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Date:   23 June, 2009  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.


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Toa Payoh Vets Clinical Research
Making veterinary surgery alive
to a veterinary student studying in Australia
using real case studies and pictures


A Mission Impossible
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case recorded:
23 June, 2009


"The surgery must be completed in 15 minutes if the dog is to survive," I said to my two assistants. They looked at each other and grinned, looking skywards. It was just not possible and I must be a nutty veterinary surgeon.

This 16-year-old dog had not been eating for 5 days. Dark coloured vaginal discharge in large amounts. Was this the end of her life? Without emergency surgery to remove her infected womb, she would die. She might die if she was operated.

"Please wait," the best friend said to me as the lady owner made some phone calls outside the surgery. Her eyes were red. 16 years in a dog would be equivalent to over 100 years old in a person. Too old to survive an operation. The lady finally consented to the surgery and knew that it could be the last goodbye when I asked her to go home.

However, if the operation could be performed in 5 minutes, she might survive. But pyometra surgery would take more than 5 minutes. The shorter the anaesthesia, the higher the chances of survival. How to do it? Was it a Mission Impossible?

1. 20 ml dextrose saline with baytril, lasix and spasmogesic injections were given 1 hour ago. Her temperature was 39.5 degrees C, pulse was strong and respiratory rate was normal.

2. I/V dextrose saline drip given after preparing and shaving the operation site.

Isoflurane gas by mask, intubate, gas at 0.5 to 1% to effect. My assistant, Mr Saw was now much more experienced in assessing the depth of anaesthesia. I noted that the blood during my surgery was bright red instead of bluish and so I knew he was doing a good job. It was great surgical anaesthesia. "Keep lowering the % till the dog react" I advised him to check for pedal pain and eye blinking reflexes. Only during the end of surgery did the dog move a bit. Mr Saw increased the % to 5% but I told him that 2% would do.

"More haste less speed" seemed to be presented when I incised the linea alba, the midline fibrous tissue connecting two halves of the abdominal muscles. I incised but found that the muscles did not separate. I saw the brown muscle fibres instead. The linea alba was faint in this region and my incision missed it by 4 mm. "Look further cranial," my second assistant advised me as he saw me looking for the linea alba which was faint at this area, around 6 cm from the umbilical area. I checked anteriorly and followed the direction of the linea alba backwards. Got it.

The muscles separated. I put my gloved finger into the abdomen. The small and large intestines were blocking my view. A few seconds passed. I hooked out the swollen uterine tubes.

Ligated the ovarian tissues. Then the uterine body. Time was passing by fast. The dog had not given me cause to worry as the bright red blood indicated that she had sufficient oxygenated blood and her heart was beating normally under general anaesthesia. Still I could not be complacent or slow. Anytime the heart could just stop beating and a dead dog would be presented.

After getting rid of the uterus, I quickly put 3 simple interrupted sutures at 0.8 cm apart to close the muscles. No fanciful subcutaneous sutures as this would take more time. I just stitched up the skin with 3 horizontal mattress sutures.

"Switch off the anaesthesia," I said to Mr Saw. He had already reduced the gas to 0.5% and the dog was still anaesthesized. This showed that the dog was very weak as normal dogs would need 2% to be knocked out. "Switch off," I said as I tied the 2nd of 3 skin stitches. Mr Saw did it. I completed the 3rd stitch. The dog just woke up suddenly.

"Take out the endotracheal tube," I said to Mr Saw who had by then, untied the four legs. "Put the dog's head to the side in case she vomits."

The dog just looked as if she had a nap. She wailed and wailed. This happened sometimes after isoflurane gas anaesthesia without any other tranquilisation or sedation. Why would a 16-year-old dog wail and wail, I cannot say. Neither do I receive many case of such very old dogs with pyometra. I thought the old female dogs had menopaused and would never get pyometra. This case proved me to be mistaken.

But such loud wailings were good signs of a dog being much alive at the end of surgery and were a joy to hear. Sleeping dogs that don't wail at the end of surgery would be dead. So, you could understand why I enjoyed hearing this old cougar wailing. Well, she was not really the "old cougar" as the term refers to a lady marrying a much young man.  

"What time is it?" I asked Mr Saw as I completed my last stitch. "4.55 pm," he said. He was at the far end to my left and opposite me at the other side of the operating table, nearer to the isoflurane vaporiser. I looked at the clock, just above the door of the operating room and to my right. "It is 4.53 pm" I was facing the clock directly and so could see the correct time. I had used 16 minutes to perform the surgery. It was really Mission Impossible as my key performance indicator was 15 minutes. 

Closed Pyometra. 16-year-old Shih Tzu after surgery. OK. Toa Payoh VetsThe naughty Shih Tzu was alert but refused to eat. Well, what do I expect? She had just completed a major surgery. Her temperature dropped to 36 deg C one hour after surgery. She had the IV drip but I was worried. I phoned her owner. She could still die despite a successful surgery if she did not eat. She could be suffering from hypoglycaemia (low blood sugar).

I phoned the lady owner to get the dog home to nurse. This would be a finicky dog and would not eat unless hand fed. The best friend had a car and her gentleman friend and the owner went home with the dog. Some two hours later, the owner, "My dog passed blood. Is it normal?"

"Yes," I said. "The blood is from the vestibule of the vagina." I doubted that the lady knew what vestibule was about. In any case, she said that the dog ate and everything was OK.

It is best to get your female dog spayed young when she is healthy. Pyometra is sometimes missed and anaesthesia in very old dogs is usually very risky.  Not all aged dogs recover from anaesthesia as in this case.

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