Friday, June 14, 2013

1460. Update: KPI - How long it takes to remove one bladder stone from a poodle?

Friday June 14, 2013

I share my surgical experience with regards to the removal of a bladder stone from an old poodle.

How long it takes to remove one bladder stone from a poodle?

Poodle, 10 years, 4.1 kg 38.2 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension.

Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)  

2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin

A: Injection of Induction Drugs  2.50 pm
B:  Isoflurane gas first given:     2.55 pm
C: Isoflurane gas stopped:         3.39 pm
D: First skin incision:                3.11 pm
E: Completion of skin stitching   3.41 pm

E-D = 30 minutes for a vet with 40 years of experience. 
E-A = 51 minutes
C-B = 44 minutes of isoflurane gas + oxygen used.

1. Domitor + Ketamine 0.1 + 0.11 ml IV in 3 ml of saline
2. Dog intubated 5 minutes after Dom + Ketamine IV. She was intubated a few times but seemed not to be breathing the isoflurane. Barked twice. Eyes blinking. I did not want to waste time to mask and intubate as this is an old dog and every second counts towards her survival rate. I decided to use gas mask which was excellent anaesthesia from 3% maximum for maintenance.

1. I palpated the empty bladder with stone. In female dog, I do not catherise unless necessary.
2. I incised where the bladder was located. Spread out the SC fat, linea alba cut and pop out the empty bladder.
3. I turned the bladder backwards, exposing the dorsal part of the apex.
4. Incised 1 cm. Popped out the stone which would be slightly >1 cm across.
5. My assistant flushed bladder with saline. I squeezed out any remaining debris or crystals, known to be struvites.
6. A urinary catheter passed from inside bladder to outside the vulva to dislodge any stones if present in the urethra.
7. I suture the 8-mm thick submucosa first with a layer of inverting sutures, parallel to incision.
8. At one end, I anchored the artery forceps and proceeded to suture a similar continuous inverting suture layer to the other end from bladder serosa and mucosa. "Suturing is similar to Caesarean section uterus," I said to Dr Daniel. I used 3/0 polysorb sutures and throw 5 knots/tie.
9. "Some vets inject saline into the bladder of the femal dog after suturing to see if there is a leak," I said to Dr Daniel. "I don't do it as the closure is tight with two layers." He took a video.
10. Closure of the linea alba (simple interrupted & continuous overlay).
11. Skin - horizontal mattress x 3 with 3/0 nylon.
12. There was some profuse bleeding post -op.  "Probably the bigger artery from the caudal epigastric blood vessel," I said. After bandaging, the bleeding stopped.

The dog vomited twice, yellow gastric juice but seemed OK. "Barking non-stop before surgery," I said to the owner who visited. The dog sprang onto him as if she did not have any major op. Still barking non-stop as at 7.35 pm when I recorded this case. Incredible. The owner is advised to give the S/D diet but the dog did not like it. There are still small stones inside the left kidney and S/D may dissolve them. But the dog would not eat the S/D. "Give 10% mixed with home-cooked food and increase daily," I said. "It is important to avoid kidney stone operation!"  

An unusual old dog so active 2 hours post op. Compared to the overweight Jack Russell who is drinking lots of water and depressed, lying down 2 days after 10 small bladder stone removal surgery. He would stand up when the owner came.

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