Neutering of the Bitch and Queen

Question 1

1. Define ovariohysterectomy.
2. Define ovariectomy.
3. Define ovary sparing hysterectomy.
4. Medical method desexing females.
   – Licensed for?

Answer 1

1. Surgical removal of both ovaries and uterus.
2. Surgical removal of both ovaries only, uterus left intact. Laparoscopic spray.
3. Surgical removal of uterus and cranial cervix only, ovaries left intact. Rare in UK.
4. Temporary, not commonly used; Delvosteron (proligestone) injections.
   – Dogs, cats, ferrets.

Question 2

Indications for neutering in bitches.

Answer 2

• Population control.
• Control of hereditary diseases.
• Owner convenience – attention, bleeding etc.
• Therapeutic procedure.
  – Treatment and/or prevention of pyometra, glandular hyperplasia, torsion, prolapse, abortion, ovarian cyst, neoplasia.
• Prevention of pseudopregnancy.
• Reduced incidence of mammary tumours?
• Assist management of diabetes, epilepsy.

Question 3

Drawbacks of neutering females.

Answer 3

• Urinary incontinence – if spayed early.
• Joint disease – certain medium / large breeds, if spayed <1-2 y.o.
• Neoplasia – certain breeds e.g. boxers, if spayed <2 y.o.
• Earlier cognitive decline ?

Question 4

Timing of a bitch spay.

Answer 4

• In anoestrus – avoid seasons!
  – Uterus more friable so more risk of haemorrhage.
• Before first season (at 6m) or 3m after end of a season.
  – 3m after end of season to avoid false pregnancy (prolactin usually settled down by then). Do not spay if still having false pregnancy.
• Most benefit in terms of mammary cancer if performed before or after first season.
• Early spay at 8-12wks – may increase risk of urinary incontinence, obesity and prevalence of some cancers especially in large breed dogs.

Question 5

1. Cat spaying indications.
2. Timing for cat spaying.

Answer 5

1. • Population control.
     - Behavioural: calling, roaming, fighting.
     – consider effect on injuries and disease transmission.
2. • Transitionally: 4-6m (prepubertal).
     - Cat-Kind advocates early neutering by 4m.
     - Charities may neuter any time after weaned.
     - Can spay if in season, but increased friability / haemorrhage risk.

Question 6

Pre op check for female neutering.

Answer 6

• Confirm sex.
• Discuss what happens if they’re found to be pregnant during surgery (i.e. a termination and spay will be performed).
• Check whether they could be in season (history taking and vulval enlargement).
• Check whether they could be having a false pregnancy (history taking and check for milk expressible from mammary glands).
• Standard pre-surgical discussions re fasting / medical conditions / possible risks and complications / cost etc.

Question 7

Bitch spay: incision.

Answer 7

• Dorsal recumbency.
• Midline incision just caudal to the umbilicus.
  – slightly more caudal in prepubertal bitches
• Incision should be the length you need it to be to exteriorise, visualise and ligate tissues.
  – less trauma less stressful.
  – but shorter incisions are quicker to close.
• If right-handed, easiest to stand so that dog’s head is to your left.

Question 8

Bitch spay: finding and exteriorising the uterus.

Answer 8

• Gently use fingers (+/- spay hook) to locate uterus.
• Think about where it will be sitting in abdomen in relation to other structures e.g. bladder, kidneys
• Gloves need to be skin-tight over fingertips so can feel and identify abdominal tissues. Baggy wrinkly gloves will make surgery more difficult.

Question 9

1. Which ligament do we have to stretch/break to help exteriorise ovary?
2. Top tip for this part of the surgery.

Answer 9

1. Broad ligament.
2. Most painful part of the surgery! Warn your anaesthetist beforehand so can monitor reaction closely and prep to give analgesia.

Question 10

Ovarian peduncles: Clamp, ligate, cutting.

Answer 10

Aiming for 2 x ligature on each ovarian peduncle.
- 4 x clamps proximal to ovary. apply deepest first.
- Tie ligatures into crush of the 2 most proximal clamps.
- Cut between 2 most distal clamps .
- If cannot fit 4th clamp cranial to ovary, can go caudal to it, but be careful not to cut into ovary.

Question 11

Bitch spay: Getting your clamps on.

Answer 11

• Make hole in broad ligament through which to apply clamps. Choose avascular area.
• Some place first clamp above ovary – keeps broad ligament window open, helps control pedicle (e.g. from accidentally dropping back into abdomen).
• Ensure at least 1cm gap between 2 ligatures so they each ‘bite’ into the tissue separately.

Question 12

Bitch spay: Ligatures.

Answer 12

• Ideally, tie ligatures into a crush first.
  – Tie suture loosely around clamp.
  – Slide clamp out.
  – Tighten ligature into crush (checking nothing caught).
• Ligature and suture choice is surgeon’s preference.
  – Transfixing –> needs swaged on needle.
  – (Modified) Miller’s knot –> absorbable synthetic monofilament e.g. PDS.
  – Surgeon’s knot – absorbable synthetic multifilament e.g. vicryl.
  – Avoid catgut.

Question 13

1. What is the (modified) Miller’s knot?
2. Why is (modified) Miller’s knot useful?
3. What surgeries will (modified) Miller’s knot help with?

Answer 13

1. A type of friction knot.
   A circumferential knot that can be used for ligation.
2. Doesn’t spring open as much as a surgeon’s knot or square knot.
   A more secure ligature.
3. Spays, castrates. Anything where you have to ligate a blood vessel.

Question 14

Bitch spay: Cutting the ovarian pedicle.

Answer 14

• Cut w/ scalpel between clamps / just proximal to ovary. Cut away from yourself and patient.
• Check ovary to ensure has been removed in its entirety and not accidentally cut into.
• Grasp the pedicle w/ rat toothed forceps, released final clamp, gently lower pedicle into abdomen whilst checking for bleeding.

Question 15

Bitch spay: Repeat on the second ovary.

Answer 15

• Work your way along uterine horn to other horn, and down to the ovary.
• Repeat process for second ovary.

Question 16

Broad ligament.

Answer 16

Can be fatty and vascular.
Reduce bulk so don’t have to ligate whole thing for cervical pedicle.
Can tear but may prefer ligating to reduce bleeding.
Don’t ruin the uterine artery that runs close to the uterus.

Question 17

Uterine body.

Answer 17

Broad ligament out way, clearly see body of uterus, ligate here.
Place forceps first or if worried it’s friable, place ligature first (e.g. cat spays).
Aim for 2 ligatures and an appropriate number of clamps.

Question 18

Ligatures on the uterine body.

Answer 18

• 1 circumferential constricting ligature placed first most proximally (deepest).
• Then 1 transfixing ligature.
  – Several methods –> idea = to anchor ligature and prevent slipping off stump.
  – Place this second and more distally as risk piercing blood vessel as pass needle through.
• Cut stump above ligatures and check for bleeding as you release.

Question 19

Bitch spay: closing.

Answer 19

• Inspect ovaries to make sure have got all ovarian tissue.
• Standard midline closure in 3 layers:
  – Linea alba –> absorbable monofilament simple continuous or simple interrupted (PDS in 0 or 2-0).
  – Subcutaneous –> absorbable monofilament or multifilament in simple continuous (Monocryl or Vicryl 3-0).
  – Skin –> either external nylon sutures or most common in practice is intradermals w/ an absorbable monofilament and swages on reverse cutting needle (Monocryl 3-0).

Question 20

Why do we normally spay cats using flank approach in UK?

Answer 20

• Easier for owners to inspect surgical wounds post-op in feisty cats.
• Tradition.

Question 21

1. Easiest way to find incision site for flank cat spay.
2. If suspect pregnancy?
3. Warn owner about?

Answer 21

1. Make a triangle between wing of the ileum and the greater trochanter.
2. Midline preferable.
3. Possible temporary coat colour change due to clip.

Question 22

Other differences between cat and bitch spays.

Answer 22

• Everything smaller – often use single ligatures and no transfixing.
• More chance to be operating during season so uterus more friable.
  – Ligate w/o clamping.
  – Care when tightening ligatures not to shear through tissue.
• Smaller suture materials – 3-0 often ok.

Question 23

Closure for flank cat spay.

Answer 23

• Close muscles – don’t need to separate the layers.
• Close subcutaneous layer.
• Then close the skin.

Question 24

1. Reported benefits of laparoscopic surgery.
2. Laparoscopic spay technique.

Answer 24

1. • Faster return to normal activity.
     - Reduced post op discomfort.
2. • Ovariectomy, not ovariohysterectomy.
     - 2 or 3 ports (holes) into abdomen, through which instruments (forceps, cauteriser, camera) are inserted.
     - Good visualisation.
     – Abdomen inflated w/ CO2.
     – Camera provides magnification.
     - Blood vessels are cauterised rather than ligated.

Question 25

Main causes of complications from spaying.

Answer 25

• Surgical errors.
• Post op care.
• Procedure.

Question 26

Complications due to surgical error.

Answer 26

• Haemorrhage – ligature slip etc.
• Ovarian remnant syndrome.
• Stump granuloma/pyometra (rare).
• UTI.

Question 27

Complications due to post op care.

Answer 27

• Abdominal hernia.
• Wound infection.

Question 28

Complications due to the procedure.

Answer 28

• Obesity.
• Age at spay and breed related:
  – Urinary incontinence.
  – Increased risk of orthopaedic diseases and some cancers – unclear.
• Rare:
  – Perivulvar dermatitis.
  – Hypoplasia of external genitalia.

Question 29

What to do if surgery goes wrong.

Answer 29

• Stay calm.
• Call for backup.
• Get someone else scrubbed in.
• Ask anyone who is not directly helping you to leave the room.
• Improve visualisation. – extend incision, suction.
• Communicate w/ anaesthetist.
• Remember haemostasis options.
• Abort surgery before finished if needed.
• Ensure to discuss complications w/ owner before surgery.
• Have a debrief afterwards w/ a mentor / friend.

Question 30

1. Antibiotics for female neutering.
2. Analgesics for female neutering.

Answer 30

1. No indication.
2. Painful so excellent multi-modal analgesia required.
   - Opioid e.g. methadone (or buprenorphine in cats).
   - LA, e.g. bupivacaine, lidocaine, line block before skin incision, and/or splash block onto ligated pedicles.

Question 31

1. Post op analgesia.
2. Prevention of self-trauma at incision site.
3. Restricted exercise.
4. POC.

Answer 31

1. Dogs and cats = 5d course of analgesia (e.g. NSAIDs).
2. • Buster collar or MPS.
     - Gentle tissue handling and suturing.
3. • Traditional spay dogs = 10 days strict rest, no walks, only outside for toileting (on lead).
     - Lap spay dogs = less restrictive, can treat more like dog castrates.
     - Cats = 10d keep indoors and prevent jumping.
4. • Typically 2d and 10d (stitches out).

Question 32

Surgical preparation for caesarean?

Answer 32

• Beware causing neonatal depression – care w/ anaesthetic / analgesic agents.
• Pre-oxygenate.
• Anti-emetic (e.g. maropitant). Reduce emesis and aspiration.
• Surgical clip and place IV catheter before give pre-med.
• IVFT started before pre-med.
• Surgical equipment and theatre ready, and surgeon scrubbed in, before give pre-med.
• Keep in sternal / lateral for as long as possible.
• Intubate.

Question 33

C section technique.

Answer 33

• Speed important.
• Midline laparotomy – long incision from cranial to umbilicus to near pubis. Avoid distended uterus underneath.
• Gently exteriorise uterus and pack lap-swabs around and under to reduce spillage.
• Hysterectomy at or close to body of the uterus.
• Gentle manipulation of foetuses to extract.
• Gentle manual extraction of placentae.

Question 34

C section closure.

Answer 34

• Nursing team works on reviving neonates.
• Check whole uterus definitely empty.
• Close uterine incision (or perform spay).
  – 3-0 absorbable monofilament.
  – single layer appositional closure (simple continuous).
  – OR 2 layers, w/ outer layer inverting (Lembert/Cushing).
• Lavage uterus, remove swabs, change instruments and gloves.
• Routine closure. Intradermal skin sutures recommended to avoid irritation to neonates.