Sunday, September 9, 2012

1083. Sunday Sep 9, 2012's interesting cases

Sep 9, 2012

I went to Surgery at 8.30 am this Sunday to check on 2 in-patient cases - the urethrostomy Shih Tzu that still has a large SC swelling to the left of the penis and the old poodle with cement-grey teeth.

Crying in pain when handled. Large SC swelling over 6 cm x 6 cm caudal to the incision to remove bladder stones done by the other vet. Over 20 ml of blood-tinged fluid was aspirated with a syringe by Dr Daniel. "It can't be urine," Dr Daniel said when I suggested it could be urine from the urethrostomy hole closed by him using skin sutuers.

"The catheter shows yellow urine without blood."It is possible that it is urine mixed with blood of the SC swelling."

"The SC swelling has only fat," said Dr Daniel who excised it earlier and neutered the dog as requested by the owner.

"It could be abdominal fluid," I said. "A stitch breakdown in the linea alba where the vet did the bladder surgery. What you saw under the skin was the subcuticular suturesd which had broken down at one part. The vet would have incised the skin parallel to the penis. Then he or she would have shifted the penile shaft to one side and then incise the linea allba to take out the bladder to remove the urinary stones. What you removed earlier were the stitch breakdown of the SC continuous sutures to close the skin. There were no over the skin sutures as some vets prefer to impress the owner with this method. Unfortunately, part of the continuous sutures broke down and you had to re-stitch to close up the skin. But you did not see the linea alba stitch because the penis would have been relocated back to its original midline position covering it.

"If there is the break of stitching in this linea alba, the left SC area would swell again with fluid, just like yesterday. You have to inform the owner of this incident." The owner was uncontactable and so he was not informed.

Struvite management by diet ought to be started soon. "The dog vomited all the SD diet yesterday," Dr Daniel said to me. "80% of the old diet plus 20% of the SD diet should be given originally," I explained. "Some dogs don't eat SD immediately as it tastes different."  Will have to follow up. This seems to be a more complicated case than it appears. If the linea alba stitching had come undone, another operation needed to be done to close it. The big SC swelling on the left inguinal area apparently appeared after the other vet had done the bladder stone removal. Got to verify with the owner.

Send fluid for examination," I said to Dr Daniel.

"The blood test showed a very high total WCC and low platelets, suggesting a high bacterial infection. That is why the dog stopped eating for 2 days and your wife quickly brought her for treatment. I thought she would die, being so thin. But she is eating now, after the IV drip and medication." This was good news for his wife who is overseas.
Cement-grey teeth? Really as grey as cement as you would see from the images.
"The most likely cause of bacteria would be from the mouth - the rotten teeth," I said. "They need to be removed."
"But the other vet we consulted 2 years ago said the dog would die under anesthesia and so we did not do any dental work," the husband visited the dog this morning. "The dog keeps drooling and has bad breath," 

"I don't think the old vet can operate," the man said his dogs' anal area had a lump which bleeds. It was originally small and the wife could squeeze out the pus. But it kept growing bigger.

"So, I come to Toa Payoh Vets."
"The vet would usually refer cases to one particular practice," I said.
"Yes," the gentleman with his wife and daughter near him said." I don't like the practice this old vet refers me to.

"It is a case of circum-anal tumour," I said. "It needs to be removed as it seems to be growing bigger, now it being 5x5x3 cm. I will operate with Dr Daniel," I said. "As it is infected, it is best excised 2 days later. Otherwise the wound will not heal well."

"What is your surgical approach?" I asked. "It is a big tumour and if you have high tension, your ordinary stitching of the big gap will break down."
I asked him to draw and illustrate his treatment plan. As the dog was on a drip, I could not get to see it to sketch the surgical approach. Dr Daniel drew something. "Best is to use Z-plasty in this region and cut 1 cm away from the tumour edge, if possible," I said. "If you try to stitch the big hole in the usual way, you will find stitch breakdown."
I drew the surgical plan, advising electro-surgery and the Z-plasty (see image). Mentoring needs loads of patience.

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