Friday, July 29, 2011

Bilateral cryptorchidism surgery

On this bright Sunday, July 24, 2011 morning, I was preparing to operate on the Silkie Terrier with "the mother of all perineal hernias" as described in Perineal hernias in a Silkie Terrier repair pictures. Update on a Boston Terrier's perineal hernia. The dog had his hernias repaired 11 days ago. However, the skin where his herniated bladder and intestines had crushed had little blood supply and the cells started dying. This is called gangrene.

A young couple arrived promptly at 9.30 am as they had made an appointment with me. They wanted to neuter a good looking solidly built miniature 2-year-old "miniature" Bull Terrier.

A hyperexcitable dog, resisting handling and turning upside down to examine his testicles which were not present inside the scrotum as in normal male dogs.
 
"Listen to the whistling sounds," I handed the hearing piece of the stethoscope to the husband so that he could listen to the whistles. I could hear the heart sounds separately but the continuous whistling sounds blocked out the heart sounds. This sounds reminded me of a condition similar to the racehorse - laryngeal hemiplegia.

"They are heart sounds," the husband declared. I asked if he had medical training but he had none. He heard loud distinct whistles in the stethoscope and therefore deemed them to be heart sounds.

"Well, they are lung sounds," I said. The heart sounds were muffled and he could not hear them since he had no experience with dog heart auscultation.

SYNCOPE
It was in 1974 when I was in my 5th year of veterinary studies at Glasgow but I still remember the word "Syncope" mentioned in my veterinary lectures. At that time, syncope was a word meant to be remembered for the examinations. I seldom encountered this transient fainting and spontaneous recovery after a short while in dogs in my over 30 years of practice. This miniature Bull Terrier appeared to be suffering from this condition and more detailed heart examinations including the ECG will be needed.

The dog has a history of fainting when over-exerted. "When he plays vigorously with the bigger and younger 8-month-old standard Bull Terrier, he could just simply collapse, as if out of breath and lie down for a while. Then he would recover completely. As if he has caught his breath and behaves normally."

This bit of information from the husband is valuable. It indicates that this dog has a cardio-pulmonary problem. He is a highly risky candidate for anaesthesia. I checked the gums. Excellent pink colour. However, the left inside lip had a yellow ulcer and several holes. "Bitten by the other bull terrier?" I asked. "Probably," the husband said. "They bite each other."

Two undescended testicles. With the dog upside down, I could palpate the left one. The right one was barely felt as it slipped inside the body. "My advice is to prepare for general anaesthesia rather than just take out one. When the dog is down, his right testicle may just disappear inside. Under anaesthesia, I can open up the abdomen and locate and get it out. (Undescended testicle can become cancerous years later). Neutering was to reduce his hyperexcitability.

BLOOD TEST
The couple agreed to the complete blood test. The liver enzymes were high while the platelets were below normal.
"Why?" the husband asked.
"Did you feed herbal or other supplements?"
"Yes," he said. "One iodine capsule per day since he was a puppy."
"Is the dosage recommended for the dog?" I asked.
"I gave one capsule as recommended for adult people," he said.

HIGH ANAESTHETIC RISKS
Based on his history of syncope, the liver disorders and low platelet count, I advised against surgery for the time being. Another blood test can be taken 4-12 weeks later. Definitely, no more iodine or other supplements and wait one month for another blood test.

The liver could have had been damaged by the iodine and its other ingredients consumed over the past 2 years. "It is not just iodine alone inside the capsule," I said to the husband. "The manufacturer will add other substances. Over the years, the liver could have been damaged. As to why the dog was given iodine, I did not ask the owner. It was good that he agreed to a blood test.

UNDESCENDED TESTICLES if normally felt under the skin can be easily removed via skin incisions as shown in the case of the poodle below. In this miniature Bull Terrier, one testicle is barely felt.

To save on veterinary cost and the need for another operation to open up the abdomen to remove the hidden testicle, it is best to put the dog under general anaesthesia, open up the abdomen, locate and remove the abdominal testicle inside as well as to remove the inguinal testicle under the skin.

INFORMED CONSENT
If the dog is healthy, there should be no anaesthetic risk but this miniature bull terrier has some health problems. So, the owner has to take the risk and be given proper information of the risks and options (informed consent). It is best that this be recorded in the case files, in case of litigation and complaint when the dog dies on the operating table.

NEGLIGENCE AND REMOVAL OF THE HIDDEN ABDOMINAL TESTICLE NEEDS A LONGER SURGERY
In some practices, since the dog has only one undescended testicle felt under the skin, this is only one that will be removed during the traditional neuter while the abdominal one is not as that necessitates opening up the abdomen, prolonging anaesthesia and increasing the risks of dying on the operating table. This is not in the interest of the dog or owner as the hidden testicle inside the abdomen can become cancerous in old age and I had seen some cases (revealed by X-ray). A negligence litigation suit may result.

Therefore, the owner must be well advised and both testicles must be removed. Not just the one under the skin. The hidden testicle is usually seen located just below the mid-penile area and can be hooked up to be tied and taken off.

Cryptorchidism can be either bilateral or unilateral, and inguinal or abdominal (or both). This poodle has bilateral inguinal cryptorchidism. Therefore you can see both undescended testicles under the skin. In abdominal cryptorchidism, the testicles are inside and there is a need to open up the abdomen to take out the "hidden testicle."


 In the case of the miniature bull terrier, one testicle is in the inguinal and one is retracted into the abdomen when the dog is held upside down. Neutering or castration is strongly advised as there is a high chance of the undescended testicle becoming cancerous in older dogs.

Pictures of bilateral cryptorchidism are at:
http://www.sinpets.com/F5/20110730syncope-undescended-testicles-miniature-bull-terrier-Singapore-ToaPayohVets.htm

No comments:

Post a Comment