Congress on Demand 2021: Surgery

The Covid-19 pandemic has brought infection control into sharp focus. Many of the measures taken to halt the spread of Covid-19 (particularly hand hygiene and personal protective equipment/PPE) will have also been effective against hospital acquired pathogens. However, the risk from hospital acquired infections (HAIs) will still be with us once the pandemic recedes. Practices should therefore take the time to establish effective infection control measures that will protect their patients, owners and staff. It is important to understand the most likely organisms in each practice and how these can spread in the environmental and be transmitted between animals and humans. Essential tasks include establishing an infection control team, using effective hand hygiene, cleaning and disinfection, have high quality facilities and equipment, optimising procedures and care, using clinical audit, and practicing antimicrobial stewardship.

Over the past four decades, total hip replacement (THR) has become a well-established and largely successful procedure in dogs. More recently, the available inventory has opened up THR as an option in small breed dogs and cats. The most common indication is osteoarthritis (OA) secondary to hip dysplasia, and other candidate conditions include avascular necrosis of the femoral head, fractures of the femoral head and neck, and recurrent hip luxation. This lecture explores the indications for THR, alternative treatment options, and the advantages and disadvantages of each of these. A big part of this will be how to identify the “non-responder”: the OA patient that does not improve satisfactorily in response to medical management. The lecture should provide a greater depth of understanding of the factors used to determine whether a patient is a good candidate for THR.

How can Halsted’s Principles help me improve my surgical skills? Conceived in the late 19th century, Halsted’s Principles are as relevant for us in our surgeries today as they were then. Their central axiom is all about promoting wound healing; this seminar outlines some simple guidelines for incorporating the kind of tissue sympathy in our surgical technique that favours optimal wound healing.

Maximising the use of a scrubbed assistant in surgery: A scrubbed assistant benefits everyone involved in a surgical procedure, including the patient. As nurses we have a key role and need to understand how to support the surgical team. Developing our skills under schedule 3 of the Veterinary Surgeons Act 1966, also helps with our career progression and job satisfaction. It must be remembered though that all surgical procedures, however minor, have associated risk to the patient. This means it is important that nurses are fully trained and competent at performing surgical skills and understand the legality and limitations within their professional remit.

Presentation and triage of acute abdomen: An “acute abdomen” is defined as a condition of severe abdominal pain due to disease or injury of one or more abdominal organs, usually requiring surgery. The most common causes of acute abdomen in dog and cats are septic peritonitis and haemoabdomen. The purpose of this session is to consider different clinical presentations of acute abdomen, specifically the changes seen in different body systems, such as the cardiovascular system, and consider why this assessment is important.

What is the immediate management, in terms of bloods, drugs and tests? A patient with ‘acute abdomen’ may have a condition, or conditions affecting different organs or groups of organs and many will require eventual surgery. The purpose of the pre-surgical evaluation is to stabilise the patient appropriately but also to help diagnose the pathology, so the surgeon is better prepared. This presentation discusses the assessment of these patients in terms of appropriate pre-surgical evaluation including blood, drugs and imaging including point of care diagnostics that might influence further therapy or provide prognostic information. The aim is to enable the surgeon to optimise surgical outcomes for their patients and improve their confidence in managing these difficult cases.

Post surgical complications – overview: An ‘acute abdomen’ patient that is recovering from surgery may often have multiple and serious post-surgical complications. These complications are often due to a combination of surgery and the underlying disease process so management of these can be very challenging. The surgeon has to be well equipped to detect early deleterious changes in patient progress, whether this is bleeding, infection, leakage of bile or urine. This presentation therefore provides an overview of the most common post-surgical complications of these patients, how they can be diagnosed and practical ways to best treat them.

Dealing with post-operative peritonitis: Unfortunately, post-operative peritonitis is not unusual, intestinal surgery has about a 7% dehiscence rate and peritonitis may also be seen after other common abdominal procedures, including pyometra, prostatic surgery and cystotomy. Clinical signs of post-operative peritonitis can be difficult to differentiate from post-surgical ileus, pain and medication-related nausea or anorexia. About 50% of peritonitis cases may have concurrent pancreatitis. Imaging can be confusing as it is normal to have free fluid and gas in the abdomen after an open surgical approach (although the gas with peritonitis tends to be more diffuse). If free fluid is present on ultrasound, then sampling and performing cytology and peritoneal glucose and lactate concentration comparisons with serum levels can be most helpful. Other indications of peritonitis can include hypovolaemia, hypoproteinaemia (particularly a drop in albumin), development of respiratory acidosis and metabolic acidosis. Treatment involves intravenous antibiotics, haemodynamic support and repeat surgery to resolve the source of infection. Mortality rates are in the range of 20-50% depending on the study. Post-operative peritonitis does occur, and early detection may improve outcome. Careful monitoring after surgery and the use of a closed active suction drain in any cases that may be at higher risk may aid early detection. This presentation discusses risk factors in animals and prognostic indicators to guide decision making.

Surgical preps and autoclaves: This lecture focuses on surgical preparation of patients.

Asepsis has failed: where do we start tracking down the culprit? As nurses patient care is our number one priority and this comes in many forms. Cleanliness of the environment and patient preparation all have a huge part to play as well as ensuring good aseptic technique is followed. Aseptic technique means using practices and procedures to prevent contamination from pathogens. We all work hard to apply the strictest of rules to minimise this risk, but what happens when things are out of our control? How do we work out where the break in the chain was? Why this is important to know and what implication does it have on our patients?

For most of us who see orthopedic and neurologic gait abnormalities in cats or dogs, differentiating the two is not difficult. We look for obvious deficits such as ataxia or paresis to confidently walk down the neuro route, or evaluate with a few practised manoeuvers joint effusion, instability or pain, taking us readily down the ortho path. Of course, there is more to this, but we are often quite lucky that most of our patients present with relatively obvious signs of ‘neuro or ortho’. But what of the sneaky ones – the ones that have such an obvious lameness but despite our looking and walking and testing and probing do not give up the cause for it easily? This session dives deeper into the subtle nuances between orthopaedic and neurological lameness and how to determine which direction to pursue with further diagnostics and treatments. It can sometimes feel challenging to decide whether a gait abnormality is related to musculoskeletal or neurological abnormalities, but the differentiation is important to plan further diagnostics, or even refer appropriately! This determination is rarely ever done on the basis of further investigations, no matter how advanced. It is almost always achieved on the basis of clinical history, gait evaluation and clinical examination. This session draws on the experience of two clinicians who are well-used to investigating and managing both musculoskeletal and neurological gait abnormalities. It provides easy-to-remember, practical tips, addressing useful aspects of the clinical history (what to ask), gait evaluation (what to look for) and clinical examination (what to test), that will give the best possible chance of correctly identifying the cause of lameness in future patients.

This lecture will provide practical tips and advice on when and how to perform a thorough exploratory laparotomy. It will include a detailed ‘visual tour’ of the clinically relevant anatomy, tips for biopsying abdominal organs and recommendations for how to open and close a large coeliotomy incision. It will help you to know when an exlap is indicated and what the essential considerations are before embarking on surgery; be able to describe the clinically relevant anatomy when performing a thorough exlap; learn surgical tips for performing biopsies of abdominal organs; know the current recommendations for opening and closing a large coeliotomy incision.

Bianca Hettlich outlines a practical approach to elbow dysplasia.

Fluid therapy in acute abdomen: During this lecture we discuss the why’s, when’s, what’s and how’s of fluid therapy administration for the acute abdomen patient. We will briefly discuss what an acute abdomen means and what the clinical signs are. We will discuss why patients with an acute abdomen often present with shock, what the clinical signs of shock are and the importance of treating shock. This lecture discusses the use of crystalloid fluid therapy administration vs colloid administration and the advantages and disadvantages of both.

Anaesthetic considerations for the acute abdomen: Unlike elective procedures, critically ill patients present a number of anaesthetic challenges such as an unstable cardiorespiratory system, altered circulating fluid volume and metabolic derangements. Despite these problems a thorough pre-operative clinical examination and subsequent anaesthetic plan is vital as the key to success lies in correct preparation and anticipation of problems and this session explores how preparation may maximise subsequent anaesthetic success. Premedication may be unnecessary if the patient is obtunded and drugs such as the alpha-2 agonists which have major cardiovascular effects should generally be avoided. Induction of, and recovery from, anaesthesia are critical periods. This presentation describes a best practice approach to induction, maintenance and recovery of these patients. Finally, commonly encountered problems such as regurgitation, dysrhythmias and delayed recovery are discussed to aid correct planning. Throughout the session the emphasis is on practical first principles rather than offering an anaesthetic ‘recipe’ to allow adaption of the ideas into the participant’s own practice situation. A recording of a live Q&A session follows covering questions regarding fluid therapy and anaesthesia for the acute abdomen patient.

Nose and soft palate: In various studies, about 60% of dogs with BOAS had stenotic nares and 90% had an elongated palate. Using advanced imaging, the palate is not only long but also thickened (hyperplastic) which may be a secondary change to other areas of airway obstruction. The lesions sites are also breed specific, with nasal stenosis being more of an issue in French bulldogs and pugs than bulldogs where the hyperplastic palate is the most noticeable lesion. In an objective study of airway function the nostril status was the most significant conformational factor associated with BOAS (though we still see unaffected dogs with severely stenotic nostrils). As lesion sites vary between breeds and also between individuals of the same breed it is important to assess individuals carefully prior to surgery with a functional assessment (https://www.thekennelclub.org.uk/health-and-dog-care/health/getting-started-with-health-testing-and-screening/respiratory-function-grading-scheme/). We use a nasal grading scheme which is breed specific to assess the nostrils. Open and mildly affected nostrils are desirable (https://www.vet.cam.ac.uk/boas/about-boas/recognition-diagnosis#stenoticnares). There are a myriad of techniques described for soft palate resection and nasoplasty. This presentation covers the current surgical options for nasoplasty and soft palate resection, including alar fold resection and folding flap staphylectomy techniques along with the evidence behind them. Potential complications and outcomes (where known) are also discussed.

Laryngeal collapse and tracheostomy: Laryngeal collapse is a form of upper-airway obstruction caused by loss of cartilage rigidity that allows medial deviation of the rostral laryngeal cartilages. Although laryngeal collapse has usually been considered to be associated with progression of the BOAS, when it comes to the more advanced stages of the condition, the breed of dog is often indicative of the severity in laryngeal changes seen. Conventionally, the condition is sub-divided into three stages in the dog: in stage I laryngeal collapse there is eversion of the laryngeal saccules, in stage II there is loss of rigidity and medial displacement of the cuneiform processes of the arytenoid cartilage, and in stage III there is collapse of the corniculate processes of the arytenoid cartilages with loss of the dorsal arch of the rima glottidis. In its advanced forms, the condition is life-threatening and often very difficult to treat effectively. This presentation covers the condition and its potential management options (e.g. husbandry changes, surgical correction of primary abnormalities, sacculectomy, arytenoidectomy, cricoarytenoid and thyroarytenoid caudo-lateralisation, and permanent tracheostomy), highlighting the controversies and difficulties in its treatment.

Critical history, blood tests and urinalysis: Urinary incontinence is a common reason for presentation, particularly in neutered bitches. It is however, important to distinguish incontinence from pollakiuria, polyuria and behavioural problems. This necessitates asking the client the right questions, performing a thorough physical examination, and sometimes checking urine specific gravity. It is useful to establish the timing of the episodes, volume of urine passed and events surrounding the leakage of urine. Animals with incontinence usually present with intermittent or continuous dribbling of urine but can void normally. Potential causes of urinary incontinence include urethral sphincter mechanism incompetence (USMI), ectopic ureters, neurological abnormalities, detrusor instability and genitourinary tract neoplasia. When incontinence is confirmed, a thorough history, physical examination, neurological examination, urinalysis and aerobic urine culture should be performed. Due to the high prevalence of USMI in adult, neutered bitches and the low cost and risk of treatment, if the results of these steps are consistent, alpha-agonists or estrodiol are frequently trialled prior to further investigations. If the presumptive diagnosis is correct, this treatment is often effective. If not or if the animal does not fit these criteria, further investigations including a complete blood count, biochemistry and abdominal imaging are required to establish the diagnosis.

Imaging the urogenital tract: what test when? Diagnostic imaging can be a very powerful tool in the investigation of urogenital disease, with the differing modalities having strengths and weaknesses for the different areas of the tract. Generally, ultrasound would be recommended as the most appropriate first-line investigation for most structures in the urogenital tract, allowing clear visualisation of the internal structure of the kidneys and reproductive structures (ovaries, uterus, prostate, testes). Radiography may allow diagnosis of altered shape or size of these structures but the changes seen are usually less specific than those that can be identified with ultrasound. Ultrasound and/or contrast radiography can be used for assessment of the bladder (with ultrasound usually being more convenient (and allowing guided cystocentesis if required), but care must be taken in interpretation of the bladder wall if the bladder is not particularly distended. For the ureters and urethra, positive contrast radiography (Intravenous urography, retrograde (vagino) urethrography) often allows clearer assessment of the length of these structures. If available, Computed Tomography can be particularly useful for the assessment of ureteric anatomy (e.g. for aberrant insertion/ectopia). In many cases, multi-modality imaging may be appropriate, particularly if investigation for changes in other body areas is required (e.g. metastatic spread from a neoplastic process).

Identifying ectopic ureters – tips and tricks: Ureteral ectopia (EU) is a congenital abnormality, in which one or both ureteral openings form with their termination located distal to the bladder trigone. Intramural and extramural phenotypes are recognised, with >95% of canine cases identified as intramural, whilst the majority of feline EU are extramural. Diagnosis may be straightforward in patients presenting with significant urinary incontinence at a young age, but may be challenging in patients with a more atypical presentation, or in those with only subtle abnormalities of their urinary tracts. This session covers the variable clinical presentation of patients with ectopic ureters, explains ultrasound findings that may increase your index of suspicion for this condition, how to optimise contrast imaging to highlight an abnormal ureter and more about our current gold standard of diagnosis, cystoscopy. This information should enable you to more confidently recommend additional diagnostic tests in the correct animals and avoid unnecessary testing in those patients unlikely to have this condition. More patients can then in turn receive appropriate treatment.

USMI when medicine fails: what next? Urethral sphincter mechanism incompetence (USMI) is the commonest cause of urinary incontinence in the bitch. Medical management is the first line treatment (usually with either an adrenergic agent (e.g. phenylpronolamine) or an oestrogenic agent (e.g. estriol). The majority of bitches have a good response to these, but other treatments need consideration in a minority of cases. Before surgery is planned, the clinician should review the diagnosis and consider underlying or secondary factors (such as obesity and urinary tract infection). If the diagnosis is confirmed and these have been considered, surgical management can be offered to the owners. There are several established surgical options (colposuspension, Artificial Urethral Sphincter placement, urethral sling), endoscopic management with urethral bulking agents and some less well established procedures (vaginectomy, vaginal septum transection). The session looks at each of these and make suggestions as to their application.

This lecture discusses the reduction of human errors via the establishment of continuity of care for our veterinary patients. Using the acute abdomen as a patient example, it explores the role that care plans and structured handover tools play in preventing patient errors. Communication is key to success in veterinary practice, this involves structured communication throughout all levels of the veterinary team. The acute abdomen requires knowledge and recognition of a significant number of clinical nursing and veterinary considerations that without thorough care planning and handover may go unrecognised during or after a shift change. The lecture draws on evidence from both human and veterinary literature on the importance of these multidisciplinary communication tools and discusses how the veterinary team can adapt these for use in their own clinical environments.