Wednesday, September 9, 2015

2989. INTERN VIDEO. Z-plasty in a very large wound



Sep 9, 2015


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BKTP




On Sep 8, 2015, the dog owner WhatsApp me an image of her bleeding 14-year-old Shih Tzu and asked whether she could treat the bleeding herself using the cream I had prescribed for the skin disease some 2 months ago.



"It is very difficult to advise you based on your smartphone image," I said. "It is best you bring in the dog for examination."  Phone diagnosis can lead to a misdiagnosis. There are owners who lodge a complaint with the authorities if the dog develops sepsis and dies from bacterial infections of the blood due to a phone image mis-diagnosis.  

The next morning on Sep 9, 2015, the owner brought in the dog. Thick dark red blood oozed out from below the armpit. This was not a simple case of bleeding. It was a large shoulder abscess. The dog turned his head to bite me when I tried to touch his painful right shoulder.

This is a very old dog. Sedation with anaesthesia is risky but the dog would bite or die from the stress of treating the abscess without anaesthesia.  The owner reluctantly accepted the risk of anaesthestic death.

Sedation with IV domitor and ketamine at 0.15ml + 0.15 ml permitted my assistant to clip the wound area.

I was much surprised as the inflamed right shoulder skin was pock-marked with deep holes. The dog had bitten his swollen shoulder area to relieve the intense pain.  Dead tissues between the holes needed to be cut out to prevent the bacteria from going into the blood stream and killing the dog due to septicaemia. This is called surgical debridement.

What are the other treatment options after debridement?
1. Let the wound heal by granulation. This wound is very big and the muscles below would become badly infected, causing pain and licking for months. The owner will need to clean the wound daily for many weeks. The dog cannot walk normally.

2. Stitching a large wound is best practice.



After debridement, the wound is gigantic. How to close this skin wound without the stitches breaking down 3 days later?



2. Z-plasty. It is best to close the wound to protect the muscles. 
The procedure is described by me in:

One case done for removal of large skin tumour
https://www.youtube.com/watch?v=k_xgdWNKCi0


1.  Under isoflurane gas anaesthesia, the wound was clipped and then flushed with saline to remove the dirt and pus. The necrotic (dead) skin tissues were cut off.

2.  Then hydrogen peroxide was poured in to clean the wound further.
3.  This wound was so large and under high tension. Simply stitching the ends together would not lead to healing as the stitches will break down in 3 days.

4. The solution was to use Z-plasty surgery and give painkillers and antibiotics.

See video footage.

As at Sep 10, 2015, the dog had been tightly bandaged to stop the subcutaneous bleeding. Antibiotics and painkillers are given.
Video dog standing with bandages on Day 2 post-op.


CONCLUSION
1. Early veteirnary attention by the owner prevented sepsis and death of the dog as bacteria would have travelled to the blood stream and infect the whole body. Blood test results.


2. Z-plasty takes a long time as compared to simple suturing of the two ends of the wound. In this case, there would be poor outcome making the owner very stressed out and unhappy. .



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