Removing salivary glands

Re: Removing salivary glands

Julie Innes — Fri, 12 Jul 2013 21:39:41 GMT

Wee update- saw dog for stitches out today and saliocoele has completely resolved, all healed fine and dog is doing great . Glad I did it now, and wouldn't hesitate to do it again! thanks all!

Re: Removing salivary glands

Julie Innes — Thu, 04 Jul 2013 20:18:33 GMT

[quote user="Martin Atkinson"]

[quote user="Julie Innes"]

[/quote] Well done, I'll fall short of saying 'told you so'.

[/quote] Oh go on- you know you want to!

Re: Removing salivary glands

Martin Atkinson — Thu, 04 Jul 2013 09:43:16 GMT

[quote user="Julie Innes"]

Well, I removed the gland this morning, and it was pretty easy peasy, actually! just that slight quiver when I saw how close it was to some of the major blood vessels, but seemed to go pretty smoothly. Of course, time will tell.... thanks all for your input- fingers crossed it is unmitigated success!!

[/quote] Well done, I'll fall short of saying 'told you so'.

Re: Removing salivary glands

Julie Innes — Wed, 03 Jul 2013 13:09:19 GMT

Re: Removing salivary glands

Martin Atkinson — Mon, 01 Jul 2013 19:23:09 GMT

[quote user="Michael Woodhouse"]

[quote user="Martin Atkinson"]re-attached a totally evulsed bladder[/quote]

St Martin, we NEED this anecdote. Here is my dog and here is his bladder in a bag. Anything you can do vitinary?

[/quote] The bladder was still inside the patient, even St Martin may struggle if it was presented separately!!

Re: Removing salivary glands

Michael Woodhouse — Mon, 01 Jul 2013 16:49:13 GMT

[quote user="Martin Atkinson"]re-attached a totally evulsed bladder[/quote]

St Martin, we NEED this anecdote. Here is my dog and here is his bladder in a bag. Anything you can do vitinary?

Re: Removing salivary glands

Martin Atkinson — Mon, 01 Jul 2013 14:30:55 GMT

[quote user="Mark Holmes"]How do you judge a case as being ultimately untreatable or having unavoidable complications? [/quote] OK let's just set a standard here, we are talking about soft tissue surgery as I will refer complicated orthopaedics. I have only ever failed to complete one piece of soft tissue surgery in my career - a laryngeal tie-back which I sent off sewn back up with a tracheostomy tube in place and have not attempted one since - my claim to wussiness. I have completed lung lobectomies, adrenalectomies, liver lobectomies, partial pancreatectomies, nephrectomies, re-attached a totally evulsed bladder, sub-total colonectomies, multiple enterectomies, removed a saddle thrombus from a cat's aorta: anything less complex than these is routine in my book so I don't think I'm a poor surgeon. I would therefore consider a liver, pancreas or lungs that had metastatic disease in all lobes, an intestine with miliary tumours throughout the mesentery or an animal with 2 knackered kidneys ultimately untreatable. An unavoidable complication may be a splenectomy that turned out to have bleeding secondaries in the liver and elsewhere or a dog that had infected penetrating gunshot wounds that developed peritonitis despite repairing the holes in it's gut or a cat had severe crush injuries that developed toxic shock syndrome despite removing its crushed kidney. Does that give you an idea? I don't claim complication free surgery. I'm not God, but if it ultimately returns to full function that is a success in my book

Re: Removing salivary glands

Mark Holmes — Mon, 01 Jul 2013 11:32:51 GMT

[quote user="Martin Atkinson"]

[quote user="Malcolm Ness"]

99.9% success!! ............ I am, therefore, one of many extremely careless surgeons.

[/quote] Just as well for you there isn't an NHS-like league table for veterinary surgeon's success rates then isn't it Malcolm!

PS I was actually going to modestly downgrade this to 90% but after talking to my nurses and assistant we can think of only one case (other than those that were ultimately un-treatable surgically or had unavoidable complications unrelated to the surgery) that wasn't successful - a total hip ablation that had to be revised, in the past few years so I'm sticking with 99.9%. Sorry.

[/quote] How do you judge a case as being ultimately untreatable or having unavoidable complications? Playing devils advocate here but isn't it very easy to persuade yourself this is the case when infact in another's hands the case may have turned out different? Example I recently repaired two inter chondylar fractures. One did beautifully the seconds elbow exploded about 3 weeks later and the dog is now tripod. There are several factors involved in the latter case which didn't help. The dog spent about 90% of its time bouncing on its forelegs and the lateral fragment was slightly comminuted so I lost about 20% of the fragment and couldn't get perfect reconstruction. I would still feel arrogant suggesting that the failure was "just one of those things"

Re: Removing salivary glands

Martin Atkinson — Mon, 01 Jul 2013 10:37:15 GMT

[quote user="Malcolm Ness"]

99.9% success!! ............ I am, therefore, one of many extremely careless surgeons.

[/quote] Just as well for you there isn't an NHS-like league table for veterinary surgeon's success rates then isn't it Malcolm!

Re: Removing salivary glands

Malcolm Ness — Sun, 30 Jun 2013 19:10:00 GMT

[quote user="Martin Atkinson"]So did I and 99.9% of it worked which it will if you're a careful surgeon[/quote]

99.9% success!! ............ I am, therefore, one of many extremely careless surgeons.

Re: Removing salivary glands

Mark Holmes — Sat, 29 Jun 2013 21:01:44 GMT

You get more wussy the more you become aware of what can go wrong, have had it go wrong and had to pick up the pieces. That said removing a salivary gland is lovely surgery, much easier than it sounds and very satisfying.

Re: Removing salivary glands

Martin Atkinson — Sat, 29 Jun 2013 10:17:22 GMT

[quote user="Julie Innes"]Thank you all! martin is right,[/quote] I'm always right its just the others haven't all realised it yet! [quote user="Julie Innes"]Thing is, after 18 years in practice it DOES seem harder to try "new" things-[/quote] After 38 years, despite my apparent cavalier attitude, I have realised my limitations and refer what I am not happy with, but even after that time I do still find the odd thing I've not done before and relish the challenge.[quote user="Julie Innes"] straight out of uni I happily tackled anything[/quote] So did I and 99.9% of it worked which it will if you're a careful surgeon, have the correct equipment for the job and follow first principles, as said - wussiness seems to be part of the curriculum these days for new grads which is a pity.

Re: Removing salivary glands

Julie Innes — Fri, 28 Jun 2013 22:40:39 GMT

Thanks guys! And thanks for the cadaver tip- hadn't thought of that! I have a dog for pts tomorrow- I think I would have to ask the owners first, as I do normally treat my cadavers pretty sensitively, but I'll try to find a way to word it... I do think I will end up doing the surgery- it's a client who trusts me, but I have made my limitations pretty clear. I used to love doing new procedures, but these days I seem to be so comfortably in my comfort zone..

Re: Removing salivary glands

Rob Reid — Fri, 28 Jun 2013 21:41:37 GMT

I think you've taken the right approach in that you've offered the referral and the owner has declined this in full awareness of your ability. It's natural to feel apprehensive if you are out of your comfort zone.

Good luck when you come to doing it (and you most likely will, I've not seen one 'do' with conservative management!) There's some good diagrams in Fossum I believe and do try and get some practice on a cadaver if you can beforehand, I found it helped a great deal when I did my first one.

Re: Removing salivary glands

Kate Richardson — Fri, 28 Jun 2013 21:19:54 GMT

Most important thing is you have been honest with the owners, really hope you get to have a go!

Re: Removing salivary glands

Julie Innes — Fri, 28 Jun 2013 18:55:58 GMT

Thank you all! martin is right, actually- I like surgery, and am fairly competent (I like to think!) in most soft tissue stuff, so I suspected I might be a bit wussy to consider referral . Thing is, after 18 years in practice it DOES seem harder to try "new" things- straight out of uni I happily tackled anything- a ferret spay or cystotomy was actually less daunting to me then than a bitch spay!

I saw the dog this morning (and did some more reading of surgery textbooks!) the swelling is far smaller now, and seems more localised to the right, so if I was going to do it, I would now be more confident to take a gamble on the right hand side. The dog is insured, but more of a hassle for the owner to be referred. I have been very honest and explained that it is an op I have never done, and that I would be doing it from a book, but that I wouldn't mind having a go at it (get me being brave!) BUT I was also happy to refer to someone more experienced if she preferred. As the swelling is really small at the moment, the owner wants to wait and see (although I have warned her it will get bigger again!) but she is ok with me doing the surgery if necessary. Thanks for the reassurance, all . Just really worried I would try it, mess up and then discover it was something I should have referred!!

When I get so wussy??!

Re: Removing salivary glands

Martin Atkinson — Fri, 28 Jun 2013 17:45:05 GMT

[quote user="Rob Reid"] I certainly don't feel you can compare this procedure to a bitch spay or a thyroidectomy - it's a completely different operation. You may be able to do a thyroidectomy in your sleep, but if you've never perfromed a salivary gland removal before before I'd say you are kidding yourself if you think you are competent at it.[/quote] It is a different operation but what I'm trying to say is that if you're confident enough to do a thyroidectomy you should be able to remove a submandibular salivary gland it requires similar skills and tissue handling techniques. Unless you go ape with the scalpel blade and are cavalier with your blunt dissection the only nasty things to be aware of are the aforementioned veins which overly it and are obvious, with the thyroid you've got to worry about the jugular vein, recurrent laryngeal nerve and the parathyroid in a smaller surgical field.

Re: Removing salivary glands

Rob Reid — Fri, 28 Jun 2013 17:21:40 GMT

[quote user="Martin Atkinson"]This is just the sort of thing that scares people off into not trying things. There are some pretty big and scary blood vessels and nerves just about everywhere you are likely to lay a scalpel - quite honestly I don't know where half of them are I always assume there will be one or the other or both wherever I venture. With a little bit of care there is nothing about this operation that a competent surgeon should be scared about. If you can do a bitch spay and a thyroidectomy you can do this, both IMO have greater potential for disaster for the unwary.[/quote]

Is it such a bad thing giving an honest appraisal of the situation? I'm not trying to scaremonger, merely trying to raise awareness of the facts. Surgery is not about being cavalier. A good surgeon will be aware of all the potential risk factors involved in an operation and, if they are going to perform said procedure - should be confident that they can deal with these. Not everyone has the experience or know-how to do this. Confidence is a big factor, but at the right level. If you are underconfident you should be asking for help, and overconfidence I would say is a dangerous trait in a surgeon.

"There is nothing about this operation that a competent surgeon should be scared about." But how does one define competence in this context? I certainly don't feel you can compare this procedure to a bitch spay or a thyroidectomy - it's a completely different operation. You may be able to do a thyroidectomy in your sleep, but if you've never perfromed a salivary gland removal before before I'd say you are kidding yourself if you think you are competent at it.

Re: Removing salivary glands

Martin Atkinson — Fri, 28 Jun 2013 16:42:12 GMT

[quote user="Rob Reid"]No shame in wanting to refer this I would say. If you're unfamiliar with operating in this area, there are some pretty big and daunting blood vessels and some important nerves as well.[/quote] This is just the sort of thing that scares people off into not trying things. There are some pretty big and scary blood vessels and nerves just about everywhere you are likely to lay a scalpel - quite honestly I don't know where half of them are I always assume there will be one or the other or both wherever I venture. With a little bit of care there is nothing about this operation that a competent surgeon should be scared about. If you can do a bitch spay and a thyroidectomy you can do this, both IMO have greater potential for disaster for the unwary.

Re: Removing salivary glands

Evelyn Barbour-Hill — Fri, 28 Jun 2013 16:17:32 GMT

[quote user="Julie Innes"]Am I being a wuss to refer this?[/quote]

No.

Re: Removing salivary glands

Anthony Dennison — Fri, 28 Jun 2013 15:12:05 GMT

Have you tried using low-dose phenobarbitone to try and reduce saliva production at all?

Re: Removing salivary glands

Rob Reid — Fri, 28 Jun 2013 14:51:56 GMT

No shame in wanting to refer this I would say. If you're unfamiliar with operating in this area, there are some pretty big and daunting blood vessels and some important nerves as well.

If you are going to give this a go, I would advise you practice on a cadaver first. For mandibular salivary gland removal (your most likely culprit with a cervical mucocoele) the key is to make sure you dissect cranial enough to also remove the sublingual salivary gland as well (I think Martin pointed this out earlier.) If you don't you will likely get a recurrence of the mucocoele.

Good luck !

Re: Removing salivary glands

Mark Hedberg — Fri, 28 Jun 2013 13:40:51 GMT

[quote user="Martin Atkinson"]

[quote user="Mark Hedberg"] Saudi Arabia doesn't do lawsuits...[/quote]No they just chop off your hand or stone you if you mention Mohammed.

[/quote]

(blood money and deportation, more like it)

Re: Removing salivary glands

Martin Atkinson — Fri, 28 Jun 2013 12:18:51 GMT

[quote user="Mark Hedberg"] Saudi Arabia doesn't do lawsuits...[/quote]No they just chop off your hand or stone you if you mention Mohammed.

Re: Removing salivary glands

Mark Hedberg — Fri, 28 Jun 2013 11:01:30 GMT

[quote user="Martin Atkinson"]

I come from a different generation, when there was limited options for referral and we had to get on with things.

[/quote]

I worked in Saudi Arabia - nearest vet hospital was 1500 km away, in the capital city! I got on with things too. (and ended up with stress ulcers!) Saudi Arabia doesn't do lawsuits...

Sorry, didn't realize you were pushing the 'tough love' angle!