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

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"

"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

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

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

"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

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

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?