Calling all Surgery Junkies
Have you ever considered performing prophylactic gastropexies? I hadn’t until I’d listened to Brad Case’s presentation. Brad provided data on the mortality rates of 10-33% for dogs who are considered to be at risk with lifetime risks of approximately 40% for Great Danes and 25% for Irish Setters for example. I didn’t realise that the risk of GDV increases fivefold if the dog has had a previous splenectomy. Should we start considering performing a gastropexy when neutering at risk breeds? It would be cost effective from the owners’ point of view. Brad provided some rough figures to highlight this point. A spay and gastropexy would cost in the region of $350-500 whereas the cost of GDV surgery is around $3000-4000. Brad explained that people have raised concerns regarding potential complications, however, Brad recommended the use of the incisional technique because it is simple and safer compared to other methods. I attended another one of Brad’s presentations titled, “Tight Sleep at Night Knots”. Brad discussed the merits of the strangle and Miller’s knots and demonstrated them using video footage. I was surprised that I was in the minority when Brad asked how many people use an Aberdeen knot when ending a continuous suture line for subcutaneous and intradermal closure. The Aberdeen knot was considered to be as strong as and less bulky than a four-throw square knot plus it makes burying the knot easier. The Aberdeen knot is my favourite, is it weird to have a favourite knot?!
As a perfectionist (I think most vets are, right?) the title of Sarah Marvel’s presentation was highly appealing, “Intestinal Surgery: Getting it right the first time”. Sarah advised that in order to increase the success rate of intestinal surgery, steps should be taken to minimise contamination, identify and remove non-viable tissue and the use of good surgical techniques. Minimising contamination can be achieved by perioperative antibiotics, isolating a loop of intestines with the use of stay sutures or a helpful assistant, milking intestinal content away from the area that you are working on and abdominal lavage with warm 0.9% sterile saline. Don’t forget to use new gloves and instruments for closure of the incision site to reduce the risk of incision site infections and abscesses. When determining the viability of intestinal tissue, the colour, peristatic wave, texture and pulse in jejunal artery should be taken into consideration. Sarah’s advice for improving intestinal surgical technique included using enough tension to provide an adequate seal but not too much tension which results in crushing the tissue, the use of monofilament suture material with a taper needle, starting and finishing your suture pattern beyond the incision and atraumatic tissue handling with the use of Debakey forceps.
Esteban Pujol and Manuel Jimenez Pelaez managed to inform delegates how they treat FLUTD in cats and salivary mucoceles respectively in just 15 minutes each. Esteban described his surgical approach to perineal urethrostomy for complete urethral obstructions, distal urethral ruptures, distal stenosis, multiple failed medical treatments or for revision of a previous surgical technique. The complications that can occur with this surgery are haemorrhage, stenosis, urine leakage (and associated skin necrosis), faecal/urinary incontinence from nerve damage, UTI (in about 35% of cases), rectal prolapse and/or perineal hernia. Esteban explained that he usually uses a transpelvic approach if the patient is also suffering from a pelvic fracture whilst the prepubic approach is used as a salvage procedure. Manuel started his presentation by stating that salivary mucoceles are an accumulation of saliva and are not a cyst. Personally, I’ve never thought of a mucocele as a cyst but perhaps others do. A diagnosis can be achieved by paracentesis and differentials include abscesses and neoplasia. Then Manuel shared one of his top secrets concerning resection of salivary mucoceles… know the anatomy! Common complications include seroma formation, infection and recurrence from incomplete removal.
To be honest I have never been drawn towards orthopaedic surgery but I am really pleased that I joined Daniel Lewis’ session on minimally invasive fracture repairs. Daniel compared the open reduction and reconstruction technique as carpentry whereas using minimally invasive methods he described as more of a gardeners’ procedure using ‘biological osteosyntesis’. With minimally invasive plate osteosynthesis (MIPO) a plate is introduced via small insertion incisions. I found this surgery very interesting! The advantages put forward by Daniel were:
- Reduced Operative Time
- Decreased iatrogenic soft tissue trauma
- Fracture haematoma is not removed during surgery and increases the rate of callus formation
Continuing on the orthopaedic theme, I joined Clara Goh for her presentation on medial patella luxation (MPL) during which, she shared her advice on case selection and surgical tips. Clara explained that MPL is more common across all species but when we are faced with lateral patella luxation, it is usually seen in larger breeds. When considering surgery for MPL, Clara suggested weighing up the frequency and severity of lameness; performance goals and grade of MPL. I often find the grading system a little tricky to apply (partially because I can be a little indecisive at times!) and often say that I think it’s a grade one/two or two/three. I took great comfort from Clara who also finds it tricky to apply a discrete grade to her patients. In terms of making surgical decisions, Clara provided the following recommendations:
- Grade one/two: Surgery only if clinically significant
- Grade two/three: Surgery recommended to reduce arthritis and avoid cranial cruciate disease
- Grade four: Severe bony changes and ligament deformities. May not be repairable if surgery is delayed.
Ross Palmer visited The Webinar Vet stand at London Vet Show and my colleague passed his card onto me so whilst I had the chance to see Ross in action, I took it! Ross was presenting on how to avoid trouble using IM pins and wire fixation. Some of the basic principles of pinning included: not using pin and wire fixation for non-reconstructable fractures; not using pin and wire fixation for fractures where slow bony union is not possible; select two pins of the same length, one to insert and the other can be used as a measuring pin; and when deliberating over the diameter of the pin go for the smaller one because it’s easier to replace it with a bigger one than the other way around. I’m actually chatting to Ross via email at the moment about providing a webinar for The Webinar Vet. The final presentation in this session was provided by Laura Peycke who discussed therapeutic exercise in rehabilitation. Laura started by outlining some the goals which include: improving muscle strength, stimulating cartilage metabolism, increasing blood flow and lymphatic drainage and increasing range of movement. Passive movements, for example, massage can decrease tension, increase blood circulation, increase endorphins, mobilise adhesions and further strengthen the human bond (my little Mildred likes a massage!). Active range of movement can be achieved by voluntary movements through performed activities, for example, improved flexion can be encouraged by swimming, walking and walking upstairs. For extension, stepping over obstacles and walking downstairs. Laura summarised her presentation by stating that a personalised and well-designed exercise programme can increase the recovery time, improve movement and therefore functional activity.
Part 3 of the blog will be available to read on the website tomorrow (08/03/2017)