Ovariectomy/Ovariohysterectomy Flashcards
What is the ovarian pedicle?
where blood vessels run – it is not one vessel – not single artery, often multiple, small vessels,
What does your decision about the hole in the broad ligament depend on?
What you can see in the site
When you make a wide pedicle - what should be included?
All vessels
Where is the ovary in relation to the kidney?
Caudal pole
What forms the ovarian bursa and what is it?
• Double fold of peritoneum forms the ovarian bursa – a pouch enclosing the ovary
How does the ovary attach to the body wall?
Ovary attached to body wall dorsolaterally by mesovarium = cranial portion of broad ligament Mesovarium is a double fold of peritoneum
What does the mesovarium enclose and where does it attach?
The suspensory ligament, which attaches to the last rib
What does the suspensory ligament continue as caudally?
Proper ligament
What is the mesovarium continuous with? What do these comprise?
Mesovarium is continuous with the mesometrium – together they comprise the broad ligaments and attach the uterus and ovaries to the dorsolateral body and pelvic walls.
How do you approach OGE in the queen?
- Iliac crest, sublumbar muscles under crest, caudal extent of ribs. Initial incision cm by iliac crest – people make triangle with fingers
- Skin incision, split muscle fibres, cut out subcut fat, to fascia level of abdominal oblique muscle, cut through muscles,
How do you approach OHE in the bitch?
- Ventral midline coeliotomy. Surgeon pulling on suspensory ligament. Commonest way- caudal direction gentle traction. Hole into broad ligament – made wide so pedicle will include arteries. Using 3 clamp techniwue – crush clamp, putting sutures – modified millers. Encouraged to put two ligatures on each side.
- Ligating cervix- may ligate each artery then around all. Or transfixing – through cervix, throw on it and take it round other side.
What are the indication for flank vs midline? (3)
- Enlarged mammary gland due to lactation
- Mammary gland hyperplasia
- Older procedure when people were not good at stitching midline and the suture material was not very good
- If something went wrong, animal unlikely to eviscerate
What are the contradications for falnk? (5)
- Pregnancy
- Pyometra
- Oestrus
- Obesity
- Patient age younger than 12 weeks
What are the advantages of flank? (2)
- Evisceration is less likely if the body wall incision breaks down
- Ability to observe incision from a distance
What are the disadvantages of flank? (3)
- Limited exposure to the patient’s contralateral side if complications arise
- Difficulty identifying a previous OHE if the animal is not properly marked
- Possible imperfections in hair colour or regrowth on the flank
Why might complications happen?
- A number of studies have reported the complications following OHE:
- 1016 dogs:19% complications
- 1459 cats: 12% complications (mostly minor)
- Most complications arise because of, or are made worse by, inadequate exposure
- Complication rates increase with surgery time
- Most common – loose ligatures – e.g. when ligatures placed too close to clamps, or when they are pulled upwards when tied
What are the most common reasons for a haemorrhage? (3)
- Ovarian arteries
- Ovarian pedicles
- Uterine arteries
- Down towards cervix
- Coagulopathy (von Willebrand)
- Dobie, do a buccal mucosal bleeding time!!
- Ensure not extended
What are the steps if we have a haemhorrhage?
- Increase exposure
- Use suction
- Convert flank to midline approach
- Stay calm, try not to panic
- Ask for assistance
- Use mesenteric dam manoeuvres to look at ovarian pedicles
- Retract bladder caudally to look at cervical stump
- Before closing, check each gutter for haemorrhage
- Retract mesocolon to right to expose left ovarian pedicle
- Retract mesoduodenum or small intestines to left to expose right pedicle
- Be very careful not to clamp ureter at this stage – elevate pedicle form retroperitoneum at this stage
What do we use to prevent failure of ovarian pedicle ligation?
Modified miller knot
What is a Fistulous tract / discharging sinus often reltaed to? (2)
- Suture material
- Permanent, braided (nylon)
- Catgut
- Swab (gossypiboma, textiloma)
- Count in and out”
- Surgical checklist!
What is Fistulous tract / discharging sinus and where is it seen?
- Soft, painful swelling with or without discharging beneath the skin of:
- Flank (ovarian pedicle ligature)
- Discharging sinus = can still get it, but usually infected
- Inguinal region, medial thigh, pre-crural region (cervical ligature)
What is this showing?
Contrast showing FB site
What is this?
Swab left in
What is ovarian remnant syndrome? Which side is more common?
- More common after ‘routine’ OHE
- Hormonal investigations (refer to Gary’s lecture)
- Very unlikely to be any other organ, possible but very unlikely
- R more common than L (?)
How can we diagnose ovarian remnant syndrome?
- CT scan (usefulness of u/s dependent on user)
- May be easier to find residual tissue when in oestrus
- Normally time we wouldn’t do procedure as more likely to bleed
- Residual tissue blood, more prominent so will see it better
- May see enlarged ovarian vessels on affected side
- Submit tissue for histopathology
What clinical signs are seen with uterine stump granuloma? (4)
- Signs consistent with infection (e.g., pyrexia, lethargic, etc.)
- Vaginal discharge (often bloody - owner might mistake for being in season)
- Attractive to male dogs
- Neutrophilia with left shift
How can you diagnose uterine stump granuloma? (3)
- Vaginal swab (?)
- Abdominal u/s
- Vaginoscopy
How can you treat uterine stump granuloma? (2)
• To resolve condition further surgical intervention will be required
Also, in most cases, a course of broad spectrum ABx
What is uterine stump granuloma commonly associated with?
More commonly associated with suture material – i.e. catgut and got a pyogranuloma within suture material due to reaction
What urinary tract issues do we get with a spay? (4)
- Urethral sphincter mechanism incompetence after OE/OHE
- Can be as high as 10-20% (esp. certain large breed dogs)
- Adhesions associated with uterine stump
- Accidental ligation of a ureter (maybe more likely if bladder distended (?))
- Accidental ligation of bladder neck
When is it most common to have urinary tract issues in a spay?
Commonest time to ligate ureter is if we have ovarian bleeding stump, when you grasp it, you do blind grab, often get ureter!! Then when you ligate it, also ligate ureter!
How to we approach a laproscopic OHE?
- Must rule out diaphragmatic hernia or won’t be able to insufflate abdomen
- Establish pneumoperitoneum -10-12mm Hg established using
- Working canula on midline 3cm caudal to umbilicus
- Two additional midline canulae placed under direct endoscopic visualisation at 30-50mm cranial to umbilicus and 30-50mm cranial to pubis
- Dog tilted to one side then other – start with left ovary
- Use bipolar or ultrasonic sealing device to cut
- Observe pedicle for haemorrhage for 20-60 secs
- Incise with scalpel to remove uterine horns and ovary
What are the benefits of a lap spay? (2)
• Less post-op pain and faster recovery
What are the possible lap spay complications? (5)
SC accumulation of CO2, omental herniation, seroma formation, minor splenic or pedicle haemorrhage
