Hi, my name is Sonia Miles. I am an RCBS recognised advanced practitioner in zoological medicine and I am a WAVMA certified aquatic species vet. I have been invited by the webinar vet to do a talk on a surgical approach to the reptile patient.
So during this presentation today, I'm gonna give you a brief introduction to kind of initial assessments that we would do, but give you some kind of generalised surgical tips with regards to approaching the reptile patients, so kind of patient and surgeon considerations. Sepsis, hemostasis, but then go into a little bit more depth into some specific reptile surgical procedures that can be performed in first opinion practise. Doesn't have to be a referral practise that does these procedures.
Just need to be somebody that is comfortable doing it and hopefully at the end of this webinar, that will be you. I am doing this as the director of Just Exotics. We are an online exotic specific CPD platform that has er many webinars that will complement the presentation that the webinar that has kindly asked us to do today.
And many of the details that are on here, such as blood samples and what have you, part of what we offer at Just Exotics is a substantial amount of free content, including instructional videos. So if there are some techniques here that you would be necessarily comfortable doing, then hopefully the Just Exotics website, which is free to sign up to, whether you are an individual or a practise, will be able to give you some insight on how to perform these procedures. It should be noted that some of the pictures included in these lectures are under the copyright of other publishers.
These lectures are intended for personal use only, and reproduction, total or partial, in colour or in black and white, is not allowed. Reptiles are becoming more commonly owned, and therefore more commonly presented in clinical practise, with owner expectations of medical and surgical care often being incredibly high. Reptile surgery is a constantly evolving field with more novel surgical techniques being reported in more recent years.
But it is essential to have a basic understanding of the unique reptile anatomy and physiology prior to undertaking any surgery. And these will vary considerably between groups of reptiles and between individual species within those groups. Now during this webinar, I am going to conveniently assume that you know how to appropriately analges and anaesthetize your patient.
If you don't, I'd like to point you in the direction of our reptile anaesthesia and analgesia webinar, because we're not going to discuss it here. We are going to assume that you know all of this, and we're going to crack on with the initial assessment. We're going to talk about patient and surgeon considerations, how to perform decent asepsis in these guys and avoid blood loss, talking about equipment, and then we're going to go through the various different types of body system surgeries.
So a full clinical examination and subsequent stabilisation prior to any surgery is absolutely essential, as many reptiles will often be dehydrated and nutritionally deficient to varying degrees. Now surgery should be delayed until hydration status is at the very least improved, and it is also important to bear in mind that reptiles are ectothermic, meaning their physiological mechanisms, including drug metabolism, are affected by their external temperatures, and therefore optimised by ensuring that that individual is kept at its preferred optimum. Temperature, which is going to vary massively between species.
But not only do they need to be at an appropriate temperature, they need to have appropriate UV lighting, hydration and nutrition and what have you, supplementation, etc. Before the surgery as well, which, let's face it, can be pretty difficult. While we're hospitalising these guys.
Because inevitably we're going to need to do a degree of hospitalisation if we're operating on them. We need to ensure that that preferred optimum temperature is maintained within our facilities and the heat is provided in an appropriate way, not just during the surgery, but in the pre-operative and post-operative period as well, to optimise wound healing. Both patient and surgeon positions should be considered prior to and during surgery.
The patient should be positioned to allow appropriate visualisation of the surgical site whilst the head and neck are gently extended simultaneously, the thalamic contents should be prevented from compressing the lower respiratory tract. This will ensure optimum ventilation throughout the surgery. The surgeon's arms and wrists should rest on an appropriately elevated operating table, especially when performing microsurgery, to optimise your motor control.
In my opinion, using magnification at least 2.5 times and an appropriately focused, ideally head-mounted light source is also going to improve any surgeon's motor control. Again, I I recommend standard asepsis, which is just gonna be as important in reptiles as it is in other animals during surgery, including appropriate surgical attire.
It should also be noted that excessive use of alcohol should be avoided to minimise evaporative losses. So as I mentioned, it is just as important as mammalian species. We want to initially bathe our reptile, get most of the kind of big chunks of hard debris off of them.
Personally, I prefer iodine rather than chlorhexidine. There seem to be anecdotal reports of suspected toxicities using chlorhexidine, so, I suspect, although I have no proof, I suspect I had a very similar case to that that has been reported, so. Me personally, I prefer iodine as my surgical scrub.
I use a toothbrush, er, obviously we've got scales rather than skin to to clean up or shell, and we need to get a toothbrush right in there, in all the crevices to try and remove any kind of trapped debris. We want to be using an appropriate contact time, depending on the antiseptic solution that you're using, and again, we want to minimise our alcohol use, because we want to be minimising our evaporative losses. So as a general rule when it comes to blood loss, about 0.4 to 0.8 mL per 100 grammes of animal is the absolute maximum volume of blood that can be lost from a patient.
Now this means we need to minimise blood loss wherever possible. Obviously, it goes without saying that the red stuff during surgery needs to be in the body, not out of it. And this is especially important when we're dealing with a small patients, utterly essential.
Now, personally, I use a lot of, sterile cotton tipped applicators, so just cotton buds. Q-tips, whatever you call them, and these are excellent for small, confined spaces. I also use a lot of hemo clips, see various different types of suture material depending on what I'm operating on, but I also use a lot of radiosurgery as well.
Now this utilises radio waves that can cause a focal thermal tissue damage. And it's very, very useful to control the haemorrhage during surgery, but in comparison to electrosurgery, there is minimal collateral damage. Due to vast anatomical differences between reptiles, it is wise to have an easy access to a variety of different surgical equipment.
So for most reptiles between 5 and 50 kgs, normal surgical equipments are more than suitable. However, if you have a patient of under 1 kg, I would really recommend using some fine-tipped microsurgical equipment. Anything bigger than this, you're going to be traumatising the tissues too much.
So personally, I use oscillating saws and drills in various different orthopaedic surgeries. When I am using them, so let's say for example I'm performing a plastronotomy, I want one with as narrow a blade as possible when incising that plastron, and this is going to prevent the creation of a wide osteotomy that is going to obviously delay wound healing. We've already mentioned that we can be using magnification, it's a delightful picture of me here on the left hand side using the magnification with a focal light source as well, you want one that can focus and is head mounted.
And again, as we've mentioned in our previous slide, we want to be performing, er sorry, we want to be using either radio, preferably, or if not electrosurgery. So as promised, we have gone through kind of like the basic considerations that we need to think about when it comes to just performing reptile surgery in general, so smaller bits of kit, radiosurgery, making sure you're appropriately, checking a patient beforehand, that you're set up, ready. Everything is ready to go, and now we are ready to start performing our surgeries, and I am going to start with the skin.
The integument of reptiles is going to vary massively between the different species, with the external structures of Chilonia, for example, being significantly thicker and tougher than other species. It goes without saying, they essentially live in a box of bone. Now, as a general rule, incisions should be made between the scales to avoid any shedding issues, and integument surgery, it's going to be performed for various different things, such as wound management, for example, or the removal of neoplastic lesions or abscesses.
Now when dealing with abscesses, it's important to remove the capsule of thick fibrous tissue that's going to be surrounding the really thick pus. So it's much, much thicker than mammalian pus, it's literally like hard cheese. Now, what we want to do when we've taken that capsule is that we want to send a section of that capsule away for bacterial and fungal culture and sensitivity testing.
The underlying structures should be suitably irrigated with an appropriately diluted antiseptic solution such as povidone iodine, and the skin should be closed and appropriately sized monofilament absorbent suture material. Suture patterns are essential for closing reptile skin, and that includes both the horizontal and vertical mattress sutures. Now these are Everting patterns.
These are essential as reptile skin naturally inverts. Now reptile healing is 7 times longer than a comparatively sized mammal, and as such, sutures are going to be recommended to be in place for about 6 to 8 weeks, but obviously this is also going to vary depending on the surgery that you have been performing. So starting with oral abscesses, well, these are very commonly seen in terrestrial and aquatic chelonia, and they are often linked to things like hypovitaminosis A, poor environmental hygiene, and environmental pollutants.
Now, in my opinion, the patients should be placed internal recumbency. I find it easier that way, and the head and the neck are extended and rotated to allow you to see that tympanic, lesion, so it's gonna be your inner uppermost position. Then a semicircular incision is going to be made into the tympanum in a cranial to caudal direction.
The skin of that tympanum is then lifted, and a curette is used to remove the pus. Now, obviously we're going to be taking samples for our culture sensitivity testing like we've mentioned previously. Now that incision can be extended to remove half or sometimes the whole tympanum, depending on the extent of the abscess.
It's important that the eustachian tube is also clear of purely debris from the surgical site, it's going to be thoroughly flushed with an antiseptic solution such as the pervidone iodine, and then I often tend to follow it with a flush of sterile saline as well. Now the surgical site is going to remain open, and this is going to allow that owner to continue aseptic, sorry, antiseptic flushing at home, and that is gonna heal by second intention, it's gonna granulate up and hopefully heal slowly whilst you're able to simultaneously clean that out and have them on an appropriate antibiotic. But the key in these cases is to remove the material from the eustachian tube.
If you don't, it is just gonna laugh at you and gonna come straight back again. Next, we're gonna touch on some ophthalmic disease. Subspectacular diseases are common in snakes and geckos with spectacles, and will form when the lacrimal duct becomes blocked.
Now this often causes a condition called bullus spectaculopathy. For those that have asked, we do have some ophthalmology webinars coming for various different exotic species, which we will provide in a bundle as well, so keep your eyes peeled for these. Now this, blocked duct, this can result in secondary bacterial and fungal infections and subsequent abscess formation.
So personally, I recommend creating a 30 to 90 degree wedge, in that spectacle, and this is going to be removed completely from the ventral aspect. Samples can be taken for cytological examination and culture sensitivity testing, both mycology and bacteriology, and we're going to be wanting to flush away as much as possible, the caseous material that's going to be there. It's important to assure the lacrimal duct is patent, which I do appreciate in the very, very small patients like this crested gecko, for example, is next to impossible.
But wherever possible, we should ensure that that lacrimal duct is patent. Now this can be assessed in most species via the buckle opening and is found at the margin of the palatine teeth in snakes. The wedge is then left open to allow the application of topical ophthalmic medications.
So those species like snakes and, let's say, our crested geckos, for example, various different geckos with spectacles, you're not putting topical treatment on their eyeball if you're just plunking it on what you can see on their face, essentially, because the spectacle is a scale over the top of it. That's why in this. Surgery, we've just made a hole that we need to put it into.
So just bear that in mind when you have a species with a spectacle that you're, thinking about putting topical therapy onto their eyes, it's not gonna work, because there's a spectacle over the top of it. So, in this instance, we've cut a hole, we are going underneath that spectacle and we're putting in those ophthalmic medications directly onto the eye surface itself. Now the duct can be blocked for various different reasons to start with.
Now this is most likely going to be a hypovitaminosis A, but we can get some congenital atresias, so the, the tear duct itself just doesn't function, and that's what we had here in this, crested gecko. But we can also have various different inflammatory and infectious conditions, specifically things like, stomatitiss, so in an ascending infection from the mouth, and I've also diagnosed various different cancers. So when it comes to a nucleation, really, er, my suggestion for this is it's really needed when there's end stage ophthalmic disease or if there's irreversible ocular damage, globe prolapse or persistent pain.
This is when these annucleations should be considered. Now a circular incision that encompasses the spectacle, in our spectacled species, so, let's say, in this instance, we're using the example of the corn snake here, we do an incision around that, taking the spectacle with us. The globe is then going to be grasped with forceps and gently allowing us, like gently pulling it forward and allowing us to elevate and remove the surrounding attachments around that globe.
I personally then use hemo clips or suitably sized monofilament suture material. With a combination of radiosurgery to ligate that ocular vessel. Now this deficit can be left open.
I tend to pop a little bit of hemostatic sponge in there, it normally falls out after a couple of days, and we're aiming for this to heal via second intention. So it's going to fill from the bottom out. Now, sometimes if you've got a really, really big deficit, you could maybe pop a couple of simple interrupted sutures either side.
Obviously, if we've got a non-spectacled species, what we want to be doing is that we want to be elevating the globe and just incising around the, the muscles that are attached to the globe. I find in some instances, as long as we haven't got any sort of infectious material, just popping a stay suture through the globe itself to allow you a little bit of mobility there to move that around, works really, really well, but just remember, when we have spectacled species, we want an incision all the way around the edges. So when it comes to the ease and complexity of salamic surgery, well, this is gonna vary massively depending on the species that is undergoing the procedure.
So salamic surgery is going to allow for the visualisation of most major internal organs. We're gonna be performing it for various different procedures, implantations and biopsies. Now most lizards, except for our laterally compressed individuals such as chameleons, for example, should be placed in dorsal recumbency.
And there are two standard approaches that could be considered. We've got our paramedian and our medium. And the length of the surgical incision is going to be dependent on the procedure that's being performed, and the position of it, whether it's more cranial or caudal, is also going to vary depending on the procedure that's being performed.
So starting with lizard salamic surgery, well, the paramedian approach in lizards avoids the large midline blood vessel, the ventral abdominal vein. But this can cause significant post-operative pain as the abdominal muscles are going to be incised. Sharp incisions should be avoided to prevent significant haemorrhage, and in small lizards, the muscle in the salic membrane can actually be parted just using the cotton tip applicators or radiosurgery.
With the midline approach, both sides of the salamic cavity can be assessed, however, there's going to be an increased risk of iatrogenic trauma to that ventral abdominal vein. So to avoid this vessel, the incision should be made caudal to the umbilicus and extended cranially, with the blood vessel being localised, because it's going to be present just above where you can see this V here. This is where we want to start our midline approach, so.
As you can see, we've got this, black line, which is the paramedian approach that we've just talked about, and the red line is how that blood vessel sits and sort of demonstrates where we're going to be performing our midline incision. Now, as you can see, that midline abdominal vessel, it will bifurcate at the bottom. So if you go caudal to the umbilicus, you should be at the point where that blood vessel is bifurcating.
So if you incise underneath that bifurcation and you sort of snip your way in between the scales and move cranially, you can actually locate the bifurcation as it turns into the single ventral abdominal vein. And you can just move it out of the way. Wherever possible, we obviously wanna be, localising this and and avoiding it.
However, sometimes things just happen, I'm afraid, er, and you, you might nick it. Now it is not the end of the world if you ligate it. Obviously it is not a a good sur it's not gonna be a good surgery if you're having to incise that ventral abdominal vein, but don't panic if you do.
Tie it off. There is enough contralateral circulation that the body can cope without it. Just try not to hit it to start with.
Now, wherever possible, celiotomies should be closed with a double layer, but in our very, very small species, this can be next to impossible, especially where they've got really, really thin salamic musculature. So ideally, muscle, then skin. However, if you can't do that while we're trying to do it all in in one go.
And er as we've mentioned previously, we want to be averting the skin, so performing our horizontal mattress sutures using a monofilament absorbable suture material. My go to for skin, probably gonna be PDS. In snakes, a single celiotomy is not going to be enough to visualise all of the internal organs.
Now this means prior to surgery, it's going to be absolutely imperative that you've done your investigations to allow for an accurate surgical site to be established. Now, the celiotomy incisions in snakes should be made between the 1st and 2nd row of lateral scales. Now this is going to ensure the incision is positioned laterally off the floor to allow the patient to remain ambulatory.
The muscle layer can be blunt dissected, just ventral to the ribs, and then the salamic membrane entered into the salamic cavity. Again, a two-layer closure is recommended wherever possible, with the salamic membrane and the muscle closed in a continuous or interrupted pattern, and the skin again should be closed in an e-verting pattern. So that's your horizontal mattress sutures and a monofilament absorbable suture material.
Again, my go to is going to be PDS. So your chelon and celeotomies are going to be the most challenging ones that you're going to do because of the presence of the shell. Now there are two possible approaches to the ceiling.
You've got the transplastron, as you can see here on the right hand side, and then you've got the prefemoral, which we will be discussing in the next slide. Now the appropriateness of each of these is going to vary depending on the species and the target organ. The transplastron approach is going to require a temporary osteotomy through the plastron.
Now, I normally suggest using a thin bladed oscillating saw, and we can utilise this to create this temporary osteotomy, with the lateral incisions being performed first, followed by the caudal incision, and then the cranial incision to allow the pressure to be released and the salamic membrane to fall away from the underside of the shell, ensuring those underlying soft tissues and two dirty great big marginal blood vessels are going to be protected as much as you feasibly can while blindly cutting through the underside of the bottom of the shell. Now the edges of this osteotomy should be bevelled at a 45 degree angle and the depth of the incisions probed with a 25 gauge needle to ensure full thickness is achieved. Now I suggest that this new bone fragment should be reflected cranially with the soft tissue's blunt dissected from the underside, but the cranial attachment should be preserved in an attempt to preserve the blood supply to the fragment, and the swab, we should then place a, like a.
A damp, sterile, saline soaked swab over the top of that bone flap to cover the tissues to prevent them from desiccating because hopefully you're keeping your patient nice and warm. Now, care should be taken, obviously, to avoid those pair abdominal veins that are present, and these are present on the surface of the underlying salamic membrane. Once that shell is up, you've protected the bone fragment, you've left those cranial incisions in place, and you have localised those two, midline blood vessels, you want to then incise in between them.
Now, once you've done that, you can get into that salamic cavity and do whatever you need to do. From a closure perspective, we want to be doing a simple, continuous closure of that salamic membrane with an appropriately sized, absorbable monofilament. In, let's say a 2 kg tortoise, I'd probably be using a 40 monochryl, for example.
Once that psoric membrane is closed, we then want to be putting that bony section back in place. So what I'll normally do is I'll close my psoric membrane, I'll fill that site with intracite and I'll plonk that bone fragment back on. And then I tend to use a non-heat generating polymer, so I use cooliner, it's a dental acrylic, it's not going to cause any sort of bone necrosis or anything, while, most of it, like, Technovic, for example, chucks out a hell of a lot of heat when you're fixing it back in place.
So cooliner, is the product that I, I tend to use. You spell it K 00 L I N E R. That's the, the product that I would recommend, in most of these instances.
Now, from my experience, from a healing point of view, it depends on the size of the gap that you've made, essentially, but it can take roughly, in the best case scenario, I'd say between 12 and 18 weeks to heal. As I mentioned, there is also the prefemoral approach, and this is going to allow entrance into the salamic cavity through the soft tissues in front of the hind limb. The patient should be placed in lateral recumbency with the surgical site uppermost and the hind limbs retracted backwards.
A cranial caudal incision, a couple of centimetres big, is made in the middle of the fossa. The underlying soft tissues are blunt dissected cranial to the sartorius and ventral to the iliacu muscles, revealing the salamic aponeuroses of the transverse and oblique abdominal muscles. Now this salamic aponeurosis is really fibrous, it's literally rock hard in some instances.
So you're gonna need some force to breach that membrane. Once breached, I really prefer using a lone star retractor. You can see me using it here in this picture on the left-hand side just to hold all the soft tissues out of the way, so the skin, the subcutaneous layers, the salamic membrane.
And this is going to allow for better surgical exposure. Now, if we are performing surgery through the prefemoral approach, in my opinion, this is an endoscopic guided surgery because it is entirely possible for you to leave, say, chunks of ovary behind. These follicles are gonna.
Flake off in some instances, so we need to be making sure that we are making sure things are nice and tidy inside afterwards, checking for bleeding and what have you as well. So I do not think personally that this surgical approach should be performed without an endoscope. From a closure point of view, we can routinely close this in the two layers that we've mentioned previously, so slamic membrane and muscle, simple continuous, and using a monofilament absorbable suture material.
And then the skin, again, monofilament absorbable suture material, and our horizontal mattresses. Probably going to take 2 sutures to close the skin in these instances. The healing from the pre-femoral approach, which is my go to when we've got a case of follicular stasis.
I no longer perform a plastronotomy if I can avoid it. From a recovery point of view, these patients are much more comfortable. They are eating a lot faster as well, normally within 24 hours, and, healing, rather than 12 to 18 weeks, which was the plastronotomy healing time, you've got 4 to 6 weeks for the skin to heal, and most of the time it's probably a hell of a lot sooner than that as well.
So reproductive surgery, well, we have to bear in mind the reproductive physiology of reptiles, and that is going to vary depending on the order to which that reptile belongs. So we've got oviparous reptiles, such as Chelonia that produce eggs, and squamates that can be oviparous and viviparous, that produce live young. Now, reproductive disease is often going to require surgical intervention and is incredibly common with multiple potential causes.
And we've got various different webinars already on the specifics of reproductive diseases in various different types of reptiles. So, let's assume that we're gonna have to perform ovarriectomies in a lizard, a snake, and a tortoise. So I'm gonna go through that individually for you.
So ovarectomies in lizards can be performed as a preventative measure, as well as a treatment for reproductive disease. However, in the non-reproductively active female, the ovaries are going to be tiny, and they are located adjacent to the dorsal renal veins and the adrenal glands in the mid to caudal salamic cavity. Now when there's ovarian disease present, these ovaries are gonna be substantially larger and gonna resemble essentially yellowy orange bunches of grapes.
Now, personally, I suggest to perform ovarectomies using vascular clips or a suitably sized monofilament suture material, and we wanna be placing these along the ovarian ligament and associated blood vessels before dissecting that gonad. If the oviducts are normal, leave them alone, they don't need, you don't need to worry about them. However, we want to be removing the tissue if it is grossly abnormal, if, if we've got concerns of it being abnormal based on hopefully the initial diagnostics that we've done.
Ovaries and stasis can be elevated at the salamic cavity to allow full exposure of that suspensory ligament that contains all of those blood vessels. Bearing in mind, these branch directly off the aorta, and the renal veins go easy with them, very, very fragile, and they all bleed like stink if you damage them. So as we've mentioned previously, in the vast majority of our lizards, we will be performing either a paramedian or a median approach.
However, this is an example of our laterally compressed species, so a female chameleon. And we can see here, we've done almost like a, well, we've done a, a flying. Approach essentially, and we've just gone in between two of the ribs.
Incidentally, you can also do midline in chameleons, and go through the, the linear alba that is, is down there. It's certainly reported in the literature, just in this instance, I did the flank. So when it comes to snake ovarectomies, well, they, in comparison to lizards, are going to be much, much more invasive.
So in my experience, you're going to either require multiple or one hell of a large celiotomy to perform this. So you're looking at mid to caudal salamic cavity to find the ovaries. Don't be afraid to extend your excision to make sure that you are getting all of that.
Ovarian tissue out because that ovarian suspensory ligament is extensive. So, you want to be exteriorizing it as much as possible. And although it's extensive, you can actually see the size of these blood vessels.
I mean, they are juicy. And for me, as predominantly a surgeon, I like big blood vessels because I can see where they are and I can avoid them easier. So, ligate all of those, snip, snip, snip, job done.
Again, we don't want to be removing the oviducts unless they are diseased, so, no need to worry about removing those unless we absolutely have to. And we've already discussed how to close a celiotomy in a snake. So chelonia ovarectomies may involve an osteotomy if the prefemoral approach isn't a possibility.
Chelonian ovaries originate close to the ventrolateral aspect of the kidneys, which, when reproductively active, will extend into the central salamic cavity that these guys can be utterly chocker full of ovaries, and it can really, really just take up so much space that they can't breathe, and they certainly don't feel like eating. Now the ovarian suspensory ligament in Chilonia and snakes is extensive, and therefore it is really, really important, just the same as with snakes and these guys, to ensure all of that ovarian tissue is localised and exteriorized prior to ligating the blood vessels within. As with lizards, if the oviducts are normal, then we, there is no need to remove them whatsoever.
Incidentally, If you leave some ovarian tissue behind, the ovaries will regrow and your clients will be very, very upset. So make sure that we are exteriorizing everything fully. Salpingotomies and salpingectomies are going to be most commonly performed in cases of dystopia, with a salpingotomy being performed when breeding capacity is needed to be preserved.
The reptile oviduct contains a large number of blood vessels which will need to be ligated, takes a while, but just locate those blood vessels, go in a systematic approach, and make sure that we're getting all of them, just take your time. Now due to the extent of oviducts in snakes, there's gonna need to be either multiple celiotomies or one dirty great big one. The reptile oviduct tissue is often incredibly fragile.
I find much, much more fragile than a comparatively sized mammal, but the structure in Chilonia is much thicker than in snakes and lizards. So snakes and lizards, you've gotta be real, real careful. Tortoises, it's thick, it's really, really quite tough actually.
However, if it is incredibly diseased, then yeah, it just kind of goes and just kind of falls apart in your fingers, so. Obviously you need to concentrate with your tissue handling skills in any sort of surgery, but specifically if you're performing surgery on the oviduct of a snake or a lizard, be aware it's very, very fragile. Orchidectomies, well, they're definitely reported in lizards.
There's a lot of information out there of orchidectomies in iguanas. The testes are located adjacent to the torsal renal vein and the adrenal glands in the mid to caudal salamic cavity. They are suspended by a short, broad ligament from the dorsal body wall, and the left adrenal is located between the left testi and the left dorsal renal vein.
Therefore, you really do need to be really, really careful when operating in this area to minimise the risk of that iatrogenic trauma that you would potentially cause. Vascular clips should be used to ligate the vessels associated with the testes, which can be better visualised if that testes is just gently retracted ever so slowly. Onto gastrointestinal surgeries.
So I thought I'd briefly, I mean it's sort of gastrointestinal tract, we we were definitely operating on the er the oesophagus. And I thought it's one of the most common procedures that we perform, and a nice straightforward one as well. Now, in my experience, this is something that is gonna be, well, it can easily be performed in any sort of first opinion practise.
This procedure should be considered when repeat feedings are performed, or if oral medications on a regular basis are going to need to be required, and you're going to be stressing the tortoise out otherwise, or if the owner is just quite simply unable to medicate accurately at home. Now this procedure, is most commonly performed in chelonia, but entirely possible in other species such as your lizards. Obviously, snakes, it ain't happening.
I would suggest that the patient is either heavily sedated or under a light plane of anaesthesia. If your patient is completely collapsed, then actually just local anaesthesia alone works quite well. A tube of an appropriate diameter for that individual should be pre-measured from the cranial rim of the plastron to the junction of the pectoral and abdominal scutes and marked with a non-toxic marker.
Personally, I then suggest that the patient should be placed in lateral recumbency and a small pair of curved hemostats inserted into the mouth and down the oesophagus to be pushed up gently against the caudal lateral aspect of the neck as far down as the neck, down the neck as possible. A small incision over the point of the hemostats is made through aseptically prepared skin, taking care not to inadvertently lacerate the dorsal lateral jugular and the ventrolateral carotid artery. It's then, these hemostats, once they're kind of incised over the top of, they're pushed through that hole and gently open so you can grab the end of your pre-measured tube and retract that into the oesophageal lumen.
The tube is then going to be gently pulled out of the mouth and redirected back down the oesophagus to the stomach. Once hopefully in place, we want to be performing radiographs to make sure that it is in place before we tie that in with using either a butterfly tape suture to the skin or a Chinese finger trap suture. The tube can then be taped in place, and we want to be taping the top of the shell and the leg on the same side, so we haven't got the tortoise being able to accidentally pull that tube out.
From a gastronomy point of view, enterotomy and enterectomies are going to be performed in a similar fashion to that in mammals. However, bearing in mind that reptile tissues are comparatively thinner and more friable than a comparatively sized mammal. Now I would reckon the area of the gastrointestinal tract is exteriorized, ease of this is gonna vary depending on the species, cos the Chelonia gastrointestinal tract is gonna be really, really hard to exteriorize in comparison to that of snakes and lizards.
Now once exteriorized, I then suggest using sterile sterile saline soaked swabs, packing around that area, and packing out the salamic cavity to prevent any leakage into their standard, openings, so find the. The area that has got the, the problem in it. So let's say for example, like in this bearded dragon here, we're removing a foreign body.
So this is a, actually I think this is the top of a lighter that he'd managed to eat. We want to incise over the least vascularized area possible, and incise just away from that obstruction so we can kind of pull that out through the hole. And then from a closure point of view, we want to be just doing standard intestinal closures as we would do for our other species, and we want to make sure that the cavity is flushed copiously prior to the salamic cavity closure, and we'll want to be closing the salamic cavity into layers like we mentioned previously.
Next, we are going to discuss urinary tract surgery. So the major surgery of the urinary tract is going to be the cystotomy. Now, this surgery is going to be required for the removal of bladder stones, but also for the removal of eggs in chelonia, which can actually be retropulsed back into the bladder in cases of dystopia.
Now it should be noted that not all reptiles actually have bladders. This organ is only going to be present in Chelonia and some of our lizard species. The bladder of the chonia can be accessed via the transplastron approach, but also via the prefemoral approach, as you can see here.
But by either route, stay sutures should be put in place to prevent salamic contamination. And once completed, personally, I then close the bladder, use an appropriately sized, absorbable monofilament suture material via a single layer closure, and then I leak test it. The salamic cavity should be copiously flushed, and then the salamic cavity closed, as we've discussed previously.
And then finally on to prolapses. Well, the bladder is one of the possible organs that can prolapse from the reptile, so I've chucked it in the urinary tract surgery section. Other structures that could be prolapsed include the cloaca, intestines, oviduct, hemipes, and phallus in chelonia.
Now it is important prior to any surgery that the tissue is identified, first off, and if it's been out a while, that can be pretty challenging in some instances. But then we need to figure out the underlying cause of the prolapse and essentially it's just no good shoving it back in and hoping for the best. Figure out why it came out to start with while simultaneously protecting those tissues.
Now if it's a phallus, for example, in a chelonia, or a hemipes in any of the male reptiles, if there is irreversible tissue damage, then we can consider amputation. So if we are, amputating a penis, so let's say we've got a tortoise here on the left hand side. Our patient wants to be appropriately analgesed and stabilised prior to surgery, and then fully anaesthetized.
We want to exteriorize that, phallic tissue as much as possible, and then as close to the cloaca as possible, once you've exteriorized that tissue, you just pop a transfixing suture through that, clamp underneath that transfixing suture when it's appropriately placed, and remove that necrotic tissue. I would always just release a little bit of tension as that tissue was going back into the back into the cloaca. Just to make sure that there's no bleeding, I have in some instances placed, two lots of sutures, 2 lots of transfixion sutures in a .
An amputation that I wasn't quite happy about, but wherever possible, minimise your suture material. If the tissue is obviously viable and it can be cleaned up and replaced, well, the cloaca can then be temporarily closed using a simple interrupted suture. Either side of the cloaca, not a purse string suture.
Now this is associated with traumatic damage to the nerves in the musculature of the cloaca. So if you're doing purse string sutures, stab it. We want to be doing two single interrupted sutures either side of the cloaca.
But as we've mentioned previously, we're going to be amputating it, transfixing the ligature, base the phallus, remove the, remove the tissue distally, and just keep an eye on the area and appropriately, give your patient antibiotics wherever obviously needed, ideally based on culture and sensitivity testing. Now. It goes without saying, if you've amputated the penis of a tortoise, it's going to .
Alter and interfere with future breeding prospects, so just make sure the owners are aware of that. Definitely had a case in the very early days of of starting as a clinician that I didn't think I needed to explain without a penis, the tortoise wasn't going to be able to mate with her other tortoise, but turns out, no, I did, so just learn from my mistakes that I no longer do. Always make sure that the owner is aware that breeding prospects are going to be nadder after that penis is gone.
And then finally, I'm gonna briefly touch on orthopaedic surgery. I mean, this is something that needs a a a lecture all of itself, so we'll be in the pipeline at some point when I get a sec to do this. We're going to start with soft, with shell trauma in Chilonia species.
So, really, really common, and we'll obviously have a variable prognosis depending on the extent of the trauma and if the salamic membrane and contents are affected. Now, standard wound management techniques are going to be really, really important to initiate alongside shell fracture stabilisation. So fragments can be replaced using screws and wire, or you can get even some more inventive techniques like bra clasps and cables, for example.
Now techniques that allow you to observe and assess these areas for cleaning the fracture sites are going to be preferable to the historical techniques, which were to just completely cover the area with something like epoxy or acrylic or fibreglass. So no. Really not appropriate just to smack on some fibreglass in these fractures.
We want to be monitoring these fracture sites and making sure that we're able to continuously irrigate them to prevent dirty great big intrasalamic abscesses forming in later life. I've had a few cases referred to us. Of just non-specifically unwell tortoises.
We've gone down the route of bloods, found infection, done a CT scan, gone hunting for the abscess that is inevitably there, and one of the cases that we had that springs to mind is one that had been chomped by a dog and had been covered with. Fibreglass, massive kudos to stabilising those fractures because that is really, really important from an analgesic point of view, but just trapped all of the infection in there which quietly festered over nearly a decade to turn this tortoise into just a walking abscess, so. No longer as just covering the, the, the surgical sites up with, fibreglass or epoxy or what have you, we want to be monitoring these surgical sites, we want to be flushing them clean on a regular basis, but we always want to be stabilising fractures because it's incredibly painful and just because a tortoise isn't screaming his head off, does not mean he is not perceiving the pain.
So analgesia, really, really, really, really important, you're looking at your opiates for these cases. It is a fracture the same as it would be in a mammal. We need to be bearing that in mind.
What we . The degree of damage that can be withstood in these guys. So this tortoise, at the top here, I see him on a regular basis now.
It looks like a shark has literally taken a chunk out of his side, but he completely granulated this over and is already growing new shell there as well. It looks awful. And it's one hell of a scar, but he's alive and he's doing really, really well, and we just managed this by, anaesthetizing and debriding all the kind of loose bits of bone, and then just bandaging, essentially.
This bottom left hand side picture here, I ended up doing some, so we did imaging, proved that the salamic membrane. Was intact, flushed the hell out of the area, and I used a combination of bra clasps and very, very thin wire, so I just stuck the bra clasps either side of the, fracture site and just wrapped, wrapped some wire around those to just draw the edges of that fracture site together. Again, she's doing really, really well.
And then some, so the bottom right hand side here, are just puncture wounds. Lots of bleeding, and lots of bruising and absolutely something that should be appropriately analgesic because you've still got holes in bone that's still incredibly painful, but something that can just be managed with topical cleaning alone. And in fracture repair in reptiles, well, it follows the same principles as with other animals.
So, we want to be doing a full radiographic assessment, and that's absolutely essential prior to the stabilisation and fixation of these fractures. But depending on the fracture type, the position, there's going to be various techniques that might be possible, such as external co-optation, external and internal fixation, and in severe instances, sadly, we're gonna have to consider amputation. So when it comes to her amputations, digital amputations, I think should be performed at the level of the metacarpus or the metatarsus.
And if the problem requiring amputation is proximal to the carpus or the tarsus, then a full limb amputation through the most proximal joint, especially in these larger lizards that are likely to traumatise the stump, should be considered. Now, I suggest that a tourniquet is placed approximately alongside the use of radiosurgery and appropriately sized monofilament, suture material, or hemo clips to control any sort of haemorrhage. Soft tissue should be preserved to permit closure.
When we're talking about tail amputations, which is going to be one of the most common ones that we see in practise, bearded dragons, for example, but sometimes snakes too. Some species are able to undergo autoamputation, so our crested geckos, for example, or our leopard geckos, and we can utilise this autoamputation, this autotomy during surgery, just incise the skin, and grab and twist, essentially, proximal to the injury, they're gonna throw that tail out at you. They'll be doing that through one of their fracture planes of the the coccygeal vertebrae.
And what will happen is the tail chunk that is being chucked out at you will flap around, that is designed to distract a predator while the animal scurries away. But in inducing this autotomy, what will happen is that it will snap cleanly. The soft tissues will automatically close over the blood vessels, and there'll be utterly minimal, bleeding, and within an hour of the surgery, that skin will have started to close over and really constrict around the tip of that.
I will not be suturing it. In fact, suturing it will cause far more problems. You'll deform the tail that grows back, because, yes, a tail of sorts will grow back.
Normally podgier, different colour to the previous tail, with a, in leopard geckos, with a cartilaginous core rather than a, a bony one, but it will grow a tail back. We want to be making sure the environment is nice and clean. I err on the side of caution and I give my patients analgesia, to go home with as well.
If we do not have, a species that undergoes autoamputation, we want to be making an incision in between the vertebrae. Preserving as much of the soft tissue as possible to facilitate closure, whilst, closing the skin, you're going to be doing your horizontal mattress sutures with an appropriately sized monofilament suture material. PDS is the one that I would use to do your Everting pattern to prevent those edges from curling in.
So that's it. Thank you very much for listening. I appreciate that this is very much a whistle stop tour, but hopefully the general principles that we have gone through and some of these basic surgical techniques and how we have gone through them will give you the confidence to approach these in practise.
As I said all the way at the beginning, these are procedures that can be performed in first opinion practise, you just need to have the confidence to do that and hopefully this webinar has provided that. I am more than happy to answer any questions. The best email address that you can get me on is [email protected].
As I mentioned before, the Just Exotics websites have extensive free content on there that hopefully you will find helpful. There's a lot of information on there about anaesthesia in these patients cos I appreciate that is not something that we have touched on. I must be on the.
Scope of this specific presentation, but it all comes hand in hand. And there are plenty of details on there that will complement the content there as well. I just wanted to thank webinar vet again for inviting us back and hopefully again that you have found this content really helpful.
Thank you very much.
