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Wendy Blount, DVM

Wendy Blount, DVM

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Wendy Blount, DVM

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

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

  3. 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

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

  5. 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

  6. 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

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

  8. Finding the linea alba Cat Video(0:06)

  9. 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.

  10. 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

  11. 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

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

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

  14. Finding the uterus • Finger sweep (0:11)

  15. Finding the uterus • Finger sweep (0:21)

  16. Three Clamp Technique (2:43)

  17. 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.

  18. 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

  19. 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

  20. 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

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

  22. 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

  23. Breaking down the suspensory ligament (0:37)

  24. Breaking down the suspensory ligament (0:16)

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

  26. Bertha the 100 lb Pit Bull IN HEAT

  27. 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)

  28. 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

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

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

  31. 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.

  32. 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

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

  34. 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)

  35. 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

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

  37. 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

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

  39. 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

  40. Bertha the 100 lb Pit Bull Dealing with the broad ligament

  41. Bertha the 100 lb Pit Bull Dealing with the broad ligament

  42. 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.

  43. 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

  44. 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

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

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

  47. 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 4-5mm 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

  48. Dogs of Maturity Preventing scrotal hematoma • Meticulous hemostasis • Avoid branches of the caudal superficial epigastric a. • Disposable JorVet 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

  49. Dogs of Maturity JorVet handheld electrocautery -runs on two AA batteries -2200o cautery and three tips - $67.00 -2200o cautery - $36.00 -1100ocautery - $29.00 -replaceable tips -cautery lasts 4-6 months

  50. 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 2cc of the mixture to a sterile 4x4 • Place the 4x4 into the scrotal sac for 30-60 seconds, and then remove • Mackie uses 100% epinephrine for this