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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Pitfalls in Veterinary Surgery offers a candid examination of real-life mistakes and mishaps encountered while operating on veterinary patients. * Describes a range of mistakes and mishaps encountered by a veterinary surgeon with 30+ years of experience * Provides an honest examination of the reality of operating on pets * Offers the opportunity to learn from an experienced surgeon's mistakes * Discusses mistakes in a wide range of situations, ranging from commonplace to unusual * Presents a realistic view of veterinary surgery, including how to live with mistakes
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Veröffentlichungsjahr: 2017
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Table of Contents
Cover
Title Page
Notes on Contributors
Geraldine B. Hunt
Catherine F. Le Bars
Julie M. Meadows
Acknowledgments
Preface
1 “Can’t You Do Anything Right?”
2 Beastly Bellies
3 The Friday Night Special
4 Between a Rock and a Hard Place
5 Courage, Mystery, and Awe
6 Placed on Earth to Test Us
7 “Oops!”
8 Learning the Hard Way
9 “But I Don’t Want to Look Stupid …”
10 “It Didn’t Look Like That on Paper!”
11 “It Will Be Interesting to See Whether That Works”
12 When the Unthinkable Happens
13 Things Went South – Now What?
14 “There’s Got to Be a Morning After”
1
15 One Leg Too Many
16 Reconstruction Rescue
17 “Why Is Sam Straining?”
18 “An Alien in My Waiting Room”
19 Rewind
Index
End User License Agreement
List of Illustrations
Chapter 01
Figure 1.1 A young “Dr. Hunt,” quite obviously destined to become a small animal surgeon.
Chapter 02
Figure 2.1 The trick with massive splenic tumours is to make a long enough incision. This incision extends well past the prepuce (arrow), yet it is still difficult to exteriorize this tumor.
Figure 2.2 (A) Sometimes the “resectability” of a mass can only be assessed by sliding your fingers around it and lifting it out. (B) This liver mass was easily exteriorized, revealing a narrow pedicle that could be clamped and ligated.
Figure 2.3 (A) Grossly distended abdomen in a cat with a biliary cyst. (B) Appearance of the cyst upon opening the abdomen.
Figure 2.4 Contrast‐enhanced CT shows an invasive thyroid cyst extending from the larynx to the heart base in a dog (see also cover photo).
Chapter 04
Figure 4.1 Lateral thoracic radiograph in a dog with esophageal foreign body. The dog was fed barium‐impregnated polyethylene spheres in an attempt to diagnose the cause of its “vomiting” and suspected intestinal obstruction.
Figure 4.2 Lateral thoracic radiograph (showing pericardial effusion) in a dog following exploratory laparotomy for ascites.
Chapter 07
Figure 7.1 Kayaking can teach you a lot about how to cope with the unexpected during surgery.
Figure 7.2 A well‐loved surgical textbook.
Chapter 08
Figure 8.1 Embryonic Dr. Hunt and her sister, Kate, teaching Honey how to swim.
Chapter 09
Figure 9.1 Demonstrating what
not
to do with your surgical table. Having to sift through muddled and dirty instruments wastes valuable time.
Chapter 10
Figure 10.1 (A) Mess of cystic and saponified omentum (white arrow) emerging from perineal hernia incision. A small organizing hematoma is also present, for good measure (gray arrow). Note that the scrotum (S) has been included in the surgical field to allow a castration via a caudal approach. (B) Using surgical gauze and Langenbeck retractors to provide hemostasis and hold tissues apart to assist visualization while placing sutures.
Figure 10.2 Elasticized self‐retaining retractor being used for perineal hernia repair in another patient.
Figure 10.3 Dog positioned in dorsal recumbency for perineal hernia repair.
Figure 10.4 (A) Dog with extensive neck trauma caused by bite wounds (dorsal recumbency). (B) The same dog in left lateral recumbency, demonstrating a tie‐over bandage for open drainage following exploration and debridement through a ventral midline incision.
Chapter 11
Figure 11.1 (A) Demonstrating the extent of the vulval fold resected during an episioplasty performed with the patient in dorsal recumbency. (B) Creating the vulval fold flap to close a perineal defect in a female dog (dorsal recumbency). The incision is following a line drawn along the dorsal and ventral aspects of the vulval fold with the base of the flap to the right (white star). Before completing the incision, the surgeon is checking the mobility of the skin flap and the tension created by drawing the donor site together. The surgeon is grasping the subcutaneous tissue with a skin hook and thumb forceps to avoid damaging the skin edges.
Figure 11.2 (A) Transverse CT image of a large lipoma (L) dissecting through the body wall to the retroperitoneum in a dog. The white arrow points to the aorta. (B) External (with attached skin) and internal components of the lipoma in (A). Removal of this lipoma provided excellent surgical exposure of the diaphragm and retroperitoneal structures.
Figure 11.3 Removing a foxtail from the retroperitoneal space of a dog using the same approach for surgical exposure as in Figure 11.2.
Figure 11.4 Lateral radiograph from a cat referred with bilateral ureteral obstruction and uroperitoneum. The referring veterinarian stabilized the cat by placing a nephrostomy tube (pig‐tailed catheter), closed‐suction peritoneal drain, and a urethral catheter.
Chapter 12
Figure 12.1 Ventral rhinotomy in a dog with nasal adenocarcinoma. Don’t make my mistake by getting your left and right confused when your patient is on its back!
Figure 12.2 (A) Abdominal radiograph showing right‐sided hydronephrosis (K) in a cat. (B,C) The hydronephrosis (K) was caused by ureteral ligation at the time of ovario‐hysterectomy (arrow).
Figure 12.3 Long‐standing gossypiboma in a patient with a mid‐abdominal mass. Omentum has encased the retained surgical sponge.
Chapter 13
Figure 13.1 Surgical exploration of recurrent draining sinuses in a patient with a soft tissue sarcoma. No foreign bodies were found, and the diagnosis was made by deep tissue biopsy.
Chapter 14
Figure 14.1 (A) Dorsal and (B) sagittal dual‐phase computed tomography images of an invasive adrenal carcinoma (×) with a tumor thrombus extending into the right atrium of a dog (arrows).
Chapter 15
Figure 15.1 (A) Injury to the distal hind limb of a dog following motor vehicle trauma. All digits were destroyed, but the metatarsal pads remained viable. (B) The wound in (A) is healing well following open wound management. Granulation tissue contraction drew the foot pad under the stump to form a weight‐bearing surface. This wound eventually closed spontaneously without surgical reconstruction.
Figure 15.2 (A) Fibroma of the dorsal metacarpus in a dog. (B) The tumor was resected with a deep margin that included the common digital extensor tendons. (C) Skin flaps created by filleting the dewclaw and the fifth digit enabled closure of the excision site. The dog’s owners grew fond of the repositioned fifth digital pad!
Figure 15.3 Safety label on a dog’s head indicating that a purse string suture has been placed in the anus and alerting staff to remove it once the procedure is finished.
Figure 15.4 “Plucking” a leiomyoma from a dog’s pelvic canal using gentle digital dissection.
Chapter 16
Figure 16.1 Wound dehiscence with necrosis of a free skin graft (G) and a meshed pedicle flap (F) on the caudomedial aspect of a dog’s leg. Free grafts must be carefully immobilized to encourage adhesion to the underlying tissue. This graft probably became necrotic as a result of local movement, complicated by presence of a Penrose drain (P) under the graft. The pedicle flap was probably devitalized as a result of tension and disruption of the subdermal plexus when it was meshed.
Figure 16.2 Dissecting the subcutaneous tissue during preparation of a free skin graft.
Figure 16.3 A demonstration of how
not
to hold skin while moving flaps around during a reconstructive procedure. Try to grasp the subcutaneous tissue rather than the skin edges to avoid small strips of necrosis.
Chapter 17
Figure 17.1 Contrast urethrogram showing urine leakage (arrows) following urethral rupture as a result of repeated attempts at catheterizing a male dog.
Figure 17.2 Jubilant penis and edematous mucosa following surgical preputioplasty in a kitten with preputial stenosis.
Chapter 18
Figure 18.1 (A) Extensive draining sinuses in a dog with chronic otitis externa and media. (B) Treatment of an open wound following total ear canal ablation. (C) Local healing complete after secondary wound closure.
Figure 18.2 (A) Echocardiogram showing myxoma (arrow) of the pulmonic valve annulus causing a loud ejection‐type murmur in a dog. (B) This tumor (arrow) was removed successfully through a ventriculotomy of the right ventricular outflow tract under total venous inflow occlusion.
Figure 18.3 Christmas photo from one of my early portosystemic shunt patients, showing his ambivalence about being dressed as a reindeer.
Chapter 19
Figure 19.1 Early‐career Dr. Hunt looking for inspiration. How much simpler things might have turned out had I been able to read this book back then!
Figure 19.2 Twenty years later, Professor Hunt quizzes a student about the vascular supply to the spleen.
Guide
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Pitfalls in Veterinary Surgery
Edited by Geraldine B. Hunt
University of California at DavisCalifornia, USA
This edition first published 2017 © 2017 John Wiley & Sons, Inc.
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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication data applied for
9781119241645 [Paperback]
Cover design: WileyCover image: Courtesy of Geraldine B. Hunt
Notes on Contributors
Geraldine B. Hunt
A child of Sydney’s Northern Beaches, Geraldine Hunt graduated from the University of Sydney in 1983 and spent two years in small animal practice before commencing a PhD in cardiac electrophysiology, during which she learned about myocardial activation, open heart surgery, and critical care for thoracic patients. Following completion of the PhD, she worked for another year in small animal practice then moved on to a residency in small animal surgery. Having decided she wanted to become an academic, she took a position as lecturer in veterinary anatomy and, once she became a qualified Fellow of the Australian College of Veterinary Scientists, was also appointed as a visiting specialist to the University of Sydney Veterinary Teaching Hospital.
When a position as senior lecturer in small animal surgery became vacant, she moved full time to the Department of Veterinary Clinical Sciences. From there, she became head of small animal surgery and ultimately director of the Small Animal Teaching Hospital.
As a result of her early training in cardiac and vascular surgery, she developed a strong research interest in congenital cardiovascular diseases of dogs and cats. This developed into a particular focus on congenital portosystemic shunts. In 2008, deciding it was time to experience living and working in another country, she decided to make an even larger move, and left the University of Sydney to become Head of Small Animal Surgery at the University of California, Davis, USA.
Geraldine has been involved in training thousands of veterinary students and many surgical residents. Throughout all stages of her career, she has also maintained an interest in refining the discipline of surgery, and improving treatments for patients in private veterinary practice, and to this end has engaged in continuing education for veterinarians worldwide. This book is a continuation – and an extension – of those efforts.
Catherine F. Le Bars
Fascinated by the animal world from a very young age, Catherine Le Bars obtained her Bachelor of Veterinary Science from the University of Sydney in 1988. She spent her first four years working in mixed and companion animal practices, gaining experience and exposure to a varied client base and case load.
In 1992, she emigrated to the UK and traveled the country as a locum for two years, before settling into a busy Southampton practice. During her time there, she developed her skills in soft tissue surgery across a range of species, including companion animals, pocket pets, reptiles, and birds. Responsible for mentoring the veterinary graduates in the practice, Catherine was keen that they learned to walk before they ran, especially in the operating theater. This meant mastering the first principles of surgery and applying them to increasingly complicated procedures.
Catherine moved back to Australia in 2012 and established her own veterinary practice on the south coast of New South Wales. She takes pride in her role as a first opinion veterinary surgeon and always strives to achieve the best possible outcome for her patients and clients.
Julie M. Meadows
Julie Meadows graduated from the University of California School of Veterinary Medicine, Davis, in 1988. With great feeling for the human–animal bond she began general practice in California’s Central Valley, where the clientele ranged from wealthy agricultural families and college professors to immigrant workers. At a time when specialty care was hours away and financial resources varied, she learned to appreciate the value of excellent communication with clients and a foundational understanding of her patients’ medical problems in order to shepherd their health and that bond – what has now come to be called relationship‐centered care.
Over 20 years in practice, including 10 years as a practice co‐owner and two years teaching in a local veterinary technician program, she discovered the joy of sharing her values and experience with students and mentoring employees. With stars in her eyes for her alma mater, in 2008 she accepted a position as a clinical professor at UC Davis to develop its primary care program in response to a North American initiative to redirect veterinary education to entry level skills. There she and other pioneers shepherded the integration of core competencies such as communication and history‐taking into the traditional curriculum across all four years of the program. She also built a robust general practice that allowed senior students to receive first presentation cases, including pediatrics and preventive healthcare, without house officers.
Julie returned to her professional roots in 2016, melding her loves of general practice and beaches by becoming lead veterinarian at a small practice in Cairns, Australia. Without the luxuries of having specialists in her building and access to advanced diagnostic capabilities, she has had to “practice what she preached” to students and is busy listening carefully to navigate international accents and new vocabulary. She spends her days with hands on her patients and exchanging knowledge with her new team as they work towards maintaining the human–animal bond in Australia.
Acknowledgments
To my parents, Susan and Michel, who always believed I could fly, and still feel I can soar higher. To my sister, Kate, my touchstone, and the best vet a coastal village could ever wish for. To my husband and partner in everything, George, who has helped me build a stable perch from which to spread my wings. To the many colleagues who supported me through the years, vets, techs, and others, who embraced me into the profession, taught me, challenged me, and boosted my spirits. To my students, the future of our profession, whose expressions of delight when they mastered the Ford interlocking suture made it all worthwhile. To my clients, who entrusted me with the lives of their dear companions. And to all my patients, who gave me so many opportunities to learn, improve, and teach, and who helped pave a smoother road for those to come. Names and some identifying details have been changed to protect patient confidentiality.
Preface
The thought struck me somewhere during the subcutaneous dissection.
I am a surgeon!
Not only a surgeon, but Faculty in one of the world’s largest veterinary schools.
My patient was a skinny Rat Terrier called Rocket. Rocket hadn’t moved quickly enough just over a week ago though, and found himself launched into low orbit by his neighbor’s Prius.
He crash‐landed on his stomach, which caused an ugly shearing injury to his groin; a ragged mouth exposing the fang‐like shards of his shattered pubis.
Rocket was walking surprisingly well for a dog that had been so manhandled. His owners were maxed out on all their credit cards, so the emergency service opted for open wound management, which was complicated after only a few hours by a soaking flood of straw‐colored fluid.
Somewhere in the mess that had once been Rocket’s pubis, there was also a large hole in his urinary tract.
After reflecting on my career circumstances, my next thought was:
Why then, if I am such a well‐credentialed surgeon, do I have so little idea of what to do next?
My student assistant – who had a keen interest in becoming a surgeon herself – watched intently as I dissected through a discolored mass of fat, edema, and hematoma. Our goal was to explore the caudal abdomen and see how much of Rocket’s bladder and urethra was intact and then …
And then what, exactly?
This was truly exploratory. There had been no money for advanced imaging, so I really didn’t know what I was going to find. And it was purely a salvage procedure; the owners could not afford stents or bypass conduits, or delicate reconstructive surgery which might or might not work. Rocket’s options were very restricted.
Later, after I had located the transected end of the urethra just caudal to the prostate, brought it through the ventral abdominal wall, and anastomosed it to the caudal fornix of Rocket’s prepuce1 (Figure P.1), the student said, “Wow! I have never seen that before!”
Figure P.1 Prepubic anastomosis of the prostatic urethra to the prepuce (arrow) in a dog following trauma.
“Neither have I.”
She grinned. “Yeah, right.”
“No, I’m serious.”
She stared at me, mouth slightly open, “But you just … you went ahead and did it, as if you’d done it a hundred times before. How do you know what to do?”
It was a good question. How did I know what to do, and how to do it? It was not as simple as opening a book and following the instructions. In reality, it was a synthesis of my experiences – good and bad – with many patients. Putting my textbook knowledge into a practical context to solve a new problem.
I eventually answered, “I have some tricks I learned through the years.”
“Can you teach me?”
Another good question. It took three more years and some careful thinking to answer it, but here goes …
Note
1
Bradley RL. Prepubic urethrostomy: an acceptable urinary diversion technique.
Problems in Veterinary Medicine
1989; 1: 120–127.
1“Can’t You Do Anything Right?”: The Shocking Realization That I Was Not Perfect
My father likes to introduce me as the vet who put the parrot’s leg on backwards.
Having invested so much emotional and financial capital in my education, I am perplexed that my parents should find amusement in this embarrassing moment of my budding veterinary career. Surely they should inform their friends of my years of training, or all the letters following my name, or my position as a professor of surgery. But I am doomed to being defined in my family’s eyes by one small yet highly visible complication (I think there were extenuating circumstances, but you can make up your own mind later).
Having evolved from a childhood dream of palaeontology (which lost its appeal once I realized dinosaurs and humans never cohabited the planet), I cycled through visions of African exploration to becoming a marine scientist, a forensic pathologist and – finally – a jet‐setting equine veterinarian (Figure 1.1). Veterinary science would suit me, I decided. I preferred animals to people: people were too focused on themselves, they held silly ideas and misconceptions, and they complained too much. Ironic then, that the first harsh criticism of my career came directly from one of my animal patients.
Figure 1.1 A young “Dr. Hunt,” quite obviously destined to become a small animal surgeon.
Mrs. Sofel was a long‐term client of the small animal practice that employed me immediately after graduation. She was probably only in her mid‐sixties but looked about a hundred to a young veterinarian fresh out of university. Our relationship did not get off to a particularly good start, as she took one look at me when I entered the consulting room and wanted to know what I had “done with Dr. Davidson.”
“Dr. Davidson is on holiday for 2 weeks,” I replied.
“Well, I suppose you’ll just have to do, then,” she sniffed. She usually came in trailing a Cushingoid Maltese with more warts than teeth, but this time she swung a large birdcage onto the examination table. I realized her frail appearance belied great strength; a conclusion that did little to sooth my new‐graduate nerves. The birdcage contained a huge, sulphur‐crested cockatoo.
“Oscar has a lump,” said Mrs. Sofel.
For a moment, I was speechless; not because Oscar was a bird, or because his beak resembled a large pair of garden shears, but because he was almost completely bald. I quickly diagnosed him as suffering from beak and feather disease. Actually, it was just about the only disease I could remember from my avian medicine lectures at that particular moment. I stared at Oscar, who stared back; his beady black eye encircled by leathery grey skin. He looked little like a bird, and much more like some form of mutant dinosaur. The effect was complete when he raised the lone yellow feather on the crest of his head, and screeched. I practically hit the ceiling.
“It needs to be removed,” Mrs. Sofel announced.
My heart already pounding, I was further horrified to realize she was talking not about the single head feather which had so captured my attention, but about a large, egg‐shaped mass protruding from Oscar’s rump.
My main comfort at this point was that I had so little experience I did not yet know what to be frightened of. I knew how to anesthetize birds: we had knocked out chickens in a practical class at uni and successfully woken most of them up again. And I’d had a good training in basic surgery, so I had a rough idea of how to remove lumps. I wasn’t quite sure how I was going to get Oscar out the cage in order to do either of the above, but I was sure I could cross that hurdle when I came to it.
“Well, um, yes … we can do that,” I said.
“When and how much?” These were the days before computerized medical records, appointment systems, or account‐keeping programs, so I made a quick escape to the reception desk to find the answers. Thank goodness for Theresa, our wonderful receptionist and long‐term backbone of the practice. She gave me the information I needed (I suspect she would also have been able to tell me what drugs and surgical instruments to use, had I only asked).
Mrs. Sofel and I agreed on a price, and a date when Dr. Davidson was back in clinic, and she swept Oscar’s cage up and turned on her heel. But Oscar was not finished. He craned his neck to look back at me, and the crest feather slowly elevated again. I braced myself for the parting screech, but instead Oscar said in his parrot’s voice (closely resembling that of an old woman), “Can’t you do anything right?”
I stared at Mrs. Sofel, who said nothing. I had the uncanny sense that Oscar and his owner had formed a telepathic bond. Mrs. Sofel sniffed again and sailed from the waiting room, leaving me struggling for words. I suspect that particular phrase was heard frequently by those in her company, and never received a satisfactory answer.
Whatever the explanation, Oscar’s question proved sadly prophetic when we masked him down two weeks later, and he promptly died. In retrospect, we should have asked Theresa to do it. She later told me that parrots “always died” when anesthetized and left me wondering how many times Dr. Davidson had proven that particular theory.
Needless to say, Mrs. Sofel blamed me for Oscar’s death simply by virtue of my proximity to the saintly Dr. Davidson on the fateful day, and refused to allow me near any of her “other pets ever again.” Although such banishment was a blow to my ego, it was not an entirely unwelcome outcome, all things considered.
After incubation in primary school, hatching from high school, and being “fledged” at university, I had spent 18 years in the educational nest, so to speak. Surely that rendered me capable of doing a lot of things “right,” contrary to Oscar’s observation? Having finally launched into my career with the tenuous belief I would become airborne, I quickly realized I had not flown from the nest so much as staggered out of it, and been fortunate enough to bounce when I hit the ground.
I am sure I was a great success at many things in my early days as a veterinarian. But for some reason the comfort of our successes fades quickly, while our failures remain to irritate us, as surely as Oscar’s diseased feathers had irritated him. At least Oscar was able to pull his feathers out. Looking back on all those mystery patients, unfathomable clients, the questions for which the textbooks provided no answer, all those mistakes I made, and all the things I had to learn the hard way, I do wonder how different my years of practice might have been if I had the knowledge then that I have now.
If only I had known!
We acquire knowledge in many different ways. We have different learning styles. We memorize things by rote, but we truly learn them when we have the chance to apply them. Our profession is a fluid mix of thinking and “doing”; very much dependent on the type of case and its unique circumstances. Some patients fit the textbook description perfectly, whereas others break all the rules. Clients have particular needs and restrictions when managing their pets, and there is always the issue of finance. Sometimes, I suspected the tides or phase of the moon dictated whether things went according to plan. Were the stars aligned? Did I wear my lucky socks to work that morning? Faced with such a complex system, there is only so much our university professors and textbooks can teach us.
Our successes involve a large portion of “seat of our pants” intuition and good luck. Scientific and evidence‐based as our profession has become, we will always have to learn some things by trial and error, by simply seeing what works and what does not. Textbooks give us a definitive description, a clear way to proceed with diagnosis and treatment, and a neat explanation for cause and effect. We try to make cases fit the textbook description, or vice versa, and mentally file away inconvenient pieces of information that don’t fit in the hope that the abnormalities will either go away on their own or make sense once the patient gets better, or maybe when we’ve got more experience. What textbooks usually don’t show us, though, is the process their authors went through to evolve the crisp conclusions they share in print. They tell us about the sum total of their experience, and tend not to dwell on the cases that broke the rules.
Speaking to a group of general practitioners in rural Australia some years ago, I shared the story of a truly perplexing case. This case had no fairy tale ending, we made many mis‐steps along the way, and the ultimate answer was only revealed in the postmortem room. Standing beside me in the lunchtime coffee line, one of the older vets said:
“I liked your lecture. It gave me a lot of hope.”
“That’s good to hear. And why was that?”
“I realized you specialists don’t have all the answers, either.”
I have heard this many times since; from students, junior academics and vets in practice. There is an impression that after a certain level of training, when you achieve fellowship or diplomate status, somehow you know all there is to know, and you never screw up.
It is comforting to the people reading the textbooks, and listening to the lectures, that they aren’t the only ones who scratch their heads, find test results that defy explanation, draw the wrong conclusion, agonize over their treatment plan, or struggle for ideas when their plans don’t work.
When I ask my colleagues in specialty practice whether they have made mistakes, most of them are quick to say, “Hell, yes!” or “My oath!” (depending on which side of the Pacific they come from). But that is not always the impression we give when we deliver our lectures or write our textbook chapters. We talk about our successes, show the best photographs, sanitize our complications, and generally present a stylized version of what can be a slow, frustrating, confusing, and sometimes downright messy process.
Unpalatable as it is to admit, our cases don’t always go well. Most of us are happy to learn from someone else’s mistakes, but it is particularly intimidating to confront your own mistakes honestly. Gruelling as it can be, through my years as an academic and a teacher of veterinarians, I have reaped an ironic reward from sharing my low moments with others and thus allowing them to learn.
Of course, being a veterinarian is not just about the animals. In a perfect world, desperate clients would bring an ailing pet to us and take a healthy one home again after showering us with gratitude and admiration, and full payment of their bill. Reality, however, is not quite so Disneyesque. My experience with Mrs. Sofel was more than simply a lesson in how easily I could fall foul of others. In Mrs. Sofel, I had my first encounter with the client whose sole aim seemed to be to make my life miserable. These clients rarely had a kind word to say, and were capable of finding fault in the most benign of circumstances (Oscar’s death aside, which was understandably devastating for everyone). I wondered what it was about me that caused some people to be so very difficult, and I wanted so very badly to defend myself. Couldn’t they see that I was trying my best to help them and their pets? Where was the gratitude? The admiration? How dare they tell me how to treat their pet after I spent five years in veterinary school?
I stormed into the treatment room one day after being lectured on how to clip a Yorkshire Terrier’s nails.
“Looks like that appointment went well,” my nurse, Karen, commented wryly as I hurled the nail scissors into the sink.
“That woman is such a …,” I bit my lip. My suspicions about the human race were being confirmed, but my plan of avoiding interpersonal conflict by becoming a veterinarian was rapidly unraveling. “What did I do to deserve that?”
Karen said nothing, merely tapped a photocopied page stuck to the wall above the telephone. It was titled, “Why It Is Not About You.” One of the practice partners posted it after attending a management course. The gist was that when people become aggressive, it is more often about their personality, or what is happening in their lives, than a personal attack on you. It recommended taking time out to think about things from the other person’s perspective, and suggested some explanations:
In pain
Fearful
Stressed
Grieving
Financial trouble
Mental illness.
When we had a difficult interaction, we would take refuge in the back room and try to work out which explanation might best fit that person. It was a great way to defuse the angst, refocus ourselves on the patient and what it needed, and alleviate the often overwhelming desire to march back out and tell our clients why they were being so totally unfair. In the years before “doctoring” and “client management” courses in vet school, these client hostilities took me by complete surprise, and this simple printout was my first introduction to the complex and fascinating science of human behavior.
Naturally, we had some clients who did not seem to fit any of the categories on the printout, and thus someone had penciled at the bottom:
Just plain mean
Absolute nutter.
As time went on, I discovered that this was only one small piece of a far more complex puzzle, and as my career took me deeper into the specialty of small animal surgery, with its milieu of emotion‐charged circumstances and highly invested clients, I would face gradually escalating surgical challenges, accompanied by rich opportunities for honing my people skills.
In the following chapters I share my experiences about the “pitfalls” of small animal surgery: the things I learned the hard way, the cases that still haunt me, the clients I worked hard to “unpuzzle,” and some bright successes when things went exceptionally well. And mine is not an experience confined to the ivory towers of the university, as you will hear from others who have contributed their own stories and insights to this book.
2Beastly Bellies
Sunday nights were some of our busiest at the regional practice in which I worked for my first two years. We were the only show in town for after‐hours coverage once everyone else knocked off for the weekend and switched their phones to the answering machine.
There were many dog fanciers around the Canberra area, and during show season the required chemistry often failed to develop during a romantic weekend and the stud male did not breed the visiting bitch. This prompted a frantic call for emergency insemination before the bitch was driven home again. I had a rough idea of how to collect semen and perform artificial insemination, so Sunday night often found me crouched beneath a perplexed Maltese or Weimaraner dog, feverishly trying to press the right buttons. A quick glance at the resultant sample under the microscope to check for motility, and the accompanying bitch was inseminated by means of a syringe and urinary catheter. Amazingly, some of these emergency “matings” resulted in live puppies.
The unforseen consequence of these reproductive rescues was that our practice became known as the “go to” place for artificial insemination, and we started attracting non‐emergency cases.
Mr. Fortescue, from Brindabella Kennels, brought his Bichon Frise couple to us because he didn’t like to see them “doing that nasty stuff.” Mrs. Grande marched in her German Shepherd, Pinetree Macho III, for semen collection because he just wasn’t interested in her stud bitches.
We stumbled fortuitously on a solution for Macho’s ennui the day we had Fortescue and Grande dogs in the practice at the same time and Macho concluded that Brindabella Perfect Muffin was his ideal Playboy centerfold. We scrambled to prevent some spontaneous “nastiness” from occurring in the middle of the treatment room, but it made our job of collecting from the German Shepherd a whole lot easier. Each time Macho came in for semen collection from then on, we endeavored to produce a small white fluffy “teaser,” and it never failed to get his juices flowing. Despite being occasionally fruitful, and spawning ageless practice jokes, these cases did not impregnate me with the desire to become a theriogenologist, hence you are not reading memoirs of my career in reproduction. They did, however, teach me that sometimes you just have to give things a shot and you will occasionally surprise yourself.
An owner recently said one of the things he really appreciated about his vet was that they were at least prepared to “try.” The trick is to know your limitations, and have a good feeling for the potential consequences. For the great proportion of pets whose owners will never be able to spend the time or money on referral to a specialist center, this is equally important whether you are a boarded surgeon or a general veterinarian in a one‐person rural mixed practice. Working out which cases you should keep in your practice, which ones you should refer, and which cases are appropriate for surgery at all takes experience and self‐reflection, as you will see in the following chapters.
One particular Sunday night during my first year in practice sticks with me for many reasons. The weather was foul: winters in Canberra were cold and often wet. We rarely got the snow that blanketed the nearby Australian “Alps” but, having swept across the high country, the freezing winds and turgid clouds spent themselves over Australia’s capital city. On this night, it was blowing a gale and a mixture of rain and sleet beat against the windows. We had a ward full of dogs and nowhere to dry the washing, so we hung it across the treatment room on a spider’s web of ropes strung between cages. The combination of a fan‐forced heater and damp washing filled the room with a humid, musty fug that made it seem less like a veterinary practice and more like some inner‐city sweat shop.
We had just finished stabilizing a Border Collie with metaldehyde poisoning, who had covered much of the floor, one wall, and my trousers in a black–green slime as he purged snail bait and activated charcoal from both ends. The renal failure cat was crouched in the back of its cage; unkempt coat sticking up like porcupine quills, but not as spiky as we found his teeth and claws to be as we fiddled with his intravenous catheter to keep the fluids dripping. I was savoring a brief respite and looking forward to dressing the scratch marks on my arms and changing into clean clothes when the doorbell rang.
My newest patient was a 10‐and‐a‐half‐year‐old black Labrador who’d chosen that afternoon to go down acutely. His middle‐aged owner carried him in; no small feat, as this dog was clearly a prodigious eater. The labored breathing, pale gums, and thready pulse suggested Bill was really struggling, and Roger – the dog – didn’t look much better. I encouraged Bill to lay Roger on the waiting room floor, before we ended up with two emergency cases on our hands.
As Roger lay flat out beside the fish tank, his abdomen was grossly distended, even accounting for his body condition score of 11. It was firm and tight, and Roger groaned when I palpated it.
“Acute abdomen,” I said, envisioning necrotizing pancreatitis or septic peritonitis.
“He’s been getting quieter for a few days,” said Bill, who had now caught his breath and looked less like he was about to suffer an acute event of his own. “And he’s been straining a lot.”
I added urethral obstruction to my list of differentials.
“And his gums have been pale.”
Bleeding splenic hemangioscaroma, surely!
“We’ve had him on a diet. We thought his weight was getting the better of him. Then his tummy suddenly swelled up.”
I settled on a diagnosis of gastric dilatation volvulus (GDV), and was running through a mental checklist in preparation for anesthesia and surgery, but wanted to make sure Roger’s stomach actually was full of gas before I stuck a needle in. We had no ultrasound machine in those early days, so our in‐house diagnostics were limited to a radiograph and some very basic blood work. We rolled Roger onto a stretcher and took him through to the X‐ray room. I snapped a lateral radiograph and left Bill with his recumbent mate while I locked myself in the dark cave. When I emerged 10 or so minutes later, imbued with the vinegar‐reek of developing fluid, I held the still‐damp radiograph to the light. I saw neither the radiolucent double‐bubble of GDV, nor the ground‐glass appearance of hemoabdomen. Rather, Roger’s abdomen seemed full of something resembling aggregate pavement.
“What’s he been eating?”
“You mean, what hasn’t he been eating?” Bill shook his head. “He got into the pantry yesterday afternoon. Made a shocking mess.”
Gastrointestinal foreign body! I started towards the autoclave, then hesitated. I had hoped my first exploratory laparotomy might occur during the day, and in the presence of a more experienced colleague. Was I about to make the right decision? It seemed clear that Roger was full of something that needed to be removed, but was surgery the answer?
I belatedly decided to finish my physical examination, and pulled on a glove to do a rectal exam. The cause of Roger’s distress soon became evident; my finger emerged encased in a clay‐like material liberally reinforced with vegetable husks. On further interrogation regarding the “shocking mess” in Bill’s pantry, it became evident Roger was suffering an emergency case of constipation arising from his misguided notion that a starving dog might save its life by devouring two kilograms of pumpkin seeds.
Shifting the offending vegetation took most of the evening, a large amount of warm soapy water, contributed greatly to the Border Collie’s efforts in resurfacing the floor, and added at least one string of wet towels to our attempt at creating an indoor rainforest. I hoped to see orchids sprouting from the walls at any time, but eventually had to settle for a patchy layer of mold.
It was worth it though, when Roger trotted out the door the next morning, albeit with a sheepish expression and a phobia about anyone approaching his back end. The abdominal distention was only minimally reduced, and we suggested the owners continue the diet and bulk it out with mashed pumpkin so Roger did not feel compelled to fill the empty hole in his belly with anything that came within range of his mouth.
Roger was my first lesson in the value of rectal examination. We are taught that it is integral to the physical examination, but how often do we actually perform it thoroughly? The dog’s too wriggly, we have four clients in the waiting room, and the owner is focused on the lump on the head.
In vet school, my clinic team examined a Dalmation presented for anxiety and panting. When history and physical examination did not yield a definitive diagnosis, we auscultated the chest, checked the cranial nerves, drew blood for hematology and biochemistry, and went away to await the results, leaving one of our fellow students to babysit the dog in the treatment room. Ten minutes later, a student from another team flew in: “You have to see this!”
We raced back in time to watch John deliver a foul‐smelling object from the dog’s anus. For want of anything else to do, he had decided to perform a rectal exam, and been rewarded with the tail end of a length of fabric. As nobody had ever told us about intestinal plication or perforation resulting from linear foreign bodies, the most natural thing seemed to be to pull it out. We watched John pull and pull, like a magician drawing a scarf from a hat, until he relieved the dog of a complete pair of panty hose. Needless to say, he was the hero of the hour, and of course we did not know how close he had come to creating a rectal prolapse, or maybe even an ileocolic intussusception.
Suffering from dizzy spells as a first year PhD student, I went to my local general practitioner for a checkup. After taking my blood pressure and looking in my ears, he pulled on an exam glove. I wasn’t sure which particular cause of vertigo he was searching for in that manner, but he said, “If you don’t put your finger in it, you’ll put your foot in it.”
I can’t say I appreciated this GP’s overly thorough investigation of my vestibular system, especially when he terminated the short consultation by advising me to cut back on coffee, but it did highlight the role of rectal examination in a thorough work up and also taught me the benefit of clearly explaining the rationale for your various investigations to the subject (or in our case, its owner).
While most rectal examinations do not yield such a rewarding outcome as John’s Dalmation, or Roger the pantry raider, I can remember a handful of patients where it was not only the key part of the diagnosis, but failing to do it led to serious delays in diagnosis and treatment: they included a Labrador treated medically for recurrent constipation caused by a pelvic lipoma, a Cocker Spaniel with polyuria and polydipsia caused by an anal sac adenocarcinoma, and a Kelpie cross evaluated for syncope during defecation, whose advanced rectal adenocarcinoma was not identified until after her pacemaker was implanted.
In the week following Roger’s de‐obstruction, I saw Barney, another 10‐year‐old Labrador, with an almost identical presentation: gaining weight and becoming more and more lethargic, despite being on a diet for the last four weeks. His abdomen was distended, but this time the radiograph showed a soft tissue mass and we diagnosed a splenic tumor. This time we really were headed into the operating theater.
I had spayed a couple of cats and dogs, but wasn’t that familiar with surgery of the abdomen, but I thought I should be able to find the spleen, and I knew how to tie ligatures, so how hard could it be? We anesthetized and prepped Barney and I performed a textbook ventral midline incision into the abdomen. You might have experienced the “detour” signs that direct you down a poorly lit secondary road and then vanish, leaving you lost in the dark; well, that’s about where any resemblance to what I had seen in a textbook ceased. I’m not sure what I expected, but I suspect it was something looking vaguely like the spleen from Miller’s Anatomy of the Dog, with color‐marked hilar vessels and neatly defined gastrosplenic attachments. What emerged from Barney’s abdomen proved to be a lobulated monster liberally covered with rope‐like veins and arteries, and smothered in discolored omentum. I stared at it, waiting for inspiration.
None was forthcoming from elsewhere, so I had to work it out on my own.
I’ll explore the abdomen, I thought, and see what it’s attached to.
I could not even slide my hands around the mass, despite the fact that I had incised from xiphoid to umbilicus.
Extend the incision caudally, I thought, and promptly cut the preputial artery and vein. The exercise of clamping and ligating those vessels bought me more time to think, and sweat. It was my first taste of that dry‐mouthed, hollow feeling when you realize you don’t actually know what to do next.
Extending the incision didn’t improve my visualization very much as everything seemed attached to everything else (Figure 2.1). My next bright idea was to lift the mass out of the abdomen. It would not budge. The attempt merely served to rupture one of the fragile veins snaking across its capsule, earning me some more perspiration time as I got the bleeding under control.
Figure 2.1 The trick with massive splenic tumours is to make a long enough incision. This incision extends well past the prepuce (arrow), yet it is still difficult to exteriorize this tumor.
Realizing that there was no easy way to do this, I decided to simply start ligating blood vessels, and hope that eventually I would get around the thing. Two and a half hours and about three meters of surgical gut later, I finally hefted the massive splenic tumor out of the dog and was hugely relieved when the rest of the abdominal contents remained where they were supposed to be.
Barney was tachycardic, which we addressed with large amounts of PlasmaLyte, but he was alive and recovered slowly from anesthesia and we patted ourselves on the back. The next morning, Barney was stretched out in his cage with ghost‐white mucous membranes. I sacrificed a goodly portion of his few remaining red blood cells in order to show that he had an hematocrit of 6%. As blood transfusions were beyond the scope of our practice, we gave him an iron tablet and hoped for the best. The fact that he was too anemic to stand fortunately did not prevent this Labrador from wolfing down a couple of kangaroo steaks. Removing the massive tumor from his abdomen restored his trim waistline, and earned him a pardon from his rigid diet of the last few weeks. We discharged him – weak but happy – a couple of days later and I had learned another major lesson: when you don’t know what to do next, sometimes you just have to start somewhere and make slow and steady progress until you get where you need to be.
We encounter many large abdominal masses in dogs and cats. Fortunately, most of them are splenic in origin, mobile, and lift fairly easily from the abdomen, their stretched pedicle presenting itself neatly for ligation. But abdominal masses are not all like that, and developing a strategy for tackling the less convenient ones can make it less stressful and more effective.
Here are a couple of questions to ask yourself when deciding on your strategy.
Is my incision going to give me satisfactory access?
The traditional stem‐to‐stern ventral midline incision will serve for many mid‐abdominal masses, but does not work well for large lateral liver or kidney masses. You can join a ventral midline incision with a paracostal incision, creating a flap of lateral abdominal wall and greatly improving access to the left or right craniodorsal abdomen. But only if you clip the patient high enough laterally on each side before draping it!
Is the mass solid or cavitated?
My main concern is how richly a mass is supplied with blood vessels. It can be difficult to determine whether the great vessels of the abdomen actually run through a large mass, or are innocent bystanders. Contrast‐enhanced computed tomography (CT) has become a mainstay of evaluation for abdominal masses in people and animals. Many times we will send a patient for a CT to “work out whether the mass is resectable or not.” CT is invaluable for evaluating the vascularity of a tumor, and its relationship to the great vessels, but it does not necessarily help determine whether it is adherent to the surrounding structures, and how easily they might be separated.
I tell my owners that I use CT to decide whether a mass is not resectable (i.e., are critical structures intimately associated with it, precluding its removal without unacceptable morbidity?) but my test of choice about whether something can really be removed is to physically put my hands around the mass and see whether I can lift it out of the abdomen.
The moral of all this? Do not give up until you have either proven that the mass cannot be separated from other vital structures or that it will not lift out of the abdomen, allowing the normal structures to remain in situ and demonstrating the attachments that need to be ligated (Figure 2.2). Sometimes your patients will surprise you.
Figure 2.2 (A) Sometimes the “resectability” of a mass can only be assessed by sliding your fingers around it and lifting it out. (B) This liver mass was easily exteriorized, revealing a narrow pedicle that could be clamped and ligated.
At 16 years of age, Petunia was a venerable old lady as cats go when she was presented for evaluation of her “expanding waistline.” This was an understatement, as Petunia resembled a butternut squash. She was the same color too, suggesting that whatever had taken up residence in her abdomen was engaged in an intimate relationship with her common bile duct. Radiographs were not helpful. At her age, Petunia had developed a strong opinion of what she should and should not be required to endure, and lying on her side was one of the latter. After struggling for some time, and spending a hundred odd dollars of the owner’s money to achieve a radiograph resembling one of those torticollic dinosaur fossils chiseled from Chinese rock, I emerged from the X‐ray room with the news, “Yes, she has a large soft tissue mass in her abdomen.”
Her owners were gracious enough to nod solemnly in response to this confirmation that Petunia’s advanced state of turgidity was indeed abnormal. They also shared the information that, “The other vet said the same thing.”
This was a strong clue that mine wasn’t the first opinion they had sought, and they confirmed this with, “They said it was too advanced for them to operate, but we’ve come to the university to make sure.”
We were nearing the end of the line for Petunia; if we didn’t come up with an answer, nobody would. And I knew enough about small animal practice by now to realize this was not going to be a simple splenic tumor.
Fortunately, the University of Sydney had excellent ultrasonographers, who confirmed that the mass occupying the vast majority of Petunia’s peritoneal cavity was filled with fluid. CT was a glimmer on the horizon, but not yet a reality for our practice, so three‐dimensional imaging was out of the question. But Petunia was running out of options, and her owners were determined to at least try to diagnose, if not resolve, her problem, so we scheduled her for surgery. I had not yet formulated any particular strategy for approaching the non‐standard abdominal mass, so started with the basic ventral midline incision. We positioned Petunia obliquely on the table in the hope that whatever blood was squeezing through her caudal vena cava should not be further challenged by the dead weight of her alien passenger (Figure 2.3A).
Figure 2.3 (A) Grossly distended abdomen in a cat with a biliary cyst. (B) Appearance of the cyst upon opening the abdomen.
Petunia’s body wall was stretched enough to be semitranslucent, and parted almost gratefully beneath my scalpel to extrude a glistening gray dome (Figure 2.3B). At the caudal‐most extent of the incision, a tangle of unnaturally flattened jejunum made its bid for freedom, and Petunia’s blood pressure shot up momentarily as blood began to return from the caudal half of her body. With the rock‐hard object now half in and half out of the peritoneal cavity, I had the faintly hysterical vision of walking out to reception to report to the waiting owners that, “Yes, I am now convinced. Petunia has a large soft tissue mass in her abdomen!”
The mass was solid and sessile, and would not shift one way or the other. For some strange reason that I still don’t understand, we had not seen fit to aspirate it during the ultrasound examination, and I had no idea what sort of fluid it actually contained, although I was working on the presumption that it was bile, and this was some form of extravagant biliary cystadenoma. Did I think I really had a chance of removing it? In retrospect, I don’t think so, but we were not prepared to give up on Petunia unless we knew for sure.
Having seen my adversary in the flesh – so to speak – I began to think that perhaps we’d gone as far as we could go. I had no idea what this thing was growing from, or how invasive it was. I had no idea what other structures I might have to sacrifice in order to remove it. If only it were a little smaller, so I could look around the sides and see what was happening in the abdomen. In a fortuitous coalition of random thoughts, I decided to aspirate the cyst to confirm the fluid as bile and as I was preparing to do this, I thought, If it is bile, why not drain it completely and see whether that helps me explore the abdomen?
This might seem self‐evident, but when you are confronted with the unexpected in surgery you don’t always think clearly. In many cases, I only worked out the ideal strategy in retrospect.
