OK, thank you for joining for this, webinar on, guinea pig anaesthesia and surgery. Originally this was, billed as Being very much on the side of, of surgery. But of course, it's really important that, if we want successful surgery, we're going to have to keep our patients alive.
And for that, we need to have good anaesthetic, principles and also a good knowledge of how to look after these guys, otherwise, I amazingly fancy knife work will not come to anything. So This is what we're going to cover. We're going to cover sort of anaesthetic considerations and actually the practicalities of it.
We're talking very much about how to deal with guinea pigs in practise and practise about being practical, and about how to keep the, the, these creatures alive. We can talk about some surgical principles, for small mammals in general, but obviously guinea pigs being small mammals, it fits for them too. And this is really important.
There's certain things you really do need to know. And to be brutally honest, although we're gonna talk about, things like orthopaedic stuff and dental stuff, and we're gonna go through specific ops. If you can do for soft tissue surgery, if you can do soft tissue surgery in everything else, and you can understand the principles of the surgery in the small mammals, that really is gonna get you through most things, to be honest.
So let's see we're gonna talk about anaesthesia. So this is a big thing, you know, guinea pigs are under anaesthetic and we go back to the survey, which was the last big one, then over 3% of guinea pigs died within 40 hours of anaesthesia. So that would seem to be true.
And that's a pretty depressing, statistic, especially most of them died postoperatively, and the reason for that is generally sort of poor evaluation. Poor preparation as a result of that too. Anaesthetic choice might have been affected by that too, but of those, these areas here, I think it's probably the least important of all of them too.
But certainly poor maintenance and perioperative support, and then you end up with a guinea pig in a bad state afterwards and that's when they tend to pass away. The problems you get with guinea pigs are, one of the big things all swarms again is they're fairly tubular. So you've got a very large surface area to volume ratio.
So as a result, they lose heat quite readily. And, that, that's obviously a, a big problem, with, with any anaesthesia that, the patient really cools, then they can get up in trouble. So heat loss is important.
They also have a lot of underlying disease, that maybe overt disease, you know, we know, guinea pigs are often operating because the guinea pigs are ill. But, we may also have silent disease and things like, subclinical pneumonia in particular, any chronic respiratory disease is really, really common. And if you look at the frequency which we see, you know, lung change on X-rays for other reasons.
If you look at frequency you see consolidation and congestion of middle ears, you know, we know there's a lot of, subclinical respiratory right there. Their anatomy doesn't really help, you know, the, the, these creatures are basically, 9, 10 gastrointestinal tract, and, you know, everything else is fairly compressed in there. So it, it doesn't always help things.
And then, of course, we've got issues with pain control where we don't always understand the drugs, we don't always understand what we need to do. And, we don't always address that correctly. And to some extent, gut stasis, I will stress that postoperative gut stasis is a lot less common in my experience than it is in, say, rabbits.
So patient preparation, again, if you do identify lung problems, clinical, subclinical, try and control the best you can. So if you have got, let's say, dental issues, you don't need to rush immediately into, into, into dental care. You can actually, treat some of the underlying problems first of all, control things, you know, maybe antibisis, you've got infection lurking around, maybe get some analgesia on board, anti-inflammatories, that sort of stuff.
Give some fluids, feed them, you know, just simply getting food going through the system again, is, is really important. And how long you do that for is gonna depend on the patient and the patient's needs and, and how acutely the surgery is needed. And sometimes that might be a few days, sometimes that maybe just have a few hours to do the same.
So just, just judge it as, as you can see, see, see where the needs. In that species we do preoperative bloods and they kind of come and go, in and out of fashion, a bit like flares do. But, in guinea pigs, our standard method of taking blood, it's from vena cava, as you can see, the patient is anaesthetized.
So preoperative bloods really aren't that useful guinea pigs on the ground. You're going to have to anaesthetize them to get the sample anyway. So very rarely will you, will you be doing that.
The exception would probably be if you've got a chronic ill guinea pig who needs some surgery, it may be a good idea, and maybe thyroid, surgery would be a good example here of actually using the bloods beforehand as part of a general workup to find out what's going on before you operate. Around about the anaesthetic, you know, what are we gonna think about? We're gonna think about obviously fluids, with, with the, surgery.
We're gonna think about keeping them warm and different ways of doing that too. If you are using heat pads as in this bottom, left picture here, always obviously be very careful not to overheat and cause problems. They can go wrong if the, the guinea pig gets wet during the procedure.
And again, try to avoid that too, because, of course, that, if you haven't got good heating is going to, it is going to potentially lead to, to, cooling. And if you have got good heating, it can potentially lead to burning. So be careful of those.
And to be honest, these days, we probably use more of these hot air blowers, and, and bear huggers and stuff, and we find they work a lot, lot better. And alternatively overhead heaters and they can work as well. In terms of gut motility again, probably very much like rabbits, we'll look to address the analgesia, we'll look to address the fluid balance and try and control things from there.
And those are probably our main, main areas. So in terms of analgesia, what do we do? Well, I mean say really insights.
And then say they're, we know they're pretty effective. We know the mechanism they were worked by, and we know those mechanisms are present in guinea pigs. So.
Therefore, they, they are a pretty sensible way to go. There's good likelihood of good evidence for them, even though there are few, if any, efficacy studies within guinea pigs themselves. What there are though, are pharmacokinetic, studies, and this is important because although meloxicam is licenced for guinea pigs and is licenced at a very low rate, there is PK work showing that a dose rate of 1.5 meg per kg, once a day by injection.
Twice a day orally is probably the more effective dose to achieve plasma levels, which should be therapeutic. Other NSAIDs are available. We've always used carbon in the past, they probably these days we would stick to meloxicam, so there's just so much more data to it.
You do have to be careful with the kidneys. There's a lot of underlying renal disease in guinea pigs, nephro sclerosis is common. And also they are stressy creatures and gastric ulceration as seen in this picture here is not rare in guinea pigs either, so you can be a little bit careful.
So personally, I'll give my NSAIDs at the end of a surgery. I don't, I won't give preoperative NSAIDs because I'm about to get a hypertensive episode with, with the anaesthesia, and I'd probably rather leave that to the end. We do have opiates as well.
You can maintain to be buprenorphine or butterphennil. B is probably one I'd use most of all, and if I'm doing preoperative analgesia, that's what I'll start with. Pure agonist can be used, .
Again, I'll be a little bit worried about gut me in these guys. Again, the important thing with them is just the lack of studies with a lot of these opiates and, and dose rates and stuff. And as we know, opiates can do some funny things and do vary quite a lot in, in action and side effect between different species.
So you have to be pretty good evaluating them because you need to be sure you're getting general analgesia and not getting just sedation, from, from a drug drug you're using. So again, just, just, just just use your eyes, watch a guinea pig, watch and understand. And it is difficult, pain signs for mammals are very, very nebulous and very non-specific.
So you have to know the species quite well, and often you're relying on the owner, reporting back to you well because they know their animal better. If you're using a combination of ketamine, don't get ketamine as analgesic, and it's quite a nice drug to be using in there. Of course, alpha 2 agonists as well, and these combinations are analgesic too, but obviously when you reverse the alpha 2 sedation, you reverse the analgesia as well.
The big one, this is probably the only true painkiller we actually use, that's local anaesthesia. It actually genuinely does stop the impulses, therefore, to stop the pain. And this, we use a lot of this.
So, big thing is be aware of maximum doses. There is a maximum dose for each sort of drug. Be aware of that about species and obviously know your, your guinea pig's weight.
Which hopefully you would before you do any sort of procedure and stuff. But do use that maximum dose. You go, go up close to it.
There's no price for doing much, much less, you know, you can use it, you can use lots of those kind of setting up to that maximum. And you can do it different, different ways. So you can do like specific blocks that might be good for dental stuff.
You can do regional blocks for end of limb and stuff, or for going around a lump, . You can do infiltration, underneath the lesion or around it. Here we pictures showing doing incisional block before we do, exploratory in a guinea pig here.
And to talk about later on, we talk about variectomies, about doing intraabdominal, local anaesthesia when we actually put it into the abdomen and immediately after surgery and then put a lot of fluid around to take it around the abdomen and get direct contact there too. And again, before you close up and a bit of splash block around, it does no harm either. So you can do 2 or 3 different methods for each or surgery, and I think we see a lot better results, from, from using, local anaesthesia a lot.
So when it comes to anaesthetic recipes, I'm not gonna give you one, I think the old saying that there's no such thing as a good anaesthetic and a good anaesthetist probably really holds true with with small mammals. And that is because you got to taking that care of a whole animal is probably at least as important, if not more so, than the actual drug you use. So you can use injectables, you can use gas only, which what we tend to do is use isofluorine, use a premedication, plus plus gas and in some instances too if you want to.
And it very much is a case of what works for you to some extent. And how to moderate that with, regard to to the animal or patient its needs at the time. So if you do have a guinea pig protocol, you know, you may have to adapt that if you're very old or very debilitated animal because that might not be necessarily a good thing for them.
Just like with any other species really. So the next big controversy intubation, . We are instinctively want to protect airways.
It's a very good principle to do. The trouble is that enemies looked to a guinea pig will know that in the back of its mouth there's a lot of crud. You know, if they're eating at all, you know, there's a big pile of semi-chewed, sort of, plant material.
Sometimes you've got passive regurgitation being anaesthesia as well, so you actually get material up in there as well. So, you know, there, there's always stuff there. Now, Some people like cleaning us out, some people don't.
The danger of over vigorous cleaning is you put a lot of fluid in there, you're more likely to get inhalation of that material, and that's going to lead to pneumonia. If you're very careful or be very happy, they can get all the material out just for the anaesthetic, and they can do that. If you are going to do it, make sure the guinea pig is conscious so it can swallow.
If you do this with the unconscious, you've got relaxed, larynx, you've got inability to swallow, so you are definitely gonna flush it down into a trachea, and that's gonna be a big problem. And if you just physically, you know, again, it's gonna be like with cotton bud or something like that, you're gonna actually get this like canon ramrod sort of situation where you're pushing it down and pushing it down and packing it, which is not going to help either. But if you are going to intubate, you do need to get rid of this stuff because it's gonna get in the way and you're gonna get, and if nothing else, you get a situation where you take some down into the larynx with the tube and that's gonna lead to a post-op post-op pneumonia too.
So really important to do so. For our practise, we very, very rarely intubate, because of this. It might be because the way we anaesthetize that we, we find we have fewer problems with it.
We tend not to use injectables so much. We tend to use a lot more, more gas anaesthetic, and that might be partly why we do that. Also because Because it's a little bit longer in induction, we're going to potentially have more problems with more material forming in there after we've cleaned out at the beginning, which is what we found in the past.
. We also feel that because pneumonia risks are increased with intubation, that actually it's a pretty moot point whether the intubation is actually going to help. So risk benefit, and again, we'll be talking a lot about that as we go through this talk. The risk benefit of intubation is a lot.
Less, a lot less is beneficial than it would be safe for a dog or a cat. If we do chew, we do under endoscopic guidance. We do clean out, we, we, we do, we do place tube under endoscopic guidance, we can see what's going on there.
We can see we've got a lot of material about that so we can really visualise it well before we put the tube down. And we will then do postoperative antibiosis in every case. Once they are asleep again, beware of passive regurgitation.
So if you have the head downwards, then you will get ingestor flowing out of the stomach and into the oesophagus and into the mouth from there. So raise the head and keep it raised the whole way through and always be aware as you. Whenever you operate, you move the animal around a bit and just curses you.
But, you know, be aware of where that head is during that whole anaesthetic and make sure it's kept high and make sure your anaesthetist is actually, perfectly capable of telling you to stop moving the animal and leave it where it is and also keep packing it and keep keeping it high. So always listen to your anaesthetist. I think that's very important.
I think this day and age that, you know, that hopefully hierarchies are falling and people are too scared to tell surgeons things. So hopefully with better medicine we're going over that. And in small mammals where you've got pretty critical patients, which can change quite quickly, we need to have at least they're telling you stuff you do need to stop and listen to them.
If you do have an emergency, you'll have some stuff ready. We'll typically have doxopram, adrenaline, if you're gonna use injectables and stuff too, . We will have fluids potentially for that too.
It's be very hard to intubate in a hurry, so we'll have a tracheostomy kit to hand. We can get down into touch with Kia by a different route quite fast. And also we'll have a ventilator available so once we are got tube in, we can ventilate and do that too.
And then really this is a slide that's really wrong way around. Those principle ABC airway, breathing, circulation are just the same in guinea pigs as they are in every other mammal species we deal with. So, you know, it it is have that track kit ventilated.
Massage the heart, and then we finally get around to thinking about using our drugs and fluids. So my apologies for a very, very badly written slide. We use fluid therapy again, subcutaneous, intraperitoneal osseous intravenous, are all the routes we have available to us.
Per I tend to very rarely use intravenous, which is so hard to maintain. Intraosseous is a bit too amazing, but for most of our surgery, we're using subcutaneous and intraperitoneal bonuses. Because we get a lot of fluids in very quickly that way.
We're doing, peritoneal surgery, then we can actually by putting fluids into, we're also diluting down what we've done in there, so we're actually hopefully reducing the chance of having adhesions. So, we tend to use this a lot to and subcutanes again, really nicely absorbed, usually in 15 to 20 minutes of of coming around just fluid's gone, a lot of fluids in very quickly and without much stress and hassle of handling or restricting. Fluid type and volume, typically we use saline, .
We were for intravenous use probably go by sort of if you like cat maintenance rates, rabbit maintenance rates, and, for, subcutaneous interper will go in about 30 mL per kilo. But typically saline, unless we've done some electrolyte work, in which case we will adapt the fluid to what the animal actually needs from that. But back to problems about doing blood sampling and these guys.
Post-operatively, they're gonna need various things. You want to be warm. Again, they can be well we can thermoregulate properly and they are warmer than we are.
And, so you do want to make sure that that's OK. You don't feel secure because you don't want to be stressed our whole thing is about stress reduction. And also, if they've got companions, here are two pictures, lone guinea pigs, you really want, to, get the owners to bring them in with their companion at the start of the day.
So we're not separated, guinea pigs don't like being separated. They're very much of like herd animals and so they they want to be kept together. And one of the best things you can provide in their box with them is a, a nice big car box, you know, so you can get into, get out of the way, and not, and, and not, not, not, not feel open and exposed.
And obviously food, . And in those terms, we'll always get people to bring their own food with them. They will like to eat that first of all, and you may look at the thing that's totally unsuitable, you know, on this day of all days, you know, when they're being operated on, you want them back eating as quickly as possible.
Grass and hay are always good, so nice quality hay, we always go and pick some grass, local playing fields, or wherever, maybe a bit of weed, a bit of vegetables, so a bit of dandelion, something like that too would do no harm. For other foods, I mean, whether we stock XL dual care, we find that works really well in guinea pigs. They really do, do, do seem to like that a lot, so it's good food to have available.
And we'll give a force feed or assist feed whatever we like to call it, and that may be where there's lots of products available now we we've got the Obo product, we've got ERA, we've got, Burgess have one too, and there's lots of different foods available. But overall, successful anaesthesia is all about stress relief. So we're gonna keep try and keep the adrenaline levels down in these guinea pigs, try and keep them as happy as we can, and that's gonna lead to a lot less effects with adrenaline, the heart, of adrenaline, the circulation and things and hopefully overall make life a lot less exciting than it could be.
So certainly in terms of monitoring as well, but the other thing that people ask about as well. There are lots of different things available, there's lots of things you can use. If you are intubating, please use capnography.
That's gonna be your big early warning system of poor perfusion, poor ventilation, that's really important. . Don't often use pulse ox.
I tend to tend to like, you know, listening with, with Dopplers on the, on the extremities. You can do indirect blood pressure reading at the same time, whether it's a little bit less evaluating these guys. Esophagous stethoscopes don't tend to work so well, we could probably use that packing in the back of your throat, more stuff going through there.
But the big thing is just having a dedicated anaesthetist who's just gonna sit there listening. And we're gonna talk about preparation in a minute, but have everything ready. You don't want your niece just disappearing off, getting stuff, doing things.
You actually want them sat on the animal, listening to it with their full attention on the anaesthesia, and that way, you know, they really are aware of what's happening, what's going on. So surgical considerations, . You know, you really want to avoid excess time and generally the short and snappy, you can make the anaesthetic, the more likely you are to have have good success rate there too.
You want to avoid tissue excess tissue handling, so don't pore over it and fiddle with it and stuff. That leads to bruising, that can lead to more haemorrhage, can lead to some desiccation of tissue, all of which are going to . I'm going to lead to more like the wound breakdowns, chewing stitches, and other other issues from that.
So just be, you gotta be really quite, quite sharp and quite, decisive with, with what you're doing and also not rough with the tissue. One thing people do is we will be in a habit too, you know, we're dealing with nice big dogs and cats, you know, you drape up and you put your insurance on top of drape on top of the animal. Please don't do that with things like guinea pigs.
A nice big heavy pair of hemostats will actually potentially restrict breathing to some extent in these guys. So just be a little bit careful with that too. And again, try and keep your suturing, sort of sympathetic.
We, we, we know that, suture removal can be a big problem with these guys. So just be careful not to over tight and not to use really sharp, irritant, nylon type sutures, and use those sympathetic patterns to, to, to, to help reduce them being bothered by it. So we can start with orthopaedics, and the reason you start with orthopaedics is pro I like at least actually the whole whole what we do, and, it gets out of the way nicely, but actually, nice thing with these guys is the other reason we start with is because it's so rare in them.
That's why I like guinea pigs a lot, . It's really unusual. And that, that's the question of why, because they've got 4 limbs, they've got lots of bones.
That was the greatest quality bones either. So why? Now a part of it might be their behaviour.
They they don't tend to jump up on things. They don't tend to be leaping from, from place to place like rabbits do, and they tend to be a little bit more stable than rabbits, in terms of running around and running into stuff. So that might be one factor.
The other thing just probably just a shape, if you think they're little like little barrels with very short legs, all very close. Close to the body. So actually having these injuries where they catch a leg and twist it and and and just just break it distally are quite unusual.
So that's probably a more major factor just topography of the guinea pig. Above all, with all these things, especially for a normal autopod like me, is just keep it simple. So don't get too complicated what you're doing.
So here's 11 example. I'm afraid you've got very few examples. Here's one example, because you've got a basically a fractured electron on here.
You know, what can you do for that? It's highly unlikely with, they have, could have got quite strong legs, there's a lot of force going through that. You see how displaced it.
So the chance of being able to wire that on there the size is with the effect of, you know, the, the, the suture material onto the bone and stuff is quite unlikely and probably can cause more harm than good. So this is what we do for a lot of fractures, just rest them with a non-steroidal in case you should be short term opiate, and, see how they go. And for a lot of these they do very well.
But something like that electronal fracture, well, you know, they can, they usually do pretty well with that if they're really in discomfort afterwards too, we do have the option of amputation. And that's something which we probably do more in small mammals. We certainly what we do do dogs and cats, and it's not always the worst option because it's pretty well tolerated, you know, they again, they, they're, they're, they're sort of small scuttly things, and they do very, very well on three legs and .
That are pretty OK. And that's again, you hear things too about you know whether you should do front legs or back legs, they can do well on with either removed as long as the other limbs are OK. And that's the important thing.
If you are thinking about amputating, then do evaluate the other limbs, properly first of all. The other thing too is you really want to take the limb off contact with the floor and make it non properly non-weight bearing. So either on a for limb, do it proximal to the elbow, hind limb proximal to the stifle.
In terms of technique, it's really just like every other species. So basically, you know, you cut the skin, you you go in through the muscle layers, you clamp and ligate the blood vessels, you know where they're gonna be because they're gonna use you generally sort of medial plane and just slightly cordal to the to to the bone. You know, you cut the bone and then stop bleeding, over so the muscle over the end of the bone, and then, oversse the skin over that too.
And it's just a really nice simple technique, and can be pretty good, especially with complicated fractures. In some cases, we can think about doing external co-optation, . It's usually pretty badly tolerated, and they are really good at chewing away at bandaging and stuff like that too.
And the other two thing problem we have as well is that we do have these very short stubby legs, and if you look at the shape of them, they're almost conical, and it's very, very hard to secure joint and joint proximal and distal to a fracture. So very often bandaging doesn't work well. About the only time I probably would do that is I'd probably use a gutter splint technique, using a little hexalite type, type, .
Gutters, nice and light, in other words, and radi the possibly, but certainly metatarsals, metacarpals, fractures there are better, will respond quite well to external captation as long as they leave it alone. The nice thing is they heal quite quickly, so don't 2 to 3 weeks, so you don't have to keep it on for very long. If you are gonna fix, generally these are gonna be femur, femoral or or humeral fractures you're gonna fix.
Again, simple pinning techniques, you really just want to keep the roughly the same plane. And I also stress that for a lot of these, femoral fractures in particular, if they are, Non pretty non-displaced, or if you can under anaesthesia, reduce them manually so they're non-displaced, they'll often do really, really well with just rest, because it's so much muscle there holding them together that they can do pretty well. However, you've got like this fracture here, this is a long way apart, and this was when we did decide to pin.
You can see it's not the world's greatest pinning, I'm sorry. again, this is, . It's one of my very, very rare examples of of pinning a guinea pig, .
I would try if possible to pin these normal grade, so to enter the pin from the top of the femur and pass it down manually realign as you go along. And that less disturbance, less opening of a fracture site, less less chance of complications and stuff too. Generally we use in very tiny guinea pigs we'll probably use a hypodermic needle, a very big hypodermic needle, or we use a K wire, if we're in a, in a, in a larger animal, .
And Even though his, his pinning looks pretty terrible, I actually did really, really well. And the pin came up after about 2 or 3 weeks, and that's generally how long you need to leave it in there for. And, it had a nice, formed a nice big callus and then it remodelled it from there and it's doing pretty well to this day.
Supporter KY on there, I would definitely carry on with analgesia and to get to be non-steroidal. But also, I would tend to use, a calvitamin D supplement. My favourite being Nutribe from Betark.
And the reason for that is that they're not quite as labile with their calcium as rabbits are, but it's, it's good to help encourage them to, to lay the calcium down properly. Probably our biggest reason why we anaesthetize guinea pigs and do things surgically to them is because we've got dental disease and we're often operating on the teeth, if you like. This is the common reason for true anorexia linked into Crohn's disease in guinea pigs, and you can see as we got, maybe these overgrowth slow mos and entrapment of the tongue, with with the teeth growing over the top and, that, that's .
Going to be pretty pretty advanced and pretty severe disease. Equipment needed, very similar to rabbits, tend to use much smaller cheek dilators, and these bits I find a real problem. Did try these ones with these long thin, spatula, they could not bad actually, for the very back molars, because the better visualisation, but they, they are hard to retain.
Otherwise we tend to be using our usual, gags and files and clippers. I would stress with image first of all. And a bit like rabbit that first time you have dental disease, do do some imaging before you do anything else, sir.
It's gonna set the prognosis, it's gonna give her how advanced that disease is, to which teeth are there, and you can really hope give some advice about how far progress is to the owner and how much it's, how quickly it's gonna progress from there. We got CT, great, fantastic. It's beautiful, and it is lovely images.
If you haven't used X-ray, it is fantastic and gives it again a lot of good information. I would tend to a standard DV view. I'll give us a standard lateral view of the skull.
You can do more complicated views if you want to, but these tend to do very well. So obviously this animal here we can see we got roots coming through the bottom of the jaw. We can see we got a lot of reaction around here with this all along the cortex of the mandible and the maxilla, we can see we got sort of splaying of the roots and this is really very advanced root disease.
And we can say to be at that point that we have got a pretty Grave prognosis with guinea pig. So in terms of therapy, obviously we can trim down hooks, we can do that too. Most of the time we don't get such large hooks.
Most of these and guinea pigs is root related rather than being, truly, crown related. So, we may see abscesses, and we'll talk about that in a moment. Most of the time we're giving a lot of pain relief, because the jaws are just sore and we don't like using them to.
Don't forget things like the temporal mandibular joints may be affected, and sort of middle ear disease as well, or which can make chewing quite painful, so just be a little bit careful on that too. So the prognosis is often guarded, even if what you seem to be early stages, and if they don't respond to analgesia, you have got a problem. But antibibiosis on there too, if we've got, infection, we're not going to necessarily operate on and probably use long-term antibiosis, but again, relatively uncommon compared to rabbits.
Guinea pig abscesses are dreadful, and these are really, really difficult. The fortunate thing is that they are much less commonly seen than in rabbits, which is great because they're much, much more difficult to treat. Part of that may just be due to the chronicity of the problem.
Part of it may well be the, probably mostly is the difficulty in removing the teeth. You have a solid block of teeth here and if you want to remove them, you're gonna have to drill them out. If you've got an incisor rap system get incisor all the way along here.
And so there's a lot of tooth to go to, but you're gonna have to drill it out too. It's not gonna, not gonna cut out like we were rabbit. The space inside the mouth to do so is also really difficult, so you are gonna have to basically in size over the affects area and then simply just drill the bone away, remove the teeth through the hole.
And that is really quite tricky, and it is going to impact more again more than a rabbits on the opposite, teeth with chewing. So by the time you got to that stage is you really have got, you know, really quite a, a poor prognosis with these and quite severe surgery to try and do something about it. The other issue too is we have you have also, you know, maybe maybe the abscess here that you're gonna have almost certainly have lots of change in the other arcades and that's gonna impact on your, on your prognosis as well.
So it's not great. Adding to that too that guinea pigs don't live as long as rabbits, . It is quite depressing how short time guinea pigs live for about 57 years it would be about typical.
And very often we can see this in 34 year old guinea pigs, and it's questionable how much extra time we're really going to, to buy for them. So very much often there's some more palliative care with them, so we might lance and flush a large abscess, a lot of analgesia involved and sometimes euthanasia because there just is nowhere to go and they're not responding to analgesia. So you're gonna run through, some soft tissue surgeries now.
We've got a few to go through, and we're gonna look at things like neutering, lump removal, the common stuff too, about thyroidectomy and cystectomy and nuculation. And we're going to talk about GDVs as well because they do get this. And I think they get this a lot more frequently get foreign bodies in the gut.
I think foreign bodies in the intestine are quite rare. Again, gut this is a little bit less common than it is in rabbits. They do get medical issues, but they.
Don't tend to get quite as many foreign bodies, perhaps they're just more sensible about what they eat. So we're gonna talk about nutrient first of all, and we'll start with the male, so. We tend to do this really as soon as they mature, so it's a few weeks old.
Now, at the same time is there actually are alternatives to this too. And if you are, are, having choice, and I think this is one of those things too about in terms of preventing disease, there's not much we're gonna preventing male guinea pigs. And all male groups can work really, really well.
They're not anywhere near as aggressive as rabbits are, and not so affected by having even an all female group nearby. So bachelor groups in guinea pigs can work pretty well, and that can actually save you the need for surgery and also in terms of like the cost benefit to a patient, it's also quite a good thing to do. In terms of technique, you know, typically, I want to do a scrotal approach, beware of that in guinea pigs, they, it doesn't work anywhere near as well.
We get a lot of problems postoperatively in, in, in male guinea pigs. One of them is herniation. We see these very wide open inguinal canals, but linked into that scrotal approach there too we may see infections.
We may very often see foreign body entering, so, that maybe things like bits of hay embedding, suture material. And we've also seen all kinds of weird reactions and even unusual fat tumours on the end of the, ligated, cord. So there are lots can happen there too.
Now that led to is a paper a few years ago, on a very small number of guinea pigs that suggested an abdominal approach was much more applicable. Now, that's great. Now, we went through a bit of a study period which we're hoping to get published at some point.
Of post castration reactions in both our guinea pigs and in those referred to us. And we, we took out the reactions where we, we said histopathology, we sent them away for, with the away for culture. And yeah, we got some true abs, we got some foreign bodies from hay going up in in the from the scrotal wounds, but we also got suture material reactions, and again, we got this peculiar, lipomas.
Now, that's fine. So, you know, if we do abdominal approach, we can certainly cut down a lot of the problems, but it's not going to remove them all. And of course, they're can be harder to spot and the consequences and the remains of dealing with them getting much more severe.
So personally, I would tend not to do an abdominal approach. In other words, don't make this an even bigger surgeon is already. So we use a pre-scrotal approach.
We adapt our technique to try and reduce these problems, . And so we go pre-scrotal a bit like we used to in dogs, bilateral, so, so an incision on each side. This means it's no longer sort of like a big opp.
It's more complicated than going through a scrotum, but it's not a big op like going abdominal. This is nice and simple though too. But because of the shape of a guinea pig, the incisions are not scraping on the floor, and I think that's the big deal with with guinea when they have scrotal incisions, is they just scrape on the floor the whole time too.
And we're also avoiding things like intraabdominal reactions. So that seems to work quite well. So here, here's a picture of doing it.
So basically got the usual, set up, with these sort of . Scrotum here. We then will make an incision just a pre-scrotal down onto the testes.
We can withdraw the testes from there. We got huge fat pads too. We got we can we'll clamp the guberne and separate it from there, and then we'll ligate the cord and fat.
I take all the fat out as well, . I'll then ligate the tunica. I'll split it up there.
I'll tend to strip it away, so I'm tying basically as cranial as possible. And I sometimes double ligated for the larger ones. So if you see something spectacular, I have operate I have castrated capybara, which is very, very large guinea pigs, and, one of those did have a, an inguinal hernia afterwards, and, that's quite dramatic.
So I tend to, I'm a bit more worried about ligating tuica, so I tend to double ligate sometimes. And afterwards I'll suture the skin. Again, was using sms, I would tend to just glue, but with the guinea pigs, I want to shut for a little bit longer and make sure they really are sealed so I don't get bits of material up up inside them.
So with suture and glue. And then the analgesia, I tend to use a lot of local anaesthetics. So these guys will have intratesticular local.
They will have, an incisional, block, and they'll also have splash block at the end. And we use meloxicam afterwards to try and reduce some, do anything with it. In terms of post-op care, we'll get people to clean the wounds daily.
Always get them to a clean bedding, so paper or vet bed, keep them inside for about 4 or 5 days, not running around ass normally a sort of like dirty hay sort of thing or with bits and pieces you have to get up there too. And make sure they do keep them inside, bring their companions with them so you don't want to isolate guinea pigs. They do not get on well with that.
And we've had good results with it, and since we changed over. We've had barely any post castration reactions. Where we have had them, it's usually, usually in herniation, because we haven't fully identified the hernia there too, but they're quite unusual.
The soon we've got away from the foreign body reactions and all that kind of material there too, so we think it's works quite well, and it's, it's a lot less complicated than going abdominally. If you do have a post castration reaction, again, what we tend to do is we, I tend to put on antibiotic and anti-inflammatory for probably 1 week, 10 days before I operate to try and bring it down in size as much as possible. And we'll again do a pre-scrotal approach and we'll simply dissect it out, .
I would stress the importance given the diversity of what we're, what what type of thing we're seeing there of sending the reaction rate for histopathology and for culture and just to see what you get back. It is quite, quite interesting what what's there. You some idea about the aetiology of it, in our case that we could touch change technique to get around it.
Where you do close, I tend to use a model of filament material, absorbable material, afterwards, rather than only wicking or or more or they get less reaction from that too, so I closed tunic and the skin with that too. And we use plenty of local anaesthetic just to reduce them by having a go at the being the wounds afterwards. And again, that seems to work quite well, very, very rarely, if ever, get a double reaction.
Where we have herniation, and this may be just occurring naturally, it's not uncommon to actually find, to open the, the tunic to get a test and you find this other stuff in there as well. So again, when you incise over the over the tunic of the testicle, just do be careful. There's nothing else there because you don't want to open a piece of gut while you're going through it.
So it does feel a bit weird then, you know, just be, be very, very, very careful opening that tunic. . So, we do see, we do see hernias too in, in guinea pigs who haven't been castrated.
We've got material passing through the canals. The canals are very, very wide, and so that's where we can be aware of it. Post-surgery is probably most common.
So what we tend to do, I'll show you a picture in a moment, I tend to open them both abdominally and also over the tunics where it's like a push and pull approach to pull everything back identify and back in. And then we can. Simply pull the the the the contents back through, if they haven't been castrated, that's great.
We, we can pull the testes into the abdomen, and that will, if I invert the tunic so we can close it properly. Otherwise, we'll grasp the tunic from within, from the, from, from within the, from the hernia and push it back through so we can actually ligate and close that abdominally and make sure that that's fully gone. As I said, it is easier for castrating at the same time.
So that's great. So here, so so the pictures we've got . Here we are very large, scrotal hernia here, incising a midline there, and this is what we end up with incision over the hernia, incision midline, and first bits and pieces too.
And as you can see in this case, we've got small intestine entering into the hernia, and we're basically identifying where it comes from, and we're pulling from here and pushing from there until everything comes through and then at the end, we're inverting the the tunic so we can tie that off. Now the case here, again, fatty material here we can just pushing them through and closing from there. So we end up with two reasonably large wounds, but, hopefully with everything thoroughly closed off and not gonna herniate again.
So you also to watch out for these are what you very commonly find at castration. These are seminal vesicles. They are massive in guinea pigs.
They're not small intestine, so, but do make sure because you see them binding the sacks. If you really are struggling to replace them. During castration, then you can hold the option of actually amputating obviously their job and they are they are secondary sexual glands.
So once you castrated their job is largely done, but you can actually remove those at the same time. So, I'm gonna mention about using exploratory midline closure, I'll tend to use 30 coated brading materials. I find them easier to work with.
I would do simple interruptive and muscle layer. I'll do fat layers as required, depending on how fat the guinea pig is, and then I'll do subcuticular, in the subcutaneous tissue just to, just to finish clothes off, usually that's going to be simple, continuous. And then finally I'll glue the skin over the top just as a belt and braces.
Some people think that glueing skin it will lead to more chewing and stuff. Perhaps it depends on the guinea pig. We don't see a big issue with it, maybe that's linked to our local usage and stuff, but again, if you're chewing at that, at least they're not chewing with stitches, which is good.
Gonna move on females before we do that, obviously, things go wrong, we may have to do caesareans and stuff too. And a few little tips, these, these are not like doing dog and cat caesareans. Guinea pigs are precocial when they're born.
They are really up for it. Definitely you can wean them at 24 hours. So, Like all surgeon I talk about, be prepared, have all your gear ready, try and minimise that time and be nice and quick and slick during the caesarean, and concentrate on the sow's health.
Normally if you have to do sarean, a sow is in a lot of trouble. There might be a pregnancy toxaemia, that might be due to, long term dystopia, but they're usually in a bit of trouble there too, so concentrate on her health though. The babies are generally pretty fine.
They're either, they're either dead, which is always very sad, and the sows in deep trouble at that point. Or you've got them live and kicking. And so rather than having lots of towels and reviving aids, very often actually what you need is a big strong box because they will be running around the table if you're not careful, they are that precocial.
But basically the only thing really I say with the with the babies is to ensure they suck and do that straight after the surgery because they, they have a sow is in problems. You may want to wean these at 24 hours like you can, but they do need some colostrum, so try and get that into them as quick as they can. Now, before we get to that stage, hopefully, we will, maybe we spade, debate too about we do a very hysterectomy ovarectomy.
They have certainly anatomical issues too. They have very short ovarian pedicals to make it difficult to sterize the ovaries for removal. They have a really short vagina and the cervix is often very close to the bladder, often we get an adhesion to the cervix and the bladder as well can be really hard to ligate just this, just, just below the, the cervix, without damaging the bladder and the ureters.
So I find it's a problem too. What we're doing is we get a cyst so that can make life more interesting with the, with the ovaries. And we also see a lot of of uterine pathologies too.
Benign tumours, malignant tumours, all kinds of stuff too. So how we approach it may depend on need. So if we have got, uterine tumour, obviously, we're gonna have to do, ovarian hysterectomy.
If we've got, simple cyst, ovarectomy should be enough. And if we're doing preventive, spaying again, I think the jury is fairly out on, . Whether that's actually a cost benefits is enough for the guinea pig to do that.
But again, what are we trying to prevent? Are we trying to prevent all tumours, are we trying to prevent cysts, so what do we need to remove? So again, we're looking at elective spade, don't forget, you know, risk that procedure, you know, 3%.
Look at the complications you might be getting from that too. Again, look at the benefits. So, you know, in terms of sys, you know.
Over 80% of sows will get this. The vast majority will show no signs. You won't see them.
We certainly don't see 80% of all sows over 18 months old, which when they get them. So, you know, bear in mind it may not need doing. They do get pymetrin and obviously you can prevent that too, but there are, we can talk about them there are other means of treating that other than surgical.
We get tumours, instances not quite known, and again, is that enough reason when you can put some very often these, most of them are benign. So you can operate later on. In terms of birth control, is there are other options available, so single sex groups work very well indeed.
And also if you're keeping, one male with a few females, you can castrate the balls a lot less invasive, surgeon operating a few animals too. If I am doing elective, Spaying, I will use ovarectomy as being less invasive and less complicated, the most. So if we're doing treatment wise, again, tend to be a variectomy, if I'm doing, CIS, because we can use and that method you either use a bilateral flank approach or midline.
I tend to use midline, I show you in this moment, a flank approach if I've got very, very large cyst, I can't move and I can't really access them very well from the midline. If I've got uterine pathology, then I'll be going for a midline ovarian hysterectomy. And here we've got a picture of what we can get, which is both sometimes got bilateral cysts, we got a really big benign uterine tumour.
Brief mention of Pymetra, again, you can spray those midline as per dog, and, again, ligate below the cervix, remove both ovaries, and they, you know, very turgid, pus filled, . You try, often not as possible as you think, because we can be more cystic, like getting a bit like do dogs can be. But actually, before you do that, try alopristone, so Aazin, with antibiotic first of all.
The aclipristone you use it 10 MB per gig, twice, 24 hours apart. And remember, you really have got to be pretty close on that 24 hours. So, we only, only an hour or two difference there to don't, don't do like morning, one day and evening, the next, it just won't work.
So if we're going to do a ovarectomy, analgesia is important, we use the Marcaine, local anaesthetic, incisional, intraperitoneal, and as a splash block, afterwards too. Use meloxicam post-op, and buprenorphine we use preoperatively and again, 4 to 5 hours post-op. We put fluid into peritoneal at the time we put the .
The Marcaine in into the abdomen, and we'll also give subcutaneous fluids out afterwards. We'll give one or two doses of trimeterm sulfonamides peritative antibiosis, and we'll get try and get the guinea pig feeding as quickly as possible afterwards, and we usually assist feeding within 1 hour of the surgery. So routine abdominal opening.
So again, I'm very paranoid what I'm going to find underneath this. So I'll always pull up, tent up the baby in the alba and cut and cut into there rather than cut down onto the abdomen. You, the the guinea pig intestines which can be right underneath there, can be very thin walled and you just don't want to touch on the scalpel.
Once we've done that, we'll, I will locate the, ovary, the key points, can you actually elevate that out of the wound. If you can, great, if you can't, you're gonna have to sort of close up and go into the flanks, and do that too. And I will use Hema clips, and I like these titanium hemoclips very much indeed.
They're made by Weck. And I usually got a nice scoop on the applicators. And what I'll do is basically, once I've isolated the ovary, I will, clip, onto the attachment onto the uterus, .
Our clips applied here as you can see. And once we, we do that, we'll we'll just clip and cut. So clips, cut, cut through the next attachment.
We now expose a bit more put we now put another clip and then we can cut the attachment. And basically as I go around the variant attachment, all right along a pedestal, I'll clip and cut, clip and cut, and until we get a final one there and we can then remove that final piece. And that's great.
I find it much easier than on other techniques, certainly much easier than than simple ligation. We have got to get right underneath there, and there's always that worry you might incorporate something else into the ligature. And that seems to work really nice and clean and just takes that over isolated away from the uterus.
. Again, the important thing about putting fluids in afterwards, just again, reduce adhesion formation, to spread our local anaesthetic around and again, of course, provide fluid therapy. And then as I mentioned before, I tend to close the linear alba in a simple interruptive fashion, before, closing the subticular layers. Brief venture of prolapses because that's sort of tie into here too, and that's many of these prolaps aren't actually prolapses.
So this is a true or vent prolapse and bit of cloicchiis normally, and normally you can replace it quite easily, maybe put a little bit of space each either side just to close it down a bit for a couple and keep things together. But often you know that most of them, in my experience tend to be these masses. We get these huge masses hang out so often if you pull them slightly, you see them on a pedestal, and these are very commonly uterine masses.
I have had a true uterine products a whole horn has come back through there, but so just be careful about checking it and don't tie it off until you're sure that really is a lump and not something like something really odd like the bladder or or part of the uterus. But if you do have something like that too, you can ligate this, you can tuck it away and everything's fine, and then you can send the mass away for histopathology and get confirmation of what you've removed. It's a little bit of a bit of .
Sort of to mass or thing or sort of heartym type of thing, while you're waiting for the results to come back. But, you know, once you find out if there's a benign tumour, you can simply wait and see, or we can do some imaging of your uterus and see if any others in there as well. So an in tissue makes about replacing or removing.
Don't forget too, if it is a true product, so it may well be underlying issues you have to sort out too. There may be metabolic, it may be space occupying inside the abdomen too. So you do have to investigate, do some imaging, do some bloods potentially and correct these.
We do see mass in other places as well and obviously one of the most common things we operate on for a guinea pig is going to be on the skin masses. If we have a mass there, we, you know, we can do our usual things. They do have things commonly, they do have nice lipomater, very often.
A lot more steatits in other species, I think, but they do have, have fat tumours. They'll also have true cysts, so follicular cysts and stuff. That's quite common, usually on the dorsum.
But again, you can need to identify those and decide how to operate and how to remove, they can be quite large. And otherwise, you know, don't forget to investigate before you go and you're going into. They do get lots of lymphomas and stuff as this aspirates from, and it's good to know what you're going into before you try and remove it.
Mammary tumours are really common again, many possibilities too. So it can be proper mammary tumours, but lipoma is very common in that mammary tissue area. And this picture here is of a lipoma.
You get mammary cysts, you get some of those get mastitis, and sometimes sometimes hypertrophy glands as well. So an FNA really is important before you go into that. Firstly, you may not need to do surgery, and secondly, you know, you want to know just what sort of, what sort of margins you're gonna take and that kind of stuff.
And certainly if you you are getting a results suggesting a tumour, then do check for metastasis in the, lungs, especially before you go in. Cystostomy is another relatively common surgery, probably less common in our hands than we used to be. I mean anybody's listened to any of the webinars on urine disease, well no, I don't tend to do so many now.
Indications really obviously are urus, but in my accounts, really only if we have actual blockage and if you like a life-threatening situation, or if we have a situation where the, we can't control the pain from a urolith medically, we are gonna have to go in and do something about that too. Otherwise, I avoid if possible because the risk of relapse afterwards and recurrence of the lithiasis is very, very common indeed. Post-op support is therefore really important.
So basically the anti-inflammatories, these are very often to correct the underlying reasons for lack of urination because your list tend to tend to occur due to urine stasis. So very often we got things like spinal arthritis or hip arthritis, something we need to do something about that too. We want to increase urine flow.
Diuresis can be used. Can be a little bit careful with furosemide, or it's about the only one we've got available most of the time. It does increase calcium excretion, that can be a problem.
So we might, if you got, . The thiazide, that's great. If you haven't, you can't.
I tend to use a lot of dandelion, because you got a nice natural diar and very potent diuretic as well. And also you increase drinking, so flavour water, you know, when you give lots of greens and things, wet them down so we're taking a lot more water with that, too, so this watering has to come out somewhere too. We use nutraceuticals, I tend to use nutricalmutrosy combination.
Try and take that information down too and also have this really important thing of stress relief. And we can do that both with with things like muttrical, but also with good husbandry, so deep litter, bedding up, with lots of hiding places, companionship, that kind of stuff. We're gonna do the surgery again, midline approach, opening the same way, theorise the bladder.
Very often you get instructions to open up the bladder on the dorsal side and flip it over. I don't do that because actually you're gonna have to then try and get the stone out and very often then right in the neck of the bladder. And be careful.
These stones can be pretty well concreted and reacted into the lining, so it can be really difficult to lift. So if you, you know, we basically reflex the the . The bladder, then you're going to often find it even more difficult to access it.
So I go into the ventral surface, because this everything is a straight line then too. So simple scalpel incision enlarged with scissors. Often the stage of the bladder wall tends to bleed a bit, often it's very thickened because it's a chronic cystitis situation too.
And then we'll also open it, I think you get some idea of the, here's the serosa, here's the mucose here, you know, see the thickness of that too. It's really quite hyperemic as well. And then we'll remove the here's we've got stone, a typical mucoid sludgy type of material alongside it was come out along as well.
So, very, very, very, very common findings within there. And then we'll close. I'll generally do a simple continuous pattern through the mucosa and then a simple continuous pattern through the serosa second layer.
And so there's some mucosa closing off there. There's our sutralo too, and then we'll do another suture on on top of it and then just close midline, simply interrupted muscle and then our subcuticular through the skin layer. Next year we're gonna talk about is thyroidectomy.
Hyperthyroidism is surprisingly common. We see several cases each year. It's in 2 guinea's 2.5 years older or more.
They, they show just like cats, weight loss, usually eating a lot, usually a massive heart rate. And very often you can actually palpate the, goitre in the throat. I think you can see on this picture here, it can be quite large, and if in doubt you can FNA and get typical sort of fluid away from that too.
To confirm, take a total thyroid measurement. Again, take a full panel as well, just to make sure there's nothing else going on at the same time. Interpretation very similar to that of cats.
And again, I suspect like cats as well, the older the animals that the, the less high the thyroid has to be before it really is significant, but just the same sort of levels work quite well in guinea pigs. Now, typically we'll start them with, with, I usual methimazole, so flimazole, thriorm or topical. I find this is not enough to fully reverse signs.
I haven't ever had a single case that's really totally responded to this. The only way I've used long term, I did use very high doses compared to what doses, and that's because a guinea pig was the most remarkable animal I've seen. It's about 13 years old.
I've never seen one that before, and at a heart murmur I didn't want to operate. And that one we controlled quite well for about 6 months, but it was. Incomplete controlled I think best say.
So typically what I'll do is I will. Just use that just to stabilise them a bit for about a couple of weeks. And alternatively radioactive iodine, you have have access to that, and there has been a couple of cases now written up of using radioactive iodine in guinea pigs.
Otherwise, once stabilised, I go onto thyroidectomy because it's simple, it's effective. Actually we have very, very, very few problems. Obviously you worry because they tend to be older animals, but, you know, as long as they're healthy enough, otherwise you're OK.
We don't seem to see the same concomitant issues as we do in cats. Not in cats, the big thing about is about unveiling renal disease. It hasn't happened so far in guinea pigs, I guess I've got to be a little bit worried about it, but don't seem to see it quite so much.
And we don't also, we tend to be unilateral problems. I have not seen issues with hypercalcemia afterwards either. But again, normally you can identify the parathyroid and you can try and leave it behind.
It's a very simple surgery, we've got a nice goitre here. We cut midline, we get that through, we identify the goitre, and we theorise it and then simply just basically dissect it away, clamp it, tie it off, and that's it. It really is a very simple subcutaneous lump, basically.
There are a few vessels around you want to avoid, but they're easily separated, nice, nice gap between them. Again, I think it's the idea here we can actually got nice tissue clamping below the goitre. Gastric torsion mentioned briefly too, this presentation is when we got an acutely unwell guinea pig, collapse, usually bloated in deep shock normally.
It usually is an acute per acute condition, very rare to have this vaguely chronic. So big deal if you do have a guinea pig, always, always, radiograph and the big clue if you've got the stomach on the right side of the body, then you'd be pretty sure you've got a torsion there. And then you have got a problem.
. So The prognosis is really, really grim. They don't do well. If you're gonna do something, you've got to operate immediately, just like in a dog, you'd have to stabilise.
You can deflate like in a dog. You can put a needle into that, just buy yourself a bit of time. You can go in there, you can untwist it, and then Pexi it to the to the abdominal wall.
The outlook is very, very poor indeed, and owners need to be informed of that too, and sometimes they decide not to go ahead with surgery. Other causes of abdominal distention, and don't forget they're not always going to be bloated, they will have fluid, they will have mass there too. So you can have ileus if you want to it is getting gas from most rare, but you can have fluid from heart disease.
That's not uncommon how how astattic fluid. So again, X-ray, ultrasound. Tap fluid for, for, for analysis if you find fluid, and if you find lumps and things, yep, you know, by all means go and do exploratory and have a look and see what we can do about it too.
This was a lymphoma case, and I think you can see just kind of see how extensive that was. And obviously once you're inside, always telling the outlook can be pretty poor and you may be unlikely to do anything about it. Moving on to another thing we do comics in mutation.
Indicators tend to be, eye tumours, chronic eye pain, or eye collapse or penetration, quite common after high high pokes and stuff. It is very similar to taking the use in rabbits, but it's much easier because you don't seem to have that really horrible, plexus of, of blood vessels just, in the dorsal part of the eye. So again, we'll tend to operate similar to that.
I tend to take the, cut away the eyelids, cut alongside the, the eye muscles, and then ligate, clamp and ligate behind and then left with this nice big socket. And I'll generally close that in two or three layers. Again, we don't seem to bleed quite as much as rabbits do, which is nice as well.
So in summary, guinea pigs can be operated on, take a lot of care regarding patient preparation and regarding sort of peri and post-operative care. And, and always make sure your analgesia is good, your fluid therapy is good, and really reduce the stress wherever possible too. And in terms of surgical technique, can be very careful about hemostasis obviously.
Be careful about your tissue handling and just make sure you're ready and your mind's clear, so you're thinking precisely, you're moving precisely. All your stuff is to hand so you can be as quick as you can be without rushing and you're not, you know, looking for stuff and prolonging procedures don't need to be and damaged tissue that way. Thank you very much for listening.