Equine Female Repro Surgery

Question 1

1. What mares tend to need episioplasties?
2. When else may episioplasty be performed?

Answer 1

1. • Poor peritoneal conformation.
     - Previous foaling trauma.
     - Pneumovagina.
     - Faecovagina.
     - +/- urovagina (2 degrees to Pneumov).
2. Before or after coving/AI.
   - reduce endometritis.
   - reduce risk of ascending placentitis.

Question 2

1. Restraint for episioplasty.
2. Goal of episioplasty.
3. How to perform episioplasty (basic).

Answer 2

1. • Stocks alone adequate for most mares.
     - Sedation occasionally.
2. Improve vulval seal.
   - to improve vaginal and endometrial environment pre/post covering.
   - allow subsequent cover attempts?!
   – breeding stitch.
3. • Assess pubic brim level and aim to extend repair beyond this.
     - Surgical prep (clean).
     - Inject LA into proximal part of vulval lips.
     - Remove narrow margin (few mm) of tissue from vulval lips.
     - Suture or staple closed.

Question 3

1. Goal of episiotomy.
2. When would an episiotomy be performed?

Answer 3

1. Remove obstruction caused by vulval lips at birth.
2. Post Caslicks.
   - 2w before foaling date.
   - Can tack back together w/ umbilical tape if v poor seal then watch and remove at foaling assisted.
   - Vertical incision – through previos scar tissue.
   At foaling if dystocia and insufficient space to deliver foal.
   - At 10-11 or 1-2 on clock face to avoid anus if tear further.

Question 4

1. Presentation of urovagina.
2. Dx urovagina.

Answer 4

1. Often thin multiparous mare.
   Sloping vaginal floor.
   Consequences of urovagina.
   - Vaginitis.
   - Cervicitis.
   - Endometritis.
2. Exam w/ speclum.
   Rectal US - NB endometritis (ddx and sequelae).
   Perform cytology on fluid (ddx from uterine infection).

Question 5

1. Goal of urethral extension.
2. When would you perform a urethral extension?
3. How to perform urethral extension.

Answer 5

1. Extend urethra so urine exits more caudally.
2. Before breeding to remove effect of urine pooling on endometritis on infertility.
   Well before natural covering.
   - ID at prebreeding check.
   - End of breeding season in Autumn better.
3. • Catheterise bladder.
     - Incise vaginal floor mucosa and blunt dissect.
     - Pull together over catheter.
     - Inverting closure.

Question 6

1. Goal of uteroplexy.
2. When to perform uteroplexy.
3. How to perform?

Answer 6

1. Elevate a dependant uterus so allowing fluid to drain out via cervix rather than pooling.
2. Usually in multiparous / older mare.
   Overcome uterine flid accumulation.
   Performed when barren.
3. • Standing laparoscopy surgery.
     - Fix uterine horn to dorsolateral abdominal walls.

Question 7

1. How is c section usually approached in horses in UK?
2. Indications for equine c section?

Answer 7

1. Ventral midline GA.
2. Emergency.
   - Dystocia.
   - Uterine tear.
   - Uterine torsion.
   - Ruptured prepubic tendon.
   Elective.
   - Terminal (mare).
   - Pelvic injury.
   - Gnotobiotic foal.

Question 8

1. Goal of c section.
2. Pre-op drugs for equine c section?
3. Anaesthesia for equine c section?

Answer 8

1. Remove (live) foal.
   Deliver <20mins from start of surgery.
2. • Fluids.
     - Prophylactic broad-spectrum ABX.
     - NSAIDs.
     - Epidural?
3. Choice if foal alive/dead.
   Minimise uterine haemorrhage.
   - Avoid halothane, isoflurane better.

Question 9

1. Teams for equine c section.
2. Approach to equine c section.

Answer 9

1. Anaesthesia – mare.
   Surgeons – mare.
   Medics – foal resuscitation.
2. Mare in dorsal recumbency.
   - slight skew improves venous return.
   Aseptic prep.
   Incision options:
   - Midline ventral (faster, less bleeding, easier to extend, familiar).
   - Low oblique left flank (Marcenac).
   ID and exteriorise gravis horn.
   Isolate w/ swabs.
   Incise uterus.
   - greater curvature.
   - over foal limb usually (hock to fetlock).
   - long enough to avoid tearing.
   - be ready for haemorrhage.
   Incise placenta (allantochorion).
   - scissors or scalpel.
   Ropes on foal limbs.
   Elevate foal:
   - strong tall surgeon.
   - winch.
   - lower table.
   If foal alive:
   - lay beside mare for little while (until umbilical artery stops pulsing and foal breathing).
   - hand over for resus.
   If foal dead:
   - cut umbilical cord (may need to suture if still bleeding mare side).
   Remove fluid (lochia) by suction.
   Remove placenta.
   - entirely if loose.
   - partially around incision site if adherent.
   Sterile lavage.
   Haemostatic suture.
   Inverting closure (Utrecht) x2 uterus then oxytocin.
   Routine abdominal closure.

Question 10

Ebryotomy.

Answer 10

• Dead foal.
• Experienced clinician.
• Take great care – huge risk of causing damage to mare.
• If cutting blindly, se foetotome to minimise iatrogenic damage.
• Single cut is preferable.
  – E.g. remove FL incl. scapula.
  – OR remove head.
  – Need more cuts if transverse presentation.

Question 11

Complications of dystocia.

Answer 11

• Repro tract trauma.
  – uterus / cervix / perineum.
• RFM.
• Delayed uterine involution.
• Bladder prolapse.
• Metritis.
• Arterial haemorrhage.
• Neuropraxia.
• Pressure necrosis.

Question 12

1. When is a cervical laceration usually sustained?
2. When should the cervix of a dystocia patient be examined?
3. How to examine.
4. Consequences of cervical tears?
5. Goal of cervical laceration treatment?
6. Outcome of treatment?

Answer 12

1. At birth.
2. 3w post partum.
3. Visualise w/ speculum.
   Palpate around 360 degrees.
   Note that mucosa can heal over muscle deficit.
   Not all lacerations require repair.
4. • Endometriosis.
     - Failure to conceive.
     - Abortion.
5. Recreate functional seal.
6. Post of fertility 75%.

Question 13

1. What if uterine laceration identified before birth?
2. What if uterine laceration identified after birth?
3. What condition is imminent w/ uterine laceration?
4. Management of uterine laceration.

Answer 13

1. • Perform c section.
     - If foal known to be dead and laceration to uterine body esp. near cervix, consider repair 1st before delivering foal.
     - If foal alive, deliver foal but may repair laceration before incision.
2. Consider location.
   - GA midline ventral.
   - Laparoscopic.
3. Peritonitis.
4. • ABX.
     - NSAIDs.
     - Antiendotoxic drugs – polymixin.
     - Lavage.

Question 14

Degrees of perineal tearing.

Answer 14

1st degree - vulva lips and/or vaginal mucosa.
2nd degree - vaginal submucosa +/- perineal muscles.
3rd degree - complete disruption recto vestibular shelf – common opening.
4th degree - penetration from vagina into rectum – anal sphincter intact.

Question 15

Treatment of 1st and 2nd degree perineal lacerations.

Answer 15

If minimal bruising,
- repair when fresh (as Caslick’s).
- small may leave to heal by granulation, but consider how this may affect vulval seal.
If severe bruising,
- may perform temporary repair of skin to prevent faeco and pneumo vagina.
- allow swelling to resolve, wash daily then repair.
Possibly from episiotomy.

Question 16

Treatment of 3rd degree perineal laceration.

Answer 16

Leave to granulate.
- clean daily.
Potential to stage repair.
Goal is to recreate separate rectal/anal and vaginal/vulval structures.

Question 17

Method of 3rd degree perineal repair.

Answer 17

Incise horizontally across mucosal junction in cr-cd direction.
Dissect up under rectal mucosa.
Dissect down under vaginal mucosa.
Close rectal mucosa together.
Close vaginal mucosa together.
Close peritoneal body.
Close skin between anus and vulva.

Question 18

3rd degree perineal repair after care.

Answer 18

Ensure soft faeces to allow healing.
- Grass diet.
Provide time to heal before covering again.
- Likely faecovagina will cause endometritis.
- AI rather than natural covering.

Question 19

1. What is a recto-vaginal fistula caused by?
   2.

Answer 19

1. Forceful kick from foal during birth; through vagina wall through rectum then retracts.
   - if no retraction&raquo_space; 3rd degree perineal laceration.
   Partial dehiscence of 3rd degree repair.
   - less likely if 2 staged repair.

Question 20

1. Indications for caudal female repro tract surgery.
2. Until when should healing of the caudal female repro tract be delayed?
3. General method of caudal female repro tract surgery?

Answer 20

1. Injuries sustained during birth.
   - unassisted foaling.
   - dystocia.
   - primparous mares.
2. • Tissue oedema and necrosis gone.
     - Healthy granulation bed.
3. Standing sedation and epidural.

Question 21

Indications for ovariectomy.

Answer 21

Behavioural changes.
- “Marey” mare in oestrus – altrenogest trial 1st.
- Granulosa cell tumour.
Large ovary.
- Granulosa cell tumour.
- Melanoma.
- Terratoma.
- Adenocarcinoma.
- Haematoma/abscess.
Stud use (AI collection).

Question 22

1. Ovariectomy technique options.
2. Base decision for ovariectomy technique on…

Answer 22

1. Laparoscopic.
   - Flank.
   Laparotomy.
   - GA ventral midline.
   - Paramedian.
   - Median.
   - (Flank).
   Colpotomy.
2. • Pathology.
     - Ovary size.
     - Mare size.
     - Temperament.
     - Experience.
     - Finance.

Question 23

1. How do mares w/ granulosa cell tumours present?
2. Malignant or benign?

Answer 23

1. • Any age mare – most are 5-9.
     - Aggressive mare w/ stallion like tendencies.
     - Nymphomania.
     - Persistent oestrus behaviour.
     - Poor fertility.
2. Benign - rarely spreads, hormonally active.

Question 24

1. Dx of granulosa cell tumour.
2. Tx of granulosa cell tumour.

Answer 24

1. Rectal ultrasound exam.
   - 1 large and 1 small ovary.
   - Multiple cystic structures.
   Serology.
   - Antimullerian hormone.
   - (Inhibin).
   - (Testosterone).
2. Remove affected ovary.
   - Laparoscopy.
   - Laparotomy.

Question 25

1. Advantages of laparoscopic ovariectomy.
2. Disadvantages of laparoscopic ovariectomy.

Answer 25

1. Standing sedation.
   Minimally invasive.
   Good visualisation and manipulation in site.
   Good haemostasis.
   Minimal complications.
   Quicker return to work.
2. Flank incisions - large ovaries?
   Expensive - equipment / experience.