33 Tobias Uterus and Ovaries

what are 9 therapeutic benefits to spaying dogs

• prevent estrous cycles

• prevent unwanted pregnancies

• Pyos

• dystocia

• uterine or ovarian cancer

• vaginal hyperplasia/prolapse

• congenital clotting disorders

• diabetes melitus or epilepsy

• ↓infectious, degenerative, vascular dz, risk of trauma

spaying increases life expectancy by 26.3% for all female dogs EXCEPT

rottweilers

sterilized dogs are more likely to die from what 2 pathologies

neoplasia and immune mediated diseases

6 potential adverse effects of OVE/OVH

• obesity

• joint disease

• urinary incontinence

• poor development of external genitalia

• increased fear response

• decreased lifespan in some studies

what are 6 different dx to do pre-surgery

• PCV

• TP

• glucose

• renal function - see if NSAIDs are safe

• lactate - see if NSAIDs are safe

• breed specific diagnostics

3 drugs/things pre-surgery to reduce pain and MAC

• gabapentin, trazodone

• maropitant

• TAP block

**express bladder before surgery too

area to clip before surgery

xiphoid to pubis

incision in older puppies, adult dogs

cranial 3rd of distance between umbilicus and pubis

incision in cats and young puppies

middle 3rd between umbilicus and pubis

what is the main reason surgical errors are made in spays

incision is too small

• drop pedicle

• cannot see or retract tissues

2 ways to reduce pain in surgery

• lidocaine on susp ligament - reduce intraoperative and post-op pain

• splash lidocaine on SQ tissues - reduce post-op pain

what 2 things might you need on hand for dog spay with coagulopathies

• cryoprecipitate

• Fresh frozen plasma

2 things to avoid in coagulopathy dog spays (think of pre-sx and set up)

• IM injections

• penetrating towel clamps in skin

where does most bleeding occur in spays, and what should we do for dogs with coagulopathies to avoid this

• SQ tissues bleed the most

• careful handling of SQ + try to stay on linea

what are 3 things we should do in coagulopathy dog spays to prevent post-op bleeding

• ligate susp and broad ligament before cutting (place encircling ligatures below and before placing transfixing sutures)

• tack down subcutis to rectus fascia to reduce dead space

• place abdominal drain post-op

why do greyhounds have crazy SQ hemorrhage after spay/neuter

early or excessive fibrinolysis

what can we give greyhounds to mitigate bleeding risk

• epsilon aminocaproic acid (EAEC) - day of sx and 4 d after (total 5 d tx)

• tranexamic acid

what are 3 types of MINOR post-op spay complications

• post-op pain - resolves in 3 days

• incisional inflam

• GI upset

**risk of death is low at high vol spay clinics

what 2 factors predispose to incisional complications and hemorrhage

• larger animals

• longer anesthesia/sx times

what are 12 MAJOR complications of spay

• hemorrhage from dropped pedicle

• seroma

• ovarian remnant syndrome

• vaginal bleeding - trauma or inadequate ligation of uterine stump vesels

• incisional infection

• dehiscence

• urinary incontinence

• suture or sponge granuloma

• intestinal obstruction

• esophageal stricture - anesthesia thing

• accidental ligation of ureters instead of uterine body

hemorrhage rates are higher in what demographic of dogs

overweight dogs with surgeons throws and not constrictor knots

how to prevent seroma formation and pain

tacking down SQ fat to deep fascia during subcutis closure (quilting)

what 4 factors increase post-op infection rates (2.2-5.7%)

• larger dogs

• longer incisions

• inexperienced surgeons

• procedure > 90 min, anesthesia > 2 hr

Incisional dehiscence occurs in what percentage of animals and why

less than 1% and because of poor surgical technique

what is the process to address a dropped pedicle

• sponge on general area of bleeding

• extend incision cranially and place retractors

• move duodenum or colon (depending on what side you dropped)

• pick up vessel with thumb forceps - DO NOT CLAMP until you are sure it is NOT the ureter

What is the process of addressing uterine stump bleeding

• extend incision caudally

• retract bladder out of abdomen to expose stump

• grasp stump with thumb forceps before clamping

• make sure you are NOT ligating the ureters

4 causes of post-op vaginal bleeding

• uterine wall not crushed good

• uterine ligature erodes thru tissue

• uterine wall artery penetrated with transfixing suture

• stump infection

what to check for in dog with vaginal bleeding that does not stop with sedation and time, no infection but big anemia

coagulopathies

• then re-explore and ligate and culture uterine stump

post-op swelling differs from hernia how

hard welling and not reducible

• will resolve with time and limit activity levels

CS of ovarian remnant syndrome

• vulvular swelling or discharge

• breeding behavior

• signs of estrus

Ovarian remnant syndrome sequella

stump pyo if all that endometrial tissue becomes hyperplastic and infected

dx of stump pyo

• cornified vag cytology + CS heat

• AMH and progesterone levels - should be low

  • AMH decreases 14 days after sx so wait a little

• ultrasound or exploratory - right pedicle most commonly affected

• Tx: remove residual tissue

what happens when stump pyos go undiagnosed for years

become neoplastic

cause of pedicle granuloma and what is the result. How do we tx this

• cause: non-absorbable ligatures

• result: fistulous tracts that drain out flanks or sublumbar abdomen

• Tx: abdominal approach to remove

how do intestine obstruction and ischemia from a spay

• intestines herniate thru holes in mesentery

• entrapped because of adhesions of organs or mesentery to abdominal wall

adhesions

• locations

• CS

• dx

• tx

• locations: broad ligament, colon, uterine stump → colonic obstruction

• vomiting lethargy, constipation, dysuria, dyschezia, and focal abdominal pain

• Dx: ultrasound, rads - confirm with exploratory

• tx: intestinal resection and anastomosis and prognosis good before peritonitis present

what makes us more prone to ligate cat ureters

• closely associated with uterine body and cross over gonadal vessels

• drop pedicle or tie off with the uterus during spay

how to treat ligated ureter

• ureteral resection and anastomosis to the bladder

• unilateral ureteronephrectomy

CS of gossypiboma and how ot fix

• intermittent vomiting, diarrhea, pyrexia, pain, lethargy, weight loss and draining tracts from the flank

• because of adhesions remove sponge with surrounding tissues

does OHE increase risk of pyo or endometritis

NO - endometria and pyos require progestagens to develop

what risk is still present with an OVE over an OHE

future development of uterine tumors

• mostly benign leiomyomas

• but since stumps are left with OHE’s sometimes, risk ends up being about even with OVE vs OHE

2 reasons why clients want ovary sparing surgery

• prevent pyos

• avoid inconvenience of vaginal heat discharge

what borders must we remove in ovary sparing surgeries to prevent pyos

• ENTIRE uterus and proximal cervix - ideally take whole cervix because of remaining glandular tissue

• ligate between horns and ovaries

what is something to warn the owners about with ovary sparing procedures

• still experience hormones of estrus (vulvar swelling, behavioral changes)

• attract males and can result in vaginal rupture and peritonitis if try to mate 2 mo post-op

4 reasons why do owners come back to do OHE after ovary sparing techniques

• undesirable heat cycles

• mammary gland neoplasias

• cystic ovaries

• diabetes

what are 2 indications to do a flank spay in cats

• mammary fibroadenomatous hyperplasia

• lactating cats

**plus they are faster and have small incisions with the right surgeon

4 cat flank spay post-op complications

• wound drainage

• dehiscence

• infection

• bleeding

**esp catch and release cats

benefits of autoligation/pedicle tie

• low complication rates

• hemorrhage is detected during surgery and rarely fatal

• 2 min faster

• students have better success with them

laparoscopic OVE/OHE benefits and cons

• 50% longer procedure

• more active/less painful after sx

• cats same pain as normal spay, but have more inflammation

• only a 12 mm incision necessary

• OHE is hard so often OVE is done instead

pyometra risk is greatest in what set of dog breeds < 10 yr age

>50% risk!!

• BMD

• great dane

• leonbergers

• rottweilers

• irish wolfhounds

• stafforshire bull terriers

• keeshound

• bull terriers

• bouvier

• newfoundland dogs

lowest risk of pyometra dog breeds (<10%)

• spitz

• maltese

• coton de tulear

• salukis

• gordon setters

which cats have high risk of pyos compared to DSH

• Norwegian forest cats

• siamese

what is the incidence of pyos in intact dogs

0-16% (median 4%)

before pyometra sx what should be done pre-sx to help animal and dx conditions

• IV fluids

• electrolyte and glucose if needed

• broad spectrum abx

• coag panels, platelet count

• blood cultures

• blood pressure

What is the pathogen most commonly seen in pyos

E. coli

• affinity for progesterone sensitized endometrium and myometrium

dog with pre-sx leukopenia have high risk of what

peritonitis

how does pyo sx differ from spay

• longer incision - get the whole pyo out and under lap pads

• no spay hooks

• no claps/use atramatic clamps (doyens)

• suspensory ligaments stretched out already

• one encircling distal and 1-2 transfixing proximal

• NO oversew stump - will end up leaving behind badness

• cysto to rule out UTI

• lavage with warm saline

• place abdominal continuous suction drain if peritonitis

how long do we continue IV fluids for after pyo sx

until animal is eating and drinking

what do we look out for with white cell count after pyo sx

• HIGH 1 day post-op

  • improved 2-3 d later, normal after a week

when do we decide to use post-op abx for pyo sx

• case by case

• if cystitis/peritonitis present - do based on C&S and tx for 3-7 d

  • culture 1 wks after abx stopped to verify resolution

what lab value should be monitored post pyo sx

renal function and UA q 6-12 mo because dogs with pyo often have renal dz

complications of pyo sx related to what

surgical site infections and suture reactions

3 really bad post-op pyo sx complications

• sepsis, endotoxemia, peritonitis

• UTI

• neuro, osteomyelitis, spleen infarct 5-6 days post op

mortality rate of pyo sx

1-8%, 57% in dogs with ruptured pyos and secondary peritonitis

most common congenital abnormality of uterus

Unicornuate uterus

• others: segmental agenesis and uterine horn hypoplasia

what other congenital abnormality is commonly present with uterine abnormalities

ipsilateral renal agenesis (dogs > cats)

where are ovaries when you have animal with uterine anomaly

• both ovaries present

• more cranial than normal

with segmental agenesis what happens to the unaffected portion

cr filled with fluid

uterine anomalies are associated with what in cats

ectopic and mummified fetuses

uterine prolapse associated with

prolonged parturition

• one or both horns intussuscept into cr. vaginal and vulvar

CS, dx, Tx of uterine prolapse

• CS - hemorrhagic shock, pain, perineal bulging, or excessive grooming.

• Dx - index finger can be slipped between the prolapsed tissue and vestibular wall

• Tx - stabilization, manual reduction with temporary vulvar suture closure OR amputation and OHE in dorsal recumbency with all areas prepped and draped

causes and CS of uterine torsion

• causes: uterine distension from pregnancy, dystocia, pyometra, or a mass (e.g., an endometrial polyp)

• CS = “acute abdomen” - abdominal pain, pyrexia, anorexia, and vomiting and dystocia in pregnant animal

how to tx uterine torsion

• fetuses can be successfully passed from the unaffected horn.

• cats, uterine torsion may cause severe anemia

3 uterine rupture associated conditions

• pyo

• torsion

• trauma

how to repair uterine rupture

• small tears- unilateral ovary or uterine removal

• OHE for larger tears, severe hemorrhage or pyos

• lavage abdomen

• place abdominal drain for peritonitis

most common uterine mass in dogs

endometrial polyps from cystic endometrial hyperplasia

what are the types of uterine cancers dogs can get

• leiomyoma - most common in intact female dogs

• lymphoma, hemangiosarcoma, fibroma, mast cell tumor, leiomyosarcoma,

  poorly differentiated sarcoma, and SCC

• = can lead to uterine horn torsion, rupture, compression of abd organs, and predispose to pyos

tx of dog uterine masses

OHE including cervix

most common uterine mass cats and how to tx

• endometrial adenocarcinoma - < 1 yr age

  • focal uterine T-cell lymphoma has been dx before too

• Tx - OHE ± chemo