Semi-Final Surgery Notes (PDF)

**CYSTOTOMY** **Bladder stone removal** may be accomplished through the urethra (standing) or via cystotomy (general anesthesia). Gradual urethral sphincter dilation and/or sphincterotomy can allow stone removal in mares. Stones in males are often removed via perineal urethrotomy or, less commonly...

**CYSTOTOMY** **Bladder stone removal** may be accomplished through the urethra (standing) or via cystotomy (general anesthesia). Gradual urethral sphincter dilation and/or sphincterotomy can allow stone removal in mares. Stones in males are often removed via perineal urethrotomy or, less commonly, via a perirectal incision. In both cases, stones may need to be broken up prior to standing removal. Other options include stone buster lasers, laparoscopy and lithotripsy. Standing removal is most common and can be done in the field with proper facilities (stocks are advisable). **Laparocystotomy** - Removal of stones via cystotomy under general anesthesia is considered by many to be the procedure of choice. - This method allows intact stone removal, culture of the bladder wall, and removal of all stone debris. Leaving stone debris can lead to future obstruction and/or stone formation. However, bladder access is difficult in adult horses and is occasionally impossible. General anesthesia and laparotomy is also the most expensive option with the longest associated recovery period. **Laparoscopic cystotomy** - This method of removal has been reported. It does require experience with laparoscopy and specialized instrumentation. The stone needs to be caught in a bag and it is difficult to close the bladder with inverting sutures that don't penetrate the lumen. Having suture penetrate the lumen predisposes to more stone formation and unhappy client. It is possible to remove stones up to 6-8cm in diameter using this method. **Pararectal cystotomy (Gokel's operation)** - This procedure is not often used but may be an economical approach for removing large cystic calculi. It has been recently suggested to be a useful method with lower risks than PU's. **Tube Cystostomy** - **Tube cystostomy** is a urinary diversion or urethral bypass technique, in which a Foley's catheter is placed into the urinary bladder lumen via a small skin incision. - It has been used in the treatment of urethral obstruction, urethral rupture or ruptured urinary bladder in small ruminants. - **Urine diversion by Foley's catheter** can be done either temporarily in urethral repair/acute urethral obstruction or permanently in bladder cancer or neurogenic bladder atony. - Tube cystostomy catheter also **provides avenue for normograde contrast cysto-urethrography**, which may be beneficial for evaluating the extent of urethral obstruction or urethral integrity post-operatively and therefore, may potentially be used to monitor urethral healing, assess medical therapy for calculi dissolution and determine when the animal should be encouraged to micturate through the urethra by occluding the drainage catheter. - The technique can be utilized effectively in the cases of urethral or bladder ruptures in calves and goats. - The animal is restrained under lumbosacral epidural analgesia as for cystotomy. - **Left ventral abdominal area** from the **level of umbilicus** to the scrotum is prepared for aseptic surgery. - A **2 cm long paramedian incision** is given 5 cm lateral to midline and 2-3 cm cranial to rudimentary teats in prepubic region, so as to facilitate approach to the urinary bladder. - A **straight artery forceps** is passed anteriorly from the incision to a distance of about 15 cm making subcutaneous tunnel, the tip of the artery forceps is brought out of the skin near preputial orifice by making another nick incision. - A tract is thus formed for the fixation of Foley's catheter. A No. 14 French Foley's catheter is pulled through the tract with the help of the same artery forceps. - **Rectus abdominis muscle** and its sheath are separated using pointed end scissors. The abdominal viscera are reflected aside, urinary bladder is palpated and is held in position with two fingers. Foley's catheter is anchored to a K-wire by its eye and passed into the urinary bladder (just behind vertex in ventral midline) with a sudden thrust applied to the K-wire without exposing the abdominal organs. - As soon as the urine starts coming out from the catheter, the balloon of Foley's catheter is inflated with 5 ml of sterile saline, the K-wire is retracted slowly and then 10 ml of saline is infused into the balloon of the catheter. - A **purse string suture** using a monofilament absorbable suture of 1/0- size is placed in the bladder wall to secure the catheter in place and prevent urine leakage. Care is taken to avoid puncturing of the catheter or its balloon during suture placement. - The external end of the catheter is then pulled gently to appose the bladder wall to the body wall at the interior aspect of the incision. The abdominal muscle layer is sutured with No.1 catgut and skin with No.1 silk or nylon. The part of Foley's catheter outside the abdomen is fixed with abdominal wall using 5-6 stay sutures. - **Ammonium chloride 500 mg/kg body** wt. is given as **acidifier** to the animals from day 3 of surgery. Urethra is examined for the reestablishment of patency by examining the signs of urination, and if possible by positive contrast cysto-urethrography. - **Treatment** is continued for at least 15 days so as to maintain urine pH within a range of 6.0-6.5. **Clamping of Foley's catheter is started from day 5** to encourage urination through prepuce and animal is examined for the signs of urination. - Cystotomy catheter is blocked when the urethral passage is clear of obstruction. - **Foley's catheter is removed by deflating its balloon** and is **pulled out of bladder and abdomen 3-4 days after clearance of urethral passage.** The tract left by catheter is dressed until healing, which takes place without any complications. **Cystotomy in Bovine** **Indications** - Vesical calculi, Neoplastic growth. **Anaesthesia and Control** - General anaesthesia; dorsal recumbent state. **Site** - The prepubic (antepubic or suprapubic) site is chosen along linea alba starting in front of the pubic symphysis to a length of about 3 to 4 inches forward. (In the male the skin incision is placed lateral to the sheath and subsequently operated along the linea alba.) **Technique** - After opening the abdomen, the bladder is brought over to the incision on the abdominal wall, turned over its neck and is isolated by packing suitably to prevent contamination of the peritoneal cavity. An incision about 2 to 3 inches long is made on the dorsal surface of the bladder towards its neck, to gain access into the bladder for necessary manipulations and removal of contents and neoplastic growth, if any. The incision on the bladder is closed by Cushing\'s inversion sutures. - The opening on the linea alba is closed by interrupted apposition sutures reinforced by mattress sutures. The skin wound is closed by ordinary interrupted sutures or by vertical mattress sutures. - (It is sometimes difficult to bring out a collapsed urinary bladder in the bovine through the wound because of its deep retraction into the pelvic cavity.) - Blood vessels of the bladder: The arteries are derived chiefly from the internal pudic but branches also come from obturator artery. The veins terminate chiefly in the internal pudic veins. **RECTAL PROLAPSE** **Etiology** - Prolonged tenesmus or straining due to rectal inflammation and irritation, diarrhoea, enteritis or parasites, and during act of parturition. Intestinal neoplasia, foreign bodies, perineal hernia, constipation and congenital defects. In incomplete prolapse, only mucosa is prolapsed and in complete prolapse, whole thickness rectal wall is involved. Prolapsed mass is more prone to ischaemia and oedema, contamination and trauma. **Diagnosis** - Protrusion of mass through anus. Many a times it is associated with vaginal prolapse. Differential diagnosis: Intussusception with prolapse, especially in young dogs, and tumours like venereal granuloma. **Treatment** - **Fresh Cases** - Easy to repose - Lavage with astringent solutions and apply antiseptic ointment + lignocaine jelly before repositioning - Apply purse string suture for 2-3 days, when no signs of straining - Epidural analgesia - Laxative diet for few days - **Recurrent/Chronic Prolapse** - When severe necrosis, damage of the rectal tissue - Amputation of rectum under epidural analgesia - Comlications include peritonitis from wound dehiscence, stenosis or stricture **Eye Worms** **Indication** - Removal of eye worm (Oxyspirum mansoni) found under the nictitating membrane of the fowl, causing scratching with resultant inflammation and swelling of eye. **Anaesthesia** - Instill into the eye a few drops of a suitable local anaesthetic. (e.g., Anethane (Glaxo); Butyn). **Technique** - After lifting the third eyelid with fingers or a blunt instrument, instill one or two drops of a 5% solution of Creolin on the worms and immediately thereafter, irrigate the eye with clean water. The worms are killed in this manner and can then be removed with a forceps. **Rumenotomy** **Indications** - Exploratory. Foreign body reticulitis. Severe impaction. **Site** - Left flank, in the para-lumbar fossa, a vertical incision 6 to 8 inches long. **Anaesthesia and Control** - Paravertebral or local infiltration analgesia. Control in standing position preferred. **Anatomy** - The muscle fibre of the obliqus abdominis externus run downward and backward and that of obliqus abdominis internus downward and forward. The fibres of transverse abdominis are directed vertically. - **Nerve supply:** Lumbar nerves. See under paravertebral analgesia. - **Blood supply:** The blood supply to the flank is contributed by the phrenico-abdominal and deep circumflex iliac vessels. - The blood vascular channels of the rumen are located in the left and right longitudinal grooves and the anterior and posterior-transverse grooves of it. **Technique** A vertical incision about 6 to 8 inches long is made commencing about 2 inches below the level of the lumbar transverse process. The abdominal muscles and the parietal peritoneum are traversed by a direct incision corresponding to the skin incision. The wound is kept retracted and the rumen wall is fixed to the skin edges by a set of temporary through-and through mattress sutures before opening into the rumen. This is to prevent escape of rumen contents into peritoneal cavity. (Instead of such fixation, the McLintock\'s method or Weingart\'s method may be used). A short incision is made on the rumen and this is extended enough to permit easy access by hand into the rumen and reticulum. The rumen contents are removed without contaminating the peritoneal cavity by proper packing. The reticulum can also be examined by stretching the hand through the rumen. The large rumeno-reticular passage, the oesophageal groove, and the opening of oesophagus into the stomach are also palpable this way. The temporary fixation sutures of the rumen to the skin are removed only after the incision on the rumen wall is closed by inversion sutures. Connell or Cushing\'s sutures are used to close the rumen commencing slightly above and extending a little below the line of incision. A continuous Lembert\'s suture is also placed over this. The parietal peritoneum is closed by continuous suture. The incised muscles are brought into apposition by continuous sutures. The skin incision is closed by vertical mattress sutures or ordinary interrupted apposition sutures. Note: Instead of suturing the parietal peritoneum, muscles and skin by separate layers of sutures described above, some persons prefer a \"figure-ofeight suture\" to close these different layers of tissues in the abdominal wall. **Vulval suture to prevent vaginal prolapse in cow** **Method 1-** A purse-string suture going around the vulva subcutaneously. **Method 2**- One or more mattress-sutures passing through and connecting both lips of the vulva. **Method 3**- \"Cross-lacing method\': This is found to be more efficient and causes less discomfort to the patient. A number of independent interrupted skin sutures are made with sterile umbilical tape or similar suture material on one side (say left side) of vulval lip. A corresponding equal number of sutures are made on the opposite (right) side. Using these sutures as \"loops\", separate pieces of tapes are \"laced through\" them, so as to support the vulval lips both diagonally (cross-wise) and transversely and tied. The lacing tapes can be changed daily or whenever required without damaging the loop sutures. **Note:** In order to understand the cross-lacing method described above, the student may draw a diagram wherein the loops stitched on one side of the vulva may be represented as A, B, C, D and the loops at corresponding level on the opposite side marked as P, Q, R, S, respectively. If these loops are to be tied together by three independent tapes, the first tape should be passed through loops in the order of A, P, B, Q, before its two ends are brought back and tied at loop A. In a similar fashion, the second tape is passed through in the order of B, Q, C, R, B and is tied at B. Finally, the third type is looped and tied in the order C, R, D, S, C **Medial Patellar Desmotomy (Section of** **Internal Straight Ligament of Patella)** **In Bovine** **Anatomy** The 3 straight ligaments of patella are: - Lateral (outer or external) straight ligament; - Median (middle or anterior) straight ligament; - Medial (internal or inner) straight ligament. The word desmos (Gr.) means ligament. **Indications** - In chronic subluxation (upward fixation; dorsal fixation; recurrent fixation; or upward displacement) of patella, the patella gets fixed above the trochlea of femur and the medial straight ligament is tightly over stretched behind the medial trochlear ridge, which prevents the downward return of the patella. The object of the operation is to mechanically bring down the patella by cutting the tensed medial ligament. **Control** - The animal is cast and secured in lateral recumbency on the same side of the affected limb. - A rope is tied to the affected limb at its pastern and is pulled backwards in the extended position. The other 3 limbs are tied and secured together. **Anaesthesia** - Local infiltration anaesthesia or epidural anaesthesia. **Site** - A skin incision, 1 to 2 cm is made close to and parallel to the posterior border of the medial straight ligament at the site chosen out of the following 3 sites: - **Site No.1**: Close to the insertion of the medial ligament to the anterior tuberosity of tibia. - This is the most suitable site as it is easier to locate, causes lesser bleeding and there is no danger of injuring the joint capsule. - **Site No.2:** At the middle portion of the medial ligament. Since there is a thick padding of fat here between the ligament and the joint capsule which (although protects the joint capsule from any injury during surgery) is likely to protrude through the incision. There is also chance of causing injury to articular vessels in this area. Hence this is a less desirable site than the former. - **Site No.3:** Close to the origin of the medial ligament from the patella. This site is not at all recommended because there is added chance of causing injury to the joint capsule, adjacent vessels and musculature. **Technique** - Either the open technique or the closed technique may be followed: - **Open technique:** A sufficiently long vertical incision, 2 to 3 cm, is made at the site described above, cutting through the skin and subcutaneous facia, and through it the ligament is pulled out with a tenaculum and is cut. Instill about 1 ml of Tr. Iodine into the wound before it is sutured. - **Closed technique (Blind technique):** A small incision or stab wound is made at the site, through the skin and subcutaneous facia, and a scalpel (or, a probe pointed tenotomy knife) is introduced flat-wise under the ligament from its posterior aspect until the tip of the scalpel/knife can be palpated anteriorly under the skin in the space between the medial and median patellar ligaments. Afterwards turn the sharp edge of the knife towards the ligament to cut it by a sawing movement. Then the knife is turned back to the flat-wise position and is withdrawn. Protruding fat tissue, if any, is snipped off and a few drops of Tr. Iodine are instilled into the incision before it is sutured. No suture is necessary if the wound is small. - **Note:** Three common mistakes to be avoided during the operation are: - 1\. Avoid injury to the prominent cutaneous vein; - 2\. Do not mistake the thick subcutaneous facia with the ligament; and - 3\. Avoid injury to the joint capsule. **Medial Patellar Desmotomy** - **Medial patellar desmotomy** is a surgical incision to severe the medial patellar ligament in the animals suffering from dorsal/upward fixation of patella. **Indications** - Upward/Dorsal fixation of patella. **Etiology/Predisposing Factors** - Exploitation activity - External trauma leading to laceration or elongation of the ligamentous structures - Breed and genetic predisposition - Faulty conformation of the hind limb - Morphological changes of the medial trochlear ridge of femur - Damage to the nerve supplying the quadriceps femoris muscle. **Symptoms** - Upward fixation of patella can be unilateral or bilateral, and can be permanent or recurrent in nature. It occurs mostly in buffaloes but is also reported frequently in young working bullocks. In horses, it occurs most frequently in young ponies working on hills and in animals with a faulty conformation of the hind limbs. - Recurrent dorsal fixation is not apparent in resting animals in which the patella occupies its normal position in relation to the femoral trochlea. It is manifested during progression by an intermittent fixation of the patella through the hooking of the medial patellar ligament over the prominent upper extremity of the trochlear ridge. When the animal is forced to move, the condition becomes evident by occasional jerky steps during otherwise normal progression. It frequently disappears as the animal "warms up". - In due course as the condition progresses, the symptoms become more frequent and the gait more obviously disturbed. Stifle and the hock joints are periodically fixed in extension and this gives the limb an unusual rigidity, while over-flexion of the fetlock causes the toe of the hoof to drag upon the ground during progression. - Animals suffering from permanent dorsal fixation, when forced to walk, carry their leg rigidly with the fetlock flexed and the toe dragged on the ground with the weight supported by the flexed digit. After some time, animal adapts its gait by bringing the limb forward in abduction in the swinging phase, without flexion of the hock and stifle joints. When an attempt is made to back the animal, it often refuses to move. **Clinical Examination** - On clinical examination of the animals having recurrent dorsal fixation, the patella is found to be unusually mobile and in these cases it can readily be carried dorsally by slight manual pressure. If this is done and the animal is induced to move, the typical "locked" gait is seen and later, when the patella frees itself, a thudding sensation may be detected. The symptoms may be induced to appear in an exaggerated form by circling the animal with the affected limb on the inner side, while circling in the opposite direction with the affected limb outermost, lessens the symptoms. **Anatomy of Stifle Joint** - Stifle joint consists of two major articulations viz. femoro-patellar and femoro-tibial. The femoro-patellar joint is formed between trochlea of the femur and articular surface of the patella. Patella is connected to the cranial tibial tuberosity by patellar ligaments. The patellar ligaments are medial, middle and lateral. In blind method of surgery, it is very important to identify and palpate the medial patellar ligament. **Surgical Procedure** - Main aim of medial patellar desmotomy is to dislodge the patella from medial trochlear ridge, thus leading to free movement of stifle joint. Surgery can be performed with the animal in the standing position or in lateral recumbency. **There are two common methods to this surgery viz. blind/closed method and open method.** **Standing Approach with Blind Method** - The site of the skin incision is indicated by a small depression that may be felt between the middle and medial patellar ligaments above their insertion on the tibial tuberosity. The operational site is shaved and painted with tincture of iodine. Local anaesthetic (2 per cent lignocaine, 2-5 ml) is injected subcutaneously over and around the ligament. Sterile surgical gloves are worn and the usual aseptic precautions observed. A small incision is made in the skin between the middle and medial patellar ligaments just proximal to the tibial tuberosity, taking care not to penetrate the joint capsule. - A tenotom is then pushed through the skin incision under the medial patellar ligament, near its insertion at tibial tuberosity, with its cutting edge in vertical direction. Once positioned correctly, the cutting edge is then directed towards the ligament. The tenotom is then slowly moved while strongly pressed against the ligament, which is normally transected in a single movement of the blade. - Severance of the ligament is indicated by the development of a deep depression between the cut ends. If the ligament is not completely transected the procedure is repeated. **Blind Method in Lateral Recumbency** - In uncooperative patients, it is difficult to perform surgery in standing condition and such animals are cast and restrained on the ground with the affected limb at lower side. Forelimbs and the upper hind limb are tied together, and the affected limb is extended backward by pulling a rope tied at the region of fetlock. Pushing the point of hock towards the ground, rotates the stifle joint to better expose the site of incision. Cranial tibial tuberosity is located and the groove between the medial and middle patellar ligaments is then palpated. In this position, medial patellar ligament occupies the topmost position and is traced easily. Surgery is then completed in the same manner as in standing approach. **Open Method** - In open method, after aseptic preparation of the surgical site on the affected limb and infiltration of local anaesthesia, a 3 cm linear incision is given 0.5 cm lateral to the medial patellar ligament near its insertion on the tibial tuberosity. Artery forceps are used for blunt dissection of the fascia from underneath the medial patellar ligament, and the ligament is then lifted over the forceps. After properly exteriorizing the ligament, it is cut transversely using a scalpel. The skin incision is closed by a few interrupted sutures. **Post-operative Care** - Daily antiseptic dressing of the surgical wound and post-operative antibiotic cover, especially after open method, is all that is needed post-surgery. The results are miraculous and animal walks without a limp immediately after successful surgery. **Possible Post-operative Complications** - Transaction of middle patellar ligament - Transaction of collateral ligaments - Penetration of joint capsule - Haemorrhage - Infection