Congress on Demand 2021: Surgery

Jonathan Bray discusses axial pedicle flaps.

Patient safety: where do we start?: ‘Do no harm’ is a fundamental principle for any caregiver – in both human and animal worlds. Human healthcare has long acknowledged and quantified the iatrogenic harm inflicted on patients through the errors and mistakes of caregivers. In the complex world of healthcare, 1 in 10 visits to hospital involve an error in the chain of care, and an estimated 400,000 people a year die as a result of doctors’ or nurses’ mistakes (De Vries et al. 2008). In contrast, there are no published studies of incident rates in the veterinary literature. We acknowledge that they happen, yet we have no measure of them – how often, how severe, the most common, the most expensive, the most preventable. If we want to ensure and improve patient safety, knowing the current situation would be the most logical place to start.

Clinical audit: where can we start and why?: Patient safety is the priority for everyone in veterinary practice, but what has clinical audit got to do with this? Well quite a lot actually. Clinical audit provides the tools to look at results of procedures and put preventative methods in place, making veterinary procedures safer. Do you know the rate of post-operative complications in your practice for routine neutering and how they compare with national benchmarks? What about anaesthetic monitoring, do you audit the process of filling in anaesthetic monitoring sheets as well as the outcomes and complications of anaesthesia? If you use surgical safety checklists do you audit their use and look at what the barriers are to them being used more widely? Collecting the data is only a small part of audit. Discussing the results with the team who are involved in the work on the ground – what could be changed, what prevents current systems working as they should be – is a very important part of the audit process. Once the team is on board and changes have been made, re-audit is vital to see if the changes have had any impact. Implementing small changes that do make a difference can have a big impact on patient safety. This session will introduce delegates to clinical audit and the free learning materials, case examples, and the tools that have been created specifically for veterinary teams to put into practice straightaway.

Ask many veterinary professionals, especially vets, what they understand by Schedule 3 of the Veterinary Surgeons’ Act (1966) and they will probably mumble something about it relates to ‘surgery not entering body cavities’. Schedule 3 is however the legislation that underpins the ability of Registered Veterinary Nurses (RVNs) to work to their full potential as part of a vet-led team. Many veterinary practices fail to fully value and utilise their RVN staff by not training, encouraging and supporting them to undertake Schedule 3 tasks. This results in a lack of job satisfaction and career progression. Appropriate post-graduate training, both in-house and more formally, builds RVN competence and confidence. There is no doubt that veterinary surgeons need to acknowledge the skills of RVNs and communicate these more effectively to clients. RVNs working to their strengths and abilities, especially via protocol-driven systems within practices, can bring benefits to the whole team, patients and clients. As the RCVS Legislation Working Party considers enhancing the RVN role, there has never been a better time for the whole practice team to become more confident with Schedule 3.

Orthopaedic exam review: This highly practical and clinically-applicable presentation demonstrates how to approach the orthopaedic examination in order to maximise the amount of diagnostic information that can be gathered in a short time. Video footage demonstrates various aspects of the examination, including practice tips on patient restraint and performing important manoeuvres. This session is heavily orientated towards the first-opinion clinical setting, and aims to provide delegates with useful tips and tools that can be applied to help improve the efficiency and usefulness of the orthopaedic consultation.

Visual gait analysis – how to be objective: This presentation discusses visual gait analysis. This is an extremely important part of an orthopaedic examination, being necessary to determine which limb is affected as well as the severity of the problem. The session covers how best to perform gait analysis, what to look for and how to gain the most information from this part of an examination. The aim is to increase confidence in performing visual gait analysis so as to aid in ability to correctly diagnose orthopaedic disease. A recording of a live discussion follows regarding various aspects of the orthopaedic evaluation of dogs and cats.

There are a number of conditions that can cause acute or intermittent vomiting, including gastrointestinal foreign bodies, pancreatitis and gastroenteritis. With foreign bodies, palpation may be diagnostic though in most cases, imaging confirmation of gastrointestinal foreign bodies is paramount, using radiographs, ultrasound or CT. On radiographs, signs consistent with obstruction include masses (soft tissue or radio-opaque, distended loops of small intestine (diameter > twice the height of L5) and plication. Ultrasound can be very useful in the hands of a skilled operator, often giving location of obstruction and any evidence of peritoneal effusion with high sensitivity and specificity. Surgical considerations include enterotomy versus enterectomy, suture techniques, needle type, stapling versus sutures and use of drains to aid post-operative surveillance. Post-operative management is crucial, with early enteral feeding important and careful monitoring and management of pain and ileus. Post-operative analgesia will be examined, including the evidence base for the use (or with-holding) of non-steroidal anti-inflammatories. Known risk factors for increased complications are covered and methods of decreasing complications such as the surgical check list discussed.

Appropriate tissue handling is an essential part of good surgical technique. Indeed, ‘gentle tissue handling’ is one of Halstead’s principles of surgery. Tissue handling involves respecting the tissues during surgery to ensure that they are not damaged. This can be achieved by the prevention of crushing, drying out, haemorrhage and damage to the vascular supply. An understanding and appropriate use of instruments and other techniques to aid tissue handling is essential. Good tissue handling is important as it will reduce or prevent complications such as surgical site infection (SSI), wound dehiscence, haemorrhage and seroma formation. The first step of improving tissue handling is to understand the basic principles. This can then be refined through practise and experience. It is vital that the surgeon reflects on their performance and strives for ongoing improvement. This can be enhanced by observation of peers, advice from an appropriate mentor and good planning prior to surgery. Refinement of tissue handling should improve surgical outcomes. Good surgical technique is characterised by accuracy and security rather than speed and apparent ease of performance.

Lumpectomies made interesting: Veterinary surgeons love lumpectomies but each extent of oncological surgery depends on the type and stage of the tumour. A pre-resection biopsy is often necessary to anticipate sufficient margins of resection and behaviour of the primary tumour. Staging the tumour will prevent treatment failures caused by early metastasis and will help in deciding the type of resection and use of adjuvant treatment modalities. Diagnosis of intercurrent diseases often will alter surgical treatment options and should be evaluated beforehand to assess the risk versus benefit of surgical intervention. The surgical field should be prepared carefully to allow changes in the extent of resection based on new information obtained during the operation. The necessary surgical margins depend on the tumour type, grade, and the anatomical location of the tumour. The most rational approach is to think of biologic rather than geometric margins and to combine this information with the expected growth behaviour of the given tumour type. Tumours with a high probability of local recurrence (e.g. mast cell tumours, feline mammary tumours) should have 2 to 3 cm margins removed three-dimensionally. Collagen/matrix-rich and poorly vascularised tissues are least vulnerable to tumour invasion and may be used for margin determination. All previously performed biopsy tracts should be removed in continuity with the primary tumour to prevent tumour seeding. With a proper resection the tumour is never visualized.

Skin reconstruction techniques: The reconstruction of wounds – either traumatic or those created following resection of tumours – provides an opportunity to bring skin edges into approximation. Dogs and cats have very adaptable skin, and a range of reconstructive procedures are described allowing sections of skin to be rotated, advanced and transposed to cover an adjacent defect. However, skin can be very unforgiving of inappropriate technique. As the complexity of a reconstructive surgery increases, the potential for disastrous outcome increases with either partial or complete failure of the skin flap. A successful outcome requires an understanding of blood supply, effective management of tension and a sound operative technique. Ideally, a wound should be closed without tension. Excessive tension may lead to vascular compromise and delayed healing. At worst, this may result in catastrophic dehiscence of the wound. Less serious complications include increased post-operative discomfort (which may lead to self-aggravation of the wound by the patient) and more unsightly scar formation. If excessive effort is required to achieve wound closure (e.g. brute strength, excessive use of stents, heavy gauge suture), it would be preferable to consider an alternative approach to wound reconstruction that recruits additional skin into the defect. A successful wound reconstruction will take account of skin tension. The surgeon should have an understanding of the methods used to ameliorate the effects of skin tension on wound healing. Many of these methods are straightforward, whilst others require some innovation and ingenuity. This lecture explores some of the many local flap and reconstructive options available in the dog and cat. Case examples are used to illustrate issues of importance and how to manage any complications should they develop.

Laparoscopy is most commonly used in small animal general practice for routine ovariectomy/ovariohysterectomy in bitches. However, it is far from a ‘one trick pony’ and the potential to utilise laparoscopic techniques for a wide variety of abdominal procedures has been largely overlooked. The excellent visualisation afforded through a small 5mm incision, coupled with the ability to perform biopsies or operative surgery provides the clinician with the tools to diagnose and treat many cases of acute abdominal disease with greatly reduced morbidity and minimal tissue trauma in both dogs and cats. Many clients are reluctant to allow their pet to undergo exploratory laparotomy or invasive surgery “just to get a biopsy”. However, they are much more open to a keyhole approach which enables collection of excellent, diagnostic biopsies from multiple tissues with excellent haemostasis. Many, if not most procedures currently carried out by open laparotomy can be performed laparoscopically or lap assisted with lower morbidity and quicker recovery. Even seemingly unlikely candidates for laparoscopy, such as splenectomy, can be carried out lap assisted with some advantages for the patient. This lecture discusses the use of laparoscopic techniques for diagnosis and treatment of acute and chronic abdominal conditions in the dog and cat.

My favourite myths around FHO: Femoral head and neck ostectomy is a salvage procedure for various conditions affecting the coxofemoral joint of cats and dogs. Considering that it is a relatively common procedure done by general practitioners and specialists alike, it is fraught with wide-ranging options, some labeling it as a perfectly innocuous solution to many hip problems and others as a sure method to cripple the animal. Never in large breeds, perfectly fine in cats, never bilaterally, simple salvage after total hip prosthesis gone bad – not much to be found in the veterinary literature on these opinions. The goal of this talk is not to argue for or against FHO as a surgical option. It is aimed at evaluating different clinical situations and possible treatment options, and other considerations to help improve function after FHO if this was the chosen treatment.

Cat fractures will heal as long as the two bone ends are in the same room: This session discusses one of my favourite orthopaedic myths: cat fractures will heal as long as the two bone ends are in the same room. I remember first hearing this as a veterinary student, believing for many years that cat fractures were pretty much bound to heal however they were treated and very unlikely to suffer complications. There is very little in the literature regarding these common injuries, giving a limited evidence base for our decision-making. There is, however, some recent evidence showing that feline fractures suffer from exactly the same complications as canine fractures. The evidence is discussed, aiding us in making the best choices for our feline patients and ensuring they have the best outcomes possible.

Surgical management of the acute abdomen: When approaching the ‘acute abdomen’ patient, the surgeon often does not have a clear understanding of the pathology prior to the celiotomy. It is therefore important that the approach to these patients should enable the surgeon to explore the entire abdominal cavity to determine the cause and extent of the condition and also, to obtain biopsies if definitive treatment is not possible. This presentation reviews a thorough abdominal exploration of a patient via video and discuss practical ways (including instrumentation, approaches and biopsy techniques) that allow the surgeon to optimise their approach to these tricky patients.

Otomies and ectomies in the acute abdomen – how to improve outcomes: When managing cases with an acute abdomen that require surgical intervention, there is often the need for the surgeon to either enter a hollow viscus (for example, gastrotomy, jejunotomy, etc.), or, to remove a portion of the organ (for example, partial gastrectomy, enterectomy, etc.). This presentation reviews the basic principles of such gastrointestinal surgeries using clinical examples and live video feed to emphasise key points, errors in technique and controversies. The talk aims to provide clear and practical advice that can be used in day-to-day surgical practice – hopefully, improving both confidence and surgical outcomes.