Veterinary Surgery Dr Sing

51. When to operate on a closed pyometra case?

2010-08-08T16:36:00.001-07:00

SUNDAY'S CASE

August 8,2010

Sunday, August 8, 2010

Consultation at Vet 1.
The 9-year-old, 5-kg Jack Russell passed out some sticky vaginal discharge and also blood in the stools on Saturday. The young lady and her brother googled "pet clinic" and went to North-east Singapore.

Vet 1 shaved bald the dog's ventral area for an abdominal ultrasound scan. "Lumps of around 3 cm in diameter can be seen", he told the owner. Vet 1 diagnosed pyometra based on vaginal discharge, fever, abdominal palpation and scan. Surgery and anaesthesia quoted was $1,000.

The kind vet advised surgery as soon as possible and presented the young lady a list of vet practices in Singapore. She was living in Toa Payoh and phoned me for a quotation. I was surprised when she told me that she did not know of Toa Payoh Vets existed (since 1982) although she is a Toa Payoh resident.

CHANCES OF SURVIVAL
It is difficult to guarantee 100% survival. The dog had actually been vomiting occasionally in the past 3 months, not just last week.

Vet 1 gave a Rimadyl 0.5 ml (50mg/ml) injection 2 hours ago. The temperature before Rimadyl injection was 39.7 deg C (fever). When I checked the dog 2 hours later, it was 38.5 deg C (normal). So I had to decide to operated soon as the fever would return when the drug effect went off.

I gave an antibiotic (Baytril) 0.6 ml SC 1 hour before surgery. The dog was operated and recovered well.

She was still drowsy when the young lady and her brother visited her 2 hours after surgery but could recognise them.
I showed the pyometra to the young lady and her brother. "Vet 1 said it was 3-cm lumps," she said. "The ultra-sound cannot measure all lumps accurately," I said. "Some of the lumps in this uterine body are 3 cm in diameter and some are more or less." I told her. She was very relieved that her dog was alive and that was what counted.

RIMADYL (a class of pain-killer called NSAID).

1. I have never used Rimadyl before surgery although the manufacturer (Pfizer's website) does recommend it, at 2 hours before surgery so that the dog will not feel any pain after surgery.

2. The manufacturer advised the use of parenteral fluids during surgery to reduce the potential risk of renal complications when NSAID is use perioperatively.

3. In this case, the first vet had given 0.5 ml Rimadyl (50 mg/ml) SC 2 hours ago and no antibiotics. The dog had a fever of 39.7C. When I was consulted 2 hours later, I checked the temperature. It was 38.5C. The owner commented that the dog looked better. Rimadyl had reduced the pain. It also appeared to be anti-fever too.

Calculation of dosage in this case.
Jack Russell, Female, 9 years old, 5 kg.
Manufacturer advised: 4.4mg/kg for 24 hours or 2.2mg/kg two times a day by injection. Same dosage for oral administration.
Therefore, the first vet gave 25 mg SC or 5 mg/kg.

I decided to operate on the dog 2 hours after consultation as the fever had subsided and might return if there was a delay. The dog growled after some time when I checked her gums which were pink but dry-looking. I could feel a large swelling in her lower 1/3 of the abdomen but not the lobes felt by the first vet. She looked "pregnant". Rimadyl might have made abdominal palpation difficult. There was no pain reaction from this Jack Russell.

Rimadyl provides pain relief and was already given by the first vet during consultation. I did not give anymore for the next 24 hours.

SEVERE DRUG REACTIONS ASSOCIATED WITH NSAIDs
include gastrointestinal, renal and hepatic signs and in rare situations, death.

Therefore, in pyometra post-surgery, I don't give NSAID before or after surgery as I don't know how badly damaged the dog's kidneys are. This dog had been vomiting for the last 3 months and would not be considered healthy.

It is safer as the owner wants a dog alive at the end of the surgery.

photos and updates are at www.toapayohvets.com

50. Right perineal hernia repair in the Boston Terrier

2010-08-06T13:38:00.000-07:00

Today is Saturday, August 7, 2010. It is my day off but I better record my recent surgery on the right side of the backside of the Boston Terrier before I forget as there are so many things to do and read in Singapore as compared to Perth, Australia where the pace of life is much less hectic.

"The backside lump keeps getting bigger," the young man and caregiver of the Boston Terrier phoned me in the first week of August 2010. "My dog can't poop normally. You need to operate on him."

I had repaired the left perineal hernia in a Boston Terrier in Jun 2010. The surgical outcome was excellent and I was glad. Surgeries take a long time and can result in complications.

Left perineal hernia in a Boston Terrier has been repaired in June 2010
The right perineal hernia started to enlarge bigger and bigger

"The swelling is the rectum full of stools. Part of the rectum had dropped into this perineal hernia and you can see it as a lump. It is therefore hard for the dog to pass motion. Use your finger to push the lump back into the abdomen so that he can poop and make an appointment for surgery," I had just neutered this dog 7 days ago. Neutering is reported to reduce the incidence of perineal hernias in the male dog. It was better late than never.

ANAESTHESIA
The owner is worried that his old dog may not survive a 3rd anaesthesia. The first two were for the repair of the left perineal hernia in June 2010 and neutering. Many dog owners in Singapore are aware of the risk of the dog dying on the operating table and the internet forums of such cases frighten them. In this dog, the only cure was to operate to close the big hole inside the right perineum as the dog had great difficulty and pain in pooping.

Domitor 0.2 ml IV and isoflurane gas. An I/V saline drip. No problem. I did not use Antisedan to wake up the dog as he would wake up naturally.

SURGERY
The hole was even larger than the left perineal hernia I did in June 2010. My assistant Mr Saw wore a glove and asked me: "Do you want me to dig out the stools?" I said: "It is better not to do it. The dog's rectum may be traumatised. In any case, it is not necessary to empty the stools from the rectum." I was never more mistaken.

Under anaesthesia, the solid stools started to pop out of the anus. My assistant removed them with a tissue paper. I had not plugged the anal opening with the syringe or something.

I used electro-incision to open a big curved incision of the skin. Fatty mass spilled out of the wound. I used the retractor to open widely and horizontally the herniated muscles.

I could not believe it. The whole defect was over 4 cm x 6 cm in diameter and very deep. As deep as 3 cm. There was not much muscle layer to stitch from the right lateral side to the anal sphincter. Would the stitches hold? There would be no second chances.

Right perineal hernia in a Boston Terrier has been repaired in August 2010
In this case, I could see the reddish right ventral wall of the rectum. I placed several layers of 2/0 absorbable stitches to close the gap. "The retractor is very useful," Mr Saw remarked. "Yes," I said. "It opens up the hole so that I can stitch up properly."

The whole area was a mess. I could see one big vein but not the nerve which was supposed to be present in theory.

POST-OP CARE
In theory, the dog should be crated for 14 days and given limited movements for another 14 days so that the stitches would not break down. To save money, the owner would take the dog home in 4 days and confine the dog himself.

CONCLUSION
Sometimes it is better to neuter the dog when he is young. For the past years, I have had not seen a case of perineal hernia in neutered dogs. The incidence in neutered and female dogs is very low. In just the past 2 months, I have had operated on 2 male not neutered dogs with perineal hernias.

One of the recent cases of a right perineal hernia in an 8-year-old Shih Tzu is at:
http://www.asiahomes.com/singaporetpvet/0514haematoma_perineal.htm

Right perineal hernia in an 8-year-old non-neutered Shih Tzu. The hernia was discovered by the teenaged girl "recently". The complaint was "constipation"
Perineal hernias are not common conditions in the sense that I don't see them every week. But they are commonly present in non-neutered dogs. When you see a swelling to the right or left of the anus, get your vet to quickly repair the perineal hernia rather than wait for a long time as it is extremely difficult to stitch up a big gap in the pelvic diaphragm compared to a small one.

Pictures are at www.toapayohvets.com, goto DOGS

49. Perineal hernia in a male Boston Terrier

2010-06-24T13:27:00.000-07:00

A knowledgeable young man who has his own views of dog care.
He presented a Boston Terrier with constipation for the past 3 weeks. He went to Vet 1 who referred him to another vet after taking a blood test as she did not want to perform the surgery. She had given him a laxative for the dog and the dog had passed loose stools instead of hard ones.

"Why don't you see the referred vet?" I asked.
"The Surgery had a bad reputation," he had googled the name of the practice and there was a nasty complaint from one dog owner.
"All practices will have one or two bad complaints about service," I said. "The busier the practice, the higher the chances of getting complaints as the vet may have no time to handle each case. This applies to over-worked doctors in human medicine too especially in the emergency wards."

"Has your dog been vaccinated?" I asked.
"No vaccination for the past few years. Do you have parvovirus in your Surgery?" the young man asked me.
"Fortunately for your dog, my practice does not have parvo-viral cases for many months as I seldom provide service to the dog breeders nowadays. You have taken a big risk exposing your dog the risk of parvoviral and canine distemper infections."

PRE-OP BLOOD TEST IMPORTANT FOR OLD DOGS BEFORE SURGERY
I checked Vet 1's blood test results. It is wise not to trust the blood results of other practices based on one of my experiences (see one case I had written). However, he had paid $130 for the test and I would not insist as that would increase his vet bills. Overall, the dog was examined and was healthy. So I took the chance.

ANAESTHESIA
Domitor and isoflurane gas was OK. The dog recovered smoothly.

SURGERY
I gave him antibiotics to take and schedule perineal hernia surgery 2 days later. The surgery took nearly an hour as the hernia was large.

CONCLUSION
The dog was OK and was warded for at least 4 days as the owner did not have a crate to prevent the dog running loose. I checked the dog every day to ensure that he had proper nursing care and pain-killers. The boy's parents came to visit the dog yesterday. The dog should be back home after 7 days. He had managed to rub his backside onto the floor of the crate despite tolfedine 60 mg at half a tablet per day for 3 days. I decided to give him 1/4 dose of a 30mg phenobarb and then rimadyrl for another 3 days to prevent pain and inflammation.

Updates at www.toapayohvets.com

48. Serious heart disease + deep eye ulcer

2010-03-02T13:57:00.000-08:00

The mother and teenaged daughter adopted the abandoned Chihuahua. For the past 2 weeks, the dog was rubbing her eyes. Dirt and bacteria get trapped inside the eyes, irritating the dog. So, she rubbed more. When I was consulted, the eye cornea was deeply ulcerated. A 3rd eyelid flap would be the surgery and would have saved his eye sight if the owner had not delayed seeking vet treatment.

In addition, this Chihuahua had a serious heart disease. Panting when at rest. More panting when excited. A pre-anaesthetic sedation using Domitor might be too risky.

Therefore, I did not proceed with the surgery as she would likely just die on the operating table. A 90% chance of dying. The owner accepted the risk but since this is a very high risk, I did not want to risk my reputation in handling this case.

The dog went home with heart drug medication, antibiotics, eye ointment and an e-collar. It was better to have a live pet as the teenaged daughter was attached to her. No vet wants a dead dog as a result of anaesthesia. No owner wants that too.

One week later, the eye ulcer had perforated. A white plug of gel oozed out. What to do now? Bacteria would get inside the eye causing enopthalmitis. Uveitis was controlled by eye drops. There was one solution. Surgery to remove the whole eyeball (enucleation).

Performance counts. In this case, a good performance is a live dog at the end of the surgery. The following management of this case is shared with readers and vets:

1. Dog was already on Fortekor for the past 7 days. She was no longer panting but dislike direct mask isoflurane gas. Struggled. I did not risk masking her since she might just collapse of heart failure during the fight to get out of the mask. So, a sedation injection was needed. Domitor or zoletil? Which is safer? Does Domitor cause heart rate to slow down? How about xylazine? It causes hypotension. Eventually, I used Zoletil. But how little that can be effective is needed for this 2.5 kg dog?

2. Pre-anaesthetic dextrose saline 20 ml SC and antibiotics.

3. Weight was 2.5 kg. Thin.
Pre-anaesthetic dose of Zoletil 50 @ 0.2 ml IM.
Atropine 0.65mg/ml @ 0.2 ml IM to prevent salivation, neck twisting from Zoletil injection.
Isoflurane gas mask and then intubate.
4. The dog's eyelids were shaved fast. The eyeball was taken out in <10 minutes.

5. The teeth were scaled. 4 loose ones extracted.

6. The dog was on <1% isoflurane gas and was anaesthesized without problems. For a short period, I disconnected the gas and the dog was not awake. So, I could continue surgery. When the dog moved, I re-connect the gas. This close observation and not giving too much anaesthesia ensures the survival of the patient.

7. Post-op dextrose saline 20 ml SC, antibiotics and tolfedine painkillers.

8. Dog went home on Day 2. No problems. Everybody is happy when a dog is alive at the end of surgery and anaesthesia. If the dog had been operated earlier, she would have had died on the operating table as she never had been checked up for heart disease and was not stablised on heart medication. Pictures of the eye injuries are below.

Pic at www.toapayohvets.com

47. Oxytocin v. elective Caesarean section

2010-02-13T17:04:00.000-08:00

If the female dog can't give birth naturally, give an injection of oxytocin and see what happens. This is fine in theory and in lectures.

In private practice, the owner wants a good outcome when he brings in a barrel-shaped Miniature Schnauzer that had difficulty in giving birth to the vet for Caesarean section. With a fully distended abdomen, the Schnauzer is likely to have 5 or 6 puppies. In this case, an X-ray by a vet said 4 puppies but the owner did not bring the X-ray.

Now, what the owner wants is that he gets all puppies alive and ensure that the dam is safe. Oxytocin may or may not work.

If it does not work, there is a long delay which may result in a dead pup or two. If it works, the first pup may be delivered but not every of the 5 pups. A Caesarean section will still be needed and one of the pups may have died in the interim period.

Therefore, in theory, your lecturer advises oxytocin injection to wait and see. Oxytocin does work in some cases but you have to wait. Assuming that the first pup is born 30 minutes after the oxytocin injection, it does not mean that the second pup will follow. If the second pup is born naturally, the 3rd pup may be too big to follow or the dam may be too weak to contract. A few hours pass by. The remaining pups go into distress. When the Caesarean section is performed, one pup may have died. So what? As a vet, you have nothing to lose but your reputation. Some vets don't care about their reputation because deaths are part and parcel of veterinary practice.

In this particular case, at the 6lst day of pregnancy and rectal temperature of 37.1 deg C, I would do an elective Caesarean section. No mucking around with oxytocin to wait and see. It was obvious from the barrel-shaped abdomen that the dam had large pups (X-ray by a vet said 4 pups).

This case was not my case and therefore the judgment to wait after oxytocin injection or do a Caesarean section would be the other vet's judgment. I was an observer. It was Chinese New Year's Eve and my day off as it was also a Saturday. A blue sky, white clouds sunny day.

I did not have a car and taxis would be hard to flag down since most people in Singapore seemed to have closed in the afternoon. The vet in charge decided on a Caesarean section. It was such a bright sunshine afternoon and the lighting would be excellent for beautiful puppy photography. So, I hitched a motor bike ride from Mr Goose to transport me to the other vet practice so that I could take some good pictures of new born puppies. I love taking pictures of neonate puppies. They represent new life.

For the past 20 years, I had never had to ride a bike. I may be a senior citizen but I am still kicking and alive. So I rode pillion behind Mr Goose who is a careful man. His small red bike chugged along as if groaning under my weight. His bike is similar to the ones I show in the picture below. Nothing fanciful.

I put my hands on his shoulders in case I fell off. I hoped for the best. Bike accidents are common in Singapore and here I was taking a calculated risk that no other cars would collide into me from the side or behind.

Mr Goose had one or two minor accidents in the past 10 years and that was considered an excellent safety record. So, I trusted him. So, I had to strain my right hip to get onto the back seat. My backpack with my camera took up some space and so we went down the expressway. Cars whizzed by. I kept my fingers crossed and onto the shoulders of Mr Goose. I tried to maintain an upright posture as he swerved and turn to reach the practice.

The wind from Mr Groove's helmet whistled into my helmeted ears. The afternoon sky was blue. White cotton clouds dotted the sky and bright sunshine radiated downwards as I enjoyed the fresh breeze. Fortunately, it was not a rainy day and we arrived safely.

All 5 puppies were delivered by Caesarean section by the vet. I took a few pictures. This was a day full of happy memories for of a Chinese New Year's Eve on a very rare instance when I got onto a motor bike.

Births of new pups are always wonderful. New born pups are hard to photograph. The evening sunshine was what I wanted to get a good picture. Now it was up to my expertise to produce some for readers. I did not have to use Photoshop to touch up. There were some of my favourite pictures. I hope the readers enjoy them and wish all a Happy Chinese New Year 2010.

I am quite sure that the family of 5 Miniature Schnauzer pups must be having a very happy New Year too. I don't know them nor did I meet them as this was not my case. Senior citizens do not need to behave and walk as if they have one foot in the grave. Be alive. Think alive. Old age does not mean impending death. Live life as if every day is our last day on earth. We are not youthful but we should feel brand new and share our experiences with the young ones. Today is Chinese New Year and Valentine's Day. I hope you have a good holiday.

46. Breast tumours in an old spayed cat

2010-02-11T13:29:00.000-08:00

"Can I get some medicine for my cat?" the man came to Toa Payoh Vets and showed me a handphone picture of his 10-year-old cat with a large growth.

"Your cat appears to have breast tumours," I said. "No drugs can make them disappear. She needs surgery. What cream did you apply onto the tumours? Is she still eating?"

"I applied some antiseptic cream. My cat eats very little for the past 2 weeks," the man showed 1 cm width between his forefinger and thumb of his right hand.

What can be done now? Surgery would be the answer. There was the cost. More important this was a high-risk anaesthetic case as the cat had lost appetite for 2 weeks. Surprisingly, her temperature was normal. She was thin. I informed the owner that the cat could just die on the operating table due to her poor health. The pre-blood test was not done to save veterinary costs.

The following was done for this cat on the day she was admitted.

CONSULTATION. To enhance her survival chances, I injected baytril, anti-fever and anti-spasm drugs in 10 ml dextrose saline SC and had to decide whether to operate 2 hours later or wait till the next day. This was a difficult judgment. I decided to operate 2 hours later as the cat was not eating but her rectal temperature was normal. IV glucose was given first and continued during surgery.

PRE-ANAESTHETIC SEDATION Zoletil 50 @ 0.1 ml IV. The cat shot out a paw wanting to scratch my assistant Mr Saw when he put the Zoletil bottle noisily on the table. Today, Mr Saw seemed to be noisy. The cat had hissed at him before that. This was surprisingly as she did not behave similarly towards me and my second veterinary assistant Mr Goose.

"Maybe you are too noisy," I said. Mr Goose said as he grasped the scruff of the cat's neck and held the hind leg for IV injection of Zoletil. "Cats and rabbits at the preparation room for surgery get nervous when the place is noisy."

(In retrospect as I type this report at 5.46 am on Friday Feb 12, 2010, the cat could be defending herself from being given antiseptic ointment by her owner who had cleaned her breast tumours for some time. Her owner had a dark complexion like Mr Saw. This was one explanation as the cat associated Mr Saw with her owner and knew that she would be applied antiseptic ointment. It must be painful getting this application.)

Mr Goose pressed the medial side of the thigh to bring out a dark blue vein. Zoletil 0.1 ml IV is safe for this 2 kg cat. She was sedated. She had an IV glucose drip in her forearm prior to this sedation.

Gas mask isoflurane anaesthesia after this gave her freedom from pain during surgery. 3 minutes before the end of surgery, the isoflurane gas was cut off. The cat was given oxygen to breathe.

SURGERY
Two things to note:
1. The wound was very large as the tumours were scattered. Ensure sufficient skin to stitch up.
2. Bleeding from the superficial epigastric arteries (cranial around MG1 and MG2 and caudal around MG4 and MG5). Clamp the bleeding points and ligate.
3. Subcutaneous fat stitched to provide less tension for the skin.
4. Skin stitched.
5. Body wrapped. E-collar.

POST-OP CARE
The cat was very weak and slept. I checked her tongue at the end of surgery. It was bright pink as she had been given glucose IV. Glucose by IV drip is necessary for such cases to have a chance of survival under general anaesthetic. Continue IV drip of dextrose saline and Hartmann's solution over the next 24 hours.
Will the cat survive? It is hard to say. Goto: www.toapayohvets.com for updates.

TIPS FOR OLD OWNERS
This is a case where a spayed cat still gets breast tumours. Spaying reduces the incidence and most spayed cats and dogs don't get breast tumours.
It is a matter of probability rather than a guarantee that spaying will prevent mammary tumours in old age.

It is best to get breast tumours in cats and dogs removed by your vet when they are much smaller. It will be less costly. I can give a high discount for some cases with financial distress. I can't do it for every case as it is costly for the surgery and post-operation complications and nursing for the next 7-14 days. Big tumours of the mammary glands get ulcerated and infected. The cat would then stop eating and die a painful death.

45. Breast tumours in old dogs in Singapore

2010-02-11T13:28:00.000-08:00

"Can spay be done together with the removal of sternal abscess?" the young man who brought in his old dog to the surgery as scheduled, on this bright Sunday May 18, 2008 morning asked.

"Sternal abscess" --- actually mastitis, now reduced after 2 weeks of antibiotics

"Yes, it can be done" I explained. "It is not good for the old dog as the anaesthetic time will be longer. The chances of the old dog dying on the operating table increases as the anaesthesia is prolonged. The spay itself takes around one hour."
"I thought it takes 30 minutes to spay a dog?" the young man must have done his home work and research.

"Yes, in some cases" I said but did not elaborate that his dog was a bit on the fat side and spay surgery would take longer. "The actual surgery can be as fast as 30 minutes from skin incision to last stitch of the skin if the vet can hook up the uterine horn at the first try.

"However, if you include the pre-operation shaving, scrubbing and anaesthetic gas given to get the dog to sleep, the whole spay takes more than 1 hour. In removing the sternal abscess, I need to pull skin from nearby areas, so it is not a simple stitching of just the wound left from removing the sternal abscess. This takes a lot of time, around 30 minutes or more. "

He nodded his head. Do one surgery at a time to avoid anaesthetic complications. Spay today. Then 2 weeks later, remove the mammary tumour and sternal abscess.

So, I started to time this spay surgery commenced at 10 am. The patient was not slim and had difficulty breathing, being a flat-faced Shih Tzu.

Procedure:
The dog was clipped at the preparation room. Then she was brought to operating room and given 8% gas to knock her down using a face mask. She struggled for 2 minutes and was asleep. This took around 15 minutes. She was then intubated with a breathing tube to connect her lungs to the gas machine, using a maintenance dose 2% gas until the last 3 stitches when the gas was reduced to 0%. Dog woke up within 2 minutes at end of anaesthesia. The four legs were stretched out tautly as I find this method enabled me to hook up the uterine horn much easier.

Gas anaesthesia is best and safe for old dogs. Do intubate all the time although gas mask can be used

The vet must check the anaesthetic settings systematically to ensure a smooth anaesthetic process

Surgery:
Incision to last stitch was 40 minutes actually.
I incised 1 cm from the umbilicus, making a 1-cm cut. The linea alba was identified after snipping off some subcutaneous fat. There was some bleeding but this was not serious.

I inserted the spay hook to fish out the left uterine horn. I slanted the hook 45 degrees from the horizon, put it into the abdomen to the right and downwards in the direction of the bladder. The hook skimmed over the surface the liver lobes.

Then I rotated the hook 90 degrees and pulled it out of the skin incision, hopefully with the left uterine horn. In slim female dogs, this was not a problem. But in this dog, I tried 8 times. Omental fat kept appearing in the hook. This was not good as the minutes passed quickly. In such cases, I switch to hooking the right uterine horn. One loop of pink intestine kept coming out in the hook. What to do? Persevered.

If the dog was slim, it would normally be easy for me to hook the left uterine horn with the left ovary after 1 or 2 tries. Fortunately, I caught the right uterine horn on the 3rd try. What a relief you would imagine.

But there was so much fat surrounding the right ovary. I could not fish it out with the right uterine horn. "Release the string's tension on front legs," I asked my assistant to loosen the strings."

Still, the ovary could not be hooked out. I knew I had to extend the skin and linea alba incision 0.5 cm cranially. This bigger incision was sufficient. I pulled out the right fat- enclosed ovary. I felt for the taut ovarian ligament with my left forefinger. A very tight ligament. The dog moved as the ovarian ligament was pulled.

"Increase gas to 5% for 30 seconds and then go back to 2%," I said to the assistant. This happened when the dog was just slightly under surgical anaesthesia and had not felt any pain till the ovarian ligament was pulled. Previously I used to pull this the ligament broke from its attachment. Nowadays, I used the scalpel to break it and continued ligating the ovarian stump.

I ligate the stump 2 times after placing 3 artery forceps clamps on the ovarian tissues cranial to the ovary. Now, the ovary could not be seen as it was enveloped inside a thick clump of fat. I had to estimate its position.

After ligation and incision of the ovarian fat, I lifted up the right uterine horn. The assistant had loosened the tension of the front legs. In some cases, I asked the assistant to put his hands under the shoulders and elevated the dog so that I could access the uterine horn easier. In this case, on pulling the right uterine horn, I could see the uterine body and the left uterine horn arising from there.

The same process of getting the ovarian ligament was repeated. Then the uterine body was clamped using the 3-forcep technique as for the ovarian tissue. 2 ligations were used.

3/0 absorbable sutures did not feel strong enough compared to 2/0 but was used in this dog. I closed the muscle layer with 3 simple interrupted sutures placed a good 5 mm away from the muscle edge. If you place it too close, the suture might break down and you would get a hernia.

Reduce gas to 0% before after closing the muscle layer. Dog wakes up as the last skin stitch is placed
It would be best not to use continuous sutures to close the muscle layer unless you are very confident of your suture placement. Otherwise one too close to the muscle edge stitch may burst open. The whole stitching breaks down and there would be a lump. Also, I do not use continuous subcutaneous suture as advised in some veterinary surgery books. They cause more irritation and may break down. I used 2 horizontal mattress sutures to close up the skin incision. One packet of suture was fully used in this case. In bigger sized dogs, 2 packets may be needed. Around 2 cotton swabs would be used as there was little bleeding.

12-year-old Shih Tzu 7.7 kg, 38.4 deg before spay. Large mammary tumours (X). First skin incision to last skin stitch took 40 minutes in this case as the first time hooking did not fish out the uterine horn.
Carprofen a non-steroidal anti-inflammatory injection 0.5 ml was given to prevent pain and swelling. Antibiotics given. The dog went home in the evening after sufficient rest at the surgery. Do not send the dog home immediately even if the owner wanted to do so as the dog needed time to be stable after anaesthesia.

NEXT STAGE
Spay was advised first to remove the female hormone production by the ovaries. Once deprived of the hormones, it was hoped that the breast tumours would not grow so aggressively. 2 weeks later, the breast tumour and the sternal abscess would be removed, hopefully without any anaesthetic complications and death.

CONCLUSION
Can this dog survive the anaesthesia the second time? Nobody can guarantee survival under general anaesthesia. In any case, never attempt to spay and remove breast tumours in one surgery as the vet prolongs anaesthesia time. Every second that the dog is under anaesthesia, his or her heart may fail. So, it is best to do one surgery at a time to minimise the risk.

UPDATE AS AT FEB 11, 2010
The owner did not return to Toa Payoh Vets for surgery nor follow up. Spaying the dog when she was young would be ideal as breast tumours seldom occur in spayed female dogs. This is not to say that spayed female dogs don't get breast tumours but the probability of them getting such tumours are much lower.

44. Medial entropion surgery in the Shih Tzu

2010-02-06T16:12:00.000-08:00

Saturday Feb 6, 2010 was my day off. However, a person wanted a meeting. So, I was flexible and took the time to meet the 3 young vets and had an interesting discussion with them and at the same time educate myself regarding the veterinary industry and trends.

One of the problems of young vets is the prospective clients' remark: "You look so young...can you perform the surgery (e.g.repair the bite wounds)?"

Well, this is a common remark and applies even to medical surgeons. Last year, I was at the Singapore General Hospital for an operation to be done by Dr Foo Chee Liam, an experienced surgeon in his late 50s and an old friend. All prospective patients will be comforted by the appearance of his grey hairs. They testify to his abundant surgical experience over the years.

His assistant, a young surgeon known as "The Registrar" attended to me in the administrative matters. I asked her how's her posting as we walked to another section to make the booking and she said to me: "Singaporeans look at me and query whether I am capable of doing their operation." I was not surprised at her comments as Singaporeans say the same thing to newly minted veterinary surgeons too.

How should one reply to such queries? It will be difficult unless one is a show man and produce testimonials. The business of surgery is serious and is not a theatre. I guess, the young ones who don't have senior vets in the practice have to take such remarks in their stride and assure the prospective client that his dog is in good hands. "Such remarks are made about the young vets in established vet practices in Singapore," I told the 3 young vets. "All vets will have to go through such challenging remarks."

Other than real people in this real world, is there another invisible world supervising us? I ask this question because I had this 10-year-old Shih Tzu with corneal ulcers, acute conjunctivitis and pus in his left eye. A 1-year-old Shih Tzu had come in 3 days ago for medial entropion surgery. This 10-year-old Shih Tzu was my answer to "what happens if there was no medial entropion surgery done for the Shih Tzu?" Where can I get a recent photograph to illustrate my medial entropion surgery?

Well, you can call it a coincidence. I have had 3 Shih Tzus recently. But the 10-year-old Shih Tzu was presented with corneal ulcerations and black eye bags due to many years of irritation from excessive tear production and rubbing of the eyes. All these could be avoided if the owner had got a medial canthoplasty and nasal fold excision. "I don't know there is such a surgery," the lady owner told me. It is a surgery seldom mentioned by vets in any case.

The following pictures explain the surgery. Goto www.toapayohvets.com for the pictures.

http://www.bekindtopets.com/dogs/20100153Medial_Entropion_Shih_Tzu_ToaPayohVets.htm

43. Blood in the urine of an older male dog

2010-02-04T14:47:00.000-08:00

"Around 8 months ago, Vet 1 checked the bladder with his hand and said that he could feel no urinary stones," the young man said to me. "So he prescribed medication. My dog stopped passing blood in the urine for 2 months only."

"Why didn't Vet 1 X-ray the dog?" I asked. The young man who wanted to be a Food and Beverage entrepreneur said, "Vet 1 felt the bladder and since there was no stones, there was no need to X-ray the bladder. He even refer me to Vet 2 who had better X-ray and equipment." Vet 1's X-rays did give erratic quality and that might be why he did not take the X-ray. Most likely, to remain price-competitive with Vet 2, he would rather not increase his fees due to X-ray charges.

This amenable young man was a good conversationalist. He joked with me, pointing to his tummy and saying: "I enjoy eating food as you can see." Yes, I could see he looked very much like a successful chef with the proportions and size to prove he loves good food.

The owner then sought a second opinion from Vet 2.
"Vet 2 did an ultrasound scan and said there were no urinary stones. I got the medication and the dog stopped passing blood in the urine for 2 months. So, I asked Vet 2 to do an X-ray and there were urinary stones."

"why didn't you ask Vet 2 perform the operation?" I guessed the vet fees would be it more expensive as it was a much bigger set up with vets. Price has always been important in this period of recession and job losses.

But the young man said: "Two of my dogs died at Vet 2. One of them was old. The other one died on the operating table. So, I do not want my dog to be operated there."

This survey showed that this dog owner does not forgive or forget the death of his dog on the operating table. All vets will get pet deaths on the operating table as not all surgical cases are in excellent health.

Urinary sand and stones in the bladder and penile urethra. Actual stones are placed on top of the X-ray for comparison
Abundant fine urinary sand is found in the bladder during surgery. The sand can be seen on X-ray but it is not so clear

Day 2 after removal of urinary stones
Well-formed sharp urinary stones inside the penile urethra
I did this survey to help me understand the owner's point of view as many owners do hop between vets. Dogs are family members and a large number of dog owners in Singapore and all over the world is very worried about deaths during anaesthesia. This survey shows that the owner never really forgives such episodes.

Fortunately, the old dog operated by my Associate Dr Jason Teo was much alive during and after the surgery. Otherwise it would be another black list in this young man's book of vets to avoid.

VETERINARY TIP
In retrospect, during the surgery in Feb 2010, this old dog had abundant amount of urinary sand inside the bladder. This urinary calculi was obvious in the excellent X-ray taken by Vet 2 but the contrast using air inside the bladder could not be made due to large obstruction by stones in the penile urethra. Bladder palpation will not reveal the presence of urinary sand.

More info about this case is at:
Urinary stones. Which surgical approach?

I did this survey to help me understand the owner's point of view which is so much different from the vet's point of view. Dogs are family members and a large number of dog owners in Singapore and all over the world is very worried about deaths during anaesthesia

42. Urinary stone removal - Urethrostomy or Cystostomy?

2010-01-31T15:13:00.000-08:00

URETHOSTOMY METHOD
The surgical approach depends on the vet.
I remember a Chihuahua owner from Toa Payoh some years ago. He preferred an older vet to handle his Chihuahua's urinary stone obstruction behind the os penis after getting a diagnosis from me. Such situations happen to all vets and so I was not offended. The older vet did a urethrostomy behind the os penis. Problem solved. However, the owner did not like the post-operation complications, saying that the dog "leaked urine" all over the apartment after the surgery.

I don't know whether this male dog was urine-marking or not as I did not make further queries. He wanted euthanasia. Vets do urethrosomy if the bladder has no stones. But should the dog continues urine-marking, the urine just "leaks" everywhere.

If there are no stones inside the bladder, most vets will use the urethrostomy method. It is logical. However, in the above case, it had an unhappy ending as the owner got the dog euthanased for dirtying the apartment. Would a cystostomy approach as done below save this Chihuahua's life?

CYSTOSTOMY METHOD
Yorkshire Terrier, Male, 9 years. 3.6 kg 39.4C
Urethral obstruction.
X-rays showed urinary stones in the bladder and behind the os penis.
What is the surgical approach?

30.1.2010
Domitor 0.3ml IV
Isoflurane gas
Antisedan 0.3 ml IM at the end of surgery

IV glucose 200 ml pre-surgery
Hartman Solution IV 2 days post op
Baytril 0.3 ml and Rimadyl 0.2 ml SC

31.1.2010. Ate l can A/D diet. T=38.7 deg C
To flush bladder again. Lots of bleeding and debri

SURGERY on 30.1.2010
Cystotomy only. Used catheter via bladder and via penile urethra to dislodge all stones via flushing many times. No need urethostomy in many cases although on first impression, a urethostomy behind the os penis would seem logical.
Catherised 3 days. Warded.

Roboroskvi's black lump - strangulated testicle?

2010-01-25T13:37:00.000-08:00

This dwarf hamster bit me and Alice, a 4th-year vet student seeing practice at Toa Payoh Vets in Jan 2010. The Roboroskvi did not mind being handled but got fed up of being handled to be examined so many times. He bit my finger as I checked on him post-operation. Sharp incisor teeth. There was no blood at first. Suddenly the dam burst and I had to wash the blood off my finger. I asked Alice if she had been bitten. She said "Yes".

This high-speed Roboroskvi was 9 months old. His lady owner brought him in for a consultation as she saw this blackish lump in the lower groin area on the right side. A rather big black lump of 8mm x 4mm appeared on the right inguinal area. What was it? Was it a gangrenous testicle? How did it appear? What to do now?

There was no on the other side. Surgery to remove the lump was the only option.

Zoletil 50 given IM. Growth removed. Skin wound of 6 cm long was stitched with 5/0 absorbable sutures. Hamster was OK and I sent him home to a happy lady owner. I did not send the lump for histopathology as that meant the owner had to pay more. There was considerable bleeding on excision of the growth. Unlike dogs, it would be difficult to clamp below the growth in this hamster. Fine ophthalmic forceps could be used to clamp but there was little space. In any case, this hamster survived.
For hamsters with growths, there is no justification to give antibiotics and hope they will disappear. The vet has to use his or her good judgment as regards ethics and the economics of the practice. Vets must be careful as there may be negligence litigation/complaints if the hamster with an obvious growing tumour is treated with just drugs, powder and some homeopathic/herbal medication.

If the vet does not want to do hamster surgery, it is best to ask the owner to go elsewhere rather than just prescribing some drugs. In this case, a strangulated testicle or gangrenous lump may rot, become infected or ulcerated and kill the hamster after some weeks.

P.S. Examine speedy dwarf hamsters like the Roboroskvi above a big bowl so that the hamster will drop onto the bowl if they escape your grasp. On the examination table, they may sprint away before the vet assistant or nurse could react and fall off the table!

Update and more pictures at: www.toapayohvets.com

40. Electro-surgery in a dwarf hamster

2010-01-15T11:43:00.000-08:00

E-MAIL TO DR SING
Jan 8, 2010

Subject: For Doctor Sing (Enquiries on Dwarf Hamster - Ear Irritation)
To: judy@toapayohvets.com
Date: Friday, January 8, 2010, 2:58 PM

Dear Doctor Sing,

Happy New Year to you & I hope this email finds you well...

I would like to seek your advice on one of my dwarf hamster. She's currently 1.5yrs old and had been in good health all these while.. Just 2 days ago, i notice that she is excessively scratching her right ear & it became obvious that the outer ear area turns red and slightly sore...

Few months back my other male dwarf hamster (Name) had ear infection as the bathing sand and bedding went into his ear, he recovered after treated by you in Oct 2009. I've since then stopped all bathing sand and switched to towel as bedding for all my hamster. I rule out the possibility of mites or mange as their cage are kept clean and i change their towel twice a day.

I wonder if it helps if i were to purchase from your clinic the same medicines (pink & white colour to stop itchness and prevent inflammation if i remembered correctly) to treat this hamster.

I've enclosed pictures of my hamster and I hope the above information is useful.

Looking forward to hearing from you soon.

Thank you so much & wishing you a good weekend ahead :D

Best regards,

Name of Lady Owner

E-MAIL REPLY FROM DR SING was given to the owner. "It is best to examine the hamster as e-mail pictures are not clear. The owner brought the hamster in for consultation and accepted my advice to get the tumour/swelling on the side of the ear removed. It may become infected or grow larger."

E-MAIL REPLY FROM DR SING
Jan 10, 2010
Subject: Re: For Doctor Sing (Enquiries on Dwarf Hamster - Ear Irritation)

Thanks for pictures of the previous hamster I treated. As I don't read email regularly, pl tel me if you need any answers. In any case, your hamster is OK (after electro-surgery). It has the same inflammation of the ear canal as the previous one. Liquid and black particles inside the ear canal were exposed during surgery to remove the lump outside the ear canal. I thought you had used some ear lotion or normal saline.

E-MAIL TO DR SING
Jan 15, 2010
...@hotmail.com> wrote:
Subject: RE: For Doctor Sing (Enquiries on Dwarf Hamster - Ear Irritation)
To: drsing_98@yahoo.com
Date: Friday, January 15, 2010, 3:06 PM

Hi Doctor Sing,

It's been 5 days since i brought my hamster back and have fed her with the required medication on a daily basis. She's eating & exercising normally and looking at her ear, the little wound has dried up but she's rather sensitive whenever i tried to clean or remove the layer of dried skin which is in dark red or black color.

Just to check if i can leave it alone, will the dried layer automatically drop off by itself or will there be a likelihood that she may accidentally push it further into her ear?

Thank you.

Regards,

Name of Lady Owner

E-MAIL REPLY FROM DR SING
Jan 16, 2010

I just returned from overseas. The blood clot is the wound left over when the tumour/swelling in the lateral canal of the ear was removed. It will dry up later and replaced by new skin. Remove it slowly. Remove bit by bit with the smallest cotton bud (dipped in warm water). It is hard to say whether the clot will cause a problem, but I don't think it will.

UPDATED INFO AT www.toapayohvets.com, goto HAMSTERS

39. Pyometra in aged female dogs cause pain to the sister

2009-12-20T17:01:00.000-08:00

Pet Shop Visit in December 2009
Three years had passed by. I seldom kept in contact with this pet shop girl till recently as I don't go to the shop to do puppy vaccinations. However, I visited to ask her to re-pack some Hill's Prescription d/d dog food for me as many owners want small packets.

Another aged female Cocker Spaniel of around 12 years old, belonging to her sister had open pyometra some months ago. The sister had put the dog on antibiotics for some time. "It is best to spay her," I advised. But the sister just would not want to. I don't know why.

Finally, the dog was operated by another vet and survived. "But I have to provide my dog (Golden Retriever) for blood donation as the platelet count was very low," the pet shop girl said when I visited her pet shop. That was good news. But there was a high cost involved.

Spaying the female dog early would have prevented pyometra in these two cases which were not handled by me or my Surgery. As an alternative, inspect your female dog monthly. Record her dates when she has her heat. Observe the colour and nature of the blood spots. If the blood looks brownish or yellowish and starchy, it is time to get her spayed. Unfortunately, in closed pyometra, there are no discharge. Just vomiting. Or loss of appetite and lethargy.

It seemed a repeat of history during this visit. There was the pyometra of her sister's dog. There was also a slim teenaged girl working as a part-timer busy cleaning up the kennels at 11 am when I visited. However, this short girl was not thin She was OK and could be considered "handsome". But she had a ring in between her nostrils. Her unique selling proposition.

She reminded me of the bulls I saw practice as a 4th year vet student some 30 years ago in Scotland in 1973. Such bulls have a ring between their nostrils if my long-term memory is still intact. Why would such a young teenaged girl with normal good looks put ring her nose I just cannot understand. She hung with her friends past midnight at the Junction 8 shopping mall in Bishan and was working part-time to earn some money.

"Do you want to employ her as a part-timer," the pet shop girl asked me. "She can try out for one day without payment first."

"I need a girl who knows how to write reports and use the Excel and Microsoft Word," I told the pet shop girl. It is difficult to find such part-timers. I can't employ any nose-ringed girl or boy as part-timers no matter how hard working they are. Buttons embedded in the girl's tongue. Well, I don't know how such girls do it. It must be very painful. However times have changed for some young adults.

As for pyometra in aged female dogs, things have not changed much in the treatment or cure. Prognosis is poor when the owner delays veterinary treatment and when there is vomiting. Spaying would not be of much help once the female dog has persistent vomiting for several weeks as the kidneys had been damaged. Some 10 years ago, I had an uneducated owner bad-mouthing me for not curing the dog after the spay of her persistently vomiting dog. The dog survived the spay but continued vomiting due to kidney disease, not to professional incompetence of spaying! The lady owner did not want any blood test but the cheapest veterinary cost. Sometimes it is best not to handle such personalities who want "cheap and good" veterinary services if the vet cares about the reputation built up over the years. They tend to bad-mouth the vet in the Singapore internet forum nowadays and this webpage will persist forever for people all over the world to see.

For aged female dogs with pyometra, family members may get is the pain or in this case, the younger sister felt the pain of the suffering of the aged female dog.

For those who believe in prevention of pyometra, spay your female dog early, 3 months after the first heat.

38. Stump pyometra

2009-12-20T15:32:00.001-08:00

Dec 12, 2009
I searched www.google.com.sg for "pyometra+singapore+dogs" and my reports on pyometra listings (except for no.6) are as follows:

1. http://veterinarymedicinesingapore.blogspot.com/2008/06/3-pyometra-in-old-female-dogs-to-spay.html
2. http://veterinarymedicinesingapore.blogspot.com/2008/06/toxaemic-12-year-old-golden-retriever.html
3. http://www.bekindtopets.com/dogs/20080738Closed_pyometra_Lhasa_Apso_ToaPayohVets.htm
4. http://www.asiahomes.com/singapore-rent/1026Ads_Nassimwoods.htm
5. http://www.asiahomes.com/singaporetpvet/dogs/1220dangerousdogs.htm
6. http://answers.yahoo.com/question/index?qid=20091126232338AAqGi8u (stump pyometra). Not recorded by Dr Sing.
7. http://www.toapayohvets.com/surgery/20061024Pyometra_Toa_Payoh_vets.htm
8. http://www.bekindtopets.com/animals/tpvets_Jul1708.htm
9. http://www.toapayohvets.com/surgery/050609periodontal_disease_cat_dog.htm
10. http://www.sinpets.com/dogs/20090509Bones_Dogs_ToaPayohVets.htm
11. http://veterinarysurgerydrsing.blogspot.com/2009/06/21-mission-impossible-in-16-year-old.html
12. http://toilettrainingpuppy2.blogspot.com/2008/02/13-female-submissive-urination-dogs.html
13. http://www.angelfire.com/ks/singaporecondos/8251glamourousdanger.html
14. http://bekindtopets.blogspot.com/2007/09/48-is-spaying-necessary-e-mail-queries.html
15. http://veterinarysurgerydrsing.blogspot.com/2009/08/25-vaginal-prolapse-breast-tumours-in.html
16. http://www.sinpets.com/letters/tpvets_May705.htm
17. http://bekindtopetssingapore.blogspot.com/
I have seen only one case of stump pyometra in my 30 years of practice. Will edit later.

37. Declawing of cats in Singapore interview

2009-12-19T16:07:00.000-08:00

On Dec 18, 2009, I agreed to an interview by Ms Amanda Wong, Media Journalist from the Straits Times Razor TV, www.razortv.com.sg. Here are her questions:

1. How is declawing done?
2. What are the reasons for it?
3. Is it harmful to the animal?
4. Are there many people who request for declawing to be done to their cats? Who are these people? How many to date? Is there an increase?
5. What is your personal view towards it? Why do you choose to provide this service?
Answers:
1. Surgery under general anaesthesia - remove the 3rd toe bone (phalanx). An illustration was given. Now, there are video clips of a cat being declawed in the webpage. This is NOT from Toa Payoh Vets but it would appear to be since it was included in the webpage. It was taken from the internet. I told Ms Amanda Wong that I had not done any declawing surgery for the past 9 years and I would not the appropriate interviewee. According to "My Paper", 6/10 vets reported an increase in request for declawing. Certainly, I do not have any request for declawing in the last 9 years as regards my area of practice. However, this was not mentioned in the webpage!

2. Two reasons I would do declawing as a last resort and after asking the owners to wait 1-2 weeks to re-consider. These are damage to property and injury to family and other pets. These are the two of various reasons cats are euthanased or sent to the animal shelter where they may be put to sleep.

3. Besides anaesthetic risks, post-operation complications, there is the worry from cat lovers that the cat will have behavioural problems like being more aggressive. However, there are owners who say that the cat becomes more gentle. The big worry is that the cat can't defend itself when attacked. This is unlikely in an indoor cat.

4. Nobody has requested for cat declawing in the pat 9 years in my practice. I can only remember one case where I advised buying a scratching post and clipping the cat nails regularly and the owner did not continue further. In fact, there is a trend for younger owners not to declaw as they are more knowledgeable. This answer did not appear in the webpage of www.razortv.com.sg

5. My personal view is that I will perform the surgery only when the cat-owner relationship is strained such that the cat will be sent to the animal shelter where it will be put to sleep or the cat owner will need to get the cat put to sleep.

Failure in training e.g. use of a solid scratching post, anti-clawing spray, nail caps, food treats for positive reinforcement training, balloons, noises, water guns, noisy paper wrapping over furniture and weekly nail clipping during the 1-2 week cooling off period.

If the owner still can't resolve the problem, declawing is preferred to euthanasia. Many young children feel distressed when the cat is euthanased due to parents having to do it if they don't have declawing as an option. In such instances, I will perform the surgery.

I had told Amanda Wong, I do not have any declawing surgeries in the last 9 years. I don't know whether she believed me.

Training needs time.
Get a strong scratching post for the new kitten. Train it to use the scratching post or give it an unwanted piece of carpet to declaw. Firm verbal commands when the kitten starts clawing furniture and give treats on success? Clip nails weekly for older cats.
"You have got the wrong vet to interview. You need to interview a vet who performs such surgeries recently," I said to her. She said she was interviewing other vets. She asked me whether declawing was a recent American concept. I said declawing had been practised for some 40 years or more but nowadays the younger generation in Singapore does not favour declawing as it is cruel. I was surprised that she said that there was an increase in demand for cat declawing. She asked why I did not have any cases since a newspaper dated Dec 14, 2009 said that 6/10 vets interviewed reported an increase in demand. "Maybe it is the type of cat owners in Toa Payoh and the surrounding neighbourhood," I said. "My clients do not buy expensive cats or I don't get their consultation. Or I don't have many feline cases. I don't know."

This is one of the subjects that vets don't want to be interviewed if they perform declawing as the animal rights activists will put them in the "declawing hall of shame" and there is one such website. It would not be good for business.

However, many cat owners need to be educated that regular nail clipping and the provision of a strong scratching post or training the cat to use the scratching post is the possible solution to destructive damage of expensive sofas, cupboards and curtains or scratching injuries to children and pets. I don't do declawing on demand.
I risk this interview of getting into "the declawing hall of shame" to bring out the issues in the open and to educate the younger Singapore cat owners as to the alternatives to declawing. Animal rights activists must understand that cats are family members and if the cats have to be put to sleep or sent to the animal shelter to be put to sleep and there is only one alternative to the lethal injection for the family to retain the cat, declawing may be needed.

P.S. The interview webpage is at:
http://www.razortv.com.sg/site/servlet/segment/main/news/41168.html

36. Anaesthesia - Giant Rabbit & 3-month-old German Shepherd puppy

2009-12-11T15:42:00.000-08:00

Dec 11, 2009

I type the following 2 interesting cases I had while I visited the National Library at Victoria St at 5 pm while the details are fresh in my mind.

Sharing knowledge of anaesthesia for Giant Rabbits.
1. Usually, Singapore pet owners keep small rabbits of around 2-3 kg.
Giant Fleming Rabbit, 5.2kg
Extremely hyperexcitable. This type of temperament is a high anaesthetic risk

METHOD 1. One method is to use injectable anaesthesia of zoletil IM, 5 minutes later, give domitor IV via the ear vein.
However, this method seems to be unsuitable as restraint and injection causes the rabbit to move a lot.
Zoletil 50 0.2 ml IM
Waited 15 minutes
Wanted to give Domitor 0.2 ml IV, ear vein.
Still struggling. Abandoned this method in favour of Method 2.

METHOD 2
Zoletil 50 0.2 ml IM given. In around 7 minutes, the rabbit staggers and by the 15th minute, the rabbit was recumbent. However it exhibited excitation when the ear vein was pricked and moved away. So, I used isoflurane 5% gas by mask.
Isoflurane gas - mask - maintenance at 0.5% - 1% was excellent.

METHOD 3
Xylazine IM, Ketamine IM is another method I used for smaller rabbits.

CONCLUSION:
The interesting thing about this case is that my staff under-quoted the cost of neutering as we usually neuter the non-giant rabbits at $75.00/neuter! Life is full of surprises even after graduating 40 years ago!

Sharing knowledge of anaesthesia for 3-month-old German Shepherd puppy.

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 occupied the 100% of the stomach (seen during surgery) and would not be vomited out nor passed out with the stools. Surprisingly the puppy did not vomit at all.

No food and water after 10 pm yesterday.
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. Mucosa. Quite thick. Reddish brown. Inverting suture - one layer closing the mucosa only.
2. Muscle layer. As in a Caesarean section, I stitch 2 layers of inverting suture.
3. Abdominal muscles - simple interrupted sutures one cm apart.
4. Skin - horizontal mattress suture.
5. IV baytril given. Dextrose saline drip is continued. Electrolytes for next 2 days. No solid food to permit the stomach to heal.

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.

3rd year vet student from Murdoch Univ saw the surgery. His job was to take pictures. During an earlier discussion, 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?

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.

More info at www.toapayohvets.com

35. Questions about Spaying A Dog

2009-12-05T15:02:00.000-08:00

Thank you for your e-mail. Please see my reply in CAPITAL LETTERS below:

2009/12/5 <...@hotmail.com>

Hi Dr. Sing,

This is (Owner's Name). I have brought my toy poodle, XXX, to see you last month for her leg sprain, if you still remember. She has since recovered and is walking normally, thank you.

I would like to make an appointment for my dog to be spayed and have 2 of her puppy tooth to be removed at the same time (2 have since dropped on their own), since she has to be under general anaesthetic for these procedures respectively. My thought is that she need not go through general anaesthetic twice if done together.

She is currently coming to 9 months, weights around 4.3kg, has not have her first heat yet, and is not on heat at the moment. I hope to seek your advice on the following:

1. What is the main difference spaying her now at 9 months, before her first heat, compared to 3 months after the first heat? any major downside if I wish to spay her now?

SPAYING BEFORE HEAT AT 9 MONTHS OF AGE - The female dog is no longer a puppy. There is no problem in spaying if she is healthy. I recommend spaying 3 months after the first heat is to ensure that the surgery is much less bloody as the uterine, ovarian and omental blood vessels are not enlarged at this time. Therefore they are not so fragile when clamped and ligated. Most likely, your poodle may have her first heat with little vaginal bleeding, from 6-9 months, but you did not know.
You could observe a period of her cleaning her private parts for a week and that would be her first heat.

9 2. What are the things to observe with regards to food intake before her surgery?

NO FOOD AND WATER AFTER 10 PM the night before the surgery.

3. How long is the procedure and how soon can I pick her up from the clinic after the surgery?
ANAESTHESIA AND SURGERY TAKE AROUND 30 MINUTES normally.You can pick her up in the evening around 7-10pm during weekdays.

4. After surgery, any medications or special diet required? ANTIBIOTICS AND PAIN-KILLERS ARE GIVEN. NO SPECIAL DIET normally. Do i need to cage her to restrict or minimise her movement? RESTRICTION OF JUMPING FOR FIRST 7 DAYS WILL BE IDEAL.

5. How big/long is the incision usually? AROUND 2.5 CM USUALLY IF THERE ARE NO COMPLICATIONS.

6. What is the cost for spaying and removal of 2 puppy teeth? COST FOR SPAY IS ESTIMATED AT $200 excluding medication. PUPPY TEETH REMOVAL + ANAESTHESIA estimated to be around $100.

Thank you for your time, Dr Sing.

Pictures are not that of the dog mentioned in the e-mail.

34. Infected facial tumour. Dwarf Hamster

2009-11-29T13:39:00.000-08:00

HAMSTER SURGERY
Dwarf Hamster, 1 year. Young lady
Dehydrated, Not eating
Facial swelling 2-3 weeks growing fast. Rounded, 1cm X 0.8 cm.
Abscess?

Zoletil 50 IM. Duration 5 minutes. Need to be prompt in surgery. But large tumour is not easy to remove in <60 seconds. Therefore I needed to use isoflurane gas to maintain the anaesthesia.

Tip:
Give isoflurane gas when it moves. If you continue without anaesthesia, the hamster will struggle and die of fright and pain.

1 cm incision. Watery pus drained. Multiple rounded fat-like cells of 1 mm globules widespread. Can't remove all without affecting nerves. Owner informed.
Hamster OK. Picture.
Advice: Removal will have been easy and effective when it is around 2-4 mm in diameter some 2 months ago.

Goes home on Day 3. It is likely that the tumour will recur as it is widespread inside the cheek.

33. Large infected skin tumour in an old dwarf hamster

2009-11-16T15:36:00.000-08:00

In the dog or cat, this would be an easy surgery as general anaesthesia using isoflurane gas is very safe and predictable in these two species.

In a 2-year-old dwarf hamster, the successful outcome depends greatly on the anaesthesia. Insufficient anaesthesia may kill the hamster due to great pain and fright from surgery. Lots of movement hampered surgery. Death could be due to fright during restraint and not due to anaesthesia.

Pre-operation
In the dog and cat, pre-operation examination and blood tests are helpful. In the dwarf hamster, ask the owner about the amount of stools passed and water drank. In this case, the lady owner was very observant. The hamster was eating as faecal pellets could be seen. She noted that the hamster recently drank at least 3x more water than normal in a week by judging the amount of water in the water bottle drank per week. Based on her observation, the hamster was drinking 18 ml/day compared to the normal 5 ml/day. This polydispsia is abnormal.

Warded for 2 days
Oral Baytril antibiotic was given on Day 1 and 2. Surgery started on Day 3 as the hamster was suffering from a red itchy infected skin tumour.

Anaesthesia and Surgery
It is extremely difficult to see the signs of surgical anaesthesia in the hamster under isoflurane gas (gas into a plastic container with the hamster inside) and Zoletil sedation. A bit more will mean death. So, it is a matter of observation of anaesthesia to effect. What does that mean when the vet can't check the pedal and eyelid and other reflexes as in the dog? It is just not possible. "Count to 10" I advised my assistant when the hamster has been placed in the container. This is not scientific. We took the hamster out for surgery. When it moves, we put it in again. This happened 3 times. By the 3rd time, the hamster looked "dead".

"The hamster has died," I tried to revive it by rubbing the skin of its neck above the shoulder area. "Can give Biolapis," my assistant proposed. I was busy trying to revive this hamster. Blow air via a 3-ml syringe into its nose area may be useful.
Cardiac massage?

In this case, my assistant put a drop of Biolapis which is an oral electrolyte for small animals like rabbits and hamster. An oral respiratory stimulant and oxygen would be useful.

The hamster was still breathing as I could see its chest movements. I left it alone, under the warmth of light.

In around 30 minutes, it was up and alert. As if it had a good lunch-time nap. The Caucasian school teacher was very happy as she was prepared for the worst. Always examine your older hamster daily for small tumours. Small tumours less than 3 mm in diameter take less than 1 minute to remove and the chances of survival are very high.

Not all stories have happy endings as vets are not Gods.

P.S.
More pictures and update at www.toapayohvets.com, goto "Hamsters"

32. Retained puppy teeth in a Yorkshire Terrier

2009-11-12T15:24:00.000-08:00

Yorkshire Terrier, Male, 8 months.

Most dogs have no more deciduous (temporary, puppy) teeth by 8 months of age. Yet in this rare case, this tea-cup Yorkshire Terrier had 14 puppy teeth that should have dropped off.

The permanent teeth erupts in an abnormal position as their place is occupied by the puppy teeth. He resisted strongly when I tried to open his mouth as he had a very painful mouth. If only he could talk. Tartar had formed in the retained canine teeth and soon, there will be tooth decay.

Many Singapore owners don't bother with such dental problems due to economic and anaesthetic risk reasons. What if the puppy dies under general anaesthesia?

This mindset is unfortunate for the puppy. General anaesthesia is safe in puppies over 3 months old. Much depends on the selection and experience of the veterinarian. Worried owners have to look for more experienced vets if they are worried about anaesthetic risks.

Timely removal of the retained deciduous teeth enable the permanent teeth to erupt in normal position and angle. In older dogs, food and dog hair get trapped between the permanent and retained teeth, leading to tartar formation. Bad breath. Painful mouth. But the uneducated owner just ignore such dental problems. Teeth start dropping off. So what? The dog gets his food and water. What more can a dog want?

The introduction of the internet has benefitted many puppies through education of the newer and younger owners. Compared to 10 years ago, more lady owners and young couples are aware of the future dental problems in retained puppy teeth and have got them extracted.

After checking that his heart is OK, I used general anaesthesia isoflurane gas prior to extraction of the puppy teeth. Intubation was done. Still it took >30 minutes to extract 14 teeth. After extraction, I note that it was not such a difficult struggle to open this Yorkshire's mouth for photography.

I am happy for this Yorkshire Terrier as he will be able to chew and bite without oral pain anymore. Tooth brushing ought to be done and should be easier nowadays.

His market value is S$2,500 as Yorkshires are very rare in Singapore. It sure was an expensive present given to this young lady owner.

TO REDUCE ANAESTHETIC RISKS
1. I don't use tranquilisers. Just isoflurane gas mask to induce.
2. Intubate
3. An assistant who just monitor anaesthesia and nothing else.
4. Minimal gas at 1% to effect.
5. Extraction of teeth as fast as possible.

A pre-anaesthetic blood test will be good but most owners are interested in least cost. Checking of overall health and heart will be the cheaper alternative but it is not ideal.

31. Electro-surgery in 3-day-old pups

2009-11-11T15:29:00.000-08:00

The home-alone first-time-mother Shih Tzu bit off the ear lobes of her 3-day-old pups. "She must have scratched off the ears," the male owner would not believe that mothers would bite progeny. "The male dog may be responsible." The pups had full rounded abdomen showing that they had suckled well.

I showed him one puncture wound of 3 mm above the ear of one pup and one wound on the chin of the second pup. These wounds would heal.

Surgery: Stitching.
Four tattered ears in 2 pups. What should the vet do? The first thought would be to suture the skin and cover the ear cartilage. However the bite wounds were irregular in shape with more skin torn off in some parts of the ears and there would be insufficient skin to stitch up.

Cosmetic Surgery:
This was my first time in over 3 decades of practice to encounter two 3-day-old pups being presented with bitten ears and were still alive. In most cases, the dam just killed the pups by biting their skulls, neck and abdomen.

Lacerated ear wounds are usually treated by stitching. So, my assistant took out a rabbit anaesthestic mask to give isoflurane gas anaesthesia to the puppy after washing the ear area for surgery. He got out a small hair clipper which we use to clip the coat of hamsters.

"Puppy anaesthesia is high risk," I said. "The rabbit mask is not suitable for flat-nosed 3-day-old puppy. Use the plastic container. Some vets use plastic bags to contain the gas.

Electro-surgery
Stitching the torn ears would not present a good appearance for these Shih Tzus when they grow older. Buyers will notice that two ears of the pups are not symmetrical in shape and size. Therefore I decided on the use of electro-surgery. But can electro-surgery be performed in such a young pups? Would they die of heart failure due to the passage of electricity into their bodies? If you know the theory of electro-surgery, this does not happen as the electricity passes through the surgical area and incise and coagulate. But theory may not translate into practice. I could just incise the ears using scalpel. But the results would not be so good. Therefore I commenced electro-surgery.

Electro-surgery in 3-day-old Shih Tzus.
After cleaning the ears and after light gas anaesthesia, I placed the puppy's belly onto the saline-damped gauze which was placed on the indifferent electrode. This electrode was placed onto of a plastic tray which was then placed on the stainless steel operating table. Stainless steel does conduct electricity*

I used the artery forceps to clamp the remaining part of the ear, exposing the jagged ends. Electro-incision electrode cut off the tattered ends. Then electro-coagulation electrode sealed all bleeding. The results were 2 "ear-less" pups. When they grow up, their lack of ear pinnae is obvious but will not be distracting as one ear bigger and more irregular than another.

The dam was isolated. She was watched while she suckled her pups after 24 hours of my assistant hand-feeding the pups. The pups are then removed from her. Today is Day 5. The pups are OK and have had reduced their earlier puppy fat.

Conclusion

*Stainless steel operating table conducted electricity. Therefore do not place your elbows onto the table. At one stage, I had an electric shock during electro-surgery as my elbow touched the operating table.

Electro-surgery is safe in 3-day-old Shih Tzu pups. The use of saline-moist gauze on top of the indifferent electrode helps to conduct electricity better.

More pictures and final report will be at www.toapayohvets.com

30. What is the cure for tail gland hyperplasia in the male Husky?

2009-10-22T17:05:00.001-07:00

Case: Male Siberian Husky, 9 years old.

History:
3 years ago, the Husky bit away all hairs of his backside and tail due to tail gland hyperplasia. The disease was controlled using steroids and antibiotics given by Vet 1. Then, the dog started biting his tail gland area again, as if possessed.

Is there a complete cure for the tail gland disease in dogs? Various treatments are proposed but the owner needs a complete cure. Here are my thoughts on this subject.

Surgery:
1. Tail Gland Skin area excised. Removal of the hyperplastic skin area. This is quite a large area of over 3 cm x 3 cm leaving a big hole and a very tight area to stitch up. If there is infection due to stitch breakdown, the result will be worse for the dog. Will electrosurgery do the job? Maybe, if the area is small and seen during the first time. There is no guarantee. In this dog, there seems to be another nearby area with the same problem.

2. Tail amputation. Will this method definitely resolves the problem of tail biting? Most likely since the tail gland area is removed. But the owner did not want a tail-less Husky.

3. Castration. Since this disease happens mostly in male dogs, testosterone hormone may play a part. The Husky is already 9 years old and his testicles were checked and found to be normal by palpation. No pain, nor enlargement or irregular lumps. The owner did not wish to have him neutered. I can't guarantee that neutering will resolve this problem too.

Now, in some skin disease cases in female dogs, spaying resolves the problem based on anecdotal evidence. In such cases, hormonal imbalances could be the cause of skin inflammation and itchiness. But not all cases are resolved and some skin disease occurs due to hormonal deficiency after sterilisation. Therefore sterilisation may or may not help.

This Husky was given a second intra-lesion steroid and we have to wait and see. Updated info will be at www.toapayohvets.com. Please accept my apologies. Not much time to update my blog.

28. Post-op irrigation of the bladder

2009-10-06T16:29:00.000-07:00

SHARING SOME POST-OP MANAGEMENT EXPERIENCES

Poodle, Male, 5 years

Swollen painful abdomen, peeing dark red urine. Bladder about to rupture. Vomiting brown yellow fluid. High surgical risk. No choice but to do emergency surgery as dog would die soon. Cystostomy opened up the bladder to get spiky stones attached to bladder wall removed by using forceps. IV Hartman's 1 hour and blood collection.

In this case, the dog's bladder was thoroughly flushed. I used normal saline and a rigid catheter from bladder to flush out any spiky urinary stones in the urethra. Then I used a smaller sized catheter to flush urine from the penile opening.

Post-op

The following occurred.
1. DAY 1: Urine backflow from prepuce to under the penile skin. Swollen penile area. A catheter was not stitched earlier as the dog would usually pull it out despite wearing an e-collar. He would not pee normally, so urine collected in this way.
Solution: A catheter was inserted and the urine pool removed. One side near the penile opening was taped to the skin using elastoplast (see pic). Urine stained the elastoplast by Day 3. Elastoplast removed. No more catheter.

2. Irrigation of urine daily for 5 days to remove blood clots from the bladder. Urine still bloody. Small clots seen even on Day 2(Oct 6).

3. Acidify urine, antibitoics and close monitoring. Dog is eating and should recover. He could not pee normally due to pain. Pain-killers given.

Owner wanted the dog home after 5 days. Dog was still passing blood in the urine. No more complaints for the next 14 days. Updated info will be at www.toapayohvets.com

27. The right-nose sneezing dog

2009-09-16T16:28:00.000-07:00

Sep 16, 2009

"No gas mask anaesthesia," I stopped my assistant from using the mask. "The dog may breathe in foreign bodies lodged in his right nose and get inhalation pneumonia and then dies."

Zoletil 50 at 0.25ml was given IV. The dog was recumbent. Saliva flowed out, as this was Zoletil's side effect. Not profuse salivation compared to IM injection. I gave atropine 0.5 ml IM. Salivation soon stopped.

Faint blood-tinged right nasal discharge. Not like some 2 weeks ago. Profuse red blood from right nose. Had medication and one nasal flushing via catheter.

5ml of oral antifungal solution were flushed into the back of the right nose where the foreign bodies were suspected to be located as seen in the X-ray. The dog sneezed our violently. On 2x1 cm piece of cartilage - snow white smooth surface encrusted by soft yellowish brown tissue presumed pus. Another 4 small pieces of pus were sneezed out. Little blood sneezed.

These could be fungal infected nasal tissues. The dog was warded for observation.

Recurring struvite stones in the dog - How to prevent recurrences

2009-08-31T14:18:00.000-07:00

Many times, it is a death sentence when the pet dog produces urinary stones again as the average dog owner feels that the surgical treatment, hospitalisation, nursing care and medication from around S$900 at Toa Payoh Vets and over $1,500 elsewhere are "expensive". Unfortunately, urinary stones do recur in some dogs such as the Miniature Schnauzer.

Some tips to prevent recurrences of struvite stones are:

1. BREED. Breeds like the Miniature Schnauzer are prone to producing urinary stones. Urinary examination at least 3-monthly will be ideal. If not, during the yearly vaccination, ask your vet to do a urinary analysis.

2. DIET. No dry dog food definitely. No canned foods or treats. Special low stone prescription diet or home-cooked food.

3. URINE pH, S.G and Red and White Blood Cells measured weekly using dipsticks in collaboration with your vet.

4. WATER INTAKE. Measure diligently and scientifically 24-hourly water drunk in collaboration with your vet. Some sedentary dogs need to be encouraged to drink by more exercise or supervision.

5. ACIDIFICATION OF THE URINE if the urine pH is 7.0 and higher in collaboration with your vet.

6. BLADDER PALPATION. If stones or a crackling gassy sound are felt, it is bad news. Consult your vet promptly.

The objective is to prevent struvite crystal formation by ensuring that the bladder is free from bacterial infections and that the urine pH is alkaline. The guidelines apply to the prevention of struvite (triple phosphate) urinary stones only.

More info is at toapayohvets.com

25. Vaginal prolapse & breast tumours in a 15-year-old dog

2009-08-02T16:45:00.000-07:00

Logically, one combined surgery to spay and remove the breast tumours under one anaesthesia would be economical for the dog owner and good for the dog as she does not need to have another operation.

That was what my assistant said to me. "Well, people are not so kind when the dog dies on the operating table when the vet does what is logical and the dog dies. They will just bad-mouth about the vet's incompetence to anyone who comes into contact with them. You have heard such remarks recently."

"A short surgery means a short duration of anaesthesia," I explained to the man who was very keen on veterinary medicine and surgery. "It is less risky for the old dog. I mean she is 15 years old. She would be equivalent to a 105-year-old woman now."

Surprisingly she still had the estrus cycle as vaginal prolapse is associated with the onset of the heat cycle. The owner agreed to a blood test which showed slight increase in liver enzymes. This dog was quite healthy and had a 60% chance of survival under a short anaesthesia and surgery. The owner had to decide. She gave the go-ahead.

The spay was completed in 15 minutes. Total time taken was 25 minutes of anaesthesia using isoflurane gas at 1-2% and intubation as the dog took some time to be given gas mask. Excellent anaesthesia. Before stitching, I had the gas switched off to 0%. The blood colour was excellent and bright red. However, the dog did not wake up as what other younger and normal dogs would do under such low anaesthesia. He took about 10 minutes to wake up and was very sleepy. 5% glucose IV drip was given during surgery and then a bottle of dextrose saline overnight. The dog was OK and the lady owner was happy.

Teamwork is important in old dog anaesthesia. My first assistant, Mr Saw monitored the anaesthesia like a hawk. My second assistant who had thought that this case should be 2 surgeries in one (spay and breast tumour removal) helped me in the surgery and that is the secret to a shorter 15-minute spay. Normally, I don't give myself unnecessary stress and a normal dog spay takes around 30 minutes.

It was great to see the old female dog alive. As for the breast tumour, it may be best not to operate. The spay showed that the uterine tissues had gone cystic - as in a closed pyometra case. The dog should not have any more vaginal prolapse as she would not by having heat. Do such old dogs still have estrous cycle? Apparently so in this case. Spay is the treatment to prevent any more recurrence of vaginal prolapse in female dogs and this is why I did the spay first. The complaint from the owner was vaginal prolapse and not breast tumour. Therefore, know what the client wants and don't get side-tracked. The dog did get her teeth scaled and four rotten teeth extracted under one anaesthesia but this did not take more than 10 minutes. She should have a better quality of life now, with clean mouth and not having to lick her protruding vaginal prolapsed mass.

24. The Cat Had "Kuru"

2009-07-20T14:00:00.000-07:00

"What a load of rubbish," the 3rd year Veterinary Student commented when I described a case where the male neutered cat had no penis visible at all times. "Yet he could pee but how did he do it? Could this cat be suffering from a case of "Kuru?".

What is "Kuru?" the young man asked as his mum laughed when I told her about this case. It is funny when I described the case but I don't know how to translate the humour in this report.

"It is a Malay word for a human medical condition in which the penis disappears inside the body after eating pork," I speculated. "Suddenly the affected man loses his manhood!"

The student rolled his eyes upwards and said: "The cat's penile retractor muscles pulls the penis inside the prepuce, just as in the horse. When the retractor muscles relax, the penis will be visible." He did not say so, but he could not imagine a man having his manhood disappeared completely inside his body.

"It is hard to believe me," I said. "But 'Kuru' was reported in the Singapore newspapers when I was around 15 years old. My mum mentioned this report to me."

Although 4 decades had passed, I could vividly recall the name of "Kuru" as it struck adversely affecting manhood. At 15 years of age, I was impressionable and I was male. I could not remember whether I stopped eating pork when "Kuru" was rumoured to exist in Singapore in the 1960s.

Now, I encountered an equivalent case of "Kuru" in the animal kingdom and after nearly 4 decades of practice. This cat fell four storeys and had 3 wounds in his backside. No penis was visible at all. Maybe it was inside one of the holes. However, I operated to create a new hole as the urine was diverted into one hole and then into the thigh fascia and muscle areas.

So, was this a case of "Kuru" or not? I have some pictures to show readers. The only time I could barely see the penis was when the cat suddenly peed during my review before going home on the day of surgery. He just shot out his full bladder's urine, missing me by a few cm as I swerved. I grabbed my camera, switched it on and managed to capture a photograph for readers to see. Certainly, this cat could pee normally but he appeared to have "Kuru". In any case, the owners were happy with his newly created urinary hole and he no longer urine-stained his backside.

23. Spaying stray cats in Singapore

2009-07-15T16:58:00.001-07:00

Caterwauling cats x 2

Cat 1. Around 6 months
Jul 3, 09. Caterwauling. Owner got Ovarid. Gave Ovarid 20 mg x 1. 1/4tab/day x 4 days.
Jul 12, 09. Spayed.
3.2 kg
Xylazine 20 @ 0.1 ml, Ketamine 100 @ 0.4 ml in one syringe IM
Insufficient time, cat growled. Top up isoflurane gas 5% for < 1 minute
Ovaries - Yellow corpus luteum.

Cat 2. Around 6 months
Jul 6, 09. Caterwauling 7 days ago.
Jul 13, 09. Spayed.
3.65 kg
Xylazine 20 @ 0.15 ml, Ketamine 100 @ 0.5 ml in one syringe IM
Excellent anaesthesia. I took note of the time for surgery in this case.

2.40 pm Injection xylazine & ketamine. Clipping after 3 minutes.
2.47 pm Incision started.
3.16 pm Skin suture (horizontal mattress) completed.
Duration: 29 minutes.

Surgery not under pressure as Cat 2 is in excellent anaesthesia.
Ovarian blood vessels large as in Cat 1. Around 3 mm in diameter
Uterine blood vessels around 3 mm in diameter
Ligate ovarian bv. Double ligate uterine body. In Cat 1, I had to transfixed ligature as well as double ligate the uterine body.

Ovaries - One cystic ovary?

Delays are caused by:
1. Too much time is spent in waiting (> 5 minutes in Cat 1 for the cat to be sedated before clipping hair and preparing the site for surgery).
2. Incorrect restraint. Experienced assistant like James Ang tended to forget the proper procedure. The correct restraint here is to hold the cat upwards by the scruff of the neck. I asked him to lift the cat off the table. I injected IM. There was no reaction from the injection unlike Cat 1. In Cat 1, James positioned incorrectly, gripping the cat on the table with his right hand across the shoulder of the cat from the right side of the cat, instead of being on the left side of the cat., so that his grip was not firm. The cat moved as I injected 60% of the anaesthetic. He got scratches on his hand, in earlier case of another cat spayed by Dr Teo.

Fierce stray cats
How to inject such cats?
1. Put cat inside small crate. Put telephone books and other books to push him into corner. Tilt the crate. Inject IM when the cat is distracted. Not really ideal as some cats reacted first during injection. Xyalzine 0.2 ml IM in local Singapore cats would be easy and quick for injection, but not the larger amount in xylazine:ketamine combinations. Isoflurane via gas mask is used in cases where xylazine 0.2 ml is given.
2. Lasso held the cat's pelvic area and back towards side of crate. Inject IM.
3. Do not give 2nd injections if the vet missed or gave insufficient amount as the cat may die of heart failure due to the stress. Postpone surgery to another day.

Conclusion
My assistant James said that I had performed the surgery faster in Cat 2. The dosage of injectable anaesthesia for cats 3.5 - 4 kg kg should be that for Cat 2.

SHARING MY EXPERIENCES ABOUT SURGERY - SPAY IN A CAT
The cat below was not spayed by me.

22. Electrosurgery in hamster wart removal

2009-06-27T13:59:00.000-07:00

The hamster's nose wart had a stalk made up of normal skin. If I used the scalpel to cut off the stalk, there would be a lot of bleeding. Shooting blood spurting all over her face. If the hamster was a dog or had a longer stalk, I could ligate the stalk. The stalk was the passage for large blood vessels to supply nutrients to the fast-growing wart. A wart bigger than the hamster's eyes.

"She rubbed off the wart previously," the teenaged girl who was accompanied by her concerned parents told me. "But the wart came back." Now, I had to decide whether to do electrosurgery on this hamster or not.

Could the hamster survive electric currents coursing through her body? What happens if the electrical circuit did not close completely. Would this old hamster be burnt or die out of shock? I doubt many vets will perform electrosurgery on hamsters to remove a wart. It sounded too risky.

In theory, the hamster should not get electrical burns if the circuit was well connected. The electric current would flow from one electrode out of the machine, pass the hamster's stalk, incising and coagulating the tumour and back to the machine.

To ensure the smooth flow of electric current without burning harming the patient or doctor, the following must be done:
1. A plastic sheet on the operating table which is metallic.
2. Normal saline on the gauze which is then placed on top of the pad of the indifferent (neutral) electrode. Saline, unlike water, conducts electricity well so that the current goes home via the indifferent elctrode back to the machine.
3. The hamster's lower body must be in full contact with the gauze.
4. No saline should be present outside the indifferent electrode.
5. No explosive anaesthetic gas to be used.
6. The hamster must be fully anaesthesized, otherwise she would move about.
7. No sparks should be seen if the procedure is well done as there would then be no resistance to the current flow.
8. The lowest intensity should be used for electroincision and electrocoagulation modes. I intended to incise and then coagulate the wound.
9. An alternative is the use of the blending mode (known as "coagulation 2" in my machine). In the blending mode, the wart is incised and coagulated at the same time. It would be ideal in this case.

Anaesthesia
The hamster was given isoflurane gas in a container for a few seconds. When she was observed to be "sleepy", she was taken out, put on the saline-wetted guaze on top of the indifferent plate.

Surgery
I used forceps to lift up the nose wart. The electroincision wire cut the stalk. There was resistance to the cutting. So I had to increase the intensity of the current. The hamster woke up suddenly and seemed shell shocked just after the passage of the electric current.

That is the problem with using gas isoflurane. It enabled rapid recovery. I had cut 80% of the stalk. There was no return. Quickly I stepped on the foot switch and lanced off the last piece of skin attachment.

There was no bleeding. That was excellent. Previously, I had bloodied noses after excision of the wart with scalpel. This was great. I took the hamster to the consultation room and handed her over to the teenaged girl. She was very happy to see the wart gone.

The hamster was much awakened now. Suddenly the girl said, "My hamster rubbed her nose. It is bleeding a lot." This bleeding was profuse. As if a dam had burst. I took a piece of tissue and put pressure on the nose to stop the bleeding. I wiped the blood away with another tissue. Still there was bleeding.

The hamster moved away from my fingers. Suddenly she squeaked as I pressed the tissue paper in an attempt to stem the flood of bright red blood spurting all over the hamster's face.

"I have never heard my hamster squeak before," the girl sounded distressed. I realise that I had to take the hamster away from the girl, back into the operating room to treat the bleeding. This bleeding was not life-threatening but it was very traumatic for the owner to watch and hard to explain to the owner. "I will use potassium permanganate powder to cauterise the wound," I said to the teenaged girl. "Have you studied this chemical in your class?" She shook her head. Probably she was in Secondary Two and had not studied chemistry. So she had not heard of this chemical.

In the silence and peace of the operating room, I wiped off the blood from the hamster's nose, applied potassium permanganate powder. There was no bleeding. Now, the hamster had a purplish black nose. Later one, she would have her normal coloured nose.

In this case, the alternative blending or "coagulation 2" mode might be more useful in the electrosurgical excision of the big hamster wart. As very few hamster surgeries are done, I would have to wait for the next case. Not many hamster owners have problems with warts.

Life is a continuous learning and hands-on experience is the only way for the vet to hone his skills in electrosurgery of the hamster.

Full report is at www.toapayohvets.com

21. Mission Impossible in 16-year-old canine pyometra

2009-06-21T15:57:00.000-07:00

"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 with a grin. It was just not possible.

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. The following were done:

Pre-operation
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.

Anaesthesia
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.

Surgery
"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 many case of such old dogs with pyometra. I thought the old dogs had menopaused and would never get pyometra. This case proved me to be mistaken.

But such loud wailings are good signs of a dog being much alive at the end of surgery and were a joy to hear. I don't want to see a dog knocked out and still sleeping when the last stitch is completed as there is a risk that the dog may die
later.

"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 said. So, I had used up 18 minutes to perform the surgery. It was really Mission Impossible.

The naughty senior citizen 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 30 minutes after surgery. She had the IV drip but I was worried. I phoned her owner. She could still die despite a successful surgery.

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 the dog went home. Some one hour later, the lady phoned, "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.

20. Electro-cautery in a Jack Russell

2009-05-28T12:41:00.000-07:00

Will electro-surgery kill the old Jack Russell who has a weak heart?

The Jack Russell needed to be unconscious so that the gigantic mouth tumour could be excised using electricity. Yet he had a weak heart. Anytime his heart could fail and he would be gone from this world. Therefore, general anaesthesia using isoflurane gas was kept to the minimum.

The gas was like the force shield in Star Trek's Enterprise, protecting the starship from powerful killing forces.

As the electricity shot through the electro-cutting bladder to slice off the tumour at the edges of the gum, the dog started to jerk. The protective force shield was insufficient to protect the dog's systems.

His tongue moved and he opened his mouth. His heart stopped pumping blood. I could see that his tongue changed from pink to purplish in colour.

"Increase the dose to 5%," I stopped the electro-surgery. The dog was feeling the pain. The force shield needed to be at its maximum. However, it could overload the dog's heart and kill him. There was a need to know how long the 5% had to be given. One minute or more? There was no formula. The longer, the higher the risk of death on the operating table.

The dog started to slip into unconsciousness. The electro-cutting blade transferred electric current into the tumour. Zap, zap, zap... the electric sparks flew.

"Smells like burnt meat," Intern 1 who had never seen electro-surgery probably thought of her barbecue parties. The 9-sq m operating room with 2 interns, 2 assistants and myself was packed.

The faster the operation was done, the better chances of survival it was for this old dog. 15 minutes had passed. Now the dog was unconscious at 1% gas anaesthesia. The 2nd tumour in the hard palate was zapped and removed. Now, the electro-cautery electrode was used. The blood flew profusely from the gum after the tumour had been cutting. The red light at the end of the electrode blinked indicating that electricity was coursing through. However, the bleeding continued.

"Turn the dial to higher intensity," I said. The assistant turned the knob to No. 3. I put the electrode onto the bleeding point. The steam rose as the electricity burned the blood vessel as I stepped onto the foot-switch. The surgical area was now dried. No more bleeding.

The dog moved suddenly and darted his tongue in and out of his mouth. His tongue changed to a deep purple.

I looked at Intern 2. "Is the indifferent plate still in contact with the dog?" She was to ensure that the dog's abdomen was in contact with the "indifferent plate" which had been moistened with a wet gauze swab in normal saline. This plate conducted the electricity away from the dog to the machine. A complete circuit.

"Yes," Intern 2 said. I checked. The interns were inexperienced students from the Junior College waiting to study veterinary medicine. They had never seen electro-surgery in their 18 years of living. Neither did the two Myanmar assistants. Electro-surgery is seldom performed as there are not many indications requiring this machine.

Therefore, I had to be extra vigilant and yet needed to educate the younger ones on the application of electro-surgery. Seeing is believing for them.

"OK," I said to my assistant. "Take out the endo-tracheal tube now. The operation is completed." There was not a single drop of bleeding from the gum. The dog got up as if he had a short nap. It took team-work to complete the surgery in 18 minutes.

The Jack Russell wagged her tail. She was a most friendly dog and would never threaten people unlike some crazy Jack Russells I had encountered. She was not able to communicate as a human being. But she appeared quite happy as the she could now close her right upper lip normally.

NOTE: Oral tumours form when there is poor dental hygiene in dogs. In old dogs, it would be best not to attempt surgical removal of the oral tumour and dental scaling and extraction at the same time. This increased anaesthetic time considerably and the risk of anaesthetic death. Therefore, do the surgery and forget about the dental for the time being if you want a positive and happy outcome.

19. Focal dystonia in a veterinary surgeon

2009-03-11T20:45:00.000-07:00

FOCAL DYSTONIA IN A VETERINARY SURGEON

For the past year, sometimes, the 4th finger of my left hand curls inwards involuntarily and I have to uncurl it with my right hand to continue surgery. What's the cause of this sporadic problem?

I presume it was due to aging. After all, I am no spring chicken, being 58 years old.

Could this be carpal tunnel syndrome which is commonly diagnosed in people such as mothers holding babies?

This problem does not happen all the time and has never happened while I do typing or writing. I do use the keyboard a lot to write and create pictures for the "Be Kind To Pets" (www.bekindtopets.com) educational website everyday.

Today, I read in the Straits Times, March 12, 2009, Pg C6 "Back with two hands" that the famous Ameican pianist Leon Fleisher could not uncurl the last 2 fingers of his right hand for 30 years. So he could not play the piano with his right hand. His condition was correctly diagnosed in the late 1990s as "focal dystonia". This is a neurological disorder originating in the brain. Wrong impulses from the brain cause the muscle of the finger to contract and twist involuntarily inwards.

Apparently, focal dystonia affects musicians, writers and surgeons. I had found the correct diagnosis for my problem. Botox injections and regular hand exercises can treat the problem but there is no permanent cure as at 2009.

Or is there? More research needs to be done by me. Maybe I will be forced to stop doing surgery later. A new career as a licensed travel agent?

1. Post-spay complications - The "surgical signature" of a vet

2009-01-23T14:09:00.001-08:00

The surgical signature

"Everything was OK for the past 2 weeks after spay," the cat owner I had not met before brought in a black cat with yellow pus in her spay wound matching the colour of her yellow eyes.

As I did spay a black cat with yellow eyes recently, I assumed that this was the cat I had spayed and there was the post-spay complications of wound breakdown or infection which do happen in rare cases.

In the black cat I spayed recently, the owner pressured me to charge him $35 for spaying as it was the fee offered by some vets. Spaying of a cat is a commoditised such that the lowest priced vet gets the most business (my presumption).

"The reason I do not pay $35 to the vet who charges much lower than you is that my cat's left ear tip must be snipped off after the spay."

It is difficult to sustain the profitability and upgrading of a veterinary practice if I compete on "lowest spay price". So I was prepared to let the case go as I don't want to lose money doing a surgery. I will become bankrupt providing loss-making services in time to come.

Unlike a human general practitioner, a veterinary practice has surgical and anaesthetic equipment to buy and maintain. The rentals and staff overheads are high. Therefore, going down the path of the being the lowest priced vet is not sustainable for profitability in the long term.

Back to the black cat on my consultation table, the owner said he did not know who had spayed his cat as he was not the one who brought the cat to the vet. One look at the cat's incision wound told me that my "surgical signature" would be around 1 cm from the umbilical scar. This cat's wound was at least 2 cm away. Therefore it was not me who had spayed the cat.

In any case, the owner said that there was no problem for the past 14 days. The cat I spayed was 7 days ago and I had never heard from the other owner with the black cat.

I noted some brown stains of an iodine-like antiseptic further away encircling the wound. I did not ask the owner whether he applied antiseptic which had been licked off. How could his black cat do it when she had worn an Elizabeth collar?

"Do you have another cat in the house?" I asked him.
"Yes,"
"It is likely that the other cat cleaned up the wound for this black cat," I said. The owner nodded his head.

So, what's the solution? The cat had a fever. It would cost the owner more money to get her treated. In times of recession, this post-surgical treatment is not kindly accepted by a pet owner.

I removed the stitches, warded the cat and gave antibiotic injections for 3 days at minimal cost of $50.00. For the last 7 days, I did not hear from the owner and presumed that the cat had resumed a normal life.

Other pets licking the wound of the spayed cat or dog are unexpected causes of post-spay complications. Vets seldom if ever ask the owner to separate the spayed pet from another as we never think of such situations.

Chicken bone was neither here nor there

2008-11-16T14:58:00.000-08:00

Sunday Nov 16, 2008

A bright sunshine day. The Maltese had survived day 6 of the surgery and should be OK. So she was going home.

VETERINARY SURGERY TO REMOVE A CHICKEN BONE BETWEEN THE OESOPHAGUS AND THE STOMACH

This was a rare case of a chicken humurus bone trapped between the gullet and the stomach. Neither here nor there. I mean, if it was in the stomach it would be an easy surgery. But it was 3/4 in the gullet and 1/4 in the stomach as shown in the X-ray taken by Vet 1.

The major problem was before induction of anaesthesia. The dog had already vomited twice over 40 ml of white bubbly saliva onto the consultation table. Frothy white saliva covered the front of the epiglottis - obstructing any view of the epiglottis opening. So this was a difficulty airway and aspiration risk case. No intubation should be done as the opening of the epiglottis was masked by foamy white saliva.

Should I use injectable anaesthetic? Well, if this old dog did not have heart disease, topping up injectable anaesthetics should do. But gas anaesthesia is the safest method in old dogs with heart disease. I had never done surgery using topping up of injectable anaesthesia as I feel that this was not the safest way to do it. Yet, in this situation, there seems to be no choice.

15. Ear gangrene in a Maltese

2008-10-31T14:25:00.000-07:00

"Bluish black ear tips. What did you do to Gom's ears?" I asked the well groomed young Korean lady. Her English was excellent and so it was easy to communicate.

"I tied her ear tips with a rubber band," she had watched and adopted the same procedures done in a Korean TV program on Malteses. Shih Tzus do get their long hair tied up above their forehead so that they can see and look pretty.

"The blood supply to the ear tips is no more," I explained. "The ear tips have no blood supply due to the rubber band cutting off the flow of blood. Now the tissues are dying. This is called gangrene. Did you use a groomer's rubber band for Shih Tzus?"

"No," the lady showed me a red rubber band normally used for tying things.

What to do with these two dying ear tips? Nothing much could be done to reverse the cell death. 3 days later, the young lady came as the left ear tip had become black and hard. I asked Groomer Aung to clean it.

"The ear tip dropped off," Groomer Aung showed to the dead triangular piece to me and the lady owner. She cupped her hands to cover her eyes. It was too much for her to see.

I took away the gangrenous ear tip. What to do now?

"The right ear tip is becoming black," I showed the owner. "It will also drop off in a few days' time. I advise cutting it off now."

"How much it will cost me?" the lady had a tight budget as she was studying in Singapore. Many foreign students in Singapore and I am sure, even in Australia and other countries survive on a tight budget as their parents skim and save to pay for their expensive undergraduate fees and accommodation.

In theory, such students ought not keep any dogs to minimise expenses. But they are not from the frugal baby-boomer generations that have had experienced the deprivations of World War Two. So, some of these Internet Generation do buy puppies and if they do make great companions in a foreign land. If they don't fall sick, expenses are affordable.

"$60.00 to cut off the gangrenous right ear tip," I said. It was take less than 10 minutes of anesthesia and cutting off the tip would be two seconds. Potassium permanganate powder applied on the wound would stop bleeding. Hence the quotation was low.

"Can you make both ears of the same size?" the fair lady assumed that cutting off a larger piece of the right ear tip instead of the small gangrenous tip would be the same effort.

To the owner, aesthetics are important. Which owner wants to see her companion with uneven sized ears every morning? Friends would ask awkward questions too.

I thought of a Singapore boy with a Bichon Frise studying in Murdoch University. He was on a tight budget as his parents had to pay for his high undergraduate fees and accommodation of at around $50,000 a year.

So I understood the financial situation of this fair Korean lady. It is expensive living in Singapore. Fortunately she did not buy a car but taxi fares add to the veterinarian add up. Pet dogs are not permitted on buses and the subway in Singapore and so taxis are the sole transportation.

I did not explain that it takes 10 times longer to give Gom ears of equal sizes and therefore the veterinary fees would be much more than $60.00.

Gom was a happy puppy. I masked him and tubed him to give him the isoflurane gas anaesthesia. He did not sleep well under intubation and was gagging as if he did not like the endotracheal tube.

The anaesthesia was uneven and delayed my surgery. I had to worry whether he would die on the operating table since he could not get to the surgical stage of anaesthesia unlike other puppies.

When I took out the endotracheal tube and just gave him gas via the mask, he slept like a baby. The gangrenous left ear tip was placed against Gom's right ear to get the area to be cut. I drew the incision line with a marker pain. Pulled back some skin so that I could suture over the cut cartilage. It was not possible in Gom as her skin was taut. A curved artery forceps was clamped below the black marker line and the cartilage was covered with an inverting 5/0 absorbable suture, as in stitching the uterus during Caesarean sections.

The left ear tip was clamped and similarly cut to remove the gangrenous edges and dead cells. There was much less bleeding and the suturing stopped the bleeding. The right ear tip area bled a lot as it was normal tissues cut by me to ensure that both ear had equal sizes. The bleeding was not serious, so I did not bandage up the right ear to stop the bleeding. I would have had done in a Doberman after ear cropping.

Ear cropping by vets for cosmetic reasons is prohibited in Singapore in the past decade or so. However, it was not prohibited when I started practice some 25 years ago.

Gom had to stay one night for observation. Early the next morning, her owner came to take her home. The bleeding had stopped. Everything should be all right for Gom (Bear in Korean language).

Can the vet deliver?

2008-09-27T15:39:00.000-07:00

"Today may be the last day you will see your Chihuahua alive," I said. "She has heart disease and had one episode of heart failure during anaesthesia two years ago during dental scaling. She may die on the operating table."

The dog needed to be revived during dental scaling. I had advised the quiet lady that the dog should not take "further general anaesthesia". I had noted this in my case record. Two years had passed and the dog now had pyometra.

Today, Friday Sep 26, 2008 was the day the Chihuahua was to be operated. She had antibiotics from me for the last 5 days and had seen Vet 1 six days ago. Pyometra was also diagnosed by Vet 1 who advised surgery and gave antibiotics and oral painkillers.

Antibiotics given some 3 weeks ago worked to stop the vaginal discharge. The owner was advised to get the dog spayed after one month. But at the end of 10 days of antibiotics, more "liver-coloured" vaginal discharge flowed continually. The dog had no appetite and needed hand feeding. She was losing weight and now had a fever. Therefore she was high anaesthetic risk. A type of case I would prefer to pass to other vets.

Anaesthetic deaths are so unpleasant events as vets get the blame. Newspapers loved to sensationalise the case too. There was a recent case of a Jack Russell that died on the operating table after being admitted for spay and dental scaling. I had not read this newspaper report but one complaint in the newspapers was that the vet still charged his fee even though the dog had died. No delivery of a good service, no payment?

I had spoken to the quiet lady and her husband for some time on the 2nd recurrence of vaginal discharge 5 days ago after cessation of antibiotics and the emergency visit to Vet 1. When was the optimal time to operate? It was hard to define exactly. I advised that once the dirty and sticky vaginal flow ceased, the dog should be operated. The time was 5 days after antibiotics.

So the dog was here now. She has fever. Still would not eat by herself and had lost 0.3 kg during the past 2 weeks. She still looked alert.

"I will wait at the surgery," the quiet lady said.

"It is best you go home," I said. "Waiting at the surgery is very stressful for me in such situations of high risk anaesthesia. I need to focus on the dog surgery and if you are hanging around, the atmosphere is very tense."

The lady went home. She might be seeing her pet alive for the last time. There was no way I could be less frank. "Do your best," the husband phoned some 30 minutes later to enquire about the dog but I had not operated yet. His wife was very upset at the thought of the dog not being able to be alive from general anaesthesia.

Anaesthesia and Surgery of this high risk anaesthetic case.

1. Dextrose saline 200 ml SC, antibiotics and anti-fever injections given.
2. Pre-operation shaving and washing of operation done. Let the dog rest for some minutes.
3. Gas mask anaesthesia starting at 5%. Reduce to 1.5% after intubation. The dog was too light as she moved. Increase to 2% but not more and wait to staablise.
4. Incise 2 cm from umbilical scar. Make incision 2 - 3cm caudally. Hook up left uterine horn which could be seen easily from this bigger incision. I used the scalpel to cut the tight ovarian ligament. Ligate ovarian blood vessel. Take out the right uterine horn and repeat same procedure. Get the uterine body out. 3-clamp method. Ligate below clamp 3 after clamping the horn. Ligate the crushed area after removing clamp 3. This meant that there would be two ligations.
5. Reduce gas to 0.5% to effect. Stitched linea alba. The dog reacted to pain. Increase to 2%. Reduced to 1% to effect.
6. Reduced gas to 0.5% when the skin incision is stitched. Switched off gas at the 2nd last skin incision.
7. Dog woke up without crying, as if from a deep sleep, after the placement of the last skin stitch.
8. Placed dog in a quiet cage. The cyanotic tongue was not a good sign. This dog did not have sufficient haemoglobin in her red blood cells according to a blood test some 3 weeks ago.
9. The owner took the dog home some 1 hour after surgery. She could care for the dog better at home.

Surgery can be shorter if one follows the Formula One teams where each person handles a specific task when the sports car comes to the pit stop. My assistant focused on the anaesthesia. Another assistant held the forceps to lift up the ovaries for me while I ligate.

In this case, the dog's heart did not fail and she recovered and went home. If she survived the next 48 hours, she should be regaining her appetite after the toxic womb had been removed and should live a long time as her care was excellent. As for her tartar in her canine and other teeth, I dared not suggest any dental scaling or did any scaling after the removal of the womb. I don't advise such procedures although it does save money for the owner. The shorter the anaesthesia, the better the outcome.

What the owner wants is a live dog at the end of anaesthesia. Pets are family.

If the vet cannot deliver, there will be much sorrow on the part of the caregiver of the pet. And unpleasantness from family members and sensationalism in the tabloids and internet forums.

13. Follow up to Post 11. Seizure in the Maltese

2008-09-11T15:08:00.000-07:00

http://www.toapayohvets.com/surgery/20080815Maltese_
Uroliths_Male_ToaPayohVets.htm
is the webpage documenting the Maltese's bladder operation to remove numerous green stones.Clinical Case Study: Toa Payoh Vets

BLADDER STONE REMOVAL SURGERY ON AUGUST 5, 2008
1. General anaesthesia. IV drips.
2. Skin incision cranial to prepuce
3. Linea alba incised
4. Bladder hooked out or use forceps. Bladder was empty.
5. Ventral surface of the bladder was incised, between large blood vessels seen on the bladder wall.
Maltese, Intact Male, 5 years. Stones must be flushed out thoroughly. Toa Payoh Vets
Cystotomy. Surgical approach in this case was via the dorsal wall of the bladder as contrasted to the ventral approach in the Miniature Schnauzer case of the young lady.

Both approaches are acceptable. The ventral approach is easier, in my opinion. Some vets believe that there will be less pressure on the bladder if the dorsal approach is used.
Maltese, Intact Male, 5 years. Incision to access the bladder. Toa Payoh Vets

6. Forceps to pick out as many stones as possible, esp. large ones.
7. Insert catheter into urethra to bladder.
8. Flush 20 ml of Hartmann's solution via catheter into bladder. More stones are flushed out. Repeat.
9. Clamp incision with forceps and flush Hartmann's solution to distend bladder.
10. Release forceps to let stones flush out. Numerous sandy ones. Repeat.
11.Insert catheter via bladder to urethra and flush stones along the length of the urethra out. Numerous small sandy ones.
12. 2 layers of inverting stitches 3/0 dissolvable. Not to stitch into mucosa.
Mucosa looks white. Bladder wall is thickened.
13. Flush 10 ml of Hartmann's solution into bladder via catheter. No leakage seen as bladder distends. Repeat.
14. Close skin.
15. Collar. No need catheter.

Dog is active and normal as at August 9, 2008. Any person interested in adopting him, please e-mail
judy@toapayohvets.com

UPDATE AS AT AUGUST 9, 2008 (National Day, Singapore)

The urinary stones in this Maltese were removed by cystotomy.

However, there is no guarantee that he will not get a similar problem another time. X-rays after the surgical removal of stones and every 3-6 months are ideal. 2-weekly urine tests for the next 3 months are recommended to check for bacterial infection and crystal formation.

Absence of crystals in the urine or X-rays do not mean that the dog has no stones (>100 numerous green ones)

Friday Sep 12, 2008

http://www.toapayohvets.com/surgery/20080815Maltese_
Uroliths_Male_ToaPayohVets.htm
is the webpage documenting the Maltese's bladder operation to remove numerous green stones. He was adopted by a dog lover who has a female Maltese some 2 weeks ago.

On Wednesday Sep 10, 2008, the Maltese had a seizure for around 3-5 minutes and was brought to the Surgery in the evening. He was warded for the next 36 hours and had no seizure. He was extremely energetic.

The cause of seizures are not easy to say. He did have a seizure prior to his urethral obstruction according to the son of the patriarch who did not want him. Therefore this is his second seizure.

"Could he be having too much sex?" the new owner surprised me with his observation that the Maltese had been trying to mate the female Maltese. Both were sniffing each other for the past few days but she did not permit him to mount her.

"The female is not receptive for the first 7-10 days of estrus," I said. "So the male must be exhausted. Did he eat?"

I asked because this dog may have hypoglyceamia or low blood sugar if he does not eat twice a day. Some small breeds like the chihuahuas do suffer from such a condition.

"The female ate his food in the evening, as he did not eat it. He was not interested in his food." The male Maltese may be getting seizure soon and did not have the appetite.

As the cause of seizures are unknown in most cases, it is hard to treat. The Maltese had no seizures for the past 36 hours and went home.

"What should I do if he has a seizure again?" the new owner asked. "The dog keeps banging his head on the floor."

"For dogs with seizure, try to prevent the dog from injuring himself. For the small breed, it is possible to wrap him in a blanket and protect his head from injury. The owner is give a diazepam tube to stop the fits is used to pump the drug into his rectum.

In this Maltese, I suspect that extreme pain as in urethral obstruction earlier or exhaustion as in recent seizure could be the triggering factor. He had been warded in the Surgery for a few weeks till he was adopted 2 weeks ago. He never had fits. Neither did he have the sexual tensions too.

This dog needs to be monitored. As far as more X-rays and urinalysis to monitor the recurrence of bladder stones, many Singapore dog owners are not willing to spend money and time to do the monitoring.

The cost of living for the ordinary people in Singapore goes up every year. So veterinary advices are frequently ignored.

Caesarean Sections - Toa Payoh Vets

2008-09-05T13:35:00.000-07:00

DRAFT

Caesarean sections - Dr Sing Kong Yuen, Toa Payoh Vets

Sep 3, 2008
The following searches from Google showed 12 pages related to Caesarean sections done by Dr Sing Kong Yuen over the past years at Toa Payoh Vets. From 2004 - 2006, I had numerous Caesarean sections from most of the dog breeders in Singapore.

1. http://www.asiahomes.com/singaporerealty/expat/analysis/analysis-6.htm
2. http://www.toapayohvets.com/tpvets_Jul904.htm
3. http://www.asiahomes.com/singaporetpvet/sales.htm
4. http://www.toapayohvets.com/fees.htm
5. http://www.asiahomes.com/singaporetpvet/dogs/030607umbilical_hernia_Singapore.htm
6. http://www.asiahomes.com/new1/puppy_Mar2004.htm
7. http://www.asiahomes.com/singaporepets/031026two_waterbags_Silkie_Singapore.htm
8. http://www.asiahomes.com/singaporeaur/0532condos_East.htm
9. http://www.asiahomes.com/Email_house_listing/house_listing2.htm
10. http://www.asiahomes.com/singapore_condos2000sf/
11. http://www.asiahomes.com/singaporerealty/0515hunting_$4K.htm
12. http://www.asiahomes.com/singaporetpvet/services.htm
13. http://www.asiahomes.com/singaporetpvet/dogs/030518pomeranian_caesarian_section_Singapore.htm
The Single Pup Syndrome
14. http://www.asiahomes.com/dev/Atomic_031215elective_caesarean.htm
Elective Caesarean sections save puppies
15. http://www.asiahomes.com/040113Yorkshire_explosion.htm
The Yorkshire Terrier had an explosive Caesarean section
16. http://www.asiahomes.com/singaporetpvet/031109spay_bitch_Singapore.htm
Spay or get breast cancer
17. http://www.asiahomes.com/singaporepets/Atomic_031214caseareans_large_litters.htm
How to be successful in canine breeding. 3 Caesarean cases
18. http://www.asiahomes.com/singaporetpvet/54thday_Chihuahua.htm
Will oxytocin save the mother's life?
19. http://www.asiahomes.com/Email_house_listing/house_listing2.htm
No puppies can survive 40 degrees C
20. http://www.asiahomes.com/puppy.htm
21. http://www.asiahomes.com/singapore-rent/030306Queens_condos_Singapore.htm
Dog transport man Ah Chye

11. Follow up on Post 10. Maltese is normal after surgery.

2008-08-08T17:57:00.000-07:00

In response to 2 comments:

http://www.toapayohvets.com/surgery/20080815Maltese_
Uroliths_Male_ToaPayohVets.htm
has the details of the surgery to remove the bladder stones.

As at Aug 9, 2008, the Maltese is living a normal life now.

10. Money back as dog could not pee

2008-08-07T15:40:00.000-07:00

"If your car can't move after returning from the mechanic, what do you expect?" the trim man in his 60s asked me as I was about the leave the Surgery at the end of a long day. Without waiting for my reply, Mr Lee said, "Surely you expect the mechanic to repair your car till you can drive it. Free of charge."

A veterinarian who had warded his dog for 3 days had released the dog to him. "Look, look, no urine came out," the man directed my attention to the small mini-Maltese cocking his right leg against the wall of a column for a few seconds."

"This is the first time I see your dog. I don't know anything about your dog treatment," I said, not wanting to get involved with potential litigation. "You will have to talk to your vet." I went back to the Surgery to collect my things.

Mr Lee knocked on the glass panels in front of the Surgery to attract the attention of Mr Saw, my vet technician who was at the waiting area doing some administration work. "Ta boleh kenching (Cannot urinate in Malay)," he cricked his knucles onto the glass panels and shouted from outside.

I went out of the Surgery: "No point talking to Mr Saw. He is not a veterinarian in Singapore. He does not speak the Malay language. He is a Myanmarese." Mr Saw had been mistaken for an Indian and now as a Malay as he has sunburnt tanned skin.

If possible, I would help to resolve any dispute affecting the veterinary profession even if the veterinarian is from the competition. I spent some time finding out what Mr Lee wanted.

"All my money back," he said. "After all, the dog still cannot pee and I still paid the fees. If your car goes to the mechanic and he cannot repair your car, you ought to get your money back."

Mr Lee went on about the roles and responsibilities of the mechanic. Non performance, money back guarantee.

"Well," I said. "You really have to speak to your vet directly if you want your money back. He had done a lot of work. I don't know what really happened."

Mr Lee said, "I understand that this vet had a business to run and has his overheads." He waved a veterinary bill for me to see, "I don't know whether he had really given the drugs or treatment to the dog. Vet 1 (the first vet) who treated him had said there was no bladder stones and after his X-ray, the dog could pee normally for some weeks. On another occasion, I went to Vet 1 and he prescribed some antibiotics without seeing the dog. The dog could pee normally. Last week Vet 1 refused to give me the antibiotics. He wanted me to bring the dog down for examination. I came to consult Vet 2 because he is nearer to my home."

I had no comments about the actions of Vet 1 and 2 and should not comment on professional matters I had no idea about.

I said, "Mr Lee, how much money do you want back from Vet 2?"

"All my money," Mr Lee said. I shook my head, "Vet 2 had spent time and did work on your dog. I don't know what he advised you. The only thing I can do for you is to phone him and ask him for some money back for you."

Mr Lee nodded his head.

Vet 2 said to me when I phoned, "Mr Lee had contacted me some 20 times. The dog has urinary stones and need a cystotomy."

"Can you give him back some money so as to resolve the matter?" I asked. "Negotiate."

Vet 2 said in some serious tone, "I am non-negotiable."

I focused him on the problem of money without wasting time on listening to his treatment because it was none of my business. Mr Lee wanted was "money back".

"Negotiation is the best way in this case. Give Mr Lee a counter-offer," I urged Vet 2. My experience in Singapore real estate helps me a lot in matters of negotiation in sales and purchases of houses.

"This dispute can be resolved with money and you will never see Mr Lee again." I advised. I did not want to say much about the ugliness of veterinary investigation by the authorities and prospective litigation as all veterinarians in practice would have had suffered some time or another. I presumed Vet 2 had never encountered such ugliness personally.

However, giving money back is perceived by some owners to admission of guilt or negligence. So, if Vet 2 stood his ground, I could just go home. Still I talked to Vet 2 to advise him to give back some money to avoid all unpleasantness and paperwork of veterinary investigation and litigation. It would cost more than $1,000 to engage a lawyer to defend Vet 2 and how about the tremendous amount of time involved in case writing?

Here we are talking of giving back around $100 back to the owner.

"50% back," Vet 2 said. I conveyed the message to Mr Lee. "80%," Mr Lee said. I asked Mr Lee to sit on the chair and talked to him. "Vet 2 had told you that your dog had bladder stones. Even though Vet 1 had said there were no bladder stones some months ago and that antibiotics cured the dog, it is Vet 2's diagnosis that the dog has bladder stones. Veterinary surgery for bladder stone removal and other tests would be expensive."

Mr Lee did not wish to proceed further with surgery, "I sell this dog to you,"

"I am sorry to say that a 4-year-old mini-Maltese has no commercial value," I said. "As a puppy he might sell for $800 but once adult, very rarely will anybody pay to buy him."

Lots of talking proceeded. "Veterinary expenses for a dog is much lower than bringing up a child," I said. "When children grow up, they don't pay the parents back the large amounts of money spent on educating them. They have their families to support and so do not give any allowance to their parent. Is that right, James?"

James is a 73-year-old working as a receptionist for me. James nodded his head.

"No, no" Mr Lee disagreed, shaking his head vigorously. "My son gives me money." He took out a worn out name card of his son who had worked for a foreign multi-national bank. Then another card of his new job with a premier financial institution."

"You are one fortunate father," I said. It was past 7 p.m. A lady in shimmering brown dress and high heels was seen at the glass panels of the entrance. She walked in.

"Look at this pretty lady," I pointed to the young woman well dressed and in the prime of her life. "Her dog had urinary stones and could not pass urine 2 months ago. Then after the operation, the dog could not pass urine 3 days ago. Now she is taking her dog home from the Surgery. She spent a lot of money on treating him and he might have problems not able to pee again."

I gave some instructions to the young woman as to how to care for her Miniature Schnauzer. She rolled her eyes upwards as she read a long lists of what to do to prevent recurrence and to give prescription diets on medical dissolution of the struvite stones.

Mr Lee was watching intently. She paid around $600 inclusive of the X-rays and 20 cans of prescription diet. On paper, it seemed that $600 was for 3 days of warding and treatment at the Surgery by me. What a large amount for a dog that can't pee again.

From Mr Lee's encounter, I asked the young woman to put the dog down on the grass to see whether he could pee normally or not. The Schnauzer sniffed here and there. After one minute he wandered further away and the young lady followed him.

"He peed normally," the young lady said as it was too dark for Mr Lee and I to see. It was nearly 7.30 p.m.

"Do you want this Maltese?" I asked the young lady. You need to get this dog surgery tor remove his bladder stones."

"I have 3 dogs," she said. "I can't take this one."

Mr Lee decided to give me his Maltese. No point throwing good money after bad, in a case of a Maltese that now had problems. Now, what to do with this dog? Nobody wants him. Euthanasia is the only option.

UPDATE AS AT AUGUST 9, 2008.
The urinary stones in this Maltese can be removed by surgery. However, there is no guarantee that he will not get a similar problem another time. X-rays after the surgical removal of stones and every 3-6 months are ideal. 2-weekly urine tests for the next 3 months are recommended to check for bacterial infection and the pH of the urine. Absence of crystals in the urine as in this case (urine sent for checking prior to surgery) do not mean that the dog has no stones (>100 numerous green ones).

SURGERY ON AUGUST 5, 2008
1. General anaesthesia. IV drips.
2. Skin incision cranial to prepuce
3. Linea alba incised
4. Bladder hooked out or use forceps. Bladder was empty.
5. Ventral surface of the bladder was incised, between large blood vessels seen on the bladder wall.
6. Forceps to pick out as many stones as possible, esp. large ones.
7. Insert catheter into urethra to bladder.
8. Flush 20 ml of Hartmann's solution via catheter into bladder. More stones are flushed out. Repeat.
9. Clamp incision with forceps and flush Hartmann's solution to distend bladder.
10. Release forceps to let stones flush out. Numerous sandy ones. Repeat.
11.Insert catheter via bladder to urethra and flush stones along the length of the urethra out. Numerous small sandy ones.
12. 2 layers of inverting stitches 3/0 dissolvable. Not to stitch into mucosa.
Mucosa looks white. Bladder wall is thickened.
13. Flush 10 ml of Hartmann's solution into bladder via catheter. No leakage seen as bladder distends. Repeat.
14. Close skin.
15. Collar. No need catheter.
16. Dog is normal as at August 9, 2008. No problem peeing. Eating well.

URINE ANALYSIS
Urine was sent to the laboratory for analysis prior to surgery.
No crystals in the urine in the report. No crystals do not mean that there are no urinary stones! Many stones.

9. Beginning of a urethral obstruction by urinary stones in this Jack Russell?

2008-08-05T16:27:00.000-07:00

--- On Mon, 8/4/08, ...@gmail.com> wrote:

Subject: Regarding Neuter of Jack Russell
To: judy@toapayohvets.com
Date: Monday, August 4, 2008, 10:29 AM

Hi Dr Sing

(I can't seem to find the email for Dr Sing, could you put this email through to him, thank you very much, :) )

This email is regarding the neuter of my 3year old jack Russell terrier some time late May, XXX. After 3 weeks the blood clot has subsided. Till now all is well and his is also less aggressive and more good natured now. However.. every time I return home, Pepsi would greet me enthusiastically as usual. But after a while, he would stop to lick his genitals. I have noticed that there seems to be another set of testicles, which seems to have emerged from nowhere. It would appear at the middle along the penis.Is this normal? Everything else has been normal and his wound is completely healed.

I look forward to your reply. Thank you!

Owner

Flag this message
Re: Regarding Neuter of Jack Russell
Tuesday, August 5, 2008 11:17 PM
From:
This sender is DomainKeys verified
"David Sing"
View contact details
To:
...@gmail.com>

Thank you for the feedback.

It is hard to diagnose by internet. As the dog is very fierce, it is hard for him to come to the surgery to be examined properly. Do you mean there are two swellings?

From your description, the area is probably above the os penis (penile bone). If the male dog licks that area, it is possible that he has had some small urinary stones stuck behind the os penis. If he can pee normally, there is no problem. However, he may pee abnormally sometimes. Do observe him well. Here are my recommendations:

1. Use a sterile syringe, collect the urine for analysis.
2. Come to the Surgery to get a urine collection bottle to put the urine in.
3. The urine will be sent to the Lab for analysis for urinary stones and bacteria.
3. E-mail me a picture of the area involved (front view & side view).

http://www.bekindtopets.com/dogs/20080808Aggressive_Jack_Russell_neutered_ToaPayohVets.htm
is the case report.

8. Old female unspayed dogs "on heat" bleeding

2008-06-24T14:54:00.001-07:00

From: ...@singnet.com.sg>
Subject: Question re Dog Licking Herself More Often
To: drsing@toapayohvets.com
Date: Tuesday, June 24, 2008, 6:31 AM

Hi Dr. Sing,

It has been a while since we last corresponded.

Can I please get your advice as my dog Coco has been licking her private parts
more often recently? There's no discharge on the floor, and she's
eating per normal and active as usual. Normal urine and poo too. However when I
check inside her vulva, I see a clear discharge. It isn't much and
doesn't ooze or drip out of her body too.

Her vulva is not swollen or red; it is just normal in colour with one or 2
faint tinges of pink. When I check, her vulva feels soft to the touch, but the
part right after that, i.e. the area between the vulva and the anus, feels
firm/hard to the touch. Is that normal?

Is
there anything I should worry about? FYI, Coco is 9 years old and unspayed.

Could her licking be related to the possibility of her coming into heat soon?

My dog's last heat was in Feb 8 through 25. The one before that was in Sept
23 through Oct 11. It was 5 months or 20 weeks between last year's heat and
the most recent one in Feb. Do you think my dog is going on heat again soon?

When does a female dog start licking herself before her season? 2 weeks before
or?

Please advise. Thanks very much!

Best regards,
Name given

Back to Messages
Re: Question re Dog Licking Herself More Often - PYOMETRA
Tuesday, June 24, 2008 9:20 PM
From: "David Sing"
To:
...@singnet.com.sg
Cc:
drsing_98@yahoo.com

Most likely on-line diagnosis (which is not recommended or advised) is that your dog is suffering from open pyometra. In this condition, the womb of the old dog has been infected by bacteria. Large amounts of pus are produced inside the uterine tubes.

Toxins from the bacteria get into the bloodstream to damage the kidneys and other organs. In time to come, the dog cannot cope with the licking away of the copious flow of vaginal discharge. The dog gets septicaemia and starts vomiting more and more often.

The only treatment of pyometra is surgery to remove the womb and ovaries (spay). Pyometra can be an emergency in many cases as many Singapore owners delay treatment thinking that the unspayed female dog is just having heat.

I just had a 12-year-old Golden Retriever with "heat" 2 months ago. (I presumed the dog licked her vaginal discharge so the owner did not see any more discharge). 2 weeks ago, sticky yellow vaginal discharge attracted flies which would not be swatted away. She vomited 2 days before surgery. Would not eat.

Depending on its health status, some dogs die before, during or after surgery. As many Singapore pet owners consider spay as "cruelty" but are uneducated as to what is pyometra, they often seek surgical treatment very late and the vet sometimes gets blamed for the death of the dog during or after surgery.

In your case, you have no choice but to see your vet and get a professional examination and opinion. It seems that your unspayed dog has been infected for some weeks. Female dogs spayed when they are young will not get pyometra for obvious reasons - they don't have the womb. There are pros and cons of spaying.

SUNDAY JUNE 29, 2008

CASE: 9-year-old Lhasa Apso. Not spayed.
Presenting sign: Vaginal discharge.

History: Licking vulva for past few days.
Previous heat around 5 months ago.

Examination. No thick copious vaginal discharge at consultation. Dog could have cleaned herself.
Fever: No. Active and eating. Urine said to be clear although there may be cystitis from a recent urine analysis.Bladder wall not palpable nor is bladder full.

Palpation: Acute pain in bladder/uterine horn area.

Diagnosis: Pyometra (open) and possible cystitis (bladder infection). It is possible that the dog had been licking off the pus. Usually pyometra starts 4-8 weeks after the previous heat. The owner noted that the vulval-rectal skin area is thickened. This is due to continuous irritation by licking for some weeks.

1) On which day after surgery can we stop worrying about whether she jumps, stretches or runs, for fear that her stitches come apart? When can we rest assured that we can leave her to move around as normal?

10 DAYS WILL BE THE BEST. Most dogs move around with no problems (90%) on day 2 in my experience.

Since I will arrive in the evening to collect my dog, only after you have left for the day, would you be kind enough to give me a call on my mobile to let me know how she is after the surgery?

OK. Must ask my people to phone you and do this as a routine. Most times we don't phone when there is no bad news. NO NEWS IS GOOD NEWS?

Will there be any pain killers for her after the surgery?
YES

2) Wound.

Will there be visible stitches on both the nipple and abdomen areas? You mentioned in your blog that these will dissolve on their own, but when do they go away, so that we can't see them anymore?

STITCHES DISSOLVE IN 21-35 DAYS. YOU CAN REMOVE THEM OR WE REMOVE THEM AT DAY 14.

How long do you think the incision for removing her womb will be?
ESTIMATED FOR LHASA APSO LENGTH OF INCISON TO BE 4 CM. IN YOUR CASE, IF THE INFECTION HAD GONE AND THE WOMB IS BACK TO ALMOST NORMAL SIZE, I CAN HOOK IT UP. INCISION WILL BE LIKE THE USUAL SPAY INCISION. AROUND 1-1.5CM.

IT IS POSSIBLE THAT I CAN HOOK THE WOMB OUT IF IT REVERTS TO NORMAL SIZE AFTER ANTIBIOTICS. IN SUCH SITUATIONS, THE BEST TIME TO SPAY HER IS 1 MONTH LATER.

IF YOU CAN BE OBSERVANT, WAIT 1 MONTH AS THIS IS AN OPEN PYOMETRA CASE PROBABLY. THEN I WILL JUST SPAY HER AS AN ORDINARY SPAY. SKIN INCISION WILL BE 1.0 TO 1.5 CM IN THIS SITUATION. YOU NEED TO DECIDE YOURSELF.

IN CLOSED PYOMETRA (pus stuck inside the womb as the cervix is closed tight, pus accumulates), NOT ADVISABLE TO WAIT.

On which day after surgery can we bathe her without worrying about her wound/stitches?

FROM DAY 2 AS THERE IS A PLASTER COVERING INCISION.

3) Breast Lump

Will you be sending the minute breast lump to the lab to see whether it's benign or malignant? If you don't, since the additional cost may not be worth it, would you be able to tell from your professional perspective and experience your best opinion on the nature of the lump, just by looking at it?

CAN'T TELL WHETHER IT IS MALIGNANT OR BENIGHT, FROM LOOKING ESP. WHEN IT IS SUCH A SMALL TUMOUR OF LESS THAN 0.5 CM. DIAMETER. ONLY HISTOPATHOLOGY BY THE AVA LAB WILL CONFIRM.

4) E-Collar

On which day after surgery can we remove the E-collar? Do we need to keep it on her even at night when she sleeps? How many days must she wear it?

USUALLY NO NEED E-COLLAR IF GIVEN PAIN KILLERS. HOWEVER, KEEP IT ON FOR 2 DAYS. IF PLASTER IS NOT LICKED AWAY, AS SOME FEMALE DOGS DON'T BOTHER, THEN NO NEED E-COLLAR. THIS LICKING IS UNPREDICTABLE AS NO 2 DOGS BEHAVE THE SAME AFTER SURGERY.

YOU HAVE GOOD QUESTIONS FROM THE OWNER'S POINT OF VIEW. WILL NEED TO GO OFFLINE TO GET TO WORK. MANY QUESTIONS ABOUT SURGERY ARE BEST ANSWERED BY WRITING THAN BY PHONE. I will need to include the answers in my case study so that others in your situation may benefit.

IT'S 8.30 AM. NEED TO GO TO WORK. BYE.

Unclotted blood in a dog's ear. 3rd incredible but true story.

2008-06-10T15:24:00.000-07:00

Things happen in threes. This is the first of the 3 "blood-related" incredible stories about my experiences in seeing blood with no apparent cause, within a period of 2 months in April and May 2008.

The old dog had been having ear pain and discharge and weepy left eye for some months. As the owner wanted to put the dog to sleep, I arranged for the dog transport man to bring the dog to my surgery. His wife did not want the dog to die by lethal injection. So, the dog was treated. The owner requested his skin growths to be removed. After that

I advised the owner to bring the dog back for the ear surgery in 7 days' time as that was the primary problem. At the 7th day, the gentleman phoned: "I will wait a few more days." I said OK.

A few days later, he phoned saying that there was blood inside the dog's left ear. I got the dog transport man to send the dog. Yes, there were fresh unclotted blood in the dog's left ear. The blood was red but would never clot. The dog must be scratching its ear and has self-inflicted damage to the ear. Yet, normally, there would be an aural haematoma - a swelling of the ear flap. This was just fresh unclotted blood inside the ear canal.

I sent the dog back on antibiotics and scheduled to operate 7 days later. This time the owner kept his appointment. Yet there was still unclotted blood inside the left ear. I took a picture for readers to see.

During surgery, I could see grey globules of cells inside the horizontal and middle canals. They could be ear cancerous cells. I did not do a histopathology as it would add up to the veterinary costs and it served no purpose for the owner. All owners want are least cost.

The vertical ear canal was removed. Hard as a rock. I had to use a bone cutter to split it.

An incredible but true story

The owner's wife came to visit the dog. She wanted the dog home after surgery. This was not advisable as the dog's ear needed careful nursing to prevent infection and stitch breakdown. Once the stitches break down, there would be a big hole and the owner would construe that the vet is incompetent, as owners seldom blame themselves for the poor outcome of a surgery.

In such a situation, I would advise that the husband be advised as the husband had not asked for the dog to be discharged. Ideally, the wound should be healed first and that would take 14 days at least.

However, to save on veterinary costs, the dog was discharged on day 9. After a few days, the owner sent the dog back as the dog had a swollen area in front of his surgery. The dog had been scratching and the horizontal canal opening had not been cleaned. The dog just would not permit the owner to do it.

So, another 10 days of stay and more veterinary expenses including the cost of several trips by the dog transport man. Fortunately, this was an owner who was able and willing to pay the expenses which could amount to a big sum in view of the to-and-fro of the dog and the transportation.

Vertical ear canal ablation needs a lot of nursing. It would have been cheaper to just let the dog stay at the surgery for 14 days and let the wound be cleaned daily by the veterinary assistant. The dog was quite fed up with the ear cleaning which must be painful for him. But he was muzzled and was more well behaved.

On the last day of nursing, before going home, I saw him wagging his tail as if he was happy to be free of his chronic ear pain. He never barked and was a dog of few barks.

6. Reaction to gas anaesthesia? Undescended testicle.

2008-06-05T15:33:00.000-07:00

This Maltese looks healthy. Solid body. Good weight. He was much loved by the couple in their late 30s. We could spend lots of time talking about him just as parents loved to talk about their children if the world cares to hear.

"How was he toilet-trained?" I asked as this Maltese lapped up all attention. This was a case of paper-training in a confined playpen which can't be unhinged. The playpen has a door unlike most cheaper playpens sold at Singapore's pet shops. The newspapered floor area was 100% at first, reducing to a corner. The Maltese was given commands and praises to use the papers.

"How long does it take to paper-train him?" I asked.

"We can't remember. It was 3 years ago. A few weeks" the wife said.

The Maltese was coming in for neuter. Although not all undescended testicles become cancerous during old age, the owner heeded my advice to get the undescended testicle removed. Just in case they are not aware of the growth of the hidden under the skin undescended left testicle in later years.

I thought this would be a simple routine neuter. What is so difficult about neutering a docile Maltese that never bites and that looks as strong as any Maltese can be.
Gas mask 8% knocked him down fast. He was not the aggressive type so it was much easier to anaesthesize him.

I put in the endotracheal tube to connect the gas to his lungs as is my normal routine. It is best to intubate all dogs I always advise young vets. In this case, the dog stopped breathing and the tube could deliver emergency oxygen if required.

Anaesthetic complications do happen and intubation is important just in case of emergency. In this routine neuter case, gas mask will do. But it is hard to predict which dog will stop breathing. I would expect this Maltese to take gas mask anaesthesia with no problem. But he did stop breathing. Know what to do as there is not much time before death occurs.

The dog recovered well and the owners were most happy. Their e-collar was loose and had to be fitted so that the dog would not pull it out of the neck and lick his skin incision. Pain-killers are given as a routine in 2008. Just in case the dog licks the wound.

5. Restraining an aggressive Jack Russell for neuter

2008-06-05T13:24:00.000-07:00

He curled his upper lips up and bared his fangs if any outsider wanted to touch him. I had encountered such aggressive Jack Russells. Usually males.

What to do in such a case?

When the owner brings him in for neuter, ask the owner to restrain him for tranquilisation. In this case, I injected 0.2 ml of xylazine 2% tranquiliser IM as the owner arm-locked the dog.

I put the dog into the crate. Normal ones would feel sleepy. This dog was fully alert and baring his fangs 30 minutes later.

"What should you do?" I asked my new vet assistant who has to learn on the job. He took out a dog muzzle. His usual way was to put his hand beside the dog's chest and slowly touch the dog, moving the muzzle up.

The Jack Russell eyed his hand movement and snapped in anticipation of being handled by a stranger.

"The muzzle is of no use," I said. "What to do if you don't want to be bitten?"

The assistant was silent. He had to get the dog out of the crate to the surgery room for neuter. The dog was a bright as daylight waiting to pounce onto his hand.

What to do?
There are 2 ways. Use a thick towel and cover his head. Use a lasso over his neck and get him out.

He had never seen a lasso before and we used this method. The dog was not as strong as before. Gas mask using 8% gas anaesthesia knocked him down. An endotracheal tube was put into his lungs to bring the anaesthesia to keep him pain free. Surprising 1% anaesthesia instead of the usual 2% kept him pain-free for neutering. He was put in the crate after his skin wound was plastered.

No dogs would be allowed to go home till around 4 hours after surgery. Preferably overnight but most Singapore owners want their dog home in the evening or earlier.

In this case, the owner said he had an elizabeth collar but he did not bring it with him. So he needed not purchase one from the Surgery and increased his veterinary cost of neutering.

30 minutes later, my assistant said: "The dog is bleeding a lot!" The dog's muzzle was stained bright red. The newspapers were stained bright red too. The Jack Russell's eyes stared directly at me, pupils dilated, fangs exposed, ready to attack.

What to do?
I did not expect the dog to lick vigorously his surgical wound. Blood flowed and seeped into his scrotum. It looked as if he was not neutered as his scrotum swelled to the full. It seemed to be a "con" job from an outsider's point of view as the scrotal bags should be deflated with the removal of two testes.

How to handle this bleeding episode?
In this case, the dog's adrenaline level was at all-time high. He should not be given any tranquiliser or painkiller injection in case his heart fails and he dies attributed to adverse drug injections.

"As long as you stand in front of him," I said to the vet assistant. "He will not lick his wound. He has to look at you and anticipate when you are going to nap him." So the assistant stood around him for a full hour while I asked the owner to come down.

"I can't come down now," the owner said. He was working.

"You need to come down," I said. "Your dog is bleeding and he is too aggressive. When you come, he quietens down."

The owner and his daughter came with the e-collar. They did not comment but the bleeding was a lot and the swelling of the neuter site and the scrotum was as big as it could be. A few bright red drops of blood trickled out of the stitched area.

"This 12.5-sized collar will not stop the dog from licking," I said. The owner put in the 15.0-sized collar from the Surgery.

What to do now?

So the dog be put under anaesthesia and the wound opened up to drain the blood out? This was one option.

Now, the vet has to be aware that any anaesthesia or tranquiliser in this highly strung dog may or may not kill him as he had anaesthesia recently. A dead dog is never appreciated by the owner no matter how clever the vet surgeon is.

I had to choose the safer option of maintaining the status quo. Not doing anything.

"Take the dog home and put him in a cage. No running around the house." I advised the owner. "Tel me if the swelling gets bigger or there is more bleeding. The bleeding is due to the dog licking the wound vigorously and not due to the bleeding from the neuter." I showed the owner the extensive bluish black skin discoloration of the whole penile area bruised by the dog's tongue.

Could the dog's licking cause the sutures to loosen and cause bleeding from the spermatic artery and veins?

In my experience, this was not the case. In any case, I had ligated the stump twice and ensured the stump had gone back into the inguinal canal and probably into the abdomen. I ligate quite near the testes so as to minimise trauma by not stretching out the cord and separating the spermatic blood vessels from the cremaster muscle as I used to do. This is the open method. There are two methods of neutering and I use the closed method ligating the whole sheath with the spermatic blood vessels and the cremaster muscle inside nowadays. If the first ligation broke down during licking, there would be a second one.

Experience gained
An appropriate-sized e-collar should be given to any dog after neutering or spaying.
This is our usual practice although large breeds are seldom given e-collars. In this case, the owner said he had one. Although he did not bring it, we did not expect the dog to be so vigorous in his licking of the skin wound as he had a xylazine tranquiliser.

4. Siberian Husky bit the experienced vet assistant

2008-06-05T13:03:00.000-07:00

"Can you make a house-call?" the 5-year-old Siberian Husky owner asked. "My dog has some bleeding on the neck."

"It will be better and less expensive for you to bring the dog to the Surgery, using a pet transport person," I advised. "Your dog may need stitching. Your place may be not suitable for surgery."

"Why not bring your surgical instruments and do a house call?"

"Sometimes the dog may not be so easy to handle at the house and there may be more than one house-call needed. So, it will be most costly for you. I can get a pet transport man to bring the dog in."

When the Husky arrived, he had a line of five holes curving upwards in the right side of his neck. Dark brown blood trickled down. Some greyish things moved and appeared to peek out of the wounds. Like alien eyes staring at me.

They were maggot wounds. As the dog had a high fever, no tranquiliser was used to remove the wounds.

How to do it?

Muzzle the dog. Put him onto the table so that you can do the removal easily.

How the experienced vet assistant did it?

"The Husky bit my hand," the vet assistant showed me his left hand as one would show the battle wounds like a badge of honour. The new vet assistant was bitten too and showed his hand. The bites were not serious as they removed around 30 5-cm long maggots.

"You did not muzzle the dog," I shook my head. "You removed the maggots at floor level. You lease the dog in a corner and he was not in a position to escape. Don't you know dog psychology? If the dog is cornered and felt the pain of maggot removal, he will bite."

Siberian Huskies seldom bite people, in my observation. So, there was complacency even though the experienced vet assistant had more than 15 years of small animal practice.

I always advise the adoption of a safety procedure using muzzle to prevent being bitten. Sometimes, with years of experience under his belt, a vet assistant will take short cuts by not muzzling the dog or letting the owner do the muzzling.

It seems to be part of their daring personality. So they get bitten out of their complacency as they misjudge the docile behaviour of the Siberian Husky.

3. Spaying big dogs - bilateral alopecia

2008-05-26T14:42:00.000-07:00

EDUCATIONAL ARTICLE FOR VET STUDENTS

"My vet does not spay big dogs," the young couple said. "So I was asked to see you."
Big dogs take longer to spay. Big dogs with some fat as in this case may be much more difficult to spay if the vet uses hook and a small incision.

Personally, I do not look forward to spaying big fat dogs too. The spay hook gets obstructed and one gets omental fat coming out of the spay incision so many times.

In this case, the dog has a skin disease, with hair loss from back to past the chest. Now, if the vet has not informed the owner of this finding, the worsening of the skin condition some weeks after spay, leading to a "botak" (bald) dog might be attributed to the vet having spayed the dog or not informing the owner.

I advised treatment first. The dog was already 4th month after the ending of heat. There would need to be a waiting of another 4 months for the next spay and for the treatment of the skin disease.

"I will not be able to manage when she comes on heat in 2 months' time," the lady said she would be in later stages of pregnancy herself. Cleaning up the blood stains dripping over the floor for at least 2 weeks during the dog's estrus can be quite exhausting.

The dog was spayed and the gentle couple will need to follow up and monitor the skin disease. Vets need to let the owners know about pre-existing skin conditions before spaying the dog so as to build positive relationships and avoid misunderstandings.

2. 40 minute-spay surgery from incision to last stitch.

2008-05-22T21:24:00.000-07:00

May 23, 2008

12-year-old with large mammary tumours and sternal abscess.
Best not to operate immediately. Antibiotics for 2 weeks.
7.7 kg, 38.4 deg. normal.
Sternal abscess has reduced by 80% to 1 cm.

Young man brings in the dog as scheduled.
"Can spay be done together with removal of sternal abscess?" he asked.
"Yes," I said. "It is not good for the old dog as the anaesthetic time will be longer as the chances of the dog dying on the operating table increases as the anaesthesia is prolonged. The spay itself takes around one hour."

"I thought it takes 30 minutes to spay a dog?" the young man must have done his home work and research.

"Yes," I said. "In some cases, the surgery is as fast as 30 minutes. But if you include the pre-operation shaving, scrubbing and anaesthetic gas given, the whole procedure takes 1 hour.

He agreed to take one surgery at a time. Spay, then 2 weeks later, sternal abscess and then mammary tumour removal.

So, I started to time this spay surgery commenced at 10 am. The patient was not slim and there would be some difficulty accessing the ovaries.

Procedure:
The dog was clipped first. Then proceed to the operating room. Body stretched out tightly.

Gas anaesthesia was given by mask, taking around 15 minutes. Dog snoring. Intubated. Maintenance dose 2%.
Last 3 stitches 0.5% to 0%. Dog woke up within 2 minutes at end of anaesthesia.

SURGERY - Incision to last stitch is 40 minutes.
Incision 1 cm from umbilicus. Inserted the spay hook. Could not get the left ovary for 5 tries. Omental fat kept appearing. Getting desperate. Switch to hooking the right ovary. Intestine kept coming hooked out. What to do?

If the dog is slim, it would normally be easy for me to hook the left ovary after 1 or 2 tries. Hooked further caudally at 45 degree away from rib cage and liver.
Caught right uterine horn. What a relief. I hope not to get fat dogs to spay as they are very challenging hook cases.

So much fat surrounded the ovaries. Asked assistant to release the tension on front legs tied to strings. Ovarian ligament very tight. Extended incision cranially by 0.5cm, skin and linea alba. This extra space permitted the huge ovary to be pulled out.

How do I know it is the ovary? Connected to the uterine horn and a very tight ovarian ligament can be felt. High tension. I used the scalpel blade to rupture it. Ligate 2 times. Finally pulled out the left uterine horn and repeated process. Uterine body ligated 3 times. 3/0 absorbable sutures did not feel strong enough compared to 2/0. 3 simple interrupted sutures in the muscle layer. No fanciful continuous subcutaneous sutures. 2 horizontal mattress sutures in the skin. One packet of suture was fully used in this case.

This whole procedure took more than 60 minutes. Not much bleeding. Carprofen injection 0.5 ml given to prevent pain and swelling. Antibiotics. Dog should be going home in the evening.

NEXT STAGE
As the female hormones have had been removed, it is unlikely that the breast tumours will grow fast. 2 weeks later, scheduled for tumour removal plus removal of sternal abscess probably.

Could the dog be able to take the anaestehsia again?

1. FAQ. Dog Neuter - Owner's point of view

2008-05-21T15:35:00.000-07:00

QUESTIONS ON NEUTER FROM THE OWNER'S POINT OF VIEW

--- On Tue, 5/20/08, Dog Owner wrote:

Subject: Hello
To: judy@toapayohvets.com
Date: Tuesday, May 20, 2008, 3:06 AM

Hi
May I check what is the price for sterilizing a male Shih Tzu dog about two years old... how many days for them to recover. . thanks

Warmest regards
Name of Dog Owner

----- Original Message -----
From: David Sing
To: Dog Owner
Sent: Wednesday, May 21, 2008 2:48 AM
Subject: Re: Hello, dog neuter

I am Dr Sing.
Cost of surgery is S$150 if it is less than 5 kg. $200 if more than 5 kg. Should be able to eat by day 2.

--- On Wed, 5/21/08, Dog Owner wrote:

Subject: Re: Hello, dog neuter
To: drsing_98@yahoo.com
Date: Wednesday, May 21, 2008, 12:30 AM

Thank you Dr Sing. Does he needs to be hospitalized? Any other charges...how many days do I need to book in advance the appt? May I have your clinic number and full address.
Name of Dog Owner

Dog neuter at Toa Payoh Vets
Wednesday, May 21, 2008 10:20 PM
From:
This sender is DomainKeys verified
"David Sing"
View contact details
To: Dog Owner

Thank you for your reply. Will not need to stay overnight. Come in at 9 am and goes home in the evening.

Additional charges may be $20 for e-collar (if you don't have one) and $15.00 for painkillers and antibiotics.

Book 1 day in advance. No food and water after 8 pm. the night before. Clinic tel no. is 6254 3326. Address: Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074.