cat gut in muscle in midline bitch spays..

Re: cat gut in muscle in midline bitch spays..

Rob Reid — Wed, 03 Feb 2010 18:06:02 GMT

Hmmm I think you'd have a pretty hard time justifying using catgut in a court of law against an expert witness, where there are other far superior alternatives. I don't see the justifaction on the cost basis either (even for charity neuterings) vicryl/polsorb/biosyn/PDS/whatever you choose really is not that much more expensive you're really only adding £5 tops onto the cost - what price an animal's wellbeing?

I did work with a vet who used catgut, simple interrupted and we did get the odd breakdown of his. I have also heard tales of locums who used catgut in a continuous pattern with some spectacular consequences! As a practice we use polysorb for our routines though I have to confess I favour Biosyn for my 'ex laps!'

Re: cat gut in muscle in midline bitch spays..

Simon Neuhoff — Wed, 03 Feb 2010 16:20:50 GMT

The first practice I worked at (a few years ago now ;-) ) was rather o"old school". We had two choices - nylon (this in fact was fishing line in surgical spirit) and catgut. So all enterotomies/cystotomies etc were closed with catgut! Midlines were closed with simple interrupted fishing line nylon.

As I remember there were very few issues with this. I remember only one midline breakdown but that was immediately post surgery (on recovery the dog chewed its stiches out) and may have happened regardless on suture choice (I was the - rather inexperienced- surgeon). I also once used silk to stich a dog bite wound cause everything esle had run out! Again healed uneventfully.

Whilst I now happily use the "approved materials" I do smile a bit when people get overly excited about using catgut etc.

Re: cat gut in muscle in midline bitch spays..

listhestar — Wed, 03 Feb 2010 15:41:49 GMT

[quote user="Richard Carter"]

Wasn't there a VDS article on the subject a few years ago with the conclusion that using catgut for closure of midline muscle layers was pretty close to negligent?

[/quote]

That's what I was told- I believe while being taught at Uni. Now use PDS midline in dogs, vicryl in cats in simple interupted pattern (was taught to do simple continous at uni) as most of my colleagues/bosses prefered me to do that.

Lisa

Re: cat gut in muscle in midline bitch spays..

warwickshire vet — Sun, 31 Jan 2010 02:30:58 GMT

ah yes i remember silk thread - still picking bits out of me from a childhood op... I went from continuous pds to continuous nylon (blue so it looked like pds if someone queried it..according to impecunious boss) to vicryl then pds after a surgery course... If you are happy with knots then one should be ok. In answer to the semantics about rectus sheath the aforesaid contrite and admonished 'surgeon' tacked a continuous suture through the muscle belly and not the sheath - hence our full length breakdown. It would have happened whatever the choice in this case , BUT catgut choice was only revealed at said breakdown(there have been others!) .

Re: cat gut in muscle in midline bitch spays..

Anthony Todd — Sat, 30 Jan 2010 21:43:40 GMT

"The only total breakdown I can recall was in early days in a practice where linen was the material. Even there, I don't think it was the linen itself that was the cause, I think it was sutures of too fine a material done up too tight by an inexperienced surgeon (me) with an unfamiliar material."

See what I mean

Re: cat gut in muscle in midline bitch spays..

Evelyn Barbour-Hill — Sat, 30 Jan 2010 19:28:57 GMT

[quote user="robloxley"]And looking at the topic title, aren't we really suturing the the rectus sheath rather than suturing the muscle. Maybe semantics, but again another thing that I remember our surgery professor railing on about.[/quote]

Very much so. Maybe you can't always avoid incorporating some muscle fibres but the more muscle fibres you incorporate the more post-operative pain there is.

I'd defend to the death (well, metaphorically) anyone accused of negligence for using catgut, as long as they used it properly.

Continuous sutures are more difficult for an inexperienced surgeon to get right; the tension is the skilled bit; too easy to end up with a beautifully laid and knotted line, with the edges of the wound falling apart, or else something puckered up with a drawstring like the waist of a NATO parka.

The only total breakdown I can recall was in early days in a practice where linen was the material. Even there, I don't think it was the linen itself that was the cause, I think it was sutures of too fine a material done up too tight by an inexperienced surgeon (me) with an unfamiliar material.

Re: cat gut in muscle in midline bitch spays..

Rob Loxley — Sat, 30 Jan 2010 18:12:53 GMT

Few thoughts:

Had a guide dog puppy to spay recently and the GDBA specifically prohibit the use of catgut to close the linea.
I use Vicryl as I prefer the handling to PDS, and always do continuous pattern. If I had low albumen level or other reason to fear slow healing, then might consider something longer lasting.
We see a number of dogs closed with nylon and the stitches are prominent to feel and often to see, and I wonder whether they cause lifelong irritation too?

I was always taught similar about shouldn't be tying knots if you don't trust their strength - and similarly if I couldn't trust that one ligature on an ovarian pedicle would hold, why should I think that two questionable ligatures should be any better?

And looking at the topic title, aren't we really suturing the the rectus sheath rather than suturing the muscle. Maybe semantics, but again another thing that I remember our surgery professor railing on about.

Re: cat gut in muscle in midline bitch spays..

Clive Ansell — Sat, 30 Jan 2010 16:38:54 GMT

We were taught in both equine and small animal surgery to use simple continuous sutures with with either PDS or Vicryl. Even large draught horses that had had 30-40 cm midline incisions for colic surgery were closed with continuous sutures of vicryl.

I use both materials, but prefer PDS for midlines as there seem to be fewer reactions to it. I prefer Vicyrl to PDS for ligatures. Many people use catgut for ligatures then PDS and/or Vicryl - don't know why?. many bosses don't want you to open more than one packet of suture material, so often have to choose PDS or Vicryl and use it for ligatures, midline and skin. Ideally I would open a PDS, then use vicryl off a reel as needed.

I rarely use a subcut layer suture and have had no problems, although I sometimes do in large or fat dogs where there is greater distance between linea alba and skin, just to close any dead space.

Re: cat gut in muscle in midline bitch spays..

Anthony Todd — Sat, 30 Jan 2010 13:00:31 GMT

It's important to distinguish "breakdowns" as "fault" in technique or "fault" in material.

If the suture is unknotted then it's technigue, if the suture breaks or is not contiguous then it's a fault in material.

Of course when we get a breakdown it is a natural tendency to blame the material, or at least change it "just in case" and whilst this is going on we are gaining experience at a character building rate so the chance of a breakdown diminishes at a greater rate than the number of breakdowns.......

The "mature" or old flatulants will probably have done more spays/speys than the modern up-to-daters and their total breakdowns will be less, I'd wager.

I suggest that if we were all really honest we might find that catgut was just as effective with a similar breakdown rate if any.

By the way from the SOED

spay /spey verb trans. Also (rare) spey. LME.
[ORIGIN Aphet. from Anglo-Norman espeier, Old French espeer, from espee (mod. épée) sword from Latin spatha: see spathe. Cf. splay verb².]

†1 Stab or cut (a deer). Only in LME.

2 Sterilize (a female animal) by removing the ovaries. LME.

Re: cat gut in muscle in midline bitch spays..

warwickshire vet — Sat, 30 Jan 2010 10:54:29 GMT

The line from the VDS was you have negligence insurance, therefore you would be covered. They inferred that the 'indefensible catgut' idea was put about by bosses getting staff to follow protocol!

Re: cat gut in muscle in midline bitch spays..

Clive Ansell — Sat, 30 Jan 2010 10:49:23 GMT

[quote user="Hannah Wynne Richards"]

Clive Why am I not totally astonished that it is a low-cost clinic that uses catgut ?-and has the breakdowns ?

Richard. I certainly wouldn't like to defend the use of midline catgut as not being negligent

Wynne

[/quote]

All of the wound breakdowns resulting in evisceration I have dealt with from one particular clinic were, I think, a result of poor surgery rather than the material failing. The material, catgut (about 10,000 metric I think!) would have come undone or had broke where it was knotted.

Re: cat gut in muscle in midline bitch spays..

sarah mason — Sat, 30 Jan 2010 05:41:25 GMT

Interesting remark about the VDS. when I spoke to them about 18 months ago about a midline wound break down they told me they would cover any complications as long as cat gut had not been used-that they did not defend the use of catgut in the midline. conflicting advice??

I always used PDS or vicryl for bitches. simple continuous

Re: cat gut in muscle in midline bitch spays..

Vikki Halliday LLB — Fri, 29 Jan 2010 23:25:23 GMT

[quote user="warwickshire vet"]

I remember getting flak for asking for a new surgical kit between bitch spays and daring to ask for another piece of PDS... we have all been there (probably)

[/quote]

even worse, how about having to resterilise all your needles and syringes, yep had a boss made me do it..............

Also agree with your comment on vicryl ligatures: I can never get the same confident grip on the first throw, so I never use them to ligate, only ever use catgut for this. Generally use very fine catgut for a sub-cut layer too, and always put in an intradermal layer, usually catgut but sometimes vicryl, depends on how big and bouncy the dog is.

am intrigued by the comments on continuous midline suture use, I was taught by the more knots is safer proponents, but since I use PDS, I'll give it a go. Usually use cruciate sutures sometimes interspersed with SI in the linea alba.

Next question, what knots are most popular with folk for various suture materials?

Re: cat gut in muscle in midline bitch spays..

warwickshire vet — Fri, 29 Jan 2010 23:10:59 GMT

The employee has understood my reasons and is contrite about their use of catgut, agreeing to abide by protocol. They appreciate the points we have raised with them. Worries about 'confidence knocking' are unfounded - this was/is an overconfident surgeon 'running before walking' (not my comment - my other vets/co workers). I do however use catgut for ligatures in bitch spays (always 2 ligatures on each bit) every post op bleeding bitch spay I have had to re ligate has used vicryl (small study of approx 14 dogs in 23 years) of the thin variety. Surely someone taking a protocol backwards is far worse than one going forwards (eg including pain relief). If someone 'walks' over something like this (not following agreed rules because they know better) then I would be glad to lose them! I am all for discussion of protocols and where evidence to improve standards exist we follow within reason (market forces). I just find it sad people are teaching new graduates bad habits straight out of college! Or may be I am sad new graduates are happy to ignore what they are taught in college when faced with a conflicting pressure in work.

I remember getting flak for asking for a new surgical kit between bitch spays and daring to ask for another piece of PDS... we have all been there (probably)

Re: cat gut in muscle in midline bitch spays..

ruths — Fri, 29 Jan 2010 22:17:34 GMT

I've worked in charities for a long time- and never used catgut in the midline.

I'd have been too worried about it tbh. I do use gut in ligatures- as a habit- probably age related. I used monofilament nylon off the reel in a SI pattern for years until a colleageu convinced me to use PDS simple continuous. I said I'd do this until I got a break down- 12yrs later I'm still happy with it!

I think the banning is a bit to me. I don't think it will resolve any issues between you and your employee. It seems a bit like sending a child to a naughty step. I would have thought thatshowing somebody the reasons why you've made your rules would make them more responsive. it's a bit public too and makes me shudder a bit tbh.

I once worked in a practice where pre-operative analgesia wasn't part of the protocol and got into trouble for adding vetergesic into premeds... it took some discussion but we got to some agreement in the end. I'm afraid I'd have walked if smebody had banned me from surgery due to a disagreement in belief.

Anyway, I think you are right and I would totally support your policy- but I don't think it'll sort out so well with your employee in the end!!

Re: cat gut in muscle in midline bitch spays..

Vikki Halliday LLB — Fri, 29 Jan 2010 21:18:56 GMT

[quote user="Malcolm Ness"]"If your Knots are in danger of coming untied you should learn to tie them properly. Or take up dermatology!"[/quote]

Does that mean Judith can't sew?

Re: cat gut in muscle in midline bitch spays..

Jillian Hall — Fri, 29 Jan 2010 21:08:38 GMT

I was always taught that the weakest point of any suture line is the knot. So if you're happy with your knots at either end then there's no reason not to use a continuous pattern.

For cat spays I've recently downgraded my continuous pattern to a single cruciate suture in the muscle, which I've been quite happy with. (If I make an unusally big hole in it's flank I'd adjust my technique accordingly). It seemed pointess to be doing a knot, one stitch, then another knot.

I very rarely use catgut, only for obese bitch spays where I feel I need something resembling rope. Vicryl is my standard.

Re: cat gut in muscle in midline bitch spays..

Niall Taylor — Fri, 29 Jan 2010 21:00:01 GMT

[quote user="Robert Whiteford"]What's wrong with monofilament nylon in a continuous pattern with secure surgeon's knot with multiple throws at either end? No inflammation, no reaction and persists forever.[/quote]

I'm not so sure about the 'no reaction' bit. In my last practice we used to use monofilament nylon to close the linea alba and on a couple of occasions after a year or two in thin skinned bitches with little in the way of sub-cut fat I had to re-operate to remove spiky nylon sutures as they were causing a marked reaction - that was simple interrupted rather than continuous mind you.

Like some of our more (ahem) 'mature' posters I too was taught to use catgut mid-line but after one disembowelment (that thankfully survived) I changed; initially to nylon (as above) and later to pds or vicryl depending on the weight of the bitch. I used to do simple interrupted as taught but now, following a memorable BSAVA congress lecture, am happy to use simple continuous apart from bitches more than about 30-35kg when I still use simple interrupred 3.5 metric pds.

Sometimes I do sub-cutaneous sutures, sometimes I don't, mainly as the mood takes me - not convinced "closing the dead space" makes much difference.

Skin is closed using sub-cuticular, 1.5 metric swaged-on vicryl - much more comfortable than those messy skin sutures.

I still, however continue to close flank cat-spays with no 3 or 4 metric cat-gut - less tension bearing than the linea alba, and I've never had a single breakdown (hope you're getting this Andy ).

So, all well and good but this thread is missing the real point - how do you spell spay/spey?!

Cheers,

Niall

Re: cat gut in muscle in midline bitch spays..

Charlotte Marshall — Fri, 29 Jan 2010 20:15:53 GMT

We use monofilament nylon midline for bitch speys. I always do a subcut layer and I do use cat gut for that. I tend to use vicryl midline in cats and rabbits.

Re: cat gut in muscle in midline bitch spays..

warwickshire vet — Fri, 29 Jan 2010 15:54:42 GMT

I did speak to the VDS about the use of catgut in midline muscle repairs in spays, and they said they would cover any complications under their insurance cover if necessary. They said it is a commonly stated belief that they would not cover a vet using cat gut - IT IS NOT TRUE, THEY DO! A vet using a technique, that is used by other vets commonly, is not being negligent according to their definition. I echo the previous post about after hours clinics seeing low cost clinic catgut breakdowns in spays - I saw quite a few whilst working in an after hours clinic, but the clinical director of said low cost establishment seemed unperturbed about it when I spoke to them.

Re: cat gut in muscle in midline bitch spays..

Hannah Wynne Richards — Fri, 29 Jan 2010 15:25:40 GMT

Clive Why am I not totally astonished that it is a low-cost clinic that uses catgut ?-and has the breakdowns ?

Richard. I certainly wouldn't like to defend the use of midline catgut as not being negligent

Wynne

Re: cat gut in muscle in midline bitch spays..

Lucie Allcutt — Fri, 29 Jan 2010 15:24:46 GMT

[quote user="Malcolm Ness"]

SI suture patterns are much loved of teaching institutions because of the knotting practice though it is puzzling that despite this, many vets can't tie sutures properly. In reality, they have few advantages over continuous patterns and as one of my teachers pointed out when I proposed the "SI is safer if a knot comes untied" theory, "If your Knots are in danger of coming untied you should learn to tie them properly. Or take up dermatology!" Continuous patterns work fine in most applications and there is some work out there to indicate that the starting knot and finishing knot should have a single additional hitch over what would be normally used (the precise knot design varies between suture material).

For anybody sad enough to want more information about this kind of thing, the first few chapters of standard surgical textbooks (Slatter for SA and Auer for equines) has everything you will need to know. Unfortunately, nobody ever reads these bits (unless studying for a Board Exam) preferring to turn straight to the surgical "recipes" instead.

[/quote]

UF surgeons teach their students to close the linea with a simple continuous pattern now (this used to not be the case), and on externships I have had a few vets that were horrified by this practice!

Some more recently graduated vets that I have worked with will sort of pick and choose, simple continuous for cats and smaller dogs, simple interrupted for larger dogs and explores. I have yet to do an explore on my own, though I have helped one vet who decided to close an explore on a medium sized dog using simple continuous. Her rationale was less time under anesthesia, and that's just how she closes.

I haven't spayed very many dogs yet but most of the ones I have (four out of five) I have closed simple continuous and they have done well. I close all my kitties (at the monthly trap/neuter/release program I volunteer for) simple continuous.

Re: cat gut in muscle in midline bitch spays..

Hanna Bennett — Fri, 29 Jan 2010 15:01:22 GMT

most definitely yes to the subcut layer - our new grad last year had all her speys come back with massive seromas and we only figured out watching her stitch one up while i was chatting to one of the nurses in theatre that she was missing out the subcut layer, having peeled back the subcutaneous fat to expose the linea alba, thus creating a lovely dead space to fill with fluid...

Re: cat gut in muscle in midline bitch spays..

Robert Whiteford — Fri, 29 Jan 2010 14:54:05 GMT

What's wrong with monofilament nylon in a continuous pattern with secure surgeon's knot with multiple throws at either end? No inflammation, no reaction and persists forever. . . . OK may not be a good thing but if it is represented as a stray in 2 years time you know it has at least had a laparotomy and may well have been spayed (by me!) It is also cheap and no waste cause its on a reel.

Do most people also do a sub-cut layer?

Re: cat gut in muscle in midline bitch spays..

Richard Carter — Fri, 29 Jan 2010 14:29:54 GMT

Wasn't there a VDS article on the subject a few years ago with the conclusion that using catgut for closure of midline muscle layers was pretty close to negligent?