Bitch spays - when can I stop worrying?!

Re: Bitch spays - when can I stop worrying?!

Robin Grimmer — Sun, 08 Sep 2013 15:17:02 GMT

[quote user="Anthony Todd"]

What do folk mean by "wound breakdown" or "ligature failure"? Especially when they blame the material......

Does anyone get "infection" and blame the suture material? If you do, say the suture is not sterile, how does it look?

Once we can define a "breakdown" we can decide if the material is really to blame.

[/quote]

The case I described was definitely a ligature failure. Both dog castrations went fine, there was no haemorrhage at the time and the ligature appeared secure. The haemorrhage appeared a few days later - and I had to open one up to find the knot intact but the catgut suture broken. I'd call that a ligature failure.

I've seen some reactions to vicryl when used in the intra-dermal layer, particularly if too thick Vicryl is used - ie a vet trying to do the whole op with one pack. You see it most where the knots are - ie where there is most suture material. I've never had a problem with this as I use 2m Vicryl or thinner for my intra-dermals as Evelyn mentioned earlier in the thread.

Re: Bitch spays - when can I stop worrying?!

Michael Woodhouse — Sun, 08 Sep 2013 14:45:15 GMT

[quote user="Christina Smith"]I see significantly fewer seroma type reactions in bitch spays since switching from multifilament to mono filament suture material.[/quote]

We use PGA on a reel and I have never seen a seroma reaction after a spay. Always have taken a lot of care to close fat and remove dead space.

I toyed with using PDS (we use it for cattle abdominal walls after DA ops) but the ends are very prickly and I don't like the memory.

Re: Bitch spays - when can I stop worrying?!

Gillian Mostyn — Sun, 08 Sep 2013 08:06:38 GMT

The 'breakdown' I saw was due to knot failure. (Not my op - I did the repair - looked like the ends were cut a bit too short.)

Re: Bitch spays - when can I stop worrying?!

Christina Smith — Sat, 07 Sep 2013 18:21:47 GMT

I see significantly fewer seroma type reactions in bitch spays since switching from multifilament to mono filament suture material. To be fair to vicryl though I think we were using polysorb. I believe the difference is in the coating.

Re: Bitch spays - when can I stop worrying?!

Anthony Todd — Sat, 07 Sep 2013 17:21:08 GMT

What do folk mean by "wound breakdown" or "ligature failure"? Especially when they blame the material......

I've had gut sutures actually untie so you can pull short lengths of gut, [sorry catgut, not the gut...] from one side or the other of the incision, obviously my knots have failed. [? not enough left after the knot tied, ie cut too close to the knot??]

Seen catgut sort of disintegrate with the knot intact after a few days so I'd blame the gut for that.

Seen fine catgut pull through tissue, knots intact.

What else happens and who or what to blame?

Does anyone get "infection" and blame the suture material? If you do, say the suture is not sterile, how does it look?

Once we can define a "breakdown" we can decide if the material is really to blame.

Catgut, if I did the knots right, always seemed fine for me; always fine in cat skin too if they weren't too tight.

Come to think of it some cheap catguts used to sort of pull apart like a strand of wool, obvious material failure.

Re: Bitch spays - when can I stop worrying?!

Gillian Mostyn — Sat, 07 Sep 2013 15:11:05 GMT

I hate using vicryl for ligatures. Personal opinion

I have seen a complete wound breakdown with vicryl and yet still use it routinely. Thus I obviously don't blame the vicryl.

People will use the same materials for years and yet, if they get a complication, it becomes easy to blame those very same materials. (Bad workmen always blame their tools! )

Not sure why/how I puzzled you but I hope that makes it a bit clearer?

Re: Bitch spays - when can I stop worrying?!

Robin Grimmer — Sat, 07 Sep 2013 14:32:49 GMT

[quote user="Gillian Mostyn"]

Actually, I agree completely that vicryl is awful for ligatures - wouldn't use it unless it was the only thing in the practice! Also, although I use it routinely for closure, the only complete wound breakdown I've seen was sutured up with vicryl ....

[/quote]

"I love how it seems that surgical complications are always due to the suture material, never the technique... "

Re: Bitch spays - when can I stop worrying?!

AmeliaB — Fri, 06 Sep 2013 11:40:36 GMT

Definately not a silly question. In the most cases any major problem should be detectable before discharge, tachycardic, weak pulse, pale mm, prolonged CRT and cold breath.

Life cannot be complete without the Millers knot or modified millers. If you are 100% confident with your ligatures you should sleep easy. If you are not then don't be releasing them back into their natural habitat.

Using the technique that only uses 3 clamps for the whole surgery makes thing much simpler and less stressfull.

I can recommend The Veterinary Training Camp to get rid of any bitch spay hang ups, you might even enjoy them.

Re: Bitch spays - when can I stop worrying?!

Mike Dale — Fri, 06 Sep 2013 08:21:29 GMT

I think I may have been the "older guy". Thanks for not saying "very much older"!

The most useful part of the big fat bitch video was demonstration of the simple way of shifting abdomen contents to visualize the ovarian stumps when pursuing a potential bleeder. Used it yesterday to help a younger colleague in trouble. A colleague showed me years ago how he carefully divided the ovarian stump of extraneous tissue and applied his (PDS) suture as close the blood vessels as possible leaving out slippery fat etc. On the cervical stump I secure the cervix with a bowel clamp, ensure each vessel bundle on either side is securely tied off, clamp and cut the cervix then oversew, inverting the stump with pds (especially reassuring in pyos). I exchange the bowel clamp for allis forceps which I use to lower stump back into the abdomen to check the effect of tension release before saying goodbye forever.

We always count swabs - radio opacity does not prevent leaving one in. I tell all my young assistants that the most important thing about an ovariohysterectomy is that they sleep easy themselves that night. Therefore I don't care about the size of the wound, how long they take (within reason- too - long and they should be asking me or someone for help) or how much suture material they use. My own dog (ridgeback) was spayed by a class surgeon who used abdominal wall retractors to ensure he had best possible view. She was a bit colourfully bruised but she recovered rapidly and he slept well afterwards.

Re: Bitch spays - when can I stop worrying?!

Anthony Todd — Thu, 05 Sep 2013 20:56:16 GMT

[quote user="bob lehner"]One tip I learned very early on, which helps in accessing the deeper/more cranial right ovary: Ligate and separate the left ovary first. Then go the cervix and ligate and separate it. Then you can free off the entire right uterine horn from its broad ligament - all the way down to the right ovarian pedicle. This allows you to then pull the right uterine horn cranially and makes access to and handling of the right ovary rather easier I find.[/quote]

Wish you'd told me that before many years of tentative stretching and terrified [it's that sudden snap that does it] breaking of ovarian ligaments. Bob.....

Re: Bitch spays - when can I stop worrying?!

bob lehner — Thu, 05 Sep 2013 13:59:12 GMT

[quote user="Neil Wheadon"]1) Get a nurse to scrub in and hold that ovary, they love it.[/quote]

I agree - I always think it odd how vets struggle away doing surgery single-handed. I'm sure no human surgeon would dream of tackling some of these procedures without another pair of hands to assist. I suppose historically we didn't have the extra hands available, but nowadays there is often an extra nurse or student lurking somewhere - and it certainly makes a bitch spay a lot easier, let alone an enterotomy etc.

One tip I learned very early on, which helps in accessing the deeper/more cranial right ovary: Ligate and separate the left ovary first. Then go the cervix and ligate and separate it. Then you can free off the entire right uterine horn from its broad ligament - all the way down to the right ovarian pedicle. This allows you to then pull the right uterine horn cranially and makes access to and handling of the right ovary rather easier I find.

Re: Bitch spays - when can I stop worrying?!

Mark Hedberg — Thu, 05 Sep 2013 09:31:10 GMT

[quote user="Gillian Mostyn"]

Same here Hanna.

I love how it seems that surgical complications are always due to the suture material, never the technique...

[/quote]

Do you know, I think this should be engraved above the doorway in stone in every hospital and university in the land!

Re: Bitch spays - when can I stop worrying?!

Neil Wheadon — Thu, 05 Sep 2013 00:38:36 GMT

Try this, takes the stress away (well a bit)

1) Get a nurse to scrub in and hold that ovary, they love it.

2) I don't put a clamp behind the ovary. Put a clamp above the ovary and lift up, then transfix the pedicle with catgut and put another in for luck. I have heard of someone who cuts the uterus away from the ovary before ligating and has the ovary on a stalk and then simply lifts this with the artery forcep to get the ligature underneath, must try that.

3) Even after 22 years, I still worry a little, it's natural I guess, everyone expects the operation to succeed 100% and it is a major op. A bit like bomb disposal I guess, you need to respect it a bit !

Neil

Re: Bitch spays - when can I stop worrying?!

Julie Innes — Wed, 04 Sep 2013 23:56:27 GMT

God, I used to tie myself in knots over bitch spays when I was first qualified (no pun intended!) I was obsessive about bleeding, and was even known to call my poor boss back from the 60 cows he was dehorning because a bit of oozing was making me nervous (sorry, boss!) I lay awake all night worrying about them before AND after, so I can truly sympathise. But if it makes you feel a bit better, OP, by 5 yrs in, i actually started to enjoy them, and still do.

The big turning point for me was being brave enough to properly break down the ovarian ligament (although still sometimes gives me a moment of heart failure when it suddenly "gives"...) Being able to exteriorise the ovary and get a clamp well behind it is really a huge part of the battle (remembers guddling around trying to tie sutures with ovary buried in mounds of fat in deep chested labrador, sweats at the thought)

THe second thing that worked for me is the modified slip knot- make a loop (so catgut is folded in two) pass loop round behind ovary, pass two ends through the loop and pull two ends in opposite directions- means you can bed the ligature in and tighten with one hand, while holding the ovary up with other, meaning you can get your ligature well behind the ovaryand it doesn't slip at all as you tie it, which means you get a nice 1cm in front of your ligature, so you know it's really unlikely to slip off, as opposed to the just-behind-the-forceps ligature which always looks precarious! Gives you space and confidence.

But I do still occasionally worry! I used to worry about bleeding then I had one where I DID pull the ovary right off- the blood hit the ceiling! there was no doubt in my mind that that was indeed ovarian arterial bleeding, as opposed to the oozing I had always fretted about, and seeing the difference made me less worried ironically. But as others have said, confidence only comes with practice, and worryng at this stage (although it feels horrible) is normal and probably not a bad thing.

Re: Bitch spays - when can I stop worrying?!

Gillian Mostyn — Wed, 04 Sep 2013 22:26:48 GMT

hahaha!

Re: Bitch spays - when can I stop worrying?!

Hanna Bennett — Wed, 04 Sep 2013 22:23:33 GMT

lol I know - yesterday was probably the wrong day to try a new technique...

Re: Bitch spays - when can I stop worrying?!

Gillian Mostyn — Wed, 04 Sep 2013 22:22:37 GMT

Same here Hanna.

I love how it seems that surgical complications are always due to the suture material, never the technique...

Re: Bitch spays - when can I stop worrying?!

Hanna Bennett — Wed, 04 Sep 2013 22:17:00 GMT

would never use less than 5 metric catgut for ligatures - happily use 6 or 7 in a fat bitch!

Re: Bitch spays - when can I stop worrying?!

Robin Grimmer — Wed, 04 Sep 2013 22:07:27 GMT

Had a problem with catgut recently. I only use it on dog castrates as I don't want to open a whole packet of Vicryl just for two ligatures. 2 dogs got severe bruising post-op - must have been due to ligature failure. I used 4m catgut on these. The bitch spay I did on the same day was fine (VIcryl), and the other dog castrate was fine (5m catgut). I rarely get any problems with dog castrates, especially since changing to closed technique some years ago. I'll be sticking with Vicryl from now on!

Re: Bitch spays - when can I stop worrying?!

Hanna Bennett — Wed, 04 Sep 2013 21:38:11 GMT

interestingly I've always been a catgut and cervix transfixation girl. had a busy day yesterday and ran out of sterile needles to run thru my catgut so thought 'i'll try vicryl, that is what other folk do'. transfixed my cervix, was happy with my ligatures but it started to ooze as soon as I ease it back into the abdomen. pulled it back out and put two encircling ligatures with catgut which solved the problem. sticking to catgut and the transfixation just makes me happy...

Re: Bitch spays - when can I stop worrying?!

Miriam Lodewyks — Wed, 04 Sep 2013 20:59:59 GMT

Regarding the OP, it took me a good 8 years before that lurch in my stomach when I'd see "bitch spey" on the diary, really started to recede (didn't think it EVER would!). Nowadays I'm "wary" but not really stressed about it (15 years), but I was sitting next to an older gentleman at a CPD event the other day who told me speys still filled him with horror after 35 years!!!

Re: Bitch spays - when can I stop worrying?!

Miriam Lodewyks — Wed, 04 Sep 2013 20:59:57 GMT

Re: Bitch spays - when can I stop worrying?!

Miriam Lodewyks — Wed, 04 Sep 2013 20:55:39 GMT

Mariette, I've tried the slipknot too, and found the same problem. Probably a matter of practice. I've reverted back to a classic surgeon's knot, always grab ovarian stump with alice forceps and then give my knots a little tug. If they stay, I'm happy, if the slip, I re-apply clamp and tie again.

Re: Bitch spays - when can I stop worrying?!

Sammy82 — Wed, 04 Sep 2013 20:46:45 GMT

Thanks. I don't really use slip knots in surgery, more often to tie cows feet/halters etc. to allow for easy release. Making hundreds of these knotted bracelets as a teenager helped a great deal to get a deeper understanding of the anatomy and behaviour of knots ;-)

Re: Bitch spays - when can I stop worrying?!

mariette asselbergs — Wed, 04 Sep 2013 19:00:13 GMT

Brilliant drawing! But in the video the loop of the red part round the black string is double, and for some reason, while sliding down in the depth, with me it tends to sometimes lock before the tightest position, especially in wet catgut! But I'll experiment a bit more in safe situations.....

Mariette