Hello, everybody, dear colleagues, wherever you are around the globe. Hope you stay safe and healthy during this pandemic that our world is suffering from. I'm Doctor Stefanos Slavakis.
I'm from Thessaloniki, Greece. I'm the head of the veterinary referral clinic of C Army Veterinary Hospital and also working in private practise at Veterinary referral Surgery centre. Currently, I'm the president of the Lending Panamal Veteran Society.
And before starting this lecture, I'd like to thank the organisers of VC 2021 and Anthony Chadwick, the webinar vet, for inviting me to speak in this global veterinary event. In the next one hour, I will try to share with you my knowledge about Spain and uterine complications. Believe me, they exist.
Let's see the outline of the, today's webinar. We will start talking about the top Spa complications. I'll try to give you some prevention tips.
We'll finally talk about when it's the best age. For an animal to be spayed or neutered and finally, before saying goodbye, we will wrap up what things we said. I always try to talk about principles of surgery before starting a surgery lecture, and it's very important for me to remind you what William Tur Halston, a human surgeon back in 1890, if I recall, shared with us.
He asked, he asked from us to handle issues gently, to arrest all bleeding, to leave the blood supply intact, to Adhere to strict as sepsis during surgery to make sure that we oppose tissues nicely without tension and without dead space. These are very critical things that we always when going to the OR, we have to remember and stay focused with them. So the top spa other complications that we're going to talk about are in seasonal complications, intraabdominal haemorrhoids, scrotal hematoma, postoperative pain, surgical errors, and hormonal changes.
Starting with in seasonal complications, we more often see those in cats and dogs weighing more than 20 kg. We see in seasonal or scrotal swelling, pain, redness, seromas, possibly the hiss. Hernias, dermatitis around the incision and skin bruising.
The question is, can we prevent them from happening? We certainly cannot avoid them, but if we are efficiently fast, and if we use appropriate surgical techniques, And stay very close to what Halsted. Taught us that we should do as surgeons.
The complications rate would be. Minimum. So be gentle with tissues, leave no dead space, be aseptic.
This is very critical. What about intraabdominal haemorrhage? Depending on the paper you read, this may come in a percentage up to 11%.
We see it more often in dogs weighing more than 20 kg. And rarely in cats because the ovarian pedicles in cats are small, less vascular, and more mobile than dogs, meaning that it's easier for us to isolate them from the abdominal cavity, perform the ligations, send them back, and go home safely. One thing that we should always take care of students.
When students are performing this kind of operations, this kind of procedures, a senior surgeon has to be with them and help them and guide them through the procedure in order to avoid this kind of mistakes that would lead to haemorrhage intraabdominally. But why is this happening? This is happening because we are dealing with the tissues roughly.
We're handling them roughly. Maybe we lacerate the spleen during our initial incision either with our scalpel blade or by using the spay hook or even for those who are doing laparoscopy, when they're trying to establish the pneumo peritoneum. It may be caused due to a poor ligation technique or inexperience or Due to inadequate exposure and this brings up the dilemma or the question if you prefer, Should I do a small incision or a large incision to do a spade.
Well, my answer to that is that we should do an adequate incision, and we have two landmarks for that. We have the umbilicus and we have the cranial border of pubic synthesis. If we divide this distance in 3 equal thirds, then we can use the green.
Third for a virus ectomy of a female adult cat, and the yellow 1, 3rd, the crino 3 for a virus sterectomy for a female adult dog. There is no need to go to the red zone. If we're talking about a puppy, a female puppy, you can use.
The blue zone. Stay ad here to the zones, it will, it will help you do your ovarro hysterectomy very easily. Now, When entering the abdominal cavity, I'd like to do this in a safe manner, and after my initial incision, We try always to stay in the middle.
We try to identify the line alba. Grab the linealba with a thumb forcep in size, do a stub incision with a 15 blade, and then we insert a group director and then with our scalpel, we are doing this cut. Following the group.
In this way, we are certain, certain that there is nothing. Underneath the linear alba that may be lacerated like the spleen. This is a very easy way of safely entering the abdominal cavity.
But if we have an abdominal Emirates, how can we fix it? Intraabdominal haemorrhage should be recognised and addressed prior to closure. But what if it happens postoperatively?
In this case, we have a patient who is Recovering from anaesthesia very slowly. Probably his tachycardic, hypothermic, maybe having pale mucous membranes, we have to make our diagnosis either by ultrasound or abdominal centesis. If during abdominal centesis, we retrieve not clotting blood, that confirms our diagnosis that we have an intraabdominal haemorrhage and how should we treat this haemorrhoids.
Conservatively, placing an abdominal bandage, possibly sedating our patient, and further monitoring the patient. No, I think that exploratory surgery is the key. So we go back, we extend our decision, so we have an adequate exposure of the abdominal contents.
We check all the ligatures, and if we have any doubt, we perform ligations from the very beginning, and that's it. This is the standard way of performing a virus ectomy as described in Surgical textbooks. Probably this is the way that all of you, including myself, are doing this operation until today.
Take care one removing the ovaries to open the el bursa in order to be certain that the ovary is all in this place. If you leave residual ovarian tissue. Probably in the future you will have an ovarian remnant syndrome and possibly a stomp pyometra.
We don't want this to happen. After ligating the ovarian pedicles, You can use your cutlery or Do a couple of ligatures to the broad ligament, then. One more ligature at the point where the uterus meets the cervix, the body of the uterus meets the cervix, you cut.
You're done and you're closed. This case is a pymetra, same things happen here. The only difference is that If you want to work easy, you should remove.
You can choose of the. Abdominal cavity and It's easier for the surgeon then to do his ligations and manipulate the field. In cats, You can use if you want the 3 climb technique.
Or you can do a pedicle time. Both are accessible and we can always do what we prefer to do. No problem.
But how can we deal with this Emirates during surgery? There are a couple of manoeuvres that we can do in order to find the ovarian pedicles. And be certain that there is no hammorrhage there and if it is, To solve the problem.
So the first thing we do is the duodenum manoeuvre, and by this manoeuvre, we move the miso duodenum to the midline. And that leaves a good space for us to find the right ovary or the right ovar pedicle. If there is an haemorrhage there, you use your forcep, you grab the arm and pedicle, you put.
A clamp beneath and, and your ligature and you're done. That's how you deal with the right ovary. In this case, that was an interesting case because we, as you can probably see here, was an ulcer in the Duodenum that we Pressing up and close together with your vasectomy.
One more manoeuvre that is very useful is the colonic manoeuvre, and this is very useful because it helps us identify the left ovary or the left ovarian pedicle. Very easily we grasp the column we Bringing the column in the midline and the left abdominal cavity is free for us for inspection. We're not done yet.
Retract the the urinary bloodcholy, inspect both ureters, urine stump, the ligated uterine arteries, and the cervix, and then you're done. This is how you can address any haemorrhage that may happen in the abdominal cavity during the space. But Sometimes we're not talking about females who also have male dogs.
Another Going to surgery to remove an abdominal testicle because they are cryptoid. Same principles for the surgery too. We remove the testicle from the abdominal cavity.
We're putting our ligations and we're done. If any haemorrhage is not it, then we do the same things as we did with. The female dogs.
I like to do the Miller not. Makes me feel safe and sleeping easier at night. I am doing this many years now, and this is how I advise you to do this.
This is what I teach my junior vets. At the hospital, in the dry lab. I'm using a Penrose drain to resemble an ovary.
And you can use this not either with an non-absorbable feature, a multifilament, sorry, switch, or monofilament switch depending on what you have available, no problem. You can use Micro, for example, you could use Maxon, PDS. Whoever suits you.
Tie the knot, do at least 2 square knots. And you're done. Then you release the clamp.
We check the pedicle for any haemorrhage, of course, in this dry lab, there is no haemorrhage. And then you send the pedicle back in the abdominal cavity. You're done.
Now let's see how this works in real life. Amelia's not in a like surgery. We're making a window to the broad ligaments.
We're putting our first carmel clamp, one clump, one click. The 2nd clamp Two clicks. The 3rd clamp 3 clicks.
This is a three clamp technique. Then we use our scalpel, blade or scissors, whatever you prefer to cut just beneath the third clamp. As shown here.
You can use a sponge to make the field even more. Clear And then you're putting your Suture This is viral, if I recall. And doing your Miller's not.
You can tie the knot either by instrument tie or a hand tie, whatever makes you feel comfortable. Tie the knot And then do at least 2 square knots in order to secure. The final night.
You're done. Grasp your seizures. Cut With friends And then grasp your thumb forcep.
And Go back to the pedicle, grasp the pedicle. As shown In the video, Release the caramal forcep, check for haemorrhage and leave the pedicle to go back in its position in the abdominal cavity. Same thing happens at the point where the body of the uterus meets the cervix, put the caramal forcep.
To make an impression. And use your suture. Say again, it's A multi-filament suture or a monofilament suture.
It's your preference, what they're gonna use. At this point you can release the forcep and you will see that the suture will go at the point where the impression was made. Tie the knot with 2 square knots, and you're done.
At this point I use an instrument tie. And 3 square knots. Sorry, 4, that's it.
You cut Check for haemorrhage and you're done. Replace In the abdominal cavity and go on with your closure. Scrotal hematoma.
There are 2 techniques performing castration in in dogs. It's the open technique. And the close technique, whatever suits you.
Both work fine. Same thing with cats, and open technique with tomcats, and open technique, a closed technique, wherever you do. My preference is the open technique.
No matter what, you can do whatever you prefer to do. There's a study where in 437 cases of male dogs that were neutered after 6 months old, with either a pre-scrotal or scrotal codes, 16% of them developed a scrotal hematoma. Scrotal hematoma is more commonly seen in larger dogs, and the bleeding comes from the tunics or the sinus tissue.
And if not treated, it may lead to abscessation, scrotal necrosis, and scrotal necrosis necessitates scrotal ablation. And if a scrotal ablation is needed to be done, Remember that It's very, this small tip that I will give you, once you remove the scrotum and you make your final switch, at this point, there is some tension. So in order to avoid this tension, It's very good to remember that you should cut.
This quotum At the point where it meets. The skin. In this way, You will have no tension when you close the wound.
Small t. Now, how you treat choral hematoma with local pressure, ice packs, possibly sedation and of course exercise restriction for the patient. OK, you can use some PCP checks in order to be certain that the matter is not dropping.
And usually resolves in a few days or no more than a couple of weeks. Post-operative pain, hmm. I hope that if you ask you if you administer analgesia for Spain your procedures, you will be at the always group.
And I'm saying this before, pain is not our friend, and we do not want our patients after surgery to be in pain. We want them to be pain free so they can eat. And act nicely from the very beginning.
This is very important if we want them to heal properly. 12% Of clinicians do not administer postoperative analgesics or Administer only burophrenil, which has insufficient analgesic effects, and that is a problem. Is there a reason why we're treating this postoperative pain inadequately?
Well, maybe there is some lack of access to appropriate drugs or maybe. We are considered the additional cost that these drugs may pose. Or there's an insufficient knowledge of pharmacology.
Or pain detection and of course in cats, we do know that pain is often underestimated. And of course, if you read the literature, you will find some papers showing differences between how clinicians think about pain. But if you have an owner that noticed that his animal, his pet is lethargic or has restlessness or vocalisation or not eating well postoperatively, believe me, these all are indications for administration of analgesia.
WCVA Global Pain Council has made some nice work here and established some pain management protocols for castration and ovarectomy or ovarectomy depending on what you do for dogs and cats with controlled drugs or with limited availability of drugs. You can find those at the WCVA website. Read them, you will find some very useful tips and resources here that you can help, yeah, that they can help you during your, your, procedures.
This is a new one. This is a very nice thing. This is the feline green mass scale.
This is an assessment of acute pain in cats based on changes in facial expressions, and this great work. Has been instituted by Professor Paullosteal from University of Montreal and his team. What they have done, they have established 5 action units that they score with 01 or number 2, depending what, what's the finding as shown here.
And if the final score of these 5 action units, the air position, the orbital tightening, the muscle tension, the whiskers position, and the head position, if the score is above 4, This is What they need to provide analgesia to the cat. This is a very nice tool that you should check and use. In our, web page and in our Facebook page of our society page, there is a nice podcast where Professor Steal explains, this work on facial expression, .
To our colleagues and I certainly invite you to check this if you like to hear from power, how this works. These are some useful web links that you can reach and see things about analgesia and small animals during sterilisation techniques, . They're all free to everybody of us, to all vets around the globe, and can be easily reached from our computers.
Now, the take home message multimodal analgesia. This is an invaluable part of management of all surgical procedures, including spay and utter and Pain management should start before, pre-operatively, during the operation, and continued postoperatively as needed by the patient. Very, very, very important.
Surgical errors. Hmm. We don't want them to happen, of course, but Surgical errors may happen.
We may have incisional hernias impedance is very low, of course. Has shown in the current literature, surgical side infections. Retain foreign bodies, either sponges or instruments.
The ovarian remnant syndrome, remember at the first slides, if you, if we forget. An ovary inside the abdominal cavity or some ovarian tissue in an ovarian pedicle, then an ovarian remnant syndrome and possibly a stumpymetra may occur. Fistulas and pedicle granulomas due to the usage of materials like cutgut or silk for our ligations, accidentally ligating the ureters.
At the point where we ligating the uterine arteries or even prostatectomy has been reported. While searching the abdominal cavity for an abdominal testicle. Oh.
Why is it happening? This may happen because we have insufficient anatomic exposure, and that means we have made a small incision. Or we have an inadequate tissue recognition as it happens routinely in obese animals.
Or it is just a lack of, of attention or inexperience or overconfidence or overspeed or even fatigue or burnout. Or finally we have a patient who is not sleeping well, and he's an anaesthesia challenge. In all these cases, a surgical error may easily be done.
You can see here Two pictures of ovarian remnant syndrome. At this one, this is from a cat. And the big one, this is the sammymitra and the ovarian remnants from both left and right pedicles.
Of a bull mastiff. Surgical side infections are reported in the literature when talking about pain or neutering in low percentages, similar rates reported for clean elective procedures, and I would like to remind you that spaying in neuter. Procedures are clean elective procedures.
So, the percentages, in our practises if are At these numbers is OK, but if these numbers. Are rising, then we should go back and see what's wrong and Is there a way for us to prevent the surgical side infections where Well, we need to see at least 3 things. First of all, how we prepare the patient.
How our team worked during surgery and how do we prepare our surgical team and of course, How the operating room has been working. It's been shown that using acid wound dressings, for at least 2 days postoperatively, is very, very, very useful in reducing surgical site infection rates. By protecting the initial abdominal wound.
Of course, antibiotics are not a substitute to incomplete surgical preparation of our patients, or if we are using inadequate surgical techniques, and it should be used if necessary precaution. Oh yes, Eas. Are also very rare.
Less than 1% is reported in the literature. The good part here is that we can identify the problem by the time of its occurrence. If the hernia occurs in the first week after surgery, then this is possibly due to a technical error.
We either missed the external recti fascia or we have been using a suture size or material that was inappropriate. All the steps or bytes we have with the sutures were inadequate or we just had a suture or not failure. But if these ears happened, happening after the first week.
Then it's possibly patient related and that means that you have a patient with a reduced healing ability due to initialpression if you have a patient who's receiving steroids, for example, or a patient who hasn't been eating well and he's hypoalbuminemic. Is there a way for us to Make this percentage even lower. Yes, let's talk about the sutures that we use for suring the abdominal cavity and performing ligations.
Well, I like to use absorbable sutures like polydioxinone and polyglyconate or for closing the abdominal cavity, you can also use a non-absorbable suture like polypropylene, and the right size depends. On the weight of the animal, and this is a useful guide that It is widely accepted by surgeons about the size of the suture that used to use depending on the weight of your Patient. Now, this is a very interesting case of a German shepherd dog, 7 years old, if I remember well, that was spayed when he was 2 years old.
And during these 5 years, Had some GI problems. And couldn't gain weight. Well, when this dog was referred to us, We need some Abdominal checking, palpation, ultrasound, and we found What was proved to be a granuloma, and this was a gas sponge.
This is a foreign body. And you can see how this granuloma was formed. It's very impressive.
Is there a way for us to Not to, to see how we can prevent this from happening. Well, This is a sponges, and some of them have. Radio markers, resolution, radio pack markers.
So we have to use the radio pack marker sponges, either laroom sponges or The smaller ones, and always do a sponge count before starting the surgery and after the end in order to be certain that there is no sponge left behind. Let's talk now about hormonal changes. Hormonal changes that have been associated with Spaniard procedures are obesity, urinary incontinence, neoplasia, and joint diseases.
Let's talk about obesity. We do know that by removing the hormones, the ovaries, and the testicles, metabolism changes. And we have an increased consumption of food.
If this is combined with reduced activity levels, then it's very easy to understand how obesity. Comes up. So we must advise.
Pet owners to adjust food intake and activity level, and we must encourage them to regularly visit us. So we can Do the body condition score. And let them know if everything is OK or if they need to make adjustments.
Don't forget that obesity may exacerbate systemic illnesses like osteoarthritis. So it's something that we don't want to happen. But he does.
Urinary incontinence. One more thing that we usually talk about very rare for the intact female dogs, less than 1%, but it seems that it can be as high as 20% for spayed female dogs. The clinical signs may start early after.
The spa Even 4 weeks, a month after pay, or even 10 years postoperatively. And if you ask me if ages pay counts, I will tell you yes. And no, depending on the paper that we read.
What we do know for sure though, is that there is an increased risk for spayed female dogs weighing more than 50 kg. We should always keep in mind that for females of small breeds, these are at increased risk for panit mammary neoplasia instead of urinary incontinence. That means that if we need to decide when and if we should perform a spa on neuter at.
Decisions should be balanced based on risks versus the benefits, and these are things that we must discuss with the owners. At this point, I'd like to remind you of this correlation between palmeron and mammal neoplasia with hit at pay. Risk of mammary neoplasia is 0.5% if hits at pay have never been done.
No hits. If the dog had been in heat ones, the risk of mammal neoplasa is 8% and It can be as high as 40% for dogs more than 2.5 years old, haven't been in heat for more than 2 times.
We all know that. How we treat urine incontinence. I think that what you see here from the small animal formula of BSAVA, the fein propanolamine is the treatment of choice.
This is our number one drug for treating urinary incontinence. You can see the usual dosages has a success rate of approximately 50, 90% in spayed female dogs. Choice number 2 we have is istriol.
61% of dogs are successfully treated with this. 22% of dogs are improved, that makes an overall of 83%. But This is our choice number 2.
Choice number 1 final proper no mean, choice number 2 S. Joint disorders. Is there a correlation?
Well, we do know that for large and giant breed dogs like the golden retrievers, the German shepherds, the Rottweilers, they are at greater risk for morbidity or mortality from joint disorders, neoplasia, and uterary incontinence due to young AIDS, spa or uterus. Especially if this procedures have been performed when these dogs were under 6 months old. This has been shown to increase the incidence of joint disorders in large breed dogs by 2 to 5 times more than the intact dogs, and on the on the nearby table, you can see this.
Gonotectomy and incidence of joint disorders. For example, in golden retrievers, this is a paper of 2014 where we had some neutered males and they're 6 months old, where the incident was found as high as 27%, 1 in intact, adult males, the incident was only 5%. So there's a big difference.
That we should know about. Neoplasia. We do know that Spain usually prevents from uterine ovarian, and testicular tumours.
We do know that castration treats successfully perianal gland tumours in male dogs. We also know that varioussterectomy protects against vaginal leomyomas, and we have already discussed how the mammary tumour risk is combining with the timing of space. But we do know also that Spain uterus may be associated with an increased risk for certain cancers like hemangiosarcoma, osteosarcoma, and transitional cell carcinoma.
There is a strong evidence for that for the large breed dogs, but of course, because some data in the literature are controversial, and make some conflicts, we need some more research to be more certain and I believe that there is. Research, running at the moment we speak. There's a paperback from 2002, from Cole, from Cole where in a population of 683 Rottweilers, 12.6% of those were diagnosed with osteosarcoma.
And for those that were spayed or neutered and 1 year of age, they had tripled. The risk to develop osteosarcoma, very huge numbers. Of course, we have to keep in mind that sterilisations.
Offer an increased life expectancy and that is Maybe why we have more neoplasia cases. We always should keep this in our minds too, but it seems that the layingspan neutrus until physical maturity comes, seems in favour of large breed dogs. What is happening in cats?
Well, the only hormonal change that has been established and we do know that actually happens in cats is the fact that the a sterilisations, they increase their body weight and they probably get obese. In many countries, early Spain usually is acceptable, . In in the United States, there is an initiative with felafix5.org where owners are encouraged to bring their pets for fixing before the age of 5 months.
We do know that if cards are spayed or neuter under the age of 7, y closure, 7 months, y closure will delay, and this will probably places an additional risk for fractures. Keep this in mind when you're consulting the owners of the optimal age for, fixing their cats. And about longevity, keep in mind that there's a paper, a report from 2013 for brownfield State of Pett Hill from a population of half a million cats, approximately were sterilised, sterilised females live for approximately 13 years.
And at the same time the entirefemales live approximately 9 years, so We can see that sterilisation offers the GVD so some of the, of what is happening may be due to that. This is a very nice paper for UC Davis published July 2020 in the front end of Science. Our colleagues there, what they did, they tried to associate it, joint disorders, cancers, and urinary incontinence.
Cases and they try to make us, to assist us to make the decision which is the best age to neuter 35 different breed, breeds of dogs. Well, if you read this paper and I will show you an example in the next slide. You can definitely understand that there is no optimal age for all.
One size does not fit all and Although timing of Spanure may play a role in the development of certain diseases, patient genetics and environmental factors are likely to be equally, if not more important. If you read this paper, you will see, for example, that researchers recommend for a boxer from a Durban shepherd to a male one to be neutered beyond 2 years of age. Same thing with the female boxer or the female German shepherd.
But if you talk for a cocker spaniel, a male cock cocker spaniel, this should be neutered after 6 months of age. But the female cocker spaniel after the 2 years of age. For a golden retriever.
They proposed that the males should be neutered beyond one year. And for the females, they recommend to leave them intact or stay them at one year and remain vigilant for the cancers. So you see that there are some differences.
Between breeds that we should take into account. This is a very nice study. Hopefully in the future we will have more of them with bigger, population or with, more breeds, and we could probably have better results to share and to talk with our clients.
So if Someone asked us, spay neuter, when we have to discuss with the owners the pros and cons of spaying muttering. The optimal age may vary among species and among breeds, but I think that we do have a consensus that when it comes to dogs, for male dogs, we should agree that they should be spayed. Beyond, it should be neutered beyond their physical maturity, that means at least after 12 months of age, for females between 1st and 2nd heat and for large breeds.
After one year. 4 cats Beyond 7 months, but we do know that, as I said before, in many countries, fixing the cats by the age of 5 months is also acceptable and We're approaching the closure of this lecture. It's time for us to wrap up, and I have to tell you that.
These surgical procedures, spa and ming are the most commonly procedures performed in veterinary practises around the globe. We always have to choose proper technique based on our skills and our equipment. These procedures are not an easy procedure to perform, so we have to be always aware of we are in the surgery.
We are doing surgery, and we have to take care of our patients at all time. Stay very focused on what Halsted said one century ago about his principles that we should Follow and of course we have to use techniques always in favour of our patients, in favour of ourselves, and of course in favour of the vetting profession because if any error, a surgical error probably might come up, probably this will reflect. To us as persons.
Complications may occur. Complications will occur. It's a surgery.
Yes, it will have complications. These complications may be either short term or long term, OK. There is no surgery without complications, and we finally must discuss with the owners the risks and benefits of spaying or neuting and determine the optimal age for each of our patients.
So We reached the end very fast. And time flies. We know that.
Thank you very much for watching this webinar. This scenery is my It's from my beautiful country. It's from Greece.
Hopefully for all of you, if you haven't visited Greece when the pandemic goes away, I hope you have the opportunity to visit either the mainland or some of our beautiful islands. If you have any questions about today's webinar, please don't hesitate to email me or even better reach me through the social media. I'll be more than happy to answer.
Hopefully, many questions. I'd like to interact with colleagues from around the world, . Thank you very much for listening one more.
I'd like to thank the organisers for inviting me. Stay healthy, stay safe. Enjoy the rest of for VC 2021.
Have fun and goodbye.