Methods of ligating ovaries

RE: Methods of ligating ovaries

Mark Hedberg — Sun, 21 May 2017 18:06:35 GMT

1 x transfixing suture with roundbodied needle, 1x external suture circle around the stump. If you're very worried, angiotribes are amazing things and squash the stump flat. I have a set but haven't needed to use them in many years. Keep the clamp on for a few minutes while ligating other stumps.

RE: Methods of ligating ovaries

nikki — Thu, 18 May 2017 22:12:00 GMT

How I was taught and how I've always done it. Had no probs in 11yrs so rather reluctant to change.

RE: Methods of ligating ovaries

Rob Loxley — Wed, 17 May 2017 20:12:31 GMT

[quote user="nikki"] I then double ligate with encircling ligatures[/quote]

I'm an advocate of not changing something that works for someone, but I was taught that if you can't be sure with one knot then why are you sure with two?

Re miller/modified miller's knot, the latter is simpler to tie - is there any comparison between the two?

RE: Methods of ligating ovaries

Elivet — Wed, 17 May 2017 13:29:56 GMT

Single Millers knot using 2/0 Surgicryl in all cases including cervical stumps, hasn't let me down for about 4 years since I started using it (touch wood). Always in previously crushed tissue cranial to ovary. Had various problems with catgut and surgeon's knots.[quote user="Jill Butterworth"]

What are your experiences of speed, and especially, reliability of the techniques?

For the record, I treble ligate, and transfix, with Vicryl, I leave long ends on the suture material, on the clamps, so I can quickly find and double check for bleeds, cutting them shorter just before closure. I was taught this method many years ago, it is laborious, but meticulous.

[/quote]

RE: Methods of ligating ovaries

nikki — Tue, 16 May 2017 22:51:06 GMT

In cats I do a single encircling ligature then tear between the clamps for the ovaries. I don't clamp the uterus, just double encircling ligatures.

In bitches, I cut the ligament with metzenbaums - I hate stretching it with my fingers, paranoid something else will break other than the ligament. Much prefer visualising it and cutting it and gives good exposure. I then double ligate with encircling ligatures, check the ovary is intact before releasing the stump. For the uterus I usually do one encircling and one transfixing ligature unless it's a very small bitch with a uterus the size of a cat in which case 2 encircling.

RE: Methods of ligating ovaries

Lucy Fleming — Mon, 15 May 2017 15:39:19 GMT

[quote user="David Mills"]Sometimes used to rip the blood vessels /ligaments and he left them - nothing bleeds to death from an ovarian artery was the mantra[/quote]

My boss in my first job used to say this - a bitch would get pale and be slow to wake up from an ovarian bleed but die from a bleeding uterine stump. I've not been brave enough to put this to the test!

FWIW - I tend not to break down the ligament - I find I get good enough exposure without doing so, though I seem to mainly get little pre-pubertal or pre 12 month old dogs with nice stretchy suspensory ligaments. Single encircling ligature on ovarian pedicles and on the cervix. I used to do stick ties and a transfixing ligature on the cervix but have stopped (some years ago) and not had any concerns. I use swabs to push the abdominal viscera out of the way, and return my pedicle into the abdomen with clamp on, then remove clamp and observe in situ before moving on to the next bit. Not the quickest, and not a tiny incision but it makes me happy.

RE: Methods of ligating ovaries

Michael Woodhouse — Mon, 15 May 2017 15:22:09 GMT

[quote user="David Mills"]Sometimes used to rip the blood vessels /ligaments and he left them - nothing bleeds to death from an ovarian artery was the mantra[/quote]

This is why I always tear between the clamps with spays (after ligating). A rough torn end is going to achieve better haemostasis if something went wrong with the ligature cf a cut with a scalpel. I think there may be an element of 'farm vet' in that too.

I saw practice with a vet who used to double clamp cats and tear, only ligated cervix end. Never had a problem in a lot of years. I do ligate cats but just let them go, I don't watch like I would in a bitch.

RE: Methods of ligating ovaries

bob lehner — Mon, 15 May 2017 15:12:03 GMT

[quote user="David Mills"]I worked with a Saffa in Botswana who used to do them with a 1cm incision and spay hook. Amazing to see. Sometimes used to rip the blood vessels /ligaments and he left them - nothing bleeds to death from an ovarian artery was the mantra and AFAIK he was right and this was in an ehrlichia area where the blood was rather watery.[/quote]

Yes - must be the same guy I worked with in Botswana - amazing to see, but a bit scarey when things tore off. He had spent virtually his entire working life doing charity spays in fairly primitive conditions - must have done many, many thousands - he'd crack thro' 40 a day no probs.

RE: Methods of ligating ovaries

David Mills — Sat, 13 May 2017 23:18:13 GMT

[quote user="villagevet"]

[quote user="David Mills"]rip the blood vessels /ligaments and he left them - nothing bleeds to death from an ovarian artery was the mantra and AFAIK he was right[/quote]

Have you been fool-hardy enough to adopt this method? Would love to hear your results and any advice you give to new graduates on this one!

Arlo - how about a poll on whether vets think bitches could bleed to death from a spay haemorrhage / ovarian artery bleed?

[/quote]

Ha, no.

There was a study (I think) a while ago that showed upto a third of ovarian arteries bleed following bitch spays, asymptomatically. Uterine ones are the killers apparently.

Since I switched to catgut things became easier. One clamp Encircling around each pedicle proximal to clamp and same around uterus. Cut the most cranial band of the ligament with a scalpel both sides to give a bit of access. Think it was Bob Lehner on here who suggested doing left ovary then uterus then finishing with right. Access much better. Was a revelation. 20 minutes max.

RE: Methods of ligating ovaries

Lindsey Edwards — Sat, 13 May 2017 21:55:07 GMT

[quote user="David Mills"]rip the blood vessels /ligaments and he left them - nothing bleeds to death from an ovarian artery was the mantra and AFAIK he was right[/quote]

Have you been fool-hardy enough to adopt this method? Would love to hear your results and any advice you give to new graduates on this one!

Arlo - how about a poll on whether vets think bitches could bleed to death from a spay haemorrhage / ovarian artery bleed?

RE: Methods of ligating ovaries

David Mills — Sat, 13 May 2017 21:13:39 GMT

[quote user="villagevet"]

Majority I perform now are ovariectomy, with a slightly more cranial incision and nicer ovarian exposure; stretch/break ligament less often now. One transfixing and one encircling suture on ovarian pedicle (PDS) unless juvenile then only one encircling; encircling ligature proximal uterine horn.

[/quote]

I worked with a Saffa in Botswana who used to do them with a 1cm incision and spay hook. Amazing to see. Sometimes used to rip the blood vessels /ligaments and he left them - nothing bleeds to death from an ovarian artery was the mantra and AFAIK he was right and this was in an ehrlichia area where the blood was rather watery.

RE: Methods of ligating ovaries

Neil Wheadon — Sat, 13 May 2017 17:37:49 GMT

[quote user="Jill Butterworth"]in particular those of you who rely on more modern techniques such as Ligaclips[/quote]

Has anyone used these? I've never seen it and strikes me as a great idea, combined with ovariectomy it would potentially turn this into a pretty straightforward operation?

Neil

RE: Methods of ligating ovaries

Jill Butterworth — Sat, 13 May 2017 15:25:16 GMT

I ovariectomised my own bitch 20 years ago, but it hasn't caught on at any of the practices I have worked at. It's great: quicker, easier, safer, smaller incision, it must be one of those superstitions as a profession, that we hang on to! Presumably, theoretical risk of pyometra might be the only objection? But it can't happen if the ovaries have been completely removed. ..

RE: Methods of ligating ovaries

Lindsey Edwards — Fri, 12 May 2017 20:29:53 GMT

RE: Methods of ligating ovaries

Julian Earl — Fri, 12 May 2017 18:58:51 GMT

I developed my own method a short while after qualifying, having found the clamp method too difficult leading to a couple of ligatures slipping off during the op. Therefore decided that I needed to do something differently. I slowly break the ligament with my fingertips, place a single clamp on now that ovary is more mobile and place my gut-ligature tightly., I then place another ligature over the top of that one. Vicryl ties very secure knots but the material is so soft it isharder to identify amongst viscera if you need to find the stump again. Catgut is fine. Being stiffer and easier to identify by palpation. One ould tighten catgut by fingertip, not by forceps, and if it starts to go white or just pale brown, stop pulling because it is about to snap. This method prevented any further ligatures coming loose. In a bitch I would use 4-5 metric or 3 metric in a cat.

At the stump of the uterine body, I place one clamp, use it to manipulate the body closer to the surface and double ligature there as well.

I am still unsure if cats always need a ligature, even after spaying cats for forty year now!and I don't double ligature cats.

If an ovary does bleed then one should goto the uterine body-stump, identify the mesometrium and follow that through your fingers cranially and it invariably leads you strght to the ovarian stump or stumps as the case may be. No need to delve around the ovarian site looking for a bleeding vessel. Start looking at the stump and be guided forward by the broad ligament.

RE: Methods of ligating ovaries

Clare Tapsfield-Wright — Fri, 12 May 2017 18:29:51 GMT

[quote user="Gareth C."]

obviously its not a race but when I was doing a lot of spays i found trying to be efficient made me less likely to unecessarily handle tissue etc. Time and tissue trauma are major factors in getting an infection when the abdomen is open. also shorter ga which must be a good thing?

[/quote] I agree to some extent. Some bitch spays go like a dream with minimal faffing about which is a definite benefit, but there are still those which take longer than expected and make your heart rate go up and make you sweat even after thirty years experience.

It is one of the most underrated and underpriced surgeries and I can remember arguing this point with one of the SPVS management gurus years ago when they were advising practices to make bitch spays loss leaders to win clients. All it achieved was a reduction in perceived value by clients which persists today.

RE: Methods of ligating ovaries

Neil Wheadon — Fri, 12 May 2017 18:02:11 GMT

[quote user="Gareth C."]obviously its not a race but when I was doing a lot of spays i found trying to be efficient made me less likely to unecessarily handle tissue etc. Time and tissue trauma are major factors in getting an infection when the abdomen is open. also shorter ga which must be a good thing?[/quote]

Fair enough, you're one of the quickest out there though, before all those new grads get 'time and motioned'

Neil

RE: Methods of ligating ovaries

Gareth C. — Fri, 12 May 2017 17:58:48 GMT

RE: Methods of ligating ovaries

Neil Wheadon — Fri, 12 May 2017 17:37:12 GMT

[quote user="Gareth C."]Also I think trying to do it efficiently and quickly is important. I am yet to break the 20minute barrier but one of our vets can do 18minutes. [/quote]

Why? I can see how it is desirable, but good surgery is also about soft hands and checking. I have seen one other vet do one in about 20 minutes but you're a rare beastie.

As an aside? does anyone do ovariectomies?

Neil

RE: Methods of ligating ovaries

Gareth C. — Fri, 12 May 2017 17:00:28 GMT

first job is find ligament and break it down. then with that extra mobility clamp below ovary and encircle ligate with 6M catgut. for small dogs like shitzus and westies who seem to like to keep their ovaries close to their kidneys I will transfix as the pedicle is short. for this I use 4m vicryl with swaged on needle.

I never double ligate as I can't see the logic. If you just have one ligature you make damn sure its a good one in the right place!

I think whatever works for you is probably the right way!

Also I think trying to do it efficiently and quickly is important. I am yet to break the 20minute barrier but one of our vets can do 18minutes.

RE: Methods of ligating ovaries

Daniella Sellick — Fri, 12 May 2017 16:51:49 GMT

[quote user="Rob Davis"]

[quote user="Daniella Sellick"]For the uterine pedicle I always place stick ties (unless pyometra)[/quote]

What are stick ties?

[/quote]

Sorry two ligatures one on either blood vessel on uterine pedicle, I do these above my encircling ligature for extra security

RE: Methods of ligating ovaries

Rob Davis — Fri, 12 May 2017 16:33:14 GMT

[quote user="Daniella Sellick"]For the uterine pedicle I always place stick ties (unless pyometra)[/quote]

What are stick ties?

RE: Methods of ligating ovaries

Daniella Sellick — Fri, 12 May 2017 16:29:00 GMT

I always try and break the ligament for better exposure. Use a modified three clamp technique. Place a millers knot over the bottom clamp and then remove tightening knot into crush zone. I love the Millers knot, it is tricky to learn but well worth it and feels nice and secure. Never place a second suture unless I'm not happy with the first. Cut away from ligature above second clamp and then place allis forceps onto pedicle (not on suture). Check ovary then slowly drop pedicle back into abdomen watching to assess any haemorrhage. If all ok then release.

For the uterine pedicle I always place stick ties (unless pyometra). Tend to use quite large suture material as otherwise I break it and on that note always vicryl as I always seem to snap catgut.

RE: Methods of ligating ovaries

Anthony Dennison — Fri, 12 May 2017 15:19:05 GMT

[quote user="Malcolm Ness"]

[quote user="Anthony Dennison"]Exactly this, but I use PDS not Vicryl. [/quote]

Why?

[/quote]

Because I just don't get on with Vicryl. Admittedly I've only been qualified 5 years but I've found I get a good, safe ligature with PDS and never had any problems. I'm sure if things started to go wrong I'd re-assess my technique. I also use the same packet of PDS with the swaged on needle to close the linea alba, before moving to a smaller gauge for s/c and intradermals.

I changed what I do with dog castrates after discussing something similar a couple of years ago on here too, maybe I'll look more closely into how I do my bitch spays now too.

RE: Methods of ligating ovaries

Robin Grimmer — Fri, 12 May 2017 15:12:40 GMT

[quote user="Thomas Johnson"]

I completely break down the ligament, place 2 clamps on the ovarian pedicle, then remove the bottom clump and place it between the second clamp and the ovary (pseudo triple clamping?). I tie a single Vicryl encircling ligature into the crush left by the first clamp, 3/0 for small dogs, 2/0 for bigger dogs. Cut between the 2 clamps. Check that the ovary is intact. Grip the ovarian pedicle with rat toothed forceps, remove artery forceps and gently lower back into abdomen ensuring that it's not bleeding. I find that completely breaking down the ligament I can get good enough exposure, even in deep chested dogs, that I don't need to pack anything off or have a second person scrubbed in.

[/quote]

Very similar, but I wouldn't use anything smaller than 2/0 vicryl for ligating, and use 1 Vicryl on larger dogs. Plus breaking down the ligament is key. I generally just cut it, sometimes will tie off first if there is a bv - it's usually fairly small. Once you've done this, much easier to exteriorise the ovary and get a good ligature on it.

PS - I got zero tuition on this at Glasgow Vet School.