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65 Cards in this Set
- Front
- Back
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What are some of the indications for reproductive surgery?
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Eliminate reproductive ability
Relieve dystocia Tx of reproductive tumors Tx dz of the repro tract (pyometra etc) Stabilize systemic dz (diabetes) |
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Describe the location of the ovaries.
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The right ovary lies dorsal to the descending duodenum and left ovary lies dorsal to the descending colon and lateral to the spleen.
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Name the attachment b/t the ovary and the uterine horn.
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Proper ligament.
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Describe the attachments of the suspensory ligament
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Runs b/t the ovary and the transversalis fascia medial to the last couple of ribs.
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What is the mesovarium?
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The section of the broad ligament which holds the ovary in place. AKA the ovarian pedicle.
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What is contained in the mesovarium?
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Ovarian arteries and veins.
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Describe the origins and drainage of the ovarian a. and v.
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A. originate from the aorta. L. ovarian vein drains into the L. renal vein. R. vein drains into the caudal vena cava
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What is the broad ligament?
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Peritoneal fold which suspends the uterus.
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What is the mesometrium?
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Portion of the broad ligament below the mesovarium.
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Describe the course of the round ligament.
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Originates from the proper ligament of the ovary, travels in the free edge of the broad ligament, through the inguinal canal with the vaginal process.
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What are some of the pros of early gonadectomy in dogs?
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Incidence of mammary neoplasia is dramatically reduced.
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What are some of the cons of early gonadectomy in dogs?
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Increased urinary incontinence
Anaesthesia risk with young patients. |
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What are the recommendation if a bitch is:
a)in oestrus b)pregnant c)lactating |
a) Avoid OHE during oestrus as inc. oestrogen prolongs clotting time and the repro tract is enormously vascular at this stage.
b) Aim to carry out OHE prior to mid-point of gestation d/t inc. vascularity. c) Allow 2 weeks after whelping to enable weaning. |
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Where should the spay incision be made?
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Ventral midline, 5-10 cm long extending from a point just cranial to the umbilicus and extending caudally. Prep-ed area should be from xiphoid to pubis.
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Which side of the uterus should be exterioised first?
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Left - more caudal and thus easier.
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Describe how to prevent trauma to the abdominal viscera while making the midline incision.
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Initial incision is only through the skin and subcutaneous tissue to expose the linea alba. The linea alba is then grasped with forceps (producing a tent) which can then be cut using a stab incision with scalpel. Extend incision to the appropriate size using Mayo scissors.
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Describe how to locate the left ovary.
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Elevate the left abdominal wall with thumb forceps and slide a spay hook (hook-side against the body wall) towards the region immediately caudal to the left kidney. Turn the hook medially to ensnare the uterine horn or broad ligament. Anatomically confirm the identification of the structure held.
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Describe how to exteriorise the ovary.
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Palpate the suspensory ligament as a taut, fibrous band at the proximal edge of the ovarian pedicle. Detach the suspensory ligament by applying caudolateral tension while ensuring the safety of the ovarian blood vessels.
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Describe how to place the clamps on the ovarian AV complex/suspensory ligament.
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Perforate the avascular portion of the broad ligament caudal to the ovarian vessels. Insert 3 clamps on through this slit to grasp the suspensory ligament/ovarian AV complex proximal to the ovary.
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Describe the placement of the initial ligature.
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Remove the most proximal clamp and place a catgut/monocryl or PDS circumferential ligature in the crush mark left by the clamp.
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What is vitally important to have happen while tying your ligatures?
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Have your assistant 'flash' the second most proximal clamp to ensure a tight ligature. Replace the clamp once the ligature is tied.
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What is done next once the ligature is tied?
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The tissue b/t the two remaining clamps is cut. Ensure no ovarian tissue is left behind.
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Describe the process in which the cut ovarian stump is returned to the abdominal cavity.
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Grasp the ovarian pedicle b/t the remaining clamp and ligature - this prevents perforating the remnant of the pedicle. Use Crille, Aliss, Adson or rat-toothed forceps. Carefully remove the clamp. Check for haemorrhage, and if there is none gently return the stump to its normal position. Reflect organs so that the stump may be visualised in its relaxed position. Again check for haemorrhage.
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What is done next once the stump has been replaced?
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Gently tear the mesometrium to the level of the cervix. Do not damage the uterine a. and v. In those animals with a vascular mesometrium it would be appropriate to ligate the mesometrium (inc. the round ligament) prior to transection. Reflect the uterine horns caudally onto the draped ventrum of the patient.
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Describe the clamping of the uterus.
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Place three clamps either cranial or caudal to the cervix.
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In which cases should you place caudal clamps as opposed to cranial clamps?
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In closed pyometras - in order to minimise contamination.
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Describe the process of tying the uterine ligature.
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Remove the most caudal clamp and tie a transfixation ligature in the remaining crush mark. R-handed surgeons pass the needle from the caudal side to cranial. In larger bitches a second ligature is placed starting from the other side of the vessels. In pregnant animals the ligation of the individual vessels may be appropriate
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What is done next once appropriate ligature(s) have been tied?
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The tissue b/t the remaining clamps is cut - check for haemorrhage. Gently lower the uterine stump into the abdominal cavity and once again check for haemorrhage.
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What suture and suture pattern is appropriate to close the linea alba?
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3/0, 2/0 or 0 PDS (depending on size of patient) in a simple continuous pattern.
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What suture and suture pattern is appropriate to close the subcutaneous tissue?
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3/0 caprosyl or monocryl ina simple continuous pattern with buried knots at each end or subcuticular closure.
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What suture and suture pattern is appropriate to close the skin?
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3/0 nylon or monosof in a simple interupted pattern.
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List complications of elective OHE.
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Haemorrhage
Peritoneal abscessation (occurs when non-abs sutures are used or swabs are left behind) Stump pyometra (can occur when not all of the uterine body is removed and patient is put on progesterone tx) Recurrent oestrus Post-sx vaginal bleeding from transfixed ligatures Ureteral ligation Vagino-ureteral fistulation Urinary incontinence Obesity |
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What are the four stages of pyometra?
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I – cystic endometrial hyperplasia = aging
change by middle age, not linked to estral cycle II - diestral changes under influence of progesterone, plasmocytic infiltrate III – acute inflammatory reaction IV – chronic endometritis |
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Pyometra is associated with which part of the oestrus cycle?
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Dioestrus
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Describe the pathophysiology of pyometra.
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In normal bitches, a period of dioestrus occurs for 2 months. Progesterone secretion occurs during this period following oestrus. Repeated exposure of the endometrium to high concentration of oestrogen (such as during oestrus) followed by high concentrations of progesterone without pregnancy leads to cystic endometrial hyperplasia. The secretions associated with CEH provide an excellent medium for bacterial growth - vaginal commensals ascend the partially open cervix during proestrus and oestrus.
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Define cystic endometrial hyperplasia.
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Hormonally mediated progressively pathological change in the uterine lining.
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Define pyometra.
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Secondary to CEH - occurs when bacterial invasion of the abnormal endometrium leads to intraluminal accumulation of purulent exudate.
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Describe the risk factors associated with pyometra development.
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Older, nulliparous bitches are at risk.
Younger animals may be at risk if treated with oestrogen or progesterone. Precise outcome may depend on the stage of oestral cycle the hormones are applied. |
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Describe the clinical signs associated with pyometra.
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Abdominal distension/uterus large on palpation
+/- vaginal dc - depends on cervical patency. May range from sanguinous to mucopurulent Depression Lethargy Anorexia PU/PD Vomiting Signs of septicaemia/shock may be seen in pyometras with a closed cervix |
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Describe the clin path associated with pyometra.
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Left-shift neutrophilia - more severe in closed pyometra
Mild,normocytic, normochromic anaemia HyperGlb and hyperPrn Azotemia ALT and ALP may be high with septicaemia and severe dehydration Electrolyte disturbance - precise nature depends on clinical course |
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How would you confirm a suspected pyometra?
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The diagnosis can be established from the history, physical examination, abdominal radiography, and ultrasonography. Vaginal cytology is often helpful in determining the nature of the vulvar discharge. A CBC, biochemical profile, and urinalysis help exclude other causes of polydipsia, polyuria, and vomiting; they also evaluate renal function, acid-base status, and septicemia. The uterine exudate should be cultured and sensitivity tests performed.
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Outline treatment options for pyometra.
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Treatment aims consist of eliminating bacterial infection and removing the build-up of exudate which acts as a nidus of infection.
Immediate IV fluids and empirical broad spectrum antibiotics are indicated with both medical and surgical cases. Fluid, electrolyte, and acid-base imbalances should be corrected prior to surgery. Oral antibiotics (based on the results of the culture and sensitivity) should be continued for 7-10 days after surgery. OHE is the treatment of choice. If the owner wishes to keep the animal intact medical management may be undertaken with PGF2α. It causes luteolysis, contraction of the myometrium, relaxation of the cervix, and expulsion of the uterine exudate. It should not be used in animals >8 yr old, those not intended for breeding, those critically ill and used should be used with caution in bitches or queens with a closed-cervix pyometra because of increased risk of uterine rupture. Pregnancy must be ruled out, as prostaglandins can induce abortion. |
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What fluids can be used to support the haemodynamic and oxygenation status of patients in shock?
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Hypertonic saline with a colloid (also useful for patients with hypoproteninemia).
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What is the preferred intra-op drug for inotropic support in hypotensive anuric patients? Why?
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Dobutamine or dopamine - dobutamine is less arrhythmogenic and chronotropic and is the preferred choice
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Describe the surgical approach for a pyometra.
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Ventral midline incision from just caudal to the xiphoid and extending to the pubis. Locate the uterus and observe the abdomen for evidence of peritonitis (serosal inflm, inc abdominal fluid and petechiation). Gently exteriorise the uterus - do not use a spay hook. Isolate the uterus using laparotomy pads or sterile towels. Place clamps and ligature according to standard OHE protocol - ensure the cervix is also removed. Use monofilament absorbable suture material for ligatures. Thoroughly lavage the abdomen - ensuring contaminated drapes and instruments are removed prior.
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What are the risk factors associated with hypoplastic vulvas/vulval inversion/vulvar folds?
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Obese bitches
Congenital recessed vulva - may be seen as stenosis of other regions of the reproductive tract Bitches spayed prior to puberty |
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Describe the progression of the condition.
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Redundant skin folds result in friction at contact points, retention and accumulation of secretions and bacterial proliferation. This macerates and leads to superficial skin ulceration - superficial perivulvular dermatitis. Pain associated with the dermatitis leads to self-trauma which exacerbates the problem.
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What must be conducted prior to corrective surgery?
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Dermatitis must be cleared with topical antiseptics or steroid/antibiotic
creams. Weight reduction may also be useful. |
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Describe the surgical approach of an episioplasty.
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Following patient prep, assess the amount of skin to be resected. Begin cutting the most dorsal crescent by starting the incision near the ventral commissure of the vulva. Make a second smaller crescent inside the first. Excise the segment with its underlying subcutaneous tissue. Ease the smaller curve onto the large curve using simple interrupted sutures and assess the degree of resection. Oppose the subcutaneous tissue with monofilament absorbable sutures using buried knots.
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What are the three categories of vaginal hyperplasia/prolapse?
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Type I = slight eversion of the vaginal floor but no protusion through the vulva
Type II = vaginal tissue prolapses through the vulvar opening Type III = 360 degree protusion of vaginal tissue - including the urethral orofice |
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Describe the pathogenesis of vaginal hyperplasia.
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High levels of oestrogen cause oedema of the vaginal mucosa. The glands in the mucosa become markedly hypertrophic and the tissue becomes cystic. Severe oedema causes vaginal tissue protrudethrough the vulva. Proplapsed tissue promotes straining - worsening the condition.
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Describe the signalment of patients with vaginal hyperplasia/prolapse.
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Young large breed or brachycephalic bitches
Familial predisposition |
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Describe the typical history/findings of a patient with vaginal hyperplasia/prolapse.
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Onset of pro/oestrus
Late pregnancy/parturition (although less common at this stage) +/- Mass protuding from vulva Licking vulva Failure to allow copulation Dysuria Pollakiuria |
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What tx would you recommend for a Type I vaginal hypertrophy?
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Prolapse will spontaneously resolve when oestrogen influence diminishes. If in oestrus GnRH or HCG can be administered to induced ovulation. Animals with this condition shouldn't be bred from as it has familial tnedencies.
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What tx would you recommend for Type II and III vaginal prolapse?
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Both categories have a degree of tissue protusion through the vulva. OHE is curative as it eliminates the source of the oestrogen which produces the condition.
If a Type II proplapse doesn't have any trauma to the tissue, conservative medical management may be undertaken - this involves keeping the everted tissue clean and well lubricated. Elizabethan collar would be helpful to prevent self-trauma. Condition is self-resolving once in dioestrus. Recurrence rates are relatively high. In Types II with tissue trauma and severe Types III a resection via episiotomy may be indicated to remove damaged tissue. Surgery is associated with significant haemorrhage. With any resection of vaginal tissue the urethra should be catheterised. OHE should be recommended. |
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Describe the nature of vaginal tumors in dogs.
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Generally benign - leiomyomas or fibromas. Benign tumors are attached by a pedicle, with malignant tumors with more of a broad base.
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What is the proposed pathogenesis of benign vaginal tumors? How would you treat a benign tumor?
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Thought to be hormonally mediated since incidence is low in spayed bitches.
Tx involves conservative episiotomy and OHE. Reoccurence following OHE not documented. |
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What surgery is recommended for malignant vaginal tumors?
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Vulvovaginectomy
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Describe the approach to an episiotomy
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Clamp Doyen forceps onto the dorsal vaginal commissure either side of midline. Incise the skin from the dorsal commissure to just distal to the external anal sphincter muscle with a scalpel. Continue the incision through the muscle and vaginal mucosa using Mayo scissors. Control haemorrhage using ligatures, haemostats or electrocoagulation. Once finished the intended procedure, close the vaginal mucosa using simple interupted or continuous sutures with the knots in the lumen. Reappose muscles and subcutaneous tissue using continuous sutures.
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Define uterine prolapse.
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Eversion and protusion of a portion of the uterus through the cervix into the vagina during or near parturition. Usually occurs with prolonged labour.
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Describe the typical findings associated with uterine prolapse.
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Excessive straining during parturition
Mass protruding from the vulva Abdominal distress Tenesmus Licking Dysuria Abnormal posture Haemorrhagic shock if the uterine vessels have ruptured |
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Describe the medical management of a patient with uterine prolapse.
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Treat shock with fluids
Corrects acid/base and electrolyte disturbances Hypertonic solutions and gentle massage may help reduce oedema Prophylactic antibiotics if the prolapse is contaminated/traumatized Assessment of the tissue viability |
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What are the treatment options for uterine prolapse?
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1) Manual reduction
2) Manual reduction and immediate OHE 3) Reduction via celiotomy 4) Mass amputation (similar to vaginal prolapse tx) |
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What are the indications for OHE in this case?
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Devitalized or irreducible tissue - may require mass amputation to enable reduction prior to OHE
Broad ligament rupture |
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Describe the surgical technique of reducing acute prolapses.
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Lavage protuding tissue with warm saline or water and diluted antiseptic. Hypertonic solutions and gentle massage may reduce oedema. Lubricate the mass with sterile KY and manually replace the tissue using external pressure. Insert a urethral catheter. Suture the vulvar lips with a horizontal mattress suture to maintain reduction and prevent recurrence
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