Wendy Blount DVM Tricks of the Trade Reducing

Wendy Blount, DVM Tricks of the Trade Reducing Spay-Neuter Time

Marvin Mackie, DVM – Quick Spay James Wright, DVM, MPH, ACPVM SUPER HUMAN PUBLIC HEALTH GURU Dr. Sara White Dr. Bob Judd, ABVP BOD, ASV; Spay ASAP Inc. Judd Veterinary Clinic Dr. Karla Brestle Dr. Philip Bushby, ACVS Medical Director, Humane Alliance Mississippi State CVM Dr. Mark Bohling, ACVS Brenda Griffin, ACVIM University of Tennessee CVM University of Florida CVM

I Feel the Need for Speed! • Speed per se is not the desired goal • Efficiency is the goal and not the same as speed • Efficiency is elimination of all unnecessary tissue handling and any wasted motion • Experienced surgeons who are very fast are not necessarily rushing, they just make very few “false moves. ” • Less tissue handling means less trauma and less pain for the patient

Halsted’s Principles of Surgical Technique • Gentle tissue handling • Strict asepsis • Meticulous hemostasis • Elimination of dead space in the surgical wound

Terms Definitions • Suspensory ligament - suspends the ovary from the dorsal wall of the abdominal cavity, and continues in the broad ligament to suspend uterus • Broad ligament – peritoneum and fat lateral to uterine body • Proper ligament – tethers the ovary to the uterus, containing the uterine tube • Pedicle – usually refers to the ovarian or testicular vessels and vas deferens • Stump – usually refers to the uterine stump

Trouble Spots Rate Limiting Steps to Spay-Neuter • Finding the linea alba • Finding the uterus • Breaking down the suspensory ligament • Finding a dropped pedicle or stump • Waiting for light anesthesia to become surgical again • Waiting for the next patient

Finding the linea alba • Overweight – excess subcutaneous fat • Lactation (flank approach) • Cats – herringbone meeting of left and right rectus rather than linea alba

Finding the linea alba Cat Video (0: 06)

Finding the uterus • Visual – requires largest incision • Spay hook – smallest incision – More likely to cause trauma than your finger in the hands of an inexperienced surgeon – the spay hook has no sensory nerve endings • Finger sweep – big enough to get your finger with uterus out.

Finding the uterus • Full bladders, full colons and increased intra-abdominal fat are my greatest obstacles – Technicians gently express the bladder prior to prepping – Tech trained to “leave it” if to much pressure is required – It is possible to rupture the urinary bladder with manual expression – Sometimes excessive manual pressure is not perceived to be used – If manual expression can’t be done safely, intra-operative expression or even cystocentesis can help

Finding the uterus • Finding the uterus quickly not only minimizes surgery time, but also minimizes tissue handling trauma. • When I have to hunt for the uterus, I usually give an extra intra-operative pain injection IM. – Butorphanol, buprenorphine, morphine – NSAID on recovery

Finding the uterus • Spay hook sweep (0: 36)

Finding the uterus • Spay hook sweep Cat Video (0: 48)

Finding the uterus • Finger sweep (0: 11)

Finding the uterus • Finger sweep (0: 21)

Three Clamp Technique (2: 43)

Three Clamp Technique • Need big clamps for big dogs – I like Rochester-Carmalts. – We have only one in most spay packs, and open 2 more for big fat spays. We have 8 extra. • Need small clamps for cats and small dogs – Large clamps can tear small pedicles – 4 small clamps and 2 mosquitos in each pack • Good quality clamps prevent letting loose.

Three Clamp Technique • 1 click on the first clamp, 1 cm proximal to the ovary • 2 clicks on the second clamp half way between the first clamp and the ovary. – always place your thumb and forefinger around the ovary when you apply clamp 2 to avoid clamping or cutting the ovary. • 3 clicks on the third clamp on the proper ligament

Breaking down the suspensory ligament to get good exposure • avoid “catchage” – Slipped ligatures and pain – Check for catchage by running your finger around the ligature before you release it into the abdomen • plenty of “tissue tag” above and beyond your ligature to prevent a slipped ligature • Plenty of room to use the 3 clamp technique if you like it • Avoid disrupting the ovary when you sharply dissect the pedicle away

Breaking down the suspensory ligament to get good exposure • Sometimes stretching the ligament is fine for exposure • If the ovary does not retract back into the abdomen when you set it on the drape, your exposure is fine • Some break it down from cranially and some from the proper ligament window toward cranial – In either case, the artery is avoided

Breaking down the suspensory ligament to get good exposure (1: 03)

Breaking down the suspensory ligament to get good exposure - techniques • strum with the fingers • cut with blade or scissors • Combination – nick then strum • break down with hemostats

Breaking down the suspensory ligament (0: 37)

Breaking down the suspensory ligament (0: 16)

Breaking down the suspensory ligament Cat Video (0: 18) Pregnant Cat Video (0: 17) Kitten Video (0: 05)

Bertha the 100 lb Pit Bull IN HEAT

Bertha the 100 lb Pit Bull Challenges spaying overweight dogs • Incision Placement • Finding the linea • Finding the uterus • Grease control and getting ligatures tight when lots of fat is in the pedicle • Dealing with the broad ligament • Closing the linea (BCS 9/9)

Bertha the 100 lb Pit Bull Incision Placement • More important in large dogs because the reproductive tract is longer • Especially important in deep chested dogs where distance between incision and dorsal attachment of suspensory ligament is longest • 1 -2 cm caudal to the umbilicus • Extend back 3 -4 cm • Extend caudally as needed to exteriorize an enlarged uterus or the uterine body

Bertha the 100 lb Pit Bull Incision Extension • Bluntly with hemostats or dull edges of the scissors if <1 cm extension (cat video) • With blade and thumb forceps (next video) • Cutting with Mayo scissors, while elevating the ventrum

Bertha the Finding the linea (0: 27) 100 lb Pit Bull

Bertha the 100 lb Pit Bull Finding the uterus • In my hands, finger sweep works much better than spay hook for fat dogs. • Have to make incision that big to get the uterus out anyway • If all else fails, extend the incision caudally and exteriorize the bladder to expose the uterine body or stump found between the colon and bladder. • occasionally a uterine horn can seem to be trapped beneath a very full colon – look there if not found in the usual place.

Bertha the 100 lb Pit Bull Grease control • sterile huck towel in the pack to wipe grease off your gloves as needed • If it’s really bad and you can no longer grips the suture material without slipping, change your gloves for a fresh start • Use Miller’s Knot for fat dog pedicles & stumps – Fat cats don’t seem to carry much fat in their ovarian pedicles

Bertha the Miller’s Knot (0: 45) 100 lb Pit Bull

Bertha the 100 lb Pit Bull Miller’s Knot • 2 passes around the pedicle increases surface area of the ligature pressure • Reduces tendency of ligature to cut tissue • Particularly useful for large or edematous uteri • Elevating the suture ends as you tighten helps to tighten both loops equally Cat Video (1: 15)

Bertha the 100 lb Pit Bull 2 Clamp Technique for Fat/Enlarged Uterus • Do not clamp the uterus prior to ligation – To do so on an enlarged uterus risks transecting it with the clamp prior to ligation – It can retract under the pelvis • Better exposure by breaking down broad ligament • Place clamps after ligation • Preserve 1 cm tag of tissue on the uterine stump

Bertha the 100 lb Pit Bull 2 Clamp Technique for Fat/Enlarged Uterus (0: 45)

Bertha the 100 lb Pit Bull Should uterine arteries be ligated separately? • Almost all experts in HQHVSN say it’s not necessary • There is a post on the ASV listserve several times yearly about problems with not ligating separately – Massive bruising on the abdomen, usually a cat – 2 -3 days after OHE – Occasionally the hemorrhage is fatal the first night – The uterine artery slips caudally beneath the ligature and there is retroperitoneal bleeding which seeps out the inguinal ring into the SC tissues

Bertha the 100 lb Pit Bull Dealing with the broad ligament (0: 20)

Bertha the 100 lb Pit Bull Dealing with the broad ligament Self Tie of Cat Broad Ligament (0: 40) • Watch using a scalpel blade with no handle on it • Especially if you place your blade on the drape

Bertha the Dealing with the broad ligament 100 lb Pit Bull

Bertha the Dealing with the broad ligament 100 lb Pit Bull

Bertha the 100 lb Pit Bull Dealing with the broad ligament • Break down the broad ligament – Better access to the uterine arteries for ligation – Allows exteriorization of the uterine body (cat video) • Use Rochester-Carmalts to crush and tear broad ligament rather than breaking down manually – 3 clicks • Easier to tear the suspensory ligament with less tissue trauma • Ligate if needed – encircling or Miller’s. • Pedicle tie does not work well in my hands for fat dogs.

Bertha the 100 lb Pit Bull Closing the linea • Place one interrupted suture in the center with a surgeon’s knot to keep fat from erupting out every time Bertha breathes • This is probably more important when closing obese dogs with longer incisions – Dropped stumps or pedicles – Multiple adhesions – Exploratory to confirm spay

Bertha the 100 lb Pit Bull Closing the linea • Continuous or interrupted? ? – Apposition and seal better with continuous – Interrupted provides back-up for suture or knot failure – Cruciate rather than simple interrupted cuts knot number by half • Suture reaction is greatest at the knots • Knot tying takes a little more time

Bertha the 100 lb Pit Bull Closing the linea • Bites at least 5 -10 mm from edge of rectus • Suture ears at least 3 -4 mm • 4 -6 throws per knot • Avoid crushing tissue with the first two throws – Impedes healing – Causes animals to lick and chew at suture line

Bertha the Closing the linea (0: 54) 100 lb Pit Bull

Tips Tricks Ovarian Pedicle Ties • don’t work well on animals with lots of fat in the pedicle. • can often do a pedicle tie in even fat cats. • Leave 4 -5 mm tissue tag beyond the hemostat to establish clamp security Pedicle Tie Female Cat (0: 14) Pedicle Tie Pregnant Cat (0: 27) • Same techniques used for testicular pedicles in routine and cryptorchid castrations in cats and puppies

Dogs of Maturity Preventing scrotal hematoma • Meticulous hemostasis – Avoid branches of the caudal superficial epigastric a. • • • Disposable Jor. Vet handheld electrocautery Epineprine: Lidocaine Splash The socket is dry when I close, or I don’t close Ligation of SC vessels only when needed Reduced scrotal swelling from 2 in 100 to 2 in 1000

Dogs of Maturity Jor. Vet handheld electrocautery -runs on two AA batteries -2200 o cautery and three tips - $67. 00 -2200 o cautery - $36. 00 - 1100 o cautery - $29. 00 -replaceable tips -cautery lasts 4 -6 months

Dogs of Maturity Epi-Lido “Splash” • Mix 1: 9 epinephrine (1: 1000) and 2% Lidocaine • Getting the dilution backward can cause scrotal necrosis if used as a true splash • Apply 2 cc of the mixture to a sterile 4 x 4 • Place the 4 x 4 into the scrotal sac for 30 -60 seconds, and then remove • Mackie uses 100% epinephrine for this

Dogs of Epi-Lido “Splash” (1: 57) Maturity

Dogs of Maturity Open or closed? • I do most of mine closed – Strip the fascia away to have minimal connective tissue around the ligation – Run a hemostat along the cord • If open, I do the Mackie modified open technique – Ligate the spermatic cord and let it retract back in the tunic – Ligate the tunic and amputate most of it

Dogs of Open or closed? (3: 14) Maturity

Dogs of Maturity What to do with the pendulous scrotum? • A significant amount of contraction will occur with time • Not necessary to avoid scrotal swelling • We offer scrotal ablation in older dogs for cosmetic reasons for $20 extra

Tips Tricks Skin Sutures or Not? • Not necessary in most cases with intradermal closure • Elected in high energy female dogs likely to chew • Elected for very large incisions – Alternatively, can do several segments of continuous for very large incisions • Elected if significant skin pathology • Coming back for suture removal can be an issue for low cost clients • I almost never put skin sutures in a dog castration

Tips Tricks Burying the knot • If the knot protrudes through the incision, it will likely need to be removed with suture scissors • Tie the knot with suture ends parallel to the incision • Take a deep last bite prior to tying the knot • Use an Aberdeen knot to reduce knot size • Close SC and skin with a continuous for only one knot, when incision is longer than can be closed with a cruciate or two • Choose suture size that is not too large to reduce knot size • “smurf” the knot just prior to applying glue to skin edges

Tips Tricks Burying the knot Aberdeen knot (1: 32)

Tips Tricks Burying the knot Continuous SC and skin closure – single knot • Only two throws in the first knot anchoring to rectus • Tack to body wall by taking bites between the cruciate knots in the linea • Discussion about fetal euthanasia • Example of tattoo ink placed in the incision Continuous Closure (3: 50)

Tips Burying the knot Smurf the knot (2: 54) • Don’t forget to trim the suture tag! Tricks

Tips Tricks Incision Size – smaller really is better • “incisions heal side to side” • Other reasons to limit incision size to the minimum allowed to exteriorize the reproductive organs • Minimize instruments and fingers in the abdomen to minimize tissue trauma, post-operative pain and adhesion formation – Also limit exposure of abdominal contents to trauma • Decrease likelihood of foreign bodies left in the abdomen • Minimally invasive surgery for quicker recovery and lower incidence of post-operative complication • Larger incisions take longer to close and allow fewer procedures each day

Tips Tricks Transecting the pedicle before you ligate • Scary at first – the pedicle is no longer tethered if the clamp fails prior to ligation • Bushby – “When you consider the increased tissue manipulation necessary when ligating the pedicle prior to transection, the risk of tearing the pedicle at the proximal clamp is actually greater than a clamp slipping off” – True IF you have good clamps • 1 -2 -3 click technique minimizes risk of tear by proximal clamp – 1 click on the proximal clamp – 2 clicks on middle clamp – 3 clicks on clamp on proper ligament

Tips Tricks Transecting the pedicle before you ligate • Preserving adequate tissue tag distal to clamp is key (1 cm) – Also makes the ligature more secure – If you can’t do this, work on better ovarian exposure • Incision placement cranial enough • Break down suspensory ligament properly • Remove the proximal clamp just prior to the final tightening of the Miller’s knot – Increases distance between the clamp and ligation by reducing “spreading” of the pedicle by the closer clamp • If you double ligate, try transecting after the first ligation

Tips Tricks Tattoo and Glue • Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies HEALTH AND SAFETY CODE. TITLE 10. HEALTH AND SAFETY OF ANIMALS. CHAPTER 828. DOG AND CAT STERILIZATION • Sec. 828. 001. DEFINITIONS. Releasing agency - a public or private animal pound, shelter, or humane organization. The term does not include an individual who occasionally renders humane assistance or shelter in the individual's home to a dog or cat.

Tips Tricks Tattoo and Glue • Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies RULES PERTAINING TO THE PRACTICE OF VETERINARY MEDICINE. TEXAS ADMINISTRATIVE CODE. TITLE 22, PART 24. CHAPTER 573. RULE § 573. 77 STERILIZATION OF ANIMALS FROM RELEASING AGENCIES • (c) Identification markers. An animal sterilized under this section must be identified by a microchip and/or a tattoo indicating that it has been sterilized. • (1) A new owner of an animal with a microchip shall be responsible for providing information to the data base registry of the microchip manufacturer indicating that the animal has been sterilized.

Tips Tattoo and Glue Tricks • Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies RULES PERTAINING TO THE PRACTICE OF VETERINARY MEDICINE. TEXAS ADMINISTRATIVE CODE. TITLE 22, PART 24. CHAPTER 573. RULE § 573. 77 STERILIZATION OF ANIMALS FROM RELEASING AGENCIES • (2) A tattoo must: • (A) be placed on the inside of the animal's thigh near the abdomen or on the caudal-ventral abdomen; • (B) be imprinted with ink that is manufactured in the United States; • (C) meet the standards of the federal Food and Drug Administration for tattooing; • (D) be of a contrasting color to the predominant color of the skin in which it is tattooed; and • (E) consist of the universal symbol for male or female overlain by a slash through the circle to indicate sterilization.

Tips Tricks Tattoo and Glue • The required tattoo is almost never done • green tattoo line on the ventral abdomen is the standard of care • NOTE – ear tip is not a legal way of identifying TNRed cats in Texas • TNRed cats must be either microchipped or tattooed in addition to ear tip • Most tattoo parallel to the incision • Some put tattoo ink in the incision • It’s not uncommon for an owner or even a GP vet to think that

Tips Tattoo and Glue (0: 34) Tricks

Tips Tricks Tattoo and Glue Tattoo even tomcats on the ventral abdomen Video incision is full thickness skin I just score the skin so there is no need for glue Blot the extra ink (peroxide) to prevent a temporary case of “green tongue” • Ketchum tattoo paste is a favorite (tube) • Don’t get the roll-on kind – it gets contaminated with first use • Apply with paper indicator strip of the back end of the scalpel blade handle • •

Tips Tricks Tattoo and Glue • Take care to avoid getting glue in the subcutaneous tissues • It causes a terrible foreign body reaction – Delays healing – Potentiates infection • If you touch the glue to the animal’s skin change out the application straw prior to the next patient • Describe the tattoo in the discharge instructions

Tips Tattoo and Glue Tricks

Tips Tricks Minimizing Time Between Patients • Often the rate limiting step to the number of procedures that can be done each day • Less than 2 minutes surgeon down time between surgeries • Should be able to reglove, regown if needed, and start the next one without rushing • 2 minutes x 30 procedures = an hour of down time per day • 5 minutes x 30 procedures = 2 -1/2 hours down time per day • 10 minutes – you might was well get the cot out

Tips Tricks Minimizing Time Between Patients • Learn at what point in the procedure to call for the next induction – When I am ligating the first ovary – A little more time to induce cats – A little more time for a “Labdomen” • Alternate spays with neuters • 3 male cat neuters per surgery unit, unless infectious disease • Go on the next one as soon as a neuter or group of neuters is brought into the OR

Tips Tricks Minimizing Time Between Patients • Packs and gloves opened for the next patient during skin closure • Careful communication – respond, “Heard!” • Forms or travel sheets minimize writing (http: //omalleypet. org) – Circles and checks as much as possible – Blanks to prompt information gathering – Better yet, have a scribe for computer entry as you go • Colored tag system – Green – pre-A exam completed, premedicated and ready for induction – Blue – needs vet exam prior to premedication and induction – Yellow – infectious disease, surgery at the end of the day

Zinc Neutering Zeuterin (formerly Neutersol) • “Esterilsol” in other countries • Ark Naturals says infertility is “permanent and irreversible” in 99. 6% of dogs • Approved only for dogs 3 -10 months of age • One uncontrolled study in Mexico on adults • No studies assess fertility >12 months postinjection • A very small number of dogs do show uptick in fertility near the end of the 12 months

Zinc Neutering Zeuterin (formerly Neutersol) • A very small number of dogs suffer scrotal rupture with exposed testicle 1 week to 4 months postinjection • “Oligospermia” is considered “infertile” in the FDA approval studies – <20 million sperm per ml – Unlikely, but not impossible that these dogs could successful breed • Other uncommon adverse reactions include scrotal draining tracts, erosions, self trauma, pain on injection, and preputial swelling

Zinc Neutering Zeuterin (formerly Neutersol) • All dogs have scrotal swelling which peaks at 48 hours post-injection • 0. 5 -2% are fertile after injection • 2 -5% have adverse reactions requiring castration • 5% euthanized for excessive testosterone driven behavior • Infertility occurs within 30 days

Zinc Neutering Zeuterin (formerly Neutersol) • Example - 2, 500 castrations per year – 10 -50 will remain fertile – 50 -125 will need to be castrated • ACC&D - Potential for mild adverse injection site reactions to progress to serious reactions in dogs that are not properly supervised should be considered carefully. • ACC&D recommends Esterilsol use be limited to dogs with owners/caregivers that can provide appropriate care. – Alliance for Contraception in Dogs and Cats • Reasonable option when anesthesia potentially dangerous

Tips Tricks Suture Size and Material • Monosorb seems to break a little bit easier than PDS – – may need one size larger for stumps and pedicles – If you break the suture, grab one size up to try again • Polysorb in my hands has poor knot security, as compared to Vicryl and other similar generics. • Suture size for closing the linea alba – – No larger than 0 PDS for even the largest spays 3 -0 PDS fewer suture reactions than 2 -0 for cats 2 -0 PDS for medium dogs 3 -0 to close SC and skin

Tips Tricks Suture Size and Material • Swaged on more expensive than reel • Less tissue trauma with swaged on – Needle sharper – No double thickness as suture loops through needle eye – Don’t need thumb forceps for intradermal suturing • Reels allow you to pick and choose different suture types and sizes for the same surgery without waste • Threading needles with reel suture takes more time • Don’t cold pack suture pack leftovers – feline retroviruses are transmitted with way

Tips Tricks Patient Positioning • Front legs pulled down to the side rather than over the head can help for deep chested dogs • Decreases traction on the ovarian pedicles via the suspensory ligament • Tables that “V” keep patients from tipping right and left • Crossing the front legs before tying can also help with this in deep chested dogs

Tips Patient Positioning (0: 30) Tricks

Tips Tricks Avoiding Dehiscence of the Abdominal Wall • Avoid crushing tissue as you close the first two throws of each knot • Make sure you are closing the rectus sheath, not subcutaneous tissues • Take bites at least 5 -10 mm from the edge of the incision • Knots are not properly tightened, or don’t have enough throws • The sheath, not the muscle tissue is the holding layer

Tips Tricks Dealing with a Dropped Pedicle • Extend the incision cranially to the manubrium • Use the biological retractors to move organs out of the way to caudal to each kidney – Left pedicle dropped – reflect descending colon to the right – Right pedicle dropped – reflect duodenum to the left • Grasp the pedicle with 2 fingers to exteriorize, then clamp • The ureter is just beneath the ovarian artery – Using a clamp to grasp the pedicle can result in trauma to or ligating the ureter – Pooling hemorrhage can obstruct the normal view of the ureter

Treasure Hunt Tips for Cryptorchid Surgery • Determine which side is cryptorchid by retropulsing the normal testicle into its inguinal canal • If testicle can be palpated, make an incision over the testicle • If not, make incision same as spay in the cat • Paramedian incision along the cranial half of the prepuce in the dog – Find the vas deferens there and follow it to the testicle

Treasure Hunt Tips for Cryptorchid Surgery • MIA cat testicles are more often in the inguinal canal • Can be very difficult to dislodge • Have an assistant put pressure upward on the inguinal canal with a gloved hand from inside the abdomen • This allows palpation of and incision over the hidden testicle – They can be very small in the cat

Tips Tricks Why are these Techniques Different from those taught in Vet School? • These skills are for the experienced surgeon • Those taught in vet school are for the inexperienced surgeon – Larger incisions to compensate for infamiliarity with surgical anatomy – Double ligation to compensate for poor knot security – Ligation prior to transection to prevent a dropped pedicle due to overmanipulation of the instruments or other poor technique • MASTER BASIC TECHNIQUES BEFORE WORKING ON INCREASING EFFICIENCY