Cryptorchidism in Dogs: 5 ways to make surgery easier

1. Determine which testicle is retained

Perform a thorough physical examination.(1) Carefully evaluate the scrotum, prescrotal area, inguinal canals, and abdominal cavity. If only 1 testicle is present in the scrotum, push it dorsally and cranially into the inguinal canal to determine whether it is the right or left testicle. After determining which testicle is retained, carefully palpate the prescrotal area and inguinal canal on the affected side. Palpation of the testicle in the inguinal region may be difficult since it can be confused with inguinal fat or lymph node. Ultrasound examination may be helpful to identify the testicle since it has a characteristic appearance (See recent paper on ultrasonography for retained testicles by Felumlee, Reichle, Hecht, et.al. http://onlinelibrary.wiley.com/.../j.1740-8261.../abstract)

Fig. 1: Ultrasound of a cryptorchid dog with a retained testicle found in the abdomen (arrow)

Also perform abdominal palpation, but unless the retained testicle is severely enlarged it will be difficult to palpate.

2. Begin with an incision over the pre-scrotal or inguinal region

Testicles located just cranial to the scrotum can be removed either by pushing the testicle caudally and exposing it through a standard pre-scrotal midline incision, or by simply incising directly over the testicle. Retained testicles in the inguinal area require incision directly over the inguinal canal. (Fig. 2a)

Fig. 2a: Inguinal incision for removal of right sided retained testicle
(Figs 2a through 2f are from: Birchard SJ, Nappier M. Cryptorchidism.
Compend Contin Educ Vet. 2008 Jun;30(6):325-36; quiz 336-7.)

Meticulous and thorough dissection may be required to expose the testicle. Be careful not to injure the pudendoepigastric artery and vein and its branches. It is possible to confuse the inguinal lymph node with the testicle. However, careful dissection and gross examination of the structure should allow differentiation before proceeding with the excision. Once the testicle and associated structures are exposed, remove them as described for prescrotal or normal testicles.

3. For an abdominal testicle, perform a paramedian approach

If one testicle is retained in the abdominal cavity, the paramedian approach to the abdomen offers the advantages of avoiding dissection around the prepuce, which necessitates ligation of the caudal superficial epigastric artery and vein, and not creating dead space in the subcutaneous tissues adjacent to the prepuce. Although the paramedian approach can allow removal of the testicle through a smaller incision than the ventral midline approach, the surgeon should not compromise the exposure of the intra-abdominal structures. Carefully identify the caudal abdominal structures, and expose and remove the testicle only after verifying that the correct structures have been identified. In one clinical study, the prostate gland was inadvertently removed in 3 dogs when insufficient exposure had been obtained while attempting to remove an abdominal testicle.(2) If additional exposure is needed to identify key structures, enlarge the abdominal incision and use appropriate retractors to find the testicle and surrounding organs.

For the paramedian caudal abdominal approach, place the dog in dorsal recumbency, and prepare the ventral abdomen for aseptic surgery. Depending upon the size of dog, make a 6-10 cm incision in the ventral abdomen, approximately 3-4cm lateral to the prepuce. (Fig. 2a)  Incise the subcutaneous tissue to expose the fascia of the rectus abdominus muscle using a scalpel, make a nick incision in the fascia, and sharply incise the fascia with Mayo scissors (not the muscle). (Fig. 2b) 

Fig. 2b: Sharply incise the rectus abdominus fascia with Mayo scissors

Bluntly separate the fibers of the rectus abdominus muscle, beginning with Mayo scissors, then continuing with the index finger of both hands. (Fig. 2c) 

Fig. 2c: Bluntly separate the muscle fibers of the rectus abdominus with fingers

Sharply incise the peritoneum. (Fig. 2d) 

Fig. 2d: Sharply incise the peritoneum with scissors

Place moistened laparotomy sponges on both sides of the body wall, and place a Balfour retractor or hand held retractors to retract the abdominal wall and expose the viscera.

4. Exteriorize the urinary bladder and palpate the prostate gland

If the retained testicle is not immediately seen in the abdominal cavity after making the paramedian approach, exteriorize the urinary bladder and retract it caudally. Identify the prostate gland, and the vas deferens entering the prostate.

Fig. 2e: Exteriorize the urinary bladder and identify the prostate gland and vas deferens

5. Find the vas deferens and follow it to the testicle

Follow the vas deferens cranially until the testicle is located. (Fig. 2e) Triple ligate the vas deferens and the vessels with absorbable suture, cut between the distal 2 ligatures, and remove the testicle.

Rarely, the abdominal approach and identification of the vas deferens may reveal that the testicle is in the inguinal canal. Remove the testicle as previously described in the inguinal approach.

Close the abdominal incision by first closing the external rectus fascia with absorbable suture (e.g. polydioxanone) in either a simple interrupted or simple continuous pattern.(Fig. 2f) Close the subcutaneous tissue and skin routinely.

Fig. 2f: Close the external rectus fascia, subcutaneous tissue, and skin routinely

Fig. 3: Testicular torsion of an abdominal testicle in a 5 month old Boxer
(same dog as in Figure 1) removed by the paramedian approach. 

References

1. Birchard SJ, Nappier M. Cryptorchidism. Compend Contin Educ Vet. 2008 Jun;30(6):325-36; quiz 336-7.
2. Schulz KS, Waldron DR, Smith MM, et al: Inadvertent prostatectomy as a complication of cryptorchidectomy in four dogs. J Am An Hosp Assoc 32: 211-214, 1996.

Blog Update: Dr. Birchard has published a new book: "Their Tails Kept Wagging", a collection of moving stories about pets with serious illness who survived. Click here for more information. 

Surgical Correction of Enlongated Soft Palate in Dogs: Helping brachycephalics breathe.

The soft palate (SP) in the dog forms the partition between the oral and nasopharynx. The cranial border of the SP is attached to the hard palate, and the caudal border extends to the tip of the epiglottis.  Elongated soft palate is one aspect of brachycephalic syndrome and is common in dogs such as English bulldogs, pugs, and Boston terriers. The soft palate is considered elongated if it extends caudally beyond the articulation with the epiglottis. (Fig. 1) 

Fig. 1: Elongated soft palate in a bulldog. (the dog is in ventral recumbency).
Note the tonsils on each side of the palate.

It causes obstruction of the glottis and stertorous breathing which can be a significant respiratory problem in affected dogs. Concomitant stenotic nares worsen the condition by increasing inspiratory effort and causing further extension of the SP into the airway. (see blog on stenotic nares, May 10, 2014)

After obtaining a thorough history and performing a physical examination, take thoracic radiographs to rule out hypoplastic trachea and complications of upper airway obstruction such as pneumonia or pulmonary edema.

Surgical Procedure

A variety of surgical techniques have been described for correction of elongated SP.  The basic objective of surgery is to remove the portion of SP that is causing airway obstruction.  The amount of tissue to be resected is determined by either measuring the portion of SP that extends beyond the tip of the epiglottis, or by removing the portion of SP that extends beyond the caudal pole of the tonsils. (Fig. 2)  

Fig. 2: Incision line for removal of the excess soft palate.
The line connects the caudal pole of the tonsils.

Resection of too much tissue can result in nasal regurgitation of food and water with resultant aspiration pneumonia.

Since hemorrhage is a potential complication of resection, some authors recommend placing a clamp across the area to be removed, removing tissue using electrocautery, or injecting the tissue with epinephrine.  The author does not recommend these techniques since they encourage tissue edema that can be a life-threatening post-operative complication. Surgical laser and the Ligasure device have also been used for soft palate resection.  An atraumatic “cut and sew” technique described many years ago has been very successful in the author's experience and remains my procedure of choice.(1)

Place the animal in ventral recumbency with the head at the end of the table and the mouth held open with an oral speculum. (Fig. 3)  

Fig. 3: Patient positioning for soft palate surgery

Be sure that the endotracheal tube has a competent cuff that is appropriately inflated to prevent aspiration of blood during the procedure. Administer intravenous dexamethasone (0.1 mg/kg) to help control tissue edema secondary to surgical manipulation. Briefly remove the endotracheal tube to examine the soft palate and compare its length to the epiglottis. Replace the tube and secure it in place. Grasp the middle of the SP with an Allis tissue forceps and place stay sutures (4-0 PDS or Monocryl, taper needle) at the lateral aspects of the SP where the incision will be made. (Fig. 4)  

Fig. 4: Stay sutures have been place at the proposed site of incision (dotted line)
From: Bright RM, Wheaton LG (1983) A modified surgical technique for elongated soft palate.
J Am An Hosp Assoc 19: 288-92

Sharply incise the soft palate with long-handled curved Metzenbaum scissors. (Fig. 5)  

Fig. 5: Angled Metzenbaum scissors (above) are useful for incision of the soft palate.
Conventional scissors are shown below.

Incise half way across the palate; the mucosa of this cut portion is then sutured with the long end of the stay suture in a simple continuous pattern. (Fig. 6) 

Fig. 6: The soft palate has been partially incised and suture closure begun.
From: Bright RM, Wheaton LG (1983) A modified surgical technique for elongated soft palate.
 J Am An Hosp Assoc 19: 288-92

Then incise across the remaining palate and suture the mucosa in a similar fashion. (Fig. 7)

Fig.7: Completed excision and closure of the soft palate.
From: Bright RM, Wheaton LG (1983) A modified surgical technique for elongated soft palate.
J Am An Hosp Assoc 19: 288-92

Hemorrhage is usually not a significant problem once the incisions are closed.  The trachea is gently suctioned if hemorrhage was excessive. To check the soft palate for adequate resection of tissue, briefly remove the endotracheal tube to allow comparing the soft palate length to the epiglottis, then replace the tube for the remainder of the dog's recovery from anesthesia.

Postoperative Care

Post-operatively, leave the endotracheal tube in place as long as possible until the animal is fully awake.  The animal should recover in a cool environment and be observed closely for evidence of airway obstruction due to tissue edema.  Keeping the chin elevated seems to help brachycephalic dogs move air during anesthesia recovery. The intravenous steroids can be repeated if edema is suspected. Tramadol is administered for 5 days for analgesia.

Although most dogs recover without incident after soft palate resection, if complications occur they can be life threatening. Therefore recovery from surgery should be in a hospital that has 24 hour care at least for the first night after the procedure. Results of surgery are usually very good; some inspiratory noise may remain but respiratory function should be improved. One study found a good to excellent outcome in 34 dogs with long-term follow up after surgery for brachycephalic syndrome.(2)

References

1. Bright RM, Wheaton LG. A modified surgical technique for elongated soft palate. J Am An Hosp Assoc. 1983; (19): 288-92.

2. Surgical correction of brachycephalic syndrome in dogs: 62 cases (1991-2004).

Riecks TW, Birchard SJ, Stephens JA. J Am Vet Med Assoc. 2007;230(9):1324-8.

For Dog Owners: Ice cubes or ice water do NOT cause GDV (bloat) in dogs

Gastric dilatation volvulus (GDV) is a disorder of dogs characterized by extreme dilation and mal-position of the stomach. It is primarily seen in large breed dogs and is due to a number of predisposing factors. There is no scientific evidence supporting the claim that ingestion of ice cubes or ice water has any relationship to GDV in dogs, and I have never seen a case in which there was a correlation between the two.

On hot days if a large breed dog becomes overheated they will pant heavily in attempt to cool themselves down. This can lead to aerophagia (swallowing air) that can cause excessive gas in the stomach and lead to GDV if other contributing factors are present. Keep your dog cool by avoiding exercise during the hottest part of the day, avoid leaving them in a hot car in the sun in a parking lot, and give them access to plenty of cool, fresh water and a shady place to rest. Also, do not let your dog drink massive amounts of water all at once. After drinking a reasonable amount, take the bowl away and offer more after 15 to 30 minutes. A cool bath can also be helpful if you think your dog has become mildly overheated. Severe hyperthermia is an emergency situation requiring immediate care by a veterinarian.

For more information on GDV in dogs, search this blog for GDV, or contact your local veterinarian.

Case Outcome on Betty: The pit bull with a vaginal mass

 This is the case outcome on Betty, a 2 year old in tact pit bull that presented with an acute onset of a vaginal mass. 

The appearance and palpation of the mass was characteristic of a vaginal prolapse. Betty was likely in estrus at the time of presentation. She was not having difficulty urinating. Some areas of mucosal necrosis were evident on the prolapsed tissue. (Fig. 1) 

Fig. 1: Vaginal prolapse in the 2 year old pit bull

We advised the owner to have Betty spayed as soon as possible. In the meantime, we recommended that they keep the tissue clean and lubricated, and place an Elizabethan collar on her to prevent self trauma of the area. 

Within a few days of having her spayed, Betty's prolapse was significantly improved. (Fig. 2)

Fig. 2: Appearance of the vaginal prolapse on Betty a few days after
ovariohysterectomy

The superficial necrosis had sloughed and completely healed, and Betty was doing well otherwise. Approximately 2 weeks later, the vaginal prolapse had completely resolved. (Fig. 3)

Fig. 3: Complete resolution of vaginal prolapse on Betty after
ovariohysterectomy

This case exemplifies the rapid resolution of vaginal prolapse after ovariohysterectomy without the need for resection of the vaginal tissue. A key element of this case is that there were only very focal areas of mucosal necrosis, not severe full thickness vaginal necrosis that would require removal. Resection of vaginal tissue with either hyperplasia or prolapse is rare in my experience. 

Etiology

Vaginal prolapse usually occurs during estrus due to estrogen stimulation of the tissues. Other causes are exogenous estrogens or prolapse during parturition. 

Diagnosis

Vaginal prolapse is suspected when a doughnut shaped mass has protruded from the vagina in an in tact female dog. It can appear similar to vaginal hyperplasia (edema); both usually occur during estrus. Vaginal neoplasia is a differential diagnosis.

Treatment

Keep the prolapsed tissue clean and well lubricated. On initial presentation, hyperosmotic solutions of dextrose or granulated sugar can be used to reduce swelling and possibly permit reduction of the tissue back into the vagina. If necessary, temporary sutures across the labia can be placed to cover the tissue and keep it moist until the swelling reduces. Recommend ovariohysterectomy to allow prompt reduction of tissue swelling and resolution of the prolapse. In breeding animals, warn owners that recurrence of the prolapse is possible in subsequent estrus cycles.

What is Your Diagnosis and Treatment? Acute onset of a vaginal mass in a pit bull.

Betty, a 2 year old in tact female pit bull.

"Betty" is a 2 year old in tact female pit bull with an acute onset of a vaginal mass. The owners just noticed the problem today and presented her to the emergency service. She had a small amount of pinkish vaginal discharge for a few days before her owners discovered the mass. They do not remember when she was in heat last. She had no other history of any medical problems.

The dog was bright and alert and her physical examination was unremarkable except for the vaginal mass. 

Vaginal mass on Betsy

What additional diagnostic tests would you do?

What is your diagnosis and how would you treat this problem?

Post answers either here or on Facebook.

Postoperative Pain Control in Dogs and Cats: How much is enough?

Postoperative comparison of four perioperative analgesia protocols in dogs undergoing stifle joint surgery

Kerrie A. Lewis, DVM, MS; Richard M. Bednarski, DVM, MS; Turi K. Aarnes, DVM, MS;

Jonathan Dyce, MA, VetMB; John A. E. Hubbell, DVM, MS

(J Am Vet Med Assoc 2014;244:1041–1046)

Summary

In this study the authors compared 4 protocols for perioperative analgesia in dogs undergoing TPLO surgery for the treatment of a ruptured cruciate. Forty-eight dogs were included in the study. The dogs were randomly assigned to receive one of the following protocols:

            IM premedication with morphine

            CRI of morphine, lidocaine, and ketamine (MLK)

            Lumbosacral epidural of morphine and ropivicaine

            Both MLK and the epidural of morphine and ropivicaine.

All dogs received NSAIDS after surgery. Pain and sedation scores were collected from the dogs for 24 hours postoperatively. Morphine was administered as a rescue analgesic if a pain score of > 5 of 24 was determined.

No differences in anesthetic parameters were found between groups, and no differences in postoperative pain parameters (pain scores, sedation score, rescue analgesia requirement, or time to first rescue analgesia administered after surgery) were found. The authors concluded that all 4 analgesic protocols were acceptable for postoperative analgesia for the first 24 hours.

Commentary

The most conservative analgesic protocol, i.e., premedication with morphine alone, was as effective as the more aggressive protocols. Based on the results of this study, the conservative approach of an opiod premedication combined with postoperative NSAID therapy appears to be an appropriate method of pain control in dogs having TPLO.

This well designed study provides us with valuable clinical information. The authors chose dogs having TPLO, which is a painful surgical procedure involving osteotomy of the proximal tibia followed by plate fixation. The fact that 1 preoperative dose of morphine combined with postoperative non-steroidal therapy provided acceptable postoperative analgesia suggests that more aggressive pain management may not be necessary.

The findings of this study bring up a larger question: what is the appropriate level of pain control for postoperative patients? How much analgesic therapy is needed after other types of surgeries such as abdominal or thoracic procedures?   An aggressive approach to pain management ensures that we are addressing the needs of the patient, however, all medications have side effects and these must be considered when formulating our approach.  Regurgitation, aspiration pneumonia, dysphoria and excessive sedation are all complications that are associated with drugs used for analgesia.  The subjective nature of our pain assessment methods makes it difficult to know when we are administering an appropriate amount of analgesia. Hopefully more studies like this one in which objective measures were used to assess sedation and pain will be conducted to answer these questions.

What is your opinion? What routine analgesic protocols do you use and what is your experience with them? Leave a comment on the blog or on facebook; I would love to hear your thoughts.            

Surgical Correction of Stenotic Nares: Or how to do a nose job in a brachycephalic dog.

Fig. 1: normal anatomy of the nose in a dog
From: Evans HE. The respiratory system. In Evans, HE, editor, Miller’s Anatomy of the Dog. 3^rd edition, WB Saunders, 1993, pg. 464.

Stenotic nares are one aspect of brachycephalic syndrome, the upper airway obstructive disorder seen in brachycephalic dogs such as bulldogs, pugs, and Boston terriers. Stenotic nares are characterized by a malformation of the alar folds resulting in abnormally small nostrils.

The mobile portion of the external nares is comprised of 3 cartilages, the dorsal and ventral parietal cartilage and the accessory cartilage.  The alar fold (also called the wing of the nostril or the lateral cartilage) is the nasal structure that forms the lateral border of the nostril.(1)  This fold is collapsed medially in dogs with stenotic nares.  During inspiration, the alar fold may collapse further, causing complete occlusion of the nostril.

Surgical Procedure

Fig. 2: Wedge resection for correction of stenotic nares in brachycephalic dogs.
From: Fingland RB, Obstructive upper airway disorders, in: Saunders Manual of Small Animal Practice, 3^rd ed., editors: Birchard SJ, Sherding RG, Elsevier, St. Louis, pg. 1651.

The surgical procedure to alleviate stenotic nares is either to remove a wedge of tissue from the alar fold, or to do a subtotal excision of the alar fold. The author usually performs the wedge excision technique which is described here. (Fig. 2) Position the animal in ventral recumbency with the head at the end of the operating table.  The nose is surgically prepared. A scalpel with #15 blade is used to make angled incisions in the alar fold so the portion to be removed in the shape of a triangle. (Fig. 3)

Fig. 3: Angled incisions made to begin triangular wedge excision of alar fold.

Be sure to include a pie-shaped section of cartilage from the inside of the alar fold in the excised section. Remove the tissue via sharp dissection.  Control hemorrhage with direct pressure.  Place simple interrupted sutures (4-0 Monocryl) in the alar fold, taking bites from inside the nostril to the outside (Fig 4). 

Fig. 4: direction of suture bites for closure of the alar fold after wedge excision.

Hemorrhage subsides after the sutures are placed. If the nostril does not appear adequately open, remove the sutures and excise more tissue from the either the lateral or medial aspect of the alar fold. Try to achieve symmetrical openings to the nostrils. (Figs. 5,6)

Fig. 5: Completed correction of one side of stenotic nares in a Shih Tzu

Fig. 6: Completion of both sides of correction of stenotic nares via wedge excision.

Postoperatively, keep the nostrils clean with moist sponges, and prevent self-mutilation with an Elizabethan collar if necessary.  Suture removal is not necessary since absorbable suture material is used.