Friday, July 22, 2011

512. Auditing Veterinary Surgery - Accuracy, completeness and speed

I do a surprise audit of veterinary surgery of my associate vets now and then to ensure that the standard of care and surgery is to a high standard as I am the licensee. Besides, good surgical outcomes mean more referrals and business.

SUTURES
All young vets want to use their own sutures and drugs. However, there is a need to be sensible in a young vet's demands and to be aware of the costs of veterinary practice.

In this audit I did today, I noted that 2 packets of 0 chromic catgut and 2 packets of absorbable 3/0 monofilament have had been used during the spay of a poodle. From my experience, the most is 2 packets of sutures. Not four. There was a need for an explanation as this is just a small breed. I would have used at the most 2 packets of 2/0 absorbable sutures. With suture placements at the optimal distance and the use of 3 horizontal mattress sutures of 0.8 cm placed at 0.8 cm apart, I could use just one packet.

I was quite surprised that 4 packets were used. One explanation was the need to use subcuticular sutures to seal off dead space. Another was 3 ligations on the uterine body and 2 ligations each on the ovarian stumps, totalling 7 ligations and therefore needing more suture lengths and time.
The skin incision and linea alba were closed with interrupted sutures. Still, there was a waste of one packet.

NO SUBCUTICULAR SUTURING NECESSARY

Excessive suturing does not mean better suturing. The dog gets irritated with the numerous subcuticular sutures. I have explained this many times to my associate vets but it seems they have had great difficulty accepting my advices.

There is no need to do this line as the dog keeps licking its skin wound during healing resulting in redness. And there are a few cases despite NSAID painkillers.

On my side, I don't get any complaint over my 30 years of practice as I use just one or two horizontal mattress suture and no subcuticular. Yet the two young vets don't agree with dispensation of subcuticular sutures. So, it is up to each vet to do what they have had been taught. The Australian professors of veterinary surgery still preaches SC sutures

HORIZONTAL MATTRESS V. SIMPLE INTERRUPTED
Horizontal mattress provide stronger bonding and is less easy to lick off. Interrupted sutures placed at 0.5 mm apart are too close and unnecessary. Read surgery suturing books yourself if you don't believe my experience. In small dogs, interrupted sutures at 0.8 cm apart will be OK and ideal in neuter and spay cases. In dwarf hamsters, I stitch the skin with interrupted at 0.3 cm apart. DEFINITELY NO subcuticular sutures.

E-COLLARS
In my experience, e-collars are unnecessary after spay and neuter in most cases. I protect the wound with a plaster bandage. NSAID painkillers must be effective and given by injection post-op. Tolfedine may need to be given every 12 hours for the first 2 days. Altogether 4 days. My associates use rimadyril.

CONCLUSION
As each vet has his or her own mindset, it will be best if they read more and find out for themselves the most cost-efficient way to perform stitching. Accuracy, completeness and speed are the 3 tenets for surgery. No point doing fanciful stitching esp. concealed subcuticular sutures to impress the client as most owners just want the least cost and least need to come back for stitch removal or complaint of licking and inflammation of the skin.

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