Surgery for Female Reproductive Tract Flashcards
What peritoneal sac do the ovaries sit within?
Ovarian bursa
What anatomical feature is present to prevent loss of oocytes into the peritoneal cavity?
At the entrance near the opening of the ovarian bursa, it has a wide, funnel-shaped infundibulum which is fringed with fimbriae
What is the exit of the oviduct called?
Uterine osteum
What holds the ovary in place? (2) and where are these attached?
The suspensory ligament, which attaches to the last rib, and the proper ligament, which connects to the uterine horn.
What is the blood supply to the ovaries? Where have these branched from?
Via paired ovarian arteries, which branch from the aorta
How do the ovaries drain:
A) Left?
B) Right?
Ovarian veins
A) Into left renal vein
B) Into caudal vena cava
Lymphatic drainage of the ovaries?
To lumbar lymph nodes
What is the mesovarium anatomically?
The cranial portion of the broad ligament and attaches the ovary to the dorsolateral body wall.
Mesovarium:
A) What does it contain? (2)
B) What is it continuous with?
A) Suspensory ligament and the utero-ovarian vessels
B) Mesometrium
What is the mesometrium anatomically?
The caudal part of the broad ligament, which attaches the uterus to the body wall.
Round ligament:
A) What is it continuous with?
B) Where does it run?
C) What does it pass through? D) With..?
A) Proper ligament
B) In the free edge of the broad ligament
C) Inguinal canal
D) Vaginal tunic
What suspends the uterus from the abdomen?
Broad ligament
How does the cervix lie in dogs?
Diagonally
How does the cervix lie in cats?
Horizontally
A) What is the blood supply to the uterus?
B) Branching from?
A) Paired uterine arteries + Anastomosing ovarian arteries
B) Vaginal arteries
What is the lymphatic drainage of the uterus? (2)
Hypogastric LN
Lumbar LN
Where does the vagina extend from and to?
From cervix to vestibule
What can the vestibular mucosa be described as?
Smooth
What is present in the mucosa of the vagina?
Longitudinal folds
What is palpable at the vestibulovaginal junction?
mucosal ridge
Where does the urethral tubercle lie within the vagina?
1cm caudal to vestibulovaginal junction on ventral surface
Is the clitoris found dorsally or ventrally?
Ventral
What is the blood supply to the vagina, urethra, and vestibule is provided by? Arising from?
Vaginal artery branches arising from internal pudendal a.
What is the vulva blood supply?
External pudendal a.
What is the lymphatic drainageof the vagina and vestibule?
Internal iliac
What is the lymphatic drainage of the external genitalia?
Superficial iliac
What are the dog mammary gland pairs?
the cranial and caudal thoracic glands (pairs 1 and 2), the cranial and caudal abdominal glands (pairs 3 and 4) and the inguinal glands (pair 5).
How many pairs of mammaries in cats?
Cats have four pairs, though a rudimentary fifth (inguinal) pair is sometimes present.
What is the thoracic mammary gland blood supply? (3)
Internal thoracic
Intercostal
Lateral thoracic arteries
What are the caudal thoracic mammary glands additionally supplied by?
Branches of the cranial superficial epigastric arteries
What is the supply of the cranial abdominal mammary?
Branches of Cranial superficial epigastric a.
What is the caudal abdominal mammary blood supply?
Caudal superficial epigastric arteries
What happens with the cranial and caudal epigastric arteries?
Anastomosis
What are the primary drainage LN for mammaries? (2)
Axillary
Inguinal
Where do thoracic mammaries drain in the dogs? (2)
Axillary and sometimes the sternal LN
Where do the abdominal mammary drain? (2)
Axillary
Inguinal
Where do the inguinal mammae drain? (2)
Inguinal LN
Medial iliac LN
Where does the popliteal occasionally drain?
4th + 5th
What is the difference in cat mammae LN drainage of the caudal thoracic and cranial abdominal mammae?
May drain caudally to the inguinal lymph nodes or cranially to the axillary lymph nodes.
With mammary neoplasia what may change with the LN?
Lymphatic drainage
How does thoracic gland mammary neoplasia lymphatics drain?
The thoracic gland is normally drained by the axillary lymph centre, but in mammary neoplasia either the superficial cervical or ventral thoracic lymph centres can be involved
How many ORS are at:
A) Right pedicle?
B) L pedicle?
C) Bilateral?
A) 62%
B) 29%
C) 10%
What are the clinical signs of ORS?
Relating to oestrus
How can hormone bloods diagnose ORS in dogs? (4)
- Serum oestradiol exceeding 15 pg/ml
- Serum progesterone exceeding 2 ng/ml
- A single low luteinizing hormone level
- Anti-müllerian hormone assays have been shown to be diagnostic for ovarian remnant syndrome in some studies and are independent of the ovarian cycle.
How to diagnose ORS in cats? (3)
- Increased plasma oestrogen concentrations are supportive of a diagnosis of ovarian remnants but also seen with adrenocortical problems;
- Progesterone assays are available, but they require prior administration of GnRH;
- Anti-müllerian hormone assays are useful for detecting neutering status in cats and are also used in the diagnosis of ovarian remnant syndrome.
When is the best time to ex lap for ORS?
The tissue may be better visualised during oestrus due to the presence of follicles or corpora lutea.
How many masses that affect the vagina/vestibule/vulva are benign?
84%
What is the most common mass of the vagina/vestibule/vulva?
Leiomyoma
Most common malignant vulva/vestibule/vulva?
Leiomyosarcoma
What clinical signs may be seen with vagina/vulva/vestibule neoplasia?
Protrusion of the mass from the vulva, however, a vaginal discharge, a perineal swelling, dysuria or urinary incontinence and tenesmus can be seen.
What is the surgical approach to vaginal masses?
Episiotomy
What diagnostics should be performed for vaginal masses? (5)
- Digital vaginal exam
- Rectal exam
- Vaginoscopy
- Excisional biopsy
- Abdo/thoracic imaging
How to perform an episiotomy?
- A purse string suture should be placed to occlude the anal orifice and prevent faecal contamination of the surgical site.
- Starting at the dorsal vulval commissure an incision should be made dorsally toward the anus to expose the most dorsal aspect of the vestibule, guided by placement of a finger or blunt surgical instrument into the vestibule.
-The surgical incision is then progressively deepened through subcutaneous tissue, vestibular constrictor muscle and vestibular mucosa. - A stay suture should be placed in either side of the incision to retract laterally and aid visualisation.
How to close an episiotomy site?
Including suture material etc.
To close the episiotomy incision, mucosa and muscular layers are sutured separately. A rapidly absorbable monofilament suture material is appropriate.
Why does vaginal oedema occur in young female dogs? When does it happen?
in proestrus or oestrus due to the influence of oestrogen. A mass of oedematous tissue develops on the ventral floor of the vagina, just cranial to the urethral orifice, and protrudes from the vulva when large enough.
Define a grade 1 vaginal oedema/prolapse?
Mass is not protruding but visible on vaginal inspection.
Define a grade 2 vaginal oedema/prolapse?
Mass is protruding ventrally between the labiae of the vulva.
Define a grade 3 vaginal oedema/prolapse?
The prolapse is fully exteriorized and has a “doughnut-shape” appearance.
How to treat grade 1-2 vaginal prolapse if acute?
conservative treatment by lubrication and application of an Elizabethan collar to prevent self-trauma is appropriate. It may be possible to reduce the mass via an episiotomy followed by placement of vulvar sutures to maintain its position; the oedema will resolve spontaneously once oestrogen levels reduce.
If an animal has had a vaginal prolapse, what is recommended?
Spay
Treatment of grade 3 vaginal prolapse
manual reduction of the tissue followed by OHE is recommended.
How is a vaginal prolapse approach if there is traumatised and non-viable tissue?
surgical excision is required. An episiotomy is performed to access the base of the mass, and the urethra is catheterized before resection.
Why is electrosurgery advised in prolapse surgery in oestrus?
Haemorrhage significiant
Vaginal oesema:
a) Where is the incision made?
b) How is it closed?
A) the mucosa around the base of the mass on the ventral vaginal floor.
B) This should be done in stages, and the resulting mucosal defect is closed with monofilament absorbable suture in a continuous or interrupted appositional pattern.
What can be performed if a wider vaginal mass surgery is required?
vulvovaginectomy
Following a resection of the vagina and vulva, what must be performed surgically?
The urethral mucosa is sutured to the skin, creating in effect a permanent perineal urethrostomy.
What tumour is common in the vulva and peri-vulva region which may require wide resection?
Mast cell
How can a skin flap be used in the vulva region?
Utilising the dorsal vulva skin
Leiomyoma is diagnosed most commonly in older intact females. True or false?
True
Vaginal oedema occurs in young female dogs due to the influence of progesterone. True or false?
False - Vaginal oedema occurs in young female dogs in proestrus or oestrus due to the influence of oestrogen.
A grade 1 vaginal oedema is not visible on vagina inspection. True or false?
False - When there is a grade 1 vaginal oedema the mass is not protruding but it is visible on vaginal inspection.
The vulvar and peri-vulvar regions are common sites for mast cell tumours. True or false?
True
What is present anatomically in a recessed vulva?
This condition, in which a fold of skin covers the most dorsal aspect of the vulvar labia,
What breeds are more affected by a recessed vulva?
Medium - large breed
What clinical signs does a recessed vulva typically present with? (5)
- Skin fold dermatitis
- Urine scalding
- Vaginitis
- Recurrent UTI
- Urinary incontinence
How to treat a recessed vulva? What must be achieved first?
Following attempts to treat and resolve secondary pyoderma in the area, recessed vulva is treated surgically with vulvoplasty, also knowns as episioplasty
What is the patient position for vulvoplasty?
The patient is placed in sternal recumbency with hindlimb over a padded table end.
What must be placed to prevent faecal contamination during a vulvoplasty?
Rectal purse string
How is the initial incision made with a vulvoplasty?
Following routine skin preparation, a crescent shaped incision is made dorsal to the dorsal vulva commissure and extended lateral and ventral to the vulva.
After the initial crescent shape incision for a vulvoplasty - what is the next step?
A second matching incision is made dorsal to this to allow a crescent shaped portion of skin to be removed. The size of this section of resected skin should be estimated by retracting the skin dorsally using fingers of towel clamps until the dorsal skin fold covering the vulva is resolved.
How to close following a vulvoplaty?
The subcutaneous tissues and skin are then closed in a simple interrupted pattern.
Main complications following a vulvoplasty? (2)
Complications following vulvoplasty are unusual unless large skin resections are required,
-Dehiscence
-Infection secondary to faecal contamination of the wound is possible.
Outcomes following vulvoplasty are typically good.
How many tumours are mammary?
42%
How many mammary tumours are malignant in dogs?
40-50%
How many mammary tumours are malignant in cats?
80-90%
How is metastatic spread of mammary neoplasia and where to? (2)
Lymphatic and blood to LN and lungs
What is the chance of a mammary neoplasia if spay:
A) Before first oestrus?
B) Before second oestrus?
C) After second oestus?
A) 0.5%
B) 8%
C) 26%
What is the reduction of mammary neoplasia in cats if spayed:
A) Before 6mo?
B) Before1 yr?
A) 91%
B) 86%
What do mammary tumours loose if they transform from benign to malignant?
Their hormonal dependency
What is the most aggressive mammary malignancy?
Inflammatory carcinoma
Most common benign mammary tumours in dogs? (3)
- Adenoma
- Fibroadenoma
- Mixed
What is the most common malignant mammary tumour?
Carcinoma
How are mammary carcinomas sub classified?
Complex and simple
What are the categories of simple mammary carcinomas? (4)
Papillary
Tubular
Solid
Anaplastic
What type of mammary tumours represent 90% in cats?
Adenocarcinoma
What are the 2 types of benign mammary tumours in cats?
Adenoma
Fibroadenoma
(either simple or complex)
What is fibroadenomatous hyperplasia caused by in cats?
endogenous or exogenous progestins
Where do cat mammary tumours met to? (2)
LN and lungs
What are the subtypes of mammary adenocarcinomas in cats? (4)
Tubular,
Solid,
Papillary,
Cribriform
How do mammary carcinomas often look in cats?
Firm and ulcerated
What should be performed when ruling out concurrent dx for mammary tumour? (3)
CBC
Biochem
Urinalysis
Define
A) T1
B) T2
C) T3
A) <2 cm maximum diameter
B) 2-3 cm maximum diameter
C) >3 cm maximum diameter
Define :
A) N0
B) N1
A) No histologic or cytologic evidence of metastasis
B) Histologic or cytologic evidence of metastasis
Define:
A) M0?
B) M1?
A) No evidence of distant metastasis
B) Evidence of distant metastasis
What stage is:
T1N0M0
1
What stage is
T1 or T2 N1M0
III
What stage is
T3 N0 or N1 M0
III
What stage is
T2N0M0
II
What stage is
Any T Any N M1
IV
Diagnostics as part of staging work up? (3)
- 3 xray thorax vs CT
- Abdo U/S or CT
- FNA LN
How to approach surgery in a cat with a mammary mass?
In cats, chain mastectomy of the affected side should always be performed regardless of the number or size of mammary masses, due to the high risk of early metastasis
What margins should be achieved with mammary mass?
1cm
What depth should be removed for mammary mass?
The depth of excision should be to the pectoral muscles/abdominal wall fascia except for tumours that are not mobile, in which case the fascial layer (rectus sheath) should be removed too.
Mammary Lumpectomy:
A) When is this appropriate?
B) Margin taken?
C) Disadvantage?
A) This is only appropriate for known benign masses which are less than 0.5 cm in diameter.
B) The mass is removed with a marginal rim of normal tissue.
C) milk and/or lymph can leak from the incised mammary tissue causing local inflammation and pain.
Simple mastectomy:
A) What is this?
B) What should be included if fixation to underlying skin?
A) For larger masses, a simple mastectomy may be performed, which involves removal of a single gland.
B) If there is suspicion over fixation to the underlying muscle fascia or to the skin, the fascia and first muscle layer and skin should be included in the surgical margin.
Regional mastectomy:
A) When is this indicated?
B) Which glands are removed together, why?
C) What problem is avoided?
D) What should be removed if cranial mammaries involved?
A) when masses are between glands
B) en bloc removal of glands 1-3 or 3-5 is often performed even when the mass only affects one gland.
C) postoperative milk/lymph leakage is avoided
D) Axillary LN
What unpredictable nature of mammary glands mean chain mastectomy is considered?
Metastasis can be unpredictable due to lymphatic drainage of the third and sometimes fourth mammary glands to both the axillary and inguinal lymph nodes, and the possible existence of lymphatic communication between several other glands.
When is chemo recommended for mammary neoplasia?
Highly invasive cancers and high-grade carcinoma.
What chemo agents have reports of increased survival times in combo with surgery? (3)
A combination of 5-fluorouracil and cyclophosphamide, or carboplatin
