Tricks of the Trade Reducing SpayNeuter Time Marvin Mackie DVM Quick Spay James Wright DVM MPH ACPVM Dr Sara White BOD ASV Spay ASAP Inc Dr Karla Brestle Medical Director Humane Alliance ID: 531034
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Slide1
Wendy Blount, DVM
Tricks of the Trade
Reducing Spay-Neuter TimeSlide2
Marvin Mackie, DVM – Quick Spay
James Wright, DVM, MPH, ACPVM
Dr. Sara White
BOD, ASV; Spay ASAP Inc.Dr. Karla BrestleMedical Director, Humane AllianceDr. Mark Bohling, ACVSUniversity of Tennessee CVM
Dr. Bob Judd, ABVPJudd Veterinary ClinicDr. Philip Bushby, ACVSMississippi State CVMBrenda Griffin, ACVIMUniversity of Florida CVM
SUPER HUMAN PUBLIC HEALTH GURUSlide3
Speed per se is not the desired goal
Efficiency is the goal and
not the same as speed
Efficiency is elimination of all unnecessary tissue handling and any wasted motionExperienced surgeons who are very fast are not necessarily rushing, they just make very few “false moves.”Less tissue handling means less trauma and less pain for the patientI Feel the Need for Speed!Slide4
Halsted’s Principles
Halsted’s Principles of Surgical Technique
Gentle tissue handling
Strict asepsisMeticulous hemostasisElimination of dead space in the surgical woundSlide5
Terms Definitions
Suspensory ligament
- suspends the ovary from the dorsal wall of the abdominal cavity, and continues in the broad ligament to suspend uterus
Broad ligament – peritoneum and fat lateral to uterine bodyProper ligament – tethers the ovary to the uterus, containing the uterine tubePedicle – usually refers to the ovarian or testicular vessels and vas deferensStump – usually refers to the uterine stumpSlide6
Trouble Spots
Rate Limiting
Steps to Spay-Neuter
Finding the linea albaFinding the uterusBreaking down the suspensory ligamentFinding a dropped pedicle or stumpWaiting for light anesthesia to become surgical againWaiting for the next patientSlide7
Finding the linea alba
Overweight – excess subcutaneous fat
Lactation (flank approach)
Cats – herringbone meeting of left and right rectus rather than linea albaSlide8
Finding the linea alba
Cat
Video
(0:06)Slide9
Finding the uterus
Visual – requires largest incision
Spay hook – smallest incision
More likely to cause trauma than your finger in the hands of an inexperienced surgeonthe spay hook has no sensory nerve endingsFinger sweep – big enough to get your finger with uterus out.Slide10
Finding the uterus
Full bladders, full colons and increased intra-abdominal fat are my greatest obstacles
Technicians gently express the bladder prior to prepping
Tech trained to “leave it” if to much pressure is requiredIt is possible to rupture the urinary bladder with manual expressionSometimes excessive manual pressure is not perceived to be usedIf manual expression can’t be done safely, intra-operative expression or even cystocentesis can helpSlide11
Finding the uterus
Finding
the uterus quickly not only minimizes surgery time, but also minimizes tissue handling trauma
.When I have to hunt for the uterus, I usually give an extra intra-operative pain injection IM.Butorphanol, buprenorphine, morphineNSAID on recoverySlide12
Finding the uterus
Spay hook
sweep
(0:36)Slide13
Finding the uterus
Spay hook sweep
Cat
Video (0:48)Slide14
Finding the uterus
Finger
sweep
(0:11)Slide15
Finding the uterus
Finger
sweep
(0:21)Slide16
Three Clamp
Technique
(2:43)Slide17
Three Clamp Technique
Need big clamps for big dogs – I like Rochester-Carmalts.
We have only one in most spay packs, and open 2 more for big fat spays. We have 8 extra.
Need small clamps for cats and small dogsLarge clamps can tear small pedicles4 small clamps and 2 mosquitos in each packGood quality clamps prevent letting loose.Slide18
Three Clamp Technique
1
click on the first clamp, 1 cm proximal to the ovary
2 clicks on the second clamp half way between the first clamp and the ovary. always place your thumb and forefinger around the ovary when you apply clamp 2 to avoid clamping or cutting the ovary.3 clicks on the third clamp on the proper ligamentSlide19
Breaking down the suspensory ligament
to
get good exposureavoid “catchage”Slipped ligatures and painCheck for catchage by running your finger around the ligature before you release it into the abdomenplenty of “tissue tag” above and beyond your ligature to prevent a slipped ligaturePlenty of room to use the 3 clamp technique if you like itAvoid disrupting the ovary when you sharply dissect the pedicle awaySlide20
Breaking down the suspensory ligament
to
get good exposureSometimes stretching the ligament is fine for exposureIf the ovary does not retract back into the abdomen when you set it on the drape, your exposure is fineSome break it down from cranially and some from the proper ligament window toward cranialIn either case, the artery is avoidedSlide21
Breaking down the suspensory ligament
to
get good exposure (1:03)Slide22
Breaking down the suspensory ligament
to
get good exposure - techniquesstrum with the fingerscut with blade or scissorsCombination – nick then strumbreak down with hemostatsSlide23
Breaking down the suspensory
ligament
(0:37)
Slide24
Breaking down the suspensory
ligament
(0:16)
Slide25
Breaking down the suspensory ligament
Cat
Video (0:18)Pregnant Cat Video (0:17)Kitten Video (0:05)Slide26
Bertha the 100 lb Pit Bull
IN HEATSlide27
Bertha the 100 lb Pit Bull
Challenges spaying overweight dogs
Incision Placement
Finding the lineaFinding the uterusGrease control and getting ligatures tight when lots of fat is in the pedicleDealing with the broad ligamentClosing the linea (BCS 9/9)Slide28
Bertha the 100 lb Pit Bull
Incision Placement
More important in large dogs because the reproductive tract is longer
Especially important in deep chested dogs where distance between incision and dorsal attachment of suspensory ligament is longest1-2 cm caudal to the umbilicusExtend back 3-4 cmExtend caudally as needed to exteriorize an enlarged uterus or the uterine bodySlide29
Bertha the 100 lb Pit Bull
Incision Extension
Bluntly with hemostats or dull edges of the scissors if <1cm extension (cat video)
With blade and thumb forceps (next video)Cutting with Mayo scissors, while elevating the ventrumSlide30
Bertha the 100 lb Pit Bull
Finding the
linea
(0:27)Slide31
Bertha the 100 lb Pit Bull
Finding the uterus
In my hands, finger
sweep works much better than spay hook for fat dogs. Have to make incision that big to get the uterus out anywayIf all else fails, extend the incision caudally and exteriorize the bladder to expose the uterine body or stump found between the colon and bladder. occasionally a uterine horn can seem to be trapped beneath a very full colon – look there if not found in the usual place.Slide32
Bertha the 100 lb Pit Bull
Grease control
sterile huck towel in the pack to wipe grease off your gloves as needed
If it’s really bad and you can no longer grips the suture material without slipping, change your gloves for a fresh startUse Miller’s Knot for fat dog pedicles & stumpsFat cats don’t seem to carry much fat in their ovarian pediclesSlide33
Bertha the 100 lb Pit Bull
Miller’s
Knot
(0:45)Slide34
Bertha the 100 lb Pit Bull
Miller’s Knot
2 passes around the pedicle increases surface area of the ligature pressure
Reduces tendency of ligature to cut tissueParticularly useful for large or edematous uteriElevating the suture ends as you tighten helps to tighten both loops equallyCat Video (1:15)Slide35
Bertha the 100 lb Pit Bull
2 Clamp Technique for Fat/Enlarged Uterus
Do not clamp the uterus prior to ligation
To do so on an enlarged uterus risks transecting it with the clamp prior to ligationIt can retract under the pelvisBetter exposure by breaking down broad ligamentPlace clamps after ligationPreserve 1 cm tag of tissue on the uterine stumpSlide36
Bertha the 100 lb Pit Bull
2 Clamp Technique for Fat/Enlarged
Uterus
(0:45)Slide37
Bertha the 100 lb Pit Bull
Should uterine arteries be ligated separately?
Almost all experts in HQHVSN say it’s not necessary
There is a post on the ASV listserve several times yearly about problems with not ligating separatelyMassive bruising on the abdomen, usually a cat2-3 days after OHEOccasionally the hemorrhage is fatal the first nightThe uterine artery slips caudally beneath the ligature and there is retroperitoneal bleeding which seeps out the inguinal ring into the SC tissuesSlide38
Bertha the 100 lb Pit Bull
Dealing with the broad
ligament
(0:20)Slide39
Bertha the 100 lb Pit Bull
Dealing with the broad ligament
Self Tie of Cat Broad Ligament
(0:40)Watch using a scalpel blade with no handle on itEspecially if you place your blade on the drapeSlide40
Bertha the 100 lb Pit Bull
Dealing with the broad ligamentSlide41
Bertha the 100 lb Pit Bull
Dealing with the broad ligamentSlide42
Bertha the 100 lb Pit Bull
Dealing with the broad ligament
Break down the broad ligament
Better access to the uterine arteries for ligationAllows exteriorization of the uterine body (cat video)Use Rochester-Carmalts to crush and tear broad ligament rather than breaking down manually – 3 clicksEasier to tear the suspensory ligament with less tissue traumaLigate if needed – encircling or Miller’s. Pedicle tie does not work well in my hands for fat dogs.Slide43
Bertha the 100 lb Pit Bull
Closing the linea
Place one interrupted suture in the center with a surgeon’s knot to keep fat from erupting out every time Bertha breathes
This is probably more important when closing obese dogs with longer incisionsDropped stumps or pediclesMultiple adhesionsExploratory to confirm spaySlide44
Bertha the 100 lb Pit Bull
Closing the linea
Continuous or interrupted????
Apposition and seal better with continuousInterrupted provides back-up for suture or knot failureCruciate rather than simple interrupted cuts knot number by halfSuture reaction is greatest at the knotsKnot tying takes a little more timeSlide45
Bertha the 100 lb Pit Bull
Closing the linea
Bites at least 5-10mm from edge of rectus
Suture ears at least 3-4mm4-6 throws per knotAvoid crushing tissue with the first two throwsImpedes healingCauses animals to lick and chew at suture lineSlide46
Bertha the 100 lb Pit Bull
Closing the
linea
(0:54)Slide47
Tips Tricks
Ovarian Pedicle Ties
don’t
work well on animals with lots of fat in the pedicle.can often do a pedicle tie in even fat cats.Leave 4-5mm tissue tag beyond the hemostat to establish clamp securityPedicle Tie Female Cat (0:14)Pedicle Tie Pregnant Cat (0:27)Same techniques used for testicular pedicles in routine and cryptorchid castrations in cats and puppiesSlide48
Dogs of Maturity
Preventing scrotal hematoma
Meticulous hemostasis
Avoid branches of the caudal superficial epigastric a.Disposable JorVet handheld electrocauteryEpineprine:Lidocaine SplashThe socket is dry when I close, or I don’t closeLigation of SC vessels only when neededReduced scrotal swelling from 2 in 100 to 2 in 1000Slide49
Dogs of Maturity
JorVet handheld electrocautery
-runs on two AA batteries -2200o cautery and three tips - $67.00 -2200o cautery - $36.00 - 1100o cautery - $29.00 -replaceable tips -cautery lasts 4-6 monthsSlide50
Dogs of Maturity
Epi
-Lido “Splash”
Mix 1:9 epinephrine (1:1000) and 2% LidocaineGetting the dilution backward can cause scrotal necrosis if used as a true splashApply 2cc of the mixture to a sterile 4x4Place the 4x4 into the scrotal sac for 30-60 seconds, and then removeMackie uses 100% epinephrine for thisSlide51
Dogs of Maturity
Epi
-Lido “Splash”
(1:57)Slide52
Dogs of Maturity
Open or closed?
I do most of mine closed
Strip the fascia away to have minimal connective tissue around the ligationRun a hemostat along the cordIf open, I do the Mackie modified open techniqueLigate the spermatic cord and let it retract back in the tunicLigate the tunic and amputate most of itSlide53
Dogs of Maturity
Open or closed
?
(3:14)Slide54
Dogs of Maturity
What to do with the pendulous
scrotum?
A significant amount of contraction will occur with timeNot necessary to avoid scrotal swellingWe offer scrotal ablation in older dogs for cosmetic reasons for $20 extraSlide55
Tips Tricks
Skin Sutures or Not?
Not necessary in most cases with intradermal closure
Elected in high energy female dogs likely to chewElected for very large incisionsAlternatively, can do several segments of continuous for very large incisionsElected if significant skin pathologyComing back for suture removal can be an issue for low cost clientsI almost never put skin sutures in a dog castrationSlide56
Tips Tricks
Burying the knot
If the knot protrudes through the incision, it will likely need to be removed with suture scissors
Tie the knot with suture ends parallel to the incisionTake a deep last bite prior to tying the knotUse an Aberdeen knot to reduce knot sizeClose SC and skin with a continuous for only one knot, when incision is longer than can be closed with a cruciate or twoChoose suture size that is not too large to reduce knot size“smurf” the knot just prior to applying glue to skin edgesSlide57
Tips Tricks
Burying the knot
Aberdeen knot
(1:32)Slide58
Tips Tricks
Burying the knot
Continuous SC and skin closure – single knot
Only two throws in the first knot anchoring to rectusTack to body wall by taking bites between the cruciate knots in the lineaDiscussion about fetal euthanasiaExample of tattoo ink placed in the incisionContinuous Closure (3:50)Slide59
Tips Tricks
Burying the knot
Smurf the knot
(2:54)Don’t forget to trim the suture tag!Slide60
Tips Tricks
Incision Size – smaller really is better
“incisions heal side to side”
Other reasons to limit incision size to the minimum allowed to exteriorize the reproductive organsMinimize instruments and fingers in the abdomen to minimize tissue trauma, post-operative pain and adhesion formationAlso limit exposure of abdominal contents to traumaDecrease likelihood of foreign bodies left in the abdomenMinimally invasive surgery for quicker recovery and lower incidence of post-operative complicationLarger incisions take longer to close and allow fewer procedures each daySlide61
Tips Tricks
Transecting the pedicle before you ligate
Scary at first – the pedicle is no longer tethered if the clamp fails prior to ligation
Bushby – “When you consider the increased tissue manipulation necessary when ligating the pedicle prior to transection, the risk of tearing the pedicle at the proximal clamp is actually greater than a clamp slipping off”True IF you have good clamps1-2-3 click technique minimizes risk of tear by proximal clamp1 click on the proximal clamp2 clicks on middle clamp3 clicks on clamp on proper ligamentSlide62
Tips Tricks
Transecting the pedicle before you ligate
Preserving adequate tissue tag distal to clamp is key (1cm)
Also makes the ligature more secureIf you can’t do this, work on better ovarian exposureIncision placement cranial enoughBreak down suspensory ligament properlyRemove the proximal clamp just prior to the final tightening of the Miller’s knotIncreases distance between the clamp and ligation by reducing “spreading” of the pedicle by the closer clampIf you double ligate, try transecting after the first ligationSlide63
Tips Tricks
Tattoo and Glue
Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies
HEALTH AND SAFETY CODE. TITLE 10. HEALTH AND SAFETY OF ANIMALS. CHAPTER 828. DOG AND CAT STERILIZATIONSec. 828.001. DEFINITIONS. Releasing agency - a public or private animal pound, shelter, or humane organization. The term does not include an individual who occasionally renders humane assistance or shelter in the individual's home to a dog or cat.Slide64
Tips Tricks
Tattoo and Glue
Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies
RULES PERTAINING TO THE PRACTICE OF VETERINARY MEDICINE. TEXAS ADMINISTRATIVE CODE. TITLE 22, PART 24. CHAPTER 573. RULE §573.77 STERILIZATION OF ANIMALS FROM RELEASING AGENCIES (c) Identification markers. An animal sterilized under this section must be identified by a microchip and/or a tattoo indicating that it has been sterilized. (1) A new owner of an animal with a microchip shall be responsible for providing information to the data base registry of the microchip manufacturer indicating that the animal has been sterilized.Slide65
Tips Tricks
Tattoo and Glue
Texas state law requires us to either microchip or tattoo animals sterilized by releasing agencies
RULES PERTAINING TO THE PRACTICE OF VETERINARY MEDICINE. TEXAS ADMINISTRATIVE CODE. TITLE 22, PART 24. CHAPTER 573. RULE §573.77 STERILIZATION OF ANIMALS FROM RELEASING AGENCIES (2) A tattoo must: (A) be placed on the inside of the animal's thigh near the abdomen or on the caudal-ventral abdomen; (B) be imprinted with ink that is manufactured in the United States; (C) meet the standards of the federal Food and Drug Administration for tattooing; (D) be of a contrasting color to the predominant color of the skin in which it is tattooed; and (E) consist of the universal symbol for male or female overlain by a slash through the circle to indicate sterilization.Slide66
Tips Tricks
Tattoo and Glue
The required tattoo is almost never done
green tattoo line on the ventral abdomen is the standard of careNOTE – ear tip is not a legal way of identifying TNRed cats in TexasTNRed cats must be either microchipped or tattooed in addition to ear tipMost tattoo parallel to the incisionSome put tattoo ink in the incisionIt’s not uncommon for an owner or even a GP vet to think that tattoo ink in the incision is gangreneSlide67
Tips Tricks
Tattoo and Glue
(0:34)Slide68
Tips Tricks
Tattoo and Glue
Tattoo even tomcats on the ventral abdomen
Video incision is full thickness skinI just score the skin so there is no need for glueBlot the extra ink (peroxide) to prevent a temporary case of “green tongue”Ketchum tattoo paste is a favorite (tube)Don’t get the roll-on kind – it gets contaminated with first useApply with paper indicator strip of the back end of the scalpel blade handleSlide69
Tips Tricks
Tattoo and Glue
Take care to avoid getting glue in the subcutaneous tissues
It causes a terrible foreign body reactionDelays healingPotentiates infectionIf you touch the glue to the animal’s skin change out the application straw prior to the next patientDescribe the tattoo in the discharge instructionsSlide70
Tips Tricks
Tattoo and GlueSlide71
Tips Tricks
Minimizing Time Between Patients
Often the rate limiting step to the number of procedures that can be done each day
Less than 2 minutes surgeon down time between surgeriesShould be able to reglove, regown if needed, and start the next one without rushing2 minutes x 30 procedures = an hour of down time per day5 minutes x 30 procedures = 2-1/2 hours down time per day10 minutes – you might was well get the cot outSlide72
Tips Tricks
Minimizing Time Between Patients
Learn at what point in the procedure to call for the next induction
When I am ligating the first ovaryA little more time to induce catsA little more time for a “Labdomen”Alternate spays with neuters3 male cat neuters per surgery unit, unless infectious diseaseGo on the next one as soon as a neuter or group of neuters is brought into the ORSlide73
Tips Tricks
Minimizing Time Between Patients
Packs and gloves opened for the next patient during skin closure
Careful communication – respond, “Heard!”Forms or travel sheets minimize writing (http://omalleypet.org)Circles and checks as much as possibleBlanks to prompt information gatheringBetter yet, have a scribe for computer entry as you goColored tag systemGreen – pre-A exam completed, premedicated and ready for inductionBlue – needs vet exam prior to premedication and inductionYellow – infectious disease, surgery at the end of the dayRed tag – surgery complete or canceledSlide74
Zinc
Neutering
Zeuterin (formerly Neutersol)“Esterilsol” in other countriesArk Naturals says infertility is “permanent and irreversible” in 99.6% of dogsApproved only for dogs 3-10 months of ageOne uncontrolled study in Mexico on adultsNo studies assess fertility >12 months post-injectionA very small number of dogs do show uptick in fertility near the end of the 12 monthsSlide75
Zinc
Neutering
Zeuterin (formerly Neutersol)A very small number of dogs suffer scrotal rupture with exposed testicle 1 week to 4 months post-injection“Oligospermia” is considered “infertile” in the FDA approval studies<20 million sperm per mlUnlikely, but not impossible that these dogs could successful breedOther uncommon adverse reactions include scrotal draining tracts, erosions, self trauma, pain on injection, and preputial swellingSlide76
Zinc
Neutering
Zeuterin (formerly Neutersol)All dogs have scrotal swelling which peaks at 48 hours post-injection0.5-2% are fertile after injection2-5% have adverse reactions requiring castration5% euthanized for excessive testosterone driven behaviorInfertility occurs within 30 daysSlide77
Zinc
Neutering
Zeuterin (formerly Neutersol)Example - 2,500 castrations per year10-50 will remain fertile50-125 will need to be castratedACC&D - Potential for mild adverse injection site reactions to progress to serious reactions in dogs that are not properly supervised should be considered carefully. ACC&D recommends Esterilsol use be limited to dogs with owners/caregivers that can provide appropriate care.Alliance for Contraception in Dogs and CatsReasonable option when anesthesia potentially dangerousSlide78
Tips Tricks
Suture Size and Material
Monosorb seems to break a little bit easier than PDS –
may need one size larger for stumps and pediclesIf you break the suture, grab one size up to try again Polysorb in my hands has poor knot security, as compared to Vicryl and other similar generics.Suture size for closing the linea albaNo larger than 0 PDS for even the largest spays3-0 PDS fewer suture reactions than 2-0 for cats2-0 PDS for medium dogs3-0 to close SC and skinSlide79
Tips Tricks
Suture Size and Material
Swaged on more
expensive than reelLess tissue trauma with swaged onNeedle sharperNo double thickness as suture loops through needle eyeDon’t need thumb forceps for intradermal suturingReels allow you to pick and choose different suture types and sizes for the same surgery without wasteThreading needles with reel suture takes more timeDon’t cold pack suture pack leftovers – feline retroviruses are transmitted with waySlide80
Tips Tricks
Patient Positioning
Front legs pulled down to the side rather than over the head can help for deep chested dogs
Decreases traction on the ovarian pedicles via the suspensory ligamentTables that “V” keep patients from tipping right and leftCrossing the front legs before tying can also help with this in deep chested dogsSlide81
Tips Tricks
Patient Positioning
(0:30)Slide82
Tips Tricks
Avoiding Dehiscence of the Abdominal Wall
Avoid crushing tissue as you close the first two throws of each knot
Make sure you are closing the rectus sheath, not subcutaneous tissuesTake bites at least 5-10mm from the edge of the incisionKnots are not properly tightened, or don’t have enough throwsThe sheath, not the muscle tissue is the holding layerSlide83
Tips Tricks
Dealing with a Dropped Pedicle
Extend the incision cranially to the manubrium
Use the biological retractors to move organs out of the way to caudal to each kidneyLeft pedicle dropped – reflect descending colon to the rightRight pedicle dropped – reflect duodenum to the leftGrasp the pedicle with 2 fingers to exteriorize, then clampThe ureter is just beneath the ovarian arteryUsing a clamp to grasp the pedicle can result in trauma to or ligating the ureterPooling hemorrhage can obstruct the normal view of the ureterSlide84
Treasure
Hunt
Tips for Cryptorchid SurgeryDetermine which side is cryptorchid by retropulsing the normal testicle into its inguinal canalIf testicle can be palpated, make an incision over the testicleIf not, make incision same as spay in the catParamedian incision along the cranial half of the prepuce in the dogFind the vas deferens there and follow it to the testicleSlide85
Treasure
Hunt
Tips for Cryptorchid SurgeryMIA cat testicles are more often in the inguinal canalCan be very difficult to dislodgeHave an assistant put pressure upward on the inguinal canal with a gloved hand from inside the abdomenThis allows palpation of and incision over the hidden testicleThey can be very small in the catSlide86
Tips Tricks
Why are these Techniques Different from those taught in Vet School?
These skills are for the experienced surgeon
Those taught in vet school are for the inexperienced surgeonLarger incisions to compensate for infamiliarity with surgical anatomyDouble ligation to compensate for poor knot securityLigation prior to transection to prevent a dropped pedicle due to overmanipulation of the instruments or other poor techniqueMASTER BASIC TECHNIQUES BEFORE WORKING ON INCREASING EFFICIENCY