vet reference guide

7/21/2019 Vet Reference Guide

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Reference Guide

Sponsored by:

Veterinarian Training Program

H

UMANE

ALL

IANCE

Veterinarian

Training

Progr

am


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Table of Contents

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Training Team

Clinic Map

Schedule

Procedural Overview

Tattooing

Canine Ovariohysterectomy

Canine Castration

Feline Sterilization

FAQs

Page 3

Page 4

Page 6

Page 7

Page 9

Page 10

Page 12

Page 13

Page 14

Program Syllabus Page 5


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Training Team

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Karla Brestle, DVM

[email protected]

Anne Bayer, DVM

Medical Director, [email protected]

Rob Seal

Training Program Manager

[email protected]

Nellie Goetz, DVM

Medical Director, NSNRT

[email protected]

HUMANE ALLIANCE

Stuart Hovis, DVM

Veterinarian

[email protected]

Michelle Amtower, DVM

[email protected]
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Clinic Map

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Program Syllabus

Our goal for our Veterinarian Training Programis to polish the individuals surgical skills, withemphasis on sterilization procedures (the high-quality piece), and enhance their organizationalskills to make most efficient use of time (the high-volume piece).

Therefore, the Veterinarian Trainingsyllabus may include but is not limited to the following:

1. Pre-surgery

! Patient selection/review of the specifics of the physical exam that ensure identification of

appropriate low-risk surgical candidates.

! Drug/anesthetic protocols.

! Staff management.

2. Surgery

! Recognition of surgical packs and the value in minimizing their contents.

! Maintenance of sterile surgical technique in a high-volume situation .

! Review of anatomy as it applies to the efficient and successful completion of

! the sterilization procedure.

! Review of instrument and tissue handling skills.

! HVHQ specific surgical techniques:

! Pedicle tie;

! Overhand knot;

! Incision placement.

! Efficiency of motion/movement.

! Body mechanics.

3. Post-surgery

! Identification of complications.

! Management of complications.

! Pain management.

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Schedule

! This schedule will serve as a guideline for your week of training at Humane Alliance. All timesshould be considered approximate, since the nature of this business dictates that we may

have fluctuations in patient numbers that, in turn, may necessitate rearranging the schedule(i.e. classroom topics in the afternoon instead of morning).

! During inclement weather conditions, we will always do our very best to provide you with asteady flow of patients, but when factors are beyond our control, we may have to end the

day early.

! Demonstrations of each surgical procedure will be performed by your instructor before youare expected to perform the procedure.

! Please let your trainer know at the beginning of the week if you need to leave before4:00pm on Thursday, so that we can adjust your schedule to best accommodate you.

Monday

Tuesday - Thursday

Potential Classroom Topics:

! Feral Cats

! Surgery 101: Surgical Anatomy & Basics

! Surgical Complications

! Cryptorchidism & Uterine Anomalies

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Procedural Overview

The surgical procedure itself should maintain a routine sequence of events to verify that eachpatient is receiving the same standard of care. The surgeon should ensure that the technicians

follow a thorough protocol for surgical prep of the patients, including, but not limited to,complete clip, debris removal, surgical scrub, and bladder expression in females.

As the surgeon approaches the patient in the OR, a generally accepted practice would be todouble-check the status of the patient, including, but not limited to, the following:

1. The patient should be properly connected to the anesthesia machine

2. Oxygen and isoflurane levels should be appropriate3. The monitoring equipment should be operational.4. It should be confirmed that the patient is at the correct plane of anesthesia and the

veterinary surgeon must verify sex of the patient, especially with cats.5. Finally, it should be noted that the patient is in proper position for the surgery and that the light

source is directed toward the incision site. At this point, the veterinary surgeon may proceed.

The patient is draped in with 3 or 4 quarter drapes, with or without a fenestrated drape. Any

combination of the above is considered acceptable, with the most important feature being thatthere is an appropriate barrier to prevent contamination of the surgical site.

The incision placement will obviously vary with both the sex and the species of the patient. We

have also determined that varying the incision placement depending on the age of the patientcan improve the efficiency of the entire procedure. Incisions in adult female dogs are generally

placed approximately 1 inch caudal to the umbilicus (see Figure 1), while the incision in apediatric female dog would be placed approximately half-way between the umbilicus and

pubis (see Figure 2). When spaying an adult or pediatric cat, the incision is also placedapproximately half-way between the umbilicus and pubis.

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Fig 1:

Adult dog incision placementFig 2:

Feline/pediatric dog incision placement


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Procedural Overview

In dogs, there are several factors which will influence the craniality of your incision placement.The older, larger, heavier, and deeper-chested a dog is, the more cranial the incision should be

centered.

Adult male dogs are neutered with either a pre-scrotal or scrotal incision. However, in pediatricmale dogs, the routine approach is scrotal. In fact, many spay/neuter veterinary surgeons willactually perform a modified scrotal castration in adult dogs that have pendulous scrotums.

Dogs with this modified scrotal approach will go home with an open incision, and therefore mustgo home with an additional set of discharge instructions.

Suture size selection should follow these guidelines:

The most important factor in proper surgical technique is that meticulous, careful tissue handlingis observed in any procedure. The following additional points will also be emphasized:

Five throws (2 square knots) on all sutures. This technique has been proven to decrease

the incidence of dehiscence, and must always be used.

Large bites on the linea alba: include at least 5 to 8 mm muscle tissue in the linea closure

in cats and up to 10 to 12 mm in large dogs. A cruciate suture pattern is used to

decrease tension and speed closure time.

No crushing sutures in closing - linea and subcutaneous tissue should be snugly and

completely closed but never crushed.

Dead space should be closed and the SQ should be anchored at least at both ends of

the linea incision. Linea and subcutaneous tissue are closed with PDS suture (see FAQ's for

discussion on suture material).

At least 3-layer closure-linea, SQ, and subcuticular plus skin glue. Staples are used if skin

edges are not apposed.

Skin edges should be properly apposed - never allow one side to flap over the other or

extend above the other. Skin glue should not be applied between the skin edges but on

the surface after apposing the edges.

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Tattooing

A tattoo is applied to all patients to ensure no future unnecessary anesthesia or surgery.

We perform a scoring procedure to accomplish the tattoo, by placing a small (~1cm) incision

in the dermis near the incision site, or near the umbilicus in the case of male cats, and applyingink.

We prefer paste vs. liquid ink, in that it is neater and stays in place better, and green-colored

paste is more obvious, especially on animals with darkly pigmented skin.

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Tattoo Site


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1. The overall size of an incision for a canine ovariohysterectomy will vary depending uponvarious factors, the most obvious being the experience and/or comfort level of the surgeon.

Repetition over time will tend to naturally decrease the size of the incision to as little as 0.75

cm in some patients. A factor that may aid in efficiency is the use of the blade without thescalpel handle; even a practice as minute as this saves time and creates less instrumentcleaning.

2. Once the skin has been excised, a small amount of subcutaneous adipose tissue is removedto improve visualization of the linea. This technique decreases the time necessary to enter

the abdomen, but it also decreases both the time and difficulty of the closure. With thisapproach, the layers of linea, subcutaneous and subcuticular tissues can be more

straightforwardly apposed.

3. The linea is incised by utilizing the thumb forceps to tent the linea. The scalpel blade is

positioned sharp side up to incise the linea and the incision is extended while using thethumb forceps as a guide to safeguard the abdominal contents. Once entry is made to the

abdomen, the falciform ligament is dissected as necessary.

4. Due to the small size of the incision, it is typical practice to utilize a spay hook to locate andexteriorize the first ovary. Learning to properly use a spay hook can occasionally be achallenge in itself. As a rule, the thumb forceps are used to elevate and tense the body wall

and the spay hook is inserted with the hook toward the midline but held tightly against thebody wall. The spay hook is advanced to the dorsal most aspect of the abdomen and lift

between colon and bladder. The ovary retrieved first is surgeons preference,but we suggestand teach removal of the right ovary first. The ovary is frequently higher on the right and

therefore, more obvious tension is felt when the spay hook is retracted.

5. After locating the ovary, the suspensory ligament is broken. This is accomplished by placing

tension on the ligament and applying digital pressure to tear. It is helpful to recognize the

groove created just below the border of the proper ligament. In rare cases you may needto nick the suspensory ligament with a blade to facilitate its rupture. After breaking thesuspensory ligament, in order to isolate the ovary, create a window low in the broad

ligament side of the ovarian pedicle and place the appropriate size carmalt well below theovary. A second carmalt clamp can be placed above the first clamp if the surgeon prefersmore security. It is extremely important to allow enough room for a 4-5mm tissue tag above

the ligature when it is finished. This will prevent slippage of the ligature off the pedicle whenthe final clamp is released. Place a clamp above the ovary for hemostasis and, while leaving

the tissue tag, cut the ovary away with scissors. Ligate, cut, or tear the broad ligament(depending on vasculature). It is more efficient to tear away or ligate the broad ligament

before proceeding to ovarian pedicle ligature as it provides more room to ligate thepedicle. Select appropriate size suture and place Millers knot below carmalt. Doubleligation is not necessary if the first ligature is properly tied. Release the clamp on the pedicle;

the pedicle can be inspected for hemorrhage at this time.

6. Follow the uterine horn to the bifurcation and repeat the steps above on the opposite ovary.

7. Proceed to the uterine body and exteriorize to allow for proper placement of ligature(s).Place a Millers knot securely above the cervix but below the bifurcation, if possible. It is not

necessary to place the Miller's knot below the bifurcation, as research has shown no benefitto ligating the uterine body in this manner. As long as the ovaries are completely removed,there is no risk of a "stump pyometra", since that is a hormone-driven disease process. In fact,

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it is prudent not to place excess tension on the uterus to achieve ligation at the bifurcation,as it can contribute to post-op spay incontinence. Keep in mind that in pregnant patients

when the uterus is removed, a natural reflex will be contraction of the tissue. Thus, the knotsecurity should be closely checked. In some in heat or pregnant patients a modified

transfixing suture may also be necessary. In patients with extremely friable tissues, take carenot to cut through the uterus with the ligature. After ligating the uterine body, although it isnot necessary, you can place a clamp for additional crushing hemostasis; do not place the

clamp too close to the ligature as it may cause unnecessary distortion of tissue. Cut proximalto clamp and remove uterine body. Check for oozing as the clamp is released and tension

on uterine body is decreased. Complete a visual sweep of the abdomen.

8. Perform closure of the linea making certain to bites of the external rectus (the holding layer

of the abdomen). Bites do not need to be full thickness. The surgeon should select anappropriate suture size and close with cruciates. NO continuous patterns should be used in

the linea. The cruciate is more efficient because it allows for effective apposition withoutrelying on one pattern to hold the entire incision closed, is faster than simple interrupted, and

is a tension-relieving pattern.

9. Perform closure of the subcutaneous and subcuticular tissues. The runner from the linea isused to place a simple continuous closure of the subcutaneous tissue to the opposite end ofthe incision tacking down to the fascia as you go. Then, the subcuticular tissue is closed with

a horizontal continuous pattern, parallel to the incision, back to the last tag of the linea. Therunner is then tied off to the last tag which will bury the knot. The knot is buried to prevent

wicking and to ensure appropriate skin apposition. The closed incision then has glue appliedto the skin surface. The glue should be applied on, NOT in the incision. Glue in the incision

can act as a foreign body and delay healing. Rolling of the incision (inverting the incision)can be helpful in to avoid issues with licking and wound contamination by creating a naturalbandage.

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Canine Castration

In the adult male, the closed technique is the preferred method because it is more efficient(saves time not to close tunic), there is less foreign material (suture) in closure, and there is lessbleeding.

1. The testicle is exteriorized (to minimize incision size, expose from pole to pole vs. side to side)

by sharp excision of excess fibrous tissue.

2. Once exteriorized, a Millers knot is placed while leaving a 4-5mm tissue tag to ensure no

slippage. One ligature is usually sufficient. A modified transfixing ligature (pass needlebetween the cord & vessel) can be used in place of or in addition to the Millers knot if

preferred. This method is repeated on the opposite testicle.

3. Closure can be accomplished on males with a simple continuous pattern in the

subcutaneous and subcuticular tissues by using the runner method as utilized in the OHE.Glue is placed over the incision as with the OHE.

4. Another option for adult male castrations would be a scrotal approach. The testicles are

exteriorized through an incision in the median raphe of the scrotum, and ligated with amodified Millers knot, or whatever the surgeon prefers. The incision is then apposed with one

simple interrupted suture in the subcutaneous tissues using 3-0 absorbable suture.

1. In the pediatric male, one incision is placed over the scrotum along the median raphe. Thetesticle is exteriorized and excess tissue is stripped away. Either the open or closed techniquework equally well in the pediatric male.

2. A figure 8 or overhand knot is placed and a tag left. This procedure is repeated on theopposite testicle. The incision is closed with glue and the rolling technique is used to

prevent licking.

3. A modified scrotal approach is sometimes used, which is essentially the same procedure,except the tunic is opened but the tunic is not removed from the pole until after the tied

cord/vessel is placed back into the tunic. The tunic is then stripped of excess tissue and tiedwith a simple instrument tie. This technique is used on large breed puppies and other non-pendulous scrotums.

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CANINE CASTRATION (ADULT)

CANINE CASTRATION (PEDIATRIC)


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Feline Sterilization

The feline spay is performed in much the same way as the canine spay, with one notableexception. We routinely use a method commonly referred to as the pedicle tie.

1. An overhand instrument tie is performed on the ovarian pedicle, similar to the technique

many veterinarians use in neutering a male cat.

2. Upon isolation of the ovarian pedicle, the pedicle is feathered over the surgeons finger toallow identification of the individual structures.

3. The suspensory ligament is located and torn/cut. The ligament can be cut with scissors orblade or torn with digital pressure or a hemostat.

4. A curved mosquito forcep is utilized to tie off the ovarian pedicle. The surgeon then slides theknot off of the hemostat.

5. When ligating the ovarian body, the same techniques that were used in the female dog areused in the female cat. The only notable exception is that close attention must be paidwhen ligating a friable uterus in a post-partum or multi-parous cat, as the ligature can cut

through the uterine tissue easily if attention is not paid when tightening it. The Miller's knot isspecifically designed not to cut through tissue, as it is a 2-pass knot, and therefore distributes

pressure over a larger surface area. However, it can still cut through friable tissue, at whichpoint, suture of a larger size must be used to tie a new ligature.

1. An incision is made centrally or over each testicle. Open or closed techniques both work

well.

2. An overhand knot or figure 8 knot can be used to ligate the cord, depending on thesurgeon's preference, and the thickness of the cord (figure 8 knots are more difficult to

perform on thick cords). This technique is repeated on the opposite side and the incisions areleft open.

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FELINE CASTRATION

FELINE OVARIOHYSTERECTOMY


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FAQs

We clip for all surgical procedures, including cat castrations. While plucking is an acceptable

form of hair removal, we choose to clip these patients to give us a broader hair-free surgicalfield, which can decrease contamination, particularly in long-haired cats. Clipping is also a

faster way of preparing the surgical site for us than plucking is.

While we make every effort to provide the types of surgeries that you would like to perform,ultimately, this is up to the discretion of your instructor and the types of animals that we have

come through the clinic. If your instructor feels that you need work in a certain area, he/she willlet you know and will work with you to also incorporate the cases that you would like to work on.

Keep in mind that some cases (such as cryptorchids) are not always available.

Yes. Please first check our website under E-Learningto make sure that the video you need has

not already been posted there. We do ask that any pictures or videos taken at Humane Allianceare used for your personal education only. We do not allow videos or pictures that include

patients to be posted on social media sites, and ask that permission be requested and credit begiven if the videos or pictures are to be used in presentations.

Simply put, it is the best choice for the HQHVSN arena. Suture on a reel is much less expensivethan swaged-on suture (suture with the needle attached), and PDS has the balance of strength

and decreased reactivity that we need in an absorbable suture that is to be used on a large,varied population of cats and dogs. Keep in mind that the body wall takes 2-4 weeks to healcompletely after surgery. When you look at the chart below of commonly used suture types, you

will see that PDS retains its strength longer than plain catgut, chromic catgut, and Monocryl TM.Catgut's short duration of strength and high level of reactivity makes it unsuitable for use in the

HQHVSN setting (even on the pedicles, uterine stump, and testicular cords).

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3. CAN I TAKE PICTURES/VIDEO OF PROCEDURES, EQUIPMENT, SETUP, ETC.?

2. CAN I FOCUS ON CERTAIN PROCEDURES DURING MY TRAINING?

1. DO YOU PREFER CLIPPING OR PLUCKING FOR CAT CASTRATIONS?

4. WHY DO YOU USE PDS SUTURE? WHY ON A REEL INSTEAD OF IN PACKETS?


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FAQs

Although Monocryl TMhas less reactivity in subcutaneous tissue than PDS, it's short duration ofstrength retention makes it a less than ideal choice for anything but young, fast-healing patients.

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