Surgery of the female repro tract Flashcards
Give some Therapeutic/Diagnostic indications for surgery?
- Pyometra
- Dystocia
- Neoplasia – ovarian/uterine
- Uterine Torsion
- Uterine Prolapse
- Metritis/Mucometra
- Intersexuality
What are some preventative/elective indications of surgery?
Prevention
of oestrus
Pregnancy
Pyometra
Uterine neoplasia
Ovarian neoplasia
Mammary neoplasia?
What are some Congenital causes fo diseases fo the ovary
- agenesis, hypoplasia, supernumerary – incidenta
What are some acquired surgical diseases of the ovary
- Ovarian cysts - prolonged oestrous, cystic mammary hyperplasia, fibroleiomyoma
- Follicular – ↑ oestrogen
- Luteal – ↑ progesterone
- Parovarian – incidental – no Clinical Signs
- Neoplasia - Abnormal oestroussymptoms in entire animals
- Epithelial – adenoma or adenocarcinoma
- Germ cell - dysgerminoma, teratoma, teratocarcinoma
- Sex cord stroma tumours – granulosa cell tumours
What surgical diseases fo the uterus? Congenital
- Uterus unicornis
- Hypoplasia
- Agensis
- Atresia
- Segmental aplasia
What acquired surgical dx of uterus?
- Pyometra
- Hydrometra/mucometra
- Metritis
- Torsion
- Prolapse
- Rupture
- Neoplasia
- Dystocia
- Intersex
describe risk of mammary tumours & neutering
Before 2.5 years marked reduction
Neutering with mammary tumour removal or 2 yrs before diagnosis,
associated with longer survival and reduced risk of tumour recurrence
Mammary neoplasia in cats?
▪ Entire female cats 7 times more likely to get mammary neoplasia
▪ Induced ovulator, large litter sizes, multiple litters per year
➢ pregnancy prevention very important
» Median survival <1 year and 96% malignant
What other dx prevented by spaying?
Pyometra - potentially lfie threatening
Complications of spay?
HAEMORRHAGE
OVARIAN REMNANT SYDROME
URINARY INCONTINENCE
STUMP PYOMETRA
SPLENIC/ORGAN LACERATION
FISTULAS
WOUND BREAKDOWN/HERNIATION
URETERAL TRAUMA
OBESITY
BEHAVIOUR PROBLEMS
What do we do abotu haemorrhage as psot- op complication?
➢ Is the bitch bleeding-consider ultrasound
➢ Is there a coagulopathy?
➢ Stabilisation-fluid therapy
➢ Bandaging
➢ Ex lap when stable
➢ Use an assistant/abdominal retractors /lap swabs
➢ Colonic manoever/duodenal manoevre
➢ Check ovarian pedicles and cervical stumps
➢ Check for bleeding broad ligament
➢ Check other organs
Describe Diagnosis of Ovariant Remnent Syndrome
> vaginal cytology
* keratinisation of epithelial cells
* absence of polymorphonuclear leukocytes consistent with oestrogen secretion
> hormone assays
* serum progesterone ↑
* oestradiol ↑ than neutered bitch
* dynamic testing hcg or gnrh
> abdominal ultrasonography or CT
What used to be a good tool to diagnose ORS?
AMH
Describe Stump Pyometra
➢This is thought to be rare if no uterine tissue left
➢ More commonly granuloma secondary to suture material
Describe Ureteral Trauma
➢ More commonly reported at cervical end
➢This is why ovariectomy has become more popular
Describe urinary incontinence
- common; middle-aged to olderspayed bitches
- incidence 5-20%-> more in large breed dogs
- medical treatment successfully controlssymptomsin 65-75% of dogs
Describe obesity risk
➢ Neutered animals = ↑ overweight
➢ It is not clear if age at neutering affectsthis
➢ some studies, neutered animals have ↓ metabolic rate
➢ others have found comparable metabolic rates
➢ There is evidence that neutered animals eat more and expend less energy
How can we avoid haemorrhage as complication?
➢ Increased risk in large dogs with lots of fat
- Ensure good visualisation
- Controlled rupture of suspensory lig
- Good lig technique -> double
- Check pedicles
What routine complications?
➢ Infection/wound dehiscence
➢ Seroma
➢ Incisional hernia
Why don’t we want to use cargut?
Stump granuloma/abscess - catgut
How can we decrease risk of ORS / stump pyo
➢ Good exposure
➢ Large incision
➢ Break suspensory ligament
➢ Palpate ovary when placing clamps – hold between thumb/forefinger of nondominant hand
➢ Place ligatures as deep as possible
➢ Inspect ovary at removal
➢ Open bursa and check intact
How to avoid iatrogenic pseudopreg?
Spat around 3 months post season
What do we call swab being left in?
Gossypyboma
How to avoid ureteral injuries
➢ Good exposure
➢ Know anatomy
➢ Ureteral injury at the ovaries or bladder
➢ Direct visualisation if pick up pedicle/place extra ligature after transection
➢ Empty bladder pre op
Describe Pyometra
- CEM can precede pyometra but not always
- Normal vaginal flora enters relaxed cervix
- Progesterone → endometrial growth & secretions → thickened endometrium lined with cysts
* inhibits immune response
* supresses myometrial activity/contractions
- Progesterone → endometrial growth & secretions → thickened endometrium lined with cysts
- Oestrogen – enhances effects of progesterone
CLS of Pyo?
- +/- vaginal discharge
- PU/PD
- Depression/Lethargy
- Anorexia
- Vomiting/Diarrhoea
- +/-Pyrexia
- 4-8 weeks post season
Diagnosis of Pyo?
- Hx & CLS
- Abdo palp
- Haem /Biochem
- Acidosis
- ULTRASOUND
- Urine sample
Describe Haem and biochem for pyo?
> Haematology
* Leucocytosis-Neutrophilia+left shift
* Anaemia
> Biochemistry
* Hypoalbuminaemia
* Hyperglobulinaemia
* Azotaemia (prerenal)
Best tx for pyo?
OVH -> fluid therapy & antibiotics
What would medicalmanagement of pyo be?
- Reserved for bitches with high breeding value/unable to undergo GA/Sx
- Not always successful
- High rate of recurrence at next season
- Delay in response – septic/peritonitis/closed cervix
describe uterine inertia?
= lack of sufficient uterine contractions to expel foetus
➢ large litter, small litter, hypocalcaemia, hypoglycaemia, obesity, septicaemia, fetal oversize (small
litters/brachys), fetal mortality, pelvic obstruction, uterine torsion/rupture
Signs of Dystocia
- Gestation >70 days
- Green vaginal discharge without delivery of a foetus
- > two hours after foetal fluids released with no foetus delivered
- > three to four hours since birth of last foetus
- Bitch/queen exhibits extreme discomfort, systemic illness
or exhaustion - > 30 minutes of strong, regular contractions without delivery of
foetus - Significant bloody discharge for more than 10 minutes
How to investigate dystocia?
➢ Vaginal examination
➢ PCV, TP,Electrolytes, blood glucose, iCa
➢ Ultrasound +/- Radiographs
Medical tx for dystocia?
➢ Oxytocin – 3 doses 30 min apart
➢ Correct hypoglycaemia, hypocalcaemia
➢ Lubrication
➢ Digital manipulation
Surgical tx of dystocia?
➢ Caesarean- incision in uterine body
➢ En bloc ovariohysterectomy
Indications for surgical intervention ?
How to do a C section? Pt 1
➢ Incise body of uterus
➢ Milk foetuses toward uterine body and out incision
➢ Clamp umbilical cord
➢ Remove placenta via gentle traction
➢ leave if firmly attached
C section pt 2?
➢ Pass neonate to non sterile assistant
➢ Repeat for each foetus
➢ check pelvic canal for foetus
➢ Check for uterine contractions – administer oxytocin
C section pt3
➢ Uterine closure; absorbable, monofilament in single or double continuous layer
➢ (1st appositional or inverting, 2nd inverting)
➢ Close abdomen routinely
➢ intradermal skin closure to avoid interference with nursing of neonates
How do we do a En bloc OVH?
- Isolate entire uterus
- Manipulate foetuses away from cervix, back into uterine body
- Place forceps across the ovarian pedicles and uterine body and transect routinely (as if OVH)
- Pass entire uterus to non sterile assistant for rapid removal of neonates
- Time from clamping to removal of neonates should be <60sec
- Then ligate pedicles as previously described
Rescuc of neonates?
- Clear nares with towels or suction
- Gentle rubbing and drying to stimulate breathing
- Reverse opioid with naloxone
- Mask oxygen if needed
- Do not swing
- No evidence for use of doxapram
How to care for neonates
- Keep neonates warm while dam is recovering
- Reunite dam & litter as soon as safely possible under supervision
- Clean mammary glands of surgical scrub prior to feeding
- Return to home as soon as safely possible
- Check regularly for signs of uterine haemorrhage or infection and that suckling and milk production is
going smoothly
Choice. ofan ovariectomy. -why?
- Does not increase risk of pyometra (multiple studies, spanning decades)
- Less traumatic
- smaller incision and handle tissues less
- Decrease chance of ureteral trauma
- Still risk of uterine neoplasia development
No advantage if OVH over OVe in study
How to do an ovariectomy
- Locate ovary
- Fenestrate mesovariam caudal to the ovarian vessels
- Place clamps between pedicle and ovary
- Double ligate vessels by passing suture through fenestration
- Ligate just cranial to uterine horn by passing suture through fenestration
and around mesosalpinx (can clamp and crush) - Incise between the pedicle ligatures and ovary
- Incise between uterine horn ligature and ovary
- Gently release pedicle and uterine horn and check for bleeding
Describe Lap Spay?
- Min invasive
- Dec pain post op
- Quicker recovery
- Reduces blood loss
- No suture materials
What are some congenital vaginal abnormalities?
- Segmental vaginal aplasia/hypoplasia
- Persistent hymen
- Rectovaginal/rectovestibular fistula (with atresia ani)
What acquired vaginal abnormalities?
- Vaginal neoplasia
- Vaginal hyperplasia/vaginal fold prolapse/vaginal prolapse/vaginal oedema
- Vaginal prolapse
What types of neoplasia do we see from vagina?
- Most benign- leiomyomas, fibroleiomyoma, fibroma, lipoma
- 30 % malignant- adenocarcinoma, squamous cell carcinoma, leiomyosarcoma
- Transmissible venereal sarcoma exotic disease
CLinical signs of vaginal neoplasia?
- dysuria, stranguria, vaginal discharge, faecal tenesmus, bulging perineum or vulva or protruding mass
Describe Transmissible venreal sarcoma ?
▪ Transmitted during mating
▪ Exotic disease to the UK
▪ May be seen in imported dogs
▪ Can be treated with vincristine
Diagnosis of vaginal neoplasia?
- vaginal exam, location of the mass in relation to the urethral papilla
- FNA/biopsy if neoplasia suspected
- Rads/US/CT to see extent & staging
Tx of vaginal neoplasia?
- Surgical resection via episiotomy +/- ovariohysterectomy.
- leiomyomas are hormonally dependent, spay prevents recurrence
- Malignant; vulvovaginectomy + perineal urethrostomy reported
Describe vaginal hyperplasia?
- Excessive thickening & oedema of vaginal mucosa during oestrus
- Ventral vagina, cranial to the urethral orifice, protrudes from the vulva
When / who do we see vagina hypeprlasi ain?
- During first three oestrous cycles
- Spontaneously resolves
- Brachycephalic and large breed dogs
Doe surethra usually protrude with vaginal hyperplasia?
- Urethra does not normally protrude
- can be identified by lifting the protruding tissue
Tx for vaginal hyperplasia
- Keep clean and prevent trauma until resolution
- Spay to prevent recurrence
- will not hasten resolution during an episode
- Surgery via an episiotomy indicated if larger or circumferential
Describe true vaginal prolapse?
» Rare
» More common in brachys (Boston Terriers)
Tx for prolapse?
» Permanent tx = OVH
» Conservative management
» Resection if macerated/mutilated
* Care with urethral orifice
» Episiotomy to manually reduce
Compare and contrast vaginal hyperplasia, neoplasia, and prolapse
What are the surgical diseases fo the vulva?
- Anovulvar cleft
- Clitoral hypertrophy (intersex)
- Vulval hypoplasia/juvenile vulva
- Vulval stenosis
Describe Vulval hypoplasia
▪ Neutered or juvenile bitches before first season
▪ Causes moist dermatitis, vaginitis and cystitis
▪ Allow at least one season prior to neutering, may resolve with oestrogen
▪ Otherwise resection via episioplasty
Describe hypertrophy
▪ with intersexuality or in normal females receiving anabolic steroids.
▪ causes discomfort when sitting or traumatised by excessive licking
▪ assess for intersexuality
▪ clitoris can be surgically removed
What are some surgical techniques for vaginal and vulval dx?
» Episiotomy
» Episioplasty
» Vaginectomy
» Vaginourethroplasty
Considerations for vagina/vulva sx
- Epidural analgesia recommended
- Purse string suture around anus
- Hindlimb hanging posture on table
- Tail taped forward
Episiotomy closure?
Close in 3 or 4 layers:
Vaginal mucosa
Vaginal muscle +/- Subcutis
Skin
Describe episioplasty
Cut out folds causing dermatitis from vulval hypoplasia
