108. Perineal hernia repair Boston Terrier 7 years

Case: Boston Terrier, Male, Not neutered, 7 years, 12.4kg
Big swellings besides the anus, the left swelling being bigger.
Difficulty in pooping for past 3 weeks.

A knowledgeable young man who has his own views of dog care.
He presented a Boston Terrier with constipation for the past 3 weeks. He went to Vet 1 who referred him to another vet after taking a blood test as she did not want to perform the surgery. She had given him a laxative for the dog and the dog had passed loose stools instead of hard ones.

"Why don't you see the referred vet?" I asked.

"The Surgery has a bad reputation," the young man had googled the name of the practice he was referred to by Vet 1. "There is a very bad complaint about the vets from one dog owner. So I better not go there."

"All veterinary practices will have one or two nasty complaints about service," I educated this young man. "The busier the practice, the higher the chances of getting complaints. This is because the vet has no time to handle each case as thoroughly as he or she would love to. This applies to over-worked doctors in human medicine too especially in the emergency wards."

VACCINATION HISTORY MUST BE ASKED
"Has your dog been vaccinated?" I asked.
"No vaccination for the past few years. Do you have parvovirus in your Surgery?" the young man asked me.

"Fortunately for your dog, my practice does not have parvo-viral cases for many months as I seldom provide service to the dog breeders nowadays. You have taken a big risk exposing your dog the risk of parvoviral and canine distemper infections."

PRE-OP BLOOD TEST IMPORTANT FOR OLD DOGS BEFORE SURGERY
I checked Vet 1's blood test results. It is wise not to trust the blood results of other practices based on one of my experiences (see one case I had written). However, he had paid $130 for the test and I would not insist as that would increase his vet bills. Overall, the dog was examined and was healthy. So I took the chance.

ANAESTHESIA
IV saline given. Then I gave Atropine 0.4 ml IV followed by Domitor 0.2 ml IV
Waited 10 minutes. Isoflurane gas mask. Dog struggled. So, I gave Zoletil 100 @ 0.1 ml IV. This sedated the dog who was masked and given isoflurane gas at 5%. The dog slept and was intubated. Isoflurane at 1-2% maintenance was done by my experienced assistant, Mr Saw. I asked him to increase the dose when the pelvic fat kept coming out from the hernia after pushing the fat into the abdominal cavity. The dog recovered smoothly.

SURGERY
I gave him antibiotics to take and schedule perineal hernia surgery 2 days later. The surgery took nearly an hour as the hernia was large. The hernia bulge with pelvic fat is large, around 4 cm x 6 cm. An electro-incision made a big cut to the left of the anus.

It was difficult to identify the medial coccygeal and levator ani muscles in this case as there is a lot of inflammation. The internal pudendal artery and vein and the pudendal nerve on the dorsal surface of the internal obturator muscle looked compressed as I showed to my assistant Mr Saw who nodded his head. Judging from his eyes, he did not believe they were what I said.




Is there a right perineal hernia too?


Electro-incision. Big amount of pelvic fat. A retractor enabled me to have a good field of view to stitch up the defect


See the big hole through which part of the colon and pelvic fat herniated through causing a big backside swelling


Left perineal hernia repaired. Neutering in 3-4 weeks if the owner wants to do it. The right perineal hernia may need to be repaired later.
The internal obturator muscle is on the ventral aspect of the pelvic diaphragm. This was a big fatty mass horizontally covering the muscle, unlike the no-fat muscles illustrated in Small Animal Surgery, T.W. Fossum 1997, pg 354.

I used a retractor to spread open up the operating area and to see the pudendal vessels and nerve just above the obturator muscles in this case. Do not stitch these vessels or nerves.

POST-OP
Dog woke up fast. Given tolfedine painkillers.

TWO HERNIAS TO BE OPERATED AT ONE GO
I doubt that it is possible to do two hernias at one go as the muscle stitching on one side (i.e. left hernia in this case) pulled the left anal area tightly to cover the herniated hole. Therefore doing two hernia repair at the same time just is not in the interest of the dog as he will feel very uncomfortable and painful.

LOOSE STOOLS leaking out from the anus. This must be plugged. The dog had been given an oil laxative by Vet 1 for 3 days and the loose stools start to come out despite atropine injection.

CONCLUSION
The dog was OK and was warded for at least 4 days as the owner did not have a crate to prevent the dog running loose. I checked the dog every day to ensure that he had proper nursing care and pain-killers. The boy's parents came to visit the dog yesterday. The dog should be back home after 7 days. He had managed to rub his backside onto the floor of the crate despite tolfedine 60 mg at half a tablet per day for 3 days. I decided to give him 1/4 dose of a 30mg phenobarb and then Rimadryl for another 3 days to prevent pain and inflammation.

P.S
1. Yearly vaccination is important. Fortunately this dog did not get infected with parvoviral disease in the practice of Vet 1 which is a very busy practice and in my surgery. Otherwise, I end up with a dog passing blood in the stools and dying later. At the time of writing this report, it is still early at Day 5 after visiting Vet 1. Parvoviral signs come in around 10-14 days after infection.

2. "Neutering the dog when he was younger would have decreased the chances of him getting perineal hernia," I said. "Perineal hernia is more common in non-neutered dogs." The young man said: "It is cruel and that is why I don't do it." He has been advised to neuter the dog around 2-4 weeks later. As for the right perineal hernia, it is a smaller one. Wait and see. If the dog is neutered and there is
no more swelling in the backside, then there is no need to do a right perineal hernia repair.

3. High anaesthetic risks. I don't enjoy doing high anaesthetic risk surgeries as they are very stressful for me. If the dog survives, everybody is pleased. There will be deaths and the owners may be very emotional and angry. Some may post a nasty complaint in the internet. To minimise risks of deaths of old dogs on the operating table, I don't force myself to perform hernia repair and neutering at the same time. The owner has to appreciate that I don't take risks unnecessary.

Detailed report at www.toapayohvets.com

107. Lateral ear resection

Patient: English Cocker Spaniel, Male, Neutered, 5 years. Gentle dog. No Cocker Rage.
Complaint: Head shaking for several weeks. Dark red ear wax in horizontal canal. Groomer could not resolve this problem.
Solution: I advised surgery to open up the vertical ear canal so that the trapped water and debris inside the canals can flow out easily in the long term. The couple in their 40s knew what I was talking about and agreed to the surgery.

ANAESTHESIA
Jun 21, 2010. Anaesthesia and Surgery took over one hour.
Pre-anaesthetic dose Domitor 0.25 ml IV. Waited 5 minutes. Isoflurane gas. Intubate. "How about Zoletil IV?" my assistant Mr Saw asked as in the recent debarking case, I had used both.

"It is best not to give more sedation drugs than necessary. I will be using isoflurane which is safest," I advised him. "Less sedation drugs, less likely to get anaesthetic deaths. If I use Zoletil, I will need to use Atropine to prevent salivation and muscle tremors. Then I need to top up as this surgery is going to be longer than debarking as I have two ear surgeries to do. That means I still need isoflurane gas to maintain surgical anaesthesia."

Pre-anaesthetic sedation using one drug and isoflurane gas is the safest method of anaesthesia for dogs and I use this method frequently. In debarking, I had no choice but to use injectable anaesthetics and there was the hassle of topping up via the IV catheter. For gas anaesthesia, just increase the dosage and that is so convenient when the dog is intubated and given gas. For injectable anaesthetic top up, it is given by small doses via the saline drip. It is quite convenient too but nothing is as safe as the isoflurane gas.

"Any surgery consent forms to sign?" the owner had asked me earlier. "The owner can sign forms for the vet. The important thing is that the dog does not die on the operating table." Usually I assess the dog's health and the owner's personality and I seldom give them forms to sign. But I have always communicated to them the risks of anaesthetic deaths. Consent forms are common even in human anaesthesia and surgery at the Singapore hospitals.
Performance (a live dog at the end of surgery) counts a lot. I cannot be complacent as one anaesthetic death creates massive waves of emotional upheavals in the owners and the family. This English Cocker Spaniel is healthy but still no vet can guarantee the owner that the dog will not die on the operating table.

SURGICAL PROCEDURE
1. Clipped skin of ear to the base, not just partly. My assistant had to shave more, increasing the anaesthetic time. Put artery forceps to base of vertical canal to identify the location.
2. Draw the outline of the surgical area from base of vertical canal and add 50% more length (see picture).
3. Electro-incision of rectangular outline.
4. Excise subcutaneous fat to see the vertical canal.
5. Be careful of a big vein posterior to the vertical canal. If cut, ligate this vein. Elevate cut skin upwards to see the subcutaneous fat.
6. Angle forceps at 30 degrees downwards and outwards so that the drainage board is wide and clamp anterior and posterior edges of vertical canal.
7. Electro-incision on clamped groove.
8. Scissors to cut.
9. Lower the cartilage. Cut cartilage long enough to anchor it to base of skin. I stitched at the horizontal canal level first. 2/0 absorbable sutures were used.
10. Pictures to illustrate the surgical procedures are presented in:
www.asiahomes.com/singaporetpvet/dogs/0750Schnauzer_lateral_ear_resection_Singapore.htm


POST-OPERATION CARE
Tolfedine painkiller injection after surgery and orally for the next 4 days were quite effective in controlling the pain. Dosage was 4mg/kg whether by injection or oral. An e-collar was given.

I asked the owners to take the dog home on Day 4 to reduce costs for them. Ideally I would like to keep the dog for 10 days to ensure complete healing but there is always the increase in veterinary costs for the owner and this may not be in their interest.

"The left ear has a stitch breakdown on the lower right side," I said to the couple. It will close. Do not wipe the wound. The stitches will dissolve usually. I need to review in 14 days from today."

TIPS: Socialising and 3 vaccination advices for puppies in Singapore

Vaccination Schedule at Toa Payoh Vets is as follows:

1. Most puppies to be vaccinated between 6 to 16 weeks at 3-4 weeks intervals
lst vaccination at 6 - 8 weeks
2nd vaccination at 9 - 11 weeks
3rd vaccination at 12 - 14 weeks

2. Breeder's puppies and puppies at high risk
lst vaccination at 6 weeks and then 3-4 weekly.

3. Annual vaccination advised. Although there are vaccines which require 3-yearly revaccinations, these are NOT available in Singapore. They don't cover the 3 core vaccinations (canine distemper, canine parvovirus and canine hepatitis using the CAV-2 vaccine).

4. Kennel cough (Bordetella and canine influenza) vaccines are tiven twice at 6 weeks twice. At least a week before the puppy goes to socialisation class or boarding. Breeders and pet shop puppy sellers in Singapore do NOT vaccinate against kennel cough which may cause pneumonia in puppies though it is like a common cold for adult dogs.




Socialisation classes
Unsocialised puppies can become aggressive or shy. They need to socialise before 12 -16 weeks of age.

Canine parvovirus is the main risk and they do kill puppies. The environment can infect puppies as the virus remain there.

Canine distemper and hepatitis are uncommon in Singapore. Owners have to take the risk and benefits.

Advices:
1. Take the socialisation classes when puppies are 14 weeks of age and have received at least 2 parvoviral vaccination.

2. Attend classes which are not full of puppies, e.g. animal shelters, dog park or veterinary clinic. A place with easy to clean impermeable floors. A 1-to-30 leach-water solution will kill the parvovirus. Not possible to bleach grass and soil. Staff to clear faecal deposits, not owners.

3. Small class size and less than one hour of training reduces risk for your puppy.

105. Sunday Two Highlighted Cases - Can't stand up on hind legs + backside swelling

Sunday's Highlighted Case - June 20, 2010

I was surprised to see the young couple bringing the old Miniature Schnauzer with the large cheek tumour I had excised on Jun 14, 2010 to see me on Sunday. The case is recorded in: Large cheek tumour & 15 rotten teeth.

"What happened?" I asked.
"He had been crying loudly at night for past 3 nights (Jun 17-19)," the young lady said. "The neighbours thought the dog was abused and enquired about him. He just could not stand up. Previously a vet had diagnosed hip arthritis."

PALPATION
1. T/L to L/S spinal area painful.
2. Extended right hip. Dog screamed in pain.
3. Extended left hip. Dog showed painful reaction.

CHEEK TUMOUR EXCISION EXAMINATION
"The dog will not allow me to open his mouth," the lady said when I wanted her help. I wanted to see whether the large ulcer after excision of the cheek tumour had healed well. I put the dog on the table and opened the right cheek. The stitches had broken down. The ulcer was reddish but otherwise not infected. The dog did not object to the lady opening his mouth now.

"He had painkillers called tolfedine tablets of 60 mg/day for the last 7 days," I said.

"Did he behave like a young puppy by running wild?" I asked. "Painkillers made him feel good and over-exert his muscles and joints."

"Yes," the lady said. "He was most active unlike other times when we took him outdoors. He would lift his hind leg, either left or right and pee at every vertical surface till the last drop of urine. This is his usual habit."

I explained: "The reason he cried at night and could not get up on his hind feet is that he has painful hip joints and back after the exercises. Now you have to restrain him from any activity for at least one month."

I proposed that the dog be neutered to reduce his urine-marking obsession. But the owner was not keen on the idea. The male dog lifts up mainly his right hind leg to balance weight while peeing on vertical surface. So, the extra weight puts pressure on the right hip. Therefore the right hip became very painful. However, he would switch to the left leg. So both hip joints are painful. What did he do then since he had to urine-mark at all cost? "Oh, he just squat and pee on the ground," the owner said. After enjoyment during the evening of urine-marking, the dog felt the intense pain at night for 3 nights. The neighbour was concerned and so the owner came for consultation.

I did not suggest any X-rays as the owner wanted the least cost treatment and a vet had previously diagnosed hip arthritis. X-rays are needed for more detailed examination and diagnosis of hip arthritis but economics prohibit me from further investigation.

CHANGES OF LIFE-STYLE ADVISED
1. No walking over the drainage grate from void deck to grass during outdoors exercise for the next one month or more.
2. Use of a anti-obesity dry food diet. If the dog loses 1 kg, his hip joints would bear less weight. It is easier said than done as some old dogs just love to eat and put on weight easily.

Neuter your male dog at around 6 months to prevent obsessive urine-marking. During old age and weight gain, the hip joints may be worn out due to weight bearing from the lifting of the hind leg to urine-mark.


PERINEAL HERNIAS
Boston Terrier, Male, 7 years (not neutered because it is too cruel).
Two moderate sized swellings on perineal area.


Complaint: "Squats down longer to poop than usual for past 3 weeks. Hard for stools to be passed out during the first week." Vet 1 prescribed stool softeners 3x/day yesterday. Stools loose now.

104. Laryngotomy - Debarking

JR Male Neutered 10 years old

As last resort, the young girl had to de-bark her dog due to complaints.
I noted a plastic spiked collar (with spikes facing the neck).

1. Blood test done first on Jun 11, 2010.
Normal except that kidney shows in umol/L that urea is 3.9 (4.2 -6.3), creatinine is 61 (89 - 177). Dog was OK for surgery.

2. Jun 17, 2010 Weight
Laryngotomy





Jun 17, 2010 6.5 kg 39.2
2 pm Surgery
IV drip
Domitor 0.2 ml IV, Zoeletil 100@ 0.1 ml IV
Atropine 0.5 ml IV


Anaesthesia insufficient. Needed to top up Zoletil 100 0.1 ml IV

103. Webmaster uses asiaone.com to search "dog dental scaling"

A webmaster acts immediately to get rid of his dog's bad breath
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 19 June, 2010
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
Friday Jun 18, 2010 6.38 pm.
In the morning of Jun 18, 2010, I received an e-mail:

Hi, i have a 5 year old Bichon that is having tartar build up in his mouth. i would like to fix an appointment with you to have his tooth clean/ extract due to the bad odour coming from his mouth, please feel free to contact me at (tel and name given) so we can see to this problem ASAP
Regards
I asked my assistant Mr Saw to phone the dog owner. I was surprised that this bespectacled young man who would be in his early 30s really got his dog down to the Surgery in the afternoon for dental work. When he came for his dog at 5 pm, I sought feedback from him as to how he had tracked me down.

The young man said: "I use asiaone.com inserting "dog dental scaling" to find a vet who could do dental scaling for his dog and found your website. I then e-mail to you."

I usually "google" for webpages and had never considered asiaone. However I switched on asiaone.com to check its efficiency in search by using "dog dental scaling". The free-lance webmaster of 5 years had highly recommended this search engine as it specialises in locating local webpage searches.

I log in via Firefox but the search had problems loading. So I tried again for another 5 minutes and switched from Firefox to Internet Explorer. I had this unreliable Starhub internet USB plugged into my desktop as the Toa Payoh Industrial Park in Lorong 8 was not wired and could not receive wireless internet. So, the problem might be my internet connection. Just as I was about to give up, the search results via the "Web" search page displayed
toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm. This was the webpage the webmaster said he saw "pictures of dogs doing dental scaling." At first I could not understand what he meant till I saw pictures in this webpage.

It was a pity that asiaone takes a long time to download this evening at 6.49 pm. I google "dog dental scaling" and the search results came out within 0.23 seconds. I found
bekindtopets.com/dogs/20080828Dog_Dental_Problems_Singapore_ToaPayohVets.htm
on the 2nd page.

Many young people search for info on the internet. This webmaster research everything he needed to know about dog dental scaling, including anaesthetic risk and other worries. I had a good chat and learnt much about the pros and cons of online data base (Access recommended by him), domain hosting in Singapore v. in the U.S (he prefers Singapore) and fees for setting up a website (varies from $500 to $50,000).

The webmaster's 5-year-old Bichon Frise kept pawing him while we talked, as if the dog wanted to go home. "He is an attention-seeker," the webmaster told me as he answered a phone call saying he would be back soon. "It's my mum who wants to see the dog," he said to me. I thought it was his girlfriend or wife. The webmaster decided to microchip his dog and get a dog licence too.

Anaesthestic reactions to isoflurane
I used Domitor 0.1 ml IV via the IV drip. The dog was intubated but he just would not be fully anaesthesized after intubation. He kept moving when he should be asleep soundly as in the previous case of the Shih Tzu with cornea ulcerations and 3rd eyelid flap surgery. I had given this dog xylazine 20 @ 0.2 ml IM, masked with isoflurane gas and then intubate and maintain with the gas. The dog slept like a log as I did the 3rd eyelid flap for two eyes.

"There are a few dogs that just cannot be fully anaesthesized by isoflurane gas," I explained to my assistant Mr Saw when the Bichon Frise was still moving. "It is something like drug resistance from certain bacteria. Or an allergic reaction. You need to take out the endotracheal tube and use the mask to deliver the anaesthesia. If you continue, the dog may vomit out fluid and get inhalation pneumonia when the vomitus flows into his lungs."

I took out the endotracheal tube and use the mask. Mr Saw nodded his head. He had picked up much knowledge working in Toa Payoh Vets which is a small practice and so he could be hands on in various aspects of the practice.

He had ambitions to be his own boss and start his own veterinary practice in Myanmar and I expect him to do well. Mr Saw had told me yesterday that the anaesthestic machine was malfunctioning as a dog anaesthesized by my associate Dr Jason Teo was not fully asleep. Yet he saw the Shih Tzu sleeping very well just before the Bichon Frise and therefore the anaesthetic machine was operating normally.

As for the webmaster's Bichon, only the left upper premolar 3 had roots exposed. I had it extracted as this may be the cause of him feeling the pain and moody when the Chihuahua approached him to play. Nobody really knows but the webmaster suspected that this could be the problem.

Difficulty in brushing the back teeth
Many dog owners in Singapore have difficulty in using the finger tooth brush to clean the dog's teeth. The dog would just run away or refuse to open his mouth or bite.

TIP:
I advised him to use something the dog like, put it on the finger tooth brush as the dog had been avoiding him whenever the dog sees his finger brush and the canine tooth paste. "Use some food the dog likes e.g. cheese and put on the toothbrush. So the dog looks forward to tooth brushing every day." Human beings are devious creatures.

I told the webmaster that the tartar will build up again and bad breath will return after a year if he does not brush his dog's teeth daily or at least 3 times per week.

P.S
On Jun 19, 2010 at 1.38 am, I tried www.asiaone.com and do "dog dental scaling" search. The results were <1 second at:
rednano.sg/sfe/allsearch.action?allsearch=true&view=dir&querystring=dog+dental+scaling

I could see, on the right column, the following:

Marine Pet Image - One-Stop Pet Shop in Singapore:...
Visit PGA Website dog dental scaling before dog dental scaling after CHARGES Toy $80-$100 Med $100-$120 LG ...
www.marinepetimage.com/Dental.htm - 13k

20080816Fistula_Oronasal_Dog_ToaPayohVets v...
...of 3 year old dog having dental scaling. An annual dental...9-year-old dog having dental scaling and check up... Try to get dental scaling done when your dog is less than 5...
www.bekindtopets.com/dogs/20080828Dog_Dental_Problems_Singapore_ToaPayohVets.htm
- 35k

031208ASingapore Toa Payoh veterinary dog c...
...2005. Regular dental scaling means that the dog's teeth will...plaques as the dog grows older...than never to do dental scaling. If there is...drop off. The dog just can't...
www.toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm - 31k
You need to go to "Web" section to do your search correctly. If you go to the "News" section, you will get no satisfaction. It seems that asiaone.com is worth considering when one looks for Singapore businesses.

Updates are at www.toapayohvets.com

102. Dwarf Hamster has a cystic right paw

Young couple.

"The right paw shrinks and swells over the past month," the fair complexion young lady held the 15-month-old hamster in the palm of her hand for me to examine.

This is an uncommon case. The right paw had a plastic bag of light yellow fluid.
"What is the cause?" she asked.
"It is probably an embedded foreign body," I noted that the right paw was inflamed because the hamster had been trying to lick away the cyst. Whenever the cyst was broken by bites, it shrank. Then the bite wound closed and the cyst swells again.


So is there a permanent cure?

I advised the young couple: "It is difficult to know what is the exact cause. I have to cut the cyst under anaesthesia, check for abnormal tissue and and drain away the contents inside it. Hopefully, the foreign body -- probably a splinter would be removed."

I used a small sized scalpel blade to cut the cyst from toe to over the wrist for a length of 1 cm. There would be no point doing a small cut as the cyst would form again. Yellowish fluid shot out. It would be 1 ml but seemed to be 3 ml as the fluid scattered onto the operating table.
"This hamster is overweight," I was worried about the high risk of anaesthesia in plump pets. The hamster also had a red wart below the left paw. So, there would be two surgeries in one.

5% issoflurane gas anaesthesia using a plastic container enclosing the dwarf hamster was sufficient to prevent pain. "Don't wait for this hamster to close the eyelids," I said to my assistant. "By then, it would be dead." Fat hamsters are very high risk. The owner expected nothing but a hamser alive at the end of the day.

The surgical anaesthesia seen in the dog and cat cannot be observed in hamster anaesthesia. However, the pedal reflex was present in the case when the anaesthesia was lighter than needed. The hamster just pulled back its front paw as I incised. More gas for less than 5 seconds. Repeat. Incise. Cleaned up wound.

The surprising finding was a large vein from the left to the right across the carpus. Could there be an obstruction of this vein, leading to exudate from the vein into the subcutaneous tissue, causing a big cyst to form?

The wart was easily removed. Lots of bleeding but not life threatening.

The hamster seemed much more active after its right paw was back to normal size. I did not stitch up the wound. The skin was reddish and soft. "Just use a facial cotton and clean warm water to clean the wound," I advised when the gentleman asked whether he should use saline. Hamsters don't like saline or dettol onto its body.

I advised not giving the bread to reduce the weight of the hamster. Worm meals and sunflower seeds should be cut down too. 64 grams should be reduced to 54 grams for this dwarf hamster.