High Volume Spay and Neuter: A Safe and Time Efficient Approach

Description

Approaching high-volume spay and neuter as a separate discipline, this comprehensive reference addresses the unique challenges of this branch of shelter medicine. You will learn how to become faster at performing these procedures in a variety of settings, while still maintaining the safety of the patient. Safety is emphasized throughout with guidance on how to best treat patients with unknown medical histories and financial constraints that restrict the ability to do pre-anesthetic blood work. Special attention is given to considerations about surgical technique, as well as topics such as suture selection and size, suture pattern, patient order, medications, and aftercare. Coverage of mobile veterinary services examines how to provide low-cost spay and neuter to underserved communities with this emerging trend in the industry. Comprehensive coverage examines the "hows" and "whys" of the mechanics of high-volume spay/neuter, as well as how to manage complications that can occur.Written by Victoria Valdez, an experienced veterinarian who has performed more than 40,000 spays and neuters.Information on how to set up both a mobile and a stationary suite offers guidance for providing low-cost spay and neuter services in a variety of settings.Easy-to-read reference manual format ensures each chapter includes all pertinent information on a topic, eliminating the need to cross-reference throughout the book.Enhanced eBook on Expert Consult offers a fully searchable version of the text. Front Cover Inside front cover Front matter High volume spay and neuter: A safe and time efficient approach Copyright Dedication Acknowledgments Table of contents Section 1 Introduction 1 Introduction 2 Principles of high-volume spay/neuter Principles of high-volume spay/neuter The purpose of high-volume spay/neuter is trifold A high-volume problem requires a high-volume solution The unique client base associated with high-volume spay/neuter practice must be factored into protocols Certain risks are built into high-volume spay/neuter Certain benefits are built into high-volume spay/neuter The caseload must be balanced Workstations should be set up for maximum efficiency Doctor and staff must work in concert with each other as a team The surgery table should never be empty Little things can add up to large amounts of time saved The surgeon’s time should be reserved for surgery Safety always takes precedence over speed Protocol changes must meet safety standards Efficiency, not speed, is what makes high-volume spay/neuter possible Every effort should be made to make rechecks unnecessary High-volume spay/neuter surgeons must be prepared for unforeseen complications Nothing trumps experience 3 Scheduling Factors to consider when scheduling surgeries Predictable factors Unpredictable factors Factors that limit the number of surgeries that can be done in a day Average surgery time for each sterilization type Length of surgery time available per day Examination time Who does the examinations The number of large animals scheduled per day Calculations Calculating how many surgeries can be done in a day Calculating what an average surgery time needs to be to complete a given number of surgeries in a day A proposed new way of scheduling Why it is needed Relative surgery times Equivalency number based scheduling protocol A simplified scheduling protocol 4 Setting up the surgical suite Supplies needed for surgery set-up The surgery table area The side of the surgeon (fig. 4.1) Behind the surgeon Other considerations One table vs. two tables Two-table configurations (fig. 4.2) Where the surgeon stands Surgery packs Number and type of instruments Clamps Scissors “Extra” instruments Ergonomics Consider wearing a lifting belt Patient placement Type of surgery table Use a high-quality extreme standing mat Take a lunch break 5 Working as a team The team Administrative staff Licensed technician/anesthetic nurse Prep person Recovery person The doctor/surgeon Synergy between doctor and staff Support staff Doctor/surgeon Individual duties Morning check-in duties Midday/surgery duties Afternoon/postop duties 6 Establishing flow (the order in which patients are done) Principles for determining patient order Minimize contamination Be flexible: Do not leave the surgery table empty Do risky patients first Match preparation times with sugery times whenever possible Factors that increase surgery time Ancillary surgeries Difficult or unpredictable surgeries Factors that prolong preparation time Inhalant anesthesia Add-on procedures during preparation Fractious or feral patients Technician skill and availability In conclusion 7 Saving time in surgery Techniques that enhance safety and thereby save time Safely using the spay hook Making the incision more cranially in canines that have given birth Carefully breaking the suspensory ligament Placing ligatures securely Placing ligatures securely in large, obese, in estrus, or pregnant patients Closing incisions securely Providing thorough aftercare instructions Techniques that save time Tattooing to prevent unnecessary surgery Maintaining sterility between patients without rescrubbing ■ Do not pre-open gloves ■ Avoid bare hands between surgeries ■ The surgeon’s gown should be kept sterile ■ Rescrub when necessary Small incisions No skin sutures Section 2 Surgical Protocols 8 Small canine spay Protocol Make the abdominal incisions Exteriorize the right uterine horn Ready the right ovarian pedicle for ligation Loosen or break the suspensory ligament Ligate the ovarian pedicle with a miller’s knot Transect the pedicle cranial to the ovary Detach the mesometrium from the uterus Locate and ligate the left ovary/exteriorize the uterus Ligate the uterus Transect the uterus Close the linea alba with a cruciate suture Close the skin with a subcuticular mattress suture Consider applying a tattoo Apply tissue glue to the skin Other considerations Pregnancy, obesity, or estrus Lactation Troubleshooting The ligature on the ovarian pedicle is too close to the ovary The knot of the subcuticular suture will not bury 9 Large canine spay Make the abdominal incisions Exteriorize the right uterine horn Ready the right ovarian pedicle for ligation Loosen or break the suspensory ligament Place a second clamp Ligate the ovarian pedicle with a Miller’s Knot Transect the pedicle cranial to the ovary Detach the mesometrium from the uterus Locate and ligate the left ovary Ligate the two uterine arteries and the uterus Transect the uterus Close the linea alba with a continuous cruciate pattern Close the subcuticular tissue with a continuous subcuticular pattern Consider applying a tattoo Apply tissue glue to the skin Other considerations Pregnancy or pyometra Lactation Troubleshooting Bleeding from the abdominal incision 10 Standard feline spay Make the abdominal incisions Exteriorize the right uterine horn and right ovary Ready the right ovarian pedicle for ligation Loosen or break the suspensory ligament Ligate the ovarian pedicle with a Miller’s Knot Transect the ovarian pedicle Detach the mesometrium from the uterus Locate and ligate the left ovary Ligate the uterus with a Miller’s Knot Transect the uterus Close the linea alba with a cruciate suture Close the skin with a subcuticular mattress suture Consider applying a tattoo Apply tissue glue to the skin Other considerations Maintaining statistics Determining gestational age of feline fetuses in utero (table 10.1) Determining estrus status in a feline Troubleshooting Postpartum patients Lactation Cannot expose the uterine bifurcation 11 Auto-ligation feline spay Protocol Make the abdominal incisions Exteriorize the right uterine horn Perform an auto-ligation Ligate the uterus with a Miller’s Knot Close the linea alba with a cruciate suture Close the skin with a subcuticular mattress suture Consider applying a tattoo Apply tissue glue to the skin Other considerations Maintaining statistics Determining gestational age of feline fetuses in utero (table 11.1) Determining estrus status in a feline Troubleshooting Delicate ovarian vessels in very small kittens Abdominal closure is not flat 12 Canine scrotal neuter Protocol Make an incision along the scrotal midline Exteriorize the testicle Strip fat from the spermatic cord if needed Exteriorize both testicles before applying ligatures Ligate the spermatic cords with Miller’s Knots Repeat for the other spermatic cord and transect the cords Close the incision Consider a tattoo Troubleshooting Abdominal fluid (ascites) is present in the scrotum 13 Canine prescrotal neuter Canine prescrotal neuter protocol Position the first testicle Make the midline incision Incise over the testicles Exteriorize the testicles Transect the ligaments if needed Remove fat from the spermatic cord if needed Exteriorize both testicles before applying ligatures Ligate the spermatic cords using Miller’s Knots Transect the spermatic cords Close the peri-testicular incisions Close the skin Consider applying a tattoo Apply tissue glue to the skin Troubleshooting Scrotal bleeding Cannot exteriorize the testicle enough to sever ligamentous attachments 14 Feline neuter Protocol Position the patient Anesthesia Incise the scrotum Instill epinephrine Incise over the testicles Exteriorize the testicle Remove fat Perform auto-ligations Repeat for the other testicle Elevate the scrotum Allow to heal by second intention Consider a tattoo in kittens less than 4 months old Troubleshooting Fluid in the scrotum 15 Inguinal cryptorchid neuter Protocol Locate the cryptorchid testicle by palpation Remove the nonretained testicle If needed, make a prescrotal midline incision Manually relocate the testicle Expose the retained testicle Exteriorize the retained testicle Ligate the spermatic cord using a miller’s knot Close the incisions Consider applying a tattoo Apply tissue glue to the skin Troubleshooting Unable to move retained testicle sufficiently close to midline 16 Abdominal cryptorchid neuter Protocol Express the bladder Position the patient Retract the penis Make the ventral skin incision Make the abdominal incision Exteriorize the bladder Locate the bifurcation of the ductus deferens Trace the ductus deferens to the retained testicle Exteriorize the retained testicle and remove the vaginal tunic Ligate the spermatic cord and ductus deferens Transect the spermatic cord and the ductus deferens Return cord and ductus to abdomen Close the abdominal incision Close the skin Consider applying a tattoo Apply tissue glue Remove the other testicle Troubleshooting The cryptorchid testicle cannot be located in the abdomen 17 Ancillary surgeries (umbilical hernia, dewclaw removal, feral cat ear tipping) Umbilical hernia repair protocol Incise the skin Dissect the hernial sac Remove or replace the falciform fat Close the hernial ring Close the skin Nonattached dewclaw removal protocol Clamp the base of the dewclaw Excise the dewclaw Apply epinephrine Apply surgical glue to skin edges Glue the skin plantar-medial to the clamp Fold the skin over the glue Remove the clamp and hold in place while the glue dries Clean the clamp Skin sutures or bandages are not needed Ear tipping of feral cats protocol Induce anesthesia Clamp the ear Excise the ear tip Apply epinephrine Apply styptic powder Remove the clamp Other considerations regarding ear tipping The size of the ear tip The locaiton of the ear tip Ways to avoid ear tipping the wrong cat Section 3 Complications 18 Complications Splenic repair protocol Abdominal bleeding protocol Scrotal ablation protocol Preparation for major complications 19 Cardiac arrest CPR protocol Positions Assignments Crash cart Crash cart maintenance Training Index A C D E F H I L M P R S T U V