Surgical Conditions of the Ruminant (incl. Caesarean)

Question 1

Considerations when preparing for ruminant surgery.

Answer 1

• Handling and restraint facilities.
• Environment.
• Surgical procedure.
• Patient and assistant.

Question 2

1. Considerations for location of ruminant surgery.
2. Flooring considerations for ruminant surgery.

Answer 2

1. • Under cover / outdoors.
     - Sheltered from prevailing wind/rain.
     - Protection from dust.
     - Lighting.
2. • Non-slip.
     - Clean, deeply bedded straw pen.
     - Sand.
     - Rubber matting.

Question 3

Considerations for restraint for ruminant surgery.

Answer 3

Halter
- securely fitted.
- quick release knot.
- no slack.
Crush
- w/ good side access.
Tail restraint / bull holders.
Small ruminants generally in lateral recumbency. - Tied on a table / straw bale.

Question 4

Assistance esp. for laparotomy.

Answer 4

Ideally 2 helpers.
– esp. caesarean in cattle.
– one at shoulder.
– one at hip.
Remember farmers are not trained on aseptic technique!

Question 5

Environmental hygiene implications.

Answer 5

Surgical site heavily contaminated pre-op.
Preparation time-consuming.
High likelihood of contamination during surgery.
Need for perioperative ABX.

Question 6

Pre-operative considerations.

Answer 6

• Anaesthesia.
• Analgesia.
• Antibiotic therapy.
• Fluid therapy.
• Surgical preparation.

Question 7

Anaesthesia for ruminant surgery.

Answer 7

• Local anaesthetic techniques.
  – Local infiltration.
  – Paravertebral (T13 to L2 +/- L3).
  – Epidural (L6-S1 or C1-C2).
• Speed of onset (5-15mins).
• Licensed anaesthetic agents.
  – Procaine w/ adrenaline.

Question 8

Analgesia for ruminant surgery.

Answer 8

• Pre-emptive NSAIDs.
• Licenced products for cattle are:
  – Carprofen.
  – Flunixin meglumine.
  – Ketoprofen.
  – Meloxicam.
• No licenced opioids in food producing animals.

Question 9

Considerations for antibiotic therapy for ruminant surgery.

Answer 9

Responsible use – “As little as possible but as much as necessary”.
- Infection status of surgery
– Non-contaminated (e.g. LDA correction).
– Contaminated (e.g. caesarean section).
– Infected (e.g. Traumatic reticulopericarditis, C section to remove dead calf).
- Risk of contamination during surgery.
- Likely bacteria present:
– G+ = skin.
– G- = GIT, repro tract.
– Anaerobic organisms = GIT, established infections.
- Resistance
- Culture/sensitivity.
- Route of admin.
- Duration of treatment.

Question 10

Suggested ABX for ruminant surgery.

Answer 10

First generation ABX.
- Aminopenicillins.
- Early generation cephalosporins.
- Tetracyclines.

Question 11

Fluid therapy for ruminant surgery.

Answer 11

Pre-op assessment.
- Hydration status and degree of shock.
- Likelihood of electrolyte imbalances.
- Acid / base balance.
Surgery condition.
Route and timing.
- IV or oral.
- Pre, intra, post.

Question 12

Surgical preparation of the ruminant.

Answer 12

• Secure tail in cattle – prevent swishing and surgical site contamination.
• High level of contamination.
• Wide clip of area.
  – Consider whether externalisation of viscera will be necessary.
  – Generally a 25cm margin sufficient.
• Surgical scrub – 2 bucket rule.

Question 13

1. Why is access for laparotomy in the ruminant challenging?
2. What does the approach of laparotomy depend on?

Answer 13

1. • Large abdo size.
     - Cranial extension of abdo cavity beneath rib cage.
     - Short mesenteries and omenta.
     - Rumen obstructs the left flank.
2. • Area of pathology.
     - Familiarity of surgeon.
     - Compliance of patient.
     - Facilities available.

Question 14

1. Reasons for caesarean.
2. Contamination risk of caesarean.
3. Other considerations.

Answer 14

1. Foetomaternal disproportion.
   Malpresentation.
   Insufficient dilation of cervix.
   Elective.
2. Calf dead/alive.
3. Previous surgeries.
   Timing of intervention.

Question 14

Incision options for laparotomy.

Answer 14

• Ventral midline.
• Paramedian.
• Paralumbar fossa.
• Oblique.
• Paracostal.
• Ventrolateral.

Question 15

Caesarean section positioning of cow.

Answer 15

• Standing.
  – Generally preferred.
  – Facilitates easier manipulation of uterus.
• Right lateral recumbency.
  – If unable to stand.
  – or requires heavy sedation to handle.

Question 16

Anaesthesia for caesarean.

Answer 16

Paravertebral.
- Anaesthetises whole flank.
- Allows extension of incision if required.
Caudal epidural as an optional extra.
- Reduces abdominal straining.
- But risk ataxia.
- 2ml local anaesthetic maximum.

Question 17

Additional pre-operative considerations for caesarean.

Answer 17

Clenbuterol (10ml Planipart IV in cattle).
Preparation for resuscitation.
Tie a long rope to the contralateral HL.
Use of sedation.
- If required.
- Beware xylazine cause uterine contraction so can make uterus harder to handle.

Question 18

Additional useful equipment for caesarean.

Answer 18

• Sterile calving ropes.
• Embryotomy knife.
• Uterine clamps.

Question 19

How to prepare the farmer for caesarean.

Answer 19

• Get 2 clean buckets.
• Scrubbing in?
  – sometime needed.
  – ASEPSIS!
• Ensure farmer aware of calf revival techniques.

Question 20

Common approach for caesarean.
– Why is it common?

Answer 20

Left sided paralumbar fossa laparotomy.
– Rumen easier to manipulate than distal GIT.
– Minimises egress of viscera and abdominal contamination.

Question 21

Method of paralumbar fossa laparotomy

Answer 21

• Incise halfway between last rib and stifle.
• Hands breath below lumbar process ventrally.
• Large dorsoventral incision.
  – ~40cm.
  – avoids trauma to the incision while manipulating uterus.
  – think of hock-foot length of calf and add a little bit.
  – Shorter incisions would be used for DA surgeries.
• Identify and incise muscle layers individually.
  – Depth very variable.
  –> 3-13cm.
• Transverse abdominal muscle and peritoneum should be tented w/ forceps and a cut made carefully into the abdomen.
• Sharp hiss as air sucked into peritoneal cavity.
• Extend incision dorsally and ventrally, using fingers or scissors to elevate body wall.

Question 22

Incising the uterus and calf delivery in caesarean.

Answer 22

• Determine calf position within uterus.
• Identify closest calf HL in anterior, or FL in posterior and presentations.
• Gently grasp a limb, apply traction and ‘rock’ the limb toward the incision.
• Lock limb in incision, w/ hock over ventral aspect of incision and hoof pointing dorsally.
• Incise uterus outside abdomen to decrease contamination.
• Embryotomy knife can be used to safely incise inside if required.
• Longitudinal incision over plantar metatarsus and hock
  – avoid placentomes.
  – avoid damage to calf.
  – Make incision large enough to avoid tearing.
• Other limb identified and exteriorised.
• Calf can be elevated and rotated as an assistant applies traction to deliver, pulling dorsally and caudally.
  – Sterile calving ropes can help.
• ALWAYS check for a second calf.

Question 23

Calf revival in caesarean.

Answer 23

• Farmer’s job while you continue surgery.
• Give instructions to help.
• Straw up the nose.
• Cold water down ears.
• Acupuncture site: small needle in nasal septum.

Question 24

Uterine closure after caesarean.

Answer 24

• Place membranes back in uterus or cut off if contaminated w/ scissors.
• Continuous inverting pattern in two layers e.g. “Utrecht” or “Cushing”.
• 5 or 6 metric synthetic absorbable suture material.
• Care not to incorporate foetal membranes.
• Check integrity of seal before abdo closure.
• Remove blood clots from uterine wall to minimise adhesions.

Question 25

Abdominal closure.

Answer 25

3-4 layer technique.
- Peritoneum and transverse abdominis.
- Internal abdominal oblique.
- External abdominal oblique.
Simple continuous for layers 1-3 w/ absorbable suture material.
- Skin: Ford interlocking w/ non-absorbable suture material.

Question 26

Caesarean aftercare.

Answer 26

Continue analgesia - NSAIDs.
Continue antibiotic.
Inject 50 iu oxytocin IM (cattle dose).
Give oral fluids if required.
Phone or visit next day / day after to see how getting on.
- Beware peritonitis occurs at least 3 days later.
Stitches out after 14 days.
Examine calf.
Administer colostrum to calf.
Dip naval.

Question 27

Caesarean post op complications.

Answer 27

Retained foetal membranes common.
Infections.
- Metritis, peritonitis, wound infection.
Severe adhesion.
Reduced fertility.

Question 28

Left ventrolateral laparotomy approach.

Answer 28

Useful for a dead emphysematous foetus.
Improved uterine exposure and reduced contamination of abdomen.
Requires right lateral recumbency and elevated left hind limb.
Closure more involved and prolonged.
Assistance preferred.

Question 29

Indications for caesarean in sheep.

Answer 29

• Non dilation of the cervix (ringwomb).
• Foetal oversize.
  – esp. single breech lamb.
  – v hard to judge shoulder width.
• Irreversible malpresentation.
• Deformities.

Question 30

1. Anaesthesia for sheep caesarean.
2. Restraint of the sheep.
3. Uterine relaxants?
4. Where is the skin incision site?

Answer 30

1. Flank infiltration, L block or paravertebral (preferred).
2. In right lateral recumbency.
3. No need.
4. Midway between last rib and stifle.
   - over most domed part of the flank.

Question 31

1. Reaching for other lambs.
2. Uterus closure.
3. Flank closure.
4. Skin closure.

Answer 31

1. Feel towards cervix before ‘turning the corner’ and enter far horn.
2. Suture one secure inverting layer.
3. 2 or 3 layers.
4. Ford interlocking.