51. When to operate on a closed pyometra case?

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

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.




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