Laparscopic Surgery

Re: Laparscopic Surgery

Malcolm Ness — Sat, 01 Jun 2013 14:11:41 GMT

A paper about suturing episiotomies has no bearing on the question I asked which was about ligating.

Re: Laparscopic Surgery

An On MRCVS — Sat, 01 Jun 2013 14:01:17 GMT

[quote user="Malcolm Ness"]Can you direct me to the evidence that shows catgut to be an inadequate surgical ligature material? [/quote]

http://www.ncbi.nlm.nih.gov/pubmed/23543639

Re: Laparscopic Surgery

Malcolm Ness — Wed, 29 May 2013 10:28:22 GMT

[quote user="Richard Sanderson"]However, evidence based medicine is getting more importan[/quote]

No, it isn't. It has always been important.

[quote user="Richard Sanderson"]catgut: I am not against it[/quote]

Can you direct me to the evidence that shows catgut to be an inadequate surgical ligature material?

Re: Laparscopic Surgery

Mark Holmes — Wed, 29 May 2013 05:12:44 GMT

It is indeed a sad story but you cannot draw any conclusions from one sad story. I once saw a dog bleeding heavily from a large granuloma at the uterine stump some weeks after a pyo. Not sure what had been used but you could potentially blame it on the use of a braided structure material in an infected environment - or you could consider it another sad story.

Re: Laparscopic Surgery

Evelyn Barbour-Hill — Wed, 29 May 2013 02:31:57 GMT

[quote user="mariette asselbergs"]

"Has anyone ever seen a bitch spay that has started bleeding more than 24hours after surgery? Lots of us use catgut so if there were problems you would think at least someone will have seen it."

I have always used catgut and like it a lot, and in my last cpd the experts did not really criticise catgut in it self so much but expected it to go off the market so told us to be prepared to use the other stuff.

But with respect to the above: we just saw a GSD in last weekends ECC clinic, 6 days post spay bleeding to death from a slipped ligature on the cervix. Admittedly, this was a spay done during a caesarean, on a dog which had been rescued from a puppy factory, so possibly the cervix was huge and contracted or necrotised or something. But I was surprised that this could still cause acute and fatal bleeding almost a week post op.

And it wasn't the result of slowly bleeding, she had been fine and running around the afternoon before and suddenly went "off her legs" and white as a sheet overnight. She was operated on and the cervix stump was actively bleeding. Sadly she died in recovery.

You live and learn

Mariette

[/quote]

Well, a slipped ligature is a slipped ligature not a broken ligature, and a ligature of any material can slip if not adequately or competently placed.

So the lesson of this sad story may be that yes, a ligatured artery can bleed again six days later. Which rather suggests that all those catgut ligatures in fact do retain sufficient ligaturing strength for more than six days.

Re: Laparscopic Surgery

Virginia Campbell — Tue, 28 May 2013 23:19:14 GMT

[quote user="Richard Sanderson"]On average us GP vets would do ~65hours a week with an average day being 7am-9/10pm 4 days a week Mon-Fri and then 1 in 2 weekends from 7am-~10pm (covering ~100 vets who are closed + looking after ~20 referral inpatients with 2 nurses, a receptionist and a kennel assistant).[/quote]

Good grief, I'm not surprised you left. I don't think many of us would find this a sustainable model in the long term.

[quote user="Richard Sanderson"]evidence based medicine is getting more important. [/quote]

Yes, they were very keen on it when I was in college, which was a bit before you were in college. One of the things they taught us was that daily liveweight gain was better in bullocks which had received an NSAID injection at the time of castrate compared to those which had not. I assume you got taught this too as it would have been common knowledge by then. Once out in clinical practice, did you find that the cattle which received NSAIDs post castration did better than those castrated by the unenlightened?

Re: Laparscopic Surgery

vs0u — Tue, 28 May 2013 20:26:43 GMT

[quote user="Richard Sanderson"]On average us GP vets would do ~65hours a week with an average day being 7am-9/10pm [/quote]

[quote user="Richard Sanderson"]I would suggest, rather than assume you are busier than everyone else, you consider it may be your efficiency and organisation which would benefit from overhaul[/quote]

I hope I never have to work anywhere that efficient and organised!

Re: Laparscopic Surgery

Mark Holmes — Tue, 28 May 2013 20:21:53 GMT

Richard I apologise in the length of the thread I had misunderstood the op and got the impression you were selling laparoscopes. I agree rushing is different from operating time efficiently which is why I don't understand how laparoscopic spays help. I didn't assume to be the only one who is busy, I don't claim to be busier than anyone else. Actually I have worked in a practice which operated those hours. It was in many ways less stressful because there was time in the day to find flexibility. The practice was staffed entirely with people who had no outside responsibilities and working until the work was done just part of the job. In fact in one stretch I worked 42 days straight. These days those hours would be impossible and somehow the work needs shoehorning into a 9-6 day.

Re: Laparscopic Surgery

Evelyn Barbour-Hill — Tue, 28 May 2013 20:11:24 GMT

[quote user="Richard Sanderson"]Re: catgut: I am not against it persay - I used it for 15 months without any real complication. However, evidence based medicine is getting more important. 999 times out of 1000 if you run a red light you won't cause a crash - doesn't make running the red light any less risky or any better an idea ....[/quote]

Not analogous at all.

[quote user="Richard Sanderson"]Re: primapore. I like using primapore on wounds.[/quote]

I've never used anything like that and my wounds heal fine.

[quote user="Richard Sanderson"] In addition, it is reported to reduce environmental bacterial invasion in the first few hours post surgery.[/quote]

Interesting, but I reckon the body has a pretty good mechanism to minimise bacterial invasion anyway.

Re: Laparscopic Surgery

Richard Sanderson — Tue, 28 May 2013 18:41:54 GMT

Re: primapore. I like using primapore on wounds. It protects the wound from strikethrough/ooze in overweight patients which is better for the owner. In addition, it is reported to reduce environmental bacterial invasion in the first few hours post surgery. I, like others on here, have the owner remove them the next morning. Judging its efficacy on my individual experience in my individual case load is subjective and has a very small sample size - not good evidence based medicine so I am not recommending it, just stating my preference to use it.

Re: catgut: I am not against it persay - I used it for 15 months without any real complication. However, evidence based medicine is getting more important. 999 times out of 1000 if you run a red light you won't cause a crash - doesn't make running the red light any less risky or any better an idea ....

This thread, has opened some really interesting debate/discussion :) Maybe it highlights we should do more to collect national information on people's techniques, frequency of complications and try to get an appropriate sample size from which some bright epidemiologist can make useful conclusions which could be applied to our everyday practice ....

Re: Laparscopic Surgery

Richard Sanderson — Tue, 28 May 2013 18:35:20 GMT

[quote user="Mark Holmes"][quote user="Richard Sanderson"]

[quote user="Mark Holmes"][quote user="Michael Woodhouse"]

Richard, what an 'interesting' argument. 10 swabs cost 32p. Still need to suture skin. Couple of pounds worth of catgut. There's not much more than £5 of consumables in a spay. I would still give NSAID and don't routinely send dogs home with more. Don't use buster collars for spays ever. Hardly ever use Primapore.

My experience of laparoscopy was not favourable even when done by surgery specialists. I remember a cryptorchid horse at college where they fished about for 2 hours, removed one testicle then opened it up - 20 mins later all done.

The equipment is very expensive. There are ongoing costs with instrument sheathing etc. The cleaning is slower and more involved. The set up is longer. I can do 3 bitch spays in quick succession if I want using normal kit. How much would I have to spend on this type of kit, in duplicate to do the same?

With a following wind and a thin bitch you can spay in less than half an hour.

[/quote] It's not the length of surgery that's important it's how many you can do. Nice bitch spays 2.5 per hour is achievable. Expensive outlay on equipment means you cannot keep it in duplicate. Slow turnaround limits efficiency. Technically difficult turn around means that you cannot deligate it to cheap staff. I know some practices that do laparoscopic spays but they generally have the equipment, staff and facilities to suport it. Most smaller practices couldn't justify setting up to do it.

[/quote]

Is it not more about welfare and pain in th provision of the best most minimally invasive surgery rather than speed or volume .... (i agree both are factors but certainly not the driving force)

[/quote] Then you need to go back to a busy small animal practice. We have few means to control workload. X hours to complete X+1 hours work. Staff often HAVE to leave because they have other responsibilities. Flexibility on working hours requires flexibility in those in the rest if your life who bear no responsibility to the case in front of you. Many days there is a constant pressure to keep a 10 balls up in the air at anyone time. - and if a BSAVA talk on customer services is to be believed not show it when speaking to clients. Further any increase in costs of a bitch spay may reduce the likelihood of the dog getting spayed. Having a long term negative impact on welfare which can be managed in the short term with adequate analgesia. I use medetomidine, methadone meloxicam ketamine and buprenorphine on discharge. You wouldn't know they had been done. Immediate knot security is prefered to 7d tensile strength and I have used gut on thousands of spays. Laparoscopic spays have a place but a small clinic cannot justify the cost or often the space as the scopes I have witnessed have been bulky things.

[/quote]

Mark I felt I wanted to clarify this. I am, and always have been, in first opinion practice. My last job happened to be sited with a referral and emergency out of hours clinic. I was responsible for both first opinion and out of hours - Mon-Fri we would not only balance a busy 1st opinion clinic but also be responsible for out of hours inpatients and procedures - most days we would squeeze in a f# repair or splenectomy. So split responsibilities is the normal for all vets not just you. On average us GP vets would do ~65hours a week with an average day being 7am-9/10pm 4 days a week Mon-Fri and then 1 in 2 weekends from 7am-~10pm (covering ~100 vets who are closed + looking after ~20 referral inpatients with 2 nurses, a receptionist and a kennel assistant). On an average weekday (per vet), when we looked at the figures, we would do ~32 appointments a day. In addition an average surgical list to be completed on top of this would be 2 elective procedures (neuteuring/dental) and 2-3 'illness' procedures to include diagnostic imaging, mass removals, chemotherapy, f# repair etc. Average turnover, again per vet, would be ~75k per month. Doing procedures properly (and not rushing) ensures you find additional things and do more and provide higher standards of care. All this with a 'team' of 1.5 vets, 1.5 RVN, an animal care student and a receptionist. For the record we produced 'average procedure times' - when these were exceeded a 2nd vet (whether junior or senior) had to be informed - for example a bitch spey after 50mins, a cat spey after 20mins, any procedure at 1hr. This was implemented after a junior colleague took 1.5 hrs for a bitch spey without informing one of us senior clinicians and was adapted from my first small animal practice. The point is rushing is different from operating properly but time efficiently.

I would suggest, rather than assume you are busier than everyone else, you consider it may be your efficiency and organisation which would benefit from overhaul. I believe you can pay for external companies to come in and help with this?

Re: Laparscopic Surgery

Rob Loxley — Tue, 28 May 2013 18:29:15 GMT

Interestingly (back to the OP) our local referral centre offer lap-spays but their diplomate surgeon was of the opinion that it was often slower than someone good at conventional surgery, always more costly to perform (equipment and consumable costs) and the differences in outcomes were minimal.

I can certainly see the advantages of thoracoscopy over open surgery, but as for most abdominal procedures (especially spays) am less than convinced

Re: Laparscopic Surgery

Christopher Saul — Tue, 28 May 2013 17:52:42 GMT

[quote user="Michael Woodhouse"]I don't want tensile strength after 7 days. I suspect you could go back after 24 hours and remove the ligatures on the ovaries with zero problems. [/quote]

[quote user="mariette asselbergs"]we just saw a GSD in last weekends ECC clinic, 6 days post spay bleeding to death from a slipped ligature on the cervix. [/quote]

Well, but very sadly, illustrating the point I was trying to make ( but got a red star for) when I was suggesting that it was an oversimplification to say one could remove ligatures after 24 hours, and also I suspect the reason why Richard is against catgut......

Re: Laparscopic Surgery

Michael Woodhouse — Tue, 28 May 2013 17:41:25 GMT

[quote user="James Laidlaw"]Have used it in all our routine ops for first 3 days (if they stay on!) for last 18 months in a new practice and seen zero cases of "very nasty dermatitis" so far.[/quote]

Why?

I stick them on something if there is a little skin ooze after Sx (fat lab spays, mainly) but remove them before sending home

Re: Laparscopic Surgery

mariette asselbergs — Tue, 28 May 2013 17:40:09 GMT

"Has anyone ever seen a bitch spay that has started bleeding more than 24hours after surgery? Lots of us use catgut so if there were problems you would think at least someone will have seen it."

You live and learn

Mariette

Re: Laparscopic Surgery

Rob Loxley — Tue, 28 May 2013 16:15:49 GMT

[quote user="Richard Sanderson"] I may be wrong but I believe the VDS now also follows this advise and recommends against the use of catgut as a suture choice[/quote]

Not what the VDS have said to me - John Hird, lecture, 2012

Re: Laparscopic Surgery

Bob Russell — Tue, 28 May 2013 16:06:58 GMT

[quote user="Mark Holmes"]Primapore is the surgical dressing which causes a very nasty dermatitis in a large proportion of dogs.

[/quote]

But does not if you only leave it on overnight! We get owners to remove it the next day.

If the dog has removed its dressing by itself it probably needs a buster collar. If it is neat and untouched it probably doesn't need one!

Re: Laparscopic Surgery

James Laidlaw — Tue, 28 May 2013 15:56:13 GMT

[quote user="Mark Holmes"]Primapore is the surgical dressing which causes a very nasty dermatitis in a large proportion of dogs.

[/quote]

Have used it in all our routine ops for first 3 days (if they stay on!) for last 18 months in a new practice and seen zero cases of "very nasty dermatitis" so far.

Re: Laparscopic Surgery

Mark Holmes — Tue, 28 May 2013 15:45:56 GMT

Primapore is the surgical dressing which causes a very nasty dermatitis in a large proportion of dogs.

Re: Laparscopic Surgery

Bob Russell — Tue, 28 May 2013 15:20:25 GMT

The laparoscopic surgery I have seen has involved more than one person scrubbed up - does this get entered into the budget?

I cannot see this type of surgery becoming routine until pet owners become more willing to spend more.

Having spayed our puppy a couple of weeks ago the nightmare has been keeping her from bouncing around and chasing the other dogs. She was almost back to normal next morning!!

Re: Laparscopic Surgery

bob lehner — Tue, 28 May 2013 15:14:24 GMT

[quote user="Richard Sanderson"]times for laparoscopic speys can be as little as 12 mins[/quote]

Hmm - I suspect a very great deal of experience would be needed to get anywhere near this.

Most people I have spoken to say they take longer than the old-fashioned method - and with a pretty steep learning curve.

Surely the fact is that humans do not tolerate surgery particularly well and therefore minimally invasive techniques have been found to be very beneficial in terms of reduced post-op morbidity. As others have pointed out our species absolutely do seem to cope far better (whether this is physiological or psychological is open to debate). I therefore believe conventional surgical techniques will continue to be used by the majority of the profession, along of course with appropriate p.o. analgesia.

Re: Laparscopic Surgery

Christopher Saul — Tue, 28 May 2013 10:40:59 GMT

[quote user="Evelyn Barbour-Hill"]But injuries that stop bleeding by themselves (or with "firm digital pressure") don't start bleeding again two days later. [/quote]

They don't have the pressure of the ovarian arterial blood flow behind them though!

I'm not particularly anti catgut (though I use PGA myself), just pointing out that the idea you could remove ligatures from an ovarian pedicle after 1day is somewhat oversimplified!

Re: Laparscopic Surgery

Michael Woodhouse — Tue, 28 May 2013 10:21:02 GMT

[quote user="Christopher Saul"]How about asking my mother who had a hysterectomy and was on morphine CRI for 36 hrs. I don't think a hernia op is comparable[/quote]

Christopher - I missed this comment.

I don't think a bitch spay and a hysterectomy are the same in terms of the patients reaction to them. Dogs go out wagging their tails. Mine wanted me to take her for a walk. A few days later the dog feels fine and seems somewhat confused why it is on a lead and can't play frizbe. You ask your mother how long before she'd want to chase a frisbe! I understand people cannot drive for a number of weeks after the op - hardly the perfectly normal bouncing bitch at 10 days for sutures out.

Re: Laparscopic Surgery

CatherineThomas — Tue, 28 May 2013 07:17:51 GMT

Has anyone ever seen a bitch spay that has started bleeding more than 24hours after surgery? Lots of us use catgut so if there were problems you would think at least someone will have seen it.

Primapore is the stick on dressing that some people put over a surgical wound.

I'm struggling to get my practice to agree to buy me just the endoscope at the moment. There's no way they'd pay out for all of the extra equipment needed to do laproscopic surgery! From what I've seen of prices you'd have to charge a hell of a lot for it's use to make up the price of it anytime soon. And I'd imagine it would take a while of practice before you could confidently say that you could complete a proceedure such as a spay.

Re: Laparscopic Surgery

Evelyn Barbour-Hill — Tue, 28 May 2013 01:50:13 GMT

[quote user="Christopher Saul"]Interesting point of view there. I would agree that after 24 hours you would have a lovely strong fibrin clot. BUT you have to remember that a fibrin clot is a dynamic entity and is being constantly broken down by the fibrinolytic pathway. ( that's plasmin , issue plasminogen activator etc etc) This is normal as the clot is a temporary measure designed to hold things together whilst the vascular endothelium can migrate across and repair the defect. I really can't remember the length of time a fibrin clot holdis its strength for, but I cannot imagine it's longer than a couple of days at most.[/quote]

But injuries that stop bleeding by themselves (or with "firm digital pressure") don't start bleeding again two days later.