La Surgery Packet 9

Front 1

components of the exam of the vagina and rectum

Back 1

- discharges
- rectal exam: vagina, cervix, uterus and ovaries
- vaginal exam: visually with speculum, by palpation including palpation of the cervix
- bimanual exam: one hand in the rectum, one hand in the vagina

Front 2

components of the uterine exam

Back 2

- palpation
- endoscopy
- uterine culture
- uterine cytology
- uterine biopsy

Front 3

description: pneumovagina

Back 3

involuntary aspiration of air into the vagina

Front 4

etiology: pneumovagina

Back 4

faulty seal of the vulva because of poor closure or incompetence:
- sometimes associated with poor general condition
- tipped vulva (frequently seen in old multiparous mares)
- inversion of the lips of the vulva
- associated with perineal lacerations

Front 5

treatment for pneumovagina

Back 5

- correct the underlying cause of poor general condition if part of the problem: feed, deworm, float teeth, etc.
- surgical correction: Caslick's, variation of the Caslick's, Gadd technique, perineal body transection

Front 6

indications for Caslick's technique

Back 6

- correct vaginal contamination associated with poor conformation of the vulva
- to make a performance mare or filly more aesthetically acceptable (objectionable noises)

Front 7

restraint for Caslick's technique

Back 7

standing with rear quarters stabilised to prevent injury to the surgeon:
- stocks, cross ties or held
- sedation or tranquilisation if necessary

Front 8

preoperative preparation for Caslick's technique

Back 8

- wrap tail and tie it out in the field
- surgically prepare the perineum
- infiltrate the lips of the vulva at the mucocutaneous junction with local anesthetic to provide anesthesia and also to distend the tissue

Front 9

Caslick's technique

Back 9

- with scissors remove a small band of skin and mucosa at the mucocutaneous junction, starting at the most dorsal aspect of the vulva and extending distally to the floor of the bony pelvis
- suture the skin edges with 0-0 suture and simple continuous suture pattern (first and last bites should be deep enough to prevent the suture from pulling out): non-absorbable suture should be removed after 10 days

Front 10

breeding following the Caslick's technique

Back 10

- breeding by natural cover usually requires opening the sutured tissue and then resuturing following breeding
- it is sometimes possible to breed under the Caslick's by inserting a breeding stitch (heavy piece of suture placed at the ventral end of the Caslick's closure to prevent the stallion from disrupting the closure)
- it is usually possible to examine the mare with a tube vaginal speculum and to breed artificially without cutting the sutured tissue

Front 11

foaling following a Caslick's technique

Back 11

- necessary to open the suture line prior to foaling
- it is best to freshen the edges and close the vulva as soon as possible after the placenta has passed
- once the Caslick procedure is performed the seal of the vulva has been compromised so it is common to "suture the mare" for the rest of her reproductive life

Front 12

postoperative complications following Caslick's technique

Back 12

- incomplete seal
- urine pooling (if closure is extended too far ventrally): urine accumulates in the anterior vagina
- suture sinus: can be eliminated by not going through the vaginal mucosa with the suture

Front 13

variation of the Caslick's technique

Back 13

all steps are the same except removal of mucosa and insertion of sutures is slightly anterior to the mucocutaneous junction
- this doesn't compromise the seal of the vulva and as a result it is not necessary to continue to do the procedure for the breeding life of the mare
- good modification to use if the procedure is being done to make the mare or filly more acceptable (objectionable noises)

Front 14

synonyms Gadd technique

Back 14

episioplasty or perineal body reconstruction

Front 15

steps of the Gadd technique

Back 15

- same restraint as for a Caslick's procedure
- anesthesia by infiltration or an epidural
- involves the surgical removal of a right angle triangle shaped piece of mucosa from the dorsal aspect of the vestibule (one arm of the triangle is at the mucocutaneous junction, one arm at the dorsum of the vestibule and the hypotenuse anterior and ventral)
- once the tissue is dissected free, the raw edges of the vulva and caudal vagina are approximated with simple absorbable sutures
- this surgery reconstructs or increases the size of the perineal body which improves the natural seal that occurs when the perineal body presses against the brim of the pelvis

Front 16

perineal body transection

Back 16

- used for both pneumovagina and urovagina
- standing restraint and epidural anesthesia
- involves the division of the attachments between the rectum and caudal reproductive tract
- returns the vulva to a more natural conformation
- surgical preparation of the perineum
- a 6 cm horizontal incision is made between the rectum and vulva
- incision is continued cranially to sever the connection between the rectum and the caudal reproductive tract which allows the vulva to regain a more normal vertical orientation
- sutures are placed to close the incision: there is usually considerable disparity and the skin ventral to the anus must be sutured to the musculature dorsal to the vagina

Front 17

etiology perineal lacerations

Back 17

occur secondary to problems associated with delivery of a foal

Front 18

classifications of perineal lacerations

Back 18

- first degree: involves only the skin and the mucous membrane
- second degree: involves the perineal body but not the rectum
- third degree: involves the perineal body, the dorsum of the vagina and the rectum

Front 19

repair of first degree perineal lacerations

Back 19

these heal without complication and don't require special care

Front 20

repair of second degree perineal lacerations

Back 20

- possible to repair this laceration immediately after it occurs
- usually best to wait until after inflammation and infection have subsided ~5-10d
- no dietary restrictions are required
- restraint in stocks is suggested
- anesthesia by infiltration or epidural
- debride the area over the tear (if mucosa has been allowed to heal completely this will be essentially the same as the Gadd technique): debrided area will be in the form of a right angle triangle with the hypotenuse facing ventrodorsally
- insert multiple simple absorbable sutures to appose the debrided tissue
- suture placement should proceed from deep to superficial
- insert skin sutures as in the Caslick procedure

Front 21

general considerations for third degree perineal laceration

Back 21

- most commonly occur in maiden mares
- repair immediately after occurrence is supposedly possible but the normal routine is to wait 6 weeks or, if the foal is still alive, until it is weaned

Front 22

immediate wound care for third degree perineal laceration (assuming surgery is delayed)

Back 22

- careful examination to determine the extent of damage: evisceration is unlikely but possible (if there is minimal tissue between the laceration and the peritoneum consider apposing tissues with large interrupted sutures)
- debride cautiously
- tetanus prophylaxis
- parenteral antibiotics (4-5d)
- careful cleaning of the wound for several days

Front 23

preoperative conditions for third degree perineal laceration

Back 23

dietary management to maintain a soft unformed stool is extremely important:
- lush pasture
- brain and grain with no long stemmed hay
- completely pelleted feed
- frequent administration of mineral or linseed oil

Front 24

special instruments required for third degree perineal laceration

Back 24

deep lacerations require instruments with long handles

Front 25

position and anesthesia for third degree perineal lacerations

Back 25

- most commonly performed standing with epidural anesthesia
- general anesthesia and dorsal recumbency is preferred by some surgeons

Front 26

technique for third degree perineal laceration repair in standing mare

Back 26

- epidural anesthesia, tail wrapped and tied overhead
- perineum clipped
- rectum evacuated
- rectum and vagina flushed with mild disinfectant
- vulvar lips retracted in stay sutures
- sharp dissection to separate the rectal floor from vaginal roof at the cranial aspect of the laceration
- dissection continued laterally and caudally at the junction of the rectal and vaginal mucosa to the mucocutaneous junction at the vulva
- the incision is extended laterally far enough so that the edges of the rectum can be apposed with minimal tension

Front 27

modified Goetz technique for surgical repair of third degree perineal lacerations

Back 27

- either a nonabsorbable non-capillary suture or absorbable suture can be used
- the initial suture is placed slightly cranial to the most cranial aspect of the incision
- the suture is passed through the vaginal mucous membrane on one side and is inserted approximately 3 cm away from the cut edge of the rectum passing through the musculature up to but not through the rectal mucosa and then out through the cut edge of the rectum
- after exiting through the cut edge of the rectum it is inserted just ventral to the mucosa of the rectum on the other side and passed laterally approximately 3 cm to exit through the ventral aspect of the dissected rectum
- it is inserted through the vagina and vaginal mucosa from dorsal to ventral
- then back up through the vagina from ventral to dorsal
- suture is crossed to the other side and is inserted through the dorsal aspect of the vagina and the vaginal mucosa
- 2 ends of suture are tied with the suture pulled tight enough so that the raw suture cannot be palpated at the incision site
- if absorbable suture is used the ends are left long and tied together for easier ID at the time of removal
- sutures should be placed at approximately 1.5cm intervals and continued caudally to the perineal body
- perineal body is reconstructed with a number of simple approximating sutures
- anal sphincter is repaired
- lips of the vulva repaired as described for Caslick's technique

Front 28

Annes technique for surgical repair of third degree perineal laceration

Back 28

- involves same initial dissection as modified Goetz technique
- a continuous horizontal mattress suture pattern is used to close the vaginal mucosa
- simple interrupted sutures are used to close the muscle lyer of the rectum and the perineal body
- a continuous horizontal mattress suture pattern is used to close the rectal mucosa
- anal sphincter is closed at a second stage 2-3 weeks following the initial closure

Front 29

pull back technique for surgical repair of third degree perineal laceration

Back 29

- described for very shallow third degree lacerations
- dissection as for other techniques
- perineal body is reconstructed with simple opposing sutures
- the most caudal aspect of the rectum is pull back to the area of the anus and sutured

Front 30

post-operative management for third degree perineal laceration

Back 30

- maintenance of non-formed stool for 10 days
- tetanus prophylaxis
- parenteral antibiotics for 4-5 days
- remove non-absorbable sutures in 10 days

Front 31

post-op complications after third degree perineal laceration repair

Back 31

- excessive straining to defecate
- partial or complete wound breakdown

Front 32

etiology and preoperative considerations for rectovaginal fistula

Back 32

- birth related injury
- foal's foot is forced through the dorsal vagina and into the rectum
- foot is pulled or pushed back into the vagina to continue the normal birth process
- in time there is a marked wound contraction but a fistula routinely persists
- time for repair and dietary considerations are the same as for third degree laceration

Front 33

position and anesthesia for rectovaginal fistula

Back 33

as described for third degree laceration repair

Front 34

technique for the repair of rectovaginal fistulas >6 inches anterior to the vulva

Back 34

- horizontal incision made midway between the anus and the dorsal aspect of the vulva
- dissection continue 2 cm cranial to the cranil edge of the fistula (through the wound margins)
- interrupted Lembert sutures with the sutures placed in a sagittal direction are used to repair the defect in the rectum: these sutures are placed from the ventral side of the rectum, knots tied ventrally and sutures not penetrating the rectal mycosa
- simple interrupted sutures placed in a transverse direction are used to close the defect in the vagina
- the space between the rectum and the vagina starting