Female Reproductive Surgery Flashcards
1
Q
what are indications for a spay?
A
- elective sterilization
- prevention of mammary neoplasia
-feline mammary neoplasia: 7 fold higher risk if intact, majority are malignant, most commonly spreads to lymph nodes and lung
-tx: radical mastectomy recommended - prevention or treatment of uterine or ovarian disease
-cystic endometrial hyperplasia
-pyometra
-ovarian neoplasia
-uterine neoplasia
-uterine rupture or torsion - hormone level modification
-idiopathic epilepsy and diabetes mellitus change in response to the cycle
-vaginal hyperplasia, fibroadenomatous mammary hyperplasia
2
Q
describe radical mastectomy
A
- typically a bilateral staged procedure
- remove first mammary chain, wait 2-4 weeks, then remove second mammary chain
3
Q
describe fibroadenomatous hyperplasia
A
- benign mammary lesion
- hormone dependent growth disturbance of young, intact cats (<2 years)
- may develop ulceration, ischemia, or necrosis
- diagnosis:
-typically based on history and signalment
-can biopsy to confirm - treatment:
-removal of hormonal influence
-OVE/OVH
-regression over weeks to months: if no regression, may need bilateral mastectomy
4
Q
describe mammary cancer in dog
A
- approx 50% malignant
- surgical removal recommended as a portion of treatment
- commonly single or regional mastectomy (unlike cats)
- incidence related to timing of OHE
-prior to 1st estrus: 0.5%
-after 1st estrus: 8%
-after second estrus: 26%
-after 2.5 years of age: no benefit
5
Q
describe pyometra
A
- uterine infection: fluid contains bacteria and neutrophils
- can be open or closed: refers to state of cervix
-closed more dangerous: risk of rupture - cystic endometrial hyperplasia-pyometra comples is a progesterone dependent condition
-without ovaries, there is no progesterone and CEH-pyometra cannot occur
6
Q
describe surgical considerations for pyometra (4)
A
- make a large incision
- will have increased blood flow; need good ligatures!
- handle the uterus gently
- can be sick and more challenging under anesthesia
7
Q
describe technique for ovariohysterectomy
A
- prep with a neat, wide clip, allowing the opportunity to extend the incision should the need arise
- count sponges prior to surgery!
- approach:
-ventral midline typical although flank spay used in some regions
-for ventral midline: cut from pubus to xiphoid;
–dogs: cranial 1/3
–cats: middle 1/3 - increase exposure; makes it easier!
-when you are learning, when something goes wrong, or when you expect something could go wrong (pyometra, pregnancy, estrus) - find the uterus and ovaries:
-cats: easiest just to move bladder laterally, uterine body will be between bladder and colon
-dogs: use the spay hook to find the uterine horn - once you find the uterine body:
-trace it to the ovaries
-apply a clamp on the proper ligament; provides a sturdy anchor for caudal retraction - breaking the suspensor ligament
-dog: caudal medial traction on the proper ligament with hemostat, follow on the lateral aspect of suspensory ligament as cranial as possible to tear it, place craniomedial (push lateral to medial) force on the suspensory ligament at the junction with the body wall (no caudal motion! could rupture pedicle instead)
-cat: ovaries and suspensory ligament are much more mobile; can rupture suspensory ligament with two hemostats just cranial to the ovary
- after you tear the suspensory ligament, pull the ovarian pedicle STRAIGHT up to expose the vascular pedicle
- 3 clamp technique may be overkill in small dogs and cats, nothing to crush, so use 1-2 clamps
- ovarian pedicles: 2-0 or 3-0 typically
-cats: 2 encircling ligatures
-dogs: modified miller’s knot, modified transfixation ligature - broad ligament:
-make window, isolate vasculature, place clamps
-tear the broad ligament in cats and small and medium sized dogs
-can ligate the broad ligament in large dogs/dogs in heat to minimize hemorrhage - uterine body: you don’t need to take the whole uterus!
-do not ligate fat!: ureters live in the fat on either side of the uterus
-clamp uterus in medium and large dogs, clamps will tear uterine body in cats so typically not used
8
Q
describe finding the uterus in a cat
A
- the ovary is visible, not hidden by a bursa (hidden in dogs)
- suspensory ligament is not tight
- uterine body is not mobile
- not a lot of fat in broad ligament
- easiest way to find uterus in a cat is to look under the bladder
-ID uterus and trace it up to ovary
9
Q
describe finding the uterus in dogs
A
- using the spay hook: go in lateral, rotate, sweep medial to grab uterine horn/ovary
-aim caudolaterally!
10
Q
describe quality control for a spay
A
- check pedicles before you release and after uterus is out
-slow release into abdomen, watch to see if bleed once remove tension - check uterine stump before you release and after uterus is out
-same as above - mop gutters
- check to ensure complete removal of ovaries
-ovaries exposed in a cat, hidden in the ovarian bursa in a dog! - count sponges!
11
Q
what are potential causes of hemorrhage in a spay?
A
- tearing during rupture of suspensory ligament
- incomplete ligation of the ovarian pedicle
- loose knots:
-placing knots too close to clamps
-not flashing clamp during tightening
-pulling up when tightening to create a half-hitch; PULL YOUR KNOTS FLAT
12
Q
what do you do if hemorrhage occurs during a spay?
A
- extend incision to increase exposure!!!
- biological retractors
-right pedicle: descending duodenum
-left pedicle: descending colon - soak up blood with sponges
- grasp the bleeding tissue with your forceps and lift up
- clamp tissue with hemostats
- ligate tissue: double ligate if possible
13
Q
compare and contrast ovariectomy (OVE) versus ovariohysterectomy (OVH)
A
- OVE becoming more common
-most commonly performed laparoscopic procedure
-involves removing just the ovaries, leaving the uterus behind - incision is slightly more cranial
-breakdown the suspensory ligament
-ligate pedicle
-ligate ovaria vessels at cranial tip of uterine horn approx 5mm from proper ligament - abdominal hemorrhage risk comparison:
-should be similar
-maybe greater chance in OHE: larger uterine vessels near uterine body, iatrogenic trauma from traction - vaginal hemorrhage risk:
-potentially less risk with OVE bc lumen is not entered
14
Q
describe ureteral ligation during a spay OVH versus OVE
A
- most often distal ureter is ligated, but can be either site
-could be proximal - unable to ligate distal ureter with OVE: may have less risk
15
Q
describe ovarian remnant OVH vs OVE
A
- more caudal position of incision for OVH may reduce ovarian exposure
- similar ovarian exposure results in longer OVH incision
- two ligatures in OVE may predispose to leaving a small bit of ovary
