Speed Spay

Document Sample
Speed Spay Powered By Docstoc
					Speed
Spay
A Complete Spay in Less Time                                Instead make your incision more caudally.
Insight from Dr. Holly Birkett.
                                                            Near the bladder.
(view the video on our website)                             I usually place my incision at the caudal abdo-
                                                            men, roughly over the bladder region. I base my
                                                            incision at the cranial portion of the bladder in the
Before You Start
                                                            caudal portion of the abdomen. Cats’ body types
Positioning
                                                            and configurations vary, so I look at their shape
                                                            and proportions. Some cats are longer- some
Leave legs untied.
                                                            cats have their nipples and umbilicus in strange
Stretching and tying cats to the table stretches
                                                            anatomical places, so you cannot solely rely on
and tightens the entire cat, including all the inter-
                                                            markers. One size does not fit all.
nal ligaments! By simply leaving the legs untied,
the ligaments associated with the ovaries and
uterus remain loose and allow for easier                    Last nipples.
exteriorization during surgery.                             One common mistake when learning pediatric cat
                                                            spays is making the incision too far cranially. This
Position with towels or fleece.                             makes it more difficult to reach the uterine bifur-
Instead of tying the legs to secure the cats,               cation, which leads to extending to a longer inci-
simply use towels or fleece along the cat’s sides           sion. If the nipples appear ‘anatomically correct’,
to prop it up. Leave the legs relaxed and unse-             I make my incision just cranial to the last nipples
cured. If the paws droop in the way of your surgi-          or in the region just over the bladder. If the anat-
cal site, then loosely tie or tape the legs just as         omy is not typical, e.g., the last nipples are in an
far as you need to maintain your surgical field.            unusual area, then I look at overall anatomical
                                                            conformation.

                                                            Exceptions.
                                                            Exceptions to placing the incision more caudally
                                                            are: pregnant cats and post partum cats. In preg-
Remember that stretching the legs tightens the
                                                            nant cats, the uterus shifts more cranially. In post
uterine and ovarian ligaments. There is a direct
                                                            partum cats that are lactating, the ovaries are
relationship between the size of your incision and
                                                            more friable and can easily tear apart. For these
how easily you can exteriorize the ovaries and
                                                            cats, I make my incision somewhere in the middle
uterus.
                                                            between umbilicus and last nipples/pubis.

Incision Placement                                          Incision Size
Caudal placement.                                           Start Small.
Start your spay incision lower or more caudally             For a routine spay, try starting with a small inci-
than what is taught in vet school. If you were              sion, about a 1/2 to ¾ inch. Vet school surgeons
taught to begin near the umbilicus, then don’t.




      Feral Cat Spay/Neuter Project :: 11331 Roosevelt Way NE :: Seattle, WA 98125-6227 :: Phone: 206-528-8125
                                           e-mail: questions@feralcatproject.org              REVISED: 3-2007
Speed Spay                                            :: 2 ::




always preach that incisions heal from side to              incision. It just takes practice, patience and good
side, but they do not consider that we suture end           technique. The exception is that if you feel that
to end or that cats feel pain from end to end.              passing the hook is causing any tissue trauma,
                                                            then by all means, extend the incision. Often,
Why a Small Incision?                                       then you will visualize the uterus and not need
A smaller incision has many advantages: signifi-            the spay hook. Once the uterus is exteriorized,
cantly shorter closure time; greatly reduced surgi-         you can determine whether to proceed through
cal time; reduced tissue involvement thus, less             your initial incision or extend.
post operative discomfort; faster recovery; less
expense on anesthesia and surgical supplies.                Tips to exteriorize the uterus using
Improve With Practice.
                                                            the spay hook:
I did not simply start making small incisions one           Know the anatomy.
day. For me, the technique evolved. Once I                  • Review the anatomy, ideally with a cadaver,
became more comfortable with tissue handling                if the opportunity arises. (Freshman year was a
so that I could exteriorize well, then my incisions         long time ago.)
became smaller.
                                                            • Pay close attention to where the uterus lies in
Extend If You Need To.                                      relation to everything surrounding it. Study its
Remember that if you start small, you can always            position in the abdomen and trace it all the way
extend the incision. I sometimes extend if the              to the suspensory ligament and ovarian pedicle
ovaries feel too “tight” to exteriorize, and if I have      blood supply. Keep in mind where the uterus
concern that tissue might tear. With practice on            should be when using the spay hook.
incision placement and using small incisions, you
will find that most spays are easy to exteriorize           • See where the ovarian blood supply originates,
with little effort through a small incision.                in case you ever need to go hunting for your
                                                            pedicles.
“Listen to Your Gut”.
There are always exceptions to small incisions,             • Review where the ureters lie so you know how
so use your best judgment. One good rule: if you            to avoid them.
feel you should do something differently or you
feel unsafe, then listen to yourself. Don’t second-         • On the cadaver, try using the spay hook on dif-
guess. Implement those changes that you feel                ferent structures, ligaments, ureters, etc to feel
are necessary.                                              the difference when you retract without being able
                                                            to see them.
Options.
For pediatric spays, I rarely extend the incision           Passing the Spay Hook.
to find the uterus with the spay hook. The uterus           • Review the process for passing the spay hook.
can always be found in a kitten through a small
                                                            • With the hook facing the body wall, go down one




      Feral Cat Spay/Neuter Project :: 11331 Roosevelt Way NE :: Seattle, WA 98125-6227 :: Phone: 206-528-8125
                                           e-mail: questions@feralcatproject.org              REVISED: 3-2007
Speed Spay                                            :: 3 ::




side tightly along the body wall. When you feel             Tissue condition and handling varies for any
the hook has hit bottom, turn the hook towards              given uterus.
the midline.
                                                            Grasp the Ovary
• Now slant the arm of the spay hook about 45               Holding the horn between my fingers, I slide or
degrees instead of straight up and down. Move               walk my fingers toward the ovary and clamp the
the hook slightly towards the center of the abdo-           proper ligament. Then I slide over with my thumb
men. Elevate the hook keeping it slanted at 45              and index finger and grasp the ovary, pinching
degrees.                                                    below on the pedicle area. With this technique,
                                                            if something friable tears, I have the ovary in my
• Often, you do not retrieve the uterine horn, but          fingers and will not lose it.
instead elevate a ligamentous structure. This is
the broad ligament. Grasp it with your fingers of           Don’t Pull the Horn
one hand and remove the hook. While still hold-             I see some vets try to pull up the pedicle by pull-
ing the ligament, use the other hand to insert the          ing on the horn. This approach can tear the ovary
hook down with the hook side facing the ligament            away from the proper ligament, a complication
and then lift up. This usually elevates and exteri-         that will lengthen your surgery and increase your
orizes the horn.                                            stress.

• If for any reason you think something does not            Break Down Suspensory Ligament
feel right or feels too tight to lift with the hook,        I hold the ovary until I completely break down
then trust your instincts. STOP the pass, let the           the suspensory ligament. With my free hand, I
tissue free, and then try again. Never compro-              isolate the suspensory ligament and try to tear
mise if something does not feel right. This is why          it free. If it does not tear easily, I use another
reviewing anatomy comes in handy, such as see-              approach. While still grasping the ovary, I shield
ing the position of the ureters.                            the pedicle blood supply with my index finger and
                                                            push the suspensory ligament outward with my
Identifying the uterus by touch.                            thumb. With a scalpel blade, I make a tiny nick in
If passing the spay hook is repeatedly unsuccess-           the ligament, which allows me to easily tear the
ful, you can extend the incision and digitally pal-         remaining ligament.
pate the area. You will feel the uterus with your
finger. The skill to identify the uterus by touch           Can’t Break the Suspensory Ligament?
takes time to develop, but it works very well.              If there is ever a reason that you do not break
                                                            free the suspensory ligament, then you must
Tips for Exteriorizing and                                  transfix the pedicle. Encircling ligatures around
Securing the Ovary                                          a pedicle with an intact suspensory ligament are
Tissue condition.                                           not secure. There is strong tension on the liga-
Once I exteriorize the first horn, I handle it              ment coursing at a different angle than the pedi-
carefully to get a sense of the tissue’s condition.         cle vessel supply.




      Feral Cat Spay/Neuter Project :: 11331 Roosevelt Way NE :: Seattle, WA 98125-6227 :: Phone: 206-528-8125
                                           e-mail: questions@feralcatproject.org              REVISED: 3-2007
Speed Spay                                            :: 4 ::




Place Ligatures                                             until I reach my ligatures. Be careful, because the
Breaking down the suspensory ligament isolates              broad ligament can be very friable and thin.
the pedicle very isolated so that the ligatures
tighten down and secure well. Once the suspen-              Bladder Interference
sory ligament is free, I place ligatures. Using only        If the bladder interferes with exteriorizing one
one clamp on the vasculature, I place one ligature          of the horns, one strategy is to simply push the
proximal to the clamp. Next I loosen the clamp,             bladder laterally toward the body wall on the side
‘walk it” distally on the pedicle and place an ad-          where you are working. Example: if you are trying
ditional ligature. When both ligatures are secure, I        to exteriorize the left horn (right horn already re-
separate the pedicle.                                       moved and ligated) but the bladder is in the way,
                                                            on the midline and pushing the left ovary down,
Clamp the Ovary/Horn                                        simply displace the bladder with your finger all the
Once the pedicle is excised free, I use the clamp           way to the left side. Suddenly the left horn and
from the proper ligament to clamp the blood sup-            ovary frees up.
ply on the horn/ovary to prevent blood loss until
surgery is complete.                                        Intestinal Interference
                                                            The procedure to move the bladder also works for
General Tips for Spays                                      small intestines that are in the way. In this case,
Making things easier when life                              I push the intestines or displace them cranially.
                                                            Don’t struggle with them in your way.
isn’t perfect.
                                                            Security Sutures
Checking Ovarian Pedicles:
                                                            A good rule of thumb for both the ovarian and
• If you ever lose an ovarian pedicle or want to
                                                            the uterine stumps is to first place an encircling
double-check the pedicles for bleeding, use the
                                                            ligature, and then follow with a transfixing ligature
“natural guide” of the broad ligament. The broad
                                                            distally. Your first ligature acts as a “safety” liga-
ligament attaches to the sides of the uterine
                                                            ture that will not tear through the tissue causing
stump, so simply identify the ligament attachment
                                                            potential hemorrhage of friable tissue.
to the uterus and follow it down to each ovarian
pedicle.
                                                            Create Room to Work
• In an emergency (hemorrhage), you have al-                By placing one encircling ligature first, you can
ready extended the incision. Once you see where             cut free the rest of the tissue. In other words,
the broad ligament courses, it may be easiest to            place your transfixing ligature after separating
place your finger down in the area and feel your            the stumps. This gives easier access for placing
ligatures. Be careful not to tear anything; gently          other ligatures, because the clamps and tissue
lift up the pedicle with your fingers.                      are moved out of the way. Tying around a single
                                                            forcep is much easier than trying to tie under-
• Another method I have used is to “walk” clamps            neath three clamps and the mass of uterine tis-
one in front of another along the broad ligament            sue. With more workspace, the resulting ligature




      Feral Cat Spay/Neuter Project :: 11331 Roosevelt Way NE :: Seattle, WA 98125-6227 :: Phone: 206-528-8125
                                           e-mail: questions@feralcatproject.org              REVISED: 3-2007
Speed Spay                                            :: 5 ::




can be made more secure.                                    gers on the uterus itself. This places less tension
                                                            on the entire uterus.
Freeing a Uterine Horn
If you free one horn but have trouble exterior-             When Clamping is Cutting
izing the second one, it may be trapped under               Especially for post partum cats, tissue may be too
the bladder or intestines. Try pushing the blad-            friable to clamp without tearing the uterus. This
der over (if you need left horn push it to the left         is a great situation to place an encircling ligature
body wall) or push the intestines cranially. Do this        first without clamping. I like to use chromic catgut
without extending the incision by pushing from              when tissue is friable, because it is less likely to
outside the body wall, as in palpation. This often          cut through fragile tissue. Then I use my regular
releases the trapped horn.                                  suture for the second ligature.

Do Sit Ups for Better Access                                Closure
Another tip to exteriorize the uterine horn is to           Make it a happy ending.
have the surgery tech remove the mask and
place the cat in a sit-up crunch position while             Suture Pattern
maintaining all sterile fields. This relaxes the liga-      • Small incisions rarely need SQ layer closure.
ments and when you grasp one horn, the other                Close the linea using a simple interrupted or
exteriorizes more easily.                                   cruciate pattern. Close skin with a subcuticular
                                                            pattern and be sure to bury your knot. Add a spot
Years ago, I relied on the sit-up crunch position,          of tissue glue to seal, if desired.
but with my incision placement more caudally and
moving the bladder when needed, I rarely need
                                                            Less Time, Less Trauma, Less Pain
this position anymore. This is a great technique
                                                            • The best thing about becoming proficient at
that facilitates performing many types of spays.
                                                            spays through a small incision is that closing
Keep it in mind.
                                                            only requires a few lineal sutures. It’s a breeze.
                                                            You save time while you drastically reduce tissue
R-E-S-P-E-C-T the Tissues                                   trauma and associated pain. Incisions heal side
• When moving from the ovaries to the uterine               to side, but sutures and discomfort run end to
body, take time to assess the tissue condition,             end.
appreciate how much handling is safe and how
much you can stretch the uterus to exteriorize the
body.

• Never stretch or pull on the uterine horns with
the clamps. Never pull from the ends near the
ovaries. You are more likely to tear the uterus
and lose it. Instead, go down the horns to the
uterine body and lift from there, holding your fin-




      Feral Cat Spay/Neuter Project :: 11331 Roosevelt Way NE :: Seattle, WA 98125-6227 :: Phone: 206-528-8125
                                           e-mail: questions@feralcatproject.org              REVISED: 3-2007

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:26
posted:8/31/2011
language:English
pages:5