Ovariectomy or Ovariohysterectomy?

Re: Ovariectomy or Ovariohysterectomy?

Anthony Dennison — Wed, 18 Dec 2013 12:49:49 GMT

[quote user="Martin Atkinson"] whether you can easily find the left ovary (through a left side approach) by picking up the sub-renal fat like in a cat then follow the uterus down to the bifurcation to pick up the other horn and follow that to the right ovary?[/quote]

The flank (well, paramedian) spays I did in India used a spay hook at about 2 o'clock to the wound following the body wall and 98% of the time you'd come back with the uterus

Re: Ovariectomy or Ovariohysterectomy?

Martin Atkinson — Tue, 17 Dec 2013 11:33:56 GMT

[quote user="Virginia Campbell"]One of our vets has also done some flank OEs in bitches since coming back from a stint volunteering at a spay/neuter clinic on the Amazon.[/quote]Interesting: the very first job I did after qualification did flank spays and I've hardly done one since so I've forgotten the technique so I was wondering throughout this thread if, as accessing the ovaries seems to be the biggest concern with mid-line bitch spays, whether you can easily find the left ovary (through a left side approach) by picking up the sub-renal fat like in a cat then follow the uterus down to the bifurcation to pick up the other horn and follow that to the right ovary?

Re: Ovariectomy or Ovariohysterectomy?

Virginia Campbell — Mon, 16 Dec 2013 18:14:16 GMT

We have been doing OEs in prefernce to OVH in the majority of bitches for about 2 years now. We explain the differece to the owners and they aren't really that interested - mostly "you're the vet" responses. Although they do like the small incisions (only has to be big enough to admit one finger in most cases I find- I slide a finger down the left body wall then use it as a spay hook - would use an actual spay hook if we had one) In very deep chested bitches or when I just can't find it, I don't spend too long looking, just lengthen the incision a little and go back for the bifurcation.

The actual technique is just as you think it would be if you were told to invent it- pedicle as normal, then pick a spot caudal to the ovary, ligate and chop. That's it. Bit annoyingly floppy to get the ligature on but you get used to it. You can usually get the bifurcation almost up to the wound and thus find the second ovary easily.

One of our vets has also done some flank OEs in bitches since coming back from a stint volunteering at a spay/neuter clinic on the Amazon.

Re: Ovariectomy or Ovariohysterectomy?

Martin Atkinson — Mon, 16 Dec 2013 16:36:51 GMT

[quote user="Henry L'Eplattenier"]I am not convinced by the argument that the uterus should be removed because it is redundant as you could equally argue that the cervix and vagina are also redundant in a spayed bitch and should also be removed.[/quote] Which is why I remove the cervix as well. However the vagina is a bit more surgically challenging without damaging the urethra and blood supply to the bladder and may take a tad longer!!

Re: Ovariectomy or Ovariohysterectomy?

Henry L'Eplattenier — Mon, 16 Dec 2013 14:51:43 GMT

Interesting discussion!

Having trained in Switzerland, I was taught OVH as the standard spaying technique for dogs (and OVE as the standard for cats). But then I spent some time as a lecturer at Utrecht University and had to teach the students to do OVEs, as that is the standard in Holland, and I now find OVE easier to perform.

I completely agree with all of Tim's remarks and see no reason for doing OVHs, as long as the uterus looks normal, of course. As a surgeon, my priority is always to be as little invasive as possible and therefore I would only consider removing the uterus if I had a good reason to do so. I am not convinced by the argument that the uterus should be removed because it is redundant as you could equally argue that the cervix and vagina are also redundant in a spayed bitch and should also be removed.

I know that studies comparing the size of the incision have showed no significant difference between OVH and OVE, but as Tim has pointed out (and this is a key point in my opinion), if you are not removing the uterus, you can position your incision more cranially, which significantly improves the ease with which you can remove the ovaries. Intuitively, one would therefore have to believe that this will necessarily reduce the risk of haemorrhage form the uterine stump, even though there is no randomised study published to prove this point.

For those who are still dubious and waiting for more evidence of the safety of performing OVE, I would just point out that OVE has been the standard technique for spaying bitches in The Netherlands since 1981. So there is plenty of evidence out there.

My ex-colleagues from Utrecht published a literature review about the subject a few years ago, for those who are interested in reading more about it: van Goetem et al., Making a Rational Choice Between Ovariectomy and Ovariohysterectomy in the Dog: A Discussion of the Benefits of Either Technique Veterinary Surgery 35: 136-143 (2006).

Re: Ovariectomy or Ovariohysterectomy?

Rob Loxley — Sun, 15 Dec 2013 18:51:57 GMT

[quote user="Clive Ansell"]I'm always open to new ideas, but given that OVH is tried and tested, complications are rare, and if executed well and with care is fairly atraumatic, I would be reluctant to change to OE[/quote]

My feeling similarly

[quote user="Tim Charlesworth"]does represent additional "tissue trauma" and requires a larger incision[/quote]

Agreed on the latter, but not convinced of the significance. As for trauma/pain, a 2011 JAVMA study reported "Significant differences in total surgical time, pain scores, and wound scores were not observed between dogs that underwent OVH and dogs that underwent OVE via standardized protocols", so again I'm not convinced.

A review of the evidence (again in JAVMA in 2011) concludes "it is our view that ovariectomy provides an equally effective technique for elective sterilization of female dogs and cats" rather than somehow streets ahead, so I feel your suggestion that people performing OVH are' stuck in a rut' and somehow working in the dark ages is not borne out by the evidence

Re: Ovariectomy or Ovariohysterectomy?

Emma Middleton — Sun, 15 Dec 2013 10:29:21 GMT

We offer OE in bitches and have done for about 2 years. We give out a factsheet at time of booking and then we discuss it on admit if the owner has any questions. The outcome is always either they choose OE or they say "you're the vet" and go with whichever technique we think is best. So we do mostly OEs now. My boss showed me the technique, which differs slightly from Tim's (you ligate the ovarian vessels rather than the stump, then ligate just proximal to the ovary and then dissect the ovary out of its bursa. The latter I have never understood, is time consuming and more likely to leave ovarian tissue behind, so I have ended up doing it more like Tim describes as it's easier. My incision length is not much smaller than for OVH, but I do make longer incisions than my boss generally as I find it easier to locate the uterus/ovaries then. I have found it difficult but it does become easier with practice.

Re: Ovariectomy or Ovariohysterectomy?

Mark Hedberg — Sat, 14 Dec 2013 19:53:08 GMT

[quote user="Clive Ansell"]

I have seen and operated on 3 stump pyometras in the past, all had remaining ovarian tissue, 2 were confirmed by histology. I have also seen one walled of abscess at the cervical stump with a reaction to a braided nylon ligature.

If I started doing OE's instead of OVH's would the rest of the profession support me if anything went wrong and I was up in front of the VDS, RCVS or small claims court?

[/quote]

Would I support you? Yes.

Tim's used a more complicated explanation here, but basically all you're doing is cutting the uterus at the tip instead of the cervix; clamp and tie off like you would anyway. Want more space between you and the ovary? take some more uterus if you feel like it. (Yes, that's phrased unscientifically, I know.) Plus you don't need to dissect the uterus out of those pounds and layers of fat some dogs seem to have.

The bit on the other side of the ovary (with the ligament you need to stretch or break) you do exactly the same as you would in an OVH, so I admit that if a surgeon is having issues there, I agree that changing from OVH to OE won't help you. The 'stump' pyometra is caused by ovarian tissue; not because the stump is still there. The cervix is blamed because in times past, a surgery that left the stump was probably sloppy enough to crush the ovaries and leave other bits in there too - stump was easy to find and easy to blame.

I don't believe I'd use braided nylon to tie off a cervix but if it was clean and sterile suture, I'd think it would be ok. I tend to be swayed by the argument that many suture reactions are actually misnamed infections. (You yourself said it was an abscess.)

(As always, I claim no secret or expert knowledge, I'm just a vet who's banged around a few consult rooms and op theaters, just the same as you - although I admit it's probably far, far fewer practices! )

Re: Ovariectomy or Ovariohysterectomy?

Tim Charlesworth — Sat, 14 Dec 2013 19:13:54 GMT

You're right but we still see stump pyometra in dogs that have undergone OHE and these dogs have to have some uterine tissue inadvertently left behind to have pyometra!

Re: Ovariectomy or Ovariohysterectomy?

Evelyn Barbour-Hill — Sat, 14 Dec 2013 15:46:13 GMT

[quote user="Tim Charlesworth"]the 4-5mm that is commonly left behind during OHE [/quote]

Is it ?

Not when I do 'em. As far as I'm aware the uterus terminates at the cervix.

Re: Ovariectomy or Ovariohysterectomy?

Tim Charlesworth — Sat, 14 Dec 2013 15:18:43 GMT

The technique is pretty intuitive - you can make the initial incision more cranial than for OHE as you don't need to get down to the cervix so tend to start just cranial to the umbilicus. Find ovaries by retraction of the colon medially (L ovary) or duodenum medially (R ovary), break down the suspensory ligament (or tie/cauterise it depending on your preference) and place ligature on vascular pedicle as per normal OHE. Place an artery clamp immediately caudal to the ovary and then place a 2nd clamp 3-5mm caudal to this 1st clamp. Remove this 2nd (crushing) clamp and place either circumferential or transfixing suture at this site. I tend to then cut on the caudal side of the first clamp as you know that all ovarian tissue is cranial to this and you don't risk incomplete removal of the ovary. This technique does mean that you don't have a clamp on the tip of the uterus as you cut so if you haven't tied the suture properly you will get some H+ from the uterine vessels at this point but they are low pressure and the uterus is slack enough that it won't retract away from you. You can do a routine "triple clamp technique" instead but you tend to find yourself amputating the tip of the uterus (though this is not a problem) as many smaller dogs don't have room for 3 clamps between the ovary and the uterus. The uterine vessels run on the mesometrial side of the uterus so I tend to incorporate them in a transfixing suture in larger dogs.

It's not as complicated as I'm making it sound!, if you have removed both ovaries then it's mission accomplished!

Re: Ovariectomy or Ovariohysterectomy?

Yantha Smyth — Sat, 14 Dec 2013 13:01:50 GMT

Tim, I wonder if you could elaborate on the OE technique you use for the benefit of those on the forum who are not familiar with it and cannot find it described in surgical texts. For example I had to do some when locumming in a clinic whose policy was OE, but just kind of guessed what was to be done on the other side of the ovary as I did not have the opportunity to observe it done by those who do it routinely. It sounds like there are others in the forum in a similar situation. Cheers Yantha

Re: Ovariectomy or Ovariohysterectomy?

Tim Charlesworth — Sat, 14 Dec 2013 12:11:33 GMT

There is definitely no problem with OVH. It's just not necessary to remove the uterus. We're not alone in the UK at being reluctant to adopt OE over OHE, the USA is lagging behind as well. OE has been commonplace in some European countries for >10 years now and that's where a lot of the data is coming from. Interestingly there is no difference in the incidence of pyometra between dogs that have had OE and dogs that have had OHE, i.e. you are just as likely to have a "stump" pyometra with the 4-5mm that is commonly left behind during OHE as you are when leaving behind the whole uterus. In either case, in theory you need an ovarian remnant to get a stump pyometra (source of progesterone) and you could argue that a "whole" pyometra would be easier to detect than a "stump pyo".

I completely understand the concerns about possible confusion and we had to make a practice policy about 7 years ago to perform OE for all bitch spays so that we were all doing the same thing, the last thing you want is somebody doing an ex-lap to remove that strange soft tissue structure found between the rectum and colon on ultrasound so people need to be aware that a neutered bitch may have a uterus.

Re client acceptance - we had no problems, in fact we had quite a few clients come to us for neutering specifically because we did OE and not OHE which wasn't offered by neighbouring practices at the time. It's important for vets to be able to do OHE for when they do get pyometra and this may be a valid reason for encouraging new grads to become familiar with the technique..

Re: Ovariectomy or Ovariohysterectomy?

Clive Ansell — Sat, 14 Dec 2013 11:47:38 GMT

And as far as I know, once the ovaries are removed the uterus has no function at all, doesn't excrete or convert anything. Unless someones knows something I don't it becomes completely useless and redundant?

Re: Ovariectomy or Ovariohysterectomy?

Michael Woodhouse — Sat, 14 Dec 2013 11:32:17 GMT

[quote user="Mark Hedberg"]It's not rocket science, the op is just taking out less![/quote]

Yes, but no one can tell me a good reason to leave a perfectly redundant organ behind. (the spleen does do stuff even though we can remove it)

Re: Ovariectomy or Ovariohysterectomy?

Clive Ansell — Sat, 14 Dec 2013 11:24:20 GMT

I'm always open to new ideas, but given that OVH is tried and tested, complications are rare, and if executed well and with care is fairly atraumatic, I would be reluctant to change to OE.

I am not convinced that OE would be less traumatic, and cannot see that an incision would be much if any smaller. Most of my OVH incisions are 3-4 cm, just enough for 2 fingers.

I have in effect done OE's in cats where it has been difficult to exteriorise the uterus, no problems to date that I am aware of. Maybe I''ll try it bitches next time I do some charity work that has a large throughput of cases?

If I started doing OE's instead of OVH's would the rest of the profession support me if anything went wrong and I was up in front of the VDS, RCVS or small claims court?

Re: Ovariectomy or Ovariohysterectomy?

Mark Hedberg — Sat, 14 Dec 2013 11:05:05 GMT

[quote user="Hannah Wynne Richards"]

I'm waiting until ovariectomy has been common for around 10 years. If the incidence of neoplasia is still incredibly low, I'll rethink.

Wynne

[/quote]

The irony here is that if we keep waiting for someone else to start doing it, it'll never BE common, and you'll be waiting a good long time for that 10 year period! :) It's not rocket science, the op is just taking out less!

Re: Ovariectomy or Ovariohysterectomy?

Hannah Wynne Richards — Sat, 14 Dec 2013 10:21:10 GMT

I think a lot of us are scared of attempting a procedure we've never actually seen for a case of elective surgery where we have confidence in our ability to perform the traditional technique. I'm not 100% convinced by the argument that the incidence of uterine neoplasia is incredibly low. The instance of uterine neoplasia DIAGNOSIS may be incredibly low - but that's another thing entirely.

The vast majority of pet bitches are ovario-hysterectomised - so naturally the incidence of uterine neoplasia in these is incredibly low (0%) A very high % of un neutered bitches either have bad owners, or are puppy farm bitches. What % of these poor animals will have the work up done to diagnose uterine neoplasia? Not many.

I'm not usualy a stick in the mud (see alfaxan thread) but on this one, I'm waiting until ovariectomy has been common for around 10 years. If the incidence of neoplasia is still incredibly low, I'll rethink.

Wynne

Re: Ovariectomy or Ovariohysterectomy?

bob lehner — Sat, 14 Dec 2013 10:02:01 GMT

[quote user="Tim Charlesworth"]There is also less stretching/tugging [/quote]

How come ? You've still got to elevate the ovary - esp. the right, more cranial one, which is the tricky one in a big fat deep-chested animal.

The way I do bitch spays is to ligate and separate the left ovary first, then the cervical stump, then separate the right uterine horn from the broad ligament. You can then pull the right horn well cranially, which makes elevating the r ovary rather easier.

As others have said, unless done laparoscopically I can't see much benefit in terms of time taken or incision length.

Re: Ovariectomy or Ovariohysterectomy?

Utlendigur — Fri, 13 Dec 2013 21:44:28 GMT

I've been considering trying to introduce the idea of doing OE rather than OVH - eg had a borzoi spay a couple of weeks ago where the ovaries were relatively easy to find and ligate, but I had to massively extend the incision (and op time) in order to get to the cervix which was in the deepest recesses of the caudal abdomen - especially since it was pre-season and the cervix was about the thickness of a cat cervix so I didn't want to put too much tension on it. I was under the impression that OE was best reserved for young bitches, before there are any significant changes in the endometrium - is that correct?

Re: Ovariectomy or Ovariohysterectomy?

Mark Hedberg — Fri, 13 Dec 2013 20:41:17 GMT

[quote user="Mark Holmes"]I went though a period of performing ovariectomy but the boss said he wanted OVH doing so I went back to OVH. It wasn't worth an argument.

[/quote]

This describes me perfectly. In my previous job (Saudi) I was doing OE, when I came to the UK, my boss requested i do OVH. Like he said, not worth the fight. :) I prefer OE because I feel it's quicker and easier, especially in fat dogs. (IME, of course.)

edit: I didn't get taught the technique, but using a bit of logic I picked a spot between the uterus and the ovary and ligated away. Worked fine. (as the closest one was 1500km away, i didn't get taught an official OE.)

Re: Ovariectomy or Ovariohysterectomy?

John Flynn — Fri, 13 Dec 2013 19:54:25 GMT

I went through considering trying to switch from OVH to OVE about 5 years ago, but didn't for the following reasons:

I'm familiar with OVH and if it ain't broke don't fix it
I figured it might take me longer (at least initially as I became familiar with technique, but also 2 ovaries to find rather than just following 2nd from bifurcation?)
Is there an extra ligature to place? (I currently put one on each ovarian stump and one on the cervix)
I wasn't 100% sure on the technique and couldn't find it in the standard surgery text I had at the time
I wasn't convinced there would be any advantage and uterine neoplasia would ahve to be added to differential lists (even if uncommon).

(I also mused that this was another trend coming full circle so to speak as when I was at Vet School we were taught that we shouldn't be doing OVH through small wounds and there was no advantage to a small wound as "wounds heal side-to-side, not front-to-back" - of course that's what we were told, not what was done )

Re: Ovariectomy or Ovariohysterectomy?

Michael Woodhouse — Fri, 13 Dec 2013 19:42:08 GMT

[quote user="Tim Charlesworth"]More practices are offering laparoscopic OE now and so at least the concept is being implanted in more minds[/quote]

I don't know if any one else follows the 'Anaesthetic Registrar' on Facebook, but the following post rang fairly true to some of the laproscopic surgery I saw performed by recognised specialists at college:

Laparoscopic surgery can be a beautiful combination of manual dexterity, precision and hand-eye coordination. It can also look like trying to pick up a pineapple with a toothbrush. Don't ask me which version I sat through this morning.

Re: Ovariectomy or Ovariohysterectomy?

Rob Davis — Fri, 13 Dec 2013 18:45:14 GMT

I have only ever done OHE and continue to do so purely out of habit and expectation (owners and colleagues). I would consider changing to OE if there was a compelling argument, but I'm yet to be convinced. As others have said, I find ligating and removing the ovaries takes much more time than removing the uterus, so am not convinced that there would be much reduction in surgical time or wound size, but having never tried OE it's difficult to comment with any certainty.

Out of interest is there a particular technique which should be used for OE, or is it simply a matter of doing a spay as normal and cutting off the ovaries from the uterine horns, presumably leaving the broad and round ligaments intact?

Re: Ovariectomy or Ovariohysterectomy?

KMurphy — Fri, 13 Dec 2013 18:18:45 GMT

For practices that do offer OE over OHE - do you explain the difference to the owners? Do they care particularly? I'm not brave enough to break with convention yet and I'd need to familiarise myself with the technique but, if I did, what is the best way to put it across to owners?