Surgery of the Female Reproductive Tract

Question 1

What are the differentials for ovarian remnant syndrome? (4)

Answer 1

•Conditions resulting in male attractiveness

–Atrophic vaginitis

–Urinary incontinence

–Anal gland disease

• Gives the female a smell
• Conditions resulting in clinical signs of oestrus

–Oestrogen secreting adrenal tumour

Question 2

How does a granuloma present?

Answer 2

–Usually presents within a few weeks post surgery as haemorrhagic/purrulent vulval discharge

Question 3

How do you diagnose a granuloma? (3)

Answer 3

–palpation, radiography, ultrasonography

Question 4

How do you treat granuloma? (2)

Answer 4

Laparotomy and resection

Question 5

What is this?

Answer 5

Granuloma

Mass lesion (dorsal to bladder)

Transducer on ventral bladder

Question 6

What can cause concurrent pyometra with uterine stump dx? (2)

Answer 6

concurrent ovarian remnant or progesterone administration (or more rarely oestrogen administration)

Question 7

What surgical conditions are there of the vagina? (4)

Answer 7

• Persistent hymenal bands
• Episiotomy
• Prolapse of hyperplastic vagina
• Vulval hypoplasia (peri-vulval dermatitis)

Question 8

What do we do for persistent hymenal bands and what does it depend on?

Answer 8

–Best to do oestrus – very thick and lots of cell layers. Reduced risk of damage.

–May be broken with finger pressure

–May require ‘lassoing’ and ligation – suture and tie round top and bottom and cut between

–May require episiotomy

–May not be amenable to surgery

Question 9

What is the advantage of mending Persistent Hymenal
Bands in proestrus?

Answer 9

Mating can occur at oestrus

Question 10

How do you approach an episiotomy?

Answer 10

• Animal in sternal recumbency pelvis elevated
• Tampon and purse-string suture to anus
• Lavage vestibule with dilute antiseptic
• Skin incision from dorsal commisure towards anus but not external anal muscle
• Scissors placed into vestibule/vagina and cut vestibule muscle and mucosa
• Cut edges retracted with stay sutures
• Always identify and catheterise urethra!!! Allows us to always know where it is
• Close vaginal and vestibular mucosa (simple continuous; multi or mono filament), dead space and skin

Question 11

How do you approach Prolapse of
Hyperplastic Vagina?

Answer 11

• Mass originates cranial to external urethral orifice (usually from the ventral floor- origin in vagina)
• Conservative management and spay during anoestrus is usually all that is required
• In animals required for breeding the mass can be removed during oestrus (there may be significant haemorrhage as the tissue is vascularised and oedematous
• Sternal recumbency
• Episiotomy usually required
• Identify and catheterise urethra
• Incise one aspect of mass place stay suture in midline
• Incise opposite aspect of mass place stay suture in midline
• Blunt dissect /cautery for vessels
• Close dead-space (simple continuous) and suture edges
• Close episiotomy

Question 12

What is Prolapse of
Hyperplastic Vagina?

Answer 12

Exaggerated response to NORMAL oestrogen at oestrus = thickening

Question 13

What phase can help mend a prolapse of hyperplastic vagina?

Answer 13

Luteal - oestrogen will make it fall

Question 14

How do you approach Episioplasty for Vulval Hypoplasia?

Answer 14

• Commonly results in peri-vulval dermatitis
• May be associated with pre-pubertal neuter

–Before first season – don’t get such a development of external tract; the skin hangs over and you end up with a chronic lond standing pyoderma with them licking

–This is commonly described wrongly as vaginitis!

• Is always associated with some degree of obesity
• Could try to clean prior to surgery – but the problem is the overhanging skin and a lot of the time wont resolve
• Sternal recumbency
• Use marker to indicate horse-shoe incision
• Incise skin – use a 10 or maybe 15 scalpel blade for better control
• Dissect and cautery to fat
• Appose edges of horse-shoe to produce lateral splaying of vulval (simple interrupted)

Question 15

What is this?

Answer 15

Peri-vulval pyoderma

Fat in the area around the perineum

= skin fold dermatitis

Question 16

What % of mammary neoplasia is malignant in:

Dogs?

Cats?

Answer 16

• 50% of mammary tumours in the dog are malignant and up to 50% of these have metastasized by the time of presentation
• 85% of mammary tumours in cats are malignant

Question 17

How can we calssify and stage mammary tumour?

Answer 17

Size of tumour

LN involvement

Mets

Question 18

Should you take a biopsy if presented with a mammary tumour?

Answer 18

–Small nodules: yes (excise it)

–Suspect inflammatory carcinoma: yes

•But generally:

–Therapy does not alter based on the biopsy

–Sometimes it is just as easy to remove the gland as to biopsy it

–Better to spend the money and time on staging

• Examine the local lymph nodes (FNA)
• Both lateral thoracic radiographs

Question 19

Do you submit mammary tumour for histo path?

Answer 19

Yes

Question 20

How do you assess lungs for mets with mammary tumour?

Answer 20

Radiographs

R lateral – congestion of R lung and better aeration of upper lobe and no likely to see in lower

To assess for mets always do R and L lateral

Upper lung most easily assessed.

Question 21

What are the surigical options for mammary tumours? (4)

Answer 21

• Lumpectomy (removing lump from within the gland)
• Single mastectomy (one gland)
• Regional mastectomy (more than one gland)
• Complete mastectomy (all glands - either unilateral or bilateral)

–Bilateral to do at one time

Question 22

Which is the surgical technical used for mammary tumour guided by? (5)

Answer 22

1. Size and number of tumours
2. Location of the tumour - anatomy
3. Reported rate of growth
4. Condition of the animal
5. Dog or cat?

Question 23

How does the size/number of the tumour affect surgery?

Answer 23

• Masses less than 1cm in diameter and firm on palpation can be treated by lumpectomy
• Masses greater than 1cm and those attached to skin or deeper tissue should be treated by mastectomy
• Multiple masses can be treated by regional mastectomy

–If glands drain to different lymph nodes the radical mastectomy is required (complete mammary strip)

Question 24

How does the location of the mammary tumour affect surgical removal?

Answer 24

Anatomy of the Lymphatics from the individual glands. Lymph drainage is cranial and caudal but there is communication between the each mammary glands

• Axillary and inguinal lymph nodes
• Lymphatic drainage runs cranial from 1 and 2 (and 3)
• Lymphatic drainage runs caudal from (3) and 4 and 5

Question 25

How do we know which gland to remove with mammary tumours?

Answer 25

Glands may need to be removed in groups if lymphatic spread is possible:

• Gland 1 – just remove this
• Gland 2 – remove with 1
• Gland 3 – consider remove all

–Potential for cd and cr spread

• Gland 4 – remove with 5
• Gland 5- just remove this

Question 26

How does the condition of the animal affect the mammary removal?

Answer 26

•Clinical condition

–Bitches are more likely to be in poor condition if there are metastases

Consider Staging the Disease

Question 27

What is the difference between treating a dog/cat for a mammary tumour?

Answer 27

•Always treat cat mammary tumour more aggressively

–Radical mastectomy is recommended

–Increases chance of removing all affected tissue

–Decreases chance of local recurrence

Question 28

What is a lumpectomy good for?

Answer 28

• Good for little nodules
• Difficult for anything larger than the mobile ‘peas’

Question 29

What is the surgical procedure for a masectomy?

Answer 29

• Appropriate for single gland involvement
• Not appropriate for gland 3
• Need to make sure you dissect down to the deeper fascia levels.
• Technique

–Remember that the vasculature may be principally cranial, medial or caudal

• Identify the arterial supply to the gland and ligate
• MASTECTOMY DOES NOT INVOLVE LARGE NUMBERS OF SWABS!!!

–Surgery should be as atraumatic as possible

–Avoid sectioning of the capsule and if this occurs change instruments

–Excision should include a 2 cm margin around the tumour

–Veins from the proximity of the tumour should be ligatured early in order to prevent the diffusion of emboli

Question 30

Why is gland 5 tricky to remove? (3)

Answer 30

–it extends all the way to the vulva in the bitch

–It has an extra arterial branch caudally from the external pudendal artery

–The inguinal lymph node usually comes with it

Question 31

What tips are there to help with masectomy? (3)

Answer 31

• Always take the whole gland off down to the fascial plane
• Never try to dissect through the middle of a gland
• Identify and ligate the specific arteries and veins early on

Question 32

How do you close post masectomy?

Answer 32

• Close the dead space meticulously – especially in the caudal inguinal fat pad
• Keep the fascial surface moist with saline during reconstruction
• Good sterile technique is important
• Closure – drains

Question 33

What do we need to do post op masectomy?

Answer 33

•Monitor recovery carefully

–Consider effect of fluids/blood loss in older patients

–Calculate and maintain fluids into post op.

–Consider concomittant renal/hepatic disease

•MASTECTOMY is PAINFUL!

–Multi modal pain relief

Question 34

What is the prognosis of masectomy?

Answer 34

Overall death rate perhaps 10%.