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Date:   11 January, 2010  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.

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

FOREIGN BODY IN A PUPPY'S STOMACH
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: Dec 11, 2009. Updated: Jan 10, 2010  

  toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0001

This is a high-risk age group as the puppy is still young. However there was no choice as the domestic worker's hair band was swallowed and now occupied 100% of the stomach (as seen during surgery) and would not be vomited out nor passed out with the stools. Surprisingly the puppy did not vomit, according to the worker. 

No food and water after 10 pm yesterday. However, the puppy was warded and had wolfed down the dog food at 6 pm yesterday. The owner decided upon surgery and thought I would operate on arrival. It was not good to operate immediately on a puppy unless it was an emergency. So, I warded the puppy for the operation the next day.

December 11, 2009.
Surgery day. No stools passed out. Only urine this morning.
Surgery started at 1.30 pm today (5th day after swallowing of the hair band).

IV dextrose saline drip given
Xylazine 0.2 ml IV via the drip.
5 minutes later, isoflurane gas by mask. Intubate. 2-3% maintenance. No problem.
Skin incision around 6 inches (15 cm long). Linea alba excised. The tip of brownish red liver was visible. The stomach was just below. It was swollen and looked "crumpled". Deep pink in colour suggestive of an inflammation going on due to the foreign body hair band being there for 5 days. I could exteriorise easily as it was impacted with the hair band inside.

Stomach incision 3-cm long. Between both ends at avascular area (no blood vessels).
Hair band covered with brownish green feed. I thought it was the dog feed. Would the hair band come out from this 3-cm incision? The shorter the incision, the better in this case. I used the scissors to cut the hair band but did not manage to cut the rubber band inside. Surprisingly, the hair band could be manipulated out of this incision.

Suturing the stomach.
1. Internal surface: Quite thick, around 4 mm. The mucosa looked reddish brown due to inflammation. The hair band had been inside the stomach for 5 days. Inverting suture - one layer closing the mucosa only.

2. Muscular coat. It has 3 layers - outer longitudinal layer, inner circular layer and innermost oblique layer. As in a Caesarean section, I stitched 2 rows of continuous inverting suture at 4 mm apart.
3. Abdominal muscles - simple interrupted sutures one cm apart.
4. Skin - horizontal mattress suture 1.0 cm apart.
5. IV baytril given. Dextrose saline drip is continued. Electrolytes for next 2 days. No solid food to permit the stomach to heal.

Post-op Management.  Best not to go home for the next 7 days. How long should the stomach not be given solid food? How long does it take the mucosa layer to heal? The answers vary. By the 3rd day, I give A/D diet. Antibiotics are given by injections. Careful monitoring. The owners were phoned to visit the puppy as this is a high-risk case and anything can happen.

TIPS
Stomach will empty all food 10-16 hours after eating. This puppy was operated around 20 hours after eating. The stomach was empty of food.

No food inside the stomach makes surgery much easier. 

Daniel, a 3rd year vet student from Murdoch Univ saw the surgery. His job was to take pictures. During an earlier discussion prior to seeing the X-rays and the case, he had thought that the hair band would be easily passed out and therefore wait and see rather than operate on a high-risk puppy. What if the puppy dies on the operating table?

The purpose of the pictures is to make veterinary surgery and clinical anatomy come alive for him and the others. Lectures are very dull and I presume they are the same format as my lectures some 40 years ago. I presume a lecturer will drone on and on and the students just sit and take notes?  No real dog stomach surgery during lectures for practical and anti-animal cruelty reasons. I hope these pictures of real case may be helpful for 4th year students. It took me 2 hours to process them. I took 10 minutes to do the surgery! I prefer the latter anytime.  A video clip is produced by Ms Daphne Low. See:
Gastrotomy educational video for 4th & 5th year vet students

After seeing the hair band was large, he agreed that the only option was surgical removal. He found the surgery interesting as he was going into the 4th year. This operation would bring veterinary surgery alive during his lecture. I asked him to write a report. No way! He had enough of writing for his examinations. The young ones are a visual breed. Writing and recording help in archiving and understanding the process. One  can review the records at leisure or refer to them. Sometimes, what steps to improve for the next surgery can be forthcoming after the review.  

Hair bands to tie up the hair into a pony tail. I never took any notice of the vast variety of hair bands being worn by ladies and girls in Singapore till now. As for the maid, I asked the man who met me on the 4th day. "I better not take the puppy home till his skin wound heals," he was worried about the large skin cut. "The skin wound breakdown is never a serious problem," I replied. "You ought to worry about the stitch breakdown of the stomach wound as that would be disastrous for the puppy!"

Well, so far so good. The puppy was just his normal self. I asked the man where the caregiver was. "She is very upset for the past few days," he told me. His family members had said the same thing.

"Will you make her pay for the surgery?" I asked. "No," he said firmly. He was a successful man although I do not know what he was doing for a living. This was the first time we met as the maid was a very efficient person who spoke excellent English and who brought the puppy in for veterinary matters.

The man was quite happy that the puppy was OK.  On the 6th day, I noted that the puppy had lost 1.2 kg and would increase his feeding to 4 times per day. He had passed stools and was normal as a puppy. Yesterday a Rottweiler pup of 4 months of age was brought inside the animal holding area where he was to weigh the Rottweiler puppy on my animal electronic weighing scale. He barked so loudly that the Rottweiler got frightened.  He would make a good guard dog.
 
P.S.
Gastrotomy educational video for 4th & 5th year vet students
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0001
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