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Cystotomy Marry Rose Estrera Definition Cystotomy is a surgical procedure involving the incision into the urinary bladder. It is performed to access the bladder for various therapeutic or diagnostic purposes, such as removing stones, tumors, or foreign bodies, repairing bladder tissues and explora...

Cystotomy Marry Rose Estrera Definition Cystotomy is a surgical procedure involving the incision into the urinary bladder. It is performed to access the bladder for various therapeutic or diagnostic purposes, such as removing stones, tumors, or foreign bodies, repairing bladder tissues and exploration. Relevant Anatomy Muscular organ located in the pelvic cavity, consisting distinct layers: Serosa (outermost layer) Muscularis (detrusor muscle) Submucosa (rich in blood vessels and elastic fibers) Mucosa (transitional epithelium) Anatomical Relationships Cranial attachment: Umbilical ligament remnants Dorsal surface: Relationship with rectum (males) or reproductive tract (females) Blood supply: Internal pudendal and umbilical arteries Innervation: Sympathetic and parasympathetic nerves from the pelvic plexus  Indication Mineral Composition (Foreign 4. High protein feeds Bodies) 5. Vitamin A deficiency 1. Struvite (Magnesium Ammonium 2. Environmental Factors Phosphate) 1. Most common in sheep and 3. Physiological Factors goats 1. Urinary pH alterations 2. Calcium Carbonate 2. Dehydration 1. Predominantly found in 3. Urinary stasis horses 4. Hormonal influences 3. Calcium Phosphate Rupture Bladder 1. Common in cattle 1. Urethral obstruction 4. Silica 2. Trauma (parturition, breeding, falls) 1. Frequent in cattle and sheep on grain diets 3. Severe inflammation 4. Pressure necrosis from Risk Factors and Formation distension 1. Dietary Factors Neoplasia growth (rare) 1. High grain diets (increased 1. Transitional cell carcinoma phosphorus) 2. Squamous cell carcinoma 2. Insufficient water intake 3. Metastatic tumors 3. Mineral imbalances (Ca:P ratio)  Species Predisposition 1.Cattle Clinical Signs 1. Males more affected due to anatomical Early clinical signs include: structure Blood in the urine 2. Higher risk in feedlot animals Straining to urinate 3. Common in young, rapidly growing Decreased urine production animals Painful urination 2.Sheep and Goats Prolonged urination Dribbling urine 1. Males (particularly castrated) at highest Tail flagging risk Abdominal pain (stretching out all four limbs, 2. Early-castrated animals at increased risk kicking at the abdomen, looking at the side) 3.Horses Late clinical signs include: Loss of appetite 1. No significant gender predisposition Lethargy (apparent depression) 2. More common in aged animals Abdominal swelling (from a ruptured bladder) 3. Performance horses at increased risk Swelling around the prepuce (the skin covering the penis)  SURGICAL PROCEDURE Preoperative Positioning Patient: Dorsal recumbency General anesthesia Surgical site: Caudal abdomen, adjacent to prepuce Skin incision: 10-30 cm (size-dependent) Bladder Exposure and Exploration 1.Incision through linea alba or paramedian adjacent to the prepuce 2.Perform either paramedian or midline celiotomy 3.Identify bladder 4.Exteriorize the urinary bladder 5.Place two 3-0 stay sutures at dorsal bladder aspects 6.Incise bladder near trigone/pelvic urethra SURGICAL PROCEDURE If bladder is ruptured: Perform cystorrhaphy In cases of chronic distension, resect necrotic regions of bladder wall Perform routine cystotomy Stone Removal Aspirate and lavage: Trigone, bladder neck, & most proximal urethra Remove adhered uroliths: Use soft-edged surgical spoon Clear uroliths attached to bladder wall with fibrin or cellular debris Flush bladder Retrograde hydropulsion with 5-10 Fr catheter SURGICAL PROCEDURE Urethral Obstruction Management 1.Attempt normograde urethral catheterization: 1. Use 8-10 French polypropylene catheter 2. Perform hydropulsion with saline 3. Exercise caution to avoid urethral rupture 2.If needed, perform retrograde hydropulsion: 1. Assistant occludes distal urethra 2. Surgeon occludes proximal urethra 3. Goal: Maximize urethral dilation SURGICAL PROCEDURE Catheter Placement 1.Secondary bladder incision matching prepuce side 2.Insert Pezzar catheter through bladder wall 3.Place purse string suture around tube 4.Angle tube exit through body wall layers Closure Techniques Bladder: Two-layer inverting 3-0 absorbable suture Stay sutures: Trim, secure Body wall: Routine closure Linea alba: Continuous 0 slowly absorbing Subcutaneous: Continuous 2-0 absorbable Skin: Nonabsorbable Ford interlocking/continuous Catheter Management Secure Pezzar to body wall Align with preputial opening fingertrap knot to the Pezzar Post Treatment (medications) Medication Protocol Removal of the Tube 1.Antimicrobials If dripping stops, the tube may be 1. Broad-spectrum coverage blocked by a stone or blood clot. 2. Duration typically 7-14 days Once the patient is urinating and 2.Pain Management it has been at least 8 days, the 1. NSAIDs (Flunixin meglumine, tube can be removed. Phenylbutazone) The fingertrap knot is removed, 2. Opioids as needed the body wall is held in place with 3.Fluid Therapy one hand while the tube is pulled 1. Maintenance requirements forcefully with the other. 2. Electrolyte monitoring 3. pH management Complications Immediate Complications Long-Term Complications 1.Surgical 1.Medical 1. Hemorrhage 1. Recurrent urolithiasis 2. Bladder rupture 2. Chronic cystitis 3. Anaesthetic complications 3. Bladder dysfunction 4. Contamination 4. Adhesion formation 2.Post-Operative 2.Management 1. Urinary leakage 1. Incisional herniation 2. Infection 2. Persistent urinary issues 3. Ileus 3. Behavioral changes 4. Pain management issues 4. Reduced performance Refences Erin Malone, D. V. M. (n.d.). How to – Tube cystotomy. Open.lib.umn.edu. https://open.lib.umn.edu/largeanimalsurgery/chapter/how-to-tube- cystotomy/ https://www.msdvetmanual.com/urinary-system/noninfectious- diseases-of-the-urinary-system-in-large-animals/urolithiasis-in- ruminants#Treatment_v51048461 Bovine Urolithiasis | Veterian Key Ron Adriel Lylm A. Lauron Rumenotomy Objectives:  To understand rumen anatomy and recognize digestive system of ruminants  To evaluate, the need for rumenotomy  To learn about rumenotomy, including its indications and perioperative management  To comprehend surgical measures for rumenotomy and perioperative care and its complications Introduction The rumen is a large fermentation vat. The layers should be gas (dorsal), recent fiber, older fiber and fluid (ventral). The reticulum is sac off the dorsal aspect. The esophagus empties into the rumen from the dorsal cranial wall while the reticulum empties into the omasum on the medial wall just above the pillar separating the rumen and reticulum. The omasum and abomasum are often palpable through the rumen wall. Ruminants, such as cattle and sheep, have a unique digestive system consisting of four compartments: the rumen, reticulum, omasum, and abomasum. The abomasum is the only compartment that produces digestive enzymes, playing a crucial role in breaking down food. In small ruminants, the rumen can hold about 5.3 liters, which is roughly 13% of their body weight. Other estimates suggest that the rumen content in sheep is around 4- 6 kg and for adult cattle, the rumen volume ranges from 102 to 148 liters, making up about 16% of their body weight. Rumenotomy, a common surgical procedure, is particularly prevalent in goats, accounting for up to 94% of all surgeries in that species. Although the surgical approach is similar for both small and large ruminants, most detailed descriptions focus on cattle, with less emphasis on small ruminants. Indications and implications Rumenotomy is performed for conditions such as vagal indigestion, hardware disease, rumen acidosis, and certain types of chokes. This procedure allows for exploration of the rumen, reticulum, and parts of the omasum. It is often necessary to empty the rumen due to dysfunctions affecting its ability to transit or fill properly, as well as urgent issues like acute ruminal acidosis or severe bloat. Approximately 50% of rumen surgeries are conducted to remove foreign bodies that can hinder the absorption of volatile fatty acids, negatively impacting the animal's productivity and causing economic losses. Small ruminants, especially goats, are prone to ingesting indigestible materials, leading to blockages and lesions in the reticulum, which disrupt normal ruminal fermentation. While goats are more likely to consume non-digestible items like ropes and plastics, studies suggest that sheep experience a higher incidence of related issues despite their selective eating habits, often developing phytobezoars from thick plant materials. The ingestion of foreign materials can be linked to pica, a condition where animals crave non-food substances, sometimes due to nutritional deficiencies. This accumulation can lead to impaction, gas buildup, and potentially fatal outcomes, making rumenotomy necessary to resolve the issue Perioperative management Before a rumenotomy, if possible, the cow should be held off feed for 24 hours prior to rumenotomy, as this can aid the procedure, although fasting may not be necessary in emergencies. Non-steroidal anti-inflammatory drugs, like flunixin meglumine or meloxicam, are recommended during and after surgery, while broad- spectrum antibiotics should be given to prevent infections. A single dose of penicillin at surgery can significantly lower the risk of abscesses, making extended antibiotic use often unnecessary. A line block, inverted L or paravertebral are all reasonable options. Anesthesia can be tricky in small ruminants, and a combination of sedatives like xylazine and diazepam with ketamine is often effective. In some cases, sedation might not be needed, and the animal can be safely restrained in a standing position. Preventing gas buildup in the rumen is crucial, which can be achieved with a gastric tube or needle decompression. Once sedated, the surgical area is prepared by shaving and cleaning it thoroughly. Various anesthesia techniques, including nerve blocks, can be used for pain management, but caution is needed with lidocaine due to its potential toxicity in goats and sheep. Surgical techniques To start the procedure, make an incision in the rumen and, if available, use a wound protector (a plastic ring and drape). If not, temporarily suture the rumen open to minimize exposure to ingesta. Remove any ingesta along the incision path, particularly if addressing hardware disease or rumen acidosis. Next, explore the reticulum, esophageal opening, and omasal opening. Check for foreign bodies if the reticulum is immobile and palpate for any abscesses that may need drainage. Remove any hardware, leaving one magnet in place, and consider performing rumen transfaunation. If an abscess is found, drain it into the rumen, being careful not to extend the incision too far to avoid leakage into the peritoneum. Remember that pus does not drain uphill easily, and if a scalpel blade is dropped, retrieve it promptly tying it to your wrist can help. If contamination or peritonitis is suspected, do not lavage the abdomen, as cows can often wall off infections. Fixation using four holding sutures: involves using four sutures to secure the rumen to the skin at various points. However, it poses a risk of ruminal contents leaking into the abdominal cavity  Skin clamp technique: rumen is clamped to the skin with towel clamps at various locations around the incision  Anchoring devices after exteriorization of the rumen: to anchor the rumen during surgery, including the rumenotomy ring, which features an aluminum ring with a rubber interior, the Weingarth ring that uses hooks, and the Gabel rumen retractor with screws.  Fixation with cutaneous suture: the cutaneous suture technique, commonly used for rumen fixation, involves suturing the rumen to the skin in a Connell or Cushing pattern, using size #1 USP silk to create a secure seal  Ruminal mortise or shroud: a rubber device with a large flat surface and an internal edge secures a temporary ruminal fistula. It expands inside the rumen, preventing contents from contacting the surgical site.  Fixation to the peritoneum: main disadvantage is weak union, risking rumen retraction and increased contamination risk.  After fixing the rumen, a 15 cm vertical incision is made, leaving a 3 cm margin for access. The surgeon palpates the reticulum, omasum, and abomasum, checking for injuries and foreign bodies in the ventral sac. Approximately 1 kg of fibrous material is left in the rumen after addressing any issues. The rumen is closed in two layers: the first layer uses size #1 USP absorbable sutures in an inverted Cushing or Lembert pattern to prevent leakage. After cleaning, the rumen is released from the skin and closed with size #2 USP absorbable sutures in an inverted pattern. The flank incision is closed in three layers with #2 or #3 USP absorbable sutures, securing the internal and external abdominal oblique muscles. The skin is closed with non-absorbable #3 USP sutures in a Ford interlocking pattern, with 2–3 interrupted sutures at the bottom for potential drainage. Alternatively, sterile cotton or non-absorbable #2/0 USP sutures can be used in a simple discontinuous pattern. Postoperative management and complications Administering a single dose of penicillin during surgery, other references prefer broad-spectrum cephalosporins (10 mg IV) with 200 ml of physiological saline and dextrose or 20 mg/kg oxytetracycline Still other authors add 200 ml of intravenous lactated ringer, in addition to 1 ml of intravenous tramadol for 5 days. Studies indicate that postoperative antibiotic administration does not reduce abscess formation. Daily cleaning of the surgical wound with povidone-iodine is essential, and sutures are typically removed on the 10th day.  Common complications of rumen surgery include abscesses at the incision site, peritonitis, and abscesses between the muscle and skin due to suture dehiscence. The probability of postoperative complications from rumenotomies in cattle ranges from 5- 15%, influenced by the animal's general condition and concurrent diseases. Incisional infections, seromas, and regurgitations are frequent issues. The type of suture used affects postoperative pain and tissue reactions; PGA-type (polyglycolic acid) sutures cause less inflammation than catgut. In goats, using diazepam-ketamine anesthesia with a subanesthetic dose of ketamine reduces postoperative pain, although intraoperative pain may still occur. REFERENCES: Malone, E., DVM PhD. (n.d.). How to – rumenotomy. Pressbooks. https://open.lib.umn.edu/largeanimalsurgery/chapter/how-to-rumenotomy/ Martin, S., López, A. M., Morales, M., Morales, I., Tejedor-Junco, M. T., & Corbera, J. A. (2021). Rumenotomy in small ruminants – a review. Journal of Applied Animal Research, 49(1), 104–108. https://doi.org/10.1080/09712119.2021.1894156 SUPPLEMENTAL LINKS: https://www.sciencedirect.com/science/article/abs/pii/S0749072008000133 https://accedacris.ulpgc.es/bitstream/10553/105887/2/Rumenotomy%20in%20small%2 0ruminants%20a%20review.pdf https://basu.org.in/wp-content/uploads/2020/11/RUMENOTOMY.pdf Flores, Shay Paulaine R. DVM-5 Removal of Eye Worm Thelaziasis is a parasitic infection caused by Thelazia nematodes, commonly known as eyeworms. - Primarily affecting various animals such as cattle and horses. - cause infestation of the orbital cavities and associated tissues. o Adults of Thelazia spp. localize under the eyelids and the nictitating membrane, as well as in nasolacrimal ducts, conjunctival sacs, and excretory ducts of lacrimal glands. Anatomy of the eye (cow) - Face flies are the intermediate hosts, transmitting the parasite to large ruminants. - Thelazia species include: T. gulosa,T. skrjabini, and T. rhodesii. o Transmitted by non-biting muscid flies, particularly face flies (Musca automnalis) Photograph of the face fly, Musca autumnalis—the Face flies, cow, Musca sp face flies feeding on female is on the left, male is on the right, which acts lacrimal secretions of a cow infected with Thelazia as one species of vectors for eyeworm disease. gulosa.  Buffalo eyes infected with 3 eye worms Adult female Thelazia gulosa. (Thelazia gulosa). Characteristics of Thelazia spp. (source: Taylor, M. L., et al., (2016). Veterinary Parasitology 4th Ed., Wiley Blackwell) Thelazia Rhodesi Description: Small, thin, yellowish-white worms 1.0–2.0 cm long. Males are 8–12 mm and females are 12–20 mm in length. The cuticle has prominent striations at the anterior end. The male worms have about 14 pairs of pre-cloacal and three pairs of post-cloacal papillae. Life cycle: The prepatent period is 20–25 days. Thelazia gulosa Description: Thelazia gulosa are milky-white worms, with thin transverse cuticular striations (less evident in rear part of the body), and a large deep cup-shaped buccal cavity. Males are 4.8–10.9 mm long and have a variable number of pre-cloacal papillae (from 8 to 33 pairs) and three pairs of post-cloacal papillae. There are two asymmetric spicules. The females are 4.8–18.8 mm long with a tapered caudal extremity. Thelazia skrjabini Description: Adult worms are whitish in colour, with transverse fine cuticular striations. The buccal cavity is small and shallow. Males are 5–11.5 mm long and curved posteriorly, with 16–32 pairs of pre-cloacal and three pairs of post-cloacal papillae. The spicules are unequal in length. The females are 7.5–21 mm long with a truncated caudal extremity. Pathogenesis Adults reside in the conjunctival sac of the definitive host where the ovoviviparous females release first-stage (L1) larvae ensheathed in a shell membrane. L1 larvae are ingested by the face fly intermediate host during feeding on tears and lacrimal secretions. In the digestive tract of the intermediate host, L1 larvae become exsheathed and invade various host tissues, including the hemocoel, fat body, testis, and egg follicles where they develop in capsules. The encapsulated larvae molt twice to become infective L3 larvae. The fully developed L3 larvae break out of the capsules and migrate to the fly’s mouthparts, where they remain until the fly feeds on the tears of the definitive host. The larvae invade the conjunctival sac of the definitive host upon the fly intermediate host’s feeding and become adults after about a month and two additional molts. Humans may also serve as aberrant definitive hosts following exposure to an infected fly intermediate host in the same manner. (Source: https://www.cdc.gov/dpdx/thelaziasis/index.html) Clinical Findings and Diagnosis - Clinical signs: o Adults in the eye cause varying degrees of inflammation and lacrimation accompanied by a foreign body sensation. In heavier infections, photophobia, epiphora, edema, corneal ulceration, and conjunctivitis may occur. - Diagnosis: o Ophthalmic examination to identify the presence of nematodes.  generally recommended for T rhodesii, commonly found in the conjunctival sac. o Topical anesthetics allow for tissue manipulation and are useful for detection and recovery of worms o Microscopic examination of lacrimal fluids o for embryonated eggs or larvae may be attempted. Methods for diagnosis: Ophthalmic examination: Visual inspection of the eye to identify adult worms. Removal of nematodes: Swabbing the eye with cotton or saline lavage to collect worms for identification. Microscopic examination: Examination of lacrimal fluids for embryonated eggs or larvae. Surgical procedures: The animal is restrained and an auriculo-palpeberal nerve block and retro bulbar nerve block is administered with 2% lignocaine solution. The worms are manually removed from the pouch of the nictitating membrane and a lacrimal duct flushing may attempt with normal saline as many of these worm cause dacryocystitis. Topical antibiotics and anti-inflammatory drugs are indicated along with administration of broad spectrum anthelmintic Therapeutic measures:  Mechanical removal: Removal of adult worms using forceps after instillation of a local anesthetic.  Irrigation: Irrigation of the eyes with 50–75 mL aqueous solution of 0.5% iodine and 0.75% potassium iodide has been recommended for T. gulosa and T. skrjabini, and T. lacrymalis in horses.  Topical medication: Topical application of organophosphates, such as echothiophate iodide or isoflurophate, for T. lacrymalis in horses.  Systemic anthelmintics: Administration of levamisole, ivermectin, or doramectin, either subcutaneously or intramuscularly.  o In cattle:  Levamisole: 5 mg/kg, SC  Ivermectin/ Doramectin: 0.2 mg/kg, SC or IM  Pour-on formulations delivered to achieve a dosage of 0.5 mg/kg, are also effective. o In horses:  single doses of the commonly used anthelmintics, including ivermectin, administered via stomach tube at 0.2 mg/kg.  Multidose of fenbendazole (10 mg/kg per day for 5 days) Preventive measures:  Fly control: Environmental measures to control face flies, including reducing breeding sites, using fly traps, and applying insecticides.  Good hygiene: Maintaining good hygiene in stables and pastures.  Regular deworming: Regular administration of anthelmintics to prevent the spread of the parasite. Expected Course and Prognosis  Full recovery in about 2 months although long-term persistence of areas of corneal opacity may occur. Case: Surgical removal of eyeworm in indigenous cow - Signalment o Specie: Cattle o Age: 10 y. o. o Sex: F (nonlactating) - History  opacity of right eye  not dewormed and maintained on pasture - Clinical examination o revealed epiphoria, corneal opacity, severe conjunctivitis with loss of vision. o close examination of the affected eye, the white threadlike structure found in the anterior chamber of the eye. - Procedure o The cow was gently restrained in lateral recumbency on large animal operating table. o Affected eye was irrigated with normal saline initially, later 4 to 5 drops of 4% lignocaine hydrochloride were instilled to attain topical anaesthesia.  o Peterson nerve block using lignocaine hydrochloride was done to immobilize globe. The eye speculum was applied to retract eyelids. o nick incision was given at limbus region on 10’ o clock position and worm pulled out with the help of forceps. o The incision is left open. - Treatment o Postoperatively, corneal opacity was managed by moxifloxacin eye drop instilled topically 4 drops 3 times for 5 days. o affected eye was irrigated with normal saline and boric acid, before topical medication. o After 15 days, opacity resolved completely. Photograph showing eye worm in the anterior chamber of eye and nick incision being made in the limbus region at 10’o clock position for removal of eye worm. Sources: https://www.msdvetmanual.com/eye-diseases-and-disorders/eyeworm-disease/eyeworms-of- large-animals#Pathogenesis_v3270076 Das, J., Kuldeep, S. K., and Singh R. (2021). Surgical removal of eyeworm in indigenous cow. Journal of Entomology and Zoology Studies, 9(1): 1487-1489 https://www.vetscraft.com/eye-worm-affections-in-large-animals/ VSG 511 – Large Animal Surgery RECTAL PROLAPSE AND ITS SURGICAL PROCEDURE Definition Relevant Anatomy Rectal prolapse in large animals refers to the protrusion The anatomy involved in rectal prolapse includes: of the rectal tissue through the anus, which can vary in Rectum: The final section of the large intestine, which connects to the anus. severity from partial eversion of the rectal mucosa to complete prolapse involving all layers of the rectum. Anal Sphincter: A muscular structure that controls the expulsion of feces and This condition is a serious health issue that can lead to can be involved in the constriction or relaxation during prolapse. complications such as necrosis and infection if not Surrounding Tissues: Includes connective tissues and blood vessels that addressed promptly. The length of the prolapsed tissue support the rectum's position within the pelvic cavity. directly correlates with prognosis and treatment options. Clinically, a rectal prolapse appears as a pink to red Grade II rectal prolapse in an ewe rosette-like structure protruding from the anus. The rectum is caudal to the small colon. Much of it is retroperitoneal as it progresses to the Any breed, sex, or age can be affected; however, rectal prolapse occurs most commonly anal canal which is only approximately 1 cm in feedlot cattle from 6 months to 2 years of age. long in small ruminants. The blood supply to Rectal prolapses have been classified by the extent of involvement of various tissues: the distal colon and rectum is located dorsally, which is important to remember as one dissects the rectal tissue for resection and anastomosis. Ochea, Shane Marie G. 9200346 VSG 511 – Large Animal Surgery Physiology Rectal prolapse is probably the most common GI problem in pigs due to diarrhea or weakness of the rectal support tissue within the pelvis. In cattle, it may be The rectum functions primarily as a storage site for feces until defecation. Under associated with coccidiosis, rabies, or vaginal or uterine prolapse; occasionally, normal circumstances, the anal sphincters maintain continence. Typically, rectal excessive “riding” and associated traumatic injury may be causative in young bulls. It prolapse occurs due to increased intra-abdominal pressure, which can result from is common in sheep with short tail docking and especially in feedlot lambs, in which various factors such as straining during defecation, severe coughing, or other stressors. high-concentrate rations may be causative. The use of estrogens as growth promotants, This pressure causes the rectum to evert, leading to potential swelling and damage to or accidental exposure to estrogenic fungal toxins, may also predispose large animals the mucosal layer due to exposure and trauma to rectal prolapse. Pathogenesis and Predisposing Factors Indication Rectal prolapse generally results from an increase of the pressure gradient The indications for performing surgical intervention in cases of rectal prolapse between the abdominal/pelvic cavity and the anus. In normal conditions, the sphincter depend on the severity of the prolapse, the presence of devitalized tissue, and the effectively creates a barrier for the normal pressure gradient. Conditions that cause underlying causes contributing to the condition. inadequate tone of the sphincter and/or a high-pressure gradient can result in eversion of mucosa. Exposure of the mucosa to the environment further irritates the mucosa and Indications for Surgical Intervention may initiate a vicious cycle of straining until a complete prolapse of the rectum occurs. Severity of Prolapse: Short exposure causes damage to the superficial layer, which quickly resolves when the prolapsed tissue is replaced. Prolonged exposure results in progressively deeper ▪ Grade I Prolapse: Surgical intervention may not be immediately necessary if involvement. Unreduced prolapses become edematous, hemorrhagic, and finally there is minimal swelling, and the tissue can be replaced easily. necrotic. Predisposing factors that contribute to rectal prolapse include increased ▪ Grade II Prolapse: Surgical options may be considered if there is prolonged abdominal pressure or fill, excessive coughing, colitis, cystitis, diarrhea, and tenesmus exposure or if the tissue becomes devitalized. from dystocia. ▪ Grade III and IV Prolapses: Surgical intervention is often required due to the high risk of ischemic damage and necrosis Ochea, Shane Marie G. 9200346 VSG 511 – Large Animal Surgery Presence of Devitalized Tissue: severe cases. Complete amputation has a higher incidence of rectal stricture formation, especially in swine. A prolapse ring, syringe case, or plastic tubing may be used as an If there is any indication that the prolapsed tissue has lost its blood supply alternative to surgical amputation in pigs and sheep. Usually, it is not economically (necrotic), surgical resection becomes necessary to prevent systemic infection feasible to repair rectal prolapses in lambs ready for market. and further complications such as peritonitis Surgical Procedure Management Caudal epidural anesthesia is suggested to reduce straining, facilitate repositioning of The management of rectal prolapse includes elimination of predisposing the prolapse, and permit surgical manipulations. After analgesia, the tail will be factors, soothing of the irritated mucosa, elimination of straining, and resolving the wrapped and isolated from the operative field and the prolapsed part will be rinsed with prolapse. The condition of the prolapsed tissue plays the most important role in warm physiological saline and povidone-iodine (Betadine antiseptic). The visible dirt choosing the treatment method. The color of the membranes, degree of materials will be removed carefully using a piece of gauze and then the prolapse will edema/hemorrhage, and presence and depth of erosions are the parameters used to be immersed in enough amounts sugar for 20–30 minutes. After that, the sugar will be decide whether the tissue is salvageable. Caudal epidural anesthesia is performed first. rinsed away from the prolapse. Then, the prolapse will be treated by one of the This temporarily eliminates straining, allows evaluation of the tissue, facilitates following surgical techniques: repositioning, and allows surgical intervention, if necessary. The prolapsed tissue is cleaned with a mild antiseptic. The tissue is evaluated for necrosis, trauma, or tears. i. Reduction and retention purse-string suturing (RR) technique: The treatment options include replacement and purse-string suture, submucosal This technique was performed with reducible rectal prolapse grade I and resection, or amputation. II where the mucosa was viable, and no laceration was found on close inspection. By the palm of both hands, gentle pressure was applied to More aggressive treatment of the prolapse is dictated by the condition of the reposition the prolapse back into its normal anatomical position after rectum. In general, the prolapse may be salvaged by conservative measures, unless lubrication. Finally, a purse-string suture was placed through the skin and obvious deep necrosis or trauma to the tissue exists, or the everted tissue is firm, the deep fascia around the anus where two fingers can easily be passed indurated, and cannot be reduced. Under these circumstances, submucosal resection or through the anus. The suture usually is left in place for 5 to 10 days. amputation should be considered. Amputation of the rectum should be reserved for Ochea, Shane Marie G. 9200346 VSG 511 – Large Animal Surgery ii. Submucosal Resection Preparation and Initial Steps: 1. Select a flexible tubing of appropriate diameter Submucosal resection is the preferred technique if the prolapsed mucosa is necrotic, ulcerated, or traumatized but the underlying tissue is healthy. 2. Insert the tubing into the lumen of the prolapse This technique includes removal of the affected mucosa and salvage of Cross-Pin Fixation: the healthy underlying tissue. 3. Take two 15-cm, 18-gauge needles. Insert the first needle at a 90-degree angle near the anal opening, crossing through the prolapse and tubing and insert the second needle at a 90-degree angle to the first needle, also crossing through the prolapse and tubing. Ensuring that the needles exit at the opposite site Tissue Incision: 4. Make two circumferential incisions through the mucosa on both sides of the tissue to be removed 5. Create a connecting longitudinal incision at the same depth between the circumferential incisions Tissue Removal: 6. Remove the collar of affected tissue using blunt dissection in the healthy submucosal plane. 7. Control any hemorrhage by ligating individual blood vessels Mucosal Alignment: 8. Place four simple interrupted sutures equidistant around the circumference of the prolapse. 9. Appose the four quadrants using one simple continuous suture pattern for each quadrant 13. Use 2-0 to 3-0 monofilament absorbable suture material with a taper-point swaged needle Ochea, Shane Marie G. 9200346 VSG 511 – Large Animal Surgery iii. Rectal amputation (RA) technique: This technique will be performed with nonreducible rectal prolapse III and IV and in cases with grade II with extensive rectal tears where a suitably sized firm rubber tube was passed into the lumen of the prolapse. Then, a circumscribed incision will be made 3–5 cm away from the mucocutaneous anorectum, to separate the mucosa, submucosa, and muscularis (both the inner circular and the outer longitudinal smooth muscle layers) of the prolapsed part. Serosa was easily distinguished by its blood supply. Minute bleeding (if any) will be controlled by an electro- cauterization. Using 2-0 chromic catgut sutures, all serosal blood supplies were double ligated and transected in between. After that, the first quadrant of the serosa was resected. Using 2-0 triclosan-coated polyglactin 910 the outer layers (mucosa to the serosa) and inner layers (serosa to the mucosa) of the resected part were sutured together, using simple interrupted sutures 5 mm apart. The other quadrants of the prolapse are then resected similarly. After amputation and suturing of all quadrants have been completed, the stump retracted manually. (A) A circumscribed incision was made to separate the mucosa, submucosa, and muscularis (white star) of the prolapsed part from the serosa (black star). N.B: serosa was easily distinguished by its blood supply (black arrow). (B) Minute bleeding was controlled by electrocauterization. (C) Using chromic catgut sutures, all serosal blood supply were double ligated and transected in between. (D) Using coated polyglactin 910, the rectal wall was sutured together. Ochea, Shane Marie G. 9200346 VSG 511 – Large Animal Surgery Treatment Plan Post-operative care for rectal prolapse typically includes: ▪ Strict dietary rest followed by feeding on green easily digested food from day 7 onward and then gradually changed to normal food. Antibiotics: To prevent or treat infections in damaged tissues. Anti-inflammatories: To reduce swelling and pain for at least 3 days or as needed. Laxatives or stool softeners: To ease defecation and reduce straining during recovery. Epidural or Lidocaine infusion if straining continues Complication Failure of the suture line will lead to a catastrophic breakdown of the closure. However, this is a rare occurrence. The most common complication is stricture of the rectum leading to difficulty with defecation. Abscesses may also occur. The prognosis is good provided any predisposing condition that led to the prolapse has resolved Complications associated with rectal prolapse include: Necrosis: Prolapsed tissue may die if blood supply is compromised. Infection: Exposure of mucosal tissue can lead to severe infections. Strictures: Scarring from previous prolapses may lead to narrowing of the rectum over time, causing chronic issues with defecation. (A) The prolapsed rectum was resected. (B) The rectal wall was sutured using simple Recurrence: Without addressing underlying causes, there is a risk of repeated episodes of prolapse interrupted suture pattern. (C) Resected prolapsed rectum. (D) The stump was retracted manually. Ochea, Shane Marie G. 9200346 Aislin Kester P. Patalinghug DVM-5 Vaginal Prolapse in Large Animals Vaginal prolapse in large animals, including cattle, sheep, goats, and pigs, refers to the protrusion or eversion of the vaginal walls through the vulva. This condition typically occurs during late pregnancy or parturition, but it can also occur in non-pregnant animals due to factors such as hormonal imbalances, obesity, or mechanical stress. Vaginal prolapse is categorized by severity into four grades:  Grade I: Intermittent prolapse, often visible only when recumbent, with the vaginal tissues appearing normal when reduced.  Grade II: Continuous acute prolapse of vaginal tissue.  Grade III: Continuous acute prolapse involving the vagina, bladder, and cervix.  Grade IV: Chronic prolapse, which could involve Grade II or III, leading to tissue trauma, infection, or necrosis. Vaginal prolapse is a serious condition that, if left untreated, can result in severe complications, including bladder rupture, necrosis, and evisceration. Vaginal prolapse in a Prolapsed caudal dairy cow vaginal mucosa, ewe Grade I vaginal prolapse Prolapsed caudal in a dairy cow at late vaginal mucosa in a gestation. The prolapse ewe at late gestation. was present while Rectal prolapse is also recumbent but resolved present in this animal when the cow was able due to persistent to stand. (Grade I straining. prolapse = intermittent, vaginal tissue appears healthy) Vaginal prolapse with Grade IV vaginal prolapse, dairy cow. evisceration, ewe. This ewe This late-gestation, multiparous Holstein had been previously cow presented with a Grade I vaginal diagnosed with a Grade II prolapse. It progressed to a Grade IV vaginal prolapse. Despite with continuous eversion of the vagina placement of a retention and cervix and necrosis of the vaginal suture, the ewe continued to tissue. Although the cow calved normally, strain, resulting in rupture of she was culled from the herd due to the the vaginal wall and likelihood of recurrence of the vaginal subsequent evisceration. prolapse in her next pregnancy. (Grade Treatment in this case was IV prolapse = chronic prolapse of either humane euthanasia. (Grade grade II or III with resultant trauma, II prolapse = continuous infection, or necrosis) acute prolapse of vaginal tissue) Diseases Involved Vaginal prolapse in large animals can be caused or exacerbated by several factors, including hormonal imbalances, obesity, and breed predisposition. In cattle, prolapse typically occurs during the late stages of pregnancy due to intra-abdominal pressure and hormonal changes that relax the pelvic tissues. Pigs are also prone to prolapse, particularly in sows during late pregnancy due to the size of the fetuses, hormonal fluctuations, and obesity. Breeds like Large White pigs may have an increased predisposition. In both cattle and pigs, prolapse can also be triggered by the excessive use of estrogenic plants or hormonal treatments. The most common surgical techniques include: Buhner Stitch Indications Used for short-term retention of vaginal prolapses, especially in beef cattle or embryo flush cows, and as a primary method in monitored dairy cattle. Relevant Anatomy The stitch is placed deeply around the vulva, exiting through the perineal body dorsally and subcutaneous tissues ventrally.  Buhner suture: A purse-string suture is placed around the vaginal vestibule to retain the prolapsed tissues temporarily. This method is often used in Grade I and II prolapses. Steps of the Buhner Stitch Procedure 1. Incision Preparation - Make a 1 cm skin incision at the 5:00 position below the vulva. 2. Needle Insertion - Insert the Buhner needle through the incision, exiting dorsally above the vulva but below the anus. 3. Additional Incision - Create a 1 cm dorsal incision above the vulva for needle exit. 4. Thread Tape - Thread umbilical tape through the needle, pulling it ventrally. 5. Repeat Opposite Side - Repeat on the opposite side with a 1 cm incision at the 7:00 position. 6. Tie Tape - Tie the tape in a bow at the ventral side, ensuring it's secure but allows urination. 7. Adjust Tightness - Ensure only 1-2 fingers can fit through the vulvar opening. 8. Postoperative Management - After the procedure, it is crucial to monitor the cow closely for signs of impending parturition. The Buhner stitch must be removed before calving, as leaving it in place during delivery can cause severe trauma to the cow and her calf.  Minchev pexy: A more advanced procedure where the vaginal wall is secured to the pelvic structures to prevent prolapse in recurrent or severe cases. Minchev Pexy Indications Suitable for retaining vaginal prolapses when animals cannot be observed during parturition or when long-term retention is required (e.g., embryo flush cows). Relevant Anatomy The suture passes through the vaginal vault and sacrosciatic ligament. Care is taken to avoid the rectum and internal iliac artery, which runs horizontally across the pelvis and is palpable. Step-by-step procedure: Restrain the animal standing, administer local anesthesia (epidural, pudendal, or line block), clean the surgical area, and give antibiotics and NSAIDs. Buhner Needle Technique (Minchev Pexy) 1. The surgeon palpates the vagina to locate the internal iliac artery and determine placement of two buttons near the cervix. The exit site is marked externally. 2. The Buhner needle is inserted vaginally and exits the vaginal wall at the 1-2:00 position, ensuring the internal iliac artery is avoided. 3. Umbilical tape is threaded through the Buhner needle and pulled back into the vagina. 4. The procedure is repeated to create a horizontal mattress suture. The tape is passed through a button or stent externally and internally to prevent suture pull-through. 5. A second pexy is performed on the same side to strengthen the adhesion without constricting the rectum. Straight Needle Technique (Minchev Pexy) 1. The surgeon palpates the vagina to locate the internal iliac artery and mark where the buttons will be placed near the cervix. 2. A long suture is threaded onto a straight needle, which is inserted into the vaginal wall at the desired location. 3. The needle is pushed through the vaginal wall with assistance from a thimble or gauze, and the assistant grabs the needle as it exits. 4. One strand of suture is pulled outside and held, while the internal strand is threaded through a button or stent. The needle is replaced on the internal strand. 5. The procedure is repeated close to the initial puncture. Both ends of the suture are tied over a second button externally. 6. A second pexy is performed on the same side for added strength without constricting the rectum. Rectal palpation is used to ensure no suture has entered the rectum. Postoperative care and complications - Leave sutures in place until parturition or at least three weeks for non-pregnant animals to prevent recurrence. Requires close monitoring for infection, which, while common, rarely leads to abscess formation. In cases where the suture enters the rectum, it should be removed. Although the Minchev pexy is effective, there is still a possibility of recurrence of prolapse, especially if the pexy is not placed cranially enough, if the sutures tear out, or if the animal has other predispositions to prolapse.  Cervicopexy: The cervix is sutured to the prepubic tendon or pelvic muscles to provide long-term support, often used in severe or chronic cases of prolapse. Cervicopexy Indications Recommended for valuable cattle with recurrent vaginal prolapses, particularly when other therapies fail. Relevant Anatomy The vagina’s floor is sutured to the prepubic tendon, avoiding the artery and bladder to prevent complications. Step-by-Step Procedure of Cervicopexy 1. Restrain the animal standing. Administer epidural and local blocks, antibiotics, and NSAIDs. Place a rigid bladder catheter and withhold feed for 24 hours. 2. Vaginal Approach - Insert a bent needle through the vaginal floor, just off midline, into the peritoneal cavity. 3. Flank Approach - The second surgeon retrieves the needle, passes it through the prepubic tendon, and re-directs it into the vagina on the opposite side of the midline. 4. Securing the Cervix - Tie the needle ends through the ventral cervix (without puncturing the lumen), anchoring it to the prepubic tendon. 5. Closure - Confirm no abdominal structures are compromised, then close the flank incision. 6. Alternative Method - Use a colpotomy incision if only one surgeon is available, though it carries a higher risk of complications. Postoperative Care - Antibiotics and NSAIDs are continued for 3 days post-surgery. The surgical site should be monitored for vaginal discharge. The cervicopexy sutures are considered permanent. Complications - Contamination of the procedure can lead to persistent drainage or peritonitis, requiring suture removal. The procedure may be more difficult to perform in obese cattle. Materials Used Buhner Stitch  Buhner needle  Scalpel blade  Umbilical tape Minchev Pexy  Straight needle (strong, at least 3″ long) or Buhner needle/Minchev kit  Umbilical tape or large nonabsorbable suture  Buttons, ligapak inserts, gauze rolls, or stents  Optional: Gauze (padding for glove) or thimble Cervicopexy  Standard surgery pack  Bent S-needle (curved into a backward C with a shorter lower leg)  3 Vetafil sutures (approximately 12 feet long) Surgical techniques vary depending on the animal species and the severity of the prolapse:  In cattle, epidural anesthesia is typically administered for better immobilization. The prolapsed tissue is lubricated, and the bladder is drained if necessary. For Grade I and II prolapses, a Buhner suture is placed around the vaginal vestibule. If the prolapse is more severe, procedures like cervicopexy or Minchev pexy are used for long-term support.  In sheep and goats, the procedure is similar to that in cattle, with a primary reliance on the Buhner suture for Grade I and II prolapses. For chronic or recurrent prolapse, cervicopexy or Minchev pexy may be necessary.  In pigs, the procedure involves cleaning and sterilizing the prolapsed area, followed by the application of a Buhner suture or other retention techniques to prevent the recurrence of prolapse. For more severe cases, cervicopexy can be performed to provide additional support, especially in larger sows. References Roberts, J. N. (2021b, April 13). Vaginal and cervical prolapse in cattle and sheep. MSD Veterinary Manual. https://www.msdvetmanual.com/reproductive-system/vaginal-and-cervical-prolapse/vaginal-and- cervical-prolapse-in-cattle-and-sheep Large Animal Surgery - Supplemental Notes Fubini, S. L., & Ducharme, N. (2016). Farm Animal Surgery - E-Book: Farm Animal Surgery - E-Book. Elsevier Health Sciences. Rio, Luigi Carl T. Large Animal Surgery DVM-5 Dr. Jennifer Laurente Patellar Osteotomy in Large Animal Definition A patellar osteotomy in large animals is a surgical procedure where the patella (kneecap) is realigned to correct knee joint abnormalities or instability. Used to treat conditions like patellar luxation (kneecap dislocation) or conformational issues. Aims to improve joint mechanics, reduce pain, and prevent further dislocation or damage Relevant Anatomy Patellar osteotomy in large animal involves the stifle joint, where the patella articulates with the femur's trochlear groove. The patella, a sesamoid bone embedded in the quadriceps tendon, is stabilized by three patellar ligaments: medial, intermediate, and lateral. These ligaments extend from the quadriceps tendon to the tibial tuberosity, anchoring the patella and facilitating joint movement. The femur's trochlear ridges guide the patella during flexion and extension, while the tibia provides structural support. Surrounding soft tissues, including the quadriceps femoris muscle and joint capsule, also play critical roles in maintaining patellar stability and should be considered during surgical planning. Indication (Diseases) Patellar osteotomy is primarily performed to address patellar luxation, a condition where the patella dislocates from its normal position within the femoral trochlear groove. The procedure often includes trochleoplasty, which involves reshaping or deepening the trochlear groove to improve patellar stability. This surgical approach is especially important in cases of congenital patellar luxation, where the condition is caused by developmental abnormalities of the stifle joint. Realigning the patella helps restore proper biomechanics of the joint, reducing pain, improving mobility, and preventing recurrent luxation. Early intervention in congenital cases can also minimize long-term joint damage and associated complications. Patellar luxation can be classified according to the level of severity: Grade I — Clinical signs are mild and infrequent, and the patella can be manually luxated but easily returns to the trochlear groove. Grade II — The patella luxates during flexion of the joint and is repositioned during extension, causing animals to have a resolvable skipping lameness. Grade III — the dislocated patella is more frequently out of, instead of in, the trochlear groove, and lameness is consistent. Bone deformities are evident in these animals.  Grade IV — Lameness and limb deformations are most severe. Procedure (step by step) Step 1: Preoperative Preparation Patient Evaluation: Conduct a thorough physical examination and imaging studies (e.g., radiographs) to assess the severity of patellar luxation. Anesthesia Induction: General anesthesia is typically used for the procedure. Positioning: Once sedated, the animal is positioned in lateral recumbency, ensuring that the surgical site is accessible. Step 2: Surgical Site Preparation Skin Preparation: The surgical site on the affected limb is shaved to expose the skin clearly, followed by disinfection with antiseptic solutions. Draping: Sterile drapes are placed around the surgical site to maintain a sterile field. Step 3: Surgical Exposure Incision: Make a lateral longitudinal incision over the femoral trochlea. The incision should be sufficient to expose the knee joint thoroughly. Layered Dissection: Carefully dissect through the subcutaneous tissue and fascia to expose the patella and femoral trochlea while minimizing trauma to surrounding structures. Step 4: Patellar Mobilization Patella Mobilization: Gently dislocate the patella from the trochlear groove, allowing for adequate access to the groove itself. Articular Cartilage Protection: It is crucial to protect the underlying articular cartilage during this mobilization to prevent damage. Step 5: Trochlear Groove Modification Groove Deepening: Using a surgical chisel or specialized orthopedic tools, deepen the trochlear groove by removing a wedge of bone, either rectangular or elliptical shape. This creates a more pronounced sulcus for the patella to sit securely. Wedge Insertion: o Rectangular or elliptical wedge of bone is then reinserted into the newly fashioned groove at a lower position, which creates a more effective space for patellar seating. This technique helps in maintaining the anatomical integrity of the joint. Step 6: Closure of the Joint Suturing Techniques: Utilize appropriate suturing techniques to close the joint capsule and the fascia: Simple Interrupted or Continuous Sutures can be employed to close the joint capsule. Retinacular Imbrication may be performed to maintain the alignment of the patella. Subcutaneous Closure: After ensuring alignment, close the subcutaneous tissues with absorbable sutures to prevent synovial fluid leakage. Skin Closure: Finally, close the skin incision using appropriate sutures (e.g., nylon or absorbable sutures). Treatment Plan (post op) Restricted movement for several weeks. Medications: o Anti-inflammatory Drugs: Reduce pain and inflammation (e.g., NSAIDs like flunixin meglumine or phenylbutazone). o Analgesics: Manage post-operative pain. o Antibiotics: Prevent or manage infection, especially in surgical wounds. Regular wound care and monitoring for infection. Gradual Rehabilitation: o After initial healing, implement a controlled exercise regimen to restore mobility. Complication The most commonly reported of the major complications of patella luxation surgery include patella reluxation and problems associated tibial tuberosity transposition, tuberosity fracture or displacement, and fracture of the proximal tibia.