Thank you very much. Good evening, everyone. So today we are hopefully not going to have too much of a whistle stop tour on reproductive diseases in Tilonia, but, one of my main area of interests, certainly reproductive disease in reptiles in general.

So thank you very much for the introduction. So, to start with, we need to be aware that tortoises are oviparous, so they lay eggs. They are often undergo seasonal reproduction in temperate species and all year reproduction in tropical species.

So this is gonna, we need to be aware of this when we are thinking about reproductive diseases. They do not always need a male for egg production, so some females, having never had contact with a male can produce eggs, and they can do this randomly, or they can do this kind of seasonally, between them. Environmental stimulus is incredibly important, so we'll often see reproductive activity with an increase in temperature, a change in photo periods, but also changes in humidity and atmospheric pressure as well.

Female tortoises and children in general can store sperm for a significant period of time, and they've evolved to do this because in the wild there's no guarantee that they will come across a male. So even if a female has not been around a male for months to years, that doesn't necessarily mean that any eggs that they produce are necessarily going to be infertile. So sexting is incredibly important.

When we're dealing with reproductive diseases, we need to need to make sure that we know what sex the species is that we're dealing with. So with males and females, males will have a long tail, so like we can see down the bottom, this male Herman's tortoise and a female herman's tortoise, the male has a significantly longer tail than the female. They will often have a vent beyond the caracal rim, whereas females will have the vent before the carapaceal rim, so, this is the, the carapacial rim here.

And this is a really, a good diagraphic, kind of example from one of the, the tortoise pages on Facebook as to what the cloakas will often look like because immature males and females can, a little be a little bit confusing, especially when they're younger. So it's, you're gonna gonna get your, sex incorrect sexual maturity. So males will often have a concave plaster on and females will be flatter.

And then you've obviously got species specifics as well. So in certain species, males will have red irises such as the eastern box turtle, in red-eared and yellow bellied sliders, so your aquatic ellonia, they'll have, incredibly long front nails. You do still get a lot of these guys come in for nail trims with the owners thinking that they've grown extra long when actually that's completely normal for them.

A species such as Socatas will have enlarged gula scutes. So these are the scoots right underneath their chin, and they use those for kind of sparring with each other. And males of certain species are are bigger, so desert tortoises, they're larger, but, in some other species, females are larger.

So map turtles, for example, the females of the species are going to be a lot bigger. We can also, rather than relying on, kind of external characteristics, we can perform endoscopy to sex them. This is not something that is done particularly very commonly, but, sometimes with, rarer species of breeding collections that we want to know the sexes from a young age, endoscopy by the cloaca, looking into the urinary bladder and almost using that like a window to view the salamic cavity, that can sometimes, help you sex it.

Misdiagnosis is unfortunately a high possibility, and there are problems with iatrogenic trauma as well, so it's not something that we would, expect, the, the vast majority of people to, to do. And then we've obviously got radiographs as well. So if there's eggs, odds are it's a female.

So, courtship and mating behaviour. Now these are really important things to understand. They depend on the species.

We'll get a lot of head bobbing, head swaying. Certain species will stroke the females. So, your yellow bellied sliders and your red-headed sliders, for example, with those front nails, they will use them to kind of flick the faces of the females.

Apparently. They, they take that as a common. They will be, you know, biting, they will be ramming them.

But this is where it becomes a bit of a problem, because if we've got a lone female with a very persistent male, and, and those of you who have, have seen, sexually mature males, and, and those that are, that have owned them as well, you'll know that they're pretty persistent and they do not stop. And if that female is not given the space to move away. From that male or that male's not taken away from them for certain periods of time.

Over the years, it can cause quite significant damage and and will have bony changes. We've even had cases where they've had quite severe abscessation from kind of constant ramming of the females by males, but also with keeping males together over the years, they can cause quite significant damage to each other as well. So, Knowing what to expect will allow them that that you you to recommend that your owners provide the best environments for them to kind of prevent these injuries from happening.

They'll also trail the females, so they will just constantly pester them and and this where it becomes a bit of an issue with er egg laying. If you've got a male constantly harassing a female, then she can't lay her nest, then then we could be potentially prone to more issues like dystopia, but we'll get to that in a bit. They'll do things like cloacal touching, sniffing, and these can last for minutes to days, to be perfectly honest, even longer, certainly through the summer months, is that we, we can have some quite serious injuries from kind of persistent males, pestering the females.

So, a little bit about anatomy. Males have paired testicles. These are, attached to the kidneys, and they often have melanin on the surface in some species.

So when you look at them with an endoscope, they can look very, very black. They will have a single phallus, delightful picture. And it's, it's got a single groove down it, and the most important thing to know about the, the male phallus in in Tilonia is that it is used for copulation only.

It is not used for. And this comes in handy if we have, penile trauma that is being caused by an overamous male or, that it is prolapsed for some other reason become damaged. It's actually something that can be surgically removed without causing any issues to urination whatsoever.

So female anatomy, we have the clitoris. Now it looks like a very, very small version of the, of the penis, but in younger species, or younger tortoises, sorry, that it can actually be confused with the phallus, so it can confuse sexing sometimes. So being aware that females have a, a very similar but smaller organ is really important, if you have a client say, well, something's popped out of the tail, it must be a boy, not necessarily.

They've got paired ovaries. These are dorsal and the, in the dorsal cord or salamic cavity, and the size of these ovaries varies depending on where they are in their reproductive cycle. They can really take up the whole salamic cavity.

So we've got some pictures coming up that that demonstrates this. They've got the oviduct, which is caudal to the ovaries and it's suspended by the mesoarium, and there are 5 segments to this. As the, the kind of egg develops through the reproductive tract, each area of this oviduct has a different role to play.

So, follicular stasis, this is probably one of the most, complex things that we end up discussing. It is when the ovaries go, a a little bit haywire, basically. But what we need to know definitively is, is this tortoise actually in stasis or have we performed imaging, seen lots and lots of follicles, and this could quite possibly be just a snapshot in time of normal reproductive activity.

So it's taken the whole picture into account that's really, really important. Just because we've got a, a tortoise or a turtle that has got a salamic cavity full of ovaries doesn't necessarily mean that we're in follicular stasis. So you have to look at at the complete clinical picture.

So it is incredibly common. It is a failure of ovulation, so all of these follicles haven't ovulated, they haven't moved through the reproductive tract, they haven't turned into eggs. There is something that is causing this failure of ovulation.

And multiple follicles will form on those ovaries. Over time, they will become insipated, they will become necrotic, they will often rupture and then we end up with something like a yokelomittis, which, will have obviously secondary knock-on effects, causing I guess, a massive inflammatory response, . It's when we're doing surgery to, to remove these follicles, we really, if we, if we're seeing a yolkselomittis, we really should be taking, samples for, cytology, bacterial and fungal cultures.

And unfortunately, if there is evidence of a selomitis, it does hold a worse prognosis, than, than if we just had follicular stasis alone. If we've got rupture of those follicles already, then that is something that we need to be discussing with the owners. The cause is, not completely understood, not necessarily it's an unknown cause, but it tends to be very multifactorial.

So, poor husbandry is often implicated. We will see this a lot in these garden tortoises that aren't looked after appropriately, that are outside all year round, that hibernate themselves for six months of the year and have no kind of environmental. Control inappropriate heating, inappropriate lighting, diet, supplementation, that there are, there are so many things that, that, that play a role in this.

But by far, these kind of older garden tortoises that have just kind of been chucked out in the garden and left to their own devices, we will most commonly see this condition in, in, in these guys eventually. And it's something that is really difficult to get across to the owners that they've been keeping their tortoise this way for 30, 40 years, and the whole time it's been inappropriate and only now is it causing an issue when in reality it's been causing an issue for a long time and it's just, it kind of evolved into this. So, diagnosis is often based on clinical signs, so we will have a tortoise that is lethargic, is off its food, not surprising because it's entire salamic cavity will be full of, of, of follicles, so there's no room for it to eat, even if it wanted to.

We'll often see them in poor body condition, but some of the things that we'll often see as well is lameness and constipation. And we see a lot of tortoises that are kind of unwilling to use their back legs and move around appropriately, maybe because it's uncomfortable because they've got all of these follicles inside of them. And constipation again, the, we'll often see this alongside if there's lots of follicles in there that they're unable to avoid their bowels appropriately.

Imaging to diagnose is, is really helpful, so I'm very fortunate to have access to a CT scanner. Which is fantastic because you can assess the entire tortoise, not just its, the, the kind of size and shape of its follicles and the number of them, but you can see if there's evidence of a selomitis, you can assess the, the, the liver that we will often see hepatic lipiddosis alongside these guys as well. It's kind of like the, the, the gold standard.

But obviously, in most practises, everyone's got an ultrasound. And popping the, the probe in the prefemoral windows, so where the, the leg joins the, the, the body, that, that soft tissue gap. If you place the probe small enough there, then you'll be able to see these follicles that way as well.

X-rays, unfortunately, for follicular stasis are probably the least helpful, just because you're not gonna necessarily see the, the, the, the evidence of them. So this is a picture of a CT scan, and you can see the kind of lung fields and the dorsal aspect of the shower and the ventralal aspect. You've got kind of intestines and then you've got all these follicles which are different sizes and shapes and textures and and things.

So this is a a tortoise that we'll be seeing a little later. Blood samples are incredibly helpful. So, a baseline biochemistry and haematology, because swift surgical intervention is gonna be something that we're gonna need to be considering in these guys.

We wanna check that they are, they haven't got any other underlying issues, that their kidney function is as, as good as it can be before we put them under general. Anaesthetic, but also, there will be evidence of kind of elevated albumin and total proteins and and things like that that would be consistent with reproductive activity, as well as in some instances elevated white blood cell counts if we've got acilomitis, for example. So we need to determine the difference between normal reproductive activity and follicular stasis.

So obviously we've, we've touched on the clinical signs already, that's gonna be a bit of a big giveaway. And we've performed our ultrasound scan and we've seen loads of follicles, but is this a snapshot of normal reproductive activity, or is this something that we need to be a little bit more concerned about? And if my patient is otherwise well, but maybe just a bit.

Off colour, not kind of lame, constipated, significantly lethargic and anorexic. Obviously, then I would be concerned that this is a true follicular stasis. But if the tortoise is just a bit off, and it's a female in summer, and we ultrasound scanner and there's lots of follicles there, if the tortoise is stable, I would recommend repeating imaging, and, and monitoring these follicles as long as that patient is able to, to, to kind of tolerate that.

As a general rule, if we've got 50+ abnormal type follicles, and we might be leaning more towards, a follicular stasis than normal reproductive activity, especially if they're all different sizes and things, but we may need to repeat imaging. So just because there's follicles there does not necessarily mean this is follicular stasis. If you're able to monitor the patient and monitor these follicles, then you should do.

And it plus it gives you time to stabilise the patient if necessary before jumping straight into surgery. Stabilising them prior to a major procedure like this is, is essential. And if we are concerned, based on our imaging that we might have hepatic lipidosis, then it would be wise if we were performing surgery, however we perform it, we might need to consider taking biopsies of that liver.

So it's something to always discuss with your owners. So, treatments. In less advanced cases, so if we're a little bit, we've got those tortoises that we've just done the scans and we've seen that there are a few, enlarged ovaries on there and we're quite happy to monitor them, we need to make sure that the environment is as good as it can be, that we, are producing or providing them with the correct heating, the correct lighting, that they've got access to the kind of appropriate diet and supplementation.

There's a question whether the actual presence of a male, so that, that, reproductive behaviour, that ramming, that biting, and, and everything that they do, there is a, a, an idea that this could quite possibly trigger ovulation. So although we've said you need to be careful keeping your males together, your males and females together, because the male can harass us so much, while actually potentially not having a male there at all might predispose them to follicular stasis. So.

I guess if we were keeping tortoises perfectly, we maybe would have one male to a few females in a massive enclosure, with additional room for the male to be kept separate in times where the females are needing to to be reproductively active. In advanced cases, this very much depends on, on, how they are presented to the, the vetting question. So are they lethargic, anorexic?

How are they, how are their bloods looking and things? But swift surgical intervention is the main thing that we need to, to kind of head towards, and we, it is really, really important. That we need to have a stable patient beforehand to have a favourable outcome.

So giving them fluids, appropriate heating, calcium supplementation, nutritional support, and in the vast majority of the cases, we will end up performing, an ovarectomy. So we would just remove the ovaries if the rest of the oviduct is completely normal. .

In some cases, unfortunately, euthanasia should also be considered. And so if we have kind of like a critically ill patient, maybe concurrent diseases that we found on bloods, or even something that the owners aren't willing to change the environment for the better, that is something that I will be having a frank discussion about euthanasia because essentially, from my point of view, if an owner is unwilling to provide the basic care that this animal needs. Then we should not be performing this sort of surgery.

If they're not gonna provide heating and lighting and appropriate diet, then this tortoise isn't gonna have a good life after this sort of surgery, and most likely will struggle to heal appropriately without complications as well. So knowing your owner's kind of limits and how much they're willing to do is, is gonna be really helpful in deciding that is it worth putting them through this major procedure. So, dystopia.

Dystopia is post-ovulatory stasis, so this is kind of like the follow on from, the ovaries ovulating. And there are many, many causes. So we need to know, have we got ectopic eggs?

Is this an obstructive issue or is this a non-obstructive issue? And each of those have got kind of like all of the other things that that that can come off of it. So obstructive issues, we've got massive eggs, if we've got pelvic canals, stenosis, so previous fractures or trauma or, or even in some instances severe metabolic bone disease, in previous life.

If we have those tortoises that are kind of almost like pancakes, when they, when they shouldn't be, they should have a nice round dome shell. We can often see a pelvic canal collapse from that. Do they have any other obstructions that could be causing things getting in the way?

So kind of urinary stones, for example. And then with your non-obstructive, there's obviously husbandry issues, so we need to make sure that they've got the appropriate nesting sites that they've away from a male and they're actually physically allowed to, to, to lay their egg. And nutritional things like hypocal calcemia, metabolic bone disease as well as your infectious and systemic illnesses.

This can often be also seen alongside ovarian disease, just because we've kind of our ovaries have, have, ovulated and formed eggs and we're having a problem with the eggs specifically, a lot of the times when we end up going in for surgery that we've still got abnormal ovaries, in there, so we can see them alongside each other. We can often see a salpingitis, so, infection of the oviduct, when we are, when we've opened the salamic cavity and we're assessing the, reproductive tract, this is one of the things that we will be looking at and certainly with chronic, infectious processes that can cause a narrowing, of the reproductive tract, and that in itself causing a, a functional obstruction. In some instances, we can end up with an oviductal rupture.

So I've had a few cases where I've had oviduct or torsions, and, and unbeknownst to the, the vet that's been dealing with the case, he's been merrily giving, things like oxytocin and things to cause contractions of the reproductive tract to get these eggs out. It was never coming out because we had a massive torsion there and what has happened is that the oviduct is completely ruptured. We quite often have a salpingitis alongside that because of the, the, the torsion that is there and we now have a infected material entered into the salamic cavity and sometimes we can end up with a yokellomitis that way as well.

And obviously we've got the Euroimmune colonic obstructions that we mentioned before. So, diagnosis for dystopia, we need to determine that is this an advanced gravidity or is this a true dystopia? We need to, improve the environment, so in cases where the patient is stable and we have found that there are lots and lots of eggs in there, we need to make sure that our owner is providing multiple nesting areas, suitable nesting areas as well.

A, a, a tray with soil in it is not gonna do it. Just allowing the tortoise to kind of ponder around on a grassy, garden isn't going to do it. They need, ideally soil as deep as they are long, so they can really dig down a deep nest and, and, and kind of get their core into the soil to, to, to lay this nest.

So we need to make sure that they're provided with a suitable nesting sites, multiple nesting sites, and they're provided with the appropriate heating, lighting, and supplementation as, as well as hydration as well. They, like we mentioned, can retain sperm for years. So, even females that aren't currently with a male, if they have been with a male previously, then the eggs that they lay might be fertile.

In clinical signs with dystopia, again, we'll have anorexic lethargic tortoises, but we'll often see them straining. Restlessness is definitely one of the most common clinical signs that I will see. If I ever have a client call to me, call me up and say that their female tortoise is just pacing and pacing and pacing and cannot settle, that is one that I definitely want to be X-raying.

And if they're only laying one or two eggs, rather than an entire clutch, then we kind of want to be double checking what's going on there, and if they're showing signs of constipation again. You can sometimes feel the eggs, inside them. So if you pop your finger inside the prefemoral fossa, that soft tissue area by their back legs, and you, kind of tilt the tortoise up so the head is facing up and the tail is down with your finger in the prefemoral fossa, and you kind of gently rock that tortoise up and down.

Sometimes you can feel the eggs actually. Bounce against your finger, but that relies them being quite low down in the salamic cavity and almost getting ready to pass. You can definitely miss eggs that way if they're still quite high up in the reproductive tract.

But worth trying at least. And imaging is, is really, really important. So this is where we'll probably consider doing our X-rays because, eggs are gonna show up really, really well.

But CT scan, ultrasound, and endoscopy are still really important imaging modalities that we can consider. So this is a, a female tortoise that came in for, I think this was actually one of the ones that was restless. So she was pacing and pacing and pacing the garden and she'd dig a nest and then she'd wander off.

And this had been going on for actually a couple of years. She did it one year and the owner didn't think anything of it because she didn't pass any eggs and thought that was a bit strange. Came back the second year, and said that she'd done it the previous year but hadn't passed anything.

Had hibernated the. Tortoise. But as you can see with these eggs, the eggshell is incredibly thick and it's lumpy and bumpy as well.

And that's telling us that we've got kind of hyper, we've got extra calcium, being deposited there because those eggs have been in there for such a long period of time. And actually, this tortoise ultimately underwent surgery because she'd had a chronic salpingitis. And these eggs were actually adhered to the inside of the oviducts.

So they, they, they were never coming out. And we were suspicious of this, We'd given her a course of oxytocin prior to the surgery, and the eggs had not moved at all. So we, we kind of cut it off with a certain amount of medical treatment and then consider surgical intervention so we don't increase the risk of oviductal rupture and things, but we'll, we'll get to that in a second.

With regards to the imaging, we want to be considering the size, the shape, and the number of the, the eggs. Are there any anatomical, issues or are there any pelvic fractures that we need to consider, Whereabouts are the eggs in that salamic cavity, so what is their position? But also sometimes is the egg in the bladder?

And this is something that actually we see on a shockingly regular basis, actually. And you can kind of get that from the, the positioning on the X-rays. And blood samples can also be really important.

The same with pre-ovulatory follicular stasis, we'll see signs of reproductive activity with elevated proteins, and albumins and. And we'll be looking for our elevation in white blood cells to see if we've got any any sign of infection or inflammatory process and how are the rest of our organs functioning. So, treatment, again, really, really important that if our patient is stable, we need to correct any environmental deficiencies.

How are they at the right temperature? Are they provided with the right UV lighting? Are they provided with suitable areas?

And have they been just allowed time away from an amorous male who's constantly trailing that female, biting her legs, ramming her, that she just is too busy getting away from him to have time to, to lay a dig and lay a nest. You can take a female a few hours to, to really, dig the nest, lay the eggs, and bury it over over afterwards. And if she hasn't got time to do that, she'll often move on and, and the longer she does that, the longer she holds on for her eggs, the more chance we're increasing the risk of, of, of having issues.

If there are no obstructions, so if there's nothing obvious on the X-rays and we're not suspicious of that from our clinical examination or our clinical history, then we can consider alcium, calcium and oxytocin injections. We ideally would want to base calcium therapy on the bloods, but in not all instances, we're gonna be able to take baseline biochemistry. So, .

We have to be, be sensible with it. But what we would normally do, or what my general kind of protocol is, is that I would give, 3 lots of injections 90 minutes apart, as an absolute maximum. I would expect that within 90 minutes of the first injection, I would expect to be seeing the eggs.

So a lot of the time, I will, offer hospitalisation to the clients because we've got. That we can get our tortoises to to dig down. We've got big indoor enclosures that we can fill with soil for them to lay nests.

But a lot of the time I will give them a calcium and oxytocin injection, send them home if the client has got a suitable environment, and within a few hours normally, the clients will phone me back saying they've passed all the eggs. Thank you very much. If we have no movement of eggs on X-ray after calcium and oxytocin injections, and if we've got a female that is still unproductively straining, we, we need to be very careful of not continuing our calcium and oxytocin injections because we're on the risk of another ductal obstruction.

And this is exactly what happened in this case. So this was a case that that that was referred to us for dystopia, that had been given lots and lots of, of calcium and oxytocin. In fact, I think had been given about 5 or 6 injections a day for about a week.

And what had actually happened is that. That had an overduct or torsion. So, it's overduct had actually tied itself in a complete knot.

I couldn't even really fathom which bit was which. It also had, the, the development of, salpingitis as well, because of the oviductal torsion. They often come hand in hand.

But a horrible selomitis and everything is as well, and actually, on discovering what was going on inside the salonic cavity of this tortoise, we phoned the owners and they elected to euhanna on the table, unfortunately. So, again, with any surgery, we want to be stabilising the patient through therapy, nutritional support, and if your patient can take in oral fluids, then we should be encouraging that as much as possible. But in our really collapsed patients, we were going to be wanting to place intravenous catheters.

The jugular is the the main site that we want to go to, and we want to be given fluid therapy is appropriate for those guys. And surgical intervention for these, these true dystopia cases, is often implicated. So.

Sometimes we can do an overcentesis, so we can, place an otoscope up the cloaca, visualise the egg, crack it and remove it. Sometimes if that's not possible, then we've got a plastotomy, approach versus the prefemoral approach, and we will get to those now. So this is a plasttroomy approach, this is a fairly normal oviduct.

This is actually one of our receptionist tortoises who every single year without. Failed for the last 30 years, ended up needing oxytocin and calcium. We had corrected the environment as much as possible.

The, she'd actually had a fantastic setup eventually with a suit suitable calcium supplementation and everything, and, in the end she elected that rather than, continuing with the injections multiple times a year sometimes, that we would go for a a full spray, which is exactly what we did. And she's doing very well, which is great. So overcentesis, stabilise the patient, you can see a theme here.

Otoscope up the cloaca, so just like this, this, this patient is, sedated. We want to visualise the egg, crack the egg, and remove the shell and its contents. Now, the downside of this is that you're obviously cracking an egg in very delicate tissues.

So you need to be making the client aware that, well, just because we can do this doesn't mean there are a lot of issues with it, and that's the risk of potential trauma to the oviduct and infections afterwards. . It's less invasive than cutting through the shell, granted, but it's got its issues.

So plasttroomy, again, stabilise the patient. We want the patient in dorsal recumbency. We want to really scrub the shell and, and sometimes that actually can take a lot longer than the, the surgery itself, especially if these tortoises have been outside for decades.

So we've got our tortoise in dorsal recumbency, we've been scrubbing the shell, and we use a lot of sandbags to kind of partition the position the tortoise and stop it from rocking from side to side. We want to bevel the edges of the plastotomy cup with an oscillating saw. So what that means is that, we want to slightly angle it, when we're cutting it, so when we, when we put the, the bone kind of window back in place, it sits there nice, it doesn't just fall straight through to the salamic cavity again.

We want to blunt dissect the muscle off from the underside of it, so, you will have muscle attached to the underside of that shell. We want to blunt dissect it off the kind of edge that you're entering through, but leave it attached to the other side. So there's still the kind of what would be actually the most cranial muscles in this instance attached to the bone to preserve blood supply.

And what I tend to do is get a saline soaked swab, cover that bone window to kind of keep those tissues from from drying out underneath the surgical lights. We want to visualise the paramn blood vessels, so these are a little bit terrifying when you're blindly cutting through with an oscillating sore. But once you know where they are and you know you can be careful, I mean that the lateral edges you can kind of cut through fairly easily, but the cranial and caudal edge, you have to be obviously be very, very careful of these blood vessels.

It is not the end of the world. If you cut one of them, you can tie them off. In fact, tortoises have got enough contralateral circulation that you can actually tie both of them off.

It's just not ideal. So we try and preserve those as much as possible, and yeah, they're they're, they're pretty big blood vessels. We want to open the salammic membrane.

So this is the salamic membrane that we've cut through in between those two blood vessels and gently pushed them to one side. And you can see in these pictures that as soon as you open it up, you've got, quite a mottled liver on the left hand side and then a salamic cavity full of these follicles. So we use a lot of, of, of cotton buds to kind of lift these guys out and actually having a, a, a sterilised teaspoon works an absolute treat just to lift these guys up gently.

So you wanna exteriorize the area of interest, just like this, again you can see the liver just inside that salamic cavity, and those ovary, that ovary is now being exteriorized and you can kind of visualise your blood vessels really well. Hema clicks and ligatures to tie off those blood vessels and remove the follicles, so that's what we have here. And we want to flush the salamic cavity, if, if necessary, it's especially salammic cavity and salammic membrane, if there especially if there's a yokellomitis or something in there.

We want to close the salamic membranes, a simple continuous of a 4 or 5 knot, monofilament is, is the ideal way of of doing that. Fill the cavity with intrasy, so we will use intray to kind of pack over the top of the syammic membrane, and that allows kind of almost like a nice cushion for the bone, flap that you've made to go back down again. I want to replace the bone window and then we use a, a plastic, it's like a culinary, it's a, it's a dental acrylic almost that that we use.

It doesn't get hot, so whereas Technovit is what we, we always used to use, it gets very, very hot when it's curing, and we don't necessarily, we definitely don't want that because we can cause bone necrosis from that, this cooling doesn't get hot at all. So we can put that around the bone window to hold that in place and most of the clients, even, even though you've just done this, this fantastic surgery on their patient, the thing that they're worried about the most is what it looks like on the outside. So, definitely always try and keep the, the plastic nice and clean and explain to them that that can stay on there for years.

We don't need to remove it, we don't need to replace it. It might eventually fall off, but as long as that does that kind of months to years down the line once everything's all completely healed, then we're good. And a lot of the time, we will want to be considering placing a feeding tube in these guys.

A lot of them will have been anorexic for a long period of time. So, placing it while they're waking up from the anaesthetic is kind of like the, the, the best time to do it because you can guarantee that you're got access for medications, but also that you're able to, suitably give fluids and, and nutritional support as well. And postoperative radiographs to make sure that your feeding tube is in place.

So, prefemoral approach is what I tend to use now. I, I don't tend to often do, plastotomies unless I can absolutely, unless I absolutely have to. So I've got an absolutely giant egg, for example, or multiple issues that I need to kind of have better access for.

Again, stabilise the patient, dorsal recumbency, I want to tie the legs back. So this is actually one of the tortoises that, that, I ended up taking on, . She's a sulkarta that actually she was having two surgeries in this one.

She was having an ovarian hysterectomy or a salpingectomy, and she was also having a bladder stone removed. So we did all of this through the prefemoral windows. So you can tie that leg back and that really does open that prefemoral window and expose those soft tissues quite nicely.

We want to open the salammic cavity, so there's 3 layers, you've got the skin, the muscle, and then the salamic membrane. So that's where the, the hole that you will be opening, it's kind of make it as, as, as big as you can to make your life easier and I'm using a Lone Star retractor here to hold the tissues out of place. We want to exteriorize the area of interest again, so a lot of the time these patients will be on a ventilator.

The area of interest will often exteriorize itself when the, the, the ventilator kind of fills the, the, the lungs up. And a lot of the time the reproductive tract it comes spilling out of the way even if you don't necessarily want it. Again, hemo clips and ligatures to remove the reproductive tract.

So that that's exactly what we're doing here. And I want to flush the salamic cavity if it's needed. We use endoscopy, with this surgery, you can't do it without, to make sure that everything has been removed and examine the rest of the salamic cavity, appropriately.

And then we want to close the salamic membrane, we want to close the muscle, and then the skin. And rather than having a dirty great big hole cut in the shell, there's gonna be 3 or 4 sutures, and that is it. So the recovery time, if this procedure is appropriate for that, that patient, and I'm, I must stress the fact that that this procedure isn't suitable in all cases.

But if it is, the recovery period in these guys is, is fantastic. We'll often place a feeding tube, but, and do the radiographs afterwards, but in this instance, this tortoise had a much quicker recovery. So this is her eating, 6 hours after surgery.

So I took her home with me that night, she woke up really, really quickly, and yeah, that, that was her grazing that evening. So whereas the recovery for the plasttroomy approach, you, you're talking about weeks to months of, of, it's often intensive nursing and. Pain management and, a kind of environmental tweaking at home, she literally just went straight back out into the garden and, and cracked on and, and she'd had, nearly 250 gramme bladder stone removed and her entire reproductive tract and that's 6 hours after surgery.

And so that was a fantastic recovery. And not all cases are like that, granted, but definitely see a much better improvement, a much better recovery, rate with this prefemoral approach. So medical therapy, fluid therapy is essential.

We should try and get intravenous access wherever possible. It's very daunting for, for, for people to, to, to, to try and do that, but definitely the, the jugular is the place to go and practise makes perfect. We want to be considering nutritional support, so I tend to favour the Lefever's Emirate herbivore for these guys.

Antibiotics, wherever appropriate, and obviously if we have a elomitis, we should be really pushing for cultures and sensitivities, to target our antibiotic approach, and, and use our antibiotics, appropriately. Analgesics, so your opiates and your anti-inflammatories are really, really important, and Honestly, the, the environment is the key thing. If you, if we have a client that is unwilling to change things, then this is something that I will be really having a frank discussion with them and saying if, if you're not willing to provide appropriate heating, lighting, supplementation, if you're not willing to actually look after your your tortoise appropriately, there is no point in doing any of this because it is not going to help in the long run.

So, prolapses, the kind of final part of rep or semi-final part of reproductive active reproductive diseases. There so many things can prolapse in tortoises, and we need to identify the tissue that is prolapsed. Is it intestine?

Is it bladder? Is it oviduct? Is it penis?

Is it cloaca? Is it, if it's intestinal, it will have a lumen, and you'll often find faecal material associated with it, like this one. Funnily enough, this one, was euthanas, because that's quite a substantial one.

Poor thing. Of the ducts, you'll often see longitudinal striations on that tissue, and bladder is translucent and thin-walled, like this one. So you'll often see a very thin walled sac attached to it.

And this little guy actually, had a, a, a bladder stone. So he was straining and straining and straining and actually prolapsed part of his bladder, and the bladder stone was anchoring the rest of it inside the poor little thing. And then the clitoris and the penis are obviously very obvious from the pictures that we showed earlier.

So this is a male tortoise with a penile prolapse. It's grossly edematous. This one actually had quite severe metabolic bone disease, and we suspect that it had prolapsed its penis due to hypocalcemia.

But we always, always, always need to find the underlying reason. It's no good popping the thing back in that shouldn't be out and closing the cloaca and hoping for the best. You, you're not fixing the underlying reason, so we need to be considering doing bloods, imaging, taking an appropriate history, both from a specifically from the environmental point of view, how is it kept, have we done parasite testing because things like hypocalcemia, hypersexual behaviour, obstructions and impactions, dystopia and parasites are all gonna be underlying reasons that we could quite possibly be dealing with.

A lot of the time. I will get male tortoises brought in for a prolapsed penis, and by the time it comes to me in the hospital, it's gone. Unfortunately, male tortoises, we, we've already established that they're a bit of a sex pest.

They don't necessarily need a female to kind of, to, to cause a hassle. They will do what's called flashing when they're sexually. Mature, so they will get their penis in and out on a regular basis.

And a lot of the time the owners have never seen this before. They completely freak, they Google it. It must be a prolapse.

They bring it in, it's gone away. So we have to establish that is this a tissue that is permanently staying out, or is it one that's kind of going backwards and forwards, and we need to monitor it if that's the case. So treatment wise.

We need to differentiate a temporary protrusion from a prolapse that we just mentioned. We need to keep it clean, warm, clean water is best, use a hypertonic solution, so a a a glucose solution and even a cold compress to cause vasoconstriction. We want to keep it moist.

So what I'll actually do is, is mix a glucose solution with KY jelly, and it holds it in place a lot longer and often wrap the area in clingfilm or, or wrap the actual, the caudal part of the, the tortoise in clingfilm to kind of hold it in place for a while, and it works really, really well actually. We want to replace it, obviously, if the tissue is viable. And purse string sutures in, in these guys is actually something that we wouldn't necessarily recommend anymore.

We actually recommend two simple interrupted sutures either side of the cloaca instead. And we can remove some of the tissues. So obviously we're only going to be removing the the the the tissue that is non-essential.

So this is a tortoise that has had its penis amputated. Again, it is just used for copulation, it is not used for urination, and yeah, they are better off without it if it's gonna keep falling out. So in some instances, unfortunately, we also do have to consider euthanasia, especially if we've got kind of large amounts of necrotic tissue, or again if if owners are unwilling to change the environment and this is something that the, if the environment is exacerbating this situation, it's likely to happen again.

So, finally, neoplasia. It is not common. The, the tumours that we will often see tend to be things like ovaria adenocarcinomas, ovarian teratomas.

I actually see that more in iguanas, to be honest. Granulosa cell tumours, oviductal adenocarcinomas, ladig cell tumours, and the diagnosis, unfortunately, is often on postmortem. We'll maybe find a lot of these on endoscopy, but a lot of the time it is, postmortem.

Amnesia, neoplasia should always be a differential, but realistically it's gonna be a lot further down on your differential list. That's it, all done. Perfect, thank you very much, Sonia, absolutely brilliant talk, really, really impressive and some great photos in there.

So we do have a couple of questions. So the first one, where do you purchase the retractor and what is it called again? It's called a Lone Star retractor, and I'm not gonna be a very helpful answer.

Our our delightful pharmacist Amy orders everything for me and I have no idea where they come from. So I, I, it's really not very helpful and I'm sorry. I imagine.

Veterinary instruments or something like that is probably a place that we would get that from. We're a CVS practise, so, we order everything through MVS or, or them, and it rocks up. So I imagine one of those.

But Lone Star retractor is, is, is what it's called. And honestly, for any, any sort of soft tissue surgery in any small patient, it is an absolute lifesaver, because it's gonna hold those very delicate tissues out of the way, especially in a, in reptiles, like I use it for pretty much every single surgery. Perfect.

And then somebody else is asking, can you use local blocks on the plastroomy area? Yeah, yeah, so actually, yeah, that's, something that I've completely forgotten to mention. That's something that we, we would normally do.

So we would do a, a splash block, on, on that area with, like a lidocaine grouppivocaine mix. So we would do that. And honestly, in, in, we, we use local anaesthesia for a significant proportion of any.

Of our reptile surgeries, even when we're doing something as simple as endoscopy, we'll put a local block there, just underneath our incision line to try and keep things as comfortable as possible. So actually, local anaesthesia in, in reptiles, we, we pretty much use it in every single surgery in one form or another. Oh, brilliant.

Yeah, local anaesthetic is not something that you ever think about when it comes to exotics. You kind of, yeah, sure, yeah, how commonly they were used. It's really interesting to know that they are used quite a lot.

De definitely in our, in our reptile and mammalian surgeries, pretty much every single one with our our Avian stuff, we have to be a lot more careful with it because their, their, their, their tolerance for local anaesthetics is is not great and they've. Got a very narrow therapeutic margin, so it, it, you can actually overdose birds very easily with it, but certainly for, for the reptiles that, that, that I, I, I predominantly deal with, and certainly, even our routine mammalian surgeries, like our neuterings then definitely postoperative, issues very much minimalized with with using it a lot. Brilliant.

And then another question about Astosia, how many, how many cases occur and what proportion are asso associated with poor husbandry? Pretty much all of them, if I'm perfectly honest, so, . There will be some degree of environmental deficiency in pretty much every single case of dystopia that we see.

It is whether that is inappropriate nesting, an overamorous male, or whether that tortoise has been grown inappropriately has had severe metabolic bone disease and then pelvic collapse and the deformed shell as a result of that, or hypocalcemia because they're not given appropriate lighting and heating and supplementation. It's very, very rare for me to find a true case of dystopia that doesn't have something wrong in the environment. It might not necessarily be completely horrendous, but some think we need a little bit of a tweak.

It, it definitely tends to be these garden tortoises that, well, it's lived outside for 40 years, it couldn't possibly be that. It, but they do tend to be the ones that, that eventually have issues, no matter what the age. We had one actually today that was pushing 100 that, we had to help her with her eggs and she's still laying, so they, they, they don't seem to stop, bless them.

Wow. That's such a shame given that it's something that's so easily prevented. It is, it's it's really, really sad.

I'm pleased to say that I actually don't have many of these garden tortoises anymore. A lot of my clients, are, are really on board and up to date with, with kind of having heating and lighting outside, which is actually fairly straightforward and safe to do. It, it's.

Pretty, pretty rare for me to have a, a true garden tortoise that they kind of still feed it cat food and, and God knows what else. That, that doesn't happen very often, but when it does, they're normally unwilling to do anything about it. So it's.

Yeah, I can imagine. And we have one other question, what are you using as a premedication for tortoise ovarian ovarectomy? Yeah, so, we will have our patients in 24 hours before, so we have them, in the night before, making sure that, that we definitely have them at the appropriate heat and provide them with the appropriate lighting as well.

We will place our intravenous catheter and we will give them, . Morphine beforehand. So they have, I think we normally use about 1 mg per gig of morphine, and we get that on board 24 hours before the surgery and it can be given every 24 hours.

But we know that that patient is being kept at the appropriate heat and UV, appropriate temperature to make those medications work. In my opinion, there's no point in having a tortoise that you know lives out in the garden or doesn't have the appropriate heating and lighting. Get it admitted that morning, give it the jab of in the, the, the, the jab of medication, and expect that pre-medication to work in an appropriate way.

So we have ours in and we make sure that they're nice and warm to have those medications work. We also give combinations of, an alpha 2, so we use dexameddoomidine. intravenously or, or intramuscular, depending on whether we've got a catheter in place, alongside our opioids, and then we, induce with alfaxolone.

I pretty much use ourfaxan for, for pretty much all of my inductions now. And, and then, yeah, there, it's. Using the, the, the, the, the kind of combination, the, the pre-medication with the alpha 2, the opiates and the alfaxan will massively decrease the amount of iO, or ISO that you end up keeping these patients on during the surgery, so it's, it is a much smoother anaesthetic.

Perfect. Is it quite tricky to intubate these patients? Honestly, really easy actually.

So they, they've got a, a, a really open glottis. So if you open a tortoise's mouth and you look at the base of the tongue, their airway will literally be opening and closing at you. So actually they're, they're really easy to intubate.

The, the main thing that you need to bear in mind is that the tortoise's trachea bifurcates about halfway down the neck. So if you put a really long tube in there and you kind of push it to where you think the lungs would, would be or or where you sort of imagine it to be in other species where you would place the tube, you're quite possibly only gonna be, intubating one side of that bifurcated trachea. So in these guys, you actually use a lot shorter tube than you would ever think of, of using.

You you kind of don't want that tube to go any further than halfway down that tortoise's neck, so you can ventilate them appropriately. Yeah. Oh, brilliant.

Lovely, and we've had plenty of comments coming through saying how good the talk has been. And there's just one more, which is saying, is there a good reference book for husbandry for different species? Not quite.

There, there, there's, I mean, everyone always argues about it, doesn't it? So the, the, the, the, I haven't. I haven't actually fully read the new BSAVA reptile book yet, which my friends were part of writing it, so we were very, very upset about hearing, but I imagine that would be a very good go to one and there's also, there's a medicine and surgery of tortoises and turtles, by, .

Stuart McArthur, that is a very good textbook and it's sort of like kind of like my go to Bible that's got some good information in there. The same for, the reptile medicine and surgery textbook by Doug Mader, that's a very good textbook too. But honestly it's a lot of A lot of websites and things that can be very, very helpful.

The, the Tortoise Trust, is a very, very good one. There's a lot of, of, of information on there, up to-date information as, as well, that can be very, very helpful. So the, the Tortoise, Trust website is a great one to go to.

Brilliant. That seems to be the last of the questions. It's an absolutely brilliant webinar, really interesting topic.

So thank you so much for delivering such a great webinar this evening. Thank you to all of the listeners and thank you for being so engaging, asking so many questions. It's great to have people participating, and thank you to you, Sonia, for delivering such a great webinar.

Great, welcome. Thank you very much. Thank you very much.

Bye bye. Bye.