilola M.A.: Retrograde vaginocystography: A contrast
point of attachment with a 3-0 absorbable suture and transected study for evaluation of bitches with urinary incontinence. Compend
cranial to the ligature. Nephroureterectomy without the removal Contin Educ Pract Vet 13:934, 1991.
of the associated intramural ureteral remnant will likely result McLaughlin R., Miller C.W.: Urinary incontinence after surgical repair of
in continued incontinence after surgery. A ventral midline ureteral ectopia in dogs. Vet Surg 20:100, 1991.
cystotomy and urethrotomy is performed to identify and remove McLoughlin M. A., Chew D.J.: Diagnosis and surgical management of
the submucosal remnant of the ectopic ureter as previously ectopic ureters. Clin Tech Sm Anim Pract 15:17, 2000.
described. Mason L.K., Stone E.A., Biery D.N., et al.: Surgery of ectopic ureters:
Pre- and postoperative radiographic morphology. J Am Anim Hosp
Assoc 26:73, 1990.
Post-Surgical Considerations Stone E.A., Mason L.K.: Surgery of ectopic ureters: Types, method of
Mild to moderate ureteral dilation occurs following surgical correction, and postoperative results. J Am Anim Hosp Assoc 26:81,
manipulation of the ureter and generally resolves within 4 to 6 1990.
weeks after surgery. However, moderate to severe hydroureter, Samii V.F., McLoughlin M.A., Mattoon J.S., Drost W.T., Chew D.J.: Digital
present prior to surgery, is most likely a developmental response fluoroscopic excretory urography, helical computed tomography and
of the ureter to increased lower urinary tract outflow pressure. cystoscopy in 24 dogs with suspected ureteral ectopia. J Vet Int Med
Successful surgical correction of ureteral ectopia may improve 2004:18:271-281.
but will not completely resolve the hydroureter in this situation. Sutherland-Smith J., Jerram R.M., Walker A. M., Warman C.G.A.: Ectopic
ureters and ureteroceles in dogs: presentation, cause and diagnosis.
Persistent urinary incontinence is the most common compli- Compend Contin Educ Pract Vet 4:303, 2004.
cation after surgical repair of unilateral or bilateral ureteral Sutherland-Smith J., Jerram R.M., Walker A. M., Warman C.G.A.:
ectopia. Urinary incontinence has been reported to occur in 44 Ectopic ureters and ureteroceles in dogs: treatment. Compend Contin
to 67% of patients undergoing either ureteral reimplantation, Educ Pract Vet 4:311, 2004.
neoureterostomy or ureteronephrectomy alone. Patients with
continuous or recurrent symptoms of urinary incontinence
should be completely evaluated for additional causes of incon-
tinence including urinary tract infection,other congenital abnor-
malities of the urogenital tract and primary sphincter mechanism
incompetence. Aerobic bacteriologic cultures of urine samples
obtained via cystocentesis should be performed and appropriate
antibiotic therapy administered based on results of antibiotic
sensitivity testing. Alpha-adrenergic drugs such as phenylpro-
panolamine, ephedrine sulfate and oxybutinin have been used
successfully to manage some patients with mild urinary incon-
tinence after surgery. An additional consideration for patients
Urinary Bladder 481
Chapter 30
Urinary Bladder
Cystotomy and
Partial Cystectomy
Elizabeth Arnold Stone and Andrew F. Kyles Figure 30-1. Retention sutures are placed cranial and caudal to
the ends of the proposed cystotomy incision. Urine is removed by
Introduction cystocentesis.
Cystotomy
A caudal midline incision is made in female dogs and cats. In
the male dog, a paraprepucial incision is used; the skin incision
curves lateral to the prepuce, the prepuce is retracted laterally,
and a midline abdominal incision is made through the linea alba.
Calculi are removed with a bladder spoon or forceps. Passing by intermittent catheterization or with an indwelling urethral
a urethral catheter and flushing the urethra from the bladder catheter connected to a closed urine collection system.
and from the urethral opening alternately can often dislodge Following cystotomy, retrieved calculi are submitted for quanti-
urethral calculi. The bladder lining is inspected, and abnormal tative mineral analysis, and appropriate medical management
appearing areas are sampled for biopsy. The ureteral openings is initiated to help prevent urolith recurrence. Following partial
can be identified in the trigone and catheterized if necessary. cystectomy, an indwelling urinary catheter should be placed if
The bladder is flushed with warm saline before closure. more than 50% of the urinary bladder is excised. Excised tissue
should be submitted for pathologic examination. With suspected
The bladder is closed in one layer with absorbable suture material. bladder neoplasms, evaluation of the tissue margin is facilitated
An inverting pattern (e.g., Cushing) or simple continuous is used by pinning the specimen flat to a corkboard and marking the
in a bladder of normal thickness, and a simple interrupted pattern edges of the excised tissue with India ink before fixing in formalin.
is used in a thickened bladder wall (Figure 30-4). The suture
material should not enter the lumen of the bladder, but should
incorporate the submucosal layer. The bladder closure can be References
tested by injecting saline to distend the bladder and evaluating 1. Desch JP II, Wagner SD. Urinary bladder incisions in dogs: comparison
the incision for leakage. The abdomen is lavaged with warm of ventral and dorsal. Vet Surg 1986:15:153-158.
saline and is closed routinely. 2. Blake EH III, Ellison, GW, Roberts JF, et al. Biomechanical and
histologic comparison of single-layer continuous Cushing and simple
continuous appositional cystotomy closure by use of poliglecaprone 25
in rats with experimentally induced inflammation of the urinary bladder.
Am J Vet Res 2006; 67:686-692.
3. Gilson SD, Stone EA. Surgically induced tumor seeding in eight dogs
and two cats. J Am Vet Med Assoc 1990:11:1811-1815.
Introduction
Cystostomy tube placement is a method of diverting urine from
Figure 30-4. The bladder is closed in a single layer inverting pattern. In its normal bladder and urethral flow. Clinical indications for
a thickened bladder wall, a simple interrupted appositional pattern is cystostomy tube placement include temporary and permanent
preferred. urine bypass of the urethra. Temporary bypass is indicated in
patients with urethral obstruction due to urethral calculi, inflam-
Partial Cystectomy mation, or neoplasia. Temporary bypass may also be indicated
Up to 75% of the urinary bladder can be excised and the remaining in patients with bladder atonia while awaiting response to
tissue closed around a 5 mL Foley catheter bulb. A return to normal medication and for temporary urinary diversion after urethral
bladder volume and function within 3 months is anticipated. surgery. Permanent cystostomy tubes can be used as palliative
treatment for bladder neck or urethral neoplasia.
If bladder neoplasia is suspected, the bladder wall is gently
palpated and a cystotomy incision is made at least 2 cm away Latex or mushroom tipped or Foley urinary catheters have
from the bladder mass. The mucosal surface of the bladder is been used most commonly as cystostomy tubes. Low profile
inspected for additional tumors. The mass should not be manipu- cystostomy tubes are more expensive but are less cumbersome
lated during the cystectomy. The bladder wall with the mass is and less prone to accidental removal. They are also more suitable
excised with a 1 to 2 cm margin of grossly normal tissue. Care is for long term use.
taken to preserve as much of the blood supply to the bladder as
possible. It is preferable to preserve the trigone with the ureters Preoperative Management
intact, but if necessary, the ureters can be reimplanted into
In a patient with suspected urethral obstruction, placement of
another location in the residual bladder. After tumor excision,
a transurethral catheter should be attempted. If a transurethral
gloves and drapes should be changed and new instruments used
catheter cannot be passed, urethral obstruction can be tempo-
to close the bladder and abdomen, to prevent tumor seeding.2
rarily bypassed by placement of a cystostomy tube. The tube
Closure of the bladder incision is similar to the cystotomy closure
can be placed quickly and with minimal anesthetic compromise
described previously. Placement of simple interrupted sutures
to the patient. This placement allows for drainage of urine while
may facilitate apposition of the bladder remnant.
awaiting more definitive diagnostic procedures or for stabilization
of a critically ill animal before instituting more definitive therapy.
Postoperative Management
The patient should be allowed to urinate frequently. If this is If urethral or prostatic neoplasia is causing significant urethral
not possible, the bladder should be kept empty for 2 to 3 days obstruction, a cystostomy tube can be placed through a
Urinary Bladder 483
minilaparotomy or during a staging laparotomy. The cystostomy prepuce, or alternatively, the prepuce can be retracted laterally
tube can be used as permanent palliative therapy, or it can be to make a midline incision. The bladder is exteriorized, and
placed while awaiting response to more definitive therapy, such two retention sutures are placed to allow for retraction (Figure
as chemotherapy or radiation. 30-5B).
Figure 30-5. Cystostomy tube placement. A. Site of the skin incision. B. Exteriorized bladder held by retention sutures. C. Placement of the purs-
estring suture and stab incision into the bladder wall. D. Insertion of a Foley catheter into the bladder after passage through body wall. E. Omen-
tum incorporated around the catheter to help secure the pexy of the bladder. F. Sagittal section with catheter in placed, with optional omentum
wrapped around the cystostomy tube.
484 Soft Tissue
Figure 30-6. A. Prepubic fat and fascia separated by blunt and sharp dissection on both sides of the midline at the level of the prepubic brim. B.
A finger inserted into the vagina helps to clear out fat and fascia. C. The vaginal wall is exposed by using a dry swab to clean off the overlying
fat and fascia in a caudolateral direction. D. Technique repeated on the other side of the vagina (see text). E. Sutures are passed through the ab-
dominal wall caudal to the tendon, in and out of the vaginal wall, and back out of the abdominal wall cranial to the tendon. F. Sutures are placed
around the prepubic tendon, depending on the size of the bitch and the position of the external pudendal vessels laterally. The optimal number of
sutures in medium or large dogs is two.
486 Soft Tissue
Figure 30-6 (continued). D. Technique repeated on the other side of the vagina (see text). E. Sutures are passed through the abdominal wall
caudal to the tendon, in and out of the vaginal wall, and back out of the abdominal wall cranial to the tendon. F. Sutures are placed around the
prepubic tendon, depending on the size of the bitch and the position of the external pudendal vessels laterally. The optimal number of sutures in
medium or large dogs is two.
Urinary Bladder 487
congenital urethral hypoplasia may be unsuitable for colposus- the vagina, and, fortunately, most bitches with urethral sphincter
pension. In such animals, the bladder neck cannot be returned mechanism incompetence are of a size compatible with one’s
to abdominal position by colposuspension. Fortunately, such finger. It is sometimes helpful in extremely large or small bitches
severe urethral hypoplasia is rare, and its treatment is described to identify the vagina by inserting a Poole suction tip or a closed
elsewhere.2 In older bitches, colposuspension is reserved for Carmalt clamp.
animals that have failed to respond to medical therapy.
The vagina must now be anchored cranially to maintain the
bladder neck in an intra-abdominal position. The vagina is sutured
Surgical Technique to the prepubic tendon on each side of and approximately 1 to 1.5
After general anesthesia is induced, the bitch is placed in dorsal cm away from the midline. The sutures (monofilament nylon) are
recumbency with the hind limbs flexed. The ventral abdominal passed through the abdominal wall caudal to the tendon, in and
skin and vagina are prepared for aseptic surgery, the vagina out of the vaginal wall (as far laterally as possible), and back
by douching with dilute aqueous povidone iodine solution. An out of the abdominal wall cranial to the tendon, avoiding any
8 French (smaller bitches less than 35 kg) or a 10 French (larger abnormal twisting of the vaginal wall (Figure 30-6E). The sutures
bitches more than 35 kg). Foley catheter is inserted through the may enter the vaginal lumen during this procedure, hence the
urethra into the bladder, and the cuff is inflated. The catheter is need to prepare the vagina for aseptic surgery.
then gently withdrawn until the cuff rests in the bladder neck.
The presence of the catheter facilitates identification of the One or two sutures are placed around the prepubic tendon,
urethra and bladder neck during surgery. depending on the size of the bitch and the position of the external
pudendal vessels laterally. Most affected bitches are medium to
A midline, caudal abdominal approach is made. The prepubic fat large breeds, and the optimum number of sutures is two around
and fascia are separated by careful blunt and sharp dissection each tendon (Figure 30-6F). Number 0 nylon is suitable for most
on both sides of the midline at the level of the pubic brim, and the bitches, but No. 1 nylon should be used in very large breeds. On
prepubic tendons and external pudendal vessels are identified the rare occasions when colposuspension is performed in small
(Figure 30-6A). These vessels must be avoided during subse- or toy breeds, it may only be possible to place one suture through
quent placement of sutures around the prepubic tendon. each side of the vagina and around each prepubic tendon.
The midline incision is continued through the linea alba of the Before the sutures are tied, they are pulled tight to ensure that,
abdominal muscle wall and extends caudally to the pubic brim. after they are tied, the urethra will not be compressed against
Self retaining (Gosset or Balfour) retractors are used to hold the pubis by an arch of vagina (See Figure 30-6F). Compression
the rectus abdominis muscle edges apart, and the bladder is on the urethra may result in postoperative dysuria. The surgeon
identified. Cranial traction on the bladder allows the intrapelvic should be able to insert the tip of a blunt instrument such as
bladder neck to be pulled into the abdomen and identified by the Mayo scissors or Carmalt forceps easily between the urethra
presence of the inflated Foley catheter cuff. Seeing the bladder and the vaginal arch and pubis. If the urethra is compressed, the
neck and proximal urethra is often difficult because of the sutures should be repositioned. This is rarely a problem when
presence of local retroperitoneal fat. the sutures have been placed as far laterally on the vagina as
possible. After the sutures are properly placed, they are tied, the
The vagina is displaced cranially and is cleared of fat and fascia Foley catheter is removed, and the abdomen is closed routinely.
on both sides of the urethra. This is most easily accomplished by
inserting a finger into the vagina (Figure 30-6B and C). The urethra
is palpated through the ventral vaginal wall and is displaced to Postoperative Care
the bitch’s left. Using the finger in the vagina, the vaginal wall Preoperative, perioperative, and postoperative analgesics are
on the right side of the urethra is pushed cranially and ventrally used routinely. These are not usually required after the first 24
toward the caudal end of the abdominal incision. The vaginal hours. Antibiotic therapy (e.g., amoxicillin) is used for 10 days
wall is exposed by using a dry swab to clean off the overlying fat postoperatively as a precaution to minimize the risk of perito-
and fascia in a caudolateral direction (Figure 30-6C). The bladder nitis in case colposuspension sutures have entered the vaginal
neck can be seen as a swelling because of the Foley catheter lumen. We have never encountered this complication. The use
cuff in the bladder. The vaginal wall is grasped with Allis tissue of a rectal thermometer to take the animal’s temperature postop-
forceps. The technique is repeated on the other side of the vagina eratively is avoided because some bitches are sensitive in this
(Figure 30-6D). The surgeon then changes gloves, and the vulva area for a few days after surgery. In some bitches, local subcu-
is covered with a large sterile swab or surgical drape throughout taneous tissue swelling occurs, presumably because of the
the remainder of the procedure. small dead spaces left after dissection to expose the prepubic
tendons. Such swelling is not a problem and resolves sponta-
When the surgeon’s finger and the patient’s vagina are of incom- neously within 5 to 7 days. The animal is closely observed for
patible sizes (very large or very small bitches or those with signs of dysuria and to determine whether the incontinence has
gross vaginal strictures or septa), the vagina has to be located resolved. In most successful cases, the response is immediate,
by blunt and sharp dissection of the overlying fat and fascia on although some bitches remain incontinent for weeks before
either side of the urethra, grasped with tissue forceps, and then becoming continent. Skin sutures are removed routinely 7 to 10
pulled cranially. This is more difficult than the use of a finger in days after the surgical procedure.
488 Soft Tissue
Acknowledgment
We wish to thank Brenda Bunch, MA, of the College of Veter-
inary Medicine, North Carolina State University, for drawing the
illustrations.
References
1. Holt PE. Long-term evaluation of colposuspension in the treatment
of urinary incontinence due to incompetence of the urethral sphincter
mechanism in the bitch. Vet Rec 1990;127:537-542.
2. Holt PE. Surgical management of congenital urethral sphincter
mechanism incompetence in eight female cats and a bitch, Vet Surg
1993;22:98-104.
3. Rawlings CA, Barsanti JA, Mahaffey MB, et al. Evaluation of colpo-
suspension for treatment of incontinence in spayed female dogs. J Am
Vet Med Assoc 2001;219:770-775.
Urethra 489
Figure 31-1. Prescrotal urethrotomy. A. Site of skin incision and dissection of subcutaneous tissue to the retractor penile muscle. B. Longitudinal
incision into the corpus spongiosum and urethra after lateral retraction of the retractor penis muscle. C. Retention sutures in the corpus cavernosum
and exposure of the urethral interior. After removal of uroliths, the urethrotomy can be left open or closed in a simple interrupted pattern (inset). (From
Stone EA. Urologic surgery: an update. In: Breitschwerdt, EB, ed. Contemporary issues in small animal practice. Vol. 4. Nephrology and urology. New
York: Churchill Livingstone, 1986.)
the urethra occurs concurrently with urination especially in the to the owner or the lesion is more proximal, however, other
first few days following surgery if second intention healing is urethrostomy locations should be considered.3,4
selected. Hemorrhage does not typically reach serious levels
but does increase hospitalization time. Should stricture occur,
scrotal urethrostomy is recommended.
Indications
Scrotal urethrostomy is indicated for the following conditions: (a)
Editor’s Note: Laser lithotripsy of urethral calculi can be an recurrent urethral calculi that are not responsive to appropriate
effective mode of therapy for relieving obstruction without medical therapy; (b) acute calculi obstruction in dogs antici-
surgery. Cystoscopic capability and laser access are required. pated having recurrent episodes (e.g., metabolic stone formers);
(c) severe distal urethral wounds secondary to penile or os
penis trauma; (d) urethral stricture distal to the scrotum from
Scrotal Urethrostomy trauma or previous urethral surgery; and (e) diseases requiring
amputation of the penis or prepuce and formation of a more
Daniel D. Smeak proximal urethral stoma (e.g., extensive neoplasia in the region,
penile strangulation, certain congenital diseases such as severe
Introduction hypospadias, and deficiency in penile or preputial length).1
Scrotal urethrostomy is the procedure of choice in the canine Because a permanent stoma that bypasses the normal opening
when creation of a permanent urethral orifice distal to the pelvic of the urethra may increase the risk of ascending urocystitis, a
urethra is necessary. Scrotal urethrostomy has several advan- urethrostomy should not be performed unless due consideration
tages over prescrotal, prepubic, or perineal urethrostomy. The is given to the indications and complications of the procedure.5,6
membranous urethra in the region of the scrotum is larger and
more distensible than the prescrotal urethra. These charac- If both urethral and bladder calculi are found in dogs requiring
teristics reduce the risk of stricture formation and calculi scrotal urethrostomy, I prefer to perform the urethrostomy
pass more readily through the stoma following urethrostomy. first. After the urethrostomy stoma is created, the surgeon can
The urethra in the scrotal area is also more superficial and flush any remaining (more proximally located) calculi back into
surrounded by less cavernous tissue than in the perineal region the bladder, and then perform a cystotomy. This allows both
(Figure 31-2). Surgical exposure is easier, there is less tension on normograde and antegrade urethral irrigation during cystotomy
the urethrostomy, and the risk of hemorrhage or urine extrava- to ensure that all urethral calculi have been removed. If the
sation into periurethral tissues is reduced. Scrotal urethrostomy cystotomy is completed first, any urinary stones remaining in
diverts urine directly downward and away from perineal skin. the proximal urethra often cannot be removed via the scrotal
Skin surrounding the urethrostomy is kept dry and this reduces urethrostomy, and are then flushed back into the bladder during
the risk of intractable dermatitis from urine scalding.1 Most retrograde irrigation.
urethral calculi are readily removed from the distal urethra or
flushed back to the bladder by scrotal urethrostomy. I do not A modified urethrostomy technique is described here because
recommend a urethrostomy in the prescrotal region since urine the standard simple interrupted scrotal urethrostomy technique
expelled from the stoma often becomes misdirected and tends often results in unacceptable bleeding and bruising complica-
to soil the skin of the scrotum, inguinal region, and medial thighs tions.6 In a retrospective study of dogs undergoing standard
and this area tends to stricture more readily than urethrostomies scrotal urethrostomy, active hemorrhage (requiring patient
performed in the scrotal region.1,2 If castration is objectionable hospitalization) was noted an average of 4.2 days following
surgery; in some patients bleeding persisted up to 10 days.6
Urethra 491
Figure 31-2. Schematic diagram showing cross sections of the penis and urethra in the prepubic A. scrotal B., and perineal C. locations. The ure-
thra in the prescrotal and scrotal area is more superficial and is surrounded by less cavernous tissue than the perineal area. The scrotal urethra
is more distensible and larger in diameter than the prepubic urethra, allowing easier passage of calculi and reducing the risk of postoperative
stricture formation.
The following modified scrotal urethrostomy technique uses a the lateral aspect of the incision so no tension is placed on the
continuous suture pattern and a three-needle bite sequence for urethrostomy during closure or with rear limb abduction. If there
urethrostomy closure.5 In my experience, this modification has is any doubt, ample scrotal skin should be preserved and any
dramatically reduced active bleeding, bleeding after urination, redundant skin can be removed later in the procedure. If the dog
and bruising postoperatively. Furthermore, no stricture or suture is sexually intact, the testicles and spermatic cords are isolated
line breakdown has been observed to date. This closure is also and the dog is neutered in a routine manner (Figure 31-4). The
faster to perform. underlying connective tissue is dissected to expose the paired
retractor penis muscles, which appear as a thin brownish-tan
The rationale for the modified technique is several fold. Simple band on the ventral surface of the penile shaft. The surgeon
continuous suture patterns produce a better seal by apposing sharply dissects and mobilizes the retractor penis muscles, and
tissues more completely. Continuous suture patterns require
fewer knots, and irritation from “prickly” knot ears is reduced.
Needle bites are placed closer together and this also improves
urethra-to-skin apposition. Incorporation of a bite of tunica
albuginea adds additional strength to the incision line and
helps seal incised cavernous edges (see surgical technique).
When the needle is passed outward from the urethra to skin,
better apposition of cut surfaces results. All these advantages, I
believe, help reduce suture line breakdown and hemorrhage.
Surgical Technique
The surgeon must obtain the owner’s consent for the animal’s
castration before performing scrotal urethrostomy in intact
dogs. Metabolic disturbances are stabilized in the obstructed
patient preoperatively. I prefer to give an epidural adminis-
tration of a narcotic to help alleviate pain in the immediate
perioperative period. While the patient is under general
anesthesia, the surgeon places the patient in dorsal recum-
bency with the rear limbs gently abducted and secured caudally.
The proposed surgery site including the scrotum is clipped
and scrubbed routinely and is draped for aseptic surgery. An
Figure 31-3. A. and B. An elliptical incision is made at the base of the
elliptic full-thickness skin incision is made around the base of scrotum. Enough lateral skin is retained to allow tension-free closure
the scrotum. Hemostasis is maintained and the isolated scrotal of the urethrostomy. Redundant skin can be resected later in the
skin is discarded (Figure 31-3). Enough skin should be left on procedure.
492 Soft Tissue
Figure 31-4. A and B. The isolated scrotal skin is removed, and castration is performed.
fibrous tunica albuginea and, finally a 2 to 3 mm split-thickness the cranial aspect of the incision to create a cosmetic closure.
bite of skin (Figure 31-7). A simple continuous suture line is used, If the cranial aspect of the skin incision extends beyond the
with tissue bites 2 to 3 mm apart beginning caudally and working urethral incision, it is closed with simple interrupted sutures.
cranially (Figure 31-8). The urethral mucosa and skin margins
are grasped gently and only when necessary to avoid excessive
inflammation, which can lead to dehiscence and stricture. The
Postoperative Considerations
urethral mucosa and skin are approximated without gapping. Creation of a urethrostomy will not cure urinary tract infection or
The suture line should not be tight and each suture pass should remove the source of urinary calculi. It can be expected that any
have even tension. After the first side of the urethrostomy is procedure that shortens the functional length of the urethra such
closed, a separate simple continuous suture closure completes as urethrostomy, increases the risk of urinary tract infection.3
the new stoma. The surgeon should excise any redundant skin in Strict aseptic procedures should be adopted during stoma
inspection and urethral catheterization to reduce this risk. Since
the urethrostomy is located distal to the pelvic urethra (the area
that controls urethral flow) there is no concern about creating
incontinence following surgery. Owners should understand that
urethrostomy reduces but does not completely eliminate the risk
of urethral obstruction by calculi. If obstruction occurs, these
patients are usually readily managed by catheterization and
hydropropulsion of the calculi.
Swollen, bruised, and painful areas of skin surrounding the The explanation for this difference resides in the anatomic
urethrostomy may signal leakage of urine into the subcutaneous differences in urethral structure between the sexes. The urethra
tissues. Placement of an indwelling soft urinary catheter is in the male cat is long and narrow, whereas it is short and wide
indicated in these dogs for three to five days, or until the edges in the female.
of the urethrostomy are sealed. In general, catheters should be
avoided because they increase the risk of urinary tract infection Crystals composing a concretion have razor-sharp edges, which
and may increase the risk of stricture. Dehiscence of the protrude from the concretion margins. In the male cat, at the
urethrostomy should be repaired primarily, without tension, using root of the penis just proximal to the bulbourethral glands, the
the materials and suturing techniques described previously if the urethral lumen diameter narrows, creating a funnel effect. As a
tissues are healthy; otherwise allow the area is allowed to heal concretion passes down the urethra, it may become lodged at
by second intention and either reconstruct the strictured stoma this point. Initially, the cat can usually force a concretion through
or divert urine through a more proximal urethrostomy site. the penile urethra by straining. This action, however, forces the
sharp edges of the crystals into the urethral mucosa, resulting in
multiple lacerations. This trauma results in hemorrhage, urethral
References inflammation, edema, and swelling, which decrease the urethral
1. Smeak DD, Newton JD: Canine scrotal urethrostomy, in Bojrab MJ, diameter even further. Passage of another concretion through
ed.: Current Techniques in Small Animal Surgery (ed 4) Baltimore, MD: the urethra results in an obstruction that cannot be dislodged
Williams & Wilkins, 1998, pp 465-468.
by the animal. This situation requires emergency treatment to
2. Bellah JR: Problems of the urethra: surgical approaches. Prob Vet remove the urethral obstruction and reestablish urine flow.
Med 1:17-35, 1989.
3. Dean PW, Hedlund CS, Lewis DD, et al: Canine urethrotomy and
urethrostomy. Comp Contin Ed Pract Vet 12:1541-1554, 1990. Diagnosis
4. Smeak DD: Urethrotomy and urethrostomy in the dog, Clin Tech in The diagnosis of FUS is based on history, clinical signs, and
Small Anim Prac 15:25, 2000. palpation of a large, firm, tense bladder. The history may include
5. Newton JD, Smeak DD: Simple continuous closure of canine scrotal urination in unusual locations along with increased frequency in
urethrostomy: results in 20 dogs. J Am Anim Hosp Assoc 32:531-534, attempts to urinate. This increased frequency may be mistaken
1996. for tenesmus by the client. Frequent licking at the genital area
6. Bilbrey S, Birchard SJ, Smeak DD: Scrotal urethrostomy: a retro- and occasional hematuria may also be present. With progression
spective review of 38 dogs (1973-1988). J Am Anim Hosp Assoc 27:560- of the condition, the cat may become depressed, listless, or
564, 1991. comatose. Prolonged obstruction results in hyperkalemia, which
can lead to cardiac irregularities and subsequent death.
Perineal Urethrostomy
in the Cat Medical Treatment
The first step in emergency treatment of urethral obstruction
M. Joseph Bojrab and is to relieve obstruction. This can be done by catheterization
of the urethra, which in the severely depressed or comatose
Gheorghe M. Constantinescu
patient can be accomplished without the use of anesthetics.
If attempts to dislodge the obstruction are likely to result in
Feline urologic syndrome (FUS), a synonym for lower urinary tract
additional urethral damage or to induce urinary tract infection,
disease in the feline, can result from various single, multiple and
pharmacologic restraint should be considered. An ultrashort
interacting, or unrelated etiologic factors. Factors implicated in
acting anesthetic should be selected for sedation since the cat
the development of FUS are infectious agents such as viruses
may have metabolic abnormalities. Anesthetics must be given
and bacteria, diet, and urachal anomalies, especially bladder
cautiously, because effective doses in patients with postrenal
diverticula.
azotemia tend to be lower than in animals with normal renal
function.
Crystalluria is a common clinical finding in cats and is charac-
terized by microscopic precipitates in the urine. The most
To relieve the obstruction, concretions lodged in the distal penis
prevalent crystal type is struvite (magnesium ammonium
are first milked out by gently rolling the penis between the thumb
phosphate). In normal cats, these crystals are passed in the urine
and forefinger. Additionally, massaging the urethra through the
during normal micturition. Urine from cats with FUS contains
animal’s rectum may help to dislodge abdominal or pelvic urethral
crystals that coalesce with a matrix of mucus and debris, to form
concretions. Voiding is then induced by gentle urinary bladder
a macroscopic semisolid mass, or concretion. Crystal formation is
palpation. If urethral massage and bladder expression fail to
enhanced in an alkaline pH and is inhibited in a more acidic pH.
dislodge the obstruction, retrograde urethral flushing is attempted
to dislodge the concretion into the bladder by hydropropulsion.
Urethral obstruction has been associated with concretions and
urethral plugs. Other causes of urethral obstruction are stric-
The penis is exposed, washed, and a 3.5-French open-ended
tures, lesions of the prostate gland, and extraluminal masses
tomcat catheter, lubricated with a sterile gel, is placed into the
that compress the urethral lumen. Obstruction of the urethra by
distal urethra. Once the catheter has been placed, the prepuce
plugs occurs commonly in male cats but infrequently in females.
is grasped digitally and is retracted caudodorsally, so the urethra
Urethra 495
Antibiotics are given for 30 days; three different drugs are used
for 10 days each. The cat’s diet is changed to Prescription Diet
Feline Multicare (Hills Packing Company, Topeka, KS). This diet is
low in magnesium and tends to acidify the urine, thus decreasing
crystal formation. The food should be salted to increase fluid
intake and to promote diuresis, to flush out urinary bacteria and
precipitates. Instead of salting the food, the owner may admin-
ister a 1-g salt tablet orally once a day. If obstruction recurs,
perineal urethrostomy is indicated.
Figure 31-9. After the perineal area is draped and a urinary catheter is
placed, an elliptic incision is made around the scrotum and prepuce.
Perineal Urethrostomy
Preoperative Considerations
Cats who have had urinary tract obstruction are poor anesthetic
risks. Diuresis after unblocking is indicated. Induction of
anesthesia with an ultrashort-acting anesthetic agent followed
by maintenance with a gas anesthetic is recommended.
Surgical Technique
The animal is prepared for aseptic surgery. The hair is clipped
from the entire perineal area including the base of the tail. A
pursestring suture is placed in the anus, and a 3.5-French open-
ended tomcat catheter is placed. The animal is positioned on the
surgery table in ventral recumbency with the hind legs draped
over the end of a titled table. The tail is taped over the dorsal
midline of the back, and the genital area is draped.
After both sides of the skin incision have been sutured, the penis
is cut off with scissors (Figure 31-16A) at the level of the caudal
urethral incision. The cut end (Figure 31-16B) is sutured as shown
in Figure 31-17. This helps to seal the cut end of the corpus caver-
nosum penis and eliminates much of the excessive postoperative
hemorrhage often encountered with this surgical procedure.
The final sutures are placed approximating the caudal skin
edges (Figure 31-18). The wide end of the tomcat catheter is cut
(approximately 2.5 cm), inserted into the new urethral opening,
and sutured to the skin on each side (See Figure 31-18).
Postoperative Care
The pursestring suture in the anus is removed. An Elizabethan
collar is placed on the cat to prevent licking of the incision.
The same medical therapy as outlined previously is begun. The
catheter is removed on the fifth postoperative day. The sutures
and Elizabethan collar are removed on the tenth postoperative day.
Complications
The major complications of perineal urethrostomy are postop-
erative hemorrhage, subcutaneous urine leakage, infections,
Figure 31-15. A. The first suture approximates the dorsal skin edges; then the first urethral suture is placed, engaging both skin edges and the
pelvic urethral roof. B. Urethral suturing continues down the skin incision on each side.
498 Soft Tissue
Figure 31-16. A. Excess penis is cut off with scissors at the level of the caudal incision. B. The cut end of the penis is shown, revealing the corpus
cavernosum penis.
Figure 31-17. The exposed cut surface of the corpus cavernosum penis Figure 31-18. After suturing of the incision is completed, a 2.5-cm seg-
is sutured. ment of catheter is sutured into the urethrostomy opening.
Urethra 499
strictures, fecal and urinary incontinence, and rectal prolapse. level. In contrast with the more common but increasingly contro-
Hemorrhage can be greatly reduced by taking care to include versial indications for perineal urethrostomy (PU), the indica-
the cavernous tissue in the skin sutures. Infections can be tions for PPU are more easily recognized despite being less
decreased by eliminating postoperative contamination of the frequently indicated. Conditions in which distal urethral function
incision with litter and licking and by use of prophylactic antibi- is lost include salvage of perineal urethrostomy (PU) compli-
otics. Strictures can be prevented by adequate freeing of the cations, management of cats with perineal skin deficits that
urethra, to eliminate inpulling and suture line tension. preclude PU, complex urethral ruptures and strictures, granu-
lomatous urethritis and neoplastic disease. Paradoxically, PPU
requires considerably less surgical expertise and experience
Urethroplasty for Stricture After than PU and is easier to perform and this occasionally leads to
Perineal Urethrostomy its inappropriate substitution for PU.
Cats with urethrostomy stenosis present with stranguria
producing only scanty urine and a palpably full bladder. If the The potential risks and complications of PPU are probably less
stricture is due to improper dissection in the original surgical frequently encountered than those associated with PU, however,
procedure (i.e., failure to transect ligaments and muscle attach- the procedure should only be performed when all medical strat-
ments and free the urethra) or to failure to open the urethra egies have been exhausted and where PU is not considered to
properly, then the operation should be redone. If the original be a feasible option.
urethrostomy was done properly and a stricture subsequently
occurred, a urethroplasty is performed. Preoperative Preparation
The more common indications for this procedure may be
The area around the stricture is clipped and prepared for surgery.
associated with some risk of urinary tract infection or bacte-
The opening is located. The surgeon should use a 10X loupe to
ruria and hence perioperative antibiotic therapy based on urine
aid in visualization during surgery. A procedure similar to that for
culture from a sample obained by cystocentesis is usually appro-
anal stricture (See Chapter 20) is used. Four cuts (dorsal, ventral,
priate. An opioid analgesic that can be continued into the postop-
left lateral, and right lateral) are made with a No. 15 scalpel.
erative period (e.g. buprenorphine) should be administered,
Each cut incises the skin and underlying urethral mucosa. As
and if renal function is normal, non-steroidal anti-inflammatory
each cut is made, the incisions open and form a diamond shape.
therapy may be appropriate to provide additional analgesia.
The incisions are then sutured with 5-0 polydioxanone in the
The patient should be positioned in dorsal recumbency and the
opposite direction in a manner similar to that shown in Figures
ventral abdomen including the pubic region should be asepti-
20-41 through 20-45. This technique alleviates the stricture.
cally prepared for surgery. Urethral catheterization is helpful but
often not possible due to the obstructing indication; the absence
Prepubic Urethrostomy in of a urethral catheter should not unduly hinder the procedure.
Figure 31-19. Isolation of bladder neck/prepubic urethra via posterior Figure 31-22. Urethral stoma created by suturing to surrounding skin.
laparotomy.
Postoperative Care
Patients normally benefit from receiving opioid analgesia for 48
hours and should be prevented from self-trauma by means of
an Elizabethan collar. Litter trays with shredded paper instead of
litter are provided to minimize the potential for debris adhering
to the stoma site. Depending on the original indication for the
procedure, it may be necessary to initiate management of under-
lying pre-existing lower urinary tract disease. Patients will need
to modify their squatting posture for urination somewhat and the
interval until this is successfully accomplished will vary between
individuals. In the intervening period, any urine-staining or
scalding of the skin in the inguinal region should be carefully
managed to prevent secondary pyoderma complicating the
healing of the urethral stoma. Urinary retention due to discomfort
and pre-existing lower urinary tract disease should be managed
with analgesia, striated muscle relaxants (e.g. diazepam) or
smooth muscle relaxants (e.g. phenoxybenzamine); repeated
catheterization of the urethra is avoided if possible.
Figure 31-20. Elevation of bladder neck / prepubic urethra with umbilical
tape.
Complications
Healing of the stoma is usually uncomplicated but, as with any
urethrostomy procedure site, leakage of urine into the subcu-
taneous tissues surrounding the stoma before an effective seal
has formed may lead to peristomal skin irritation and in severe
cases, incisional dehiscence postoperatively. More chronic urine
leakage can promote low-grade periurethral cellulitis which can
lead to stenosis and stricture of the stoma; revision of stenosis
may be complex. Stricture of the stoma occasionally occurs but
the overall incidence is low. Occasionally, peristomal cellulitis
can spontaneously occur in long-term PPU patients although
the etiology for this is uncertain. Temporary urinary diversion
by urethral catheterization or in some cases by tube cystostomy
allows the cellulitis to resolve and patients will resume normal
continent urination. Cutaneous urine scalding can be a transient
problem in cats that do not modify their urination stance.
Cranial transplantation of the prepuce with the stoma located
inside or subpubic urethrostomy have been recommended to
avoid this complication. These are more complex procedures
Figure 31-21. Repair of linea alba allowing exteriorization of urethra. and not usually necessary. Transient urinary incontinence may
Urethra 501
occur in some cats in the immediate postoperative period but pelvic surgery. Absence of skeletal injury does not preclude
2,3
usually resolves as the stoma heals. Some cats with pre-existing urethral damage. Traumatic urethral injury usually occurs in
lower urinary tract disease may continue to be dysuric postop- male dogs because the postprostatic pelvic urethra is fixed at
eratively which can be mistaken for incontinence; appropriate the greater ischiatic notch. The incidence of urethral injury after
management of lower urinary tract disease should be initiated. car accidents is reported to vary from less than 5% to 11%.4
Conclusion Diagnosis
PPU is an acceptable surgical procedure for the management of Urethral injury is suspected when dysuria or anuria is observed.
cats where distal urethral function has been lost. The procedure Hemorrhage from the urethral opening or hematuria, usually at
is comparatively easy to perform and does not necessitate the first portion of the urine stream, may be noted soon after
complex or prolonged postoperative care. Cats remain continent injury. Urethral trauma is not excluded on the basis of an animal’s
and most accommodate quickly to the change in posture ability to void urine, however. Animals with urethral rupture may
necessary for urination without inguinal skin scalding. They will be depressed and anorexic, and penile urethral urine leakage
continue to lead a normal life. PPU should however be regarded may cause pyrexia and perineal or inguinal bruising and swelling.
as a salvage procedure and not substituted where medical Uremia may or may not be present. A distended urinary bladder
management or PU would be a more appropriate operation. may be palpable. Proximal urethral lacerations or rupture may
result in uroperitoneum, and clinical signs mimic those of a
Editor’s Note: Urinary incontinence may occur postoperatively in ruptured urinary bladder. Urine leakage may he detected from
cats that have had PPU. open wounds in the region of the pelvic cavity. If urine leakage
is chronic a cutaneous urine fistula may result.4 Suspicion of
urethral injury should be evaluated initially by positive-contrast
Suggested Readings urethrography using a water-soluble organic iodide preparation.
McCully RM: Antepubic urethrostomy for the relief of recurrent urethral Injection of air is avoided because it is difficult to delineate the
obstruction in the male cat. JAm Vet Med Assoc 126: 173-179, 1955. site of urethral injury after air dissects periurethrally, and also
Ford DC: Antepubic urethrostomy in the male cat. JAm Anim Hosp because the use of air as the distending gas can result in fatal
Assoc 4: 145-149, 1968. air embolism.5 Extravasation of contrast material occurs with
Mendham JH: A description and evaluation of antepubic urethrostomy both urethral laceration and urethral rupture, but in the latter
in the male cat. J small Anim Pract 11: 709-721, 1970. instance, contrast material usually does not pass proximal to the
Snow HN: Surgical transpositions of the feline urethra necessary to complete tear. Cystoscopic examination may be used for evalu-
ameliorate urolithiasis. J small Anim Pract 13: 193-200, 1972. ation of the lower urinary tract.6 Animals with proximal urethral
Emms SG: Antepubic urethrostomy in a cat. Aust Vet J64: 384-385, trauma should also be evaluated by intravenous pyelography
1987.McLaren IG: Prepubic urethrostomy involving transposition of the because concomitant ureteral injury may be present.
prepuce in the cat. Vet Rec 122: 363, 1988.
Bradley RL: Prepubic urethrostomy: An acceptable urinary diversion
technique. Prob Vet Med 1: 122-127, 1989. Surgical Techniques
Menrath V: Repair of a mid-pelvic urethral rupture in the cat using Management of urethral injuries depends on the type of injury
antepubic urethrostomy. Feline Pract 121: 8 ó 11, 1993. sustained and on the overall health of the animal. Uroperi-
Mahler S, Guillo JY: Antepubic urethrostomy in three cats and a dog: toneum and its systemic metabolic effects must be resolved
Surgical technique and long-term results. Rev de Med Vet 150: 357-362, before lengthy surgical intervention. If uroperitoneum is present,
1999. its effects are resolved by urine diversion and intravenous fluid
Baines SJ, Rennie S and White, RAS: Prepubic Urethrostomy: A therapy to alleviate dehydration, acidemia, and hyperkalemia.
long-term study in 16 cats. Vet Surg 30: 107-113, 2001. Gentle catheterization of the urethra may be accomplished,
Ellison GW, Lewis DD and Boren FC: Subpubic urethrostomy to salvage depending on the site of the urethral laceration, but often the
a failed perineal urethrostomy in a cat. Comp Cont Ed 11: 946-951, 1989. catheter tip finds the urethral defect and cannot be passed
successfully. Urine can be diverted by percutaneous placement
of a prepubic drainage catheter (Stamey catheter) or by insertion
Management of of a cystostomy tube (Foley or Pezzar catheter). Both techniques
Urethral Trauma require sedation and (narcoleptic) local anesthesia unless the
animal is moribund. Abdominal drainage may be necessary if
Jamie R. Bellah more proximal urinary tract injury does not allow urine diversion
by the aforementioned techniques.
Introduction Definitive surgical treatment of urethral injuries requires careful
Blunt abdominal trauma and traumatic displacement of bone preparation because often the site of injury is difficult to access
fragments, especially pubic fragments, can lacerate the (postprostatic rupture). Lacerations may be managed solely by
membranous urethra.1 Urethral injuries from other sources are urethral stenting if a catheter can be successfully manipulated
less common but include gunshots, bite wounds, and iatrogenic into the urinary bladder, and it may need to remain in place for
trauma. The pelvic urethra may also be entrapped between 7 to 10 days. Conservative treatment of urethral injury requires
pelvic fragments or mechanically compressed after elective that longitudinal mucosal continuity across the region of urethral
502 Soft Tissue
trauma be present for successful urothelial repair. Despite the Postoperative Care
ability of urothelium to migrate, larger urethral defects require
Postoperative management of patients with urethral trauma and
stenting for as long as three weeks for complete repair.7 Surgical
obstruction is intensive. Management of pain is often required
correction of urethral rupture often requires pubic osteotomy to
for 12 to 24 hours. Animals must be restrained from prematurely
expose the severed urethra adequately. Sufficient exposure so
removing urethral stents and cystostomy tubes. Restraint must be
debridement and precise anatomic anastomosis are feasible
adequate, and may require Elizabethan collars, side braces, wire
cannot be overly stressed.7 After debridement, simple inter-
muzzles, and in some instances tranquilization. Prolonged cathe-
rupted sutures of absorbable material are used to perform the
terization (4 days or longer) often results in urinary tract infection,
anastomosis over a urethral stent (catheter), with the knots
and periodic culture and susceptibility screening are important
outside the lumen of the urethra (Figure 31-23). The urethral
to avert a serious ascending infection. Proper use and care of
mucosa must be anatomically apposed (without tension) or
closed urine drainage systems are mandatory. When urethral
granulation tissue will be produced and contract the anasto-
stents are removed, urine culture and susceptibility testing are
mosis, resulting in stricture despite the presence of a stent. Use
done and antimicrobial therapy is based on those results.
of a catheter stent in addition to accurate suturing is believed
to help prevent urethral stricture, however, overstretching the
Urethral stents (catheters) may be pulled when urothelium has
urethra may enhance fibrous tissue formation.8 Monofilament
bridged the urethral defect, as early as 5 days after repair. Careful
absorbable suture material such as polydioxanone (PDS), polyg-
injection of contrast material at low pressure is performed when
lyconate (Maxon), and poliglecaprone (Monocryl) are appro-
contrast urethrograms are repeated, so the urethral wound is
priate for urethral anastomosis. Interrupted appositional sutures
not disrupted. Difficult anastomoses, when repair is tenuous (or
are recommended and continuous patterns are avoided as the
unsutured defects), may require urethral stenting for as long as
latter tends to “purse-string” the urethral lumen. Fine nonab-
14 to 21 days.
sorbable monofilament sutures such as nylon and polypropylene
may be used for urethral apposition, but because the sutures
The most common complication of urethral trauma repair is
remain long after tissue healing is complete, they are not
stricture. Stricture may occur early, resulting from dehiscence
desirable.9 Urine diversion may be accomplished by placing a
of the anastomosis, or a technically poor repair (tension or
cystostomy tube (if necessary), and the urethral stent (catheter)
inadequate mucosal apposition), with a fibrous scar that may
remains to support the anastomosis and to divert urine away
partially or completely occlude the urethral lumen. Stricture may
from the urethral wound to promote normal wound healing. The
also occur months after surgery or conservative management
urethral stent should be large enough to maintain lumen size,
if contraction of periurethral scar tissue results in stenosis of
but it should not be so large that it causes excessive pressure or
the urethral lumen. Correction of urethral stricture may require
tension on the anastomosis. If a large segment of pelvic urethra
resection and anastomosis or a urinary diversion procedure,
must be debrided, a permanent urine diversion procedure may
however balloon dilatation of a urethral stricture in a dog has
be required. Antepubic urethrostomy or extrapelvic urethral
been reported. Strictures involving the more distal aspects of the
anastomosis may be performed in those cases.
urethra may be resolved by performing scrotal urethrostomy.
References
1. Bellah JR. Problems of the urethra. Probl Vet Med 1989:1;17.
2. Remedios AM, Fries CL: Implant complications in 20 triple pelvic
osteotomies. Vet Comp Orthop Traumatol 6:202,1993.
3. Messmer M, Rytz U, Spreng D. Urethral entrapment following pelvic
fracture fixation in a dog. J Small Anim Pract. 2001;42(7):341-4.
4. Bjorling DE. Urethral trauma. Slatter’s Textbook of Small Animal
Surgery, 3rd Edition. WB Saunders Co, Philadelphia. 2003:1647-1651.
5. Ackerman N, et al: Fatal air embolism associated with pneumoure-
thrography and pneumocystograpy in a dog. J Am Vet Med Assoc
176:1616, 1972.
6. Messer JS, Chew DJ, McLoughlin MA. Cystocopy: Techniques and
clinical applications. Clin Tech Small Anim Pract 2005;20:52-64.
7. Boothe HW. Managing traumatic urethral injuries. Clin Tech Small
Anim Pract. 2000;15(1):35-39.
8. Layton CE, Gerguson HR, Cook JE, Guffy MM. Intrapelvic urethral
anastomosis – a comparison of three techniques. Vet Surg 1987;16:175-
182.
9. Jens B, Bjorling DE. Suture selection of lower urinary tract surgery in
Figure 31-23. Anastomosis of the urethra requires accurate apposition small animals. Comp Cont Educ Small/Exotics 2001;23:524-528.
of the urethral mucosa. Failure to do so results in stricture and dysuria.
Urethra 503
Resection
A sterile catheter is placed in the urethra. An incision is made 90
to 180° at the base of the prolapsed tissue, resulting in a clean
A incision in healthy mucosa of urethra internally, and glans penis
externally, using the catheter for support. The mucosal edges
are apposed with 4-0 or 5-0 absorbable monofilament suture,
preferably with a taper-point needle, in a simple interrupted
pattern, spaced 1-2 mm apart. Absorbable braided suture (e.g..
Polyglactin 910) is also acceptable, but results in more tissue
drag, and requires more throws for knot security, adding bulk to
the repair. Care must be taken to achieve adequate bites of the
B urethral mucosa, and good mucosal apposition. This results in
less second-intention healing and hemorrhage. Once apposed,
the incision is completed around the orifice, and the process
repeated. Proceeding as above, in stages, minimizes retraction
of urethral mucosa, enabling better visualization and apposition.
Postoperative Care
The urinary catheter is removed following correction. Recovery
should employ the use of sedatives and pain medication as
C judged necessary to ensure a quiet and smooth emergence from
anesthesia. An Elizabethan collar should be worn at all times by
the patient for a minimum of 10 days following the procedure,
to prevent self-trauma. Exercise is limited to leash-controlled
walks for 10 to 14 days. The prepuce should be monitored daily
for irritation and swelling. It is normal for minor bleeding to be
observed, intermittently and during urination, for 3 to 5 days post-
operatively. Mild straining is also occasionally observed, but the
urine stream should be consistent and adequate at all times
following surgery. Underlying urinary tract disease or infection
should be treated appropriately. Patients may be discharged with
D standard post-operative pain medication for elective soft-tissue
procedures (NSAIDS). On an individual basis, short term (5 to 10
days) oral sedation with acepromazine is beneficial, and even
advisable. Prognosis is good. We recommend the urethropexy
technique as the easiest and most effective technique.6
References
1. Hobson HP, Heller RH: Surgical correction of prolapse in the male
E
urethra. Vet Med/ Small Anim Clin 1971;66:1177.
2. Sinibaldi KR, Greene RW. Surgical correction of prolapse of the male
urethra in three English Bulldogs. J Am Anim Hosp Assoc 1973;9:450.
Figure 31-25. Urethropexy technique for treatment of urethral pro- 3. Fossum TW, Hedlund CS. Surgery of the urinary bladder and urethra.
lapse in the dog. A. Prolapsed mucosa visible at distal tip of penis, In: Fossum TW, ed. Small Animal Surgery. St. Louis: Mosby-Year Book
B. introduction of grooved director into urethral lumen to reduce Inc., 1997:503-505.
prolapsed mucosa, C. first suture pass is external-to-internal, exit- 4. Boothe HW. Penis, prepuce, and scrotum. In: Slatter D, ed. Textbook
ing urethral orifice, D. second suture pass from internal to external, of Small Animal Surgery. Philadelphia: Saunders, 1993:1336-1348.
exiting just distal to initial suture entry point, E. resulting full thick- 5. Lowe FC, Hill GS, Jeffs RD, Brendler CR. Urethral prolapse in children:
ness suture is tied snugly. Process is repeated until reduction is Insights into etiology and management. J Urol 1986; 135:100.
maintained. All diagrams represent patient in dorsal recumbency.
6. Kirsch JA, Hauptman JG, Walshaw R. A urethropexy technique for
surgical treatment of urethral prolapse in the male dog.. J Am Anim
Hosp Assoc 2002; 38 (4): 381-4.
Prostate 505
Surgical Techniques
Excisional Prostatectomy
Excisional prostatectomy is used to treat cancer. This treatment
is usually palliative, but it can be effective in extending the
patient’s normal life for several months because transitional and
prostatic carcinomas usually grow slowly. Another treatment
option for proximal urethral cancer is excision of the lower
urinary tract and implantation of the ureters into the colon. This
produces ascending renal infections. Dogs with neoplastic
urethral obstruction can be successfully managed for months
by a cystostomy tube. Neither medical therapy nor radiation
treatment provides significant benefits in patients with prostatic
cancer. Urethral stents can provide temporary relief of urethral
obstruction. Prostatectomy also can successfully cure prostatic
abscesses and cysts, but the high rate of incontinence makes Figure 32-1. Incisional biopsies are performed through a ventral midline
this procedure less desirable than partial prostatectomy or laparotomy. Multiple biopsy specimens should be obtained, with each
peritoneal omentalization. sample at least I cm wide and 2 cm deep. After each biopsy specimen
is taken, interrupted cruciate sutures are placed at least 5 mm from the
Incisional biopsies are done by cutting deeply into the prostatic biopsy margins. Hemostasis is achieved as the sutures are tightened.
gland and then placing deep mattress sutures into the capsule
to produce hemostasis (Figure 32-1). The prostate is approached are left in place for 1 week, and urine is collected by a closed
by a midline laparotomy (Figure 32-2A). The periprostatic fat is system. The balloon of the cystostomy catheter is deflated, and
incised on the ventral midline and is reflected laterally (Figure the catheter is withdrawn 1 week after the surgical procedure.
32-2B). An excisional prostatectomy requires dorsal dissection. The urethral catheter is left in place for another day and then is
Before prostatic surgery, a temporary tourniquet is placed about withdrawn.
the distal aorta, just cranial to its bifurcation into the external
iliac arteries. After placement of a urethral catheter, a retraction Partial Prostatectomy
suture is placed around the urethra caudal to the prostate. Caudal
Partial prostatectomy is my preferred procedure for treatment
dissection is facilitated by cranial incision of the ventral ligament
of patients with prostatic cysts and abscesses, but it is contrain-
of the penis. The prostate is rotated to ligate vessels close to the
dicated for cancer. The use of the ultrasonic surgical aspirator
prostatic capsule and to ligate the vas deferens. The surgeon
permits removal of up to 85% of the prostatic glandular tissue
attempts to preserve the caudal vesical artery bilaterally and
in addition to all cysts and abscesses. Because the remaining
to preserve much of the urethra, both on the side of the neck
prostatic tissue is dorsal and close to the urethra, most of the
and distally. Prostate tissue or fluid should be cultured. Multiple
urethral innervation and muscles appear to be left intact. Incon-
biopsy specimens are taken from the prostate and sublumbar
tinence is much less frequent and severe after partial prostate-
lymph nodes. Neoplastic tissue must be excised, and this can
ctomy of dogs with severe cavitary disease than before the
require extensive urethral resection. Margins, especially of
surgical procedure or after ex-cisional prostatectomy. As with
the urehra, are sampled in order to stage the cancer spread.
excisional prostatectomy, castration should be performed.
Retraction sutures in the urethra caudal to the prostate can
reduce traction problems. The urethra is transected cranial
The prostate is approached in the same fashion as previously
(Figure 32-2C) and caudal to the prostate (Figure 32-2D). The
described, except dorsal and lateral dissections are avoided
prostate is removed, and the urethral catheter is redirected into
or at least limited. After obtaining biopsy specimens and after
the bladder. The urethra is anastomosed with interrupted sutures
placing the aortic tourniquet and retraction suture about the
using an absorbable monofilament synthetic suture material,
urethra caudal to the prostate, the surgeon incises poles of
usually of 4-0 or 5-0 size (Figure 32-2E). Some urethras are thick
the prostate ventrally with electrocautery (Figure 32-3A). The
enough that a second layer of sutures can be placed in muscle
Cavi-tron Ultrasonic Surgical Aspirator (CUSA System 200
tissue. A cystostomy catheter is placed in addition to the urethral
Macro-Dissector, Valleylab, Inc., Pfizer Hospital Products
catheter to ensure that urine is diverted and that little tension
Group, Boulder, CO) is used to fragment, irrigate, emulsify, and
is placed on the anastomosis (Figure 32-2F). Both catheters
Prostate 507
Figure 32-2. A. A ventral midline laparotomy is performed to approach the prostate for an excisional prostatectomy. Most prostate glands can be
adequately exposed if the incision is extended caudally to the brim of the pubis. B. The periprostatic fat is incised on the midline and is reflected
from the ventral and lateral surfaces. Hemostasis is improved if a tourniquet is placed about the aorta just cranial to its bifurcation. The vasa def-
erentia are ligated and divided, as are the prostatic vessels. Care must be taken to preserve the caudal vesical artery on both sides. Dissection
should be close to the capsule, especially dorsal, cranial, and caudal to the prostate. A traction suture placed around the urethra, caudal to the
prostate, and incision of the ventral ligament of the penis aid prostatic exposure. C. The urethra is transected cranial to the prostate. If excisional
prostatectomy is done for cancer, the resection may need to be wider to ensure tumor-free margins. D. The urethra is transected caudal to the
prostate. After the prostate is removed, the urethral catheter is replaced in the bladder. E. The urethral anastomosis is made with interrupted
sutures of 4-0 or 5-0 absorbable synthetic monofilament material. The sutures are placed through all layers of the urethra, but additional sutures
may be placed in a second pattern in some urethras. F. In addition to the urethral catheter, a cystostomy catheter is placed into the ventral region
of the bladder. A double pursestring is used to secure the catheter.
508 Soft Tissue
aspirate approximately 85% of the glandular tissue (Figure 32-3B Postoperative Care and Complications
and C). A catheter is placed within the urethra to identify and
Early potential complications can include shock potentially
avoid damaging it. Urethral fistulas are identified by inflating
leading to death, infection (sepsis), pain, and renal shutdown.
the urethra with fluid (Figure 32-3D). After glandular dissection
Fluid support should be continued at greater than mainte-
and excision of the ventral hemisphere on the ventral midline of
nance rates based on monitoring results of, initially, arterial
the capsule, omentum is placed over the urethra and the dorsal
blood pressure and, later, volume of diuresis. If shock develops,
prostatic capsule is suture around the omentum and urethra on
treatment must be aggressive. Urinary output is recorded, and the
the ventral side to form a cuff around the prosatic urethra.
bladder is evaluated frequently to ensure that it remains decom-
pressed. Urinary catheters are usually removed during the first
Figure 32-3. A. Ventral view of a partial prostatectomy. After lymph node biopsy and placement of an aortic tourniquet, a 14- to 18-French urethral
catheter is placed through a cystotomy, and a traction suture is placed about the urethral caudal to the prostate. Two parallel incisions are made
into the ventral prostatic capsule using electrocautery. B. Transverse view. The ultrasonic aspirator is used to resect glandular tissue. All identifi-
able cystic pockets are entered. C. Transverse view. The surgeon attempts to remove 85% of the glandular tissue, including all abscess pockets.
During ultrasonic aspiration, the urethral catheter and the dorsal capsule are frequently palpated and are avoided. D. Ventral view. The urethral
catheter tip is withdrawn into the prostatic urethra, and the urethra is inflated by injecting saline. Urethral openings are identified and closed by
suturing. E. Ventral view. Prostatic tissue between the paramedian incisions and ventral to the urethra and the excessive capsule are excised. The
capsule is closed with interrupted sutures. An indwelling urethral catheter is left to decompress the bladder during the early postoperative period.
From Vet Surg 1994;23:182-186.
Prostate 509
2 days after partial prostatectomy. For excisional prostatectomy, Mullen HS, Mathieson DT, Scavelli TD. Results of surgery and postop-
catheters are left for 1 week and require protection with side erative complications in 92 dogs treated for prostatic abscessation by a
braces or Elizabethan collars. Antibiotics are continued. Pain multiple Penrose drain technique. J Am Anim Hosp Assoc 1990;26:369-379.
medications are normally given at least during the initial 8 hours Rawlings CA, Crowell WA, Barsanti JA, et al. Intracapsular subtotal
after surgery. Intensive care monitoring is critical for several prostatectomy in normal dogs: use of an ultrasonic surgical aspirator. Vet
hours postoperatively. In addition to monitoring of urine output, Surg 1994;23:182-189.
temperature, pulse, and respiration, and attitude, complete Stone EA, Barsanti JA, eds. Urologic surgery of the dog and cat. Phila-
blood counts with platelet counts, blood urea nitrogen, albumin, delphia: Lea & Febiger, 1992.
glucose, and urinalysis should be performed. Liver enzymes are White RAS, Williams JM. Intracapsular prostatic omentalization: a new
also useful to detect signs of sepsis and septic shock. In dogs technique for managment of prostatic abscesses in dogs. Vet Surg
with signs of sepsis, decreasing albumin concentrations indicate 1995;24:390-395.
a need for plasma. Nutritional status should be documented by
measuring food intake and body weight daily. No deaths have
been reported in dogs treated by partial prostatectomy.
Use of Omentum in
Prostatic Drainage
Long-term complications of surgical treament in dogs with severe
prostatic disease include persistent infections and disease, as Richard A. S. White
well as incontinence. Dogs usually urinate normally after partial
prostatectomy, and fewer than 20% of dogs have even minor Causes of Prostatic Abscesses and Cysts
urinary control problems. After excisional prostatectomies, most
Abscessation of the prostate gland in dogs is considered to
dogs develop mild incontinence, and a few (approximately 10%)
result from an ascending bacterial infection that overcomes the
have continual dribbling of urine. Prostatectomy of normal dogs
normal urethral defense mechanisms and thereafter colonizes
produces no decrease in urinary control function and only minor
the prostatic parenchyma. A suppurative infection resulting
urodynamic changes, but the combination of prostatic disease
in parenchymal microabscesses is thought to develop subse-
and removal of the prostate increases incontinence. Some incon-
quently, but the precise mechanism by which these microab-
tinent dogs with low urethral pressures have been successfully
scesses coalesce into larger, loculated abscesses rather than
treated with phenylpropanolamine (1.5 mg/kg orally three times
remaining as diffuse prostatitis is unclear. The most commonly
daily), and those with detrusor instability have been treated with
recovered organism is Escherichia coli, with Staphylococcus
oxybutynin (2.5 mg orally three times daily). Recurrent prostatic
spp. and Proteus spp. occasionally encountered.
infections and disease should not occur when the prostate has
been excised. Dogs with partial prostatectomy have not had
Discrete cysts involving the prostate gland are a well-defined
recurrence during the first year after discharge from the hospital.
but uncommon manifestation of prostatic disease. Two distinct
Complications have been seen during hospitalization when a
categories of cyst have been previously described namely,
urethral to cyst fistula either persisted or recanalized. This fistula
paraprostatic and prostatic retention cysts. It now seems clear
can been repaired during an additional surgery. Since a small
that both types of cysts in fact share a common etiology and
amount of prostatic tissue is present and can be infected, at
are thought to develop as the result of obstruction of ducts
least two dogs have developed recurrent disease more than 1
within the parenchyma of the gland promoting the accumulatic
year after surgery. The potential for urinary tract infection is high
of prostatic secretions. Concurrent prostatic disease is always
in any dog following surgery for major prostatic disease. These
present, and this may include benign prostatic hyperplasia,
dogs must have regular urinalysis and cultures combined with
squamous metaplasia, abscessation, or neoplasia. Discrete
aggressive antibiotic therapy. Intense surveillance and treatment
cysts are capable of attaining considerable size and should be
should reduce problems with recurrent infections.
distinguished from the diffuse cystic changes that often occur
in combination with benign prostatic hyperplasia.
Acknowledgment
The illustrations by Dan Biesel and Kip Carter are appreciated. Clinical Signs and Diagnosis
Dogs with prostatic abscesses are pyrexic and have signs of
Suggested Readings caudal abdominal pain on rectal and transabdominal palpation of
Basinger RR, Rawlings CA. Surgical management of prostatic diseases. the prostate gland. The prostate gland is invariably enlarged and
Compend Contin Educ Small Anim Pract 1987,9:993-1000. may have a doughy feel when palpated. Many dogs have neutro-
Basinger RR, Rawlings CA, Barsanti JA, et al. Urodynamic alterations after philia (white blood count higher than 17 x 109/L), but this is not a
prostatectomy in dogs without clinical disease. Vet Surg 1987;6:405-410. consistent feature of the disease. Alkaline phosphatase concen-
Basinger RR, Rawlings CA, Barsanti JA, et al. Urodynamic alterations trations may be elevated in some patients. Radiography enables
associated with clinical prostatic diseases and prostatic surgery in 23 one to confirm the prostatic enlargement, but ultrasound imaging
dogs. J Am Anim Hosp Assoc 1989;25:385-392. is necessary to demonstrate the characteristic loculation within
Cowan LA, Barsanti JA, Crowell W, et al. Effects of castration on chronic the parenchyma that contains the slightly echodense purulent
bacterial prostatitis in dogs. J Am Vet Med Assoc 1991,199:346-350. fluid. Fine-needle aspiration may be used to recover purulent
Hardie EM, Barsanti JA, Rawlings CA. Complications of prostatic surgery. material, but it should be performed with care to avoid the risk of
J Am Anim Hosp Assoc 1982;20:50-56. peritonitis after this procedure.
510 Soft Tissue
Prostatic retention cysts are encountered mostly in large reinforcement of gastrointestinal or urogenital repairs, and
breed dogs, especially boxers. Signs of urinary dysfunction, resolution of chronic wounds. The omentum is able to resolve
including stranguria, dysuria, hematuria, and incontinence, are bacterial contamination from perforated viscera and even can
invariably seen. Palpation identifies a caudal abdominal mass. A function in the presence of infection. The omentum can be used
presumptive diagnosis of prostatic cyst can be made by evalu- as a “physiologic drain” to resolve lesions of the prostatic paren-
ation of survey abdominal radiographs and ultrasound exami- chyma such as abscesses or to provide continued drainage of
nation of the prostate in all dogs. Mineralization of the cyst wall ongoing secretions from residual cystic tissue without merely
is evident in some dogs. Biopsy may be indicated because some walling them off from the abdominal cavity. Additionally, the
retention cysts accompany prostatic neoplasia, but fine-needle omentum creates adhesions at the operative site, thereby
aspiration should again be performed with care. minimizing the risk of visceral adhesion.
Figure 32-5. Bilateral stab incisions are made into the abscess to permit Figure 32-7. Schematic illustration of a prostatic retention cyst in trans-
drainage and digital disruption of the loculations within the cavities. verse section. The cyst wall develops as a dilatation of the prostatic
The stab incisions are then enlarged by resection of the capsular tissue parenchyma caused by the accumulation of secretions within the
to permit the introduction of a leaf of omentum into the dorsal abscess gland. From Vet Surg 1997;26:202-207.
cavity by means of forceps positioned through the contralateral capsu-
lectomy wound. From Vet Surg 1995;24:390-395.
Figure 32-8. The cyst is drained by a single stab incision into the lumen.
Suction is used to minimize spillage of cyst contents into the abdomi-
Figure 32-6. The leaf of omentum is then returned through the ventral nal cavity. From Vet Surg 1997;26:202-207.
cavity of the abscess to complete the periurethral packing. The omen-
tum is anchored to itself by means of horizontal mattress sutures using
absorbable material. From Vet Surg 1995; 24:390-395.
relatively small blood volume of pediatric patients makes metic- on large puppies) absorbable (polydioxanone, polyglyconate, or
ulous hemostasis very important. Fortunately, the small size polyglactin 910) suture. The subcuticular layer may be closed
of blood vessels and the presence of minimal abdominal and with an absorbable suture material (3-0 to 4-0, poliglecaprone
ovarian bursal fat allow for excellent visualization of the vascu- 25 preferred) in a continuous intradermal pattern to avoid the
lature, and makes precise hemostasis simple to achieve. use of skin sutures. Alternatively, skin sutures may be loosely
placed following closure of the subcutaneous tissues. Although
Pediatric ovariohysterectomy may be performed similarly to adult some veterinarians avoid using skin sutures in pediatric patients
ovariohysterectomy with some slight modifications.3,5,6 Incisions to prevent premature removal by the patient, we routinely use
in puppies are started more caudal to the umbilicus than in adult loosely placed skin sutures without complication or premature
dogs. Generally, the uterus is more easily exposed in puppies if removal.
the incision is started at least 2 to 3 cm caudal to the umbilicus.
This results in the incision positioned at, or near, the middle To prevent unnecessary abdominal exploratory surgery in the
third of the distance from the umbilicus to the cranial brim of the future, all animals undergoing early age ovariohysterectomy
pelvis, similar to an incision made for the adult cat. In kittens, the should be tattooed to identify their neutered status. The recom-
incision is placed in a similar location as in the adult cat. Upon mended tattoo site is the prepubic area in females. The female
entrance into the abdomen, it is common to encounter substantial gender symbol along with an encircled “X” is used to denote the
amounts of serous fluid in both puppies and kittens. It may be neutered status. Tattooing may be performed after the surgical
necessary to remove some of the fluid using gauze sponges to site has been clipped but prior to the surgical prep of the area.
improve visualization. In contrast to adult dogs and cats, it is
recommended that the use of a Snook ovariohysterectomy hook
be avoided in pediatric patients due to the delicate nature of the
Postoperative Care
uterine tissues. Because of incision location in both puppies and Postoperatively, pediatric patients should be monitored for
kittens, the uterus is easy to locate by retracting the bladder hypoglycemia, hypothermia, pain, or dysphoria. Supplemental
laterally and looking between the urinary bladder and colon. If heat, glucose containing agents, or additional analgesics
necessary, and if incision length will allow, the urinary bladder or sedatives may be used to ensure smooth recovery from
may be elevated from the abdomen and reflected caudally to anesthesia. These patients may be fed a small meal one to two
permit easier visualization of the uterus. If this technique is used, hours after recovery since they tend to recover much more
once the uterus has been identified and secured, the bladder quickly from anesthesia and surgery than adults. Unlike tradi-
should be returned to the abdomen so as to preserve body heat. tional age patients undergoing ovariohysterectomy, pediatric
Uterine tissues are extremely small and friable in young puppies puppies and kittens are typically hungry at this time and are
and kittens, therefore care must be taken to avoid excess traction often ready to eat and resume normal activity.
and tearing of tissues. After the uterus has been located, the
suspensory ligament may be carefully broken down to improve Postoperative Complications
exposure and visualization of the ovary. A window is made Although the anesthetic and surgical procedures for early-age
through the broad ligament adjacent to the ovarian vasculature. gonadectomy have generally been reported as safe, veterinarians
A hemostatic clamp is then placed just proximal (medial) to the have been concerned about long-term health risks. Veterinarians
ovary across the ovarian vessels using a mosquito hemostat on have questioned whether the immune system of puppies and
kittens and small puppies and a Kelly, Crile, or Carmalt forceps kittens would be adversely affected by the stress of anesthesia
on larger puppies. Although the triple clamp method may be and surgery at early ages and during a time when animals are
used in pediatric OHE, it is often cumbersome and difficult to being immunized against potentially fatal infectious diseases.
place multiple clamps proximal to the ovary without tearing Veterinarians have also been concerned about the risk of urinary
tissues. The ovarian vessels are doubly ligated using 3-0 to 4-0 incontinence and neoplasia in female dogs, abnormal long bone
absorbable suture material or stainless-steel hemostatic clips. A growth patterns, and obesity in dogs and cats neutered at an early
single ligature may be sufficient to prevent hemorrhaging in very age. Since the 1990’s, several studies have been published that
small pedicles, and transfixation ligatures are usually avoided. critically evaluate these concerns among dogs and cats altered
After ligation and transection of the ovarian vessels on both at different ages prior to, and following, puberty. These studies,
sides, the remaining broad ligament should be broken down (if as well as more recent studies, have begun to clarify the long
it has not already torn) and the uterine pedicle ligated at the term health risks and benefits of early age ovariohysterectomy as
junction of the uterine body and cervix with two fully encom- compared to traditional age gonadectomy.
passing uterine body ligatures or hemostatic clips. After the
reproductive tract has been removed, it should be examined to
ensure complete removal (of ovaries and uterine body), and the Infectious Diseases and Long-Term
abdomen should be examined for evidence of hemorrhage. As Immune Suppression
abdominal wall closure is performed, it is important to carefully
identify the ventral fascia (external rectus sheath) and differen- In some short-term studies conducted at animal shelters,
tiate it from the overlying subcutaneous tissues since they can puppies and kittens neutered at early ages had no higher risk of
occasionally be difficult to tell apart (particularly in puppies). The infectious diseases than older animals. One study involved dogs
ventral fascia can be closed using either a simple continuous and cats from two animal shelters undergoing gonadectomy
or simple interrupted suture pattern using 3-0 (or possibly 2-0 surgeries in association with the fourth-year student surgical
514 Soft Tissue
teaching program of a university teaching hospital.5 Twelve of and 269 dogs8 examining outcome of gonadectomy performed at
1988 (0.6%) animals died or were euthanized because of severe an early age or traditional age, no differences in the incidence of
infections of the respiratory tract or as the result of parvovirus musculoskeletal problems were seen between groups. Further,
infection during the 7-day postoperative period, and the deaths in the long term studies of 1660 cats9 and 1842 dogs,2 age at
(or euthanasias) included similar numbers of animals from all gonadectomy was not associated with the frequency of long
age groups. bone fractures. In all these studies, long bone fractures were
rare overall, suggesting that physeal fractures are not a common
In long term studies of 263 cats7 (36 month median follow up) problem in gonadectomized dogs and cats in general.
and 269 dogs8 (48 month median follow up), prepubertal gonad-
ectomy did not result in an increased incidence of infectious Long-term studies have examined the incidence of hip dysplasia
diseases after adoption in cats, compared with traditional age in dogs and the association with age at gonadectomy. Although
gonadectomy. In dogs, however, gonadectomy before 5.5 months one study of 269 dogs8 found no association between age at
of age was associated with increased incidence of parvoviral gonadectomy and hip dysplasia, another study of 1842 dogs2
enteritis. In more recent studies of 1660 cats9 (47 month median found that early age gonadectomy was associated with a
follow up) and 1842 dogs2 (54 month median follow up), those significant increased incidence of hip dysplasia. Puppies that
gonadectomized before 5.5 months of age were no more likely underwent gonadectomy before 5.5 months of age had a 6.7%
than those gonadectomized after 5.5 months of age to have any incidence of hip dysplasia, while those that underwent gonad-
conditions that might be presumably associated with long term ectomy at the more traditional age had an incidence of 4.7%.
immune suppression. Further, in cats, the study showed that early However, those that were gonadectomized at the traditional age
age gonadectomized cats had a lower incidence of gingivitis, were three times more likely to be euthanized for the condition
a condition that may be associated with immune suppression. as compared to the early age group, suggesting that early age
On a short-term basis, however, dogs from the study that were gonadectomy may be associated with a less severe form of hip
gonadectomized at an early age had an increased incidence of dysplasia. A recent study showed that in the Golden Retriever
parvoviral enteritis that often occurred soon after adoption. In breed, cranial cruciate ligament rupture was seen more
both of the long-term dog studies8,2 (269 dogs and 1842 dogs), the frequently in dogs neutered before 1 year of age (early neutered)
increased incidence of parvoviral enteritis on a short-term basis than those neutered after a year of age or remaining intact.17
probably represented an increased susceptibility of the younger Although the incidence of hip dysplasia was higher in males of
puppies during the periadoption period, rather than long-term the early neutered group as compared to the intact group, this
immune suppression. was not the case in the female dogs.
Neoplasia 20. Ware WA, Hopper DL: Cardiac tumors in dogs: 1982-1995. J Vet Intern
Med 13(2):95-103, 1999.
Compared to intact dogs, gonadectomized dogs have been 21. Prymak C, McKee LJ, Goldschmidt MH, et al.: Epidemiologic, clinical,
reported to have a higher risk of osteosarcoma, despite the fact pathologic, and prognostic characteristics of splenic hemangiosarcoma
that the neutered dogs actually lived longer than the intact dogs.18,19 and splenic hematoma in dogs: 217 cases (1985). J Am Vet Med Assoc
193(6):706-712, 1988.
Additionally, it has been suggested that ovariectomized females 22. Norris AM, Laing EJ, Valli VE, et al.: Canine bladder and urethral
may be at an increased risk of hemangiosarcoma when tumors: a retrospective of 115 cases (1980-1985). J Vet Intern Med
compared to intact females,20,21 although this was not confirmed 6(3):145-153, 1992.
in a later study.17 Although rare, transitional cell carcinoma of
the bladder may be seen more frequently in neutered dogs than
in intact dogs.22
516 Soft Tissue
Ovariohysterectomy
Roger B. Fingland and Don R. Waldron
Indications
The most common indication for ovariohysterectomy (OVH) is
elective sterilization. Ovariohysterectomy is the treatment of
choice for most uterine diseases including pyometra, uterine
torsion, localized or diffuse cystic endometrial hyperplasia,
uterine rupture, and uterine neoplasia.1 In a study of 1712 ovario-
hysterectomies in dogs, 82% were performed for elective steril-
ization, 18% for reproductive tract disease, and 7% as adjunctive
therapy for mammary neoplasia.2 Ovariohysterectomy is
indicated for diabetic and epileptic animals to prevent hormonal
changes that alter the effectiveness of medications.
Figure 33-3. Two clamps are placed on the ovarian arteriovenous Figure 33-5. A circumferential ligature is loosely placed around the most
complex proximal to the ovary, and a third clamp is placed over the proximal clamp. The clamp is removed, and the ligature is tightened in
proper ligament. the groove of crushed tissue created by the clamp (inset).
518 Soft Tissue
Figure 33-6. A transfixation suture is placed between the circumferential suture and the cut edge of the ovarian arteriovenous complex. A. Approxi-
mately one-third of the width of the ovarian arteriovenous complex is included in the initial suture. B. The initial suture is tied. C. The ends of the
suture are directed around the ovarian arteriovenous complex and are tied.
Figure 33-7. Separation of the broad ligament. A. The uterine artery and vein are protected with the thumb and index finger, and a window is made in
the broad ligament. B. The broad ligament is grasped. C. The broad ligament is torn. Large vessels should be individually ligated.
Uterus 519
The uterine body is exteriorized, and the cervix is located. Various that is ligated; therefore, the potential for cutting the tissue with
techniques may be used to ligate and divide the uterine body, the clamp is eliminated. Depending on the size of the uterine body
depending on the size of the uterus and the surgeon’s preference. and vessels, either mass ligatures, transfixation, or individual
The triple-clamp technique may be used when the uterine body ligatures may be used to safely ligate the uterine vasculature.
is small, such as in cats and small dogs. Three clamps are
placed immediately proximal to the cervix. Care must be taken A Parker-Kerr suture pattern has been used for ligation when
when applying clamps to the uterine body particularly in the cat the uterine body is greatly enlarged (i.e.-pyometra) but is seldom
because the clamps may cut rather than crush the tissue. Some if ever indicated. A Parker-Kerr pattern has the potential for
surgeons prefer to not use crushing clamps on the feline uterine creating a closed cavity of tissue thus preventing drainage of
body. The uterine body is severed between the middle clamp and infected material. The uterine arteries and veins should be
the proximal clamp. The uterine arteries and veins are individually ligated separately distal to the Parker-Kerr suture pattern.
ligated between the distal clamp and the cervix. A circumfer-
ential suture is loosely placed around the distal clamp, the clamp The ovarian pedicles and uterine stump should be evaluated
is removed, and the suture is tightened in the groove of crushed for bleeding before abdominal closure. The left ovarian pedicle
tissue. A transfixation suture is placed between the circumfer- is located by retracting the descending colon medially to
ential suture and the remaining clamp. The remaining clamp is expose the left paralumbar fossa. Retraction of the descending
removed, and the uterine stump is evaluated for bleeding and duodenum medially exposes the right paralumbar fossa and
replaced into the abdomen. the right ovarian pedicle. The ovarian pedicles lie immediately
caudal to the caudal pole of the kidneys. The uterine stump lies
A second technique for ligation of the uterine body involves between the bladder and colon and is located by retroflexing
placement of bilateral individual ligatures on each uterine artery. the bladder. Sutures should not be grasped when evaluating the
The uterine body is exteriorized and retroflexed. Sutures that ovarian pedicles and uterine stump because excessive traction
initially incorporate the uterine artery and vein and a small bite on the suture may cause it to loosen.
of uterine serosa are placed on either side of the uterine body
(Figure 33-8A and B). A clamp may be loosely placed proximal to The abdominal incision is closed with either a simple interrupted
the sutures to prevent backflow of blood after transection. The or simple continuous suture pattern using appropriately sized
uterine body is severed between the clamp and the proximal polydioxanone suture. Sutures should be placed in the external
sutures (Figure 33-8C). The uterine stump is evaluated for bleeding rectus sheath.6 It is not necessary to suture the internal rectus
and is replaced into the abdomen. This technique is advantageous sheath or the peritoneum.6 The subcutaneous tissue and skin are
because clamps are not placed on the section of the uterine body closed routinely.
Figure 33-8. Ligation of the uterine body. A. A transfixion suture is placed to include the left uterine artery and vein. B. A similar transfixion suture is
placed to include the right uterine artery and vein. C. A clamp is placed across the uterine body proximal to the transfixion sutures, and the uterine
body is transected.
520 Soft Tissue
8. Richter KP: Laparoscopy in dogs and cats. Vet Clin North Am Small The uterus is well supplied with arterial blood from the ovarian
Anim Pract 31:707-727, ix, 2001. and uterine arteries (See Figure 33-1). The uterine vessels
9. Rothuizen J: Laparoscopy in small animal medicine. Vet Q 7:225-228, greatly enlarge during gestation and potentially complicate an
1985. ovariohysterectomy performed in conjunction with a cesarean
10. Austin B, Lanz OI, Hamilton SM, et al: Laparoscopic ovariohyster- section. Lymphatic drainage of the uterus is through the internal
ectomy in nine dogs. J Am Anim Hosp Assoc 39:391-396, 2003. iliac and lumbar lymph nodes. Autonomic nervous innervation is
11. Dusterdieck KF, Pleasant RS, Lanz OI, et al: Evaluation of the harmonic through the hypogastric and pelvic plexuses.
scalpel for laparoscopic bilateral ovariectomy in standing horses. Vet
Surg 32:242-250, 2003.
12. McCarus SD: Physiologic mechanism of the ultrasonically activated
Preoperative Preparations
scalpel. J Am Assoc Gynecol Laparosc 3:601-608, 1996. Animals considered for cesarean section are often in poor
13. Bailey JE, Freeman LJ, Hardie RJ: Endosurgery, in Bojarab WJ (ed): physiologic condition at the time of presentation and should
Current Techniques In Small Animal Surgery. St. Louis, Williams and be carefully examined. Abdominal radiographs are useful in
Wilkins Company, 1998, pp 729-741. documenting the presence and number of fetuses, thus helping
14. Van Goethem BE, Rosenveldt KW, Kirpenstein J: Monopolar Versus the surgeon to avoid inadvertently leaving a fetus in the uterus or
Bipolar Electrocoagulation In Canine Laparoscopic Ovariectomy: A pelvic canal. Laboratory tests are often limited to measurement
Nonrandomized, Prospective, Clinical Trial. Vet Surg 32:464-470, 2003. of the animal’s hematocrit, total plasma protein, serum urea
nitrogen, or urine specific gravity. These tests assist in evalu-
ating the need for corrective fluid therapy or cross matching of
Cesarean Section: potential blood donors. Most pregnant animals are mildly anemic
Traditional Technique because of an increase in plasma volume during gestation
without a concomitant increase in red blood cells. The surgeon
Curtis W. Probst and Trevor N. Bebchuk should consider this physiologic anemia when deciding whether
the dam requires a whole-blood transfusion.
wire, may also be used to close the linea alba. The subcutaneous
tissue is closed with 3-0 or 2-0 absorbable suture, and the skin is
closed with nonabsorbable suture.
Figure 33-12. As the fetus is removed from the uterus, the amniotic sac
is broken to allow breathing to begin.
Resuscitation of the Neonates
After the neonate has been handed to the assistant, its umbilical
cord should be temporarily clamped, the fetal membranes should
be removed (if this has not yet been done), and its viability should
be ascertained. If a heartbeat can be palpated, the nasopharynx
should be cleared of fluid and mucus by gentle suction or cotton
swabs. If a suction apparatus is not available, a bulb syringe can
be used for suction. A gentle, controlled, downward swing of
the neonate may help to clear fluid from the upper airways by
centrifugal force. The neonate is then vigorously dried because
skin stimulation stimulates respiratory drive in a reflex manner.
uterine contraction. Although drugs can be transferred to the Probst CW, Webb AI: Postural influence on systemic blood pressure
neonate in the milk, this is not important unless drugs are admin- gas exchange, and acid/base status in the term-pregnant bitch during
istered to the mother on a continuing basis. Drugs that are weak general anesthesia. Am J Vet Res 44:1963, 1983.
bases and become ionized at a low pH usually accumulate in the Probst CW, Broadstone RV, Evans AT: Postural influence on systemic
milk at a higher concentration than in the dam’s blood. blood pressure in large full-term pregnant bitches during general
anesthesia. Vet Surg 16:471, 1987.
Before the litter is discharged, puppies or kittens should
be inspected for obvious congenital abnormalities, such as
deformed limbs, cleft palate, and imperforate anus. This check,
Cesarean Section by
together with advice to the owners on neonatal care, ensures Ovariohysterectomy
good veterinarian-client relations. The dam and her litter can
be discharged as soon as she is able to stand and appropriate Holly S. Mullen
behavior patterns toward the litter are confirmed. Owners
should be instructed to monitor the dam carefully for the next 24 Indications
to 48 hours. They should look for evidence of continued uterine Traditional cesarean section (hysterotomy) has been the
hemorrhage, anorexia, or signs of infection or dehiscence of the treatment of choice for canine and feline dystocia that is not
abdominal incision. The dam should be returned in 7 to 10 days responsive to medical management. Hysterotomy is a well
for suture removal. described and widely accepted technique. Most references
advise against ovariohysterectomy at the time of hysterotomy,
Postoperative Complications citing additional stress to the female, increased blood loss,
Certain complications are associated with both emergency and longer anesthetic time, and problems with neonatal survival.1,3
elective cesarean section. Perioperative maternal mortality rates Sometimes, no reason is specified.4 Many practicing veteri-
of over 4% have been reported, perhaps owing to the emergency narians have performed ovariohysterectomy for dystocia in
nature of the operation and the patient’s stressed condition at the dog and cat with excellent results. The technique of “en
the time of surgery. Hypovolemia and hypotension are the most bloc” cesarean section (ovariohysterectomy) followed by rapid
common complications and are treated with vigorous fluid removal of neonates from the gravid uterus) has been shown
therapy or blood replacement. Hemorrhage of uterine origin to be safe and effective for both cats and dogs.5 Future repro-
should be controlled with oxytocin (5 to 20 units IM or IV). In duction is impossible after this technique, a fact that pleases
severe hemorrhage, the dosage may be repeated after 2 to 4 most owners. The technique described is easier, quicker, and
hours, and whole blood transfusion may be started. Persistent has less chance for intra-operative contamination than tradi-
hemorrhage may require an emergency ovariohysterectomy. If tional cesarean section.
an infected uterus is encountered during the surgical procedure,
ovariohysterectomy or packing of the uterus with antibiotic Surgical Technique
boluses and systemic antibiotics should be considered. Preoperative considerations and anesthetic techniques are
identical to those for routine cesarean section. A caudal ventral
Postoperative peritonitis should not be a problem unless a break midline incision is made through the skin, subcutaneous tissue,
in surgical technique or abdominal contamination with septic and linea alba of the abdomen. Care is taken as the linea is
uterine contents has occurred. Infection can be controlled with incised to not lacerate the large gravid uterus which may be in
careful surgical technique, intraoperative abdominal lavage, contact with the ventral abdomainl wall. The incision is packed
and antibiotic therapy in most cases. Agalactia may occur in off with sterile, saline moistened laparotomy sponges. The gravid
the queen or bitch after cesarean section, but normal milk flow uterus is exteriorized, and the uterine horns are laid out laterally
usually occurs within 24 hours. Oxytocin (0.5 units/kg intra- to the incision (Figure 33-15). Next, the suspensory ligaments
muscularly) may be administered to stimulate milk production are cut or broken to allow mobilization of the ovaries by their
if necessary. Excessive depression of either the mother or vascular pedicles. No clamps are applied at this time. The broad
the offspring after anesthesia indicates that one should criti- ligament is broken down manually or incised on both sides of
cally review the anesthetic protocol for reduction in doses of the uterus from the ovarian pedicle to the cervix. This leaves the
analgesics or barbiturate depressants. blood supply to the uterus and fetuses intact while freeing up all
attachments except the ovarian pedicles and the uterine body
Suggested Readings (Figure 33-16).
Abitbol MM: Inferior vena cava compression in the pregnant dog. Am J
Obstet Gynecol 130:194, 1978. Ovariohysterectomy can now be performed rapidly and safely,
with a maximum of no more than 45 to 60 seconds elapsed
Gilroy BA, DeYoung DJ: Cesarean section. Vet Clin North Am 16:483,
1986. between clamping of the ovarian pedicles and uterine body and
delivery of the neonates by assistants. The surgeon palpates
Macintire DK: Emergencies of the female reproductive tract. Vet Clin
North Am 24:1173, 1994. the patient’s cervix and vagina to check for a fetus. If one is
present, it is manipulated gently back into the uterine body. Two
Moon PE, Erb HN, Ludders JW, et al: Perioperative management and
mortality rates of dogs undergoing cesarean section in the United
hemostatic clamps are placed across each ovarian pedicle, and
States and Canada. J Am Vet Med Assoc 213:365, 1998. three clamps are placed across the uterine body just distal to the
528 Soft Tissue
Figure 33-15. The gravid uterus is exteriorized, and both horns are laid Figure 33-17. The gravid uterus can be removed in 45 to 60 seconds by
out laterally to the abdominal incision. first placing two hemostats on each ovarian pedicle and then three
clamps on the uterine body and transecting between them as shown.
Figure 33-16. The suspensory ligaments are broken down to exteriorize Contraindications for Ovariohysterectomy
the ovaries, and the broad ligament is torn on both sides of the uterine No important complications or contraindications for this
horns. The ovarian pedicles and the uterine body provide blood supply
technique have been described.5 Some limitations include the
to the uterus and are the only structures remaining that need to be
transected and ligated to remove the gravid uterus.
Advantages of Ovariohysterectomy In the bitch, physiologic enlargement of the vulvar labia during
proestrus and estrus is a normal estrogenic response. It may
Ovariohysterectomy for dystocia is rapid and safe for both
be mimicked or exaggerated by masses within the vestibule
the bitch and the neonate. Use of this technique minimizes
of the vulva or the vagina that cause the labia to protrude.
anesthetic time and reduces intraoperative peritoneal contami-
Such masses include hyperplasia of the vaginal floor, vaginal
nation by uterine contents, which may occur during hyster-
prolapse, vestibular or vaginal tumors, and clitoral enlargement.
otomy. Both dogs and cats continue to lactate normally as long
Subtle perineal bulges may be detected, but the masses usually
as the babies continue to nurse. There is scant to no pos-toper-
become apparent to an animal’s owner when they protrude
ative lochial discharge, as is common for several days after birth
through the vulva, cause irritation and licking, or interfere with
because the uterus has been removed. Ovariohysterectomy also
mating. They may cause dysuria. Prolonged estrogenic stimu-
provides an opportunity for future population control in pets that
lation from follicular cysts or granulosa cell tumors can cause
are unable to reproduce naturally or whose owners may not be
persistent hyperplasia of the labial and vaginal mucosa, making
able to afford a second operation for sterilization of the animal
the labia larger, firm, pigmented, and hairless.
in the future. The health of the mother and of the neonates is not
compromised when cesarean section by ovariohysterectomy is
Inspection, digital vaginal or rectal palpation, and vaginoscopy
used as the surgical treatment for dystocia.
provide preliminary identification of most vaginal lesions. In at
least one instance, an intraluminal vaginal tumor was diagnosed
References by pneumovaginography. Surgical treatment of these lesions is
1. Herron MR. Herron MA. Surgery of the uterus. Vet Clin North Am facilitated by episiotomy. Excised neoplasms should be identified
1975;5:471 476. histologically.
2. Probst CW, Webb M. Cesarean section in the dog and cat: anes¬thetic
and surgical techniques. In: Bojrab AU, ed. Current tech¬niques in small
animal surgery. 2nd ed. Philadelphia: Lea & Fee¬iger, 1983:346 351.
Hyperplasia of the Vaginal Floor
During proestrus and estrus, the vestibular and vaginal mucosae
3. Gaudet DA, Kitchell BE. Canine dystocia. Compend Contin Educ Pract
normally become swollen, thickened, and turgid. Exaggeration
Vet 1985;7:406 418.
of this estrogenic response occasionally leads to the devel-
4. Probst CW. Uterus: cesarean section. In: Bojrab AU, ed. Current
opment of a transverse mucosal fold on the floor of the vagina
techniques in small animal surgery. 3rd ed. Philadelphia: Lea & Febiger,
1990:404 408. just cranial to the external urethral orifice. Although “hyper-
plasia” is the accepted term for this condition, histologically the
5. Robbins MA, Mullen, HS. En bloc ovariohysterectomy as a treatment
of dystocia in dogs and cats. Vet Surg 1994; 23: 48 52. swelling is mostly edema with some fibroplasia. If the redundant
fold becomes large enough, it protrudes between the labia of the
6. Fox MW. Neonatal mortality in the dog. J Am Vet Med Assoc
1963;143:1219 1223. vulva as a red, fleshy mass (Figure 34-1A). The disorder occurs
most often during a bitch’s first, second, or third estrus. Sponta-
neous regression occurs during metestrus, but recurrence is
common at the next estrus. The condition has been reported in
more than 20 breeds of dogs, with frequent mention of brachyce-
phalic breeds, such as boxers and English bulldogs.
self-abuse. If breeding during the same estrus is important, to reduce bleeding. Hemorrhage is controlled with hemostatic
artificial insemination can be performed. Simultaneous excision forceps, ligation, or electrocoagulation. Retracting the margins
of the mass and artificial insemination are technically possible of the episiotomy incision exposes the vaginal lumen. The mass
but seldom indicated. must be elevated for catheterization of the urethra, to identify
and protect that structure (Figure 34-1B and C). The superfluous
A third option is to try to shorten the duration of estrogenic tissue is amputated by making connecting, curved, transverse
stimulation of the vaginal tissue by inducing ovulation at the incisions through its base. One incision is made on the dorsal
onset of clinical signs. A single dose of gonadotropin-releasing surface of the mass (the cranial aspect of its base), and the other
hormone or human chorionic gonadotropin has been used for is made on its ventral surface (the caudal surface of the base of
this purpose. Regression of the prolapse occurs about 1 week the mass). The incisions should be no deeper than necessary to
after induction of ovulation. excise the mass. The mucosal opening is closed with absorbable
suture material in a transverse, simple continuous pattern (Figure
34-1D). The catheter is removed, and the episiotomy incision is
Surgical Treatment closed (Figure 34-1E). The mucosa is apposed with simple inter-
The animal is positioned in ventral recumbency with the rupted absorbable sutures. In obese or heavily muscled animals,
hindquarters elevated, and the perineum is prepared aseptically. the musculature should be sutured separately with absorbable
The vestibule and vagina are cleansed with a mild antiseptic sutures. The skin incision is closed with simple interrupted
solution (1:10 povidone-iodine [Betadine] or 1:5000 benzalkonium nonabsorbable sutures. If bleeding persists, a vaginal tampon
chloride [Zephiran chloride] solution). A median episiotomy may be left in place for 12 hours.
incision is begun with a scalpel or an electrosurgery unit and
is completed with scissors. Doyen intestinal forceps can be
positioned on each side of the incision to serve as a guide and
Figure 34-1. Hyperplasia of the vaginal floor. A. The broken line indicates the site of the episiotomy incision. B. The vestibule has been opened
by performing an episiotomy, and a urethral catheter has been inserted. C. Lateral view. Episiotomy and urethral catheterization have been
performed. The broken line on the floor of the vagina indicates the incision site for amputation of the redundant mucosal mass. D. The mass has
been amputated, and the mucosal incision is closed with a simple continuous suture. E. Postoperative view. The catheter has been removed, and
the episiotomy incision is being closed.
Vagina and Vulva 531
Vaginal Prolapse kling the mucosal surface with table sugar may further reduce
the swelling, and episiotomy makes reduction easier. Once
Cylindric prolapse of the vaginal wall is much rarer than hyper-
accomplished, reduction is maintained by placing heavy nonab-
plasia of the vaginal floor. In this condition, which also occurs
sorbable sutures across the vulvar labia.
during estrus, a donut-shaped eversion of the entire vaginal
circumference protrudes from the vulva (Figure 34-2). Vaginal Reduction of a vaginal prolapse can be facilitated by traction on the
prolapse has been reported after forcible separation of the male uterus through a ventral abdominal incision. When this technique
and female during the genital tie. As in hyperplasia of the vaginal is used, suturing the uterine body or horns to the abdominal wall
floor, the external urethral orifice is ventral to the entire mass, (hysteropexy) provides protection against recurrence.
but access to the vaginal canal is through the center of the
protrusion, rather than dorsal to it. If reduction is impossible or inadvisable, the protruding tissue
must be amputated. Paying careful attention to the distorted
anatomy minimizes errors. With a catheter in place to identify
and protect the urethra, a circumferential incision is made in
stages through the vaginal wall. The outer, everted mucosa is
incised first. The incision is deepened to penetrate all layers
of prolapsed vaginal tissue until the inner, noneverted mucosa
is reached. Hemostasis is maintained by ligation or electroco-
agulation, and the proximal mucosal margins are united with
horizontal mattress sutures. The incision is extended for another
short distance, the exposed segment is sutured, and the process
is repeated until the amputation is complete.
Episioplasty
Dale E. Bjorling
Introduction
Episioplasty is a procedure performed most often to treat
recessed or juvenile vulva in female dogs. This conformation
results in deep perivulvar folds of tissue causing the vulva to
be partially or totally hidden from view by overlapping perineal
skin dorsal and lateral to the vulva. Older veterinary surgery
texts indicate that ovariohysterectomy performed in dogs prior
to the completion of puberty prevents normal development of
secondary sex characteristics.1 Although this association has
never been proven, it has been postulated that this may result in
recessed or juvenile vulva.1,2 Particularly in obese female dogs,
Figure 34-3. Vestibular leiomyoma. Episiotomy has been performed, and a recessed vulva in conjunction with redundant vulvar skin folds
a mucosal incision has been made to facilitate submucosal resection of may prevent complete elimination of urine and vaginal secre-
the tumor. tions. However, this condition may be associated with clinical
signs in young, relatively thin female dogs. Recessed or juvenile
Clitoral Enlargement vulvar conformation can also be observed in female dogs in the
Enlargement of the clitoris, sometimes with an os clitoridis, is absence of any associated clinical signs.
an androgenic response. The condition has been caused by
administration of exogenous androgens or anabolic steroids, Retention of fluid within the vulva and perivulvar folds combined
and it has been reported in bitches with hyperadrenocorticism. with frictional irritation predisposes the area to bacterial growth,
Clitoral enlargement has occurred in puppies whose dams were infection, and ulceration.3 In addition, urine dribbling has been
treated with androgens during pregnancy. Friction between reported in these dogs, possibly as a result of urovagina due to
the protruding clitoris and the vulva may cause inflammation. the conformation of the vulva and overlying skin folds that act
Treatment includes topical antibiotic ointments, removal of the as a dam to retain urine within the vagina.4 Affected dogs may
androgen source, or excision of the enlarged clitoris. If an os exhibit perivulvar dermatitis, pollakiuria, urinary incontinence,
clitoridis is not present, the clitoris regresses to normal size licking or other signs of irritation, chronic urinary tract infection
when exogenous androgen is withdrawn. (UTI), or vaginitis with or without discharge. In extreme cases,
chronic perivulvar dermatitis leading to hyperpigmentation has
been associated with neoplasia of the canine vulva.2
Suggested Readings
Adams WM, Biery DN, Millar HC. Pneumovaginography in the dog: a Recessed vulva is often accompanied by vaginal stricture
case report. J Am Vet Radiol Soc 1978; 19:80. located cranial to the urethral orifice. Vaginal stricture is usually
Alexander JE, Lennox WJ. Vaginal prolapse in a bitch. Can Vet J diagnosed by positive contrast radiography (vaginourethrog-
1961;2:428. raphy) or by digital palpation. Although it has been suggested that
Brodey RS, Roszel JF. Neoplasms of the canine uterus, vagina, and vaginal stricture may contribute to persistent vaginitis or chronic
vulva: a clinicopathologic survey of 90 cases. J Am Vet Med Assoc urinary tract infection,5 vaginal stricture is commonly observed
1967;151:1294.
in asymptomatic female dogs. It is my opinion that episioplasty
Johnston SD. Vaginal prolapse. In: Kirk RW, ed. Current veterinary should be performed prior to revision of vaginal stricture.
therapy X. Small animal practice. Philadelphia: WB Saunders, 1989:1302.
Krongthong M, Johnston SD. Clinical approach to vaginal/vestibular Many treatments have been used to palliate conditions that result
masses in the bitch. Vet Clin North Am Small Anim Pract 1991;21:509.
from abnormal vulvar conformation, including weight reduction,
Madewell BR, Theilen GH. Tumors of the urinary tract. In: Theilen GH,
regular cleaning of the affected perivulvar tissue, repeated
Madewell BR, eds. Veterinary cancer medicine. 2nd ed. Philadelphia:
Lea & Febiger, 1987:591.
vaginal flushes with antiseptics, and various topical or systemic
medications to control dermatitis or urinary incontinence. Of
Purswell BJ. Vaginal disorders. In: Ettinger SJ, Feldman EC, eds.
the various techniques used, the most successful appears to
Vagina and Vulva 533
be removal of redundant tissue overlying the vulva (i.e., vulvar to estimate the amount to be removed (Figure 34-4). Concentric
folds), a procedure referred to as episioplasty or vulvoplasty.2 crescent-shaped incisions are made between the vulva and the
This procedure increases exposure of the external genitalia anus to remove redundant skin (Figure 34-5). These incisions extend
and eliminates redundant skin folds that overly the vulva, which laterally on either side of the vulva and meet at points lateral and
appears to eliminate primary clinical signs such as dermatitis ventral to the vulva. If insufficient skin is removed initially to satis-
and urine dribbling, as well as secondary signs such as licking factorily improve the conformation of the vulva, additional skin
and self-induced trauma.2 is removed to achieve the desired effect. The crescent-shaped
skin and associated subcutaneous fat are removed (Figure 34-6),
taking care to avoid the dorsal wall of the vagina. The resultant
Surgical Technique wound is closed in 2 layers. Subcutaneous tissues are closed with
The surgical procedure is relatively simple. The dog is placed synthetic absorbable suture (3-0 or 4-0) in an interrupted pattern,
in ventral recumbency with the hindquarters elevated. The skin and the skin is closed with monofilament non-absorbable suture
dorsal and lateral to the vulva is compressed with the fingers (3-0 or 4-0) in an interrupted pattern (Figure 34-7). Closure of the
Figure 34-4. The extent of skin to be removed can be estimated by Figure 34-6. The isolated skin and associated subcutaneous fat are
pinching the skin dorsal and lateral to the vulva between the thumb removed. The dorsal wall of the vagina should be avoided. Hemor-
and index finger. It is often helpful to use a sterile marking pen to draw rhage is primarily encountered from vessels dorsal to the vagina and
the lines of intended incision. lateral to the midline.
resultant skin defect eliminates the fold of skin that previously lay
over the dorsal aspect of the vulva and also removes the depres-
References
sions lateral to the vulva. Although removal of too much skin may 1. Archibald J. Canine Surgery, 2nd ed. Santa Barbara: American Veter-
complicate wound closure, failure to remove enough skin may inary Publications. 1974; p 757.
result in persistence of the recessed conformation of the vulva. 2. Dorn AS. Biopsy in cases of canine vulvar-fold dermatitis and periv-
Closure of the defect is rarely a problem due to the large amount ulvar pigmentation. Vet Med Small Anim Clin 1978;73:1147.
of redundant skin available in the area of the perineum and caudal 3. Bellah JR. Intertriginous dermatitis. In Bojrab MJ, ed. Disease Mecha-
aspects of the thighs. However, in heavily-muscled dogs, or dogs nisms in Small Animal Surgery, 2nd ed. Philadelphia: Lea and Febiger.
with a great deal of tension within the perineal skin, care should 1993; p 168.
be taken to avoid removing too much skin. 4. Appeldoorn A, Lemmens P, Schrauwen E. Urinary incontinence due to
urovagina. Vet Rec 1990;126:121.
5. Crawford JT, Adams WM. Influence of vestibulovaginla stenosis,
Postoperative Care and Outcome pelvic bladder, and recessed vulva on response to treatment for clinical
Wound infection rarely occurs. An Elizabethan collar should be signs of lower urinary tract disease in dogs: 38 cases (1990-1999). J Am
used to prevent self-mutilation, if necessary. Vet Med Assoc 2002;221:995.
6. Hammel SP, Bjorling DE. Results of vulvoplasty for treatment of
In one study of the results of episioplasty in 34 dogs, the most recessed vulva in dogs. J Am Anim Hosp Assoc 2002;38:79.
common clinical signs at initial examination were perivulvar 7. Lightner BA, McLoughlin MA, ChewDJ, et al. Episoplasty for the
dermatitis 20/34 dogs (59%), and urinary incontinence and treatment of perivulvar dermatitis or recurrent urinary tract infections
chronic urinary tract infection, each present in 19/34 dogs in dogs with excessive perivulvar skin folds: 31 cases (1983-2000). J Am
(56%).6 Other common complaints included pollakiuria, irritation, Vet Med Assoc 2001;219:1577.
and vaginitis. Most dogs developed clinical signs before 1 year
of age. All dogs except one bichon frise were medium to giant
breeds, suggesting that vulvar conformation may be related to Episiotomy
growth rate or body conformation. Eighty-two percent of owners Roy F. Barnes and Sandra Manfra Marretta
rated the outcome of the surgery as at least satisfactory. The
incidence of urinary incontinence was reduced by vulvoplasty;
however, it remained the most common residual sign after Introduction
surgery, suggesting a multifactorial etiology. The incidences Episiotomy is a surgical procedure that temporarily enlarges
of urinary tract infection, vaginitis, and external irritation were the vulvar cleft. This procedure provides exposure of the caudal
greatly reduced after surgery. Wound dehiscence occurred in female urogenital tract which cannot be reached with a conven-
a Bull Mastiff, and multiple additional surgeries were performed tional laparotomy or ventral pubic osteotomy. Indications for an
to correct the resultant defect. This complication appeared to be episiotomy in the dog include vaginal and vestibular masses,
due to removal of too much skin combined with a lack of mobility vaginal prolapse, vaginal and vestibular trauma, congenital
of skin in adjacent areas. vaginal strictures, and dystocia from an inadequate vulvar cleft.
Surgical Technique A median skin incision is made from the level of the caudodorsal
aspect of the horizontal vaginal canal, extending to the dorsal
A digital examination precedes the surgical incision. During digital commissure of the vulvar cleft (Figure 34-8). A pair of thumb
examination, the caudodorsal aspect of the horizontal vaginal forceps or the handle of a scalpel blade can be inserted into the
canal is identified. To avoid incising the external anal sphincter, vaginal canal to aid in the stabilization of the incision site. The
the episiotomy incision should not extend any further dorsally remaining layers of the episiotomy incision, including the thin
than the caudodorsal aspect of the horizontal vaginal canal. musculature, subcutaneous tissue and mucosal layers are cut
with Mayo scissors (Figure 34-9). Hemorrhage may be brisk. The
in the surgical sterile field. Because of the mobility and small Postoperative Care
size of the puppy testes, including the scrotum in the surgical
All animals undergoing early age castration should be tattooed
field can facilitate locating and manipulating the testes during
to identify their neutered status so as to avoid unnecessary
surgery. Clipping and surgical preparation of the scrotum does
abdominal exploration in the future. The recommended tattoo
not result in scrotal irritation in puppies as it does in adult dogs
site in males is the inguinal area. The male gender symbol along
because the scrotal sac of puppies is not well developed as
with an encircled “X” is used to denote the neutered status.
compared to adult male dogs. Puppies are positioned on the
Tattooing is best performed after the surgical site has been
surgery table in a similar fashion as adult males, however, it is
clipped but prior to the surgical prep of the area.
often useful to very loosely secure the hind legs to the table so
as to facilitate testis identification and palpation after draping.
During recovery from anesthesia, pediatric patients should be
Puppies may be castrated through a single midline (preferred)
monitored for hypoglycemia, hypothermia, pain, or dysphoria.
prescrotal or scrotal incision, or through two scrotal incisions
Supplemental heat, glucose containing agents, or additional
positioned similarly to a feline castration. When a midline
analgesics or sedatives may be used to ensure smooth recovery
incision is used, the testicles must be securely held underneath
from anesthesia. These patients may be fed a small meal one to
the incision site to prevent iatrogenic penile or urethral trauma.
two hours after recovery since they tend to recover much more
Following exposure of the testicle and spermatic cord in a closed
fashion, (testes remain enclosed in the parietal vaginal tunic quickly from anesthesia and surgery.
during castration), the spermatic cord is doubly ligated with 3-0
absorbable suture material or stainless steel hemostatic clips. Postoperative Complications
If the parietal vaginal tunic is inadvertently penetrated and the Veterinarians have long been concerned about the potential
testis extruded, an open castration technique may be performed health risks of early age castration. These concerns have
using standard adult canine castration techniques. Adequate included increased risk of urethral obstruction in male cats,
hemostasis should be verified prior to return of the vascular obesity, and abnormal long bone growth patterns in dogs
pedicle to the inguinal region. The skin incision is closed using and cats neutered at an early age. Concerns have also been
one or two buried interrupted sutures of absorbable suture in expressed regarding the immune system of puppies and kittens
the subcuticular layer, or the incisions may be left open to heal and the effects of the stress of anesthesia and surgery at an early
by second intention healing. Closure of the incision is preferred age. The development of neoplasia has also been a more recent
and prevents postoperative wound contamination with urine or concern. Recent studies have begun to clarify the long term
feces, and extrusion of subcutaneous fat from the incision. health risks and benefits of early age castration as compared to
traditional age castration.
Kitten castration is performed using identical techniques as
in the adult cat. Two separate scrotal incisions are used to
approach the testes. When preparing the surgical site of a kitten Urethral, Penile, and Preputial Development
castration, it is often easier to shave the scrotal region than to in Male Cats
pluck the scrotal region. Positioning and draping of the kitten is
A major concern of veterinarians regarding performing early age
identical to positioning of the adult male cat prior to castration.
neutering is that of feline lower urinary tract disease (FLUTD)
As with the pediatric puppy, the testes of the pediatric cat are
and urethral obstruction in male cats. It was thought that early
extremely small, highly mobile, and occasionally difficult to
neutering of the male cat would result in a smaller diameter
stabilize in the scrotal region in preparation for incision. The
urethra thus predisposing the cat to urinary obstruction caused
testis should be securely stabilized in the scrotal region and the
by FLUTD. Numerous experimental and clinical studies dating
incision made directly over the testis at the ventral most aspect
to the 1960’s have studied this concern. Recently, two experi-
of the scrotal “sac”. After the incision, the testis is carefully
mental studies examining cats castrated at seven weeks and
exposed using gentle caudoventral traction. It is important to
seven months of age as compared to sexually intact cats have
realize that the pediatric testis cannot be exteriorized to the
studied this concern.3,4 The first study examined urethral devel-
same distance as in the adult cat without potential tearing of the
opment when cats were one year of age, and found that urethral
spermatic cord. The closed castration technique is preferred,
diameters as determined by contrast retrograde urethrography
using a hemostat to place an overhand throw in the pedicle, or
were similar among both groups of neutered cats as compared
using suture or hemostatic clips for hemostasis. If the parietal
to intact cats.3 Additionally, no difference in urethral dynamic
vaginal tunic is inadvertently opened, an open technique using
function as determined by urethral pressure profiles was seen
either a hemostat to place an overhand throw in the spermatic
among groups. In the second study, voiding cystograms were
cord, or the use of spermatic cord tissues (vas deferens) for
used to measure the diameter of the preprostatic and penile
knot tying may be employed. Alternatively, sutures or hemostatic
urethra when cats were 22 months of age.4 As in the previous
clips may be used to achieve hemostasis in an open castration.
study, no differences were seen in urethral diameter of male cats
Care must be used when manipulating tissues to prevent rupture
neutered at seven weeks or seven months of age as compared
or tearing of the small and fragile spermatic cord. As with adult
to intact cats.
cat castrations, the scrotal skin incisions are left open to heal by
second intention.
In addition to experimental studies, two recent long-term clinical
studies have examined the effect of early age castration on the
incidence of urinary tract disease. The first long-term (37 month
538 Soft Tissue
median follow-up) study examined 263 cats neutered at an early of the balanopreputial fold are not objective reasons to delay
age (< 5.5 months) as compared to the traditional age > 5.5 castration in male cats.
months.5 There were 108 male cats which were divided into two
groups based on age at the time of castration: early age (median
age at castration = nine weeks; n = 70) and traditional age
Obesity
(median age at castration = 51 weeks; n = 38). In that study, tradi- Obesity is influenced by a number of factors, including neuter
tional age neutered cats had significantly more overall urinary status, and studies suggest that gonadectomized cats may
tract problems (17%) as compared to early age neutered cats gain significantly more weight than intact cats. The literature
(3%). “Cystitis” was the most common problem seen, and the regarding whether dogs are more likely to become obese after
incidence was significantly greater in cats neutered at an older castration is less clear.
age. There was no significant difference in the rate of urethral
obstruction between groups although 2/38 (5%) traditional age When comparing neutered cats to sexually intact cats, intact
neutered cats suffered urinary obstruction, while 0/70 (0%) early cats were found to weigh less than cats neutered at seven
age neutered cats became obstructed. A second recent study months, but there was no difference between intact cats and
examined 1660 cats neutered at an early age (< 5.5 months of those neutered at seven weeks.8 Another study9,10 has assessed
age) as compared to the traditional age (> 5.5 months of age).6 obesity by body mass index at 24 months of age in 34 cats. Body
The median follow-up time for that study was 47 months, with condition scores and body mass index values were higher in
follow-up available for as long as 11 years after surgery. That animals gonadectomized at seven weeks or seven months than
study found no association between the incidence of FLUTD or in intact animals. This indicated that animals gonadectomized at
urethral obstruction and the age at gonadectomy. either age were more likely to be obese than intact cats. Heat
coefficient, a measure of resting metabolic rate, was higher in
Abnormal penile and preputial development in male cats intact cats than in gonadectomized cats. Based on these data,
castrated at an early age has also been a concern for many the author suggested that neutered male cats require an intake
veterinarians. The balanopreputial fold is a fold of tissue (a of 28% fewer calories than intact males.10
continuous layer of epithelium) connecting the penis to the
prepuce at birth. The balanopreputial fold separation process is In dogs, one study found no differences in food intake, weight
androgen dependent and is complete at birth in some species, but gains, or back-fat depth among neutered (seven weeks or seven
not until after puberty in other species such as the cat. Concerns months) and intact animals during a 15-month prospective
have been expressed that prepubertal castration in cats might study.11 A long-term study of 1842 dogs12 actually found that
delay or prevent dissolution of the membrane, and predispose the proportion of overweight dogs was lowest in the early
to ascending urinary tract disease since these cats may not age gonadectomized dogs, as compared to the traditional age
be able to fully extrude the penis for cleaning.7 Recent studies neutered dogs.
examining separation of the balanopreputial fold have reported
conflicting results. In one study of cats castrated at seven weeks Body and Long Bone Growth
and seven months of age, it was reported that at one year of age, Several research studies have refuted the concern that early
the penis could be fully extruded in all males.8 Penile spines were neutering will “stunt” growth. In a 15-month study of 32 dogs,
atrophied in those castrated at seven months, and were absent growth rates were unaffected by gonadectomy, but the growth
in those castrated at seven weeks of age. This is in contrast to period in final radial/ulnar length was extended in all neutered
another study reporting on penile extrusion in cats at 22 months male dogs (neutered at seven weeks or seven months).11 Thus,
of age.4 In cats neutered at seven weeks of age, the penis could neutered animals were not stunted in growth but were actually
not be fully extruded in any cat, while in intact cats, the penis slightly taller. In a similar study,8 31 cats were neutered at seven
could be fully extruded in all cats. Of the cats neutered at seven weeks or seven months or left intact. Distal radial physeal closure
months of age, the penis could be fully extruded in 60%. In those was delayed by approximately eight weeks in neutered cats
males incapable of complete penile extrusion, only 1/3 to 2/3 as compared to intact cats, and no differences were detected
of the length of the penis could be visualized. It would appear, between the two groups of neutered cats, for mature radius
however, based upon the long-term clinical studies of 263 and length or time of distal radial physeal closure. A third study in
1660 cats,5,6 that failure of separation of the balanopreputial cats showed that male cats neutered at seven weeks or seven
fold (when present) does not cause a clinical problem in cats months of age reached the growth plateau on average 35% later,
neutered early and does not lead to an increase in the incidence and achieved radial length of 13% longer than intact males.13
of FLUTD or urinary obstruction. Should cats neutered at an
early age become obstructed however, penile manipulations The clinical significance of delayed closure of growth plates
for catheterization may be more challenging because of smaller is not clear, but it does not appear to render the growth plates
penile size and the inability to fully extrude the penis. more susceptible to injury. In the long term studies of 263 cats,5
269 dogs,14 1660 cats,6 and 1842 dogs,12 no differences in the
All studies reported to date indicate that urethral development incidence of musculoskeletal problems were seen between
and diameter in male cats is not an androgen dependent groups. Further, in the long term study of 1660 cats6 and 1842
process, even though penile size and development is androgen dogs,12 age at gonadectomy was not associated with the
dependent. Therefore, it would appear that concerns about frequency of long bone fractures. Based on the low incidence
FLUTD, urinary obstruction, or potential failure of separation of long bone fractures in this study, it would seem that physeal
Testicles 539
Orchiectomy of Descended and solution. (Should the scrotum be prepared with antiseptics
there is a high incidence of contact dermatitis). Because the
and Retained Testes in the scrotum has not received aseptic preparation the fully prepared
prescrotal operative field is quadrant toweled to cover the
Dog and Cat scrotum. A fenestrated drape is positioned over the prescrotal
Stephen W. Crane area and the remainder of the patient. All further manipulations
of the testes and scrotum are performed through the sterile
fabric layers of the towel and drape.
Introduction
Castration (orchiectomy) is performed frequently for reproductive
neutering and for reducing or eliminating the behavior patterns
Surgical Procedure for Castration of the Dog
characteristic of intact males. The procedure continues to be the To begin the orchiectomy a skin and subcutaneous incision is
first line of defense against the plague of animal overpopulation. made on the ventral midline of the prepuce at the cranial base
Testicular neoplasia, severe traumatic injury, refractory orchitis, of the scrotum (Figure 35-1). The length of the incision must
and epididymitis are primary medical indications for unilateral or allow for the outward expression of each testis (Figure 35-2A).
bilateral orchiectomy. Removal of the primary endocrine sources Next, one testis is manipulated forward and into the incision by
of androgenic hormones are secondary reasons for castration pressure on the scrotum through the drape and towel. The tissue
in that androgens may be complicating mediators in benign that limits the outward extrusion of the testis at this point is the
prostatic hypertrophy, prostatitis, perianal adenoma, and perineal spermatic fascia which must be incised down to the parietal
hernia. In addition, castration, coupled with scrotal ablation, is layer of the vaginal tunica. The latter structure is a white, dense
the initial surgical step in creating the perineal urethrostomy glistening layer of fascia that closely surrounds the testis. Once
of the cat…a salvage procedure for a scar damaged urethra. the spermatic fascia has been divided, the tunica covered testis
Castration and scrotal ablation are the first steps in creating a can be delivered (“popped”) forward, outward and into the skin
permanent scrotal urethrostomy in dogs…a procedure to allow incision (Figure 35-2B). Shortly after the testis appears, however,
urolithic debris in urine to be discharged prior to the narrowing its outward progress is again resisted this time by the additional
of the urethra within the os penis. attachment of the spermatic fascia which connects the tail of
the epididymis to the scrotal wall. This ligament may be broken
by traction but often requires isolation by blunt dissection and,
Surgical Anatomy then, sharp transection. Using a hemostatic forceps across the
The spermatic cord must be exposed, exteriorized and transected ligament to crush small vessels is good practice in younger dogs
in any castration. The cord originates at the vaginal ring as its and is often sufficient for hemostasis. However, in the case of
individual components exit the abdominal cavity. In the center mature adults, testicular neoplasia or orchitis, the ligament
of the spermatic cord are the mesorchium, the testicular artery, should be ligated to preclude the potential complication of
the testicular vein and the associated pampiniform plexus. The postoperative scrotal hematoma. After clamping or ligation of
lymphatic vessels, deferent duct and the testicular plexus of the ligament of the tail of the epididymis, the structure is divided
autonomic nerves complete the structure. Externally, the cord to release the invagination of the scrotal skin and to allow
is wrapped in a double tunicae of the vaginal process which is further exteriorization of the testis (Figure 35-3). Steady caudal
covered by the spermatic fascia, an extension of the fascia of and outward traction is next applied to the testis to break down
the abdominal wall. Between the visceral and parietal layers of
the vaginal process the cavity is continuous with the peritoneal
cavity. Two thin layers of spermatic muscle overlay the tunicae
as flat extensions of the internal abdominal oblique muscle. The
muscle runs along the external surface of the parietal tunica of
the vaginal process to insert on the spermatic fascia and parietal
vaginal tunic. Surgically, the cremaster is considered and handled
as though it were part of the spermatic cord. Between the subcu-
taneous inguinal ring and the scrotum, the spermatic cords pass
ventral and medial to the thigh adductor muscles in a subcuta-
neous position. When the spermatic cords are delivered into a
surgical incision they are often covered with a thin layer of fat.
Closed Castration
In patients under 20 kg, a “closed” castration technique is used.
“Closed” means that the contents of the spermatic cord are triple
clamped, ligated, and divided with the tunicae of the vaginal
process intact around the cord (Figure 35-4). Additionally, the
vaginal process is transfixed to the cremaster muscle to provide
extra security in ligation. After triple hemostatic forceps are
applied to the proximal portion of the exposed cord, the most
proximal clamp is removed, and a slowly absorbable suture
material, swaged to a taper needle, is passed through the
Figure 35-2. A. The skin, subcutaneous tissue, and the spermatic fascia
are incised. The body of the penis is visible deep to the incision. B.
Once the spermatic fascia has been completely divided, the testis,
covered by the vaginal process, can be manipulated cranially into the
incision. The scrotum is handled only through the sterile fabric of the
towel and drape. Figure 35-4. After exteriorization of the testis and most of the spermatic
cord, any fat around the cord is removed. The initial step in closed
castration is the application of triple hemostatic forceps across the
unopened vaginal process and the cremaster muscle.
Figure 35-7. Open castration involves opening the parietal tunic of the
vaginal process with scissors to directly reveal the internal vascular
structures of the spermatic cord. The vaginal process and cremaster
muscle are amputated proximally (dotted line). Ligation of the vaginal
process and cremaster is not usually performed, but it may be required
if larger blood vessels are present.
Figure 35-6. The spermatic cord is severed between the two most
distal clamps to prevent backflow hemorrhage from the testis into the
operative field and to retain control of the cord.
Figure 35-8. The testicular artery and vein and then the deferent duct are
triple clamped. They are ligated just distal to the most proximal clamp.
Testicles 543
control of thumb forceps (Figure 35-10). Control during the Editor’s Note: Intradermal closure of the skin is practiced by
release of the cord is important because the vessels shorten and many surgeons instead of skin closure as it is believed that
dilate as tension on them is released. Any ligature slippage and self-trauma of the incision by licking is less of a postoperative
hemorrhage will probably occur at this time. If bleeding occurs, problem when skin sutures are omitted.
the vessels or cord can be immediately retrieved for further
attention if held by thumb forceps. Ancillary Techniques to Orchiectomy
The remaining testis is produced by incising the contralateral Scrotal Ablation
spermatic fascia and the second gonad is removed in the same Veterinarians and clients may prefer scrotal ablation in the
manner to complete the castration. At no time is invasion of the opinion that it cosmetically complements the orchiectomy. This
scrotal wall or scrotal septum necessary and any incision into is especially true in larger breed dogs with short hair coats.
Preperation for surgery includes full antiseptic scrubbing of the
scrotum and the inner thigh and perineal areas. Scrotal ablation
is initiated by a circumfrential incision around the scrotum with
the incision made slightly toward the scrotal side of the junction
between the skin. Such an incision placement reduces skin
tension and utilizes incision-induced spasms of the tunica dartos
layer of the scrotum to help reduce intra-operative hemorrhage.
The incision is extended through the entire subcutaneous tissue
by sharp dissection where pinpoint electrocautery may be
useful. After removal of the scrotum and following orchiectomy,
attention to dead space ablation during the subcutaneous layer
closure is important.
Figure 35-11. Simple interrupted intradermal sutures, with the knots buried, are used to ablate dead space and to appose wound edges. Each suture
is just “catching” superficial portions of the retractor penis muscle. Ablation of dead space helps to prevent post operative hematoma or seroma.
Skin suture should loosely approximate wound edges.
with the perineal skin. After the spermatic fascia is incised, the exposure of the spermatic cord is obtained and resistance to
testes are delivered dorsocaudally into the operative field by further traction is met. Any fat investing the spermatic cord is
upward pressure on the toweled scrotum. With outward traction stripped from the cord and, in a proximal position, two Halstead
applied the ligament of the tail of the epididymis is identified, mosquito forceps are placed across the spermatic cord. As the
isolated, clamped, and divided. The spermatic cord and testis proximal forceps is removed a ligature of absorbable suture
are then delivered into the incision and the remainder of the material is tied tightly in the crush mark. The spermatic cord is
operation is performed as previously described for a closed or then transected and released up into the scrotum under direct
open technique. control of the remaining mosquito forceps. As an alternative
to ligature placement, kittens and juveniles, but not adults, can
have their spermatic cord looped with an overhand knot and
Castration of the Cat cinched tight (Figure 35-12). After the testes are removed, both
Male cats are usually neutered at or before sexual maturity. scrotal incisions are dilated by spreading the tips of mosquito
The intact male cat is usually not well tolerated as an indoor forceps between the wound edges to preclude an early fibrin
companion animal because of marking and spraying with an seal across the incision. The application of topical ointments or
odoriferous urine. Nocturnal fighting and roaming are other systemic antibiotics are unnecessary.
behavior patterns of male cats that are often successfully
controlled by orchiectomy.
Cryptorchidism
The only instruments needed for cat castration are two mosquito Unilateral or bilateral cryptorchidism is encountered frequently
forceps, a pair of smaller, sharp sharp scissors, a No. 10 scalpel in dogs and is transmitted as a hereditary disorder in a simple,
blade, absorbable ligature material, and a nonfenestrated autosomal recessive manner. The condition occurs most
paper drape. The cat is placed under ultrashort acting general frequently in small purebred dogs, with a right to left ratio of 2.3:1.
anesthesia and positioned in dorsal, ventral, or lateral recum- Unilaterally cryptorchid males are typically fertile and possess
bency. While in dorsal recumbancy the cat’s perineal area is normal libido so the trait is widely disseminated.
conveniently exposed by bringing the hindquarters to the edge of
a table and allowing the tail to fall toward the floor. The patient’s Testicular descent should be complete shortly after birth and
pelvic limbs are secured in a laterally abducted position, and the testes not located within the scrotum by 2 months of age should
hair covering the scrotum is either plucked with the fingers or be considered permanently retained. Veterinarians should
clipped with a No. 40 clipper blade. The scrotal area is prepared strongly recommend the castration of cryptorchid animals
with scrub soap and skin antiseptics. A drape is easily and because testes retained in an inguinal or abdominal position are
economically made from paper drape material that is sterilized predisposed to the malignant changes of seminoma and Sertoli
with the other instruments and a fenestration about the size of cell tumor. Orchiopexy or prosthetic testicular implantation is
a dime is cut in the center of the drape. The prepared scrotum illegal and unethical for show purposes and can contribute to
is expressed through the hole to create an acceptably draped the perpetuation of cryptorchidism.
surgical area without any exposure of hair.
The palpable absence of one or both testes during several
The skin, tunica dartos and spermatic fascia over each testis examinations confirms the diagnosis of cryptorchidism. Once a
are vertically incised with a No. 10 scalpel blade. The incision diagnosis of cryptorchidism has been established, the surgeon
should extend amply from the dorsal to the ventral aspect of must determine at what point along the normal path of testicular
the scrotal compartments. With a pinching maneuver the testis, descent migration became arrested. This point can be anywhere
still enclosed in the vaginal process, is “popped” out of the from just cranial to the scrotum in the subcutaneous tissue of the
incision. The testis is pulled caudoventrally until considerable groin all the way up to the position of embryonic organogenesis
Testicles 545
Figure 35-12. Feline Castration-Closed technique. This is a six step technique where the spermatic cord is tied on itself using a mosquito hemostat.
This technique is applicable to a closed castration for kittens and juvenile aged males. The spermatic cord should be well exteriorized, free of ten-
sion and stripped of fat prior to forming the loop and pulling tissue with a curved mosquito hemostat.
just caudal to the kidney. Careful palpation usually enables the descent is arrested at this location, the testis can usually be
examiner to detect most gonads if they are distal to the super- palpated by moving a finger along the abdominal wall toward the
ficial inguiinal ring in the subcutaneous tissue of the groin. ring. After the cryptorchid testis is located, the testicular vessels
and ductus are isolated, triple clamped, and doubly ligated either
Many retained canine testes are located within the abdominal collectively or individually with a slowly absorbable ligature
cavity and exploratory celiotomy or laparoscopy is required material. After division of vascular structures, the abdominal
for their removal. With the patient under general anesthesia cavity is checked carefully for bleeding, and the celiotomy is
and the ventral abdominal wall prepared for aseptic surgery, a closed. True agenesis of the testis and vas deferens is reported,
midline celiotomy is performed through the linea alba from the but it is rare. If the testis has descended through the inguinal
umbilicus to the prepuce. Frequently, the testis is located in the canal and is located in the subcutaneous tissue of the groin,
mid abdominal region as a highly movable organ smaller than the removal is by a standard prescrotal incision with manipulation of
descended gonad. Arterial supply from the testicular artery, a the testis into the incision by digital pressure.
direct branch of the aorta, and a small artery in the gubernacular
remnant or the deferential fold of the peritoneum are typically
visualized. Also, the ductus deferens courses toward the caudal Selected Readings
aspect of the abdomen and can be a reliable primary landmark Baumans V. Dijkstra G, Hensing CJG. Testicular descent in the dog.
for tracing to the retained testis. Zentralbi Veterinaermed [A] 1981;1O:97.
Evans HE. Miller’s anatomy of the dog. 3rd ed. Philadelphia: WB
If the testis cannot be located initially in the mid abdominal area, Saunders, 2005.
the area of the inguinal ring is next examined. When testicular Hates HM, Wilson GP, Pendergrass TW, et al. Canine cryptorchidism
546 Soft Tissue
Amputation Techniques
Partial or “complete” amputation of the penis may be indicated in
certain congenital, traumatic, or neoplastic conditions. The most
common neoplasm of this area, transmissible venereal tumor,
is generally responsive to chemotherapy or radiotherapy. Thus,
amputation of the penis should be considered rarely, if ever, as a
corrective measure for this condition. Cryotherapy has also been
used successfully for removal of benign tumors of the penis.
Partial Amputation
The exact location of the amputation is determined by the site
of the lesion. In most cases, the penis can be extruded (Figure
36-1A) and held in the extruded position by clamping the preputial
orifice with a towel clamp just caudal to the bulbus glandis. The
sheath can be opened full thickness on the ventral midline, when
necessary, to expose the penis. The penis can be extruded
through a ventral opening in the prepuce, or the entire length of
the prepuce can be opened for better exposure. A Penrose drain
tube works well as a tourniquet around the base of the penis.
Figure 36-1. A. Amputation of the tip of the penis. B. Securing the ure-
thral mucosa to the penile mucosa. C. Triangulating the urethral orifice
with stay sutures. D. Placement of a simple continuous pattern between
the stay sutures with the orifice in maximal dilatation.
Penis and Prepuce 547
mucosa of the penis, and then complete the excision of the tip Preputial Amputation
of the penis (Figure 36-1B). The triangula-tion technique (Figure When pooling of urine within the prepuce becomes a concern
36-1C and D) conserves a patent lumen to the tip of the urethra. after partial amputation of the penis, shortening of the entire
Careful apposition of the cut mucosal edges to the penile tunica prepuce may be desirable. For the best cosmetic results, a full-
helps to avoid excessive scar tissue proliferation and stricture. thickness section of the prepuce can be removed (Figure 36-3).
A continuous suture pattern helps to control seepage from the The length of prepuce to be removed should be the same as the
cavernous erectile tissue. Synthetic absorbable suture is used length of the penile resection. In patients with congenital micro-
for mucosal closure. penis, the tip of the prepuce should cover the tip of the penis by
approximately 1 cm. The cranial transverse incision is made 2 cm
An Elizabethan collar or a side-bar restraint device should caudal to the cranial junction of the prepuce and the body wall,
always be used to prevent the patient from licking the wound. to allow adequate circulation to the cranial end of the prepuce.
Castration or careful hormone therapy may be indicated to help The location of the caudal transverse incision is determined by
to prevent erection during healing. the length of the penis. The two incisions are extended laterally
in an elliptic fashion to facilitate a smooth closure of the skin.
Amputations of the main body of the penis require the severing
of the os penis, as well as the salvaging of enough urethra distal Next, the dorsal aspect of the section of prepuce to be removed
to the severed os penis for a distance of 1 cm. The os penis and is dissected free from the body wall with scissors. With careful
urethra are severed with bone-cutting forceps and a scalpel. The dissection, most of the preputial vessels, which lie immediately
urethra is isolated subperiosteally from the groove of the os penis subcutaneously on both sides of the sheath, can be identified
with a small dental chisel. The urethra is split, flared, trimmed, and preserved. To close the amputation, the preputial mucosa is
and sutured to the infolded tunica albuginea, as shown in Figure apposed with 4-0 absorbable suture, using a submucosal pattern.
36-2. Care should be taken to appose the mucosal surfaces. If a continuous pattern is used around the circumference of the
Although it is perhaps easier to achieve excellent apposition with prepuce, care should be taken to avoid a pursestring effect,
fine, closely placed interrupted sutures, a continuous pattern which limits the movement of the penis. The veterinarian may
is more likely to control bleeding. Some bleeding, especially at find it easier to close the dorsal mucosa if the penis is allowed to
the end of urination, is common, even for several days after the protrude through the incision site during this phase of closure.
operation. It is difficult to identify and to ligate individual vessels
in this area. Releasing the tourniquet while the wound is open,
in an effort to identify and to ligate the vessels within the corpus
Complete Amputation
spongiosum penis, may prove unrewarding. The initial skin incision is made in an elliptic fashion around the
entire external genitalia (Figure 36-4A). The preputial vessels are
ligated, as are any additional branches of the caudal superficial
epigastric vessels that cross the incision line. The spermatic
cords are isolated, ligated, and severed. Care must be taken to
place the ligatures tightly enough to prevent retraction of the
severed spermatic artery if the tunicae are incorporated in the
ligature. When the penis and the prepuce have been stripped
from the body wall in a caudal direction, the dorsal penile vessels
are identified and ligated just caudal to the level of the desired
penile amputation site. The retractor penis muscle is reflected
from the urethra, and, with a catheter in place, a midline incision
is made into the urethral lumen at the desire urethrostomy site.
A 1-0 absorbable, ligature, which circumscribes the penis, is
placed just caudal to the amputation site and just cranial to the
urethrostomy site (Figure 36-4B), to control seepage bleeding
from the erectile tissue further, if necessary. The shaft of the
penis is amputated in a wedge fashion, and the tunica albuginea
is apposed over the amputation stump. The urethrostomy should
be located in the scrotal area whenever possible. Careful
apposition of penile urethra and skin edge, as the urethrostomy
is completed, minimizes postoperative bleeding and scar tissue
formation (Figure 36-4C). Although suture patterns and materials
are a matter of choice, a continuous pattern aids in controlling
Figure 36-2. A. Amputation of the penis proximal to a lesion. The corpus
hemorrhage from any incised erectile tissue. The use of synthetic
spongiosum penis is incised at a 45° angle. The os penis and urethra absorbable suture eliminates the need for suture removal.
are incised I cm further distal than the corpus spongiosum penis. B. The
urethra (a) is elevated subperiosteally from the groove in the os penis. Particular care should be taken to obliterate dead space,
The os penis (b) is trimmed away with a rongeur to the level of the cor- especially cranial to the stump of the amputated penis, when
pus spongiosum penis. C. The urethra is sutured to the penile mucosa, closing the subcutaneous tissue. The use of a restraint device
and the remainder of the penile stump is closed. to prevent licking of the surgery site by the patient is imperative.
548 Soft Tissue
Figure 36-3. Shortening of the prepuce in cases of pooling of the urine within its lumen. A. Removal of a section of the entire prepuce. B and C. Reap-
position of the mucosa and skin.
Figure 36-4. Ablation of the external male genitalia. A. The skin incision extends from cranial to the prepuce to caudal to the scrotum. B. Amputation
of the shaft of the penis in the area of the scrotum. The penis is ligated, incised, and sutured. C. The urethrostomy is established by careful apposition
of the urethral mucosa to the edge of the skin.
Correction of Hypospadias pulls the penis into a deforming ventral curvature (chordae) (See
Figure 36-6).
Hypospadias is a congenital anomaly of the external genitalia in
which the penile urethra terminates caudal to its normal opening.
Minimal defects usually require no urethral surgery. The
The urethra can terminate at any level from the perineum to the
constant extrusion of the tip of the glans penis can often be
tip of the penis (Figure 36-5) because the urethral folds fail to
relieved by closing the prepuce to its normal extent (Figures 36-7
fuse (See Figure 36-9). In severe cases, the two halves of the
and 36-8) on its caudoventral aspect. Should the resulting orifice
scrotum can fail to fuse, the penis fails to develop normally,
be too small to allow extrusion of the penis, the opening can
and the urethra fails to close in the perineal area (Figure 36-6).
be increased to the desired diameter by enlarging the lumen of
Frequently, the analog of the urethra can be present as a fibrous
the craniodorsal aspect. Simply leaving the orifice larger by not
cord that runs from the glans penis to the urethral opening and
Penis and Prepuce 549
closing the caudoventral defect to its fullest extent can cause absorbable synthetic material are preferred. Should the orifice
the tip of the penis to continue to droop from the prepuce and need to be enlarged dorsally, one scissor jaw is inserted into the
may thus subject it to continual drying, licking, and trauma. lumen of the prepuce, and the orifice is cut to the needed extent.
With a minimum of undermining, the cut mucosal and skin edge
Caudoventral closure is accomplished by incising the mucocuta- can be apposed (Figure 36-8B). Failure to appose the skin and
neous junction, separating the mucosa from the skin, and closing mucosal edges adequately may result in closure by granulation,
the two layers individually (Figure 36-8A). Sutures of 4-0 to 6-0 or, should the patient be allowed to lick out the sutures, stricture
formation is likely to follow.
Figure 36-6. A. and B. Severe hypospadias with concurrent defects of penile and preputial development. Excision of the entire external genitalia is
the approach of choice.
550 Soft Tissue
Figure 36-7. A. Glandular hypospadias with a concurrent preputial defect. B. The defect is closed ventrocaudally. If the resulting orifice is too small,
it is enlarged by incising the prepuce dorsocranially. The preputial mucosa is sutured to the skin edge.
Figure 36-8. A. Closure of a ventrocaudal preputial defect. The mucocutaneous junction is trimmed away, the skin is undermined, and the mucosa
(1) and the skin edges (2) are closed as separate layers. B. Enlargement of the dorsocranial aspect of the preputial orifice. The prepuce is cut at full
thickness. The mucosa (1) is sutured to the skin edge (2) along the margin of the incision.
Figure 36-9. A. Penile hypospadias with a catheter in the urethra. B. Incisions are made lateral to the defect (1). Skin can be used to reconstruct the
ventral wall of the urethra if mucosa is insufficient. Hair follicles need to be destroyed if skin is invaginated. C. The tissue is undermined sufficiently
to allow the ventral urethral wall to be reconstructed (1) and the skin to be closed (2) without undue tension.
Penis and Prepuce 551
Correction of Phimosis
The inability to extrude the penis from the sheath (phimosis)
is usually the result of too small a preputial orifice. Because
surgical enlargement of the orifice with a ventrocaudal preputial
incision can cause persistent extrusion of the glans, the orifice
should be enlarged on the craniodorsal surface. A full-thickness
incision is made to the desired length with heavy scissors. The
severed preputial mucosa is then undermined sufficiently to allow
apposition to the ipsilateral skin edge (See Figure 36-8B). The use
of a restraint device to prevent licking or chewing is imperative.
Figure 36-10. A and B. A crescent-shaped piece of skin is removed with
subsequent cranial movement of the cranial aspect of the prepuce
Correction of Paraphimosis by folding the preputial muscles (a). C. Excision of a segment of the
The inability to return the penis to the sheath can result in preputial muscles.
severe trauma or circulatory compromise. The animal can
develop necrosis or injury sufficient to require penile amputation. the hypoplastic prepuce; in the second step, the lateral sides of the
Persistent exposure of the glans can also result in chapping and grafted mucosa are freed, are formed into a tube, and are anasto-
excessive licking. mosed to the isolated mucosa of the cranial end of the prepuce.
Single pedicle skin flaps are advanced to the ventral midline from
Many patients with acute paraphimosis can be managed by nonin- both sides of the ventral body wall to cover the mucosal tube and
vasive methods to return the penis to the lumen of the sheath. The to complete the cranial extension of the prepuce.
extruded and visually edematous penis should be cleansed, and
the sheath should be thoroughly irrigated with nonirritating soaps. Correction of Ventral Deviation of the Penis
A combination of massage and locally applied hypertonic and
hygroscopic agents, such as sugar, can help to reduce swelling. Wedge osteotomies reportedly have been successfully performed
Once swelling is reduced, the constricting preputial orifice can to correct ventral penile deviation. The os penis is approached
usually be pulled over the lubricated penile shaft. Preputial on the dorsal midline over its greatest curvature. The os penis is
enlargement can be accomplished by incision and primary repair fractured with a bone cutter, and a small pie-shaped wedge of
of the mucosal and skin layers, to reduce refractory paraphimosis. bone is excised to allow for straightening of the os penis. After
wound closure, an open-ended catheter is sutured in place
On occasion, the tip of the penis can remain exposed when no within the urethra and is left for a minimum of 3 weeks. One
obvious orifice defects are present. Once the mucosa has been disadvantage of this procedure is possible damage to the penile
exposed for some time and has become dry and cornified, the skin urethra at the time of surgery or during healing. Rigid fixation
of the prepuce rolls inwardly as attempts are made to return the of the os penis should definitely be maintained to help alleviate
penis to its sheath. After adequate cleansing and lubrication, the the likelihood of nonunion or malunion. Animals with congenital
penis can be returned to its sheath. If the tip of the penis is well anomalies should not be used for reproductive purposes.
covered by the prepuce (at least 1 cm), narrowing of the preputial
orifice will probably prevent recurrence (See Figure 36-8A). Removal of Penile Urethral Calculi
Should the prepuce not cover the tip of the penis well, cranial Most urethral calculi causing impairment of urine flow are
movement of the prepuce should be performed (Figure 36-10). lodged just proximal to the os penis. On rare occasion, particu-
This translocation can be accomplished by removing a crescent- larly when the groove within the os penis is narrowed, calculi
shaped piece of skin from the ventral body wall just cranial to its lodge within the penile urethra. This narrowing can be the result
juncture with the prepuce. Care should be taken to preserve the of a congenital deformity or injury, with or without fracture of
preputial vessels. The preputial muscles, which lie superficial to the os penis. Whenever possible, these calculi should be hydro-
the rectus abdominis muscles, can then be shortened by either an pulsed into the bladder. Extraordinary efforts should not be used
overlapping technique (Figure 36-10A) or simple excision followed to relocate these stones, however, because debridement of the
by reapposition (Figure 36-10B). The closure of the subcutaneous urethral mucosa is likely to result in stricture formation.
tissue and skin is routine.
The penile urethra is approached from a ventral midline incision,
after exposure of the penis as in Figure 36-1A or by splitting
Preputial Reconstruction the prepuce. A catheter is advanced from the urethral orifice
A hypoplastic prepuce can be lengthened in a two-step surgical caudally to determine the exact location of the obstruction.
procedure. The first step involves transplanting oral mucosa to a Ideally, the incision is made exactly on the ventral midline of
prepared graft site on the ventral body wall immediately cranial to the penis, to avoid the erectile tissue. The incision is extended
552 Soft Tissue
The calculi are grasped with forceps and carefully are removed.
The area is flushed with sterile saline, and the catheter is
advanced to the bladder, while one checks for the presence of
more calculi. A cystotomy is performed if indicated. The penile
urethral incision is closed with fine absorbable suture over a
catheter with a continuous suture pattern. The penile incision is
then closed over the urethra in similar fashion.
Suggested Readings
Ader PL, Hobson HP. Hypospadias: a review of the veterinary literature
and a report of three cases in the dog. J Am Anim Hosp Assoc 1978;
14:721.
Bennett D, Baugham J, Murphy F. Wedge osteotomy of the os penis to
correct penile deviation. J Small Anim Pract 1986;27:379.
Burger RA, Muller SC, et al. The buccal mucosal graft for urethral
reconstruction: a preliminary report. J Urol 1992;147:662.
Chaffee VM, Knecht CD. Canine paraphimosis: sequel to inefficient
preputial muscles. Vet Med Small Anim Clin 1975;70:1418.
Hayes AG, Pavletic MM, et al. A preputial splitting technique for surgery
of the canine penis. J Am Anim Hosp Assoc 1994; 30:291.
Leighton RL. A simple surgical correction for chronic penile protrusion
(dog). J Am Anim Hosp Assoc 1976; 12:667.
Pope ER, Swaim SF. Surgical reconstruction of hypoplastic prepuce. J
Am Anim Hosp Assoc 1986,22:73.
Poppas DP, Mininberg LH, et al. Patch graft urethroplasty using dye
enhanced laser tissue welding with a human protein solder: a preclinical
canine model. J Urol 1993; 150:648.
Proescholdt TA, DeYoung DW, Evans LE. Preputial reconstruction for
phimosis and infantile penis. J Am Anim Hosp Assoc 1977; 13:725.
Smith MM, Gourley IM. Preputial reconstruction in a dog. J Am Vet Med
Assoc 1990,196:1493.
Varshney AC, Sharma VK, et al. Surgical management of carcinomatous
urethral obstruction in a dog. Indian Vet J 1985; 62:1073.
Endocrine System 553
Figure 37-1. Surgical anatomy of the medial surface of the adrenal gland, depicting the neurovascular structures to be encountered during dissection.
(Modified from Evans HE, Christensen GC. Miller’s anatomy of the dog. Philadelphia: WB Saunders, 1993: 578.)
Endocrine System 555
Cardiac dysrhythmias
Esmolol (short acting Beta 1-adrenergic antagonist): slow bolus
0.5 mg/kg, then 50-200 µg/kg/minute infusion.
Propranolol (Beta-adrenergic antagonist): 0.02-0.1 mg/kg slow
IV over 2-3 minutes.
Lidocaine (ventricular antiarrhythmic agent): 2 mg/kg bolus, up
to 8 mg/kg; if responsive then CRI of 50-100 µg/kg/minute.
Figure 37-3. The surgical field during ligation of the phrenicoabdomi- Figure 37-4. Thrombusectomy of an intracaval thrombus. Following
nal vein and smaller perforating arteries. Attention to hemostasis is complete tumor dissection the affected segment of vessel is isolated
paramount, therefore, use of hemostatic clips and electrocautery is with Rumel tourniquets. Occlusion of blood flow is implemented. The
recommended. (Modified from Birchard SJ. Adrenalectomy. In: Slatter dotted line indicates the site of circumferential incision of the vessel
D. Textbook of Small Animal Surgery. 3rd ed. Philadelphia: WB Saun- wall at the site of tumor penetration. The thrombus is removed by exert-
ders, 2003:1697.) ing traction on the tumor base with one hand, while the other hand is
used to “milk” the thrombus out. The incision is extended as needed to
En bloc nephrectomy is occasionally required because of tumor prevent tearing the vessel wall. The vessel wall is closed as air is dis-
invasion into the renal vessels or parenchyma. The tumor and placed from the lumen by releasing the caudal Rumel tourniquet prior
kidney are isolated en bloc before great vessel incision to to tightening the final suture. Finally, the cranial tourniquet is released.
(Modified from Birchard SJ. Adrenalectomy. In: Slatter D. Textbook of
minimize occlusion time and facilitate rapid thrombus removal.
Small Animal Surgery. 3rd ed. Philadelphia: WB Saunders, 2003:1697.)
Thyroidectomy in the Dog glandular tissue. Small blood vessels may be located on the
capsule surface and between the capsule and the parenchyma
and Cat of the gland. Two parathyroid glands are usually associated with
each thyroid lobe. The external parathryoid gland usually lies
Stephen J. Birchard and Joao F. de Brito Galvao in the loose fascia at the cranial pole of the thryoid lobe.2 The
internal parathyroid gland is usually embedded in the thyroid
Introduction parenchyma and is variable in location. The external parathyroid
glands are much smaller than the thyroid lobe and can be
Thyroid neoplasia is the primary indication for thyroidectomy
distinguished from the thyroid tissue by their lighter color and
in dogs and cats. Thyroid tumors in dogs are usually malignant
spherical shape. The blood supply to the parathyroid glands also
and non-functional, whereas in cats they are usually benign and
arises from the cranial thyroid artery.1
functional. Thyroidectomy can range from a straightforward to
complex surgical procedure, depending on the invasiveness and
size of the tumor. A working knowledge of the regional anatomy, Thyroid Tumors in Dogs
pathophysiology of thyroid and parathyroidectomy disorders,
and the principles of pre and postoperative care is necessary Pathophysiology
for successful patient management. Animals with thyroid tumors Thyroid tumors in dogs account for 1.2% of all canine tumors.3
tend to be geriatric and frequently have disorders of other organ The majority of the tumors are malignant, and adenocarcinoma
systems that should be recognized and treated appropriately. is the most common tissue type reported.4 Less than 20% of dogs
This is particularly true for cats with hyperthyroidism, a poten- with thyroid tumors have hyperthyroidism.5 Boxers, beagles, and
tially severe multi-system disorder that can increase the risks golden retrievers appear to have a greater risk of developing
associated with anesthesia and surgery. thyroid carcinoma.3
The purpose of this chapter is to provide an overview of the The most common presenting signs in dogs with thyroid tumors
pathophysiology of thyroid neoplasia, to review the anatomy of are the presence of a palpable neck mass and coughing or
the thyroid and parathyroid glands, and to describe the surgical respiratory distress.4 Other reported clinical signs are vomiting,
technique for thyroidectomy. Postoperative care and complica- dysphagia, anorexia, and weight loss.5 Signs of hyperthyroidism
tions are also covered. are usually not present because elevation of thyroid hormone
level is infrequent in dogs with thyroid neoplasia. However, the
author has seen 2 dogs with functional thyroid adenocarci-
Surgical Anatomy nomas that had elevated triiodothyronine (T3) and thyroxine (T4)
The thyroid gland in the dog and cat is divided into two lobes levels but did not have signs of hyperthyroidism. Most thyroid
which are located adjacent to the trachea and just caudal tumors in dogs are malignant and are carcinomas. Thyroid carci-
to the larynx. The left lobe is slightly caudal to the right.1 The nomas in dogs most frequently metastasize to the lungs.4 Studies
normal gland is pale tan. The principle blood supply to each lobe have indicated that over 50% of all thyroid carcinomas produce
is the cranial thyroid artery, a branch of the common carotid lung metastases.3,6 The larger the primary tumor, the greater the
artery1 (Figure 37-5). The caudal thyroid artery in the dog arises chance for lung metastasis.6 The second most common site of
from the brachiocephalic trunk or common carotid artery. The metastasis is the cervical lymph nodes.
caudal thyroid artery is absent in the cat.2 Venous drainage of
the thyroid is through the cranial and caudal thyroid veins.1 The A key factor in the preoperative evaluation of a dog with
thyroid has a distinct capsule that can be bluntly separated from suspected thyroid neoplasia is determining whether or not the
affected gland or mass is movable. Thyroid masses that are freely
movable on palpation tend to be less invasive into surrounding
tissues, are surgically resectable, and have a better long-term
prognosis than those masses that are invasive and non-movable.
One study found that, of 82 dogs with thyroid carcinoma, 20 had
movable tumors.7 These tumors were resected and median
survival of the group was 20.5 months. A more recent study
evaluated dogs with bilateral thyroid tumors that underwent
thyroidectomy. As with unilateral tumors, long-term postoper-
ative survival was good but many dogs required treatment for
hypoparathyroidism.8
Diagnosis
Diagnosis of thyroid neoplasia in dogs is by physical exami-
nation (palpation of a neck mass), and biopsy of the tumor. Fine
Figure 37-5. Gross appearance of bilateral thyroid tumors in a cat. (From
needle aspiration of the mass should yield cells characteristic
Panciera DL, Peterson ME, Birchard SJ. Diseases of the thyroid gland.
In Saunders Manual of Small Animal Practice, 3rd ed., Birchard SJ, of a carcinoma but may be inconclusive due to hemorrhage.
Sherding RG, eds. Elsevier, St. Louis, 2006, pgs. 325-340.) A Tru-cut needle biopsy of the tumor may be considered if
Endocrine System 559
Preoperative Considerations
Surgical thyroidectomy is indicated for those dogs with small,
movable thyroid masses that are not invasive. Treatment options
other than surgery should be considered for dogs with large,
fixed neoplasms. Radiation therapy has recently been shown to
be effective in several dogs with infiltrative thyroid carcinoma.9
Chemotherapy can also be used and may benefit dogs with Figure 37-7. Removal of a canine thyroid tumor with a combination of
nonresectable tumors, or with tumors that have been incom- blunt and sharp dissection. The surgeon must identify and preserve the
pletely excised. Consultation with an oncologist is recommended recurrent laryngeal nerve. (From Panciera DL, Peterson ME, Birchard
in such cases. SJ. Diseases of the thyroid gland. In Saunders Manual of Small Animal
Practice, 3rd ed., Birchard SJ, Sherding RG, eds. Elsevier, St. Louis,
2006, pgs. 325-340.)
Surgical Technique
The dog is placed in dorsal recumbency with the front legs tied If involved with the mass, the carotid artery, jugular vein,
caudally and the neck slightly hyper extended over a rolled towel vagosympathetic trunk, and recurrent laryngeal nerve may be
or other cushion. The ventral cervical region from the caudal removed unilaterally. These tumors are extremely vascular and
mandible to the manubrium is prepared for aseptic surgery. A strict hemostasis is important to prevent serious blood loss.
ventral midline cervical skin incision is made from the caudal The Ligasure® vessel sealing device is a very useful tool for
aspect of the larynx to 2 to 3 cm cranial to the manubrium. hemostasis of the highly vascular thryroid tumors in dogs. Even
The paired sternohyoideus and sternothyroideus muscles are small vessels should be ligated or cauterized since surgery is
separated on the midline and retracted with self-retaining hampered by a bloody field. Removal of large tumors results in
retractors. The trachea is gently retracted and both thyroid lobes dead space in the tissues; a closed suction drain (e.g. Jackson-
are carefully examined. Pratt) should be placed in the area of resected tumor to prevent
hematoma or seroma formation. The sternohyoideus and sterno-
An attempt should be made to identify the parathyroid glands, thyroideus muscles are closed with absorbable suture, such as,
although visualization of the glands may be impaired by larger (3-0 poliglecaprone 25 (Monocryl) or polydioxanone (PDS)) in a
neoplasms (Figure 37-6). The tumor is carefully dissected from simple continuous pattern. The subcutaneous tissues are closed
surrounding tissues (Figure 37-7). The author usually starts in the same fashion. Skin is closed with non-absorbable suture
at the caudal aspect of the lobe and works cranially. Care is (4-0 nylon) in a simple interrupted pattern or with 4-0 absorbable
taken to avoid injury to the esophagus, carotid artery, jugular intradermal suture in a simple continuous pattern.
vein, vagosympathetic trunk, and recurrent laryngeal nerves.
The thyroid tissue should always be submitted for histologic
examination. Results of histologic examination help to determine
the need for adjunctive therapy, such as chemotherapy, and
to evaluate the patient’s long-term prognosis. One study found
that surgery and chemotherapy did not improve survival in dogs
compared to surgery alone.10
Postoperative Care
Post-operatively, the animal should be closely observed during
recovery for bleeding at the surgical site. Serum calcium levels
should be monitored daily for 2 to 4 days post-operatively if a
bilateral tumor is resected. Hypocalcemia due to hypoparathy-
roidism is treated according to the protocol in Table 37-4.11
of surgical excision. As previously mentioned, even thyroid on the myocardium. Some cats have apathetic hyperthyroidism,
carcinoma can be associated with a good prognosis if the tumor a syndrome characterized by signs opposite to the classic
is mobile and is completely excised. presentation for hyperthyroidism, such as depression, lethargy,
and anorexia.5
Thyroid Tumors in Cats
Diagnosis
Pathophysiology Diagnosis of feline hyperthyroidism is based on the history and
Thyroid masses in the cat are usually benign and functional. clinical signs, palpation of a neck mass, and elevated serum
The disease can be unilateral or bilateral and histologically the triiodothyronine and thyroxine concentrations.5 One or more
tumors are usually adenomatous hyperplasia. Rarely, (in 1 to 2% thyroid nodules are palpable in approximately 85 to 90% of
of cases), the tumors are carcinomas.6 Thyroid tumors in cats affected cats. The cats may also have leukocytosis, higher than
produce excessive amounts of thyroxine and cats develop the normal packed cell volume, and high alkaline phosphatase.5
clinical syndrome of hyperthyroidism. Classic clinical signs of Hyperthyroid cats may also have hypertrophic cardiomyopathy
hyperthyroidism include tachycardia, hyperactivity, weight loss, with hypertrophy of the left ventricular free wall and ventricular
polyphagia, and polyuria/polydipsia.5 In addition to tachycardia septum.5 Renal function should be carefully evaluated prior to
a gallop rhythm, systolic murmurs, and arrhythmias can occur treatment of hyperthyroidism in cats. Hyperthyroidism may mask
due to the catecholamine like effects of the excessive thyroxine chronic renal failure by increasing renal blood flow.12 Treatment
Endocrine System 561
of the hyperthyroidism can result in exacerbation of the renal propanolol (0.1 mg IV) can be given to control the arrhythmia.
dysfunction when renal blood flow returns to normal. Some
clinicians recommend a thirty-day therapeutic trial course of The surgeon should be comfortable with the regional anatomy,
methimazole to assess the effect of decreased renal blood flow and with performing fine dissection of very small anatomic struc-
on kidney function. tures. Surgical instruments that are helpful include tenotomy
scissors, DeBakey or Simkin thumb forceps, sterile cotton tipped
Radionuclide scan of the thyroid gland in cats with hyperthy- applicators, and bipolar electrocautery.
roidism reveals increased uptake and size of the affected lobes.
Nuclear scan can be a useful diagnostic tool in cats that do Adequate postoperative monitoring is mandatory for recognizing
not have a palpable thyroid nodule or that have had relapse of and managing potential complications, such as hypocalcemia.11
hyperthyroidism after thyroidectomy.5 However, nuclear scans It is recommended that facilities and personnel be suitable
have limited practicality because of the specialized equipment for providing intensive postoperative care that is occasionally
and expertise needed to perform the studies. required.
the cranial pole of the thyroid to avoid injury to the blood supply
of the extracapsular parathyroid gland. If the thyroid gland
becomes fragmented during dissection, the surgical field is
carefully examined for remnants of thyroid tissue that were not
removed. These remnants and associated capsule are removed.
Remaining remnants of capsule are also removed since micro-
scopic thyroid tissue may be attached to them. The incision is
closed as described under the extracapsular technique. All
resected tissue is submitted for histologic evaluation.
Postoperative Care
Postoperatively, the cat is closely monitored for evidence of
hemorrhage from the surgical site. Serum calcium levels are
monitored for at least 2 days postoperatively. If hypocalcemia
develops due to removal or damage to the parathyroid glands,
the cat is treated with calcium (parenteral and/or oral admin-
istration) and vitamin D as described in Table 37-4. Calcium
supplementation potentiates the effect of calcitriol, but calcium
supplements alone are not effective for control of hypocalcemia.
Early signs of hypocalcemia are muscle soreness or spasm,
anorexia, and depression. Later signs are collapse and tetany.
Figure 37-8. Extracapsular dissection for removal of a thyroid lobe in Thyroid replacement therapy (L-thyroxine, 0.1 mg orally once
a cat. (From Graves TK, Peterson ME, Birchard SJ. Thyroid gland. In: daily) is not given routinely but it may be indicated for cats that
Birchard SJ, Sherding, eds. Saunders manual of small animal practice. have had bilateral thyroidectomy and show clinical signs of
Philadelphia: WB Saunders, 1994:218-228.) hypothyroidism (e.g. lethargy, weight gain, skin problems).
in the sternohyoideus muscle using absorbable suture, simple Renal function should be monitored closely in cats after thyroid-
continuous pattern in the subcutaneous tissues with absorbable ectomy, especially if they have evidence of chronic renal failure
suture, and interrupted sutures in the skin with non-absorbable preoperatively. As previously described, renal function in some
sutures. As an alternative to skin sutures, a continuous cats worsens after thyroidectomy, presumably due to a decrease
absorbable intradermal suture layer may be placed. in renal blood flow after lowering the thyroxine levels.12
Modified Intracapsular Technique The prognosis for hyperthyroid cats after thyroidectomy is good.
A small nick incision is made in an avascular area of the thyroid Treated cats show improved behavior and significant weight
capsule (Figure 37-9). This incision is extended with small scissors. gain. Histologic examination of the thyroid tissue usually reveals
The thyroid tissue is then gently separated from the capsule adenomatous hyperplasia. Rarely, histologic exam of the excised
with sterile cotton tipped applicators. Meticulous hemostasis is mass reveals thyroid carcinoma.17 These tumors are much larger
critical to maintain good visualization of the surgical field. Hemor- and more vascular than the more common benign adenomatous
rhage from small capsular vessels is controlled using pinpoint hyperplasia.
electrocautery. Extreme care is required during manipulation of
Figure 37-9. A.-C. Intracapsular dissection for removal of a thyroid tumor in a cat. (From Graves TK, Peterson ME, Birchard SJ. Thyroid gland. In:
Birchard SJ, Sherding, eds. Saunders manual of small animal practice. Philadelphia, WB Saunders, 1994:218-228.)
Endocrine System 563
References
1. Evans HE, Christensen GC: Miller’s Anatomy of the Dog, The Endocrine
System, WB Saunders, Philadelphia, 1979, pp. 611-618.
2. Nicholas JS, Swingle WW: An experimental and morphological study
of the parathyroid glands of the cat. Am J Anat 34:469-508, 1925.
3. Brodey TS, Kelly DF: Thyroid neoplasms in the dog. Cancer 22: 406-416,
1968.
4. Birchard SJ, Roesel OF: Neoplasia of the thyroid gland in the dog: A
retrospective study of 16 cases. JAAHA 17:369-372, 1981.
5. Panciera DL, Peterson ME, Birchard SJ. Diseases of the thyroid
gland. In Saunders Manual of Small Animal Practice, 3rd ed., Birchard
SJ, Sherding RG, eds. Elsevier, St. Louis, 2006, pgs. 327-342 .
6. Leav I, Shiller AC, Rijnberk A, Legg MA, derKinderen PJ: Adenomas
and carcinomas of the canine and feline thyroid. Am J of Path 83:61-
93,1976.
7. Klein MK, Powers BE, Withrow SJ, et.al. Treatment of thyroid
carcinoma in dogs by surgical resection alone: 20 cases (1981-1989)
JAVMA 206:1007-1009, 1995.
8. Tuohy JL, Worley DR, Withrow SJ,. Outcome following simultaneous
bilateral thyroid lobectomy for treatment of thyroid gland carcinoma in
dogs: 15 cases (1994-2010). J Amer Vet Med Assoc 241: 95-103, 2012.
9. Pack L, Roberts RE, Dawson SD, et.al. Definitive radiation therapy for
infiltrative thyroid carcinoma in dogs. Vet Radiol Ultrasound 42:471-474,
2001.
10. Nadeau ME, Kitchell B E. Evaluation of the use of chemotherapy
and other prognostic variables for surgically excised canine thyroid
carcinoma with and without metastasis. Can Vet J 52: 994-998, 2011.
11. Schenck PA, Chew DJ, Van Gundy T. Diseases of the parathyroid
gland and calcium metabolism. In; Saunders Manual of Small Animal
Practice, 3rd. ed. Birchard SJ, Sherding RG, eds., Elsevier, St. Louis,
2006, pgs. 343-356.
12. DiBartola SP, Broome MR, Stein BS, et. al. Effect of treatment of
hyperthyroidism on renal function in cats. J Am Vet Med Assoc 208:875-
878, 1996.
13. Peterson ME, Kintzer PP, Hurvitz AI. Methimazole treatment of 262
cats with hyperthyroidism. J Vet Intern Med 2:150-157, 1988.
14. Birchard SJ, Peterson ME, Jacobson A: Surgical treatment of feline
hyperthyroidism: Results of 85 cases. JAAHA 20:705-709, 1984.
15. Welches CD, Scavelli TD, Matthiesen DT, et. al. Occurence of
problems after three techniques of bilateral thyroidectomy in cats. Vet
Surg 18:392-396, 1989.
16. Flanders JA, Harvey HJ, Erb HN. Feline thyroidectomy: A comparison
of postoperative hypocalcemia associated with three different surgical
techniques. Vet Surg 16:362-366, 1987.
17. Turrel JM, Feldman EC, Nelson RW, et. al. Thyroid carcinoma causing
hyperthyroidism in cats: 14 cases (1981-1986).
18. Swalec KM, Birchard SJ. Recurrence of hyperthyroidism after
thyroidectomy in cats. J Am An Hosp Assoc 26:433-437, 1990.
564 Soft Tissue
Clinical Signs and Diagnosis is contraindicated during repair of acute incisional hernias
unless wound edges are nonviable or necrotizing fascial tissue
Signs of acute incisional herniation usually develop within the
is present. Removing healthy wound edges creates excessive
first three to five days after surgery.8 Wound edema and inflam-
and unnecessary tissue trauma and spreads contamination into
mation are signals of altered wound healing from any cause, and
sterile areas. Debridement of this actively healing tissue sets the
these signs may be seen early in the sequence of events leading
wound back to the substrate phase and delays the onset of rapid
to herniation. Serosanguineous drainage from the incision
wound strength gain.
and swelling are important and consistent signs of impending
acute abdominal wound dehiscence across animal species.4,17
Swelling is usually soft and painless unless infection or organ Chronic Incisional Hernias
compromise is present. Incisional drainage often occurs from a Chronic incisional hernias that are not incarcerated have enough
benign problem after surgery such as a seroma, however, this strength in the overlying hernia sac and skin to prevent eviscer-
condition must be differentiated from those patients with acute ation, so these hernias may be repaired on an elective basis
incisional hernia. Early diagnosis and treatment of incisional or conservatively managed.1 Palpable adhesions to protruding
hernias are vital to reduce the possibility of complete wound organs are, however, indications for early surgical intervention
dehiscence and evisceration (organ protrusion).1 because adhesions may cause obstruction, torsion and vascular
compromise of entrapped tissue.
Any wound exhibiting signs of altered wound healing (edema,
swelling, inflammation) should be examined carefully for Conservative management of asymptomatic patients with small
incisional herniation.1 Seroma, hematoma, cellulitis, or excessive hernias should be considered only if the patient’s owners can be
foreign body response to buried suture material are differential trusted with wound monitoring. Affected patients require daily
diagnoses for acute incisional hernias. The skin incision line hernia palpation. Pain, discoloration, incarceration, and rapid
should be manipulated laterally during deep palpation over the increase in hernia size are indications for immediate examination
muscle wall closure to aid in definition of the abdominal suture of the animal by the veterinarian. Chronic hernias usually do not
line. Further diagnostic testing (radiography, ultrasound, and cause significant patient discomfort, however, they may be of
fine needle aspiration) may be required for definitive diagnosis concern when the animal is used for breeding.4 Large hernias
if displaced viscera or a hernial ring cannot be identified. Small may prevent delivery (causing dystocia) because of uterine incar-
amounts of omentum herniated through a small defect cause ceration or lack of adequate abdominal contraction during labor.
persistent wound swelling and is rarely diagnosed without
wound exploration. Chronic incisional hernias are usually approached surgically
over the original incision area. Muscle edges may retract some
distance away from the defect, producing a functional loss of
Treatment abdominal wall. This results in excessive tension during primary
Acute Incisional Hernias hernia repair and thus increases recurrence risk.7,18
Most incisional hernias should be repaired without delay unless
they are chronic and freely reducible. Prognosis dramatically A major technical difficulty in repair of chronic incisional hernias
worsens if evisceration occurs. Immediate hospitalization and is accurate identification of normal tissue layers. Surgical
support of the hernia with bandages should be performed as dissection and accurate identification of primary strength-
the patient is prepared for surgery. Early surgical intervention holding tissue at hernia margins are critical for lasting repair.
is recommended for those patients with eviscerated hernias, or Simple imbrication of the hernial sac without extensive scar
those with overlying skin incision breakdown or devitalization excision from the hernial ring usually results in recurrence of
because exogenous contamination could result in fatal septic the hernia because of attenuation of the relatively weak scar
peritonitis.1 tissue. In chronic hernias, muscle and subcutaneous tissues are
usually scarred together in one layer. Conservative excision of
The approach is made over the original incision unless organ surrounding scar tissue is recommended until identification of
damage is present; otherwise, a ventral midline approach may the strength-holding layer is possible.
be used. When technical failure is suspected (knot, suture, or
tissue failure) the entire wound is reopened and repaired. If one A condition termed “loss of domain” occurs when the abdominal
significant technical error is present in the hernial ring area, cavity has become accustomed to a smaller intra-abdominal
other adjacent areas are also at risk of impending breakdown. volume than normal. A functional loss of abdominal wall occurs
The surgeon should pay particular attention to identification of in this instance. As a result, reduction of the hernial contents and
the strength-holding layer and include appropriately sized tissue primary closure of the (usually large) defect may be impossible.
bites (at least 5 mm) during suturing of this layer. Acute incisional Closure of the abdominal wall by forcing herniated contents
hernias are repaired with primary musculofascial reconstruction back into the abdomen results not only in excessive tension
if adequate tissue is present to close the hernia without undue on the repair, but also in acute pulmonary compromise from
tension. The surgeon should remove fat completely between restriction of diaphragm function.7 In most veterinary patients
edges to be approximated. Knots are carefully tied with the with large chronic defects or areas of abdominal tissue loss,
appropriate number of snug square throws and attention is paid surgical repair is performed with prosthetic materials such as
to intrinsic suture tension to avoid crushing tissue. Debridement polypropylene mesh.7,19
566 Soft Tissue
20. Mueller MG, Ludwig LL, Barton LJ: Use of closed-suction drains to white terrier. The Pekingese also exhibits a greater incidence of
treat generalized peritonitis in dogs and cats: 40 Cases (1997-1999). J concurrent umbilical hernia.3 The cause of congenital inguinal
Am Vet Med Assoc 219:789, 2001. hernias is unknown, but the disorder has been attributed to
21. Woolfson JM, Dulisch ML: Open abdominal drainage in the treatment normal anatomic variations, polygenic inheritance, and infec-
of generalized peritonitis in 25 dogs and cats. Vet Surg 15:27, 1986. tious diseases.3
Inguinal Hernia Repair in Acquired inguinal hernias are noted most often in the middle-
aged intact bitch.4-6 Most cases of herniation occur in the estral or
the Dog pregnant bitch, suggesting hormonal involvement. Inguinal hernia
has not been reported in the neutered bitch.6 Other factors that
Paul W. Dean, M. Joseph Bojrab and may be involved include weakening of the abdominal wall, trauma,
Gheorghe M. Constantinescu obesity, and the accumulation of fat in the vaginal process.1,5
Figure 38-1. Lateral retraction of the midline incision exposes the hernial Figure 38-3. The edges of redundant sac are excised. Twisting of the sac
sac and its contents. facilitates maintenance of the reduced contents within the abdomen.
The inguinal ring on the other side is inspected, the vaginal Figure 38-4. The edges of the inguinal ring are apposed using nonab-
process in female dogs or the vaginal tunic in males is removed, sorbable suture material in a simple interrupted pattern. Care must be
and the ring is sutured closed. The mammary tissue is then drawn taken not to compromise the external pudendal vessels and genito-
femoral nerve as they exit the caudomedial border of the ring.
Postoperative Care
The caudal abdomen is bandaged immediately after the
procedure. Bandaging helps to eliminate dead space and
increases the comfort of the patient. If used, drains should be
covered with an absorbent dressing and bandage and can be
removed 3 to 5 days postsurgicaly, before the patient’s discharge
from the hospital. Broad-spectrum antibiotic treatment is used if
a drain is in place and for 3 days after drain removal.
Figure 38-2. The hernia sac is incised, and its contents are inspected and
returned to the abdomen. (The line indicates the incision in the sac.)
Hernias 569
F. A. Mann, G. M. Constantinescu and Retroflexion of the urinary bladder into the perineal hernia
Mark A. Anderson may result in urinary obstruction. The obstruction results from
an abrupt change in direction of the urethra.16 Clinical signs
associated with bladder retroflexion include stranguria, dysuria,
Introduction and anuria.16 Although perineal hernia is not considered a
The perineum is the region that closes the pelvic outlet, surrounding surgical emergency, immediate repositioning of the bladder or
the anal and urogenital canals.1 On the surface of the dog, the urine evacuation is required. If the bladder cannot be reduced
perineum is limited by the tail dorsally, the scrotum or beginning and urine evacuation cannot be achieved, surgical intervention
of the vulva ventrally, and the ischiatic tuberosity on both sides. on an emergency basis may be required.
Deeply, the perineum is bounded by the third caudal vertebra
dorsally, the sacrotuberous ligaments on both sides (absent in Other less commonly reported clinical signs have been
cats), and the arch of the ischium ventrally. The pelvic diaphragm depression/lethargy, vomiting, anorexia, perineal pain, stringy
is the vertical closure of the pelvic canal through which the last stool, weight loss, and fecal incontinence.15
segments of the digestive and urogenital viscera pass.2
between rectal sacculation (full-thickness outpouching of the the initial presentation are reported to have a poor response to
rectal wall) and diverticulum (protrusion of mucosa/submucosa medical management over an extended period of time.20
through a muscular defect) requires inspection of the muscular
coat of the rectum at surgery. Hormonal therapy either by castration, low-dose estrogen
therapy, or progestins can decrease the size of the prostate and
When there are clinical signs of urinary tract involvement with alleviate clinical signs associated with prostatic hyperplasia.
a perineal hernia, caudal abdominal radiography including the However, there are no reported studies that have evaluated
perineum are performed. The contents of the perineal hernia the efficacy of hormonal therapy on controlling the long-term
and the location of the urinary bladder is identified. If the urinary clinical signs associated with prostatomegaly and a concomitant
bladder cannot be visualized on routine radiography, retrograde perineal hernia.17 Castration is recommended by the authors
urethrography and/or cystography can be done.3,16 Alternately, because of its beneficial effects regarding prostatic disease
ultrasonography can be used to identify the location of the prophylaxis despite its questionable role in perineal hernia
urinary bladder (either within the hernia or abdomen) and can be recurrence prevention. The authors caution against other forms
used to assist decompression via syringe and needle. of hormonal therapy for prostatic disease since severe and fatal
complications such as bone marrow aplasia may result.
Conservative Therapy
Conservative management of perineal hernia includes the use of Surgical Anatomy
stool softeners, periodic enemas, and digital evacuation of the The structures involved in surgical repair of perineal hernia
feces from the rectum as needed.3,17 Dogs considered for conser- include the pelvic diaphragm, the perineal fasciae, and the
vative medical and dietary management include dogs that are poor nerves and vessels in the proximity of these structures (Figures
anesthetic/surgical candidates because of known organ disease 38-5 and 38-6). Additionally, extraperineal muscle flaps can be
and dogs with owners who refuse to have surgery performed.3,20 transposed for perineal herniorrhaphy (i.e., the semitendinosus
Dogs with straining as the primary clinical complaint during muscle flap).21
Figure 38-5. Surgical anatomy of the canine left perineum, caudal aspect.
Hernias 571
Figure 38-6. Surgical anatomy of the canine left perineum, lateral aspect. a- Rectum, b- Pelvic urethra, c- Sacrocaudalis lateralis ventralis m.
(labeled twice), d- Intertransversarii dorsales caudae mm., e- Rectococcygeus m., f- Coccygeus m., g- Levator ani m., h- External anal sphincter
m.–superficial part, i- Internal obturator m., j- Root of the penis, k- Ischiocavernosus m., l- Retractor penis m., m- Bulbospongiosus m.
The levator ani and coccygeus muscles originate from the medial the cutaneous part, the superficial part, and the deep part. The
side of the ischial spine and medial side of the body of the ilium/ cutaneous part lies directly under the skin in the subcutaneous
dorsal surface of the pubis cranial to the obturator foramen, fascia. The superficial part attaches to the third and fourth caudal
respectively. The levator ani and coccygeus muscles insert on vertebrae and passes around the lateral aspect of the anus and
the third through seventh caudal vertebrae, and the first through anal sacs to insert on the bulbocavernosus muscle (male) or the
the fourth caudal vertebrae, respectively. These two muscles constrictor muscle of the vulva (female). The deep part surrounds
form the lateral boundary for the rectum or the medial boundary the anal canal, passing medial to the anal sacs. The superficial
of the pelvic diaphragm.2,20 and deep parts can interchange with each other.2,17
The sacrotuberous ligament and the superficial gluteal muscle The semitendinosus muscle is a striated muscle that originates
form the lateral aspect of the pelvic diaphragm. The sacrotu- from the ischiatic tuberosity and inserts on the tibia and on the
berous ligament originates from the ischiatic tuberosity and tuber calcanei.1 Although it does not directly bound the perineal
inserts on the sacrum and first caudal vertebra. The superficial region, the semitendinosus muscle has been used to reconstruct
gluteal muscle originates on the lateral aspect of the sacrum, perineal hernia defects.21
first caudal vertebra, and the cranial half of the sacrotuberous
ligament. The superficial gluteal muscle forms a tendon lateral The internal pudendal artery and vein, and the pudendal nerve
to the perineal region and runs over the dorsal aspect of the are bound together by loose connective tissue, and this neurovas-
greater trochanter to insert on the third trochanter.2,20 cular bundle passes ventrolaterally to the coccygeus muscle and
continues caudomedially across the dorsal surface of the internal
The ventral aspect of the perineal region is bounded by the obturator muscle. At the caudal border of the ventral aspect of the
internal obturator muscle, which can be transposed for perineal external anal sphincter muscle, the pudendal nerve gives off the
herniorrhaphy. The internal obturator muscle originates on the caudal rectal nerve. This branch of the pudendal nerve provides
cranial and medial border of the obturator foramen and the motor innervation to the external anal sphincter muscle.2
internal surface of the ischium (ischiatic table), and inserts as a
flat tendon embedded in the bellies of the gemelli muscles in the The perineal fascia is the connective tissue covering of the
trochanteric fossa of the femur.2,20 perineal musculature and is divided into deep and superficial
layers. The deep perineal fascia is the fascia that tightly covers
The external anal sphincter muscle is a striated muscle that the musculature. The superficial perineal fascia is the loose
surrounds the anal canal. This muscle is divided into three parts: connective tissue that makes a thin hernial sac. The superficial
572 Soft Tissue
Patient Preparation
A perineal hernia is not usually considered a surgical emergency
unless the urinary bladder is retroflexed.16 If the urinary bladder
is retroflexed into the perineal hernia, the urinary bladder should
be manually reduced. If the urinary bladder cannot be reduced,
a urinary catheter should be placed or paracentesis must be
performed. Removal of urine from the urinary bladder should
assist in reduction. Serum biochemistries (serum urea nitrogen
and creatinine) should be evaluated. Dogs with azotemia should
be treated appropriately and surgery postponed until the patient
is stable.16
If the perineal hernia does not contain the urinary bladder, the
surgical repair is a nonmergent procedure. Since the majority of
dogs with perineal hernias are geriatric, a minimum data base
including a complete blood count, serum biochemistries, thoracic
radiographs and a complete urinalysis should be performed.3
Some surgeons prepare the dog for surgery by having the rectum
cleaned of all feces with several enemas the day before surgery,
and by fasting the dog for 24 hours prior to surgery. Enemas run
the risk of rectal trauma and make for fluid fecal material which
is difficult to contain during surgery; therefore, the authors
prefer to avoid enemas. Instead, gentle digital extraction of
feces is performed after the dog is anesthetized immediately
prior to surgery.
obturator and SIS techniques is facilitated by an understanding the anal sphincter muscle caudally. The coccygeus muscle and,
of the traditional perineal herniorrhaphy procedure. Therefore, if present, the levator ani muscle are dorsolateral to the defect.
the traditional technique is discussed first below. The sacrotuberous ligament can be palpated as the lateral
landmark of the repair. This ligament is a broad fibrous cord that
extends from the sacrum and first caudal vertebra to the ischiatic
Traditional Perineal Herniorrhaphy
tuberosity. The ventral boundary of the hernia is formed by the
The incision is made over the hernia from just lateral of the internal obturator muscle on the floor of the pelvis. Ventrolateral
tail base to just below the hernial mass (See Figure 38-7A and to the coccygeus and levator ani muscles and dorsal to the
B). The incision is curved slightly laterally in a dorsoventral internal obturator muscle is the neurovascular bundle (internal
direction. Care must be taken to not incise too deeply and injure pudendal artery and vein, and pudendal nerve) of this region.
the hernial contents. Identification of the neurovascular bundle is important because
the pudendal nerve supplies motor function to the external anal
Blunt dissection is used to enter the hernial sac (superficial sphincter muscle. Bilateral pudendal nerve injury may result
perineal fascia) and expose the hernial contents. Once the in permanent fecal incontinence.3 Unilateral pudendal nerve
contents of the hernia are exposed, redundant fat can be excised injury may lead to temporary incontinence until reinnervation or
and hernial fluid removed. If jejunum, prostate, colon, or urinary compensation from the opposite side occurs.
bladder are encountered, these structures can be reduced by
digital manipulation in a cranial direction back to their pelvic Before pelvic diaphragm repair the presence or absence of
or abdominal location and maintained with a gauze sponge. A rectal disease must be ascertained.4,8 Rectal deviation occurs
suture can be tied to the gauze sponge to facilitate its removal as a result of a potential space created by the hernia. Perineal
prior to tying the herniorrhaphy sutures. herniorrhaphy should alleviate rectal deviation and small saccu-
lation. Large rectal sacculation and rectal diverticulum may
Following reduction of the hernia, the muscular defect and cause straining to expel feces. Therefore, surgical excision of
landmarks for surgical closure are identified (Figure 38-8). The rectal diverticulum or large sacculation, followed by an inverting
medial side of the defect is bounded by the rectum, ending with suture pattern, should be performed to prevent perineal hernia
Figure 38-8. Operative view of left perineal hernia with placement of the first suture using the standard herniorrhaphy technique. The first suture
is placed in the most ventral position, from the internal obturator muscle to the external anal sphincter. [Note: The levator ani muscle may be
atrophied such that it is not recognizable.]
574 Soft Tissue
recurrence due to straining caused by impacted feces.4 entire structure. When placing sutures through the external anal
sphincter muscle multiple fibers are gathered onto the needle.
All herniorrhaphy sutures should be preplaced before they are Care should be taken to avoid penetration of the rectum or anal
tied (Figure 38-9). The authors recommend synthetic nonab- sac(s). Once all sutures are preplaced they are tied from dorsal
sorbable monofilament suture such as polypropylene for the to ventral. As sutures are tied the anus may be visualized to
primary closure of the hernial defect. Suture placement is begun ensure that it has not been grossly distorted.
from the most ventral aspect of the defect. The first suture is
placed from the internal obturator muscle laterally to the external Following closure of the hernial defect, the superficial perineal
anal sphincter muscle medially, or vice versa, depending on the fascia is mobilized laterally from the skin. After mobilization, the
side of the hernia and the surgeon (right- versus left-handed). perineal fascia can be used to reinforce the closure by suturing
Care should be taken when passing sutures through the internal the fascia caudally to the external anal sphincter muscle using
obturator muscle to not incorporate sutures into the neurovas- synthetic absorbable suture material. The subcutaneous tissue
cular bundle in this region. Since the recurrence rate is high and skin are closed routinely. Strategic subcutaneous suture
with the traditional suture technique, placement of an adequate placement to minimize dead space eliminates the need for
number of sutures ventrally is important to success.3 Additional placement of drains. Drains are to be avoided in the perineal
sutures are placed dorsally to the internal obturator suture(s) region because of postoperative contamination risks.
incorporating bites from the external anal sphincter into the
sacrotuberous ligament, the coccygeus muscle, and, when If bilateral hernia repair is considered, the hernias can be
present, the levator ani muscle.3 When placing sutures through repaired at the same surgery; however, some surgeons will
the sacrotuberous ligament, care must be taken to not include wait 4 to 6 weeks between repairs to decrease the stress and
the caudal gluteal artery/vein or the sciatic nerve which lie distortion of the external anal sphincter muscle associated with
cranial to the ligament. Placing a finger medial and cranial to the traditional herniorrhaphy technique.3
the sacrotuberous ligament may assist in determining the depth
of suture placement by palpation of the caudal gluteal artery’s We believe that castration should be performed for its benefits
pulse.3 Furthermore, the suture should be placed through the relative to treating prostatic disease. It is unlikely that castration
fibers of the sacrotuberous ligament instead of encircling the prevents pelvic diaphragm muscle weakness.12,13,25
Figure 38-9. Placement of sutures in the standard perineal herniorrhaphy technique. Suture placement is from ventral to dorsal: (1), (2), (3), and
(4). All sutures are preplaced and then tied. More than one suture may be placed in any of the four basic positions depending on the size of the
dog. If the levator ani muscle is recognizable, it is engaged with suture along with the coccygeus muscle in positions (3) and (4).
Hernias 575
Figure 38-10. Exposure of the right perineum for perineal herniorrhaphy using the internal obturator muscle transposition technique.
576 Soft Tissue
Figure 38-12. Right internal obturator muscle transposition. The transposed internal obturator muscle has been sutured to the external anal
sphincter medially, and to the sacrotuberous ligament and coccygeus muscle laterally.
necrotic portion of the urinary bladder may be required; however, progresses distally on the caudal aspect of the pelvic limb to end
in some cases, excessive urinary bladder necrosis may prohibit at the caudomedial aspect of the transition between the stifle
a successful resection.25 and the crus (Figure 38-14). The hernial contents are exposed
and reduced in similar fashion to other herniorrhaphy techniques
Recurrence of a perineal hernia after repair has ranged from 5 to prior to isolation of the semitendinosus muscle. The subcuta-
46%.8-11,28 Although some surgical procedures offer better results neous tissues over the semitendinosus muscle are incised to
and less chance of recurrence, the accurate identification expose the muscle (Figure 38-15). The semitendinosus muscle
of all anatomic structures is paramount to the success of any is bluntly isolated from surrounding structures taking care not
procedure. Furthermore, understanding the limitations of each to injure the proximal vascular pedicle (the caudal gluteal artery
particular technique is important in the surgical decision-making and vein). The semitendinosus muscle is transected as distally as
process and may help in reducing the failure of any technique. possible near the stifle and is further isolated for mobilization to
the perineal region. Incision of the lateral portion of the semiten-
The association between castration and the recurrence of a dinosus tendinous attachment to the ischium may be necessary
perineal hernia after surgical repair has been reported to be 2.7 for maximal mobilization, but care must be taken to avoid
times greater in dogs that were not castrated versus those dogs proximal vascular pedicle trauma or kinking that may occur with
that were castrated.9 However, in a later study, no correlation excessive mobilization. Using polypropylene or nylon suture,
was found between castration and perineal hernia recurrence. the transected portion of the semitendinosus muscle is sutured
Failure of perineal hernia repair was thought to be more related to the sacrotuberous ligament and the coccygeus muscle. The
to lack of experience with the surgical technique than any effect medial aspect of the semitendinosus muscle (now adjacent to
from castration.15 the external anal sphincter muscle dorsally) is sutured to the
external anal sphincter, and the lateral aspect of the semiten-
dinosus muscle (now adjacent to the ventral aspect of the
Salvage Techniques for Failed perineum) is sutured to the remnant of the internal obturator
Perineal Herniorrhaphy muscle, the ischiourethralis muscle, perineal fasciae, and/or the
Recurrence of canine perineal herniation following traditional periosteum of the dorsal surface of the ischium (Figure 38-16).
herniorrhaphy has been reported to be as high as 46%.10 Recur- Synthetic absorbable sutures are used to obliterate dead space
rence rates as low as 5% have been reported for the internal and close the subcutaneous tissues. The skin is closed with the
obturator muscle transposition herniorrhaphy technique.11 routine closure of the surgeon’s choice.
Nonetheless, until the ultimate cause of canine perineal hernia
can be identified and controlled, a certain degree of recur-
rence can be expected regardless of refinements in surgical
technique. When the traditional herniorrhaphy technique fails,
the simplest and usually most effective means of salvage is to
perform an internal obturator muscle transposition to recon-
struct the pelvic diaphragm. Alternately, the SIS technique could
be employed. When the internal obturator muscle transposition
fails, SIS might be used to close the defect; however, absence
of the internal obturator from its normal ischial location may
make it difficult or impossible to anchor the SIS ventrally. When
the internal obturator muscle transposition and SIS techniques
are not options, the authors recommend choosing from one of
the following two options: (1) semitendinosus muscle transpo-
sition21,29 for perineal reconstruction or (2) colopexy/cystopexy30-32
for preventing herniation of important structures.
Figure 38-15. Left semitendinosus muscle exposed prior to isolation and mobilization to reconstruct a failed right perineal herniorrhaphy.
Figure 38-18. Exposure of caudal abdominal organs and positioning of the descending colon adjacent to the left dorsolateral body wall for colopexy.
Abdominal organs are packed cranially with moist laparotomy sponges.
Figure 38-20. Cystopexy via deferent duct fixation. The left deferent
duct is passed through a belt loop created in the left transversus
abdominis muscle with the aid of a stay suture (inset) and is folded
onto itself and sutured to itself and to the belt loop.
Figure 38-23. Three clamp technique for caudal castration (open technique) of the left testicle. A fenestration (1) is made in the mesofuniculus to
allow a Carmalt forceps (2) to be placed across the tunic containing the cremaster muscle. An incision (3) is made distal to the Carmalt forceps.
A transfixation ligature (not shown) is placed proximal to the Carmalt forceps and tied as the forceps is removed to control hemorrhage from
the cremaster muscle. Three Carmalt forceps (4, 5, and 6) are placed across the spermatic cord, the proximal forceps applied first and the distal
forceps applied last. The testicle is excised by cutting (7) between the two most distal forceps, and a ligature (8) is placed proximal to the most
proximal Carmalt forceps and tightened as the most proximal forceps is removed. After the ligature is tied, the remaining forceps is removed. The
numbers represent the steps of the procedure. (Alternately, the pampiniform plexus testicular artery complex and the deferent artery and ductus
deferens may be excised and ligated using two separate three-clamp procedures.)
Perineal Herniorrhaphy in the Cat less common than in dogs, but one should be vigilant for the
same possible complications as described for dogs. Additionally,
The etiopathogenesis of perineal hernia in cats differs from
concurrent disease that might contribute to straining, such as
that of dogs. In cats, perineal hernia may occur as a long-term
megacolon, must be addressed for optimal success.
complication of perineal urethrostomy or may be associated
with megacolon. Feline perineal hernias that are not associated
with either of these two situations are considered idiopathic; a References
hormonal influence has not been seriously considered because 1. Constantinescu GM, Schaller O, Habel RE, Hillebrand A., Sack WO,
both genders are typically represented, most affected cats Simoens P, deVos NR. Illustrated Veterinary Anatomical Nomenclature
being spayed or castrated.33-36 A left-sided perineal hernia in an 2nd Edition. Enke F, Stuttgart, 2007, p. 222.
8-week-old cougar was thought to be congenital.37 Most perineal 2. Constantinescu GM. The pelvis and genital organs. In: Constantinescu
hernias in cats are bilateral.33 GM. Clinical Anatomy for Small Animal Practicioners. Ames, Iowa: Iowa
State Press, 2002, pp. 267-301.
The perineal herniorrhapy techniques used in dogs may be 3. Bojrab MJ, Toomey A. Perineal herniorrhaphy. Comp Cont Ed Pract
applied to cats, but attention should be paid to anatomical differ- Vet 1981;8:8-15.
ences. Feline perineal muscles are smaller than like muscles in 4. Krahwinkel DJ. Rectal diseases and their role in perineal hernia. Vet
the dog, and the cat does not possess a sacrotuberous ligament Surg 1983;12:160-165.
(Figure 38-24).38,39 Because feline perineal hernia is often bilateral, 5. Spruell JSA, Frankland AL. Transplanting the superficial gluteal
the internal obturator muscle transposition is preferred to the muscle in the treatment of perineal hernia and flexure of the rectum in
traditional technique to avoid excessive tension on the external dogs. J Small Anim Pract 1980;21:265-278.
anal sphincter. Although not yet reported in cats at the time of 6. Holmes JR. Perineal hernia in the dog. Vet Rec 1964;76:1250-1251.
this writing, SIS repair could also be performed. The seminten- 7. Walker RG. Perineal hernia in the dog. Vet Rec 1965;77:93-94.
diosus muscle transposition repair has been reported in a cat.40 8. Pettit GD. Perineal hernia in the dog. Cornell Vet 1962;52:261-279.
9. Hayes HW, Wilson GP, Tarone RE. The epidemiologic features of
Complications after perineal herniorrhaphy in cats seem to be perineal hernia in 771 dogs. J Am Anim Hosp Assoc 1978;14:703-707.
Hernias 583
10. Burrows CF, Harvey CE. Perineal hernia in the dog. J Sm Anim Pract Med/Small Anim Clin 1976;71:469-473.
1973;14:315-332. 23. Stoll MR, Cook JL, Pope ER, et al. The use of porcine small intestinal
11. Sjollema BE, Venker-van Haagen, van Sluijs FJ, et al. Electromyog- submucosa as a biomaterial for perineal herniorrhaphy in the dog. Vet
raphy of the pelvic diaphragm and anal sphincter in dogs with perineal Surg 2002;31:379-390.
hernia. Am J Vet Res 1993;54:185-190. 24. Desai R. An anatomical study of the canine male and female pelvic
12. Mann FA, Boothe HW, Amoss MS, et al. Serum testosterone and diaphragm and effect of testosterone on the status of the levator ani of
estradiol 17-beta concentration in 15 dogs with perineal hernia. J Am male dogs. J Am Anim Hosp Assoc 1982;18:195-202.
Vet Med Assoc 1989;194:1578-1580. 25. Matthiesen DT. Diagnosis and management of complications
13. Mann FA, Nonneman DJ, Pope ER, et al. Androgen receptors in the occurring after perineal herniorrhaphy in dogs. Comp Cont Ed Vet Pract
pelvic diaphragm muscles of dogs with and without perineal hernia. Am 1989;11:797-823.
J Vet Res 1995;56:134-139. 26. Piermattei DL, Johnson KA. Approach to the caudal aspect of the hip
14. Niebauer GW, Shibly S, Seltenhammer M, et al. Relaxin of prostatic joint and body of ischium. In: Piermattei DL, Johnson KA, eds. An Atlas
origin might be linked to perineal hernia formation in dogs. Ann N Y of Surgical Approaches to the Bones and Joints of the Dog and Cat. 4th
Acad Sci 2005;1041:415-422. ed. Philadelphia: Saunders, 2004, pp. 310-314.
15. Hosgood G, Hedlund CS, Pechman RD, et al. Perineal herniorrhaphy: 27. Dean PW, O’Brien DP, Turk MA, et al. Silicone elastomer sling for
perioperative data from 100 dogs. J Am Anim Hosp Assoc 1995;31:331- fecal incontinence in dogs. Vet Surg 1988;17:304-310.
342. 28. Orsher RJ. Clinical and surgical parameters in dogs with perineal
16. White RAS, Herrtage ME. Bladder retroflexion in the dog. J Sm Anim hernia- analysis of results of internal obturator transposition. Vet Surg
Pract 1986;27:735-746. 1986;15:253-258.
17. Bellenger CR, Canfield RB. Perineal hernia. In: Slatter DH, ed. 29. Philibert D, Fowler JD. Use of muscle flaps in reconstructive surgery.
Textbook of Small Animal Surgery. 3rd ed. Philadelphia: Saunders, 2003, Compend Cont Ed Pract Vet 1996;18:395-405.
pp. 487-498. 30. Bilbrey SA, Smeak DD, DeHoff W. Fixation of the deferent ducts for
18. Weaver AD, Omamegbe JO. Surgical treatment of perineal hernia in retrodisplacement of the urinary bladder and prostate in canine perineal
the dog. J Sm Anim Pract 1981; 22:749-758. hernia.Vet Surg 1990;19:24-27.
19. Dieterich HF. Perineal hernia repair in the canine. Vet Clin N Am 1975; 31. Brissot HN, Dupré GP, Bouvy BM. Use of laparotomy in a staged
5:383-399. approach for resolution of bilateral or complicated perineal hernia in 41
20. Harvey CE. Treatment of perineal hernia in the dog- reassessment. J dogs. Vet Surg 2004;33:412-421.
Sm Anim Pract 1977;18:505-511. 32. Yoon H, Mann FA, Clinical evaluation of three different colopexy
21. Chambers JN, Rawlings CA. Applications of a semitendinosus flap in techniques in dogs. Indian Vet J 2009; 86:1129-1131.
two dogs. J Am Vet Med Assoc 1991;199:84-86. 33. Welches CD, Scavelli TD, Aronsohn MG, et al. Perineal hernia
22. Knecht CD. An alternate approach for castration of the dog. Vet in the cat: a retrospective study of 40 cases. J Am Anim Hosp Assoc
1992;28:431-438.
584 Soft Tissue
34. Johnson MS, Gourley IM. Perineal hernia in a cat. Vet Med
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35. Ashton DG. Perineal hernia in the cat: a description of two cases. J
Small Anim Pract 1976;17:473-477.
36. Leighton RL. Perineal hernia in a cat. Feline Pract 1979;9:44.
37. Anderson M, Pope ER, Constantinescu GM. Perineal hernia in a
cougar. J Am Vet Med Assoc 1992;201:1771-1772.
38. Martin WD, Fletcher TF, Bradley WE. Perineal musculature in the
cat. Anat Rec 1974;180:3-14.
39. Constantinescu GM, Amann JF, Anderson MA, et al. Topography and
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40. Babic DV, Stejskal M, Capak D, et al. Application of a semitendi-
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Blunt trauma severe enough to cause rupture of the abdominal Stabilization of the patient’s condition takes precedence over
wall may also cause widespread crush, rupture, or avulsion hernia repair. Because these hernias are usually large, the risk
damage to surrounding structures and intra-abdominal organs. of incarceration or strangulation of viscera is low. Therefore,
As many as 75% of small animals with traumatic abdominal if the patient is stable and serious intra-abdominal trauma has
hernias have other serious injuries, most are orthopedic in nature been ruled out, the hernia can be repaired several days later,
usually involving the pelvis. Other important common injuries are after swelling and hemorrhage begins to subside and tissues
to soft tissues, including respiratory, gastrointestinal, and genito- reestablish their blood supply. If the patient does not stabilize
urinary systems.2,3 Following patient stabilization, a thorough with resuscitative measures, serious intra-abdominal injury or
physical examination and diagnostic workup are indicated to contamination should be suspected and further diagnostic tests
evaluate for more insidious, often life-threatening, injuries. and/or emergency exploratory laparotomy may be indicated.
Hernias 585
Surgical Technique
Surgical correction is usually performed through a ventral midline
approach. When an exploratory laparotomy is indicated, the
entire abdomen should be prepared aseptically, and if the hernial
sac extends to adjacent areas, these areas should be liberally
prepared also. The way in which the patient is positioned on the
operating table may be critical for successful closure of a prepubic
hernia. Closure may be virtually impossible if the patient is placed
in a routine dorsal recumbent position (limbs pulled caudally and
abducted and trunk in slight dorsal flexion (Figure 38-26A). The
rear limbs should be pulled cranially and the body ventroflexed to
relieve tension during hernia repair (Figure 38-26B). If transposition
of the cranial sartorius muscle is planned to augment the primary
hernia repair, the adjacent hind limb is also prepared for aseptic
surgery (Figure 38-27). Prophylactic antibiotics are administered
during preparation of the surgical site.
hernia recurrence, wound infection, seroma, and skin slough are obstructing important vascular and neural structures of the
the most common complications after repair.6 Traumatized skin inguinal or femoral canal. If mesh is used for reconstruction,
and soft tissues are handled with utmost care, and excessive blunt I prefer to transpose the cranial sartorius muscle to provide a
dissection is avoided because the vascular supply may be tenuous seal and bring additional blood supply over the repair to support
and further insult could result in tissue loss or an increased risk rapid healing and incorporation of the mesh (See Figure 38-27).7,8
of infection.6 After abdominal exploration, and necessary organ I also consider using this muscle to augment inguinal or femoral
repair is completed, the abdominal cavity is lavaged, and the linea defects when tissue edges are tenuous or when the wound will
alba is closed routinely. not support synthetic mesh (heavily contaminated wounds).
The surgeon should recognize that this muscle is not covered
The prepubic hernia is exposed by careful dissection and by heavy fascia so the muscle alone should not be expected to
debridement of devitalized tissue (Figure 38-28). Excision of maintain abdominal wall continuity under excessive tension.
connective tissue surrounding the hernia is avoided unless it is
devitalized or infected, and will not support sutures. The surgeon Usually a large amount of dead space is present in the subcu-
carefully inspects the lateral margins to determine whether the taneous tissues after herniorrhaphy. Gravity dependent drains
hernia extends into the inguinal and femoral areas. Important such as Penrose drains or, preferably, closed suction drain
vascular and neural structures are isolated and protected, systems (Jackson-Pratt) should be used in most cases. Avoid
particularly if the femoral region requires reconstruction. If placing open-drain systems directly against buried mesh to
femoral or inguinal areas are involved, the regional anatomy is reduce the risk of ascending infection.
studied carefully before undertaking herniorrhapy. The prepubic
hernia component is repaired first, to help align tissues correctly
for anatomic reconstruction of the inguinal and femoral hernias,
if present. The cranial public ligament is reattached with large
2-0 to 0 size monofilament (prolonged absorbable) suture or
nonabsorbable suture. If enough healthy tendon is present, the
surgeon anatomically repairs the hernia with preplaced inter-
rupted sutures incorporating large bites of tissue. As adjacent
preplaced sutures are pulled firmly, knot the individual sutures.
This maneuver helps reduce the risk of suture cutout during
repair. In most prepubic hernias, the ligament is avulsed from the
pubic bone leaving scant soft tissue attached. In this case, holes
are drilled in the cranial brim of the pubis to anchor sutures. When
the hernia cannot be repaired without excess tension, a cuff
mesh reinforcement of the prepubic tendon can be performed
using polypropylene mesh (Figure 38-29). Concurrent femoral or
inguinal hernias are repaired by carefully isolating the hernia
edges and anatomic reconstruction. Often, the inguinal ligament
is ruptured, and sutures are preplaced between the abdominal
oblique fascia and the musculature of the proximal medial thigh.
Extreme care is required to avoid damaging, incorporating or
B
Figure 38-29. Cuff mesh reinforcement of a prepubic hernia. A. The pre-
pubic defect is closed with preplaced sutures between holes drilled in
the pubic bone, and a mesh reinforced edge of torn rectus abdominis
muscle and prepubic tendon. B. Section through caudal abdominal
Figure 38-28. Ventral view of pelvis showing prepubic defect. Dashed wall showing cuffed mesh reinforcement of the rectus abdominis ten-
line indicates hernia ring. (Modified from Robinette JD, Hernias. In don, and fixation of the mesh to the pubis. (A, modified from Robinette
Gourley IM, Vasseur PB eds. General Small Animal Surgery. Philadel- JD, Hernias. In Gourley IM, Vasseur PB eds. General Small Animal
phia, JB Lippincott, pp759, 1985.) Surgery. Philadelphia, JB Lippincott, pp755-776, 1985.)
Hernias 587
Postoperative Care
Monitoring and postoperative care instructions are dictated
by the nature and severity of the injury. The surgeon should
continue to monitor the patient’s vital signs and remains aware
of possible problems related to occult visceral damage. Patients
should be given analgesic agents for at least 24 hours after the
surgical procedure. An epidural using narcotic analgesics is very
effective to prevent postoperative pain. Unless contraindicated,
nonsteroidal anti-inflammatory drugs are also administered
to reduce postoperative wound edema and pain. Wounds and
drains should be monitored for signs of infection or hernia recur-
rence. Drains should be bandaged, if possible, and removed when
discharge has diminished. This is usually possible within 3 days.
If infection occurs, wounds are opened, cultured, debrided, and
secondarily closed. Strict exercise limitation is recommended
for at least four to six weeks particularly if a prosthetic mesh
was implanted. If the inguinal or femoral areas have been recon-
structed along with the prepubic hernia, the surgeon should
consider placing the patient’s hind limbs in hobbles to prevent
tension from excess limb abduction. An Elizabethan collar is used
to guard against premature drain removal or wound mutilation.
Prognosis
Based on a report of a series of patients undergoing prepubic
herniorrhaphy, approximately 80% will survive and have
successful hernia repair. If a hernia recurs (about 15% do) the
defect is usually evident by one month after surgery. Repair of
these recurrent hernias is usually successful provided the repair
is anatomic, is free of tension, and incorporates strong tissue.
The remaining 20% have poor results because of the severity of
accompanying injuries.1,3
References
1. Mann FA et al.: Cranial pubic ligament rupture in dogs and cats. J Am
Anim Hosp Assoc 22:519, 1986.
2. Waldron DR et al.: Abdominal hernias in dogs and cats: A review of 24
cases. J Am Anim Hosp Assoc 22:818, 1986.
3. Shaw SP, Rozanski EA, Rush JE: Traumatic body wall herniation in 36
dogs and cats. J Am Anim Hosp Assoc 39:35-46, 2003.
4. Green RB, Quigg JA, Holt PE: Vesicocutaneous fistulation following
prepubic tendon rupture in a bitch. J Small Anim Pract 30:315-317,
1989.
5. Hanson RR, Todhunter RJ. Herniation of the abdominal wall in pregnant
mares. J Am Vet Med Assoc 189:790-3, 1986.
6. Smeak DD: Management and prevention of surgical complications
associated with small animal abdominal herniorrhaphy. Prob Vet Med
1:254, 1989.
7. Weinstein MJ, Pavletic MM, Boudrieau RJ, Engler SJ: Cranial
sartorius muscle flap in the dog. Vet Surg 184:286-291, 1989.
8. Philiber D, Fowler JD: Use of muscle flaps in reconstructive surgery.
Comp Contin Ed Pract Vet 18:395-405, 1996.
588 Soft Tissue
Section H
Onychectomy requires general anesthesia. Adjunctive preop-
erative opioids and non-steroidal anti-inflammatory drugs have
been shown to greatly improve postoperative comfort in cats.
Buprenorphine (0.01 mg/kg intramuscularly) and application of
Integument a transdermal fentanyl patch (25 ug/hr) were shown to be the
most effective opioids. Meloxicam (0.3 mg/kg subcutaneously)
was proven more effective than butorphanol for pain control.
Additionally, local anesthesia in the form of a ring block proximal
to the paw is routinely performed. Bupivicaine (1 mg/kg) is
Chapter 39 distributed perineurally through a 25 gauge needle to selec-
tively block nerve impulses in the sensory branches of the radial,
median, and ulnar nerves (Figure 39-1). Bupivicaine has a 15 to
Feline Onychectomy 20 minute onset of action and lasts 6 to 8 hours.
Figure 39-1. Note the anatomic location of needle placement for regional nerve block to the cat paw prior to forelimb declaw.
Lymph generally flows from the cranial three pairs of mammary consistency, and location of the tumor; the size, age, and physi-
glands toward the axillary lymph nodes and from the caudal two ologic status of the patient; and the beliefs and prejudices of the
pairs toward the inguinal lymph nodes. A lymphatic connection surgeon. Unfortunately, subjective criteria still play a major role
between the cranial and caudal abdominal glands is present in in the selection of a mastectomy procedure because objective
some bitches. data for choice are inconclusive.
Only about half of all canine mammary tumors are malignant, Partial mammectomy: Removal of the tumor and a surrounding
whereas most (86%) feline mammary tumors are malignant. margin of mammary tissue. This procedure usually is indicated
Prognosis for both dogs and cats with malignant tumors is for tumors that are small to moderate in size (up to 2 cm in
guarded to poor. Although length of survival is inversely corre- diameter) and occupy only a portion of an individual gland. The
lated with the growth rate of the tumor, the extent of local infil- tumor may be suspected to be invasive and may or may not have
tration, and the status of regional lymph nodes and lungs, the palpable distinct margins.
major statistically significant survival factor is tumor volume.
Both dogs and cats with large (> 3 cm) malignant mammary Simple mastectomy: Removal of the entire mammary gland
tumors have significantly shorter survival times than those with containing the tumor.
small malignant tumors, emphasizing the importance of early
diagnosis and treatment. Regional mastectomy (modified radical mastectomy): Removal of
groups of mammary glands depending on which glands contain
Treatment failure is represented by intractable local recurrence tumor. The rationale for regional mastectomy depends on the
or, more commonly, by the development of metastatic disease. presumed anatomy of mammary gland lymphatic drainage and
Because metastatic mammary cancer is found most frequently the assumption that mammary cancer spreads from one gland
in the lungs, thoracic radiography is a common screening test to another along lymphatic pathways, which are not altered by
before mastectomy. Dogs with mammary cancer affecting the space-occupying masses.
caudal mammary glands, especially when the inguinal lymph
nodes are palpably enlarged, should also be radiographically Complete unilateral mastectomy (radical mastectomy): Removal
or ultrasonographically checked for enlarged sublumbar lymph of all ipsilateral mammary glands, intervening tissues, and
nodes, because metastasis through sublumbar lymphatics is regional lymphatics.
often detectable before the radiographic appearance of lung
metastases. Enlarged lymph nodes should be excised at the Complete bilateral mastectomy (bilateral radical mastectomy):
time of surgery in dogs and the draining lymph nodes routinely Removal of both entire mammary chains, intervening tissues, and
removed in cats. Axillary lymph nodes are not routinely removed regional lymphatics. If performed, a 3 to 4 week interval between
unless palpably enlarged while the inguinal lymph node is sides is recommended to reduce skin tension and postoperative
removed when the inguinal mammary gland (#5) is excised. complications.
Lymph node removal is regarded as a staging rather than thera-
peutic procedure in most dogs. Available data indicate that the extent of surgery had little
influence on either the survival time or the rate of recurrence of
Mammary neoplasia can be prevented by ovariohysterectomy mammary cancer in dogs. In other words, no evidence indicates
performed when the bitch or queen is young (i.e., before the first that complete unilateral mastectomy (radical mastectomy) is any
estrus). Ovariohysterectomy loses its protective effect after the more beneficial for treating a 2 cm tumor in the fourth mammary
4th estrus in the canine. However, although estrogen, proges- gland of a dog than is a simple mastectomy. Until further data is
terone, and other receptors have been found in canine and feline available, selection of a surgical procedure in dogs is dictated
mammary tumors, it is controversial as to whether ovariohys- by what is most efficient with the goal of attaining clean surgical
terectomy has any beneficial effect as a treatment for existing margins by complete removal of the tumor. Good oncologic
mammary neoplasia. The current recommendation is to spay the surgical principles still apply, however, regardless of the
animal at the time of mammary tumor excision. procedure used, invasive tumor should be widely resected with
deep and centrifugal 2 cm en bloc margins of normal tissue with
early ligation of blood vessels performed.
Selection of Surgical Procedure
The amount of mammary tissue to remove from a dog or cat with In cats, complete unilateral mastectomy is the surgical procedure
mammary neoplasia is influenced by several factors: the size, of choice for all mammary tumors. This approach has been
592 Soft Tissue
recommended by veterinary oncologists because most feline more important, because most affected dogs also suffer from
mammary tumors are highly malignant. The 10 to 15% of cats with disseminated intravascular coagulation. Attempts at extensive
benign mammary nodules are overtreated by this philosophy. surgical therapy often result in severe, intractable bleeding
from the incision, deterioration of the patient over 12 to 24 hours,
Surgery is contraindicated for inflammatory carcinoma of the and death. Inflammatory mammary carcinoma is invariably
mammary gland. Inflammatory carcinoma of the mammary fatal, usually within a month after clinical signs are obvious.
gland is a fulminant and aggressive malignant disease. Treatment is strictly palliative and consists of antiinflammatory
Affected tissues are diffusely thickened, inflamed, painful, and drugs, analgesics, and antibiotics.
frequently ulcerated. A space-occupying mammary mass may
or may not be obvious. Commonly, the tissues are so diffusely
thickened that discrete tumors are not apparent. The condition
Surgical Techniques
closely resembles severe mastitis and is frequently misdiag- Mastectomy procedures are performed similarly in cats and
nosed as such. Surgery is unrewarding because it is virtually dogs, although the laxity of feline skin generally makes surgery
impossible to remove the affected tissues completely, and, easier in cats.
Figure 40-1. Comparison of extent of tissue removal with different mastectomy procedures. A. Lumpectomy. Skin incision is made directly over the
tumor. B. Partial mastectomy. An elliptic skin incision is made, encompassing the tumor and a portion of the surrounding mammary tissue. C. An
elliptic skin incision is made to encompass the gland that contains the tumor completely. D. Regional mastectomy. An elliptic skin incision is made to
encompass the glands to be removed, as determined by the location of tumor and the presumed pathways of lymphatic drainage (inset). Generally,
the first three glands are removed en bloc when tumor exists in any one of them; likewise, the last two glands are removed en bloc when tumor ex-
ists in either of them. Some authors recommend that the third gland be removed whenever the fourth and fifth are excised because of the “incon-
stant” lymphatic drainage between the third and fourth glands. E. Complete unilateral mastectomy. The skin incision encompasses all ipsilateral
mammary glands. See the text for details of the dissection.
Mammary Glands 593
Figure 40-2. Developing a proper plane of dissection greatly facilitates simple, regional, and complete unilateral mastectomy procedures. A. In the
abdominal and inguinal regions, the loosely adherent mammary glands can be stripped from the underlying fascia with a sponge. B. In the thoracic
region, the glands adhere to the underlying muscle, so dissection with scissors is required.
594 Soft Tissue
Suggested Readings
Alenza MDP, Tabanera E, Pena L. Inflammatory mammary carcinoma in
dogs: 33 cases (1995-1999). J Am Vet Assoc 2001;219:1110-1114.
Allen SW, Mahaffey EA. Canine mammary neoplasia: Prognostic
indicators and response to surgical therapy. J Am Anim Hosp Assoc
1989;25:540-546.
Hayes AA, Mooney S. Feline mammary tumors. Vet Clin North Am
1985;15:513-520.
Kristiansen VM, et al. Effect of ovariohysterectomy at the time of tumor
removal in dogs with benign mammary tumors and hyperplastic lesions:
A randomized controlled clinical trial. J Vet Intern Med 2013;27:935-942.
Morris JS, et al. Effect of ovariohysterectomy in bitches with mammary
neoplasms. Vet Rec 1998;142:656-658.
Overley B, et al. Case-control study of hormonal influences on the
development of feline mammary gland carcinoma. Proc Vet Cancer Soc
2002:36.
Figure 40-4. An interrupted cruciate suture pattern is recommended for
closure of skin incisions with simple, regional, or complete unilateral Rutteman GR, Withrow SJ, MacEwen EG. Tumors of the mammary gland.
mastectomies. In:Withrow SJ, MacEwen EG, eds. Small animal clinical oncology. 3rd
Skin Grafting and Reconstruction Techniques 595
Anatomic Considerations
Preserving circulation is key to skin survival in wound
management and closure. Direct cutaneous vessels are the
primary vascular channels to the interconnecting cutaneous
vascular network: the deep or subdermal plexus; middle or
cutaneous plexus; and the superficial or subpapillary plexus
(Figure 41-1). The elastic direct cutaneous arteries travel parallel
to the overlying skin surface: they arborize to supply blood to the
major capillary network, the subdermal plexus.1,2
The direct cutaneous vessels and subdermal plexus reside in the especially in those cases where contraction and epithelization is
hypodermal tissue layer beneath the dermis. Both are closely slow. Bandages, dressings, topical agents, and recheck appoint-
associated with the panniculus muscle layer, in areas where this ments cumulatively can approach or exceed surgical closure.
cutaneous muscle layer exists. The major panniculus muscles Periodic reassessment of the wound, and clear communication
include the cutaneous trunci, platysma, sphincter coli superfi- can eliminate misunderstandings that occasionally occur with
cialis, and supramammarius muscles. This close relationship can the pet owner. Flap and/or graft closure may be reserved for
be exploited to help preserve skin circulation during surgery.1,2 those wounds where 2nd intention healing fails to make signif-
icant gains in wound closure.5
Undermining Skin Unlike humans, skin flaps generally are considered a more
Undermining skin is normally performed to facilitate the mobili- practical method to close problematic wounds in veterinary
zation of the skin for wound closure and skin flap elevation. The medicine; in human reconstructive surgery skin grafts are often
following points should be considered to help preserve circu- preferred. Skin grafts are most useful for the more problematic
lation to the skin: lower extremity defects, and large surface area wounds where
1. Undermine skin below the panniculus muscle layer when flaps and skin stretchers are not practical options.5
present, to preserve the subdermal plexus and associated direct
cutaneous vessels supplying the overlying skin.
2. Undermine skin, lacking a panniculus muscle layer (eg. middle, Skin Flaps (Pedicle Grafts)
distal portions of the extremities) in the loose areolar fascial A skin flap is an elevated portion of skin and subcutaneous tissue
plane below the dermis. with a vascular attachment to the body. The base or pedicle of
3. Preserve direct cutaneous vessels encountered during under- the flap may be a cutaneous attachment (with its intact capillary
mining of the skin, if possible. network), or an “island” segment of skin tethered by a single
4. Elevate skin closely associated with an underlying muscle by direct cutaneous artery or vein. Flaps also may be elevated with
including a portion of the outer muscle fascia with the dermis to an underlying muscle which provides a source of circulation
preserve the subdermal plexus. though interconnecting vascular channels: they are termed
5. If possible, avoid or minimize the surgical manipulation of skin myocutaneous or musculocutaneous flaps.3,5
recently traumatized until circulation improves, as noted by the
resolution of contusions, edema, and infection. Skin flaps are particularly useful in small animals, allowing the
Avoid direct injury to the subdermal plexus by using atraumatic veterinarian to utilize local or regional loose skin for closure
surgical technique. Sharp scalpel blades should be used to incise of problematic wounds. They can be transplanted into areas
skin; avoid cutting skin with scissors. Skin hooks, stay sutures, devoid of circulation, unlike skin grafts which rely on revascular-
Brown Adson forceps and DeBakey forceps can be used to ization from underlying healthy vascularized tissues for survival.
manipulate the skin; avoid crushing instruments, including the Because the complete dermis and hypodermis are present,
use of Allis tissue forceps.2-5 skin flaps have excellent durability and hair growth. Properly
developed and transferred, skin flaps do not require the more
elaborate bandage protection and immobilization needed for
Technique Selection skin graft survival.3,5
Wound size and location usually dictates the technique(s) that
should be considered for closure. The local availability of a loose, Pedicle grafts can be classified according to their (1) type of
elastic skin will help determine if simpler closure techniques can circulation; (2) location in relation to the recipient (wound) bed;
be considered in a given case. Other potential sources of donor and (3) tissue composition (eg., myocutaneous flaps, compound/
skin are then assessed. The primary goal is to restore function to composite flaps). Most skin flaps are based on the subdermal
the injured area, preferably with reasonable cosmetic results.5 plexus circulation (subdermal plexus flap) (Figure 41-2) incor-
poration of a direct cutaneous artery and vein results in the
Lower extremity wounds are particularly problematic due to formation of an axial pattern flap (Figure 41-3). A variation of the
the relative lack of circumferential skin. Wounds less than 90° axial pattern flap is the island arterial flap, in which the entire
circumference may close by second intention in some cases; skin flap is detached from the body, but tethered by a paired
the probability of contraction and epithelization decreases as direct cutaneous artery and vein (Figure 41-4). Because of their
the circumference of the defect increases.5 excellent blood supply, axial pattern flaps can be developed of
greater dimensions for closing sizeable skin wounds.3,5-7
Clearly wounds approaching half or more of the limb’s circum-
ference require closure with a skin graft or flap. By contrast, Flaps elevated immediately adjacent to the recipient bed are
the trunk has variable amounts of loose, elastic skin to facilitate termed local flaps, whereas flaps elevated from a more remote
wound closure by second intention, skin advancement, flaps, or location are termed distant flaps. Flaps made adjacent to a
simply by applying skin stretchers. In many cases, skin stretchers wound are technically easier to perform, provided that sufficient
are simpler and more effective to use for closure of moderate to skin is available for their development. Distant flaps normally are
large skin defects.5 more difficult to elevate and transfer. Historically distant flaps
have been classified according to the method of transferring
Although open wound management may be both practical the skin to a given wound, including: delayed tube flap (indirect
and economical in managing many wounds, costs can add up
Skin Grafting and Reconstruction Techniques 597
Figure 41-2. The subdermal plexus flap in the dog and cat. This flap is analogous to the random or cutaneous flap in human patients. The flap is
nourished by the subdermal plexus and attenuated branches of the direct cutaneous vessels some distance away. (From Pavletic MM. Canine axial
pattern flaps, using the omocervical, thoracodorsal, and deep circumflex iliac direct cutaneous arteries. Am J Vet Res I98l;42:39l.)
Figure 41-4. Island arterial flap (island axial pattern flap) in the dog. The graft is nourished solely by the direct cutaneous artery and vein. Island flaps
have greater mobility than axial pattern flaps. Vessels have the potential to be severed and reanastomosed with microvascular surgery at a distant
recipient site. (From Pavletic MM. Canine axial pattern flaps, using the omocervical, thoracodorsal, and deep circumflex iliac direct cutaneous
arteries. Am J Vet Res 1981;42:391.)
Single-Pedicle Advancement Flap Under these circumstances, a 90° transposition flap should be
The single-pedicle advancement flap (sliding flap) is simple in considered, since this rotating flap closes wounds by “donating”
design and execution. The width of the flap approximates the additional skin to the immediate area.3,5
width of the defect. Their effective use requires the flap to
advance or stretch directly into the defect. The advanced flap Bipedicle Advancement Flap
simultaneously closes both the donor and recipient beds.3,5 A bipedicle advancement flap is created by making two
parallel incisions and undermining the skin segment: the flap is
To create a single-pedicle advancement flap, two skin incisions advanced at a right angle to its long axis. Bipedicle flaps are
equal to the width of the wound are made in a staged or incre- usually considered for closing adjacent elongated wounds.
mental fashion. In general, it is useful to have the two incisions Although circulation is derived from two pedicles, long release
slightly diverge to assure that the base of the flap is not inadver- incisions may result in a more centrally located “ischemic zone”
tently created too narrow thereby compromising circulation. The with necrosis. If sufficient skin is present, the donor area can be
distant edge of the flap, bordering the wound is gently grasped, closed (Figure 41-8).3,5
elevated, and the flap undermined. The process is continued
until the flap stretches (advances) over the recipient bed. In The release or relaxing incision in design and execution is a
most dogs and cats, 3-0 monofilament suture material is used to bipedicle advancement flap. Release incisions are used to
secure the flap (Figure 41-6).5 reduce tension on an adjacent incision. Used in this fashion, the
release incision is left open to heal by second intention. Release
As noted, the length of the flap should be kept to the minimum in incisions may be little more than 1 or 2 centimeter “stab wounds”
order to close the wound without excessive tension. Two shorter or extended several centimeters to close a problematic skin
single-pedicle advancement flaps, on opposing sides of the wound. As a general rule release incisions are no closer than 3
wound, can be used to close longer defects. Termed “H-Plasty” to 5 centimeters from incision.5
two shorter flaps may close the wound without resorting to a
single, longer advancement flap (Figure 41-7).5
Transposition Flap
The primary problem associated with advancement flaps is their A transposition flap is a rectangular pedicle graft that pivots into
reliance on stretching over the wound. There is a tendency for position. Normally transposition flaps are rotated at a 45° to 90°
elastic retraction by the collagen fibers in the flap’s dermis. This angle in relation to the long axis of the skin defect. Flaps can be
can contribute to postoperative distortion in some clinical situa- transposed at an angle greater than 90° although the flap length
tions. For example, advancement flaps, used to close problematic will shorten with this greater arc of rotation. One border of the
eyelid wounds, occasionally will distort the lid margin resulting flap generally contacts the wound border (Figure 41-9). Trans-
in an unsatisfactory result both cosmetically and functionally. position flaps can be developed in most body regions, although
their size is somewhat limited in the mid- to lower extremities.5
Figure 41-6. Single-pedicle advancement flap. A. Removal of skin lesions and outline of intended flap incisions. B. The flap is lengthened and under-
mined enough to allow for closure without excessive flap tension. C. Preplacement of tension sutures may aid in flap alignment. D. Closure.
600 Soft Tissue
Figure 41-7. Sliding H-plasty. A. Removal of lesion and outline of the flaps on both sides of the defect. B. Undermining of both flaps. C. Alignment. D.
Closure.
Deep circumflex iliac artery (dorsal branch) Cranial edge of wing of ilium
Great trochanter
Dog in lateral recumbency, skin in natural position, pelvic limb in
relaxed extension
Vessel originates at a point cranioventral to wing of the ilium
Deep circumflex iliac artery (ventral branch) Anatomic landmarks of flap base same as dorsal branch of deep
circumflex iliac artery
Shaft of femur
Lateral caudal arteries (left and right) Proximal third of tail length
Transverse processes of vertebrae
Figure 41-12. Four major cutaneous arteries are illustrated in relation to their anatomic landmarks (1 to 4). (From Pavletic MM. Canine axial pattern
flaps, using the omocervical, thoracodorsal, and deep circumflex iliac direct cutaneous arteries. Am J Vet Res 1981 ;42:391.)
Figure 41-13. Reference lines for the omocervical, thoracodorsal, deep circumflex iliac, and caudal superficial epigastric axial pattern flaps. A.
Standard peninsula flaps (dashed lines). B. L or hockey-stick (dashed and dotted lines) configuration. (From Pavletic MM. Canine axial pattern flaps,
using the omocervical, thoracodorsal, and deep circumflex iliac direct cutaneous arteries. Am J Vet Res 1981 ;42:391.)
Skin Grafting and Reconstruction Techniques 605
Figure 41-14. Anatomic landmarks for the latissimus dorsi and cutaneus
trunci myocutaneous flaps: (1) ventral border of the acromion and (2)
Skin-Stretching Techniques
adjacent caudal border of the triceps muscle; (3) head of the last rib; Skin is a nonhomogeneous viscoelastic tissue with the combined
(4) distal third of the humerus, which corresponds to the (5) axillary skin characteristics of a viscous fluid and elastic solid. Three factors
fold. The flap is drawn onto the skin with a marking pen by connect- account for skin extensibility as a stretching force is applied: (1)
ing landmarks 2 and 3 to form the dorsal flap border (A). A second line progressive straightening of dermal collagen convolutions; (2)
is drawn from landmarks parallel to line A to the border of the last rib Parallel alignment of dermal collagen fibers; (3) extension of fully
forming the lower flap border (B). A third line (C) is drawn along the aligned collagen fibers with increasing stretching force applied
caudal border of the last rib, connecting lines A and B. (From Pavletic
to the skin.43
M, Kostolich M, Koblik P, et al. A comparison of the cutaneus trunci
myocutaneous flap and latissimus dorsi myocutaneous flap in the dog.
Vet Surg 1987; 16:283.) Skin in various regions of the body has its own natural or “inherent
extensibility”. This is assessed by grasping and lifting the skin, a
procedure all surgeons perform when assessing wound closure
options. Mechanical creep is the biomechanical property that
enables skin to extend or stretch beyond the limits of its inherent
extensibility. As a stretching force is applied to the skin over time,
collagen fibers align with the applied tension; collagen fibers
compact and slowly displace interstitial fluid during the process.
As the skin stretches beyond the limits of its natural extensibility
over time, stress relaxation occurs. Stress relaxation refers
to the progressive decrease in the force required to maintain
the length of the stretched skin. For skin to stretch beyond the
limits of its natural extensibility, the skin best deforms from the
application of a constant load or force over time. Similarly inter-
mittent application of force or “load cycling” also can assist
in the process of skin stretching. A natural variation of this
phenomenon is “biologic creep”, or the progressive increase in
cutaneous surface area noted as a result of expansile masses
located beneath the skin.44
Figure 41-15. Vascular levels of the latissimus dorsi myocutaneous flap:
(A) skin, (B) subcutaneous flap, (C) cutaneous trunci muscle, (D) fat,
and (E) latissimus dorsi muscle. The vessels involved include: (1) the
There are a few techniques that are currently used to stretch
main branch of the thoracodorsal artery traveling within the latissimus skin in humans and small animals, to facilitate wound closure.
dorsi muscle; (2) short perforating branches of the thoracodorsal artery They include tissue expanders; presuturing; and an elastic cable
to the cutaneus trunci muscle and overlying skin; (3) the subdermal system developed by the author, termed “skin stretchers.5,44”
(deep) plexus to the skin associated with the cutaneous trunci muscle;
(4) the proximal lateral intercostal arteries divided during elevation of
the latissimus dorsi muscle demonstrating anastomotic connections
Skin Expanders
with the thoracodorsal artery intramuscularly; and (5) the intercostal Skin expanders are inflatable devices composed of an
arteries. (From Pavletic M, Kostolich M, Koblik P, et al. A comparison of expandable silicone elastomeric bag or reservoir; an attached
the cutaneous trunci myocutaneous flap and latissimus dorsi myocuta- silicone tube is connected to a self-sealing injection port. The
neous flap in the dog. Vet Surg 1987; 16:283.) entire device is placed beneath the skin. Controlled inflation of the
device is accomplished by injecting sterile saline; a hypodermic
606 Soft Tissue
Upon completion of the expansion process, the expanded skin Skin stretchers have two components; skin pads to which elastic
can be advanced or rotated into the recipient bed, usually in the cables are affixed. The present design uses Velcro hook pads
form of a pedicle graft. This must be carefully planned in advance, for the skin pads, and specially designed one inch elastic cable
since the initial access incision for implantation of the expander covered by Velcro “felt.” Pads are placed on opposing sides of
should not be incorporated into the base of the proposed flap a wound and are secured to the skin with cyanoacrylate glue.
(Figure 41-16).5,45 Cables are applied to the opposing pads under moderate tension.
Cable tension is gradually increased every 6 to 8 hours for 48 to
72 hours prior to surgical closure of the defect. At the time of
surgery, pads can be pulled off the skin. Left in place, skin pads
normally loosen within 7 to 10 days of application, as a result
Skin Grafting and Reconstruction Techniques 607
of normal skin desquamation. Nail polish remover is a solvent skin tension is applied over the wide footprint of the skin pads,
for cyanoacrylate glue, although the author has not used it to patient comfort is maintained and allows for more forceful appli-
facilitate skin pad removal (Figure 41-17).5,44 cation of cable tension. The skin stretcher system can be used to
prestretch skin prior to elective surgical procedures, including
The primary complication is the occasional need to replace a the surgical removal of problematic skin tumors. Skin stretchers
skin pad that displaces as cable tension increases during their are also very effective in minimizing incisional tension after
48 to 72 hours of application. Pads are reglued or replaced wound closure; pads and cables can be used for 3 to 5 days to
until completion of the stretching procedure. Because the help prevent wound deshiscence.5,44
Figure 41-17. Illustration of a skin wound. The fur has been liberally clipped from around the area. Surgical soap and water are used to remove
cutaneous oil and debris. Isopropyl alcohol swabs are then used to remove skin and residual skin oil. Excess alcohol is removed with gauze or
towels and the skin allowed to completely dry before pad application. The hook pads can be applied to the skin after peeling off the protective tab
or cover; cyanoacrylate glue is applied in a thin film to enhance pad adherence to the prepared skin surface. Note the long axes of the rectan-
gular pads have been placed perpendicular to the wound borders, parallel to the tension cables to minimize the potential for pad displacement.
Pads normally are placed 10-20 cm from the wound borders. An additional row (tier) of pads and cables can be applied outside this suggested
zone, if further skin recruitment is required (and feasible) to recruit skin more distant to a large trunk defect. [Skin stretchers also can be effec-
tively used to pre-stretch the skin prior to elective surgical removal of large tumors or diseased skin segments.] Completion of cable application.
A mild amount of tension is initially applied to each cable. Cable tension is progressively increased every 6 hours as the skin stretches toward
the defect. One end of the elastic cable is disengaged from a skin pad, stretched, and recoupled to the skin pad, as illustrated. E. In general skin
is stretched for 48 to 96 hours prior to surgery. Pads are peeled off the anesthetized patient, the skin is prepared for surgery, and the recruited
skin advanced over the wound. On occasion, the outer corneal layer will be stripped off during pad removal, but the surface rapidly reforms. [Nail
polish remover can facilitate pad removal, but is unnecessary from the author’s experience.] In this illustration, a second set of pads and a short
cable segment are being used to offset postoperative wound tension upon completion of the surgery. Stretchers are very effective in reducing
incisional tension; the author uses this device for 3-5 days.
608 Soft Tissue
Free Skin Grafts bed within 5 days. Chronic radiation ulcers lack the circulation
to support a skin graft. In wounds lacking sufficient circulation
Free skin grafts lack a vascular attachment on transfer to the
to support a graft, a skin flap or muscle flap (covered with a skin
recipient graft bed. As a result, their initial survival at the time of
graft) may be necessary.5
transplantation is by absorbing tissue fluid (plasmatic imbibition)
from the recipient bed capillary circulation is established from
the vascular wound bed. Initial reestablishment of circulation to Skin Graft Classifications
the free graft is noted approximately 48 hours after application. Free grafts can be classified according to the source of the
During this period, capillaries from the recipient bed establish graft, its thickness, and its shape or design. Autogenous grafts
contact with the exposed vascular channels (exposed graft are used exclusively for permanent coverage in dogs and cats.
plexuses) to reestablish vital circulation. Termed “inosculation,” Allografts (homografts) and xenografts (heterografts) are rarely
reestablishment of vascular flow will give the skin graft a pink used in veterinary medicine as a temporary biologic dressing:
coloration. Grafts with a lavender color are the result of venous left in place, these grafts are eventually rejected by the patient’s
congestion; they assume a pink hue as circulation improves. The immune system. Isografts, or the exchange of skin grafts between
thickness of the graft will determine whether the superficial, highly inbred strains of animals is usually limited to research rats
middle or deep (subdermal) plexus is exposed to the under- and mice.5,48
lying vascular bed. The finer vascular network of the superficial
plexus has a greater chance at revascularization, a major reason Free grafts are commonly classified according to the thickness
why thin split-thickness skin grafts have a greater likelihood of of the graft. Full- thickness skin grafts include the entire dermis,
vascularization. Similarly, a medium split-thickness skin graft thereby retaining a large percentage of the compound hair
has a greater likelihood of revascularization compared to a full- follicles. Split-thickness skin grafts, harvested by a graft knife,
thickness graft. Despite these earlier research findings, properly razor blade, or dermatome include variable portions of the
prepared, full-thickness skin grafts have an excellent chance of dermis. They are broadly classified as thin, medium, or thick
surviving or “taking.5,48” split thickness skin grafts. Thinner grafts have relatively few hair
follicles and are less cosmetic in fur-bearing animals, unlike the
Once initial contact (inosculation) occurs between the capillary human. Although thin split thickness grafts reportedly survive or
buds and exposed vascular channels of the skin graft, the capil- “take” more readily, they also lack the hair growth and overall
laries grow into the graft and remodel the capillary network over durability of full-thickness skin grafts. Split-thickness grafts,
the next several days. However, there are several factors that harvested with a dermatome, normally are reserved for large
may delay or prevent revascularization of a skin graft, resulting wounds (especially large full-thickness bums) with more limited
in necrosis. Any accumulation of material between the graft donor skin.5,48,49
and recipient bed can block inosculation, including pus, blood
(hematoma), serum, or foreign material. Grafts techniques that
provide effective drainage, can reduce the probability of graft Surgical Techniques
loss from this potential complication.5,48 Free grafts are most commonly used for the more problematic
defects involving the lower extremities. Most surgeons will
Subcutaneous fat must be removed from full-thickness skin use full thickness grafts when possible due to the superior hair
grafts; presence of the fatty tissues will prevent revascularization growth, durability and relative ease of harvesting. Full thickness
of the free graft. The graft must conform to the contour of the skin grafts can be harvested and applied as a “sheet” or cut into
wound bed: excessive stretching of the graft will create a “drum various shapes including punch-pinch grafts, strip grafts, stamp
skin” over depressions in the recipent bed, preventing revascu- grafts, or mesh grafts (Figures 41-18 through 41-21).
larization. Folds or wrinkles in the graft will have a similar effect.
Lastly, grafts must be immobilized to prevent motion between the Punch, pinch, strip, and stamp grafts afford partial coverage of a
recipient bed and overlying graft: shearing forces will prevent wound surface. The space between grafts provides drainage as
revascularization.5 their epithelial cells migrate over the exposed granulation tissue.
Grafts that provide reasonable drainage are more likely to survive
Skin staples or sutures are frequently used to secure skin grafts in the presence of a low-grade bacterial infection. Punch and
to the recipient area. Fibrin deposition between the graft and pinch grafts are easy to perform and are used most commonly
underlying recipient bed serves as a natural glue to help stabilize to promote epithelization of smaller, slow healing open wounds.
the graft. The fibrin serves as a scaffold for fibroblasts and subse- However, depending on their numbers and spatial relationship,
quent collagen deposition. A protective bandage is required to they do not provide a particularly durable epithelial surface for
prevent motion to the area during the healing process.5 those body regions subject to periodic external trauma. Full-
thickness mesh grafts are better suited for larger wounds.The
As noted, a healthy vascular wound bed is required for graft techniques for punch, strip, and stamp grafts are described in
survival. Healthy granulation tissue, viable muscle, and (See Figures 41-18 through 41-21).5
periosteum are capable of supporting a skin graft. Chronic
granulation tissue is laden with collagen and has an unsatis- Full-thickness mesh grafts are especially useful for coverage of
factory blood supply to support a graft. In many cases, this tissue larger wounds involving the distal extremities (See Figure 41-21).
may be excised, promoting reformation of a healthy granulation An impression template of the moist wound surface can be
performed using gauze or absorbable paper [the paper packaging
Skin Grafting and Reconstruction Techniques 609
Figure 41-18. Punch graft technique (pinch grafts). A sharp 5- or 6-mm biopsy punch is used to harvest the graft plugs from a suitable donor site.
The donor area is clipped, leaving the hair shafts exposed. Subcutaneous fat is trimmed off the graft base. A single stitch is used to close the donor
bed. The grafts are placed between two moistened saline pads until needed. A 4-mm biopsy punch is used to remove cores of granulation tissue
in the recipient bed. Holes are spaced 8 mm apart (twice the width of the biopsy punch). Fine scissors are required to remove the granulation
core. A sterile cotton swab is inserted into each hole for 5 minutes. The graft plugs are then inserted in the direction of natural hair growth. A firm
dressing is applied postsurgically to maintain the position of the grafts. This procedure has the following advantages: 1) 4-mm granulation holes
compensate for graft shrinkage and allow the grafts to fit more snugly; 2) the epithelial surface of the graft is level with the granulation bed, and
re-epithelialization is unimpeded; 3) as many hair follicles as possible are included into each graft to promote hair growth; 4) re-epithelialization is
possible despite partial graft necrosis from surviving hair follicles and skin adnexa deep in the graft; and 5) graft revascularization occurs around
the circumferences as well as through the base of the graft plug, a comparatively large surface area.
Figure 41-19. Strip grafts. Application of strip grafts is similar to that of punch grafts. Linear strips of skin are laid in granulation troughs cut with a
special blade. Granulation tissue between the strips is eventually reepithelialized from the graft.
610 Soft Tissue
the opposing border. The process is repeated in the opposite the owner can remove the collar temporarily with the pet under
plane. The graft is applied with sufficient tension to allow the close supervision. If the patient does not rub or lick at the grafted
graft to flatten and conform to all surface areas. Graft holes are area, the collar can be eliminated completely, usually within a
stretched to allow a gap of a few to several millimeters to form, month after the surgery.5 Bandages can have adverse effects on
facilitating drainage. As a general rule, grafts are not sutured the graft. Excessive bandage tension and pressure points from
to the wound bed in order to avoid hemorrhage. If the graft is uneven bandage application can result in partial or complete
tenting over a depression, a fine suture can be used to assure graft failure. Bandages also can have an abrasive effect on the
proper graft to bed contact. Fibrin deposition occurs several graft if immobilization of the affected area is inadequate.5
hours after application, forming a natural glue to immobilize the
graft. Skin sutures or staples can be removed in 7 to 10 days;
the overlapped skin border will undergo necrosis and can be References
trimmed off at this time.5 1. Pavletic MM. The Vascular supply to the skin of the dog; a review. Vet
Surg 1980;9:77.
2. Pavletic MM. The integument. In: Slatter DH, ed. Textbook of small
Pad Grafting animal surgery, 3rd ed. Philadelphia: WB Saunders, 2003.
There are several articles discussing the use of pad grafts to 3. Pavletic MM. Pedicle grafts. In: Slatter DH, ed. Textbook of small
replace the loss of the metacarpal and metatarsal pads, with the animal surgery, 3rd ed. Philadelphia: WB Saunders 2003.
simultaneous loss of the digital pads. With the presence of the 4. Pavletic MM. Underming the skin in the dog and cat. Mod vet Pract
adjacent toes, digital pad flaps can be used to reconstruct the 1986;67:16.
metacarpal/metatarsal pads more effectively.5,50-52 5. Pavletic MM. Atlas of small animal reconstructive surgery, Phila-
delphia: WB Saunders, 1999.
Grafts: Postoperative Care 6. Pavletic MM. Caudal superficial epigastric arterial pedicle grafts in
the dog. Vet Surg 1980;9:103.
Proper protection and immobilization is essential to graft survival.
7. Pavletic MM. Canine axial pattern flaps, using the omocervical, thora-
It is preferable to confine the patient to a cage. Sedation may be
codorsal, and deep circumflex iliac direct cutaneous arteries. Am J Vet
advisable for hyperactive patients. Res 1981;42:391.
8. Alexander JW, Hoffer RE, MacDonald JM. The use of tubular flap
A nonadherent dressing covered with a thick layer of bland grafts in the treatment of traumatic wounds on the extremity of the cat.
ointment [triple antibiotic ointment is economical to use] is Feline Pract 1976:6:2.
applied to the grafted area.and stapled over the area to prevent 9. Yturraspe DJ, Creed JE, Schwach RP. Thoracic pedicle skin flap for
displacement. This is followed by layers of sterile gauze pads, repair of lower limb wounds in dogs and cats. J Am Anim Hosp Assoc
and self-adherent roll gauze alternated with cast padding. A 1976;12:581.
firm, thick bandage is formed prior to application of an outer 10. Pavletic MM, Kostolich M, Koblik P, et al. Comparison of the cutaneous
elastic wrap. To further immoblize the area, tongue depressors, trunci myocutaneous flap and latissimus dorsi myocutaneous flap in the
aluminum bars, half casts, metasplints, slings, and Shroeder- dog. Vet Surg 1987:16:283.
Thomas splints may be employed. The Latter splint is especially 11. Matera JM, Tatarunas AC, Fantori DT, asconcellos CNC. Use of
useful for immobilizing the knee, elbow, and tibiotarsal joints. scrotum as a transposition flap for closure of surgical wounds in three
Spica splints/bandages are advisable to immobilize the upper dogs. Vet Surg 2004;33:99.
extremity, especially in cats, whose reputation for extricating 12. Hunt GB, Tisdall PLC, Liptak JM, et al. Skin fold advancement flaps
themselves from bandages is legendary.5,48 for closing large proximal limb and trunk defects in two dogs and cats.
Vet Surg 2001:30:440.
The author prefers to change the initial bandage 3 to 5 days 13. Hunt GB. Skin fold advancement flips for closing large sternal and
postoperatively. Bandages can be changed 48 hours after inguinal wounds in cats and dogs. Vet Surg 1995;24:172.
surgery, but in this early period there is a risk of displacing 14. Anderson DM, Charlesworth TC, White RAS. A novel axial pattern
the graft and damaging the fragile reestablished blood supply. flap based on the lateral thoracic artery in the dog; lateral thoracic skin
Adherent dressings occasionally adhere to the grafted area. flap. Vet Comp Orthop Traumatol 2004;17:57.
Saline can be applied to facilitate its removal, although it is more 15. Fahie MA, Smith MM. Axial pattern flap based on the cutaneous
prudent to apply additional ointment to the area and rebandage branch of the superficial temporal artery in dogs: An experimental study
the area. The exposed graft is inspected for viability and signs of and case report. Vet Surg 1999;28:141.
infection. A culture can be taken if infection is suspected.5 16. Fahie MA, Smith MM. Axial pattern flap based on superficial temporal
artery in cats; an experimental study. 1997;26:86.
Early signs of graft necrosis are discouraging but not always 17. Aper R, Smeak D. Complications and outcome after thoracodorsal
catastrophic: hair follicles in the deeper dermal layer of the graft axial pattern flap reconstruction of forelimb skin defects in 10 dogs,
may survive and serve as a source for epithelization. Subse- 1989-2001. Vet Surg 2003;32:378.
quent bandage changes may be performed every 2 to 4 days, 18. Lidbetter DA, Williams FA, Krahwinkel OJ, et al. Radical lateral
depending on the condition of the graft. This routine is continued body-wall resection for fibrosarcoma with reconstruction using
for approximately 2 weeks or until epithelization is complete. polypropylene mesh and a caudal superficial epigastric axial pattern
This can be followed by application of a lighter bandage for an flap: a prospective clinical study of the technique and results in six cats.
additional 10 to 14 days, if necessary. An Elizabethan collar is Vet Surg 2002;31:57.
advisable to prevent self-mutilation of the graft site. Eventually, 19. Lester S, Pratschke K. Certral hemimaxillectomy and reconstruction
612 Soft Tissue
using a superficial temporal artery axial pattern flap in a domestic short 43. Hunt GB. Use of the lip to lid flap for replacement of the lower eyelid
hair cat. Fel Med Surg 2003;5:241. in cats. Vet Surg 2006;35:284.
20. Stiles J, Townsend W, Willis M, et al. Use of a caudal auricular axial 44. Pavletic MM. An external skin-stretching device for wound closure
pattern flap in three cats and one dog following orbital exenteration. Vet in dogs and cats. J. Am Vet Med Assoc 2000; 217:350.
ophthal 2003;6:121. 45. Spodnick G, Pavletic MM, Schelling S, et al. Controlled tissue
21. Smith MM; Carrig CB, Waldron DR, et al. Direct cutaneous arterial expansion in the distal extremities of dogs. Vet Surg 1993;22:436.
supply to the tail in dogs. Am J Vet Res 1992;53:145. 46. Keller WG, Anon DN, Rarich PM, et al. Rapid tissue expansion for the
22. Kostolich M, Pavletic MM. Axial pattern flap based on the genicular development of rotational skin flaps in the distal portion of the hind limb
branch of the saphenous artery in the dog. Vet Surg 1987;16:217. of dogs: an experimental study. Vet Surg 1994;23:31.
23. Pavletic MM, Macintire D. Phycomycosis of the axilla and inner 47. Johnston DE. Tissue expanders. Vet Clin No Am. 1990;20:227.
brachium in a dog: surgical excision and reconstruction with a thora- 48. Swaim SF, Henderson RA. Small animal wound management. Phila-
codorsal axial pattern flap. J Am Vet Med Assoc 1982;180;1197. delphia Williams and Wilkins, 1997.
24. Henney LHS, Pavletic MM. Axial pattern flap based on the super- 49. Bradley DM, Swaim SF, Alexander CM, et al. Autogenous pad grafts
ficial brachial artery in the dog. Vet Surg 17:311, 1988. for reconstruction of a weight - bearing surface: a case report. J Am
25. Sardinas JC, Pavletic MM, Ross JT, et al. Comparative viability of Anim Hosp Assoc 1994;30:533.
penisular and island axial pattern flaps incorporation the cranial super- 50. Aragon CL, Harvey SE, Allen SW, Stevenson MA. Partial thickness
ficial epigastric artery in dogs. J Am Vet Med Assoc 1995;207:452. skin grafting for large thermal skin wounds in dogs. Compen Contin Edu
26. Remedios AM, Bauer MS, Bowen CV. Thoracodorsal and caudal 2004;26;2005.
superficial epigastric axial pattern skin flaps in cats. Am J Vet Res 51. Pavletic MM. Foot salvage by delayed reimplantation of severe
1992;53:145. metatarsal and digital pads using a bipedicle direct flap technique. J
27. Smith MM, Payne JT, Moon ML, et al. Axial pattern flap based on the Am Anim Hosp Assoc 1994;30:539.
caudal auricular artery in dogs. Am JVet Res 1991;52:922. 52. Bradley DM, Scardino MS, Swaim SF. Construction of a weight-
28. Pavletic MM, Wafters J, Henry RW, et al. Reverse saphenous conduit bearing surface on a dog distal pelvic limb. J Am Anim Hosp Assoc
flap in the dog. J Am Vet Med Assoc 1982;182:380. 1998;34:387.
29. Cornell K, Salisbury K, Jakovljevic S, et al. Reverse saphenous
conduit flap in cats: an anatomic study. Vet Surg 1995;24:202.
30. Milton SH. Experimental studies of island flaps. I. The surviving Mesh Skin Grafting
length. Plast Reconstr Surg 1971;48:574. Eric R. Pope
31. Gourley IM. Neurovascular island flap for treatment of trophic
metacarpal pad ulcer in the dog. J Am Anim Hosp Assoc 1978;14:119.
32. Pavletic MM. Surgery of the skin and management of wounds. In: Introduction
Sherding R, ed. Diseases of the cat: diagnosis and management. New Skin grafting in dogs and cats is most commonly used for
York: Churchill Livingstone, 1994. reconstructing degloving injuries on the extremities, but can
33. Lascelles BDX, White RAS. Combined omental pedicle graft and also be used to cover skin defects on other areas of the body
thoracodorsal axial pattern flaps for the reconstruction of chronic when simpler techniques may not be indicated or applicable.
nonhealing wounds in cat. Vet Surg 2001;30:380. The use of both full-thickness and split-thickness grafts has
34. Mayhew PD, Holt DE. Simultaneous use of bilateral caudal super- been described but I have almost always used full-thickness
ficial epigastiric axial pattern flaps for wound closure in a dog. Sm Anim grafts. Full-thickness grafts consist of the epidermis and entire
Pract 2003;44:534. dermis, whereas split-thickness grafts consist of the epidermis
35. Krizek TJTani T, Desprez JD, et al. Experimental transplantation of and variable portions of the dermis (Figure 41-23). Of the various
composite grafts by microsurical vascular anastomoes. Plast Reconstr types of skin grafts described in the literature, the mesh skin
Surg 1965;36:358. graft offers many advantages for the veterinary surgeon. A mesh
36. Tsai TJ et al. The effect of hypothermia and tissue perfusion graft is a full-thickness or split-thickness skin graft in which
on extended myocutaneous flap viability. Plast Resconstr Surg parallel rows of staggered slits have been cut either manually
1982;70:444. with a No. 11 scalpel blade or mechanically with a commercial
37. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. mesh dermatome. Mesh grafts have the following advantages:
Plast Reconstr Surg 1973;57:294. 1) they can be expanded to cover large defects if donor sites are
38. Schlenker JD. Discussion: the effect of hypothermia and tissue limited (e.g., burns); 2) they conform well to irregular surfaces; 3)
perfusion on extended myocutaneous flap viability. Plast Reconstr Surg the creation of numerous slits allows drainage from underneath
1982;70:453. the graft; and 4) they can be placed over areas that are difficult
39. Erol 00, Spira M. Secondary musculocutaneous flap: an experimental to immobilize. The primary disadvantage of mesh grafts is that
study. Plast Reconstr Surg 1980;65:277. when they are expanded and the interstices heal by epithelial-
40. Schechter GL, Biller HF, Ogura JH. Revascularized skin flaps: a new ization, resulting in islands of nonhaired epithelium throughout
concept in transfer of skin flaps. Laryngoscope 1969;79:1647. the graft. For this reason, a nonexpanded or minimally expanded
41. Swanson SW, Goring RI, Dehann JJ, et al. Reconstruction of a facial graft is preferred.
defect using the ear pinna as a composite flap. J Am Animal Hosp Assoc
1998;34:399.
42. Pavletic MM, Nafe LA, Confer AW. Mucocutaneous subdermal
plexus flap from the lip for lower eyelid restroration in the dog. J Am Vet
Med Assoc 1982;180:921.
Skin Grafting and Reconstruction Techniques 613
Donor Sites
Important criteria in selecting a donor site are the color and
length of hair with respect to that surrounding the recipient site
and also the ability to close the donor site after harvesting the
graft. Because abundant skin generally is present on the thorax
and neck, large grafts can be harvested from these areas, and
primary closure of the donor site is possible.
to the surface of the recipient bed, and digital pressure is used are then used to cut the subcutaneous tissue from the graft. The
to control hemorrhage. Excessive use of cautery or ligatures base of the hair follicles is visible when the subcutaneous tissue
should be avoided. is removed, giving the graft a cobblestone appearance. Because
the hair follicles extend into the subcutaneous tissue in part of
Donor sites for full-thickness grafts usually are abundant. Large the hair growth cycle, the hair follicles may be damaged and hair
grafts can be harvested by the technique described here, and growth reduced. Failure to remove all the subcutaneous tissue
the donor site can be closed primarily. The first step is to make a impairs revascularization of the graft and is an important cause
pattern of the defect if a nonexpanded technique is to be used, of graft loss.
especially if the edges of the defect are very irregular. A pattern
can be made by obtaining a blood imprint of the recipient site Meshing the Graft
after it is prepared as described previously. After the pattern
is made, it is placed on the donor site, with care taken not to Meshing can be accomplished with a No. 11 scalpel blade or
reverse the pattern (i.e., turning the pattern over so the dermal a mesh dermatome but I typically use a scalpel blade because
side is up and a mirror image of the needed graft is harvested). it is convenient and inexpensive. If a scalpel is used, the graft
The pattern should also be placed so the direction of hair growth is left attached to the sterile cardboard, and staggered rows of
of the graft matches that of the skin surrounding the wound. An parallel slits (approximately 0.5 to 1 cm in length) are cut in the
arrow is drawn on the imprint indicating the direction of hair graft (Figure 41-25). The degree of expansion achievable is influ-
growth on the pattern before removing it from the defect. A skin enced by the number of rows and length of the slits. Increasing
scribe, sterile new methylene blue, or a scalpel blade can be the number of rows and the length of the slits increases the
used to transfer the pattern to the skin before cutting the graft. amount of expansion possible.
This is performed so the borders of the pattern can still be
followed if the skin is distorted while the graft is being cut.
beyond the level of a single secondary angiosome should be Recipient Site Preparation
considered tenuous and likely to lead to partial flap failure. The recipient site should be free of devitalized tissue or active
infection. Judicious debridement and lavage should be used to
Anatomic descriptions of many cutaneous and muscle angio- minimize contamination and necrotic tissue in open wounds.
somes have been provided for the dog, with few specific Early reconstruction of open wounds using vascularized tissues
descriptions for the cat.13-22 Based on this information, as well minimizes the risk of wound complications. In my experience,
as on experimental data, several regional angiosomes and free most open wounds can be converted to a state suitable for
flaps have been described. The importance of understanding microvascular reconstruction within 48 hours of injury. Minimal
the anatomy, consistency, and variability of regional vascular debridement should be required at the time of microsurgical
patterns cannot be overstated when undertaking microvascular reconstruction. The wound bed may be lavaged preoperatively
tissue transfer. with an antibacterial solution, such as 0.05% chlorhexidine
gluconate, to decrease bacterial contamination.
Flap Dissection
The particular approach to flap dissection depends on the Recipient vessels, appropriate for anastomosis to the artery and
tissue harvested. Several guidelines and recommendations vein of the flap to be transferred, must be identified and dissected.
are common to dissecting all flaps for microvascular transfer. A knowledge of regional vascular anatomy is obviously a prereq-
The tissue to be harvested must be isolated to the level of its uisite. In patients with severe trauma, or a past history of trauma
source artery and vein. All supporting microvasculature must or surgery involving the affected area, preoperative angiog-
be preserved during this process. All underlying subcutaneous raphy should be considered to identify variations in vascular
tissue should be incorporated with cutaneous flap dissec- anatomy. Recipient vessels should approximate the diameter of
tions; underlying superficial cutaneous musculature should be donor vessels, assuming end-to-end anastomosis. End-to-side
incorporated in regions where such musculature exists. For technique is often used for arterial anastomosis, to preserve
example, the cutaneus trunci muscle should be incorporated arterial supply distal to the wound. In this event, the recipient
with elevation of the thoracodorsal cutaneous flap. Muscle is artery should be of larger diameter than the donor artery.
readily dissected because of surrounding fascial sheaths. A soft Recipient vessels should be dissected beyond the wound’s zone
tissue envelope is incorporated with dissection of vascularized of trauma. The surgical approach used for vascular dissection
bone grafts to preserve myoperiosteal vasculature. The reader should involve elevation of a skin flap such that the incision will
should consult references pertaining to specific flaps, as well as not directly overlie the vascular anastomosis after skin closure.
the first section of this chapter, for details of surgical harvest.
The free flap is secured at the recipient site before initiating
Tissue is generally elevated beginning at a site distant to the microvascular anastomosis. In the case of soft tissue flaps, this
vascular pedicle. Flap dissection is then continued until the is accomplished using a few strategically placed simple inter-
source artery and vein are identified. Bleeding vessels encoun- rupted sutures. Cutaneous flaps are sutured under minimal
tered during this process should be meticulously controlled with tension. Muscle flaps are sutured under sufficient tension to
bipolar electrocoagulation, suture ligation, or vascular clips. approximate their initial resting length at the donor site. Vascu-
Once the vascular pedicle is identified, the artery and vein are larized bone grafts are stabilized using suitable orthopedic
skeletonized. Small branches encountered during vascular fixation. Microvascular anastomosis of the donor and recipient
dissection may be electrocoagulated or clipped with vascular artery and vein is then completed using an operating micro-
clips, depending on size. The surgeon must avoid damage to the scope and standard microvascular technique. Approximating
intima of the parent vessel by excessive traction on small vascular clamps are not released until the completion of both artery and
branches or aggressive electrocautery. As much surrounding vein repair.
ad-ventitia as possible should be removed during initial dissection
of the vascular pedicle. Surgical loupes providing a magnification Pedicle length must be planned to avoid excessive length and
of 3x to 4x facilitate identification of fine anatomic detail and redundancy of the pedicle or insufficient length resulting in
atraumatic dissection of the vascular pedicle. tension or kinking. The vascular pedicle must be carefully
positioned to avoid compression of the anastomosed vessels
The length of vascular pedicle depends primarily on the anatomy during closure. The venous pedicle is particularly sensitive to
of the donor flap. As a general rule, as much length as possible these effects. The vascular pedicle is assessed for patency, and
should be included with the initial vascular dissection. Excess remaining sutures are placed between the flap and the recipient
length may be trimmed after transfer to the recipient site. A wound bed. Patency should be reassessed before final skin
minimum vascular pedicle length of 1 cm is preferred, to allow closure. Total operative time is minimized by using two surgical
manipulation of vessels during microanas-tomosis. teams. One team harvests the donor tissue while the second
simultaneously prepares the recipient site.
To minimize flap ischemia time, the vascular pedicle should not
be ligated and divided before preparation of the recipient site. Flap Perfusion and Anticoagulation
At that time, the artery and vein are independently ligated with Uncomplicated free tissue transfer generally requires approxi-
vascular clips and are transected using fine vascular scissors. mately 4 hours of general anesthesia. More complicated
procedures, such as those requiring orthopedic fixation, may
618 Soft Tissue
necessitate 6 to 10 hours of general anesthesia. Adequate problem is easily avoided through meticulous attention to flap
flap perfusion depends on maintaining the cardiovascular dissection. Little can be done to rectify the situation after its
stability of the patient during the operative and postoperative occurrence. Extended ischemia time may lead to reperfusion
periods. Intravenous fluid support during and after surgery is injury and subsequent occlusion of venous microvasculature
an absolute requirement. by neutrophil adhesion. Therapy aimed at alleviating ischemia-
reperfusion injury is indicated, but it is of questionable benefit
Hypothermia must be controlled to avoid peripheral vasocon- after the period of reperfusion.
striction and deleterious effects on flap perfusion. Patients are
maintained on circulating water blankets, and temperature is Postoperative Monitoring
monitored both during and after the surgical procedure. A heat
lamp may be placed over the flap during the immediate postop- Free flaps entirely depend on the integrity of the microvascular
erative period, before the patient’s recovery from anesthesia. anastomsoses. Free flap failure may be caused by venous or
Bandaging of flaps using a lightly applied, heavily padded arterial thrombosis, either of which must be recognized early and
bandage protects the flap from trauma and assists in trapping investigated aggressively if the flap is to be salvaged. Venous
body heat. failure of cutaneous flaps is most easily recognized by the onset
of congestion in the flap (Figure 41-27). A purplish-blue discol-
No consistent recommendation exists on the use of antithrom- oration is noted. Bandaged flaps may be assessed by creating
botic agents before, during, or after microvascular tissue a window in the bandage to allow visualization of a portion of
transfer. The most critical factor in preventing thrombosis of the the flap. Flaps tolerate venous outflow occlusion poorly. At
microvascular anastomosis is appropriate surgical technique, the earliest indication of this problem, the patient should be
and no amount of antithrombotic therapy can salvage a poorly returned to the operating room, and the vascular pedicle should
performed anastomosis. Heparin and saline (10 units heparin per be dissected using the operating microscope. Careful attention
1 mL saline) are used topically at the anastomotic site to clear is paid during the approach to look for evidence of vessel
the lumen of vessels before anastomosis. Other antithrombotic compression or kinking caused by positioning of the vascular
therapy is determined by the preference of the surgeon and pedicle or restrictive skin closure. If this is the case, the anasto-
identified patient risk factors. mosis may actually be patent, and the problem is addressed by
simple repositioning of the pedicle or release of the overlying
Aspirin may be used at a dose of 5 to 10 mg/kg body weight preop- skin incision. In the event of a thrombosed anastomosis, the
eratively, to inhibit platelet aggregation.23 I routinely administer
dextran 40 at a dose of 10 mL/kg body weight intraoperatively.
Dextran administration expands the vascular space, thereby
improving flap perfusion, and it may have an inhibitory effect
on platelet function.24 Anticoagulation using systemic heparin is
rarely indicated.
region of thrombosis is excised, and venous effluent from the flap is difficult or impossible. Vascularized bone grafts should be
is documented. Once flow through the flap is established, venous assessed using [99m] technetium scintigraphy within 5 days of
anastomosis is repeated. Sluggish venous outflow may also be operation.
treated by application of medicinal leeches. Leeches reduce
flap congestion by direct ingestion of blood and by promoting
continued hemorrhage from bite wounds resulting from local
Free Flaps in the Dog and Cat
infusion of hirudin.28 Several free flaps have been described experimentally, clinically,
or both in the dog and cat. Other flaps have been described as
Arterial failure can be more difficult to diagnose because it pedicled flaps, maintaining a vascular attachment to the donor
is not associated initially with overt color change of the flap. site. These flaps may be used reliably for free transfer as well,
Flap temperature can be monitored; a drop in temperature assuming adequate dimensions of the vascular pedicle. Vessel
indicates arterial insufficiency. This method is unreliable in diameters for most described flaps in the dog approximate 1 to
bandaged flaps, because the bandage traps body heat and 2 mm. Vessel diameters of less than 0.5 mm are associated with
artificially elevates flap temperature. Doppler flow probes increased rates of anastomotic thrombosis.
may be used to monitor arterial patency more reliably in the
postoperative period. A window is created in the bandage Cutaneous Flaps
overlying the arterial pedicle distal to the anastomosis. A pencil Cutaneous angiosomes have been described extensively, and
Doppler probe is then easily inserted through the window to anatomic landmarks for dissection of pedicled cutaneous axial
monitor arterial patency. Bleeding may be a useful indicator pattern flaps are well documented. Axial pattern skin flaps may
of flap perfusion. Cutaneous flaps are punctured with a 20- be used for free transfer as well.
or 22-gauge hypodermic needle and are monitored for active
bleeding from the site. More specialized monitoring techniques The superficial cervical axial pattern flap, based on the direct
such as laser Doppler flowmetry or fluorescein clearance cutaneous pedicle of the prescapular branch of the superficial
have been described, but they are usually beyond the realm of cervical artery and vein, has been documented as a free flap in
clinical necessity. a series of cases (Figure 41-28).29,30 The vascular pedicle perfo-
rates the septum formed by the omotransversarius, cleidocervi-
Monitoring of flaps that do not incorporate a cutaneous calis, and trapezius muscles. The cutaneous angiosome extends
component is more difficult. Doppler techniques are useful for dorsally from the point of origin to the midline and roughly incor-
monitoring arterial adequacy in such flaps. Venous monitoring porates the caudal two-thirds of the cervical skin in a cranio-
Figure 41-28. The anatomy of the superficial cervical cutaneous free flap is indicated. The direct cutaneous artery arises from a septum formed by
the trapezius, omotransversarius, and sternocephalicus muscles. The muscular branch to the cervical portion of the trapezius muscle also arises
from the superficial cervical artery.
620 Soft Tissue
caudal direction. The amount of skin harvested for transfer is groups. Neovascularization of compromised wound beds is facili-
determined, first, by the requirements of the recipient site and, tated to a greater degree by muscle than by other tissues. Finally,
second, by the ability to close the donor site primarily. donor muscles may be selected that closely match the dimensional
and functional requirements of nearly any wound reconstruction.
I have also used the caudal superficial epigastric axial pattern
flap sporadically for microvascular transfer. The primary The angiosomes of muscles may be classified into one of five
advantage of selecting an axial pattern skin flap for microvas- types (Figure 41-30). Type I muscles have a single dominant
cular transfer is ease of dissection. Disadvantages include vascular pedicle. Type II muscles have a single dominant pedicle
excessive bulk from inclusion of associated subcutaneous and one or more minor pedicles. Type III muscles contain two
tissue and poor cosmetic result caused by differential hair dominant vascular pedicles, each of which has an approximately
growth characteristics between donor and recipient sites. equal contribution to the muscle’s blood supply. Type IV muscles
have a segmental blood supply formed by numerous small
The saphenous fasciocutaneous free flap has been documented pedicles of approximately equal contribution. Type V muscles
in experimental and clinical cases.28,31 The flap is based on have a single dominant vascular pedicle near their insertion
the medial saphenous artery and vein and includes the skin and a segmental system near the origin of the muscle. Based on
overlying the medial aspect of the thigh (Figure 41-29). Flap assumptions of physiologic blood supply through angiosomes,
dissection includes the superficial fascia of the medial gastroc- one can surmise that any type I muscle will survive entirely after
nemius muscle, giving the flap its designation as fasciocuta- free transfer based on the single dominant pedicle. Most type II
neous. Numerous small direct cutaneous vessels arise from muscles willl survive based on the dominant pedicle, depending
the saphenous vessels as they course through the flap. The on the number and relative contribution of the minor pedicles.
saphenous fasciocutaneous flap has the advantage of less bulk Type III muscles are expected to survive after free transfer based
and improved cosmetic results compared with other free axial on either dominant pedicle system. Type V muscles generally
pattern skin flaps. The width of the flap is limited by the ability to will survive based only on the single dominant pedicle. Type
close the donor site primarily. IV muscles are generally poor candidates for microvascular
transfer because of the large number and small contribution
of each pedicle system to the muscle’s blood supply. Detailed
descriptions of the vascular supply to muscles of the dog have
been published.21,22 The foregoing assumptions given serve as
guidelines only. The ultimate reliability of any muscle in recon-
structive microsurgery is proved only through experimental or
clinical trials that establish its utility. If at all possible, muscle
transfers should be limited to single angiosomes or previously
documented free flaps.
Figure 41-30. Diagrammatic representation of the five basic vascular patterns to skeletal muscles. A. Type I muscles have a single vascular supply.
B. Type II muscles have one dominant pedicle and one or more minor pedicles. C. Type III muscles contain two equally dominant pedicles. D. Type
IV muscles have a segmental blood supply derived from numerous small pedicles. E. Type V muscles have a single dominant pedicle near their
insertion and a second segmental system near their origin. Type IV muscles are the least suitable for microvascular application.
to the trapezius muscle. It is most commonly located immediately lymph node is intimately associated with the vascular pedicle and
beneath the cranial border of the muscle coursing from ventral to may either be included with the pedicle or carefully excised.
dorsal. In a few instances, the vascular pedicle lies immediately
cranial to the cranial border of the trapezius muscle and gives off I used the trapezius muscle free flap for distal extremity recon-
several smaller muscular branches to the muscle as it extends struction in a series of 20 cases. The trapezius muscle is broad and
dorsally. Dissection in these patients must be performed with flat, lending itself well to conformation to many wound beds. Bulk
caution, to preserve the integrity of the vascular pedicle. After of the flap is minimal and decreases dramatically over the course
identification of the prescapular branch of the superficial cervical of several weeks because of denervation atrophy. Despite dener-
artery and vein, remaining muscle attachments are dissected. One vation atrophy, transferred muscle maintains a constant vascular
or two small muscular branches to the omotransversarius muscle density beneficial to the wound bed. The trapezius muscle is resur-
are identified and clipped, and the artery and vein are skeletonized faced using a full-thickness skin graft harvested from a donor site
and dissected for a length of at least 2 to 3 cm. The prescapular with hair growth characteristics similar to those of the recipient
Figure 41-31. Barium has been infused into the superficial cervical artery to demonstrate the regional angiosome of this vessel. The superficial cer-
vical artery gives rise to the dominant pedicle of the cervical portion of the trapezius muscle, the superficial cervical direct cutaneous artery, and a
minor pedicle to the omotransversarius muscle. Any or all of these tissues may be included in a microvascular flap based on this vascular pedicle.
622 Soft Tissue
Figure 41-32. A. Cosmetic results are less than optimal after reconstruction using the trapezius myocutaneous flap because of the excessive sub-
cutaneous bulk and poor match of hair characteristics. B. Contour and hair characteristics are much more closely matched by using the trapezius
muscle flap and resurfacing with a full-thickness skin graft.
The utility of the vascularized distal ulna graft has been demon-
strated experimentally.40 I have used the distal ulna graft for
reconstruction of the distal radius after limb-sparing surgery for
osteosarcoma and for reconstruction of a mandibular nonunion
and segmental defect caused by a gunshot injury.
Figure 41-35. The proximal ulna vascularized bone graft is based on the
common interosseous pedicle and preserves both the periosteal and
nutrient vascular systems. Muscular branches to extensor muscles
indicate the approximate level of the common interosseous pedicle.
Skin Grafting and Reconstruction Techniques 625
Figure 41-36. The distal ulna vascularized bone graft is based on the
caudal interosseous artery and vein. Dissection preserves only the
periosteal vascular supply. Inclusion of a surrounding muscle cuff is
required to preserve this blood supply.
Compound Flaps
Compound free flaps incorporate tissues of more than one type. Figure 41-37. The cutaneous portion of myocutaneous flaps incor-
They may be useful for the reconstruction of complex trauma porating a direct cutaneous artery may be dissected independent of
involving loss of multiple tissue types. A detailed knowledge of the underlying muscle. In this dog, the trapezius muscle was used to
vascular anatomy allows the surgeon the flexibility of designing reconstruct the lateral aspect of a large degloving injury A. while the
cutaneous portion of the flap was rotated to cover the defect medially
many compound flaps.
B. The muscle was subsequently resurfaced with a full-thickness skin
graft. Both components of the flap are based on the superficial cervical
Musculocutaneous flaps combine both muscle and skin in the artery and vein.
transfer. The superficial cervical axial pattern skin flap may easily
be included with the cervical portion of the trapezius muscle by periosteal cuff. However, the term is recognized to designate the
maintaining the direct cutaneous branch rather than by ligating inclusion of a significant muscle component used in the recon-
it during dissection. The vascular supply to both muscle and skin struction. The successful inclusion of the scapular spine with the
is based on the prescapular branch of the superficial cervical cervical trapezius muscle flap has been demonstrated experi-
artery and vein. Similarly, the thoracodorsal axial pattern skin mentally (Figure 41-38).41 Survival of the scapular spine depends
flap may be incorporated with the latissimus dorsi muscle flap. on its periosteal vascular supply. Unfortunately, the scapular
Dissection of musculocutaneous free flaps must be carefully spine lies outside the primary angiosome of the prescapular
planned to include appropriate dimensions of the cutaneous branch of the superficial cervical artery, and this causes some
component. With inclusion of an axial pattern skin flap, the concern relative to the reliability of its vascular integrity after
cutaneous component may be used to overlie the transferred transfer. I have used the cervical trapezius myo-osseous flap for
muscle directly and to reconstruct an associated cutaneous reconstruction of metatarsal segmental defects and overlying
defect. The axial pattern skin flap may also be dissected free of soft tissue loss caused by a gunshot injury in a Chesapeake
the muscle flap, with care taken to maintain the direct cutaneous Bay retriever. Survival of the muscle flap and its overlying free
artery and vein. This allows use of both the muscle and cutaneous skin graft was evident. However, postoperative [99m]technetium
components for reconstruction of adjacent portions of large scintigraphy of the bone graft was negative. This bone graft
wound beds (Figure 41-37). proceeded to rapid incorporation and healing, a finding
suggesting either an intact vascular supply or rapid revascular-
Myo-osseous flaps incorporate both muscle and bone. By ization. Based on the negative scintigraphy results in this dog
strict definition, all vascularized bone grafts may be considered and the tenuous vascular integrity of the flap design, the cervical
myo-osseous because of the preservation of an intact musculo- trapezius myo-osseous flap should be used with caution.
626 Soft Tissue
Figure 41-38. The trapezius flap may be extended to include the scapular spine, to form an osteomusculocutaneous flap. The scapular spine lies
outside the primary angiosome of the flap, but experimentally it has been shown to survive based on perfusion through “choke” anastomoses from
the trapezius muscle. Elevation of the flap based on the superficial cervical vessels is demonstrated.
Both the digital pad flap and the carpal pad flap have been transfer requires appropriate instrumentation and a familiarity
used for reconstruction of severely traumatized feet in dogs. with microvascular technique, both of which are increasingly
The transferred pads have proved resilient to weight-bearing available at larger veterinary referral centers. Further experience
stresses and have undergone hypertrophic change in response with, and definition of, these techniques will inevitably lead to
to continued weight bearing. Precise positioning of the pad is increased veterinary clinical application.
essential to avoid trauma to surrounding hirsute skin. The most
common complication of microvascular footpad transfer has
been chronic incisional breakdown at the junction of donor and
References
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difficult. Further research and experience are needed before firm 2. Asaadi M, Murray KA, Russell RC, et al. Experimental evaluation of free
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3. Richards RR, Schemitsch EH. Effect of muscle flap coverage on bone
Complications of Free Flaps blood flow following devascularization of a segment of tibia: an experi-
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may be divided into recipient site and donor site problems. 4. Richards RR, McKee MD, Paitich B, et al. A comparison of the effects of
Donor site complications are site specific, depending on the skin coverage and muscle flap coverage on the early strength of union at
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should not be seen if appropriate consideration has been given J Bone Joint Surg Am 1991; 73:1323-1330.
to selection of a donor site. Seroma formation is common after 5. Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment
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amount of dead space and inherent movement between tissue after treatment. Plast Reconst Surg 1991; 88:311-318.
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Tacking or walking sutures are not recommended for dead space improvement of perfusion from free myocutaneous flaps. In: Stuttgart
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restrict movement and increase postoperative discomfort. Dead 1989:217-222.
space is managed by provision of surgical drainage; drainage for 7. McKee NH, Kuzon WM. Functioning free muscle transplantation:
5 to 7 days is adequate in most instances. making it work? What is known? Ann Plast Surg 1989; 23:249-254.
8. Manktelow RT, Zuker RN. The principles of functioning muscle trans-
Cross-contamination from the recipient site to the donor site plantation: applications to the upper arm. Ann Plast Surg 1989;22:275-281.
may result in donor site infection. Care should be taken to use 9. Taylor GI, Minabe T. The angiosomes of the mammals and other verte-
separate instrumentation in each surgical field. The surgical brates. Plast Reconst Surg 1992;89:181-215.
team responsible for dissection of the donor site should avoid 10. Gregory CR, Gourley IM, Koblik PD, et al. Experimental definition of
contact with the recipient site, and vice versa. latissimus dorsi, gracilis, and rectus abdominis musculocutaneous flaps
in the dog. Am J Vet Res 1988;49:878-884.
Recipient site complications may be caused by inappropriate 11. Weinstein MJ, Pavletic MM, Boudrieau RJ. Caudal sartorius muscle
preparation of the recipient wound bed or by flap-related compli- flap in the dog. Vet Surg 1988,17:203-210.
cations. Microsurgically transferred flaps are excellent sources 12. Solano M, Purinton PT, Chambers JN, et al. Effects of vascular pedicle
of vascularized tissue for reconstruction, but they should not be ligation on blood flow in canine semitendinosus muscle. Am J Vet Res
viewed as a panacea for a poorly prepared wound bed. Necrotic 1995;56:731-735.
tissue and debris must be surgically removed from the wound 13. Pavletic MM. Canine axial pattern flaps, using the omocervical, thora-
before transfer. In the case of osteomyelitis, infected bone must codorsal, and deep circumflex iliac direct cutaneous arteries. Am J Vet
be thoroughly debrided. Free flaps should not be placed onto Res 1981;42:391-406.
heavily contaminated or overtly infected wound beds. Such 14. Pavletic MM. Caudal superficial epigastric arterial pedicle grafts in the
wounds should be aggressively converted to a clean contami- dog. Vet Surg 1980;9:103-107.
nated state and subsequently reconstructed. 15. Henney LHS, Pavletic MM. Axial pattern flap based on the superficial
brachial artery in the dog. Vet Surg 1988; 17:311-317.
Flap-related complications may be specific to the tissue trans- 16. Smith MM, Shults S, Waldron DR, et al. Platysma myocutaneous flap
ferred, such as loss of orthopedic fixation in vascularized bone for head and neck reconstruction in cats. Head Neck 1993;15:433-439.
grafts or incisional dehiscence of transferred footpads. Compli- 17. Smith MM, Payne JT, Moon ML, et al. Axial pattern flap based on the
cations common to all flaps relate to the integrity of the micro- caudal auricular artery in dogs. Am J Vet Res 1991; 52:922-925.
vascular anastomosis. Meticulous attention to anastomotic 18. Remedios AM, Bauer MS, Bowen CV. Thoracodorsal and caudal super-
technique, astute postoperative monitoring and early surgical ficial epigastric axial pattern skin flaps in cats. Vet Surg 1989;18:380-385.
re-exploration of compromised flaps are mandatory. 19. Weinstein MJ, Pavletic MM, Boudrieau RJ, et al. Cranial sartorius
muscle flap in the dog. Vet Surg 1989,18:286-291.
The relative advantages and disadvantages of microsurgical 20. Degner DA, Bauer MS, Steyn PF, et al. The cranial rectus abdominis
reconstruction are well documented in the human literature. Our muscle pedicle flap in the dog. Vet Comparative Orthop Traumatol
understanding of the potential of these techniques in veterinary 1994;7:21-24.
surgery is expanding. Successful use of microsurgical tissue 21. Purinton PT, Chambers JN, Moore JL. Identification and categorization
628 Soft Tissue
of the vascular patterns to muscles of the thoracic limb, thorax, and neck
of dogs. Am J Vet Res 1992;53:1435-1445. Paw and Distal Limb Salvage
22. Chambers JN, Purinton PT, Allen SW, et al. Identification and anatomic
categorization of the vascular patterns to the pelvic limb muscles of dogs.
and Reconstructive Techniques
Am J Vet Res 1990;51:305-313. Mark W. Bohling and Steven F. Swaim
23. Jackson M. Platelet physiology and platelet function: inhibition by
aspirin. Compend Contin Educ Pract Vet 1987;9:627-638.
24. Concannon KT, Haskins SC, Feldman BF. Hemostatic defects associated
Indications
with two infusion rates of dextran 70 in dogs. Am J Vet Res 1992;53:1369- The paws of a dog and cat play a significant role in their
1372. ambulatory abilities; thus, when an animal has paw skin defects,
25. Zelt RG, Olding M, Kerrigan CL, et al. Primary and secondary critical
some form of reconstruction or salvage surgery is necessary to
ischemia times of myocutaneous flaps. Plast Reconstr Surg 1986;78:500- preserve normal ambulation. Minor paw defects may only require
503. a simple reconstructive surgical technique, such as suture of a
26. Picard-Ami LA, Thomson JG, Kerrigan CL. Critical ischemia times pad laceration. Conversely, major defects may require a more
and survival patterns of experimental pig flaps. Plast Reconstr Surg involved reconstruction or salvage surgical technique as with
1990;86:739-743. a skin graft to reconstruct a massive skin defect. With severe
27. Kerrigan CL, Zelt RG, Daniel RK. Secondary critical ischemia time of paw trauma, limb amputation is often performed, whereas if
experimental skin flaps. Plast Reconstr Surg 1984; 74:522-526. paw salvage techniques are available, limb amputation may
28. Degner DA, Walshaw R. Medial saphenous fasciocutaneous and possibly be avoided. In other instances of severe paw trauma,
myocutaneous free flap transfer in eight dogs. Vet Surg 1997; 26:20-25. limb amputation is not an option, and reconstruction or salvage
29. Fowler JD, Miller CW Bowen V, et al. Transfer of free vascular becomes necessary, as in the instance of a cat with bilateral
cutaneous flaps by microvascular anastomosis: results in six dogs. Vet avascular necrosis of the forepaws caused by excessively
Surg 1987;16:446-450. tight bandages following onychectomy. In the working dog and
30. Miller CW, Fowler JD, Bowen CVA, et al. Experimental and clinical free canine athlete, in which limb and paw functions are essential
cutaneous transfers in the dog. Microsurgery 1991;12:113-118. for performance, strong functional reconstruction and salvage
31. Degner DA, Walshaw R, Lanz O, et al. The medial saphenous fasciocu- procedures are especially important.
taneous free flap in dogs. Vet Surg 1996;25:105-113.
32. Philibert D, Fowler JD, Clapson JB. The anatomic basis for a trapezius Defects of the paws can involve the dorsal surface, palmar or
muscle flaps in dogs. Vet Surg 1992;21:429-434. plantar surface (pads), interdigital surfaces, or interpad surfaces.
33. Philibert D, Fowler JD, Clapson JB. Free microvascular transfer of the Certain larger wounds on the dorsum of the paw and distal limb
trapezius musculocutaneous flap in dog. Vet Surg 1992;21:435-440. can be managed by techniques such as skin grafts and flaps,
34. Nicoll SA, Fowler JD, Remedios AR, et al. Development of a free latis- which are described in earlier sections of this chapter. This
simus dorsi muscle flap in cats. Vet Surg 1996;22:40-48. discussion describes some of the techniques that have particular
35. Fowler JD, Levitt L, Bowen CVA. Microsurgical free bone transfer in application for reconstruction and salvage of the unique injuries
the dog. Microsurgery 1991;12:145-150. of the specialized structures of the paws.
36. Brown K, Marie P, Lyszakowski T, et al. Epiphysial growth after free
fibular transfer with and without microvascular anastomosis. J Bone Joint A unique wound affecting greyhounds is the digital pad callus/
Surg Br 1983;65:493-501. corn. These are painful lesions in need of a technique to resolve
37. Ostrup LT, Fredrickson JM. Distant transfer of a free, living bone graft the condition.
by microvascular anastomoses. Plast Reconstr Surg 1974;54:274-285.
38. Levitt L, Fowler JD, Longley M, et al. A developmental model for free Dorsal Paw Wounds
vascularized bone transfers in the dog. Vet Surg 1988;17:194-202.
Some dorsal paw wounds may be such that the wound edges
39. Szentimrey DG, Fowler JD. The anatomic basis of a free vascularized can be easily apposed after debridement and lavage. In other
bone graft based on the distal canine ulna. Vet Surg 1994;23:529-533.
instances, tension in wound closure may need to be overcome
40. Szentimrey DG, Fowler JD, Johnston C, et al. Transplantation of the by using some type of tension suture pattern, such as vertical
canine distal ulna as a free vascularized bone graft. Vet Surg 1995;24:215-
mattress sutures, horizontal mattress sutures, or far near near
225.
far sutures. Other sutures can be used to relieve tension by
41. Philibert D, Fowler JD. The trapezius osteomusculocutaneous flaps in
gradually stretching the periwound skin so that it can be apposed
dogs. Vet Surg 1993;22:444-450.
or nearly so. Examples of these latter sutures are presutures and
42. Swaim SF, Bradley DM, Steiss JE, et al. Free segmental paw pad grafts adjustable horizontal mattress sutures.
in dogs. Am J Vet Res 1993;54:2161-2170.
43. Swaim SF, Riddell KP, Powers RD. Healing of segmental grafts of digital When wound tension is too great to be overcome by undermining,
pad skin in dogs. Am J Vet Res 1992;53:406-410.
tension sutures, or skin stretching sutures, relaxing incisions can
44. Gourley IM. Neurovascular island flap for treatment of trophic be considered when wound size permits. These are used in lieu of
metacarpal pad ulcer in the dog. J Am Anim Hosp Assoc 1978;14:119-125.
skin grafts or flaps. Simple relaxing incision(s) made adjacent to
45. Basher A. Foot injuries in dogs and cats. Compend Contin Ed Pract Vet the wound can be used; however, such incisions commonly result
1994;16:1159-1176.
in wounds about as large as the one that is closed as a result of
46. Basher AWP, Fowler JD, Bowen CV, et al. Microneurovascular free their use. Multiple punctate relaxing incisions provide cosmetic
digital pad transfer in the dog. Vet Surg 1990;19:226-231. and quickly healing small wounds while providing skin relaxation.
Skin Grafting and Reconstruction Techniques 629
Although other familiar tension suture patterns and simple of removal, the limb should be observed for any swelling distal to
relaxing incisions can be used to aid in closure of dorsal paw the sutures. This swelling indicates the possibility of a biologic
wounds, this section describes presutures, adjustable horizontal tourniquet developing at the time of definitive surgery, and
mattress sutures, and multiple punctate relaxing incisions. These another form of reconstruction may be considered.
techniques have been found especially useful in closure of distal
limb and dorsal paw wounds. Adjustable Horizontal Mattress Sutures
A continuous adjustable horizontal mattress suture may be used
Presutures to aid wound contraction by applying continuous tension to the
Presutures are particularly useful in the distal limb and paws, skin edges of a wound that cannot be closed initially because of
in which “walking” sutures can encroach on vessels, nerves, tension. The suture may be placed early in wound management
and tendons. Presutures are thus termed because they are or after granulation tissue has formed.
placed before excision or debridement of a lesion. They stretch
the surrounding skin so that it can be used to close a distal limb Synthetic 2-0 monofilament suture (nylon or polypropylene) on a
or paw defect. Presutures are placed with interrupted Lembert cutting needle is used to place a half buried horizontal mattress
bites, using 2-0 or 3-0 polypropylene or nylon suture (Figure suture at one end of the defect. The suture is continued as an
41-40A and B). They are placed under tension, usually 24 hours intradermal horizontal mattress suture along the length of the
before excision or debridement. Presutures are placed while wound. Each suture bite is advanced slightly, so the suture
the animal is under the effects of a tranquilizer or neurolepta- passes at an angle across the wound. Thus, as the suture is
nalgesia and local analgesic agent in the skin to be sutured. tightened, it slides through the tissues more easily. Care is taken
Following presuturing, the area is bandaged until lesion excision not to disturb the attachment of skin to any granulation tissue
or debridement. present in the wound. At the opposite end of the wound, the
needle is passed through the entire skin thickness and through
At the time of definitive surgery, the presutures are removed. a hole in a sterile button. Traction on the suture moves the
The lesion is removed or debrided, and the skin, which has been wound edges toward each other. The skin edge advancement
stretched gradually by stress relaxation, is used to close the is maintained by a small fishing weight (“split shot”) placed on
defect (Figure 41-40C and D). the suture adjacent to the button. (Note: due to environmental
concerns from lead, non-toxic split shot made from bismuth,
An advantage of presutures is that they can be used in tin, or antimony are now widely available, and should be used,
conjunction with other tension relieving techniques to provide to prevent the possibility of toxic lead exposure in the event of
wound closure. Between the time they are placed and the time patient ingestion.) To prevent slippage, a second split shot is
placed against the first (Figure 41-41). Excess suture is cut off
about 2 inches beyond the split shot, and a bandage is applied
over the wound.
The more punctate incisions that are made and the larger they
are, the greater the tension relief. However, the opportunity to
damage the cutaneous vasculature is increased, thus increasing
the risk of necrosis. Therefore, no more punctate incisions should
be made than are necessary to provide wound closure without
excessive tension.
for damage to the blood supply of the digital pad. Dorsal filleting
is easier, but the technique takes longer because it is a two step
procedure, with digital pad transposition performed 14 days after
the phalanges have been removed.
pad as well as loss of some or all the digital pads, thus precluding A graft is placed in each of the rectangular depressions and
phalangeal fillet. sutured in place. Two simple interrupted sutures of 5-0 polypro-
pylene can be used, with one suture on each side of the graft on
After a paw wound has been managed to the point that it has the long sides of the graft (Figure 41-48A). An alternative suture
healthy bed of granulation tissue, rectangular tissue segments pattern, which the authors prefer, is a simple interrupted suture
measuring 6 x 8 mm are traced around the wound using a template placed at each corner of the graft (Figure 41-48B).
of x-ray film with a hole in its center and a sterile skin marker
or splintered applicator stick dipped in methylene blue (Figure A nonadherent bandage pad with a small amount of 0.1%
41-47A). The rectangles of tissue are incised with a number 11 gentamicin sulfate ointment is placed over the grafted site. The
scalpel blade, and the tissue is excised using iris scissors and remainder of the bandage is as described for pad lacerations.
thumb forceps, leaving a series of rectangular depressions The graft donor sites are allowed to heal by second intention
about 2 mm deep around the wound (Figure 41-47B and C). and are bandaged in a similar manner. If remaining digital pad
tissue is pliable enough to allow suture closure of the donor
In the center of other digital pads on the same animal, possibly sites, these sites may be closed with 3-0 polypropylene or nylon
the same paw, the same template is used to trace the same far near near far sutures followed by bandaging. The initial
number and size of rectangles (See Figure 41-47C). Again, a bandage is usually left in place for 3 days, followed by bandage
number 11 scalpel blade is used to incise the grafts, and iris changes every other day until 21 days postoperatively. A bootie
scissors and thumb forceps are used to remove the grafts (Figure may be indicated for a transitional period between bandage and
41-47D). All subcutaneous tissue is removed from the grafts with no bandage. Sutures in the grafts are removed between 10 and
iris scissors. 14 days postoperatively.
Figure 41-47. Pad grafts. A. A piece of x ray film with a 6 x 8 mm hole in its center is used with a splintered applicator stick dipped in methylene
blue to trace graft recipient sites around the wound. B. After incision, thumb forceps and iris scissors are used to remove rectangles of tissue
from recipient sites. C. With recipient sites prepared, the x ray film applicator stick and methylene blue are used to trace segmental grafts on
digital pads. D. A segmental pad graft has been removed from a digit. (From Swaim SF, Bradley DM, Steiss, JE, et al. Free segmental paw pad
grafts in dogs. Am J Vet Res 1993;54:2161-2170.)
634 Soft Tissue
placement of the pad may be more critical when considering the Digital, Interdigital, and Interpad Wounds
greater weight to be placed on it. Moreover, when the procedure
Paw lesions may involve the interdigital skin or the interpad skin
is performed unilaterally, that limb is significantly shorter than
on the palmar or plantar surface of the paw. The lesions are
the other limb, and the animal may tend to carry the limb or only
usually traumatic or infectious. The phalangeal fillet technique
use it intermittently.
and a fusion podoplasty technique may be used to reconstruct
or to salvage paws thus involved.
that sufficient skin and subcutaneous tissue remain at the base needed for resurfacing procedures, they may be used; however,
of the flap to provide blood supply. The flap is sutured, to the pad tissue in an abnormal location on the dorsum of the paw may
remaining skin of the adjacent digits or dorsum of the paw with be cosmetically unappealing.
simple interrupted sutures of 2 0 or 3 0 polypropylene (Figure
41-51D) and Figure 41-52D). Fusion Podoplasty
Small amounts of cotton are placed between remaining digits Fusion podoplasty is a paw salvage technique whereby all
and in the space between remaining digits and the metacarpal interdigital and interpad skin is removed from a paw, and the
or metatarsal pad for dryness. A strip of nonadherent bandage remaining strips of skin on the dorsum of the digits are sutured
pad is placed over suture lines. Absorbent secondary bandage together, as are the digital and metacarpal or metatarsal pads.
and adhesive tape tertiary bandages are then applied. The cup of The technique is indicated for the treatment of chronic fibrosing
a metal splint may also be incorporated in the bandage. Clinical interdigital pyoderma in dogs when other forms of medical
judgment should be used as to whether special considerations therapy or conservative surgical approaches have been unsuc-
are needed in bandaging to relieve pressure on the area, i.e., cessful. The procedure is usually performed on two paws at a
“clamshell” bandage, foam sponge “donut” pad, or digit-elevating time when all four paws are involved. The most severely involved
foam sponge pad (See Chapter 2). Bandages are changed periodi- paws (usually the fore paws) are operated on first, followed 1
cally for 7 to 10 days. The length of time sutures should remain in month later by the hind paws. The technique has also been
place, the frequency of bandage changes, and the length of time described for use in treating abnormalities associated with
bandages are needed are variable factors dependent on wound severed digital flexion tendons to fuse the digits against the
tension, wound healing rate, and amount of drainage. metacarpal or metatarsal pad to provide a functional paw.
The disadvantages of the procedure are that filleting of digit 3 or When this technique is used to treat chronic fibrosing inter-
4 leaves a cosmetic defect in the center of the paw, and a defect digital pyoderma, the dog is given systemic antibiotics based on
in this area can cause lameness. If digits 3 and 4 have been the results of culture and sensitivity testing before the surgical
filleted to resurface digits 2 and 5 or the dorsum of the paw, the procedure. At the time of surgery, a sterile marking pen is used to
second and fifth digits protrude and may be subject to snagging outline the interdigital skin to be removed. On the dorsum of the
on carpets or vegetation. If the pads of the filleted digits are paw, lines are drawn on the digits at the junction of normal and
affected skin. Lines are drawn near the nails, so 2 to 3 mm of skin
remains adjacent to the nail on the axial surfaces of the digits.
Because the third and fourth digits extend beyond the second
and fifth, respectively, lines on the abaxial surfaces of the third
and fourth digits are drawn so they intersect the digital pad
midway between their cranial and caudal ends. The technique
provides skin excisions on the abaxial surfaces of the third and
fourth digits that match the axial surface excisions on digits 2
and 5, respectively (Figure 41-53). This method usually incorpo-
rates all affected skin between the fourth and fifth as well as
between the second and third digits.
The skin strips on the dorsum of each digit are sutured together
with three to four simple interrupted sutures of 3-0 polypropylene
(Figure 41-60). Areas at the ends of the digits are not sutured, to
allow for drainage. After suturing the first paw, the pressure wrap
is removed from the second paw, and it is sutured in like manner.
Figure 41-59. Fusion podoplasty. A. Curved Carmalt forceps are passed across the cranial surface of the metacarpal or metatarsal pad deep to
the sutures to grasp a quarter inch Penrose drain to be pulled through the area. B. The drain is in place. (After Swaim SF, Lee AH, MacDonald JM,
et al. Fusion podoplasty for the treatment of chronic fibrosing interdigital pyoderma in the dog. J Am Anim Hosp Assoc 199 1;27:264 274.)
Metacarpal or metatarsal bones, especially the third and fourth sutures of 2-0 or 3-0 polvglyconate or polyglactin 910 are used
bones, are trimmed back until the metacarpal or metatarsal pad to suture the subcutaneous tissue on the cranial edge of the
can be folded cranially and positioned such that the thickest metacarpal or metatarsal pad to the subcutaneous tissue
part of the pad is directly beneath the ends of the metacarpal or overlying the cranial aspect of the metacarpal or metatarsal
metatarsal bones (Figure 41-61D). The skin edge on the dorsal bones after the pad is rotated into position (Figure 41-61E). Far
surface of the metacarpal or metatarsal area may also have to near near far sutures of 2-0 or 3-0 polypropylene or nylon are
be trimmed to get this positioning. If infection is present, the used to complete the closure of the metacarpal or metatarsal
heads are not removed from these bones in an effort to avoid pad to the skin on the cranial surface of the metacarpal or
the possibility of ascending infection in the marrow cavities of metatarsal bones. Simple interrupted tacking sutures are placed
the bones. After infection is controlled the area may undergo at each end of the drain to hold it in place (Figure 41-61F).
reoperation to remove the heads and trim the bones.
A “clamshell” splint is indicated when bandaging to keep
After the metacarpal or metatarsal pad has been folded cranially pressure off of the newly positioned pad. The drain is removed in
into position, a quarter inch diameter Penrose drain is placed 4 to 5 days. Sutures are removed at 10 to 14 days, and bandage
between the pad and the ends of the bones. The pad is rotated support is used for 21 days. These times are subject to variation,
under the ends of the bones. Interrupted horizontal mattress depending on healing and the size of the animal.
Figure 41-61. Pandigital amputation. A. A transverse incision is made on the dorsum of the paw proximal to the line of demarcation between
viable and nonviable skin. B. A similar incision is made on the palmar or plantar surface of the paw cranial to the metacarpal or metatarsal pad.
C. After severance of deep structures, the digits are removed. D. The distal heads of the metacarpal or metatarsal bones are removed, and the
bones are trimmed to allow proper fit of the pad under their ends. E. A quarter inch Penrose drain is placed between the pad and the ends of the
bones, and series of interrupted absorbable subcuticular horizontal mattress sutures are used to suture the pad under the metacarpal or meta-
tarsal bones. F. Far near near far skin sutures are used to complete the closure. (From Swaim SF, Henderson RA. Small animal wound manage-
ment, 2nd ed. Baltimore: Williams & Wilkins, 1997: 360.)
Skin Grafting and Reconstruction Techniques 641
Suggested Readings
Barclay CG, Fowler JD, Basher AW. Use of the carpal pad to salvage the
forelimb in a dog and cat: An alternative to total limb amputation. J Am
Anim Hosp Assoc 1987;23,527 532.
Basher AW. Foot injuries in dogs and cats. Compend Contin Educ Pract
Vet 1994;16:1159 1178.
Bradley DM, Shealy PM, Swaim SF. Meshed skin graft and phalangeal
fillet for paw salvage: a case report. J Am Anim Hosp Assoc 1993;29:427
433.
Bradley DM, Swaim SF, Alexander CN, et al. Autogenous pad grafts for
reconstruction of a weight bearing surface: a case report. J Am Anim
Hosp Assoc 1994;30:533 538.
Newman ME, Lee AH, Swaim SF, et al. Wound healing of sutured and
nonsutured canine metatarsal foot pad incisions. J Am Anim Hosp
Assoc 1986;22:757 761.
Pavletic MM. Atlas of small animal reconstructive surgery, 2nd ed.
Philadelphia: JB Lippincott, 1999:365.
Pavletic MM. Foot salvage by delayed reimplantation of severed
metatarsal and digital pads by using a bipedicle direct flap technique. J
Am Anim. Hosp Assoc 1994;30:539 547.
Swaim SF. Management and bandaging of soft tissue injuries of dog and
cat feet. J Am Anim Hosp Assoc 1985;21:329 340.
Swaim SF. Wound management of distal limbs and paws: reconstruction
and salvage. Vet Med Rep 1990;2:128 139.
Swaim SF, Amalsadvala T, Marghitu DB, et. al. Pressure reduction
effects of subdermal silicone block gel particle implantation: A prelim-
inary study. Wounds. 2004; 16:299-312.
Swaim SF, Bradley DM, Steiss JE, et al. Free segmental paw pad grafts
in dogs. Am J Vet Res 1993;54:2161 2170.
Swaim SF, Garrett PD. Foot salvage techniques in dogs and cats:
options, “do’s and don’ts.” J Am Anim Hosp Assoc 1985; 21:511 519.
Swaim SF, Henderson RA. Small animal wound management, 2nd ed.
Baltimore: Williams & Wilkins, 1997:295.
Swaim SF, Lee AH, MacDonald JM, et al. Fusion podoplasty for the
treatment of chronic fibrosing interdigital pyoderma in the dog. J Am
Anim Hosp Assoc 1991;27:264 274.
Swaim SF, Marghitu DB, Rumph PF, et. al. Effects of bandage configu-
ration on paw pad pressure in dogs: A preliminary study. J Am Anim
Hosp Assoc 2003;39:209-216.
Swaim SF, Milton JL. Fusion podoplasty to treat abnormalities
associated with severed digital flexion tendons. J Am Anim Hosp Assoc
1994;30:137 144.
Swaim SF, Riddell KP, Powers RD. Healing of segmental grafts of digital
pad skin in dogs. Am J Vet Res 1992;53:406 410.
Vig MM. Management of integumentary wounds of extremities in dogs:
An experimental study. J Am Anim Hosp Assoc 1985;21: 187 192.
642 Soft Tissue
Section I
Cardiovascular and Lymphatic
Chapter 42
Heart and Great Vessels
Conventional Ligation of
Patent Ductus Arteriosus in
Dogs and Cats
Eric Monnet Figure 42-1. PDA ligation: The patent ductus arteriosus is isolated by
blunt dissection without opening the pericardial sac. The right angle
Introduction forceps is parallel to the transverse plane for the caudal dissection of
the ductus. The right angle forceps is angle caudally 45° for the cranial
Patent ductus arteriosus is the most common congenital heart dissection of the ductus. The ligature closest to the aorta is slowly tight-
defect diagnosed in dogs. In cats, ventricular septal defects and ened and tied first.: From E.C.Orton: Congenital Heart Defect, in Small
pulmonic stenosis are more common cardiac defects. Physical Animal Thoracic Surgery, Williams & Wilkins, 1995, Chapt 19, p205.
findings include a continuous murmur auscultated at the left
heart base and a hyperkinetic pulse. Thoracic radiographs the attachment of the pericardium ventrally from the aorta to
show dilation of the descending aorta, the left atrium, and the expose this triangle. The dissection of the medial aspect of the
pulmonary artery. Pulmonary overcirculation is also present. patent ductus arteriosus is performed by passing the right angle
Surgical correction of the defect should be performed as soon forceps from caudal to cranial (Figure 42-2). Dissection should
as possible after diagnosis. Most animals with untreated patent be as gentle as possible with small movements of the right
ductus arteriosus will die within 1 year from congestive heart angle forceps to avoid tearing the medial wall of the ductus.
failure. Pulmonary hypertension may cause reversal of flow When the tip of the right angle forceps is clear of tissue, a #1
through the ductus arteriosus in a few cases. Dogs presenting or 0 silk suture is grasped by the forceps and passed around
with pulmonary edema should be treated with furosemide prior the ductus. A second suture is passed around the ductus in the
to surgery. same manner. Alternatively, some surgeons pass a doubled
strand of suture and cut the suture in the middle thus reducing
Surgical Technique the number of passes on the medial aspect of the ductus. The
PDA ligation is accomplished through a left 4th intercostal thora- ligature closest to the aorta is slowly tightened and tied first
cotomy in dogs, or a 4th or 5th left intercostal thoracotomy in cats. (Figure 42-3). The second ligature is then tightened and tied. The
The left cranial lung lobe is reflected caudally and packed with palpable thrill in the pulmonary artery present prior to ligation
a moistened laparotomy sponge or 4x4 gauze in smaller animals. should be completely eliminated after ligation. If the medial
The vagus nerve courses over the ductus arteriosus and can be wall of the ductus is ruptured during dissection light pressure
used as a landmark to locate the ductus arteriosus. The vagus should be applied to control the bleeding. If the tear is not too
nerve is elevated from the mediastinum by sharp dissection and large the bleeding will stop. However, continuing the dissection
retracted gently with a suture. The recurrent laryngeal nerve may worsen the tear and lead to uncontrollable hemorrhage. At
should be identified as it passes caudal to the ductus. Dissection this point, the options depend on the experience of the surgeon
of the vagus nerve should be performed outside of the pericardial and on the availability of vascular instruments. One option is to
sac with a right angle forceps. Dissection of the patent ductus abort the surgery and refer the case to a surgeon experienced
arteriosus starts on its caudal aspect (Figure 42-1). The forceps in cardiovascular surgery for latter closure. Another option is
should be kept parallel to the transverse plane during this part to divide the ductus between two vascular forceps and close
of the dissection. Dissection of the cranial portion of the ductus both ends with 4-0 polypropylene suture using a continuous
is performed at an angle of approximately 45° to the transverse mattress pattern. Intravenous injection of nitroprusside has
plane in a triangle delineated by the aortic arch, pulmonary been recommended to decrease arterial pressure after tearing
artery, and patent ductus arteriosus (See Figure 42-1). Careful a ductus arteriosus. Clamping of the aorta and the pulmonary
sharp dissection with scissors is sometimes necessary to reflect artery to control bleeding has also been recommended. At
Heart and Great Vessels 643
Surgical Management of
Pulmonic Stenosis
Jill E. Sackman and D.J. Krahwinkel, Jr.
Introduction
Pulmonic stenosis is reported to be the third most common
congenital heart disease in the dog with patent ductus arteriosus
and aortic stenosis being first and second, respectively.1 The
Figure 42-2. PDA ligation: Two sutures are passed from cranial to English bulldog is the most common breed represented, however,
caudal around the ductus with right angle forceps after complete dis- other dogs at risk include the beagle, Samoyed, Chihuahua,
section of the ductus arteriosus. Illustration Fig 19.1. C: From E.C.Orton: schnauzer, Boykin spaniel, mastiff, and various terrier breeds.2
Congenital Heart Defect, in Small Animal Thoracic Surgery, Williams & The disease occurs equally between male and female except
Wilkins, 1995, Chap19, p206. in the bulldog where the incidence in males predominates. The
disease is rare in cats. Pulmonic stenosis has a genetic basis in
dogs, although this is uncertain in the cat.3
Diagnosis
Many cases of pulmonic stenosis are asymptomatic early in their
life; some remain asymptomatic indefinitely. More severe cases
display exertional fatigue, dyspnea, and syncope. Signs of right
heart failure including ascites, hepatomegaly, and arrhythmia
may be present in advanced cases.4 Physical examination
reveals a systolic ejection murmur heard over the pulmonic valve
that often radiates along the sternum to both sides of the thorax.
A holosystolic murmur of tricuspid insufficiency may sometimes
be auscultated over the right hemithorax.
poststenotic dilatation of the main pulmonary artery is seen on Even though various authors have stated guidelines for surgical
the dorsoventral view. The pulmonary vessels appear normal intervention, most of these are based upon personal observations.
or somewhat underperfused. Cardiac catheterization helps to There have been no clinical trials in dogs with long-term follow-up
locate the specific site of the stenosis and to measure pressure to validate criteria for surgical intervention or to determine which
gradients for prognosis. Measuring gradients under anesthesia corrective procedure gives the best results; however in a series
gives pressure readings that are usually much lower than of 72 cases of congenital pulmonic stenosis left untreated, only
actually exist. Angiographic features of pulmonic stenosis 65% of patients were alive after two years.7 Unfortunately in this
include thickened and dysplastic valve leaflets, narrowing of the series, the severity of the stenosis was not described.
outflow tract and valve orifice, poststenotic pulmonary artery
dilatation, and right ventricular hypertrophy. In English bulldogs
an anomalous left coronary artery may be seen crossing the
Anesthesia for Pulmonic Stenosis
ventricle at the level of the stenosis. Nearly all anesthetic agents depress cardiopulmonary function
directly or alter reflex regulatory mechanisms.8 Patients with
In many cases echocardiography and color flow Doppler cardiac disease may have little to no reserve for compensation;
echocardiography examination provide sufficient data making therefore, anesthetic agents must be administered carefully and
cardiac catheterization unnecessary. Typical findings are in reduced dosages. Preanesthetic agents should be adminis-
hypertrophy of the right ventricle, muscular narrowing of the tered to relieve anxiety and to reduce the amount of depressant
right ventricular outflow tract, deformity and narrowing of the general anesthetic required. A combination of a benzodiazepine
pulmonic valve, and post stenotic dilatation of the pulmonary and an opioid are used for sedation. Opioid-induced respi-
artery. Pressure gradients measured by color flow Doppler ratory depression may occur, therefore oxygen by mask should
echocardiography are more likely than catheterization to give be provided during the induction process. Anticholinergics,
an accurate assessment of the severity of disease because the especially atropine, are not used unless bradycardia occurs
examination does not require general anesthesia. Echocardiog- because of their propensity to induce tachycardia.
raphy and/or cardiac catheterization can usually determine the
severity of the disease and locate the stenosis at the supraval- Administering low concentration isoflurane in oxygen until
vular, valvular, subvalvular, or infundibular site. This information is tracheal intubation can be accomplished completes anesthetic
crucial in determining surgical candidates, selecting the correct induction. Anesthetic maintenance is by continued low concen-
surgical procedure, and giving prognosis. In some patients it is tration of isoflurane supplemented with intermittent doses of
very difficult to delineate between a pure valvular stenosis and an opioid. Intermittent positive-pressure ventilation is provided
one that is both valvular and subvalvular. This makes selecting either manually or mechanically. Profound muscle relaxation
the proper surgical technique more difficult. can be produced by intravenous administration of atracurium, a
nondepolarizing muscle relaxant.
Surgical Guidelines Pulmonic stenosis patients must be closely monitored for cardio-
Nonanesthetized pressure gradients that are less than 50 mmHg pulmonary function. Monitoring parameters should include
are generally considered mild and do not require surgical inter- heart rate, ECG, pulse quality, direct or indirect blood pressure,
vention. Severe gradients exceeding 80 mmHg place the patient pulse oximetry, and central venous pressure. Assessment of
at risk of heart failure and death. These should have surgical blood volume and hemodilution is by serial determinations
intervention.3,4 Dogs with moderate disease (gradients of 50 to of packed cell volume and total plasma proteins. Measuring
80 mmHg) may or may not require surgical correction depending urine production assesses renal function. Blood pressure is
on the progression of the disease. One author has recommended maintained by a maintenance flow of intravenous crystalloids
surgery when: 1) the right ventricular pressure exceeds 120 mmHg supplemented with colloids. Cross-matched whole blood must
or a gradient exceeds 100 mmHg in a mature dog, or 2) the right be available should major hemorrhage occur.
ventricular pressure is 90 to 120 or a gradient of 70 to 100 in an
immature dog.5 Others recommend surgery any time the gradient
exceeds 50 mmHg and right ventricular hypertrophy is significant.6
Surgical Procedures for Pulmonic Stenosis
Various surgical procedures have been described for correction
Any animal not undergoing surgery should be re-evaluated at of pulmonic stenosis.9 These include balloon dilatation, open
three month intervals to determine if the disease is progressing. valvulotomy/valvulectomy, closed valvulotomy/dilatation, open
Symptomatic animals should have surgical intervention and closed patch grafting, by-pass conduit, and open-heart repair
regardless of their pressure gradients. A problem of waiting with cardiopulmonary bypass. The specific procedure depends
to see if a patient’s disease is progressive based on pressure upon the location of the stenosis, size of the patient, severity of
measurements or disease signs is that they may become poorer the disease, expertise of the surgeon, and equipment available.
surgical candidates with time. These animals may develop Many of the procedures have been adapted from techniques
secondary infundibular muscular stenosis, worsening right used to correct pulmonic stenosis in children although direct
ventricular hypertrophy, right ventricular fibrosis, and right heart application to animals may be erroneous. For example, valvular
failure. If possible surgery should be delayed until the animal is stenosis in children is commonly a fusion of the valve leaflets,
mature so the procedure is done on a fully developed heart that whereas in dogs it is usually a fibrotic, thickened, dysplastic
will not outgrow the correction. valve. Direct comparison of the techniques or the expected
results between children and dogs should not be made.
Heart and Great Vessels 645
Open Valvulotomy/Valvulectomy
This procedure is a modification of the technique developed by
Swan10 using transient venous inflow occlusion and a pulmonary
arteriotomy. The technique is used in patients with a valvular
stenosis and minimal to no subvalvular component. The thorax
is opened by a thoracotomy at the left fourth intercostal space.
Dissecting between the thymus and the cranial aspect of the
pericardial sac isolates the cranial vena cava. The cava is
located on the right side of the thorax and ventral to the brachy-
cephalic artery. A Rumel tourniquet of umbilical tape is placed on
the vessel. Incising the caudal mediastinum immediately behind
the pericardial sac and ventral to the phrenic nerve approaches
the caudal vena cava. The vessel can be visualized deep in the
mediastinal space to the right side of the thorax. Right angle
forceps are used to place a Rumel tourniquet similar to the cranial
cava. Dissection of the caudal cava may be impossible from the
fourth intercostal space in dogs with severe cardiac enlargement.
In these instances the caudal edge of the incised skin is retracted
and a small thoracotomy incision is made at the sixth intercostal Figure 42-5. Stay sutures (SS) are placed in the dilated pulmonary
space. The cava is easily isolated from this position. artery. The pulmonary artery (PA) is opened to just above the level of
the pulmonic valve (PV).
A third Rumel tourniquet is placed on the descending aorta just
above the heart base. Tightening this tourniquet for 1 to 2 minutes intravenous lidocaine drip help to minimize surgically induced
after inflow occlusion maximizes blood flow to the heart and brain. arrhythmias. Stay sutures of 5-0 polypropylene are placed in the
It is released slowly as cardiac function returns to normal. dilated pulmonary artery immediately distal to the pulmonary
valve. Venous inflow occlusion is accomplished by tightening
The pericardial sac is incised parallel and ventral to the phrenic the caval tourniquets. After waiting a few seconds for the heart
nerve. Four to six stay sutures are placed in the pericardial to partially empty, a 1 to 2 cm incision is made between the two
sac and secured to the surgical drapes to “cradle” the heart stay sutures (Figure 42-5). A small retractor at the ventral end
(Figure 42-4). Lidocaine applied topically to the heart and an of the incision and the two stay sutures retract the arteriotomy
site (Figure 42-6). Suction is used to empty the right ventricle
and visualize the pulmonic valve. The dysplastic leaflets are
grasped with forceps, and scissors or scalpel used to excise the
valve (Figure 42-7). After all three leaflets have been excised or
incised, a forceps is used to dilate the valve annulus. A “pop” can
be felt as the annulus stretches. One finger is inserted into the
outflow tract to assure that the stenosis is relieved. The cranial
Figure 42-8. Satinsky (SF) forceps are used to occlude the arteriotomy
site.
Figure 42-7. A. The dysplastic leaflets are excised using a No. 11 scal-
pel and/or scissors. B. The appearance of the valve after the leaflets
have been partially excised and dilated.
Figure 42-10. A closed valvulotome or bistoury is placed through a purse string in the right ventricle, and the dysplastic valve leaflets are incised.
the stenotic ring. In dogs with severe muscular hypertrophy and ventricle with an interrupted suture. The opposite end of the
a narrow outflow tract, this procedure is more easily accom- patch is sutured to the pulmonary artery above the stenotic site.
plished through a purse string in the dilated pulmonary artery. The margins of the patch are sutured in a continuous fashion
Simple dilatation without first cutting the stenotic valve may only to the ventricle and onto the pulmonary artery. It is critical that
provide temporary relief since the torn and stretched tissue may the patch is sutured in a “tented” fashion over the stenotic area.
heal with scar tissue resulting in a new stenosis. This extra graft allows for expansion of the stenotic area. Once
the patch has been applied, it is incised longitudinally at an
equal distance between the cranial and caudal margins (Figure
Patch Grafting
42-11A and B). The caval tourniquets are tightened to accomplish
The use of patch grafting for repair of pulmonic stenosis in venous inflow occlusion. A stab incision with a #11 scalpel blade
the dog was first reported in 1976.11 The graft extends over is made into the pulmonary artery and extended to the dorsal
the pulmonary artery to the right ventricle outflow tract and is and ventral margins of the patch with Metzenbaum scissors.
effective in correcting valvular, supravalvular, and subvalvular The valve is inspected and the leaflets excised (Figure 42-12).
stenosis while alleviating infundibular lesions. Patch grafting A forceps may be used to further dilate the valve and annulus.
may be performed by either a closed or open technique. The A finger is inserted into the annulus to insure that the stenosis
closed patch graft technique11,12 relies upon the placement of a has been relieved. Air is evacuated from the heart by releasing
cutting wire across the stenotic lesion under the applied patch. the cranial Rumel tourniquet. The incised patch graft is clamped
Unfortunately the technique does not allow excision of the using Satinsky tangential vascular occlusion clamps. The caudal
dysplastic valve and relies upon the surgeon’s ability to place a Rumel tourniquet is then released. The patch graft incision is
cutting wire blindly across the defect. sutured with 4-0 polypropylene in a continuous pattern (Figure
42-13A and B). Total inflow occlusion time should not exceed two
An open technique for patch grafting has been described13,14 minutes. The Rumel on the aorta is used temporarily to improve
The authors prefer a modification of this technique, which is heart and brain perfusion. The pericardium is closed loosely
performed through a left lateral thoracotomy at the fourth inter- with interrupted sutures. A thoracostomy tube is placed and the
costal space. The lungs are retracted to expose the pericardial thoracotomy incision is closed in routine fashion.
sac. Rumel tourniquets are placed around the cranial and
caudal vena cava, and the thoracic aorta as described for open Open patch grafting is effective in young animals with severe
valvulotomy/valvulectomy. The pericardium is incised parallel valvular, but preferably supravalvular, subvalvular, or infundibular
and ventral to the phrenic nerve, with an extension ventral stenosis. Care must be taken in identifying an aberrant coronary
and perpendicular. Pericardial basket sutures are placed. An artery, which crosses the right ventricular outflow tract
elliptical shaped polytetrafluoroethylene (PTFE; Gortex, W.L. occasionally in boxers and bulldogs, negating the use of this
Gore and Assoc.) patch is cut so that the graft will extend both procedure.
proximal and distal to the stenotic lesion. The patch is sutured
to the outflow tract and pulmonary artery using 4-0 polypro- A case series of nine dogs undergoing closed patch grafting has
pylene suture and a double-armed taper point needle. Suturing described significant morbidity and mortality associated with the
is started at the ventral tip of the patch, which is placed on the closed patch procedure.15 There was one intra-operative death,
648 Soft Tissue
Conduits
Vascular grafts or conduits have been used to repair supraval-
vular pulmonic stenosis in the dog.16 The use of conduits from the
pulmonary artery to the right ventricle may be used to bypass the
stenotic pulmonary valve in animals with an aberrant coronary
artery. The technique is performed through a left lateral thora-
cotomy at the fifth intercostal space. The pericardium is opened
and sutured as previously described. The stenotic region is
observed and an appropriately sized Dacron or PTFE conduit
chosen. A Satinsky partially occluding vascular clamp is applied Figure 42-13. A. Completed graft sutured to pulmonary artery outflow
to the pulmonary artery above the site of the lesion. An arteri- tract. B. Cross sectional view of patch applied across incised pulmonary
otomy is made with a #11 scalpel blade and extended with Potts outflow tract. Note increase in outflow diameter.
Heart and Great Vessels 649
scissors. The conduit is cut at an oblique angle and sutured 15. Staudte KL, Gibson NR, Read RA, Edwards GA: Evaluation of closed
end-to-side to the pulmonary artery with continuous 5-0 to 6-0 pericardial patch grafting for management of severe pulmonic stenosis.
polypropylene suture on a double-armed taper point needle. The Aust Vet J 82:33, 2004.
conduit is anastomosed to the ventricular wall in end-to-side 16. Ford RB, Spaulding GL, Eyster GE: Use of an extra cardiac conduit
fashion following coring a hole in the ventricular wall. Closures in the repair of supravalvular pulmonic stenosis in a dog. J Am Vet Med
of the pericardium and thoracotomy incisions are routine. Assoc 172:922, 1978.
17. Orton EC: Cardiopulmonary bypass for small animals. Sem Vet Med
Conduits, with the exception of those used in supravalvular Surg 9:210, 1994.
stenosis (pulmonary artery to pulmonary artery) have been met
with limited success in veterinary medicine. The procedure may
be best applied under cardiopulmonary bypass.
Interventional Catheterization
for Congenital Heart Disease
Cardiopulmonary Bypass Jonathan Abbott
Pulmonic stenosis can be repaired effectively utilizing cardio-
pulmonary bypass. This technique permits direct visualization
and repair of the lesion without the time constraints of inflow Introduction
occlusion. Valvuloplasties, patches, and conduits can all be For much of its early history, the technique of cardiac cathe-
performed with cardiopulmonary bypass permitting the surgeon terization was utilized exclusively for diagnosis. However,
to do precise surgical repairs.17 beginning in the 1960’s, resourceful pediatric cardiologists
developed methods of transcatheter therapeutic intervention.
Since that time, the indications for interventional catheter-
References ization in both pediatric and adult cardiovascular medicine
1. Buchanan JW: Causes and prevalence of cardiovascular disease. have expanded remarkably. Obstructive lesions are addressed
In: Kirk RW, Bonagura JD, eds.: Current Veterinary Therapy XI. Phila- by balloon dilation, pathologic shunts are occluded by trans-
delphia: WB Saunders, 1992, p 647. catheter techniques, stents have been used to maintain patency
2. Buchanan JW: Changing breed predispositions in canine heart of vessels and conduits and more recently, percutaneous
disease. In: Proceedings of the 10th ACVIM Forum, 1992, p 213. methods of valve replacement and repair have been investi-
3. Bonagura JD, Darke PG: Congenital heart disease. In: Ettinger SJ, gated. In veterinary medicine, transcatheter therapy has been
Feldman EE, eds.: Textbook of Veterinary Internal Medicine. Phila- confined primarily to balloon dilation of outflow tract obstruction
delphia: WB Saunders, 1995, p 892. and occlusion of patent ductus arteriosus (PDA). This chapter
4. Thomas WP: Therapy in congenital pulmonic stenosis. In: Kirk RW, reviews the current applications of transcatheter intervention in
Bonagura JD, eds.: Current Veterinary Therapy XII. Philadelphia: WB veterinary patients with congenital cardiovascular disease.
Saunders, 1995, p 817.
5. Eyster GE: Basic cardiac surgical procedure. In: Slater DH, ed.:
Textbook of Small Animal Surgery. Philadelphia: WB Saunders, 1993, p Transcatheter Occlusion of Patent Ductus
462. Arteriosus (PDA)
6. Orton EC: Pulmonic stenosis and subvalvular aortic stenosis: surgical
options. Sem Vet Med Surg 9:221, 1994. Etiopathogenesis of PDA
7. Ewey DM, Pion PD, Hird, DW: Survival in treated and untreated dogs The ductus arteriosus connects the ventral aspect of the proximal
with pulmonic stenosis. J Vet Intern Med 2:114 (abstract),1992. descending aorta with the dorsal aspect of the pulmonary artery
8. Hellyer PW: Anesthesia in patients with cardiovascular disease. bifurcation. The histology of the normal duct is distinct from that
In: Kirk RW, Bonagura JD, eds.: Current Veterinary Therapy XI. Phila- of the aorta and this is relevant to normal closure as well as to
delphia: WB Saunders, 1992, p 655. the angiographic appearance of the persistently patent duct.
9. Breznock EM: Surgical relief of pulmonic stenosis. In: Bojrab MJ, The tunica media of the aorta consists primarily of elastic fibers.
ed.: Current Techniques in Small Animal Surgery. Philadelphia: Lea & In contrast, the media of the duct is comprised of smooth muscle
Febiger, 1990, p 513. fibers in both circumferential and spiral orientations.1 During
10. Swan H: Surgery by direct vision in the open heart during hypothermia. fetal life, pulmonary vascular resistance exceeds systemic
J Am Med Assoc 153:1081, 1953. vascular resistance and the ductus diverts the majority of the
11. Breznock EM, Wood GL: A patch-graft technique for correction of right ventricular output to the systemic circulation. Mainte-
pulmonic stenosis in dogs. J Am Vet Med Assoc 169:1090, 1976. nance of fetal ductal patency primarily depends on production
12. Shores A, Weirick WE: A modified pericardial patch graft technique of prostaglandin-E.2
for correction of pulmonic stenosis in the dog. J Am Anim Hosp Assoc
21:809, 1985. In normal, term neonates, closure of the ductus begins shortly
13. Orton EC, Bruecker KA, McCracken TO: An open patch graft technique after birth and initially results from contraction of ductal smooth
for correction of pulmonic stenosis in the dog. Vet Surg 19:148, 1990. muscle. The mechanism of ductal closure is complex and likely
14. Hunt GB, Pearson MRB, Bellenger CR, Malik R: Use of a modified has a multifactorial basis. However, increases in oxygen tension
open patch-graft technique and valvulectomy for correction of severe associated with parturition limit the production of dilative prosta-
pulmonic stenosis in dogs: eight consecutive cases. Aust Vet J 70:244, glandins, initiate a vasoconstrictive prostaglandin cascade and
1993.
decrease the sensitivity of ductal smooth muscle to dilative
650 Soft Tissue
The cause of post-natal ductal patency in most if not all affected A left-to-right PDA results in a continuous murmur; the murmur
dogs is a deficiency of ductus-specific smooth muscle.4 In dogs begins during systole, peaks in intensity at the time of the
that ultimately develop a patent duct, ductal smooth muscle is second heart sound, and persists through at least a portion of
replaced by elastic tissue which generally extends from the diastole. When the heart rate is very slow, or there is pulmonary
aortic side of the duct toward the pulmonary artery. In the most hypertension related to a large shunt and high pulmonary vein
severely affected individuals, the media of the entire duct is pressures, the murmur may be inaudible during late diastole.
replaced by elastic tissue. The result is a tubular, large diameter More often, the murmur persists through the entire cardiac cycle
duct that is associated with neonatal pulmonary hypertension and has a typical aorticopulmonary or “machinery” quality. The
and a bidirectional or right-to-left shunt.5 In less severely affected intensity of the murmur generally correlates with the size of the
individuals, the elastic tissue extends a variable distance from shunt. Very soft and focal murmurs are usually associated with
the aortic-ductal junction. Because of persistence of functional a small shunt while moderate or large shunts typically result in a
smooth muscle in the more distal aspect of the ductus, most left- loud murmur that radiates widely. In patients with large shunts,
to-right shunting PDA have a conical shape and are narrowest a distinct systolic murmur due to functional mitral valve regurgi-
where the ductus joins the pulmonary artery. The duct is widest tation sometimes can be heard. The third heart sound is audible
at the attachment of the aorta and the flask-shaped dilation is in some patients; generally this finding reflects a large shunt and
known as the ductal ampulla. The cranial aspect of the ampulla high left atrial pressures. When the shunt is moderate or large, the
is partially roofed by a shelf of tissue, known as the crista (or decrease in diastolic arterial pressure widens the pulse pressure
plica) reunions, which extends caudally from the ventral wall and results in a hyperkinetic, or “bounding”, arterial pulse.
of the proximal descending aorta.1 PDA is heritable in miniature
poodles5 and, based on breed predispositions, PDA likely has a Diagnostic Evaluation
genetic basis in other purebred dogs.
In the absence of cardiac arrhythmias, the electrocardiogram
(EKG) contributes little to diagnosis although most patients do
Pathophysiology have electrocardiographic evidence of left ventricular hyper-
The ductus provides a communication between the pulmonary trophy.7 thoracic radiographs of patients with PDA typically have
and systemic circulations. The size of the shunt is primarily distinctive, if not diagnostic, features. Usually, there is cardio-
determined by ductal diameter and the relationship between megaly with left-sided emphasis. Evaluation of the pulmonary
pulmonary and systemic vascular resistance. When pulmonary vessels may provide evidence of pulmonary hyperperfusion.
vascular resistance is less than that of the systemic circulation, Prominence of the proximal descending aorta is perhaps the
blood shunts from aorta to pulmonary artery. The resultant most consistent radiographic feature. In some patients, the main
increase in pulmonary venous return imposes a volume load on pulmonary artery and left atrial appendage are also prominent
the left atrium and ventricle. Most canine PDAs provide resis- resulting in the appearance of three closely associated bulges
tance to ductal flow so that aortic pressure exceeds pulmonary in the dorosoventral or ventrodorsal projection.
artery pressure. Even then, the shunt volume can be consid-
erable resulting in left ventricular dilation and hypertrophy, left Echocardiography demonstrates variable degrees of left
atrial enlargement, functional mitral valve regurgitation and ventricular and left atrial enlargement. Echocardiographic
potentially the development of systolic myocardial dysfunction. measures of cardiac performance such as fractional shortening,
usually are normal or mildly depressed. However, ventricular
A large, non-restrictive duct necessarily results in systemic loading conditions are altered by the shunt and often, by
pulmonary artery pressures. In this setting, the development of concurrent mitral valve regurgitation which complicates inter-
obstructive vascular disease potentially results in suprasystemic pretation of functional indices such as fractional shortening.
pulmonary vascular resistance and shunt reversal. However, Indeed, evaluation of the end-systolic ventricular dimension
shunt reversal is uncommon in dogs and generally occurs in provides echocardiographic evidence of myocardial dysfunction
neonates. Patients with right-to-left shunting PDA are not candi- in most patients with long-standing, uncorrected PDA. Doppler
dates for operative therapy and are treated medically. Shunt studies confirm the presence of continuous, disturbed flow within
direction associated with canine PDA is most commonly left-to- the main pulmonary artery. Although it is sometimes technically
right. The remainder of this discussion relates to the diagnosis difficult to do so, the pulmonary-ductal junction, if not the entire
and management of left-to-right shunting PDA in the dog. duct, can be echocardiographically identified in the vast majority
of patients (Figure 42-14). Transesophageal echocardiography
may have a particular utility for more completely defining the
Clinical Findings
dimensions and morphology of the PDA (Figure 42-15).
In many, if not most cases, the PDA does not cause clinical
signs before the age of 4 to 6 months and the lesion is detected
incidentally during routine physical examination. There is a
Heart and Great Vessels 651
A B
C D
Figure 42-14A-D. Echocardiographic Images from a patient with a moderately large patent ductus arteriousus. An M-mode image A. of the left
ventrical demonstrates left ventricular dilation and hypertrophy. Cranial, left parasternal images of the main pulmonary artery with B. and without
C. a superimposed color-flow Doppler map show the ductal ampulla and ductal orifice. A continuous-wave Doppler spectrogram D. provides
evidence of contuous flow into the main pulmonary artery. The velocity close to 5 m/s suggesting that the orifice is resistive.
Other than PDA, there are few disorders that result in a continuous correction is relatively low. Therefore, occlusion of the duct,
murmur. When it is certain that there is a single continuous either by transcatheter methods or surgical ligation is advisable
murmur and not distinct systolic and diastolic murmurs as can for nearly all patients with PDA. Mortality in uncorrected PDA
result from ventricular septal defect complicated by aortic insuf- is primarily due to congestive heart failure; other complications
ficiency, the diagnosis is generally assured and the need for such as ductal endocarditis and progressive vascular disease
further evaluation can be debated. However, echocardiography are uncommon. Because of this, watchful waiting that includes
is recommended in order to confirm the diagnosis before inter- echocardiographic surveillance is probably appropriate for the
vention, evaluate myocardial function and identify concurrent occasional patient that has a small ductus and minimal or no
malformations which occasionally can complicate the presen- ventricular enlargement. With respect to treatment decisions,
tation. The need for pre-procedural echocardiography is particu- it is relevant that PDA is most common in small breed dogs.
larly acute when transcatheter ductal occlusion is contemplated Dogs of this signalment are predisposed to the development of
because echocardiographic data can be used to provide a geriatric mitral valve degeneration (MR) and conceivably, the
preliminary assessment of the ductal size and morphology. development of MR might result in clinical decompensation in
older individuals with a previously tolerated ductus. Although
there is a small risk associated with correction of PDA, the ratio
Management of PDA - General Statements of risk and benefit is in favor of repair for nearly all patients.
It is accepted that mortality for canine patients with uncor- The only exception to this general principle is the patient with
rected PDA is high and that the risk associated with operative
652 Soft Tissue
Transcatheter Occlusion
Transcatheter PDA occlusion using different devices and subtly
different techniques has been reported.8-19 Initially, throm-
botic Gianturco coils were used most commonly in veterinary
medicine, but use of the recently developed, purpose-designed
Amplatz® canine ductal occluder (ACDO) has, to a great extent,
superseded that of Gianturco coils in veterinary practice.
A B
Figure 42-17. An Amplatz Canine Ductal Occluder (ACDO) was deployed across the ductus arteriousus of a 6 year old female Welsh corgi. These
fluoroscopic images were obtained A. before and B. AFTER CONTRAST WAS INJECTED THROUGH THE DELIVERY SHEATH TO PROVIDE A PRE-
LIMINARY ASSESSMENT OF DEVICE POSITION. To ensure device stability, it is important to confirm that the proximal disk assumes it unstressed,
cup-shaped configuration prior to device release. In this case, after minor manipulation of the delivery cable, the device assumed its native cup-
shape and was then released from the delivery cable.
and attached to a delivery cable. The ACDO is deployed using The use of the ACDO is restricted to patients that have a femoral
a retrograde approach after angiographic delineation of the artery of sufficient caliber to accommodate the catheter or sheath
ductus. Femoral arterial access is routine but because some required to deploy the device. This limits the use of the ACDO to
ACDO require relatively large delivery catheters, exteriorization relatively large patients but a modification of the basic technique
of the artery after inguinal incision is probably the most appro- of ACDO placement that can be used in patients as small as 2.5
priate technique. The size of the ACDO is selected based on the or 3 kg has been described. Briefly, a 4F short vascular sheath is
smallest angiographic diameter of the duct and therefore, careful, placed in the femoral artery and after angiography, a 4F curved,
quantitative assessment of ductal size is crucial. A device with a end-hole catheter is used to enter the pulmonary artery via the
waist that is approximately twice the diameter of the minimum duct at which time, the catheter and sheath are removed over
ductal dimension is said to be optimal.19,22 After angiographic an exchange wire, the distal tip of which is left in the pulmonary
evaluation, the duct is crossed with a curved catheter such as artery. The outer diameter of a vascular sheath is generally
an MPA which is then exchanged over a wire-guide for a long 2F larger than the catheter that it will accommodate; that is,
sheath or guiding catheter. Alternatively, contrast material for the outer diameter of a 4F sheath is 6 French units. Therefore,
angiography can be injected through a long sheath such as a after the sheath has been removed, a 6F guiding catheter with
Mullins, Ansel or CHB type, and if it is possible to cross the duct hydrophilic coating can generally be advanced over the wire at
with a wire-guide advanced through the sheath, this technique which point, ACDO with waist diameters as great as 6 mm can be
obviates the need for a catheter exchange.23 Predictably, larger deployed within the duct.22
devices must be deployed through larger catheters and this
must be taken into account not only as the delivery catheter
is advanced, but also initially, when a short, vascular access
sheath is placed in the femoral artery. When the distal end of an
appropriately sized guiding catheter or long vascular sheath is in
place within the main pulmonary artery, the device is introduced
into the hub of the catheter or sheath using the loading cartridge
and then advanced using the delivery wire. The proximal disk is
deployed within the pulmonary artery at which time the wire and
catheter are withdrawn together until the disk is firmly apposed
to the ductal orifice. Then, the catheter is retracted so that the
remainder of the device is deployed within the ductus. Suitability
of positioning is then evaluated through manipulation of the wire,
injection of contrast material through the side-arm of the catheter
and potentially, through transesophageal echocardiography
(Figure 42-17). If positioning is inappropriate, the device can be
withdrawn into the deliver catheter. When the device is properly
Figure 42-18. This fluroscopic image was obtained after placement of
positioned, and it has resumed it’s unstressed configuration, it is
an Amplatz Canine Ductal Occluder (ACDO) device within the ductus
detached from the delivery wire (Figure 42-18). arteriosus of a 6 month old male Cavalier King Charles spaniel that had
concurrent valvular pulmonic stenosis; the latter malformation was
addressed by balloon dilation.
654 Soft Tissue
After angiographic evaluation, a curved, end-hole catheter Figure 42-19. Aortogram obtained after two coils were placed in the
such as a Judkins (right), JB-1, MPA or vertebral catheter ductus arteriosus angiographically shown in figure 42-16. A half loop
is advanced to the ductus. Sometimes it is necessary to use of the smaller coil was deployed in the pulmonary artery. Occlusion
a straight but floppy-tipped wire-guide to enter the ductal of the ductus was nearly complete; in a subsequent frame there was
minor opacification of the main pulmonary artery so additional coils
ampulla. It is useful to advance the catheter across the duct
were placed.
and into the pulmonary artery while monitoring intravascular
pressures in order to identify fluoroscopic landmarks that relate
to the pulmonary artery-ductal junction. Typically, this junction is Outcome/Complications of Transcatheter
close to the ventral border of the tracheal shadow. The dimen- Occlusion
sions of the coil to be deployed within the ductus are chosen Of cases in which the procedure is attempted, about 80% are
based on measurements obtained from the angiogram or trans- amenable to coil placement and occlusion although this figure
esophageal echocardiogram. The loop diameter should be likely depends on echocardiographic and angiographic criteria
about twice the minimal ductal diameter and approximate the used to select candidates.11,26 Of patients in which coils are
diameter of the ampulla. A wire-guide is used to extrude the coil deployed, complete ductal occlusion during the immediate post-
from the cartridge and into the proximal end of the catheter. The procedural period has been reported to occur in 34 to 100% of
coil then can be advanced through the catheter using the wire- cases.11,12,14,26 Specific method, patient selection and perhaps
guide until the more distal end exits the end of the catheter and operator experience are variables that likely affect immediate
begins to form a loop within the circulation. In pediatric practice, occlusion rates. In general, complete, acute resolution of the
it is accepted that one or more loops of the device should be shunt can be achieved in 50 to 60% of cases. Delayed ductal
deployed in the pulmonary artery. When using non-detachable closure occurring in the first months after the procedure occurs
coils, most veterinary cardiologists deploy the entire coil within in about 30% of cases in which a residual shunt is evident in the
the ampulla of the duct. Provided that the coil forms sufficient immediate post-procedural period. Although residual shunting
number of loops, part of the coil can be deployed in the proximal is relatively common it is not necessarily hemodynamically
aorta and then pushed into the ampulla. When coil position important and often is clinically silent. Indeed, coil occlusion
appears to be appropriate, the remainder of the coil is extruded is associated with a hemodynamically satisfactory result in the
from the catheter. When a single coil substantially occludes vast majority of patients subject to the procedure, such that
flow, the mean and diastolic artery pressures rise shortly after fewer than 5% of cases require a second intervention.14,26
deployment but a Branham response generally is not observed.
After about ten minutes the ductus is again evaluated angio- The ACDO has filled an important niche in the practice of veter-
graphically or by transesophageal echocardiography (Figure inary interventional cardiology. In contrast to coil occlusion,
42-19). Ideally, the duct is completely occluded during the the rate of short-term occlusion is high and complications are
catheterization procedure although small residual shunts may rare. More specifically, Ngyuenba and Tobias reported the initial
resolve weeks or months after the procedure. If a substantial experience using a prototype of the ACDO.19 Eighteen dogs with
shunt persists, additional coils are placed within the first coil. PDA were subject to cardiac catheterization and angiographic
A technique in which a biopsy device is used for controlled characterization of the duct. Ultimately, ACDO were successfully
release of 0.052 in coils was described and then modified for use deployed in all patients although in one case, the device, deter-
in veterinary patients by Miller.24,25 mined afterward to be inappropriately small relative to ductal
Heart and Great Vessels 655
diameter, migrated to the left main pulmonary artery. The errant minimally invasive, morbidity and hospitalization is apt to be less
device was not retrieved, adverse effects were not observed and than that associated with thoracotomy and surgical ligation.
later, during a separate procedure, an ACDO was placed without Certainly, ductal size and morphology are important determinants
complications. Complete ductal occlusion was echocardio- of procedural success for coil occlusion but the development of
graphically documented in 17 of 18 patients but in one, recurrent the ACDO has expanded the indications for transcatheter therapy
ductal patency was evident at one day and at three months to include PDA of diverse size and morphology. Still, patient size
after the procedure. Others subsequently confirmed the initial, does have a bearing on the suitability of candidates for trans-
encouraging results.23 In a series of 41 canine patients with PDA, catheter intervention. A technique for transcatheter occlusion
procedural success was documented in 40; the small size of one of PDA using 0.025 in coils in patients weighing less than 3 kg
patient precluded placement of the sheath required to deploy has been described,13 but in general, femoral arterial access can
a sufficiently large device. Complete ductal occlusion occurred be problematic in very small patients. To some extent, this diffi-
within 24 hours of the procedure in all 40 patients.19,23 Published culty can be overcome if a venous approach is used and indeed,
results suggest that the ACDO is a device that can be used to this technique has been used for transcatheter coil occlusion
successfully occlude PDA over the broad range of ductal size and of PDA in cats and dogs.31,32 However, the use of venous access
morphologies. Presumably because the device firmly engages without concurrent arterial access may pose a risk to the patient
the duct and is attached to the delivery cable until the operator in the event of aortic embolization. In contrast, patient-size and
chooses to deploy, device embolization and other complica- ductal morphology likely have a limited effect on the outcome of
tions are rare although a single case of post-procedural device surgical ligation; experienced operators can successfully ligate
migration was recently reported.27 Recently, patient outcomes PDA in dogs that weigh less than 0.5 kg.33
after transcatheter occlusion by one of four different devices
and techniques were retrospectively evaluated.28 Procedural As discussed, there are numerous potentially serious complica-
success was documented in 92% of cases but coil occlusion tions of transcatheter intervention for PDA. Most of these compli-
was associated with a greater number of complications than cations do not result in patient mortality but they may require
was placement of the ACDO. Patients were not randomized to referral to a surgeon or additional catheterization procedures.
device type and predictably, operators selected coil occlusion While the clinical importance of hemodynamically inconse-
for the cohort for which body-size was smallest as coils can be quential residual shunts has been not been defined, the preva-
delivered through relatively small diameter catheters. lence of incomplete occlusion also deserves consideration in a
comparison of surgical ligation and transcatheter intervention.
Major complications of transcatheter intervention for PDA When patients are subject to echocardiographic scrutiny after
include intra-operative death, incomplete occlusion, post-proce- treatment of PDA, the prevalence of incomplete occlusion after
dural hemolysis, and device migration. Mortality associated with surgical ligation varies but is as high as 53% when the Jackson-
transcatheter intervention for PDA generally is quite low, near Henderson technique is used.34 Furthermore, shunts that persist
2%,14,26 although higher mortality has been reported in small after coil occlusion are apt to become progressively smaller. In
studies that specifically recruited high risk patients.29 Post- contrast, the mechanism of incomplete occlusion after ligation
procedural hemolysis is sometimes associated with persistence presumably relates to inadequate dissection of the periductal
of ductal flow after coil occlusion. This complication is appar- adventitia, an insufficiently tight ligature or loosening of knots;
ently uncommon but has been reported in the pediatric literature this being the case, late closure is not to be expected. Incom-
and in dogs.26,30 plete occlusion after placement of an ACDO is considerably less
common than after coil occlusion.
Other Devices and Techniques
The Amplatzer® ductal occluder (ADO) is a mushroom shaped Balloon Dilation of
device that consists of a nitinol framework that is enmeshed with
fabric; it was designed for occlusion of the human ductus. The
Obstructive Lesions
device is extruded from a delivery sheath that is first advanced Pulmonic Stenosis
from the femoral vein, through the ductus and into the aorta. The
device is pulled into the duct and released from the delivery wire. Etiolopathogenesis
Use of this device has been reported in veterinary patients.16,17 Pulmonic (or pulmonary) stenosis (PS) refers to narrowing of the
right ventricular outflow tract. PS is a common cardiac malfor-
The Grifka-Gianturco occlusion device consists of a nylon sac mation in the dog but occurs infrequently in cats.6 Acquired PS
that contains Gianturco coils that are deposited in the ductus is rare and this discussion will be concerned exclusively with
using a controlled delivery system. The use of this device in a congenital obstruction. The obstruction of the outflow tract most
dog has been reported in the veterinary literature.15 often results from narrowing of the pulmonary valve although
subvalvular PS and supravalvular PS are occasionally observed.
Some consideration of the relative merits of transcatheter inter- Subvavular, or infundibular PS, is seldom an isolated lesion and
vention and surgical ligation is unavoidable in any discussion of is more often associated with complex malformations such as
the treatment of PDA. The advantages of transcatheter inter- Tetralogy of Fallot or is the result of right ventricular hypertrophy
vention are relatively obvious. It is a minimally invasive technique related to valvular PS.
that is generally associated with low mortality. Because it is
656 Soft Tissue
A B
Figure 42-21. Fluoroscopic images obtained during inflation of a balloon in the right ventricular outflow tract of a patient with severe pulmonary
stenosis. A “waist” was initially evident A. but disappeared at full inflation B.
cm balloon is appropriate for most canine patients. Two cm and 4 the flow-directed catheter for a thin-walled multipurpose
or 5 cm balloons are sometimes used for very small or very large catheter which is then, in turn exchanged for the balloon dilation
patients. The outer diameter of the balloon is chosen based on catheter over a stiffer, larger gauge wire. However, this extra
echocardiographic or angiographic assessment of PV annulus manipulation is time consuming and might represent a risk in a
diameter. Recommendations regarding balloon diameter have hemodynamically unstable patient. A multipurpose catheter can
become more aggressive in the years since the introduction of often be coaxed across the obstruction with or without a wire
the technique. A balloon diameter that is 120 to 150% of the valve guide. In other cases, the use of specific catheter configurations
annulus is believed to be optimal. Larger relative balloon sizes such as the Judkins (right) coronary catheter or Berenstein
have been associated with cardiovascular injury in experimental catheter can be helpful in crossing the stenosis. Tip-deflecting
models and with complications in children.46,47 Profile is the term wires can also be used to direct the tip of a straight catheter
used to describe the increment in total catheter diameter which into the right ventricular outflow tract. Knowledge of the precise
results from the structure of the balloon. Profile and physical anatomical location of the catheter tip is important because
characteristics that determine profile are inter-related. Balloons tip-deflecting wires are rather stiff and cardiac perforation is a
are best constructed of materials that exhibit low compliance potential complication.
and high burst pressures since this most effectively transmits
radial force to the valve. However, balloons with those charac-
Results/Efficacy
teristics necessarily have a larger profile than do those with
lower burst pressure. Profile is important because unneces- The safety and efficacy of PBV in the management of PS
sarily large balloons can result in intimal or valvular injury. in humans is well established. In fact, the only indication
for surgical correction of isolated PS is failure of techni-
Advances in catheter and guide-wire construction including the cally adequate balloon dilation to effectively decrease the
development of low-profile balloons, flow directed catheters, associated ΔP. There are few published data that relate to the
steerable guide-wires with soft, flexible tips and tip-deflecting efficacy of balloon dilation in veterinary patients. Case reports
wires have expanded the indication for balloon dilation to include and case series attest to short-term safety and efficacy of the
patients of virtually any size. However, balloon dilation for PS procedure.48-51 Recent retrospective cohort studies provide
can be technically difficult in patients that weigh less than 6 or 7 evidence that PBV is associated with a low rate of complica-
kg. In small patients with tight stenosis, directing a catheter into tions and generally decreases ΔP to a degree that is thought to
the right ventricular outflow tract and crossing the obstruction be prognostically favorable.42,44,52 In general, it can be stated that
are often the most difficult aspects of the procedure. It may be PBV decreases ΔP by 50% or more in roughly 75% of dogs with
necessary to make numerous attempts with different catheters PS. Analysis of patient characteristics and outcome using a Cox
and guide-wires. Flow directed catheters often can be used to multivariable regression model demonstrated that PBV confers
atraumatically cross a stenotic pulmonary valve. Flow-directed a survival advantage in dogs with an initial ΔP that exceeds 80
(“wedge”) catheters are constructed of soft materials and are mmHg.44 PBV is apparently less effective in the management of
equipped with a small balloon near the distal catheter tip. The canine PS than it is in the treatment of PS in people; possibly
balloon is filled with room-air causing it to float in the circulation this is because of a greater prevalence of obviously dysplastic
which carries the catheter tip in the direction of blood flow. valves in affected dogs. Indeed, valve morphology is an
However, marked tricuspid valve regurgitation makes it difficult important determinant of the efficacy of PBV in both humans and
to manipulate and advance these catheters. Wire-guides can be dogs. One year after PBV, the mean gradient reduction in dogs
used to stiffen the catheter but sometimes this a liability in that with PS normal annulus diameter was 63% while the reduction
flow-directed catheters do not generally accommodate large was only 39% in dogs with a small annulus and thick, immobile
gauge wires. This difficulty can be circumvented by exchanging valve leaflets.42 Restenosis after PBV is uncommon. In fact, the
Heart and Great Vessels 659
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37. Buchanan JW. Pathogenesis of single right coronary artery and 58. Orton EC, Herndon GD, Boon JA, et al. Influence of open surgical
pulmonic stenosis in English Bulldogs. J Vet Intern Med 2001;15:101-104. correction on intermediate-term outcome in dogs with subvalvular aortic
38. Kittleson M, Thomas W, Loyer C, et al. Single coronary artery (type stenosis: 44 cases (1991-1998). J Am Vet Med Assoc 2000;216:364-367.
R2A). J Vet Intern Med 1992;6:250-251. 59. Kleman ME, Estrada AH, Maisenbacher HW, 3rd, et al. How to perform
39. Visser LC, Scansen BA, Schober KE. Single left coronary ostium combined cutting balloon and high pressure balloon valvuloplasty for
and an anomalous prepulmonic right coronary artery in 2 dogs with dogs with subaortic stenosis. J Vet Cardiol 2012;14:351-361.
congenital pulmonary valve stenosis. Journal of Veterinary Cardiology 60. Oguchi Y, Matsumoto H, Masuda Y, et al. Balloon dilation of right
2013;15:161-169. ventricular outflow tract in a dog with tetralogy of Fallot. J Vet Med Sci
40. Waterman MI, Abbott JA. Novel Coronary Artery Anomaly in an 1999;61:1067-1069.
English Bulldog with Pulmonic Stenosis. Journal of Veterinary Internal 61. Adin DB, Thomas WP. Balloon dilation of cor triatriatum dexter in a
Medicine 2013;27:1256-1259. dog. J Vet Intern Med 1999;13:617-619.
41. Stamm MD C, Anderson MD F, Robert H., Ho PhD F, Siew Yen. Clinical 62. Brown WA, Thomas WP. Balloon valvuloplasty of tricuspid stenosis in
Heart and Great Vessels 661
a Labrador retriever. J Vet Intern Med 1995;9:419-424. does not act as an esophageal constricting vascular ring. Its
63. Kunze P, Abbott JA, Hamilton SM, et al. Balloon valvuloplasty for presence may complicate surgical dissection of the LA because
palliative treatment of tricuspid stenosis with right-to-left atrial-level it passes over the pulmonary artery and limits visualization of the
shunting in a dog. J Am Vet Med Assoc 2002;220:491-496, 464. surgical field. PRAA is associated with concurrent patent ductus
64. MacLean HN, Abbott JA, Pyle RL. Balloon dilation of double- arteriosus only about 10 percent of the time. When a patent
chambered right ventricle in a cat. J Vet Intern Med 2002;16:478-484. ductus is present, blood flow through the ductus is minimal and
insufficient turbulence is produced to create a murmur.
Presurgical Considerations rated. Passage of the inflated cuff back and forth at the stricture
site will help further dilate the constriction. (Figure 42-22D).
Definitive treatment for PRAA involves surgical ligation and
division of the ligamentum arteriosum as soon after weaning as With moderate esophageal dilation, passage of food improves
possible. Feeding of slurries alone without relieving the esoph- once the constriction is relieved. Plication or resection of a
ageal constriction is not effective since the pre-stenotic esoph- dilated esophagus only reduces redundant tissue and does
ageal dilation often enlarges with time. Animals with PRAA are not restore normal esophageal peristalsis. If severe chronic
often presented in a debilitated, cachectic, and dehydrated dilation is present, plication of a redundant esophagus with
state that requires special presurgical considerations. Fluid Lembert-type gathering sutures of 4-0 nylon or polypropylene
or electrolyte imbalances should be corrected before surgery. can be attempted but is of questionable benefit. If plication is
Aspiration pneumonia, if present, compromises the patient’s attempted, care must be taken to not penetrate the mucosa of
ability to effectively ventilate the lungs. Placement of gastric the esophagus, as leakage around the sutures may occur and
feeding tubes to establish esophageal bypass in combination postoperative pleuritis or pyothorax may result. Hand-sewn
with broad-spectrum antibiotic therapy may be indicated preop- resection of the dilated cranial esophagus is not recommended
eratively in patients with severe aspiration pneumonia. because of its thin wall and inherent tendency for leakage. For
intractable regurgitation, resection of a dilated esophagus with
We use propofol for rapid intravenous induction and tracheal TA55 autostapling equipment has been attempted but with only
intubation. Immediately after induction, the patient should be fair results. Plication or resection of a dilated esophagus only
assisted in its ventilatory effort. Anesthesia is maintained with reduces redundant tissue and does not restore normal esoph-
inhalant anesthesia. The dilated esophagus should be evacuated ageal peristalsis.
with suction prior to surgery since a grossly enlarged cranial
esophagus may inhibit the ability to inflate the cranial and middle After ligation and division of the LA is completed and the
lung lobes during thoracotomy. esophagus freed of constricting fibrous bands, a thoracostomy
tube is placed and routine thoracic closure is performed. Postop-
Surgical Technique erative antibiotics are continued if aspiration pneumonia is
Surgical ligation of the LA is best accomplished through a left present. I use combinations of bupivacaine rib blocks, intramus-
fourth thoracotomy. The cranial lung lobe is packed caudally cular opioids or continuous rate infusion of opioids or ketamine
with moistened surgical sponges. The esophagus, aorta, main and injectable NSAIDS to manage postsurgical pain (See Chapter
pulmonary artery, and left vagus nerve are identified. The 9). Blood glucose levels are closely monitored during recovery
mediastinal pleura is transected longitudinally and the vagus from anesthesia particularly in small breeds of dogs.
nerve is reflected dorsally with 2-0 silk. The LA is usually longer
than normal and is often difficult to visualize within the fibrous Postoperative Feeding
ring. It is most easily located cranial to the recurrent laryngeal
Elevated feedings of small quantities of semisolid food are
nerve. If a persistent left cranial vena cava is present, it may have
provided three or more times daily starting the day following
a hemizygous branch that obscures the LA. This structure can be
surgery. Feeding of liquid diets should be avoided. The semisolid
double ligated, transected and reflected ventrally. If an aberrant
solid food usually does not pocket in the cervical esophagus and
left or right subclavian artery is present, it can be ignored if
will not reflux into the trachea as easily as liquid diets if regur-
the vessel is not compressing the esophagus. If esophageal
gitated. The animal is held upright by the owner or is fed from a
constriction is present, the subclavian vessel may be elevated
stool or platform that requires the forelimbs to be elevated off the
and divided between ligatures. Adequate collateral circulation
ground. Holding the patient upright while rocking it slowly back
will be provided by the vertebral arteries.
and forth may also facilitate passage of the food. Gradually, over
several days, the food is increased in consistency until feeding
The LA is carefully elevated off the esophagus from its left
of solid food is attempted. If regurgitation subsides, elevated
lateral aspect. Blunt dissection of the LA is performed in a
feedings are continued for at least eight weeks before horizontal
caudal to cranial direction with right-angle Mixter or Lahey
feedings are attempted. Some animals will resume regurgitation
forceps (Figure 42-22A). Care must be taken during dissection
with horizontal feedings, requiring that vertical feedings be
near the pulmonary artery, as this vessel is easily torn. When
adopted as a lifelong procedure.
the ligament is successfully freed and isolated, two ligatures of
0 surgical silk are placed as close to the aorta and pulmonary
artery respectively as possible (Figure 42-22B). The LA is then Prognosis
transected between the ligatures. Traction then is placed on the Morbidity and mortality associated with persistent right aortic
ligatures, and the esophagus is dissected free of any residual arch that is seen in the perioperative period is usually due to
fibrous bands between the aorta and pulmonary artery (Figure aspiration pneumonia. Animals surviving the postoperative
42-22C). A 22 French Foley catheter is then introduced through period and leaving the hospital regurgitate less frequently
the mouth into the esophagus and passed to the esophageal following surgery and demonstrate good body weight gain with
constriction. Inflation of the cuff at the constriction helps time. Those that survive at least six months do particularly well.
visualize any residual fibrous constricting bands and facilitates In one study of 25 dogs, 70 percent of animals followed for two to
their dissection and removal. Extreme care is necessary during four weeks had no regurgitation; but in those animals followed
this dissection because the esophagus is thin and easily perfo- for 6 months 92 percent did not regurgitate after eating. Less
Heart and Great Vessels 663
Figure 42-22. Surgical ligation and division of ligamentum arteriosum. A. Right-angle forceps are used to bluntly dissect around the ligamen-
tum arteriosum and grasp 0 silk. B. Silk ligatures are knotted around the ligamentum arteriosum. C. After division of the ligamentum arteriosum
remaining fibrous bands are carefully removed with Metzenbaum scissors. D. Use of Foley catheter to ensure that constriction has been relieved.
See text for details.
than 10 percent of the cases failed to respond to surgery and as the age of the animal increases. In addition to surgical
were euthanized. Conversely, it is thought but not proven that management, prolonged upright feeding may be required.
dogs or cats with post-cardiac esophageal dilation tend to Although some degree of esophageal dilation remains after
continue regurgitation after surgery and respond less favorably surgery the frequency and severity of regurgitation is usually
to surgery. reduced over time.
Suggested Readings The following functions have been attributed to the pericardium:
prevention of overdilation of the heart, protection of the heart from
Buchanon JW: Tracheal signs and associated vascular anomalies in infection and from formation of adhesions to surrounding tissues,
dogs with persistent right aortic arch. J Vet Intern Med 18:510, 2004. maintenance of the heart in a relatively fixed position within the
Ellison GW: Vascular ring anomalies in the dog and cat. Comp Cont Ed chest, regulation of the interrelation between the stroke volumes
2:693, 1980. of the two ventricles, and prevention of right ventricular regurgi-
Gunby JM, Hardie RJ, Bjorling DE: Investigation of the potential herita- tation when ventricular diastolic pressure is increased.
bility of persistent right aortic arch in Greyhounds. J Am Vet Med Assoc
224:1120, 2004. Suggestions that the pericardium serves no vital functions have
Helphrey ML: Vascular ring anomalies in the dog. Vet Clin N Am 9:207, arisen from observations that humans and animals can live
1979. normally after pericardiectomy. Studies in animals suggest that
Holt D, Heldman E, Mikel K, et al: Esophageal obstruction caused by a the heart probably undergoes some minor dilation after pericar-
left aortic arch and an anomalous right patent ductus arteriosus in two diectomy, although significant impairment of cardiac function
German shepherd littermates. Vet Surg 29:264, 2000.
has not been demonstrated.
Macphail CM, Monnet E, Twedt DC. Thorascopic corrections of persistant
right aortic arch in a dog. J Am Anim Hosp Assoc 37:577, 2001.
Muldoon MM, Birchard SJ, Ellison GW: Long-term results of surgical Pericardial Effusion
correction of persistent right aortic arch in dogs: 25 cases. J Am Vet
Med Assoc 210:1761, 1997.
Pathophysiology
Shires PK: Persistent right aortic arch in dogs: a long-term follow-up Pericardial effusion is an abnormal accumulation of fluid within
after surgical correction. J Am Anim Hosp Assoc 17:773, 1981. the pericardial sac. Severe pericardial effusion may result in
Van Gundy T: Vascular ring anomalies. Comp Cont Educ Pract Vet 11:36,
cardiac tamponade, a potentially life-threatening compression
1989. of the heart in which intrapericardial pressure rises sufficiently
Vianna ML, Krahwinkel DJ: Double aortic arch in a dog. J Am Vet Med
to affect cardiac function. Cardiac tamponade occurs when
Assoc 225:1222, 2004. enough pericardial fluid accumulates to exhaust the limits
of pericardial elasticity. Once the pericardium can no longer
Wheaton LG: Persistent right aortic arch associated with other vascular
anomalies in two cats. J Am Vet Med Assoc 184:848, 1984. stretch to accommodate additional fluid, the addition of small
amounts of fluid begins to produce rapid increases in intraperi-
cardial pressure.
Surgical Treatment of
Cardiac tamponade primarily affects cardiac function during
Pericardial Diseases and diastole and has little effect on systolic function. Because
Cardiac Neoplasms intra-pericardial pressure is transmitted directly through the
ventricular wall, diastolic filling pressures rise until the diastolic
John Berg pressures within each ventricle are equal to one another and
to intra-pericardial pressure. The right atrium and ventricle
Diseases affecting the canine pericardium can result in either are more thin walled than the left, and are more susceptible to
pericardial effusion or pericardial constriction, both of which compression, so that signs of cardiac tamponade mimic signs
can be managed surgically. Antemortem diagnosis of feline of right heart failure. As predicted by the Frank-Starling law,
pericardial disease is rare. decreased diastolic filling results in decreased myocardial
stretching, force of contraction, and cardiac output.
Anatomy and Physiology of the Pericardium The cardiovascular system attempts to compensate for falling
The pericardium is a fibrous sac composed of an outer fibrous
cardiac output through peripheral arterial and venous vasocon-
layer and an inner serous layer. The serous layer is divided into
striction and increased heart rate.
the visceral pericardium (epicardium), which adheres firmly to
the surface of the heart, and the parietal pericardium, which lines
However, these compensatory mechanisms may themselves
the interior surface of the fibrous pericardium. The pericardial
stress the heart. The catecholamines responsible for vasocon-
cavity lies between the serous layers and normally contains a
striction increase myocardial oxygen consumption, and tachy-
small quantity of clear fluid.
cardia decreases coronary blood flow by decreasing the
proportion of the cardiac cycle spent in diastole, when coronary
The fibrous pericardium forms a tough, thick sac that blends
flow occurs. Coronary flow is further compromised by low
with the adventitia of the great vessels at the base of the heart.
cardiac output and pressure on the coronary vessels produced
It is attached to the diaphragm in the xiphoid region by the
by the pericardial fluid. These factors may produce myocardial
sternopericardiac ligament ventrally and by pleural reflections
ischemia and can eventually lead to cardiac decompensation.
caudally. The phrenic nerves course across the dorsal third of
the pericardium on the left and right sides.
Causes
The functions of the pericardium are not completely understood, The most common causes of pericardial effusion in the dog are
and its physiologic significance has been debated in literature. neoplasia and idiopathic hemorrhagic pericardial effusion. Most
Heart and Great Vessels 665
neoplastic effusions are hemorrhagic and result from acute or bacteria have been cultured from the pericardial fluid of effected
chronic hemorrhage from the tumor surface. Intra-pericardial dogs. Pericardial effusion caused by infection with Coccidioides
cysts, pericardial effusions caused by bacterial or fungal infec- immitus has been reported in geographic areas, such as the south-
tions, and other less common causes of pericardial effusion have western United States, where the fungal agent is endemic. Young,
also been reported. large breed dogs are usually affected, and dogs may or may not
have chronic histories of coccidioidomycosis. The pericardial
The most common neoplastic cause of pericardial effusion is disease is usually both effusive and constrictive.
right atrial hemangiosarcoma. This tumor generally arises from
the right auricular appendage, although the right atrial wall may Other potential causes of pericardial effusion include congenital
be involved. German Shepard dogs and other large breeds are peritoneopericardial hernias, left atrial rupture secondary to
predisposed. The tumor is highly metastatic and almost always mitral insufficiency, blunt or penetrating trauma, congestive
spreads to other organs such as the liver or lungs before it is heart failure, and uremia. Pericardial effusion resulting from the
discovered in the heart. latter two conditions is usually inconsequential and tends to be a
postmortem finding only.
Chemodectomas arise from the aortic bodies located around
the aorta at the heart base. The aortic bodies are composed of
History and Clinical Signs
chemoreceptor tissue sensitive to blood pH, carbon dioxide
content, and oxygen tension, and they are involved in the regulation Dogs with cardiac tamponade are usually presented with acute
or chronic histories of nonspecific signs suggestive of right-
of ventilation. Chemodectomas vary in their location around the
sided heart failure. These include lethargy, dyspnea, cough,
aorta and in their degree of local invasiveness. The metastatic
abdominal distension, anorexia, weight loss, and exercise intol-
rate of this tumor is unknown. Although chemodectomas may
erance. Acute collapse with no prior signs is seen occasionally.
occur in any breed, brachycephalic breeds may be predisposed,
In general, the history is not helpful in differentiating neoplastic
suggesting that chronic hypoxia may be an underlying cause.
from idiopathic hemorrhagic pericardial effusion; signs may be
Anecdotally, the apparently high incidence of chemodectoma
acute or chronic in either condition.
among dogs in Colorado further implicates chronic hypoxia in the
pathogenesis of the tumor. Several physical findings may suggest cardiac tamponade as
the cause of right-sided heart failure. These include muffled
Other neoplastic causes of pericardial effusion are much less heart sounds, pronounced jugular pulses and jugular distension,
common. Malignant diseases that may metastasize to the heart and weak arterial pulses. Hepatomegaly, ascites and peripheral
or pericardium include hemangiosarcoma, lymphosarcoma, edema may also be present. Pulsus paradoxus is an exaggerated
melanoma, and mammary adenocarcinoma. Mesothelioma can pattern of change in arterial pressure with respiration, charac-
occasionally cause pericardial effusion, either alone or in combi- terized by a weak pulse during inspiration and a stronger pulse
nation with pleural or peritoneal effusion. during expiration. The sign is often present but overlooked in
dogs with pericardial effusion, and may be best appreciated in
Idiopathic hemorrhagic pericardial effusion, a poorly understood dogs breathing slowly while lying in lateral recumbency.
syndrome, is also a common cause of pericardial effusion in the
dog. It occurs predominately in large and giant breeds, has a
distinct male predilection, and affects dogs of all ages. Patients Diagnostic Evaluation
have signs of acute or chronic cardiac tamponade, which may The diagnostic evaluation of dogs with signs compatible
respond to either conservative treatment or surgical management. with cardiac tamponade should be aimed at demonstrating
Although the cause of this syndrome is unknown, a similar pericardial effusion and determining its underlying cause.
syndrome in humans is suspected to be either viral or immune- Pericardial effusion can be demonstrated in most cases using
mediated. Histologically, blood vessels of the canine parietal (and a combination of electrocardiography, thoracic radiography,
possibly visceral) pericardium appear to be the targets of the and M-mode or 2-dimensional echocardiography. Diminished
disease process and are the source of pericardial hemorrhage. QRS voltages and electrical alternans are seen in a significant
proportion of electrocardiograms. Diminished QRS amplitudes
Intra-pericardial cysts are large, benign mass lesions that are likely caused by decreased conduction of electrical impulses
occasionally cause effusion and cardiac tamponade in young through fluid media, although decreased ventricular filling may
dogs. The cysts arise from the apex of the pericardial sac and be involved. Pleural effusion as well as pericardial effusion
resemble acquired cystic hematomas grossly and histologically. can produce decreased QRS voltages. Electrical alternans is a
Although the cause of intra-pericardial cysts is unknown, it is beat-to-beat variation in QRS amplitude produced by a swinging
possible that they develop from herniated omental or falciform motion of the heart within the pericardial sac.
fat in dogs born with small peritoneopericardial diaphragmatic
hernias. Intra-pericardial cysts usually are diagnosed in dogs Thoracic radiography demonstrates pericardial effusion if the
between 6 months and 3 years of age, although they occasionally volume of effusion is substantial. Generalized heart enlargement
is seen, and the heart may have a characteristic globoid
are identified later in life.
appearance, which is best demonstrated on dorsoventral views.
Pleural effusion, ascites, hepatomegaly and distension of the
Infectious pericardial effusion is reported to be caused most
caudal vena cava may also be present.
commonly by migrating grass awns. Many different species of
666 Soft Tissue
alone risks a sudden recurrence of life-threatening cardiac cysts are best approached through a median sternotomy, which
tamponade. Pericardiectomy does not entail long term risks for facilitates subtotal pericardiectomy and allows inspection of the
the patient, and, unlike pericardiocentesis, eliminates most of diaphragm for a peritoneopericardial hernia.
the tissue responsible for the effusion. Some evidence suggests
that idiopathic pericardial effusion may progress to pericardial Technique: Once the thoracotomy is completed, the phrenic and
constriction, although this appears to be uncommon; surgery is vagus nerves are identified. The phrenic nerve may be isolated
technically simpler, and is associated with a better prognosis, and gently retracted with a Penrose drain, although retraction of
for pericardial effusion than for pericardial constriction. Finally, the nerve usually is unnecessary. The vagus nerve is located more
early surgical exploration may allow identification of small dorsally and is unlikely to be damaged during pericardiectomy. To
tumors that were not revealed by echocardiography, and may create a pericardial window, a controlled stab incision is made in
offer the best chance for their removal. the pericardium ventral to the phrenic nerve with a scalpel blade,
and pericardial fluid is removed by suction. The incision is then
The indications for open versus thorascopic pericardiectomy extended with Metzenbaum scissors or electrocautery to create
are not firmly established. Advantages of thoracotomy include a window several centimeters in diameter ventral to the phrenic
its wide availability, the ability to more thoroughly explore the nerve. The right atrial appendage is inspected to rule out the
thorax, and its potential to permit resection of neoplastic mass presence of a right atrial mass by carefully retracting the cranial
lesions. The major advantages of thorascopic pericardiectomy and dorsal edges of the window. If partial pericardiectomy below
are reduced postoperative pain and morbidity, and a more rapid the level of the phrenic nerves is to be performed, the initial incision
recovery time. In thorascopic pericaridectomy, a small pericardial is continued cranially and caudally until it is completed circum-
window is usually created, whereas with thoracotomy, partial ferentially (Figures 42-23 and 4-24). If an intercostal approach
pericardiectomy below the level of the phrenic nerves may has been used, completion of the pericardiectomy on the left
be performed. Traditionally, creation of a pericardial window side requires elevation of the heart. An assistant should cradle
has been thought to be associated with a risk that residual the patient’s heart in one hand and gently rotate the apex of the
pericardium would adhere to the surface of the heart, resulting in heart laterally and dorsally to permit incision of the pericardium
recurrent pericardial effusion. Early experience with thorascopic below the level of the left phrenic nerve. Because elevation of the
pericardiectomy and with percutaneous balloon pericardiotomy heart impairs venous return, this maneuver should be performed
suggests that the risk of this complication is quite low. Minimally as quickly as possible. Diseased pericardia are often thickened
invasive approaches are most often indicated when there is a and extremely vascular, and care must be taken to limit hemor-
high index of suspicion that the effusion is idiopathic, eg. in dogs rhage with electrocautery. Once the sternopericardiac ligament
with no echocardiographic evidence of a cardiac mass who have is divided, either with electrocautery or between ligatures, the
developed recurrent effusion months after pericardiocentesis. pericardial sac can be removed and submitted for histopathology.
Small masses involving the tip of the right auricular appendage A thoracostomy tube is placed before closure, and postoperative
may be removed with minimally invasive techniques. Thora- management generally is uncomplicated. The thoracostomy tube
cotomy should be chosen for resection of auricular masses not may be removed after 12 hours if it is unproductive.
deemed amenable to minimally invasive surgery, and for heart
base masses. In circumstances other than these, the choice For dogs with bacterial pericardial effusion, long-term antibiotics,
between thorascopic and open pericardiectomy is a matter of selected on the basis of culture and sensitively testing, should
the surgeon’s and owner’s preferences. The technique for thora- be administered postoperatively. The prognosis for these dogs is
scopic pericardiectomy is discussed elsewhere. generally excellent.
Figure 42-24. Appearance of the pericardial sac shown in figure 42-23 Figure 42-26. A right atrial hemangiosarcoma as viewed through a right
following partial pericardiectomy below the level of the phrenic nerves. intercostal thoracotomy.
Pericardical Constriction
Pathophysiology and Causes
As in cardiac tamponade resulting from pericardial effusion,
pericardial constriction restricts diastolic volume. Diastolic filling
is limited by the fibrotic pericardium, which acts as a noncom-
pliant shell around the heart.
titers for antibodies against the organism. In general, a diagnosis cases (1999-2003). J Am Vet Med Assoc 2005; 227: 435-439.
of pericardial constriction should be considered in dogs with Holt JP, The normal pericardium. Am J Cardiol 1970; 26:455.
signs of right-sided heart failure that cannot be explained by Lombard CW. Pericardial disease. Vet Clin North Am 1983; 13:337.
pericardial effusion, congenital or acquired heart disease, McDonald KA, Cagney O, Magne ML. Echocardiographic and clinico-
or pulmonary hypertension. Surgical exploration should be pathologic characterization of pericardial effusion in dogs: 107 cases
performed if the condition is suspected. (1985-2006). J AM Vet Med Assoc 2009; 235:1456-1461.
Patnaik AK, Liu SK, Hurvitz AI, et al. Canine chemodectoma (extra-ad-
Subtotal Pericardiectomy for renal paragangliomas): a comparative study. J Small Anim Pract 1975;
16:785-80.
Pericardial Constriction Shaw SP, Rozanski EA, Rush JE. Cardiac troponins I and II in dogs with
Technique: Because significant epicardial fibrosis usually is not pericardial effusion. J Vet Int Med 2004; 18: 322-324.
present in dogs with idiopathic pericardial constriction, most dogs Sidley JA, Atkins CE, Keene BW, DeFrancesco. Percutaneous ballon
can be treated successfully by subtotal pericardiectomy, as previ- pericardiectomy as a treatment for recurrent pericardial effusion in 6
ously described. Median sternotomy is the preferred approach dogs. J Vet Int Med 2002; 16: 5431-546.
because it allows visualization and division of any epicardial Sisson D, Thomas WP, Ruehl WW, et al. Diagnostic value of pericardial
adhesions that may be present. In dogs with significant epicardial fluid analysis in the dog. J Am Vet Med Assoc 1984; 184:51-55.
fibrosis, epicardial decortication may be necessary. This is a Sisson D, Thomas WP, Reed, et al. Intrapericardial cysts in the dog. J
difficult procedure that may require partial removal of myocardial Vet Int Med 1993; 7:364-369.
tissue. Caution is necessary to avoid inadvertent damage to Thomas WP, Sisson D, Bauer TG, et al. Detection of cardiac masses in
coronary vessels. Epicardial decortication is associated with dogs by two-dimensional echocardiography. Vet Radiol 1984; 25:65-72.
significant perioperative morbidity and mortality. Thomas WP, Reed JR, Bauer TF, et al. Constrictive pericardial disease in
the dog. J Am Vet Med Assoc 1984; 184:546-553.
In dogs with effusion-constriction caused by C immitus infection, Vicari ED, Brown DC, Holt DE, Brockman DJ. Survival times of and
extensive mature adhesions to the epicardial surface of the prognostic indicators for dogs with heart base masses: 25 cases
heart are likely to be present, and pericardiectomy may be (1986-1999). J Am Vet Med Assoc 2001; 219:485-487.
significantly complicated by hemorrhage. Adhesions may be
disrupted manually and by careful instrument dissection. Strips
of pericardium overlying the coronary vessels may be left in
place if there are firm adhesions to the vessels. If fibrosed, the
epicardium may be removed from areas distant from the coronary
vessels, using scissors or a periosteal elevator to carefully lift the
epicardium from the myocardium. The perioperative mortality
rate in a series of dogs with C immitus pericarditis undergoing
partial pericardiectomy was 23.5%, and among dogs that were
discharged from the hospital, the 2 year survival rate was 82%.
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Berg RJ, Wingfield WE, Hoopes PJ. Idiopathic hemorrhagic pericardial
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Chun R, Kellihan HB, Henik RA, Stepien RL. Comparisonof plasma
cardiac troponin 1 concentrations among dogs with cardiac heman-
giosarcoma, noncardiac hemangiosarcoma, other neoplaasms, and
pericardid effusion of nonhemangiosarcoma origin. J Am Vet Med
Assoc. 2010; 237:806-811.
Ehrhart N, Ehrhart EJ, Willis J, Sisson D, et al. Analysis of factors
affecting survival in dogs with aortic body tumors. Vet Surg 2002; 31:
44-48.
Heinritz CK, Gilson SD, Soderstrom MJ, Robertson TA, et al. Subtotal
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Lymphatics and Lymph Nodes 671
lesions or thrombosis may exhibit cranial vena cava syndrome Laboratory Findings
(i.e. edema of the head, neck, and forelimbs with jugular venous Thoracocentesis with fluid analysis is imperative in every
distention). case of pleural effusion. Fluid should be placed in an ethyl-
enediaminetetraacetic acid (EDTA) tube for cell counts and
Diagnostic Imaging cytological examination. Fluid should also be saved in a serum
Radiographic evaluation of the dyspneic patient is not advised tube (i.e. “clot tube”) for biochemical analysis and aerobic and
in a significantly compromised patient. Oxygen supplementation, anaerobic culture. Chylous effusion is grossly opaque white or
minimal handling, and dorsoventral and horizontal beam imaging white with a red or pink tinge (Table 43-2).11,12 The fluid is high in
rather than lateral and ventrodorsal views may decrease the lipid, which may interfere with refractometric quantification of
stress of imaging. The index of suspicion for fluid in the pleural protein. The total nucleated cell count is usually less than 10,000/
space must be considered prior to imaging, as therapeutic thora- µL, consisting mainly of small lymphocytes.4 Lower numbers of
cocentesis can decrease the risk associated with imaging in these macrophages may be present and filled with lipid. With chronicity,
patients. Radiographic signs of pleural fluid include effacement lymphocytes may be depleted due to decreased production in
of the cardiac and diaphragmatic silhouettes, retraction of the the face of continued cell loss to the effusion, nondegenerate
lung borders from the thoracic wall, “scalloping” of the lung neutrophils then become the primary cell type in the effusion.
edges, pleural fissure lines, rounding of the lungs, widening of Neutrophils may also be the primary cell type in patients that
the mediastinum, and obscuring of the other intrathoracic struc- have undergone multiple thoracocentesis, which may induce
tures.10 The presence of a large amount of fluid decreases the pleural inflammation. If the repeated aspirates of pleural fluid
ability to diagnose cardiac, pulmonary, or mediastinal masses result in secondary bacterial colonization and sepsis, degen-
and hilar lymphadenopathy. Radiographs should be remade erate neutrophils appear in the fluid.
after removal of the thoracic effusion to increase the diagnostic
efficacy of thoracic radiographs. Table 43-2. Characterization of Chylous Pleural
Fluid in Dogs and Cats
Failure of pulmonary expansion after therapeutic thoracocen-
Dogs Cats
tesis should alert the clinician to the possibility of fibrosing
pleuritis or pulmonary parenchymal disease such as persistent Specific gravity 1.022-1.037 1.019-1.038
atelectasis, pulmonary neoplasia, or lung lobe torsion. Animals Total Protein (g/dl) 2.5-6.2 3.5-7.8
with fibrosing pleuritis often remain dyspneic, despite removal
of pleural effusion and confirmation of minimal fluid on thoracic Average nucleated cells/µL 6,127 11,919
radiographs. Fibrosis of the visceral pleura is thought to be
related to the chronic presence of chylous effusion and an The definitive diagnosis of chylous effusion relies on biochemical
alteration in mesothelial cell function, leading to an imbalance in testing of the pleural fluid and serum. With chylothorax, triglyc-
fibrin production and degradation. eride content of the pleural fluid is higher than that of the serum
and cholesterol levels in the pleural fluid is less than that in the
Air in the lungs will reflect sound and decrease the generation of serum. Other tests, (e.g. ether clearance and Sudan staining for
ultrasonographic images of intrathoracic structures. Therefore, fat) may also be used to diagnose chylous effusion. Concurrent
ultrasound examination of the thorax should be performed prior aerobic and anaerobic culture of the fluid are recommended.
to removal of all pleural fluid, as the fluid will provide an acoustic Psuedochylous effusion, opaque, white fluid devoid of chyle,
window for imaging the mediastinum. Ultrasonography is also has been associated with tuberculosis and rheumatoid pleurisy
used to evaluate cardiac structure and function and to diagnose in man but has not been identified in dogs or cats.
whether pericardial effusion is present.
Complete blood count, biochemical profile analysis, and urinalysis
Computed tomography (CT) and magnetic resonance imaging should be done and may aid in the identification of a primary
(MRI) have been used with success for thoracic evalu- cause of chylothorax. They may also be useful in monitoring
ation in dogs. Normal anatomic structure has been reported, for lymphopenia, hyponatremia, and hyperkalemia, which have
and CT has been used to evaluate questionable pulmonary been associated with repeated thoracocentesis in the medical
and non-pulmonary conditions identified radiographically. management of the condition.13 Significant protein and fluid loss
Questionable radiographic and ultrasonographic findings should due to chronic chylous effusion may also be reflected in the
be evaluated with CT to localize and determine the extent of patient’s biochemical profile and urinalysis. Feline leukemia virus
the abnormality. CT has also been used to guide fine needle (FeLV), Feline immunodeficiency virus (FIV), and heartworm tests
aspirates (FNA) and percutaneous biopsies of pulmonary and are also recommended to rule out primary disease processes.
nonpulmonary mass lesions. The complication rate associated
with FNA or transcutaneuos biopsy with CT guidance was 43% Differential Diagnoses
in one study, and the diagnostic accuracy was 65% for FNA and Other causes of cough should be included in the initial differ-
83% for biopsy. The main disadvantage of CT and MRI is the need ential list if cough is present; however, pleural effusion should be
for and risk of general anesthesia in compromised patients. CT identified early in the evaluation of the patient with chylothorax.
and MRI are becoming more available to practitioners, but the Other types of pleural effusion (e.g. hemorrhage, transudate,
cost benefit ratio must be considered prior to their use. exudate) are ruled out upon fluid analysis. Chylous effusion
Lymphatics and Lymph Nodes 673
may be classified as either a modified transudate or exudate, Octreotide (Sandostatin , Novartis Pharma B.V., Arnhem, the
®
depending on the reference used to characterize pleural fluid Netherlands) is an experimental agent for the treatment of
types (See Table 43-2). Primary disease processes that cause idiopathic chylothorax. The somatostatin analog has been used
chylothorax (See Table 43-1) should be ruled out by diagnostic to treat chylothorax in people and was associated with a more
evaluation including thoracic radiography and ultrasound exami- rapid decline in the amount of pleural chyle following experi-
nation, echocardiography, CBC, biochemical analysis, urinalysis, mental transection of the thoracic duct in dogs.17 The response
FeLV, FIV, and heartworm testing, and abdominal radiography to octreotide may be due to inhibition of pancreatic, biliary, and
and ultrasound. If primary disease conditions are eliminated, the gastric secretions, decreased gastric blood flow, decreased
diagnosis of idiopathic chylothorax, which is the most common intestinal transit time, and constriction of lymphatic vessels.17,18
form of chylothorax, is made. A small therapeutic trial of 10 mg/kg SC q 8 h therapy for 10 to 28
days resulted in resolution of signs in two of three cats. Neither of
two dogs treated with octreotide showed a response to therapy.18
Medical Management Side effects occurred in two patients and consisted of diarrhea
Any primary condition associated with secondary chylothorax and loose stools.18 The response of dogs and cats to octreotide
should be treated or the effusion may persist. Treatment of the has not been investigated investigated in a clinical trial.
underlying condition may not, however, guarantee diminution of
chyle. Resolution may also take time (e.g. months), depending on Corticosteroid treatment to combat fibrosing pleuritis and
the primary condition. While treating the primary condition, the furosemide administration to decrease chylous effusion have
accumulation of chyle within the pleural space may be managed not been evaluated. Furosemide has not been shown to alter
with intermittent thoracocentesis as dictated by clinical signs the accumulation of chyle in the pleural space. Its use could
(e.g. dyspnea associated with a restrictive breathing pattern). result in further fluid loss and dehydration, so it is not recom-
Fluid balance and electrolytes should be monitored for signif- mended for treating chylothorax. Likewise, corticosteroids have
icant alterations secondary to repeated thoracocentesis not been shown to have any beneficial effect in the treatment
(described in laboratory findings) and is of more concern in of chylothorax, and their use should be reserved for underlying
patients requiring frequent fluid removal.13 Fat soluble vitamins conditions requiring corticosteroid therapy.
should be added to the diet of patients undergoing prolonged
medical management of chylothorax due to the continued loss It is, however, important to monitor any patient undergoing
into the pleural space.3 Recurrent thoracocentesis may also prolonged medical management for the occurrence of fibrosing
result in secondary bacterial infection of the fluid, despite the pleuritis. Chronic exposure of mesothelial cells to chyle
high lecithin content, which is thought to have a bacteriostatic may result in altered fibrin production and degradation.9 An
effect.9 Immunodeficiency has also been hypothesized with the imbalance of fibrin may result, leading to the deposition of fibrin
removal of protein and cells by repeated thoracocentesis. on the visceral pleura. Fibrosis of the visceral pleura can result
in severe lung lobe atelectasis. Radiographic evidence of failure
Concurrent dietary changes may alter the fat content of the of complete pulmonary expansion following thoracocentesis or
effusion and improve fluid absorption from the pleural space, dyspnea in the face of minimal pleural effusion should alert the
thereby decreasing the frequency of thoracocentesis. Low fat clinician to this problem, which may decrease the prognosis
diets are therefore recommended in the treatment of idiopathic associated with further therapy. Due to the risk of nutritional
chylothorax. The fat content of commercially available low fat and fluid imbalance and fibrosing pleuritis, prolonged medical
diets is approximately 6%.4 Medium chain triglyceride supplemen- management (beyond 4 to 8 weeks) is not recommended.3
tation may not result in improved nutritional status; they may not be
directly absorbed into the intestinal venous system as previously
hypothesized. Dietary management and fluid removal rarely result Surgical Management
in resolution of cases of spontaneous, idiopathic chylothorax. Many surgical techniques have been developed in an attempt to
improve the resolution rate of idiopathic chylothorax in dogs and
The addition of different medications has been attempted in an cats, which indicates that the definitive therapy has not been
effort to increase the rate of resolution of idiopathic chylothorax. established. Surgical treatment is usually sought in animals with
Benzopyrones are compounds extracted from the Brazilian chronic chylothorax despite proper medical management and in
Fava D’anto tree.14 They have been used to treat lymphedema cases in which medical therapy becomes impractical. Surgical
in people and have been used to treat idiopathic chylothorax techniques include mesenteric lymphangiography in conjunction
in dogs and cats. Their action may decrease vascular leakage, with thoracic duct ligation and pericardectomy, passive or active
increase protein lysis and absorption, stimulate macrophage pleuroperitoneal or pleurovenous shunting, omentalization, and
function, and increase tissue macrophage numbers. Rutin, a ablation of the cisterna chyli.19-22 Resolution rates associated
benzopyrone agent (Rutin, Nature’s Plus, Melville, NY), resulted with thoracic duct ligation alone range from 53% to 20 to 53%
in improvement in two of four cats treated, and has been in dogs and cats, respectively.11,12,23 Concurrent or subsequent
reportedly associated with resolution of the disease in two other pericardectomy may dramatically improve the success rate of
case reports.14-16 The empiric dose of rutin ranges from 50 to 100 thoracic duct ligation to 90%.2 Both thoracic duct ligation and
mg/kg PO q 8 h.14 A large clinical trial of its use in dogs and cats pericardectomy may be performed with video-assisted thoraco-
with idiopathic chylothorax has not yet been reported, but it is scopic surgery (i.e. thoracoscopy).
commonly used as part of the medical treatment of chylothorax.
674 Soft Tissue
Chylothorax resolution rates with omentalization and ablation advantage of embolization is the lack of a thoracic approach
of the cisterna chyli have not been reported in large numbers and the use of a simple approach to the abdomen. The disad-
of dogs, but these procedures may offer future alternatives for vantages of embolization include thrombosis of the cranial vena
therapy. Redistribution of the effusion into the abdominal cavity cava and embolization of pulmonary artery branches.25 Positive
or directly into the venous system may be required in cases of pressure ventilation may stop migration of cyanoacrylate during
persistent chylous or non-chylous effusion after surgery has its polymerization phase and decrease the risk of embolization
been attempted and has failed. of structures other than the thoracic duct.25 The efficacy of
embolization can be evaluated with lymphangiography and
repeated if necessary. Thoracic duct embolization, however, has
Surgical Techniques not been studied in a large number of clinical cases.
Mesenteric Lymphangiography
Mesenteric lymphangiography is recommended prior to ligation Standard lymphangiography requires laparotomy and prolongs
of the thoracic duct to provide the surgeon with the number operative time. A simpler method of injection of the mesenteric
and location of thoracic duct branches. Lymphangiography is lymph nodes with 0.22 mL/kg of aqueous contrast did result in
repeated after thoracic duct ligation to ensure that all branches a readable lymphangiogram in four of five dogs if images were
have been ligated. If patent branches remain, ligation and made within one to two minutes.26 The difference between a
lymphangiography should be repeated. An abdominal approach pressurized lymphatic injection by a catheter and mesenteric
is required, and lymphatic catheterization may be difficult, lymph node injection is not known.
especially in cats and small dogs. The main disadvantage of
lymphangiography is prolongation of surgery time. The other
disadvantage is that small thoracic duct branches may remain
patent but not fill with contrast material during lymphangiog-
raphy. The small remaining branches could be a cause for the
high failure rate associated with thoracic duct ligation.
Figure 43-2. Ligation of the thoracic duct. A. Right, tenth, lateral intercostal thoracotomy B. Anatomy of the structures at the site of ligation.
the thoracic duct with silk (2-0 or 3-0) or hemostatic clips. As with combination of the two procedures, which is rapidly becoming
mesenteric lymphangiography, the thoracic duct may be colored the mainstay of therapy for idiopathic chylothorax.2 Pericar-
by injecting methylene blue dye into the lymphatic catheter or dectomy was done by retracting the pericardium into the inter-
directly into a mesenteric lymph node. Mesenteric lymph node costal thoracotomy used for thoracic duct ligation or by an
injection reliably colored the canine thoracic duct within ten additional intercostal thoracotomy.2 Pericardectomy is described
minutes and lasted up to one hour in one experimental study.27 in Chapter 42.
An alternative approach to thoracic duct ligation is to ligate all Ablation of the Cysterna Chyli
structures dorsal to the aorta and ventral to the sympathetic trunk,
including the azygous vein.28 Thoracoscopic ligation of the thoracic Ablation of the cisterna chyli was developed in an attempt
duct has also been developed in dogs.29 Portals are placed in to force lymphaticovenous anastomosis formation within the
the middle of the chest at the ninth intercostal space and at the peritoneal cavity, rather than in the thoracic cavity.22,30 Ablation
junction of the dorsal and middle thirds of the chest at the eighth of the cisterna chyli was theorized to relieve the increase in
and tenth intercostal spaces.29 Hemostatic clips are applied to lymphatic hydrostatic pressure caudal to the site of thoracic duct
the thoracic duct ventral to the cranial lumbar or caudal thoracic ligation, which is a proposed mechanism for collateral lymphatic
vertebrae, prior to the emergence of the azygous vein into the formation and persistence of pleural effusion following thoracic
thorax.29 With any method of ligation, the area dorsal to the aorta duct ligation. Thoracic duct ligation alone allows new lympha-
should be completely evaluated for branches of the thoracic duct, ticovenous anastomoses to form with the azygous vein, but in
some of which may lie further lateral than previously described. dogs that underwent ablation of the cisterna chyli with thoracic
duct ligation, the anastomoses formed with the caudal vena cava
or phrenicoabdominal vein, mesenteric root, or azygous vein.30
Pericardectomy
Conditions that result in increased hydrostatic pressure may Thoracic duct ligation is performed as described above. The
contribute to the accumulation of chyle in the thorax by two cisterna chyli is approached through the abdominal ventral
mechanisms. Increased hydrostatic pressure may increase the midline.22,30 The peritoneum adjacent to the left kidney is incised,
production of lymph in the viscera and caudal body, which will and perirenal fat dissected until the cisterna is identified ventral
increase the flow of chyle in the thoracic duct.2 Concurrently, to the aorta. Sharp excision of all cisternal membranes is recom-
the increased hydrostatic pressure in the cranial vena cava mended. Seven of eight clinical cases responded to the combi-
will impede drainage of lymph from the thoracic duct into the nation of thoracic duct ligation and ablation of the cisterna
venous system. Pericardectomy may decrease venous hydro- chyli.22 Pancreatitis complicated one case but no other signif-
static pressure, decreasing both causes of fluid accumulation.2 icant complications were noted.22
Pericardectomy was described in 20 patients (10 dogs and 10
cats) with idiopathic chylothorax.2 It was a primary treatment Omentalization of the Thorax
(n=2) or was done in conjunction with thoracic duct ligation in
cases with persistent chylous or nonchylous effusion following The omentum is an organ that has been used in the treatment of
thoracic duct ligation.2 chronic wounds, abscesses, cystic structures. Omentum provides
a rich network of blood and lymphatic vessels for healing and
Pericardectomy with thoracic duct ligation resulted in a 90% presumably a large surface area for the absorption of fluid and
rate of resolution of effusion in the clinical cases reported.2 All obstruction of vascular leakage. The function of the omentum in
dogs and eight of ten cats were successfully treated with the the treatment of chylothorax is unknown; its lymphatic drainage
is via the thoracic duct. Omental advancement through the
676 Soft Tissue
diaphragm has been associated with a positive outcome in one thorax, severe abdominal distention, pyothorax, peritonitis, and
dog and one cat with idiopathic chylothorax.20,21 pleural compartmentalization.19 The pump chamber moves 1mL
of fluid with each compression and may cause patient discomfort
and poor client compliance due to the amount of care required to
Pleuroperitoneal or Pleurovenous Shunting
maintain pleural evacuation. These complications may result in
Persistent chylous or nonchylous effusion following surgical shunt removal, replacement, or patient euthanasia.19
treatment for idiopathic chylothorax may respond to pleuro-
peritoneal or pleurovenous shunt placement. (Figure 43-3) A
commercially available shunt utilizes a one-way, manually Postoperative Care
compressed pump to move fluid from the pleural space into the Patients should be monitored closely for complications
peritoneal cavity or the venous system.19 Although seemingly associated with thoracotomy and or laparotomy. The need for
more physiologically sound, pleurovenous shunting can fluid evacuation postoperatively is dependent on clinical signs
cause major venous, right atrial, or right ventricular thrombus and laboratory evaluation of ventilation. Resolution of pleural
formation. Peritoneal fluid accumulation is well tolerated by fluid accumulation following surgery should be monitored, as
veterinary patients, so pleuroperitoneal shunt placement is recurrent chyle accumulation or accumulation of a modified
more commonly performed.4 Pre-existing peritoneal conditions transudate may complicate recovery. Lung lobe torsion has also
that could prevent fluid absorption are a contraindication for been associated with chylothorax or other pleural effusions.31
pleuroperitoneal shunt placement. Chronic chylous effusion may also result in fibrosing pleuritis
and dyspnea despite evacuation of fluid.
References
1. Bezuidenhout AJ: The lymphatic system In Evans HE, ed.: Miller’s
Anatomy of the Dog. Philadelphia: WB Saunders Co., 1993, p 717.
2. Fossum TW, Mertens MM, Miller MW, et al.: Thoracic duct ligation
and pericardectomy for treatment of idiopathic chylothorax. J Vet Intern
Med 18:307, 2004.
3. Birchard SJ, Smeak DD, McLoughlin MA. Treatment of idiopathic
chylothorax in dogs and cats. J Amer Vet Med Assoc 212:652, 1998.
4. Fossum TW: Small Animal Surgery. St. Louis: Mosby, Inc., 2002, 788.
5. Holt JC. A review of traumatic chylothorax with a case report of
spontaneous remission in a dog. Aust Vet Pract 8:135, 1978.
6. Hodges CC, Fossum TW, Evering W. Evaluation of thoracic duct healing
after experimental laceration and transaction. Vet Surg 22:431, 1993.
7. Birchard SJ, Cantwell HD, Bright RMI. Lymphangiography and ligation
Figure 43-3. Placement of a pleuroperitoneal shunt. (From Smeak DD, of the canine thoracic duct: a study in normal dogs and three dogs with
et al. Management of intractable pleural effusions in the dog with chylothorax. J Amer Anim Hosp Assoc 18:769, 1982.
pleuroperitoneal shunt. Vet Surg 1987;16:212.)
8. Bilbrey SA, Birchard SJ. Pulmonary lymphatics in dogs with experi-
mentally induced chylothorax. J Amer Anim Hosp Assoc 30:86, 1994.
The shunt catheter consists of an afferent portion, pump
9. Fossum TW. Feline chylothorax. Comp Cont Ed Pract Vet 15:549, 1993.
chamber, and efferent limb. The entire system is placed in
10. Suter PF. Thoracic Radiography: A Text Atlas of Thoracic Diseases
heparinized saline and filled until no air bubbles are present.
of the Dog and Cat, With Contributions by Peter F. Lord. Wettswil,
A small thoracotomy incision is made over the sixth, seventh,
Switzerland : P.F. Suter, 1984, 683.
or eighth intercostal space.4 The afferent limb is placed in the
11. Birchard SJ, Smeak DD, Fossum TW. Results of thoracic duct ligation
chest, and a tunnel is made in the subcutis through which
in dogs with chylothorax. J Amer Vet Med Assoc 193:68, 1988.
the efferent limb is passed, allowing the pump chamber to lie
12. Fossum TW, Forrester SD, Swenson CL, et al. Chylothorax in cats: 37
over and be secured to the ribs.4 Securing the chamber to the
cases (19691989). J Amer Vet Med Assoc 198:672, 1991.
adjacent ribs allows postoperative compression of the chamber
13. Willard MD, Fossum TW, Torrance A, et al. Hyponatremia and
for pleural evacuation. The efferent limb is introduced into the
hyperkalemia associated with idiopathic or experimentally induced
peritoneal cavity through a small skin incision and pursestring chylothorax in four dogs. J Am Vet Med Assoc. 199:353, 1991.
suture in the abdominal musculature.4 Alternatively, the efferent
14. Thompson MS, Cohn LA, Jordan RC. Use of rutin for medical
limb is tunneled over the shoulder and into the caudal cervical management of idiopathic chylothorax in four cats. J Am Vet Med Assoc
region, and the efferent limb is introduced into the jugular vein. 215:345, 1999.
The efferent limb should be inserted no further than the cranial
15. Gould L. The medical management of idiopathic chylothorax in a
vena cava. Alternate venous insertion sites include the caudal domestic long-haired cat. Can Vet J. 45:51, 2004.
vena cava or azygous vein.
16. Kopko SH. The use of rutin in a cat with idiopathic chylothorax. Can
Vet J. 46:72, 2005.
Unfortunately, many complications have been associated with
17. Markham KM, Glover JL, Welsh RJ, et al. Octreotide in the treatment
shunting of pleural fluid including obstruction of the catheter by of thoracic duct injuries. Am Surg. 66:1165, 2000.
clot or kink formation, dislodgement of the pump chamber from the
Lymphatics and Lymph Nodes 677
18. Sicard GK, Hardie RJ, Hayashi K, et al. The use of a somatostatin
analogue (Octreotide) for the treatment of idiopathic chylothorax in
Surgical Technique
dogs and cats. Vet Surg 32:496, 2003. The cat is placed in dorsal recumbency, and the abdomen is
19. Smeak DD, Birchard SJ, McLoughlin MA, et al. Treatment of chronic prepared for aseptic surgery. A ventral midline incision is made
pleural effusion with pleuroperitoneal shunts in dogs: 14 cases (1985- from the xiphoid cartilage caudal to the umbilicus. The jejunum,
1999). J Am Vet Med Assoc. 219:1590, 2001. ileum, and ascending co-Ion are identified and are exteriorized to
20. Lafond E, Weirich WE, Salisbury SK. Omentalization of the thorax for locate the mesenteric lymph nodes. A more caudal lymph node
treatment of idiopathic chylothorax with constrictive pleuritis in a cat. J is selected, usually the right colic, for injection of 1% Evans blue
Am Anim Hosp Assoc. 38:74, 2002. solution (Sigma Chemical Co., St. Louis, MO). Direct puncture
21. Williams JM, Niles JD. Use of omentum as a physiologic drain for with a 25-gauge needle on a 1-mL syringe is used to deliver 0.1
treatment of chylothorax in a dog. Vet Surg. 28:61, 1999. to 0.2 mL of dye into the selected node. A dry surgical sponge is
22. Hayashi K, Sicard G, Gellasch K, et al. Cisterna chyli ablation with used to contain any leakage of dye on removal of the needle, thus
thoracic duct ligation for chylothorax: results in eight dogs. Vet Surg. minimizing abdominal contamination. Lymphatic
34:519, 2005.
23. Kerpsack SJ, McLoughlin MA, Birchard SJ, Smeak DD, Biller DS. drainage of the injected dye is immediate. By retracting the
Evaluation of mesenteric lymphangiography and thoracic duct ligation descending duodenum ventrally and to the left, the stained intes-
in cats with chylothorax: 19 cases (1987-1992). J Am Vet Med Assoc. tinal lymphatic trunk is easily visualized as it courses through
205:711, 1994. the duodenal mesentery dorsally toward the cisterna chyli. The
24. Esterline ML, Radlinsky MG, Biller DS, et al. Comparison of radio- transparent wall of the intestinal trunk is covered by visceral
graphic and computed tomography lymphangiography for identification peritoneum, which can be delicately dissected away to improve
of the canine thoracic duct. Vet Radiol Ultrasound. 46:391, 2005. the ease of cannulation of the intestinal trunk with a 22-gauge,
25. Pardo AD, Bright RM, Walker MA, Patton CS. Transcatheter thoracic over-the-needle catheter (Jelco intravenous catheter x 1 inch,
duct embolization in the dog. An experimental study. Vet Surg. 18:279. Johnson & Johnson, Inc., Arlington, TX). After stylet removal,
1989. spillage of dye from the catheter should be contained by capping
26. Brisson BA, Holmberg DL, House M. Comparison of mesenteric lymph- the catheter either with an injection cap (PRN Adapter, Becton
adenography performed via surgical and laparoscopic approaches in Dickinson Vascular Access, Sandy, UT) or by attaching the 1-mL
dogs. Am J Vet Res 67:168, 2006. syringe containing the Evans blue solution. The catheter is fixed
27. Enwiller TM, Radlinsky MG, Mason DE, Roush JK. Popliteal and to the mesoduodenum with circumferential ligatures of small-di-
mesenteric lymph node injection with methylene blue for coloration of ameter suture material (4-0 or 5-0), and the viscera are returned
the thoracic duct in dogs. Vet Surg. 32:359, 2003.
to the abdomen. Gentle manipulation of viscera minimizes
28. Orton EC. Small Animal Thoracic Surgery. Baltimore: Williams & disruption of the catheter.
Wilkins, 1995, 95.
29. Radlinsky MG, Mason DE, Biller DS, et al. Thoracoscopic visual- The left side of the diaphragm is identified by retracting the
ization and ligation of the thoracic duct in dogs. Vet Surg. 31:138, 2002. stomach and left liver lobes caudomedi-ally. A left transdiaphrag-
30. Sicard GK, Waller KR, McAnulty JF. The effect of cisterna chyli matic thoracotomy is performed by incising the diaphragm from
ablation combined with thoracic duct ligation on abdominal lymphatic a point 2 cm dorsolateral to the xiphoid cartilage dorsally toward
drainage. Vet Surg. 34:64, 2005.
the left diaphragmatic crus until adequate exposure of the caudal
31. Neath PJ, Brockman DJ, King LG. Lung lobe torsion in dogs: 22 cases thoracic aorta is achieved. By curving the diaphragmatic incision
(1981-1999). J Am Vet Med Assoc. 217:1041, 2000.
to parallel the costal arch, the medial portion of the incised
diaphragm can more readily be used as a retractor to contain
Transdiaphragmatic and displace the abdominal viscera caudomedially. Several stay
sutures in the medial margin of the diaphragmatic incision are
Approach to Thoracic Duct used for retraction.
Ligation in Cats The left caudal lung lobe is displaced cranially with a moistened
Robert A. Martin sponge to expose the caudal thoracic aorta. The thoracic duct
system should be identified in the areolar tissues surrounding
This technique is one of several surgical procedures used in an the aorta by its staining from the previously injected Evans blue
attempt to disrupt the flow of abdominal lymph drainage through solution. An additional injection through the catheter in the
the thoracic duct system in cats; it is specifically aimed at intestinal trunk may be necessary to improve visualization of the
resolving chylothorax when no identified underlying cause can thoracic duct branches. The thoracic aorta is dissected from
be found. Occlusion of the thoracic duct system results in the the thoracic duct system just cranial to the aortic hiatus of the
formation of alternate abdominal lymphaticovenous communi- diaphragm. The least number of branches of the thoracic duct
cations to return chyle to the circulation.1 After a ventral midline system is present for ligation at this location.2 The aortic dissection
celiotomy, a left transdiaphragmatic thoracotomy exposes the is performed by beginning directly along its ventral ad-ventitia
thoracic duct system for occlusion with hemostatic clips.1 The to minimize disruption of any of the thoracic duct branches,
procedure allows vital staining and immediate ligation of the which are incorporated in areolar tissue dorsally and laterally.
thoracic duct system through a single body wall incision. The A moistened umbilical tape is passed around the aorta, which
technical description of the procedure follows. is then retracted ventrally to expose the stained thoracic duct
678 Soft Tissue
system completely within the mediastinal tissues. Contraction left caudal lung lobe is removed, and the lobe is reinflated. The
of aorta occurs during dissection and retraction. Without thorax is lavaged with warm balanced electrolyte solution, and
immobilization of the thoracic aorta by complete circumferential all fluid is removed from the thorax with suction. The diaphragm is
dissection and isolation, complete exposure to the thoracic duct closed in a simple continuous suture pattern dorsally to ventrally
system cannot be achieved consistently. with 3-0 monofilament absorbable suture material. Thoracen-
tesis may be performed through diaphragmatic puncture or
Multiple hemostatic clips (Hemoclip [medium], Edward Week, through a previously placed thoracostomy tube until negative
Inc., Research Triangle Park, NC) are used to mass ligate any intrathoracic pressure is established. The abdominal lymphatic
visible thoracic duct branches, without an attempt to isolate catheter is removed, and two-layer or three-layer abdominal
individual ducts before ligation. Usually, a single duct arising closure is performed.
from the cranial pole of the cisterna chyli abdominally passes
through the diaphragm and gives rise to one or two main
thoracic branches, which can be identified at this site along with
Postoperative Care
occasional minor collateral branches.2 A major thoracic duct Postoperatively, a thoracostomy tube is maintained for 24 hours
branch courses on the left dorsolateral aspect of the thoracic or until thoracic effusion becomes minimal. The success of the
aorta. Looping collateral branches or a major or minor thoracic procedure is determined by resolution of the chylothorax without
duct may be identified along the right dorsolateral aspect of the recurrence. Perioperative antibiotics are indicated and should be
thoracic aorta, and multiple cross-communications between continued until after the thoracostomy tube is removed. Frequent
longitudinal ducts usually exist more cranially. The number of short-term follow-up evaluations are indicated to monitor the cat
cross-communications increases cranial to the preferred site of for recurrent thoracic effusion.
ligation (Figure 43-4), which is just cranial to the aortic hiatus of
the diaphragm (ventral to T13). The paired sympathetic trunks
that lie lateral to the thoracic duct system should not be included
References
1. Martin RA, Richards DLS, Barber DL, et al. Sunt E. Transdiaphragmatic
in the ligation. approach to thoracic duct ligation in the cat. Vet Surg 1988;17:22-26.
2. Martin RA, Barber DL, Richards DLS, et al. A technique for direct
After thoracic duct system ligation, a second injection of dye lymphangiography of the thoracic duct system in the cat. Vet Radiol
into the intestinal trunk catheter is performed to highlight any 1988;29:116-121.
collateral branches at the site of ligation that may have been
unidentified but require ligation. The moistened sponge on the
Figure 43-4. A lymphangiogram of the cisterna chyli and thoracic duct system in the caudal thorax. Note the possible small collateral branches
coursing through the diaphragm dorsal to the major duct. Inset: the correct location of hemostatic clip mass ligation at a point immediately below
thoracic vertebra 13.
Lymphatics and Lymph Nodes 679
Figure 43-5. Superficial lymph nodes in the dog. A. Parotid lymph node B. Mandibular lymph node C. Superficial cervical lymph node D. Axillary
lymph node E. Popliteal lymph node F. Inguinal lymph nodes.
Excisional Biopsy
Superficial lymph nodes may be excised with heavy sedation
and local anesthetic depending on the patient’s temperament
and physical status. General anesthesia for superficial lymph
node extirpation is recommended in most patients and is
required for deep, abdominal, or thoracic lymph node excision.
For superficial lymph nodes, the node is palpated and stabilized
with external pressure toward the skin surface. An incision is
made longitudinally over the lymph node, and blunt dissection
is used to mobilize the node. Afferent vessels may or may not
require ligation; more frequently hilar vessels are ligated.8 Deep,
abdominal, or thoracic lymph nodes are evaluated during surgical
exploration. Care is taken when dissecting the lymph nodes
from surrounding structures, particularly nerves and vessels.
Hemostasis is achieved with ligation and electrocautery in most
cases, however, collateral damage to the lymph node can occur
if cautery is applied close to the nodal surface.
References
1. Manna L, Vitale F, Reale S, et al.: Comparison of different tissue
sampling for PCR-based diagnosis and follow-up of canine visceral
leishmaniosis. Vet Parasitol 125:251, 2004.
2. Barrouin-Melo SM, Larangeira DR, Trigo J, et al.: Comparison between
splenic and lymph node aspirations as sampling methods for the parasi-
tological detection of Leishmania chagasi infection in dogs. Mem Inst
Oswaldo Cruz 99:195, 2004.
682 Soft Tissue
Chapter 44 Multiple spleens are uncommon in dogs, but trauma may result
in the widespread dissemination of splenic tissue throughout the
abdomen. Such fragments of splenic tissue become revascu-
Spleen larized, and the resultant condition (splenosis) may be confused
with neoplasia. Intentional splenic reimplantation during surgery
has been recommended as a means of salvaging splenic
Surgery of the Spleen function,3 but the mere presence of tissue of splenic origin does
not ensure that normal splenic function will be maintained.4,5
Dale E. Bjorling
The spleen may have white fibrin deposits or siderotic plaque
Introduction on its surface. Siderotic plaque consists of iron and calcium
The spleen is suspended in a portion of the greater omentum deposits and is brown or rust colored. This appearance should
(the gastrosplenic ligament) that extends from the diaphragm, not be considered abnormal. Similarly, splenic nodules (areas
fundus, and greater curvature of the stomach to the spleen.1 of benign hyperplasia) may be confused with neoplasia. Distin-
The splenic artery arises from the celiac artery and supplies guishing splenic nodular hyperplasia from neoplasia may be
branches to the left lobe of the pancreas as it courses to the difficult without a biopsy. The size of the spleen is variable, and
splenic hilus (Figure 44-1). The splenic artery divides into a the spleen may appear abnormally large during barbiturate
dorsal and a ventral branch several centimeters from the spleen. anesthesia or when it is relaxed during minimal adrenergic
The dorsal branch continues to the dorsal portion of the spleen, stimulation. Anemia, blood loss and stress all cause the spleen
where it gives off the short gastric arteries. The left gastroepi- to contract.
ploic artery arises from the ventral branch of the splenic artery
before it contacts the spleen. Venous drainage from the spleen The spleen has several functions: blood storage, blood filtration
is through the portal vein. and phagocytosis of particles, parasites, bacteria, and damaged
or aged red blood cells; contributions to the body’s immune
The spleen contains smooth muscle and is innervated by both defenses; hematopoiesis; and iron metabolism. The spleen may
sympathetic (from the celiac plexus) and parasympathetic (from retain as much as 10% of the total red blood cell mass6,7 that
the vagus) nerve fibers. The spleen also has a considerable can be discharged into the general circulation in response to
population of adrenergic receptors that control contraction and adrenergic stimulation during stress or blood loss. The structure
relaxation.2 of the spleen places red blood cells in close contact with
macrophages; therefore, red cells that are damaged, contain
parasites, or have immunoglobulins attached to the surface are
removed from circulation in the spleen. The spleen also appears
to remove blood-borne bacteria efficiently.8 It produces immuno-
globulins (particularly I gM) and opsonins, as well.9 Although not
reported in animals, overwhelming sepsis after splenectomy has
occurred in human patients.10 Hematopoiesis is not a significant
function of the spleen in adult animals, unless it is necessitated
by decreased function of the bone marrow. Iron is extracted from
hemoglobin as red blood cells are broken down and is stored in
the spleen for future transport to the bone marrow for production
of more hemoglobin.
Indications
Indications for removal of the spleen include neoplasia, torsion
of the splenic pedicle (isolated or in conjunction with gastric
dilatation volvulus), and severe traumatic injuries. Splenectomy
has been recommended as adjunctive treatment for immune
mediated thrombocytopenia and hemolytic anemia unresponsive
to medical therapy.11 The spleen is often removed in dogs used
as blood donors to prevent undetected infection with Haemobar-
tonella canis or Babesia canis. Because the spleen has several
functions, partial splenectomy should be considered (when
feasible) to retain functional splenic tissue.
Figure 44-2. A. Laceration of the spleen. B. The vessels supplying the injured area of the spleen are ligated to control hemorrhage. C. The lacera-
tion in the capsule of the spleen is closed with absorbable sutures in a simple interrupted or continuous pattern.
684 Soft Tissue
Figure 44-3. Partial splenectomy. A. After the vessels supplying the portion to be removed are ligated and divided, crushing forceps are applied
to the tissues to be removed and atraumatic forceps are applied to the splenic remnant. The spleen is then divided between these forceps a few
millimeters from the atraumatic forceps. B. The spleen is closed with absorbable suture in a simple continuous pattern. A second suture line is
placed proximal to the first to control hemorrhage.
proximal to the first suture material in a continuous horizontal spleen, thereby increasing the potential for inadvertent ligation
mattress pattern to ensure hemostasis. Partial splenectomy can of vessels supplying the stomach and pancreas. As mentioned
be performed easily with stapling devices. Staples of a length previously, when splenectomy is performed to treat splenic
sufficient to incorporate all tissue must be used. In most animals, torsion, the splenic pedicle should not be untwisted. The vessels
staples at least 3.5 mm in length are adequate; if splenic tissue are usually adequately accessible to allow individual ligation
cannot be compressed to a width less than 2 mm, staples 4.8 near the spleen. If this is not possible, forceps can be applied,
mm in length should be used.19 If hemorrhage is observed after and the vessels can be ligated individually after the spleen has
application of staples and excision of a portion of the spleen, been removed.
individual vessels can be ligated.
The abdomen should be explored thoroughly after removal of the
spleen. When the spleen has been removed to treat neoplastic
Splenectomy
disease, particular attention should be paid to the liver and
Splenectomy is usually performed though a midline celiotomy. lymph nodes, and biopsies should be obtained if these struc-
The incision should be of sufficient length to allow the spleen to tures appear abnormal. The pancreas and stomach should be
be easily delivered from the abdomen. If an essentially normal examined to be sure that these structures and their vasculature
spleen is being removed (e.g., to prevent hidden parasitemia or to have not been damaged during surgery.
treat an autoimmune disorder), 1 to 2 mL of 1:100,000 epinephrine
can be applied to the surface to cause the spleen to contract. The splenic bed should be examined for hemorrhage before
Use of larger volumes or higher concentrations of epinephrine closure of the abdomen. Lavaging the abdomen with sterile
may predispose the animal to cardiac arrhythmias, especially if saline or another balanced salt solution helps to remove blood
anesthesia is maintained with halothane. clots and improves the surgeon’s view of the splenic pedicle.
Vessels should be ligated as close to the hilus of the spleen
as possible to minimize the potential for damage to the left Postoperative Complications
gastroepiploic and short gastric vessels that supply the greater Hemorrhage as a result of displacement of a ligature is the most
curvature of the stomach or the vessels passing to the left lobe common complication of splenectomy. Intraabdominal hemor-
of the pancreas. Ligation of vessels during splenectomy can be rhage causes a progressive decline in the packed cell volume
achieved with suture, metal clips, a mechanical stapling device and plasma protein concentration when these values are
or vessel sealing device. Although absorbable suture may be measured repeatedly. Abdominal paracentesis and diagnostic
used for ligation of vessels, I prefer 2-0 or 3-0 silk. The vascu- peritoneal lavage also are useful for detecting hemorrhage after
lature of the spleen is usually isolated, ligated, and then divided. splenectomy. If tests support a diagnosis of intra abdominal
Alternatively, two rows of hemostatic forceps may be applied hemorrhage after splenectomy, the abdominal incision should
to the vasculature. The vasculature is divided, and vessels be reopened, and the splenic bed should be examined directly.
are ligated after the spleen has been removed. This technique A transfusion of whole blood may be required to compensate
often results in placement of ligatures some distance from the for blood loss. If a donor is not available, blood may be retrieved
Spleen 685
from the patient’s abdomen, mixed with an appropriate volume 5. Cooney DR, et al. Relative merits of partial splenectomy, splenic
of anticoagulant, and given back to the patient (autotransfusion). reimplantation, and immunization in preventing postsplenectomy
This blood should be filtered as it is administered to remove infection. Surgery 1979;86:56l.
microemboli and other debris. Blood should be removed from the 6. Prankerd TAJ. The spleen and anemia. Br J Med l963;2:517
abdomen using suction or sponges, and clots should be removed 7. Song SH, Groom AC. Storage of blood cells in the spleen of the cat.
from the splenic bed to allow direct observation of the splenic Am J Physiol 1971;220:779.
vessels. 8. Sullivan JL, et al. Immune response after splenectomy. Lancet
1978;1:178.
In the absence of continued hemorrhage, anemia after 9. Andersen V, et al. Immunological studies in children before and after
splenectomy is of limited duration if the bone marrow is functioning splènectomy. Acta Paediatr Scand 1976:65:409.
satisfactorily. Splenectomy does impair the capacity of the 10. Krivit W. Overwhelming postsplenectomy infection. Am J Hematol
animal to maintain the circulating red blood cell volume during 1977;2:193.
hemorrhage. Removal of the spleen 2 to 3 weeks before experi- 11. Feldman BF, Handagama P, Lubberink AAME. Splenectomy as
mentation impaired the ability of anesthetized dogs to respond adjunctive therapy for immune mediated thrombocytopenia and
to hypoxemia.20 Although this phenomenon may be transient, it hemolytic anemia in the dog. J Am Vet Med Assoc 1985;187:617.
does suggest that animals that have undergone splenectomy 12. Fees DL, Withrow SJ. Canine hemangiosarcoma. Compen Contin
may be less able to maintain cardiovascular homeostasis during Educ Pract Vet 1981;3:1047.
surgery, anesthesia, or other stressful situations. 13. Frey AJ, Betts CW. A retrospective study of splenectomy in the dog.
J Am Anim Hosp Assoc l977;13:730.
Damage to the vasculature of the stomach or pancreas can 14. Scavelli TD, et al. Hemangiosarcoma in the cat: retrospective evalu-
cause ischemic necrosis of these organs. Pancreatitis may ation of 31 surgical cases. J Am Vet Med Assoc 1985;187:817.
result from traumatic handling of the pancreas during surgery. 15. Kapatkin AS, Mullen ITS, Matthiesen DT, et al. Leiomyosarcoma in
These complications occur infrequently. dogs: 44 cases (1983 1988). J Am Vet Med Assoc 1992;201:1077.
16. Liska WD, et al. Feline systemic mastocystosis: a review and results
Ventricular arrhythmias have been reported to occur in as many of splenectomy in seven cases. J Am Anim Hosp Assoc 1979;15:589.
as 44% of dogs after splenectomy, and it has been observed 17. Montgomery RD, Henderson RA, Home RD, et al. Primary splenic
that these may not be detected in the absence of continuous torsion in dogs: literature review and report of five cases. Canine Pract
electrocardiographic monitoring.21 Not all dogs that develop l990;15:17.
ventricular arrhythmias after splenectomy require treatment, 18. Keramidas DC. Ligation of the splenic artery in the treatment of
and treatment of arrhythmias often prolongs hospitalization. traumatic rupture of the spleen. Surgery 1979;85:530.
Treatment should be reserved for ventricular arrhythmias that 19. Bellah JR. Surgical stapling of the spleen, pancreas, liver, and
result in significant pulse deficits or ventricular rates that urogenital tract. Vet Clin North Am Small Anim Pract 1994;24:375.
exceed established standards.22 20. Ffoulkes Crabbe DJO, et al. The effect of splenectomy on circulatory
adjustments to hypoxaemia in the anaesthetized dog. Br J Anaesth
As mentioned previously, overwhelming septicemia (occasionally 1976;48:639.
observed in humans after splenectomy) has not been reported 21. Marino, DJ, Matthiesen DT, Fox PR, et al. Ventricular arrhythmias
after splenectomy in dogs and cats. However, splenectomy may in dogs undergoing splenectomy: a prospective study. Vet Surg
render animals more susceptible to infection by blood borne 1994;23:101.
organisms (Haemobartonella, Babesia). Other, as yet undetected 22. Ettinger SJ, Le Bobinnec G, Cote E. Electrocardiography. In Textbook
immunologic abnormalities may also result from splenectomy in of veterinary internal medicine. 5th ed. Philadelphia: WB Saunders,
dogs and cats. 2000; pp 800-833.
References
1. Evans HE. Miller’s anatomy of the dog. 3rd ed. Philadelphia: WB
Saunders, 1993; p 654.
2. Opdyke DF, Ward CJ. Spleen as an experimental model for the study
of vascular capacitance. Am J Physiol 1973:225:1416.
3. Mililkan JS, et al. Alternatives to splenectomy in adults after trauma:
repair, partial resection, and reimplantation of splenic tissue. Am J Surg
1982;144:711.
4. Cooney DR, Swanson SE, Dearth JC. Heterotopic splenic autotrans-
plantation in prevention of overwhelming postsplenectomy infection. J
Pediatr Surg 1979:14:337.
686 Soft Tissue
Section J
larger endotracheal tubes. Whenever possible, a cuffed tube is
recommended.
Neal L. Beeber Except for a routine spay, neuter, or other minor procedure, a 24
gauge intravenous catheter (Baxter Quickcath 24 gauge 1.6 cm)
should be placed for all surgical procedures. The cephalic vein
Introduction is the most common site for placement, but lateral saphenous,
In recent years, the domestic ferret has had a dramatic increase jugular, and intraosseous catheters can also be used. When a
in popularity. In 1990, the number of pet ferrets in the United jugular catheter is necessary, a 24 gauge cephalic catheter can
States was estimated to be more than 7 million.1 As these animals be placed in the jugular vein. The types of fluids administered
have increased in Popularity, they have become more common depend on the type of surgical procedure performed and are
in veterinary practices. This discussion deals with some of the discussed under the appropriate section. Ferrets are monitored
more common surgical procedures in ferrets. with a pulse oximeter, which works well in this species. Recovery
time depends on the animal’s condition and length of anesthesia;
Preparation and Fasting however, when isoflurane is used alone, recovery is remarkably
fast and smooth.
Healthy ferrets make excellent surgical candidates, are hardy,
and with attention to certain parameters they do not present any
unusual anesthetic risks. The intestinal tract is short, resulting General Surgical Considerations
in a gastrointestinal transit time of 3 to 4 hours.2 For this reason, Ferret skin is tougher than dog or cat skin, so slightly more
patients are only fasted for 4 to 5 hours before surgery, except in pressure may need to be exerted. One often sees a thick
the case of insulinoma resection, for which the fast is 3 hours. subcutaneous fat layer, which should be dissected bluntly. The
linea alba is readily apparent. A stab incision should be made
Sedation and Anesthesia into the abdominal cavity and extended. Care should be taken
to avoid the spleen because it is often large in this species.
Isoflurane is the anesthetic of choice; however, halothane can
Most common types of sutures can be used depending on the
also be used, except in critically ill patients. A nonrebreathing
operation performed. I prefer to close the abdomen with 4-0
system is used with a flow rate of 0.6 to 1.0 L per minute. No
polydioxanone (PDS), polypropylene (Prolene), or nylon. Most
premedication is required. In many cases, ferrets can be masked
nonabsorbable suture material with a cutting needle can be
until they are sufficiently anesthetized to allow endotracheal
used for skin sutures. Ferrets rarely chew external sutures.
intubation. This can usually be accomplished with a flow rate of
2 L and a 4 to 5% isoflurane concentration. The animal relaxes
in 2 to 5 minutes. Because struggling or excitement is minimal, Ovariohysterectomy
chamber induction is not usually necessary. Maintenance level Most ferrets sold as pets in the United States are neutered before
of isoflurane is 1.75 to 2.5%. It is often necessary to use a small 6 or 7 weeks of age, so ovariohysterectomy is not a common
amount of lidocaine (0.1 mL) to paralyze the larynx to accom- procedure, as in dogs and cats. Ferrets should be spayed by 6
plish intubation, as in the feline species. All ferrets are intubated months of age, however, if they are not to be used for breeding.
except for the most minor procedures. Use of 1.5 to 4.5 French Ferrets are induced ovulators. If they are allowed to remain in
endotracheal tubes is sufficient for most ferrets. If the tubes estrus, potentially fatal bone marrow suppression may result
are allowed to become cold in a refrigerator, they will become from estrogen toxicity. Medical treatments to terminate estrus
stiff and more easily introduced into the trachea. Because are available;3 however, spaying is recommended.
ferrets vary in body size, several tube sizes should be available.
Some breeding establishments have been importing European The surgical procedure is similar to that for cats. The ferret is
ferrets, which are generally larger than the American breeds placed in dorsal recumbency, and the abdomen is shaved and
and commonly weigh up to 5 to 6 lb. These ferrets need slightly prepared. A 3 to 4 cm midline incision is made 1cm posterior to
Surgical Techniques in Small Exotic Animals 687
the umbilicus. Blunt dissection is used to dissect through the plasia, 26%; and adrenocortical carcinoma, 10%. In the patients
fat layer and subcutaneous tissue to expose the linea alba. An with adreno cortical carcinoma, no gross or microscopic
incision is made through the linea and is extended. Usually, a evidence of metastasis was seen. In addition, 70% of the cases
layer of fat is encountered. The uterus of ferrets is bicornate, occurred in females.6 Since this study, I have had the opportunity
as in cats. The uterus can be elevated by using a spay hook, or to operate on many more cases and have found that the biopsy
sometimes it can be seen lying just under the incision by bluntly percentage has shifted to adrenocortical adenoma. Hyperplasia
moving the fat. The uterus of the ferret is not nearly as friable as now accounts for 95% of the cases, and the ratio of males to
that of the rabbit. Ferrets have a high degree of body fat, and the females has equalized. In addition, the earlier study found that
ovarian tissue and vessels may be obscured. The surgeon must 64% of ferrets had disease of the left adrenal gland, 20% had
be certain to ligate the ovarian vessels completely using 2-0 or disease of the right gland, and 16% had bilateral disease. In
3-0 gut. The uterus is easily exteriorized and the suspensory the years after the study, my colleagues and I have seen left
ligament is readily torn. The uterus is ligated with gut and is sided disease in 75% of patients, right sided disease in 15%, and
removed. The abdomen can be closed with any of several sUi bilateral disease in 10%.
types in a simple interrupted pattern using 4 U nlonl filament
absorbable or nonabsorbable material. The same suture or gut Clinical signs, in order of decreasing frequency, are vulvar
can be used for the subcutaneous or subcuticular layer. The swelling, alopecia, pruritus, polydipsia, and polyuria. The
skin can be closed with 3-0 or 4-0 nylon. Chewing of sutures has diagnosis is based on clinical signs and abdominal ultrasonog-
not been a problem. If the surgical procedure is performed in raphy. The accuracy of the ultrasound diagnosis depends on the
the morning, the ferret is released the same day. Postoperative experience of the ultrasonagrapher. Recently, a study indicated
antibiotics are not necessary. Skin sutures are removed in 7 to that the concentrations of certain plasma steroid hormones can
10 days. be used as a marker for the disease.7 Even though the clinical
signs may indicate the presence of an adrenal tumor, the
clinician should obtain a presurgical ultrasound study whenever
Orchiectomy
possible. This examination helps to rule out other causes of the
Like ovariohysterectomy, orchiectomy (castration) is usually clinical signs and indicates which adrenal gland is diseased.
done in young ferrets before they are sold to pet stores. For This distinction becomes important because removal of the right
this reason, the average practitioner is not called on to perform gland is technically more difficult, owing to its location under
this operation routinely. If an intact male ferret is presented, the the caudate liver lobe and its proximity to the vena cava. The
owners should be encouraged to have the ferret castrated. In differential diagnosis of adrenal gland disease includes ovarian
some cases, intact male ferrets are more aggressive, especially remnants, an intact female reproductive tract, pheochromo-
if intact females are nearby. The main objection to intact cytoma, seasonal hair loss of ferrets, nutritional deficiencies,8,9
males is the heavy musky odor they produce. Many times, mycosis fungoides,10 and infestation by external parasites. I have
castration alone is enough to control odor, making descenting also seen a ferret with cutaneous Malassezia pachydermatis
unnecessary. Testicular tumors have been reported, but a true infection that caused generalized hair loss. Adrenal disease in
incidence is difficult to estimate because most domestic ferrets ferrets is not the same as Cushing’s disease because the clinical
arc neutered.4,5 signs and pathologic changes are not caused by an increase in
plasma cortisol concentration.
Castration in the ferret is similar to castration in the dog. The
ferret is placed in dorsal recumbency, and the prescrotal area
is shaved. One prescrotal incision is made through which both Preparation
testicles may be exteriorized. An open or closed method can After the diagnosis is made, a complete blood screen and
be used. The spermatic cord and vessels are ligated with 4-0 chemistry panel should be evaluated for each patient. Any
gut, are iricised, and allowed to retract into the incision. The abnormalities should be investigated and treated preoperatively.
subcutaneous tissue is closed with gut, and the skin is closed One of the most common abnormalities is hypoglycemia because
with 4-0 nonabsorbable suture, which is removed in 7 to 10 days. many ferrets concurrently have insulin secreting tumors of
Chewing the sutures has not been a problem. Alternatively, two the pancreas. Because these islet cell tumors are generally
incisions can be made in the scrotum, and the vessels can be malignant, the prognosis should be discussed with the owners
clamped and ligated with 4-0 chromic gut. With this method, the before proceeding. In addition, an in hospital blood glucose
scrotal incisions are not closed, similar to the procedure in cats. determination should be made immediately before anesthesia
The ferrets are released the same day. is induced, to make certain the blood sugar is still normal after
the presurgical fasting period. Another important presurgical
consideration is the possibility of underlying cardiac disease.
Adrenalectomy
Both hypertrophic and dilated forms of cardiomyopathy are seen
Adrenal tumors are among the most common neoplasms of in ferrets.11 At this time, clients are advised that a presurgical
ferrets. In our practice, adrenalectomy is the single most common echocardiogram should be performed if possible. If this is not
surgical procedure performed in these animals, followed by feasible, chest radiographs and careful cardiac auscultation
insulinoma resection. In a retrospective study performed at our should be performed. Every patient undergoing adrenalectomy
hospital and the Animal Medical Center from 1987 to 1991, the receives an intravenous catheter. Various fluid types may be
following types and frequency of biopsy results were recorded: used; however, if one has any question about the presence of
adrenocortical adenoma, 64%; nodular adreno cortical hyper-
688 Soft Tissue
Left Adrenalectomy
The ferret is placed in dorsal recumbency, and the abdomen
is shaved from the area of the xiphoid cartilage to the inguinal
area. An incision is made starting 1 to 2 cm from the xiphoid and
extending 4 to 5 cm caudally. After dissecting through the fat and
subcuta¬neous tissue, a stab incision is made in the linea alba
and is extended with scissors. A self retaining Gelpi retractor
should be used for good exposure. As in other species, a complete
abdominal exploratory operation should be performed. It is
especially important to check the pancreas for the possibility of
insulinoma nodules (see later). In addition, all male ferrets should Figure 45-1. Appearance of the adrenal glands. The caudate lobe of
be examined for the presence of paraurethral cysts (discussed the liver has been reflected cranially. The right adrenal gland usually
later). The surgeon generally must retract the spleen and intes- adheres to the vena cava.
tines toward the right side of the ferret’s body. A laparotomy pad
soaked in warm saline can be used to hold structures away from and the vena cava. Any remaining glandular tissue is trimmed
the surgical site. Alternately, the spleen and small intestines using the iris scissors. One should have available 5-0 and 7-0
can be exteriorized through the incision and placed to the right. suture as well as sterile sponges (Gelfoam) in the event that the
This maneuver pulls the mesentery away from the area of the vena cava is lacerated. When one is certain that all hemorrhage
adrenal gland and affords excellent exposure. Any exteriorized has been controlled, closure is as described earlier.
tissues should be covered with a warm moist lap pad to prevent
tissue drying. The left adrenal gland is located just medial and
Bilateral Adrenal Disease
proximal to the left kidney. This gland is located within a fat
pad, and if diseased, it is usually irregular in shape and readily When both adrenal glands are abnormal, the surgeon removes
seen. In some cases, one sees a brownish-yellow discoloration. the left entirely and debulks the right. If incised, the adrenal
Digital palpation reveals the presence of borders on the mass. gland bleeds profusely. One begins Caudal venacava dissecting
The dissection is begun on the medial side of the gland through the gland and places a crushing suture around the part that has
the fat layer using Mayo scissors and is continued bluntly with been freed, using 4-0 monofilament absorbable or nonabsorbable
mosquito forceps and sterile cotton tipped applicators. The gland material. Iris scissors can then be used to cut above the suture.
is gently elevated as the dissection is continued. The small blood The surgeon removes 50 to 75% of the right adrenal tissue.
vessels in the fat generally do not have to be ligated. The adreno-
lumbar vein runs laterally and caudally from the ventral surface Complications
of the adrenal gland. It can be seen as the gland is elevated. The most common complication of adrenalectomy is prolonged
This vessel is ligated using 4 0 chromic gut or a surgical clip or difficult recovery resulting from hypogly cemia secondary
(Hemoclip). The gland is continually elevated and dissected until to an undiagnosed insulin secreting tumor of the pancreas. In
a suture can be placed below it. The tissue is then incised, and fact, when ferrets are referred to my practice for postsurgical
the gland is removed. Closure is the same as for an ovariohyster- problems blood glucose concentrations are frequently found.
ectomy. Because this is a major abdominal procedure, patients For this reason, a blood glucose determination is performed
are hospitalized for 1 to 2 days postoperatively. Amoxicillin oral before the surgical procedure and 1 to 2 hours postoperatively.
suspension at a dose of 10 mg/lb is dispensed for 7 days. Many times, fluids containing dextrose are used as a precaution.
Ferrets are encouragcd to eat after they are fully awake, and
Right Adrenalectomy Deliver (Deliver I 2.0, Mead Johnson Nutritionals, Evansville, ‘N)
As mentioned previously, removal of the right adrenal gland is often administered orally within 3 to 4 hours postoperatively.
is a technically more difficult procedure. After entry into the Vomiting has not been a problem.
abdominal cavity, and a general exploratory operation, the
spleen and intestines are moved to the left or are exteriorized. Another problem commonly encountered is hypothermia. Intra-
The right adrenal gland is located under the caudate liver lobe. venous fluids should be warmed before administration. We use a
The hepatorenal ligament must be incised to elevate the tip of warm water heating pad and heat lamp during and after surgery.
the liver lobe. The lobe is then reflected cranially. The adrenal Ferrets are generally hardy and are good surgical candidates.
gland is usually directly adhered to the vena cava (Figure 45-1). Postoperative infections appear to be rare.
One must be careful to avoid lacerating this major vessel. The
surgeon begins shelling out the gland by sharp dissection of the Even with the removal of the left adrenal gland and part of the
surface furthest from the vena cava and continues around the right, most patients do not appear to require hormonal supple-
gland using iris scissors, mosquito forceps, and sterile cotton mentation. Vital signs in these ferrets should be monitored
swabs. When the gland is mostly peeled away, a Hemoclip or a closely in the immediate postoperative period. If recovery
ligature using 5-0 absorbable suture is placed between the gland is prolonged or if the patient is dping poorly, a blood glucose
Surgical Techniques in Small Exotic Animals 689
is recommended as a presurgical screen. Often, surgery is be sure that clients understand that medical intervention may
performed concurrently for adrenal disease and insulinoma. need to be continued or resumed as the disease progresses.
Presurgical fasting is usually limited to 3 to 4 hours. An intra- Even with these caveats, I believe, based on many cases, that
venous catheter is placed in all cases, and warmed 5% dextrose a combination of surgical and medical management yields the
is administered during the surgical procedure. best results for the longest period.
Blood glucose should be measured postoperatively and at In some cases, endoscopy may be helpful to remove esophageal
reasonable intervals during recovery. Some ferrets become and gastric’foreign bodies. I use a pediatric bronchoscope. The
normoglycemic 1 to 2 days postoperatively. In many cases, diameter is too large to be useful for the small intestine.
I observe only a slight increase in measured blood glucose,
although the ferrets appear to improve clinically. Often, medical Surgical Procedure
management must be continued. Some patients have Postop- In many cases, ferrets with foreign body ingestion exhibit
erative hyperglycemia, which is usually transient and reso1ves anorexia and are dehydrated. Therefore, adequate rehydration
within 3 to 5 days. is important. Surgery should be considered an emergency and
performed as soon as possible. A standard midline approach
The surgeon must inform clients that this is a maiignant is used, and a complete examination of the intestinal tract is
neoplasm,15 and a cure should not be expected. One should also performed to check for multiple foreign bodies. In patients with
esophageal or proximal duodenal obstruction, the surgeon
should retropulse the material into the stomach and perform a
simple gastrotomy. Gastric surgery is similar to that in the dog
or cat. Closure is accomlished with a double layer simple inter-
rupted pattern using 4-0 absorbable material.
Introduction
References The ferret is a popular house pet; however, odor emitted from
1. Rupprecht CE, Gilbert J, Pitts R, et al. Evaluation of an inacti- the anal sacs of both sexes is often objectionable. Like nearly
vated rabies virus vaccine in domestic ferrets. J Am Vet Med Assoc all carnivores1 and all mustelids,2 the ferret has an anal sac on
1990;193:1614 1616. each side of the anus. The ducts open at 4 o’clock and 8 o’clock
2. An NQ, Evans HE. Anatomy of the ferret. In: Fox JG, ed. Biology and positions on the inner cutaneous zone of the anus, adjacent to
diseases of the ferret. Philadelphia: Lea & Febiger, 1988: 100 134. the mucocutaneous junction. The sacs are interposed between
3. Bernard, SL, Leathers, CW, Brobst, DF, et al. Estrogen induced bone the internal and external anal sphincter muscles. Material stored
marrow depression in ferrets. Am J Vet Res 1983;44:657. within the sac is secreted by a glandular complex surrounding
4. Meschter CL. Interstitial cell adenoma in a ferret. Lab Anim So the neck of the sac and 3 to 4 mm of the duct. This complex is
1989;39:353-354. evident without magnification, but a binocular loupe enhances
5. Goad WP, Fox JG. Neoplasia in ferrets. In: Fox JG, ed. Biology and visualization. The sebaceous gland component surrounding the
diseases of the ferret. Philadelphia: Lea & Febiger, 1988: 278 280. distal part of the duct is covered asymmetrically by an apocrine
6. Rosenthal KL, Peterson ME, Quesenberry KE, et al. Hyperadrenocor- gland component.3 Surgical removal of the anal sacs and their
ticism associated with adrenocortical tumor or nodular hyperplasia of ducts eliminates the odor of anal sac secretions, but some odor
the adrenal gland in ferrets: 50 cases (1987-1991). J Am Vet Med Assoc from sebaceous and apocrine tubular glands in the perianal
1993;203:271 275. region typically persists.
7. Rosenthal KL, Peterson ME. Evaluation of plasma androgen and
estrogen concentrations in ferrets with hyperadrenocorticism. J Am
Vet Med Assoc 1996;209:1097 1102. Indications
8. Ryland LM, Bernard SL. A clinical guide to the pet ferret. Corn pend Client request is the principal indication for performing this
Contin Educ Pract Vet 1983;5:25 32. procedure. However, veterinarians should recommend this
9. Ryland LM, Gorham JR. The ferret and its diseases. J Am Vet Med operation for all ferrets at 6 to 8 months of age to make them
Assoc 1978;173:1154 1158. more acceptable pets. Neutering should be recommended at
10. Rosenbaum MR, Affolter YK, Usborne AL, et al. Cutaneous epithelio- this age in ferrets of both sexes to reduce odor further. Neutering
tropic lymphoma in a ferret. J Am Vet Med Assoc 1996;209:1441-1444. also prevents development of aplastic anemia in nonbreeding
11. Stamoulis ME, Miller MS. Cardiovascular diseases. In: Hillyer BY, females, which can develop from hyperestrinism associated
Quisenberry KB, eds. Ferrets, rabbits, and rodents: clinical medicine with prolonged estrus.3,4 The client must be made aware that
and surgery. Philadelphia: WB Saunders, 1997:67-68. anal sac resection and neutering do not eliminate all “musky”
12. Feldman EC, Nelson RW. Canine and feline endocrinology and repro- odor, because of sebaceous and apocrine glands in the ferret’s
duction. Philadelphia: WB Saunders, 1987:259, 304-327. penrianal skin.
13. Baich JF, Balch PA. Prescription for nutritional healing. Garden Park
City: Avery, NY. 1990:18 19, 211-213.
14. Leifer CE, Peterson ME, Matus RE. Insulin secreting tumor: diagnosis
Preoperative Considerations
and medical and surgical management in 55 dogs. J Am Vet Med Assoc In addition to a complete physical examination, the patient’s
1986;188:60-64. packed cell volume of blood and total serum protein level
15. Caplan ER, Peterson ME, Mullen HS, et a!. Surgical treatment should be determined. One study of 11 healthy male ferrets
of insulin secreting pancreatic islet cell tumors in 49 ferrets: ACVS reported an average packed cell volume of 52.4% and average
abstract. Vet Surg l995;24:422. total serum protein of 6.0 g/dL.3 Food should be withheld for 12
16. Caligiuri R, Bellah JR, Collins BR, et a!. Medical and surgical hours. Anesthesia is induced with oxygen and an appropriate
management of esophageal foreign body in a ferret. J Am Vet Med gaseous agent in an anesthesia chamber; it can be maintained
Assoc 1989;195:969-971. with a mask or an endotracheal tube 2.5 mm in inner diameter (12
17. Mullen HS, Scavefli TD, Quesenberry ICE, et al. Gastrointestinal French outer diameter, Cole, Intermountain Veterinary Supply, N.
foreign body in ferrets: 25 cases (1986 1990). J Am Anim Hosp Assoc Kansas City, MO). An alternate method is intramuscular injection
1992;28:13-19. of ketamine hydrochloride (26mg/kg) and acepromazine (0.2 to
0.3mg/kg).5
for the surgical procedure. Aseptic neutering is accomplished, secretions are yellow. It is easy to rupture the duct and sac,
and then the surgical drape is shifted to expose the anal region. particularly if the veterinary surgeon is inexperienced. Trying to
establish a fascial plane before dissecting beyond the nodular
glandular complex is futile and particularly hazardous, because
Surgical Technique it is easy to cut into the duct lumen. If the duct or sac is incised,
A binocular loupe should be used to locate the minute opening surgical extirpation can still be accomplished, but the absence
of each anal sac duct and to aid visualization throughout the of a distended sac makes the operation more tedious. Odor from
procedure. The opening of each duct and the surrounding 2 an incised or ruptured sac is obnoxious, but not overwhelming.
mm of skin and mucous membrane are grasped with mosquito
forceps. A circumferential incision is made with a No. 15 Bard Intraoperative hemorrhage is negligible, although sterile cotton
Parker scalpel blade immediately distal to the forceps tip; one tipped applicator sticks work well to clear oozing blood from the
must be careful not to incise too deeply. Using a gentle scraping surgical field. Placement of sutures and administration of local
action with the blade, skin and mucosa are reflected from the duct or systemic antibiotics are not required.
(Figure 45-4). The glandular complex surrounding the terminal
3 to 4mm of the duct makes dissection difficult (Figure 45-4C).
This complex has a nodular surface, with skeletal muscle fibers Postoperative Care
inserting into the glandular tissue. One should not attempt to find The patient is normally discharged when recovery from
a fascial plane at this level, and dissection should be superficial anesthesia is complete. Although no serious postoperative
with respect to overlying tissue. Shifting the mosquito forceps to sequelae have been observed, complications can occur.
clamp them across skin, mucous membrane, and terminal duct Persistent minor hemorrhage may develop postoperatively, but
should prevent tearing the duct as caudal traction is applied with this ceases spontaneously. Potential complications include
the forceps (Figure 45-4E). Applying another forceps parallel to prolapsed rectum and fecal incontinence if trauma to the anal
the first provides even more support. sphincter muscles is excessive. Staying on the proper fascial
plane minimizes trauma and the possibility of these serious
A fascial plane is encountered as dissection is carried beyond sequelae.
the glandular complex (Figure 45-4B). The anal sac can be
removed readily by reflecting sphincter muscles off the sac wall
with a scraping action of the scalpel blade. Staying on the proper References
fascial plane not only enhances sac removal, but also minimizes 1. Ewer RF. The carnivores. Ithaca, NY: Cornell University Press,
hemorrhage and damage to internal and external anal sphincters. 1973:95.
If the fascial plane is followed, little muscle will be left on the sac 2. Ryland LM, Gorham JR. The ferret and its diseases. J Am Vet Med
wall. The wall appears yellowish white; it is thin, and glandular Assoc 1978;173:l154.
3. Creed JE, Kainer RA. Surgical extirpation and related anatomy of anal
sacs of the ferret. J Am Vet Med Assoc 1981;179:575.
4. Kociba GJ, Caputo CA. Aplastic anemia associated with estrus in pet
ferrets. J Am Vet Med Assoc 198l;178:1293.
5. Muir WW Ill, Hubbell JAB. Handbook of veterinary anesthesia. 2nd
ed. Philadelphia: Mosby, 1995:368.
Introduction
In recent years reptiles have become increasingly popular
as pets. Veterinarians are called upon to perform a variety
of medical and surgical procedures on these animals.1,2 The
anatomy and physiology of reptiles differs from the more familiar
mammalian patients and the surgeon must be familiar with
these differences. Skin incisions are generally made between
scales in the thin softer tissue between them. It is assumed that
healing in this skin is more rapid than when an incision is made
through the tough scales. A number 11 scalpel blade is partic-
ularly useful for skin incision as its fine tip allows the surgeon
to incise with more precision in the zig-zag pattern required to
Figure 45-4. A-C. Resection of the anal sac. External anal sphincter cut between scales (Figure 45-5). In a retrospective report there
muscle A. Wall of the anal sac B. Nodular glandular complex surround- was no difference in healing when the incision for celiotomy in
ing the duct C. End of the anal sac duct D. Tip of mosquito forceps snakes was made through the scutes (large ventral scales) on
grasping skin, mucous membrane, and terminal duct E. the midline compared with a lateral incision between scales.3
Surgical Techniques in Small Exotic Animals 693
The cloaca receives excretions from the ureters, colon and urinary membrane is not attached to the skin. The muscle of the body
bladder in those species with a bladder, and the reproductive wall is closed with a simple continous pattern using a synthetic
system. Chelonians and crocodilians have a single copulatory absorbable material on a fine atraumatic needle which will also
organ (penis) while squamates have paired copulatory organs approximate the skin edges. The skin is closed with either skin
called hemipenes (hemipenis, singular). The copulatory organs do staples or an everting pattern such as a horizontal mattress.
not contain tubular structures such as a urethra. Semen travels
along a groove in the hemipenis into the cloaca of the female. The Chelonians present a unique challenge for celiotomy because of
female reproductive tract is bilateral in reptiles with each oviduct their shell. For most procedures a plastron osteotomy is required.
having a separate opening into the cloaca. In species with a small plastron, such as snapping turtles and
sea turtles, some procedures can be accomplished through a
flank incision. Some procedures, such as cystotomy, can be
Celiotomy accomplished through this approach in other chelonians.3
The approach for celiotomy in reptiles varies with the family of
reptile. Because reptiles lack a diaphragm celiotomy can allow The pelvic bones are avoided during plastron osteotomy to avoid
access to both thoracic and abdominal viscera. injury to the appendicular skeleton. Radiographs are helpful in
assessing the location and extent of the pelvic bones. In most
Lizards and crocodilians have a body structure more similar to species, osteotomy through the femoral and abdominal epidermal
mammals than chelonians and snakes. A paramedian incision is shields (Figure 45-6) will allow access to coelomic viscera while
recommended in these species because of the ventral abdominal avoiding injury to the appendicular skeleton and heart. The
vein. This vein receives blood from the caudal abdominal wall osteotomy must be large enough to allow the procedure to be
and courses along the ventral midline 2 to 3 mm inside the body accomplished and located in a position to allow access to the
wall. It is located between the umbilical scar and the pubic bones target organ.
and is suspended by a short mesovasorum. Some surgeons
prefer a midline approach using meticulous dissection to avoid Plastron osteotomy is performed using a power or pneumatic
damaging this rather large vein.3 Making a paramedian incision bone saw, or a sterile motorized wood working tool with a fine
2 to 4 mm lateral to midline minimizes the risk of lacerating this circular saw blade. Standard bur bits are not recommended
vessel. It has been reported that this vein may be ligated without because they cut an excessively wide osteotomy which will
consequence.2,3 delay bone healing. Standard surgical preparation is performed
and the surface of the plastron must be completely free of keratin
Closure is accomplished using a simple continuous pattern with
a synthetic absorbable material on a fine, atraumatic swaged-on
needle. Because the muscle of the body wall is thin and tightly
adhered to the skin, care must be taken with suture placement
and tension on the suture or tearing through the muscle will occur.
Suturing the body wall will pull the skin edges into apposition.
Skin staples or an everting pattern of a nonabsorbable material
maintain skin apposition.
debris and soil. This requires a surgical scrub brush. Alcohol, Epoxy is mixed and applied 2 to 3 cm around the periphery of the
ether, or acetone is used to remove grease from the surface of plastron osteotomy and over the entire bone segment leaving a
the plastron to allow a better bond to form between the keratin 3 to 4 mm border around the osteotomy on both sides to prevent
and the epoxy resin that will be used to stabilize the plastron the resin from flowing into the osteotomy which would delay
osteotomy postoperative. healing. A sterile autoclaved piece of fiberglass cloth is placed
over the plastron flap with a 2 to 3 cm border extending over the
The plastron is dermal bone and efforts are made to improve osteotomy onto the plastron. The epoxy already on the plastron
the environment for bone healing. The osteotomy cut is beveled is gently worked into the cloth being careful not to allow the
slightly and the blade should be as thin as possible so when the resin to seep into the osteotomy. The epoxy is allowed to cure
segment of plastron is replaced, bone-to-bone contact will be and a second layer is applied over the entire patch. This layer
achieved (Figure 45-7). The blade is irrigated while performing should be thin enough that the resin does not soak through the
the osteotomy to dissipate heat and control bone dust. It is best cloth and into the osteotomy. Enough layers of epoxy are applied
to make a 3 sided osteotomy in species with a hinge (e.g. box to create a completely smooth surface with no texture from
turtles). An osteotomy is made on both sides as well as the the cloth remaining. During the final curing process, a piece of
caudal margin of the proposed flap. The segment of plastron plastic sheeting or wax paper is applied to the patch to prevent
is then reflected craniad based on the intact hinge which will paper or soil from adhering to the resin. This will not stick to the
provide blood supply to the segment of bone. For those species epoxy and is removed the following day. Within 24 hrs the resin
without a hinge (most tortoises), the segment is cut along the is completely cured and the turtle can resume normal activity,
cranial or caudal border and the two sides. The fourth side is including swimming. Some surgeons prefer to apply a thin layer
partially cut with the saw and then, as the section of bone is of antibiotic cream along the osteotomy site to prevent resin
elevated, it is cracked along the remaining border to preserve from entering and provide some antibacterial activity.
some blood supply as well as some stability.
Healing of a plastron ostetomy requires 1 to 2 years.3 Patches
After the bone has been osteotomized, a periosteal elevator is have remained viable for over 5 years and are generally not
used to dissect the body wall off the plastron preserving the removed. Often, the patch will fall off on its own; however if the
attachments of the pelvic or pectoral musculature. It may be borders become elevated from the plastron, the patch can be
difficult to bend the segment beyond 90 degrees and it may require pried off. In young growing chelonians, the patch is cut at the
an assistant to hold the segment up and out of the surgeon’s field growth rings after bone healing is complete to allow for shell
while the procedure is performed. There are two large venous growth. Because the epoxy is potentially carcinogenic, the cuts
sinuses within the coelomic membrane located paramedian on are best made under a hood or, at least, in a well-ventilated area
each side between the midline and the bridge (junction of the using a respirator mask. Copious irrigation will help prevent
plastron with the carapace). These are generally obvious during aerosolization of the toxic dust.
the intial approach but once manipulated, undergo vasospasm
and become relatively imperceptible. Care is taken not to damage Flank celiotomy is used in chelonians with a small plastron or
these vessels so when they dilate following closure, hemorrhage in tortoises with small cystic calculi or a small intestinal foreign
does not occur. It has been reported that they can be ligated body.3 With the animal in dorsal recumbency, the left hindlimb
without consequences.2,3 The incision into the coelom is made is pulled caudally exposing the inguinal depression. The skin
along the ventral midline. The membrane is thin and transparent is incised in either a longitudinal or transverse manner and the
in the central region where there is no muscle. muscles are bluntly separated until the coelomic membrane is
identified. The membrane is grasped with tissue forceps and
Closure is accomplished using a synthetic absorbable material incised to allow access to the coelomic cavity. Through this
in the coelomic membrane and body wall. The bone flap is approach the left lobe of the bladder can be accessed and
replaced and secured using epoxy resin and fiberglass cloth. with a digital exploratory, small intestinal foreign bodies can be
exteriorized. This approach has not been adequate for access
to the entire female reproductive tract for ovariosalpingectomy;
however, focal oviductal lesions may be approached through
the flank. A two or three layer closure is performed with the
coelomic membrane and muscle sutured either as separate
layers or together.
management have failed to relieve the dystocia or if there is absorbable material on a fine atraumatic needle in a two layer
evidence (such as radiographic) that the eggs are unable to pass inverting pattern or a simple continuous oversewn with an
because they are too large or of an abnormal shape. Ovariosal- inverting pattern. Following a properly performed salpingotomy
pingectomy is performed to treat dystocia or to prevent future the prognosis for reproductive viability is good.
problems related to the reproductive tract such as yolk coelo-
mitis, dystocia, and salpingitis. In cases where there is irreparable damage to the reproductive
tract or where the owner desires to prevent future episodes
Preovulatory egg stasis is characterized by the development of of dystocia, ovariosalpingectomy is performed. The following
yolks on the ovary that are not subsequently released. Postovu- discussion applies primarily to green iguanas. Other lizards and
latory stasis occurs when the eggs or feti are within the oviduct chelonians will have some variation in anatomy but the procedure
but do not pass normally. In either case, it is recommended that is similar. In snakes with their longitudinal configuration, the
the ovaries as well as the oviducts be removed.3 It appears that ovary is cranial to the oviduct and must be approached through a
if the oviduct is removed without removing the ovary, yolks will separate incision or by extending the celiotomy craniad until the
be released into the coelom potentially inducing yolk coelo- ovary is identified.
mitis. If the ovaries are removed and the oviducts left, they
simply atrophy and are unlikey to cause problems in the future. In iguanas, the right ovary is very close to the right external iliac
Removal of one side of the reproductive tract (unilateral ovarios- vein, while the left is more loosely attached with the left adrenal
alpingectomy) for treatment of reproductive disease allows the gland interposed between the left external iliac vein and the
patient to remain reproductively viable which may be important ovary (Figure 45-8). When the ovary is active, as with preovulatory
for herpetoculturists. egg stasis, the ligament is stretched out and it is easy to apply
hemostatic clips to the vessels supplying the ovary. Two clips are
The female reproductive tract is relatively mobile within the applied to each vessel and the vessel is transected between the
coelom. In lizards and chelonians it is readily accessible through clips. The process is continued until all vessels are clipped and
a standard celiotomy approach. In snakes, the tract is very the ovary with its multitude of yolk follicles is removed.
long and if the entire oviduct contains eggs or feti that must
be removed, it is often necessary to make several celiotomy
approaches. Generally, 3-5 eggs can be manipulated out of a
single salpingotomy incision.
When the ovary is not active, removal is more challenging. testicle and the external iliac vein (Figure 45-9). The adrenals are
Removal of the right ovary is accomplished by gently elevating elongated, granular, pink glands easily distinguished from the
the ovary, applying one or two clips between the right ovary and smooth, white testicles. The testicles are covered by a capsule
the right external iliac vein, then transecting the tissue distal to that can be ruptured during aggressive manipulation. Rupture of
the clip to allow removal of the ovary. The left ovary is removed the capsule does not result in hemorrhage but the contents flow
in a similar manner with the clips applied between the ovary and out making it difficult to continue with the dissection.
the left adrenal gland. The tissue distal to the clips is transected
allowing removal of the ovary without damaging the adjacent The testicles are removed in a manner similar to that described
adrenal gland. for removal of inactive ovaries. The right testicle is gently
elevated and one or two hemostatic clips are applied between
Following removal of the ovaries, the oviducts are removed. the testicle and the external iliac vein. The tissue distal to the
Dissection is initiated at the infundibulum and continued to the clips is transected allowing removal of the testicle. The left
cloaca. With preovulatory egg binding, the oviduct is empty and testicle is removed following application of hemostatic clips
vessels are easily controlled either with hemostatic clips or between the left adrenal gland and the testicle. If hemorrhage
bipolar cautery. One or two clips are applied to the base of each from the external iliac vein occurs, one or two hemostatic clip
oviduct at the cloaca prior to their transection and removal. are applied longitudinally along the damaged side of the vessel
to control hemorrhage (Figure 45-10). Partial occlusion of the
In cases of postovulatory egg binding where the oviducts are external iliac vein has not been associated with clinical disease;
full of eggs, the ovaries are relatively small and inactive as they however, if over half of the diameter of the external iliac vein is
have already released their yolks. The oviducts full of eggs will attenuated, signs of vascular obstruction might be anticipated.
obscure visualization of the ovaries and are removed prior to
ovariectomy. The vessels to the oviducts are generally engorged
and numerous. Each vessel is identified, two hemostatic clips are
Cystotomy
applied, and the vessel is transected between them. Dissection Urinary calculi can develop in any species of reptile that has
is initiated at the ovaries and continued caudad until the oviducts a urinary bladder but seem to occur most frequently in desert
can be ligated or clipped at the cloaca prior to transection. After tortoises (Gopherus agassizzii) and green iguanas. Improper
the oviducts are removed the ovaries are visualized as described nutrition and inadequate access to water or dehydration
above. The ovaries are removed as described previously. Closure have been suggested as initiating causes.3 Clinical signs of
is routine.
Orchidectomy
Castration is primarily performed in male green iguanas that have
become aggressive toward their owner.3 Castration has been
shown to decrease testosterone levels and sexually aggressive
behaviors in other lizard species.13-15 Most commonly, orchi-
dectomy is performed in iguanas after the aggressive behavior
has developed and it may be more appropriate to perform the
procedure in prepubertal iguanas before the inappropriate
behaviors have developed. When performed in an aggressive
animal, it appears that the aggression is not ameliorated until
the following breeding season. The prognosis for attenuation of
the behavior has anecdotally been reported to be around 50%
following orchidectomy.3
sides. Once the prolapse is reduced it is kept in place with a removal of the reproductive tract is recommended. If only one
purse string or transverse sutures in the vent. Transverse vent side of the reproductive tract is removed, the contralateral side
sutures have the benefit of allowing fecal and urinary wastes allows for reproductive viability.
to be passed more easily than through a purse string suture. In
squamate reptiles, a purse string can be placed in the vent at
the base of the tail (Figure 45-11). It is best to place a stent into
Other Procedures
the vent to prevent over-tightening allowing urine and feces to A variety of surgical procedures such as enterotomy for removal
pass while keeping the tissue in place. This technique allows for of foreign bodies may be performed in reptile patients once the
normal cloacal function.13 Regardless of the technique used the surgeon is familiar with the unique anatomy of and surgical
sutures are removed in 2 to 3 weeks. approaches used in reptile patients. Once the approach to the
celomic cavity is made, most procedures are analogous to those
If the tissue is necrotic or infected it should be amputated. performed in domestic animal surgery.
Amputation of the penis, hemipenis or both hemipenes will
not compromise urination. In snakes and lizards, amputation
of one hemipenis still allows reproductive viability.13 Mattress
References
1. Bennett RA: Reptilian surgery. Part I. Basic principles. Compendium on
sutures or encircling sutures are placed around the base of the Continuing Education Pract Vet 1989;11:10-20.
prolapsed tissue, and the organ is amputated distal to the suture
2. Bennett RA: Reptilian Surgery. Part II. Management of surgical diseases.
(Figure 45-12). The mucosa of the stump is sutured with a simple Compendium on Continuing Education Pract Vet 1989;11:122-133.
continuous pattern, and the stump is replaced into its normal
3. Mader DR, Bennett RA, Funk RS, Fitzgerald KT, et al. Surgery. In: Mader
anatomic location.
DR. Reptile Medicine and Surgery 2nd edition. Elsevier, St. Louis, Missouri;
581-630, 2006.
Prolapse of the oviducts has occurred in female reptiles.15
4. McFadden MS, Bennett, RA, Kinsel MJ, Mitchell MA. Evaluation of the
In some cases it is possible to reduce the prolapsed tissue; histologic reactions to commonly used suture materials in the skin and
however, the viability of the tissue and assessment of damage muscle of ball pythons (Python regis). Am J Vet Res 72 (10); 1397-1406,
to the suspensory ligament of the oviduct is limited.13 Amputation 2011.
of the exposed tissue has been performed but celiotomy for 5. Govett PD, Harms CA, Linder KE, et al. Effects of four different suture
complete assessment of the prolapsed tissue and repair or materials on the surgical wound healing of loggerhead sea turtles,Caretta
A B
C
Figure 45-11. A. Hemipenis prolapse in an Eastern Diamondback Rattlesnake (Crotalus adamanteus). B. The hemipenis is replaced into its normal
anatomic position with sterile lube and gentle manipulation with a sex probe. C. A mattress suture is placed in a portion of the vent to prevent the
hemipenis from everting but still allowing for passage of cloacla contents through the vent.
700 Soft Tissue
A B
Figure 45-12. A. and B. A common boa constrictor (Constrictor constrictor) with a chronic, healed, traumatic tail amputation and hemipenis prolapse.
Because the hemipenis prolapse was likely associated with the tail injury, a decision was made to amputate the hemipenis. A. The hemipenis from
the snake is being sutured with an encircling suture of 3-0 PDS. B. The hemipenis has been transected.
of surgical procedure, and detailed descriptions of commonly busy veterinary practices. This is typical of species that are
performed procedures: gastrotomy, cystotomy, ovariohyster- prey and they will hold off showing illness. The rabbit should
ectomy, orchiectomy (castration), and vasectomy. Because be examined in a quiet setting and therefore, each animal
each procedure occurs within the abdominal cavity (castration must have a complete presurgical workup including physical
may also be performed outside the abdominal cavity), several examination, history, and, if possible, complete blood count and
areas are common to all and warrant discussion beforehand: urinalysis. Diet, eating habits, and volume or consistency of
a review of the unique properties of rabbit skin, preoperative fecal production are important items to be addressed. Clinical
considerations, guidelines for preparation of the surgical area, or subclinical problems, such as dehydration or emerging septi-
general surgical principles particular to the rabbit, and useful cemia, should be corrected before any surgical procedure, to
suture patterns for closure. maximize the potential for a successful outcome. Because
rabbits cannot vomit, withholding of food and water before the
surgical procedure is not necessary, although 2 to 3 hours of
Anatomy of the Skin fasting will clear the oral cavity, and may decrease the ingesta
Except for some of the heavy skinned rabbit breeds whose pelts within the stomach, intestines, and in particular, the cecum.
are used in the fur trade, a rabbit’s skin is thin relative to body Assessment of pain requires astute observation. Signs of pain
size.1 The full thickness of the skin, including the hypodermis and include reluctance to move, sitting in a stiff, hunched posture,
panniculus carnosus, is generally only 1.0 to 2.0 mm thick. Except rapid, shallow respiration, and tensing upon palpation. An
for the tip of the nose and the inguinal region (in both sexes) and elevated rectal temperature may indicate pain, stress, inflam-
a small area on the scrotum in bucks, a rabbit’s skin is covered mation or infection.
with fine textured hair, and both underfur and guard hairs are
present. Rabbits generally molt their hair coats annually, with hair As in other species, prophylactic antibiotics may be used in
loss starting on the shoulders and moving caudally. Frequently, rabbits undergoing surgical procedures. Because of the predom-
patterns and rates of hair growth and regrowth (where the inance of gram-positive bacterial flora in the rabbit gastroin-
hair has been clipped for a surgical procedure) do not appear testinal tract, especially the cecum, any antibiotic that affects
uniform; this is often a concern of clients. After the rabbit’s hair those populations, such as oral penicillins, cephalasporins,
has been clipped, it may not begin to grow back uniformly and macrolides, and tylosin, should be avoided. Antibiotics, such
may look patchy, with some areas of hair longer and appearing to as trimethoprim sulfa combinations, or fluorinated quinolones
grow faster than others. This unusual, seemingly abnormal skin such as enrofloxacin, given either individually or together, can
coat can be more pronounced in young, white animals when the be used effectively with minimal side effects. These drugs are
hair on the animal’s flank has been removed. It does, however, generally started the day before surgery, or they are adminis-
represent normal skin responses to variations in rabbit hair tered at induction of anesthesia and are maintained for 3 days to
growth cycles. The raised, blotchy patches are areas of active ensure adequate blood levels should unexpected contamination
hair growth. Beginning with the second coat of hair, waves of hair occur during the surgical procedure. Clostridial overgrowths
growth periodically move caudally and ventrally from the neck can occur in rabbit ceca and large intestine if the diet has been
region. These “growth waves” occur in areas of the skin where high in carbohydrates and sugars when using fluoroquinolone
all the hair follicles are simultaneously in an active growth cycle. antibiotics alone. Fluoroquinolones are not effective against
Owners should be informed of this when the rabbit is discharged clostridial infections. If clostridial populations are suspected due
from the veterinary clinic. to diet or detection of spores on fecal gram stains, metronidazole
may be added to the antibiotic regimen. In the healthy rabbit,
The hair growth cycle has been divided into three main phases: cecoliths are ingested and a few make it through the acidic
anagen, catagen, and telogen. The anagen, or growing, phase, is stomach to the cecum to replenish the cecal flora. During illness
the time when the germ cells undergo a burst of mitotic activity, or antibiotic therapy, this process is interrupted. Orally admin-
leading to the formation of the sheathed hair bulb and papillary istered probiotics may not survive transit through the stomach
cavity and emergence from the skin surface. The catagen, or and small intestine. The colon and large intestine of the rabbit
transition, phase is a brief period in which mitotic activity slows sorts materials by particle size. Particles greater than 2 mm are
and the follicle shortens. The hair then passes into the telogen passed into the colon and rectum to form fecal pellets. Smaller
phase, which is a resting period. Changes in the vascularity and particles are moved back to the cecum via retroperistalsis. Thus
thickness of the skin are associated with these phases of the probiotics administered in small quantities rectally may actually
hair growth cycle. The skin thickness is approximately 1.0 mm be moved back to the cecum to enable the rabbit to reestablish
during the telogen phase and may become 2.0 mm thick during normal flora. An enema of healthy rabbit cecoliths is advanta-
the anagen period. As rabbits become older, the waves become geous when administered to rabbits with anorexia and diarrhea
less frequent and more patchy in their distribution. post operatively. In addition, administration of fluids and gastro-
intestinal motility stimulants such as metoclopromide may be
Preoperative Considerations indicated to enhance intestinal tract motility postoperatively.
Normal rabbit behavior and activity are typically sedentary, and Since anesthesia and opiate analgesics may slow gastrointes-
stoic, but nervous or wary of their environment when compared tinal motility, use of motility stimulants will often speed recovery
with dogs and cats. As such, they may have preexisting health of normal intestinal motility. The rabbit should be encouraged to
problems that may not manifest themselves clinically to their eat soon after surgery.
owners and can be easily overlooked preoperatively in today’s
702 Soft Tissue
as soon as possible following surgery. Rabbits normally have a posture, tense abdomen, hypothermia, and bloating. Although defin-
small amount of ileus in the postoperative period, and the return itive diagnosis of trichobezoar cannot be made without surgical
to voluntary food and water consumption helps to prevent this exploration, a tentative diagnosis can be made based on history,
occurrence from becoming deleterious. Offering the animals clinical signs, palpation of an abdominal mass in the vicinity of the
hay, either grass or timothy, usually stimulates reluctant animals stomach, and contrast radiography, especially with fluoroscopy.
to eat immediately. Critical Care (Oxbow Pet Products, Murdock Care should be taken when palpating the upper abdomen because
NE) can be used to encourage eating, by assist-feeding it directly the liver in these animals is often friable.
orally. Many pet rabbits will begin to eat when hand-fed and
encouraged by nursing care. If the animal returns to near normal Rabbits with trichobezoars are frequently dehydrated and
behavior, especially regarding food and water consumption, cachectic and should be treated as medical emergencies. Initial
and normal urination, and defecation within 24 hours of the efforts should be directed at reestablishing normal homeostasis,
procedure the surgeon can send it home. To help facilitate a including aggressive parenteral fluid administration before defin-
successful outcome, the owner should perform as many health itive therapy is pursued. Initial medical therapy involves the admin-
monitoring techniques as possible, especially monitoring body istration of intravenous or subcutaneous fluids, oral electrolyte
temperature, incision site, food and water intake, urination and fluids, and assist-feeding of a fiber-rich formula such as Oxbow’s
defecation (volume and consistency), movement, and overall Critical Care. Fluids such as fresh pineapple juice or crushed
attitude. Owners appreciate participating in the rabbit’s postop- papain tablets in water are promoted in many publications, but
erative care and in becoming more aware of their pet’s health. other than the fluid content, and possibly the sugar content of the
A return progress visit should be scheduled for 3 to 5 days pineapple juice, these have not been shown to dissolve or break-up
following major surgery. a trichobezoar. These fluids should be given in small amounts (10
to 20 mL) four to six times a day for up to 3 to 4 days. Often, this oral
fluid administration both “refloats” the hair mass in the stomach
Common Surgical Procedures and aids in quickly rehydrating the animal. Refloating allows the
The common surgical procedures performed in the peritoneal proteolytic enzymes and stomach acids to penetrate the trichob-
cavity are discussed in this section. The techniques presented ezoar and to begin digesting the hair. The fiber-rich roughage is
focus on procedures that I believe can be easily learned necessary to encourage gut motility. A valuable tool in assessing
and are usually successful. No attempt is made to discuss all the efficacy of medical treatment is the production of fecal pellets in
available surgical techniques. In addition, the description of increased quantities. Radiographs are useful in assessing the size
each technique begins as if the surgeon had already opened the of the trichobezoar and its movement. Barium as a contrast agent
abdomen as discussed previously. must be used cautiously in animals that depend on cecal digestion.
If the cecum becomes coated with barium, crucial metabolism and
Gastrotomy gut flora will be altered. Because of this, the author does not utilize
Rabbits are hindgut fermenters and have a simple, glandular contrast studies in rabbits with gastrointestinal motility disorders.
stomach. The stomach serves as a reservoir for most of the
ingested food, and it is never completely empty in a healthy animal. Other medical treatment strategies for treating trichobezoars,
The stomach acids in the rabbit are among the most acidic of those formerly a strictly surgical condition, have been successful in
of any species, with a pH of 1.2 to 1.5. This high acidity enables recent years, including the use of metoclopramide.4,8-10 These
rabbits to use plant proteins more efficiently than most mammals newer regimens have reduced the number of animals that
and normally minimizes problems with ingested hair. ultimately require surgical treatment. As a general rule, if no
improvement is seen with medical therapy for trichobezoars after
Unlike other species with incessant grooming behaviors, such as 3 days, these animals become surgical candidates for an explor-
cats, rabbits physiologically cannot vomit.Consequently, ingested atory gastrotomy. Animals presented for gastric foreign bodies
foreign materials, especially hair, which would normally induce other than trichobezoar are surgical candidates for gastrotomy
a protective emetic reflex in other species, have the potential to (Figure 45-14). All animals having a gastrotomy are given prophy-
become life threatening obstructions, unless sufficient roughage lactic antibiotics, as previously mentioned, which are generally
is present from the diet, and the rabbit is active, continually well- maintained for 5 to 7 days. Postoperatively, these rabbits resume
hydrated, and maintains normal gut motility. Additional predis- food and water consumption as soon as possible. I recommend
posing factors in creating an obstructing trichobezoar may include maintaining these rabbits in the hospital for several days until they
boredom-associated over-grooming or ingestion of carpet/clothing return to normal eating, drinking, and defecating.
fibers or other linear-type fabric strings, inadequate dietary
roughage, anorexia because of off flavor or off odor feed, inability Orchiectomy (Castration)
to smell from rhinitis, pain from sore hocks, malocclusion, lack of Orchiectomy (castration) is one of the most common surgical
fresh water, or other stress factors. Once gastrointestinal motility procedures performed in companion rabbits. The usual indica-
is altered the rabbit may stop eating and drinking, and critical tions for removing testicles are for birth control or to modify or
metabolic problems can result if this problem is not corrected.4,7-13 eliminate certain offensive behaviors intact male rabbits (bucks)
often develop when they reach sexual maturity. These behaviors
Common presenting complaints include anorexia, lethargy, weight include: urine spraying, territory marking with both urine and
loss, oligodipsia, diarrhea, or conversely, small or scant, dry feces. feces, and aggression toward their owners or other rabbits.
Other frequent clinical signs are dehydration, depression, hunched
Surgical Techniques in Small Exotic Animals 705
Figure 45-14. A. The animal is placed in dorsal recumbency, and the surgical site draped from 4 cm anterior to the xiphoid cartilage to 5 cm
caudal to the umbilicus. A midline skin incision is made extending from 2 cm cranial to the xiphoid cartilage to 3 cm caudal to the umbilicus. Using
thumb forceps and Metzenbaum scissors, the incision is continued through the linea alba through the muscle fascia layer into the abdomen. The
surgeon must identify and avoid cutting the xiphoid cartilage when cutting the muscle cranially. When reaching the caudal edge of the xiphoid,
the surgeon redirects the scissors and continues cutting the muscle along the edge of the cartilage for the remaining 2 cm. Both sides of the
abdominal incision are lined with moistened laparotomy sponges. Exposure is maximized by placing pediatric self retracting Balfour abdomi-
nal retractors just caudal to the xiphoid. The two fenestrated retractor blades are spread laterally, and the xiphoid cartilage is elevated gently
with the center Balfour blade to visualize the stomach, the cecum, and portions of the small intestine. B. Two stay sutures are placed 5 to 6 cm
apart midway between the greater and lesser curvature of the stomach in a visibly avascular area. The sutures are lifted in opposite directions
to elevate the stomach out of the abdomen and to provide a taut area for entering the stomach. The surgeon packs off the elevated portion of
the stomach from the rest of the abdomen with moistened laparotomy sponges. Waterproof drapes are placed over the laparotomy sponges to
prevent abdominal contamination from gastric contents when the stomach is opened. In addition, separate instruments should be available for
entering and closing the stomach. A stab incision is made with a scalpel into the stomach.
706 Soft Tissue
Figure 45-14 (continued). Suction is used to prevent accidental spillage of gastric juices onto the stomach serosal surface. This incision is
extended as needed with a scalpel or with Metzenbaum scissors until a desired opening is achieved. C. The stomach contents are examined. If a
trichobezoar is present, the hair mass is broken up and is removed with a pair of dressing forceps. The stomach is lavaged with warm saline so-
lution and is suctioned. All instruments involved with entering the stomach are discarded. The surgeon should reglove, change or discard drapes,
and begin closing the stomach with clean instruments. D and E. Closure of the stomach is accomplished with two inverting suture patterns using
3-0 polyglactin 910 or polydioxanone on a tapered needle. The first layer is a Connell pattern followed by a Halsted oversew. When performing
the Connell pattern, full thickness bites should be placed from the edges of the incision, and the anchoring knots should be placed 2 to 3 mm
from the incision at both ends. F and C. The second layer is closed using a Halsted suture pattern, which further inverts the incision and helps to
ensure a complete seal. Each suture should be preplaced before being tied, to provide for even tissue inversion and tension distribution. Once
the second layer is completed, the closure is checked for any leakage. The abdominal cavity should be lavaged with warm saline and suctioned if
one sees evidence of gastric spillage. The stomach is returned to its normal anatomic position, and the abdomen is closed routinely.
Surgical Techniques in Small Exotic Animals 707
Although not a panacea, castrating bucks generally makes them Healx Soother (Harrison’s Pet Products, West Plam Beach, Fl).
more docile, reduces fighting, and diminishes urine spraying. Post-operative analgesics and NSAIDS are continued for 2 to
Other indications for castration are related to scrotal injury, 4 days. With gentle tissue handling, the scrotum is not bruised
including trauma from fighting or severe urine scalding.4 or irritated, and with systemic pain control, most bucks seem
unaware of the surgery.
Male rabbits have two separate scrotal sacs, rather than one, as
found in other placental mammals. These hairless structures lie An abdominal castration technique has also been described, and
slightly cranial to the penis. The testes are found in the abdomen although it avoids the potential trauma to the scrotal or penile
at birth and descend into the scrotal sacs at approximately 3 area, it does require post-operative use of a cervical collar and
months of age. Bucks reach sexual maturity between 4 and 5 is more invasive. This method must be used in cryptorchid bucks
months of age, depending on the breed of rabbit. Dwarf breeds (Figure 45-15).
mature more quickly than giant breeds. Castration is usually
performed after the testicles descend. In addition to their peculiar When the animal is discharged from the clinic the owners must
scrotal anatomy, rabbits have open inguinal canals that allow be advised that the desired effects of castration are not instan-
the testicles to move easily between the scrotal sacs and the taneous. Although the animal’s testicles have been surgically
abdomen.8 In intact bucks, epididymal fat, which lies cranial and removed, male hormone levels have not been eliminated. Urine
medial to the inguinal canal on each side is normally inhibited spraying, territory marking, and aggression may continue for a few
from entering the scrotal sac by each testicle. Because this fat weeks. In addition, libido and probably viable sperm (remaining in
lies on the abdominal side of the inguinal ring, it, in turn, inhibits the vas deferens) are present for a month, and thus the potential
intestinal herniation through the canal. Castration techniques for impregnating intact females does exists during that time.
involving incision of the scrotal sac and removal of the testicle
could potentially lead initially to epididymal fat herniation and, Cystotomy
subsequently, herniation of the intestine into the scrotum unless
the inguinal canal is closed surgically following castration. Urinary calculi (urolithiasis) are commonly encountered in
clinical practice in pet rabbits, particularly in rabbits on an
alfalfa-based pelleted diet. A healthy adult rabbit produces an
Most of the techniques described for castrating male rabbits
average of 130 mL/kg of urine each day; this urine is usually
are adaptations of techniques used in dogs and cats: scrotal
turbid and varies in color from white to yellow to brown to orange
approach open castration with incised tunica albuginea and
to bright red.8-11,14-16 The turbidity of the urine is due primarily to
preservation of the epididymal fat; scrotal approach closed
mineral precipitates. Because urine is the primary route for
castration without incising the tunica albuginea; and the
calcium and magnesium excretion in rabbits, various crystals,
prescrotal approach over the inguinal rings with inguinal
including ammonium magnesium phosphate, calcium carbonate
ring closure.4,6,10,12 From experience, each technique is easily
monohydrate, and anhydrous calcium carbonate precipitates,
learned and has minimal complications. However, the scrotal
are normally found on urinalysis.8 The wide spectrum of colors
perineal area can be traumatized or irritated either by the
and intensity is related to dietary pigments and the animal’s
surgical procedure or by surgical preparation using any of these
hydration status; higher alkalinity and dehydration are usually
techniques. This trauma or irritation potentiates iatrogenic injury
associated with brighter, more intense colors.8 The etiology of
and the opportunity for subsequent bowel herniation or infection.
urolithiasis is still not clear, but several predisposing factors
Pre-surgical scrubbing should be gentle and the author prefers
have been proposed, including urine stasis, genetic predis-
the use of chlorhexidine-based surgical scrubs delivered with
position, dietary imbalances or diets high in calcium such as
cotton rather than gauze, and irrigated with sterile saline rather alfalfa-based diets and concurrent hypercalcemia), chronic
than scrubbed. The rabbit is positioned in dorsal recumbency urinary tract infections, and inadequate water intake.8,9,14 Normal
with the thorax elevated. The incision is made on the midline urine pH in rabbits is around 8.2, but at 8.5, calcium carbonate
just cranial to the scrotal sacs and penis. The incision should be and phosphate crystals precipitate. Urine sludge is frequently
as small as feasible (1-2 cm in length) to allow protrusion of the seen and may or may not exacerbate the formation of calculi.
testicle. Ligation of the testicular vasculature is the same as in The sludge itself can be irritating to the mucosa of the bladder
other species. For most bucks, a single suture applied through and urethra, and add to the discomfort of the rabbit, reluctance
the inguinal ring and through the spermatic cord is adequate for to urinate, and with urine retention, increase the probability of
hemostasis and closure of the inguinal ring. In this manner, the ascending infection and stone formation. The most common
inguinal ring is closed, and no herniation can occur. The incision presenting complaint in rabbits with urolithiasis is hematuria. As
in the scrotum can be closed with a drop of tissue adhesive. The mentioned previously, rabbit urine may be any of several colors,
procedure is repeated on the opposite side. The use of manual depending on urine pH and diet. Diets high in calcium, such as
pressure to elevate each testicle may cause bruising of the alfalfa, can cause the urine to become bright red orange to red.
scrotal tissue, and therefore is not recommended. After both Hematuria should, therefore, be confirmed by urinalysis or urine
testicles have been removed, and the incisions glued, the author dipstick. This condition is often diagnosed after the animal has
applies a topical anesthetic lidocaine gel to the scrotal tissue. been presented for other problems. Hematuria was reported
Recently, the author has been applying Penetran ointment to as the chief complaint in only one of seven rabbits with urinary
the surgical area. This is an organic ammonia-based ointment calculi.10 Other signs may include polyuria, perineal irritation
that decreases pain and inflammation. It is absorbed into the from urine scalding, stranguria, lethargy, anorexia, hunched
skin completely so there is no residue for the rabbit to ingest. posture, abdominal distension, and chronic or intermittent
708 Soft Tissue
Figure 45-15. Abdominal orchiectomy (castration). A. The animal is placed in dorsal recumbency, and the surgical site is draped off to include
the scrotum and penis. A midline skin incision is made extending from 5 cm caudal to the umbilicus to the level of the pelvis or 2.5 cm anterior
to the genitalia or to the level of the last set of nipples. B. Using a pair of thumb forceps and Metzenbaum scissors, the incision is continued
through the linea alba through the muscle fascia layer into the abdomen, exposing the ventral surface of the bladder. C. The apex of the bladder
is grasped with a pair of Babcock (or other atraumatic) forceps and is reflected caudally, exposing the dorsal aspect of the bladder. D. Further
gentle caudal retraction of bladder with Babcock forceps exposes the two vasa deferentia emerging near the base of the bladder. E. Removing
the testicle involves performing the two procedures almost simultaneously: each vas deferens is gently retracted cranially (either with a spay
hook or manually) while one gently pushes the testicle (often located within the scrotal sac) through the inguinal canal into the abdomen. F. This
retraction continues until the entire testicle and blood supply are removed from the scrotal sac. These procedures are repeated for the other
testicle. A ligature is placed around both vasa deferentia and their associated blood supply near the base of bladder. A second ligature is then
placed between the head of the epididymis and its scrota attachment (at the vaginal tunic). The testicle can now be removed by cutting above
both ligatures. After removal of both testicles, each side of the invaginated scrotal sac and its associated epididymal fat is pushed back to its
normal position. The bladder is returned to its anatomic position, and the abdomen is closed routinely.
Surgical Techniques in Small Exotic Animals 709
Figure 45-16. Cystotomy. A. With the animal placed in dorsal recumbency, a midline skin incision is made extending from a point 5 cm caudal to
the umbilicus to the level of the pelvic brim. B. Using Metzenbaum scissors and forceps, the incision is continued through the thin linea alba and
through the muscle fascia layer into the abdomen, exposing the ventral surface of the bladder. C. The apex of the bladder is grasped with a pair
of Babcock (or other atraumatic) forceps and is reflected caudally, exposing the dorsal side of the bladder. The bladder is then isolated from
the abdomen with moistened laparotomy pads. Then, using 3-0 polyglactin 910 or polydioxane suture on a taper needle, two retention sutures
are placed 3 cm apart in an avascular location of the bladder. The bladder is then emptied by cystocentesis using a 25 gauge needle on a 20 mL
syringe in a visibly avascular area of the fundus of the bladder. D. Lifting both retention sutures in opposite directions further elevates the bladder
out of the abdomen and provides a taut area between them for entering the bladder. A stab incision is then made into this taut area with a scal-
pel. This incision is then extended cranially and caudally with Metzenbaum scissors. E. The bladder incision is then spread to allow inspection of
the bladder contents. Any urinary calculi are removed with forceps or irrigation and suction. A specimen of bladder mucosa may be obtained for
culture. F. The bladder is then closed in two layers using 3-0 polyglactin 910 or polydioxanone suture on a taper needle. The first layer is a Cush-
ing suture pattern which inverts the suture line when completed. The suture should not penetrate the lumen of the bladder. G. The second layer
is closed using a Halsted suture pattern, which further inverts the incision and helps to ensure a complete seal. Each suture should be preplaced
before being tied, to provide for even tissue inversion and tension distribution. Once the second layer is completed, the closure is checked for
any leakage. The bladder is returned to its normal anatomic position, and the abdomen is closed routinely.
710 Soft Tissue
Figure 45-17. Vasectomy. A. With the animal placed in dorsal recumbency, a midline skin incision is made extending from 5 cm caudal 9 to the
umbilicus to the level of the pelvis or 2.5 cm cranial to the genitalia or to the level of the last set of nipples. B. Using a pair of Metzenbaum scis-
sors and forceps, the incision is continued on the linea alba through the muscle fascia layer into the abdomen exposing the ventral surface of the
bladder. C. The apex of the bladder is grasped with a pair of Babcock (or other atraumatic) Orceps forceps and is reflected caudally, exposing the
dorsal aspect of the bladder. D. Further gentle caudal retraction of the bladder with the Babcock forceps exposes the two vasa deferentia emerg-
ing near the base of the bladder. E. A ligature is placed around each vas deferens with care taken not to include the adjacent associated blood
vessels. Each ligature is retracted to allow more exposure of each vas deferens for placement of second ligatures approximately 3 mm from the
first F. Each vas deferens is divided between the two ligatures with Metzenbaum scissors to complete the vasectomy. The bladder is returned to
its normal anatomic position, and the abdomen is closed routinely.
Surgical Techniques in Small Exotic Animals 711
Figure 45-18. Ovariohysterectomy. A. With the animal placed in dorsal recumbency, a midline skin incision is made extending from the umbilicus to
the level 2 cm caudal to the last pair of nipples. Using Metzenbaum scissors and forceps, the incision is continued through the linea alba through
the muscle fascia layer into the abdomen, exposing small portions of cecum, small intestines, uterine horns and the bladder (if distended). Gentle
retraction of the cecum laterally exposes the uterus. B. The bladder is retracted caudally with Babcock forceps to aid in visualizing the cervix and
vagina. Using either Balfour or malleable retractors, the surgeon spreads the abdominal incision to aid in exposing the complete reproductive
tract. C and D. Retracting the uterus caudally helps to expose the complete reproductive tract vagina, cervix, two uterine horns, both fallopian
tubes and ovaries, and the major blood supplies. With moistened cotton tipped applicators, the fat is dissected gently to expose the abdominal
aorta and the two ovarian arteries. Each ovarian artery is followed to the point where it branches to the ovary and the rest of the uterus. The
surgeon places two ligatures around the vessel 3 mm apart above the branching and transects between them. The ovary is elevated, and the
suspensory ligament identified and cut. The long fallopian tube and uterine horn are bluntly dissected from the broad ligament to the level 5 mm
above the cervix, with care taken to control any hemorrhage from the many small vessels within the broad ligament supplying the uterine horn.
This process is repeated on the opposite side.
712 Soft Tissue
Figure 45-18 (continued). E. Continuing (with the uterus reflected caudally), the cervix is identified and is palpated to identify its anatomy. Kelly
forceps are placed 4 mm apart on the uterus just below the cervix. Using 3-0 absorbable suture on a taper needle, a transfixion suture is started
midway between the clamps. The transfixion ligature is completed, and the uterus is transected below the most distal clamp from the cervix with a
scalpel. The uterine stump is examined for hemorrhage and is allowed to retract into the abdomen. The bladder is returned to its normal position,
and the abdomen is closed routinely.
on timothy or grass hays, along with increased fluid intake, and transgenic animals. Bucks that have undergone vasectomy are
appropriate NSAIDS and antibiotics if indicated will usually used to induce ovulation in embryo recipient does at the same
prevent recurrence of calculi. However, some rabbits may have time as the embryo donor female is mated to an intact male.17 As
a genetic predisposition to calculi formation, and despite correc- previously suggested in the discussion of orchiectomy, bucks that
tions of dietary calcium levels, correcting any hypercalcemic have undergone vasectomy should be separated from intact does
conditions, and adequate fluid intake and exercise, some rabbits for at least 30 days postoperatively to prevent possible pregnancy
repeatedly form calculi. Affected animals should be periodically resulting from viable sperm remaining in the vas deferens.
monitored radiographically for recurrence.10
Ovariohysterectomy
Vasectomy Ovariohysterectomy (OVH) is a commonly performed procedure
Vasectomy is generally performed on male rabbits for birth control in small animal practice and involves the surgical removal of the
purposes only.12 However, unlike castration, the adverse side ovaries, fallopian tubes and the uterus. Performing an OVH on
effects of an intact buck remain, including libido, urine spraying, female rabbits (does) is similar to the procedure performed on
aggressiveness, and hormonal urge to mark territory with urine dogs and cats and only requires a knowledge of the anatomic
and feces. The technique involves resection of a portion of each differences of rabbits for the procedure to be adapted. One major
vas deferens just cranial to the bladder after a midline laparotomy difference is that rather than having two uterine horns, a uterine
(Figure 45-17). This surgical technique is currently gaining more body and one cervix (uterus bicornis bicollis) as in dogs and cats,
use in biomedical research because of interest in producing rabbits have two uteri, each opening into the vagina through
Surgical Techniques in Small Exotic Animals 713
a separate cervix (duplex uterus) and no uterine body. These rodents. 3rd ed. Philadelphia: Lea & Febiger, 1989:86 90.
anatomic peculiarities, at first glance, appear to complicate the 10. Hillyer EV. Pet rabbits. Vet Clin North Am Small Anim Pract
traditional OVH surgery techniques taught for cats and dogs 1994;24:25 65.
where excision of the uterus is completed at the level of the 11. Stein S, Walshaw S. Rabbits. In: Laber Laird K. Swindle MK Flecknell
uterine body. Carefully placing a transfixion ligature just anterior P, eds. Handbook of rodent and rabbit medicine. Tarrytown, NY: Elsevier
to the cervix (analogous to placement in the uterine body of a Science, 1996:219 237.
dog or cat), however, enables the complete removal of the doe’s 12. Swindle MM, Shealy PM. Common surgical procedures in rodents
reproductive tract (Figure 45-18). and rabbits. In: Laber Laird K, Swindle MM, Flecknell P, eds. Handbook of
rodent and rabbit medicine. Tarrytown, NY: Elsevier Science, 1996:239-254.
Like cats, rabbits are induced ovulators with ovulation occurring 13. Wagner JL, Hackel DB, Samsell AG. Spontaneous deaths in rabbits
10 to 13 hours following copulation or after orgasm induced resulting from gastric trichobezoars. Lab Anim Sci 1974;24:826.
by another doe.8,10 The gestation period is from 30 to 32 days. 14. Garibaldi BA, Fox JG, Otto G, et al. Hematuria in rabbits. Lab Anim
Female rabbits normally reach sexual maturity at 4 to 5 months, Sci 1987;37:769
but it is best to wait until they reach at least 6 months of age 15. Kozma C, Macklin W, Cummins LM, et al Anatomy, physiology, and
before performing an OVH. Indications for performing OVH in biochemistry of the rabbit. In: Weisbroth SH, Flatt RE, Kraus AL, eds. The
rabbits are: (1) to prevent or treat uterine adenocarcinoma (a biology of the laboratory rabbit. New York: Academic Press, 1974:62-63.
very common neoplasia found in 50 to 80% of does over the age 16. Kraus AL, Weisbroth SH, Flatt RE, et al. Biology and diseases
of 3); (2) to correct repeated false pregnancies; (3) to prevent of rabbits. In: Fox JG, Cohen BJ, Loew FM, eds. Laboratory animal
pregnancy; (4) to treat pyometra or uterine hyperplasia; (5) to medicine. San Diego: Academic Press, 1984:207.
modify aggressive behavior and biting; and (6) to decrease 17. Robl JM, Heideman JK: Production of transgenic rats and rabbits.
urine spraying.4,8,10-12 Timing of the OVH may vary as puberty and In: Pinkert CA, ed. Transgenic animal technology. New York: Academic
seasonality varies with breed of rabbit and whether or not it is Press, 1994:265 277.
kept indoors or outside. Owners must be aware that cessation
of some of the behaviors associated with estrus will not subside
instantaneously, but may take place over several weeks. Owners Suggested Readings
are advised to launder any bedding, clean the cage well before Flecknell P (ed). Manual of rabbit medicine and surgery. British Small
returning the rabbit to its environment as urine scents and phero- Animal Veterinary Association, Quedgeley, UK. 2000.
mones may still be present in the environment. Environmental Harcourt-Brown F. Textbook of rabbit medicine. Oxford, UK. Butterworth
pheromones may trigger undesirable behaviors. As mentioned for Heinemann, 2002.
other abdominal surgeries, adequate pain control post surgery is Hernandez-Divers, SJ. Rabbits. In: Carpenter JW, eds. Exotic animal
critical to keeping the rabbit from opening the surgical incision. I formulary, third edition. St. Louis, MO, Elsevier Saunders. 2005:407-444.
(CJD) prefer to schedule a recheck incisional appointment 7 to 10 Okerman L. Diseases of domestic rabbits second edition. Osney Mead,
days postoperatively to ensure the incision has healed appropri- Oxford UK, Blackwell Science. 1998.
ately and to remove skin sutures if used. O’Malley B. Rabbits. In Clinical anatomy and physiology of exotic
species. Edinburgh, UK. Elsevier Saunders, 2005:173-195.
Quesenberry KE, Carpenter JW. Ferrets, rabbits, and rodents clinical
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3. Wixson SK. Anesthesia arid analgesia. In: Manning PJ, Ringler DH, Denver, CO: American Animal Hospital Association, 1993.
Newcomer CE, eds. Biology of the laboratory rabbit 2nd ed. San Diego: Kaplan HM, Timmons EH. The rabbit: a model for the principles of
Academic Press, 1994:87 109. mammalian Physiology physiology and surgery. New York: Academic
4. Jenkins JR. Soft tissue surgery and dental procedures. In: Hillyear EV, Press, 1979:137 142.
Quesenberry KE, eds. Ferrets, rabbitsand rodents: clinical medicine and Sebesteny A. Acute obstruction of the duodenum of a rabbit following
surgery. Philadelphia: WB Saunders 1997:227 239. the apparently successful treatment of a hairball. Lab Anim 1977;l
5. Crowe DT Jr, Biorling DE. Peritoneum and peritoneal cavity. In: Slater 1:135.
D, ed. Textbook of small animal surgery. 2nd ed. Philadelphia: WB Sedgewick CJ. Spaying the rabbit. Mod Vet Pract 1982;63:401.
Saunders, 1993:413 415.
6. Hoyt RF Jr, DeLeonardis J, Clements S. et al. Post operative use
of adjustable cervical collars in rabbits. Contemp Top Lab Anim Sci
1994;33:822.
7. Gillett NA Brooks DL, Tillman PC. Medical and surgical manage.ment
of gastric obstruction from a hairball in the rabbit. J Am Vet Med Assoc
1983;183:1176-1178.
8. Harkness JE. Rabbit husbandry and medicine. Vet Clin North Am
Small Anim Pract 1987;17:10l9 1044.
9. Harkness JE, Wagner JE. The biology and medicine of rabbits and
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Part II
Bones and Joints
716 Bones and Joints
Section K
Axial Skeleton
Chapter 46
Skull and Mandible
Surgical Repair of Fractures Figure 46-1. Lateral image of the canine mandible. A. mental foramina,
Involving the Mandible and B. angular process, C. condylar process, D. coronoid process.
Figure 46-2. Image A depicts the typical muscle forces associated with a caudo-ventral mandibular fracture. The dashed line represents the
fracture line. The arrows represent the pull of the muscles. Note the subsequent displacement that would occur as a result. Image B illustrates
the beneficial effects exerted by the muscles of the jaw when dealing with a caudo-dorsal mandibular fracture. The pull of the muscles will result
in a natural compression of the fracture.
cool and restricted as heat dissipation via panting is compro- above will apply to sizing of pre-fabricated muzzles. One of
mised. Placement of a tape muzzle is seldom a viable option for the drawbacks to muzzles is their propensity to cause a moist
brachycephalic dogs and cats. dermatitis. This typically resolves without complications once
the muzzle is removed.
To place a tape muzzle simply cut a length of the appropriate
size tape to go around the muzzle of the patient (Figure 46-4A). Bonding of the mandibular and maxillary canine teeth (Figure
The “sticky” side of the tape should be up. A spacer (a pencil or 46-5) is a conservative repair technique that may result in less
a pen) should be placed between the upper and lower incisor morbidity than stabilizing the fracture with a tape muzzle. In
teeth to ensure that a small gap is present after the tape muzzle order for this technique to be successful, it is necessary for
is applied. This gap is not large enough to jeopardize proper all canine teeth to be present and healthy. These teeth must
alignment, but is sufficient to enable the patient to lap fluid or first be cleaned, pumiced, and acid etched. The acid etching
gruel. The next piece of tape is placed behind the neck and along allows the bonding agent (acrylic) to adhere more reliably to the
both sides of the muzzle (Figure 46-4B). This piece of tape is also teeth. The teeth are then aligned with the mouth open enough
placed with the “sticky” side up. The ends of the tape on both to allow for drinking and eating as described above and the
sides should extend past the nose for an equal distance to that acrylic is then applied. If the patient is unlikely to eat due to the
from the nose to the middle of the patient’s back. The third piece severity of trauma or an inability to lap food, a temporary esoph-
of tape is placed “sticky” side down around the muzzle. Then agostomy tube should be placed. After application, any rough
the long ends of the second piece can be folded back onto itself. or sharp edges of the acrylic are smoothed with a dental burr.
A caudo-ventral mandibular support strap may also be incor- The fixation is removed with a dental burr once the fracture has
porated if desired (Figure 46-4C). It is strongly recommended healed. Although application is easy, this conservative option
to apply a tape muzzle under heavy sedation or anesthesia. An will require two anesthetic events and the risk of anesthesia
alternative to a tape muzzle is a pre-fabricated restraint muzzle. should be weighed against the benefits of intraoral bonding in
This can be conveniently swapped out with another muzzle each individual patient.
and washed periodically. The same considerations mentioned
A B
C
Figure 46-4. Image A. depicts the placement of the first length of tape. This is placed “sticky” side up. Image B. illustrates the application of the
neck strap “sticky” side down followed by another length of tape around the muzzle (“sticky” side down). The excess length of the neck strap
was then backed over onto itself. Image C. is showing the tape muzzle along with an optional caudo-ventral mandibular support strap.
Skull and Mandible 719
Figure 46-5. Dental bonding of a feline patient after sustaining a man- Figure 46-6. Image of mandible illustrating location for application of a
dibular symphyseal fracture along with multiple fractures to the maxilla mental nerve block.
and zygomatic arch which were contributing to a malocclusion after
reduction of the symphyseal fracture. This prompted placement of a
temporary esophagostomy tube and dental bonding in proper alignment.
Anesthetic Considerations
Understanding the potential ramifications of inducing anesthesia
on a patient with possible head trauma is important and the
anesthetist should plan accordingly. When repairing a mandibular
or maxillary fracture that has compromised occlusion, it is
challenging to assess proper occlusion if the patient is intubated
in the customary manner. It is recommended to translocate the
endotracheal tube to a pharyngostomy incision in these situa-
tions. Once the patient is anesthetized and intubated in the usual
fashion, locate the lateral pharyngeal region of the patient just
cranial to the hyoid apparatus, with a curved Carmalt forceps
inserted through the mouth. Incise over this region through the
skin, subcutaneous tissues, and mucous membrane. Make the
incision large enough to reroute the endotracheal tube. Grasp Figure 46-7. Medial aspect of the mandible depicting the location of
the endotracheal tube through the incision and feed it retrograde a caudal mandibular nerve block. The mandibular foramen is the exit
through the incision. Once the patient is extubated the incision is point for the alveolar nerve and vessels.
left open to heal by second intention.
If regional anesthesia of the maxillary incisors, canines and
Another anesthetic consideration that is commonly overlooked premolars is desired then a palatine nerve block should be
is the application of local nerve blocks in the oral cavity. Mepiv- performed (Figure 46-8). This block may only be partially effective
icaine, lidocaine, and bupivicaine are all commonly used agents as some of the innervation of the region comes from the infra-
in small animal dentistry. Of these, bupivicaine will have the orbital nerve. For this reason, it is not uncommon to perform a
longest duration of action (approximately 6 hours). Nerve blocks palatine nerve block in conjunction with an infraorbital nerve
are relatively simple to perform, may help prevent “wind-up” of block in dogs. To perform a palatine nerve block an injection is
pain receptors and decrease the amount of inhalant anesthesia made at the midpoint between the mesial aspect of the maxillary
required. carnassial tooth and midline of the palate. The cranial infraor-
bital block will result in anesthesia of the ipsilateral incisors and
There are several nerve blocks that are commonly utilized in canine teeth of the maxilla. To perform this block, an injection is
oral procedures and these should be considered when repairing made apical to the distal root of the maxillary third premolar. This
fractures of the maxilla or mandible. The mental nerve block is corresponds to the opening of the infraorbital foramen (Figure
performed apical to the mesial root of the second mandibular 46-9). Once the foramen is localized by palpating through the
premolar (Figure 46-6). This block will result in anesthesia of oral mucosa the syringe is advanced approximately 1 mm into
all ipsilateral incisors and canines of the mandible. A caudal the foramen prior to injection. In cats it is not recommended to
mandibular nerve block can be performed when regional advance the needle because the infraorbital canal is short and
anesthesia of all the ipsilateral teeth of the mandible is necessary. orbital trauma may result. For anesthesia of all the ipsilateral
The injection is made near the mandibular foramen on the lingual teeth of the maxilla, a caudal infraorbital block may be performed
aspect of the mandible (Figure 46-7). by advancing the needle 2 to 3 mm into the infraorbital canal.
Again, this is not recommended in the cat.
720 Bones and Joints
External Fixation
External methods of mandibular and maxillary fracture stabi-
lization include external skeletal fixation, interdental wiring
and interdental fixation. These techniques offer the potential
advantage of being less invasive than internal fixation methods.
Decreased morbidity, avoidance of iatrogenic trauma to
important structures of the mandible and maxilla, and preserving
blood supply are all potential benefits of external fixation.
Interdental Wiring
Wires that are placed around teeth adjacent to a fracture are
called interdental wires. Placement relies on a solid tooth-bone
interface and any loose teeth incorporated into the wire may result
in instability and subsequent failure of the repair. For placement,
Figure 46-8. Ventral aspect of the maxilla illustrating the proper loca- drill a hole on the superficial aspect of the mandible or maxilla
tion for application of a palatine nerve block. between the two teeth closest to the rostral fracture fragment
and then do the same on the caudal fracture fragment (Figure
46-10). An alternative method is to use a hypodermic needle or
Kirschner wire passed through the gingival line at the level of the
neck of the tooth. The cerclage wire is then fed through the holes
and contoured around the teeth in a figure eight fashion. Twist
and tighten the wire evenly. Bend the wire ends into the mucosa
to avoid damaging surrounding surfaces. Twenty to 24 gauge
wire is appropriate for most dogs and cats. Interdental wiring is
commonly bolstered with interdental fixation.
Interdental Fixation
Similar to interdental wiring, healthy, intact teeth are required
rostral and caudal to the fracture line when applying an inter-
dental fixation. As mentioned above, interdental wires are
commonly applied prior to interdental fixation in dogs. Doing
Figure 46-9. Lateral view of the skull depicting the appropriate location
for placement of an infraorbital nerve block.
so results in a stronger, more stable repair. Interdental fixation
involves placement of an acrylic layer over prepared teeth to
act as an intraoral splint (Figure 46-11). The teeth must first be
Surgical Considerations cleaned, polished and acid etched. The acrylic is then applied,
There are multiple structures that must be considered when usually spanning at least two teeth rostral and caudal to the
performing surgery of the mandible and maxilla. These structures fracture. The acrylic splint is left in place for approximately 6
are frequently compromised prior to surgical intervention, making weeks or until healing has been confirmed. The splint may then
it that much more important to limit additional iatrogenic trauma. be removed by sectioning it with a dental burr.
Use of an intranasal Folley catheter may assist with reduction and
controlling nasal bleeding. The maxillary nerve passes through the
alar canal and should be avoided during maxillary fracture repair.
External Skeletal Fixation
The advent of positive profile pins for use in external skeletal
Tooth roots must be avoided when drilling into the mandible or fixation has allowed greater versatility and success. Highly
maxilla. Damage to the nerve root may necessitate additional comminuted mandibular fractures (i.e. gunshot wounds) are
ideal candidates for repair with external skeletal fixation. Type
Skull and Mandible 721
Figure 46-10. A. and B. Figure of eight interdental wire used to stabilize Figure 46-11. A. and B. Rostral maxillary and incisive bone fracture
a transverse maxillary fracture. Wire loop is twisted from both ends to stabilized with an acrylic dental splint.
ensure uniform tension.
1-a fixators are used for mandibular fractures (Figure 46-12). Internal Fixation
Typically, all fixation pins are half-pins, but a centrally-threaded Internal fixation of mandibular and maxillary fractures may
full-pin can be applied across the mandibular symphysis. The include interfragmentary wiring and bone plating. An advantage
fixator is applied percutaneously by making release incisions of internal fixation is the ability to achieve excellent reduction and
through the skin, pre-drilling the bone, and placing positive- stabilization. It is important to remember, however, that proper
profile end-threaded pins. The pins are placed in the ventro- dental occlusion takes precedence over apparent “anatomic
lateral aspect of the mandible to avoid tooth roots. Ideally, reduction” of the internally fixated oral fracture. Additionally,
three pins are placed on either side of the fracture, but there post-operative morbidity may be reduced with internal fixation
may only be enough room for two pins on either side. This varies compared to external skeletal fixation. This is attributable to the
depending on patient size and fracture extent. The fixation frame absence of percutaneous implants.
can be built with clamps and rods, or acrylic.
Figure 46-15. Oblique fracture of the maxilla repaired with three inter-
fragmentary wires. All wires should be preplaced before tightening.
The two rostral wires are placed using a triangulated wiring technique
which may be used for oblique fractures.
After the wires are passed through the drill holes they are
tightened with wire twisters. Pull evenly on both wires and twist;
with unequal tension, one wire will twist around the other and the
fixation will fail due to knot slippage. It is important to ensure that
the wire is tight to avoid any unnecessary instability. The ends
of the wire are bent toward the bone and away from the gingival
margin to avoid damage or irritation of nearby structures. This is
done by twisting and bending the wire at the same time to prevent
any loosening of the wire while it is being bent. Care must be
taken to ensure that the wire is not over- or under-twisted. As the
wire is over-twisted and becomes tighter, its color will become
dull instead of shiny. Many surgeons twist the wire until the point
at which it starts to dull. Once the wire is appropriately bent it is
then cut with wire cutters. Three twists are typically left behind
Figure 46-13. An acrylic external fixator applied to a comminuted man- to ensure knot security of the tightened wire. Interfragmentary
dibular fracture. A. Lateral view. B. Dorso-ventral view. wires are used frequently with maxillary fractures since other
fixation methods are either difficult to apply in the presence of the
Skull and Mandible 723
Bone Plates
With recent advancement in plating technologies there are
several different options depending on the repair goals. Bone
plates have a distinct advantage of allowing the surgeon to
Figure 46-17. Image of mandibular symphyseal fracture in a cat. Note
apply them in compression, neutralization, or buttress. For easily
the step defect associated with the mandible. reconstructable fractures a limited contact plate (LC), dynamic
724 Bones and Joints
compression plate (DCP), or even better, LC-DCP is recom- needs. If oral intake is possible, easily swallowed soft foods are
mended. Small locking plates like a 2.0 mm string of pearls plate recommended. The ideal food item is nutritionally complete,
(SOP) can also be very versatile as the plate behaves as an requires minimal chewing and does not adhere to the repair site.
“internal” external fixator and allows the surgeon the ability to Recheck examination will depend on the type of fracture, repair
contour the plate in almost any direction (Figure 46-19). Miniature method used, and patient age. In general most fractures of the
maxillofacial reconstruction plates are also available and are maxilla and mandible will heal by 6 to 8 weeks. Once clinical union
very easy to work with from a contouring standpoint. Their is achieved implants may be removed if necessary. Potential
main disadvantage is weakness in comparison to other plating complications of fracture repairs include sequestra, osteomy-
options. In human maxillofacial surgery it is common practice elitis, implant failure, malocclusion, nonunion or malunion, tooth
to use resorbable plates, however, the high cost of these plates root injury and periodontitis.
generally precludes their use in veterinary medicine.
When bone plates are applied on the mandibular body they are Suggested Readings
placed on the ventro-lateral aspect of the mandible. The tooth Bennet JW, Kapatkin AS, Marretta SM. Dental composite for the
roots should be avoided when drilling and placing screws. This fixation of mandibular fractures and luxations in 11 cats and 6 dogs.
VetSurg 23:190, 1994.
may be a disadvantage as a result of the “tension band” effect
Bos RR, Rozema FR, Boering G, et al. Bio-absorbable plates and screws
on the alveolar surface. Due to the pull of the muscles of masti-
for internal fixation of mandibular fractures. A study of six dogs. Int J
cation there is a bending force at the alveolar surface causing Oral Maxillo Surg 18:365, 1989.
separation of the fracture at the tooth surface and compression
Boudrieau RJ: Fractures of the mandible In Johnson AL, Houlton JEF,
at the ventral aspect of the fracture. To counter this “tension Vannini R, ed.: AO principles of fracture management in the dog and cat.
band” effect an interdental wire may be applied or a miniature Thiemie: AO publishing, 2005, p98.
plate placed more dorsally on the mandible that will allow screw Boudrieau RJ: Fractures of the maxilla In Johnson AL, Houlton JEF,
placement between the tooth roots. Lastly, when applying bone Vannini R, ed.: AO principles of fracture management in the dog and
plates care must be taken during contouring of the plate to avoid cat. Thiemie: AO publishing, 2005, p116.
iatrogenic malocclusion. Evans HE: The skeleton In Miller’s Anatomy of the Dog. Philadelphia:
WB Saunders, 1993, p128.
Postoperative Care Johnson AL: Management of Specific Fractures In Fossum TW, ed.:
Small Animal Surgery. Saint Louis: Mosby, 2007, p1015.
In the immediate postoperative period, the patient should be
Kern DA, Smith MM, Stevenson S, et al. Evaluation of three fixation
monitored carefully for any airway obstruction secondary to the techniques for repair of mandibular fractures in dogs. J Am Vet Med
fracture repair. Adequate intravenous analgesia should also be Assoc 206:1883, 1995.
provided. Patients should be transitioned to oral analgesics and Legendre L. Intraoral acrylic splints for maxillofacial fracture repair. J
maintained on these for 5 to 10 days. If substantial discomfort Vet Dent 20:70, 2003.
is expected when trying to administer oral medications then a Lopes FM, Gioso MA, Ferro DG, et al. Oral fractures in dogs of Brazil-a
feeding tube (e.g. esophagostomy tube) should be used. These retrospective study. J Vet Dent 22:86, 2005.
are relatively easy to place and require minimal care. When Umphlet RC, Johnson AL. Mandibular fractures in the dog. A retro-
placing an esophagostomy tube, always check proper placement spective study of 157 cases. Vet Surg 19:272, 1990.
into the distal third of the esophagus with a lateral radiograph. Umphlet RC, Johnson AL. Mandibular fractures in the cat. A retro-
Initiate an appropriate feeding regimen according to the patient’s spective study. Vet Surg 17:333, 1988.
Figure 46-19. Application of two string of pearls locking plates to a fracture of the vertical ramus. Courtesy of Dr. Karl Kraus.
Skull and Mandible 725
Verstraete FJ, Maxillofacial fractures In Slatter D, ed.: Textbook of Small The homemade splint consists of methylmethacry-late, which
Animal Surgery. Philadelphia: Saunders, 2003, p2190. can be obtained as either hoof repair (Tech-novit Hoof Acrylic,
Verstraete, FJ ed.: Oral and maxillofacial surgery in dogs and cats. Jorgensen Laboratories, Loveland, CO) or dental molding acrylic
Elsevier, 2012, p233. (Orthodontic Resin, L.B. Caulk Co., Milford, DE). The acrylic
column can be free-formed or injected into a tube to serve as
a mold. When free-formed, the acrylic is molded by hand to the
Acrylic Pin Splint External required shape. The free-form method is easiest with most appli-
Skeletal Fixators for cations to the mandible, especially for smaller dogs and cats.
The tube method may be best for larger dogs. The commercial kit
Mandibular Fractures uses a tube method. Research has shown that a 3/4-inch acrylic
Dennis N. Aron column diameter provides fixation strength comparable with or
greater than that of the medium Kirschner 3/16-inch connector
Acrylic pin splints are external skeletal fixators that use acrylic rod. Given this guideline, the surgeon can extrapolate the needed
as both the connector rod and linkage. This fixation method can width of the acrylic column to various sizes of animals.
be accomplished in numerous ways, using either homemade
materials or commercial kits (Acrylic Pin External Fixation Two considerations are important to predictable and consistent
System, Innovative Animal Products, Rochester, MN). Use of an success when using acrylic pin splints for mandibular fractures.
acrylic pin splint has several advantages over standard metal First, the surgeon needs to establish normal occlusion and masti-
external skeletal fixators for the mandible. The acrylic pin splint cation for the patient. Failure to accomplish this goal predisposes
is lightweight, radiolucent, and versatile. The acrylic pin splint the patient to abnormalities of the temporomandibular joint and
enables the surgeon to position pins to avoid tooth roots and vital pain, with the possibility of negative consequences on nutritional
structures easily and to combine pins of various sizes in a singular balance. Normal occlusion in the dog is seen when the mandibular
frame (Figure 46-20). The acrylic pin splint is easy to contour to canine teeth are positioned between the maxillary incisors and
the shape of the mandible (Figure 46-20). The advantage of using canine teeth and the mandibular fourth premolar is situated
a homemade acrylic pin splint is that the surgeon can purchase between the maxillary third and fourth premolars. Achieving
specifically needed components from different sources. The normal occlusion is always a higher priority than accomplishing
commercial kit provides convenience of application because it accurate reduction at the fracture site (See Figure 46-18).
contains all materials in a single package. When performing surgical correction of mandibular fractures,
placement of the endotracheal tube through a pharyngostomy
enables the surgeon to assess occlusion during the operative
procedure. When the endotracheal tube is positioned routinely,
it interferes with normal closure of the mouth and prevents the
surgeon from assessing accurate occlusion.
added to the column to incorporate the bent pins (Figure 46-23). acrylic pin splint, with considerations and technique similar to
This technique enhances the stability of the smooth pin acrylic that described for the free-form method. A frame alignment kit
linkage. The surgeon must bend the pins over using one pair of (Innovative Animal Products, Rochester, MN) is available and is
pliers as a lever positioned at the point of bend and another pair advantageous because it allows phase 1 reduction equipment to
of pliers or hand chuck to exert bending of the pin. This prevents be placed either above or below the plastic tubes.
the formation of high stresses at the fastener-bone interface
when bending over the pin. The fracture reduction or the splint can be adjusted after the
acrylic has set by removing a short segment of the acrylic column
with a hacksaw blade, obstetric or Gigli wire, or a cast cutter. A
portion of the tubing is peeled back, and several channels are
drilled into a portion of acrylic on either end of the cut column to
provide an anchor for the new acrylic patch. A small amount of
acrylic is mixed and hand molded to fill the gap and to overlap a
portion of the exposed acrylic containing the channels. Occlu-
sional alignment or fracture reduction is then manipulated,
while the acrylic is still soft, and is held until the acrylic hardens.
New fasteners can be placed to add additional strength to the
configuration or to replace fasteners that are loose. Fasteners
are placed adjacent to the existing acrylic column using aseptic
technique. The fasteners are then incorporated into the column
with the addition of a new patch of acrylic.
Suggested Readings
Egger EL. Management of mandibular fractures with external fixation.
In: Proceedings of the 5th annual Complete Course in External Skeletal
Fixation. Athens, GA:, 1996:113-115.
Toombs JP. Nomenclature and Instrumentation of external skeletal
fixation systems. In: Proceedings of the 5th annual Complete Course in
External Skeletal Fixation. Athens, GA:, 1996:2-9.
Figure 46-23. Long pins cut short and bent to lie flush with acrylic.
Chapter 47
Cervical Spine
Cervical Disc Fenestration
M. Joseph Bojrab and
Gheorghe M. Constantinescu
Indications
Ventral fenestration for cervical disc disease is advocated in
animals demonstrating pain, stiffness of the neck, or foreleg
paresis. This technique is effective when degenerating discs
protrude and cause nerve fiber and rootlet disorders, which
account for most cervical disc problems. This procedure accom-
Figure 47-2. Trachea and esophagus are retracted to the left, and the
plishes intervertebral disc decompression by opening the ventral longus colli muscle insertions are identified and cut with scissors.
annular fibers for removal of the nucleus pulposus.
remaining ventral tubercles are midline projections that are
Cervical fenestration is not effective if foreleg paralysis or directed caudally from the caudal ventral aspect of the vertebrae
tetraplegia results from the presence of disc material within the and provide the insertion site for the two bellies of the longus colli
spinal canal. These circumstances indicate a decompressive muscle (Figure 47-3B). The ventral entrance to the intervertebral
procedure. space is covered by these bellies and their tendinous attachment.
The muscle attachment is snipped with scissors, exposing the
Surgical Technique ventral longitudinal ligament. A No. 10 scalpel blade is used to cut
The animal is placed in dorsal recumbency with a sandbag under the longitudinal ligament and ventral annular fibers (Figure 47-4A).
the neck to produce dorsal flexion of the cervical spine, facili- A tartar scraper (SCLB Miltex Tartar Scraper, Victor Medical,
tating exposure. A ventral midline skin incision is made from the Irvine, CA) (Figure 47-5) is used to fenestrate the disc (See figure
larynx to the thoracic inlet. The paired bellies of the sternohyoid 47-4B). All readily accessible cervical discs (C2-3, C3-4, C4-5,
muscle are separated (Figure 47-1), and the trachea is displaced C5-6) are fenestrated.
laterally and is held with a self-retaining retractor. Blunt dissection
of the deep fascia reveals the V-shaped longus colli muscle The self-retaining retractor is removed, and the sternohyoid
(Figure 47-2), which lies on the midline. Locating this muscle is muscle bellies are sutured with a 3-0 polydioxanone (PDS,
essential to ensure midline identification. The ventral tubercles Ethicon, Somerville, NJ). The skin is then closed.
of the first and second cervical vertebrae is located at the level
of the wings of the atlas (Figure 47-3A) for orientation. Because
a disc is not present at this interspace, it is not fenestrated. The
Figure 47-1. Ventral cervical incision from the larynx to the thoracic
inlet exposing the trachea by separating between the sternohyoid Figure 47-3. A. Ventral aspect of the cervical vertebral column. B.
muscles. Longus colli muscle identification and placement.
Cervical Spine 729
Patient Position
The patient is placed in dorsal recumbency with the forelimbs
secured caudally. The cervical spine should be supported by
placing a vacuum positioner or rolled towel beneath the neck.
Excessive dorsiflexion (hyperextension) should be avoided. The
head can be secured by placing one inch tape on the rostral third
of the mandible and securing it to the sides of the table. Gentle
traction can thus be applied to the cervical spine resulting in
distraction of the intervertebral disk spaces and enhanced
access to the spinal canal (Figure 47-6).
Figure 47-4. A. After the longus colli muscle attachment is cut, a No. 10
scalpel is used to incise the ventral longitudinal ligament and annular
fibers. B. A tartar scraper is used to fenestrate the disc.
Figure 47-5. A schematic drawing of the Miltex Scaler B tartar scraper. Figure 47-6. Proper position of patient with head and neck stretched
for ventral decompression. (From Bruecker KA, et al: Clinical evalua-
tion of three surgical methods for treatment of caudal cervical spondy-
Postoperative Care lomyelopathy of dogs. Vet Surg 1989; 18: 197.
Antibiotics are given for 5 to 10 days postoperatively. Corticos-
teroids (dexamethasone, 1 mg/lb body weight) are administered
intramuscularly once or possibly twice each week. Buffered
Approach to the Cervical Vertebrae and
aspirin is given for 7 to 10 days if pain persists. After 10 to 14 Intervertebral Disks1-5
days, complete remission of signs is expected. A cutaneous incision is made from the larynx to the manubrium.
The paired muscle bellies of the sternocephalicus muscles are
sharply separated. The paired sternohyoideus muscles are
sharply separated on the midline exposing the trachea. The
thyroid ima, a single unpaired blood vessel, lies between the left
and right sternohyoideus muscles. If the branches of the thyroid
ima are ligated and transected on the right, then this vessel can
be reflected with the left sternohyoideus muscle.
carotid sheath to the right. Care should be taken to identify and body is reached. The blade is then directed and advanced towards
protect the right recurrent laryngeal nerve. The endotracheal the midline to complete the rectangular shaped excision (window)
tube must be of sufficient length to avoid collapse of the trachea (Figure 47-7). This portion of excised ventral anulus fibrosus can
during retraction. The esophagus should also be retracted to then be removed with rongeurs and the nucleus pulposus gently
the left exposing the longus colli muscle. An esophageal stetho- removed with curettes or dental scraper (Figure 47-8). Care must
scope or soft rubber tube placed in the esophagus will enhance be taken such that additional disk material is not forced dorsally
palpation of the esophagus during retraction. Care should be into the spinal canal. This can be accomphished by directing the
used when retracting these tissues. This retraction can be aided curette or dental scraper in a direction parallel to the plane of the
with the use of 4x4 surgical sponges or laparotomy pads if the patient’s body instead of ventrodorsally.
patient is a large breed canine. These tissues can be retracted
digitally and held in place by paired self-retaining retractors that
are placed cranial and caudal to the affected interverbral disk
spaces once the paired longus colli muscles have been identified
and bluntly dissected along the median raphe.
Technique2,3
Further elevation of the longus colli muscle with a periosteal
elevator should be performed in preparation for the ventral slot.
The retractors can be repositioned between the muscle bellies
of the longus colli muscles. The prominence of the point of origin
of the longus colli muscle on the caudoventral midline aspect of
the cervical vertebral body can be removed with rongeurs and
the intervertebral disk fenestrated.
Post-operative Management
Analgesics such as opiods or NSAIDS should be continued for
24-48 hours postoperatively. Corticosteroids are not indicated in
the post-operative period. A thoracic harness should be used
instead of a neck collar.
Damage to the venous sinus results in excessive hemorrhage Neurologic recovery is generally very rapid. Neck pain usually
and obstruction of visualization of the spinal cord. This can be subsides within 24 to 48 hours. Tetraparetic patients may begin
controlled with suction and hemostatics, such as Gelfoama or to show improvement within days, as well. Owners, however,
Surgicel.b Suction can be used to evacuate the blood. A small should be counseled as to the unpredictabilty of spinal surgery
piece of precut Gelfoama, presoaked in saline, can be placed at and its complications to include delayed return to function and
the site of the hemorrhage. Cottonoidc or sponge is placed over recurrent neck pain.
the Gelfoama to prevent inadvertent aspiration of the hemostatic.
Suction of the overlying sponge or Cottonoidc is performed until
hemorrhage has stopped. The sponge or Cottonoidc can then be References
removed. The hemostatic can be removed after 5 minutes and 1. Piermattei DL. An atlas of surgical approaches to the bones and joints
disk material retrieval can be resumed. In some cases, a small of the dog and cat. 3rd ed. WB Saunders, 1993; 54-59.
remnant of either Gelfoam or Surgicel can be left at the site to 2. Swaim SF. Ventral decompression of the cervical spinal cord in the
aid in hemostasis. Monofilament absorbable suture material dog. JAVMA 1974; 164, 491-495.
Gelfoam: Upjohn Co., Kalamazoo, MI
a b
Surgicel: Johnson and Johnson, Arlington, TX Cottonoid: Codman and Scurtleff, Randolf, MA
c
732 Bones and Joints
Introduction
There are two separate philosophical approaches to the surgical
treatment of caudal cervical spondylomyelopathy (CCSM) in
large breed dogs, direct decompression versus decompression
Figure 47-12. Diagramatic cross-sectional representation of the
by distraction and stabilization. In general, patients with malfor-
inverted cone decompressive slot at the level of the intervertebral disk
mation/malarticulation or static compressive lesions benefit
space.
from direct decompressive surgical techniques whereas
patients with dynamic compressive lesions such as cervical
be retracted back into the slot and excised (Figures 47-13 and
vertebral instability (CVI) require distraction and stabilization. As
47-14). The inner cortical bone layer is removed with the high
witnessed from a review of the literature on the subject, no one
speed bur and additional anulus and dorsal longitudinal ligament
technique for repair of dynamic lesions is considered the gold
can be excised (Figure 47-15). Closure is routine.
standard. Repair of these compressions is contingent upon the
patient’s demeanor, general overall health, surgeon experience,
and owner expectations for recovery. Treatment by Distraction and Stabilization
Utilizing Pins or Screws and Polymethyl
Treatment by Direct Decompression using Methacrylate5,6
an Inverted Cone Modified Ventral Slot1 Distraction and stabilization utilizing Steinmann pins or bone
The inverted cone modified ventral slot is a direct decompressive screws and polymethyl methacrylate has been described.
technique for the removal of hypertrophied dorsal anulus fibrosus Advantages of this technique include: adequate spinal cord
associated with cervical vertebral instability. This technique decompression without entering the spinal canal, reduced risk
is most useful in patients with a static lesion, unchanged by of iatrogenic cord trauma and bleeding, as well as improvement
distraction. The hypertrophied dorsal anulus fibrosus can be in the percent, rate and duration of recovery as compared to
difficult to remove from the canal using the classic ventral other techniques. In addition, a neck brace is not required. This
decompressive slot technique.1,2,3,4 This technique or a combi- technique is used most commonly for dynamic lesions that involve
nation of this technique with the classic approach may have both the annulus fibrosus and the dorsal longitudinal ligament.
merit in allowing better retrieval of anulus from the canal. The
slot resembles an inverted cone wherein the base of the cone is Technique5
at the ventral spinal canal.1 (Figure 47-12).
A ventral approach, as described for the ventral decompressive
slot, is performed to expose the vertebral bodies and interver-
Technique tebral spaces cranial and caudal to the affected intervertebral
The approach to the affected intervertebral disk space is the space. The patient is positioned in dorsal recumbency such that
same as described for ventral cervical slot. Using a high speed the cervical spine is distracted, as described for the ventral slot.
bur, the slot is created from the caudal aspect of the interver- The affected intervertebral space is then pulled into additional
tebral disk to involve the caudal 1/4 of the cranial vertebral body. linear traction by one of two techniques. A Gelpi retractor,
The width of the slot is limited to 1/5 the width of the vertebral modified by blunting the tips, can be used as a vertebral
body. The slot is enlarged as it is deepened by moving the bur in retractor. A defect is created in the vertebral bodies cranial
a sweeping motion laterally, creating an elliptical slot. The slot and caudal to the affected vertebral bodies with a high-speed
is carried to the level of the inner cortical layer while preserving surgical bur. The defects are created just large enough to accept
the dorsal anulus fibrosus. The dorsal anulus fibrosus can then the tips of the modified Gelpi retractor. The retractor is engaged,
and the affected intervertebral space spread an additional 2 to
Cervical Spine 733
Figure 47-13. The dorsal anulus fibrosus (DAF) is retrieved into the slot Figure 47-15. A high speed bur is used to remove the dorsal cortical
by applying traction prior to removal with a rongeur. bone shelf providing surgical access to the spinal canal.
Figure 47-14. Retrieval of additional compressive material into the slot. inner cortical bone layer. The spinal canal is not entered. The width
Note retention of dorsal cortical bone shelf and progressive spinal of the slot should be no more than 1/2 the width of the vertebral
cord decompression.
body. The length of the slot is determined by the thickness of the
vertebral endplates. Once the cortical endplate on each vertebral
3 mm (Figure 47-16). This technique of vertebral spreading may
body has been removed, burring should cease. Autogenous
have merit over insertion of the tips of the Gelpi retractor into
cancellous bone is harvested from the heads of the humeri and
fenestrated disk spaces. Fenestration of the intervertebral disks
placed into the distracted slot. Two 7/64 or 1/8 inch Steinmann
may predispose them to degenerative changes and collapse.7
pins are inserted into the ventral surface of the vertebral body
Distraction results in decompression of the spinal cord.8,9
cranial to the affected intervertebral space and two similar size
pins are inserted into the vertebral body caudal to the affected
A ventral slot is performed at the affected intervertebral space,
intervertebral space. The pins are inserted on the ventral midline
however the slot is wider and shorter than a classic ventral
of the vertebral body and directed 30-35 degrees dorsolaterally to
decompressive slot. The depth is carried only to the level of the
avoid entering the spinal canal. It is important that two cortices
734 Bones and Joints
are engaged by each pin. The pins are cut leaving approximately of the PMP technique have successfully used other vertebral
1.5 to 2 cm exposed. The exposed portion of each pin is notched spreaders as well. The affected disk material is removed to
with pin cutters allowing the bone cement to grip and prevent pin the level of the dorsal anulus fibrosus. Troughs are cut into the
migration. Bone screws 3.5 to 4.0 mm in diameter long enough endplates using a high speed drill and a 2 to 4 mm bur to anchor
to engage both cortices may be used instead of Steinmann pins. the PMP. These anchor troughs should be made approximately
Sterile polymethyl methacrylate powder is mixed with liquid 5 to 10 mm in lateral width, 4 mm in depth and 4 mm in dorso-
monomer until it reaches a doughy consistency and can be ventral height (Figure 47-18). An angled attachment will allow
handled without sticking to the surgeon’s gloves. The cement better access to the caudal vertebral endplate. One gram of
is then meticulously molded around each pin (Figure 47-17). sterile cefazolin powder can be mixed with the sterile polymethyl
Irrigation with sterile saline solution for 5-10 minutes dissipates methacrylate. The polymethyl methacrylate powder is mixed
the heat of polymerization. The vertebral spreaders are removed with liquid monomer until it reaches a liquid consistency and can
once the cement has hardened. Closure of the longus colli be infused into the intervertebral disk space to the level of the
muscle is performed cranial and caudal to the cement mass. The ventral aspect of the vertebral bodies and gently packed digitally.
remainder of the closure is routine. Postoperative care includes Irrigation with sterile saline solution for 5 to 10 minutes dissipates
strict confinement for 4-6 weeks. the heat of polymerization. The vertebral spreaders are removed
once the cement has hardened. Autogenous cancellous bone is
harvested from the heads of the humeri and placed ventral to the
Treatment by Distraction and Stabilization vertebral bodies and PMP to stimulate osseous fusion (Figure
utilizing a Polymethyl Methacrylate Plug11 47-19). Closure of the longus colli muscle is performed over the
Another technique utilizing an intervertebral plug of polymethyl cancellous bone graft. The remainder of the closure is routine.
methacrylate to accomplish distraction and stabilization has been A neck brace may be used post-operatively to limit excessive
described.11 There is no apparent advantage in rate of recovery movement, but may not be required (Dixon). The Synthes Locking
and overall success rate as compared to distraction and stabili- Plate (Syncage-C intervertebral implant and cervical spine
zation using pins and polymethyl methacrylate, however risk of locking plate) may prove to be a viable option in the future. The
implant failure or iatrogenic spinal cord trauma from improperly Synthes locking plate has been discussed in the treatment of
placed pins is less with this technique. In addition, this technique dynamic lesions to include single lesions (as repaired with the
can be performed at multiple disk spaces if necessary.11 cement plug), or as a rescue technique after a failed ventral
slot decompression or with multiple lesions. To date, the use of
the Locking plates on multiple lesions is still undergoing further
Technique11 evaluation.18 Preliminary results with this technique are encour-
A ventral approach, as described for ventral decompression, aging. A swivel ring in the plate hole means that the screws may
is performed to expose the vertebral bodies and interver- be inserted at any angle within a range of +/- 20 degrees and the
tebral spaces cranial and caudal to the affected intervertebral screw holes lock in the plate via a unique locking mechanism.
space(s). The affected intervertebral space is then pulled into This device (the Syncage) is designed to maintain distraction.
additional linear traction as previously described in the pins It stays within the intervertebral space and is packed with
and polymethyl methacrylate technique. The original authors
Figure 47-17. Placement of the cancellous bone, pins and bone cement to treat CVI. (From Bruecker KA, Seim HB. Caudocervical Spondylomyel-
opathy in Large Breed Dogs. In, (ed)Bojrab, Current Techniques in Small Animal Surgery, 3rd ed. Lea & Febiger. 1989: 583).
Cervical Spine 735
cancellous bone. This device adds strength and bridge greater Treatment by Direct Decompression
than one space.18 The utility of this device for multiple lesions in
the canine is yet to be elucidated. Limitations of this technique using a Continuous Dorsal Laminectomy12
can include cost of the implants and the lack of case numbers Continuous dorsal laminectomy is a decompressive technique.
that support further use and feasibility of this technique. This technique is most useful in patients with multiple lesions
and dorsal lesions. Although this technique does not address
the underlying pathophysiologies associated with CCSM, relief
of spinal cord compression is achieved. Dorsal laminectomy is
advocated for single or multiple, dorsal, traction non-responsive
(static) lesion(s).18 The major disadvantage of this procedure is
the significant, short-term morbidity with deterioration in neuro-
logical status, which can be substantial in the giant breed dogs
who most likely require this technique. The most common lesions
associated with the use of this technique are bulbous articular
facets, ligamentum flavum hypertrophy or a combination of both.
Approach13
With the patient in sternal recumbency the front feet are secured
cranially and the head and neck elevated from the surgical table.
Tape placed over the muzzle and thorax help secure the neck. A
midline incision is made in the skin over the dorsal processes of
the cervical spine from the poll of the cranium to T3. After the
subcutaneous fascia and aponeurosis of the platysma muscle
are incised, an incision is made through the median fibrous
Figure 47-18. Partial diskectomy is performed leaving only a thin layer raphe. The origins of the splenius and serratus dorsalis muscles
of dorsal anulus fibrosus (DAF). Creation of anchor holes is accom- can be incised from the raphe and reflected to expose the nuchal
plished with a high speed bur and angle attachment. (From Dixon BC, ligament, dorsal spinous processes of the thoracic vertebrae
Tomlinson JL, Kraus KH. Modified distraction-stabilization technique and the long spinal muscles. These muscles are separated from
using an interbody polymethyl methacrylate plug in dogs with caudal the midline and reflected form the dorsal spinous processes to
cervical spondylomyelopathy. J Am Vet Med Assoc 1996; 208: 63).
expose the dorsal laminae.
Technique12
After exposure of the cervical vertebrae, the dorsal spinous
processes of the affected vertebrae are removed with rongeurs
and the dorsal lamina is carefully removed using a high speed
surgical bur. The length of the laminectomy may be from 3/4
the length of each vertebrae up to a continuous laminectomy
extending from C4 to C7. The width of the laminectomy is limited
by the medial aspect of the articular facets of the cranial
vertebra. The initial depth of the laminectomy defect is to the
periosteum of the inner cortical layer of the laminae. Following
penetration into the spinal canal, the remaining laminae and
ligamentum flava are gently excised and removed en bloc
(Figure 47-20). Kerrison rongeurs can be quite useful for this
procedure. If needed, resection of the lateral aspects of the
vertebral arches can be continued to the level of the ventral
vertebral veins using rongeurs. It is important to preserve the
articular facets. Hypertrophied joint capsule and ligamentum
Figure 47-19. The PMP is placed into the prepared disk space while flavum is resected to achieve decompression of the spinal cord.
traction is maintained. After the PMP hardens, the traction device is Transarticular hemicerclage wires or lag screws may need to
removed and cancellous bone graft (CG) is liberally packed along the be placed through the facets for additional stability. If stabili-
ventral aspect of the vertebral bodies. The remaining thin layer of DAF
zation is required, an appropriate sized hole is drilled through
protects the spinal cord from the PMP. (From Dixon BC, Tomlinson
the articular facet. Removal of the articular cartilage is achieved
JL, Kraus KH. Modified distraction-stabilization technique using an
interbody polymethyl methacrylate plug in dogs with caudal cervical using a high speed surgical bur. An 18-gauge stainless steel
spondylomyelopathy. J Am Vet Med Assoc 1996; 208: 63). wire is placed through the hole and twist tightened or, alterna-
tively, the hole is tapped and a lag screw placed. Cancellous
bone is placed around the joint to promote arthrodesis.14,15,16,17,18
An autogenous fat graft placed over the laminectomy site will
736 Bones and Joints
Figure 47-20. A. and B. The dorsal laminae have been removed from References
C4 through C7 to provide direct decompression of the caudal cervical 1. Goring RL, Beale BS, Faulkner RF. The inverted cone decompression
spinal cord. technique: A surgical treatment for cervical vertebral instability
“Wobbler Syndrome” in Doberman pinschers. Part 1. J Am Anim Hosp
prevent the formation of a fibrous laminectomy membrane with Assoc 1991; 27: 403-409.
subsequent stricture and spinal cord compression. Paraspinal 2. Chambers JN, Betts CW. Caudal cervical spondylopathy in the dog:
muscles and fascia are approximated and the remaining closure a review of 20 clinical cases and the literature. J Am Anim Hosp Assoc
is routine. A cervical bandage or brace is generally required. 1977; 13: 571-576.
3. Chambers JN, Oliver JE, Bjorling DE. Update on ventral decom-
Post-operative Management of CCSM pression for caudal cervical disk herniation in Doberman pinschers. J
Am Anim Hosp Assoc 1986; 22: 775-778.
Patients 4. Bruecker KA, Seim HB, Withrow SJ. Clinical evaluation of three
Analgesics may be necessary for 24 to 48 hours postoperatively. surgical methods for treatment of caudal cervical spondylomyelopathy
Corticosteroids are not indicated in the postoperative period and of dogs. Vet Surg 1989; 18: 197-203.
may be contraindicated. Non-steroidal antiinflammatories and 5. Bruecker KA, Seim HB, Blass CE. Caudal cervical spondylomyelopathy:
oral opiods can be used for post-operative pain management. decompression by linear traction and stabilization with Steinmann pins
A cervical bandage of rolled cotton and stretch gauze can be and polymethyl methacrylate. J Am Anim Hosp Assoc 1989; 25: 677-683.
placed postoperatively to prevent excessive head and neck 6. Ellison, GW, Seim HB, Clemmons RM. Distracted cervical spinal fusion
movements. This bandage can remain in place for 3 weeks. If for management of caudal cervical spondylomyelopathy in large breed-
dogs. J Am Vet Med Assoc 1988; 193: 447-453.
warranted and tolerated, a neck brace constructed of fiberglass
cast material or a heat moldable splint material, incorporating 7. Lincoln JD, Pettit GD. Evaluation of fenestration for treatment of
the cervical and cranial aspect of the thoracic spine may limit degenerative disk disease in the caudal cervical region of large dogs.
Vet Surgery 1985; 14: 240-246.
movement, thereby promoting fusion. Handles built into the
brace may allow for better assistance when rising and walking. 8. Seim HB, Withrow SJ. Pathophysiology and diagnosis of caudal
cervical spondylomyelopathy with emphasis on the Doberman pinscher.
A thoracic harness should be used instead of a neck collar. Post-
J Am Anim Hosp Assoc 1982; 18: 241-251.
operative management of CCSM patients is generally divided into
9. Seim HB, Bruecker KA. Caudal Cervical Spondylomyelopathy
ambulatory or non-ambulatory convalescence. Patients with an
(Wobbler Syndrome). In, (ed) Bojrab, Disease Mechanisms in Small
ambulatory status post-operatively are generally managed in the
Animal Surgery, 2nd ed. Lea and Febiger. 1993: 979-983.
Cervical Spine 737
10. Walker TL. Use of Harrington Rods in Caudal Cervical Spondylomyel- 47-21B). In chronic cases, the joint capsule may be thickened
opathy. In, (ed)Bojrab, Current Techniques in Small Animal Surgery, 3rd and may contain increased volumes of joint fluid. The joint
ed. Lea and Febiger. 1989: 584-586. may be reduced to normal position by retraction with small,
11. Dixon BC, Tomlinson JL, Kraus KH. Modified distraction-stabilization pointed reduction forceps on the caudal body of the axis. If the
technique using an interbody polymethyl methacrylate plug in dogs with dens is fractured or ununited, it should be removed through an
caudal cervical spondylomyelopathy. J Am Vet Med Assoc 1996; 208: incision through the membrane between the two articulations.
61-68.
The ligaments attached to the apex of the odontoid process
12. Lyman, R. Continuous dorsal laminectomy for the treatment of are exposed through a ventral opening in the fascia covering
Doberman pinschers with caudal cervical vertebral instability and the foramen magnum. The dens may be removed after careful
malformation. Abstracts, 5th Annual Meeting of the American Animal
severance of these apical and alar ligaments. Removal of the
Hospital Association 1987: 303-308.
dens should not be necessary if it is united to the body of C2 and,
13. Piermattei DL. An atlas of surgical approaches to the bones and
if accurate, stable realignment can be accomplished.
joints of the dog and cat. 3rd ed. WB Saunders, 1993; 60-69.
14. Walker TL, Tomlinson JL, Sorjonen DC, Kornegay JN. Diseases of
Arthrodesis of CI and C2 is optimized by removal of the articular
the spinal column. In, (ed) Slatter, Textbook of Small Animal Surgery.
cartilage from the joint spaces and placement of a cancellous
WB Saunders, 1985; 1367-1391.
bone graft obtained from the proximal humerus. Access to
15. Trotter EJ, deLahunta A, Geary JC, Brasmer, TH. Caudal cervical
the joints may be increased by gentle caudal retraction of C2
vertebral malformation-malarticulation in Great Danes and Doberman
Pinschers. J Am Vet Med Assoc 1976; 10: 917-930. with reduction forceps, and the cartilage may be removed with
rongeurs or an air drill. Because of the architecture and location
16. Dueland R, Furneaux RW, Kaye MM. Spinal fusion and dorsal lamine-
ctomy for midcervical spondylolisthesis in a dog. J Am Vet Med Assoc
of the joints, it is unrealistic to expect removal of all the articular
1973; 162: 366-369. cartilage; removal of the ventral 75% from all four articular
17. Hurov LI. Treatment of cervical vertebral instability in the dog. J Am
surfaces is probably adequate. The bone graft is packed into the
Vet Med Assoc 1979; 175: 278-285. joint spaces after adequate removal of cartilage and lavage of
the surgical site.
18. Sharp N, Wheeler S. Cervical Spondylomyelopathy. Small Animal
Spinal Disorders. Second edition. Elsevier. 2005. 211-246.
Ventral stabilization of the atlantoaxial joint may be achieved
using pins alone, pins and polymethylmethacrylate, lag
Surgical Treatment of screws, or bone plates. A power drill is necessary for accurate
placement of pins and screws. If pins alone are to be used, two
Atlantoaxial Instability small Steinmann pins or large Kirschner wires are driven from
Kurt Schulz the center of the axis across the atlantoaxial joint and are seated
in the atlas just medial to the alar notch (Figure 47-21C and D).1
This topic is written based on the available literature through The point of each pin must be kept as ventral as possible to avoid
2010 and does not cover the most current literature on this topic. penetrating the dorsal surface of the thin wings of the atlas. The
length of the pins is premeasured from the point of entry into the
Two categories of surgical techniques have been described. Both axis to the palpable medial aspect of the alar notches on the
dorsal and ventral approaches aim to stabilize the atlantoaxial atlas. When both pins are seated, they are cut off close to the
joint in the normal position; however, only ventral approaches body of the axis. The protruding ends are crimped and bent to
allow for complete fusion of the involved cervical vertebrae and prevent cranial migration of the pins into the occipital condyles.
permit excision of the dens if necessary.
The addition of polymethylmethacrylate to the stabilization
technique may increase the odds of successful arthrodesis by
Ventral Approach enhancing stability and may reduce the risk of pin migration (KS
Atlantoaxial instability can be resolved permanently by fusing the Schultz, Waldron DR, unpublished data). Pins are first placed into
two vertebrae in anatomic alignment, a procedure that is easier the atlas (Figure 47-22A). This placement is facilitated by gentle
from a ventral approach. This approach also allows access to the dorsiflexion of the atlantoaxial joint that allows visualization of the
dens if removal is indicated because of fracture or severe dorsal spinal canal. Kirschner wires or small threaded pins are directed
displacement. With the dog in dorsal recumbency, the head and perpendicular to the long axis of the spine from ventral to dorsal
neck should be extended and supported by padding under the into each of the pedicles of the atlas. The atlantoaxial joint is then
cervical area (Figure 47-21A). The surgical approach is made reduced, and pins are placed across the joints as described for pin
through a ventral midline incision extending from the larynx to the stabilization alone. One or two pins are then placed into the caudal
manubrium, followed by separation of the paired sternothyroid body of the axis (Figure 47-22B). All pins are cut short and are bent,
muscles. The trachea, esophagus, and carotid sheath are bluntly leaving enough pin length to engage a small mass of polymethyl-
dissected to allow lateralization. The paired hypaxial muscles methacrylate (Figure 47-23). Antibiotic powder should be added to
ventral to the atlas and axis then are separated carefully on the the cement, and cool saline flush should be applied during polym-
midline and are lateralized with self-retaining retractors. erization of the cement to dissipate heat.
The joint capsule of the atlantoaxial articulation should be The surgical approach and preparation of the atlantoaxial joints
identified and opened with a No. 11 Bard-Parker blade (Figure are identical for stabilization with lag screws.2 In small dogs,
738 Bones and Joints
Figure 47-21. A. Positioning of the patient for a ventral approach to the atlantoaxial joint. B. The ventral aspect of the atlantoaxial joint seen from a
craniolateral view. C. Pin placement through the atlantoaxial joints from the ventral body of the axis. Accurate seating of the pins into the medial
side of the alar notch is essential. D. A lateral view of the stabilization pin placement from the ventral body of the axis, through the atlantoaxial
joint, and into the heavy bone surrounding the neural canal.
Figure 47-22. A. Pin placement into the lateral masses of CI. B. Pin placement into the caudal body of C2.
Cervical Spine 739
Figure 47-23. Lateral and ventrodorsal radiographs showing stabilization of the atlantoaxial joint with ventral pins and polymethylmethacrylate.
1.5-mm cortical screws are placed across each of the joints in a lag more difficult, we recommend them because of their lower
fashion. This technique may be facilitated by use of a cannulated failure rate.4 Complications of dorsal techniques include insta-
drill and screw system. In either case, placement of the screws is bility resulting from breakage of the suture, wire, or graft and
in a direction similar to that of the transarticular pins. Ventral appli- fracture of the axis or atlas. Wire stabilization may fail because
cation of bone plates has also been described; however, the size of of cycling, and the addition of polymethylmethacrylate to the
most patients may limit the practical application of this technique.3 wire technique has been recommended to alleviate this compli-
cation. Fracture of the axis may be due either to inappropriate
Postoperative radiographs should be obtained after stabilization placement of the holes or to the remaining motion of the joint,
with any of the ventral techniques to demonstrate reduction of which places excessive forces on the stabilization technique.
the atlantoaxial joint and accurate placement of implants. Neck
braces should be maintained if possible for several weeks, and Medical management including cervical splinting has been
initial cage rest is strictly enforced. Radiographs may be obtained successful in selective cases; however, surgical therapy is
8 weeks postoperatively to evaluate maintenance of reduction and recommended for patients demonstrating significant neuro-
progression of arthrodesis. logic signs that have no other contraindications for anesthesia
or surgery.5 Ventral techniques are technically challenging, but
Complications of ventral stabilization techniques include implant because of the higher failure rates of dorsal techniques, the
migration and loosening.4 The result may be subsequent instability routine use of dorsal procedures should be avoided.4
and recurrence of neurologic signs. Placement of pins or screws
within the vertebral canal may also worsen the neurologic signs.
Tracheal necrosis has been reported with the ventral approach; References
therefore, gentle dissection and attention to preservation of the 1. Sorjonen DC, Shires PK. Atlantoaxial instability: a ventral surgical
delicate blood supply of the region are indicated. As with any technique for decompression, fixation, and fusion. Vet Surg 1981;10:22-29.
surgical implantation of polymethylmethacrylate, concern exists 2. Denny HR, Gibbs C, Waterman A. Atlanto-axial subluxation in the dog:
for thermal injury and infection. a review of thirty cases and an evaluation of treatment by lag screw
fixation. J Small Anim Pract 1988;29:37-47.
3. Thomas WB, Sorjonen DC, Simpson ST. Surgical management of
Dorsal Approach atlantoaxial subluxation in 23 dogs. Vet Surg 1991;20:409-412.
The dorsal arch of the atlas is secured to the dorsal spine of the 4. McCarthy RJ, Lewis DD, Hosgood G. Atlantoaxial subluxation in dogs.
axis with heavy suture material, orthopedic wire, or grafts of the Compend Contin Educ Pract Vet 1995;17:215-226.
nuchal ligament. Descriptions of these techniques are available 5. Gilmore DR. Nonsurgical management of four cases of atlantoaxial
in the third edition of this text. Although ventral techniques are subluxation in the dog. J Am Anim Hosp Assoc 1984; 20:93-96.
740 Bones and Joints
Surgical Treatment of Fractures Generally, stable fractures in patients with good voluntary motor
movements to the limbs are successfully managed by conser-
of the Cervical Spine vative means, including the use of analgesics, non-steroidal anti-
inflammatory agents, body splints, and strict cage confinement.3,4
Karen L. Kline and Kenneth A. Bruecker Serial neurologic examinations are performed (twice daily) to
determine the response to treatment.
General Considerations
Surgical management is indicated 1) if the fracture/luxation is
When considering treatment options for a patient with a spinal
considered unstable, 2) if the patient presents nonambulatory
fracture, luxation or subluxation, several factors should be
paraparetic or tetraparetic with no voluntary motor movements, or
considered; 1) results of the neurologic examination, 2) is the
3) if with conservative therapy, the patient remains unacceptably
fracture pathologic or traumatic, and 3) is the fracture stable or
static or deteriorates neurologically.
unstable.
Several factors must be considered when selecting a stabilizing
The neurologic examination is critical in determining prognosis.
technique: 1) location of the fracture/luxation (cervical, thoracic,
If the patient has lost all sensory and motor function caudal
lumbar, sacral), 2) presence of a compressive lesion within the
to the lesion, the prognosis is unfavorable and treatment is
spinal canal (ie. osseous fragment, disk material, hematoma), 3)
generally supportive. Surgery in this situation may be indicated
size of the patient, 4) age of the patient, 5) equipment available,
for prognostic purposes only (ie. exploratory laminectomy). If
6) experience of the surgeon, and 7) physical and emotional
deep pain perception is still present, the prognosis is guarded
capability of the owner to provide postoperative nursing care.
to favorable (depending on the degree of neurologic dysfunction
and the timing of the event or injury) and surgical decompression
and stabilization is performed with curative intent. Surgical Techniques
The two objectives of any surgical technique used to repair
Patients with pathologic fractures have an underlying localized spinal fracture/luxation are decompression and stabilization.
or generalized disorder. Examples of this would include a solitary Many techniques have been successfully used to stabilize spinal
plasma cell tumor, multiple myeloma or other classifications of fracture/luxation in small animals. In the following discussion,
paraneoplastic or infectious disorders. The cause of the under- techniques commonly used to repair fractures and luxations
lying disorder must be determined and therapy instituted prior to of the spine will be described as they are indicated in various
or concurrent with spinal fracture/luxation repair. regions of the vertebral column. These chapters will be divided
into surgical treatment of cervical spinal fractures, luxations and
Physical examination findings and radiographic assessment may subluxations and surgical management of thoracolumbar, lumbar
be helpful in determining the inherent stability of the fracture/ and lumbosacral fractures, luxations and subluxations. The above
luxation.1 In small animal patients, traumatic disruption of the discussion regarding prognosis and patient selection in cases of
spinal column can be divided into dorsal compartment injuries, spinal trauma applies to both categories of injury and disease.
ventral compartment injuries, or combined compartment injuries.
Combined compartment injuries are more devastating and more
common than injuries isolated to one compartment. The majority Fractures of the Cervical Spine
of spinal injuries are flexional injuries, but occasionally hyperex- Cervical spinal fractures are uncommon.4,5,6 Most fractures
tension or direct compression injuries may occur. Rotation is a of the cervical spine involve C1 (axis), particularly the dens
common concurrent force associated with these injuries. and/or body.6 In fact, the most frequent anatomic location of
cervical fracture/luxation is the cranial cervical region with 80%
Fractures may be classified as stable or unstable by the radio- occurring at C1-2. Because the cervical region has the largest
graphic appearance and by the force causing the injury. Forces ratio of vertebral canal to spinal cord diameter, conservative
resulting in damage to the dorsal compartment generally result in management consisting of external support and cage rest in
an unstable injury. Examples include laminar or pedicle fracture, unstable and/or displaced fractures may carry a more favorable
dorsal spinous process fracture, articular process fracture, and prognosis than elsewhere in the spine.7 Mortality rates can be
supraspinous/interspinous ligament rupture.2 as high as 35 to 40% with surgery.7 Severe intraoperative hemor-
rhage may also occur with C2 fractures and reduction can be
If surgery is deemed necessary, it is important to select a challenging.5,7,8 External splints, though cumbersome, may be
technique that will not further destabilize the spine. Herniated made from various materials. Surgery is best reserved for those
disk material or osseous fragments within the spinal canal may animals that 1) are tetraplegic or have poor ventilatory function
be anticipated in flexion or bursting type injuries. Concussive and 2) show neurologic deterioration despite proper confinement or
contusive forces can cause spinal cord swelling even without external fixation, and 3) remain painful beyond the initial 48 to 72
evidence of an extradural mass. Extradural hematoma formation hour period following injury.5
can be quite extensive and can be delineated on MRI or CT scan
imaging. Infolding of the ligamentum flavum during hyperex- Fractures of the dorsal spine of the axis should be approached
tension injuries may also result in spinal cord injury. dorsally and stabilized with orthopedic wire to reestablish the
continuity of displaced fragments. A decompressive hemilamine-
ctomy can be performed if fragments of bone are present in the
Cervical Spine 741
spinal canal, or if a displaced body fracture cannot be reduced. approach is that a ventral slot can be performed if disk fragments
Atlantoaxial subluxation can be repaired from a dorsal approach have extruded into the spinal canal.
utilizing either a double or single wiring or suturing technique.7
The use of pins (or screws)and polymethyl methacrylate should
C1-C2 body fractures/luxations, traumatic cervical disk extru- be considered for cervical spinal fractures involving the vertebral
sions, and atlantoaxial subluxation can be approached ventrally. bodies of C2-C7. The ventral aspect of the involved vertebrae is
Ventral cross-pin techniques may be used for stabilization of exposed.12 Once the fracture is reduced, a minimum of two trocar
atlantoaxial subluxation10 (Figure 47-24). tip pins should be placed in the cranial fragment and a minimum
of two pins should be placed in the caudal fragment. Alterna-
Fractures and luxations rarely occur from C3 to C7 however, tively, the fractured vertebral body can be bridged by insertion
a predisposition to luxations at C5-C6 may exist.6,11 Fracture/ of pins into the vertebrae cranial and caudal to the fracture. It
luxations of C3-C7 may be approached dorsally or ventrally. is important to engage two cortices with each pin. The pins are
Dorsal techniques include articular facet wiring or screwing, inserted on the ventral midline of the vertebral body and directed
dorsal spinous process plating and multiple Steinmann pins and 30 to 35 degrees dorsolateral to avoid entering the spinal canal.
polymethyl methacrylate (described in detail under Fractures In addition, the pins can be angled cranially and caudally to
of the T-L and Lumbar Spine). Ventral techniques include pins enhance stability of the implant. The pins are cut leaving 1 to 1.5
and polymethyl methacrylate and ventral body plating (plastic cm exposed. The exposed pins can be notched with pin cutters
[footnote a] or metal [footnote b]). One advantage to the ventral and covered with sterile polymethyl methacrylate13 (Figure 47-25).
Preferentially, specific purpose acrylic pins with threaded trocar
tips and knurled shaft allows good bone anchor and foothold for
the PMMA. The heat of polymerization is dissipated with 5 to 10
minutes of cool saline irrigation. A neck brace may be used for 4
to 6 weeks postoperatively. The limiting factor of this technique is
the purchasing ability of the pins in small fragments. Screws can
also be used as described above.14,15,16 The main disadvantage of
the above described techniques can be failure if used to span
more than one intervertebral space especially in cases where the
vertebral body is shattered or collapsed. In these cases, at least
3 implants should be placed on either side of the fracture and
Steinman pins used to reinforce the cement. In some reports2,11
if dorsal stability is required (ie especially after facet luxation),
screws can be placed transarticularly.5 Reduction of cervical
fracture/luxations can be facilitated by gently distracting the
affected vertebral bodies. Fenestration of the adjacent interver-
tebral disks or slots drilled into the vertebral bodies cranial and
caudal to the fracture/luxation can be created to accommodate
a vertebral distractor. A Gelpi retractor, modified by blunting the
tips, is a useful vertebral distractor.
Figure 47-25. Stabilization with ventrally placed Steinmann pins and methyl methacrylate of cervical fractures/luxation. Ventral slot can be per-
formed to remove herniated disk material. (From Blass CE, Waldron DR, van Ee RT. Cervical stabilization in three dogs using steinmann pins and
methyl methacrylate. J Am Anim Hosp Assoc 1988;24:61-68.)
References 13. Blass CE, Waldron DR, van Ee RT. Cervical stabilization in three dogs
using steinmann pins and methylmethacrylate. J Am Anim Hosp Assoc
1. Feeney DA and Oliver JE. Blunt spinal trauma in the dog and cat: 1988; 24:61-68.
neurologic, radiologic and therapeutic correlations. J Am Anim Hosp 14. Rouse GP and Miller JI. The use of methyl methacrylate for spinal
Assoc 1980;16:664-668. stabilization. J Am Anim Hosp Assoc 1975;11:418-425.
2. Swaim SF. Biomechanics of cranial fractures, spinal fractures, and 15. Rouse GP. Cervical Spinal Stabilization with polymethylmethacrylate.
luxations, in (ed) Bojrab, Pathophysiology in Small Animal Surgery. Vet Surg 8.1979.1.
1981:774-778.
16. Schulz KS, et al. Application of ventral pins and polymethyl-
3. Carberry CA, Flanders JA, Dietze AE, et al. Nonsurgical management methacrylate for management of atlantoaxial instability: results in 9
of thoracic and lumbar spinal fractures and fracture/luxations in the dog dogs. Vet Surg 26.317-325.
and cat: a review of 17 cases. J Am Anim Hosp Assoc 1989;25:43-54.
4. Feeney DA and Oliver JE. Blunt spinal trauma in the dog and cat:
insight into radiographic lesions. J Am Anim Hosp Assoc 1980;16:885-
890.
5. Sharp NJ and Wheeler SJ: Trauma. In Small Animal Spinal Disorders.
Philadelphia; Elsevier, 2005, 282-305.
6. Stone EA, Betts CW, Chambers JN. Cervical fractures in the dog: a
literature and case review. J Am Anim Hosp Assoc 1979;15:463-471.
7. Hawthorne JC, et al. cervical vertebral fractures in 56 dogs: a retro-
spective study. JAAHA, 35, 135-146.
8. Boudrieau RJ. Distraction-stabilization using the Scoville-haverfield
self-retianing laminectomy retractors for repair of 2nd cervical vertebral
fractures in 3 dogs. Vet and Comp Orthopaedics and Traumatology 10,
71.
9. Oliver JE and Lewis RE. Lesions of the atlas and axis in dogs. J Am
Anim Hosp Assoc 1973;9:304-313.
10. Sorjonen DC and Shires PK. Atlantoaxial instability: A ventral
surgical technique for decompression, fixation, and fusion. Vet Surgery
1981;10:22-29.
11. Basinger RR, Bjorling DE, Chambers JN. Cervical spinal luxation in
two dogs with entrapment of the cranial articular process of C6 over the
caudal articular process of C5. J Am Vet Med Assoc 1986;188:865-867.
12. Piermattei DL. An atlas of surgical approaches to the bones and
joints of the dog and cat. 3rd ed. WB Saunders, 1993;45-89.
Thoracolumbar and Sacral Spine 743
Chapter 48 A skin incision is made from one to two spinous processes rostral
to the anticlinal vertebra (T11) to one vertebra rostral to the ilium.
This incision may be made directly on the dorsal midline or 1
Thoracolumbar and to 2 cm lateral to the midline on the side from which discs are
to be fenestrated. The cutaneous trunci muscle, subcutaneous
Sacral Spine fat, and superficial fascia are incised in the same plane and are
reflected sufficiently to expose lumbodorsal fascia 1 to 2 cm
lateral to the dorsal midline (Figure 48-1A). Lumbodorsal fascia
Intervertebral Disc Fenestration and aponeurosis of the longissimus thoracis et lumborum muscle
James E. Creed and Daniel J. Yturraspe
Indications
Fenestration of thoracolumbar intervertebral discs is appro-
priate for dogs of breeds predisposed to disc herniation (such
as the dachshund and Pekingese), with clinical signs ranging
from lumbar pain to paresis, that are otherwise in good health
and are less than 8 years of age. One study indicated that only
5% of dogs with thoracolumbar disc herniations were more
than 8 years of age.1 Whether older dogs are less likely to have
recurrent problems is unknown, but in such dogs a conservative
approach seems advisable initially.
Preoperative Preparations
Corticosteroids and antibiotics are administered preoperatively.
Anesthesia is induced with a short-acting anesthetic agent and
maintained by endotracheal administration of an acceptable
volatile agent. Intravenous fluids are administered during
surgery and postoperatively. An area of the back extending from
the vertebral border of each scapula to the crest of each ilium
is clipped and prepared for surgery. The dog is positioned in
ventral recumbency on an insulating pad to conserve body heat.
It is most convenient for surgeons to operate from the side of the
patient opposite that of their dominant hand. Radiographs and a
skeleton should be available for reference.
Surgical Technique
A dorsolateral approach2 is used to gain access to eight inter- Figure 48-1. Surgical anatomy of the dorso-lateral approach to the
vertebral discs between T10 and L5. Discs between T9-10 and thoracolumbar discs of the dog. A. The skin, subcutaneous fascia, fat,
L5-6 can also be fenestrated if they are calcified or partially and cutaneous trunci muscle have been incised and reflected laterally
on the left side of the dog. B. The deep external fascia of the trunk, the
herniated. These discs are not routinely fenestrated because of
aponeurosis of the longissimus thoracis muscle, and the caudal edge
their low incidence of herniation. They are also technically more of the spinalis et semispinalis muscles have been incised to expose
difficult to fenestrate because of anatomic differences. Not only the underlying multifidus and longissimus muscles. C. The multifidus
is the L5-6 disc more difficult to fenestrate, but also considerable muscle is separated from the longissimus thoracis muscle by blunt
risk of creating a femoral nerve deficit exists if the adjacent dissection to expose the thoracolumbar spine for intervertebral disc
ventral nerve branch is damaged. fenestration.
744 Bones and Joints
are incised along an imaginary line from a point 5 mm lateral spinal nerve or its allied vessels. As the operation proceeds
to the spinous process of T9 to a point 1 to 2 cm lateral to the caudally from T13 to L1, succeeding transverse processes are
comparable process of L6 (Figure 48-1B). In the rostral portion of progressively deeper.
the surgical field, the caudal border of the spinalis and semispi-
nalis thoracis muscles, interposed between the lumbodorsal As the surgeon exposes lumbar transverse processes (L1-5), the
fascia and aponeurosis of the longissimus thoracis muscle, is lumbar discs are exposed. The lateral anulus of intervertebral discs
also incised (Figures 48-1B and 48-2). lies immediately rostral to the base of each transverse process
(Figure 48-4). In the caudal thoracic area, discs are rostromedial
Access to intervertebral discs is gained by opening the inter- to the head of each rib. The T10-11 disc is difficult to expose
muscular septum between multifidus lumborum and thoracis because it is 1 to 2 cm ventromedial to and is partially covered by
muscles medially and longissimus dorsi and sacrococcygeus the rib tubercle. Each disc can be visualized by elevating tissue off
dorsalis lateralis muscles laterally (Figures 48-1C, 48-2 and the lateral anulus with a periosteal elevator. Use of a small self-
48-3). This septum is the first one lateral to the dorsal spinous retaining retractor (Gelpi or Weitlaner) or hand-held retractors
processes; it is easiest to locate in the midlumbar region, where enhances visualization. Care should be taken not to invade inter-
fat is interposed superficially between muscles. Muscles are vertebral foramina, which lie immediately dorsal to each disc
easily divided by blunt dissection in the lumbar region; however,
the septum is less distinct over the ribs. All blunt dissection is
done with a curved semisharp Adson, or comparable, periosteal
elevator in each hand. As tubercles of the last four ribs are
exposed, care should be taken not to disturb small nerves and
vessels coursing craniolaterally immediately dorsolateral to
each tubercle. Separating muscles is carried to the base of the
lumbar transverse processes.
Figure 48-4. L3-4 showing the relation of the spinal nerve to the inter-
Figure 48-2. Cross section through T12. A. Multifidus thoracis muscle. vertebral disc. A. Ventral branch of L3 spinal nerve. B. Intervertebral
B. Longissimus thoracis muscle. C. Spinalis et semispinalis muscles. disc.
Thoracolumbar and Sacral Spine 745
and contain spinal nerves and allied vessels. The inexperienced Fenestrating T10-11 disc requires special care to avoid creating
surgeon may overcompensate while attempting to avoid inter- pneumothorax; pleura, directly ventral to this disc, rises and falls
vertebral foramina and work too far ventrally, where one risks with respiratory movement. If existence of pneumothorax is in
injuring ventral branches of spinal nerves. Ventral branches of question, irrigating the area with saline solution and expanding
spinal nerves pass adjacent to the ventrolateral aspect of each the lungs by compressing the ventilation bag should provide an
disc (See figure 48-4). answer; air bubbles will appear in the surgical field if significant
pneumothorax exists.
In the lumbar area, ventral branches of the spinal nerves are
located under the intertransverse fascia and are not visible in Minimal hemorrhage associated with exposure and fenestration of
the surgical field unless an attempt is made to expose them. To thoracolumbar discs can usually be controlled by topical pressure
ensure that a ventral branch is not traumatized, the tip of a curved on bleeding tissue with a periosteal elevator. Rarely, hemostatic
mosquito hemostat can be introduced into the intertransverse forceps or electrocautery is required to control bleeding.
fascia adjacent to the ventrolateral border of the anulus and
the jaws can be spread gently. This exposes the ventral nerve Every disc fenestrated should be identified to ensure no discs
branch occasionally, and creates a landmark for the surgeon to are missed between T10 and L5. If clinical signs merit decom-
avoid. If the L5-6 disc is fenestrated, the ventral branch of the pression of the spinal cord, decompression should be performed
fifth lumbar nerve should be identified and avoided to ensure it first, followed by disc fenestration. Fenestration is more
is not damaged. compatible with hemilaminectomy than with dorsal decom-
pression. Hemilaminectomy and fenestration can be performed
A disc’s lateral anulus is visualized best for fenestration if from the same side; although the multifidus muscle is badly
adjacent muscle is retracted rostrodorsally with a curved, traumatized, no adverse clinical signs have been observed.
semisharp periosteal elevator. This instrument also protects Lateralization of signs often dictates performing a decom-
dorsal branches of spinal nerves and associated vessels. A pressive surgical procedure and fenestration on opposite sides
pointed scalpel blade is used either to incise or to remove an of the spinal column.
elliptical section of the anulus fibrosus. The anulus should not be
cut where it cannot be visualized. Fenestration is accomplished Debridement of tissue is not necessary when the “tunnel”
with a modified dental-claw tartar scraper or the eye portion of technique is used to expose lumbar discs. Performing a
a large suture needle held in a needle holder. Modifications to hemilaminectomy on the same side, or division of the multi-
dental tartar scrapers include grinding off the sharp tip and sides fidus and longissimus dorsi muscles down to the level of trans-
of the claw. The nucleus pulposus is removed using a circular verse processes for improved exposure, may necessitate some
motion. The tip of the hook or needle-eye is directed upward, debridement. Aponeurosis of the longissimus and spinalis et
with care taken not to break through the dorsal anulus. A partially semispinalis muscles in the caudal thoracic area and overlying
herniated disc must he fenestrated cautiously, to avoid forcing thoracolumbar fascia are approximated with one suture line of
additional nucleus pulposus into the spinal canal (Figure 48-5). absorbable suture material. Subcutaneous tissues are apposed
The surgeon must remove as much disc material as possible. with similar material, catching underlying fascia occasionally
to obliterate dead space. The skin incision is closed with any
dermal suture. A light-pressure bandage may he applied around
the trunk of the dog and left in place for 4 to 7 days.
Figure 48-7. Paracostal incision by retroperitoneal exposure for lumbar disc fenestration.
Figure 48-8. The sublumbar muscles and sympathetic trunk have been
elevated, and the crus of the diaphragm and the aorta have been
depressed during a lumbar disc procedure.
dorsal spine can be undercut to the off side of the spinal canal.
Benefits
The ventral 1 to 2 cm of the dorsal spine can be removed, allowing Inclusion of this approach to the thoracic spine with well-known
wide lateral exposure to the off side (Figure 48-13). The resultant approaches to the neck and lumbar spine allows the surgeon to
floating dorsal spine, suspended by interspinous muscles and explore any lesion in the spinal canal from the foramen magnum
supraspinous ligament, produces no noticeable effect. Likewise, to the coccygeal vertebrae. Most extradural lesions can be
the rib head, neck, and tubercle can be removed as needed for removed from the spinal canal, especially if undercutting the
lateral cord exposure on the near side. The resultant floating rib dorsal lamina or removal of the base of the dorsal spine is used
seldom causes problems because it is supported by adjacent ribs to gain access to the far side of the spinal cord.
through the intercostal muscles. As the surgeon moves forward
in the thoracic spine, the ribs articulate higher in the inter- Limitations
discal space and may necessitate rib head, neck, and tubercle Long, wide laminectomies over many disc spaces entail removal
resection. Resection of the proximal rib head, neck, and tubercle of the bases of many dorsal spines. The need for stabilization of
allows adequate spinal cord visualization. Care must be taken to these spines to prevent their ventral collapse into the lamine-
avoid dissection below the rib that could allow penetration into ctomy site adds additional hardware, expertise, and complexity
the chest cavity, thereby creating a pneumothorax. to an already challenging approach. In addition, visualization,
especially under the spinal cord, is sometimes poor.
The length of the dorsal spines in some breeds may create a
deep surgical field. Proper instrumentation and lighting allow The scapula prevents a lateral view of the cord in the cranial
careful cord evaluation. The arteries encountered are the dorsal thoracic spine. Instruments have to be placed from a dorsal
branches of the intercostal arteries. The spinal branches supply aspect. This necessitates using right-angled instruments that
the spinal cord through the foramen just above the rib neck. These are not used in cervical and lumbar spine operations. Removal
vessels can be avoided by staying close to the midline along the of the rib head and neck, especially over many disc spaces,
dorsal spines. The veins encountered parallel the arteries and adds complexity.
join the azygos posterior to the heart and the costocervical-
vertebral trunk anterior to the heart. A surgical headlamp and 2x loop magnification are helpful
in visualizing the spine especially in deep surgical fields.
Bipolar cautery and fine tip suction are essential in providing
hemostasis. The added visual acuity gained by hemostasis is
more beneficial than the more obvious benefit of preventing
blood loss and shock.
Variations: First and Second Thoracic term “hemilaminectomy” may be a misnomer, since the lamina
of the vertebrae is the boney structure which is dorsal to the
Cord Exposure vertebral canal, dorsal to the articular facets. The pedicle, or root,
The first and second thoracic vertebral cord can be approached is the boney structure lateral to the vertebral canal between the
as a posterior extension of a seventh cervical dorsal vertebral body and articular facets. It is the pedicle, more than the
laminectomy.4,5 The thoracic dorsal spines can be exposed lamina that is removed during what is commonly referred to as a
anteriorly without disturbing the ligamentum nuchae or supra- hemilaminectomy. Some authors do refer to removal of sections of
spinous muscles, which are retracted laterally. The drill is the pedicle as pediculotomy, however the term hemilaminectomy
angled from anterior to posterior, with the right-handed surgeon is used to describe the common surgical procedure for removal of
positioned on the right side of the patient that has been placed part of the vertebral arch on a single side of the spinous process
in sternal recumbency. Removal of the lamina between the base to gain access to the vertebral canal.
of the dorsal spine and first rib head exposes the spinal cord and
canal over one side. Care must be used to leave enough of the The timing of surgical intervention and the urgency of spinal
base of the first dorsal spine to maintain the strength necessary cord decompression has been explored in several clinical
to support the head and neck through its attachment of the studies. Though there is some disagreement in interpretation of
nuchal ligament. This limits the exposure of the first thoracic the clinical studies, and hospitals have different capabilities for
spinal cord. If complete removal of the base of the first dorsal after hours imaging and surgery, a general consensus regarding
thoracic spine is needed, then enough of the base of the spine the triage of patients with spinal cord compression is available.
should be removed to prevent downward pressure of the spine In cases of thoracolumbar spinal cord compression resulting
stump on the exposed cord. Support of the head by the nuchal from presumed intervertebral disk extrusions or protrusions the
ligament, which attaches to the first three dorsal spines, pushes recommendations are as follows:
the remaining spine ventrally when its lower base is removed.
1. No deep pain less than 12 hours. Emergency operation should
Approaching the anterior thoracic cord in this way avoids the be recommended. The prognosis is 50% for ambulating. At
disruption of the musculature along the dorsal spine and attach- present, there are no clinical studies that demonstrate efficacy
ments to the scapula. The scapula influences the approach to of any glucocorticosteroid including methylprednisolone sodium
the thoracic spine only anterior to T6 or T7. Posterior to these succinate, therefore the administration of these medications in
areas, the approach is similar to that of the lumbar spine. not indicated.
2. No deep pain over 24 hours. Operate when practical.
“Practical” is defined as in the morning if presented at night, as
References soon as possible if presented during the day, but do not wait until
1. Biggart JF III. Laminectomy membrane: etiology and prevention. In: the next day. There is no reported correlation between duration
Proceedings of the American College of Veterinary Surgeons Annual of paralysis prior to surgery, and clinical outcome.
Meeting. Denver, CO: American College of Veterinary Surgeons, 1981. 3. Acute, less than 12 hours with no motor function but deep pain
2. Biggart JF III. Prevention of laminectomy membrane by free fat grafts is present. Offer emergency operation contingent on personnel,
after laminectomy in dogs with disc herniations. Vet Surg 1988;17:29. progression of neurologic signs and how long to morning (e.g. is
3. Gill GG, Sakovich L, Thompson E. Pedicle fat grafts for the prevention it 3:00am? Then wait.) These cases may loose deep pain as the
of scar formation after laminectomy. Spine 1979;4:I76. pathophysiology is not static. Prognosis is therefore guarded but
4. Piermatei DL, Greeley RG. An atlas of surgical approaches to the bones not poor.
of the dog and cat. 2nd ed. Philadelphia: WB Saunders, 1979:46-49. 4. Deep pain present, no motor function, over 24 hours. Operate
5. Parker AL. Surgical approach to the cervico-thoracic junction. J Am when practical. Prognosis is good with 96% of dogs becoming
Anim Hosp Assoc 1979;9:374-377. ambulatory. It will take an average of two weeks for these dogs
to walk.
Hemilaminectomy of 5. Non-ambulatory, purposeful motor movement. If admitted in
evening, then operate in am. Perform serial neurologic exams
the Caudal Thoracic and to assure patient’s neurologic status does not worsen. Some
facilities will delay day admitted cases if the neurologic exami-
Lumbar Spine nation is static and noninvasive imaging (CT,MR) is available in
Karl H. Kraus and John M. Weh the morning, therefore avoiding a myelogram. Prognosis is good
for ambulating. It will take an average of one week for these
dogs to walk.
Hemilaminectomy of the Caudal Thoracic 6. Ambulatory paretic. Operate the next day. Of course sooner
and Lumbar Spine if patient is stable and facilities and personnel are available.
Prognosis is excellent for ambulating. Cage rest can be
Hemilaminectomy of the caudal thoracic and lumbar spine is used
considered if cost is a factor, but owners should be warned
to gain access to the vertebral canal for the removal of offending
about worsening of neurologic status including paralysis.
masses, often impinging on or involving the spinal cord. These
masses include intra and extradural tumors, granulomas, bone
A majority of disk extrusions occur near the thoracolumbar
fragments resulting from vertebral fracture, and (by far most
junction; rostral to the lumbar intumescence of the spinal cord
common) intervertebral disk extrusions and protrusions. The
Thoracolumbar and Sacral Spine 751
and caudal to the thoracic intumescence. Therefore the neuro- be present on one side only. Since ribs are not always imaged
logic signs are normal sensation, proprioception and motor with MR, a dorsal plane scout film (dorsal plane localizer) from
function to the thoracic limbs and loss of proprioception, motor the sacrum to the twelfth thoracic vertebra will demonstrate
function, and pain sensation (in that order) to the pelvic limbs. rib anatomy. Hemi-vertebra may be present at the lumbosacral
The common neurologic localization and clinical diagnosis is a junction. These anatomic variations must be noted and kept in
T-3 to L-3 (third thoracic to third lumbar spinal cord segment) mind. With MR, a scout film (sagittal localizer) will image the
myelopathy. Disinhibition from compromise of the upper motor celiac and cranial mesenteric vessels along with the lumbar
neurons to the femoral and sciatic nerves results in hyper-reflexia vertebrae. The vessels arise below the thirteenth thoracic or
or upper motor neuron signs to the patellar and cranial tibial first lumbar vertebrae. These vessels serve as land marks for
reflexes. The progression of signs from loss of proprioception, more focal MR images.
to loss of motor function, to loss of superficial then deep pain,
is most often a function of compression on the descending and Palpation of the spinous processes can usually give the proper
ascending spinal cord axons. The larger axons, such as those location in the lumbar area. The spinous process of the seventh
that carry proprioceptive information, are affected first. Deep lumbar vertebra may be palpated between the cranial aspects
pain sensation, or spinal thalamic pathways are not discrete in of the wings of the ilium. The spinous processes are usually
domestic animals as they are in humans. Instead they are diffuse, palpable and the surgeon can count cranially to find the proper
multisynaptic and bilateral within the spinal cord. Loss of deep surgical site. In some cases where lumbar fat is very thick, the
pain perception reflects a functional transection of the spinal surgeon may need to make an approximate surgical approach
cord. Though a functional transection does not necessarily through the skin and lumbar fat, then palpate the spinous
mean an irreversible condition, the loss of deep pain sensation processes surgically. In the thoracolumbar area, the ribs serve
is a negative prognostic indicator. The alpha motor neurons as landmarks for localization. Again, confirm the anatomy of the
to the femoral nerve are located above the interbertebral disk patient, as transitional vertebrae and small vestigial ribs can
between the third and fourth lumbar vertebrae. The alpha motor confuse localization. After an initial surgical approach through
neurons to the sciatic nerve are located roughly above the the skin and fat is made, a small incision in the lumbar fascia
fourth and fifth lumbar vertebra. For this reason compressions lateral to the longissimus and iliocostalis muscles is made by
of the spinal cord in these locations can result in lower motor the thirteenth rib just large enough to accommodate one’s index
neuron signs to the segmental reflexes in these areas. Offending finger. The thirteenth rib can be palpated. This rib attaches to the
masses can impinge on vertebral nerve roots and can result in cranial aspect of the thirteenth thoracic vertebra. The spinous
pain and hyperesthesia due to the radiculopathy. Hyperesthesia process of the thirteen thoracic vertebra is also often the first
in descrete areas as assessed by the paniculus reflex can give a that can be distinctly palpated as those of the ninth to twelfth
more precise indication of the location of an offending mass. tend to be very close to each other. Once the thirteenth thoracic
spinous process can be identified with certainty, the location for
Because the neurologic examination often does not give an laminectomy can be accurately determined. Matching the shape
exact localization of the area of compression or side of the of the spinous processes seen during a surgical approach with
mass if it is lateralized, imaging should be performed to define pre-operative imaging is also helpful.
the pathology of the mass (tumor or disk, size) and location
(vertebral segment, left, right, midline). Myelography with Some surgeons use other techniques to localize the proper
conventional radiographs has classically been used to localize location for the hemilaminectomy. Specifically a hypodermic
the lesion. Though sufficient in most cases, a discrete lesion my needle (such as 22 ga.) can be pressed into a spinous process
not be apparent if there is considerable spinal cord swelling. In prior to surgery, then a lateral radiograph taken to define which
addition it may be difficult to differentiate disk extrusions from spinous process the needle is in. The hub of the needle is then
other pathologies. Computed tomography (CT) can be used since cut off leaving the shaft of the needle beneath the skin. The
many disks are partially calcified. The soft tissue resolution of needle is then found during the surgical approach, defining
newer CT scanners is very good and can image most masses. the proper surgical location. It is not uncommon, however, for
Spiral CT scanners are very fast and can noninvasively localize a a surgeon to loose the needle and spend some time finding it
lesion in less than 10 minutes in most cases. Magnetic resonance during the surgical approach. Another similar technique is to
imaging (MRI) scanners provide the best resolution of both soft use Methylene blue. Instead of leaving the shaft of the needle
and boney tissues and are becoming the standard of care for under the skin, a needle is pressed into a spinous process then a
neurologic imaging in veterinary medicine. lateral radiograph is taken. A small amount of sterile methylene
blue 1% (0.1 ml) is injected into the area of the spinous process
Once a lesion is localized with either modality, identifying the then the needle removed. The area of staining is found during
proper location for a surgical approach to perform hemilamine- the surgical approach defining the proper location. However,
ctomy can be troubling for inexperienced surgeons. Several the staining may not be as discrete as desired, especially in
strategies can be employed. First, the surgeon should count the the lower thoracic area, and therefore the surgeon may not be
number of lumbar vertebrae. This is obvious with myelograms absolutely certain about anatomic localization.
and most CT scans, but a scout image must be taken with MR
scans. Though in most cases there are seven lumbar vertebrae, in It is a standard of care in surgery on humans to take an intra-
some patients there are transitional vertebrae. Vestigial ribs may operative radiograph during the surgical approach to confirm
arise from the first lumbar vertebra, or the most caudal rib may localization. Many veterinary surgical hospitals have equipment
752 Bones and Joints
Figure 48-14. A head light and prescription 2.5X loops provide a surgeon
with illumination and magnification which is very helpful in neurosurgery.
Thoracolumbar and Sacral Spine 753
Figure 48-20. An approach with a larger burr that enters the vertebral Figure 48-21. Burring is started at the level of the dorsal aspect of
canal directly will result in a small aperture, limiting exposure and the the vertebral canal, in the center of a vertebra. The bur will progress
surgeon’s ability to remove an offending mass without manipulation of through the outer cortical bone (white in appearance), then through
the spinal cord. cancellous bone (red), then to inner cortical bone (white again). The
outer cortical bone and cancellous bone is removed progressing
ventrally.
Thoracolumbar and Sacral Spine 755
of the bur us used to remove bone from the vertebral canal and
the bur can be subtly felt to “give way” when the inner cortical
bone is removed. If skillfully and carefully performed, the inner
cortical bone can be removed without breaching the inner
periosteum of the vertebral canal. If the inner periosteum is kept
in tact, the vertebral canal can be entered dorsally with a dental
or other instrument. This periosteum can be retracted ventrally,
exposing the vertebral canal and spinal cord and in addition
avoiding and even occluding the ventral vertebral sinuses.
Figure 48-23. A smaller bur is used to enter the vertebral canal. The Figure 48-24. In some situations, such as adherent disk material or
bur, again, is held so that the surgeon is not pushing toward the Hanson type II disks, the mass cannot be removed without manipula-
vertebral canal. The side of the bur is used to enter the vertebral canal, tion of the dura, which must be avoided. In these cases the disk and
preferably without breaching the inner periosteum. vertebral end plates beneath the dorsal annulus are removed. The disk
can then be pulled into the cavity that is formed, thereby decompressing
the spinal cord.
756 Bones and Joints
resulting scar and fibrous tissue do not result in compression intervertebral disc disease and loss of deep pain perception. J Sm Anim
of the spinal cord or nerve roots. A small amount of fat placed Pract 40: 417-422, 1999.
in the laminectomy aperture will prevent some scar tissue from Slocum B, Slocum Devine T: Pediculotomy in the thoracolumbar
forming. Fat grafts are frequently used in veterinary surgery. vertebra In Bojrab MJ, ed: Current Techniques in Small Animal Surgery,
However, the surgeon should use a small amount of fat as too 4th ed, Baltimore: Williams and Wilkins, 1998, p 853.
much can result in spinal cord compression when the hypaxial
musculature swells post operatively. The deep lumbar fascia
is closed with a monofilament absorbable suture material in a
Modified Dorsal Laminectomy
simple continuous pattern. The subcutaneous tissues and skin Eric J. Trotter
are closed routinely.
Introduction
Post operative Care A variety of surgical procedures have been described for
Steroids and antibiotics are not used post operatively. If the decompression of the spinal cord in the thoracolumbar region
spinal cord is decompressed, there is no rational for continued of dogs. The procedures differ in the amount of bone removed,
administration. Complications associated with steroid use in and thus, are referred to as hemilaminectomy, mini-hemilam-
neurosurgical patients are severe and well reported. Incisional inectomy, pediculotomy, pediculectomy, dorsal laminectomy,
infections are very rare. The main consideration for postoperative modified dorsal laminectomy, and laminectomy modifications,
care is micturition. If the patient recovers with purposeful motor including laminotomies and laminoplasties. Each technique has
movement, they can usually urinate on their own. However, if the its own indications, inherent advantages and disadvantages,
patient does not have purposeful motor movement, the bladder and most, if performed properly, satisfy the two basic tenets of
must be cared for until motor function returns, or the bladder spinal cord surgery, i.e., spinal cord decompression and mass
converted into an automatic bladder that the owner can care for removal. There is no one best technique for all patients.
at home. An indwelling urinary catheter can be used for several
days, but will often result in a urinary tract infection. In many Hemilaminectomy, mini-hemilaminectomy, and pediculectomy
cases the bladder can be expressed several times a day without are particularly well-suited to the removal of extruded or
catheterization. The bladder must never be allowed to overfill, protruded intervertebral disc material from the vertebral canal
because this results in stretching of the detrusor muscle and without fear of laminectomy membrane formation. Bone removal
an atonic bladder. In male dogs it may be necessary to admin- and resultant exposure of the vertebral canal and spinal cord
ister medications that relax the urethral spincters. The internal are minimal in comparison to dorsal decompressive techniques.
urethral spincter can be relaxed with phenoxybenzamine and Vertebral column stability is less compromised with these proce-
the external urethral sphincter with Diazepam. dures, even with concurrent prophylactic intervertebral disc
fenestration than with dorsal laminectomy techniques which
Those patients requiring several weeks to recover will require require bilateral exposure and partial facetectomies.
physical therapy. The goal of physical therapy is to frequently
move the limbs in physiologic walking motions. Resolution of Objective comparison of the many decompressive techniques,
spinal cord swelling and remyelination of damaged axons will at least in intervertebral disc disease, has been clouded by
result in complete return of neurologic function if axons are the many variables associated with spontaneous extrusion or
intact. However, more severe spinal cord damage with axonal protrusion of intervertebral discs in the thoracolumbar region.
loss and gliosis will require establishment of new synaptic Personal preference and the individual surgeon’s training
connections and central plastic reorganization. Physiologic have all too frequently determined the type of decompressive
motion enhances the speed and degree of these processes. procedure utilized. Previously, severely-limited imaging modal-
Swimming is excellent if tolerated, and should be begun as soon ities, i.e., flat films and myelography, also made rational, logical
after the sutures are moved as possible. The patient’s limbs selection of the most appropriate technique for the individual
should be moved in walking motions for at least fifteen minutes patient difficult, if not impossible. With the increased availability
three times a day. The patient should be encouraged to stand, of CT and MRI, selection of the most appropriate decompressive
support weight, and walk as much as possible. technique based on the precise location of the extradural mass
became far more objective, and allowed for minimally invasive
surgical techniques. For these reasons, although performed
Suggested Readings for many years with excellent results at this hospital, dorsal or
Davis GJ, Brown DC: Prognostic indicators for time to ambulation after modified dorsal laminectomy are only infrequently performed
surgical decompression in nonambulatory dogs with actue thoraco- for uncomplicated thoracolumbar intervertebral disc extrusion
lumbar disk extrusions: 112 cases Veterinary Surgery 31:513-518, 2002. or protrusion in chondrodystrophoid or non-chondrodystrophoid
Kraus KH. Medical managment of acute spinal cord injury. In Kirk RW dogs. However, in many cases, i.e., vertebral column fractures,
and Bonagura JD. (eds). Current Veterinary Therapy XIII: Small Animal luxations, congenital vertebral malformations, synovial cysts,
Practice. W.B. Saunders Co., Philadelphia, 2000. Pp. 186-190. arachnoid cysts, vertebral or spinal cord neoplasms, or syrinxes,
Moissonnie P, Meheust P, Carozzo C; Thoracolumbar lateral corpectomy and in some cases with intervertebral disc disease, laminectomy
for treatment of chronic disk herniation: Technique description and use will be the procedure of choice to allow for expansive spinal
in 15 dogs. Veterinary Surgery 33:620-628, 2004. cord exposure, decompression, and mass removal when these
Scott HW, McKee WM: Laminectomy for 34 dogs with thoracolumbar other techniques would prove to be inadequate.
Thoracolumbar and Sacral Spine 757
Surgical Technique for Modified elevation and the cauterization of small bleeders around the
articular processes to avoid exacerbation of spinal cord ischemia
Dorsal Laminectomy by interruption of the, at best, tenuous spinal cord blood supply
Following confirmation of the neuroanatomic lesion by either through the varying intervertebral foramen (dorsal and ventral
myelography, CT, or MRI, the anesthetized patient is placed in radicular branches).1-3
sternal recumbency, without pressure on the abdomen, and
prepared for aseptic surgery of the thoracolumbar spine. Prophy- For laminectomy at the thoracolumbar junction, the 13th rib and
lactic antibiotics (cefazolin, 22 mg/kg IV at time of surgery, then first lumbar transverse process are readily identifiable landmarks
22 mg/kg PO BID, G.C. Hanford Manufacturing Co., Syracuse, to confirm the appropriate site for laminectomy. The 13th rib
NY 13201) are administered intravenously at the time of surgical arcs dorsocaudally and is located far more superficially than the
intervention, and may be continued in the early postoperative cranioventrally directed first lumbar transverse process. Partic-
period. Corticosteroids (methylprednisolone sodium succinate, ularly in obese patients, some surgeons prefer to place a sterile
30 mg/kg IV, Solu-Medrol, Pharmacia & Upjohn, Kalamazoo, MI hypodermic needle into one of the dorsal spines during preop-
49001) may be administered at the time of surgery in patients erative films to confirm anatomic location, especially in the mid
who have not already been treated with steroids. Gastric lumbar spine, since localization by palpation of the dorsal spine
protectants (Pepcid, Famotidine, 0.5-1mg/kg QD or BID, Bedford of the seventh lumbar vertebra may be difficult. The spinous
Laboratories, Bedford, OH 44146; and sucralfate, medium and processes of the vertebrae cranial and caudal to the disc space
large dogs 1 gm TID, toy dogs (< 7 kg) 0.5 gm TID, Major Pharma- (in a two level laminectomy) are removed by means of bone
ceuticals, Livonia, MI 48150) are administered preoperatively rongeurs (Figure 48-26). This is preferable to the utilization of a
when possible, and continued postoperatively. bone cutter which can result in excessive torque being applied
to the vertebral column of small breed dogs.
The skin incision, centered over the area of involvement, is made
slightly lateral to the dorsal midline. Length of this incision is By means of a high-speed air drill with a new 4 mm egg-shaped
determined by the specific pathology in the individual patient. bur with notched flutes, the remainder of the dorsal spine is
Moistened laparotomy tapes or surgical paper towels are removed. Meticulous hemostasis, and irrigation with sterile
clipped to the reflected subcutaneous tissue and/or superficial saline or lactated Ringer’s solution and fluid removal by suction
fascia on each side of the incision to cover any exposed skin. maintains a clear field, removes the bone dust produced by the
The thoracolumbar fascia is incised bilaterally immediately air drill, and dissipates the minimal amount of heat produced by
lateral to the spinous processes. Periosteal elevators are utilized a new bur. Old dull burs should not be used for this technique
to lever or reflect the epaxial muscles bilaterally to a level just because they generate significant heat by sanding rather than
ventral to that of the accessory processes (Figure 48-25). Utili- cutting away the bone of the laminae. In cases of thoracolumbar
zation of self-retaining retractors (Gelpis or Beckmans) allows disc disease, the laminectomy defect is centered over the area
for relatively atraumatic dissection under tension, which is of involvement and most often extends cranially and caudally
most easily performed from caudal to cranial. Maceration of almost to the adjacent interarcuate ligament unless significant
the epaxial musculature contributes to delayed wound healing, spinal cord compression and edema necessitate extension of
postoperative pain, and laminectomy membrane formation. Small the defect until normal amounts of epidural fat are visualized
branches of either the paired lumbar or intercostal arteries are surrounding the spinal cord in the epidural space. Length of the
cauterized by means of bipolar cautery as they are exposed both defect in other cases is determined by the specific pathology
cranially and caudally to the cranial articular processes of each encountered. Width of the defect is determined by the joint
adjacent vertebra. Care must be exercised during both periosteal spaces between the cranial and caudal articular processes
at the involved interspaces (Figure 48-26, arrow). Complete
facetectomy at multiple locations has been shown experimen-
tally to result in some vertebral column instability, although this
has not been problematic in clinical cases other than vertebral
Figure 48-25. Periosteal elevation of the epaxial musculature for dorsal Figure 48-26. The arrow indicates the joint space between the cranial
laminectomy. Arrows indicate the direction of force applied to the and caudal articular processes, which is used as a guideline for the
elevator for atraumatic periosteal elevation. lateral extent of the laminectomy.
758 Bones and Joints
The bone structure and color are reliable indices of the depth
of drilling: (1) outer cortical bone is dense and white; (2) middle
cancellous bone is spongy and reddish-brown; (3) the inner
cortical bone is dense, white, and very thin. Only cortical bone
is present at the attachments of the interarcuate ligament. Once
the limits of the laminectomy defect have been defined, drilling
continues to completely remove the outer layer of cortical bone
and then the middle layer of spongy cancellous bone (Figure
48-27). Hemorrhage from the cancellous bone is easily controlled
with bone wax.
Figure 48-30. Angled drilling into the cancellous bone around the
periphery of the thin plate of inner cortical bone avoids drilling directly
over the spinal cord and results in smooth, deeply undercut edges.
Figure 48-28. After excision of the middle layer of cancellous bone, This technique increases both exposure and decompression and
excavation of the pedicles is begun with a 4-mm-diameter bur. facilitates removal of extradural mass lesions.
Thoracolumbar and Sacral Spine 759
Figure 48-31. The inner cortical bone shelf is cut around the periphery Figure 48-32. The thin shelf of inner cortical bone is grasped with a
with the smallest bur. hemostat and is removed as a unit.
canal stenosis. Minimal spinal cord manipulation is necessary. normal dogs following durotomy. The dura mater appears to heal
The spinal cord may be gently retracted by means of a small rapidly by neomembrane formation.5
suture placed in a relatively avascular area of the dura mater.
Rhizotomy in appropriate locations releases the dural tube for Durotomy is performed with either Potts-Smith 60 degree
additional retraction or “rolling”. Fine-tipped suction and various angled cardiovascular scissors or a bent disposable 20 to 25
ophthalmic and dental instruments have proven useful for the gauge needle. The dura mater is usually incised on the dorsal
removal of mass lesions from the vertebral canal. Bleeding from midline for the full length of the laminectomy defect. Incision of
the internal vertebral venous plexus is controlled by means the inelastic, and often opaque (loss of the normal translucent
of bipolar cautery, macerated muscle, or absorbable gelatin appearance) dural sheath and frequently the underlying pia
sponge (Gelfoam, Upjohn Co., Kalamazoo, MI 49008). It is imper- mater may result in greater intramedullary decompression of the
ative that the bone of the remaining pedicles on both sides of spinal cord and associated vasculature. Neither hypothermic or
the defect be maintained at a level dorsal to the dorsal tangent normothermic perfusion are utilized routinely.
of the spinal cord to prevent the occurrence of secondary
spinal cord flattening during healing of the laminectomy defect Torn or devitalized epaxial musculature is excised prior to
(laminectomy membrane formation, epidural scar, laminectomy closure. This also appears to limit the infolding or collapse of the
scar, postlaminectomy stenosis, or constrictive fibrosis). For the epaxial musculature into the laminectomy defect, a factor in the
same reason, a hemilaminectomy, with complete excision of the formation of laminectomy membrane. A section of absorbable
facets, or articular processes, should never be converted to a gelatin sponge, creased on the midline to resemble a tent, and
dorsal laminectomy, nor should facet or laminar fragments be shaped to conform as closely as possible to the margins of the
indiscriminately removed in vertebral column fractures unless laminectomy defect is carefully placed in direct apposition with
appropriate (and as yet somewhat unproven) measures are taken the remaining pedicles (marginal fitting). With this particular
to prevent secondary spinal cord compression due to formation technique in the thoracolumbar region of dogs, the healing
of the laminectomy membrane. When the thin remaining layer pattern following implantation of absorbable gelatin sponge
of inner cortical bone has been completely isolated (See is predictable and relatively innocuous.5 Other implants such
Figure 48-32), it is grasped with a hemostat and “peeled off”, or as absorbable gelatin film (Gelfilm, Upjohn Co., Kalamazoo, MI
removed as a complete boney shelf with the periosteum lining 49008), muscle, and free or pedicle fat grafts have met with
the vertebral canal. Because laminectomy scar formation and variable and unsatisfactory or even disastrous results. Although
secondary spinal cord compression increase with an increase in highly successful in other locations, subcutaneous fat grafts in
not only defect width, but length, the length of the defect should this location, with this laminectomy technique actually increase
be limited to only what is necessary to decompress the involved spinal cord compression postoperatively.7,8 Cosmetically
segments of spinal cord or resect the offending mass lesion. unacceptable scars, structural defects, or vertebral column
instability have not been problems with this technique.
Durotomy may be performed for the removal of intradural mass
lesions or may be utilized to establish a more definitive prognosis
in paraplegic, analgesic cases in which acute focal, segmental
Postoperative Care
spinal cord necrosis, malacia, thrombosis, blanching, or chronic Postoperative analgesia, predominantly with opioids, is usually
loss of cord substance with glial scarring is suspect. Dorsal indicated for the first 12 to 24 hours. Corticosteroid therapy is no
midline myelotomy is only performed in paraplegic, analgesic longer continued in the postoperative period due to the limited
patients in which the prognosis is in question. Continued leakage benefits confirmed by experimental studies and the possibility of
of cerebrospinal fluid has not been a problem with durotomies. gastrointestinal complications. Nonsteroidal anti-inflammatories
A mild, transient neurologic deficit has been demonstrated in are rarely used since most patients have been treated with corti-
760 Bones and Joints
costeroids either pre- or intraoperatively. Their concurrent or lumbar vertebral motion units. Prog Vet Neurol 2:6, 1991.
sequential use would increase the risks of catastrophic gastroin- Smith GD, Walter MC. Spinal decompressive procedures and dorsal
testinal bleeding or perforation. Postoperative therapy includes compartment injuries: comparative biomechanical study in canine
manual expression of the urinary bladder or urinary tract cathe- cadavers. Am J Vet Res 49:266, 1988.
terization, tail walking, whirlpool hydrotherapy, exercise carts, Songer MN, Rauschning W, Carson EW, et al. Analysis of peridural scar
and general supportive care. Patients are discharged from the formation and its prevention after lumbar laminotomy and discectomy in
hospital as soon as conscious control of micturition is regained. dogs. Spine 20:571, 1995.
Early return to familiar surroundings seems to promote enthu- Viguier E, Petit-Etienne G, Magnier J, et al. Mobility of T13-L1 after
siasm on the part of the patient and owner, more rapid return of spinal cord decompression procedures in dogs (an in vitro study). Vet
urinary continence, and an early return to full function. Surg 31:297, 2002.
Yovich JC, Read R, Eger C. Modified lateral spinal decompression in 61
dogs with thoracolumbar disc protrusion. J Sm An Pract 35:351, 1994.
References
1. Caulkins SE, Purinton PT, Oliver JE. Arterial supply to the spinal cord
of dogs and cats. Am J Vet Res 50:425, 1989. Surgical Treatment of Cauda
2. Parker AJ. Distribution of spinal branches of the thoracolumbar
segmental arteries in dogs. Am J Vet Res 34:1351, 1973. Equina Syndrome
3. Parker AJ, Park RD, Stowater JL. Traumatic occlusion of lumbar Guy B. Tarvin and Timothy M. Lenehan
segmental arteries. J Trauma 14:330, 1974.
4. Funkquist B, Schantz B. Influence of extensive laminectomy on the
shape of the spinal canal. Acta Orthop Scand Suppl 56:1, 1962. Introduction
5. Trotter EJ, Crissman J, Robson D, et al. Influence of nonbiologic A definitive preoperative diagnosis of cauda equina syndrome
implants on laminectomy membrane formation in dogs. Am J Vet Res can be difficult to make. Not all practitioners have access to
49:634, 1988. magnetic resonance imaging, the best modality for defining
6. Trotter EJ. Dorsal laminectomy for treatment of thoracolumbar disc problems in the lumbosacral region. Access to computed tomog-
disease. In: Bojrab MJ ed. Current techniques in small animal surgery. raphy (CT) is equally limited, and often myelography or epidur-
3rd ed. Philadelphia: Lea & Febiger, 608, 1990. ography is required in concert with a CT scan to demonstrate
7. Trevor PB, Martin RA, Saunders GK, et al. Healing characteristics of soft tissue lesions such as nerve root entrapment. Epidurography
free and pedicle fat grafts after dorsal laminectomy and durotomy in alone is difficult both to perform and to interpret if conducted
dogs. Vet Surg 20:282, 1991. only on occasion. Electrodiagnostic testing and electromyog-
8. Trotter EJ. Unpublished data. raphy require special equipment and expertise to perform and
to evaluate, and not all dogs with cauda equina syndrome have
electrophysiologically demonstrable signs of lower motor neuron
Suggested Readings disease. Myelography is incapable of defining many pathologic
Biggart JF, III. Prevention of laminectomy membrane by free fat grafts processes involving the nerve roots of the cauda equina in the
after laminectomy in dogs with disk herniations. Vet Surg 17:28, 1988. lumbosacral area of the dog. Stressed radiographs (hyperex-
Cook S, Prewett A, Dalton J, et al. Reduction in perineural scar formation tension-flexion) of the spine demonstrate hypermobility, but
after laminectomy with Polyactive membrane sheets. Spine 19:1815, they are not necessarily diagnostic of neurologic involvement
1994. even when used in conjunction with myelography. In fact,
Einhaus SL, Robertson JT, Dohan FC, Jr., et al. Reduction of peridural many animals affected by cauda equina syndrome have normal
fibrosis after lumbar laminotomy and discectomy in dogs by a resorbable spinal radiographs. Hence, a veterinarian must use clinical
gel (ADCON-L). Spine 22:1440, 1997. acumen along with one or more of these diagnostic modalities to
Geisler FH. Prevention of peridural fibrosis: current methodologies. establish a diagnosis of cauda equine syndrome before recom-
Neurol Res 21;Suppl 1:S9, 1999. mending surgical intervention. In many cases only an exploratory
Gill G, Sakovich L, Thompson E. Pedicle fat grafts for the prevention of laminectomy can provide both a diagnosis of and cure for cauda
scar formation after laminectomy. An experimental study in dogs. Spine equina syndrome. The purpose of the surgery is to decompress
4:176, 1979. the conus medullaris or those nerve roots of the cauda equina
LaRocca H, Macnab I. The laminectomy membrane. Studies in its that are causing clinical symptoms. The surgeon should be
evolution, characteristics, effects and prophylaxis in dogs. The Journal vigilant to remove only as much bone as needed to accomplish
of Bone and Joint Surgery – British volume 56B:545, 1974. this task, especially when dealing with cauda equina syndrome
Olby N. Current concepts in the management of acute spinal cord injury. secondary to lumbosacral instability. The removal of portions
J Vet Int Med 13:399, 1999. of discs or facets progressively destabilizes the spine and may
Robertson J, Meric A, Dohan FJ, et al. The reduction of postlaminectomy predispose the patient to adverse postoperative sequelae.
peridural fibrosis in rabbits by a carbohydrate polymer. J of Neurosurg
79:89, 1993.
Schulz KS, Waldron DR, Grant JW, et al. Biomechanics of the thoraco- Surgical Procedure
lumbar vertebral column of dogs during lateral bending. Am J Vet Res The animal is placed in ventral recumbancy with the stifles
57:1228, 1996. and hips flexed and the hocks extended. If extensive foraminal
Shires PK, Waldron DR, Hedlund CS, et al. A biomechanical study of exploration is anticipated, then placement of the patient’s hind
rotational instability in unaltered and surgically altered canine thoraco- legs in the forward extended position combined with padding
Thoracolumbar and Sacral Spine 761
placed under the belly in the lumbosacral region will accentuate complete, an autologous free fat graft is harvested from the
lumbosacral kyphosis to more widely open the foramina at the subcutaneous region and placed over the laminectomy site to
lumbosacral junction. minimize cicatrix formation. Muscle, fascia and subcutaneous
layers are closed, respectively, with synthetic absorbable suture
A dorsal midline approach to the lumbosacral spine is performed. material. Inaccurate closure of the muscle results in a palpable
Several large Gelpi or hinged Weitlaner retractors facilitate midline defect, whereas inattention to subcutaneous closure
muscle retraction (Figure 48-33). Suction is essential for good results in seroma formation. The application of a compression
visualization, and most typically a No. 10 or 12 Frazier suction bandage is optimal, yet difficult to apply and maintain, given the
tip is adequate. Electrocautery, surgical sponge (Gelfoam), bone location of the operative site, especially in male dogs.
wax and small pieces of epaxial muscle placed on small bleeders
are essential for adequate hemostasis in large breed dogs.
Postoperative Care
A modified dorsal laminectomy is performed over the affected Postoperative recommendations include strict confinement to
interspaces (generally L7 to S1-2), initially leaving the caudal house and leash walking activity only for 8 weeks’ time, before a
pedicles of L7 intact. If the compression is due to either midline return to moderate function. This confinement allows time for the
disc bulging or hypertrophy of the interarcuate ligament, then musculature to adhere to the lamina and for the spine to adjust
this surgical approach alone should result in decompression. If to the added instability imposed by the surgical procedure.
the surgeon is unsure of complete decompression, then extra-
dural fat and fibrous connective tissue are removed from the In most cases, a modified dorsal laminectomy is sufficient to
spinal canal as needed to facilitate visualization of the various gain good visualization of the problem and to effect decom-
nerve roots and ganglia of the cauda equina. A nerve hook pression. Removal of the dorsal spinous processes and dorsal
helps to isolate and trace individual nerves as they enter their laminectomy minimally destabilize the lumbosacral motion unit in
respective foramina to exit the spinal canal. Unilateral or bilateral four point flexion/extension tests in vitro. Hence, one may expect
pediculectomy is performed as needed to gain further exposure resolution of nerve root symptoms without significant subse-
and decompression of the involved nerves. In some cases, quent clinical deterioration if successful mechanical decom-
foraminotomy without pediculectomy is possible and preferred. pression has been achieved (and if mechanical compression
Tethered nerve roots are freed from any fibrous connective alone was the source of the pain). Osteoarthritic symptoms
tissue constraints. In the case of a Hansen type I disc rupture, may be expected to persist however (i.e. morning and exercise
the ruptured nuclear material is removed (generally by suction). induced stiffness with occasional episodes of low back pain
If a Hansen type II disc rupture is present, the location of the lasting several days). The addition of discectomy, foraminotomy
bulging annulus in relation to a compressed nerve determines or facetectomy further destabilizes the spine. Clinically signif-
the surgical procedure. Disc material that is entrapping a nerve icant sequelae such as facet fracture, lumbosacral subluxation,
root is either cut away or, alternatively, is left alone and the nerve cicatrix formation and ongoing clinical symptomatology can
decompressed by facetectomy, pediculectomy, or foraminotomy. result. It is therefore important to use a minimalistic approach in
one’s decompression technique.
Once decompression has been achieved and hemostasis is
Decompressive laminectomy in a hypermobile lumbosacral urinary or fecal incontinence. Favorable preoperative conditions
segment should be undertaken with caution, particularly if include young age and mild clinical symptoms.
discospondylitis is suspected. In such instances, laminectomy
only further destabilizes an already unstable situation and may If there is a recurrence of symptoms in the early postoperative
have orthopedic and neurological sequelae, if the infection is not phase, a second exploratory surgery is justified in selected
brought under control quickly. cases.
The literature would indicate that on average 85% of the animals Bony or soft tissue disease at any of the L5-6 to S1-2-3 vertebral
operated on demonstrate initial improvement. However, subse- interspaces potentially can result in clinical signs of cauda
quent deterioration occurs in up to 1/3 of patients resulting in equina syndrome (sciatic or sacral nerve root involvement)
an overall longterm success rate of around 55%. Approximately (Figure 48-34). The clinician must attempt to localize the lesion to
25% of cases are improved by surgery but not symptom free, and a specific area of the spinal cord or nerve roots preoperatively. A
there is on average a 25% failure rate. Persistent postoperative “routine” dorsal laminectomy at the L7-S1 interspace may miss
clinical symptoms most probably relate to ongoing lumbosacral the underlying disorder entirely, if the signs of the cauda equina
instability, attendant discogenic pain, epidural scarring, arach- syndrome are, for example, due to an intramedullary tumor
noiditis, facet arthritis or fracture, insufficient decompression at affecting the L6 segment of the spinal cord.
the operative site, alternate segment disease, iatrogenic conus
or nerve root trauma, infection, etc. Preoperative conditions
predisposing to surgical failure seem to include advanced age, Suggested Readings
chronicity of symptoms, concurrent hind limb problems, and Danielson F, Sjostrom L. Surgical Treatment of Degenerative Lumbo-
sacral Stenosis in Dogs. Vet Surg 28: 91, 1999.
Dr. Risiol, Sharp NJH, Olby NJ, et al. Predictors of outcome after dorsal
decompressive laminectomy for degenerative lumbosacral stenosis in
dogs: 69 cases (1987-1999). J. Am Vet Med Assoc 219: No5: 624, 2001.
Janssens LAA, Moens Y, Coppens P, et al. Lumbosacral Degenerative
Stenosis in the Dog. Vet Comp Orthrop Traumatol 13:97, 2000.
Linn LL, Bartels KE, Rochat MC, et al. Lumbosacral Stenosis in 29 military
working dogs: Epidemiologic findings and outcome after surgical inter-
vention (1990-1999). Vet Surg 32:21, 2003.
Moens NMM, Runyun CL. Fracture of L7 vertebral articular facets and
pedicles following dorsal laminectomy in the dog. J Am Vet Med Assoc.
221: No 6: 807, 2002.
Smith MEH, Bebchuk TN, Shmon CL, et al. An invitro biomechanical
study of the effects of surgical modification upon the canine lumbo-
sacral spine. Vet Comp Orthrop Traumatol 17:17, 2003.
Introduction
The thoracolumbar and lumbar spine are relatively common
locations for spinal fractures, luxations and subluxations in
the dog and cat. As previously mentioned, it appears that the
higher incidence of fracture/luxations at certain sites along the
vertebral canal may not correlate to differences in muscular or
ligamentous attachments, but rather to areas of the vertebral
column with a static/kinetic relationship (ie. thoracolumbar and
lumbosacral junction).1,2,3,4 As mentioned also in the previous
chapter on cervical spine injury, the history, physical and
neurologic examinations are crucial to the determination of
prognosis and surgical outcome.
Figure 48-34. A. Dorsal view of the cauda equina. B. Nerve distribution
of the cauda equina.
Thoracolumbar and Sacral Spine 763
Technique Selection
There are numerous techniques that have been developed to
stabilize thoracolumbar and lumbar spinal fractures, luxations
and subluxations in dogs and cats.5-19 As mentioned previously,
the technique chosen is dictated by the location of the fracture,
size, age, and disposition of the patient, equipment available and
experience of the surgeon.
Surgical Techniques
Dorsal spinous process plating requires exposure of the dorsal
spinous processes and articular facets.5 The supraspinous
and interspinous ligaments should be preserved if possible.
A minimum of three spinous processes on each side of the
fracture/luxation should be exposed. Metal or plastic plates are
available for dorsal spinous process plating. When using plastic Figure 48-36. Dorsal spinal plating using metal plates. (From Lumb WV
plates, a plate is used on each side of the exposed dorsal spinous and Brasmer TH. Improved spinal plates and hypothermia as adjuncts
processes (2 plates total)6,8 (Figure 48-35). The roughened side of to spinal surgery. J Am Vet Med Assoc 1970;157: 338-342.)
the plate is placed against the dorsal spinous processes. The
plates are attached with appropriate size nuts and bolts placed Spinal stapling also requires exposure of the dorsal spinous
between the dorsal spinous processes. It is important to keep processes and facet joints. An intramedullary pin is placed
the plates as close to the base of the dorsal spinous processes through a dorsal spinous process, bent 90 degrees, laid along the
as possible. Grooves can be created in the lamina at the base of lamina between the base of the spinous processes and articular
the spine using a high speed bone burr or rongeurs to help keep processes, and secured to the base of the dorsal spinous
the plates low on the spine. This will allow maximal purchase of processes with orthopedic wire (Figure 48-37). Added security
the spinal plates to the dorsal spinous processes. Metal plates can be accomplished by wiring the pin around the base of the
are used in a similar fashion however the nuts and bolts are transverse processes in the lumbar spine or around the rib heads
placed through the dorsal spinous processes (Figure 48-36). in the thoracic spine (Figure 48-38) or by incorporating multiple
pins and wires in a modified segmental spinal instrumentation
The advantage of dorsal spinous process plating is preservation technique (Figure 48-39).9 At least two interspaces on each side
of the inherent stability provided by the articular facets, supra- of the fracture/luxation should be included in the repair.
spinous and interspinous ligament. The major limiting factors
of dorsal spinous process plating are the age and size of the Vertebral body plating (dorsal body plating) requires dorso-
patient. The dorsal spinous processes must be large enough lateral exposure of the articular facet, vertebral body and trans-
and the bone compact enough to support the stresses that are verse process of the lumbar vertebrae or the articular facet,
encountered by an unstable spine. This technique is commonly vertebral body and rib head of the thoracic vertebrae10 (Figure
used in combination with other stabilization techniques (ie. pins 48-40). Care should be taken to protect the spinal nerve roots
and polymethyl methacrylate, vertebral body plating). The most encountered cranial and caudal to the fracture/luxation. The
common postoperative complications are fracture of the spinous spinal nerve and vessels at the involved space must be severed.
processes and plate slippage. The proper length and size plate is selected and placed on the
dorsolateral aspect of the vertebral bodies. There should be at
least four cortices engaged cranial and caudal to the involved
fracture/luxation. Use of locking plates and screws may permit
monocortical screw placement. If a luxation, subluxation or
fracture close to the interspace exists, stabilization of the two
adjacent vertebrae is adequate, however if a mid body fracture
exists, three vertebral bodies should be spanned. The holes are
drilled and screws are placed in a ventral and medial direction,
being careful to avoid entering the spinal canal dorsally or the
abdominal cavity ventrally. Placement of the plate on the thoracic
vertebrae is more difficult due to the presence of rib heads.
The rib heads must be removed and the transverse process
contoured so the plate lies flat against the vertebral body. It
is recommended that an anatomic specimen be available for
visualization during placement of plates and screws. The need
for rhizotomy precludes the use of vertebral body plating caudal
Figure 48-35. Dorsal spinal plating using plastic plates. (From Lumb WV to the fourth lumbar vertebra.10,a,b
and Brasmer TH. Improved spinal plates and hypothermia as adjuncts
to spinal surgery. J Am Vet Med Assoc 1970;157:338-342.)
Lubra¨ plate, Lubra Co, 1905 Mohawk, Fort Collins, CO 80521
a
Auburn spinal plate, Richard Manufacturing Co, Memphis, TN 38101
b
764 Bones and Joints
Surgical Techniques
In cases of L7-S1 luxations or subluxations, manipulation of
L7-S1 during reduction involves grasping towels clamps or bone
forceps placed on the wings of the ilium and pulling caudally and
slightly dorsal. A non-sterile assistant can place counter traction
on the head or front legs and this can help to lever the sacrum
against the lamina of L7 while pressing ventrally on L6. Also, a
small Hohmann retractor can be used to aid reduction of an L7
fracture or luxation by hooking the jaws of the forceps under Figure 48-43. Transilial pin used to stabilize a fracture of the body of L7
the cranial lamina of the sacrum and lower the jaws against the or lumbosacral luxation. (From Bruecker KA, Seim HB: Spinal Fractures
caudal lamina of L7. Transilial pinning requires exposure of the and Luxations in Slatter DH (ed): Textbook of Small Animal Surgery, 2nd
dorsal L7-S1 region.17 The caudal segment is most often displaced ed, WB Saunders Co., Philadelphia 1993)
ventrally and cranially. Bone forceps are placed on each ilial
wing to help elevate the ilium and sacrum dorsally to align the of polymethyl methacrylate to notched pins. Transilial pinning
articular processes of L7 with the cranial articular surface of the and external skeletal fixation with a Kirschner-Ehmerc apparatus
sacrum. An appropriate sized trocar tip pin (1/8” or smaller) is has been described.15,16 In this technique the transilial pins are
driven through the wing of the ilium, across the laminae of L7 and placed percutaneously. In addition, one pin is inserted percu-
through the opposite wing of the ilium (Figure 48-43). The most taneously through the vertebral body cranial to the fracture/
common problem associated with this technique is migration of luxation. Kirschner clamps attach the pins to a connecting bar
the Steinmann pin. A more stable technique is generally recom- on each side of the spine (Figure 48-45).
mended. To help prevent migration of the Steinman pins, bending
the ends of each pin at a 90 degree angle can be done, as well Pins and polymethyl methacrylate can also be utilized to stabilize
as connecting the pins on each side with a double Kirschner lumbosacral fracture/luxations. The approach and reduction is
clamp (see below) or notching the pins’ ends with a pin cutter as previously described. Two pins are placed in the vertebral
and incorporating them with bone cement. body cranial to the fracture/luxation and two pins are placed in
the wings of the ilium. The pins are incorporated with polymethyl
The use of plastic dorsal spinous process plates and trans- methacrylate as previously described. The disadvantage of this
ilial pins has been reported6,13 This requires a similar approach technique is the large amount of polymethyl methacrylate needed
and reduction as previously described. Plastic dorsal spinous for adequate stabilization, making closure difficult. Modified
process plates are placed on each side of the three dorsal segmental spinal instrumentation has been used successfully
spinous processes cranial to the fracture/luxation and secured to stabilize lumbosacral fractures. Pins are prebent 90°, placed
with nuts and bolts as previously described for plastic dorsal through holes drilled in the wings of the ilium, laid alongside the
spinous process plating. The plastic plates extend caudad to dorsal spinous processes of at least two vertebra cranial to the
S2-3. A 3/32” or 1/8” trocar tip pin is driven through one ilial wing, fracture/luxation, and wired in place to the adjacent articular
through the plastic plate at the level of L7-S1, and through the facets, dorsal spinous processes and lamina (Figure 48-46).
opposite ilial wing. A second pin is placed caudal to the first pin. Combinations of the above techniques may be utilized in large
The ends of the pins are bent craniad at a 90° angle and cut to breed dogs with hyperactive personalities.
leave 5 mm protruding (Figure 48-44). Postsurgical complications
include fracture of the dorsal spinous processes or migration of
the transilial pins. Pin migration may be decreased by application
Kirschner-Ehmer apparatus, Kirschner Co
c
Thoracolumbar and Sacral Spine 767
Figure 48-44. Transilial pin used in conjunction with plastic dorsal Figure 48-46. The use of modified segmental spinal instrumentation for
spinal plates provides additional support for lumbar or lumbosacral the repair of lumbosacral and caudal lumbar fracture/luxation. (From
fractures. (From Bruecker KA, Seim HB: Spinal Fractures and Lux- McNaulty JF, Lenehan TM, Maletz LM. Modified segmental spinal
ations in Slatter DH (ed): Textbook of Small Animal Surgery, 2nd ed, instrumentation in repair of spinal fractures and luxations in dogs. Vet
WB Saunders Co., Philadelphia 1993) Surgery 1986;15:143-149.)
References
1. Feeney DA and Oliver JE. Blunt spinal trauma in the dog and cat:
neurologic, radiologic and therapeutic correlations. J Am Anim Hosp
Assoc 1980;16:664-668.
2. Swaim SF. Biomechanics of cranial fractures, spinal fractures, and
luxations, in (ed) Bojrab, Pathophysiology in Small Animal Surgery.
1981:774-778.
3. Carberry CA, Flanders JA, Dietze AE, et al. Nonsurgical management
of thoracic and lumbar spinal fractures and fracture/luxations in the dog
and cat: a review of 17 cases. J Am Anim Hosp Assoc 1989;25:43-54.
4. Feeney DA and Oliver JE. Blunt spinal trauma in the dog and cat: insight
into radiographic lesions. J Am Anim Hosp Assoc 1980;16:885-890.
5. Piermattei DL. An atlas of surgical approaches to the bones and joints
Figure 48-47. Stabilization of sacral fracture using lag screw and
of the dog and cat. 3rd ed. WB Saunders, 1993;45-89.
Kirschner wire; cranial A. and B. dorsal views. (From Bruecker KA,
Seim HB. Spinal Fractures and Luxations in Slatter DH (ed): Textbook of 6. Dulisch ML and Nichols JB. A surgical technique for management of
Small Animal Surgery, 2nd ed., WB Saunders Co., 1993) lower lumbar fractures: case report. Vet Surgery 1981;10:90-93.
7. Sharp NJ and Wheeler SJ: Trauma. In Small Animal Spinal Disorders.
the tail. Rarely should they be treated surgically. If anesthesia of Philadelphia; Elsevier, 2005, 282-305.
the tail persists, amputation may be the only feasible alternative. 8. Lumb WV and Brasmer TH. Improved spinal plates and hypothermia
as adjuncts to spinal surgery. J Am Vet Med Assoc 1970;157:338-342.
9. McNaulty JF, Lenehan TM, Maletz LM. Modified segmental spinal
New Horizons instrumentation in repair of spinal fractures and luxations in dogs. Vet
One new spinal fixation technique has been described in the Surgery 1986;15:143-149.
literature and involves the use of closed fluoroscopic-assisted 10. Swaim SF. Vertebral body plating for spinal stabilization. J Am Vet
spinal arch external skeletal fixation (ESF) for the stabilization Med Assoc 1971;158:1653-1695.
of traumatic vertebral column injuries in 5 dogs. In this study, 11. Blass CE and Seim HB. Spinal fixation in dogs using steinmann pins
the fixator configuration consisted of pins placed bilaterally in 2 and methyl methacrylate. Vet Surgery, 1984;13:203-210.
contiguous vertebral bodies cranial and caudal to the fracture. The 12. Rouse GP and Miller JI. The use of methyl methacrylate for spinal
protruding portion of the pins were incorporated into an external stabilization. J Am Anim Hosp Assoc 1975;11:418-425.
connecting system (IMEX Veterinary Inc., Longview Texas) for 13. Lewis DD, Stampley A, Bellah JR, et al. Repair of sixth lumbar
spinal stabilization. Results of this study were initially encour- vertebral fracture-luxations, using transilial pins and plastic spinous-
aging and this device may prove to be useful in the future.20,d process plates in six dogs. J Am Vet Med Assoc 1989;194:538-542.
14. Matthiesen DT. Thoracolumbar spinal fractures/luxations: Surgical
Post-operative Management management. Comp Cont Ed 1983;5:867-878.
15. Shores A, Nichols C, Koelling HA. Combined Kirschner-Ehmer
Post-operative management of spinal fracture patients is generally
apparatus and dorsal spinal plate fixation technique of caudal lumbar
divided into ambulatory or non-ambulatory convalescence. vertebral fractures in dogs: biomechanical properties. Am J Vet Res
Patients with an ambulatory status postoperatively are generally 1988;49:1979-1982.
managed in the following manner: cage confinement, brief 16. Shores A, Nichols C, Rochat M, et al. Combined Kirschner-Ehmer
exercise 2 to 3 times a day for 2 to 3 weeks, serial neurologic and device and dorsal spinal plate fixation technique for caudal lumbar
radiographic examinations and home on restricted exercise and/ vertebral fractures in dogs. J Am Vet Med Assoc 1989;195:335-339.
or passive range of motion exercises until radiographic evidence 17. Slocum B and Rudy RL. Fractures of the seventh lumbar vertebral in
of healing is present. Non-ambulatory patients are managed in the dog. J Am Anim Hosp Assoc 1975;11:167-174.
the following manner: elevated padded cage rack or waterbed, 18. Taylor RA. Treatment of fractures of the sacrum and sacrococcygeal
turned every 2 to 4 hours, bladder expressions 4 to 5 times a day region. Vet Surgery 1981;10:119-124.
or intermittent sterile catheterization in the male patient 2 to 3 19. Smeak DD and Olmstead ML. Fracture/luxations of the sacrococ-
times daily, passive range of motion exercises 3 to 4 times a day, cygeal are in the cat: a retrospective study of 51 cases. Vet Surgery
electrical stimulation (if available), serial neurologic and radio- 1985;14:319-324.
graphic evaluations and frequent hydrotherapy until return to an 20. Wheeler JL, Lewis DD, et al. Closed Fluoroscopic-Assisted Arch
ambulatory status is achieved. Complications as described for External Fixation for the Stabilization of Vertebral Column Injuries in 5
the recumbent cervical injury patient have been described and Dogs. Vet Surg 2007, 36: 442-448.
apply to these patients as well. The use of back braces or splints
is somewhat controversial. If the brace is comfortable, light
weight and tolerated by the patient they are helpful. However,
most braces are heavy, nonconforming, result in pressure sores
IMEX Acrylic pins, IMEX Veterinary Inc., Longview, TX
d
Fixation with Pins and Wires 769
A B C D
A B
C
Figure 49-2. A. Lateral view of a comminuted, short oblique femur frac-
ture in a 6 month old female mixed breed dog. B. Usage of a cerclage
wire distal to the major fracture line for prevention of fissure propaga-
tion. The fissure is not obvious on the pre-operative radiograph. C.
Fracture is healed 8 weeks post-operatively.
B
Figure 49-3. A wire twister is used to form twisted full cerclage wire.
A. The wire is grasped where it crosses and pulled and twisted at the
same time. B. A locking wire twister is always used to prevent loss of
tension during wire twisting and tightening.
772 Bones and Joints
Single Loop
Richards standard wire twister19
Richards loop wire tightener19
Osteo systems (through Richards) wire tightener with strain gauge19
ASIF wire tightener10
Double Loop
ASIF wire tightener10
Knot Twist
Kirschner “Bow Twister”11
Square knot
Harris knotter21
Figure 49-4. Usage of a cannulated cerclage wire passer and hemostat.
For all types of wire, it is important that they are tightened perpen-
dicular to the long axis of the bone, rather than perpendicular to
the fracture line as they will slip down perpendicular to the bone
when exposed to weight-bearing forces and become loose. In
an area where the bone diameter is changing and wire slippage
may occur, the use of a Kirschner wire to prevent slippage as a C
“skewer pin” may be indicated (Figure 49-6). The K-wire is placed Figure 49-6. A. Comminuted femoral fracture in a 5 year old FS German
perpendicular to the fracture line, and the cerclage wire is placed Shepherd Dog. B. Post-operative repair with external fixation and
around it and tightened so that the ends of the K-wire prevent it cerclage. C. Eight weeks post-operative, osteomyelitis and sequestrum
from slipping. Skewer pin configurations are not as strong as lag formation likely exacerbated by loss of blood supply due to extensive
approach required to apply 12 cerclage wires.
screw fixations, but may be considered for the treatment of short
oblique fractures if supported by another device.16
Contraindications
Cerclage wires should be placed at least one-half of the diameter Full cerclage wires are contraindicated in the treatment of trans-
of the bone apart. Multiple cerclage wires should always be used verse, short oblique (with the possible exception of a skewer
unless they are being used to prevent propagation of fissures. In pin configuration), segmental or multi-fragmented fractures.
the author’s opinion, the operator should also keep in mind that if When evaluating preoperative radiographs of fractures, all of the
more than four or five cerclage wires are being placed, that the fragments, even tiny ones, should be counted and if there are
possibility for excessive stripping of the soft tissues exists and more than three, another method of fixation should be considered.
another type of fixation should be considered (See figure 49-6). Full cerclage are also contraindicated if, for any reason, the full
360 degrees of the shaft cannot be reconstructed, or the shape of
the bone is such that wires cannot be applied so that they will sit
774 Bones and Joints
Hemicerclage wire
Hemicerclage wire refers to wire that has been passed through
at least one hole drilled through the bone. Although hemicerclage
configurations have been reported for the treatment of rotational
instability in long bone fractures, in practice they are very weak,17
reaching only about 3% of the load in Nm of an intact construct
and absorbing only 2% of the energy that an intact construct can
absorb prior to failure during mechanical testing.18 Hemicerclage
wire applied to long bone fractures may also only be effective if
rotational instability occurs in only one direction. Biomechanical
testing of a variety of interfragmentary wire designs, either with
hemicerclage wire, or combined cerclage wire and K-wire appli-
cations showed that a biplanar 90° configuration with wire and
cross pin configuration had the highest torsional yield load and
C
safe load,18 however, this configuration would be difficult to apply
clinically and has yet to be tested in vivo. Figure 49-7. A. Lateral radiograph of a comminuted, closed diaphyseal
humeral fracture in an 11 month old German Shepherd Dog. B. Lateral
Hemicerclage is primarily used where applied loads are low, post-operative radiograph of repair with intramedullary pins and 4
for example in the treatment of mandibular, maxillary and some loop cerclage wires. Note that the distal-most wire is very close to the
fracture line. C. Rotational instability evident at 8 weeks, distal wire
skull fractures. Considerations for applying these wires include
has loosened.
avoiding tooth roots and angling drill holes such that it is easy
to grasp the wires and pull them through the bone to allow tight-
ening. Holes drilled for application of hemicerclage wires should References
be at least 2 implant diameters away from the fracture line to 1. Blass CE, van Ee RT, Wilson JW. Microvascular and histological
prevent them pulling through or fracturing the fragment as they effects on cortical bone of applied double-loop cerclage. J Am Anim
are carefully tightened. Unlike full cerclage wire, hemicerclage Hosp Assoc 27:432,1991.
wire is not prone to loosening after being tightened down to the 2. Rhinelander FW, Wilson JW. Blood supply to developing, mature and
bone and it is acceptable to bend the wire ends over. Overtight- healing bone. In: Sumner-Smith G, ed. Bone in clinical orthopedics.
ening of hemicerclage wire will cause bone failure and pull-out of Philadelphia: WB Saunders, 1979, p.162.
the wire. Attention should be paid to pulling as much “slack” from 3. Ellison GW, Piermattei DL, Wells MK. The effects of cerclage wiring
the wire prior to tightening, and also to twisting the wire halfway on the immature canine diaphysis: a biomechanical analysis. Vet Surg
between two points of fixation so the twist does not sit at the level 11:44, 1982.
of the drill hole and prevent further tightening.
Fixation with Pins and Wires 775
4. Wilson JW. Effect of cerclage wires on periosteal bone in growing for example an interlocking nail. The terms “rod” and “nail”,
dogs Vet Surg 16:299, 1987. while sometimes interchanged, are not equivalent. A rod is
5. Nye R, Egger E, Huhta J, Histand M, Mallinckrodt C. Acute failure loosely applied, so that contact with endosteal bone is limited.
characteristics of six methods for internal fixation of canine femoral Examples of use of a rod would be a rod suspending a roll of
oblique fractures. Vet Comp Orthop Traum 9:106, 1996. paper towels, allowing free movement between the paper towel
6. Kanakis TE, Cordey J. Is there a mechanical difference between lag tube and the rod, or typical veterinary use of an intramedullary
screws and double cerclage. Injury 22:185, 1991. Steinmann pin. In the veterinary literature, the term “pin” is often
7. Willer RL, Schwarz PD, Powers BE, Histand ME. Comparison used interchangeably with “rod”. A nail is tightly applied to the
of cerclage wire placement in relation to a neutralization plate: a endosteal bone to the point of firm wedging, just like a carpen-
mechanical and histological study. Vet Comp Orthop Traum 3:90, 1990. ter’s nail driven into a board, displacing wood and becoming
8. Blaeser LL, Cross AR, Lanz OI. Revision of aseptic loosening of the firmly wedged.1
femoral implant in a dog using cable cerclage. Vet Comp Orthop Traum
12:97, 1999.
9. Meyer DC, Ramseier LE, Lajtai G, Notzli H. A new method for cerclage Types of Implants Available
wire fixation to maximal pre-tension with minimal elongation to failure. Intramedullary pins (IM pins) used in animals range from ¼
Clin Biomech 18:975, 2003. inch diameter (6.3 mm) down to 5/64 inch diameter (2.0 mm).
10. Wilson JW. Knot strength of cerclage bands and wires. Acta Orthop Intramedullary pins in this size range are called Steinmann pins.
Scand 59:545, 1988. Smaller pins are usually referred to as Kirschner wires (K-wires),
11. Bostrom MPG, Asnis SE, Ernberg JJ et al. Fatigue testing of cerclage and although they may be used as intramedullary devices in
stainless steel wire fixation. J Orthop Traum 8:422, 1994. very tiny animals, they are generally used as interfragmentary
12. Oh I, Sander TW, Treharne RW. The fatigue resistance of ortho- devices. K-wires are available in .035, 0.045, .054 and .062 inch
paedic wire. Clin Orthop Rel Res 192:228, 1985. diameters. Intramedullary pins and K-wires can be obtained as
13. Roe SC. Evaluation of tension obtained by use of three knots for tying fully threaded, partially threaded or nonthreaded. Although some
cerclage wires by surgeons of various abilities and experience. J Am surgeons use partially (end) threaded pins for intramedullary
Vet Med Assoc 220:334, 2002. pins with the intention of increasing rotational stability, in fact
14. Rooks RL, Tarvin GB, Pijanowski GJ, Daly B. In vitro cerlage wiring those pins do not provide additional rotational stability (Figure
analysis. Vet Surg 11:39, 1982. 49-8) and are at risk for breakage at the thread-shaft interface or
15. Roe SC. Mechanical characteristics and comparisons of cerclage in the weaker threaded portion (Figure 49-9). In addition, fully or
wires: introduction of the double-wrap and loop/twist tying methods. partially threaded Steinmann pins and K-wires are more difficult
Vet Surg 26:310,1997. to remove as the bone tends to grow into the threads. For these
16. Smith BA Kerwin SC, Hosgood G, et al. Mechanical comparison of reasons, the use of threaded pins as intramedullary devices is
two methods for interfragmentary fixation in a short oblique fracture not recommended.
model. Vet Comp Orthop Traum. 9:4, 1996.
17. Blass CE, Caldarise SG, Torzilli PA, Arnoczky SP. Mechanical
properties of three orthopedic wire configurations. Am J Vet Res
46:1725, 1985.
18. Metelman LA, Schwarz PD, Hutchison JM, et al. A mechanical evalu-
ation of the resistance of various interfragmentary wire configurations
to torsion. Vet Surg 25:213, 1996.
19. Willer R. Cerclage wiring. In: Bojrab MJ (ed): Current techniques in
small animal surgery 4th ed. Baltimore, Williams & Wilkins, 1998, p. 921.
20. Blass CE, Piermattei DL, Withrow SJ, Scott RJ. Static and dynamic
cerclage wire analysis. Vet Surg 15:181,1986.
21. Cheng SL, Smith TJ, Davey JR. A comparison of the strength and
stability of six techniques of cerclage wire fixation for fractures. J
Orthop Traum 7:221,1993.
Figure 49-11. Olive or stopper wire. Note the “stopper” placed about
2/3 of the length of the pin away from the cutting tip.
result in failure by pin bending or breakage (Figure 49-12). Use of characteristics, for example, the Orthofix self-compressing pin
multiple small pins to fill the medullary cavity, also called “stack recently reported in the treatment of humeral condylar fractures
pinning” to increase resistance to rotational stability, has been in small breed dogs.5 These pins are small diameter (1.2 to 2.2
shown not to increase rotational stability significantly more than mm threaded segment, 1.5 to 3 mm shaft) pins are designed for
single intramedullary pinning.3 use in cancellous bone. As the pin is drilled, the threaded portion
cuts a thread into the cancellous bone. When the pin’s chamfer
In addition to using ancillary devices to control rotational and (location of the thread-shaft interface where the diameter of the
axial forces on the bone with IM pins, modifications to the pin increases) contacts the near cortex, further advancement of
pins themselves, including placement of screws through holes the implant partially strips the threads cut in the bone in the near
across the pin (interlocking nail construct) and modification fragment, while the threads in the far cortex maintain purchase,
of the pin itself can be used. A recent example of this in the leading to interfragmentary compression.
veterinary literature is the Trilam nail, a stainless steel intramed-
ullary device designed with three “lamellae” extending down
its length to counteract rotational forces. The nail is driven with
Application Techniques for Intramedullary
a mallet into the medullary cavity without reaming, such that Pins and Interfragmentary Wires
the three lamellae cut into the inner cortical bone, making it a Intramedullary pins may be inserted either from the fracture
true nail. Successful use of the Trilam nail in dogs and cats for site (retrograde insertion) or from either the proximal or distal
the treatment of femoral, tibial and humeral fractures has been end of the bone itself (normograde insertion). The local anatomy
reported.4 of the bone often dictates how the pin is driven, for example,
retrograde pin insertion in the tibia often results in damage to
K-wires, while they can be used as intramedullary devices, are the articular cartilage or cruciate ligaments. An estimation of
usually used as interfragmentary devices, often to maintain appropriate pin size (60 to 75%)6 may be made from the post-
temporary fracture reduction while the primary fixation (eg operative radiographs and may be confirmed by observation of
a plate) is applied. K-wires by themselves are relatively weak the pin as it is gently introduced into the fracture site, even if
implants (See Table 49-1) and are not generally used alone. In normograde insertion is planned. If in doubt, a smaller pin should
certain fractures, for example physeal fractures in small dogs be used initially and replaced with a larger pin if necessary.
and cats, cross-pinning with K-wires can be sufficient when The pin may be inserted either open or closed. Although closed
fracture healing is expected to be rapid. K-wires are also pinning, based on palpation, can be performed by the experi-
commonly utilized in combination with cerclage wire for tension- enced surgeon this can become more difficult in larger animals
band fixations and to support full cerclage wires in areas of with soft tissue swelling, or in fractures greater than 72 hours
changing bone diameter (“skewer wires”). old. The increased use of intraoperative imaging (fluoroscopy)
can greatly facilitate IM pin placement in a minimally invasive
K-wires have also been modified to improve their anti-rotational fashion, with less damage to the soft tissues.
References
1. Chandler RW. Principles of internal fixation. In: Rockwood CA, Green
DP, Bucholz RW, Heckman JD (eds) Rockwood and Green’s Fractures in
Adults. Philadelphia, Lippincott-Raven 1996: 165-179.
2. Howard PE. Principles of intramedullary pin and wire fixation.
Seminars in Veterinary Medicine and Surgery (Small Animal) 6:52,1991.
3. Dallman MJ, Martin RA, Self BP, Grant WJ. Rotational strength of
double-pinning techniques in repair of transverse fractures in femurs of
dogs. Am J Vet Res 51:123, 1990
4. Hach V. Initial experience with a newly developed medullary stabili-
zation nail (Trilam nail). Vet Comp Orthop Traum 13:109,2000.
5. Guille AE, Lewis DD, Anderson TP et al. Evaluation of surgical repair
of humeral condylar fractures using self-compressing orthofix pins in 23
dogs. Vet Surg 33:314, 2004.
6. Piermattei DL, Flo GL. Brinker, Piermattei and Flo’s Handbook of Small
Animal Orthopedics and Fracture Repair, 3rd ed. Philadelphia, WB
Saunders, 1997: 95.
7. Nunamaker, DM. Fractures and dislocations of the hip joint. In:
Textbook of Small Animal Orthopaedics. Philadelphia, J. B. Lippincott,
1985,403.
8. Beadling L. Nancy nailing: a pediatric innovation for contemporary
society. Orthopedics Today 25:26, 2005. Figure 49-18. The pull of a muscle, tendon or ligament A. when coun-
9. Muir P, Johnson KA. Interlocking medullary nail stabilization of tered with the opposing pull of a tension band device B. results in a
a femoral fracture in a dog with osteomyelitis. J Am Vet Med Assoc compressive force across the fracture or osteotomy C.
209:397, 1996.
10. Terrell SP, Chandra AMS, Pablo LS, Lewis DD. Fatal intraoperative greater trochanter of the femur, supracondylar epiphysis of the
pulmonary fat embolism during cemented total hip arthroplasty in a dog. femur, medial malleolus of the tibia, tuber calcis, tibial tuberosity,
J Am Anim Hosp Assoc 40:345, 2004. and attachments of collateral ligaments. This is a commonly
11. Schwarz T, Crawford PE, Owen MR et al. Fatal pulmonary fat used technique because these are frequent sites of fracture and
embolism during humeral fracture repair in a cat. J Small Anim Pract osteotomies for surgical approaches. A tension band wire can
42:195, 2001. be successfully applied in many situations, if principles of appli-
12. Muir P, Johnson KA, Markel MD. Area moment of inertia for cation are followed and proper technique is used.
comparison of implant cross-sectional geometry and bending stiffness.
Vet Comp Orthop Traum 8:146,1995.
Technique
Before a tension band wire is applied, the direction of the
Tension Band Wiring distractive forces should be estimated. Because forces can
change through the range of motion of a joint, the “average”
Karl H. Kraus
distractive force should be estimated. The tension band should
be applied to the side opposite the distractive forces, the tension
Introduction side of the fracture or osteotomy.
Tension banding is a technique by which tensile forces are
converted into compressive forces. This principle can be After the fracture or osteotomy is reduced, two orthopedic pins
applied to the repair of fractures in which a fragment is (Kirschner wires) are inserted from the distracted fragment across
distracted from its original position by the pull of a muscle, the fracture line and into the attaching bone (Figure 49-19A). Two
tendon, or ligament. The area of fracture opposite the pull pins are used whenever possible to provide rotational stability.
under tension is termed the tension side of the fracture. If the The pins should be applied parallel to the direction of desired
tension side of the fracture is fixed with a tension device, the compression and so that an orthopedic wire placed over them
device pulls in a vector which counters the distractive force. If applies even, undeterred pressure to the tension side of the
the force of the distractive pull is not in a straight line with the fracture. These pins should be seated in cortical bone in the
tension device, the force of the distractive pull is redirected to opposite cortex to prevent migration.
a resulting vectoral force which is a compressive force across
a fracture or osteotomy (Figure 49-18). With a drill or orthopedic pin, a hole is drilled through the cortex
to accommodate the tension band wire. The distance of this hole
from the fracture line should be such that the figure-of-eight
Indications wire does not cross directly over the osteotomy. A section of 0.8
Indications for use of tension band wires include repair of mm, 1.0 mm or 1.2 mm orthopedic wire is looped one-third of the
fractures or osteotomies of the acromion of the scapula, supra- distance from one end. The short end is inserted through the hole
glenoid tubercle, greater tubercle of the humerus, olecranon, in the cortical bone, and the long end with the loop is brought
Fixation with Pins and Wires 781
over the two orthopedic pins in a figure-of-eight pattern, and is be small, and applying a proper tension band may be difficult.
twisted to the other loose end (Figure 49-19B). The preplaced More commonly, however, this error occurs when performing
loop and twisted ends are tightened alternatively or with the help an osteotomy for a surgical exposure, such as an osteotomy of
of an assistant so the wire is evenly tightened (Figure 49-19C). the greater trochanter of the femur or tibial tuberosity. Too small
The orthopedic wire should be cut, leaving three to four twists, a fragment will break resulting in failure of the tension band.
and bent toward the bone. The Kirschner wires are bent over One usually avoidable technical error is the placement of only
the tension band wire and are cut to secure it (Figure 49-19D one pin. Because the vector of the distracting muscle, tendon,
and 49-19E). The ends of the wires are seated against bone. or ligament pull may change through a range of motion, there
Aftercare of the tension band wire itself is minimal. No more that may be a torsional force across the fracture. Two pins prevent
standard exercise restriction is required. rotation. Small avulsion fragments may only accommodate a
single pin. However, placing two smaller pins should be used
before one larger pin whenever possible. Use of a loop instead
Complications of a figure-of-eight wire is an avoidable technical error. A loop
Complications are uncommon and are usually the result of tends to center the compression more toward the pin and allows
improper technique. The six most common technical errors the fracture line on the tension side to distract. Heavy-gauge
resulting in failure are depicted in Figure 49-20. The first error wire should be used. Although 1.2 mm to 0.8 mm wire may seem
is having too small a fragment to accommodate an appropri- difficult to manipulate, smaller wire is rarely appropriate even in
ately sized tension band device. Fractures and avulsions can
Figure 49-19. Application of a tension band wire. A. First the fragment is replaced, and two pins or Kirschner wires are driven perpendicular to the
fracture line. B. A figure-of-eight wire is placed over the pins and through a hole in the cortex. C. The wires are twisted and tightened alterna-
tively. D. and E. The pins and wires are bent, cut, and seated next to the bone.
782 Bones and Joints
small animals. The hole in the bone anchoring the tension band
wire should engage enough material to counter the force of the Chapter 50
tension device. These forces can be substantial. The pins should
be anchored into the opposite cortex. Failure to do so can allow
the pin to migrate.
Interlocking Nailing of Canine
and Feline Fractures
Suggested Readings
Kraus KH. Tension band wiring. In: Bojrab MJ, ed. Current techniques in Interlocking Nailing of Canine
small animal surgery. 4th ed. Philadelphia: Williams & Wilkins, 1998:925.
and Feline Fractures
Kenneth A Johnson
This chapter was submitted in 2006 and was based upon the
available literature through that year. Other interlocking nail
devices have emerged since that time, but are not covered in
this chapter.
Introduction
The principles of management of diaphyseal fractures of the
femur, tibia and humerus by internal fixation have evolved
considerably from the original AO concepts of complete
anatomical reduction and rigid stabilization of all the fractured
fragments. Nowadays, the concept of biological management of
diaphyseal fractures places greater emphasis on less invasive
surgical approaches, and preservation of the bone blood supply
and the fracture hematoma, especially in cases of comminuted
non-reducible fractures. Overall alignment and stabilization of
the proximal and distal fragments are obtained without inter-
ference with the intermediate comminuted fracture fragments.
Figure 49-20. Six common errors in placing a tension band wire: A. Interlocking nail fixation is the method of choice for the stabi-
bone fragment is too small; B. only one pin is used; C. the wire forms lization of diaphyseal fractures of the femur and tibia in adult
a loop and not a figure-of-eight; D. too small a gauge of wire is used;
humans.1 In recent years, it has become more widely accepted
E. the hole in the cortex does not engage enough bone; and F. the pins
as a method of treating diaphyseal fractures in small animals
are not seated in the opposite cortex.
as well.2-8
Types and Sizes of Nails the fatigue life of the 2.7 bolt is over 140 times greater than that
of the 2.7 cortical screw.13 The diameter of the medullary canal
Several different systems of interlocking nails designed for at the level of the locking bolt is also an important factor when
canine and feline fractures have been developed by surgeons considering the mechanical performance of the locking bolt.14
from various countries, world wide.2-9 In principle, all these The bending moment on the bolt is proportional to the unsup-
interlocking nails function in a similar manner, but they differ ported length of the bolt within the medullary canal. Therefore
somewhat in regard to the instrumentation used for their appli- in large breed dogs, the bending load on the locking bolt may
cation. The most widely used interlocking nails in North America be considerable in the metaphyseal region where the bone has
(Innovative Animal Products, Rochester, MN) are round in cross a relatively greater diameter. In bones that are ovoid in cross
section and made from 316L stainless steel that has been cold section, it may be possible to reduce the bending load on the
worked to increase stiffness and fatigue life in vivo. The nails locking bolt by orienting it in the direction of the shorter cross-
are available in various diameters (4.0, 4.7, 6.0, 8.0 and 10mm) sectional axis of the bone.
and lengths. An implant of appropriate dimensions (diameter and
length) must be selected to match the patient’s fractured bone Another advantage of using locking bolts instead of cortical
because the nail is not usually cut to length during surgery. One screws is that bolts more effectively control torsional instability
end of the nail has a sharpened trocar point to facilitate insertion of the construct. With loading, the threads of cortical screws in
into the medullary canal. The other end of the nail is machined the region of contact within the nail hole become deformed and
with two flanges and an internal thread to allow for precise flattened.15 This effectively reduces the outside diameter of the
attachment of the drill-aiming guide during surgery. Typically screw, and allows for greater torsional slack in the construct in
each nail has two non-threaded transverse holes near to each comparison to locking bolts.16,17
end, for the insertion of locking bolts. The spacing between
these pairs of holes is either 11 mm or 22 mm. The closer hole
spacing allows for the insertion of two locking bolts when there Techniques of Application of
is limited metaphyseal bone available. In addition, nails are also
available with just one hole proximally or one hole distally for the
Interlocking Nails
stabilization of fractures near to the metaphyses, in which case Preoperative radiographs of the fractured bone are needed for
there is less available bone for interlocking (Figure 50-1). surgical planning and selection of an appropriately sized nail.
The radiographic views need to be true medio-lateral and cranio-
Locking bolts are inserted transversely through the bone caudal projections, with minimal magnification or distortion of
and holes in the nail with the aid of a special drilling aiming bone length. In case of comminuted fractures, radiographs of
guide. This instrumentation is described in further detail in the the contralateral intact bone may be more useful for preoper-
following section about application. The locking bolts have a ative planning. The length and diameter of the nail to be inserted
smooth shaft with four self-tapping threads under the bolt head, can be estimated by overlaying the radiograph with a trans-
to engage the near bone cortex. The shaft of the bolt is almost parent plastic sheet with the outline of the nail templates printed
the same diameter as the nail holes, with just a small under-sized on it. When using digital radiography, it is necessary to use an
tolerance to prevent jamming during insertion. Prior to the avail- internal radiographic marker of known length for calibration of
ability of locking bolts, conventional cortical bone screws were the radiographic magnification, and to import digital templates
used for locking. However, the use of screws for this purpose is of the nails for planning.18
no longer recommended, because of their inferior mechanical
performance; failure of screws by bending or breakage was In case of diaphyseal fractures that are near to the metaphysis,
occasionally a problem clinically.10,11 During the course of there must be sufficient bone available for seating of the nail
fracture healing, the locking bolts are mainly loaded by bending and the locking bolt(s), without invading the adjacent joint.
or quasi-bending forces. Under these conditions, the stiffness Some juxta-articular fractures will not be suitable candidates
and fatigue life of the locking bolt are determined by its area for interlocking nailing because there is insufficient bone stock
moment of inertia which is calculated using the formulae of π for implant fixation. In these cases, alternative means of fixation
x radius4/4. For example, the calculated area moment of inertias such as bone plating or hybrid external fixation may provide
for the 2.7 mm diameter locking bolts and cortical screws are better stability.
2.61 mm4 and 0.64 mm4 respectively.12 In the case of the cortical
screw, this value is much lower because the core diameter of An open surgical approach using appropriate aseptic surgical
the screw is only 1.9 mm. Under conditions of cyclic bending technique is needed for insertion of the interlocking nail and
Figure 50-1. Interlocking nails for stabilization of canine and feline fractures have a trocar point for insertion, and one or two holes at each end of
the nail for locking.
784 Bones and Joints
A small diameter Steinmann pin held in a Jacob’s chuck is intro- After the nail is seated, the insertion handle is removed and
duced into the medullary canal to establish axial alignment of the the drill aiming guide is attached to the nail extension piece
fractured bone. Normograde insertion of the pin is recommended (Figure 50-4). Accurate drilling of the holes is the most techni-
for femoral and tibial fractures. The pin is introduced into the cally challenging part of the procedure, and can be the greatest
femur through the trochanteric fossa. In the tibia, it is inserted source of intra-operative frustration. Inaccurate drilling can
into the proximal end of the bone through a cranio-medial surgical result in the locking bolt being inserted adjacent to the nail,
approach, at a point half way between the tibial tuberosity and rather than through it. A tissue protection sleeve is inserted into
the medial collateral ligament. In humeral fractures, either retro- the drill aiming guide in a position that corresponds to one of
grade pin insertion from the fracture site or normograde insertion the distal nail holes. Then the appropriate drill guide is inserted,
from the greater tubercle is equally appropriate and safe. The and a hole is drilled though the bone and the hole in the nail.
opening in the medullary canal can be progressively enlarged by Sharp drill bits with a “stick-tight” point are used to minimize
the sequential insertion of Steinmann pins of progressively larger the risk of the drill migrating to one side of the bone. Particular
diameter. Alternatively, the medullary cavity can be opened with care is taken when the drill is entering the periosteal surface
a reamer. The reamer should only remove cancellous bone from at an acute angle, as it has a tendency to migrate “down-hill”.
the metaphyseal region. Aggressive reaming of the endosteal The diameter of the drill hole is the same as the shaft diameter
cortical bone in the diaphysis should not be performed because of the locking bolt. The bone diameter is measured with a depth
cortical bone is much thinner in dogs and cats than in humans. gauge, and an appropriate length locking bolt is inserted. After
In humans, extensive reaming of the medullary canal is often the two distal locking bolts have been inserted, the fracture
performed to improve the mechanical performance of an inter- alignment is corrected with respect to bone length and torsion
locking nail because a large diameter, stiffer nail can be used with reference to anatomical landmarks. The proximal locking
that is more resistant to fatigue and breakage. However, on the bolts are then inserted, and the drill aiming guide and extension
other hand, reaming can cause fracturing of the diaphyseal piece are removed (Figure 50-5). If possible, two locking bolts
cortex and damage to the medullary bone blood flow with conse- should be inserted into the proximal and the distal fragments.
quential delayed or nonunion of the fracture. Careful planning is needed to ensure that there are no empty
holes in the nail near the fracture zone because of the risk of nail
In preparation for insertion of the nail, an extension piece is breakage. Additionally, the minimum distance from the fracture
attached to the end of the nail (Figure 50-2). The flanges on the zone to the locking bolts should be 2 cm or more.
end of the nail must interdigitate with those on the extension
piece, and the connection is secured by tightening of the Adjunctive fixation is not required unless there are cortical
threaded, internal spindle with a hexagonal screw driver. The fissures in close proximity to the locking bolts in which case
insertion handle is then attached to the extension piece, and cerclage wire can be applied. Generally comminuted fracture
used in a manner similar to a Jacobs chuck to drive the nail into fragments are not disturbed. Autologous cancellous bone graft
the medullary cavity (Figure 50-3). The nail has to be inserted harvested from the proximal metaphysis of the humerus or tibia
by normograde technique because only one end of the nail should be inserted at the fracture site in adult dogs if an open
has a trocar point. Care should be taken to ensure that the nail fracture reduction has been performed. In case of massive bone
is adequately seated into the distal metaphysis of the bone, defects, large quantities of bone graft can be harvested from the
without accidentally going too far and penetrating the articular wing of the ilium by using an acetabular reamer (BioMedtrix,
cartilage surface of the joint. Depth of penetration is judged Boonton, NJ).
by overlying a second nail of the same length, or with intra-
operative fluoroscopy. After the nail is inserted, do not attempt
to correct any offsets in the fracture reduction by the application
of bone holders or cerclage wiring, until after the locking bolts
Interlocking Nailing of Canine and Feline Fractures 785
Figure 50-3. The insertion handle is attached to the extension piece, and used to drive the nail normograde into the medullary cavity.
Figure 50-4. The drill aiming guide is attached to the end of the nail during surgery for accurate targeting of the drill holes into which are inserted
the locking bolts.
Figure 50-5. After the nail is locked into the distal fragment, alignment of the fracture is corrected for overall length and torsion, and then locked
with the insertion of two proximal locking bolts.
Specific Fractures nerve that lies just caudal to the hip joint. Normally the femoral
diaphysis of dogs has a cranio-caudal bend, or procurvatum. To
Femur overcome this curvature, two piece diaphyseal fractures may
Insertion of the nail by normograde technique in the trochanteric need to be axially aligned in slight recurvatum to allow the nail
fossa allows it to be lateralized and thus avoid damage to the to be adequately seated in the distal metaphysis and condyles of
femoral head and coxo-femoral joint. The nail can be inserted the femur. In comminuted fractures in which anatomic reduction
by blind insertion through the gluteal muscles, or under direct of the fragments is not the goal, this curvature is not an important
visualization. The trochanteric fossa is exposed by transecting factor in determining nail placement. In cats, the femoral diaphysis
the tendon of the superficial gluteal muscle and retracting it is generally quite straight, and can readily accommodate a small
proximally, and cranial retraction of the middle and deep gluteal diameter nail without loss of normal bone alignment.
muscles. Care is taken to avoid iatrogenic damage to the sciatic
786 Bones and Joints
For more distal diaphyseal fractures, the nail can be introduced should be recognized that there is an increased risk of deviation
into the femur from the intercondylar notch and driven proxi- of the drill-aiming guide that may result in the drill missing the
mally. This allows the nail and locking bolts to engage more of distal holes in the nail.
the bone in the femoral condyles, and thus improve the stability
of the fixation. Depending on the diameter of nail, and the
amount of curvature in the femur, the nail may also be introduced References
through the articular cartilage surface at the very distal extent 1. Browner B.D. The Science and Practice of Intramedullary Nailing, 2nd
of the trochlear groove. However, it is important that the end of Ed. Baltimore: Williams and Wilkins, 1996.
the nail is buried below the joint surface so it does not interfere 2. Dueland RT, Johnson KA, Roe SC, Engen MH, Lesser AS. Interlocking
with the patella. As an additional refinement to this technique, nail treatment of diaphyseal long-bone fractures in dogs. J Am Vet Med
the buried end of the nail can be covered with a osteochondral Assoc 214:59-66, 1999.
plug that has been cut out of the trochlear groove with a bone 3. Duhautois B. L’enclouage verrouille veterinaire: etude clinique retro-
trephine, prior to insertion of the nail. spective sur 45 cas. Prat Med Chir Amin Comp 30:613-630, 1995.
4. Duhautois B. L’enclouage verrouille’ en chirurgie veterinaire: de la
conception aux premiers cas cliniques. Pract Med Chir Anim Comp
Humerus 28:657-683, 1993.
Fractures of the humeral diaphysis can be repaired via a limited 5. Durall I, Diaz MC, Morales I. An experimental study of compression
lateral surgical approach to the diaphysis. It is not necessary of femoral fractures of an interlocking intramedullary pin. Vet Comp
to mobilize the brachialis muscle and radial nerve to the same OrthopTrauma 6:93-99, 1993.
extent needed for lateral bone plate fixation. For normograde 6. Durall I, Diaz MC, Morales I. Interlocking nail stabilization of humeral
insertion, the nail is started cranially on the ridge of the greater fractures. Initial experience in seven clinical cases. Vet Comp Orthop
tuberosity, with the shoulder placed in slight flexion. It is not Traumatol 7:3-8, 1994.
started on the most proximal point of the greater tuberosity 7. Durall I, Diaz MC. Early experience with the use of an interlocking nail
because the inherent curvature of the humerus may prevent it for the repair of canine femoral shaft fractures. Vet Surg 25:397-406. 1996.
from being adequately seated into the distal fragment. Alterna- 8. Horstman CL, Beale BS, Conzemius MG, Evans R. Biological osteo-
tively the medullary canal can be reamed retrograde from the synthesis versus traditional anatomic reconstruction of 20 long-bone
fracture site. Most humeral shaft fractures involve the distal one fractures using an interlocking nail: 1994-2001. Vet Surg 33:232-237, 2004.
third of the diaphysis, and having adequate bone stock in the 9. Muir P, Parker RB, Goldsmid SE, Johnson KA. Interlocking intramed-
distal fragment and medial condyle for nail insertion will be a ullary nail stabilization of a diaphyseal tibial fracture. J Small Anim Pract
major consideration. In the majority of these types of fractures 25:397-406, 1993.
only single screw fixation distally is possible and thus a nail with 10. Durall I, Diaz-Bertrana MC, Puchol JL, Franch J. Radiographic
one screw hole distally will be selected to avoid leaving an empty findings related to interlocking nailing: windshied-wiper effect, and
screw hole at the fracture site. In very large dogs the distal end locking screw failure. Vet Comp Orthop Traumatol 16:217-222, 2003.
of the nail can be directed medially and seated into the medial 11. Suber JT, Basinger RR, Keller WG. Two unreported modes of inter-
part of the humeral condyle. As with all intramedullary devices, locking nail failure: breakout and screw bending. Vet Comp Orthop
implants should not impinge on the olecranon fossa. Distal inter- Traumatol 15:228-232, 2002.
locking screws are inserted with care, as they may be very close 12. Muir P, Johnson KA, Markel MD. Area moment of inertia for
to the radial nerve. comparison of implant cross-sectional geometry and bending stiffness.
Vet Comp Orthop Traumatol 8:146-152, 1995.
13. Litsky AS, Johnson KA, Aper RL, Roe SC: A novel screw design for
Tibia improving the fatigue life of interlocking nails. Proceedings Society for
Closed nailing of tibial fractures may be possible, especially with Biomaterials Annual Meeting, Sydney 2004.
the aid of fluoroscopic guidance, because the bone fragments 14. Aper RL, Litsky AS, Roe SC, Johnson KA. Effect of bone diameter
are readily palpable. The entry point for the nail on the tibial and eccentric loading on fatigue life of cortical screws used with inter-
plateau is located half way between the tibial tuberosity and locking nails. Am J Vet Res 64:569-573, 2003.
the medial collateral ligament, and several mm inside the medial 15. von Pfeil DJF, Dejardin LM, DeCamp CE, Meyer EG, Lansdowne JL,
cortex. This point is centrally located with respect to the axis Weerts RJH, Haut RC. In vitro biomechanical comparison of a plate-rod
of the medullary cavity, and just cranial to the articular surface combination-construct and an interlocking nail-construct for experi-
and insertion of the cranial cruciate ligament. To begin, a small mentally induced gap fractures in canine tibiae. Am J Vet Res 66:1535-
1543, 2005.
diameter Steinmann pin is inserted normograde from this point
and directed distally, ensuring it remains inside the medullary 16. Landsdowne JL, Sinnott MT, Ting D, Haut RC, Dejardin LM. Design
cavity. This hole is then enlarged with the reamer. If difficulty is and in vitro evaluation of the structural properties of a novel and current
interlocking nail systems. Proceedings American College of Veterinary
encountered, retrograde reaming from the fracture site is then
Surgeons annual meeting, October 5-7, 2006.
performed, to try to meet up with the proximal reaming tract. The
17. Dejardin LM, Lansdowne JL, Sinnott MT, Sidebotham CG, Haut RC.
tibial diaphysis is sigmoid in shape and narrowest distally, so nail
In vitro mechanical evaluation of torsional loading in simulated canine
diameter will tend to be smaller than that used in the femur. tibiae for a novel hourglass-shaped interlocking nail with a self-tapping
tapered locking design. Am J Vet Res 67:678-685, 2006.
A longer extension piece is used in tibial fracture so that the
18. Mattoon JS. Digital radiography. Vet Comp Orthop Traumatol 19:123-
connection with the drill-aiming device does not impact upon the 132, 2006.
femoral condyle and patella. Due to the longer work distances, it
Fixation with Screws and Bone Plates 787
Chapter 51
Fixation with Screws and
Bone Plates
Screw Fixation: Cortical,
Cancellous, Lag, and Gliding
Brian Beale
Cortical and cancellous screws are commonly used for fracture
repair in small animals. Cortical screws are fully threaded and
are designed for use in cortical bone (Figure 51-1). Cancellous
Figure 51-2. Screws can be used to provide interfragmentary compres-
screws are fully or partially threaded and are used where
sion. When using a fully threaded screw for this purpose, a glide hole
cortical bone is thin and cancellous bone predominates (Figure
must be drilled in the near cortex equal in size to the thread diameter of
51-1). Cancellous screws have a steeper thread pitch, deeper the screw.
threads, and a thinner core as compared with cortical screws.
fragments are reduced and are secured temporarily with an
Partially threaded cancellous screws are generally not used in appropriate bone clamp. Predrilling of the guide hole or thread
cortical bone because removal of the screw is difficult as bone hole before reduction and temporary stabilization is sometimes
grows around the unthreaded shank. Both types of screws can advantageous because it allows accurate placement of the hole
be used for different purposes, including lag screws, positional in narrow segments of the bone fragment. If predrilling is done,
screws, and plate fixation screws. a pointed drill guide is used to align the predrilled hole with the
opposite hole to be drilled. The use of cortical screws requires
Lag screws are used for interfragmentary compression of drilling of a glide hole in the near cortex, equal in size to the
fracture fragments (Figure 51-2). Compression occurs if the screw thread diameter of the screw, to prevent the screw from making
engages the far cortex and glides in the near cortex adjacent to purchase. Screw holes should be drilled in the center of the
the screw head. Cortical screws are selected for stabilization fragment to prevent shifting during tightening. The hole should
of cortical fragments in the diaphyseal region of the bone. The be drilled in a direction that bisects the angle formed by perpen-
dicular lines to the fracture line and the longitudinal axis of the
bone in fragments having less than 40° inclination. If inclination of
the fracture is greater than 40°, the hole should be drilled perpen-
dicular to the fracture line. The holes should also be placed an
adequate distance away from the edge and tip of the fragment to
prevent fracture of the fragment at the screw hole. A countersink
tool is optimally used in the near cortex to distribute loads trans-
ferred by the screw head to the bone more evenly, thus making
fracture less likely. A drill sleeve (outer diameter equal in size to
the glide hole, inner diameter equal in size to the thread hole)
is inserted in the glide hole until it meets the opposite cortex. A
thread hole equal in size to the core of the screw is drilled in the
far cortex. A depth gauge is used to measure the length of screw
needed. The selected screw should be 1 to 2 mm longer than the
measured hole depth to ensure adequate thread purchase in the
far cortex. The hole is carefully threaded with the appropriate
tap. The surgeon must insert the tap at the same angle as the drill
bit and must avoid excessive wobble during tapping to prevent
stripping or microfracture of the screw hole. The appropriate
screw is then inserted and tightened. Overtightening can lead to
stripping of the screw threads or fracture of the bone fragment;
appropriate tightness can usually be attained by grasping the
Figure 51-1. Cortical and cancellous screws. A. Cortical screws are fully
threaded. The thread pitch is less steep as compared with cancellous screwdriver with the thumb and the first two fingers, instead of
screws to increase holding power in cortical bone. B. Cancellous screws the entire hand, when tightening.
can be fully or partially threaded and are used where cortical bone is
thin and cancellous bone predominates. Cancellous screws have a Cancellous screws are often used to stabilize fragments in the
steeper thread pitch and thinner core as compared with cortical screws. metaphyseal or epiphyseal regions (Figure 51-3). When using
788 Bones and Joints
Figure 51-5. Dynamic compression principle. The horizontal movement of the screw head, as it impacts against the angled side of the hole, results
in movement of the bone fragment relative to the plane, and leads to compression of the fracture. (Copyright c 2005 by AO Publishing, Switzer-
land. Originally published in “AO Principles of Fracture Management in the Dog and Cat”. Thieme/AO Publishing, 2005)
plate protects the interfragmentary compression achieved with plate “footprint”) of the LC-DCP is greatly reduced. The capillary
the lag screw or screws from all torsional, bending, and shearing network of the periosteum is thereby less compromised, leading
forces. In comminuted fractures of the metaphysis or diaphysis, to a relative improvement of cortical perfusion, which reduces
the application of axial compressive forces may lead to collapse the osteoporotic changes underneath the plate. The geometry
and or angular deviation of the fractured bone. Lag screws can of the plate, with its structured undersurface, results in an even
not overcome these forces. In order to prevent loss of bone length distribution of stiffness, making contouring easier, and minimizing
or proper alignment in comminuted fractures, it is necessary to the tendency to kink at the holes when bent. The plate holes are
supplement the fixation with a buttress plate. The function of the evenly distributed over the entire length of the plate, which adds
buttress (or bridging) plate is simply to prevent axial deformity as to the versatility of application (Figure 51-6). The plate is available
a result of shear or bending. This type of plate fixation is subjected both in stainless steel and in pure titanium. Titanium exhibits
to full loading. Therefore, every possible effort should be made outstanding tissue tolerance.
to maintain all the soft tissue attachments and blood supply to
the fragments, since healing will depend on the formation of a
bridging callus rather than primary bone union. The proximal and
distal ends of the plate ends must each be solidly fixed to the
corresponding major bone segments by at least 3 screws. The
addition of an intramedullary rod (plate-rod fixation) decreases
the risk of plate fatigue by micromotion (Figure 51-4).
Figure 51-7. Application of a plate screw. a. Drilling of the hole in neutral position, b. measuring of the hole length, c. tapping, d. insertion of the
screw. (Copyright c 2005 by AO Publishing, Switzerland. Originally published in “AO Principles of Fracture Management in the Dog and Cat”.
Thieme/AO Publishing, 2005)
Miniplates
The increasing demand for fracture treatment in cats and toy
breed dogs and the ability of the veterinary surgeon, together
with modern diagnostic aids, led to the development of small
sized implants for stabilizing fractures in delicate areas such as
the maxillofacial region.
Technical failures and their Prevention The SOP Locking Plate System
Some common factors leading to technical failures and strat-
egies to avoid them are listed below. Technical failures are Karl H. Kraus and Malcolm G. Ness
usually due to incomplete assessment of the fracture patient,
which in turn leads to suboptimal fixation. Introduction
The SOP (String of Pearls) was designed to serve as a locking
Consider the following factors before performing osteosyn- plate system for the veterinary and human orthopedic community.
thesis: As with all locking plate systems, the SOP can be thought of
• Animals, which sustain injuries on more than one limb, need mechanically as internal – external fixators. The SOP consists
more stable fixations than those, which are able to protect a of a series of cylindrical sections (“internodes”) and spherical
single limb injury by non-weight bearing. components (“pearls”). There are three system sizes which
• In case of an infected and unstable fracture, rigid fixation is accommodate 3.5 mm, 2.7 mm and 2.0 mm screws. The cylin-
mandatory. drical component, or internode, has an area moment of inertia
• Whenever possible, the least invasive treatment is chosen. greater than the corresponding standard DCPs. Mechanical
testing using ASTM standards has demonstrated that the 3.5
Consider the following factors during osteosynthesis: SOP is 50% stiffer, and has a bending strength (load at which the
• Inadvertent stripping of the bone or detachment of muscles plate plastically bends) of 16 to 30% greater than the 3.5 mm LCP,
from fragments should be avoided. It is important to preserve DCP, or LC-DCP.
as much blood supply as possible to enable optimal fracture
healing. The SOP can be contoured in six degrees of freedom; medial
• While using power equipment, cooling with isotonic solutions to lateral bending, cranial to caudal bending, and torsion
is mandatory to prevent heat necrosis on the bone and subse- using specially designed bending irons (Figure 51-12).
quent loss of fixation at the implant-bone interface. Properly performed, contouring results in bending or torsion
at the internode, preserving the locking function of the pearl.
Consider the following factors after osteosynthesis: Mechanical testing has demonstrated that although bending a
• Postoperative resorption at the fragment ends, which were SOP will reduce its stiffness and strength by approximately one
anatomically reduced, are mostly due to the fact, that plate third, a SOP bent through 40 degrees remains almost (96%) as
osteosynthesis was not rigid enough for direct or indirect bone stiff as an untouched 3.5 DCP. Similarly, a SOP twisted through 20
healing. Due to the strain theory, the fracture gap must be degrees remains significantly stiffer than the new and untouched
widened and callus formation will start. 3.5 DCP.
• Implant related stress protection of a healing bone can lead to
bone resorption and osteoporosity. Therefore, implants should The spherical component of the SOP accepts a standard cortical
be removed, as soon as clinical fracture healing has been bone screw. There is a section of standard threads within the
completed. spherical component, and a section into which the head of a
standard screw recedes. As the screw head recedes into the
Suggested Readings spherical component, it comes into contact with a ridge causing
the screw to press fit into the pearl. This press fitting prevents
Gauthier E, Perren SM, Ganz R: Principles of internal fixation, Curr
Orthop 6: 220, 1992.
loosening of the screw during the cyclic loading of weight
bearing, and results in a very rigid screw/plate construct. This
Keller M, Voss K: UniLock: Applications in small animals. Dialogue 2:
20, 2002.
concept removes critical limitations of locking plate designs
employing a hole with either single, double, or conical threads.
Koch DA: Screws and plates. In Johnson AL, Houlton JEF, Vannini R, eds:
The larger diameter part of the pearl receives a drill/tap guide
AO principles of fracture management in the dog and cat, Duebendorf:
AO foundation, 2005, p 26.
Perren SM, Russenberger M, Steinemann S, et al.: A dynamic
compression plate. Acta Orthop Scand Suppl 125: 31, 1969.
Perren SM, Klaue K, Pohler OEM, et al: The limited contact dynamic
compression plate (LC-DCP) Arch Orthop Trauma Surg 109: 304, 1990.
Perren SM: Evolution of internal fixation of long bone fractures. J Bone
Joint Surg (Br) 84B: 1093, 2002.
and allows drilling, measuring with a depth gauge, and tapping of the plate onto bone as the screw is tightened. The threads of the
the screw hole, with familiar ORIF instrumentation (Figure 51-13). screw pull and slightly deform the bone that the threads engage.
The circular cross-section of the implant and the increased As bone is viscoelastic and remodels, the pull lessens over the
diameter of the pearls in comparison with the internodes gives first several minutes after installation due to bone relaxation,
the implant a relatively consistent stiffness profile – the screw then over the next period of days and weeks due to remodeling.
holes are not notable “weak points”. The larger size of the pearl Oval holes allow dynamic compression and load sharing since
protects it against deformation during contouring or load bearing. the screw can move slightly along the long axis of the plate. The
The use of inserts (“golf tees”) placed into the pearls protects screw can pivot in the hole of the plate.
the pearl absolutely and preserves locking function completely
during contouring. In contrast, locking systems, including the SOP, will function
invariably as “buttress” systems – even when they are applied
to an anatomically reconstructed fracture. The screws of inter-
locking plates act as transverse supporting members, subjected
to cantilever bending. The primary loads on bone during weight
bearing are axial, along the long axis of the bone. Axial loads
of a bone encounter a screw and the load is transferred at the
bone/screw interface to the screw, then to the plate, then back
to the screw on the other side of the fracture, then to bone.
Here, there is no pulling of the plate down to the bone so the
resistance to pullout of a screw is less relevant. Importantly, the
screw is integrally and always part of the transmission of forces
across areas of fracture. Locking plate systems rarely utilize
dynamic compression, and are acting as buttress devices. The
result of die back of bone in the initial healing phase, and the
reliance upon lag screws, wires or other mechanically inferior
components within the reconstruction means that even where
load sharing is achieved at surgery, locking systems invariably
function in buttress mode.
side of the bone, or two SOPs can be nested side by side. The Comminuted diaphyseal femoral fractures are best repaired
use of an intramedullary pin (SOP-rod technique) enhances the using the SOP in combination with under sized intramedullary
stiffness of a construct to an extent which is not appreciated by pins, also known as a Rod and Beam fixation. A standard
many surgeons. This increased stiffness substantially protects surgical approach appropriate to the specifics of the fracture
implants and protects against fatigue failure. The use of SOP in is made. An intramedullary pin of 1/3rd to 1/2 the diameter of the
pairs (for example, in the spine) or in conjunction with a rod (for medullary cavity is placed normograde from the intra-trochan-
example, in long bone fractures) should be considered the norm. teric fossa, threading the area of comminution, into the distal
femoral segment. The limb is aligned with reference to adjacent
Bone slicing is a potential problem associated with the use of anatomical landmarks. In the femur the coxofemoral joint should
locking systems in poor quality bone. With conventional plating be in slight anteversion while the stifle is flexed. An elevator is
systems applied to weak cancellous or osteoporotic bone, passed along the lateral aspect of the femur, under the biceps
screw pullout is the critical factor. However, with locking screw and vastus. Inserts should be placed into the SOP holes before
systems screws cannot pullout, especially if there is some contouring to prevent distortion of the holes. An SOP of appro-
divergence or convergence with screws. Instead, failure will priate length is contoured: it is helpful to have radiographic
occur through slow creep of the screw through the weak bone, images of the opposite, un-fractured femur to guide the contour.
known as “bone slicing.” Therefore, as locking plate systems The contour does not have to be perfect, as the SOP does not
are preferred in weak or osteoporotic bone, they may still exhibit need to lie directly on bone. The distal aspect of the SOP can
this mode of failure if the bone / implant system used is not suffi- be contoured to follow the femoral condyles caudally and the
ciently robust. Bone slicing has not been identified in SOP cases proximal SOP can be twisted directing the screws antegrade to
so the importance of this phenomenon in veterinary patients is the femoral neck. The SOP is placed in the soft tissue tunnel, and
not yet known. contour is reviewed. Four screws should be engaged on each
side of the fracture. Unicortical screws are appropriate and
“empty” screw holes – even over the fracture – are acceptable.
Application Techniques: Appendicular Skeleton The IM pin will prevent bending of the SOP, so there may be a
The primary utility of the SOP in the femur, humerus, tibia, radius, long area without screws in the center of the femur.
and ulna is in comminuted fractures. Although the SOP can be
used in conventional “open approach” fracture surgery, it is The drill guide is placed into a screw hole on one end of the bone
especially valuable with biologic fixation methods and minimally and the remaining screw holes observed to make sure the SOP
invasive techniques. For example, techniques involving SOP and is positioned properly. Remember that the screw will always be
screws installed with stab incisions or mini approaches, or more directed perpendicular to the spherical component of the SOP.
open approaches where the area of comminution is preserved. Though you can twist the SOP to change screw direction, this
The comminuted, diaphyseal femoral fracture will be used as an is done prior to installation of screws. The drill and tap guide
example of standard SOP methods (Figure 51-14). will direct the drill and tap in the proper direction. The insert is
removed from the SOP at the first screw location, either proximal
or distal. The drill hole is made using the drill guide, then the
depth is measured. A screw is placed. Standard or self tapping
screws can be used according to surgeon preference. It is
possible for the tap/self-tapping screw to not engage the bone
hole immediately. This results in the SOP being pulled too far
away from the bone. This can be prevented by applying gentle
axial pressure during early placement of the tap/self-tapping
screw. Note also that when using a bone tap, care must be taken
subsequently when placing the screw to ensure that the screw
threads engage in the bone as desired, and not 360° later. The
screw should be tightened so that the screw head seats firmly
into the spherical component of the SOP. If a unicortical screw is
placed, the depth gage measures the minimal length the screw
needs to be by the standard method of hooking the near cortex.
Then the depth gage is advanced to the trans cortex or, in some
cases, the intramedullary pin. A screw 0 to 2 mm longer than the
measured minimum distance is chosen. Measuring the distance
to the transcortex or intramedullary pin will assure that an
oversized screw will not interfere with any structure. The same
procedure is repeated for all screws.
Technical Guidelines
Note that these are guidelines and not rules. They are provided
to experienced, knowledgeable and sensible surgeons with
the assumption that such experience, knowledge and common
sense will be brought to bear on each individual case.
A B
Femur
SOP-rod: Figure 51-15. Combined medial and lateral approaches A. or transulnar
approach B.
IM pin 20%-40% diameter of medullary canal,
Normograde or retrograde
Open or closed placement Tibia – diaphysis
4 screws in distal and 4 screws in proximal fragments IM pin 20% to 40% diameter of medullary canal,
Single 2.7 SOP (plus rod) in patients up to 10 kg (lateral aspect) Normograde
Single 3.5 SOP (plus rod) in patients up to 35 kg (lateral aspect) 4 screws in distal and 4 screws in proximal fragments
Double 3.5 SOP (plus rod) in patients over 35 kg (lateral aspect) Single 2.7 SOP (plus rod) in patients up to 10 kg (medial aspect)
Single 3.5 SOP (plus rod) in patients up to 35 kg (medial aspect)
Double 3.5 SOP (plus rod) in patients over 35 kg.(medial aspect)
Humerus – diaphysis
SOP-rod:
IM pin 20%-40% diameter of medullary canal, Ulna – Radius
Normograde or retrograde Small IM pin in ulna
Open or closed placement Normograde or retrograde
Bed into medial epicondyle SOP on radius
Consider reverse placement through medial epicondyle in 4 screws in proximal and 4 screws in distal fragment
very distal fractures SOP on medial or dorsal aspect distally
4 screws in distal and 4 screws in proximal fragments SOP on cranial aspect proximally
Single 2.7 SOP (plus rod) in patients up to 10 kg (medial aspect, Avoid overlong screws transfixing radius and ulna
lateral aspect or “spiral”) 2.7 SOP in patients up to 10 kg
Single 3.5 SOP (plus rod) in patients up to 35 kg (medial aspect, 3.5 SOP in patients over 10 kg
lateral aspect or “spiral”)
Double 3,5 SOP (plus rod) in patients over 35 kg. (medial aspect, Spine – Fractures or Distraction-fusion
lateral aspect or “spiral”)
The SOP serves well as a locking spinal fixation system, much
like a pedicle screw system or locking cervical fusion devise
Humerus – elbow “Y” or “T” (Figure 51-16). It does not lag onto bone which accommodates
Combined medial and lateral approaches or transulnar approach irregularities of the vertebral column. The SOP is applied to the
(Figure 51-15) dorsal lateral aspect of the spine, directing the screws at 30 to
Anatomic reconstruction with lag screws, K wires etc 40 degrees from the mid saggital plane into the vertebral bodies.
Two SOPs, one medial and one lateral Two SOP plates are applied to the left and right sides of the spine.
Total of 4 SOP screws in reconstructed condylar fragment (not With vertebral luxations, two three hole SOPs are applied with
necessary to have all 4 screws in the same SOP) four screws engaging the vertebral bodies on either side of the
Total of 4 screws in proximal major fragment (not necessary to luxation. With vertebral fractures and instabilities, longer plates
have all 4 screws in the same SOP) are applied and may engage two vertebrae on either side of the
Two x 2.7 SOPs in patients up to 20 kg instability. As the SOP is not lagged onto bone, the irregularities
Two x 3.5 SOPs in patients over 35 kg do not pose a problem as seen in applying standard orthopedic
plates. The cylindrical shape lies on the pedicle and avoids
compression of nerve roots exiting the intervertebral foramen.
796 Bones and Joints
Ilium
Gluteal roll-up approach – can be extended caudally by
trochanteric osteotomy
SOP applied to lateral aspect of pelvis
Minimum 2 screws cranial and 2 screws caudal
Twist SOP cranially to optimise stability in thin bone
2.7 SOP in patients up to 20 kg
3.5 SOP in patients over 15 kg
Two SOP plates nested whenever possible (Figure 51-17)
Acetabulum
Open reduction and temporary fixation with K wires,
bone forceps etc.
SOP applied to dorsal aspect of acetabulum (Figure 51-18).
Minimum 2 screws cranial to fracture and 2 screws caudal
to fracture
Single locked screw in stable butterfly fragment is
acceptable
Figure 51-16. The SOP serves well as a locking spinal fixation system,
2.7 SOP in patients up to 35 kg
much like a pedicle screw system or locking cervical fusion device.
3.5 SOP in patients over 35 kg
As the angle of screw placement is greater in the thoracolumbar
area compared to the lower lumbar area, the SOP can be twisted Miscellaneous Applications
to vary the screw angles. SOP has been used successfully in a variety of other situations
including shoulder arthrodesis, pan-tarsal arthrodesis, augmen-
The SOP can be used for cervical fracture repair, or cervical tation of TPLO and TPO procedures and in the revision/salvage of
fusion in cases of instability. Two SOPs are applied to 4 adjacent failed fracture and arthrodesis surgeries. The information provided
vertebrae. In this way a minimum of 4 screws are on either side in these guidelines and the recommendations given for “standard”
of the fracture or instability. The screws are directed slightly cases will provide the surgeon with a starting point for implant
laterally. The screws need not penetrate the vertebral canal. It is selection and surgical planning in non-routine applications.
important to direct the screws without damaging the spinal cord,
nerve roots, venous sinus, or vertebral artery.
Always use SOPs in pairs
Cervical – ventral aspect of vertebrae
Thoracic, T-L, Lumbar - SOPs bilaterally on lateral aspects
with screws directed ventro – medially
Lumbo-sacral – bilateral SOPs with screws directed
ventro-medially into lumbar vertebral bodies. Caudally the
SOP can be twisted and contoured to engage the iliac shaft.
Minimum of 3 scews in each vertebral body (not necessary to
have all screws in the same SOP)
Use longest possible screws to engage maximum amount of
vertebral bone
Penetration of far cortex is not essential but should be performed
when possible
Stand SOP off spine to avoid damage to emerging nerve roots
2.7 SOP in patients up to 10 kg
2.7 and 3.5 SOPs can be used in combination
Pelvis
SOP can be used successfully in most pelvic fractures. The
reconstructed pelvis is inherently fairly stable by virtue of its
shape and extensive musculature. Potentially disruptive forces
tend to be very much smaller than those encountered in long
bone fractures. Consequently, pelvic implants can be relatively Figure 51-17. Pelvis. Two SOP plates nested.
smaller than those needed for long bones and, similarly, pelvic
fracture fragments can often be effectively stabilized with
relatively few screws.
Plate-Rod Fixation 797
Chapter 52
Plate-Rod Fixation
Application of Plate-Rod
Constructs for Fixation of
Complex Shaft Fractures
Donald A. Hulse
Introduction
Bone healing occurs by direct or indirect union. Direct bone union
is characterized by remodeling of existing haversian systems
through simultaneous bone resorption and bone deposition.
Indirect bone union occurs through the sequential deposition
of tissues with increasing mechanical strength: immature
connective tissue - fibrocartilage - woven bone. Another method
of indirect bone union, and possibly the mechanism associated
with indirect fracture reduction techniques, is by omitting the
stage of fibrocartilage deposition proceeding directly to the
formation of woven bone. For either direct or indirect bone
Figure 51-18. SOP applied to dorsal aspect of the acetabulum. union to occur, certain biologic and mechanical events must be
satisfied. Biologically, adequate vascular supply and appropriate
histochemicals (BMP, growth factors) are needed to support
Suggested Readings existing bone cells and provide stimulus to differentiate pluripo-
DeTora MD, Kraus KH. Mechanical testing of locking and non-locking tential cells. Mechanically, the fixation must be strong and stiff
3.5mm bone plates. Vet Comp Orthop Trauma 21: xx-xx, 2008. enough to prevent excessive micromotion (strain) at the fracture
Egol KA, Kubiak EN, Fulkerson E, Kummer F, Koval KJ. Biomechanics of interface but allow sufficient micromotion to stimulate bone
locked plates and screws. J Orthop Trauma 18(8): 488-93, 2003. formation. To satisfy mechanical conditions, surgeons often
Schutz M, Sudkamp NP. Revolution in plate osteosynthesis: new internal choose to apply a neutralization plate or a compression plate
fixator systems. J Orthop Sci 8: 252–258, 2003. to provide interfragmentary compression. Coupled with atrau-
Gardner MJ, Brophy RH, Campbell D et al. The mechanical behavior matic technique conditions are met to achieve direct bone union
of locking compression plates compared with dynamic compression and an early return to clinical function. However, if in the appli-
plates in a cadaver radius model. J Orthop Trauma 9: 597-603, 2005. cation of the bone plate small fracture gaps are present on the
Sommer C, Gautier E, Muller M et al. First clinical results of the Locking transcortical surface, high local strain will occur (small fracture
Compression Plate (LCP) Injury; 34 (Suppl 2): B43-B54, 2003. gaps concentrate strain). Additionally, with highly comminuted
fractures, the vascular envelope is often damaged during
reduction of fracture fragments delaying the appearance of the
biological elements needed for bone union. High local strain and
vascular compromise act synergistically in delaying the healing
response. The delay in healing is coupled with the fact that the
without the integrity of the bone column stress is carried by the
plate and may lead to cyclic failure of the plate. The concept of
indirect reduction is one which strives to preserve the biologic
envelope of the fracture area. This is chiefly applied to commi-
nuted fractures where reduction of fracture fragments is likely
to destroy vascular attachments. Experience suggests that
it is preferable not to disturb bone fragments or the fracture
hematoma thereby preserving the biologic milieu. The surgeon
should regain spatial alignment of the limb and then bridge the
fractured zone with a buttress plate being careful to limit manip-
ulation of the soft tissues to a minimum.
concentrates grade) an IM pin which occupies 40% the diameter of the marrow
cavity. An IM pin of this approximate size reduces the stress on
the plate by 50% or more. More importantly, the fatigue life of
strain and the plate is extended at least 10 fold. However, an IM pin which
only occupies 25% of the marrow cavity reduces the stress in
all stress is the plate by a factor of 10%. Therefore, the appropriate pin size
is critical. Inserting the intra-medullary pin establishes varus-
the bone
contour it to the anatomic shape of the bone. Use a radiograph of
the intact bone of the opposite leg as a template to help contour
the plate if the bone of the affected leg is severely comminuted.
plate Apply a plate of appropriate length to the tension surface of the
bone. When applying minimally invasive technique, the plate
must span the length of the bone from proximal metaphysis
Figure 52-1. to distal metaphysis. Insert the most proximal and distal plate
screws so that they avoid the IM pin and engage both near and
far cortices. At this point examine for proper rotational alignment:
As a general guide, the internal and external rotation of the
hip should be equal when starting at a neutral position. Once
rotational alignment is established, insert additional screws;
place an additional screw proximally and an additional screw
combining distally for a total of two screws in the end plate holes proximally
and two screws in the most distal plate holes (Figure 52-3).
a pin with If it is necessary to place screws in more central plate holes,
the plate insert the plate screws so that they engage only the near cortex
– i.e.monocortical screws (Figure 52-4). If large fragments are
A B
Figure 52-3. A. and B.
A B
Figure 52-5 A. and B.
plate by 50% or more. More importantly, the fatigue life of Fractures of the Radius/Ulna
the plate is extended at least 10 fold. The pin may be retro- Use a minimally invasive exposure or one employing the concept
graded or normograded. Apply a plate of appropriate length of OBDNT (Open But Do Not Touch); the anteromedial approach
to the tension surface of the bone. When applying minimally is commonly used for the radial exposure, whereas a postero-
invasive technique, the plate must span the length of the bone lateral approach is used for the ulna. The intra-meduallary pin is
from proximal metaphysis to distal metaphysis. Insert the most placed in the ulna for this construct. The size of the pin approxi-
proximal and distal plate screws so that they avoid the IM pin mates the diameter of the marrow cavity of the ulna. The pin can
and engage both near and far cortices. At this point examine be normograded or retrograded and should be placed prior to
for proper rotational alignment: As a general guide, the internal applying the plate on the radius. The pin will assist in re-estab-
800 Bones and Joints
Introduction
The external skeletal fixation (ESF) system integrates the use
of transfixation pins, an external frame, and sometimes an
intramedullary pin connected to the frame for definitive fixation.
Clinical use of the ESF system may include supplemental inter-
fragmentary fixation techniques such as lag screws, K-wires,
and cerclage wires when appropriate. Bone plate and screw
fixation and the interlocking nail are examples of other fixation
systems. All three of these major fixation systems are used for
similar indications including fracture management, arthrodesis,
and corrective osteotomy repair. Each fixation system has its
unique advantages and disadvantages, and no single fixation
A B system is preferred in all instances. They all provide suitably
rigid fixation of fractures. The two internal fixation systems
Figure 52-6. A. and B.
provide the advantage of more straight forward postoperative
care compared to the ESF system. ESF, however, provides better
opportunity to maximize the biologic potential for healing within
the fracture zone. Specific advantages and disadvantages of the
ESF system are summarized in Table 53-1.
This section will cover terminology and basic principles of angles relative to the long axis of the bone. Angling of this type
external skeletal fixation applicable to all of the different ESF of fixation pin was necessary to limit pin migration attributable
devices commonly used in North America. Subsequent sections to poor security of the pin-bone interface with smooth implants.
will cover specific application techniques for the acrylic and One of the most important improvements in veterinary ESF was
pin external fixator (APEF), Securos external fixator, IMEX-SK the development of affordable, properly-sized, threaded fixation
external fixator, circular external fixator, and hybrid external pins with a raised thread profile (positive profile thread). These
fixator. All of these devices provide stronger, more reliable modern fixation pins have significantly reduced the morbidity
fixation that is easier to apply compared to earlier experience formerly experienced with ESF due to the fact that they provide
with the Kirschner-Ehmer (KE) external fixator. For these reasons, reliable, long-term pin-bone interface security. The most recent
the second generation veterinary external fixation devices development in veterinary fixation pin technology is an intelli-
mentioned above have for the most part replaced the KE splint in gently designed negative profile threaded pin with a taper run
current clinical usage. out junction to alleviate the stress concentration point normally
found at the junction between the threads and the shaft of the
pin (Duraface pins – IMEX Veterinary Inc.). Owing to a larger pin
Nomenclature of ESF shaft diameter, Duraface pins have been shown to be mechani-
An external fixator has two fundamental elements regardless cally superior to positive profile pins of the same thread diameter.
of the device being used. These are the fixation pins and the
connecting column (fixation frame). Fixation pins are percuta- Fixation pins are classified as either half-pins or full-pins.
neous devices that engage both the near cortex and far cortex Half-pins penetrate the near side soft tissues to transfix the bone
of major bone segments for attachment of the fixator to the with the end-threaded portion of the pin, and they are attached
bone. Originally, fixation pins were smooth Steinmann pins to a single connecting column (Figure 53-1). Full-pins go through
with trocar points that were passed at convergent or divergent the near side soft tissues to transfix the bone with centrally
Figure 53-1. Cranial views of a unilateral frame and a bilateral frame applied to the tibia and corresponding cross-sectional views at the level of
an end-threaded half-pin (*) and a centrally-threaded full-pin (>). Note that the half-pins attach to a single medially placed connecting column
(unilateral frame), whereas the full-pins attach to two connecting columns, one medially and one laterally.
802 Bones and Joints
Figure 53-2. Different frame configurations. A. Type I-a (unilateral uniplanar) frame applied to the medial aspect of the tibia. B. Type I-b (unilateral
biplanar) frame applied to the cranial aspect of the radius. The corresponding cross-sectional view shows the craniomedial and cranilateral
pin planes that were used to build this construct. C. Minimal Type II (bilateral uniplanar) frame applied to the tibia. One full-pin has been applied
both proximally and distally and the remaining positions are completed with half-pins placed from the medial side of the bone. D. Maximal Type II
(bilateral uniplanar) frame applied to the tibia. Full-pins have been applied at all positions to build this construct. E. Minimal Type III (bilateral bi-
planar) frame applied to the tibia. F. Maximal Type III (bilateral biplanar) frame applied to the tibia. The corresponding cross-sectional view shows
the medio-lateral and cranial pin planes that were used to build this construct.
External Skeletal Fixation 803
placed threads, proceed through the far side soft tissues, and A Type I-b configuration (Figure 53-2B) is basically the combi-
are attached to two different connecting columns, one on the nation of two Type I-a frames placed on different aspects of the
lateral side of the limb and one on the medial side (Figure 53-1). bone. Mechanical performance is optimized when the second
frame is placed in an orthogonal position relative to the first
Connecting Columns are fastened to and interconnect the (i.e. the plane of the fixation pins of one frame is 90° different
fixation pins, thus providing support for the fixation pins and the from the plane of the fixation pins of the second frame). On the
fractured bone. It is in the design of the connecting columns that tibia this would translate as a medial frame and a cranial frame.
the different ESF devices find their uniqueness. Similar to the KE The two pin planes on the radius are usually craniomedial and
splint, the Securos fixator and the IMEX-SK fixator use clamps and craniolateral (coming in on either side of the extensor muscles)
rods to form the connecting column or fixation frame. However, and the degree of separation between the pin planes is often
both of the newer devices are superior to the KE splint in terms of less than 90°.
strength and versatility. The APEF uses acrylic cement to both grip
and interconnect the fixation pins. Low cost and greater freedom Anatomical restrictions necessitate the construction of modified
in terms of the shape of the frame are the inherent advantages of Type I-b frames for the femur and humerus (Figure 53-4). The
the APEF frame. The clamp and rod devices offer the advantages major safe corridor for pin placement is found laterally, although
of reusable components and greater ability to easily make adjust- a reasonably safe craniolateral corridor may also be used in the
ments of the frame in terms of fracture alignment and fixation proximal 25 to 30% of these bones. Two different modifications
rigidity. Once the acrylic frame has cured into a rigid solid, frame are shown: a two-frame construct supplemented with an IM pin
adjustments are laborious and messy. tie-in (Figure 53-4A); and a three-frame construct (Figure 53-4B).
The major frame has been placed laterally in both cases. Fixation
Classification of different external fixator frame configura- pins placed in a craniolateral plane enable the construction of
tions is useful in that it evokes a mental picture of what a given a second craniolateral frame. If a full-pin is placed through the
construct looks like, and furthermore, the classification predicts distal metaphysis, the medial aspect of this pin provides the
the mechanical performance of one construct versus others. The opportunity for construction of a third (craniomedial) frame. The
most commonly used classification system initially considers three-frame construct can also be supplemented with an IM pin
whether a fixator is unilateral (connecting column on one side tie-in (not shown in Figure 53-4B). Modified Type I-b frames are
of the limb) or bilateral (connecting columns on both sides of sometimes used on other bones as well (Figure 53-5).
the limb), and then further considers whether it is uniplanar (all
fixation pins placed in more or less a single plane) or biplanar In order for a fixation frame to qualify for Type II status, it must
(fixation pins placed in two distinctly different planes). This have a minimum of two full pins, one in the proximal segment
consideration results in four different classification types (Figure
53-2). In order of weakest to strongest they are: Type I-a (a one
column construct that is unilateral and uniplanar); Type I-b (a
two column construct that is unilateral and biplanar); Type II (a
two column construct that is bilateral and uniplanar); and Type III
(a three column construct that is bilateral and biplanar). At each
step forward in this progression, construct rigidity increases (i.e
Type I-a is the weakest and Type III is the strongest).
Figure 53-4. Cranial views of modified Type I-b frames applied to the femur. A. Two-frame Type I-b construct with an IM pin tie-in. The major frame
has been applied laterally and the secondary frame is constructed off of a craniolaterally placed half-pin in the proximal segment of the bone.
B. Three-frame Type I-b construct. The major frame has been applied laterally. The secondary frame is constructed off of several craniolaterally
placed half-pins in the proximal segment. The tertiary frame is applied to the medial aspect of a distally placed full-pin and connected to one of
the craniolaterally placed half-pins.
triangular in cross-section. At this location a properly centered it will cause postoperative morbidity. Cross-sectional anatomy of
hole should be placed slightly caudal to what feels like the center the limb at various levels proximal to distal on the injured bone
of the bone in order to increase the distance between the points should be carefully considered in order to select the safest soft
of near cortical and far cortical engagement. tissue corridors to be used for fixation pin placement sites. It is
important to avoid large muscle bellies, tendons, blood vessels,
Fixation pins are typically placed through separate release and nerves. If penetration of a muscle belly cannot be avoided,
incisions at least 1 cm in length that are made over the center an ample release incision to prevent soft tissue tension on the
of the bone. With minimally invasive technique, the surgeon is fixation pin is necessary in order to keep morbidity low. Preferred
frequently unable to see the bone. To determine the location pin placement corridors in different bones are summarized in
of the bone, the surgeon can probe through the overlying soft Table 53-2. The importance of ample release incisions at every
tissues with sterile hypodermic needles and mark the edges with pin placement site cannot be overemphasized. When placement
strategically placed needles. An incision centered over the bone of the external fixator is complete, the surgeon should release
is then made through the skin and subcutaneous tissues with traction on the leg and move the joints above and below the
a scalpel blade. The release incision through deeper tissues is
made by blunt dissection down to the bone using a mosquito Table 53-2. Preferred Pin Placement Corridors
hemostat or Metzenbaum scissors. Muscle tissue should be for Different Bones
divided parallel to the direction of its fibers (usually parallel to the
long axis of the bone). Exposure can be maintained by placement Bone Optimal Pin Secondary Acceptable
of mini Gelpi retractors in the release incision. Placement Zones
Zones
A drill sleeve is passed through the incision down to the level Tibia Medial aspect Cranial aspect of the
of the bone and walked along its surface to locate the edges. due to minimal distal 75% of the bone;
Once the drill sleeve is centered over the bone, a drill bit is soft tissue avoid tibial tuberosity
inserted through it and a hole is pre-drilled in the bone. The coverage region
diameter of the drill bit should be equal to or slightly smaller
than the diameter of the smooth shaft of the pin to be applied. Lateral aspect of the
The drill must be spinning in a clockwise direction for the drill distal 75% of the bone
bit to cut through the bone. Operation of the drill at high speed is useful for Type II
during pre-drilling is safe because the flutes of the bit allow an frames
escape channel for debris, thus avoiding thermal necrosis of the Radius Craniomedial Craniolateral aspect for
bone. In contrast, the drill must be spinning clockwise at a much aspect has 2nd frame of Type I-b
slower speed when the threaded fixation pin is applied to the minimal soft constructs
bone. This is due to the lack of an escape channel for debris as tissue coverage
the threads of the pin cut corresponding threads into the bone. Medio-lateral plane for
If the pin is allowed to spin too quickly, thermal necrosis of bone Type II frames
immediately surrounding the pin will occur, thus jeopardizing the Femur Lateral aspect of Craniolateral aspect in
security of the pin-bone interface. the diaphyseal the proximal 25% of the
region bone for 2nd plane of
Once the threads of a positive profile pin cut the initial threads Type I-b constructs
in the near cortex of the bone, the slow clockwise rotation of the
pin will advance it through the bone by gear effect. Any attempt Lateral and medial
of the surgeon to speed this up (e.g. applying greater pressure on aspects of the distal
the drill or using it a higher speed) is detrimental to the pin-bone metaphysis and center
interface and should be avoided. The full threaded diameter of portion of the condyles
the pin should engage the far side of the far cortex in order to laterally and medially
obtain a mechanically optimal pin-bone interface. This means Humerus Lateral aspect Craniolateral aspect in
that the trocar tip of the pin will extend into the soft tissues on the of the diaphysis the proximal 35 % of the
far side of the bone when a half-pin is applied. The surgeon can but be careful bone
usually palpate the tip of the pin exiting the far cortex through the distally to avoid
overlying soft tissues in order to judge proper length. Ideally, only the radial nerve
the trocar tip of the pin exits the far side. If a longer portion of the
pin protrudes and there are no vital anatomic structures near it, Lateral and Lateral and medial
it is better to leave the pin “too long” instead of switching the drill medial aspects aspects of the distal
to reverse (counterclockwise spin) and backing it up. Two-way of the central metaphysis as long as
insertion of a fixation pin (going in too far and then partially portion of the pin position does not
backing out) has been shown to weaken the pin-bone interface. condyle interfere with elbow
function
The greater the amount of soft tissue that a fixation pin must NOTE: Fixation pins should be placed at a safe distance away from
the proximal and distal joint surfaces of the bone (i.e. at least 1 bone
traverse before reaching the bone, the greater the likelihood that diameter away).
808 Bones and Joints
injured bone through full ranges of motion. If there is soft tissue it exits the bolt of the pin-gripping clamp) and where it enters
tension detected at a pin placement site during movement of the the near cortex of the bone. Soft tissue thickness over the bone
joints, the release incision should be enlarged to relieve it. basically dictates the fixation pin working length. Some degree
of postoperative swelling should be anticipated and the fixation
frame should be positioned far enough away from the skin to
Principles of Frame Construction accommodate this. It is recommended that the nearest portion
Significant mechanical gains occur with the application of of the fixation frame (usually the inner aspect of the fixation
additional fixation pins in a fracture segment up to and including clamps) should be positioned about 1cm away from the skin. This
the 4th pin. As a general rule, the surgeon should strive to place keeps fixation pin working length relatively short, but allows a
a minimum of three fixation pins proximal to the fracture region small amount of space for postoperative swelling. Fixation frame
and three fixation pins distal to it. Fixation pins in different planes working length is the distance between the fixation pins placed
can be summed to achieve this goal (i.e. a Type I-b fixator with immediately proximal to and immediately distal to the fracture
two medially placed pins and one cranially placed pin in the zone. These implants should be placed as close to the fracture as
proximal fracture segment would provide the recommended possible while respecting the guideline of safe distance, which is
minimum of three fixation pins per segment). one bone diameter away from the fracture region. Frame working
length is mainly determined by the length of the fracture zone.
The working lengths of the fixation pins and the fixation frame
(Figure 53-9) should be kept as short as possible to optimize the Clamps should be positioned on the connecting rod such that
mechanical performance of the external fixator. The concept fixation pin working length is kept as short as possible. When the
of working length can be appreciated by taking a 1/8” (3.2 mm) clamp is positioned such that the pin-gripping bolt is between
Steinmann pin and applying a controlled amount of bending force the connecting rod and the skin surface (Figure 53-10A), this
to it. When the pin is grasped with both hands, one at each end is referred to as the “clamp-in” position. This is the preferred
of the pin (long working length) and force is applied, the pin feels position because it shortens fixation pin working length. When
quite flexible. When the pin is grasped more toward the middle the clamp is positioned such that the pin-gripping bolt is toward
portion (i.e. short working length) and the same amount of force the outer aspect of the connecting rod (Figure 53-10B), this is
is applied, it feels more rigid. Fixation pin working length is the referred to as the “clamp-out” position”. This unnecessarily
distance between where the pin attaches to the frame (where increases fixation pin working length. The clamp-out position
should only be used when it provides a unique angle required to
place the pin in a safe region of the bone that cannot be obtained
with the clamp-in position.
Figure 53-9. Fixation pin and frame working lengths and the order of pin
placement. Fixation pin working length (x) is the distance between the
near cortex of the bone and the inside of the pin-gripping clamp. Frame
working length (y) is the distance between the fixation pins that are
closest to the fracture. Fixation pins are generally placed in the follow-
ing order in relation to the fracture: the pins farthest away are placed Figure 53-10. Clamp-in position A. positions the pin-gripping bolt of the
first (pins 1 and 2); the pins closest to the fracture are placed next (pins clamp closer to the bone compared to the clamp-out position B. Note
3 and 4); and finally pins are applied between the far and near pins in that fixation pin working length is shorter when the preferred clamp-in
each segment (pins 5 and 6). position is used.
External Skeletal Fixation 809
applied next. Empty clamps are placed on the connecting rod and of healing. Excessive pin tract inflammation will increase patient
pre-drilling is done via a drill sleeve passed through the pin bolts morbidity and decrease use of the limb. This inflammatory
of these clamps. This far-far-near-near strategy of pin placement response is attributed to the presence of a contaminated foreign
relative to the fracture zone provides for optimal mechanical object (the fixation pin), inadequate drainage, and too much soft
performance of the fixation frame. Additional fixation pins are tissue motion around the fixation pins.
placed in the middle portion of each fracture segment until suffi-
cient stability is obtained. Careful attention to wound management during the first five to
seven days after ESF application is critical in order to control
The simplest frame configuration that will provide adequate of pin tract contamination and soft tissue inflammation. The pin
stability for a given fracture should be used. For relatively tracts are vulnerable to infection until the proliferative stage of
straight forward two-piece midshaft fractures, a Type I-a frame healing (fibroblasts and neocapillaries) leads to development of
is often sufficient on the tibia or the radius. With this type of a bacteriostatic lining of granulation tissue. The more contami-
fracture in the femur or the humerus, use of a Type I-a frame nated the early pin tract wound becomes, the longer it remains
with an IM pin tie-in is recommended. If intraoperative evalu- in the debridement stage of wound healing (polymorphonuclear
ation by palpation of the fracture reveals that a Type I-a frame leukocytes and macrophages). The longer the pin tract remains
is allowing too much deflection of the fracture, it is easy to add in the debridement stage the greater the likelihood of infection.
a second frame in another plane thus converting it to a stronger This is because the microorganism load will begin to overwhelm
Type I-b construct. This strategy is applicable to all four bones regional defense mechanisms. Infection will further prolong
mentioned. For challenging comminuted shaft fractures or the the debridement stage, creating even more inflammation. This
tibia or radius, the surgeon should plan for a stronger frame and negative cycle of events leads to high patient morbidity, eventual
start with either a Type I-b or a Type II construct. Challenging disruption of the pin-bone interface, and finally to loosening of
fractures of the femur and humerus can often be more reliably the fixator. To avoid this vicious cycle, the microorganism load of
managed with internal fixation techniques such as interlocking the pin tracts must be kept as low as possible to enable a brief
nail (see Chapter 50), bone plate and screw fixation (see Chapter debridement stage, rapid onset of the proliferative stage, and
51), or plate-rod fixation (see Chapter 52). development of healthy granulation tissue around the fixation pins.
When application of the external fixator is complete, do not trim Reduction of soft tissue motion can be attained by packing the
the fixation pins short until acceptable fracture alignment has area around the pins and between the skin surface and the
been verified with postoperative radiographs. The ability to make fixator frame with a bulky wad of gauze as part of the standard
adjustments is often compromised once the fixation pins have postoperative bandaging regime. It makes little difference to the
been cut short. Once acceptable alignment has been obtained, pin tract microflora whether the fixation pin is moving in the soft
all fixation pins should be trimmed such that the cut edge of the tissues or the soft tissue is sliding along the pin. The effect is
pin does not extend beyond the outer edge of the clamp. Even the same, that being increased pin tract inflammation, and pain.
shorter than this is preferable, when possible (the size and style All pins will cause some degree of inflammation and drainage.
of the pin cutter often determines the degree to which pins can This drainage will inevitably contain bacteria. When the fluid can
be trimmed). drain freely, secondary infection is rare unless the pin is loose in
the bone or the soft tissues are moving excessively on the pin.
If this drainage is blocked, secondary infection of the pin tract
Postoperative Care is likely.
Effective postoperative management of an external fixator is
defined by the following goals: 1) a healthy patient that walks Adequate release incisions facilitate drainage and regularly
comfortably on the limb throughout the healing period; 2) clinical changed gauze packing acts like a wick to pull it out from the
union of the fracture and removal of the fixator as quickly as wound. Clinical signs distinguish normal drainage (usually serous)
possible; and 3) avoidance of fixator induced injuries to the from that associated with pin tract sepsis. Signs suggestive of
patient, owner, and veterinarian. Achieving these goals depends an infected pin include excessive drainage (usually thick and
upon a carefully structured program of controlled physical foul-smelling), pain, lameness, induration or erythema of the soft
activity, soft tissue care, pin tract hygiene, bandaging of the tissues, and pin laxity. Failure to keep the pin tract clean and
fixator, and appropriately timed staged disassembly of multi- freely draining and failure to relieve soft tissue tension on the
planar frames. Because the fixator is external to the limb and pin can promote infection, increase patient morbidity, and lead
has many edges (some of which are sharp), it can potentially to pin loosening.
injure the patient or owner if it is not properly bandaged. Worse
yet, if the fixator becomes entangled in elements of the animal’s
environment (i.e. chain-link fence, etc.) and the animal struggles Early Postoperative Management
to free itself, the repair may be torn apart. Careful bandaging Systemic antibiotics are given throughout surgery and during
of the fixator allows it to bounce off of environmental objects recovery from general anesthesia and are usually discontinued
rather than being caught up in them and protects the owner and thereafter. Immediate post-op pain management is generally
the patient from being injured by the sharp edges of the fixator. achieved with morphine. The day after surgery, a 1 week course
Postoperative care of the soft tissues surrounding the fixation of carprofen (2.2 mg/kg per os BID) is started.
pins is equally critical to patient comfort during the early stages
810 Bones and Joints
Pin tract wounds should be covered with a sterile dressing for Research has shown that there is an “optimum time window”
the first five to seven days (or until healthy granulation tissue for initiating staged disassembly. In mature patients this interval
develops). Pin-skin junctions are cleaned with dilute hydrogen is generally felt to be at 6 to 8 weeks after surgery. In young
peroxide solution to remove blood clots, serum crusts, etc. A thin growing patients, this window probably occurs several weeks
film of triple antibiotic ointment (polymyxin, neomycin, bacitracin) earlier. The decision to begin staged disassembly is based upon
is applied to the skin around each pin placement site. Wads radiographic appearance and palpation of the fracture. When
of “fluffed-up” gauze sponge are packed around the pins and there is scant evidence of bridging callus and palpable instability
between the skin surface and the fixator frame to immobilize the of the fracture, staged disassembly is delayed.
soft tissues, to keep the pin tracts clean, and to wick drainage
away from the wounds. Gauze packing is held in place with When disassembly is determined to be appropriate, the following
an overwrap of Kling bandaging gauze. This sterile dressing is guidelines are applied: 1) The external fixator is examined for any
covered with a modified Robert Jones bandage for at least the fixation pins that are showing signs such as excess drainage
first 36 to 48 hours to prevent swelling in the distal portion of the or inflammation. If there are “problem pins”, the disassembly
limb. The fixator dressing is changed at 36 to 48 hours and every strategy should include their removal. 2) Consider removing any
other day thereafter until healthy granulation tissue develops. pins that have the potential to cause morbidity. Examples would
Application of a Robert Jones bandage over the dressing should include a pin in the soft bone of the distal femur, or one that goes
be continued during the first week after surgery. through the thick lateral soft tissues of the proximal tibia. 3) When
possible, it is best to remove frames rather than just individual pins.
After about 1 week, the Robert Jones bandage is usually 4) When a Type II or Type III configuration is present, conversion
abandoned in favor of a simpler “bumper” bandage. This is to a Type I-a or Type I-b to encourage axial loading of the bone
intended to pad and cover the edges of the frame to reduce the is recommended. When a Type I-b is present, down-staging to a
likelihood of it causing injury or entanglement. At each bandage Type I-a is appropraite. 5) When an IM pin “tie-in” configuration
change the same methods of skin hygiene and gauze packing is present, the IM pin is usually removed last in an attempt to
described above are used. Physical activity is limited to short encourage axial loading while protecting against bending stress.
walks outside on a leash for urination and defecation. It is advisable to retain one proximal fixator pin to enable mainte-
nance of the “tie-in” in order to prevent IM pin migration. However,
if the IM pin is a significant source of morbidity, it may be the first
Care at Home
element of the fixation to be removed. 6) Staged disassembly is
After granulation tissue develops the owner is instructed to different and individualistic for each and every case depending
change the bandage and packing on an as needed basis, upon the progression of healing. With some cases, disassembly
usually every 3 to 5 days. If the bandage becomes wet or dirty, may be a one or two step process and for others more steps may
if wound drainage increases, if odor is detected, or if the animal be required. 7) Once the frame has been simplified to a Type I-a
is licking or biting the wrap, more frequent bandage changes construct, removal of central pins will increase the working length
may be necessary. Physical activity is restricted to leash walks. of the frame and reduce fixation stiffness.
Running, jumping, and playing with other animals or children
should be discouraged. Walking up and down stairs should be
kept to a minimum. Good functional usage of the limb is expected External Fixator Removal
throughout the healing period. If this suddenly declines the Radiographic exams are scheduled based upon the expected
animal should be re-examined as soon as possible. If the owner healing time for a particular fracture and patient. When radio-
is willing, rechecking these patients every other week even if graphic evidence of healing is sufficient, the frame is loosened
they are doing well is recommended. Radiographic examination and the limb segment is palpated to verify clinical union. If the
at about 6 weeks after surgery should be done to assess healing bone has united, the remaining portion of the fixator is removed.
and to enable staged disassembly of the fixator. Exercise restriction should continue for about 4 to 6 weeks after
fixator removal while the empty holes in the bone begin to heal.
These empty holes can act as stress raisers predisposing to
Staged Disassembly of the External Fixator fracture of the healed bone through a bony pin tract.
It is biologically advantageous to reduce the stiffness of the
fixator (via staged disassembly) during the later stages of
fracture healing. This involves the sequential removal of fixation Suggested Readings
elements to allow the healing bone to be stimulated by carefully Aron DN, Palmer RH, Johnson AL: Biologic strategies and a balanced
controlled increases in axial stress. During the early stages of concept for repair of highly comminuted long bone fractures. Comp
bone healing, rigid fixation benefits revascularization of the Contin Educ Pract Vet 17:35, 1995.
fracture region, maintains tissue strain at a low enough level to Johnson AL, Egger EL, Eurell JAC, Losonsky JM: Biomechanics and
enable the formation of bridging callus, and allows the patient biology of fracture healing with external skeletal fixation. Comp Contin
to walk comfortably on the limb. During the later stages of bone Educ Pract Vet 20:487, 1998.
healing, strategic reduction of fixation rigidity transfers a greater Kraus KH, Toombs JP, Ness MG: External Fixation in Small Animal
percentage of axial weight bearing forces to the injured bone Practice. Oxford: Blackwell Publishing, 2003.
while continuing to protect against disruptive bending and Griffin H, Toombs JP, Bronson DG, et al: Mechanical evaluation of
rotational forces, and stimulates bony remodeling according to a tapered thread-run-out half-pin designed for external skeletal
Wolff’s Law. fixation in small animals. Vet Comp Orthop Traumatol 24:257, 2011.
External Skeletal Fixation 811
Introduction
Acrylic frame fixators are devices in which the pin-gripping
clamps and connecting rods are replaced with acrylic columns
(methyl methacrylate) to form the external fixation frame. A
powder component (polymer) is added to a liquid component
(monomer) to form a liquid or dough that can be poured or molded.
The mixture undergoes an exothermic reaction and forms a rigid
solid about 8 to 12 minutes after mixing. The resulting acrylic
column grips and interconnects the fixation pins thus forming
the fixation frame. Different sizes of fixation pins can easily be
used in the same construct and frames can be built to any shape
that the surgeon desires (i.e. fixation pins do not have to line up
to connect with a linear rod as they do with the clamp and rod
ESF devices). The use of curved acrylic columns, when needed,
does not compromise the stiffness of the frame.
Acrylic frame fixators can be applied to most bones but they are
particularly useful for mandibular fractures and transarticular
applications because the acrylic connecting columns are easily Figure 53-11. Acrylic bi-pack (1) with liquid monomer in the top com-
contoured to the shape of the body and joint angles. The acrylic partment and powdered polymer in the bottom compartment. Sidebar
used is radiolucent, which does not interfere with radiographic tubes are available in three sizes: 21 mm standard tube (2), 15 mm small
assessment of initial reduction or fracture healing. The first tube (3), and 10 mm mini tube (4). End caps for each size are shown
reports of acrylic frame fixators involved the use of Steinmann below the tubes.
pins or very long orthopedic screws as fixation pins. The screws
were inserted in the bones leaving the heads extended exter- increasing diameter may result in heat-generated “vaporization”
nally where they were connected with a column of dental acrylic. of the acrylic monomer creating voids in the column and strength
Homemade acrylic-pin splints are similarly constructed using loss. While an objective rule for optimal acrylic column diameter
methyl methacrylate that is available as hoof repair or dental for every fracture is not possible, a convenient guideline is that
molding acrylic. “Plumber’s Epoxy” has also been described the acrylic diameter should be the same size or larger than the
for similar applications. The APEF Systema utilizes acrylic and outer diameter of the bone being stabilized. For more complex,
positive profile threaded fixation pins and provides all of the unstable, or slower healing fractures, this relationship may be
basic components required to facilitate the construction of an augmented by increasing the diameter of a single column or
acrylic frame fixator. by using multiple columns. This bi-pack preparation and appli-
cation technique minimizes the mess and odor associated with
mixing acrylic (compared to Caulk Dental Acrylic and Technovit
Components of the APEF System Hoof Acrylic used in “homemade” versions of the acrylic frame
The acrylic frame is constructed with acrylic bi-packs, plastic fixator), but the surgeon does pay an increased price for this
sidebar tubes for molding liquid acrylic, and end caps to plug convenience. Acrylic Bi-Packs are available in five different
the molding tubes. A temporary frame alignment device is useful volumes: a triple pack contains 150 ml of mixed acrylic and will
for maintaining fracture reduction/alignment while the applied fill approximately 18 inches of the 21 mm tubing (enough to apply
acrylic frame is setting. a Type III frame to a large dog); a double pack contains 100 ml
of mixed acrylic and will fill 12 inches of 21 mm tubing (sufficient
Acrylic Bi-Packs (Figure 53-11) offer pre-measured volumes of for a Type I-b frame or a Type II frame in a large dog); a single
polymer and monomer packaged in separate compartments of a pack contains 50 ml of mixed acrylic and will fill 6 inches of 21
mixing bag. When the ends of the bag are pulled, a plastic divider mm sidebar tube or 12 inches of 15 mm tubing (enough for a Type
strip pops off and the mixing bag becomes a single compartment. I-a frame in a large dog, or either a Type I-b or Type II frame in
Acrylic is mixed for 2 to 3 minutes until a smooth consistency is a small dog or a cat); a half pack contains 25 ml of mixed acrylic
achieved and then the corner of the bag is cut off. The acrylic and will fill one small tube (sufficient for a Type I-a frame in a
is poured into plastic sidebar tubes that have been pushed onto small dog or a cat); and a quarter pack contains 12.5 ml of mixed
the ends of the fixation pins thus providing an injection mold acrylic that is generally used with the 10 mm diameter sidebar
for the acrylic. The effect of acrylic column diameter has been tube (sufficient for an acrylic frame in a small bird or other small
studied. In general, bending strength increases proportionally exotic pet).
with the diameter of the column until about 2.5 cm, at which point
Innovative Animal Products LLC, 5812 Highway 52 North, Rochester, MN 5590
a
812 Bones and Joints
Sidebar Tubes (Figure 53-11) are pushed onto fixation pins to alignment device consists of four universal clamps (that can be
provide a mold for liquid acrylic to form a cylindrically-shaped tightened without a wrench) and stainless steel connecting rods.
mass that acts as both a linkage device and a connector. The result The clamps can be applied close to the skin, just inside the sidebar
is a neat, professional-looking frame (unlike some of the acrylic tubes, and can be easily removed after the acrylic frame has
frames made by hand-molding dough stage acrylic onto fixation become rigid. With bi-phase technique utilizing K-E components
pins). Sidebar tubes are less prone to leak liquid acrylic than other for the temporary splint, the clamps must be placed external to
types of tubes used for improvised versions of the acrylic frame the sidebar tubes to enable their later removal. Because of their
external fixator. Stock sidebar tubing is sold as 48 or 60 inch long closer proximity to the bone, the frame alignment clamps have
segments that are easily cut with scissors to the desired length. a mechanical advantage over traditional mechanical clamps in
Sidebar tubes are available in three different diameters: standard maintaining fracture alignment. Additionally, the position of the
sidebar tubes are 21 mm (appropriate for patients 8 to 10 kg or frame alignment clamp inside of the sidebar tube ensures that
larger); small sidebar tubes are 15 mm (appropriate for small dogs, the frame will be at least 1 cm away from the skin. Maintaining
cats, and some avian patients); and mini sidebar tubes are 10 mm this distance is important to avoid thermal injury to soft and bony
in diameter (appropriate for very small puppies and kittens, small tissue that can occur during the exothermic phase of the acrylic
birds, and other small exotic pets). setting period.
End caps are available in three sizes (21, 15, and 10 mm diameter)
to plug the dependent ends of sidebar tubes. This prevents
Technique for APEF Application
leakage when liquid acrylic is poured into the sidebar tube to The APEF system is usually applied using bi-phase technique
form the frame. (application of a temporary mechanical splint to maintain
alignment while a definitive acrylic frame is applied and sets
Frame Alignment Device (Figure 53-12.) This is used to as a up). Key steps for application to a fracture involving the radius
temporary mechanical splint to maintain fracture alignment or and ulna are illustrated in Figure 53-13. The injured limb is
reduction until the primary splint (the acrylic frame) becomes prepared for surgery and suspended using the hanging limb
rigid. This is referred to as a bi-phase technique. The frame technique. Aseptic technique must be maintained throughout
the pin placement and wound closure phases of the procedure.
A B
Figure 53-12. A. The frame alignment device uses a special clamp (1) that temporarily grips a connecting rod (2) and a fixation pin (3) to provide for
fracture alignment. A wrench is not required to tighten the special clamp which includes a tightening arm at the top of the clamp B. Clamps and
rods have been applied above and below the fracture and the frame alignment device has been tightened to temporarily maintain fracture align-
ment so that the acrylic frame can be applied. After the acrylic sets, the frame alignment clamps and rods are removed.
External Skeletal Fixation 813
A B
C D
Fixation pins are placed using appropriate insertion techniques acrylic is mixed to dough consistency and molded around the
(pre-drilling of the bone, proper centering of the pin, and slow- new pin and existing column to incorporate it.
speed power insertion). Pin orientation and order of pin insertion
are not restricted by frame or clamp design. Typically, at least 3
pins are applied proximal to the fracture region, and 3 more are
Staged Disassembly of an Acrylic Frame
applied distal to it (Figure 53-13A). Phase 1 reduction is obtained Progressive staged disassembly of an acrylic frame is done by
by applying a temporary clamp and rod device (alignment frame). cutting fixation pins to disengage them from the frame and/or
The alignment frame is attached to pins, the fracture reduced, by removal of portions of acrylic column (Figure 53-14). Acrylic
and the clamps tightened to maintain reduction (Figure 53-13B). frames can be cut with a cast saw, Gigli wire, OB wire, or a
Open reduction incisions are sutured, and pins are cut off one hacksaw blade. Different options available for staged disas-
tube diameter away from the clamps. From this point on, aseptic sembly of a Type II acrylic frame are shown in Figure 53-14. These
technique is not required as some of the components used to include: 1) Removal of central segment of the lateral connecting
build the frame are supplied from the manufacturer clean, but not column converts the construct to a Type I-a configuration (i.e. the
sterile. Our current research is finding that either using knurled lateral portion of the frame is now irrelevant mechanically). This
pins or placing at least five notches in the portion of the pin that strategy simplifies protective bandaging of the fixator compared
will reside within the acrylic column will increase the strength of to the next option; 2) Conversion to a Type I-a frame can also
the pin-connecting column interface to approximately that of the be accomplished by cutting all of the fixation pins as they exit
pin-bone interface when positive profile threaded pins are used. laterally. This strategy may increase morbidity and make safe
Sidebar tubing is pushed onto the cut ends of the fixation pins bandaging of the fixator more complicated; and 3) Cutting the
such that the pins penetrate the inner wall of the tube and stop central fixation pins on the medial aspect of the limb can be done
short of penetrating the outer wall. The dependent ends of tubes as a later staged disassembly. This increases working length of
are plugged with end caps (Figure 53-13C). Acrylic is mixed for 2 the medial frame which, in turn, decreases frame stiffness.
to 3 minutes after removing the bi- pack divider. The corner of the
acrylic bi-pack bag is cut off and acrylic is poured or injected into Acrylic Frame Removal
the open ends of the sidebar tubes (Figure 53-13D). Any acrylic Frame removal is achieved by cutting each fixation pin between
that leaks out from the tube (at points of pin penetration) can be the skin and acrylic column. Each pin is then removed using a
caught in a paper cup and poured back into the top of the tube. hand chuck or pliers. Alternatively, the acrylic connecting bar
Studies of significantly curving the acrylic column (as usually can be cut between pins and each pin removed using the small
occurs in a transarticular application) reveal a decreased resis- block of acrylic as a handle.
tance to axial compressive forces. Consequently, we often add
a 1/8 to 3/16” diameter Steinmann pin link from one end of the
curve to the other to restore overall construct strength. Similar
linkages are also commonly placed to connect different columns
in biplanar frames (Type I-b and Type III constructs).
Suggested Readings buttress thread and is self-tapping (Figure 53-15). This thread
profile results in less bone being removed during insertion
Martinez SA, Arnoczky SP, Flo GL, Brinker WO. Dissipation of heat during therefore less damage to the bone. The diameter of the core of
polymerization of acrylics used for external skeletal fixator connecting the pin in the area of threads is 2% larger than the pilot hole and
bars. Vet Surg 26:290, 1997.
shaft diameter of the pin. As the pin is inserted, the slightly larger
Ness MG. The acrylic and pin external fixator system. In Kraus KH, diameter in the area of the threads that engages bone expands
Toombs JP, and Ness MG: External Fixation in Small Animal Practice.
on the hole slightly. This effect, called radial preload, enhances
Oxford: Blackwell Science Ltd, a Blackwell Publishing Company, 2003,
the pin-bone interface. The connecting rods are 9.5 mm for large,
p. 60.
4.8 mm for medium and 3.2 mm for small fixators. The small and
Okrasinski EB, Pardo AD, Graehler RA. Biomechanical evaluation of
medium connecting rods are 308 stainless steel, which is stiffer
acrylic external skeletal fixation in dogs and cats. J Am Vet Med Assoc
199:1590, 1991.
and stronger than 316 stainless steel. The connecting rods for
the large fixator are either carbon fiber, or titanium which are
Shahar R. Evaluation of stiffness and stress of external fixators with
curved acrylic connecting bars. Vet Comp Orthop Traumatol 13:65, 2000.
both stronger and lighter than 316 stainless steel.
Staumbaugh JE, Nunmaker DM: External skeletal fixation of commi-
nuted maxillary fractures in dogs. Vet Surg 2:72,1982.
Tomlinson JL, Constantinescu GM: Acrylic external skeletal fixation of
fractures. Comp Cont Educ 13:235,1991.
Willer RL, Egger EL, Histand MB: A comparison of stainless steel versus
acrylic for the connecting bar of external skeletal fixators. J Am Anim
Hosp Assoc 27:541-548,1991.
Herndon GD, Egger EL: The effect of contouring the connecting bar in
an acrylic-pin external fixator. Vet Comp Orthop Traumatol 14:190, 2001.
Roe SC, Keo T: Epoxy putty for free-form external skeletal fixators. Vet
Surg 26:472, 1997.
Amsellem PM, Egger EL, Wilson DL: Bending Characteristics of PMMA
columns, connecting bars of carbon fiber, titanium, and stainless steel
used in external skeletal fixation and an acrylic interface. Vet Surg 39:
631-637, 2010.
Case JB, Egger EL: Evaluation of Strength at the Acrylic-Pin Interface for
Variably Treated Exteranl Skeletal Fixator Pins. Vet Surg 40:211-215, 2011.
Figure 53-16. Clamps. The small and medium Securos clamp consists
of three components, a U-shaped clamp body, a pin-gripping head, and
a bolt. The large clamp consists of four components. The clamps are Figure 53-18. Double clamps. Double clamps are composed of two U-
applied transversely onto a connecting rod. shaped components, a head component, and a sleeve and longer bolt.
Double clamps use components of regular fixation clamps.
Aiming Instrument
An aiming instrument is available for all three sizes and allows
simple pre-drilling of pilot holes, and accurate placement of
half-pins or full-pins (Figure 53-19). The handle contains a drill
sleeve for drilling pilot holes for fixation pins. Once two pins are
placed and connecting rods are installed, the handle connects
to the connecting rod. The drill guide places a fixation pinhole
in exact relationship to the connecting rod for application of a
clamp. The pin can be angled proximally and distally up to 30
degrees, and can also be angled either cranially or caudally.
With the drill sleeve removed, the handle directs the fixation pin
to the pilot hole. If a full-pin is being installed, an arm on the
aiming instrument is used to direct the fixation pin to the exact
position on the opposite connecting rod to install a clamp. The Application Technique
pilot hole and fixation pin can be directed to either side of the
The fracture is reduced and a proximal fixation pin and distal
opposite connecting rod and angled proximally and distally as
fixation pin are placed near the ends of the long bone. Connecting
much as 30 degrees.
rods are secured to the fixation pins with clamps and the clamps
are tightened. Clamps are not pre-placed on the connecting rods.
A unique feature of the Securos system is a method of simply
The aiming instrument is used to place additional fixation pins.
changing the fixation frame to allow weight bearing forces to go
In placing half-pins, only the handle of the aiming tool is used
through the long axis of the bone (axial dynamization) without
(Figure 53-21). It is placed on the connecting rod and a drill sleeve
removing fixation pins. In bilateral fixators, the clamp bolt can be
is inserted. An intramedullary pin is advanced to the desired
replaced with one that is slightly longer. This bolt has a square
head instead of a hexagonal head for easy identification. This
allows the clamps to slide along the connecting rod, but the pin
is fixed to the clamp (Figure 53-20). Therefore weight bearing will
cause pure axial loads to be exerted on a healing fracture while
the bone is supported in torsion, translation and bending.
location and used as a trochar to locate proper placement in bone. high torque. The fixation pin is placed so that it penetrates both
The aiming instrument is tightened to maintain its position on the corticies such that only the trocar point can be felt protruding
connecting rod. A releasing incision is made and the drill sleeve is from the far cortex. The aiming instrument is then removed. A
advanced to bone. The Steinmann pin is removed then a pilot hole clamp is then applied by placing the U-shaped body component
is drilled with a twist drill bit. A pilot hole the same diameter of the with the head shaped component and sliding it over the fixation
shaft of the fixation pin is used (1.6 mm, 2.4 mm, 3.2 mm, 4 mm). pins. Together, they are snapped on the connecting rod. The
There is a separate drill sleeve for each drill bit size. bolt is then inserted and tightened. The larger clamp is placed
somewhat differently in that the two body components are placed
After the pilot hole is drilled, the drill sleeve is removed and the on the connecting rod, then the head component, then the bolt.
fixation pin is inserted. The aiming instrument will guide the
fixation pin to the pilot hole. The pin should be placed with a Full-pins in bilateral fixators are placed in similar manner, but the
power drill capable of spinning a low speed while still providing arm on the aiming instrument is used. The most proximal and distal
fixation pins are placed with connecting rods on both medial and
lateral aspects of the limb. The aiming instrument is placed on
either connecting rod with the arm in place (Figure 53-22). There
are two grooves on the far end of the arm. The arm is slid so that the
opposite connecting rod rests in either one of these two grooves.
A Steinman pin is inserted into the drill sleeve and through skin to
see whether it will contact bone. A Steinman pin is also inserted
in a hole between the two grooves on the arm and through skin, Design of the SK fixator is based upon the use of larger connecting
again to see whether it will contact bone. This assures that in rods made of strong, light-weight material (carbon fiber composite
this position a full-pin will have sufficient bone purchase. If in the or titanium). Increased connecting rod strength enables the use
first position there is not sufficient pin purchase, then the other simpler, half-pin, Type I-a or Type I-b frames to successfully
groove in the arm of the aiming tool is used. If these two positions manage unstable comminuted fractures with the SK™ device. This
do not result in adequate pin purchase, the handle of the aiming in turn reduces the amount of soft tissue that will be penetrated by
instrument is flipped over so that the fixation pins starts from the the fixation pins, thus reducing patient morbidity.
opposite side of the connecting rod. This allows four possible
positions to accomplish secure full-pin fixation. If none of these
positions result in being able to place a properly-centered full-pin,
Components of the SK External Fixator
then a half-pin is placed instead. Pilot holes for full-pins are drilled Clamps
in similar manner to that described for half-pins, the drill sleeve is Both single clamps and double clamps are available (Figure
removed, then the full fixation pin is placed. It will advance through 53-24). Single clamps are used for attaching fixation pins to
the hole on the arm of the aiming instrument. The instrument is a connecting rod and double clamps are used for making
then removed and clamps slid on the fixation pins then snapped rod-to-rod connections between fixation frames that have been
on the connecting rod and tightened (Figure 53-23). applied in different planes. SK clamps are available in 3 different
sizes: mini, small and large (Figure 53-25).
Suggested Readings
Kraus KH, Toombs JP, Ness MG. External Fixation in Small Animal
Practice. Oxford: Blackwel Publishing, 2003, 43.
Kraus KH, Wotton HM: Effect of clamp type on four-pin type II external
fixator stiffness. Vet Comp Orthop and Traumatology, 12:178, 1999.
Kraus KH, Wotton HM, Rand WM: Mechanical Comparison of Two
External Fixator Clamp Designs. Vet Surg 27:224, 1998.
Kraus KH, Wotton HM, Schwartz LA, et. al. Type-II external fixation using
new clamps and positive-profile threaded pins, for treatment of fractures
of the radius and tibia in dogs. J Am Vet Med Assoc 212:1267, 1998.
Introduction Figure 53-24. SK single clamp (top) used for securing a fixation pin to
the connecting rod, and SK double clamp (bottom) used for making
In order to improve the performance of external fixators in small rod-to-rod connections between frames (also see Figure 53-34).
animal patients, newer devices have addressed the following
problems characteristic of the Kirschner-Ehmer (KE) splint: 1) weak
frame components often necessitate the use of complex full-pin
frames; 2) single clamps do not easily accommodate positive
profile fixation pins; 3) fixation pin size is dictated by clamp size
and the use of different pin diameters within a single construct is
difficult; 4) clamps are susceptible to permanent deformation and
loosening; and 5) clamps cannot be easily added to or subtracted
from the middle portion of a construct. The IMEX™ SK™ external
fixator was designed to overcome all of these problems.
The SK single clamp is comprised of B-1 and B-2 aluminum stiff. Large SK connecting rods are 9.5 mm in diameter, available
body parts, and stainless steel components including a primary in lengths ranging from 50 mm to 350 mm, and are made from
pin-gripping bolt with a slotted washer, a nut to tighten the primary either aluminum or carbon fiber composite. Large SK rods offer
bolt, and a secondary bolt. Correct assembly of the clamp is a four-fold increase in bending stiffness compared to small
shown in (Figure 53-26). The clamp is symmetrically tightened by titanium connecting rods.
a secondary bolt on one side of the clamp and by a primary bolt
and a nut at the opposite end of the clamp. The slotted washer
on the primary pin-gripping bolt enables the clamp to securely
Fixation Pins
grip a wide variety of different fixation pin diameters. Fixation pin During the 1980s, small animal surgeons began to use positive
sizes, connecting rod materials and diameters, and the appro- profile threaded fixation pins in external fixator constructs.
priate wrench size specific to each clamp size are summarized Early experience was gained with some of the smaller diameter
in Table 53-3. implants designed for human patients such as the centrally-
threaded skeletal traction pin (Synthes) and the end–threaded
Turner hip pin (Zimmer). Although improved results were seen
with these implants compared to the use of smooth fixation
pins, many of the pins specifically designed for ESF in humans
were too large to enable safe use in dogs and cats. The negative
profile end-threaded fixation pins designed for small animal
patients (Ellis™ pin from Kirschner and SCAT™ pin from IMEX)
offered only modest improvement compared to results obtained
with smooth pins. In the early 1990s positive profile threaded
pins were developed specifically for use in small animal patients.
These implants have greatly improved the success rate of ESF in
Figure 53-26. Anatomy of the SK single clamp. The modular aluminum challenging fracture cases.
clamp body has been manufactured with either a silver or black finish
and has two slightly different components. The B1 body part has a
threaded hole that enables the secondary bolt (sb) to tighten the top of
Positive profile end-threaded half-pins (INTERFACE™ pins) and
the clamp by lag effect, whereas the B2 body part has a smooth gliding centrally- threaded full-pins (CENTERFACE™ pins) made for the
hole in this location. The rod-gripping channel (R) is in the center of the SK fixator are summarized in Tables 53-4 and 53-5. These fixation
clamp. The pin-gripping bolt (pb) has a sliding washer (w) with a slot pins are available with a standard or cortical thread profile
or meniscus (arrow), enabling a wide range of different pin diameters for use in diaphyseal bone, and a cancellous thread profile for
to be securely grasped in the pin-gripping channel (P) of the bolt. The use in soft metaphyseal bone (Figure 53-27). Cancellous thread
bottom half of the clamp is tightened by a nut (n) applied to the end of versions feature a greater thread diameter, deeper threads and
the pin-gripping bolt. a larger pitch than compared to pins with cortical thread. Use of
cancellous pins should be confined to the proximal metaphysis
Table 53-3. Pin, Rod, Wrench and Bolt Sizes for of the tibia, the distal metaphysis of the femur, and the proximal
Different Sizes of the SK Fixator metaphysis of the humerus. Their use in hard diaphyseal bone
is contraindicated. Fixation pins with extended thread length
Clamp Size Fixation Pin Shaft Connecting Wrench/ are available and are occasionally required in order to fully
Diameter Rod Bolt/Nut purchase the increased diameter of the bone in some metaph-
Diameter Size yseal locations.The majority of pin sizes are available with either
MINI 0.035” to 3/32” 3.2 mma. 7 mm
(0.9 mm to 2.5 mm)
SMALL 5/64” to 5/32” 6.3 mmb. 8 mm
(2.0 mm to 4.0 mm)
LARGE ~7/64” to 3/16” 9.5 mmc. 10 mm
(3.0 mm to 4.8 mm)
Superscript letters indicate types of rods available: a.stainless steel;
b.
carbon fiber composite and titanium; c.carbon fiber composite and
aluminum.
Connecting Rods
Mini SK connecting rods are 3.2 mm in diameter, available in
lengths ranging from 50 mm to 150 mm, and are made of stainless
Figure 53-27. Different types of fixation pins (from top to bottom):
steel. Small SK connecting rods are 6.3 mm in diameter, available INTERFACE half-pin with cortical (standard) thread; INTERFACE half-
in lengths ranging from 50 mm to 250 mm, and are made from pin with cancellous thread; first version of INTERFACE NP half-pin
either carbon fiber composite or titanium. Small carbon fiber with cortical thread and atraumatic rounded tip; revised version of
composite rods have similar bending stiffness to the 4.8 mm INTERFACE NP half-pin with blunt trocar tip; CENTERFACE full-pin with
stainless steel connecting rods utilized by the size medium K-E centrally placed cortical thread; and DURAFACE half-pin with taper
splint, whereas small titanium connecting rods are twice as run-out junction and cortical thread.
External Skeletal Fixation 821
a trocar point or with an atraumatic NP (no point) tip (see Figure itself in the pre-drilled hole was slightly less than that of a pin
53-27). Since NP pins to not have a cutting trocar point, the with a trocar tip. The tip of the NP pin was later revised to a
surgeon is forced to use proper pre-drilling technique to apply blunted trocar tip to improve the ability of the pin to properly
them. Compared to pins with a trocar point, NP pins require center within the pre-drilled bone hole.
slightly greater insertional force until the initial threads engage
and cut threads in the near cortex of the bone. After that, the gear The most recent development in fixation pin technology is the
effect of pin threads moving on bone threads allows the fixation DURAFACE pin (Figure 53-27). It is a pin with a larger diameter
pin to smoothly advance across the bone. The first version of smooth shaft and a taper run-out junction leading to a negative
the NP pin had a rounded tip, and its ability to accurately center profile thread at the end of the pin. Unlike other negative profile
Table 53-4. Positive Profile Threaded Fixation Pins for IMEX-SK Fixators
PIN DESCRIPTION Recommended Thread Pin
Name – SD / TD drill bit diameter Length Length
Miniature INTERFACE half-pins
.035” - 0.9 mm / 1.1 mm – 12 mm 75 mm
.045” - 1.2 mm / 1.4 mm 1.1 mm 12 mm 75 mm
.062” - 1.6 mm / 1.8 mm 1.5 mm 12 mm 75 mm
.078” - 2.0 mm / 2.3 mm 1.5 mm 15 mm 75 mm
.094” - 2.4 mm / 2.9 mm 2.0 mm 17 mm 75 mm
INTERFACE half-pins
2.0 mmc - 2.0 mm / 2.5 mm 2.0 mm 20 mm 95 mm
small a,b,c
- 2.4 mm / 3.2 mm 2.3 mm 25 mm 100 mm
small-plus - 2.8 mm / 3.5 mm
a,c
2.7 mm 28 mm 110 mm
3.0 mm - 3.0 mm / 3.5 mm 3.0 mm 30 mm 110 mm
medium a,b,c
- 3.2 mm / 4 mm 3.1 mm 31 mm 115 mm
medium-plus - 3.5 mm / 4.3 mm
a,c
3.5 mm 35 mm 130 mm
largea,b,c
- 4 mm / 4.8 mm) 3.9 mm 38 mm 150 mm
CENTERFACE full-pins
2.0 mmc - 2.0 mm /2.5 mm 2.0 mm 15 mm 95 mm
small a,b,c
- 2.4 mm / 3.2 mm 2.3 mm 19 mm 100 mm
small-plus - 2.8 mm / 3.5 mm
a,c
2.7 mm 25 mm 115 mm
3.0 mm - 3.0 mm / 3.5 mm 3.0 mm 28 mm 120 mm
medium a,b,c
- 3.2 mm / 4 mm 3.1 mm 30 mm 125 mm
medium-plus - 3.5 mm / 4.3 mm
a,c
3.5 mm 35 mm 140 mm
largea,b,c
- 4 mm / 4.8 mm) 3.9 mm 38 mm 150 mm
SD = shaft diameter
TD = thread diameter
a
extended thread length version available
b
cancellous thread version available
c
NP (no point) version available
822 Bones and Joints
Table 53-5. Negative Profile Threaded Fixation Pins for IMEX-SK Fixators
PIN DESCRIPTION Recommended Thread Pin
Name – SD / TD drill bit diameter Length Length
DURAFACE half-pins
2.5 mmc - 2.5 mm / 2.5 mm 2.0 mm 20 mm 95 mm
small - 3.2 mm / 3.2 mm
a,c
2.3 mm 25 mm 100 mm
small-plus - 3.5 mm / 3.5 mm
a,c
2.7 mm 28 mm 110 mm
medium - 4.0 mm /4.0 mm
a,c
3.1 mm 31 mm 115 mm
medium-plus - 4.3 mm / 4.3 mm
a,c
3.5 mm 35 mm 130 mm
large - 4.8 mm / 4.8 mm)
a,c
3.9 mm 38 mm 150 mm
pins, this implant has improved mechanical performance The slotted washer of the primary bolt has a multi-toothed
compared to other pins with the same thread diameter, but does surface that engages the outer surface of the clamp body when
not have a stress concentration point at the smooth-threaded the clamp bolt is tightened (Figure 53-28). This provides positive
junction that could predispose bending or breakage of the retention between the washer and the clamp body thus elimi-
implant. DURAFACE pin options are summarized in Table 53-5. nating pin-bolt slippage in relation to the connecting rod. The
circular shape of the serrated area on the washer makes its
positive retention capability function at any desired angle using
Application Techniques either half-pins or full-pins.
The slotted washer on the primary pin-gripping bolt enables
the use of a wide range of different pin sizes for each SK clamp The split body design of the SK clamp allows for easy addition
size (Tables 53-3 and 53-6). The curvature of the meniscus in the or subtraction of a clamp from a construct without taking the
washer corresponds to the smallest pin shaft diameter that can frame apart (as would be necessary with a KE splint). Primary
be gripped by the primary bolt. The hole in the primary bolt is and secondary bolts enable symmetrical tightening of the clamp
large enough to accommodate sleeved pre-drilling and appli- to securely grip both the fixation pin and the rod. This is accom-
cation of a positive profile pin directly through the bolt. The plished without deforming the clamp body.
diameter of the pin-gripping channel in the primary bolt deter-
mines the maximum diameter of a positive profile threaded In the early phase applying a linear fixator, disruptive torque
pin that can be passed through it. When a larger threaded pin forces produced by the tightening of the first several clamps
is desired, sleeved pre-drilling of the bone is done through the may cause loss of fracture reduction or alignment. SK clamps
clamp, the clamp is temporarily removed, the pin is applied to have a feature that makes it easy to counter these forces. The
the bone, the pin-gripping bolt is applied to the smooth shaft of flat surfaces on the end of the primary pin-gripping bolt and the
the pin, and the clamp is re-assembled to attach the pin to the flat surfaces on the assembled clamp body (Figure 53-29) are
rod. This technique is applicable when a size medium cancellous the same dimension as the wrench used to tighten the clamp.
INTERFACE half-pin is used with a small SK clamp at positions A second wrench can be applied to either of these surfaces to
other than the most proximal and most distal ones within a counter disruptive torque forces during clamp tightening.
construct. The shaft and thread diameters of this pin are 3.2 mm
and 4.8 mm respectively, and the diameter of the pin-gripping While the secondary bolt allows for symmetrical tightening of the
channel in the primary bolt of a small clamp is 4.0 mm. Although SK clamp, it also enables an empty clamp to serve as a targeting
the threaded diameter won’t pass through the clamp, the primary device. For example, when the surgeon wants to place a pin in
bolt is able to grip the shaft diameter of the pin.
External Skeletal Fixation 823
Figure 53-30. Use of a drill sleeve placed through a clamp to assist with
proper targeting of the fixation pin. If desired, the surgeon can position
the drill sleeve in the same plane as a previously placed pin (proximal-
most pin in this picture). This orientation is maintained by tightening the
secondary clamp bolt to secure the position of the clamp on the rod,
and light tightening of the nut on the primary clamp bolt to secure the
position of the drill sleeve. This same strategy can be used to insure
that multiple full-pins are placed in the same plane for Type II fixators.
pre-drilled hole in the bone using slow speed power insertion Linkages are sometimes made between the lateral frame and the
technique. It is important for the threads of the pin to fully engage cranial frame to improve construct rigidity. These connections
the far side of the far cortex of the bone. In order to accomplish can be made proximally and distally (See Figure 53-33) or diago-
this, several millimeters of the tip of the pin must extend into the nally (Figures 53-34 and 53-35). Diagonal connections provide
soft tissues beyond the far cortex. If vital anatomic structures greater strength because they span the fracture region. Linkages
are likely to be present in this location, a NP pin should be used. can be built using double clamps (Figures 53-33 and 53-34) or by
The clamp is secured by alternate tightening of the secondary leaving selected fixation pins long and placing additional single
bolt and the nut on the primary bolt. These steps are repeated at clamps on the pins external to the frames (Figure 53-36) and
each pin placement site until at least three fixation pins have been connecting these “stacked” clamps with a rod.
placed both proximally and distally. The order of pin placement is
generally as follows: the most-proximal and most-distal pins are
placed first; the central pins immediately above and below the
Application of a Type II Construct
fracture region are placed next; and pins in intermediate locations Some surgeons prefer to use a Type II frame (instead of Type I-b)
are placed last (Figure 53-32). Fixation pins should not be trimmed for challenging shaft fractures. For the tibia, this entails appli-
until acceptable fracture alignment has been verified on post- cation of at least two full-pins in a mediolateral plane through
operative radiographs. Each pin should then be trimmed such that the medial aspect of the bone. The remainder of the frame is
the cut edge stops short of the outer surface of the clamp. often built with medially applied half-pins resulting in a minimal
or modified Type II construct (Figure 53-35).
Application of a Type I-b Construct A full-pin is applied using the same techniques described for the
For comminuted shaft fractures, a Type I-a construct may not placement of a half-pin except that a second release incision
provide sufficient stability. In these cases, a second Type I-a must be made laterally to enable the full-pin to exit on the
frame is applied in a different plane (orthogonal to the first opposite side of the leg. After a full-pin has been placed in both
frame is optimal mechanically). For the tibia this would involve the proximal and distal ends of the bone, these are connected
application of fixation pins in a craniolateral plane through the medially and laterally with connecting rods and SK clamps
cranial aspect of the bone (Figure 53-33). (Figure 53-36). The remainder of the construct is completed by
Figure 53-33. Medial view of a small SK Type I-b (unilateral-biplanar) Figure 53-34. Craniomedial view of a small SK Type I-b construct on the
external fixator on the tibia. A 6-pin frame has been applied medially, tibia. Note that the medial and cranial frames have been interconnect-
and a 2-pin frame has been applied cranially. The two frames have ed with double diagonal linkages using double clamps and titanium
been interconnected with proximal and distal linkages using double connecting rods.
clamps and titanium connecting rods.
826 Bones and Joints
Figure 53-35. Medial view of a small SK Type I-b construct on the tibia. Figure 53-36. Cranial view of a small SK minimal Type II construct on
The medial and cranial frames have been connected with a single the tibia. The proximal and distal full-pins were placed first and were
diagonal linkage using KE clamps and a stainless steel connecting connected with 6.3 mm carbon fiber composite connecting rods. The
rod. This same linkage could have been made with SK clamps and proximal-most half-pin was placed next and it should be noted that this
a titanium or carbon fiber composite connecting rod. Although KE is a cancellous thread pin due to the soft bone found in the metaphysis.
components are weaker than SK components and should not be used The half-pins immediately above and below the fracture were placed
for building frames, they may be safely used to apply more compact next, followed by the remaining half-pin in the distal segment. Full-pins
linkages to SK frames than is possible using SK components. This is could have been safely used at every location except the most proximal
due to the reduced height of the KE clamp compared to the SK clamp. pin site if additional frame stiffness was desired.
4.3 mm DF
4.8 mm DF
Suggested Readings
Bronson DG, Toombs JP, Welch RD. Influence of the connecting rod on
the biomechanical properties of five external skeletal fixation configu-
rations. Vet Comp Orthop & Traumatol 16:8, 2003.
Figure 53-38. Staged disassembly of an external fixator. A Type I-b Lewis DD, Cross AR, Carmichael S, Anderson MA. Recent advances in
construct has been temporarily removed from this sedated patient. external skeletal fixation. J Sm Anim Pract 42:103, 2001.
The surgeon is using the fixation pins to gently manipulate the fracture Toombs JP, Bronson DG, Ross D, Welch RD. The SK external fixation
region to detect evidence of callus deposition. If callus is present, a system: Description of components, instrumentation, and application
frame with reduced stiffness will be applied to the fixation pins. If callus techniques. Vet Comp Orthop & Traumatol 16: 76, 2003.
is not detected, the original frame will be rebuilt. White DT, Bronson DG, Welch RD. A mechanical comparison of veter-
inary linear external fixation systems. Vet Surg 32:507, 2003.
post-op. Staged disassembly can usually be done with the dog Griffin H, Toombs JP, Bronson DG, et al: Mechanical evalu-
or cat under heavy sedation, but some patients may require brief ation of a tapered thread-run-out half-pin designed for external
duration general anesthesia with propofol. The fixation frame(s) skeletal fixation in small animals. Vet Comp Orthop Traumatol
should be temporarily removed to enable critical palpation of the 24:257, 2011.
fracture for evidence of callus formation (Figure 53-38). If the
fracture feels “sticky” due to the presence of soft callus, it is
appropriate to begin staged disassembly. If any of the fixation
pins are causing morbidity, strongly consider removal of these
fixation elements as part of the staged disassembly strategy. An
example of this would be a Type I-b fixator applied to the radius
in which fixation pins have been applied craniomedially and
828 Bones and Joints
Circular External
Skeletal Fixation
Daniel D. Lewis and James P. Farese
Since the writing of the topic, methodology and nomenclature
adopted from Dror Paley’s Principles of Deformity Correction
have been adapted and become accepted as the convention in
small animal orthopedics.
Introduction
Circular external skeletal fixation (CESF) was pioneered by the
Russian physician, Gavriil Ilizarov. These are modular systems
which can be assembled in numerous configurations to stabilize
fractures and arthrodeses, perform bone lengthening and
transport as well as correct angular, translational and rotational
deformities and are being used with increased frequency in
dogs and cats. Circular fixator (CF) frames consist of a series
of complete and/or incomplete external rings that are intercon- Figure 53-39. Supporting elements: complete rings (top row) are avail-
nected by multiple threaded rods. Rings are secured in position able in 118 mm, 84 mm, 66 mm and 50 mm internal diameter. Stretch
and five-eighths partial rings and one-third ring arches (bottom row)
along these rods by placing nuts on opposing surfaces of each
are also available.
ring. Circular fixators are uniquely designed, allowing the frame
to be elongated or shortened during or following surgery.
and assembly elements are secured. Ring components are
Elongation of the frame during the convalescent period allows
available in 50 mm, 66 mm, 84 mm and 118 mm internal diameters.
for distraction osteogenesis in which regenerate bone is formed
While it is biomechanically preferable to utilize complete rings,
within the osteotomy gap resulting from gradual separation of
anatomic constraints prohibit their use proximal to the elbow
the secured bone segments.
and stifle and often adjacent to other joints. Traditional CFs are
mainly applicable for managing conditions involving or distal to
Components, Implants and Instrumentation the elbow or stifle, while hybrid linear-CF constructs (see section
The IMEXTM CESF System (IMEXTM Veterinary, Inc., Longview, on Hybrid Constructs, Chapter 55) are typically used to manage
TX) is the CF system used most commonly by North American injuries and abnormalities involving the humerus or femur. Five-
veterinarians. This system was developed in conjunction with eighths partial rings are often used to secure the proximal radius
the Comparative Orthopedics Research Laboratory of the Texas and distal tibia, while stretch ring arches have been developed
Scottish Rite Hospital for Children in Dallas, Texas and is modeled which facilitate CF application to the proximal tibia and ulna.
after a device utilized in human patients. This system has several Stretch ring arches also simplify construction of CFs for trans-
evolutionary advances which simplify frame construction, improve articular stabilization of the hock and stifle regions. One-third
precision and decrease patient morbidity. The utilization of lighter partial ring arches are also available.
metals and engineered plastics facilitated this process. Several
new components have been developed which substantially Connecting Elements
decrease the total number of parts necessary for frame assembly,
Threaded rods (6 mm thread diameter x 1 mm thread pitch) are
thereby reducing pre-operative frame preparation time.
the most commonly used connecting elements. Threaded rods
are available in 60 mm, 80 mm, 100 mm 150 mm and 225 lengths
Traditional CF constructs consist of supporting elements
with a 3 mm hex drive fitting at their ends to accommodate a 3
(complete rings, partial rings and arches), connecting elements
mm angled or straight hex driver. This hex broach fitting allows
(threaded rods, linear and angular motors and hinge assem-
rapid replacement or exchange of rods if necessary.
blies), fixation elements (small diameter wires) and assembly
elements (cannulated and/or slotted bolts, nuts, washers, plates
A unique design feature of the IMEXTM CESF System is its zero
and posts). The following section describes components of the
tolerance, zero motion connecting elements (Figure 53-40).
IMEXTM CESF System.
Adjustable components used for angular and linear distraction
have nylon drive bushings or inserts between metal parts which
Supporting Elements prevent binding, allowing adjustments to be made without
Rings in this system are manufactured from a high-strength loosening and retightening nuts. This makes the distraction
tempered aluminum alloy which imparts strength to the process simple and precise by eliminating frame instability
supporting elements while keeping the fixators weight-appro- which causes patient discomfort. Distraction or compression is
priate for use in dogs and cats (Figure 53-39). The rings have performed simply with a wrench, facilitating client compliance
holes located about their circumference in which connecting and negating the need for prolonged hospitalizations.
External Skeletal Fixation 829
(1.0 or 1.6 mm) wires, rather than larger diameter pins, as fixation
elements. Two wires are generally placed on each ring with the
wires secured to opposing surfaces of the ring. The fixation wires
are typically tensioned to improve their stiffness characteristics.
Although standard Kirschner wires can be used as fixation wires,
use of wires with an efficient single lip cutting point is recom-
mended. Fixation wires are also available with olives (or stoppers)
to increase stability of the construct and/or to manipulate and
secure bone segments. Olive (or stopper) wires have a raised
bead (olive) fixed along their length. This olive is brought into
contact with the cortex of the bone. The olive can also be used
to pull a bone segment into alignment and prevents translation of
a secured bone segment along the wire. Inexpensive calibrated
tensioning devices are now available to tension wires. Although
Figure 53-40. Connecting elements (from top to bottom): linear motor, not a part of Ilizarov’s traditional armamentarium, positive and
angular motor and hinge assembly secured to short connecting rods negative profile partially threaded (end threaded) half-pins and
with lock nuts. positive profile partially threaded (centrally threaded) full-pins
can also be used as fixation elements.
Linear motors, available in 50 mm, 70 mm and 100 mm lengths are
composed of a threaded rod encased in stainless steel housing
and are used to perform linear distraction or compression. A Assembly Elements
nylon drive bushing is positioned between the stainless steel All assembly elements have 10 mm wrench flats or 3 mm
housing and threaded rod (6 mm diameter x 1 mm thread pitch). hexagonal recesses, thus keeping instrumentation to a minimum
During distraction or compression, the drive bushing allows (Figure 53-41). Ten mm (6 mm thread diameter) stainless steel
distraction or compression without loosening and retightening nuts are also used to secure connecting and assembly elements.
nuts, eliminating frame instability and thereby minimizing patient Fixation wires are secured to the rings with 6 mm wire fixation
discomfort. Distraction or compression is performed simply by bolts which are both slotted (for capture of wires that cross rings
turning the clearly marked drive bushing with a 10 mm wrench. between holes) and cannulated (for capture of wires that cross
One complete revolution of the drive bushing produces 1 mm of rings over a hole). Slotted 6 mm washers are available to capture
linear movement. wires at sites occupied by connecting elements and 6 mm flat
washers are available to be used as a spacer for capturing wires
Threaded rods can also be used for linear distraction/ that are not inserted immediately adjacent to a ring. Pin fixation
compression if 10 mm (6 mm thread diameter) paired nylon nuts bolts are also available which allow the utilization of half-pins
are used to secure a ring to the rod. Simultaneous rotation of and full-pins. The pin fixation bolts accommodate fixation pins
the paired nylon nuts with a double jawed 10 mm wrench which ranging from 2.3 mm to 5 mm in diameter and are similar in design
can engage nuts positioned on both sides of a ring will accom- to the pin-gripping bolt of IMEXTM SKTM fixation clamp.
plish linear distraction/compression. The use of paired nylon
nuts instead of linear motors to achieve linear distraction is Hemi-spherical washers and hemi-spherical nuts are also
most beneficial when adjacent rings are in close proximity. One available. When used in combination the hemi-spherical
complete revolution of the paired nylon nuts results in 1 mm of washers and hemi-spherical nuts allow for angulation of
linear movement of the secured ring. connecting rods. Thus, rings can be secured to each other
without being in exact parallel alignment. This permits minor Ring diameter is the single most important parameter influencing
adjustments in reduction of fracture segments and fine the biomechanical profile of any CF constructs. While ring
adjustments in correcting angular deformities. When utilized diameter affects stability in all modes of loading, ring diameter
with two-hole plates, the hemi-spherical washers and hemi- has its greatest effect on axial stability. Ring diameter is selected
spherical nuts can be used to connect adjacent rings without based on anatomic constraints: the smallest diameter rings
utilizing corresponding holes and are particularly useful in which can be accommodated should be selected; however, a
constructing complex or transarticular frames. minimum 1 to 2 cm of clearance should be maintained between
the ring and the circumference of the limb to allow for soft tissue
Two-hole plates are available to allow the use of different swelling and daily management of the wire-skin interfaces.
diameter rings within the same fixator frame. The plate is bolted
to the ring extending away from its center. A connecting rod or Since the diameter of rings used in dogs and cats is much smaller
motor can then be attached to the plate and linked directly to the than those used in human patients, even children, the biome-
next larger diameter ring. One- and two-hole posts are utilized chanics of CFs used in dogs and cats are markedly different
to secure fixation wires and pins elevated remote to the surface from those used in human patients. Several biomechanical
of a ring, to create hinge assemblies and to secure connecting studies have been done evaluating IMEXTM CF constructs and
elements that are not positioned perpendicular to the surface of it appears that there is little need to tension wires when using
a ring. Plates and posts are extremely useful when constructing the 50 mm and possibly the 66 mm rings (although wires are
transarticular or other complex frames. usually tensioned to 30 kg when using 66 mm rings). Tensioning
of wires on larger diameter rings is warranted with the recom-
mendation to apply 60 kg of tension when using 84 mm rings
Biomechanics and 90 kg of tension when using 118 mm rings. Some surgeons
Circular fixators possess biomechanical characteristics advocate simultaneously tensioning wires secured to the same
which purportedly enhance fracture healing as well as allow ring (Figure 53-42) and wires secured to partial rings or posts
for distraction osteogenesis. The biomechanics of CFs differ should not be tensioned beyond 30 kg to avoid deformation of
primarily from linear fixators in that the tensioned wires stabi- the ring or posts.
lizing the bone segments adequately resist bending, shear,
and torsional forces while maintaining some degree of axial Olive wires can enhance the stability of fixation. Placing two
elasticity. Load/deformation curves of CF constructs under- opposed olive wires to secure a bone segment can significantly
going axial compression have a characteristic initial exponential improve bending stiffness and stability by minimizing translation
increase in stiffness which is ascribed to tensioning of the wires of the secured bone segment along the wire. This is particularly
when subjected to loading. Construct stiffness increases until important when wires are placed on the same ring with little diver-
the slope of the load/deformation curve becomes linear with gency. Opposing interfragmentary olive wires can also be used to
continued loading, protecting the osteotomy or fracture gap compress anatomically reduced long oblique or spiral fractures.
from excessive strain during ambulation. The “axial micro-
motion” occurring at physiological loads purportedly creates a CF constructs utilizing tensioned wires in combination with
mechanical environment conducive to bone formation. half-pins or full-pins are being used with increasing frequency.
The use of half-pins has been advocated in locations where
Numerous extrinsic (apparatus-related) factors have been divergent fixation wires would pass through prominent muscle
shown to affect the stability of the fixation including the number,
type, angle of intersection, applied tension and diameter of the
fixation wires, as well as the number, conformation, diameter
and position of the rings and connecting elements. Intrinsic
factors which theoretically contribute to stability of the bone-
fixator construct include the area of contact and nature of the
interlock between bone segments, the modulus of elasticity of
tissue between bone segments, and the tension of the regional
soft tissues.
masses, such as the proximal tibia, or near vital soft tissue genesis is referred to as “regenerate” bone (Figure 53-43).
structures. These constructs have been shown to have biome-
chanical characteristics intermediate between those of conven- Cyclic axial loading is necessary for remodeling and maintaining
tional linear fixators and traditional CFs. The combination of bone mass and numerous experimental and clinical studies
wire and half-pin fixation can be problematic. When used in suggest that axial dynamization accelerates fracture healing.
combination with wires, a single or an inadequate number of Traditional CFs allow some degree of axial micro-motion, while
half-pins may be subjected to excessive loading as the wires providing adequate bending and torsional resistance. Clinical
initially deform when subjected to loading. Thus, if the number of studies evaluating the use of CFs to manage fractures in dogs
half-pins utilized is not sufficient, excessive stress occurs at the and cats support the contention that CFs promote rapid fracture
pin-bone interface. The use of three (or preferably more) evenly healing.
distributed, divergent half-pins per bone segment (depending on
concurrent wire utilization) is advocated in these configurations Ilizarov advocated performing a corticotomy, which preserved
to avoid problems associated with premature pin loosening and both periosteal and endosteal tissues, for optimal regenerate
pin tract drainage. bone formation during distraction osteogenesis. Recent clinical
and experimental studies, however, have shown that preser-
vation of the periosteum has the most significant influence on
Distraction Osteogenesis regenerate bone formation: the method utilized to perform the
Distraction osteogenesis describes the mechanical induction osteotomy (Gigli wire, bone saw, drill holes-osteotome) has a
of new bone formation in the gap produced by the gradual nominal effect on regenerate formation as long as the periosteal
separation of two bone segments. Much of what is known envelope is preserved and most small animal surgeons perform
regarding the biology of distraction osteogenesis was eluci- subperiosteal osteotomies using a pneumatic oscillating saw.
dated by Ilizarov and his colleagues; however, recent investiga-
tions have focused on the cellular and molecular events of bone Latency or delay refers to the time period following osteotomy
formation in both fracture healing and distraction osteogenesis. before beginning distraction. The latency period used in human
Distraction osteogenesis shares many morphologic and biome- patients is typically 4 to 7 days. Several factors will influence the
chanical similarities with early fracture healing. Bone retains the prescribed latency period: the patient’s age, the bone involved,
inherent capacity to remodel and repair and these processes the location of the osteotomy, soft tissue trauma present prior
are influenced by the local mechanical environment. The new to or incurred during surgery, and the primary condition neces-
bone which forms in the distraction gap during distraction osteo- sitating treatment. Metaphyseal lengthenings produce higher
A B
Figure 53-43. A. Pre- and B. post-distraction radiographs demonstrating regenerate bone formation (gray arrows in B.) in a dog undergoing bi-level
distraction for lengthening of the crus.
832 Bones and Joints
quality regenerate bone than diaphyseal lengthenings. The latitude to adjust the angle of arthrodesis during the early
metaphyseal region has a greater blood supply and bone surface convalescent period and the use of these devices facilitates the
area in comparison to diaphyseal bone. Proximally located removal of all implants following fusion. Finally, CFs can be used
osteotomies produce higher quality regenerate bone than more to perform bone transport to resolve large traumatic segmental
distally located osteotomies. The latency period allows early bone defects and oncologic surgeons are now utilizing bone
vascularization and soft callus formation before lengthening transport in limb salvage procedures in dogs with appendicular
commences. Poor regenerate formation and non-union can bone tumors (see section on Distraction Osteogenesis as an
occur if distraction is initiated too early. Premature consolidation Alternative to Bone Grafting in Chapter 56).
can occur if the latency period is too prolonged, particularly in
young or skeletally immature animals.
Fracture Management
The recommended latency period prior to initiating distraction Circular external skeletal fixation has been utilized extensively
is typically short in dogs undergoing lengthening or angular for fracture management in human patients and there are recent
correction. In young dogs in which the periosteal sleeve was reports describing the use of CFs for fracture management
well preserved, a delay period may be unnecessary. Most small in dogs and cats. Traditional CFs are most applicable for the
animal surgeons generally initiate distraction 1 to 3 days following stabilization of non-articular antebrachial and crural fractures.
surgery in dogs in this age group. It is prudent to observe a 3 to 5 Circular fixators are particularly useful for stabilizing fractures
day delay before initiating distraction with animals that are 3 to with short juxta-articular fracture segments as the divergent
8 years of age. Longer delay periods may be advisable in older placement of small diameter wires provides multiplanar stability.
dogs or if the periosteum had been damaged substantially prior With experience, a surgeon can achieve accurate closed reduc-
to or during surgery. tions of both simple and complex fractures with relatively short
operative times.
Rate refers to the amount of distraction that will be performed over
a 24 hour period. Experimental and clinical studies indicate that Frames are constructed prior to surgery based on preoperative
the amount of lengthening performed should be in the range of 0.5 radiographs of the fractured and contralateral intact (if appli-
to 2.0 mm/day to promote viable regenerate bone formation. The cable) limb segment. When constructing the fixator, complete
formation of regenerate bone can be monitored radiographically rings are generally used to secure the middle and distal portions
and the rate adjusted accordingly. Rates for skeletally immature of the limb segment. Partial rings are used proximally to avoid soft
patients undergoing metaphyseal osteotomies may be near the tissue impingement or compromised joint mobility. Stretch rings
higher limit as these animals have a greater osteogenic potential. are useful for securing the proximal ulna and tibia, while 5/8th
rings can be used to secure the proximal radius or if the most
Rhythm describes the frequency (number of fractionations) distal ring interferes with carpal or hock motion. The smallest
at which the distractions are performed during a 24 hour time diameter rings that can be comfortably placed about the circum-
period. Ilizarov had reported that increasing the rhythm from 1 ference of the limb, allowing for post-operative swelling without
or 2 times per day up to 60 times per day significantly increased soft tissue impingement, should be selected. Pre-construction of
regenerate formation and decreased consolidation times; a frame greatly reduces surgical time. Minor adjustment of the
however, studies evaluating rhythms of 1, 4, and 720 times per frame should be anticipated and performed as necessary at the
day in a caprine lengthening model found no significant effects time of surgery.
of rhythm on radiographic, mechanical, or histomorphologic
regenerate parameters. Increased rhythms, however, allow for A standard frame configuration consists of three or four rings. A
superior accommodation of the regional soft tissues, decreasing single ring or pair of rings that engage a fracture segment and
morbidity during the distraction period. In our clinic we generally which are secured together by connecting elements constitute
perform distractions at a rate of 1.0 to 1.5 mm/day using a rhythm a functional unit referred to as a ring block. While it is preferable
of three or four distractions/day. to use two or more rings to construct a ring block, there may only
be sufficient room to accommodate a single ring in fractures
with a short proximal or distal segment. A typical CF construct
Clinical Applications in Dogs and Cats that would be used to stabilize a crural fracture is composed
Circular fixators have been used to manage a number of devel- of two independent ring blocks articulated by linear motors or
opmental and traumatic orthopedic conditions in dogs and cats. threaded connecting rods which are secured only to the rings
The most notable of these being limb deformity correction, most positioned adjacent to the fracture site. This arrangement
frequently antebrachial limb deformity correction. Pre-operative allows simple adjustment of the distance between the two ring
assessment and planning, a thorough knowledge of the instru- blocks, allowing the major fracture segments to be distracted or
mentation and its application and conscientious post-operative compressed. Thus, the frame can be used intra-operatively to
patient care are essential for a successful outcome. Traditional distract the fractured limb segment to its normal length which
CFs have also been used to perform deformity corrections and greatly facilitates reduction.
lengthenings of the crus and pes. These systems are also useful
for stabilizing complex fractures of the antebrachium and crus, When constructing a CF that will be used to distract a crural
as well as transarticular stabilization, particularly in performing fracture out to length, the two ring blocks are constructed based
arthrodeses. Frames utilizing hinges allow the surgeon the on the length of the major fracture segments. Appropriate length
External Skeletal Fixation 833
of each ring block is confirmed by measuring each ring block If a bone segment needs to be translated cranial or caudal,
against the fracture segment it will be used to stabilize on the again an olive wire can be used, but this can cause unnecessary
lateral view radiograph. The articulating intermediate linear impingement of the regional soft tissues. Alternatively, reattaching
motors or connecting rods are then placed between the two ring one or potentially both of the wires on the intermediate ring at
blocks and the construct is placed over a lateral view radiograph holes immediately cranial or caudal (direction opposite of the
of the contralateral intact limb segment (if available) to assess displacement) to its original position will result in bowing of the
appropriate frame length (Figure 53-44A). The most proximal wire as it is reattached to the ring with fixation bolts. As the wire
and distal rings should be placed at or near their respective is retensioned, the bow in the wire will be eliminated and the bone
metaphyses. The CF is then positioned so that the lateral segment will be translated in the desired direction.
radiographic image of the intact tibia is appropriately situated
within the frame and each ring should be marked, both medially If the fracture was slightly over-distracted, the distance
and laterally, along the tibia’s central longitudinal axis with a between the ring blocks should be decreased, restoring normal
permanent marker. Thus reasonable reduction can be achieved length to the limb segment. Once reduction is acceptable, the
at surgery by placing fixation wires through the tibia in a medial- remaining fixation wires are placed to complete the construct.
to-lateral plane and attaching each wire to its corresponding ring Two additional wires should be placed on each ring. These wires
at the marked location, if the limb segment has been distracted should be oriented at 45° to 90°‚ to each other and olive wires
out to normal length. The frame is then placed over the lateral should be used to minimize translation of bone segments. Fixation
view radiograph of the fractured limb segment and the inter- wires should be placed parallel to the surface of the rings. Wires
mediate linear motors or connecting rods are compressed to that are not in immediate contact with the surface of the ring
account for shortening of the limb segment as the result of the should be secured with flat washers placed subjacent to the
fracture. The frame is then sterilized in preparation for surgery. wire when it is secured with a fixation bolt. If the wire is bowed
as it is attached to the ring, displacement of the bone segment
When applying the fixator at surgery, the dog is positioned in dorsal will occur. Proper tensioning of wires will also maximize stability.
recumbency and the CF construct is slid over the limb and a wire is It is prudent not to cut the fixation wires too short or to bend the
placed in each metaphysis, parallel to both the proximal and distal wires over until the fracture reduction is evaluated radiographi-
joint surfaces. These wires should be placed in the medial-to- cally. This makes any necessary post-operative adjustments
lateral plane. The use of intra-operative fluoroscopy, if available, simpler to perform.
facilitates proper wire placement. These initial two wires are then
attached to the abaxial surface of the most proximal and distal Isolated double ring block constructs are generally not used to
rings at the predetermined locations as marked on the frame prior stabilize radius and ulnar fractures as suspension of the limb can
to surgery (Figure 53-44B). The wires are tensioned if indicated be used to facilitate reduction of antebrachial fractures. A typical
depending on ring diameter. If the fracture is over-ridden, the CF construct that would be used to stabilize an antebrachial
distance between the proximal and distal ring blocks, which are fracture consists of three or four rings, all of which are intercon-
now secured to the bones via the fixation wires, can be increased nected by long threaded connecting rods which span the entire
by turning the intermediate linear motors or the nuts securing the length of the frame. The construct is assembled and laid on the
intermediate connecting rods to bring the limb segment out to lateral radiographic view of the contralateral intact limb segment
length. Distraction will create tension in the regional soft tissues (if available) to assess that the frame length is appropriate with
which will help reduce the fracture (Figure 53-43C). An attempt the most proximal and distal rings positioned at or near their
should be made to “over-distract” the fracture by a couple of milli- respective metaphyses. Position of the intermediate ring is
meters. Alignment of the fracture can be assessed by palpation, confirmed by comparing its distance from the corresponding
or by fluoroscopy if available. proximal or distal ring to the length of the fracture segment those
two rings will secure. The frame is then repositioned over the
The next two wires should be placed in the medial-to-lateral lateral radiographic image of the intact antebrachium such that
plane through the longitudinal axis of the tibia adjacent to the the radius is appropriately situated within the frame and each
intermediate rings (Figure 53-44D). Attaching (and, if necessary, ring should be marked, both medially and laterally, along the
tensioning) these wires at the predetermined locations as radius’ central longitudinal axis with a permanent marker. Again
marked on the frame prior to surgery, should result in reasonable reasonable reduction should be achieved at surgery by placing
craniocaudal alignment of the fracture (Figure 53-44E). If one or fixation wires through the radius in a medial-to-lateral plane
both fracture segments need(s) to be transposed in a medial and attaching each wire to its corresponding ring at the marked
or lateral direction, the segment(s) can be translated along location, but in this case suspension of the limb will be used to
the initial fixation wire(s) by simply applying digital pressure to distract the limb segment out to normal length. The frame is then
the bone segment(s) (Figures 53-44F and G). Alternatively, olive sterilized in preparation for surgery.
wires can be used to translate bone segments. An olive wire is
placed on the appropriate, intermediate ring in the medial-to- The dog is positioned in dorsal recumbency for surgery and the
lateral plane with the olive positioned adjacent to the cortex on CF construct is slid over the limb. The limb is then suspended from
the side of the bone which is to be pulled into place. By using the ceiling to distract the limb segment out to length. Tension in
the tensioner, which is placed on the exposed end of the wire the regional soft tissues should again help reduce the fracture
opposite the olive, the olive wire along with the bone segment (Figure 53-45A). Wires are placed in each metaphysis, parallel to
can be translated toward the tensioning device. both the proximal and distal joint surfaces. These wires should
834 Bones and Joints
Figure 53-44A. Construction of CF for stabilization of a crural fracture. Figure 53-44B. Application of the CF. Medial-to-lateral fixation wires
The individual ring blocks are constructed according to the lengths are placed proximally and distal and attached to the frame at the
of the major fracture segments. Overall frame length is based on the marked positions. The linear motors (that were previously collapsed)
length of the intact tibia. The frame is placed over the lateral view positioned between ring blocks will be used to distract the fracture out
radiograph of the intact tibia and the optimal position of each of the to length.
medial-to-lateral fixation wires are marked on the frame.
Figure 53-44C. Distraction of the linear motors has brought the fracture Figure 53-44D. Medial-to-lateral fixation wires have been placed adja-
out to length and improved craniocaudal alignment. cent to the central two rings.
External Skeletal Fixation 835
Figure 53-44E. Attachment of these wires at the perviously marked Figure 53-44F. Mediolateral reduction can be improved by translation
locations results in good craniocaudal alignment of the fracture. of the fracture segments (in this case medial translation of the distal
segment along the fixation wires).
Limb Lengthening
Limb lengthening is warranted when length discrepancies
produce a gait abnormality that impairs limb function. Length-
ening may be done as an isolated procedure or in conjunction
with angular, translational and/or rotational corrections. Since
the radius and/or ulna are the bones which are most frequently
lengthened, this discussion will focus on longitudinal antebrachial
lengthenings. Craniocaudal and mediolateral view radiographs of
both antebrachii, including the manus, should be obtained prior
to surgery and length discrepancies between limbs measured.
Premature closure of the distal radial physis can require length-
ening of the entire antebrachium and is generally done using a
three ring construct (Figure 53-46). The proximal ring is positioned
near the radial head, the central ring is positioned over the
mid-antebrachium and the distal ring at the distal metaphysis. If
the radial head is subluxated distally (as an isolated abnormality
or in conjunction with abnormalities of the distal antebrachium),
a subperiosteal osteotomy is made at the proximal metaphyseal-
diaphyseal junction (distal to the position of the proximal ring) and
the fixation wires on the proximal ring should only engage the
radius. It is helpful to isolate the proximal radius and initiate, but
not complete the osteotomy before placing the fixator on the limb.
This limits the amount of surgery that must be performed within
the frame, but allows the fixation wires to be placed into a stable
bone segment. Once the frame and fixation wires are placed and
the bone segments are stable, the osteotomy is completed. The
proximal ring should be articulated with the central ring using
linear motors or threaded rods secured with nylon nuts. This will
allow distraction of the proximal radius to correct the existing
elbow incongruency. To lengthen the entire distal antebrachium
the wires attached to the distal ring should engage both the
distal radius and ulna. Subperiosteal osteotomies are made at
the distal radial and ulnar metaphyseal junction, proximal to the
position of the distal ring. Performing the distal ulnar osteotomy
and approaching and initiating the distal radial osteotomy prior to Figure 53-45A. Reduction and stabilization of an antebrachial fracture
placing the frame over the limb, again simplifies the procedure. by suspending the limb. Reduction is nearly anatomic as the result of
The distal ring should be articulated to the central ring using linear the traction applied and the initial fixation wire is placed perpendicular
motors or threaded rods secured with nylon nuts. When applying to the longitudinal axis of the radius. The frame is attached to the initial
the frame, the connecting elements should be positioned parallel fixation wire such that the connecting elements are in alignment paral-
to the longitudinal axis of the radius and ulna to produce the most lel with the radius.
functional lengthening.
External Skeletal Fixation 837
Figure 53-45. B and C. The construction is completed with paired divergent olive wires at each level..
838 Bones and Joints
drawn through the axial plane of the proximal and distal radial
segment. These lines are centered through the metaphysis and
perpendicular to the adjacent articular surface. The intersection
of these two lines denotes the apex of the deformity. It should be
noted that in some animals, the apex of the deformity may not be
isotopic in orthogonal planes.
the deformity. The measured length of the line on the medio- the deformity and tangent to the outline of the radius opposite
lateral radiograph constitutes the cranial or caudal component the plane of the deformity. The tangential location of the hinge
of the deformity. These same measurements are obtained from axis will result in angular correction without additional length-
line drawings developed from tracings of radiographs of the ening. The two holes on the ring that are intersected by the hinge
contralateral normal limb, and the component vectors measured axis mark the position at which the hinges should be placed. A
on the normal limb are subtracted from those obtained from single angular motor is placed opposite the hinge axis, approxi-
the abnormal limb. A tracing (or photocopy) of an appropriate mately equal distant from two hinges, which will be located on
diameter ring (Figure 53-48) which will be used to construct the concave surface of the deformity.
the fixator is made. An X (mediolateral)/Y (craniocaudal) grid
is constructed with its origin centered in the ring. This drawing The fixator is assembled prior to surgery. A three ring construct
represents the proximal surface of the rings of the proximal ring is used in most dogs with two rings used to secure the proximal
blocks and should be marked correctly with respect to medial, radial segment and a single ring used to secure the distal radial
lateral, cranial and caudal for the limb (left or right) that is being segment (Figure 53-49). It is advisable to mark the medial, lateral,
corrected. The plane of deformity is determined by plotting the cranial and caudal positions of the proximal surface of each
two adjusted (abnormal minus normal) vector components of the ring appropriately for the limb that is to be corrected. The paired
deformity on the X/Y grid. The resultant vector defines the plane
of deformity.
Cranial
Hinge
Radius
Medial Lateral
Plane of
deformity
Hinge
Motor
Caudal
angular hinges and an angular motor are placed between the ring dicular to the longitudinal axis of the radius. This wire is secured
blocks at the appropriate holes as determined on the pre-operative to the proximal surface of the proximal ring of the fixator and
drawing. The hinges can be bolted directly to the distal ring if the the longitudinal position of this wire should place the hinge axis
apex of deformity is located at or near the distal epiphysis, but the at the apex of the deformity. Consideration should be given to
hinges are usually secured to both rings using short threaded rods placing this wire the day prior to surgery and then radiographing
at the holes as determined on the pre-operative drawing. Paired the limb, as constructing the fixator based on tracings of radio-
nylon nuts can be used to secure the rods to one of the rings if graphs obtained with the first wire already in place simplifies
lengthening is anticipated. The longitudinal position of the hinges placement of the hinge axis precisely at the apex of the deformity
is located at the apex of the deformity. Construct dimensions, ring at surgery. The wire can then be bent over against the antebra-
position and hinge position are determined by laying the frame chium and the limb coapted until surgery. At surgery the wire
directly over the lateral view radiograph of the deformed antebra- can be straightened out and tensioned or carefully replaced by
chium. Frame angulation can be adjusted to conform to the inserting a new wire through the same hole in the radius. The
deformity by adjusting the angular motor. connecting elements of the frame should be aligned parallel
to the longitudinal axis of the radius and the hinges positioned
At surgery the entire forelimb is clipped and prepared for aseptic at the apex of the deformity. The frame is rotated about the
surgery and the dog is positioned in dorsal recumbency. A 2 to antebrachium until the hinge axis is positioned perpendicular
4 cm subperiosteal segmental ostectomy of the distal ulna is to the plane of deformity and tangential to the convex cortex of
performed at the level of the apex of the deformity. Following the radius. It is important to center the radius, rather than the
closure of the ulnar approach, subperiosteal isolation of the antebrachium, within the frame. A fixation wire is then placed
distal radius is performed exposing the location of the apex parallel to the distal surface of the distal ring. This wire should be
of the deformity. An osteotomy is initiated, but not completed, placed in the “true” mediolateral plane (from styloid process to
perpendicular to the longitudinal axis of the distal radial segment styloid process) which will not be co-planar with the wire in the
and parallel to the plane of the deformity. The longitudinal proximal radius if rotational deformity is present. Two divergent
location of the radial osteotomy will influence the impact acute olive wires should then be placed on each of the rings of the
rotational correction will have on the plane of deformity. The proximal ring block to stabilize the proximal radial segment and
plane of deformity should not be changed appreciably by acute the radial osteotomy is then completed.
rotational correction if the radial osteotomy is performed at or
preferably slightly distal to the apex of the deformity. Performing Rotational deformity, if present, should be corrected before
the radial osteotomy proximal to the apex of the deformity is not additional fixation wires are placed in the distal radial segment
advised if acute rotational correction is to be done, as the plane (Figure 53-50). Rotational deformity is estimated by comparing
of deformity will be altered by rotational correction. the planes of flexion and extension of the ipsilateral elbow and
antebrachiocarpal joint. The plane of extension of the elbow
The frame is then placed on the limb and a fixation wire is placed (which is caudal) is marked on the distal surface of the distal
in the proximal radius in the medial-to-lateral plane, perpen- ring. The antebrachiaocarpal joint is then flexed so that the paw
A B
Figure 53-50. Acute correction of rotational deformity. A. This dog is positioned in dorsal recumbency and has approximately 60° of external
rotation. The line of small open circles represents the plane of flexion and extension of the carpus. The line of small rectangles represents plane
of flexion and extension of the elbow. There is nearly a five hole discrepancy (on the surface of the distal ring) between these the two planes of
flexion and extension. The wire stabilizing the distal radial segment needs to be repositioned five holes in a counter clock-wise direction to resolve
the rotational deformity as indicated by the heavy arrows. B. The wire has been rotated to correct the rotational deformity.
External Skeletal Fixation 841
is positioned parallel with the distal surface of the distal ring. Bone Transport
The location of the division between metacarpal bones III and
Bone transport is a specific application of distraction osteo-
IV is marked on the distal surface of the distal ring. The number
genesis used to resolve large segmental bone defects. With this
of holes between these two marks is counted and this repre-
technique an intercalary bone transport segment is created by
sents the amount of rotation the wire securing the distal radial
performing a transverse osteotomy in the viable bone segment
segment must be rotated about the surface of the distal ring
1 to 2 cm adjacent to an osseous defect. Regenerate bone is
to have the elbow and antebrachiocarpal joint flex and extend
produced in the distraction gap which develops as the transport
through the same plane. It is highly advisable to mark this wires’
segment is sequentially moved across the bone defect. Longi-
position, and the position where the wire will be resecured at on
tudinal bone transport is typically performed using a five ring
the ring, before loosening and moving the fixation bolts.
construct, with two rings securing both the proximal and distal
bone segments and the intermediate ring securing the transport
Once rotational correction has been performed and the wire
segment. The transport ring is secured to the frame using paired
is secured to the distal ring, flexion and extension of the elbow
nylon nuts which allow the ring to be moved precisely along the
and antebrachiocarpal joint should be compared. Adjustments
threaded rods at a rate of 0.5 to 2.0 mm per day. A delay period
can be made if deemed necessary. Two divergent olive wires
of 5 to 7 days may be warranted depending upon the age of the
should be placed to secure the distal radial segment to the distal
ring. Following surgery in addition to obtaining standard cranio- animal, the condition of the regional soft tissues and the location
caudal and mediolateral view radiographs of the antebrachium, of the osteotomy. Radiographs should be obtained bi-weekly
during the distraction process and the rate increased or
a radiograph centered through the hinge axis should also be
decreased if necessitated by the appearance of the regenerate
obtained. The hinges should be superimposed over one another
bone. Docking refers to the process of the transport segment
on this view and the entire frame should be visible on the film
contacting and eventually obtaining union with the bone at
so that the distraction protocol can be calculated. Distraction is
measured along the concave cortex of the radius and a rate of the opposite end of the osseous defect. Obtaining union at the
docking site can be facilitated by placing a cancellous bone
0.75 to 1.50 mm/day fractionated into three or four incremental
graft at the site several days prior to docking and constructing
distractions is considered acceptable. The amount of distraction
the fixator such that the transport ring can be moved several mm
of the angular motor that will produce the appropriate amount of
beyond the bone defect, thus facilitating in compression of the
distraction at the osteotomy can be calculated using the method
docking site.
of similar triangles (Figure 53-51). Once the distraction period is
completed and the deformity is corrected the hex drive fastener
Bone transport has been used in dogs to resolve large segmental
elements on the hinge assemblies and the angular motor should
defects resulting from highly comminuted fractures, following
be tightened to lock the frame in position.
sequestrectomy in infected fractures and in performing limb
salvage procedures in dogs with appendicular bone tumors.
These large segmental defects have traditionally been managed
with massive bone allo- or autografts or prostheses, which
are prone to infection and implant failure. Regenerate bone is
highly vascular and resistant to infection and all implants can
be removed once the docking site has achieved union and the
regenerate bone has consolidated (Figure 53-52).
does not influence the final outcome even when the fixator
must be maintained for an extended period of time. Minor wire/
pin tract drainage may resolve with broad spectrum antibiotic
administration. If drainage is substantial and/or purulent and/
or there is substantial bone lysis and proliferation adjacent to a
wire/pin, that fixation element should be removed and replaced
if necessary. Proper insertion techniques and meticulous, appro-
priate daily care can greatly decrease the incidence of wire/pin
tract complications.
Suggested Readings
Anderson GM, Lewis DD, Radasch RM, et al.: Circular external skeletal
fixation stabilization of antebrachial and crural fractures in 25 dogs. J
Am Anim Hosp Assoc 39:479, 2002.
ASAMI Group. Basic principles of operative technique. In: Bianchi-
Maiocchi A, Aronson J, eds.: Operative Principals of Ilizarov. Milan,
Italy, Medi Surgical Vido, 1991, p 65.
Bianchi-Maiocchi A: The Ilizarov compression-distraction apparatus.
In: Bianchi-Maiocchi A, ed.: Advances in Ilizarov Apparatus Assembly.
Milan, Italy, Medi Plastic Sri, 1994, p 5.
Bronson DG, Samchukov ML, Birch JG, et al.: Stability of external
circular fixation: A multi-variable biomechanical analysis. Clin Biomech
13:441, 1998.
Catagni M: Fractures of the leg (tibia). In: Bianchi Maiocchi A, Aronson
J, eds.: Operative Principles of Ilizarov. Milan, Italy, Medi Surgical Vido,
1991, p 91.
Collins KE, Lewis DD, Lanz OI, et al.: Use of a circular external skeletal
fixator for stifle arthrodesis in a dog. J Sm Anim Pract 41:312, 2000.
Cross AR, Lewis DD, Murphy ST, et al.: Effect of ring diameter and wire
tension on the axial biomechanics of four-ring circular external skeletal
fixator constructs. Am J Vet Res 62:1025, 2001.
Cross AR, Lewis DD, Rigaud S, et al.: Effect of wire tension on the
biomechanics of asymmetric four-ring circular external skeletal fixator
constructs. Vet Comp Orthop Traumatol 15:44, 2002.
Egger EL, Histand MB, Norrdin RW, et al.: Canine osteotomy healing
Figure 53-52. Bone transport being utilized for a limb salvage proce- when stabilized with decreasingly rigid fixation compared to constantly
dure in a dog with a distal radial osteosarcoma. The distal two-thirds rigid fixation. Vet Comp Orthop Traumatol 6:182, 1993.
of the radius have been excised and the transport segment has been
Ehrhart N: Longitudinal bone transport for treatment of primary bone
moved approximately half the distance across the segmental defect
tumors in dogs: technique description and outcome in 9 dogs. Vet Surg
with early regenerate bone forming in the distraction gap. (Radiograph
34:24, 2005.
courtesy of Dr. Nicole Ehrhart)
Elkins AD, Morandi M, Zembo M: Distraction osteogenesis in the dog
using the Ilizarov external ring fixator. J Am Anim Hosp Assoc 29:419,
owners should be directed to construct a shroud or sleeve that
1993.
fits securely over the entire fixator, but can be easily removed for
Farese JP, Lewis DD, Cross AR, et al.: Use of IMEX SK-circular external
daily cleaning of the wire/pin-skin interfaces.
fixator hybrid constructs for fracture stabilization in dogs and cats. J
Am Anim Hosp Assoc 38:279, 2002.
Performing intensive, frequent (a minimum of three times a day)
Ferretti A: The application of the Ilizarov technique to veterinary
physical therapy is important during lengthening and correction medicine. In: Bianchi-Maiocchi A, Aronson J, eds.: Operative Principles
of angular deformities to reduce the development of muscle of Ilizarov. Milan, Italy, Medi Surgical Vido, 1991, p 551.
(especially flexor muscles) contracture. Contracture is less of Goodship AE, Kenwright J: The influence of induced micromotion upon
a problem with higher rhythms (more fractionated distractions). the healing of experimental tibial fractures. J Bone Joint Surg 67[B]:650,
The administration of nonsteroidal anti-inflammatory drugs 1985.
is also beneficial in encouraging weight-bearing, mitigating Green SA, Harris NL, Wall DM, et al.: The Rancho mounting technique
contracture during the distraction period. for the Ilizarov method. Clin Orthop 280:104, 1992.
Halling KB, Lewis DD, Jones RW, et al.: Use of circular fixator constructs
The most common complication associated with the use of CFs to stabilize intertarsal/tarsometarsal arthrodeses in three dogs. Vet
is wire/pin tract drainage and bone lysis surrounding the fixation Corp Ortho Traumatol 17:204, 2004.
elements. Inflammation associated with wire/pin tract drainage Ilizarov GA: The apparatus: Components and biomechanical principles
typically develops several weeks after surgery and generally of application. In: Ilizarov GA ed.: Transosseous Osteosynthesis.
External Skeletal Fixation 843
A B B
Figure 53-56. Connecting element of a HCF is the hybrid connecting rod Figure 53-57. Spherical nuts and washers A. connecting a hybrid rod
A. One end of the rod is threaded allowing it to be secured to a ring to a ring will allow approximately 15 degrees of angulation of the rod in
with two nuts B. relationship to the ring B.
846 Bones and Joints
B
Figure 53-59. A pin fixation bolt A. allows half-pins or full-pins to be
placed directly onto a ring or arch B.
Figure 53-58. Universal SK™ Hybrid Rod Adapter allows up to 32.5° of
angulation of a smooth 6.3 mm titanium or carbon fiber connecting rod
in relationship to the ring surface.
Assembly Elements
Assembly elements unique to an IMEX HCF include pin fixation
bolts, one and two hole posts, two hole plates, and threaded SK
clamps. Pin fixation bolts allow 3.0 to 4.8 mm half-pin or full-pins
to be placed directly on a 50, 60, 84 or 118 mm ring or arch (Figure
53-59). Juxta-articular fractures involving the femur, humerus
or spine are best stabilized with half-pins or full-pins instead
of divergent narrow wires. Divergent wires in these locations
can penetrate large muscle masses, or result in impingement
of normal flexion and extension of the associated joint. A pin
fixation bolt is secured to a ring or arch with a 6.0 mm nut. The
supporting element then serves as a platform for pin insertion
into the juxta-articular bone segment. The basic anatomy and
mechanics of the pin fixation bolt is identical to that of the A
pin-gripping bolt/washer assembly of the linear SK clamp. As
the 6.0 mm nut attaching the fixation bolt to the ring is tightened,
the fixation pin is trapped and secured between the hole in the
head of the bolt and the meniscus of the sliding washer. The pin
fixation bolt will accept the IMEX drill sleeve, which should be
used to minimize soft tissue trauma during pre-drilling of holes
prior to pin insertion.
wires and pins secured to the same bone segment. Axial micro-
motion occurs with bone segments secured to a ring with two or
more narrow wires during weight bearing. Fixation pins rigidly
secure bone segments and do not allow for micromotion in any
plane. Therefore if a juxta-articular bone segment is secured
to a ring with wires and a single fixation pin, the axial micro-
motion provided by the wires will result in cyclic bending forces
at the fixation pin-bone interface. This may result in premature
loosening of the fixation pin with subsequent pin tract drainage,
sepsis and patient discomfort.
A B C
D E F
Figure 53-65. Common HCF frame designs. Type I-a frame A. Type I-a frame with diagonal strut B. Type I-a frame using arch and half-pins C. minimal
Type II frame D. Type I-b frame E. and multiplaner Type I-b frame F.
Parabolic shaped arches with 140 and 220 mm internal diameters Application of a HCF
are available to create spinal HCF frames (Figure 53-66). Two to
The application of a HCF is relatively easy; however, close
four spinal arches can be connected with three or four sections
adherence to basic linear and circular fixator application principles
of 6.0 mm all-thread connecting rod. Half pins can then be placed
should be followed to improve clinical results and reduce postop-
into the vertebral bodies and secured to the arches using half pin
erative complications. One primary advantage of any external
fixation bolts. Modified threaded small SK clamps are positioned
fixation device, is that it can be applied using the principles of
along the all-thread connecting rods of the frame. Half pins can be
biological osteosynthesis. Whenever possible, the HCF should
placed into vertebral bodies from the threaded SK clamps, as well
be applied using a closed technique. If necessary, to adequately
as from the spinal arches using pin fixation bolts. In the author’s
reduce or align the major bone segments, a mini-approach can
experience a simpler two arch spinal frame used in conjunction
be used. However, the local fracture hematoma should not be
with threaded SK clamps is easier to position on the spine, and
disrupted. If a mini-approach is used, addition of an autogenous
place fixation pins into vertebral bodies, than the multi arch frame.
850 Bones and Joints
Figure 53-69. A pre-drilled pilot hole is created in the primary bone seg-
ment parallel to the corresponding joint surface. The hole is orientated
perpendicular to the tibial diaphysis and in the true medial-lateral
plane of the bone segment.
B
Figure 53-70. The correct position of the trasfixation wire and the posi-
tive profile half-pin. Each fixation element is parallel to the correspond- Figure 53-71. Digital traction placed on the ring A. with the SK clamp
ing joint surface, perpendicular to the longitudinal axis of the tibia, and loosely attached to the hybrid connecting rod and fixation pin will
in the true medial-lateral plane of the bone segments. result in axial reduction of the fracture B. Once reduction is accom-
plished the SK clamp is re-tightened to the connecting rod.
External Skeletal Fixation 853
Application of a HCF to a
Radius/Ulna Fracture
A “hanging leg prep” will often facilitate re-establishment of
axial limb length of radial/ulnar fractures. If a full ring is used,
it must be placed over the antebrachium prior to hanging the
limb. A more detailed description of the “hanging leg prep”
can be found in the Basic Principles for Application of External
Fixators section. The basic steps used to apply a HCF to the
tibia can be followed for the radius with only several modifica-
tions. One primary difference is that the position of the hybrid
connecting rod(s) in relationship to the limb will be altered to
allow placement of half pins through safe soft tissue corridors.
Due to the flat ovoid shape of the radius it is difficult to pass
fixation pins in the medial-lateral plane. However, the bone is a
relatively easy target to insert half pins in the cranial-medial and
cranial-lateral planes. Fixation pins placed in these locations will
pass through safe soft tissue corridors. Similar to the tibia, the
decision to use a type I-a frame (with or without a diagonal), or a
Figure 53-74. Additional SK clamps are equally spaced along the hybrid type I-b frame will be dependent upon the fracture configuration
connecting rod and additional half pins are placed into the primary
(load or non-load sharing), patient’s age and weight. Hybrid type
bone segment after pre-drilling pilot holes.
II frames are not recommended on the radius. To place a hybrid
type I-a frame on the radius, the hybrid connecting rod should be
positioned over the cranial-medial aspect of the antebrachium.
If a hybrid type I-b frame is used, hybrid connecting rods are
External Skeletal Fixation 855
A B
Figure 53-77. Application of a multiplaner Type I-b hybrid construct to a distal humeral fracture A. A transcondylar positive profile center threaded
full-pin is secured to a stretch ring using two half-pin fixation bolts B. The open end of the ring has been directed caudally to prevent impinge-
ment of joint function, and allow an anterior platform for other connecting elements.
is re-established. The pin also prevents translational malalignment lateral 1-a linear external fixator by removing the ring, diagonals,
of the condyle and the primary bone segment. Once the fracture is medial half-pin, and cutting the medial aspect of the full pin.
aligned, the pin is then passed distally into the condyle.
4) The stretch ring is manipulated to correct rotational and angular
malalignment of the condylar bone segment. A hybrid connecting
Postoperative Care of the HCF
rod is secured to the lateral aspect of the stretch ring using two Postoperative care of a HCF is similar to the care previously
6.0 mm nuts. To allow proper angulation of the hybrid rod, it may described for circular and linear fixators. If destabilization of
be necessary to attach the hybrid rod to the ring using either the frame is desired, it is generally performed 6 to 8 weeks after
paired spherical nuts and washers, or by creating an articulation surgery. Staged disassembly is usually not necessary if fixation
using two posts. wires have been used in the short bone segment. If a wire or
5) The proximal end of the hybrid rod is attached to the proximal pin causes significant drainage or becomes loose it should be
aspect of the primary bone segment using two - three positive removed, or replaced if necessary. Orthogonal radiographs should
profile half-pins and SK clamps. The hybrid rod can be tied into be performed every 6 to 8 weeks until fracture healing is complete
the intramedullary pin using an articulation. Alternatively the IM and the frame removed. The supporting, connecting and assembly
pin can be contoured and directly attached to the hybrid rod with elements of the HCF can be cleaned and reused numerous times.
an SK clamp (Figure 53-78).
6) To provide additional support of the condyle, a positive profile
half-pin is inserted into the condylar or supracondylar region,
Suggested Readings
Cross AR, Lewis DD, Rigaud S, Rapoff AJ: Effect of various distal
distal to the fracture. The pin can be inserted into either the ring-block configurations on the biomechanical properties of circular
medial or lateral aspect of the condyle. The author has found that external skeletal fixators for use in dogs and cats. J Am Vet Res 65; 4:
a medially placed half-pin is clinically well tolerated, penetrates 393, 2004.
less soft tissue and results in less restriction of joint motion than a Lewis DD, Bronson DG, Cross AR, et al.: Axial characteristics of circular
laterally placed pin. The half-pin is placed from either a post or a external skeletal fixator single ring constructs. Vet Surg 30: 386, 2001.
short hybrid connecting rod (Figure 53-79). Marcellin-Little DJ, Roe SC, Rovesti GL, et al.: Are circular external
7) One or two diagonal struts can be created using articulations fixators weakened by the use of hemispherical washers? Vet Surg 31:
secured to the anterior region of the stretch ring to improve frame 367, 2002.
stiffness. Additional half-pins can be placed into the proximal Toombs JP, Bronson DG, Ross D, Welch RD: The SK™ external fixation
cranial-lateral aspect of the humerus or femur from SK clamps system: description of components, instrumentation, and application
positioned along the diagonal strut (Figure 53-80). techniques. Vet Comp Ortho Traumatol 2:76, 2003.
8) The frame can easily be destabilized to enhance fracture Worsar MA, Marcellin-Little DJ, Roe SC: Influence of bolt-tightening
healing postoperatively by: a) removal of the intramedullary pin; torque, wire size, and component reuse on wire fixation in circular
b) removal of diagonal struts; or c) by converting the HCF into a external fixation. Vet Surg 31: 571, 2002.
Bone Grafts and Implants 857
A B
Figure 53-78. The proximal aspect of the hybrid rod is secured to the primary bone segment with two or three half-pins. A. The hybrid rod can be
“tied” into the intramedullary pin using a linear articulation. B. Alternatively the IM pin can be bent and directly attached to the hybrid rod using
an SK clamp.
Figure 53-79. A half-pin is inserted into the medial aspect of the con- Figure 53-80. A diagonal strut is created on the anterior or anterior-me-
dyle or supracondylar region from either a post or a short hybrid rod dial aspect of the ring using an articulation. The strut is connected to a
connected from the medial aspect of the ring. proximal half-pin using a “stack clamp” technique. Additional half-pins
can be placed into the proximal-lateral aspect of the humerus from an
SK clamp positioned on the diagonal strut.
858 Bones and Joints
bone healing. Rigid stabilization and appropriate antibiotic be found in the section “Harvesting, Storage, and Application of
therapy are required in addition to the graft in order to obtain a Cortical Allografts” in a later section of this chapter. Distraction
successful outcome. osteogenesis provides an alternative solution for dealing with
large bony defects in limb salvage patients and this technique is
When cancellous autograft is applied to a contaminated or covered in the last section of this Chapter.
infected host bed, care must be taken to avoid contamination
of the donor site. In this situation, the following procurement
and application procedure is recommended: 1) perform the
Donor Sites for Cancellous Bone Grafts
host site surgical procedure and any necessary debridement, In young adult animals, the metaphyseal regions of most major
lavage, obtain a sample for culture, and then cover the repair longbones can provide graft material with high osteogenic
site with moist sponges; 2) change gloves and use a separate set potential. With progressing age, bone marrow at some of these
of surgical instruments to harvest the cancellous bone graft; 3) sites undergoes a slow transformation from hematopoietic
close the donor site; 4) apply the cancellous graft to the recipient marrow to fatty marrow. Cancellous bone obtained from areas
site; and 5) close the repair site. where the bone marrow is still hematopoietic provides the highest
level of osteogenic function. In this regard, the best sites for
obtaining cancellous autografts in mature dogs are the proximal
Bone Cysts humerus, proximal femur, distal femur, and the wing of the ilium.
Bone cysts are benign fluid-filled lesions of unknown etiology Cancellous bone taken from these sites has a rich, deep reddish
that may be monostotic (involving a single bone) or polyostotic brown appearance. In contrast, cancellous bone taken from the
(involving more than one bone). Clinical signs include pain and proximal metaphysis of the tibia, a site where marrow becomes
swelling, but cystic bone lesions can be asymptomatic until they fatty, has more of a yellowish or tan appearance (Figure 54-1).
reach a fairly large size or until a pathologic fracture occurs.
Treatment involves curettage of the walls of the cyst, filling of The 3 most commonly used sites for obtaining cancellous bone
the resulting defect with cancellous bone graft, and stabilization grafts in dogs are the craniolateral aspect of the proximal
of the bone until healing occurs. metaphysis of the humerus, the dorsal aspect the wing of the
ilium, and the caudomedial aspect of the proximal metaphysis
Arthrodesis of the tibia. In terms of both the quality and the quantity of graft
material that can be obtained, the proximal humerus is the best
When arthrodesis is performed, stable bony union of multiple,
of these three alternatives. The proximal humerus is also an
often complex joint surfaces must be achieved as quickly as
easily accessible site. The quality of cancellous bone from the
possible. A successful outcome depends upon adherence to
wing of the ilium is quite good, but the volume of material that
the following principles: 1) removal of all cartilage from the
can be obtained is significantly less than for the humerus, and it
surfaces that must undergo bony healing; 2) liberal application
is not as easily accessible. Although the proximal tibia is easily
of cancellous bone graft to fill defects and to promote early
accessible, cancellous autograft from this site tends to provide
callus formation; 3) rigid fixation; and 4) healing of the joint in a
less volume and lower quality material compared to the other
functional anatomic position.
two sites. If additional graft material is needed from the same
donor site at a later date, restoration of cancellous bone is more
Bone Plate Removal rapid and complete in the proximal humerus compared to the
Implant removal is performed in some patients that have undergone proximal tibia. The recommended waiting time before returning
longbone fracture repairs with bone plates and screws. Implant to a site for a second graft harvest is 2 months.
removal results in a variable number of empty holes that can act as
stress concentration points until healing occurs. Some surgeons
advocate packing the empty bone holes with cancellous autograft
bone to speed the healing of these defects.
Limb Salvage
Animals with a neoplastic lesion involving the distal radius are the
best candidates for limb salvage. Wide resection of the neoplastic
portion of the bone produces a defect that is too massive to
be filled with cancellous bone alone. Typically, an allogeneic
cortical bone segment is cut to fit the defect. Rigid stabilization
is accomplished with bone plate and screw fixation that extends
from the proximal radial host segment to the distal portion of the
3rd metacarpal bone. To promote rapid healing at the alloim-
plant-host bone junctions, freshly harvested cancellous autograft Figure 54-1. Split sections of the humerus and tibia from a 5 year old
is packed into the medullary cavity at the proximal and distal mixed breed dog. Abundant cancellous bone with a dark reddish-
ends of the alloimplant (composite grafting). Cancellous bone is brown appearance is present in the proximal humerus. Much less
also liberally applied over the proximal and distal interfaces of cancellous bone is seen in the proximal tibia and it has a yellowish-tan
the alloimplant segment. Further discussion of this technique can appearance due to the absence of hematiopoietic bone marrow.
860 Bones and Joints
The femur offers two additional donor sites for obtaining patella. The incision is made from the skin to the bone on either
cancellous bone. A greater quantity can be obtained from the the medial or the lateral aspect of the femoral condyle. A Gelpi
condylar region of the distal femur compared to the greater retractor is applied to maintain exposure, which reveals the
trochanteric region of the proximal femur. Graft quality is good at stifle at the caudal margin of the reflection of the joint capsule.
both locations. Access to these sites requires more dissection An access hole is made through the cortex of the condyle with a
than is needed for access to the proximal humerus and proximal Steinmann pin or drill bit at the location shown in Figure 54-3.
tibia. The distal femur offers a convenient location for harvesting
cancellous bone graft to be used for a triple pelvic osteotomy
procedure.
Surgical Approaches to Donor Sites Figure 54-3. Lateral access hole in the distal femur. Medial access to
the distal metaphysis of the femur is an acceptable technique as well.
Proximal Humerus
A 2 to 3 cm long skin incision is made over the craniolateral aspect Proximal Tibia
of the greater tubercle, just cranial to the palpable acromial head A medial skin incision 2 to 3 cm in length is made starting
of the deltoideus muscle. Subcutaneous tissue is separated by approximately 2 cm distal to the tibial plateau, midway between
sharp dissection to reveal the periosteal surface of the bone. the tibial tubercle and the medial collateral ligament. Subcuta-
Exposure is maintained by insertion of a small Gelpi self-retaining neous tissues and underlying muscle (insertions of sartorius and
retractor. An access hole is made with a Steinmann pin or drill gracilis muscles) are separated with sharp and blunt dissection
bit through the thin outer layer of cortical bone in the proximal to reveal the proximal tibial metaphysis. The cross-sectional
metaphyseal region of the humerus (Figure 54-2). It is important shape of the proximal tibia is triangular, with the base of the
to maintain a safe distance from the growth plate in skeletally triangle located caudally. In light of this, the access hole in the
immature animals. It is also important to make the access hole metaphysis should be made at a caudomedial location as shown
in the metaphysis rather than in the hard cortical bone of the in Figure 54-4.
diaphysis. An access hole in this later location increases the risk
of a postoperative iatrogenic fracture of the donor bone.
Figure 54-2. Craniolateral access hole in the proximal humerus. Iliac Crest
A 4 to 8 cm long skin incision is made directly over the dorsal
Proximal Femur aspect of the iliac crest. Deep fascia is incised along the entire
A 2 to 3 cm long skin incision is made directly over the lateral length of the incision. The middle gluteal muscle is sharply
aspect of the greater trochanter. The subcutaneous tissues and incised from its attachment to the dorsal aspect of the iliac
the superficial gluteal muscle are sharply incised to reveal the crest and then is subperiosteally elevated from the wing of the
surface of the bone. Exposure is maintained with a Gelpi retractor. ilium to reveal the bone. The dorsomedial aspect of the ilium
An access hole is made with a Steinmann pin or drill bit. is exposed by sharp incision of the insertion of the sacrospi-
nalis muscle. Exposure is maintained with Gelpi retractors. An
Distal Femur access hole can be made in the dorsal surface of the ilium, or an
osteotome or saw can be used to remove a cap of bone from the
A 2 cm long incision is made over the bone halfway between
craniodorsal aspect of the iliac crest as shown in Figure 54-5. If
the fabella and the proximal patella, parallel to the margin of the
Bone Grafts and Implants 861
a large quantity of bone graft is needed, this cap can be cut into
multiple pieces with a pair of rongeurs to serve as a cancellous
bone extender. The corticocancellous bone chips are then mixed
with cancellous bone and applied to the recipient site. The iliac
crest may be preferable to the previously mentioned longbone
metaphyseal donor sites in young animals with open growth
plates because there is less risk of clinically significant growth
disturbance as a complication of graft procurement.
to ventral to expose the wing of the ilium. Gelpi retractors can also The gluteal fascia, subcutaneous tissues, and skin are closed
be placed to facilitate esposure. routinely.
An acetabular reamer (20 or 23 mm for small dogs, 26 or 29 mm The harvested graft has a paste-like consistency, which facili-
for medium-sized dogs, and 29 or 32 mm for large dogs) attached tates packing the graft into bone defects and results in intimate
to a low speed, high torque drill is used for harvesting the graft. contact with the recipient bed.
Reaming is initiated on the lateral ilium immediately caudal to the
iliac crest. It is continued caudally, removing the lateral cortex
and cancellous bone while leaving the medial cortex and dorsal
Postoperative Considerations
edge of the ilium intact. Reaming is carried as far caudally as The cortiocancellous graft appears more radiodense than a
is feasible, creating an oval-shaped defect (Figure 54-7). When cancellous graft on immediate postoperative radiographs because
the cup of the reamer is full, it is detached from the extension of the graft’s cortical component. Morbidity associated with ilial
and the graft is removed to be stored in a sterile receptacle corticocancellous graft harvest is minimal; however, transient,
until required. Switching to a smaller diameter reamer generally self-limiting hind limb lameness and seroma formation may occur.
allows the surgeon to extend reaming down the body of the ilium. Restricted postoperative activity is therefore recommended.
Care must be taken to avoid penetrating the medial cortex of the
ilium with the reamer. When the reaming is completed, additional
exposed cancellous bone along the periphery of the defect can be
Suggested Readings
Culvenor JA, Parker RB: Collection of cortico-cancellous bone graft
harvested with a bone curette.
from the ilium of the dog using an acteabular reamer. J Small Anim
Pract 37:513, 1996.
The donor site is thoroughly lavaged with sterile saline. A splash
Piermattei DL, Johnson KA: An atlas of surgical approaches to the bones
block of local anesthetic may be administered prior to closure
and joints of the dog and cat, 4th ed. Philadelphia: W.B. Saunders, 2004,
to decrease postoperative discomfort. Closure is performed 278.
in multiple layers to decrease the risk of postoperative seroma
Stallings JT, Parker RB, Lewis DD, et al.: A comparison of autogenous
formation. The superficial fascia of the middle gluteal muscle is cortico-cancellous bone graft obtained from the wing of the ilium with an
apposed to its periosteal insertion or to the superficial fasia of the acetabular reamer to autogenous cancellous bone graft obtained from
sacrospinalis muscle with a series of horizontal mattress sutures. the proximal humerus in dogs. Vet Comp Orthop Traumatol 10:79, 1997.
Figure 54-7. Self-retaining retractors are used to increase exposure of the lateral aspect of the wing of the ilium. Reaming begins immediately
caudal to the iliac crest and is continued caudally as far as is reasonably possible. The lateral cortical and inner cancellous bone is removed.
864 Bones and Joints
Harvesting, Storage and Absolute aseptic surgical technique is required. All donors
should be prepared as for any standard surgical orthopedic
Application of Cortical procedure, with proper aseptic scrubbing and draping. Donors
are placed under general anesthesia, and standard approaches
Allografts to the long bones are used. The bone should be exposed from
Kenneth R. Sinibaldi metaphysis to metaphysis by removing as much soft tissues
(muscle and periosteum) as possible. An oscillating bone saw
is used to cut the bone. This saw should be cooled with liquid
Introduction during cutting. After the bone is removed, it is placed in a
Cortical allografts have been used to enhance repair of long solution of lactated Ringer’s or saline. This is temporary before
bone fractures in veterinary surgery for several decades.1-4 final preparation of the graft. Once all the donor graft has been
An allograft is bone transferred from one individual to another harvested, euthanasia is performed on the donor.
individual of the same species. This type of graft elicits an
immune response because of foreign cellular antigens of the The grafts are then stripped of all remaining soft tissue attach-
allograft and the reaction of the host immune system. Fresh- ments, and the medullary contents are removed. A sharp
frozen processed cortical allografts are the most commonly periosteal elevator or scalpel blade works best for stripping,
used cortical grafts in veterinary orthopedic surgery. Allografts whereas a bone curette works best for removal of medullary
are also considered alloimplants because they are a nonviable contents. The medullary cavity should be flushed out with sterile
material (dead bone), and by definition, the term implant refers to lactated Ringer’s or saline solution. Once the graft is clean, it
any nonviable material placed in the body. can be cut into proximal, middle, and distal thirds, halved or
maintained in its full length. The graft’s medullary cavity is
An autogenous allograft (autograft) is bone transferred from a cultured for aerobic and anaerobic organisms. The graft is
donor site to a recipient site in the same individual. There are placed in a suitable glass jar that has been previously autoclaved.
definite disadvantages to this type of graft. Sufficient bone is Each jar with the graft should be marked, indicating left or right,
often not available, morbidity at the donor site is a concern, with the name of the bone, segment of bone, date of harvesting,
increased anesthetic and surgery time, and increased risk of and donor identification. The jar and graft are then immediately
infection. Fresh frozen allograft is preferred for convenience of placed in a household freezer at a temperature of -20° C. Any
storage, and reduction of disease and immunogenicity.5-9 temperature warmer than this leads to improper freezing and
possible autolysis. The American Association of Tissue Banks
Frozen allografts provide structural (mechanical), osteocon- allows 6 months storage at -20° C and recommends -40° C for
ductive, and osteoinductive support to fracture repair.10 Other longer-term storage (up to 5 years); -70° C is preferred.11 The
methods of processing bone allografts include cryopreser- colder temperatures inhibit molecular translations that result in
vation, freeze-drying (lypholized) and demineralized preparation. degradation. The author has not had any problems safely storing
The processing of bone grafts by these methods is more involved bone grafts at -20° C for 1 year. Only grafts that culture negative
technically and are not practical for the veterinary surgeon in are placed in the bone bank.
practice. Inconvience of allograft harvesting, processing,
storage, and quality assurance have limited their use.11 The most common indication for use of cortical allografts
is replacement of bone in patients with highly comminuted
fractures. Other indications are correction of nonunions,
Harvesting of Allografts delayed unions, and mal-unions with or without bone loss, bone
Harvesting of allografts is practical for the veterinary surgeon lengthening, limb-sparing procedures for bone tumors, and, in
and requires adherence to strict asepsis, preparation and time. selected cases, osteomyelitis with bone loss due to sequestrum
The procurement of cortical allografts begins with proper donor formation.14 This last indication should be considered a salvage
selection. Donors should be mature, healthy animals, preferably procedure if amputation is not an option. In preparation for
between the 1.5 to 8 years of age, with no preexisting neoplastic, surgical implantation of an allograft, radiographs of the opposite
metabolic, bacterial, or viral diseases. A complete physical limb should be made, and bone length measured. An estimate of
examination and review of history are essential. Current vacci- the graft length needed is made by comparing the intact cortical
nations and blood screening for transmissible diseases should segments on the lateral projection of the affected limb and
be performed. Immature donors have bones that may be brittle subtracting this from the total length of the normal bone. (Figure
and less developed than older donors, and this factor may cause 54-8). A graft is then selected based on this estimate as well as by
problems during implantation with stability (screw purchase). visually comparing the width of the host and graft bone. Usually,
the femur is used to replace a segment of femur, however the
Allografts can be harvested from dead donors and then sterilized use of other long bones should not be discouraged because the
with ethylene oxide. Although ethylene oxide is considered width of other bones may be adequate if a near perfect match
a superior sterilizing agent for surface contamination, but cannot be made with similar bones.
low residual levels may be toxic to recipient tissue and could
interfere with healing. It may also affect the mechanical strength
and incorporation of cortical allografts.12,13 Freshly harvested
cortical allografts are preferred.
Bone Grafts and Implants 865
veterinarian by the name of Dr. Antionio Ferretti, began using segmental defect. This method was used by Ilizarov to salvage
the Ilizarov methods in veterinary patients. The use of circular many limbs that otherwise would have been amputated because
fixation and distraction osteogenesis began to appear in North of non-union, osteomyelitis or extensive segmental bone loss.18
American veterinary literature in the early 1990s.24 Currently, Bone transport osteogenesis is also used in veterinary patients
IMEX Veterinary (Longview, TX) manufactures a circular external for limb salvage following segmental bone loss due to trauma or
fixator system that has lightweight design elements suitable for tumor excision.11,12
veterinary patients (Figure 54-10). Other circular external fixation
systems are also available in North America and Europe.
Histomorphology of Distraction Osteogenesis
Bone transport osteogenesis is a modification of the original Distraction osteogenesis requires prolonged and gradual
distraction osteogenesis technique, involving the transport of distraction of two freshly osteotomized bone ends (See Figure
a bone fragment across a bony defect with distraction osteo- 54-9). The new bone by distraction osteogenesis or bone
genesis occurring in the trailing pathway of movement (Figure transport osteogenesis is termed regenerate bone. The process
54-11). The bone fragment eventually contacts the opposite of new bone formation is often called osteoneogenesis. The
end of the defect, and is compressed to the adjacent bone in biology of distraction osteogenesis has been extensively
its new position, resulting in union between the bone fragment studied.1,4,6-8,10,21 The results of these investigations have greatly
and the parent bone. The new bone that forms in the distraction expanded the understanding of the histological, biochemical,
pathway rapidly remodels into lamellar bone, thereby filling in the vascular, radiographic, and mechanical properties of regenerate
bone formation. Ilizarov mistakenly assumed that distraction
osteogenesis recapitulated endochondral bone formation. This
belief was generated by the radiographic observation that a
radiolucent zone consistently occurred in the center of the
regenerate bone (radiolucent central zone) until distraction
was completed, similar to a growth plate which remains radio-
lucent until growth is completed. More recent studies have
shown that bone formation during distraction osteogenesis
results from both intramembranous and endochondral ossifi-
cation, with intramembranous bone formation predominating
at a ratio of 5:1.14 The radiolucent central zone is comprised of
Type I collagen columns adjacent to a zone of newly formed
vessels. This vasculature delivers proliferating and differenti-
ating osteoblasts which migrate along the collagen columns and
deposit osteoid. These collagen columns are formed in parallel
and along the lines of distraction tension. Each of these osteoid-
covered, longitudinal columns of collagen begins to mineralize
starting from either end of the gap and progressing toward the
central radiolucent zone. The mineralizing new bone columns
resemble stalagmites and stalactites projecting from each
osteotomy surface on radiographs. Each bone column expands
transversely as more collagen fibers are incorporated circum-
Figure 54-10. Circular fixator on a canine patient. ferentially and mineralized until they reach a maximum diameter
of 150 to 200 microns. The space between the bone columns
consists of large, thin-walled vessels.2,3,9,10,14 Once distraction
is completed, the bone columns begin to bridge the peripheral
aspect of the radiolucent central zone. Columns of mineralizing
new bone then rapidly bridge the entire central radiolucent zone
and are eventually interconnected transversely by woven bone
plates forming a honeycomb-like pattern. Once bridging occurs,
rapid secondary remodeling of the cortices ensues and the
Haversian system is re-established. This remodeling process
occurs much more rapidly than with classical fracture healing;
partly because the collagen fibers are more orderly and aligned
at the start of mineralization and therefore tend to remodel in a
manner parallel with the long axis of the bone. In addition, the
mechanical strain environment created in the distraction gap
seems to promote robust angiogenesis, massive osteoblast
recruitment and rapid production of osteoid.13,14
Figure 54-11. Bone transport osteogenesis 14 days following the start
of distraction. Note the wisps of new bone forming between the trans-
ported bone segment (arrow) and the parent bone.
868 Bones and Joints
14. Fink, B., Pollnau, C., Vogel, M., Skripitz, R., Enderle, A. Histomor-
phometry of distraction osteogenesis during experimental tibial length-
ening. J. Orthop. Trauma 17: 113-118, 2003.
15. Frierson, M., Ibrahim, K., Boles, M., Bote, H., Ganey, T. Distraction
osteogenesis. A comparison of corticotomy techniques. Clin. Orthop.
Relat Res. 19-24, 1994.
16. Ilizarov, G. A. The tension-stress effect on the genesis and growth
of tissues. Part I. The influence of stability of fixation and soft-tissue
preservation. Clin. Orthop. 249-281, 1989.
17. Ilizarov, G. A. The tension-stress effect on the genesis and growth of
tissues: Part II. The influence of the rate and frequency of distraction.
Clin. Orthop. 263-285, 1989.
18. Ilizarov, G. A. The principles of the Ilizarov method. 1988. Bull. Hosp.
Jt. Dis. 56: 49-53, 1997.
19. Lewis, D. D., Bronson, D. G., Cross, A. R., Welch, R. D., Kubilis, P.
S. Axial characteristics of circular external skeletal fixator single ring
constructs. Vet. Surg. 30: 386-394, 2001.
20. Lewis, D. D., Cross, A. R., Carmichael, S., Anderson, M. A. Recent
advances in external skeletal fixation. J. Small Anim Pract. 42: 103-112,
2001.
21. Welch, R. D., Birch, J. G., Makarov, M. R., Samchukov, M. L. Histo-
morphometry of distraction osteogenesis in a caprine tibial lengthening
model. J. Bone Miner. Res. 13: 1-9, 1998.
22. Welch, R. D., Lewis, D. D. Distraction osteogenesis. Vet. Clin. North
Am. Small Anim Pract. 29: 1187-viii, 1999.
23. Welch, R. D., Lewis, D. D. Distraction osteogenesis. Vet. Clin. North
Am. Small Anim Pract. 29: 1187-viii, 1999.
24. Yanoff, S. R., Hulse, D. A., Palmer, R. H., Herron, M. R. Distraction
osteogenesis using modified external fixation devices in five dogs. Vet.
Surg. 21: 480-487, 1992.
Scapula and Shoulder Joint 871
of the scapula can be managed conservatively except when they for the animal, the bandage should be monitored closely and
involve the articular surface (glenoid), when the fracture results removed in 2-3 weeks to allow for return to normal shoulder joint
in a distinct change in the angulation of the shoulder joint articu- function and to prevent unwanted contracture of soft tissues and
lation (displaced scapular neck and body fractures), and when limitations in joint motion.4 Fractures that are severely displaced
the injury is an avulsion fracture of the acromion and supra- or comminuted or those that change the angle of the normal joint
glenoid tubercle. Conservatively managed fractures require only articulation should be repaired with internal fixation. Internal
limited activity for 3-4 weeks, whereas others may benefit from a fixation improves the cosmetic result, especially in short-haired
modified Velpeau sling or spica splint.3 Support bandages add to dogs, and provides the support necessary for early return to
the comfort of the animal during the healing period. ambulation better function.
Figure 55-2. Repair of scapular body fractures. A. Interfragmentary wires with a tension band in the scapular spine. B. Inverted semitubular steel
plate with screws directed at an angle into the thickest bone at the junction of the scapular spine and body. C. Plastic plate secured to the spine
of the scapula with screws and nuts.
Scapula and Shoulder Joint 873
55-2C). In a mechanical study, when comparing single versus displaces medially and proximally, and closed reduction is
double semitubular plate fixation, single plate fixation of scapular difficult. The risk of suprascapular nerve damage is present and
body fractures may be sufficient. Any difference between single the client should be warned of the possibility. As a result, the
and double plating is likely not clinically relevant.13 Locking plate supraspinatus and infraspinatus muscles may atrophy, leaving a
technology has the potential to increase stability of the repair cosmetically altered appearance and impaired function. Internal
in light of the poor bone quality of the scapula.5 However, in a fixation is recommended to achieve the best result. The supra-
scapular fracture model, locking SOP plates were not shown to scapular nerve should be retracted and protected during repair.
have a different load to failure than an LC-DCP.14 Locking plates Many combinations of methods can be used to repair fractures
have not yet been evaluated for scapular fractures in a clinical
setting, or in a cyclic load model at the time of this manuscript
preparation. Perfect fracture alignment and anatomic recon-
struction may not be consistently achieved, but the goal of
preventing overriding and angulation of the fracture segments
with internal fixation methods is adequate to allow for good
functional and cosmetic results.
Acromial Fractures
The bony prominence of the distal end of the spine of the scapula,
the acromion, is the site at which the acromial head of the
deltoid muscle arises and runs distally. The acromion is easily
palpable under the skin and can be compared to the opposite
limb for asymmetry and identification of a fracture. Fracture of
the acromion results in distal displacement created from the pull
of the acromial head of the deltoid muscle. The diagnosis can
be made with palpation and radiographic findings. The animal
typically has a weightbearing lameness and pain is elicited
upon palpation. With constant pull from the acromial head of the
deltoid, all forms of closed reduction and fixation are inadequate
and internal fixation is required.4 Typically, one of two methods
is used to stabilize the fragment. Either two small pins and a
tension band wire can be applied, or two twisted stainless steel
interfragmentary wires are placed, depending on the size of the
animal and the fragment (Figure 55-3). If the fixation is secure,
no additional support is required, limited activity is advised for 6
to 8 weeks, and the prognosis for a complete recovery is good.
References
1. Harari, J, Dunning, D: Fractures of the Scapula in Dogs: A Retro-
spective Review of 12 Cases. Veterinary and Comparative Orthopaedics
and Traumatology, 6:105-108, 1993.
2. Cook, JL, Cook CR, Thomlinson JL, et al: Scapular Fractures in Dogs:
Epidemiology, classification, and concurrent injuries in 105 cases (1988-
1994). J Am Anim Hosp Assoc 1997; 33:528-532.
3. Piermattei, DL, Flo, GL DeCamp, CE: Brinker Piermattei, and Flo’s
handbook of Small Animal Orthopedics and Fracture Repair, ed 4, St.
Louis, Elsevier, 2006.
4. Newton, CD: Fractures of the Scapula. In Textbook of Small Animal
Orthopedics. Edited by CD Newton and DM Nunamaker. Philadelphia,
J.B. Lippincott, 1985.
5. Peck, J.: Musculoskeletal System - Scapula. In Veterinary Surgery:
Small Animal. Edited by KM Tobias and SA Johnston, St. Louis, Elsevier,
2012.
6. Ticer, JW: Radiographic Technique in Veterinary Practice. Phila-
delphia, WB Saunders, 1984.
7. Straw, RC: Thoracic Limb - Repair of Scapular Fractures. In Current
Techniques in Small Animal Surgery. Edited by MJ Bojrab, Philadelphia,
Lea and Febiger, 1990.
8. Roush, JK, Lord, PF: Clinical Application of a Distoproximal (Axial)
Radiographic View of the Scapula. J Am Anim Hosp Assoc, 1990; 26(2):
129-132.
9. Brinker, WO, Hohn, RB, and Prieur, WD (eds): Manual of Internal
Fixation in Small Animals. New York, Springer-Verlag, 1984.
10. Piermattei, DL, Johnson, KA: An Atlas of Surgical Approaches to
the Bones and Joints of the Dog and Cat, ed 4. Philadelphia, Saunders/
Elsevier, 2004.
11. McCartney, WT, Garvan, CB: Muscle separation approach to
scapular neck fractures in eight dogs. Veterinary and Comparative
Orthopaedics and Traumatology, 5:471-473, 2008.
12. Ocal, MK, Toros, G: A morphometric study on the cross-sections of
the scapular spine in dogs. Veterinary and Comparative Orthopaedics
and Traumatology, 4:281-284, 2007.
13. Mair, JJ, Belkoff SM, Boudrieau RJ: An Ex Vivo Mechanical Evalu-
ation of Single Versus Double Semitubular Plate Fixation of a Transverse
Distal-Third Scapular Osteotomy in the Dog. Vet Surg 2003;32:580-584
14. Acquaviva, AE, Miller, EI, Eisenmann, DJ, Stone, RT, Kraus, KH:
Biomechanical testing of locking and nonlocking plates in the canine
scapula. J Am Anim Hosp Assoc, 2012; 48: 372-378.
15. Johnston, SA: Articular Fractures of the Scapula in the Dog: A
Clinical Retrospective Study of 26 Cases. Journal of the American
Animal Hospital Association, 1993; 29(2): 157-164.
16. Olivieri, M, Piras, A, Marcellin-Little, DJ et al: Accessory caudal
glenoid ossification centre as possible cause of lameness in nine dogs.
Veterinary and Comparative Orthopaedics and Traumatology, 3:131-135,
2004.
17. Plesman, RL, French, S, Nykamp, S, Ringwood, PB: Partial scapu-
Figure 55-6. Supraglenoid tubercle fracture A. repaired with a lag lectomy for treatment of an articular fracture of the scapula in a cat.
screw B. or with Kirschner wires and a tension band C. Veterinary and Comparative Orthopaedics and Traumatology, 6:468-473,
2011.
18. Denny, HR: Pectoral Limb Fractures. In Canine Orthopedics. Edited
by W.G. Whittick, Philadelphia, Lea and Febiger, 1990.
876 Bones and Joints
Surgical Treatment of are described as thickened regions of the joint capsule and are not
grossly apparent from external evaluation (Figure 55-7). However,
Shoulder Luxation they are distinct structures when viewed arthroscopically. The
medial glenohumeral ligament is “Y” shaped with a cranial and
Kent Talcott caudal component while the lateral glenohumeral ligament is a
wide solitary band that tapers near its insertion. Luxation is not
Introduction possible without disruption of the joint capsule and its associated
glenohumeral ligament. The four “cuff tendons” provide dynamic
Scapulohumeral luxation is an uncommon problem in the dog
support with minimal contribution during static conditions. The
and rarely occurs in the cat. Luxation is typically the result of
“cuff tendons” include the supraspinatus cranially, subscapular
traumatic injury or congenital glenoid abnormality. Lateral
medially, infraspinatus laterally, and teres minor caudolaterally.
luxation most commonly occurs in large breed dogs with
Collectively, soft tissue structures are important restraints to joint
historical trauma. Medial luxation typically occurs in small dogs
motion and contribute to joint stability. Identifying injury to such
with congenital capsular laxity or glenoid dysplasia. Cranial and
structures is important when selecting methods of stabilization.
caudal luxations are documented but occur less frequently than
lateral or medial luxation.
A craniomedial approach is most often used for surgical
treatment of medial and lateral luxation while a craniolateral
Anatomical Considerations and approach is performed for cranial luxation. The following crani-
omedial approach provides general access to the shoulder.
Surgical Approach Once the shoulder is approached, further dissection varies
It is important to establish a thorough knowledge of anatomy dependent upon technique and is further described within
and understanding of anatomical function prior to performing the relevant section of this chapter. With the patient in dorsal
surgical correction for scapulohumeral luxation. Errors in recumbency, a parahumeral incision originating from the medial
surgical technique are not well tolerated and may contribute to or cranial aspect of the scapular neck is extended distally to
persistent lameness or disability. The following is a brief review the medial aspect of the humeral mid-diaphysis. Subcutaneous
of anatomy and surgical approach. A more detailed review of fat is incised exposing the brachiocephalicus muscle. A fascial
this information is highly recommended for individuals with incision is created the entire length of the lateral border of the
limited experience in shoulder surgery. brachiocephalicus muscle which requires ligation and division
of the omobrachial vein. The brachiocephalicus is elevated
Scapulohumeral stability is the combination of articular stability and retracted caudomedially while the humerus is externally
and soft tissue restraints. The primary soft tissue restraints rotated. The insertion of the superficial pectoral is incised from
include the joint capsule and its associated glenohumeral the humerus along its proximal border to the omobrachial vein.
ligaments, and “rotator cuff” tendons. Glenohumeral ligaments
A B
Figure 55-7. Medial view illustrating both bands of the medial glenohumeral ligament A. The lateral glenohumeral ligament is a solitary band of
connective tissue within the joint capsule B. (From Talcott KW, Vasseur PB: Luxation of the Scapulohumeral joint. In Slatter D (ed): Textbook of
Small Animal Surgery, 3rd ed. Saunders, Philadelphia, 2003, p 1898.).
Scapula and Shoulder Joint 877
Similarly, the deep pectoral muscle is freed from its insertion but humeral luxation requires tearing of the lateral aspect of the joint
requires separation from the overlapping supraspinatus muscle capsule, its associated glenohumeral ligament, and infraspi-
proximally. Both pectoral muscles are retracted medially and the natus tendon.
supraspinatus caudolaterally.
Diagnosis
Lateral Scapulohumeral Luxation Patients present with the forelimb held in flexion and concurrent
Lateral luxation commonly presents in large breed dogs with internal rotation of the foot. The greater tubercle is prominent
historical trauma. The mechanism is not well defined but is and displaced laterally. Joint manipulation is painful with overt
presumably caused by extreme adduction of the limb. Lateral crepitus. A neurologic examination is indicated to identify
Supraspinatus
Osteotomy
Subscapularis
Incision into
transverse
humeral
ligament
A B
Lateral transposition Osteotomy secured with tension
of biceps brachii band apparatus or bone screw
C D
Figure 55-8. Craniomedial approach to the shoulder. The pectoral muscles are retracted ventrally and the supraspinatus proximally. The trans-
verse humeral ligament is incised to free the biceps tendon A. Osteotomy is required to free the supraspinatus muscle B. The biceps brachii
tendon is transferred laterally over the cut surface of the greater tubercle C. The greater tubercle is stabilized with a pin and tension band ap-
paratus, maintaining the biceps brachii in a lateral position D. (From Talcott KW, Vasseur PB: Luxation of the Scapulohumeral joint. In Slatter D (ed):
Textbook of Small Animal Surgery, 3rd ed. Saunders, Philadelphia, 2003, p 1899).
878 Bones and Joints
concurrent brachial plexus injury. Survey radiographs are biceps tendon is at risk for midsubstance tearing in the future. In
performed to confirm the diagnosis and identify concurrent spite of such adverse effects, the technique is still recommended
fractures or glenoid rim erosion. Stress radiography may be as excellent clinical function is the most commonly reported
useful to identify dynamic luxation or subluxation. outcome. This technique is less successful in patients with
chronic luxation or glenoid dysplasia; in which case arthrodesis
Treatment or glenoid excisional arthroplasty should be considered.
Closed reduction and splintage is considered in patients with
acute injury and mild to moderate joint instability. Under general Medial Scapulohumeral Luxation
anesthesia the limb is extended and medial pressure is applied Medial luxation is more common than lateral and is reported in
to the humeral head while counter pressure is applied to the small and large breed dogs. Medial luxation in large breed dogs
scapular neck. Range of motion and joint stability are assessed is typically associated with trauma while congenital luxation is
after reduction and either a spica splint or non-weight bearing more common in small breed dogs. Congenital luxation may be
carpal sling is maintained for 10 to 14 days. A Velpeau sling is bilateral and is associated with developmental laxity or glenoid
contraindicated for lateral luxation as it applies lateral translation dysplasia which is difficult and potentially impossible to correct.
to the humeral head. Results of nonsurgical treatment for lateral
luxation are variable and are contingent upon the magnitude of
soft tissue disruption, success of splintage, and patient/owner
Diagnosis
compliance regarding activity restriction. Surgical stabilization The historical presentation and physical examination findings
should be considered when reluxation is easily elicited. vary depending upon the etiology for luxation. Traumatically
induced medial luxation presents with an acute persistent
Surgical intervention is performed for patients with acute unstable lameness with the affected limb held in flexion with external
injury, concurrent fracture, or chronic luxation. Numerous rotation of the foot. Joint manipulation is typically painful during
procedures are described including prosthetic ligament recon- extension and medial displacement of the greater tubercle.
struction, biceps tendon transposition, transarticular pinning,
glenoid excisional arthroplasty, and arthrodesis. The method of In contrast, congenital luxation may present with intermittent to
repair is based upon etiology of luxation, concurrent fracture, continuous lameness and joint manipulation is often well tolerated.
or the ability to restore glenoid integrity if a fracture is present. Mild to moderately dysplastic luxations are often easily reduced
The advantages and disadvantages of each technique should be and reluxated. More severely dysplastic luxations are commonly
considered in relationship to patient signalment, health status, non-weightbearing, pain is variable, and joint reduction is difficult.
and patient compliance.
Radiographic evaluation of traumatically induced medial luxation
Lateral transposition of the biceps tendon is the most is scrutinized for concurrent glenoid fracture. Congenital luxation
documented technique in the literature and is the preferred is carefully evaluated for hypoplastic glenoid development and
method of repair when patient variables are appropriate (Figure erosion of the medial glenoid rim. Stress radiography should be
55-8). A craniomedial approach is used for biceps transpo- considered to document luxation in patients with intermittent
sition. Once the pectoral muscles are retracted medially and the lameness.
supraspinatus caudolaterally, the transverse humeral ligament
is incised and the biceps tendon is freed from regional fascial Treatment
and capsular tissue. The greater tubercle is osteotomized to Conservative management for medial luxation is contraindi-
allow lateral transfer of the biceps tendon over the cut surface cated when glenoid dysplasia is present. However, conservative
of the greater tubercle. The tubercle is reattached with a screw management is considered for traumatically induced medial
or pin and tension band apparatus. The joint capsule is closed luxation when reasonable joint stability is achieved following
with absorbable suture and the pectoral muscles are apposed closed reduction. Closed reduction is performed under general
to deltoid fascia. Remaining fascia, subcutaneous fat and skin anesthesia with the patient in lateral recumbency and the limb
are routinely closed. Seroma formation is common in this area in a neutral standing position. Traction and slight adduction are
and may be avoided with careful implant technique, tissue initiated while lateral pressure is applied to the proximal medial
apposition, and postoperative recovery. Strict activity restriction humerus and counter pressure is applied to the scapular neck.
and confinement are required for 2 to 3 weeks. Passive range A Velpeau sling is ideal stabilization for medial luxation as it
of motion may be performed in the initial recovery period. Short eliminates weightbearing and compresses the humeral head
controlled leash walks begin 2 weeks postoperatively followed by laterally. The Velpeau sling is maintained for 2 weeks followed
a gradual return to full function over an additional 6 to 12 weeks. by careful gradual return to function over 4 to 8 weeks.
Prognosis and Complications Surgical techniques reported for medial luxation include
Normal return to function and full range of motion has been prosthetic collateral suture, supraspinatus transposition, trans-
reported with long-term evaluation of this technique. Mild articular pinning, medial biceps transposition, arthrodesis,
distortion of joint congruity is common at the time of repair but excisional arthroplasty, and amputation. Choosing a method of
resolves as weightbearing forces cause stretching and relaxation repair is based upon glenoid conformation, concurrent injury,
of the tendon. Progression of osteoarthrosis is expected and the patient size and chronicity of luxation.
Scapula and Shoulder Joint 879
In patients with acute traumatic luxation without glenoid dysplasia; to the mid-diaphysis of the humerus. Subcutaneous fat and fascia
medial transposition of the biceps tendon is the preferred are dissected and the deep brachial fascia is incised from the
technique (Figure 55-9). A craniomedial approach is performed cranial aspect of the acromion process extending distally along
and once the pectoral muscles are reflected, the leg is exter- the cranial border of the acromial part of the deltoid muscle. The
nally rotated to access the subscapularis muscle. The insertion deltoid is retracted caudally allowing transaction of the infraspi-
of the subscapularis is incised allowing caudal retraction of the natus tendon which is reflected dorsally. The joint capsule is
subscapularis and coracobrachialis while the biceps tendon is incised transversely and intra-articular structures are inspected.
freed by incising the transverse humeral ligament and regional The joint capsule is closed and a hole is drilled from lateral to
capsular attachments. At the lesser tubercle, a craniodorsal medial through the center of the humeral neck. A similar hole is
hinged flap of bone is created with a crescent-shaped osteotomy. drilled in the center of the scapular neck paying careful attention
Cancellous bone is removed beneath the flap to accommodate to protect the suprascapular nerve. Suture is passed from lateral
transposition of the biceps tendon. Once the luxation is reduced, to medial through the scapular bone tunnel and medial to lateral
the biceps tendon is transferred and secured into the preformed in the humeral tunnel (Figure 55-10). External rotation of the limb
groove by reattaching the bone flap with Kirschner wires. Medial and retraction of the brachiocephalic and pectoral muscles
capsular imbrication is performed with absorbable suture and the medially is required to expose the medial aspects of the humerus
subscapularis is advanced and attached to the insertion of the and scapular neck for suture advancement. The joint is reduced,
deep pectoral muscle. The pectoral muscles are secured to the suture is tied in moderate tension, and joint mobility and stability
deltoid and deep brachial fascia. The brachiocephalic muscle is are assessed. This technique reported using double strands of 0
sutured to brachial fascia. The remaining fascial, subcutaneous or number 1 monofilament polybutester for its elastic properties.
and skin layers are closed separately. The repair is supported The infraspinatus tendon is reattached and routine closure is
with a Velpeau sling for 7 to 10 days followed by gradual return to performed. The repair is supported with a Velpeau sling for 14
function over 4 weeks. to 21 days followed by 4 weeks of passive range of motion and
gradual rehabilitation.
An alternative to biceps transposition is prosthetic collateral
repair. It is less time consuming, less invasive, and simpler to If the biceps tendon is damaged or if previous repair is unsuc-
perform. The technique is not appropriate for large dogs but cessful, partial supraspinatus transposition may be considered
should be considered for acute traumatic luxation in small dogs (Figure 55-11). The approach is identical to the biceps transpo-
without glenoid dysplasia. The technique is performed using a sition technique, however, the biceps tendon and transverse
standard craniolateral approach with tenotomy of the infraspi- humeral ligament are repaired and medial capsular imbrication
natus tendon. A curved incision starts at the distal third of the
scapular spine extending distally across the joint craniolaterally
Subscapularis
muscle incised
Incision dividing
supraspinatus
Partial
osteotomy
A B
Figure 55-11. A portion of the supraspinatus muscle is mobilized by performing a partial osteotomy of the greater tubercle. A recipient site is cre-
ated medially by removing cortical bone to facilitate bone union A. The bone fragment is secured to the recipient site with pins and tension band
B. (From Talcott KW, Vasseur PB: Luxation of the Scapulohumeral joint. In Slatter D (ed): Textbook of Small Animal Surgery, 3rd ed. Saunders,
Philadelphia, 2003, p 1901).
is performed. The greater tubercle is osteotomized such that the Amputation is reserved as a salvage procedure for patients with
superficial one-half of the supraspinatus tendon is released. The multiple failed surgical correction, severe glenoid dysplasia,
insertion of the subscapularis muscle is incised and a recipient or severe degenerative joint disease. Amputation may not be
site of exposed cancellous bone is created at the lesser tubercle appropriate for giant breed dogs. Candidates for amputation
with a burr, rasp, or osteotome. The supraspinatus is divided should be carefully assessed for congenital or traumatic contra-
only to the extent that the oseotomized tubercle may reach the lateral limb abnormalities.
recipient site with moderate tension. Recurrence of luxation is
contingent upon proper tension in the transferred component Prognosis and Complications
of the supraspinatus tendon. The transferred tubercle is stabi-
lized with multiple Kirschner pins or pin and tension band. The Prognosis after medial biceps transposition is variable. The
subscapularis is advanced to the pectoral insertion and pectoral majority of dogs are expected to achieve satisfactory limb
muscles are attached as far cranial as possible to augment function; however, intermittent to persistent lameness occurs
medial support of the shoulder. Remaining layers are closed is approximately 50% of cases. Similar to lateral biceps tendon
separately. A Velpeau sling is maintained for 7 to 10 days followed transfer, transient joint incongruity, osteoarthrosis, and midsub-
by gradual return to function. stance biceps tendon tearing have been reported for medial
transfer of the biceps tendon. In general, experience with this
Arthrodesis is indicated for patients following failed attempts at technique is favorable.
surgical repair or in patients with significant glenoid dysplasia
or degenerative joint disease. Standard principles of arthrodesis Full return of limb function was reported in dogs 2 to 3 months
apply to the shoulder. In small dogs, a single screw through the following collateral prosthetic ligament reconstruction with
scapular neck and into the humerus combined with a spica splint polybutester suture. This is the authors preferred technique
may be adequate for stabilization. Large dogs typically require provided case selection is limited to small dogs without preex-
bone plate application along the scapular spine and proximal isting joint abnormalities. There are no reports of this technique
humerus. More detailed information is covered in the arthro- in cats, however; intuitively, this technique may provide similar
desis section of this chapter. favorable results.
Excisional glenoid arthroplasty has been described as an alter- Prognosis of partial supraspinatus tendon transfer is limited to
native to arthrodesis. Excisional arthroplasty may achieve a single case report describing normal function and full range
pain-free movement with limited compromise of limb length of motion 2 months following surgery. Adverse effects of joint
and joint motion. More detailed information is covered in the incongruity and tendon tearing are less apt to occur but further
excisional glenoid arthroplasty section of this chapter. study has not been performed.
Scapula and Shoulder Joint 881
Reports of shoulder arthrodesis are generally favorable due Prognosis is difficult to predict as no long-term studies have
to mobility of the scapula. Best results are seen in small dogs, evaluated cranial or caudal luxation repair. Limb function is
whereas, large dogs have a varied outcome and more apparent presumed to be satisfactory but further study is needed.
gait abnormality.
Introduction
Treatment of osteochondritis dissecans (OCD) of the shoulder
joint involves removal of all loose and damaged fragments of
cartilage and bone from all aspects of the joint. OCD lesions
in the shoulder almost always occur on the caudal aspect of
the humeral head. Loose fragments of cartilage can migrate
into the caudal cul-de-sac of the joint and/or into the cranial
bicipital tendon sheath. There is no effective surgical approach
to both areas, so dealing with each area requires two separate
approaches. Consequently, I usually recommend doing an
arthrogram prior to surgery to determine whether or not the
bicipital tendon sheath needs to be explored. Arthroscopy can
also be used.
Figure 55-13. The skin incision is made from the midpoint of the scapu-
Surgical management of OCD of the caudal humeral head lar spine to the midpoint of the humerus. (From Gahring, DR. A modified
involves removal of all loose cartilage with a sharp curette so caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc.
that no cartilage remains elevated and unattached to underlying 1985:21:613).
bone. The removal and curettage of damaged bone and cartilage
will decrease pain and inflammation resulting from irritation
and impingement of the joint capsule and other joint elements.
Exposed subchondral bone is curetted to bleeding surfaces so
that the resultant defect can be resurfaced with new fibrocar-
tilage. If any cartilage is left unattached to subchondral bone,
it may fragment and produce loose bodies in the joint. Loose
cartilage is unlikely to re-attach to the underlying bone.
Surgical Technique
The patient is placed in lateral recumbency with the affected leg in
an upward position and hung so it can be completely draped and
be free for extensive manipulation during surgery. The location
of the skin incision is identified by connecting the midpoint of the
scapular spine with the midpoint of the humerus (Figure 55-13).
The skin, subcutaneous tissue, and superficial fascia are retracted
to expose a whitish linear fascial raphe between the spinous (or
scapular) head of the deltoid muscle and the long head of the
triceps muscles (Figures 55-14 and 55-15). This fibrous raphe is Figure 55-14. The landmark to look for is the fascial raphe between
incised either bluntly or sharply. Blunt dissection between these the spinous (or scapular) head of the deltoid and the long head of the
two muscles is continued until the caudal shoulder joint capsule triceps muscles: A, spine of scapula; B, infraspinatus muscle; C, teres
is identified (Figures 55-16 and 55-17). It is easier to start the blunt major muscle; D, spinous (or scapular) head of the deltoid muscle; E,
separation digitally between the spinous (scapular) head of the long head of the triceps muscle; F, lateral head of the triceps muscle;
deltoid muscle and the long head of the triceps muscle slightly G, acromial head of the triceps muscle; H, greater tubercle of the
above the level of the caudal shoulder joint and proceed in a humerus; I, supraspinatus muscle. (From Gahring, DR. A modified
caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc.
cranioventral direction than to begin the blunt dissection from
1985:21:613).
Scapula and Shoulder Joint 883
Figure 55-15. Using the landmarks in Figure 55-13, the fascial raphe
between the spinous (or scapular) head of the deltoid and the long
head of the triceps muscles (A) should be immediately beneath the
skin and subcutaneous tissue incision. The large arrow depicts retrac-
tion of subcutaneous areolar tissue. (From Gahring, DR. A modified
caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc.
1985:21:613).
Figure 55-19. The caudal shoulder joint capsule exposed by the muscle
Figure 55-17. Digital blunt dissection between the spinous (or scapular) separation described in Figures 55-14 and 55-17 lies caudoventrally
head of the deltoid and long head of the triceps muscles is carried out to the teres minor muscle belly (A). (B) coracobrachialis muscle; (C)
to the caudal shoulder joint capsule. (From Gahring, DR. A modified brachialis muscle; (D) tendon of insertion of the infraspinatus muscle.
caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc. (From Gahring, DR. A modified caudal approach to the canine shoulder
1985:21:613). joint. J Am Anim Hosp Assoc. 1985:21:613).
884 Bones and Joints
Figure 55-21. The axillary nerve (A) exposed in this approach to the
shoulder joint runs horizontally across the ventral border of the
caudal shoulder joint capsule. (B) greater tubercle of the humerus;
(C) suprascapular artery and nerve. (From Gahring, DR. A modified
caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc.
1985:21:613).
Scapula and Shoulder Joint 885
Figure 55-22. The axillary nerve (A) is retracted with a soft rubber
seton. (From Gahring, DR. A modified caudal approach to the canine
shoulder joint. J Am Anim Hosp Assoc. 1985:21:613). Figure 55-24. Joint capsular incision exposes the caudal glenoid (A),
the caudal humeral head (B), and the caudal joint capsule cul-de-sac
(C). (From Gahring, DR. A modified caudal approach to the canine
shoulder joint. J Am Anim Hosp Assoc. 1985:21:613).
Figure 55-23. The caudal shoulder joint capsule (A) is incised longitu- Figure 55-25. Improved exposure for joint inspection is allowed by us-
dinally parallel to, and between, the axillary nerve (B) ventrally, and ing a self-retaining retractor (A) to retract the incised edges of the joint
the teres minor muscle dorsally (C). (From Gahring, DR. A modified capsule. (From Gahring, DR. A modified caudal approach to the canine
caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc. shoulder joint. J Am Anim Hosp Assoc. 1985:21:613).
1985:21:613).
886 Bones and Joints
Suggested Readings
Gahring, DR: A modified caudal approach to the canine shoulder joint. J
Am Anim Hosp Assoc 21:613, 1985.
Gahring, DR: Surgical Treatment of Osteochondritis Dissecans of the
Shoulder. In: Bojrab, MJ, ed.: Current Techniques in Small Animal
Surgery, 4th Ed. Baltimore: Williams & Wilkins 1998, p 1069.
Figure 55-28. An absorbable mattress suture is placed to close the
caudal shoulder joint capsular incision. (From Gahring, DR. A modified
caudal approach to the canine shoulder joint. J Am Anim Hosp Assoc.
1985:21:613).
Scapula and Shoulder Joint 887
Background
Injury or insult to the biceps tendon has been reported as a
frequent cause of forelimb lameness in dogs that typically requires
treatment.1-9 Reported pathologic conditions of the biceps tendon A
include tenosynovitis, partial or complete rupture, avulsion,
tendinitis, tendinosis, displacement, and bipartite tendon. The
pathology, epidemiology, and diagnostics associated with these
conditions have been described.1-9 Biceps tendon injuries occur
most commonly in middle-aged medium and large breed dogs that
participate in athletic activities. There is no documented gender
predisposition to the author’s knowledge. Apart from rupture
or avulsion, dogs with biceps tendon pathology are presented
for a unilateral forelimb lameness of insidious onset. Dogs are
typically weightbearing on the affected limb. Rupture or avulsion
may result in a lameness that is acute and more severe.
Diagnostics
B
Physical examination findings in dogs with biceps tendon
pathology are very similar regardless of the specific cause. The Figure 55-31. “Skyline” radiographic views showing osteophytosis and
most consistent findings include mild to moderate atrophy of the enthesiophytosis associated with the biceps groove A. and tendon B.
affected spinatus muscles, pain on shoulder flexion (especially
with the elbow extended), and pain on direct palpation of the
biceps tendon and/or manual tensioning of the biceps muscle.1-6,23
B
Figure 55-33. Arthroscopic views of a normal biceps tendon A. a biceps
tendon with severe partial tearing B. and a biceps tendon with teno-
synovitis and partial avulsion.
Prognosis
For arthroscopic biceps tenotomy for treatment of bicipital
tenosynovitis, good to excellent results were obtained in all
five dogs in one series based on subjective measures over a 6
month follow-up period.4 In another series of cases, excellent
outcomes were reported for 22 of 25 shoulders assessed of a
mean of 26 months postoperatively.20
Figure 55-39. Illustration showing the method of fixation of the biceps Open tenodesis has been associated with good and excellent
tendon when using the screw and tissue washer method for ar- outcomes in more than 90% of dogs treated.3,8 In the single
throscopic biceps tenodesis (reprinted from Cook JL, et al. J Am Anim
published report on arthroscopic tenodesis, all 6 dogs treated
Hosp Assoc 2005; 41:121-127 with permission).
were judged to have good or excellent outcomes according to
the owners.5 Owners reported that full return to function was
through the tendon at the level of the suture. The drill bit is then
typically evident by 12 to 18 weeks after surgery. Follow-up times
inserted over the wire and the hole is drilled. The cannulated
range from 5 months to 18 months (mean = 11.7 months, median
screw with washer is then driven through the tendon into the
= 12.5 months). Return of spinatus and brachial muscle mass
hole and tightened until the washer firmly engages the tendon
symmetry and resolution of lameness were evident in all cases
and contacts the underlying bone. Again, the elbow should be
based on subjective evaluation by the surgeon.
held in extension during final screw insertion. The skin incisions
are closed routinely and postoperative radiographs are taken.
The published literature regarding surgical treatment of biceps
tendon pathology suggests that weight management and
Postoperative Care physical rehabilitation are critical for a successful outcome
For open tenodesis cases, home care instructions included 10 to when treating biceps tendon problems using any modality.1-5,8 In
15 minute walks 3 to 4 times a day, and ice packing the surgery addition, maximal function may not be reached until 6 months
site for 5 to 10 minutes twice daily. Jumping, running, or off leash following surgery in the majority of cases.
activity were prohibited for 2 weeks. The use of a Velpeau sling
for 10 days and restriction of exercise to on-leash activities for Summary
6 to 8 weeks following open tenodesis has been recommended.3
Both tenotomy and tenodesis are used in people for treatment
of biceps tendon pathology.12-18 Indications and recommen-
For arthroscopic tenodesis cases, clients are instructed to allow
dations for tenotomy versus tenodesis vary among types of
short leash walks only, and to restrict the dog to a cage, crate,
pathology; patient age; activity level and expectations; and
or kennel when unobserved. These restrictions apply to the first
surgeons’ preferences.12-18 Good and excellent results have been
6 weeks after surgery. If the dog can bear weight on the operated
reported for both tenodesis and tenotomy in people, and many
limb with no evidence of pain or displacement of the biceps muscle,
surgeons recommend achieving competence in both techniques
and no evidence of implant failure is present at the 6 week recheck,
to provide comprehensive treatment options and patient care.14-18
a progressive return to full activity is encouraged over the subse-
Tenotomy has been reported to provide similar outcomes in terms
quent 6 weeks. Range-of-motion exercises and non-concussive
of cosmetic appearance, anterior shoulder pain, and degree of
activities such as swimming and leash walking are encouraged
muscle spasms in humans with chronic bicipital pain.14 However,
during the second 6 week period. Full, unrestricted activity is
to the authors’ knowledge, no studies have compared functional
allowed after 12 weeks of rehabilitation. Additional restrictions
outcomes of arthroscopic biceps tenotomy versus tenodesis
and rehabilitation modalities are tailored to each individual case.4,25
in terms of limb strength and activity levels in the human or
veterinary literature. Tenodesis is typically recommended over
Complications tenotomy in athletic people, especially those who participate
If osteoarthritis is present in the affected joint at the time of in overhead athletic activities.16-18 Similarly, athletic dogs may
surgery, progression is likely regardless of the surgical technique benefit from tenodesis when compared to tenotomy. In addition,
employed. For arthroscopic tenotomy cases, reported complica- since dogs have the added function of weight bearing in the
tions include progression of radiographic pathology, continued forelimb, tenodesis might be advantageous for dogs. This consid-
pain and lameness and/or recurrence of pain and lameness.4,20 eration was supported by the excellent long-term results of
Other complications that have been associated with open or open biceps tenodesis reported by Stobie, et al.3 The theoretical
arthroscopic tenotomy include seroma formation, change in advantages of tenodesis may be further optimized by employing
appearance of the brachial musculature, and infection. an all-arthroscopic technique in order to minimize soft tissue
Scapula and Shoulder Joint 891
disruption and the associated pain, morbidity, complications, 19. Agnello KA, Puchalski SM, Wisner ER, Schulz KS Kapatkin AS. Effect
and recovery time. While arthroscopic tenodesis is technically of positioning, scan plane, and arthrography on visibility of periarticular
demanding, repetition and experience allow for more efficient canine shoulder soft tissue structures on magnetic resonance images.
and precise implementation of the procedure. The technical Vet Radiol Ultrasound. 2008 Nov – Dec; 49(6): 529 -539.
demands, surgical time, and costs associated with arthroscopic 20. Bergenhuyzen AL, Vermote KA, van Bree H, Van Ryssen B. Long-term
tenodesis far exceed those for tenotomy. However, the indica- follow-up after arthroscopic tenotomy for partial rupture of the biceps
brachii tendon. Vet Comp Orthop Traumatol. 2010; 23(1): 51 – 5.
tions, as well as the long-term outcomes, of arthroscopic biceps
tenotomy versus tenodesis have not been determined in dogs. 21. Cogar SM, Cook CR, Curry SL, Grandis A, Cook JL. Prospective evalu-
Therefore, it is important to explore the feasibility and results ation of techniques for differentiating shoulder pathology as a source of
forelimb lameness in medium and large breed dogs. Vet Surg. 2008 Feb;
of both techniques until definitive conclusions regarding their
37(2): 132 – 141.
efficacy can be drawn from scientific data. Long-term studies are
22. Cook JL, Cook CR. Bilateral shoulder and elbow arthroscopy in dogs
needed to determine the effects of arthroscopic tenotomy versus
with forelimb lameness: diagnostic findings and treatement outcomes.
tenodesis on muscle, elbow, and limb function before definitive Vet Surg. 2009 Feb; 38(2): 224 – 232.
recommendations regarding indications, complications, and
23. Devitt CM, Neely MR, Vanvetchten BJ. Relationship of physical
prognosis can be made.
examination test of shoulder instability to arthroscopic findings in dogs.
Vet Surg. 2007 Oct; 36(7): 661 – 668.
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the biceps-brachialis complex to the medial coronoid process of the
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2. Bardet JF. Lesions of the biceps tendon – diagnosis and classification.
25. Marcellin-Little DJ, Levine D, Canapp SO Jr. The canine shoulder:
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26. Murphy SE, Ballegeer EA, Forres LI, Schaefer SL. Magnetic
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5:51, 1992.
8. Lincoln JD, Potter K: Tenosynovitis of the biceps brachii tendon in
dogs. J Am Anim Hosp Assoc 20: 385, 1984. Excision Arthroplasty of the
9. Davidson EB, Griffey SM, Vasseur PB, et al: Histopathologic, radio-
graphic and arthrographic comparison of the biceps tendon in normal
Shoulder Joint
dogs and dogs with biceps tenosynovitis. J Am Anim Hosp Assoc 36 Donald L. Piermattei and Charles E. Blass
– 522, 2000.
10. Beale BS, Hulse DA, Schulz KS, Whitney WO: Small Animal
arthroscopy. Philadelphia: Saunders, 2003. Introduction
11. Piermattei DL: An Atlas of Surgical Approaches to the Bones and Excision arthroplasty of the glenoid rim and humeral head
Joints of the Dog and Cat. Philadelphia: Saunders, 1993. provides a pseudoarthrosis based on fibrous tissue. It is
12. Kleps S, Hazrati Y, Flatow E: Arthroscopic biceps tenodesis. an alternative to arthrodesis or amputation in conditions in
Arthroscopy 18: 1040, 2002. which the shoulder joint cannot be adequately reconstructed.
13. Boileau P, Krishnan SG, Costa JS, et al: Arthroscopic diceps Indications for excision arthroplasty include chronic shoulder
tenodesis: A new technique using bioabsorbable interference screw luxations in which the labrum of the glenoid cavity is exces-
fixation. Artrhsocopy 18: 1002, 2002. sively worn, severe degenerative joint disease, and irreparable
14. Osbahr DC, Diamond AB, Speer KP: The cosmetic appearance of the intra-articular fractures, of which gunshot wounds are the most
biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy common example. The traditional method of treatment in these
18:483, 2002. animals has been arthrodesis, which is technically demanding
15. Gill TJ, McIrvin E, Mair SD, et al. Results of biceps tenotomy for and requires bone-plating equipment in most cases.
treatment of pathology of the long head of the biceps brachii. J Shoulder
Elbow Surg 2001; 10: 247 – 249. While encouraging results have been obtained with this
16. Berlemann U, Bayley I. Tendonitis of the long head of biceps brachii procedure, it has only been performed in a small number of
in the painful shoulder: improving results in the long term. J Shoulder patients. We recommend this procedure only as a salvage
Elbow Surg 1995; 4: 429 – 435. procedure with a fair to good prognosis for pain free normal,
17. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the nonathletic function. As in the case of excision arthroplasty of
biceps tendon. J Shoulder Elbow Surg 1999; 8: 644 – 654. the hip, more normal function can be anticipated in small breeds
18. Patton WC, McCluskey GM. Biceps tendinitis and subluxation. Clin of dogs than in large breeds. The technique has been performed
Sports Med 2001; 20: 505 -529.
892 Bones and Joints
Surgical Technique
The shoulder joint is exposed by a craniolateral approach with
osteotomy of the acromion process. The tendons of insertion
of the infraspinatus and teres minor muscles are transected
and retracted caudally with stay sutures. The joint capsule is
cut close to the glenoid rim and opened widely, and the tendon
of origin of the biceps brachii muscle is transected near the
supraglenoid tubercle (Figure 55-40). Ostectomies of the glenoid
rim and humeral head (Figure 55-41) are made with and sharp
osteotome, oscillating saw, or high-speed rotating burr. Care is
taken to protect the suprascapular nerve and caudal circumflex
humeral artery during the ostectomies. If the suprascapular
nerve passes too closely to the ostectomy site, a notch may
be cut in the base of the scapular spine to allow proximal
displacement of the nerve. An alternative to ostectomy of the
glenoid rim is removal of the articular cartilage of the glenoid to Figure 55-41. Location of ostectomies in the glenoid rim andhumeral
expose subchondral bone, thus opening vascular channels. This head. A small notch may be cut in the base of the scapular spine to
allow the suprascapular nerve to be positioned more proximally ig it
also obviates the necessity to detach the biceps tendon.
courses too near the ostectomy site(From Piermattei DL, Flo GL, DeCamp
CE: Brinker, Piermattei, and Flo’s Handbook of Small Animal Orthopedics
If the tendon of the biceps brachii was detached, it is reattached and Fracture Repair, 4th ed. Philadelphia. W. B. Saunders, 2006).
to the fascia of the supraspinatus muscle. The teres minor
muscle is pulled between the cut surfaces of the scapula and
humerus and sutured to the biceps tendon and medial joint
capsule (Figure 55-42). The remaining jont capsule is pulled
into the ostectomy site and sutured to the teres minor muscle
and tendon. This interposition of soft tissues between the cut
surfaces of the scapula and humerus is thought to hasten the
formation of a fibrous false joint (pseudoarthrosis). The infraspi-
natus muscle is sutured to its insertion on the humerus. Finally,
the acromion process is reattached to the spine of the scapula. It
may be necessary to wire the acromion process more proximally
than normal to remove laxity in the deltoideus muscle. Subcuta-
neous tissues and skin are closed routinely.
Figure 55-42. After ostectomies are completed, the teres minor muscle
is pulled medially and sutured to the biceps tendon, which has previ-
ously been sutured to the fascia of the supraspinatus muscle. Joint
capsule from the humeral head is sutured to the teres minor (arrows).
The infraspinatus is reattached to its insertion, and the acromion
process is wired to the spine more proximally than normal. (From Pier-
mattei DL, Flo GL, DeCamp CE: Brinker, Piermattei, and Flo’s Handbook
of Small Animal Orthopedics and Fracture Repair, 4th ed. Philadelphia.
W. B. Saunders, 2006).
Thirteen cases have been reported in two small series (Breucker debilitating. But, when it is and conservative therapy is no longer
and Piermattei 1988, and Franczuski and Parkes 1988). Good to controlling the pain arthrodesis becomes an option.
excellent pain-free-function was obtained in each case. As
previously noted, resection of the glenoid rim and humeral
head must be considered a salvage procedure, and return to
Surgical Approach
normal function of the limb cannot be expected. Pain-free use The approach to the shoulder is simplified by both an osteotomy
of the leg is usually achieved, although a mild gait abnormality of the acromial process of the scapula, and the greater tubercle
and shoulder girdle muscle atrophy will be seen. Full recovery of the humerus. The acromion process can then be retracted
generally requires 3 to 6 months. distally with the deltoid muscle. Osteotomy of the greater
tubercle allows retraction of the supraspinatus muscle and also
provides a smooth bed for the plate. The suprascapular nerve
Suggested Readings should be isolated and protected where it crosses the neck
Breucker KA, Piermattei DL: Excision arthroplasty of the canine scapulo- of the scapula. The biceps tendon can be transected from the
humeral joint: Report of three cases. Vet Comp Orthop Trauma 3:134, 1988. supraglenoid tubercle if necessary (Figure 55-43).
Franczuski D, Parkes LJ: Glenoid excision as a treatment in chronic
shoulder disabilities: Surgical technique and clinical results. J Am Anim
Hosp Assoc 14:637, 1988.
Procedure
Piermattei DL, Flo GL, DeCamp CE: Brinker, Piermattei, and Flo’s The cartilage is removed from both articular surfaces and a pin or
Handbook of Small Animal Orthopedics and Fracture Repair, 4th ed. K-wire is used to hold the joint in the proper position. This position
Philadelphia. W. B. Saunders, 2006, p. 273. is about 105 degrees and can be measured from the standing
Piermattei DL, Johnson KA: An Atlas of Surgical Approaches to the angle of the controlateral shoulder joint. Two flat congruent
Bones and Joints of the Dog and Cat, 4th ed. Philadelphia. Saunders, surfaces can be formed with an oscillating saw or osteotome.
2004, p. 112. This will create a stable junction and also dictate the angle of
the arthrodesis, an important consideration when making these
cuts. Cancellous bone graft or substitute is placed between and
Shoulder Arthrodesis around the fresh surfaces. Plates provide good long term, stable
fixation and are the recommended implant. Compression should
Arnold S. Lesser be used whenever possible. The scapula is a very thin bone and
to get the best purchase for the screws the plate is placed along
Indications the cranial aspect of the spine and is twisted caudally to engage
Arthrodesis of the shoulder joint is not common but any condition the bone where the spine arises from the body. Distally the plate
resulting in intractable pain and dysfunction is an indication for is placed over the craniolateral aspect of the humerus. At least 4
arthrodesis. Malunion and highly comminuted articular fractures to 5 screws should be placed in the humerus and in the scapula.
can lead to severe DJD. Untreated OCD and chronic luxation of The longer the plate the more the stresses are distributed and
the shoulder especially medial luxation in miniature breeds is therefore not concentrated over the arthrodesis site. This is
another cause of DJD. It is unusual for the arthritis to be severely especially true of the scapular portion because of the thin bone
Figure 55-43. The approach to the shoulder joint is facilitated by osteotomy of the acromial process and greater tubercle. The suprascapular nerve
should be isolated and protected.
894 Bones and Joints
and poor screw purchase. Care must be taken where the plate
crosses the suprascapular nerve. The nerve can be placed
Suggested Readings
under or over the plate depending on which places the least Piermattei DL, Flo GL: Brinker, Piermattei, and Flo’s Handbook of Small
tension on the nerve itself. Part of the greater tubercle can be Animal Orthopedics and Fracture Repair 3rd Edition. W.B. Saunders.
Philadelphia. 1997.
used for graft and the remainder can be attached to the humeral
head. If the biceps tendon was transected it can be reattached Lesser: Arthrodesis. In Slatter: Textbook of Small Animal Surgery.
Saunders. Philadelphia. 2003.
to the humeral head with a screw and washer (Figure 55-44).
Shaft Fractures
Proximal Metaphysis
The proximal metaphysis of the humerus is broad and strong
relative to the rest of the bone. Proximal fractures may be
described as transverse, short or long oblique, spiral, segmental,
or comminuted. Fractures of this area are rare and usually result
from a gunshot injury, vehicle injury, or other direct force or
from a pathologic condition. Most cases occur in medium to
large breed dogs. When animals are presented with pathologic
fractures, nutritional, metabolic, or neoplastic causes should be
considered and managed appropriately.
and is passed toward the medial epicondyle and seated at that For oblique, segmental, and comminuted fractures of this area,
site. A smaller-diameter pin placed in similar fashion often exits open reduction is the preferred method of repair. A craniolateral
through the medial epicondyle in close proximity to the ulnar approach to the proximal shaft with subperiosteal elevation of
nerve. Stack-pinning with two or more smaller pins may be used to the deltoideus muscle is used to gain exposure. Several options
increase resistance to rotational forces. Application of an external are available for fixation, including single intramedullary pinning,
half- or full Kirschner splint in combination with intramedullary stack-pins, Rush pinning, pin and tension band wire, hemicer-
pinning may also be used to neutralize rotational forces. clage wire, half- or full Kirschner splint, and bone plating.
Open reduction is required if the fracture is of long duration or Intramedullary pinning combined with half- or full Kirschner
if soft tissue swelling is significant. Fixation can be achieved splinting usually provides good fixation for transverse fractures.
with two Rush pins placed as described for repair of a proximal Shear forces that occur with oblique fractures may be neutralized
Salter epiphyseal fracture (See Figure 56-2). Alternatively, pins by the addition of full-cerclage or hemicerclage wire, Kirschner
and tension band wire may be applied using appropriately sized pins, or interfragmentary screws. Secure placement of cerclage
Kirschner wires or Steinmann pins and orthopedic wire. With the wires is enhanced by creating grooves in the cortex or by placing
tension band technique, pins are placed parallel and penetrate transverse Kirschner pins to prevent the wires from migrating
the midpoint of the greater tubercle. The wire is positioned in distal on the shaft and becoming loose. The use of single cerclage
figure-of-eight fashion over the pins and is anchored in the distal wires is avoided because it may create a fulcrum effect.
fragment through a hole drilled in the bone (Figure 56-5).
In large to giant breed dogs, or in animals with segmental and
comminuted fractures of the proximal shaft, bone plating is the
preferred method of repair. Evaluation of preoperative radio-
graphs should ensure that sufficient bone is present to allow
placement of two and preferably three bone screws on either side
of the fracture site. Subperiosteal elevation of the insertion of the
deltoid muscle is performed to provide exposure for reduction of
the fracture, and the limb is held in external rotation to facilitate
application of the bone plate. The bone plate is conformed to the
cranial aspect of the proximal shaft and is applied to the bone.
Intramedullary Pin Fixation ensure a full range of crepitus-free motion after pin placement.
Closed Reduction and Pinning For closed intramedullary pinning of fractures at the junction of
Closed reduction may be possible in small breed dogs and cats the middle and distal third of the shaft, a smaller pin is selected
with recent transverse or short oblique midshaft to distal shaft to allow for placement into the medial epicondyle. The pin should
fractures; closed reduction may be possible if the fracture site be of sufficient size to fill the medial epicondyle, based on the
can be readily palpated. In medium to large breed dogs, closed preoperative craniocaudal radiograph. The pin is inserted at
reduction can be difficult because of the large muscle mass, the midpoint of the greater tubercle, is passed in normograde
soft tissue swelling, and fragment distraction. Open reduction is fashion down the medullary cavity, and is seated in the medial
usually required for repair of shaft fractures in these breeds of epicondyle. The pin is advanced until the tip is felt to penetrate
dogs. When closed reduction is possible, an intramedullary pin the distal surface of the medial epicondyle. To ensure that the pin
is placed by inserting the pin in normograde fashion from the does not penetrate the medial olecranon fossa, the joint should
midpoint of the greater tubercle into the shaft. An intramedullary be palpated repeatedly for crepitus and limited range of motion
pin is selected that fills 70 to 75% of the medullary cavity at the during pin placement. After insertion of an intramedullary pin for
fracture site. The size of the medullary cavity can be readily stabilizing either middle or distal diaphyseal fractures, persistent
estimated and used to select the pin size based on the preop- rotational instability can be controlled by closed application of a
erative craniocaudal radiograph. half-Kirschner splint.
The pin is passed down the medullary cavity to a point just distal Open Reduction and Pinning
to the fracture site. The fracture is reduced by toggling the distal Although closed reduction is possible, open reduction is
fragment onto the exposed pin. The pin is advanced to the distal preferred for repair of midshaft and distal shaft fractures in all
fragment and is seated at a point just proximal to the supratro- breeds of dogs and cats. The animal is placed in dorsal recum-
chlear foramen. Care is taken at this point to avoid penetrating bency to allow for a lateral or medial approach to the shaft.
the olecranon fossa (Figure 56-6). The joint should be palpated to Although the medial approach avoids muscle mass, it does
encounter extensive neurovascular structures; for this reason,
most fractures are handled by a lateral approach. The lateral
approach provides exposure of the proximal three-fourths of
the humeral shaft. The superficial cephalic vein and radial nerve
lying between the brachialis muscle and the lateral head of
the triceps brachii muscle should be identified and preserved.
Proximal exposure of the shaft, when necessary, can be obtained
by subperiosteal elevation of the deltoideus muscle. Distal
exposure can be gained by extending the incision to the lateral
epi-condyle and by dissecting the brachialis muscle to allow
cranial and caudal retraction of the muscle and radial nerve as a
unit. Gelpi retractors placed at either end of the wound facilitate
muscle retraction and surgical exposure.