Tag: wound

  • Flank approach to the bitch spay

    Jordan surgery
    An experienced vet could complete the entire procedure easily within 10 minutes. We “tentatively ambled” through our surgeries in 20.

    Having finally settled in one place in Jaipur, India, my friend and I were able to relax a little, safe in the knowledge we had two weeks of neutering for population control ahead of us.

    Being in an unfamiliar environment, and with our patients mainly being strays, we were prepared for very different methods of anaesthesia, variations on drugs we’re used to at home, and potentially questionable sterility. Even so, when the vet, stood with his scalpel at the ready, said “oh yes, we use the right flank method” as if it were the norm, we were a little surprised.

    At home, we’re so used to seeing flank cat spays and midline bitch spays, my gut reaction was “is that even anatomically possible?”. As it turns out, it is.

    The method

    A small incision (<2cm) is made on the right flank, first through the skin and then each of the 3 underlying muscles (transverse abdominis, external abdominal oblique and internal abdominal oblique). A spay hook is then used to exteriorise the right uterine horn.

    Once identified, the surgeon follows the horn to the ovary and applies tension caudally to break the suspensory ligament. A ligature (note single) is placed around the blood vessel and the ovary cut from it using the three clamp method in the same way as spays in the UK. The surgeon then follows the uterus to the cervix and along the left horn to the left ovary, where the procedure is repeated. A ligature is placed just above the cervix (again using the triple clamp method) and the uterus removed.

    Closing the incision comprises placing a horizontal mattress suture in each of the muscle layers, a cruciate suture in the subcutaneous fascia, and intradermal sutures in the skin.

    The positives

    While the very idea of flank spays in the bitch just seemed alien, this method seems to be successful and works well in a charity environment in a country where certain resources are unavailable.

    The reasons for choosing this method include easier wound checking, a shorter wound healing time (meaning the dogs can be re-released sooner) and less tension at the incision site, decreasing the risk of wound breakdown – essential for animals that, once released, are unlikely to be seen again.

    Jordan surgery
    Despite her initial surprise at the method used, Jordan admits the flank approach is the best compromise, considering the resources available.

    The surgeons at the charity have found, over the years, the single horizontal mattress suture seems to be the least aggravating to the body wall muscles, and intradermals are the closure of choice in any stray or vicious animal that would be difficult to get near to remove sutures.

    Another key advantage to the flank approach is speed; important for two reasons:

    • The sheer number of stray dogs to neuter to reach an adequate level of population control means faster surgery is required to reach the target numbers.
    • The surgical time under IV anaesthesia should be kept to a minimum to avoid prolonged or rocky recoveries and minimise side effects.

    The experienced vet could complete the entire procedure easily within 10 minutes (in a normal young bitch, opposed to a pregnant or in season girl), and we, tentatively ambling through our surgeries, could complete within 20.

    The negatives

    Disadvantages to this method include more potential bleeding due to incising through the three muscle layers, a possibility of more postoperative pain and increased difficulty in extending the incision if there are complications. The most important, however, is that recovery of a dropped or bleeding ovarian stump is extremely difficult (or near impossible).

    The anaesthesia protocol used is premed: xylazine, induction/maintenence; IV ketamine and IM meloxicam as pain relief. Hence, the speed of the flank approach will also minimise the number of top ups needed and reduce the anaesthetic hangover comparing to a technique (such as midline) that is more time consuming.

    Compromise

    The method seems to be the best compromise, considering the resources available. I think the overruling disadvantage is that, if you were concerned about a slipped ligature, the ovarian and uterine stumps would be virtually impossible to find again via the original incision.

    However, that said, the only postoperative death we saw during our time on postmortem had all ligatures intact.

    It was eye-opening to see an entirely different approach to a bitch spay, and while it may not be the same as the routine at home, I still felt that we gained a lot of surgical experience and developed transferable skills.

  • Meshed skin grafts

    Meshed skin grafts

    Meshed skin grafts have several advantages over non-meshed grafts.

    Meshed skin graft
    Image courtesy Louise O’Dwyer.

    Meshing is the creation of several rows of staggered, parallel incisions into a graft. Usually, a number 11 scalpel blade is used to make incisions 1cm long and roughly 1-2cm apart along the long axis of the graft.

    The resultant mesh allows the graft to be stretched in two directions, increasing its flexibility and helping it conform to various shapes of wound.

    For a given size of wound a smaller donor segment is required for meshed grafts because of the potential expansion, which may be helpful when a large wound requires reconstruction.

    Small “pegs” of granulation tissue often grow into the meshed holes, providing further support and apposition between the graft and its bed. Also, meshed grafts allow passive drainage of fluid through the mesh holes, preventing accumulation of fluid under the graft, which could adversely affect graft take.

  • Low-level laser therapy for dogs

    Low-level laser therapy for dogs

    laser therapy
    Image ©iStockphoto.com/DenGuy

    Low-level laser therapy (LLLT) is a rapidly growing adjunctive therapy in companion animal practice.

    Low-level laser or cold laser therapy is a non-invasive procedure that uses light to stimulate cell regeneration and increase blood circulation, thus helping damaged tissue to repair.

    LLLT can be used to treat dogs with arthritis, tendon or soft tissue injuries, and to promote wound healing.

    Most lasers are programmable to a range of frequencies in order to treat many different types of problems in dogs.

  • Tie-over bandages can be great for wound management

    Tie-over dressing
    A tie-over dressing. Image source: VNT:CPD, Sept 2008 – “Wound care and management” by Alison Young DipAVN(Surgery), RVN.

    One of my colleagues showed me a technique we found to be a really useful aid to wound management.

    We all know open wounds can take ages to heal by second intention, depending on wound size, infection, blood supply and a patient’s health. My colleague recommends tie-over bandages are used until the wound is no longer infected and can then be closed without tension.

    Tie-over bandages provide a method for stretching and lengthening the local skin to facilitate wound closure. The amount of skin relaxation obtained depends on the location of the wound and the local skin character. Maximal stretch is usually noted within 2 to 3 days after placement of tension on the skin.

    Tie-over bandages are also useful for securing bandages in areas that are difficult to incorporate into a regular bandage, or to reduce tension on primarily closed wounds (mast cell tumours, for example).

    I also came across an article (Tobias, 2015) on just this subject that stated: “The laces are tightened 2 to 3 times a day to gradually increase tension on the skin. Most animals require sedation and analgesics during bandage changes for the first 3 to 5 days. If wounds are effusive or the laces are tight, the lacing material usually must be cut to change the bandage.”

    I have limited experience of this technique, but it is definitely one worth considering in cases with difficult areas to bandage.

  • How to survive insomnia

    Insomnia
    Insomnia can be incredibly frustrating – image ©iStock.com/YinYang

    It’s examination time and vet students across the UK are frantically trying to fill their heads with long, complicated words they can’t even hope to spell.

    With exams comes stress (which can manifest in many different ways), but as a professional bad-sleeper I wanted to share some advice on surviving an old adversary of mine: insomnia.

    Loosely, insomnia means “poor sleep” and could mean anything from having trouble dropping off to waking repeatedly throughout the night.

    If you see a doctor complaining of chronic sleep deprivation, they’ll give you a lovely printout describing “the science of sleep” and some advice along the lines of:

    • Don’t drink caffeine after midday.
    • Switch entirely to decaffeinated tea/coffee.
    • Get up and do something if you haven’t fallen asleep within a certain amount of time.
    • Read in bed.
    • DON’T read in bed.
    • Don’t look at a TV or laptop screen for at least half an hour before sleeping.
    • Make sure the room isn’t too hot.
    • Take a relaxing bath before bed.
    • Use your bedroom only for sleep.
    • Don’t eat too much or little before trying to sleep.
    • Do some exercise throughout the day (but be careful with timing – the gym “high” after a workout can sometimes keep you up too).
    • Do eye exercises to tire your eyes.
    • Try breathing exercises to aid relaxation.
    • Try natural remedies.
    • Try writing down your thoughts.
    • Sleep wearing earplugs.
    • Try to clear your mind with meditation.

    …and probably many more.

    Having battled insomnia for the best part of 10 years, I have tried all of the above with varying degrees of success. With that in mind, here are some of my personal findings.

    tea-stain-freeimagesFor me, cutting down on caffeine is completely out of the question, especially at exam time. I drink a lot of tea and my body is used to it; I will often have a tea just before bed and sleep just “fine” (for me, that is). That said, I have tried cutting down and switching to decaf, but it doesn’t make a difference and, quite frankly, tastes foul.

    At exam time, I tend to switch to a combination of coffee, Pro Plus and energy drinks in order to say awake following a bad night of sleep. But the main point is to know your limitations – don’t take two Pro Plus at 8pm if you’re not used to caffeine and then expect to be able to sleep straight away at 11.

    My main problem is that I overthink things, and once I have thoughts racing through a brain that can’t switch off, I’m in for a night of no sleep. However, I’m much better at managing my sleep now than I was a few years ago, and I think the main reason for this is that I aim for less sleep.

    While there are a multitude of studies that claim “X amount of hours is the optimum”, I’ve found I sleep more fully the less hours I get. If I stay up until 1 or 2am and completely crash, the sleep I do get is generally of a much better quality – and it’s far better than trying to go to bed at 10pm and only achieving three hours of sleep because I’m simply not tired enough.

    For me, quality of sleep is more important than quantity. I know some people swear by nine hours sleep, but for me, five or six is about normal, so find your personal optimum and work with it – don’t try and force yourself to comply with an “official” optimum recommended by some study or other.

    But what about those killer nights when sleep will just not come?

    Bach's Rescue Remedy can work wonders for some people suffering from insomnia. Image courtesy The Italian Voice, via Flickr [CC BY-2.0]
    Bach’s Rescue Remedy can work wonders for some people suffering from insomnia. Image courtesy The Italian Voice, via Flickr [CC BY-2.0]
    When I first experienced bad sleep, I used to write down my thoughts, no matter how nonsensical or ridiculous they might appear should anyone ever read them. This helped a lot as a way of channeling them and “emptying” my brain a bit.

    More recently, I’ve been using the natural Rescue Remedy. I wouldn’t say its an absolute quick fix for everyone, but it does work wonders for some people. My partner has always slept soundly but recently suffered a bout of stress-related insomnia. After a few drops of Rescue he was out like a light every night!

    If you’ve had a bad night’s sleep, the worst possible thing you can do is sleep in in the morning or nap during the day.

    Tempting as it may be, the quicker you kick your body back into a normal sleep pattern, the better. It’s far better to force yourself to stay awake than nap in the afternoon and find yourself wide awake the next night too.

    I often go through a few weeks of “normal” sleep and then have a few nights when I get about an hour at most. But if I force myself to stay awake during the day, after three or four horrendous nights, my body/brain crashes and restarts itself into it’s normal rhythm. You’ll be surprised how well you can function on less sleep than usual.

    counting-sheep_istk-carlacdesignDoctors will only prescribe sleeping tablets if you’ve tried absolutely everything else, but even then I’m sceptical – I’ve tried them before and they simply don’t work for me, so if it does come to this, don’t expect miracles.

    Insomnia can be incredibly frustrating and often upsetting for those not used to it – and often, for those who just have the odd bad night, something from the list of recommendations given by a doctor may work.

    My final bit of advice would be that, when insomnia does strike, try not to get frustrated – you’ll only go round in circles and get yourself even more wound up. Just hold on to the fact that your brain has to rest at some point, and sleep will come, even if not as sufficiently as you’d like for a few days.

  • Subcuticular sutures: a great idea in sensitive regions

    We routinely audit postoperative complications for our canine neutering surgery.

    Over time, it became clear we were seeing a few castration wounds come back in where the dog had licked both the wound and surrounding area, making it sore to the extent it was delaying healing. In some cases, additional treatment was required.

    We then wondered to what extent non-absorbable skin sutures were playing a role. Making the change to using absorbable skin sutures reduced our complication rate significantly – nuff said!

    How to bury knots at the start and finish of a subcutaneous suture. Video by John Inns via YouTube

  • Check out pad wounds thoroughly

    A veterinary nurse treats a paw wound on a large dog.
    A veterinary nurse treats a paw wound on a large dog. Image ©iStock/Mypurgatoryyears

    Last Saturday I had a “walk in” – a very cute spaniel that was limping slightly and had a cut pad. The owner thought she might have trodden on something.

    A good palpation didn’t seem to suggest the presence of any foreign body and the dog was very stoical. My previous experiences suggest any foreign material produces a lot of pain that is exacerbated by palpation – sometimes with dramatic effect!

    However, the insistence of the owner made me look closer and I could just see a glint of a firm object deeply embedded in the pad. A pair of rat toothed forceps later and I extracted a 5mm slither of glass from the pad.

    The result was a happy dog and owner, but oh – I could so easily have sent that poor dog away!