Soft tissue surgery Flashcards
0
Q
What is a pinnectomy?
A
removal of tip of ear. indications:trauma, neoplasia (SCC, MCT, MM), necrosis. Total pinnectomy for SCC - good prognosis with complete excision. total Pinnectomy performed to obtain adequate margins.
1
Q
Describe an aural haematoma and how it is treated
A
Cartilage usually split, trauma implicated, usually otitis externa. Requirements of therapy - drainage, limit scarring, prevent recurrence. Can treat with centesis +/- corticosteroids. eg 0.2% dexamethasone diluted 1:10 ins aline. Incisional drainage - sigmoid over linear incisions. Incisional drainage - appositional suture pattern spaced <1cm apart without stents. Penrose drain placement - through and through, bandage after.
2
Q
What is the aim of a lateral ear canal resection?
A
Provide direct entry to horizontal ear canal, improve local environment, facilitate medication. LECR does not cure ear disease. Indications: mild recurrent otitis externa, lesions on lateral wall of vertical canal, advanced otitis externa/media. LECR drainage board - cerumen produced at base of canal moves up to opening, moves onto baffle plate, dries and falls off.
3
Q
What is a total ear canal ablation with lateral bulla osteotomy?
A
TECA - LBO - remove ear canal + curette middle ear. treat otitis externa/media. indications: chronic otitis externa, recurrent otitis media, failed LECR, end stage ear disease, neoplasia, para aural abscesstation, ear canal avulsion. When ear canal ocluded in end stage otitis externa media, the ruptured tympanic membrane or bulging tympanic membrane, occluded horizontal ear canal, bulla opacification, thickening of bulla wall,
4
Q
What are the potential complications with TECA and LBO?
A
Retroglenoid haemorrhage, facial nerve damage - exposure conjunctivitis, lose palpebral reflex, drooping lip & ear, drop food from mouth, drool. Vestibular disease - lose balance on one side, nystagmus, positional strabismus, head tilt, vestibular ataxia. Horners syndrome - ptosis, third eyelid protrusion, miosis, enopthalmosis. Deafness, altered ear carriage. Para aural abscess, para aural sinus tract, pain and local swelling, leave epithelial lining to middle ear.
5
Q
What are the indications for a ventral bulla osteotomy?
A
Isolated otitis media - common in cats, rare in dogs.
Management of nasopharyngeal polyps. Complications include horners syndrome, vestibular disease, hypoglossal nerve paralysis,
6
Q
What are the ddx for middle ear polyps? What is the management?
A
chronic otitis media, middle ear neoplasia, nasopharyngeal neoplasia. Diagnosis: middle ear changes, nasopharyngeal mass, absence of signs of malignancy, histopathology. 1. traction - may combine with LECR for exposure. horners syndrome in 43%. 2. bulla osteotomy + TECA.
7
Q
What is the difference between the terms celiotomy and laparotomy
A
celiotomy- any incision into abdominal cavity.
Laparotomy - incision through muscle into abdomen, generally flank incision.
8
Q
What is acute abdomen?
A
Catastrophic abdominal pathology - shock,death, early surgical intervention needed.
9
Q
Describe the anatomy of the layers of the abdomen
A
3 Lateral muscles, rectus abdominus.
Aponeuroses - internal rectus sheat, external rectus sheath.
Linea alba, peritoneum
10
Q
Which structures can you access from a paracostal laparotomy?
A
Liver, stomach, adrenal
11
Q
When should a ventral midline coeliotomy inciision be made?
A
OVariohysterectomy
Liver biopsy
Intestinal obstruction.
Organ centred approach (quicker, lower morbidity) or full exploratory coeliotomy. (better exposure, more likely to achieve goal, evaluate entire abdomen.) Always clip for full abdominal surgery, mid sternum to beyond pubis to flank folds. Maximise exposure - excise falciform fat. Watch out for cranial preputial muscle, branches of caudal superficial epigastric artery and vein. Prevent tissues from dessicating with moistened swabs, lavage saline, suction. maximise exposure with abdominal retractors. count swabs in and out.
12
Q
What can be found in the cranial quadrant of the abdomen?
A
Diaphragm, liver, gall bladder, stomach.
13
Q
What can be seen in the right gutter of the abdomen
A
right limb of pancreas, kidney, adrenal, portal vein, vena cava, ureter, ovary.
14
Q
what can be seen in the left gutter of the abdomen?
A
Kidney, ureter, ovary, adrenal
15
Q
What can be seen in the caudal quadrant of the abdomen
A
Colon, reproductive tract, bladder, urethra, prostate, inguinal rings.
16
Q
How do you close coeliotomy?
A
Layer 1 - linea alba External rectus sheath is the main holding layer use simple interrupted or continuous patterns, monofilament synthetic suture material. 7 throws to start and finish. Layer 2- subcutaneous tissues. Close dead space, supports skin closure. Layer 3: skin apposition
17
Q
What are the complications of inadequate wound closure?
A
Incisional hernia, abdominal organs move subutaneously. skin incision dehisces, peritonitis, evisceration, death.
18
Q
What is peritonitis?
A
Inflammation of the peritoneum.
primary generalized peritonitis; spontaneous, no pre existiing abdominal disease. eg FIP.
Secondary generalised peritonitis - secondary to pre existing abdominal pathology. examples: rupture of GIT, urine leakage, penetrating trauma, bile leakage following trauma. infectious - bacteria, leakage, often iatrogenic. non infectious - urine, bile, foreign body, pancreatitis. Signs - history of surgery of FB, dullness, abdominal distension, abdominal pain, fluid thrill. Prolonged CRT, palor, tachycardia, weak pulses as signs of shock, signs of sepsis - p yrexia, bounding pulses, toxic mucous membranes. Diagnose with paracentesis and fluid analysis, 4 quadrant tap, or ultrasound guided tap. Loss of serosal detail on radiography. free abdominal gas, turbid abdominal fluid, identification of underlying pathology. manage shock and treat sepsis, address pathology, lavage abdomen, place drains.
19
Q
What are the normal openings in the diaphragm?
A
The caval foramen, the oesophageal hiatus, the aortic hiatus.
20
Q
How do Diaphragmatic hernias occur?
A
Trauma - 85% - high impact, increase abdominal pressure/open glottis, organ herniation at presentation is common.
Unknown - 10%
Congenital - 5%
Screening warranted for any patient following known trauma eg RTA, falls, with respiratory signs following trauma. 10% of cases do not have witnessed trauma so patients may present with chronic hernias.
21
Q
What are the signs of diaphragmatic hernia?
A
Dyspnoea & orthopnoea, gastro intestinal signs, dull on percussion, muffled heart, auscultation of gut sounds in thorax, shock, external signs of trauma,
22
Q
What will be seen on radiography with diaphragmatic hernia?
A
Plain - DV not VD, inflated lung p on lateral
Contrast - upper gastro intestinal, positive peritoneography
Loss of diaphragmatic and cardiac contours: pleural effusion/herniated organs.
Displacement of abdominal organs - stomach: apparent microhepatica, abdominal organ loss.
Gas or ingesta filled visci in thorax
23
Q
When should surgery be done for diaphragmatic hernia?
A
Immediate surgery - 35% mortality,
After stabilisation - 10% mortality
Delay surgery to stabilise patient perform surgery as soon as patient is stable. manage other injuries after hernia repair. Stabilise with cage rest, fluid therapy, oxygen, analgesia, thoracocentesis. Indications for immediate surgery include - deterioration despite supportive care, intrathoracic GDV, ongoing haemorrhage.
24
Describe the surgical approach for diaphragmatic hernia?
Ventral midline coeliotomy, pack off abdominal organs, gentle traction on cranial abdominal viscera, tilt table - head up. Location is most frequency - unilateral, ventral, costal. but dorsal easily missed, may be multiple hernias. To reduce contents: GI tract - gentle traction, parenchymatous organs - lift rather than pull: avoid avulsion, do not de rotate immediately. Enlarge hernia ring: extend radial and ventral, decompress hollow organs, gently disrupt adhesions,
25
How do you suture the defect in the diaphragm?
Simple interrupted or continuous, dorsal to ventral, radial component first, no tension.
26
How do you re establish negative pressure in the diaphragm?
Forced re expansion highly dangerous. needle thoracocentesis through diaphragm. Place thoracostomy tube if concerned over ongoing pleural disease. Complications: respiratory crisis, pleural effusion reforming, pneumothorax - previous injuries or thoracostomy tube, re expansion of pulmonary oedema,
27
What is re expansion of pulmonary oedema?
Alveolar flooding after lung re expansion, aetiology uncertain ? barotrauma, linked to forced re expansion of lung, fatal.
28
What are circumferential costal tears and how do you manage them?
Avulsion from the costal arch, shredding of costal muscle remnant. Management: anchor around costal cartilages & rib, anchor to abdominal body wall.
29
What are chronic hernias?
Large defects, empty abdomen syndrome, intrathoracic adhesions- may require sternotomy. consider referral.
30
Describe peritoneo-pericardial diaphragmatic hernias?
Congenital defects, pericardial & peritoneal cavities communicate, often not identified before adulthood. Often clinically silent, or have GI signs. rarely: cardiac tamponade, liver lobe tosion. Concurrent abnormalities may be present as well - cranial abdominal hernias, swirling hair pattern over sternum, fusion defects of sternum,
31
What may cause a closed traumatic pneumothorax?
Most common type
Fractured rib, or blunt trauma with closed glottis.
Other types: open pneumothorax, tension pneumothorax
32
What is a spontaneous pneumothorax?
Non traumatic leakage eg pulmonary cysts + blebs, abscess, neoplasia, severe pneumonia.
Management: intermittent thoracocentesis, thoracostomy tube placement for intermittent or continuous drainage (for tension pneumothorax) or surgery, Majority of traumatic pneumothorax cases seal within 72 hours.
33
When/ how can pneumothorax be treated with surgery?
Surgery - median sternotomy, intercostal thoracotomy.
| Indications - not resolving after 72 hours, spontaneous pneumothorax,
34
What is adrenalectomy?
Surgical removal of one or both adrenal glands. Done for cushings disease, phaeochromocytoma. risk of exsanguination, thrombo embolic disorders, recurrence or metastases, intra operative death, post op addisonian crisis. Rarely done in first opinion practice.
35
What is a partial pancreatectomy?
Surgical removal of part of the pancreas. Pancreatic biopsy - rarely performed but simple. insulinoma resection - 95% have metastasised, palliative only, requires evaluation of entire pancreas, requires careful peri operative management. concern over pancreatitis, concern over biliary tree damage, concern over loss of duodenal blood supply.
36
What is a thyroidectomy?
Surgical removal of the thyroid gland. indications - feline hyperthyroidism, neoplasia. A modified extracapsular thyroidectomy removes thyroid & preserves cranial parathyroid. Low recurrence rate. lower hypoparathyrodism rate. Complications: recurrence, laryngeal paralysis, hypocalcaemia (hypoparathyroidism), hypothyroidism. With hypoparathyroidism - most cases occur within 1-4 days, life threatening seizures and dysrhythmias, weakness, tremors, dullness, facial rubbing, panting, anorexia. calcium & vitamin D supplementation. Prognosis with unilateral thyroidectomy - 70% recurrence, bilateral thyroidectomy 5-11% recurrence.
37
What is the difference between gastrotomy, gastrectomy and gastrostomy?
Gastrotomy: incising
Gastrectomy: excising a portion
Gastrostomy: creating a stoma usually using a tube.
Gastropexy: fixing stomach to body wall
38
What are the risks with Gastrointestinal surgery? How can these risks be minimised?
Intra operative contamination - isolate from rest of abdomen with swabs or laparotomy pa, use stay sutures, babcock forceps, packing around site in abdominal cavity. Occlude stomach on either side of incision, stay sutures to tent incision up away from pool of fluid in stomach. Lavage and suction to remove spillage.
Post operative dehiscence and leakage - reduce risk of dehiscence with atraumatic tissue handling, use a serosal seal (wrapping serosa around incision site encourages an early water tight seal), or an omental warp. The submucosa is the holding layer use a swaged on cutting needle, use monofilament, synthetic, absorbable, use non crushing patterns. In stomach and colon as alternatives- use double layered, inverting.
Peritonitis
Iatrogenic blockage
39
What are the signs of gastric disease?
Vomiting , haematemesis, malaenia, dehydration, hypokalaemia, loss of appetite, weight loss.
40
Why do we starve patients prior to any general anaesthetic?
Reflux of gastric contents into oesphagus
Reflux oesophagitis, aspiration pneumonia
Many patients are starved for 24 Hours following 24 hours after GI surgery to reduce the risk of leakage, but in reality it is unlikely to make any difference.
41
How does anatomy affect surgery of the stomach?
There is a large collateral blood supply. the submucosa with mucosa separate easily from seromuscular layers.
42
What are the main indications for gastrotomy?
Foreign body removal, biopsy
Both gastrectomy and gastrostomy are based around the basic technique of gastrotomy. Expose the stomach, Pick avascular area away from the pylorus, Place stay sutures on either side of site, tent stomach up and isolate with swabs, Make stab incision with no 11 scalpel, extent with scalpel or metzenbaum scissors, Close site in one or two layers. incorporate submucosa in at least one layer of sutures. lavage site, suction and remove contaminated swabs.
43
What do gastric foreign bodies cause?
Obstruction, perforation, poisoning, May gastric FBs are incidental findings. signs may be intermittent if FB sits in body. pyloric obstruction can cause rapid deterioration and dramatic clinical signs. Foreign bodies often move into the intestine between diagnosis and surgery. beware there may be other reasons for vomiting. full exploratory coeliotomy. May show up on radiography if radio opaque FB. On radiography there will be gastric distension - normal fundus 6 icsp suspect pathology. Use contrast to delineate FB.
44
What is treatment of a gastric foreign body
1. Endoscopic removal
| 2. Gastrotomy
45
What is gastric dilatation and volvulus sydrome?
An acute life threatening disease characterised by rapid accumulation of gas and air int he stomach which increases pressure within the stomach, resulting in malposition of the stomach and shock. Stomach distends and rotates. dyspnoea and profound shock develop rapidly. Gastric necrosis & perforation follow. Stomach dilates with gas - aerophagia, bacterial proliferation, failure to eructate or to pass gas into intestine, Fills with fluid -food and gastric secretion, transudate from mural venous congestion, blood and mucosal slough as stomach necrosis develops. Usually clockwise rotation, 90 to 360 degrees. pylorus moves ventrally & to left. fundus moves right. The spleen displaces to right dorsal - gastroplenic ligament. congestion:stretching of splenic vessels. ischaemia : infarction or ischaemia of vessels. Intra gastric pressure increases, venous then arterial compression: venous congestion - transudation of fluid, mucosal hypoxia leads to tissue ischaemia, ultimately gastric wall necrosis and erforation. Reduced venous return to the heart, reduced circulating blood volume, cardiac arrhthmias. Diaphragmatic compression. GDV syndrome - acute abdominal crisis, recurrent gastric dilatation, chronic gastric torsion. Intrinsic risk factors: breed, conformation, genetics. Extrinsic risk factors: Diet, husbandry. Predominantly in large breed dogs - gordon stter, irish setter, poodle, Great Dane, weimeraner, St. Bernard. in some bassetts. Deep chested dogs. Diet - single source diet & once daily feeding, processed dry (ceral or soya based) but no single diet has been shown to reduce risk of developing gdv. commonest > 7 yo. 80% recurrence rate if previous episode. Presentation: rapid onset persistent vomiting fluid, tympanic abdomen, collapse. On radiography - cannot identify pylorus on right lateral, fundus distended. > 6icsp.
46
How is GDV treated?
Stabilisation must start immediately. 1. fluid resuscitation 2. gastric decompression. Derorotation is less important than decompression for preserving gastric wall. Stabilisation with fluid resuscitation at shock doses, crystalloids, colloids. Decompression with orogastric intubation with a lubricated, soft, large bore tube, premeasured to last rib, gag tied in place. or percutaneous decompression (paracentesis). Give IV antibiotics, oxygen therapy, therapy for arrhythmias, analgesia. Delayed intervention risks include gastric necrosis, perforation. Decompress and reposition stomach. 180 degrees clockwise rotation most common, check cardia & pylorus. assess stomach and spleen for necrosis- not viable- wall thinning, green, grey, black. compromised - avulsed vessels, red haemorrhagic. viable - active haemorrhage from nick, pulse, peristalsis. Partial gastrectomy: non viable areas. gastric wall invagination: questionable areas. inverting suture pattern, non viable sloughs. Splenectomy is rarely necessary. consider of persistent congestion after 10 mins of repositioning, avulsion or infarction of vessels, gross necrosis. Prevent recurrence with an incisional gastropexy - right sided antrum anchored to body wall. this prevents pylorus moving, incise seromuscular layer of pylorus and transverse abdominus muscle, suture incision edges together.
47
What are the complications of GDV?
Early post op - cardiac arrhythmias, gastric wall necrosis, peritonitis. longer term: gastric hypomotility, recurrence 5-10%.
Prognosis with gastric necrosis - 66% survival.
Gastric wall intact - 90-95% survival.
Consider elective gastropexy in high risk cases. restrict excercise before and after feeding & avoid single large feeds.
48
When is a tube gastrostomy placed?
Tube in pylorus - gastropexy for GDV
Tube in fundus - stomach tube for feeding
Cranial midline coelitomy, pull tube through tunnel in left body wall Feed tube into gastric lumen, make purse string sutures . Place pexy sutures. Secure tube to body wall with a chinese finger tap suture. Prevent patient from removing tube. Introduce feeding gradually over 72 hours. maintain tube for a minimum of 7 days to encourage adhesion formation. early removal risks peritonitis. Tube is removed by traction and site is left to heal by second intention.
49
What is a hernia?
Protrusion of a structure through a defect in the wall of its normal anatomical cavity. May be umbilical, inguinal, scrotal, femoral or perineal - often congenital or acquired degenerative,less commonly traumatic. Internal abdominal hernias and external abdominal hernias are often traumatic.
50
What is external and internal abdominal hernia?
External - Usually traumatic, herniation of organ out of abdomen through a defect in the abdominal wall. e.g paracostal hernia, prepubic: avulsion of cranial prepubic tendon, usually RTA, often associated pelvic fractures.
Internal - usually traumatic, herniation of abdominal organs through a ring/defect confined within the abdomen or thorax e.g diaphragmatic hernia
51
Describe a true hernia, why is this different to a 'false' hernia?
Congenital or acquired degenerative. contents within outpouching of peritoneum. Has a hernial sac.
False hernia - usually traumatic, contents are not restrained by a hernia sac.
52
Which hernias herniate through a natural abdominal opening?
Inguinal, scrotal, femoral - vital structures run through these
Umbilica, internal abdomina, external abdominal - do not herniate through normal body cavity opening.
53
Describe an umbilical hernia?
Usually congenital - often closed during elective neutering. foetal umbilical rings fail to close. Umbilical hernia is a true hernia.
54
What are the physical findings in an external abdominal hernia?
Asymmetry of body contour, palpable organs in subcutaneous location, hernia ring (body wall defect). Other clinical signs depend largely on the organs that have herniated, how herniation affects their function, the health of herniated organs. Use radiography/ultrasound. The contents may be reducible, non reducible, incarcerated, strangulated. In strangulated contents the organ blood supply is compromised - distension, torsion, constriction.
55
How is a hernia repaired?
Access hernia by direct approach or midline coeliotomy. Assess health of contents and take appropriate action e.g remove portion of bowel. Reducing contents may necessitate enlarging hernia ring. Ensure debride devitalised tissue in traumatic hernias. Repair hernia defect. Usually direct apposition of muscle edges. Difficult repairs - large defects; lead to tension on suture line, tension leads to dehiscence. tension free repair must be achieved. May use surgical meshes for repair such a polyproylene. If the body wall is avulsed - anchor around ribs, anchor through bone tunnels.
56
What are inguinal hernias?
Herniation through inguinal canal. contents adjacent to vaginal process. may be congenital or acquired. may be unilateral or bilateral. sex hormones, pregnancy and obesity may play a role in acquired hernias. Midline incision and dissect over hernia. consider coeliotomy if cannot reduce easily. avoid damaging externnal pudendal vessels. Advise neutering - may reduce recurrence, makes repair in male dogs easier.
57
What is a scrotal hernia?
Rare, unilateral, organs herniate beside testicular vessels and ductus deferens into scrotum. organ strangulation is common. Castrate, then repair in a similar fashion to inguinal hernia.
58
What is a femoral hernia?
Usually traumatic. herniation of organs through femoral canal. femoral artery vein and nerve located there, repair difficult. Be aware they exist. be aware they are usually misdiagnosed as inguinal hernias. refer for repair.
59
What is a perineal hernia?
Pelvic diaphragm degenerates. Rectum, prostate and abdominal organs herniate. Acquired degeneration of pelvic diaphragm, levator ani muscle. May be linked to androgens, straining (prostate), neurogenic muscle atrophy. Seen in mature, male entire dogs (93%), occasionally male neutered and female. can be unilateral or bilateral . right > left. The rectum: deviates + dilates. may be abdominal fat, prostate or retroflexed bladder. Presentation - faecal tenesmus, perineal swelling, constipation. If retroflexed bladder - dysuria, systemic collapse/acute renal failure. For bladder - cystocentesis or urinary catheterisation, reduce hernia - with digital pressure. leave indwelling urethral catheter until surgery. Treatment - with simple herniorrhaphy, or internal obturator muscle transposition flap. Castration reduces risk of recurrence. Complications: recurrence, rectal eversion/prolapse, suture penetrating rectal mucosa, faecal incontinence, sciatic nerve injury.
60
What are the indications for colonic surgery?
Biopsy, neoplasia, obstipation, fb removal rare. Must consider - gram negative anaerobes, highest bacterial flora, perioperative antibiotics indicated. Colon has linear blood supply, poor collateral circulation, care not to cause ischaemia.
61
What is megacolon?
Large intestinal enlargement and hypomotility with sever constipation/obstipation. Congenital megacolon (rare) - primary or secondary (imperforate anus).
Acquired megacolon idiopathic common in cats, secondary to colonic obstruction, (functional obstruction, intraluminal, mural, extraluminal obstruction) secondary to colonic inertia. Intraluminal and mural obstruction may be foreign body, neoplasia, stricture. Extraluminal - caused by pelvic fracture >50% narrowing, intrapelvic mass, prostatic disease, perineal neoplasia, pain. Functional colonic obstructions include acquired dysautonomias, neurological injury.
62
Describe feline idiopathic megacolon?
It is the most common form of megacolon. an acquired disorder. Uncertain aetiology - environment, stress, obesity, primary colonic inertia. Regardless of aetiology retained faeces becomes dry and impacted. large faecoliths physically difficult to pass. chronic stretching injury to colonic wall. self perpetuating cycle. prognosis for return to normal colonic function is poor. Investigation - repeated episode of constipation, neurological exam, rectal exam, radiographs eg fractured pelvis.
63
How is megacolon managed?
Rehydrate and support patient. Evacuate colon with enemas or digital evacuation. dietary modification, laxatives, prokinetic agents - aim for defecation at least once every 48 hours.
64
What is a colotomy?
it is of no long term benefit for megacolon. colonic function is unlikely to return. invasive short term measure that should not be recommended.
65
What is subtotal colectomy?
Used for feline megacolon. very sucessful. remove 90-95% of colon. removal of ileocaecocolic junction. Dogs do not tolerate this surgery. refer for surgery. Postop diarrhoea is inevitable. managable within 2 weeks. clip perineum and warn owners. faecal incontinence may occur - rare in long term. recurrence of megacolon in residual section of colon.
66
Describe large intestinal neoplasia
Common in dogs. rectum > colon. adenomatous polyps, adenocarcinoma. Colorectal adenocarcinoma - rectum most common place. they form strictures. may be annular (intramural) or intraluminal) they are extremely aggressive - poor prognosis. medical - piroxicam. surgical- 3cm margins, rectal pull through.
67
What are colorectal polyps?
usually at anocutaneous junction. pedunculated. do not invade into submucosa. local resection generally curative.
68
Describe anal sac disease
```
Anal sacculitis (impaction and infection)
Anal sac abscess + rupture
Apocrine gland adenocarcinoma - 90% female, 50% metastasised by the time of diagnosis, cause pseudohyperparathyroidism, poor prognosis. Treat with anal sacculectomy.
```
69
What causes rectal prolapse & how should it be treated?
Secondary to causes of tenesmus, should be treated as an emergency. manual reduction or surgical management.
70
What are the functions & components of diarthrodial joints
They allow movement, provide stabilisation. They are made up of articular cartilage, synovial membrane/fluid, joint capsule and ligaments, other structures - intra articular fat pads, menisci.
Articular cartilage has 4 distinct layers - chondrocytes, extracellular matrix - type II collagen, proteoglycan matrix.
71
What are the functions of articular cartilage?
Low friction, protect bone, growth zone.
Synovial membrane;
Intimal layer - type A synoviocytes (macrophages) and type B synoviocytes( fibroblasts).
Sub intimal layer - blood vessels, lymphatics, connective tissue.
84
Why are perioperative antibiotics used in liver surgery?
There is an anaerobic (clostridial) residual population - which may proliferate in ischaemic liver tissue.
85
Describe the blood supply to the liver
Portal vein - stomach, intestines, spleen, pancreas - 80%
| Hepatic artery - 20%
86
Why may a liver biopsy be done?
Diagnosis of diffuse hepatopathy, diagnosis of heritable disease e.g copper toxicosis of bedlington terriers, diagnosis of isolated liver lesions. Can either do an ultrasound guided needle biopsy or a surgical biopsy - safer for patients with coagulopathies to do surgical biopsy as bleeding can be visualised and addressed by methods that do not rely on coagulation cascade. Use guillotine method or for focal liver biopsy - gullotine technique.
87
What is a portosystemic shunt?
Common congenital liver disease, easily missed during evaluation of signs. requires specialist assessment for medical and surgical therapy. Anomalous vessels enable portal blood to bypass the liver. portal blood passes directly into the systemic circulation. Systemic effects of PSS - stunting, failure to thrive, hypoalbuminaemia, hepatic encephalopathy, dullness, aggression, failure to house train, seizures, PUPD, urate crystalluria. Extrahepatic more common in small breed, intrahepatic vessel shunts more common in large breed dogs. Cats get either. Biochemical changes: liver dysfunction, high postprandial bile acids. Diagnosis with ultrasound, portal venography, nuclear scintigraphy,
88
What is microhepatica?
Loose up to 80% of blood supply to liver. lose hepatotrophic factors in portal blood, chronic liver insufficiency. Seen with pss.
89
What is the management of portosystemic shunt?
Medical management - manage hepatic encephalopathy, manage liver dysfunction, give small frequent meals regularly. quality of life and life expectancy may be reduced.
Surgical management - increase hepatic blood flow by closing anomalous vessel - overall quality of life improved, life expectancy may be higher, 5-10% mortality rate, unpredictable responses to surgery.
90
What are the indications for surgery in the extrahepatic biliary tree?
Biliary obstruction - pancreatitis, cholelith.
Biliary trauma
Proximal duodenal resections
Cholecystectomy
Choledochotomy
Cholecystojejunostomy
High morbidity and mortality. results influenced by experience - refer.
91
What are the indications for splenic surgery?
Splenomegaly, splenectomy, siderotic plaques.
spleen is in Left cranal quadrant, parallel to greater curvature of stomach, in greater omentum. the splenic artery ; supplies left limb of pancreas, splenic hilus, short gastric vessels, left gastroepiploic artery. May do splenic biopsy, partial splenectomy, total splenectomy. with total splenectomy - double ligate, absorbable suture material, try to preserve short gastric vessels.
92
What is splenic torsion?
spontaneous torsion is rare - usually large breed dogs, usually present as acute abdomen. Vomiting, depression, abdominal distension, collapse. DDx symmetrical splenomegaly - physiological, infiltration, congestion. Treatment for shock then total splenectomy.
torsion secondary to GDV - common.
93
What different types of splenic neoplasia might you see?
bleeding splenic masses - haemangiosarcoma - very common, early metastases, other sites involved - right atrium, prognosis very poor. 50% of cases have gross abdominal metastatic lesions at presentation. 95% of cases are expected to die of metastatic lesions within 3 to 5 month period.
haemangioma: uncommon, clinically impossible to distinguish from haemangiosarcoma, total splenectomy.
haematoma - grossly impossible to distinguish from haemangiosarcoma, total splenectomy.
94
What are the complications of splenic surgery
Haemorrhage, arrhthmias, recurrence.
95
What non bleeding splenic masses are possible
Haemangiosarcoma, haemangioma, haematoma, nodular hyperplasia, other splenic neoplasms, other mass lesions e.g abscess
96
What are the presentations with splenic neoplasia?
Acute abdominal haemorrhage, incidental finding
97
List 7 principles of hernirraphy
Check health of the hernia contents, viable?
reduce contents - may necessitate enlarging hernia ring,
ensure debride devitalised tissue
repair defect usually by direct apposition of the muscle edges
Tensiion free repair must be achieved
98
Describe the procedure of coeliotomy
Skin incision from xyphoid to pubic brim. incise through fat layer. ligate branches of caudal superficial epigastric artery and vein. if male need to go through prepuscial muscle. Incise through linea alba. Extend incision with thumb forces/scissors. Remove falciform fat. incise b ladder ventrally or dorsally. ventrally more easily accessible, no increased risk of leakage. Close in a double layer using absorable suture material such as polyglecaprone-25. Close the abdmen in three layers using absorbable suture
99
What are the benefits of orchiectomy? (castration)
prevents breeding, reduces aggression and roaming, reduces risk of prostatic disease, perineal hernia, perianal adenoma, removes risk of testicular neoplasia.
100
How does castration in dogs and cats differ?
Dogs - prescrotal castration, castrate by scrotal ablation. Cat - scrotal castration.
101
What are the advantages and disadvantages of open and closed castration?
Open - open the parietal tunic. haemostats is better. however - risk of evisceration, risk of peritonitis. Closed: parietal tunic intact, no risk of evisceration, no risk of peritonitis, haemostats less effective.
102
Describe closed castration
Push testicle into prescrotal position, incise skin longitudinally over testicle, continue incision to parietal tunic but do not incise into it, squeeze testicle out of skin incision, break down fascia to elevate testicle using a dry swab. triple clamp technique ensuring tat anchor transfixing suture in the cremaster muscle.
103
Describe an open castration
Incise parietal tunic to expose testicle. Break down ligament of the tail of the epididymis. exteriorise testicle, separate ductus & vessels, ligate separately. For both - push second testicle up to skin incision & repeat, check for haemorrhage before releasing stump.
104
Describe cat castration
Pluck or clip and prep scrotum. Incise longitudinally through scrotum over the testicle (avoid penis). Continue dissection down through parietal tunic (open) or keep parietal tunic intact (closed). Squeeze testicle to exteriorise it. Knot spermatic cord around itself or ligate. Remove the second testicle through a separate incision directly over the testicle. leave scrotum open to heal by second intention.
105
What are the complications of castration?
Haemorrhage - scrotal haematoma, usually cutaneous vessels. intraabdominal haemorrhage. Herniation, dehiscence, incontinence.
106
What is cryptorchidism?
Testicle may be inguinal, in inguinal canal (difficult to find), abdominal. With inguinal testicle - incise directly over testicle, perform open castration. for abdominal testicle - caudal midline coelitomy, find testicle, trace testicular vessels from kidney or trace ductus deference from prostate.
107
Describe testicular neoplasia
types: sertoli cell tumour, interstitial cell tumour, seminoma. Sertoli cell tumour and seminoma common with cryptorchidism
108
What paraneoplastic syndrome is seen with Sertoli cell tumours?
Sertoli cell tumours are oestrogen secreting. they cause alopecia, feminisation - attractiveness to male dogs, gynaecomastia, atrophy of contralateral testicle, myelosuppression, hyper pigmentation. <10% of sertoli cell tumours metastasise.
109
What are the treatment options for testicular neoplasia?
Castration, castration with scrotal ablation
110
Describe mammary gland tumours
The most common neoplasm of female dogs. rare in male dogs. uncommon in cats. may be benign or malignant. In canine mammary tumours 25-50% are malignant. in feline mammary tumours 90% are malignant. Malignant tumours metastasise by both haematogenous and lymphatic routes.
111
How does influence of neutering affect mammary gland tumours in dogs
Protective effect by early neutering. protective effect lost after 2nd oestrus. suggests hormonal aetiopathogenesis. risk before first oestrus 0.05%, after 1st oestrus 8%, after 2nd oestrus 26%.
112
What types of mammary tumours can you find?
Benign tumours - mixed mammary tumour (fibroadenoma), adenoma, benign mesenchymal tumour.
Malignant tumours: carcinomas, sarcomas, carcinosarcomas. Inflammatory carcinomas - very aggressive.
113
Describe feline mammary tumours.
99% of cases are entire female cats. most tumours are mammary carcinomas. rapid growth and early metastasis seen. prognosis is poor. Caudal gland most frequent. fixed masses are uncommon and require more aggressive dissection. ulcerated masses often inflammatory carcinoma - very poor prognosis.
114
How are mammary tumours staged?
Palpate local lymph nodes: axillary & inguinal. evaluate sublumbar lymph nodes: ultrasound. evaluate for thoracic metastasis: xray. 25-50% of malignant canine mammary tumours have metastasised by the time of diagnosis. Histopathological assessment of primary tumour - FNA, try cut biopsy, incisional biopsy, excisional biopsy usually preferred as diagnostic & may be curative in single procedure.
115
What are the DDX for mammary tumours?
Mastitis, other skin neoplasms, hypertrophy. cats - fibromatous hyperplasia.
116
What is the treatment for mammary tumours?
Mastectomy. outcome not affected by surgical technique unless resection is incomplete. resect with minimum of 1cm margin of healthy tissue. cats - survival improved by mammary strip. surgical options - lumpectomy/mastectomy, regional mastectomy, unilateral mammary strip, bilateral mammary strip. In dogs - multiple glands on one side are usually affected. do mammary strip as staged procedures 3-4 weeks apart to remove all mammary tissue if multiple glands on both sides affected. cats- may reduce local recurrence compared to lumpectomy.
117
What is the prognosis for mammary tumours?
Dogs - benign tumours - excellent. malignant tumours - >50% dead within 2 years. poor prognosis if metastases at time of dx if inflammatory carcinoma. in cats >80% malignant.
118
What are the preoperative clinical signs with surgery of the oral cavity?
Drooling, oral bleeding, dysphagia, anorexia, pain, halitosis. will my patient eat? how will i prevent wound dehiscence? how will i provide pain relief?
119
Describe oral neoplasia clinical signs
Drooling +- blood, halitosis, oral/facial pain, dysphagia
120
What is a malignant melanoma?
the commonest canine oral tumour. may be melanotic or amelanotic. behave aggressively. high metastatic rate >80%. high post op recurrence.
121
What is a squamous cell carcinoma?
commonest feline tumour, low metastatic rate, high local recurrence rate, prognosis guarded due to high rate of regrowth. Rostral - low metastatic rate 10%, lingual or tonsillar - 73% distant site metastasis. Good prognosis for non metastatic lesion, providing achieve wide surgical excision. Alternative therapies: radiotherapy.
122
Describe a fibrosarcoma
Dog - upper carnassial region, proliferative, non ulcerated. Cat - no predilection site. Low metastatic potential :10%. recurrence rates - 40% maxilla. require large margins.
123
What are epulis?
From periodontal orogin. May be fibromatous - pedunculated or acantomatous: bone destruction. excellent prognosis with wide excision/radiotherapy.
124
What is an ameloblastoma
A benign tumour, very uncommon, originate from dental lamina, good prognosis with wide excision.
125
what are oral papillomas
Seen in young dogs, viral aetiology: papillomavirus, papovavirus. They spontaneously regress.
126
How are oral neoplasias staged
Tumour biopsy: FNA, exfoliate cytology, incisional biopsy:ensure biopsy site is within field of planned future excision. Tumour imaging. Node metastases - submandibular, thoracic imaging. Following careful case selection - mandibulectomy or maxilectomy.
127
What is a sialocoele or salivary mucocoele
Submucosal or subcutaneous collection of saliva, leakage of saliva from gland or duct may be submandibular, cervical, sublingual (ranula). Most cases are idiopathic - trauma including iatrogenic, inflammation, also occ neoplasia, sialolithiasis, foreign body. sublingual duct most common. Signs: fluctuating swelling, dysphagia, oral bleeding, hyper salivation, may cause respiratory obstruction. Aspiration - will be honey coloured, viscous, mucin. Contrast radiography may be used - sialogram.
128
Describe a Sialogram
2 to 3mls of nonionic contrast agent, lacrimal canula or intravenous catheter.
129
What is sialocoele treatment?
Subcutaneous sialocoele - sialoadenectomy, submandibular salivary gland complex. Ranula management - marsupialisation + sialoadenectomy.
130
What is an oronasal fistula?
signs; chronic rhinitis, nasal regurgitation of food, aspiration pneumonia, malnutrition. May be caused by dental disease, trauma, neoplasia. Repair surgically - high failure rates, refer.
131
How is a cleft soft or hard palate treated?
Congenital - refer.
| Acquired - follow trauma, more amenable to repair, stabilise maxillary fractures. Close in 2 or 3 layers.
132
What is the advantage of an oesophagostomy tube?
Well tolerated - allowing early oral feeding. bypasses nasomaxillary area. does not obstruct pharynx. can be removed immediately. contraindications include oesophageal disease, vomiting, neck injuries. Premeasure to 8th intercostal space. Pull out of the mouth, feed back into oesophagus.
133
What are the complications of oesophageal surgery?
Very uncommon. Leakage - mediastinitis + pyothorax, cellulitis, stricture, necrosis high complication rate.
134
Describe oesophageal foreign bodies
The points of narrowing - thoracic inlet, heart base, cardia. Radiography - screen entire length, 85% will be at heart base. Endoscopy - 100% diagnostic, 95% therapeutic, 5% require oesophagotomy.
135
Describe an intestinal foreign body
may cause partial or complete obstruction, may be in proximal duodenum or distal, may be acute or chronic mild or severe. Complete high intestinal obstruction are most severe. partial obstructions can be chronic - linear foreign bodies, other forms of obstruction e.g neoplasia. Signs include - vomiting, loss of appetite, abdominal discomfort - diarrhoea, melena. Systemic - may cause dehydration, electrolyte loss, weight loss (chronic). Local - pressure necrosis, perforation, peritonitis.
136
Describe an intestinal foreign body
String foreign body, lodges proximally, intestine placates around the string, there may form multiple adhesions + perforations. For a linear foreign body, multiple enterotomies required. Signs - abdominal discomfort, mass lesion, distended bowel. On radiography - may be radio opaque foreign body, or distended loops of smell intestine, peritonitis, plications around linear foreign body.
137
Describe the management of an intestinal foreign body
Enterotomy or enterectomy. Control of contamination by occlusion of intestinal lumen - milk the contents away from incision and occlude the lumen. For enterotomy - do not incise over the FB as this area is compromised. incise distally in the healthy bowel. extend incision to prevent tearing enterotomy site. use instruments to handle the FB. Make a linear incision on anti mesenteric surface with a no1 blade, relatively avascular, will not compromise blood supply to rest of intestine, extend with scalpel or metzenbaum scissors. The submucosa is holder layer - simple, full thickness, appositional, interrupted or continuous. Leak test -with 25g needle and syringe, slight pressure but no more.
138
What is enterterectomy
Done if intestinal wall is not viable - not viable - wall thinning, green, grey black. compromised - avulsed vessels, red, haemorrhagic, viable - active haemorrhage from nick, pulse, peristalsis. Intestinal resection & anastomosis - identify area to resect including healthy margin, ligate vessels to section, incise mesentery. Apply crushing forceps at resection site on diseased bowel, incise bowel angling incision to ensure good vascular supply to anti mesenteric border. Hold resected ends apposed, place sutures at 1 and 2 mesenteric and anti mesenteric borders, fill in between with sutures. close mesenteric defect.
139
What is luminal disparity?
common with intestinal obstruction. common when resecting ileocaecocolic junction.Incise along anti mesenteric border of smaller end. cut smaller diameter end more obliquely.
140
Describe an intestinal biopsy
Trim edge of entertomy incision, 5mm in length, 2mm in width, ensure include mucosa, linear or transverse closure.
141
Describe intussusception
common in young animals, spontaneous, possible link to worm burden or enteritis. uncommon in mature animals, usually secondary to other pathology such as masses or peritonitis. can cause complete or partial obstructions, acute or chronic presentations, jejunocolic at ileocaecocolic junction commonest. May protrude from anus. Intestinal obstruction on radiographs.
142
How do you resolve an intussusception?
Reduce intussusception, Intestinal resection and anastomosis when; adhesions prevent reduction, tissue non viable, tissue tears. Recurrence is common. Can do enteroplication.
143
How can you do thoracic drainage? When is this indicated?
1. needle thoracocentesis
2. thoracostomy tube placement a)intermittent drainage b)continuous drainage. Indicated for pneumothorax - traumatic, spontaneous, iatrogenic. Pleural effusion - transudate, modified transudate, exudate. May be diagnostic or therapeutic.
144
Describe the procedure of needle thoracocentesis?
Unilateral or bilateral, 6th to 8th intercostal space, 3 people minimum - restraint, needle placement, syringe.
145
What are the indications for a thoracostomy tube placement? How is this placed?
Repeated thoracocentesis, continuous suction required, pre emptive following thoracic surgery. Tube diameter must be smaller than main stem bronchus. (smaller than intercostal space) subcutaneous tunnel as air tight valve. Make skin incision at the 10th intercostal space, tunnel under fat & muscle, enter via 7th or 8th intercostal space. Check radiographically. Prevent leakage. Monitor intensively - use a buster collar at all times, body bandage at all times. continuous monitoring if fractious, continuous monitoring if continuous drainage. Continuous suction - risk of patient interference. What are the complications - iatrogenic pneumothorax, haemothorax, pyothorax, open pneumothorax.
146
What are the indications for temporary tracheotomy?
Indication - relief of upper respiratory tract obstruction, e.g laryngeal foreign body, laryngeal oedema. elective prior to upper airway surgery. Anaesthetise patient, intubate if possible, dorsal recumbency, place pad under neck. Make a ventral midline skin incision behind larynx, separate bluntly sternohyoideus muscles. Incise between tracheal rings, incision 1/3 circumference. Place stay suture around tracheal rings Lift up distal stay suture and push tube in, partly close skin incision, bandage in place. Monitor intensively - risk of obstruction if tube dislodged, risk of emphysema, risk f laryngeal paralysis, risk of tracheal stenosis.
147
What is brachycephalic airway syndrome?
Seen in brachycephalic dogs & cats, shortened nasal cavity, soft tissue obstruction of nasal and pharyngeal cavities. BAS: primary disorders - stenotic nares, elongated soft palates. Secondary disorders - everted laryngeal saccules, laryngeal collapse. Signs; stertor, breathing difficulty, exercise intolerance, cyanosis
148
What is the treatment for brachycephalic airway syndrome?
for emergency presentation; cage rest, cool, oxygen therapy, corticosteroids.
149
What are stenotic nares?
Less 'comma' shape - Treat with medial incision first, remove cartilage.
150
What is an elongated soft palate?
Primary - elongation, secondary - hypertrophy oedema. The soft palate resection landmarks are the caudal poles of the tonsils and tip of epiglottis. Appose nasopharyngeal and oral mucosae and suture with simple continuous pattern.
151
What are everted laryngeal saccules?
Obstruct ventral half of glottis, can grasp and excise,
152
What is laryngeal collapse
Secondary to other upper airway disease, progressive, severe respiratory tract compromise, no definitive surgical cure. May be cuneiform collapse or total collapse.
153
What is the treatment of laryngeal collapse?
Address other causes of BAS, weight control, life style modification, or permanent tracheostomy. Although laryngeal surgeries can be performed for laryngeal collapse we do not recommend them as success is limited. A safer approach is to address concurrent problems of brachycephalic airway syndrome.
154
What is stridor?
A harsh respiratory noise, often associated with laryngeal disease. the glottis fails to abduct on inspiration, dorsal cricoarytenoid muscle, recurrent laryngeal nerve. Glottis fails to adduct during swallowing.
155
Describe the different types of laryngeal paralysis
Acquired idiopathic - medium to large, male, older in retriever breeds. Congenital - bouvier des flandres, rottweilers, dalmation, 9-24 months of age, white german shepherds.
Secondary - to polyneuropathy, polymyopathy, neuromuscular junction, pharyngeal or oesophageal swallowing disorders, recurrent laryngeal nerve injury.
156
How is diagnosis made of laryngeal paralysis?
No abduction of glottis during inspiration, assessed as regains consciousness, false positive diagnosis very common, inspiratory stridor, loss of active abduction on inspiration.
157
How do laryngeal paralysis present as emergency presentation?
Hot environment; excitement, exercise, cyanotic, large, unproductive inspiratory effect, inspiratory & expiratory stridor.
158
What is the surgical treatment for laryngeal paralysis?
Arytenoid lateralisation. outcome - tolerate moderate exercise, avoid respiratory crisis, stridor &dysphonation unaltered.
159
Describe penetrating pharyngeal injuries
e.g stick, hook, needle, bone, grass awns. acute presentation; dysphagia, blood tinged saliva, pain, pyrexia, pyothorax,mediastinitis. or chronic; abscess, cervical lateral ventral or intermandibular.
160
How are penetrating pharyngeal injuries treated?
Explore tracts & remove debris. oral or ventral cervical approach. prognosis worse if surgery delayed. for chronic; remove debris and infected tissue en bloc resection where possible, open & curette remaining tracts. 62% cure.
161
Describe the renal blood supply
Renal arteries - Left may be multiple, renal veins - left branches off testicular or ovarian veins.
162
What is the purpose of a nephrectomy?
Indications for a uretero- nephrectomy- unilateral renal disease, trauma to ureter or kidney. Contraindications - inadequate contralateral renal function.
163
What are the indications for cystotomy?
to remove bladder and urethral stones, collect biopsies, assess trigone and ureters, remove tumours (cystectomy).
164
How is a cystotomy done?
Include genitalia in field - so can catheterise intra operatively. the bladder is easily traumatised - minimise handling, use atraumatic forceps and stay sutures and suction. Isolate bladder from abdomen, place stay suture in apex, select cystotomy site. Ventral cystotomy - readily accessible, visualise trigone wall, no increased risk of leakage. Prior to incision perform cystocentesis to reduce spillage. Make a stab incision, extend with metzenbaums, additional stay sutures as required. Longitudnal incision from apex towards trigone. Remove clots before closure, one layer or two layers, appositional or inverting, one layer, simple, continuous. use omental wrap.
165
What is a tube cystostomy?
Allow bladder drainage whilst bypassing the urethra. used to pixy bladder to body wall e.g retroflexed bladder in perineal hernia. use foley catheters. Exactly the same technique as tube gastrostomy.
166
What are the indications for urethral surgery
Urethral obstruction, penile trauma or diesease, urethral prolapse.
167
Describe urethral obstruction
Most frequently urolithiasis or FLUTD, Causes postrenal azotaemia, hyperkalaemia, hydronephrosis, bladder damage.
168
What are the options for urolith management
1. push them into bladder.( urethral catheterisation, retrograde hydropulsion, remove by medical dissolution or cystotomy) 2. remove them from urethra.(create temporary hole into uretrha, remove stones, allow urethra to heal by second intention, stones tend to lodge at os penis, prescrotal urethrotomy commonest). 3 create new stoma into urethra above obstruction.
169
Describe how a prescrotal urethrotomy is performed?
Place urinary catheter, incise skin behind os penis, reflect retractor peni muscle, incise urethra. flush to ensure all stones are removed. Either suture or leave open to heal by second intention. not suturing reduces risk of stricture.
170
Describe a permanent urethra stoma
Urethrostomy. performed when cant dislodge stones, stricture has formed, or repeated obstructions occur. To make a scrotal urethrostomy - castrate and make stoma large. Scrotal urethrostomy and urethrtomy cannot be performed in the male cat. in order to re establish urine flow in severely obstructed FLUTD cases penile amputation with perineal urethrostomy may be performed. this is well tolerated by most.
171
what are the complications of urethrostomy?
Haematuria, stenosis, incontinence, urinary tract infection.
172
Describe urethral prolapse
seen in young male dogs, sexually intact, usually brachycephalic breeds, may cause self inflicted trauma. Resect prolapse, castrate, urethropexy.
173
What is uroabdomen
caused by trauma - ureter avulsion, bladder rupture, urethral rupture, pelvic fracture, or secondary to bladder disease, or iatrogenic e.g. urinary surgery, traumatic catheterisation, cystocentesis. signs - recent history of trauma, deteriorating condition, dull collapsed, signs of uraemia and hyperkalaemia, ascites, abdominal discomfort. Bladder will still often be palpable, often animal will still be able to urinate, initially abdominal radiography will be normal.
174
How do you confirm a diagnosis of uroabdomen?
Serum biochemistry & urinalysis, abdominal fluid analysis, urinary tract imaging. urea will be increased, creatinine increased, potassium increased (post renal azotaemia), may have haematuria. Urine SG 1.008 >1.050. Collect fluid either by abdominocentesis or diagnostic peritoneal lavage. urea - small molecule - equilibrates quickly. creatinine - large molecule - does not equilibrate.
175
What is incontinence?
Involuntary passage of urine - intermittent or constant problem. congenital vs acquired, neurological vs non neurological. congenital causes - ectopic ureters, other uncommon. acquired - urge incontinence, sphincter mechanism incompetence, neurogenic incontinence.
176
What is urge incontinence?
Unsuppresible urination as bladder fills. Inflammation, reduced bladder volume, polyuria. may be caused by cystitis, urolithiasis, neoplasia, systemic causes of polyuria.
177
What is sphincter mechanism incontinence
Post spay incontinence, hormone responsive incontinence, sphincter mechanism incompetence, intra pelvic blader.
178
What are the etiological factors for SMI?
Majority of patients are neutered female dogs. respond to oestrogen supplementation. Many affected patients are obese. weight control helps reduce signs. fat at bladder neck ? Incidence of intrapelvic bladder is higher in dogs with SMI. surgical repositioning of bladder neck can improve incontinence.
179
What is juvenile SMI?
Seen in female entire bitches, before first oestrus, often associated with ectopic ureters. 50% resolve after oestrus.
180
Juvenile animal with incontinence - likely ddx?
ectopic ureters, juvenile form of SMI
181
adult animal with incontinence - ddx?
urge incontinence, acquired SMI, neurogenic incontinence.
182
What is adult acquired SMI?
Seen in medium to large breed dogs, female neutered> entire. breed OES, doberman, Irish setter, rottweiler, overweight often. Continent for most of the day, urine passively leaks when lying or sleeping, continuous dribbling of urine is uncommon. Check bladder position & tone, check external genitalia for urine drip/scalding. observe urinating. perform neurological exam.
183
What investigation should you do with adult SMI?
Urinalysis - may have concurrent urinary tract infections, exclude urge incontinence, radiography - contrast studies to evaluate bladder and ureter positions and to exclude other causes of incontinence.
184
What is the treatment of SMI?
Juvenile - weight loss, treat concurrent UTI, 50% resolve after first oestrus. Adult - medical therapy oestrogen's - oestriol (incur in) causes improved smooth muscle contractility and increased a-adrenergic responsiveness. A adrenergic agonist - phenylpropanolamine - urethral smooth muscle. weight loss , control urinary tract infection.
185
What is the surgical management of SMI?
Colposuspension - repositions bladder neck forwards, increases pressure at bladder neck. This is performed even in patients that do not have intra pelvic bladder with effect - the mechanism of action is not fully understood. Anchor cranial vagina to prepubic tendon - increases pressure on proximal urethra. combined with OVH. Complications - dysuria, dyschezia. 50% good outcome.
186
Describe ectopic ureters
A congenital abnormality. ureter bypasses trigone - empties into urethra, vagina or uterus. may be unilateral or bilateral. May be extramural or intramural. Cause hydroureter, hydronephrosis, UTI & pyelonephritis, renal function likely to deteriorate over time, females > males, retrievers, poodles, huskies, typically incontinence since birth, occasional adult onset presentations, continual dribbling of urine, urine scald, unilateral - can pass stream of urine, bilateral - may have no bladder filling.
187
How is ectopic ureter diagnosed?
contrast radiography - intravenous urogram with pneumocystogram, ultrasound, cystoscopy.
188
What is the treatment of ectopic ureter with sugery?
1. redirect urine flow into bladder - neoureterostomy, ureteroneocystostomy, ureteronephrectomy - unilateral, end stage renal disease.
189
What are the signs of prostatic disease?
Dysuria, dyschezia, haematuria, urethral obstruction. In young or neutered dogs - intrapelvic, small walnut sized. in mature entire dogs: benign prostatic hyperplasia, moves cranially into abdomen.
190
What should the prostate feel like on rectal exam?
Position, smooth, bi lobbed (sulcus), symmetrical, non painful. Anything else is abnormal.
191
What is benign prostatic hyperplasia?
95% of intact males over 9 years. androgen stimulation - reversible hyperplasia. non painful, symmetrical prostatic enlargement. Predisposes to prostatic infection. Treatment is anti androgen therapy. Castration. do not use oestrogens - promotes irreversible squamous metaplasia.
192
What is bacterial prostatitis?
Prostatitis is common - acute - chronic. any prostatic disease predisposes to infection, commonest site of infection in male UTI, physical/physiological drug: fluoroquinolones, castration. Chronic - some discomfort, bilaterally symmetrical prostatomegaly, persistent signs of UTI, other signs of prostatic disease. Acute bacterial prostatitis - systemically unwell, extremely uncomfortable, bilaterally symmetrical prostatomegaly, pyuria, haematuria.
193
What is prostatic abscess?
Extension of bacterial prostatitis, abscessation of prostatic cyst, asymmetric, painful prostatomegaly, systemic illness. Acute abdomen - surgical emergency. Complications include urethral erosion, septic peritonitis, uroperitoneum.
194
What is the treatment for prostatic abscess?
supportive therapy, septic shock, surgical drainage, castration, prolonged antimicrobial use. Omentalisation
195
What are prostatic cysts?
Non septic fluid filled cavity, within the parenchyma prostatic cysts, attached to the prostate - paraprostatic cysts. Can be acquired or congenital. Both are asymmetrical, turgid, non painful, prostatomegaly, abdominal or pelvic mass.
196
What is a paraprostatic cyst
Congenital but enlarge as patient ages, abdominal or intrapelvic, do not communicate with prostatic tissue.
197
What is prostatic neoplasia
Usually adenocarcinoma, extremely painful, metastasise early, often PTS on diagnosis. radiography - extravasation of contrast, periosteal reaction in lumbar spine & pelvis. use prostatic wash & biopsy to diagnose.
198
How do you take a prostatic biopsy?
Place urethral catheter - isolate from abdomen, wedge from each lobe, ventral surface.
199
What is prostatectomy?
NOT recommended, high complication rate, incontinence in all cases total, profuse haemorrhage.
200
What are the indications for spaying?
control of reproduction, control of oestrus associated behaviour, protective against mammary tumours, management of pyometra, dystocia, pseudopregnancy, vaginal prolapse, termination of pregnancy.
201
What is the timing of elective neutering?
Traditionally in bitches from 6 months of age before first season, after first season. before first season reduces risk of mammary neoplasia. In queens - 5 to 6 months of age. Early neutering avoids teenage pregnancy, neuter before breeder/rescue centre, from 6-8 weeks of age, slight modification of technique required. Ideally non gravid and in ancestors. Follicular phase: highly vascular, reduced coagulation. In luteal phase - pseudopregnancy.
202
What is the standard practice for ovariohysterectomy?
Bitch: midline ovariohysterectomy. alternatives - ovariectomy - laparoscopic or open surgical, flank not recommended. Cat - flank ovariohysterectomy, midline ovariohysterectomy.
203
What should you include on your preoperative assessment for spaying?
General physical exam - cardiovascular, respiratory, concurrent disease, reproductive tract exam, signs of previous surgery, signs of concurrent disease, evidence of oestrus/prooestrus, pathological vulval discharge, cryptorchid, correct sexing of cats,
204
Describe elective neutering
A clean contaminated surgery - negligible bacterial load, short, healthy patient, no requirement for preoperative antibiosis. For pedicles use synthetic absorbable knots well e.g. PDS. For line alba use synthetic, long lasting, absorbable or non absorbable. Midline skin incision, from umbilicus to midway to pubic brim, identify uterus between bladder and colon, Y shaped uterine body, Uterine horn - most lateral structure in abdomen, ovary at proximal end, linear blood supply. Use triple clamp technique. circumferential in proximal crush line, preplace suture, release clamp & tie. Grasp pedicle with atraumatic forceps before releasing the middle clamp. check for bleeding. Gently break down broad ligament. Pull round ligament out of inguinal canal.
205
Describe a flank ovariohysterectomy
Triangle between wing of ilium ,greater trochanter, spay site. Quarter drape. incise through skin and subcutaneous tissue to abdominal musculature. Tent up abdominal musculature, incise with mayo scissors. Locate uterus with a spay hook. Triple clamp technique as per bitch spay. Use circumferential ligature proximally and transfixing ligature distally. Locate second uterine horn. Do not need to reach cervix in a cat. ligate both uterine horns. Check uterine stump for haemorrhage, suture muscular layer with a continuous suture. suture subcutaneous tissue. close skin.
206
What are the complications of OVH
Haemorrhage, weight gain post op, acquired incontinence, uncommon - ureteral damage, flank sinus tract, ovarian remnant syndrome.
207
Describe a cesarean section procedure
Exteriorise uterus, isolate from abdomen using laparotomy pads, incision in uterine body or in each horn. milk each pup out, clear sac from nose, clamp & cut umbilicus. check uterine body for pups, placenta - remove if detached, leave if attached, close uterus in one or two layered closures.
208
Describe neonatal resuscitation
Clear nostrils, suction airways, centrifugal clearance, stimulate respiration, pharmacological or rub. Ligate and clean umbilicus, warm and feed, discharge same day.
209
What is pyometra? when is it seen?
6-8 weeks after season - luteal - progesterone. Spayed dog - stump pyometra - signs of oestrus, vulva discharge, ovarian remnant will be present. Typically >6 years, as young as 6 months. dullness, toxaemia, vaginal discharge, enlarged abdomen, peritonitis. Presentation is characteristic, radiography - uterine enlargement, ultrasound. E coli, aerobes, facultative anaerobes, or pure anaerobes. 30% of cat pyometras are sterile, 20% concurrent urinary tract infection. 25% of cases are azotaemic - hypovolaemic, chronic renal failure, toxin induced renal damage, IVFT, monitor renal parameters. treat with standard spay technique, longer abdominal incision.
