Wound Management Post-op

Re: Wound Management Post-op

Joyce Whitehead — Fri, 16 May 2014 22:37:46 GMT

So sorry to hear about your dog Anthony. It is never easy, but observing it is so much worse for you. Many sympathies to you and yours.

Re: Wound Management Post-op

Tim Charlesworth — Fri, 16 May 2014 08:54:27 GMT

Hi Anthony, really sorry to hear about your loss. It doesn't matter how hardened to pet loss we think we are, it's always so much harder when it's one of your own. In answer to your question, if the mass was pea-sized then it would not be worth taking a tru-cut biopsy. I'd have taken the mass away as a controlled (ie not getting carried away) excisional biopsy ie mass + 2-3mm around it. If the mass came back as non-sarcoma or low-grade then the dog may not have needed further surgery. Sadly lots of lab reports put a "cut and paste" comments section on their reports suggesting eg 3cm margins without any consideration for the size of the mass or the location. It is sometimes better to consider margins in terms of multiples of the primary mass's diameter so if the mass was eg 5mm then 15-20mm (3-4 x diameter) around it would be considered wide. Hope the dog does well and that you feel better soon,

Tim

Re: Wound Management Post-op

Michael Woodhouse — Fri, 16 May 2014 01:37:06 GMT

[quote user="Mark Hedberg"]

Sorry to hear of your loss. Please accept my condolences.

[/quote]

(typing with a laptop and a cocker spaniel on my knee )

Re: Wound Management Post-op

Mark Hedberg — Thu, 15 May 2014 14:58:00 GMT

Sorry to hear of your loss. Please accept my condolences.

Re: Wound Management Post-op

Anthony Dennison — Thu, 15 May 2014 12:29:10 GMT

Yeah, it was instant. Stupid dog never runs off like that, had made it across the road safe but it was when he was coming back towards me he got hit. Will never get the image out of my head, seeing him go under the tyres. Grief comes in waves, I'll be fine then have to go curl up in a ball somewhere. Really don't know how owners keep it together so well.

Re: Wound Management Post-op

Kate Richardson — Thu, 15 May 2014 12:23:12 GMT

Jeez really sorry to hear that Anthony. I hope for for his/her sake it was quick and didn't suffer for long and I hope you are doing ok. How awful

Re: Wound Management Post-op

Anthony Dennison — Thu, 15 May 2014 11:51:43 GMT

Many thanks for all your helpful replies. Unfortunately I didn't do the op myself yesterday, my dog was hit by a van and killed as I was about to go to work so I wasn't in a fit state to do anything. One of the senior vets did the procedure, by the sounds of it no dressing was put on and the owner has been told to restrict exercise. I will be seeing him on Friday hopefully, so can check the wound then.

In the future I will look at more incisional biopsies. The mass in question was small and dermal, approx the size of a pea with no palpable attachments to the underlying tissues. Taking a trucut of the mass may have taken out most of it, is it still worth doing or is excisional appropriate?

Re: Wound Management Post-op

Braden Collins — Wed, 14 May 2014 15:39:59 GMT

[quote user="Tim Charlesworth"]

I would biopsy the mass before doing any form of surgery. Cytologists cannot accurately grade sarcomas and so you don't know what margins you need (and if the mass is small it may not even be a sarcoma). If the sarcoma was low grade, for example, you could get away with treating it relatively conservatively and just taking a relatively narrow margin around the periphery of the mass (ie just outside the capsule, NOT just a "shell-out"). Equally there is no point achieving wide lateral margins if you can't take a decent deep margin as just taking s/c fat layer is unlikely to suffice if it is intermediate/high grade and the popliteal artery may give you some fun and games if you go deep.

How big is the mass and how old is the dog?

Most of the recent literature supports the fact that conservative surgery on "extremity sarcoma" achieves tumour control for the duration of the dogs lifespan (but most dogs are 8-9 y.o. when diagnosed). Extremity sarcomas are different from truncal sarcomas, they tend to behave in different ways are are generally less likely to give rise to the "skip-mets" for which the standard margins of excision are cited. I have no doubt that 3cm would be curative (if you get a decent deep margin and if it is not high grade) but you may well not need this level of invasiveness and if the dog is bouncy then I would urge you to get more information. The simplest thing to do would be to give the dog a little bit of sedation, put a bit of local over the tumour and take a trucut (depending on the size of the mass). Get the grade of the mass and then make a more informed decision about how to treat the dog (it may even have metastatic potential so I would FNA the LN at the same time as the biopsy). I have seen many dogs referred for big surgery and have never had a problem managing the owners' expectations when you explain that you are trying to make sure that their dog gets the appropriate "dose" of surgery!

[/quote]

Agree strongly with the idea of a biopsy first. I've had a lot of false positives (and false negatives) on FNA's. I'll rarely do a large tumour resection based on FNA alone as the rate of false positives can be high (off the top of my head - couldn't find the reference but will look again tomorrow, I believe the positive predictive value for sarcomas on FNA was around 74%, so 26% are false positives)

Re: Wound Management Post-op

Anthony Todd — Wed, 14 May 2014 09:52:19 GMT

[quote user="Bob Russell"]

Stent bandage - I know the name for the technique for the first time in 30 years of practice!!! Thanks!

[/quote]

This seems the most comprehensive discussion:

http://www.phenix-veterinaire.com/download/file1682_article71.pdf

although I can't relate the suture to the modern use of a "stent"??

Are "relaxation" mattress sutures still used?

Re: Wound Management Post-op

Bob Russell — Wed, 14 May 2014 09:16:07 GMT

Stent bandage - I know the name for the technique for the first time in 30 years of practice!!! Thanks!

Re: Wound Management Post-op

Nicola Lawlor — Tue, 13 May 2014 21:34:26 GMT

Some great advice above. I would personally suggest the owner crate the dog for much of the time for at least the first week or so post op in this circumstance as goes a long way to stopping that bouncing.

Re: Wound Management Post-op

Malcolm Ness — Tue, 13 May 2014 17:21:05 GMT

[quote user="Tim Charlesworth"]Extremity sarcomas are different from truncal sarcomas, [/quote]

[quote user="Tim Charlesworth"]I would biopsy the mass before doing any form of surgery. [/quote]

Bear in mind that a genuine 3 cm deep margin in a mass caudal to the stifle will almost certainly involve major vessels and important nerves and therefore leave you with a limb that needs amputating.

I am not a big fan of FNAs. Sure, they are easy to do and the cytologists love the business but they frequently (in my experience) yield equivocal information that is at best useless and sometimes harmfully misleading in terms of case-management decision-making. I think it verging on foolhardy to contemplate major surgery without a biopsy read by a reliable clinical histopathologist

Re: Wound Management Post-op

Tim Charlesworth — Tue, 13 May 2014 16:27:06 GMT

How big is the mass and how old is the dog?

Re: Wound Management Post-op

Wren — Tue, 13 May 2014 15:59:50 GMT

Ignore my earlier reply. For some reason I read hock when you said stifle!

Re: Wound Management Post-op

Michael Woodhouse — Tue, 13 May 2014 15:55:42 GMT

[quote user="Bob Russell"]My first boss would place a second row of sutures about 1cm from the wound edges, under the wound and 1 cm the other side. These went along the entire wound. After suturing the wound normally he would place a rolled up swab and tie the second row of sutures. This would take some of the tension (that should not really be there!) and these would be removed a few days post surgery. [/quote]

A stent bandage. I have used them, but specifically to apply pressure in difficult to bandage areas, rather than to reduce any tension.

[quote user="Bob Russell"]I have used it once or twice for mammary strips (remember them?) and it seemed to be helpful.[/quote]

Remember them? I still do some small animal surgery and I'd say mammary strips were one of the most common operations we do! (lots of unspayed working dogs).

Re: Wound Management Post-op

Wren — Tue, 13 May 2014 15:49:42 GMT

On a horse we cast wounds to reduce movement (primarily lower leg admittedly). Would it be feasible to cast it, then cut the cast and replace it (bandaged on) while the dog is still under GA, so that you can remove it as necessary to check would healing/pressure points/remove stitches?

Re: Wound Management Post-op

Bob Russell — Tue, 13 May 2014 15:38:04 GMT

My first boss would place a second row of sutures about 1cm from the wound edges, under the wound and 1 cm the other side. These went along the entire wound. After suturing the wound normally he would place a rolled up swab and tie the second row of sutures. This would take some of the tension (that should not really be there!) and these would be removed a few days post surgery.

I have used it once or twice for mammary strips (remember them?) and it seemed to be helpful.

To show the age and origins of the technique he sprayed them with purple spray!!