Cable ties on the ovarian ligament - discuss!

Re: Cable ties on the ovarian ligament - discuss!

Romain Pizzi — Mon, 18 Oct 2010 17:40:20 GMT

Great tip on the landing nets Steve - I only wish you'd mentioned this 8 years ago when I had to get sometime rabid dogs out of vulture traps in Rajastan with only a jab stick made from a broom handle....

I agree about OV versus OVH, no intervention (or lack of intervention) is without risk. A review in Vet Surgery a few years ago (copied below) came out in favour of OV, as the authors felt that the risks of longer anaesthesia, larger surgical procedure etc, outweighed the small risk of a metritis etc if the uterus was not removed. I had a dissapointment recently when one of the first dogs I performed a laparoscopic ovariectomy on 4 years ago developed a metritis (only one in over 300), but of course this one happened to belong to a consultant gynaecologist who initially helped me get into lap surgery in the first place. Such is life....

Vet Surg. 2006 Feb;35(2):136-43.

Making a rational choice between ovariectomy and ovariohysterectomy in the dog: a discussion of the benefits of either technique.

van Goethem B, Schaefers-Okkens A, Kirpensteijn J.

Abstract

OBJECTIVE: To determine if ovariectomy (OVE) is a safe alternative to ovariohysterectomy (OVH) for canine gonadectomy.

STUDY DESIGN: Literature review.

METHODS: An on-line bibliographic search in MEDLINE and PubMed was performed in December 2004, covering the period 1969-2004. Relevant studies were compared and evaluated with regard to study design, surgical technique, and both short-term and long-term follow-up.

CONCLUSIONS: OVH is technically more complicated, time consuming, and is probably associated with greater morbidity (larger incision, more intraoperative trauma, increased discomfort) compared with OVE. No significant differences between techniques were observed for incidence of long-term urogenital problems, including endometritis/pyometra and urinary incontinence, making OVE the preferred method of gonadectomy in the healthy bitch.

CLINICAL RELEVANCE: Canine OVE can replace OVH as the procedure of choice for routine neutering of healthy female dogs

Re: Cable ties on the ovarian ligament - discuss!

Steve Leonard — Tue, 28 Sep 2010 08:15:43 GMT

From the long term follow ups (not ours - in the study paper we found) there was no significant increase in any complications. I assume from this that stump pyos are really not true pyometra (hormone induced hyperplasia followed by infection) but ascending infection. If this is true then we are less likely to see stump pyos (pure speculation I know). What reassured me was the fact that for years we have been effectively performing OVE (not OVH) on cats with no long term complications (and I know that dogs are not big cats).

Steve

PS Landing nets - big jaspers with long poles and a large opening - I've caught wolves and sea otters in them (not at the same time) and they are fantastic. I have been thinking of getting a smaller version to use for getting fractious or feral cats out of cat kennels as I'm sure it is far less physically traumatic (and possibly psychologically) than the current methods employed.

Re: Cable ties on the ovarian ligament - discuss!

Hannah Wynne Richards — Mon, 27 Sep 2010 17:42:40 GMT

I thought either ovarian tissue, or sometimes adrenal hormones could cause probs

Wynne

Re: Cable ties on the ovarian ligament - discuss!

Edward Jones — Mon, 27 Sep 2010 16:15:19 GMT

[quote user="Hannah Wynne Richards"]

Steve Aren't you worried about stump pyos, or is this just me being old-fashioned ?

Wynne

[/quote]

I thought the theory on this is that if no ovarian tissue remains then a stump pyo should be impossible. I wonder if the 'traditional' stump pyo typically occurred due to poor surgical technique resulting some ovarian tissue remaining as well as the uterine stump.

Re: Cable ties on the ovarian ligament - discuss!

Malcolm Ness — Mon, 27 Sep 2010 15:55:45 GMT

As has previously been mentioned there was, a few years ago, a transient fashion for using nylon cable ties for fabello-tibial stabilisation of cruciate deficient stifles. Entirely predictably, the proponents reorted "95% success and no problems".

Using uncoloured cable ties and ethylene oxide sterilisation was advised but I don't recall anything appearing in the peer-reviewed literature.

re Stainless steel cable ties - there are very many variants of stainless steel. Surgical implants are (or at least should be) made from machined 316LVM surgical stainless steel. Instruments may be made from 316LVM or occassionally 420 stainless which can be made harder. The chemical variations between these and other stainless steels can be considerable and there are already reports in the vet literature associating some neoplasms with adverse chemistry in some metallic implants. Beware.

Re: Cable ties on the ovarian ligament - discuss!

Hannah Wynne Richards — Mon, 27 Sep 2010 15:54:14 GMT

Steve Aren't you worried about stump pyos, or is this just me being old-fashioned ?

Wynne

Re: Cable ties on the ovarian ligament - discuss!

Hannah Wynne Richards — Mon, 27 Sep 2010 15:35:36 GMT

Steve Do you mean a landing net, or a coracle net ????????????????????

Wynne

Re: Cable ties on the ovarian ligament - discuss!

Steve Leonard — Mon, 27 Sep 2010 15:30:28 GMT

http://www.vetcontact.com/en/art.php?a=81&t=

Hello all,

With regards spaying bitches, after 13 years of doing the same old method, we have reduced surgery time and size of wound by performing ovariectomy as opposed to ovariohysterectomy in most cases of bitch neutering in our practice. By shifting the incision cranially (as we have no need to exteriorise the cervical region of the uterus) you get better exposure of the ovaries and a smaller wound. The above link is a summary of some work that has been done to show the benefits of this method (I cannot find the full paper which we had at the practice).

As to using zip ties: I spend a great deal of time teaching vet students how to tie proper surgical knots as most of the ones I see cannot do it (even final year students who have been already been allowed to neuter pets at university!) I can usually teach someone how to do this in about 10 minutes and with a little practice it will last a lifetime (I am forever indebted to Alan Mayo who took the time to teach me). I used to get students to do surgery as much as possible but now spend much more time stitching up bananas and soft toys before I let them loose on live animals. Maybe they should all just pop down B&Q and get some zip ties!

PS Luke, invest in a salmon landing net for catching feral dogs - they are totally mint. They are far less traumatic than a snatch pole, easier to get over a dog and allow you to bundle them up for IM injection really easily. Keep up the good work!

Steve

Re: Cable ties on the ovarian ligament - discuss!

Nixthevet — Mon, 27 Sep 2010 13:31:14 GMT

I agree - the aim of Luke's 'missions' is to do the greater good for the animal and human populations in those areas- and blanket neutering leads to huge advantages for these populations as a whole.

The risk: benefit analysis of using cable ties for a population as whole is surely a favourable one- whereas for an individual animal in the UK ( where we are looking for a favourable outcome in every individual) I am sure that the use of cable ties may well be very hard to justify unless the concept is developed much further.

But, I don't think that Luke has ever suggested that cable ties are going to be the answer to UK OVH's.

WVS does an amazing job around the world and I hope that Luke's involvement in this post leads to lots of interested vets signing up to help!

Re: Cable ties on the ovarian ligament - discuss!

Hannah Wynne Richards — Thu, 23 Sep 2010 16:44:58 GMT

I think with feral/3rd world charity work, it's a case of doing the greatest good to the greatest many, while in private practice the individual is valued, or would not be in the surgery in the 1st place

Wynne

Re: Cable ties on the ovarian ligament - discuss!

Michael Woodhouse — Mon, 20 Sep 2010 23:50:09 GMT

More cable tie literature

http://www.goldjournal.net/article/S0090-4295%2800%2901009-8/abstract

Re: Cable ties on the ovarian ligament - discuss!

Martin Atkinson — Mon, 20 Sep 2010 22:17:55 GMT

Did a pyo on a fat mastiff today, the cable ties would have been very welcome, I did consider raiding the supply we have for tying up the bin bags but then thought better of it.

Re: Cable ties on the ovarian ligament - discuss!

Luke Gamble — Mon, 20 Sep 2010 21:42:14 GMT

[quote user="Michael Woodhouse"]

Luke - do you know stainless steel cable ties are commercially available? They would autoclave.

Stainless cable tie

[/quote]

Thanks Michael - no I didn't - I'll look into them and see how they shape up.

best,

Luke

Re: Cable ties on the ovarian ligament - discuss!

Ian Battersby — Mon, 20 Sep 2010 10:55:20 GMT

HI Luke,

So alittle off the original post but in summary yes i am happy for you to drop me a conversation post re the ITC training tprojects. Let me know how i may be of use.

But it sounds like you also need surgical hands to help . I will mention your projects to my friends. If they are interested are all the details on the charity website or at another information point . I presume the locations are exotic.

Ian

PS - By the way - love your new photo - hadn't realised how much you resembled boris

Re: Cable ties on the ovarian ligament - discuss!

Andre Escudeiro-Vieites — Sun, 19 Sep 2010 21:49:25 GMT

[quote user="Michael Woodhouse"]

Luke - do you know stainless steel cable ties are commercially available? They would autoclave.

Stainless cable tie

[/quote]

I think they would cut though tissue as you tighten them

Re: Cable ties on the ovarian ligament - discuss!

Michael Woodhouse — Sun, 19 Sep 2010 19:43:26 GMT

Luke - do you know stainless steel cable ties are commercially available? They would autoclave.

Stainless cable tie

Re: Cable ties on the ovarian ligament - discuss!

Luke Gamble — Sun, 19 Sep 2010 18:51:02 GMT

Thanks Romain, appreciate it and I'll look out for the video, maybe even twist your arm into helping me with the exotic module in the ITC in India next year!

best,

Luke

Re: Cable ties on the ovarian ligament - discuss!

Romain Pizzi — Fri, 17 Sep 2010 20:25:37 GMT

Hi Luke,

Good for you looking into better, absorbale materials like PDS (posted my last message before your reply), although judging by current prices of surgical mesh, absorbable orthopaedic plates etc, I suspect that these will always be much more expensive than good old fashion sture material (similar to steel/titanium ligaclips, hem-o-loc clips, etc).

If it is time saving you are after, perhaps the best, and definately more economical option would be to prepare large numbers of locking slip knots (such as the western knot, etc), that we commonly use in laparoscopy, from braided absorbable suture from a reel, and this can be pre-sterilised in numerous ways (ethylene oxide etc). While these are availble as "endoloops" commercially, most of us, and even many of the human surgeons in the UK tie them by hand during surgery. I learnt a nifty trick from a human surgeo in India to use the little three legged plastic stand one finds in pizza boxes, to help tie these knots quickly and easily. One could easily teach a technician to tie hundred of these in an hour from suture off a reel, strilise them, and they will definately speed up your OVHs. I will be posting a video of the knot on www.vetlapsurg.com during the nex month or so, but am happy to give you further info if interested....

"pizza"

Re: Cable ties on the ovarian ligament - discuss!

Romain Pizzi — Fri, 17 Sep 2010 20:02:37 GMT

Many may be unaware work was done more than 25 years ago in South Africa where commercial cable ties were used for cranial cruciate ligament rupture surgery (pre-Slocum, and clearly less expensive). The practice was abandoned due to high post-operative complication and infection rates. However, many believed this was due to the lack of proper sterilisation (is liquid sterilisation truly "sterilisation" or simply disinfection?, to open another can of worms...) rather than the technique itself. However, a recent article in the journal of comparative clinical pathology, shows there is renewed interest in this area: http://www.springerlink.com/content/8k13x62433w26q21/ . In relation to cable tie use for ovarian pedicle ligation, There are several reports of adverse effects, such as: JOHNSON-NEITMAN, J. L., BAHR, R. J. and BROADDUS, K. D. (2006), FISTULA FORMATION SECONDARY TO A NYLON CABLE BAND IN A DOG. Veterinary Radiology & Ultrasound, 47: 355–357, and adverse effects are also reported in the "good old" Textbook of Small Animal Surgery, edited by Slatter, most of us have on our bookshelves (page 440, for those as equally sad as me, that are interested...). Having also myself on one occasion had to perform surgery with a teaspoon on a wild vulture in India, due to a lack of suitable equipment, and on the other hand performing thoracoscopy with the exact same instruments and equipment used in paediatric human surgery, veterinary surgery truly is a profession of many shades. As veterinary surgery is sadly a business, our clients (and, of course our regulatory body and prof indeminity insurance) expectations of the required clinical standards are determined by the prevailing socioeconomic culture in which we practice, which differs widely from country to country. With the well documented complications associated with polyamide cable tie use in veterinary surgery, one would have to be a foolhardy veterinary surgeon indeed, so use them in the UK for OVHs - the RCVS and VDS would no doubt take a very dim view....

....just my two-pence worth.

Re: Cable ties on the ovarian ligament - discuss!

Luke Gamble — Fri, 17 Sep 2010 20:01:52 GMT

Hi Ian and Bob,

Cable ties that we can buy from the local B&Q are made from a grade of plastic that isn't safe to use surgically and the hard bit is persuading a company to make them in pds or a higher spec material. I'm working with a firm to try to develop a prototype but it is a much bigger harder mission than I anticipated! Ed Friend at Bristol is a incredibly supportive of WVS and is keen to help me trial properly but they can't make ones that could be suitable for medical use in the same place or with the same mould as the ones they make cable ties for industial use with. 3D printing is another option but again, pds is expensive stuff and the trialling of it isn;t straight forward. This really isn't my forte and anyone who wants to get involved in this or a myriad of other ideas it would be great to work with you.

WVS currently has over 370 non-profit organisations and animal charities registered for help around the world. The ones I personally love are the smaller organsations that don;t have the fancy websites, in remote places and where you can really help both the animals and people - and they often have the best 'tricks' - but if an organisation is a winner and is big - it doesn;t mean it doesn;t do fantastic work like The Dogs Trust or SPANA for instance. WVS can;t help all these organisations on a long term sustainable basis by sending out teams every week. We don;t have enough volunteers, we don't have the resources and at the end of the day it is three people working out the back of a second hand bookshop driving it on. All the vets who help manage it do so on a voluntary basis. To this end we're setting up an International Training Centre in Ooty, South India and the plan is to run a series of modular courses throughout the year in best practice techinques, covering all species of animals, and offer training to vets/paravets and animal welfare workers all over the world. We're linking in with VBB (who run Vet Train), Brigitte Bardot Foundation, loads of other charities and the Dogs Trust have pledged £150k for the next three years for the canine modules which is fantastic.

The plan is that we can not only create a hub which is a resource for vets and charities working out in the field but also utilise it as a base for pooling knowledge and skills in order to do the best for the animals and the communities in which we work. We're also setting up a national network throughout India with indian charities registered with WVS and we'll run outreach progarmmes to these, with the aim of reducing the prevelance of rabid dog bites by 5% over the next three years. If we do this, according to fairly lose WHO stats - 30,000 people die from reported rabid dog bites in India annually and 60% of those are children under 15. If we reduce by 5% we'll prevent the death of at least one child under 15 every day.

I really need help with it and for example a specialist medic would be amazing - I would pull your arms off to go over there and spend a week at the ITC, I'd build a course around you and fill it in seconds. We'd look at how to structure studies and it would great to have your help and advice. Equally I need experienced vets to help with the practical training- Bob Lehner placed a post earlier and they still mention him at Maun but vets with his practical experience are gold dust and brilliant to have teams and trips - the charity still mention him to me several years on. I think we all have slightly different techniques in how we do things, we can only gain from sharing them and ideas like the cable ties really typify that. Flank spays - not such a bad idea to be honest. Injectable anaesthesia - the different ways of doing are as long as your arm and some charities have protocols you simply wouldn;t believe but work brilliantly.

The hard bit is always finding the time to get away for a week but I'm really hoping that with the establishment of the ITC, I can bring to bear some of the valid points of forums like these and get colleagues involved in driving it forward and shaping it so it can be all it can be.

best,

Luke

Re: Cable ties on the ovarian ligament - discuss!

Ian Battersby — Fri, 17 Sep 2010 18:13:14 GMT

Hi Boris ( or Luke )

I have been watching your series and have enjoyed what i have seen so far.

I can certainly really see the value in some of the schemes you have been involved in . In particular the scheme in which you were setting up classes to teach local farmers how to look after their cows feet in Nepal. I guess relatively basic teaching can have a big impact in those parts of the world.

I thought it was really interesting to see the adaption of the bitch spey to fit the environment and situation at hand. The technique obviously had advantages for the vets who use it as you describe their techniques is so efficient. that allows then to utilise their resources ( the operating time avalaible ) as efficiently as possible.

Certainly the trail would be interesting you never know it could be a new way of doing things . Are you able to give more details yet or are things in the pipeline??

Could you also outline a bit more about the trips /missions that your charity organises. Given the program i presume a number will be surgical bias but i would be interested to know of any trips were a medic skills may be of use.

As outlined above it is interesting to see how the spey has been adapted and i wonder weather there are other things that have been adapted on a roof top in the mountains which could offer an alternative to what we do now.

Ian

Re: Cable ties on the ovarian ligament - discuss!

Bob Russell — Fri, 17 Sep 2010 17:50:51 GMT

Has anyone contacted any of the human surgical consumable manufacturers? They seem to make a gizmo for almost everything for human surgery. With the very widespread use of endoscopic surgery there must be a chance that these ties already exist.

How would a cable tie do for a splenectomy in practices without these £150 a go staplers? If us mere mortals could do a splenectomy in 5 minutes as is possible in larger/referral practices that must improve the surgical survival rate! These dogs have an average survival rate of months so long term issues are going to be of less importance than getting the patient through the actual surgery in the first place.

Any volunteers?

Re: Cable ties on the ovarian ligament - discuss!

Luke Gamble — Fri, 17 Sep 2010 16:29:29 GMT

Hi Tom,

It's incredibly easy to pull the zip tie, cut the tag flush and that's it. It is quicker than placing a ligature - no question. They use them simply for time, ease and economy - ligatures sometimes snap if you use cheap material or too much pressure - you don;t have this as an issue with the ties - they also trap in more tissue than we would normally catch in a carefully placed ligature. In the TV show I was doing it and I was chatting to them so it wasn't the slickest demonstration of the technique.

I was skeptical going into it, but it was undeniably impressive and they have come up with a very practical method but it needs published data to show it is safe and doesn;t cause harm rather than ancedotal evidence. The fact these vets are welcomed back to the same communities year after year and they run training courses throughout Central America implies that there aren't major problems with the dogs - having said that the average life of these street dogs is typically about three years.

My main worry is that the grade of plastic used in commercial zip ties is not deemed safe for internal use of any sort - I checked this out when I got back so despite the fact they sterilise them isn't going to justify me trialling them as they are.

Re: Cable ties on the ovarian ligament - discuss!

Tom butler — Fri, 17 Sep 2010 14:33:24 GMT

Why is this technique preferable to placing a ligature?

It requires similar exposure to place the cable tie, also the size of material used to place the ligature is directly related to how tight the ligature can be applied.

In the TV show it didn't seem to reduce op time significantly.

I think are some pictures in Slatter of abdominal abscessation associated with this technique.

Re: Cable ties on the ovarian ligament - discuss!

Luke Gamble — Fri, 17 Sep 2010 10:20:04 GMT

[quote user="Michael Woodhouse"]

I do wish I had taken the time to find the gentleman's name and not likened him to Borris Johnson now...........

[/quote]

Haha! No problem - I get called a lot worse. http://www.dailymail.co.uk/femail/article-1093637/Britains-UNLIKELY-male-sex-symbols.html so every cloud has a silver lining!

We should hopefully get a trial finished by the end of next year but I'll use something I would use in my own dog so it won't be the cable ties used in Costa Rica - they are literally from the local hardware store and immersed in sterilising solution for five minutes prior to use. Incidentally though I would absolutely love help with the courses and practical components of the ITC and if anyone does have a spare 10 days - I have heaps of airlmiles and would pull your arms off to go over there and work with the WVS India team developing the centre and improving what we're trying to do.

Re flank - there are quite a few practioners in the UK that do flank. I've seen three different techniques of this - the best is probably one with a small horizontal incision RLR about an inch long and just so super slick. Widely practiced in SE Asia, the vets work with a technician assistant who works allis tissue forceps and holds the uterus up for the vet. They ligate as we would and I worked with a Nepalese new grad who did a perfect job in about 7 minutes. I realise the idea of going through muscle is potentially more painful but the recovery of these dogs is astounding and I've done a few in my practice here and whilst nowhere near as slick as some of the vets super proficient at it - it really doesn;t seem to cause any particular discomfort. For ferals the idea is that when the dogs go back out they don't lay so much on the wound and being on the flank it keeps it a bit cleaner and should it break down it has a better chance of healing.