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.
SHIH TZU WITH URETHROSTOMY
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.
POODLE WITH CEMENT-GREY TEETH
"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,"
CIRCUM-ANAL TUMOUR IN A MALE SPITZ
"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."
SURGICAL APPROACH
"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.
Sunday, September 9, 2012
Saturday, September 8, 2012
1082. Service Audit of Toa Payoh Vets: Recurreing urinary stones review case
DRAFT INVESTIGATION OF RECURRING UROLITHIASIS IN A SHIH TZU
A lot of time is needed to investigate this case to come to a solution for the dog.
At 9.50 am, today Saturday, I am at the Surgery and I review the case of the recurring urinary stones
in a gold/black male Shih Tzu, 4 years old. The patriarch came to see him yesterday and the day before (Thursday) and spoke to me twice, at length.
NOVEMBER 2011. TOA PAYOH VETS
"Why did you take the dog to another vet for "blocked bladder" after X-rays by my associate vet in Oct 2011?" my associate vet hadI asked. "Is there some worries about Toa Payoh Vets not being able to perform this surgery?"
"No," he said. "I was recommended a vet. After all, my dog had been to your place as a puppy earlier." Vet 1 opened a hole in the urethra and allegedly told him that the hole would close in time and the dog would pee from the normal orifice of the penis. He was not happy that Vet 1 had to operated a 2nd time the next day without informing him. The dog's e-collar was smaller in size leading to the dog licking the urethral opeing.
APRIL 2012. VET PRACTICE X
"Was there any difficulty in urination or blood in the urine after Vet 1 operated?" I asked.
"Not for 7-8 months. My dog would lift his leg to pee a large volume of urine. However, he started having problems peeing. So, I rushed him to another practice (X). This practice has all the facilities and you can understand why I did not bring the dog to Toa Payoh Vets. Vet 2 operated on the bladder and removed the stones. The vet said he flushed the bladder several times."
AUGUST 2012. VET PRACTICE X
The dog could not pee normally again. Less volume of urine and difficulty in urination.
"My dog's stomach was getting bloated and so I rushed him down to Vet 2. The bladder operation was done to remove the stones. However, Vet 2 told me that he need to open another hole and close the first hole as my dog could not pee. I do not want another operation and that is why I brought the dog to your Surgery."
Yesterday, Dr Daniel said there was an obstruction around the bend of the urethra. As I am not operating on this case, I will follow up.
WHAT'S THE SOLUTION?
This is a highly emotional case. The owner had spent over $2000 in Practice X recently and was assured that an X-ray post-removal of bladder stones was done. "This is good practice," I said. "So that there is proof as to whether all stones had been removed by the vet. I don't do it because of the costs involved." But this X-ray could not be located presently.
Thursday, September 6, 2012
1081. Sep 5, 2012 dog disease in Singapore with Zhao Pao newspaper
Educating the dog owners is important. The Zhao Pao reporter wanted me instead of the younger ones to talk about diseases in the dog in Singapore as I am an old vet. Some questions he asked were:
1. Commonest dog disease problems in Toa Payoh Vets.
Number 1 will be skin diseases of various causes like ringworm. Ear infections are part of skin diseases. Food allergies tests can be done but it costs money.
Vomiting and diarrhoea, coughing, urinary tract infections, tumours in skin and elsewhere in the body. Eye diseases in Shih Tzus common due to their big eyeballs. Tick infestations hard to control by some owners.
2. Bladder stones. Quite common in some breeds like Miniature Schnauzers.
3. Advices to dog owners.
3.1 Daily check up of the dog for tumours or ticks.
3.2 If dog is not eating for more than one day or not active, consult the vet promptly.
3.3 Annual vaccination is still recommended as Singapore vaccine suppliers do not sell those vaccines which last 3 yearly as reported in the internet forums. They supply combined vaccines and so important diseases like parvovirus and distemper cannot be separately vaccinated 3-yearly as in the USA dogs.
3.4 Bladder stones and eye injuries are emergencies. Do not wait and see.
1. Commonest dog disease problems in Toa Payoh Vets.
Number 1 will be skin diseases of various causes like ringworm. Ear infections are part of skin diseases. Food allergies tests can be done but it costs money.
Vomiting and diarrhoea, coughing, urinary tract infections, tumours in skin and elsewhere in the body. Eye diseases in Shih Tzus common due to their big eyeballs. Tick infestations hard to control by some owners.
2. Bladder stones. Quite common in some breeds like Miniature Schnauzers.
3. Advices to dog owners.
3.1 Daily check up of the dog for tumours or ticks.
3.2 If dog is not eating for more than one day or not active, consult the vet promptly.
3.3 Annual vaccination is still recommended as Singapore vaccine suppliers do not sell those vaccines which last 3 yearly as reported in the internet forums. They supply combined vaccines and so important diseases like parvovirus and distemper cannot be separately vaccinated 3-yearly as in the USA dogs.
3.4 Bladder stones and eye injuries are emergencies. Do not wait and see.
1082. Blocked bladder case - urethrotomy twice
Today, Dr Daniel operated on a Shih Tzu who could not pass urine. Vet 1 and Vet 2 in another ractice had operated and made two "holes" in the lower part of the penis ie. urethrotomy. This case was referred to him by his brother as the dog could not urinate and the dog owner was his brother's friend.
I reviewed this case done by my associate vets and discovered that this 4-year-old Shih Tzu had been examined by Dr Vanessa on Oct 24, 2011. She confirmed bladder stones from X-rays and the cathether was blocked about 6 cm from tip of penis. She recorded that the owner "declined all treatment."
The infected areas were cleared. The urethral opening was stitched again and a catheter was passed through. "Pus in the penis," he said to me. "According to the book, the penile head should have been amputated." I said: "Normally I don't do it. Just open the urethra behind the os penis to let the urine flow out if the front part is completely blocked. Only in this case, there were complications of infections after surgery done by Vets 1 and 2."
As more new vet surgery text books are produced, there are new concepts. Amputation of the penile head, in my opinion, is unnecessary despite what the new vet surgery text books say. I mean, this amputation causes more pain and bleeding and I have done urethrotomy without the need to cut off the penile head and the dog was OK. "The only problem with urethrotomy is that the male dog leaks urine onto the floor and the owner does not like cleaning up," I replied to him.
In urethrotomy, the owner needs to take special nursing care as the area can close up due to infections and scarring. So Vet 2 did another urethrotomy. This gave complications as the dog could not urinate. Vet 3 proposed another opening of the urethra further back.
In conclusion, this case would be difficult to treat. In my opinion, the solution is to open up the first urethral stricture. It must be debrided and opened up to join the 2nd one. Both stitched up as one opening ventral. A catheter is to be placed for over 10-20 days for healing to take place. Not just 4 days and take out the catheter as the urethral opening will closed up and obstruct urine flow again!
Wednesday, September 5, 2012
1080. Retrospective study: Vaginal hyperplasia & Prolapse Type II in an old female chihuahua
"Very tired, not moving," the home-breeder said. "Not eating 1's for the past 9 days and vomit when given canned food." There was a red"tongue-like" tissue hanging from the backside of this 10-year-old female Chihuahua, fawn/white.
On Nov 18, 2011, he had consulted Vet 1 who noted "vaginal/uterine" prolapse and advised spay. She informed him there could be pyometra. She recorded that he declined blood testing. He did not want surgery as the vet warned of high anaesthetic risk. So he took some medication. However, his dog did not eat again. Four days had passed. Vet 1's Nov 19 blood test records showed elevated liver enzymes and marginal elevation of WBC (Total WCC 17.2). Her ultrasound showed mainly liver, gall bladder and kidney issues. Urine tests showed presence of glucose (3+), blood (4+), bacteria (2+), epithelial cells, WBC and RBC. However, in retrospective review today, of the differential count, neutrophils was 88% (high) and platelets 181 (200-500) was low.
The owner wanted non-surgical treatment. But there was none. Surgery was the option but highly risky as the dog had been sick for some days.
He wanted me to do the surgery which was done on Nov 27. I got a blood test done on Nov 25. This time the Total WCC was 33.2 (6-17), Neutrophils was 96%, platelets 14 (200-500). NOW, the haemoglobin 5.3 (12-18) and red cell count 2.7 (5.5 - 8.5), Haematocrit 0.15 (0.37-0.55), MCV 55 (60-77) indicated severe anaemia too. Platelets are 14 - clotting problems exist now - dog unable to clot when the tissues are cut (see image of my report case).
CONCLUSION
1. Spaying the dog when she was young would not have caused this serious health problem.
2. Often the owner is not aware of the seriousness of the problems as the vet mentioned "high risk" and death likely.
3. The vet was not able to communicate the need for prompt surgery (1-2 days on Nov 19 , not wait longer) as delays would make survival very low.
On Nov 18, 2011, he had consulted Vet 1 who noted "vaginal/uterine" prolapse and advised spay. She informed him there could be pyometra. She recorded that he declined blood testing. He did not want surgery as the vet warned of high anaesthetic risk. So he took some medication. However, his dog did not eat again. Four days had passed. Vet 1's Nov 19 blood test records showed elevated liver enzymes and marginal elevation of WBC (Total WCC 17.2). Her ultrasound showed mainly liver, gall bladder and kidney issues. Urine tests showed presence of glucose (3+), blood (4+), bacteria (2+), epithelial cells, WBC and RBC. However, in retrospective review today, of the differential count, neutrophils was 88% (high) and platelets 181 (200-500) was low.
The owner wanted non-surgical treatment. But there was none. Surgery was the option but highly risky as the dog had been sick for some days.
He wanted me to do the surgery which was done on Nov 27. I got a blood test done on Nov 25. This time the Total WCC was 33.2 (6-17), Neutrophils was 96%, platelets 14 (200-500). NOW, the haemoglobin 5.3 (12-18) and red cell count 2.7 (5.5 - 8.5), Haematocrit 0.15 (0.37-0.55), MCV 55 (60-77) indicated severe anaemia too. Platelets are 14 - clotting problems exist now - dog unable to clot when the tissues are cut (see image of my report case).
CONCLUSION
1. Spaying the dog when she was young would not have caused this serious health problem.
2. Often the owner is not aware of the seriousness of the problems as the vet mentioned "high risk" and death likely.
3. The vet was not able to communicate the need for prompt surgery (1-2 days on Nov 19 , not wait longer) as delays would make survival very low.
Tuesday, September 4, 2012
1079. Follow up: Will my dog still have bleeding after spay?
Sunday Sep 2, 2012 was a busy day. So I did a spay of a fat SilkieXMaltese, 5 years old. This case was written earlier. Today, Tuesday, I phoned the owner to find out what happened after spay and to let them know the blood test results were OK.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.
Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit). Slept sideways.
Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.
Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.
CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.
Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit). Slept sideways.
Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.
Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.
CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.
1078. Follow up: Will my dog still have bleeding after spay?
Sunday Sep 2, 2012 was a busy day. So I did a spay of a fat SilkieXMaltese, 5 years old. This case was written earlier. Today, Tuesday, I phoned the owner to find out what happened after spay and to let them know the blood test results were OK.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.
Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit). Slept sideways.
Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.
Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.
CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.
Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit). Slept sideways.
Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.
Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.
CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.
1077. Email advices regarding eye tumour
Dear Dr Sing,
My pet maltese is diagnosed with malignant high grade anaplastic mast cell tumor. A first operation was performed to remove a tumor from her left thoracic flank. The histological report revealed that there is no margin of tumor-free tissue along the deepest border.
Two months after the surgery, a new lump developed on the right neck and was surgically removed. An ultrasound abdo scan also showed that the cancer has metastasized to the spleen.
She began her first chemotherapy: Prednisolone and Vinblastine (8 sessions; 4 x weekly, 4 x biweekly). Her second chemotherapy: Palladia was on for two weeks and interrupted due to a swollen right eye lid.
We seek a vet with special interest in ophthalmology today and she was definite that the swollen eyelid is a malignant tumor, without doing any biopsy. Surgically removal of the entire eye is the only option but the tumor is likely going to reappear. My pet is given a prognosis of 3 weeks.
Aside from the swollen right eyelid, she is still a very active pet and has good appetite. The tumor in the eyelid has pushed her eyeball to the side and looking very uncomfortable. She is given Prednisolone for now.
After doing some research online, most commented that eyelid tumor is benign.
Given that my pet is still in good spirits, I am not willing to put her down in any case. However, the unwelcome tumor in the eyelid seems like an time-ticking tumor. It is getting more inflamed as each day passes.
EMAIL REPLY FROM DR SING DATED AUG 24, 2012
I will be back from HK on Friday aug 24. It will be best to tel me 96686468 on Sat 10am. Most likely eye tumor is malignant.
Monday, September 3, 2012
4000. Educating the rabbit owner about his rabbit abscess
If a vet wants to build up his reputation and expertise, he has to review his cases, esp. challenging ones and must be able to communicate in the layman's language.
I heard a new graduate telling the owner he wants a "history" of the panting dog. To the owner, "history" means nothing.
It requires a lot of time to process the X-ray image so that the rabbit owner understands the pathology of the rabbit's impacted molar and bone infection as shown in the images below:
I heard a new graduate telling the owner he wants a "history" of the panting dog. To the owner, "history" means nothing.
It requires a lot of time to process the X-ray image so that the rabbit owner understands the pathology of the rabbit's impacted molar and bone infection as shown in the images below:
Sunday, September 2, 2012
1075. KPI for a fat dog spay by Dr Sing. Sunday Sep 2, 2012's interesting cases
Sunday Sep 2, 2012. Sunny day, blue skies
Myths
Three dog owners told me today:
1. Dog at 5 years old, if neutered, will develop prostate cancer
2. Dog at 11 years old. Too old to neuter to prevent urine marking. I checked the health. Has heart disease now. So, anaesthesia not advised.
3. Dog, 4 years old. If spayed, will still get heat bleeding. "This is not possible," I said."Unless the vet leaves behind some ovarian tissue after spay."
I took over the spaying of this overweight Maltese X, at 9.15 kg, as Sunday is a busy day and I can spay faster, due to more years of experience. Still, I pray not to get fat dogs.
A. 10am Sedation with D + K at 50%. Dom = 0.18ml Ketamine = 0.23ml IV.
B. 10.28 am Isoflurane gas first given
C. 11 am Isoflurane gas stopped
D. 10.34 am First skin incision
E. 11.02 am Completion of stitching
Lots of oily fat. Hooked 2nd attempt.
10.42 am Left ovary hooked out
10.48 am Right ovary hooked out.
10.51 am Uterine body pulled out
10.55 am Uterine body ligated twice at 2 locations
10.56 am Linea alba stitched
11.02 am End of stitching.
12 noon Dog alert and goes home.
E-D = 28 minutes
E-A = 62 minutes (includes dental scaling before spaying). Therefore, excluding dental scaling, just for spay, E-A should be lesser.
SPAY TIPS FOR YOUNG VETS
1. The incision started 1.5 cm from the umbilical scar.
2. Ensure ovaries are exposed thoroughly including at least 5 mm of the ovarian suspensory ligament. Incise anteriorly 5mm more if you find difficulty in pulling out the ovary or can't access the suspensary ligament. In this dog, I was able to pull out the whole ovary and my finger could feel at least 5 mm of the suspensory ligament.
3. NICK INSTEAD OF RUPTURING THE SUSPENSORY LIGAMENT AS ADVISED BY THE PROFESSORS.
What to do with this suspensory ligament. I know the professors in the University may say "snap" it off with the finger by pulling hard to break it. The danger in fat dogs and small breed is that the force may break the whole ovarian ligament including the ovarian blood vessels, leading to profuse bleeding.
3.1 I use the scalpel blade and nick off the taut suspensory ligament on the dorsal side at around 2 mm depoth. A young vet asked me whether I would also nick off the ovarian blood vessels with the scalpel. My answer is no if you just nick at the taut ligament. You can feel it very tight when you pull out the ovary and at the tight area, use the scalpel to nick it. For big breeds, you can feel this tight ligament. I also nick it in big breeds.
4. TRANSFIXING SUTURE. The professors advise transfixing the uterine body. Now, the theory is great but in practice, the uterine body of a small breed like the Maltese or even this fat Maltese X Silkie is less than 8 mm in width. Transfixing ligature may rupture this uterine body as there is not much space. In this dog, I ligate the uterine body 2 times at 2 locations.
5. PROFUSE BLEEDING SEEN. If you incise the linea alba correctly and not the muscles, you seldom get profuse bleeding. I don't separate the omental fat surrounding the length of the uterine horn in this fat dog. Some vets will pull off the omental fat before ligating the uterine body and in big breeds, this may need to be done. In small breeds, I don't do it and ligate it together with the uterine body. Hence two ligatures at 2 locations. Profuse bleeding may come from omental blood vessels and it can be very alarming, as the body fills with flowing blood.
In cases where bleeding is non-stop, even when swabs are used, it is necessary to extend the incision to look for the bleeder and to save the dog from bleeding to death. There is no choice. Sometimes, the dog is on heat and the omental vessels are fragile and bleed easily. If the vet does NOT clamp the omental fat from the uterine horn area but just bursting it away with fingers before ligating the uterine body, there may be alarming profuse bleeding.
5. NO. OF SUTURE PACKETS
I used one packet of PDS 2/0. The last bit was to suture one horizontal mattress suture on the skin.
In conclusion, for the young vet, keep spaying simple by:
1. Making a large skin incision of over 4 mm. It is unlikely you can do a 2 cm incision and so don't try till you know the best location.
2. Try not to use fanciful stitching. Simple interrupted stitches x 3 (in this dog where the linea alba is around 2.5 cm long) and one horizontal mattress suture for the skin. No subcuticular or hidden sutures to impress the owner. Efficiency (short surgery, accuracy, speed and completion) rather than take your sweet time to do a spay.
Myths
Three dog owners told me today:
1. Dog at 5 years old, if neutered, will develop prostate cancer
2. Dog at 11 years old. Too old to neuter to prevent urine marking. I checked the health. Has heart disease now. So, anaesthesia not advised.
3. Dog, 4 years old. If spayed, will still get heat bleeding. "This is not possible," I said."Unless the vet leaves behind some ovarian tissue after spay."
I took over the spaying of this overweight Maltese X, at 9.15 kg, as Sunday is a busy day and I can spay faster, due to more years of experience. Still, I pray not to get fat dogs.
A. 10am Sedation with D + K at 50%. Dom = 0.18ml Ketamine = 0.23ml IV.
B. 10.28 am Isoflurane gas first given
C. 11 am Isoflurane gas stopped
D. 10.34 am First skin incision
E. 11.02 am Completion of stitching
Lots of oily fat. Hooked 2nd attempt.
10.42 am Left ovary hooked out
10.48 am Right ovary hooked out.
10.51 am Uterine body pulled out
10.55 am Uterine body ligated twice at 2 locations
10.56 am Linea alba stitched
11.02 am End of stitching.
12 noon Dog alert and goes home.
E-D = 28 minutes
E-A = 62 minutes (includes dental scaling before spaying). Therefore, excluding dental scaling, just for spay, E-A should be lesser.
SPAY TIPS FOR YOUNG VETS
1. The incision started 1.5 cm from the umbilical scar.
2. Ensure ovaries are exposed thoroughly including at least 5 mm of the ovarian suspensory ligament. Incise anteriorly 5mm more if you find difficulty in pulling out the ovary or can't access the suspensary ligament. In this dog, I was able to pull out the whole ovary and my finger could feel at least 5 mm of the suspensory ligament.
3. NICK INSTEAD OF RUPTURING THE SUSPENSORY LIGAMENT AS ADVISED BY THE PROFESSORS.
What to do with this suspensory ligament. I know the professors in the University may say "snap" it off with the finger by pulling hard to break it. The danger in fat dogs and small breed is that the force may break the whole ovarian ligament including the ovarian blood vessels, leading to profuse bleeding.
3.1 I use the scalpel blade and nick off the taut suspensory ligament on the dorsal side at around 2 mm depoth. A young vet asked me whether I would also nick off the ovarian blood vessels with the scalpel. My answer is no if you just nick at the taut ligament. You can feel it very tight when you pull out the ovary and at the tight area, use the scalpel to nick it. For big breeds, you can feel this tight ligament. I also nick it in big breeds.
4. TRANSFIXING SUTURE. The professors advise transfixing the uterine body. Now, the theory is great but in practice, the uterine body of a small breed like the Maltese or even this fat Maltese X Silkie is less than 8 mm in width. Transfixing ligature may rupture this uterine body as there is not much space. In this dog, I ligate the uterine body 2 times at 2 locations.
5. PROFUSE BLEEDING SEEN. If you incise the linea alba correctly and not the muscles, you seldom get profuse bleeding. I don't separate the omental fat surrounding the length of the uterine horn in this fat dog. Some vets will pull off the omental fat before ligating the uterine body and in big breeds, this may need to be done. In small breeds, I don't do it and ligate it together with the uterine body. Hence two ligatures at 2 locations. Profuse bleeding may come from omental blood vessels and it can be very alarming, as the body fills with flowing blood.
In cases where bleeding is non-stop, even when swabs are used, it is necessary to extend the incision to look for the bleeder and to save the dog from bleeding to death. There is no choice. Sometimes, the dog is on heat and the omental vessels are fragile and bleed easily. If the vet does NOT clamp the omental fat from the uterine horn area but just bursting it away with fingers before ligating the uterine body, there may be alarming profuse bleeding.
5. NO. OF SUTURE PACKETS
I used one packet of PDS 2/0. The last bit was to suture one horizontal mattress suture on the skin.
In conclusion, for the young vet, keep spaying simple by:
1. Making a large skin incision of over 4 mm. It is unlikely you can do a 2 cm incision and so don't try till you know the best location.
2. Try not to use fanciful stitching. Simple interrupted stitches x 3 (in this dog where the linea alba is around 2.5 cm long) and one horizontal mattress suture for the skin. No subcuticular or hidden sutures to impress the owner. Efficiency (short surgery, accuracy, speed and completion) rather than take your sweet time to do a spay.
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