An Atlas of Veterinary Surgery, 3rd Edition (VetBooks - Ir)

An Atlas of
Veterinary Surgery
JOHN HICKMAN
JOHN HOULTON
BARRIE EDWARDS
THIRD EDITION
-.le --- =---" -------- ~--
/ Blackwell
_.. . _. _---..;J Science
An Atlas of
Veterinary Surgery
An Atlas of
JOHN HICKMAN MA, FRCVS
FORMERLY READER IN ANIMAL SURGERY
DEPARTMENT OF CLINICAL VETERINARY MEDICINE
UNIVERSITY OF CAMBRIDGE
Veterinary Surgery
JOHN E.F. HOULTON
MA, VetMB, DSAO, DVR, MRCVS
UNIVERSITY SURGEON
DEPARTMENT OF CLINICAL VETERINARY MEDICINE
UNIVERSITY OF CAMBRIDGE
BARRIE EDWARDS
BVSc, DVetMed, FRCVS
PROFESSOR OF EQUINE STUDIES
DEPARTMENT OF VETERINARY CLINICAL SCIENCE
UNIVERSITY VETERINARY FIELD STATION
LIVERPOOL
THIRD EDITION
b
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ISBN 0-632-03268-5
All rights reserved. No part of this
publication may be reproduced, stored
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in a retrieval system, or transmitted,
Cataloging-in-Publication Data
in any form or by any means,
electronic, mechanical, photocopying, Hickman, John.
recording or otherwise, except as permitted An atlas of veterinary surgery/
by the UK Copyright, Designs John Hickman, John E.F. Houlton,
and Patents Act 1988, without the Barrie Edwards. - 3rd ed.
prior permission of the copyright p. cm.
owner. Includes bibliographical references
(p. ) and index.
First published 1973 ISBN 0-632-03268-5
Italian edition 1977 I. Veterinary surgery - Atlases.
Spanish edition 1977 I. Houlton, John E.F.
Second edition 198o II. Edwards, Barrie. III. Title.
Portuguese edition 198o SF911.H5 1995
ELBS edition 1983 636.089'791 - dczo
Third edition 1Q95
Set by Setrite Typesetters, Hong Kong

Printed and bound in Great Britain
at the University Press, Cambridge
Contents
PREFACE TO THIRD EDITION vii
PREFACE TO FIRST EDITION viii
1 GENERAL SURGICAL PRINCIPLES .r

Operating theatre routine, 3; Preparing the patient, r r; Surgical
approach, 15
2 SURGERY OF THE HEAD AND NECK 27

The external ear, 29; The face, 33; The mouth, 41; The poll, 44; The neck,
46; The mandible, 58
3 ABDOMINAL SURGERY 61
Laparotomy, 63; Gastro-intestinal surgery, 68
4 SURGERY OF THE GENITO-URINARY

SYSTEM
Castration, 85; Caesarean section, 97; Cystotomy, 99; Urethral
obstruction, 101; Amputation of the penis, 107; Ureteral ectopia, rro
5 SURGERY .OF THE MAMMARY GLAND II3

AND TEAT
Mammary neoplasia, n5; Teats, 116
6 HERNIA AND RUPTURE II9

Incarcerated hernia, 121; Umbilical hernia, 121; Inguinal hernia, 124;
Rupture, 126
7 THORACIC SURGERY 129

Thoracotomy, 131
8 OPHTHALMIC SURGERY
Eyelids, 143; Nictitating membrane, 145; Cornea, 146; Intraocular surgery,
148; Surgery of eye trauma, 150; Ophthalmic instruments, 152
9 NEUROSURGERY 155
Nerve suture, 157; Neurectomy - horse, 157; Cervical spine, 158;
Thoracolumbar spine, 163; Tibial neurectomy - calves, 164
10 ORTHOPAEDIC SURGERY
Thoracic limb - horse, 172: Elbow, 172; Carpus, 173; Metacarpus, 177;
Fetlock joint, 18o; Phalanges, 182; The foot, 184; Thoracic limb - dog,
186: Shoulder joint, 188; Humerus, 191; Elbow joint, 193; Radius and ulna,
199; Carpus, 205; Phalanges, 206; Pelvic limb - horse, 207: Stifle joint,
207; Hock joint, 210; Pelvic limb - dog, 211: Pelvis, 211; Hip joint, 212;
Femur, 218; Stifle joint, 222; Tibia, 230; Hock joint, 232; Orthopaedic
instruments, 236
v
VI CONTENTS
11 AMPUTATIONS 245
Amputation of a limb, 247; Amputation of digits, 252; Amputation of a tail
(docking), 256
12 MISCELLANEOUS PROCEDURES 259

Repair of accidental skin wounds, 261; Tendon injuries, 261; Prolapse
of the rectum, 264; Excision of anal sacs - dog, 264; Caslick's operation
for pneumovagina - mare, 265; Perinea! reconstruction - mare, 266;
Cryotherapy, 267
BIBLIOGRAPHY
INDEX
Preface to
Third Edition
Since the publication of the first edition there have been many changes
in operative surgery. Fundamental changes have occurred such as the
development of synthetic absorbable suture materials and the refine-
ment of anaesthetic techniques. Improved understanding of tissue
healing has lead to new suture patterns being adopted and the develop-
ment of new instruments, such as staple guns and arthroscopes, has
changed many procedures, particularly in equine surgery.
It would be impossible to include all of these in one volume and
maintain the original concept of the Atlas. Thus we have attempted to
concentrate on the basic surgical procedures and make no apology for
omitting others. A bibliography is provided from which readers can
obtain information about those not included here.
The original format is largely unchanged although many new figures
have been included and new procedures added. Section 10 has been
considerably revised in view of the now widespread application of the
AO/ASIF principles of fracture repair. The terminology has been
changed to conform with that used in Anatomica Veterinaria, although
to maintain the style of the first edition some terms in common usage
have been retained.
Sadly, Robert Walker is no longer with us although his influence is
still very much in evidence. I am pleased, however, to welcome my two
new co-authors, happy in the knowledge that they will perpetuate
Robert's ideals. These ideals are summed up by the words of Sir
Robert Hutchinson who wrote 'from inability to let well alone, from
too much zeal for the new and contempt for what is old, from putting
knowledge before wisdom, science before art and cleverness before
common sense; from treating patients as cases, and making the cure of
the disease more grievous than the endurance of the same - Good
Lord, deliver us'.
JOHN HICKMAN
Vil
Preface to
First Edition
The best way of learning to perform an operation is to assist or watch

an expert. Therefore any book on operative surgery must emphasize
the visual aspects. In this book we have attempted to illustrate by line
drawings and diagrams most of the standard surgical procedures
employed in veterinary surgery. We have tried to describe each
operation stage by stage with drawings, and have only used captions
and text for clarification. No two. surgeons perform an operation in
exactly the same way. In consequence we have concentrated on the
standard techniques that have stood the test of time and have illustrated
those methods which we, through experience, have come to prefer. No
attempt has been made to introduce accepted variations or operations
which can only be performed in special centres.
To prevent unnecessary repetition care has been taken not to over-
illustrate or to duplicate simple procedures. Some operations are
difficult to illustrate satisfactorily with drawings and in these cases
diagrams have been introduced. At the same time special attention has
been given to the accuracy of anatomical relationships, although only
the important blood vessels and nerves have been included.
The book is divided into 12 sections, each of which deals with the
surgical procedures either on a regional basis or as a surgical discipline.
The illustrations for each operation have been arranged in sequence
with accompanying captions and explanatory text interposed.
Although this book deals essentially with the technique of individual
operations we considered it would not fulfil its purpose unless the basic
surgical . principles, not only of each body system, but surgery in
general were introduced. This latter has been dealt with in Section 1
and has been reduced to the practical measures we employ and have
found adequate.
As far as possible the anatomical terminology of Anatomy of the
Domestic Animals by Sisson and Grossman and Anatomy of the Dog
by Miller, Christensen and Evans has been used except where common
usage has demanded otherwise. A bibliography has been included at
the end of the book which includes standard and more recent works to
give readers an introduction into the literature, should they wish to
pursue any specific aspects in more detail. Most of the orthopaedic
instruments in daily use which have not been illustrated in the text will
be found at the end of Section IO - Orthopaedic Surgery.
Primarily, this book has been written for veterinary students, but it
is hoped it will serve as a useful book for those engaged in general
practice.
Vlll
Section 1
General Surgical Principles
I
I
i
I
The success of operative surgery depends not only and finally the exploration of grossly infected tissue
on an understanding of the basic principles of such as infected sinuses and fistulae.
dividing tissues, haemostasis and wound closure Potentially infected cases should always be kept
but also on a well-equipped operating theatre which to the end of a surgical list and particular care
is maintained by a trained staff who have an should be taken to avoid the transfer of infection
organized and established routine for sterilizing through instruments, drapes and clothing. To this
instruments and for preparing and assisting at end, it is normal practice in operations that involve
operations. opening portions of the gastro-intestinal tract to
No operating theatre provides all the ideal make use of an additional, distinctively coloured
requirements but this is no excuse for not attaining side-towel. On this towel are placed all the instru-
the highest possible acceptable standards of asepsis ments that are used to open and close the bowel so
within the theatre facilities and the equipment that they may be discarded as potentially contami-
available. nated before abdominal closure is undertaken.
I The types of operation vary. from those carried 2 It should be an established rule that no persons
out on normal uninfected tissues such as routine shall be permitted to enter the operating theatre
ovariohysterectomy and most orthopaedic pro- without first changing into appropriate protective
cedures; operations on the gastro-intestinal tract, clothing, which should include theatre boots, cap,
during which the intestinal contents may contami- mask and scrub suit.
nate both instruments and the surgeon's hands;
Operating theatre routine

PREPARING THE INSTRUMENT
TROLLEYS
If trolleys are prepared for a series of operations it

is impossible to guarantee their sterility even if
they have been carefully covered and therefore
instrument trolleys should be prepared immedi-
ately before the operation (Figs r.1-r.5).
Fig. 1.1. The surface of
the trolley is wiped clean
PREPARATION OF PERSONNEL
with an antiseptic
After the instrument trolley has been prepared the solution ( 1 per cent
cetrimide BP).
nurse then gets ready to assist with the operation.
This involves scrubbing-up and putting on a sterile
gown and gloves.
Scrubbing-up
Care must be taken when scrubbing-up to ensure

the hands and forearms are cleansed thoroughly
with special attention being paid to the nails and
between the fingers. See Figs 1.6-1.11.
Putting on a sterile gown
As it is impossible to render the hands completely Fig. 1.2. Using Cheatle

sterile by washing and scrubbing they must not forceps the trolley is first
covered with a sterile
come into contact with any part of the outside of
impervious material
the gown. See Figs r.12-r.i4. and then with a sterile
drape.
3
4 SECTION If GENERAL SURGICAL PRINCIPLES
Fig. 1.3. The sterilizer is opened and the autoclave tray withdrawn. Fig. 1 .4. Instrument tray being removed from the sterilizer and
placed on the draped instrument trolley.
Gallipot Receiver
Tray with suture materials
-, \ /
Bowl of swabs
Tray containing
general instruments ---
Sucker tubing
and ends
Instruments
pertaining to
specific
operation
Fig. 1.5. After the instrument tray has been placed on the trolley the instruments and accessories arc laid out using
sterile Cheatlc forceps. This figure shows a standard general instrument trolley.
OPERATING THEATRE ROUTINE 5
Fig. 1.7. The forearms and hands arc scrubbed with a conventional nail brush and soap
for not less than 3 minutes with special attention to the nails and between the fingers.
Fig. 1.6. The hot and cold water taps arc adjusted to
obtain a satisfactory flow of water at an agreeable
temperature.
Fig. 1.10. The sterile towel for drying the

hands is removed from a drum.
Fig. 1.8. The correct position of the arm when Fig. 1.9. The correct method of using the
rinsing to ensure that the water flows from the elbows to turn off the taps.
hand to the elbow.
6 SECTION I/ GENERAL SURGICAL PRINCIPLES
Fig. 1.13. Correct method of putting on a sterile gown:

Stage 1. The arms arc thrust through the sleeves and then
held up to allow the gown to unravel and fall into
position.
Fig. 1. II. Correct method of drying the hand and

forearm. Note that the elbow is dried last.
Fig. 1.12. Correct method of unfolding a gown. Note Fig. 1.14. Stage 2. Assistant adjusts the gown from
that it has been folded with the inside to the outside to behind and tics the tapes.
prevent the outside coming into contact with the hands.
Putting on sterile gloves
The principle of putting on sterile gloves ensures

that at no time does the hand come into contact
with the outside of the gloves. The gloves in their
paper envelope are lifted out of the drum and
placed on a sterile towel. The envelope is then
opened so that the packet of powder and each
glove can be removed separately.
Open method
For method see Figs 1. 15- 1. 17.
Fig. 1.15. The right-hand glove is picked up with the left

hand, holding the inside of the cuff only, and the right
hand inserted .
.Fig. I. 16. The left-hand glove is picked up with the Fig. I. 17. Correct method of turning back the first cuff.
gloved right hand and held so that it is only in contact The second cuff is turned back in like manner.
with the outside of the glove. The left hand is then
inserted.
risk of contamination caused by touching the wrist

Closed method
while pulling the cuff of the glove over the sleeve
The closed method (Figs 1.18-1.21) reduces the of the gown.
Fig. 1.18. The left hand is kept within the sleeve of the Fig. 1.19. The fingers of the left hand arc worked
gown so that no partof the hand is exposed. The glove is through the end of the gown as the glove and sleeve of
grasped by the gown-covered right hand and laid along the gown arc pulled simultaneously over the wrist. The
the left wrist. right hand is kept within the sleeve of the gown. The left
glove only comes into contact with the right-hand sleeve
of the gown.
Fig. 1.20. The right-hand glove is put on in similar Fig. 1.21. The glove and sleeve are then pulled over the
fashion to Fig. 1 .19, keeping the fingers within the sleeve wrist.
of the gown until the glove is over the wrist. The glove of
the left hand only touches the outside of the right-hand
glove and the sleeve of the gown.
Glove drum
Gown drum
Hand towel drum
Glove trolley
Fig. 1.22. A suitable layout of facilities to enable theatre personnel to proceed from scrubbing-up to putting on sterile
gloves in an orderly and methodical manner.
Allis tissue
Counted swabs: 2 packs of 5 forceps
PREPARING FOR THE OPERATION Kocher forceps
The theatre nurse having prepared the instrument

trolley and put on a sterile gown and gloves has
next to arrange the instruments. These have to be
placed so that she can most readily assist the i.--=.,.;;:;.---'- Diathermy lead
surgeon throughout the operation. with point
In most cases this is best attained by laying up a
Mayo table with a set of general instruments and
swabs from the instrument trolley (Fig. 1 .23). The
Mayo table is placed over the foot of the operating
.......____ Scalpel, scissors,
table where it is accessible to both surgeon and Mayo (straight
nurse (Fig. 1.24). The instrument trolley is then and curved),
left with any special instruments required for a forceps, dissecting
(plain and toothed)
particular operation, reserve instruments and swabs
and suture materials for closure.
In addition to instruments there are certain items
of operating theatre equipment which are essential
if acceptable standards of surgical practice are to
be attained. These include a transfusion stand,
swab rack, suction machine and diathermy unit
(Figs 1.25-1.27).
Fig. 1.23. Mayo table with instruments for immediate

use.
IO SECTION I/ GENERAL SURGICAL PRINCIPLES
Fig. 1.24. Arrangement of instrument trolley

and Mayo table in relation to the patient. The
nurse stands with the instrument trolley on her
left and facing the surgeon on the opposite side
of the table.
Fig. 1.25. Swab-rack. It is necessary to have a system to check the

total number of swabs used during an operation. Swabs should be
packed in units of five and the number ofpacks put out for each
operation indicated on the swab-rack. Used swabs are hung upon the
rack and are counted at the end of the operation. This figure
Fig. 1.26. Portable suction machine. Essential for
subtracted from the total put out should give the number of unused
aspirating fluid from the abdominal or thoracic cavities,
swabs. Any discrepancy must be accounted for before the incision is
nasopharynx, trachea and bronchi. It is important to
closed.
ensure that the tubing is in good condition, without
In addition, blood lost during surgery can be easily estimated by
punctures and of adequate bore to prevent blockage or
weighing each pack of swabs and each swab used. This information is
collapse.
essential if the blood loss is to be accurately assessed.
These machines have a spark-free switching
mechanism and a flame-proof motor. They arc all
basically of the same design. The pump creates a vacuum
in the glass suction bottle into which the aspirated fluid
collects. Incorporated into the cap of the suction bottles
are internal connections to the pump unit and external
connections for the suction tubing. It is advisable to
select a unit to which two suction tubes can be connected,
one for use by the surgeon and the other for the
anaesthetist.
PREPARING THE PATIENT II
Fig. 1.27. Surgical diathermy unit. A surgical diathermy machine produces a high
frequency alternating current ranging between 500 kilocycles and 5 megacycles. When
this current is passed through the body from a large neutral or indifferent electrode to a
small active electrode there is an intense concentration of current under the small active
electrode. This produces a destructive heat effect which results in the coagulation or
disruption of the tissues immediately under the active electrode.
The local effect depends on the waveform. An interrupted waveform results in the
coagulation of tissues and therefore is used to seal blood vessels and avoids the need to
ligate them. A continuous waveform produces a destructive effect on the tissues and is
used for cutting.
A variety of active electrodes arc available which range from long needles for
coagulation to small blades for cutting. These electrodes fit into an insulated handle
which has a standard socket to enable electrodes to be easily changed during an
operation.
It is necessary to complete the electrical circuit back to the machine after the current
has passed through the patient. This is achieved by a second large neutral or indifferent
electrode and conductive gel.
When using a surgical diathermy machine care must be taken to prevent burns of the
patient. These can occur if the indifferent electrode becomes dry or any exposed part of
the patient comes in contact with any metal parts of the operating table or accessories.
Also the possibility of explosions exist if anaesthetics such as ether or cyclopropanc arc
being administered.
Preparing the patient

Care must be taken to bring the patient to the ing or to interference with the normal circulation
operation table in the best possible state to with- of fluid and electrolytes within the body as occurs
stand both the anaesthetic and the surgical pro- in cases of intestinal obstruction.
cedures. To this encl attention must be directed to Such losses initially cause a reduction of the
premcdication to overcome fear and anxiety, to extracellular fluid volume and are borne by the
ensuring that the circulating body fluids are within interstitial fluid, but if the losses continue they lead
normal limits and that the operation site has been to reduction in the circulating blood volume, to
rendered aseptic. impaired renal function, and to changes in the
Prolonged starvation or depriving the patient of acid-base balance of the body. The body responds
fluids is not recommended. In the dog, food need to a diminished circulating blood volume in the
not be withheld for more than 2 or 3 hours prior to early stages by selective vaso-constriction. As this
surgery even for operations on the gastro-intestinal is likely to be inhibited by the induction of general
tract. In the horse a bran mash should be given the anaesthesia it is important to assess fluid and elec-
evening prior to surgery, after which it must be trolyte deficits so that they may be replaced before
muzzled but an opportunity to drink to within 3 surgery is undertaken.
hours of operation is permissible. In prernedicated Fluid therapy should always be given by the
operations on ruminants water should be withheld intravenous route and preferably into the jugular
for at least 6 hours and green foodstuffs and other vein. The use of the jugular vein allows the patient
easily fermentable food for at least 24 hours before to move about with relative freedom without
anaesthesia. danger of obstructing the drip flow, and also
enables measurements to be taken of the central
venous pressure. Modern disposable equipment
PRE-OPERATIVE FLUID THERAPY
makes intravenous therapy a comparatively simple
Many disease conditions give rise to abnormal undertaking, and the use of pliable intravenous
losses of fluid and electrolytes from the body. cannulae overcomes many of the difficulties that
These losses are due either to diarrhoea and vomit- used to be associated with long-term intravenous
therapy in animals. The carefully tapered end of all

plastic cannulae is easily damaged and splayed, in
which state it can inflict serious damage to the
endothelium of the vein. In all cases, therefore, a
small skin incision must first be made under local
anaesthesia at the proposed site of venepuneture
so that the needle and plastic cannula (Fig. 1 .28)
Fig. 1.28. Plastic trochar and cannula for short-term intravenous infusion, consisting of
have to penetrate the minimum of tissue before
(I) plastic cannula, (2) needle, and (3) obturator with rubber diaphragm. The assembled
puncturing the vein wall. Jugular venepuncture is cannula is inserted into the vein and the needle and obturator arc withdrawn. The
greatly simplified if the dog is restrained on its cannula is fixed in position by means of a skin stitch.
side, and a small sandbag is placed under its neck.
Estimation of fluid loss

The clinical examination of a dehydrated animal
will show the characteristic signs of venous engorge-
ment of the conjunctiva, dry mucous membranes Balloon distended
and a dry inelastic skin, but various other methods with water
are available which enable the extent of the fluid
loss to be more accurately assessed:
I The haematocrit or packed cell volume will be
increased in cases of dehydration.

2 Plasma protein levels will be raised. This esti-
mation tends to be more helpful than the haema-
tocrit which may be misleading in cases of
established anaemia.
3 Blood urea levels are raised when haemoconcen-
tration leads to poor renal perfusion, but they are
also raised in cases of primary renal dysfunction.
4 Urinary output is naturally reduced when renal
perfusion is poor. A measured increase of the 6
urinary output is of value in order to assess the 6
6
efficacy of rehydration. Repeated catheterization t
of the bladder is undesirable owing to the risk of Water ---------- Non-return valve
introducing infection, and use should be made of Fig. 1.29. The Foley self-retaining catheter for use in the female. The catheter is
an indwelling catheter (Fig. I .29). Urine may then inserted and the small balloon inflated by water injected into the non-return valve.
be continuously collected by attaching a plastic bag
to the catheter, or the catheter may be blocked by
an obturator, and urine collected at regular inter-
vals. In the male, a polythene catheter is inserted
into the bladder, fixed by means of a stitch through
the corpus cavernosum of the penis, and then cut
off so that I cm of catheter protrudes from the end
of the penis. The end of the catheter will thus lie
within the prepucial orifice and will not be inter-
fered with by the patient.
5 Monitoring the central venous pressure (CVP).
Measurement of the CVP is a valuable indication of
both the fluid deficit and of the amount of fluid that
may safely be given to rectify that deficit. It is thus
a dynamic guide to the blood volume in relation to
the pumping ability of the heart.
A suitable flexible cannula is inserted into the
jugular vein, so that its tip lies adjacent to the right
atrium. The cannula is attached by one limb of a
PREPARING THE PATIENT 13
Normal CVP
Zero on scale level with right atrium +4to +6cm
of saline
+10
+5
-5
-10
(a) (b) (c)
Fig. 1.30. (a) The saline reservoir is connected to the jugular cannula. (b) The three-way tap is turned to connect the
saline reservoir to the manometer tubing, which is filled to some 10-.12 cm above the zero mark on the scale. (c) The
manometer is connected to the jugular cannula. The saline level will drop until it approximates in pressure to the blood
in the right atrium, at which level it will oscillate up and down in time with respiration.
Normal CVP in the dog is between +4 and +6 cm of saline. A negative CVP is invariably an indication of severe
hypovolacrnia. In these circumstances, fluid may be run into the patient until a normal CVP is established. Care must be
taken in cases where the CVP is higher than normal, as this is an indication of right-sided heart failure.
three-way tap to a bag of saline, and by the other operation proceeds. Major haemorrhage can be
limb to a piece of open ended, flexible transparent avoided by following lines of cleavage to avoid
drip tubing of at least 120 cm in length. This must blood vessels and by isolating and ligating large
dip well below the level of the patient so that it blood vessels, but the innumerable small blood
provides a reservoir of saline sufficient to prevent vessels which are unavoidably severed have to be
air being aspirated into the jugular vein. A length picked up with artery forceps and either tied off or
of at least 45 cm of this open-ended tubing is sealed by diathermy.
strapped to the giving-set stand alongside a centi- A tourniquet can be used to produce a bloodless
metre scale, which is adjusted with the zero mark field for operations on the limbs (Figs 1.31-1.33).
on a level with the patient's right atrium. Once this Before applying a tourniquet the limb is exsangui-
tubing is filled with saline and is connected to the nated by means of a rubber bandage applied from
jugular cannula, it acts as a simple saline mano- the foot to the level of the tourniquet.
meter, giving a direct reading of the pressure of A tourniquet correctly applied will compress the
venous blood in the right atrium (Fig. 1.30). vessels sufficiently just to stop the arterial flow. If
excessive pressure is used or if a tourniquet is left
on an exsanguinated limb for more than I hour the
Control of haemorrhage
ischaemia may result in damage to muscle and
It is ideal to perform an operation in a bloodless nerve fibres.
field. In the majority of cases this is not possible When a tourniquet is used to produce a bloodless
and haemorrhage has to be dealt with as the field it is important that, as far as possible, all large
Fig. 1.32. A length of rubber tubing is used as a tourniquet and tied above the elbow. In
the hind leg it is tied above the stifle joint.
Fig. 1.31. The front leg of a dog being cxsanguinatcd by

applying a rubber bandage from the extremity.
blood vessels are conserved, but if severed they

must be ligated. Many small vessels will be severed
and when the tourniquet is released considerable
haemorrhage will occur. This haemorrhage may be
prevented either by releasing the tourniquet and
picking up the blood vessels before closure or
controlled by applying a pad and pressure bandage
before releasing the tourniquet. The latter method
saves time and although inevitably there is some
haemorrhage it is of little consequence.
PREPARING THE
OPERATION AREA
The principle of aseptic surgery aims at preventing Fig. 1.33. The rubber bandage is unravelled from the extremity to expose the operation
bacteria from contaminating the operation area. site.
Theoretically it is possible to operate in a sterile
atmosphere, with sterile instruments and the site
surrounded by sterile drapes, but the skin itself is on removing the hair and dirt which protects the
impossible to sterilize completely. bacteria from the enzymes and then sterilizing the
Normal healthy skin produces enzymes which skin by the application of an antiseptic.
destroy most pathogenic organisms on its surface In elective procedures the first pre-surgical skin
and the organisms present in the hair follicles, preparation is performed in the kennel or loose-
sebaceous and sweat glands arc generally non- box and consists of clipping the hair and washing
pathogenic. Unfortunately the pathogens are de- the site clean with a cationic detergent and bacteri-
stroyed but slowly and many are located in hairy, cide such as I per cent chlorhexidine (Fig. 1 .34). If
dirty and greasy areas which arc inaccessible to the an open or contaminated wound is present it must
enzymes. Therefore the skin preparation is based be thoroughly cleaned under anaesthesia before
SURGICAL APPROACH 15
Fig. 1.34. (Righi) Dog positioned for a laparotomy. The clipped

operation area is painted with an antibacterial agent (2 per cent iodine or
I per cent chlorhexidine gluconate in spirit) using a swab held in sponge-
holding forceps. The area painted must be much larger than that
required for the purpose of the operation. The application should
commence at the site of the incision and continue in ever widening
squares until the area is covered. After the first application has dried a
second application is made using a fresh swab.
Fig. 1.35. A laparotomy sheet with a rectangular window in the middle Fig. 1 .36. The edge of the window is folded over and retained in position
is draped over the patient. The window is positioned over the site of with towel clips.
incision and the proximal edge held in position with towel clips. The
distal edge is folded over to reduce the area of skin exposed to the
minimum required.
the patient is brought into the operating theatre. through it or to clip drapes to the edge of the skin
Sterile isotonic saline or lactated Ringer's solution incision. Satisfactory asepsis is obtained by protect-
are good wound irrigants. ing the area with sterile drapes but obviously
It is no longer considered necessary to cover the leaving the minimum of skin exposed (Figs 1.35-
area with sterile material and make the incision 1 .36).
Surgical approach
INCISION DISSECTION
An incision is fundamental to all surgical pro- To expose tissue it is necessary to separate anatom-
cedures. Surgical incisions (Figs I .37- I .38) must ical structures by either sharp or blunt dissection
be of adequate length. The length of the incision (Figs 1.39-1.41). Sharp dissection with a scalpel
does not bear any relationship to healing time. results in less damage to tissues than so-called
Fig. 1.37. The skin is tensed by the operator using the

index finger and thumb of the left hand as stretcher and
presser. The scalpel is held with the handle resting in the Fig. 1.40. A line of cleavage is found by inserting and
palm of the hand and with the blade at an angle of about then opening the blades of a pair of scissors or artery
30° to the skin. The incision is made at right angles to the forceps.
surface of the skin, which only requires light pressure to
divide it.
Fig. 1.41. Two large muscles can be separated or their

Fig. 1.38. To make a 'stab' or 'puncture' incision, the line of cleavage established by placing the index finger of
side of the scalpel blade is held against the middle finger each hand together, thrusting them between the muscles
which acts as a stop. The length of blade thus exposed and then drawing them apart.
controls the maximum depth of the incision.
blunt dissection which is used to separate connec-

tive tissue planes and to avoid damage to blood
vessels and nerves.
INSTRUMENTS FOR INCISION

AND DISSECTION
Scalpels
These are probably the oldest instruments in

surgery and are used for incision, dissection and
excision (Fig. 1.42). There is a great variety of
scalpels, many of which are designed for special
purposes, and they include cartilage knives, ten-
Fig. 1.39. The handle of a scalpel being used to separate otomy knives, and bistouries which are used for
tissues by blunt dissection. laying open sinuses and fistulae.
(a) (i)
(iii) ·~(iv)
(b)
Fig. 1.42. (a) Standard solid or forged scalpel. The dorsal edge of the blade is straight, passing to a point with the
cutting edge on the ventral aspect which is rounded or 'bellied' to different degrees. They arc manufactured in sizes
from I to 6, the blade lengths varying from 2.5 to 6.5 cm. (b) Scalpel handle with detachable blade. There arc six sizes of
scalpel handle and a large selection of blades of different shapes and sizes. They have almost replaced the solid scalpel
as the blades arc sharp and the minimum of labour is required for their upkeep. (i) Small general purpose blade, (ii)
blade for opening abscesses, (iii) blade for fine dissection, and (iv) tenotomy blade.
Scissors
There is a large variety of shapes and sizes of

scissors. Scissors may have both points sharp, both
blunt or one sharp and one blunt. Scissors can be
used as an alternative to a scalpel for cutting and
dissection. Often they are safer than a scalpel
in deep wounds and for opening the perito-
neum. Mayo scissors (Fig. 1 .43) are the most
useful for general purposes and the curved on flat
variety are especially useful for dissecting close to
(a)
a rounded mass. Metzenbaum scissors are preferred
for fine dissection as they have smaller blades.
Dissecting forceps
These forceps, as the name implies, enable the
surgeon to grip and hold tissues when dissecting. A
number of varieties is available and their suit-
ability depends on the type of tissue to be held
(Fig. 1.44).
HAEMOSTASIS
The methods of controlling haemorrhage are either
by direct pressure, or by picking up the vessel
with forceps and tying it off with fine suture (b)
material (Fig. 1 .45) or by sealing it by diathermy
Fig. 1.43. (a) Mayo's straight scissors, and (b) Mayo's
(Fig. 1.46). curved on flat scissors.
Transfixing ligature
The best method of preventing a ligature from

slipping is to pass the material through the tissue
and tie it before completing the ligature around the
tissue mass (Fig. 1 .47). This technique is useful
when it is impossible to isolate a large vessel from
(a)
(b)
Fig. 1.44. (a) Dissecting forceps - serrated jaws used for holding soft tissue, blood vessels and nerves and hollow
organs such as stomach, intestine and the bladder. (b) Dissecting forceps - toothed forceps with strong teeth required
for holding skin and fascia and for slippery tissue such as fat and glands. Forceps with fine teeth are required for
dissecting delicate structures.
(a) (c)
(b)
Fig. 1.45. Tying-off a blood vessel. (a) The bleeding point is clamped with artery forceps and 'tied-off' either
immediately or at the termination of the operation. The forceps are held almost horizontal to assist the surgeon to tie
the first throw of a ligature around the vessel or clamped tissue. (b) One-hand method employed by the assistant to
release the artery forceps. (c) As the forceps are released the surgeon maintains tension on the suture and completes a
reef knot. The surplus length of suture is cut off a short distance from the ligature.
its surrounding tissues or when occluding a uterine

stump or hernia sac.
Instruments for controlling haemorrhage
Artery forceps are designed for preventing and

arresting haemorrhage at operation (Fig. 1 .48).
Either the vessel alone or the piece of tissue contain-
ing the bleeding point is clamped. Their action is to
Fig. 1.46. Diathermy. The vessel is picked up with artery exert pressure on the vessel and compress its walls
forceps which arc touched by a diathermy needle, which together.
results in occlusion of the vessel.
WOUND CLOSURE
A surgical incision inflicts the minimum of trauma

to the wound edges. If these cut edges are held
(d)
(a) (b) (c)
Fig. 1.47. (a) Using a needle the ligature material is passed through the edge of the tissue. (b) The ligature material is
tied and held in position with a single knot. (c) Both ends of the ligature material are passed round the tissues and tied
opposite the first knot. (d) As the forceps arc removed the knot is pulled tight and completed with a second knot so that
the ligature lies in the crushed tissues.
securely together with sutures, union will occur in

between 7 and IO days and the end result will be a
thin line of scar tissue which will be almost obliter-
ated with the passage of time.
To achieve this result an inert suture material of
sufficient strength is used to keep the edges of the
wound immobilized and in apposition until healing
is established. It has to be attached to the type of
needle which is most easily passed through the
tissues causing the least damage. The correct
material has to be selected in relation to the type of
wound, to the tissues being co-apted and to the
degree of tissue tension. Finally the suture has to
be tied with a secure knot.
Fig. 1.48. (a) Spencer Wells artery forceps are the

SUTURE AND LIGATURE standard artery forceps in general use. The jaws arc
MATERIALS designed with transverse serrations to provide a firm hold
and the arms have a double ratchet catch. (b) Dunhill
In the past the selection of surgical sutures was artery forceps. Similar to the Spencer Wells type but
based largely on the physical characteristics of the curved on flat. (c) Kocher's artery forceps. They have
material itself. In making a rational choice from teeth and are especially useful for seizing blood vessels
the ever-widening array of products available which have retracted into tough fibrous tissue.
today, however, one should also take into con-
sideration the biological interaction of the suture
Absorbable sutures
material and the tissue, which can alter the mech-
anical properties of the suture and the physical Currently five types of absorbable sutures are
properties of the wound. commercially available.
Based on in vivo measurements of material
degradation, sutures can be placed into two classifi-
Surgical gut
cations, absorbable and non-absorbable. Sutures
that undergo rapid degradation in tissues and lose Surgical gut is substantially pure collagen and is
tensile strength within 60 days are considered prepared from the submucous layer of the intestine
absorbable. Those maintaining tensile strength of lambs. It is available in plain and chromic forms.
for longer than 60 days are referred to as non-
absorbable. Plain catgut evokes a severe sterile pyogenic
reaction in tissues and within 3 days rapidly loses
20 SEC Tl ON I / GEN ER AL SUR GICA L PR INC I PL ES
its tensile strength. Therefore it should not be used Inherent disadvantages of these materials are
when the tissue layers are under tension. It is poor knot security and a tendency to drag through
seldom used except in plastic surgery and for tissue and to cut soft organs. It is necessary, there-
ligating small blood vessels. fore, to use a surgeon's knot with multiple throws
to overcome the low coefficient of friction and
Chromic catgut is produced by hardening strands prevent slippage. In order to make the sutures
of plain catgut by immersion in a chromic salt smoother, to decrease pulling, and to improve
solution thereby decreasing its tissue reactivity, overall handling the manufacturers have coated
while increasing its resistance to digestion and its them with an absorbable lubricant.
tensile strength. It is classified by the duration of
its effective tensile strength in tissues. The absorp-
Polydioxanone
tion period is given in days (i.e. io-day, zo-day,
but the most popular for all general purposes is the Polydioxanone (PDS) is a monofilament, synthetic
medium or 15-20-day variety). It is used to ligate absorbable suture which retains its strength in tis-
blood vessels, co-apt muscle and fascia and for sue twice as long as other synthetic absorbable
suturing peritoneum, stomach, intestines and materials, thereby providing extended wound sup-
bladder. When used for these latter purposes, it is port. It is absorbed by slow hydrolysis and is
customary for it to be mounted on an atraumatic completely removed within 6 months. The material
needle. is easily handled and has good knot security.
Collagen sutures Non-absorbable sutures
Collagen sutures, which are derived from the long The non-absorbable suture materials are charac-
flexor tendons of steers, are similar to catgut with terized by their tensile strength and ease of
regard to tissue reaction, tensile strength and histo- manipulation. These features enable them to hold
logical profile. They are only made in fine sizes. tissues together until a stable union is established.
In the past it was generally accepted that 11011-
absorbable materials were only used when the
Synthetic absorbable sutures
sutures were to be removed. This is no longer
Synthetic absorbable sutures were introduced to necessary as many of them are inert in tissues and
reduce the variability in absorption and subsequent can be left indefinitely. The sutures constitute only
loss of tensile strength associated with natural small inert foreign bodies which are zoned off by
products. fibrous tissue.
Polyg/ycolic acid and polyglactin 910 Silk
The synthetic absorbable sutures polyglycolic acid Obtainable as either twisted or plaited gossamer
(Dexon) and polyglactin 910 (Vicryl) have largely strands. It has a high tensile strength, handles
replaced catgut. They are made from braided fila- easily and knots well. It requires meticulous steril-
ments of polymerized glycolic acid (Dexon) or ization as bacteria tend to lodge in the strands. Its
glycolic acid and lactic acid (Vicryl). The materials chief disadvantages are the tissue reaction it pro-
resemble dry silk in texture and maintain their vokes and its tendency to perpetuate any minor
tensile strength in the presence of both normal and wound infection as a foreign body giving rise to a
infected body fluids. They are degraded in the sinus which persists until the stitch is removed. In
body in an orderly manner by hydrolysis. This spite of these disadvantages it is common practice
markedly reduces the inflammatory process com- to use silk, serum-proofed in order to reduce
pared with that associated with enzymatic absorp- capillary attraction, in sizes ranging from 0.7 to 2.0
tion of catgut. Because neither of these suture metric for nerve anastomosis and in vascular and
materials contains protein they are non-antigenic. ophthalmic surgery.
The breaking strength of polyglycolic acid and
polyglactin 910 diminishes more or less in a straight
Nylon
line compared with the almost exponential decline
of the strength of catgut in tissues. Their more Monofilament nylon has a high tensile strength,
consistent and reliable disappearance pattern gives smooth surface, uniform texture and calibre, and is
them a major advantage over catgut. relatively inert and unabsorbable. It is non-
capillary and therefore an ideal material for skin

Metal wire
sutures. Its chief disadvantage is that it tends to
break and knots tied with it tend to slip unless they Suture wire is prepared from either stainless steel
are double tied and the ends left relatively long. If or tantalum. It is available in monofilament or
it is used as a buried suture the sharp ends may twisted (multifilament) forms. The latter is more
irritate the tissues and provoke a tissue reaction. flexible and is less likely to kink, but both are
difficult to handle and have a tendency to cut
Braided nylon is made up of a large number of very tissues as well as surgeons' gloves. However, it is
fine nylon threads spun and braided together. It is the strongest of all suture materials and one of the
of high tensile strength, is flexible, easy to handle most unreactive. Unlike the braided synthetics,
and produces a stable knot. It tends to provoke stainless steel does not harbour bacteria and can be
some tissue reaction and therefore should not be used in the presence of infection.
left as a buried suture. Its best use is as an alter-
. native to monofilament nylon for skin sutures when
SUTURE NEEDLES
the tissues are under tension.
Suture needles are classified according to their
shape and cross-section. They may be straight,
curved, half-curved or circular and on cross-section
Polypropylene (Prolene) is available in monofila- either round or triangular (Fig. 1.49).
ment form. It has greater knot security than nylon The design of the needle selected depends on
to its ability to deform and flatten when tied. the site of the operation and the type of tissues to
multiple knots are required to ensure be co-apted. It should be as small in calibre as the
"knot security. Polypropylene is one of the most suture material will permit and in general a straight
inert and non-reactive suture materials and loses needle is preferable to a curved one as it is easier
little strength in situ over a 2-year period. It is to handle and to anticipate where the point will
suitable for use in infected wounds than the emerge.
synthetic materials. It is customary to thread monofilament nylon
twice through the eye of a needle to prevent the
end from pulling out. This procedure results in a
· Polyesters
large knot which damages delicate tissues, but it
(Mersilene). Polyester fibre can be overcome by threading the material only
once or by using an eyeless atraumatic needle to
which the suture is swaged. Eyeless needles are
· causes minimal tissue reaction. Because of the advisable for all gastro-intestinal, cardiovascular
rnultifilament nature of the polyester sutures, and ophthalmic surgery.
and tissue fluids can penetrate their inter-
producing a nidus for infection. Conse-
Round-bodied needles
they must only be used under aseptic
These needles should always be used except where
resistance to tissues demands a cutting point for
polyester (Ethibond). Coating the suture easy penetration. They do not cut tissues and cause
polybutylate decreases the capillary action only the minimum of trauma. They are used in
and tissue drag but also results in reduced knot- particular for thin membranes which tear easily
. holding ability. such as the peritoneum and for the wall of the
gastro-intestinal tract, bladder, mucous mem-
branes and fat.
polyamide
Multifilament polyamide polymer encased in a

Cutting needles
outer sheath (Yetafil, Suprarnid) has high
tensile strength and causes little cellular reaction in The conventional cutting needle is triangular in
It behaves like a monofilament suture pro- cross-section and has two opposing cutting edges
the outer sheath is not damaged. It is pack- with the third on the inside curvature of the needle.
in plastic dispensers in which it is chemically For particularly tough tissues which are difficult to
sterilized. It is suitable for skin closure but should penetrate a reverse cutting needle is used. This
only be buried under strict aseptic conditions. also has two opposing cutting edges but with the
•
I
(a)
(b)
•I
•I
(c)
•
I
Fig. 1.50. Skin incision being closed with interrupted

sutures. To ensure accurate apposition of the skin edges
(d) they are held together with dissecting forceps and the
straight cutting needle is passed through both edges with
a single thrust. Note that the knots have been pulled to
one side away from the edge of the incision. Properly
inserted interrupted sutures give good apposition and
(e)
holding power.
requisite to perfection in suturing and sutures

Fig. 1.49. Types of suture needles recommended for should only be pulled sufficiently tight to bring the
general surgery, with cross-sections shown above each. edges of the wound into perfect apposition and to
I (a) Round-bodied straight needle. Used for delicate control bleeding. If tension is excessive the sutures
I tissues which easily tear such as the peritoneum, mucous may cut through or give rise to areas of ischaemic
I,
I
membranes and liver. (b) Cutting needle, straight. Used
on strong tissues which are not easily damaged such as
tissue which contribute to wound breakdown.
I
:~
skin, fascia and tendon. (c) Cutting needle, half-curved.
One half of the needle is straight and the other half is
I curved, so that the point lies at 45° from the needle eye
Simple or interrupted sutures
Ir
line. This needle is particularly useful for penetrating The commonest suture in general use (Fig. 1.50).
thick and tough tissue such as the skin of farm animals.
(d) Cutting needle, half-circle. This needle allows the
A needle, with suture material attached, is passed
point to cut into tissue at almost 180° from the direction through the borders of the tissue. This single loop
of suture is then tied. The distance that the needle
l of the eye. Used on all strong tissues in the depth of
wounds. The round-bodied half-circle needle is very
popular for gastro-intestinal surgery. (e) Mayo needle. A
is inserted from the edge of the tissue and the
distance between the sutures is a matter for indi-
very strong half-circle needle with a cutting point and a
large square eye. A most satisfactory needle for
vidual judgement but must be related to the size of
penetrating tough tissues and especially when stitching in the wound and the tension of the tissues. The bite
depth and when excessive leverage is required. from the cut edge and the space between sutures
should not be less than the thickness of the tissue
being sutured.
third cutting edge on the outer curvature of the
needle. These needles cut a tract through the tissues
Continuous suture
and leave sharp angles which under tension can
easily be converted into a tear. Formed by passing a needle through the divided
tissues, securing the first stitch with a knot and
then continually passing and repassing the needle
METHODS OF SUTURING
and suture through the whole length of the wound,
When tissues are divided they must be held together finally securing the suture with a second knot (Fig.
until normal healing has taken place. There are 1.51). This suture saves time but must not be
various and elaborate methods of suturing but it pulled too tight as it results in ischaemia of the
must not be overlooked that the purpose of suturing tissue's edge and should it break then the whole
is to hold the tissues together in the optimum wound may disrupt.
position for healing and this should be achieved by
the simplest methods and by using the minimum
Mattress suture, horizontal
amount of suture material.
Absence of undue tension is an essential pre- This is an interrupted suture made by passing a
(b)
Fig. I.SI. (a) Muscle fascia being co-aptcd with a continuous suture. (b) Method of tying the second knot.
needle through the wound edges as for a simple

suture and then recrossing so as to
a loop at one side and two free ends on the
other, which are then tied (Fig. 1.52).
Mattress suture, vertical

suture is used to close skin incisions. It takes a
bite of the skin, one very near the skin edge
the other some distance away (Fig. 1.53). It
Fig. I .52. Skin incision being closed with a horizontal
combines good apposition and strength when com- mattress suture. This suture tends to evert the skin edges,
with the simple suture. especially if pulled too tight. It is a good suture for tissues
under tension and for friable tissues, such as the liver, as
it does not cut through like a simple suture.
This suture is designed to invert the wound edge,

and was commonly used in gastro-intestinal sur-
gery. Healing of the apposed peritoneal surfaces is
very rapid and prevents leakage from the gastro-
intestinal tract. Similar sutures are used to close
the uterus following Caesarean section. Inversion
sutures may be interrupted or continuous. They
must penetrate the submucosa, but preferably
should not penetrate the mucous membrane (Fig. (a)
1.54).
Removing sutures
Skin sutures should not be removed for at least

7-9 days after operation by which time a firm
union should be established. Any individual sutures
that become loose or cut into the tissue causing
must be removed forthwith. The common
(b)
practice of gradually removing sutures over 2 or 3
days commencing on the 7th day has much to Fig. I .53. Skin incision being closed with a vertical
commend it. mattress suture. (a) The needle has been passed through
To remove a suture one end should be picked up both lips of the incision, as for a simple suture, and is
being passed back through the skin very near its edge. (b)
with dissecting forceps and tensed, thus allowing
The needle is being continued back through the second
one blade of the scissors (Fig. 1.55) to be passed lip of the incision, very near the skin edge to complete
under the loop which is cut close to the skin. This the suture.
24 S EC TI O N I / G EN E RA L S U R G IC A L PR IN CI PL ES
~ Peritoneal surface
~uu~~~cosa
(b) ----- Mucous membrane
Fig. 1.54. (a) A series of inversion sutures before tying. (b) The stitch must penetrate into the submucosa.
(c) The inverted edges of the wound.
·'--==" .-
•
'
~
1,c ~=:;.
I
I
:1
I
I
I ~
(a} (b)
Fig. 1.55. Suture scissors. These scissors, as the name

implies, arc especially designed for the expeditious
removal of sutures. The curved and pointed blade is for
easy insertion between the skin and suture material.
-=
=·
=•
=•
=•
=•
(e} (d)
ensures that the material which has been lying on

-••1r=:;;;,"
the surface, and is probably contaminated, does
not pass through the subcutaneous tissues when
withdrawn.
TYING KNOTS (e)
The object of a knot is to lock a strand of suture Fig. 1.56. The two-hand tic. (a) The end of the material with the needle attached
material in position until it has accomplished its (dotted line) is held in the left hand and tensed. Using the right hand, the free end of the
material is looped over and under the tensed portion. (b) The two ends of the material
purpose. Because knots are invariably subjected to are pulled to form the throw of the knot which is made to lie flat against the tissue. (c) A
some tension a variety of complicated knots has second loop has been made as an assurance against slipping. This manoeuvre is
been advocated but they have no place in surgery. especially useful when the tissues arc under tension. ( d) The free end is reverse looped
The surgeon's or reef knot, securely and carefully around the end attached to the needle. (c) Reverse loop being pulled tight to complete
tied meets all requirements. It is important that the the knot. This is called a surgeon's or reef knot.
first throw is made to lie flat, and if added pre-
cautions are to be taken against the knot slipping
then either make two throws when tying the first to obtain a secure knot. All surgeons must learn to
knot or tie a third knot. tie knots using needle holders or artery forceps
Knots are most effectively tied using both hands (Fig. I .57) as this technique is useful when the end
(Fig. 1.56). The one-handed tie is popular but the of the suture material is short, when working in a
first throw does not always lie flat which is essential deep cavity, or when the material is slippery.
(a)
(b)
(c)
(d)
(e) (f)
(h)
(g)
Fig. 1.57. Tying a knot with forceps. (a) The material is pulled through until only a short end remains, and the needle
holder placed over the long encl. (b) The point of the needle holder is passed under and then over the long encl. (c) The
short end of the material is picked up. (cl) The short encl is pulled through the loop formed around the needle holder to
complete the first throw. (e) The needle holder is placed under the long end. (f) The point of the needle holder is passed
over and then under the long end. (g) The short encl of the first throw is picked up. (h) The short end is pulled through
the loop formed around the needle holder to complete the knot.
Section 2
Surgery of the Head
and Neck
The external ear
HAEMATOMA
A haematoma of the ear is most frequently seen in
the dog, cat, and pig, and is caused by violent head
shaking. This results in the rupture of blood vessels
and the accumulation of blood between the peri-
chondrium of the auricular cartilage and medial
integument, the haematoma appearing as a cyst-
like swelling of the medial aspect of the ear. Unless
it is treated surgically by removing the blood clot
(Figs 2. 1-2.3), providing drainage and obliterating
the cavity, resorption of the haemorrhage is
accompanied by extensive cicatricial contraction
which results in a crumpled and distorted ear.
Before surgery is undertaken the cause of the head
shaking must be diagnosed and treated. Fig. 2.2. The cavity is evacuated of all blood clots and
Post operation, the ears are strapped together fibrinous deposits which arc carefully removed with a
over the top of the head with adhesive tape. cotton wool tampon or gauze swab.
A SPLIT EAR
Cuts extending through all layers of the ear will not
unite, unless the skin edges are brought into appo-
sition and infection controlled. In most cases the
skin retracts exposing the auricular cartilage which
prevents accurate co-aption of the skin edges. This Auricular
cartilage
is overcome by freeing the skin and removing a
strip of auricular cartilage, which permits the skin
edges to be accurately sutured together (Figs
2.4-2.6).
Post operation, the ear should be bandaged over
the top of the head between two layers of cotton
wool.
Fig. 2.3. The cavity is occluded by placing a roll of gauze

on each side of the incision and retaining it in position
with a series of interrupted sutures, using monofilamcnt
nylon, which pass through all layers of the car.
Fig. 2.1. An elliptical section of skin, extending the

length of the haematoma and 0.2-0.5 cm in width, is
removed with a scalpel.
29
30 SECTION 2 f SURGERY OF THE HEAD AND NECK
Auricular
cartilage Auricular
cartilage
Skin
Fig. 2.5. A strip of the exposed auricular cartilage is

removed from both edges.
Fig. 2.4. The skin on both surfaces of the cut is carefully

freed by dissection from the auricular cartilage.
AURAL RESECTION - DOG
In many cases chronic infections of the external

auditory meatus do not respond satisfactorily to
conservative methods of treatment because of the
absence of drainage, the tendency for ulceration to
occur due to local inflammatory swelling and the
lack of ventilation. Surgical exposure of the exter-
nal auditory meatus usually provides the necessary
drainage and ventilation.
There are two common forms of aural resec-
tion lateral wall resection and vertical canal
ablation. The lateral wall resection facilitates drain-
age from the horizontal aural canal and improves
aeration of the remainder of the ear.
Fig. 2.6. The edges of the skin are accurately co-apted. Vertical canal ablation involves removal of the
on both the internal and external surfaces of the car with medial wall as well as the lateral wall, leaving the
interrupted sutures using monofilament nylon.
patient with the horizontal canal opening through
a stoma in the skin. Vertical canal ablation permits
excision of the verrucose proliferations typical of
chronic otitis externa.
Lateral wall resection

In the modified Zepp technique adequate drainage
is ensured by the creation of a cartilaginous lip
which acts as a baffle plate (Figs 2.7-2.12).
THE EXTERNAL EAR 31
Ventral surface
of skin flap
+cwh;;:;;;;:.,!,;;+",,,-.,.,-=~~~m~&-- Connective
tissue
Parotid gland
Fig. 2.8. The flap of skin is dissected free and reflected to

Fig. 2.7. A probe is inserted the length of the vertical expose the underlying connective tissue covering the
part of the external auditory canal. A flap of skin is conchal cartilage and the parotid gland.
fashioned by commencing it at the cranial edge of the
external opening to the auditory meatus and extending it
parallel with and half as far again below the junction of
the vertical and horizontal canals. It is then curved round
and brought up the caudal edge of the conchal cartilage
to terminate at the posterior edge of the tragus.
Concha I
cartilage
Parotid
gland
Fig. 2.10. Using straight scissors the conchal cartilage is

cut down its cranial and caudal edges. It may be
necessary to make slight adjustments to these cuts, in
Fig. 2.9. The conchal cartilage is exposed by blunt order to ensure that the entrance to the horizontal canal
dissection taking care not to damage the parotid gland. is widely exposed after the cartilage is reflected ventrally.
32 SECTION 2 / SURGERY OF THE HEAD AND NECK
Entrance to
horizontal canal
Fig. 2.12. Post operation, the ears arc strapped together with
adhesive tape over the top of the head. Healing tends to be slower
than normal and stitches should be left in for at least IO days.
Fig. z.r r. The central portion of the conchal cartilage

together with the skin flap is reflected ventrally. The skin
edges arc co-aptcd to the integument of the car canal
with interrupted sutures of monofilamcnt nylon. The
reflected cartilage is severed to form a cartilaginous lip
which is stitched to the. distal edge of the skin incision
(inset).
Vertical canal ablation

When carrying out this procedure (Figs 2. 13-2.17)
it is essential to provide an adequate stoma for the
horizontal ear canal. Failure to do this may lead to
the accumulation of exudates and the development
of pressure within the canal, which will eventually
destroy the ear drum and the middle ear.
Fig. 2. 14. The cartilage is freed from the

surrounding tissue and the parotid gland
by blunt dissection .
~, .•~.:.~.
. :';•:.i.fJ
. .. ,, .. ",. . ....... ~-- : : :::::.:,~ .
Fig. 2.13. The vertical car canal is

exposed by a T-shapcd incision through
Fig. 2.15. The cartilage of the vertical
the overlying skin.
canal is severed: (1) just below the
tragus; (2) at the point where the vertical
and horizontal canals meet.
THE FACE 33
Fig. 2.16. The edges of the auricular

cartilage below the tragus are sutured Fig. 2.17. The upper segment of the
together in order to obliterate the upper horizontal canal is sutured to the skin to
auditory canal. The lower segment of the complete the stoma. The operation is
horizontal canal is sutured to the lower completed by the replacement and
edges of the skin incision. suturing of the skin flaps.
The face
OPENING THE FACIAL
SINUSES - HORSE
Chronic inflammation of the facial sinuses fre-
quently follows respiratory infections such as influ-
enza or strangles and is also associated with necrosis
of the turbinate bones, dental disease, foreign
bodies or malignant neoplasms. Pus formed in the
frontal sinus gravitates into the superior maxillary
sinus and escapes via the nostrils as a purulent and
foetid discharge.
In many cases it is necessary to open the sinuses
to make a diagnosis and to treat the infection by
providing drainage (Figs 2. 18-2. 19). Although the
frontal and superior maxillary sinuses are con-
fluent both must be opened to obtain satisfactory
drainage and to enable them to be flushed out. If
the septum between the superior and inferior
maxillary sinus has been destroyed by necro-
sis then the latter has to be opened to provide
drainage.
The operation of trephining can be performed
with the horse standing under sedation and local Fig. 2.18. A standard trcphine with adjustable trocar.
analgesia but, in the majority of cases, it is advisable The following sizes arc available: o.6- 1 .25-cm, 1 .q-cm
and 2.5-cm diameters.
to perform the operation with the horse recumbent
and under general anaesthesia. There are a number
of recognized sites for opening the facial sinu-
ses but the following are those most frequently
employed and meet the requirements for drainage
Frontal sinus
and flushing out the cavities (Figs 2.20-2.21).
In cases where the sinuses are opened for ex-
High site
ploratory purposes only, a semi-circular skin flap is
raised over the area to be trephined. At the com- Take a line joirung the supraorbital processes,
pletion of the operation this skin flap is sutured in bisect it and trephine in the inferior angle of the
position over the trephine hole, thus preventing intersection, 1 .5-2.5 cm below and to one side of
the formation of unsightly scar tissue. this point.
34 SECTION 2 f SURGERY OF THE HEAD AND NECK
Fig. 2.19. (a) With either a I .o-crn or z.y-cm

trcphinc, mark the overlying skin. (b) Incise the
skin around the outside of the trephine marks and
dissect it off the underlying periosteum. (c) Scrape
the periosteum off the exposed bone with either a
periosteal elevator or curcttc. ( d) The centre of
the exposed area of bone is penetrated with the
trocar point of the trephine. ( e) The trephine is
worked, first with a to-and-fro movement until it
bites and then with a continuous rotary movement
in one direction until the isolated disc of bone
comes away in the trephine.
Superior
maxillary
sinus Opening into
frontal sinus
(high site)
Site for opening

into superior
maxillary sinus
Opening into
frontal sinus
(low site}
Site for opening
Nasal bone
into inferior
maxillary sinus
Inferior Premaxilla
maxillary bone
sinus
Fig. 2.20. Frontal view of the horse skull showing the high and low sites for trephining the frontal sinus and the sites for
trephining the superior and inferior maxillary sinuses. The area of the sinuses is shown in black.
THE FACE 35
--- - . --·· -·-·-~· . - ---- -· . :·::·- ·- - - _-·-__·:· ---- - "."--_-:--:· _: - ~---- -::· .--:_~_.=.-..:. :. .--=--=-----------====
~··. ~?~~~== ~!~~:~~'.t:

Superior
maxillary·-------':'==1t.._+---
sinus Opening into
frontal sinus
(low site)
Nasal bone
Openinginto
inferior
maxillary sinus
Premaxilla
Inferior
bone
maxillary
sinus
Fig. 2.21. Lateral view of the horse skull showing the sites for trcphining as indicated in Fig. 2.20.
medially from the distal extremity of the facial

Low site
crest.
Take a line joining the inner canthus of the eye and Following the operation of trephining, the
junction of the nasal and premaxilla bones. Tre- sinuses are irrigated twice daily with normal saline
phine 6.5 cm clown and 2.5 cm in front of this line. until all infective material has been removed. The
This is the lowest part of the sinus when the head is trephine opening is kept patent between irrigations
held vertical. with a gauze plug.
Superior maxillary sinus Alternative method
With the head vertical, trephine about 4.0 cm An alternative method is to insert a self-retaining
cranially from the distal extremity of the facial catheter for post-operative irrigation (Figs 2.22-
crest and about 2.5 cm medially. This position
places the lower portion of the trephine hole almost
level with the osseous septum separating the su-
perior and inferior maxillary sinuses. This septum
provides a natural floor for drainage and prevents
the 'pocketing' of purulent material behind the
trephine opening.
In young horses it is advisable to select a site
4-5 cm from the facial crest to avoid damaging the
alveoli of the molar teeth.
Using these sites there is little chance of injuring
the facial vein but the levator labii superioris pro-
prius muscle is exposed and has to be displaced
from the site by reflecting it dorsally.
Inferior maxillary sinus

Fig. 2.22. A semicircular flap of skin measuring
This sinus is opened by trephining about 2.5 cm approximately 4 cm x 4 cm is reflected dorsally.
2.25). When removed, the catheter leaves a fistula

between the sinus and the nasal passages providing
drainage from the sinus for a further period.
The sinus should be irrigated at least twice daily
and the catheter, which can remain in position for
up to 3 weeks, should not be removed until nasal
swabs are free of bacterial infection.
OPENING THE FACIAL

SINUSES - CAT
Chronic rhinitis and sinusitis in the cat are very

Fig. 2.23. The exposed periosteum is reflected using a
resistant to medical treatment and radical pro- periosteal elevator.
cedures such as the surgical removal of the turbi-
nate bones have been described. It has been shown
that if irrigating fluid is introduced into the frontal
sinuses of normal cats it reaches all areas of the
turbinate bones and nasal chambers.
The two frontal sinuses are separated by a thin
bony septum. In the young cat, under 4 months of
age, they are situated on either side of the midline
of the skull on a line joining the medial canthus of
the eyes. In adult cats, over I year old, they are
situated more caudally on a line joining the cranial
border of the supraorbital processes (Fig. 2.26).
The precise site for trephining will vary with the
age of the cat. In cats under 4 months of age, a
point is selected slightly to the side of the midline
and midway along a line joining the inner canthus
of the eye and the supraorbital process. For adult
Fig. 2.24. A flap of bone is removed with an ostcotome.
cats over I year old, a point is selected slightly to The sinus is inspected and flushed out with normal saline.
the side of the midline and just above a line joining
the cranial borders of the supraorbital processes.
A skin incision about 0.5 cm in length is made to
expose the underlying frontal bone which is then
penetrated with a bone awl. The sinus and nasal
cavity are irrigated with warm normal saline sol-
ution, until the fluid flows out free of pus. This is
repeated every second day followed by instilling
the appropriate antibiotic solution as determined
by sensitivity tests.
-----,-~~---- Balloon of
Foley catheter
Fig. 2.25. A Foley catheter is inserted via the middle

meatus. Injury to the turbinate bones is minimal but may
occasion slight haemorrhage. The balloon of the catheter
is filled with sterile water to anchor it, and the exposure
closed in three layers, the periosteum, fascia and skin.
The reflected periosteum should be kept moist to prevent
shrinkage which makes suturing difficult.
THE FACE 37
Frontal sinus
Supraorbital
process
/
/ --
/
Fig. 2.26. Dorso-rostral view of the skull of an adult cat showing the site of the frontal sinus.
REPULSION OF TEETH - HORSE Table 2.1 Sites for trephining to repulse the teeth of the upper jaw.
In the horse it is not possible to extract a molar Tooth Site Location of site
tooth by conventional methods unless it is loose,
and so it is necessary to repulse it. Second premolar Nasal cavity On a line through centre of tooth
The operation of repulsion comprises removing Third premolar Nasal cavity
a disc of bone with a trephine to expose the root of Fourth premolar Nasal cavity Along a line from the caudal
the tooth and then to drive it into the mouth with a edge of the crown of the tooth to
First molar Inferior maxillary sinus
punch placed between the two roots of the tooth. the line of the nasolacrimal duct
It is often necessary when repulsing the molars of Second molar Superior maxillary sinus
the upper jaw, to have to chip away the outer wall Third molar Frontal sinus On a line joining the medial
of the alveolus, in addition to making a trephine canthus of the eye and about
hole, in order to expose the root. 4.0 cm from the medial line
It is essential to trephine exactly over the root of
the tooth to be repulsed. To determine accurately Table 2.2 Sites for trephining to repulse the teeth of the lower jaw.
this site is not always easy, especially as the natural
curvature of the long axis of the teeth varies with Tooth Site Location of site
age. The site can be located either by taking a
Second premolar Immediately below table of tooth
radiograph with a hypodermic needle placed in the
Ventral border of the
skin as a marker or by relating the table of the Third premolar
tooth (a) in the upper jaw to the line of the Fourth premolar
) mandible
Along a line from the caudal
nasolacrimal duct, and (b) in the lower jaw to the edge of the crown of the tooth to
First molar Lateral aspect of the
ventral edge of the mandible (Tables 2. 1 -2.2, Fig. the ventral edge of the mandible
Second molar mandible over root of
2.27).
The course of the nasolacrimal duct corresponds Third molar
) tooth
On a line through centre of tooth to
to a line drawn from the medial canthus of the eye point of greatest curvature of
mandible
to the angle formed by the nasal and premaxilla
-----3 m
-- Nasolacrimal
duct
--=-2m
-1m
3m
-4pm
2m
3pm
4pm
3pm
2 pm -------
Fig. 2.27. Lateral view of the horse skull showing the sites for trephining to repulse the molar teeth of both the upper
and lower jaws. The area of the sinuses arc outlined by clashed lines.
Superior
--·~a~~
maxillary sinus
Frontal sinus
lnfraorbital foramen
;I I
Mandibular
alveolar nerve
Mental foramen (a) (b)
Fig. 2.28. Repulsion of the first molar tooth of the upper jaw by trephining the inferior maxillary sinus and exposing the
root. Two types of punch arc required for tooth repulsion: (a) standard straight punch, and {b) an off-set punch. This
punch is especially useful for inserting through the trcphine hole to make contact with the root of the tooth and to
commence its repulsion.
THE FACE 39
bones, and therefore to avoid injuring it the tre-

EXPOSING THE NASAL
phine holes must be placed below this line. When
CA VITI ES - DOG
trephining to repulse the fourth premolar, care
must be. taken to avoid the infraorbital nerve and Exposure of the various compartments of the nasal
the lateral nasal artery. cavities (Figs 2.29-2.33) is necessary for the re-
The molars of the mandible cannot be repulsed moval of foreign bodies, necrotic bone and in the
without causing some damage to the mandibular treatment of chronic rhinitis.
alveolar nerve which fortunately does not appear Removal of portions of the ethrnoid and turbi-
to have any adverse effects. When exposing the nate bone is always accompanied by severe
site to repulse the first molar (Fig. 2.28) care must haemorrhage. Elevation of the head will reduce
be taken not to injure the facial artery or vein, or bleeding. Further control of haemorrhage can be
the parotid duct, and when exposing the site for effected by temporary occlusion of the ipsilateral
either the second or third molar the masseter muscle carotid artery. Before suturing the periosteum,
has to be split and the masseteric artery avoided. haemorrhage is controlled by packing the cavity
Following repulsion of a tooth the alveolus is with tape impregnated with iodoform. The end of
searched with a finger and any fragments of bone the tape is brought out through the nostril and
are removed by curetting. To prevent food from anchored to the edge of the muzzle with a single
entering the sinuses or alveolus, the alveolus is interrupted suture. The tape pack is carefully
plugged with gutta-percha. The object is to close removed via the nostril in 5-7 days.
the oral entrance to the alveolus without filling the Trephining the frontal sinuses in the dog,
alveolar cavity completely thus allowing healing to followed by placement of irrigation tubes and top-
take place by granulation. This is accomplished by ical medication with enilconazole (Imaverol) is the
first softening the gutta-percha in warm water and most satisfactory treatment of nasal aspergillosis.
then, with one finger inserted through the trephine Trephining is performed at the level of the supra-
hole to block the depth of the alveolus, the gutta- orbital process and the drug is flushed through the
percha is packed into the alveolus via the mouth nasofrontal ostium into the nasal chambers, twice
and moulded over the gum. In the majority of daily, for rn- 14 days.
cases the plug is rejected in 2-3 weeks by which Rhinotomy may worsen the prognosis for many
time healing is well established. nasal tumours and, if employed, should be com-
bined with radiation.
Turbinate
portion of
Fig. 2.29. Dorsal view of the dog skull showing the nasal ethmoid
cavity which is· divided into left and right compartments bone
by the nasal septum. Each nasal cavity comprises a Nasal
rostral portion which contains the superior and inferior septum
Turbinate
turbinate bones and a caudal portion which is mainly
bones
occupied by the turbinate portion of the ethmoid bone.
The shaded area shows the extent to which the nasal
bones and portions of the maxillary and frontal bones can
be safely removed to expose the nasal cavities.
Frontal
crest
Supraorbital
process
Frontal
bone
Maxillary
bone
Orbit
Ill
IV Fig. 2.30. Access to the rostral portion of the nasal cavity is obtained by making
a midline skin incision which extends from site II to IV, i.e. from a line joining the
rostral margins of the orbit to the caudal edge of the muzzle. Access to the
caudal portion is by a midline skin incision which extends from site I to Ill, i.e.
from a point level with the supraorbital processes to a point approximately
Nasal bone halfway to the muzzle. The skin is reflected to the appropriate side to expose the
underlying frontal and/or nasal bone.
Periosteum Reflected Maxillary

periosteum bone
Turbinate
portion of
ethmoid bone
Nasal bone Maxillary

bone Turbinate bone
Fig. 2.31. The periosteum is reflected from the nasal and Fig. 2.32. The maxillary and nasal bone is removed with Luer bone-nibbling forceps to
maxillary bones with a periosteal elevator and a hole expose the underlying nasal cavity, the turbinate portion of the ethmoid bone, and the
drilled, using a o.6-cm trcphinc, at the junction of the turbinate bones. Alternatively, the bone may be removed with an oscillating saw.
frontal and nasal bone.
THE MOUTH 41
I I Periosteum
I
1·1,
11
·1
I I .......__ Tape pack
, I
Fig. 2.33. The incision is closed by co-apting the
pcriosteum and subcutaneous tissues with a series of
interrupted sutures using a synthetic absorbable
material. and closing the skin in the customary manner. I
The mouth
the depth of the tonsillar fossa, mitigates against
TONSILLECTOMY - DOG
the successful use of the popular 'guillotine'
The indiscriminate removal of the tonsils is to be method. To ensure complete removal of the tonsil
deprecated. A persistent cough is sometimes due it must be dissected out (Figs 2.34-2.36).
to a chronic hypertrophic tonsillitis and in these Haemorrhage, which is always a problem when
cases tonsillectomy affords relief. Tonsillectomy removing tonsils, is satisfactorily controlled by this
for carcinoma results in only temporary relief as method. If diathermy is not available then the
invariably the neoplasm either recurs locally or vessels must be picked up with artery forceps and
metastasizes. tied off using 2 metric synthetic absorbable
For the operation to be successful all tonsillar suture material. Post operation, no special atten-
tissue must be removed. The very shape of the tion is required and complications are rare.
tonsil, i.e. elongated and fusiform, coupled with
Tonsil
Triangular fold
of mucous
membrane
Tonsillar
fossa
Fig. 2.34. The tonsil is grasped with Allis forceps and

drawn out of its fossa until its pcdiclc is taut.
Fig. 2.35. The pedicle of the tonsil is clamped with

curved Dunhill artery forceps.
42 SECTION 2 f SU R G ER Y OF TH E H EA D AN D N ECK
Palatine bone
Fig. 2.36. The tonsil is removed by severing it along the ._,.,....___ Mucous membrane
blade of the artery forceps with a diathermy needle. of hard palate
SPLIT PALATE - CAT

Fig. 2.37. By careful dissection the mucous membrane of the hard palate is freed from
A split palate is a common cause of epistaxis in the
the underlying palatine bones which permits its edges to be brought together with a
cat. The injury comprises a central and longitudinal series of interrupted sutures using absorbable synthetic suture material.
split of the hard palate complicated by a separation
of the underlying palatine bones. If this is not
immediately suspected by epistaxis it soon becomes
evident due to the escape of ingesta from the
nostrils.
It is not possible to co-apt satisfactorily the
separated palatine bones but the breach can be
occluded by co-apting the mucous membrane of
the hard palate (Fig. 2.37).
Post operation, no special precautions are
necessary except to control infection and to keep
the cat on a fluid diet until healing is established.
EXTRACTION OF TEETH - DOG

(a) (b) (c)
The extraction of a dog's teeth, with the exception
of a canine or carnassial tooth, is accomplished by Fig. 2.38. Selection of dental forceps. (a) Forceps with
conventional methods. The basic principles too great a curvature cut the tooth and break off the
crown. (b) Forceps with too little curvature crush the
comprise: crown of the tooth. (c) Correctly shaped forceps
accurately grip both the crown and root of the tooth.
Correct adjustment of the forceps
The blades of the forceps must be selected to fit the
contour of the tooth (Fig. 2.38).
Rupture of the periodontal membrane
The periodontal membrane binds the root of the

tooth to the alveolar wall and in many cases it is
necessary to break it down and dilate the socket Fig. 2.39. The elevator blade, with the flattened
with a dental elevator before the tooth can be surface towards the tooth, is inserted between the
extracted (Fig. 2.39). root and the alveolus. The blade is forced as far as
necessary into the alveolus. The elevator is then
used as a lever which raises the tooth in its socket
and displaces it in the required direction. Note the
method of holding the elevator and the position of
the finger in relation to the top of the elevator
blade.
THE MOUTH 43
Mucous
membrane
Alveolar
plate
Mouth gag
Fig. 2.41. A dental chisel is worked under the lateral

Fig. 2.40. The mucous membrane is incised along the central and lateral axis of the alveolar plate which is gradually removed to expose the
tooth and reflected to expose the underlying alveolar plate. lateral surface of the tooth.
Removal of the tooth
When using forceps the periodontal membrane is

ruptured and the socket dilated by force with either
a rotary or lateral movement. Rotary movement is
only admissible for those teeth with single conical
roots. The blades of the forceps selected are applied
parallel to the long axis of the root and pressed
under the gum and alveolus, in the direction of the
apex of the tooth, until a firm grip of the root is
obtained.
The incisors, the first premolar of the upper jaw,
the first and second premolars and the third molar
of the lower jaw all have single conical roots and Fig. 2.42. A dental gouge is thrust
therefore are suitable for forceps extraction. between the anterior and posterior edges Fig. 2.43. The tooth has been freed and
of the tooth and the alveolus to break is now easily lifted out of the alveolus
The remaining teeth, with the exception of the
clown the periodontal membrane. with dental forceps.
fourth upper premolar or carnassial tooth and the
canine tooth - which are dealt with as separate
problems - have either two or three roots. In
consequence these teeth cannot be loosened in
Excision of a canine tooth
their sockets by rotation and the periodontal mem-
brane has to be broken clown with a dental elevator It is extremely difficult to loosen or remove a
before applying forceps. canine tooth with forceps because it curves cau-
Sometimes when using forceps the tooth breaks dally, is flattened laterally and its buried central
and the roots are left in situ. In these cases an portion is wider than the opening of the alveolus at
attempt should be made to remove them using the jaw margin. For this reason it has to be excised
either a dental elevator or special stump forceps. If (Figs 2.40-2.43).
they are so firmly embedded that they cannot be Following extraction, the mucous membrane is
extracted without causing local tissue damage it is co-apted with a series of interrupted sutures using
best to leave them alone for 2 or 3 weeks by which 2 metric synthetic absorbable suture material.
time they will have become loose and can be easily Haemorrhage is slight and it is seldom necessary to
removed. control it by packing the alveolus.
Posterior
cusp of
carnassial
tooth
First
molar
First molar Fourth upper premolar '·

or carnassial tooth
Fig. 2.45. Division of the tooth is completed Fig. 2.46. The remaining caudal portion of
Fig. 2.44. Using a hack-saw blade the crown
by thrusting a dental chisel down the saw cut. the carnassial tooth is loosened by thrusting a
is divided by making a cut parallel to the
Next, using the single caudal root as a dental gouge between the caudal edge of the
rostral border of the tooth to extend from
fulcrum, the double-rooted rostral portion root and the alveolus.
just behind the main cusp to the space
is loosened, elevated and removed with
between the rostral and caudal roots.
forceps.
Extraction of an upper carnassial tooth
The extraction of the fourth upper premolar or

carnassial tooth presents a difficult problem be-
cause of the shape of the tooth and the size and
disposition of its three roots, two rostral and one
caudal. The most satisfactory method is to divide
the tooth between its roots and then to extract
each half separately (Figs 2.44-2-47). No special
treatment is required following extraction.
Fig. 2.47. Using the first molar as a fulcrum, the

caudal portion which is already loose is elevated with a
dental gouge before applying forceps and extracting it.
The poll
There are numerous patterns of disbudding
DISBUDDING - CALF
irons, but most are heated by calor gas or elec-
Cattle are polled so that they cannot gore one tricity. The head of the iron is made of copper to
another and are less dangerous to handle. If retain the heat and its end is hollowed out to form
possible, every effort should be made to disbud a dome-shaped depression 12 mm in diameter,
calves rather than wait until they are adult and 8 mm deep and with a rim 3 mm thick.
then dehorn them. This method has the advantage that haemorrhage
Calves should be disbudded when they are be- is controlled, no post-operation dressings are
tween 5 and IO days old. The application of caustics required, and healing is complete in 10- 14 days
is an unsatisfactory method and the best method is leaving little or no scar.
to remove the horn buds with a disbudding iron Once calves have begun to grow horns, disbud-
under local analgesia (Fig. 2.48). ding is no longer possible, and the rudimentary
THE POLL 45
Fig. 2.48. (a) The disbudding iron, heated to a dull red heat, is applied over the horn bud with a stamping movement.
Next, with a rotary movement a groove, 3 mm wide, is burnt through the skin at the base of and surrounding the horn
bud. (b) The disbudding iron is angled and using the edge of the rim the horn bud is removed by scaring it off the
underlying frontal bone. (c) Horn bud removed. Note the circle of burnt skin round the base of the horn which has
destroyed the corium and prevents any further development of horn.
(a) (b)
Fig. 2.50. (a) Haemorrhage is controlled by tying a length of string around the base of
both horns; in (b) note how the tie is completed to tighten it. The actual method of
Fig. 2.49. The jaws of the forceps arc placed over the removing the horn is relatively unimportant provided the corium is removed with the
horn and pressed well down so as to include the skin horn. Note the angle of severance which conforms to the contour of the poll and gives
around the base. The jaws of the forceps are closed and the animal the neat appearance of the polled breeds.
then with a sharp twist and pull, the horn, including the
processus corn us or 'horn core', is neatly separated from
the frontal bone, with a fringe of skin attached.
horns are removed with special gouge forceps under local analgesia and preferably restrained in a
(Fig. 2.49). crush. The horns can be removed with a hack saw,
In the majority of cases haemorrhage is slight, a dchorning guillotine or cmbryotomy wire. The
but if it does not cease within a few minutes the method employed is very much a matter of per-
artery should be picked up with forceps and tied sonal preference but whichever method is practised
off. it is essential to remove the horn together with
1.5 cm of the skin around its base (Fig. 2.y1). This
ensures that the corium is removed and prevents
DEHORNING - CATTLE
the development of any stumps of distorted horn.
Adult cattle are satisfactorily dehorned standing, Post-operation complications are rare, the most
troublesome being a purulent sinusitis, due to the the opening at the top of the sinus. Occasionally
inevitable opening of the frontal sinus when the this opening will heal before the infection is
horn is amputated. The condition will frequently cleared, and this may necessitate draining the pus
clear following irrigation and drainage. This can through a trephine hole placed low in the frontal
only be achieved by tilting the head until the sinus in order to attain dependent drainage.
accumulated inflammatory exudate drains from
The neck
LARYNGEAL
YENTRICULECTOMY - HORSE
Paralysis of the left recurrent laryngeal nerve in

the horse is followed by paralysis of the intrinsic
muscles of the larynx which gives rise to a laryngeal
hemiplegia. As a result the affected side of the
larynx fails to dilate during inspiration so that the
flaccid vocal cord with a relaxed arytenoid cartilage
encroaches on the lumen of the larynx. With exer-
cise this obstruction results in the production of a
characteristic inspiratory noise which is commonly
referred to as 'whistling' or 'roaring'.
Laryngeal hemiplegia may be relieved by per-
forming a laryngeal vcntriculectorny, i.e. stripping
the mucous membrane of the laryngeal saccule via
the lateral ventricle (see Figs 2.51-2.60). Healing
is by granulation and cicatrization which anchors Fig. 2.51. The operation is performed under general
the vocal cord and arytenoid cartilage to the thyroid anaesthesia with the horse in dorsal recumbency and its
cartilage, thus widening the airways and preventing head and neck fully extended.
obstruction on inspiration.
Post operation, the incision is not sutured but
left to heal by granulation which is complete in
about 3 weeks. The wound is cleansed of all dis-
charges two or three times daily. The only immedi-
ate post-operation complication which may develop
is a spasm of the larynx and for this contingency an
emergency tracheotomy tube (see Fig. 2.72) should
be at hand. At a later date a chondrorna of either
the thyroid or cricoid cartilages may develop if
they are injured during the operation.
Fig. 2.52. A midline skin incision is made over the larynx

from a point just in front of a line joining the angles of
the jaws to the level of the first tracheal ring.
THE NECK 47
Sternothyrohyoideus m.
Cricoid
cartilage
Thyroid cartilage Cricothyroid ligament
Fig. 2.53. The underlying sternothyrohyoideus muscle is divided and retracted to expose the cricothyroid ligament.
This ligament is triangular and its edges arc bordered by the wings of the thyroid cartilage which converge to a point
cranially. The cricothyroid ligament and underlying mucous membrane arc punctured with the point of the scalpel and
the incision extended cranially to the body of the thyroid cartilage and caudally to the cricoid cartilage, care being taken
not to damage either cartilage.
Left vocal
cord
Left lateral
ventricle Right
of larynx vocal cord
Ventricular Cricothyroid
fold ligament
Sternothyrohyoideus m.
Fig. 2.54. The interior of the larynx is inspected and the component structures identified. Note that the lateral ventricle
is located under the vocal cord and to obtain a good view of it the vocal cord has to be retracted laterally.
48 S EC Tl O N 2 / S U R G ER Y OF THE H EA D AND N EC K
Cricothyroid Cricoid
ligament cartilage
/
Fig. 2.56. The burr is directed caudo-ventrally into the lateral

ventricle making sure that it engages the depth of the laryngeal
saccule.
Aryepiglottic fold Ventricular
fold
Fig. 2.55. The laryngeal saccule is cleared of mucus and dried with a gauze
swab with the horse in dorsal recumbency. The figure shows the left side of a
sagittal section of the larynx.
Gallbladder
forceps
Everted laryngeal
saccule
Fig. 2.58. The burr is removed. Traction is applied to the

Edge of laryngeal saccule to ensure that it is completely everted. It is
ventricular fold removed by cutting along its attachment to the edge of the
lateral ventricle.
Fig. 2.57. The burr is pushed firmly into the depth of the laryngeal saccule
and slowly rotated until it picks up the mucous membrane. Rotation is
slowly continued and at the same time the burr is withdrawn from the lateral
ventricle, with the mucous membrane attached, thus everting the laryngeal
saccule. The base of the saccule is then clamped with gallbladder forceps.
THE NECK 49
Fig. 2.59. Alternatively the lateral ventricle is dilated

with 'glove-stretching' forceps and, using a special scalpel
with an edge on each side of its point, an incision is made
between the edge of the laryngeal saccule and the length
of the ventricular fold. Then, by blunt dissection using a
finger, the connective tissue attachments arc broken
down and the laryngeal sacculc cvcrtcd. It is then {a) {b) {c)
grasped with forceps and removed by severing it along
the other edge of its attachment to the lateral ventricle. Fig. 2.60. Special instruments required for performing laryngeal ventriculectomy:
(a) 'glove-stretching' forceps, (b) laryngeal retractor, and (c) a burr.
the larynx. Coughing has also been associated with

PROSTHETIC LARYNGOPLASTY -
faulty placement of the prosthesis; in particular,
HORSE
penetration of the lumen of the larynx has resulted
Laryngoplasty offers the best chance of improving in the formation of granulomas.
exercise intolerance and reducing the inspiratory The horse is placed in right lateral recumbency
noise associated with paralysis of the left recurrent with the head and neck extended. A 12-cm incision
laryngeal nerve. Two sutures placed between the is made immediately ventral to the linguofacial
muscular process of the arytenoid cartilage and the vein and the underlying omohyoideus muscle is
caudodorsal aspect of the cricoid cartilage mimic identified (Fig. 2.61).
the action of the paralysed cricoarytenoideus Blunt dissection is followed by elevation of the
muscle and abduct the arytenoid. Although the fascia from the omohyoideus muscle to expose the
principle is simple a thorough knowledge of the lateral aspect of the larynx. The dorsal aspect of
anatomical landmarks is essential if disappointment the cricoid cartilage is identified and the fascia!
is to be avoided. septum between the thyropharyngeus and crico-
Laryngoplasty is always augmented by a laryn- pharyngeus muscles is divided with scissors to
geal ventriculectomy. If this has been performed expose the muscular process of the arytenoid
previously the ventricle is re-opened to encourage cartilage (Fig. 2.62).
the formation of new adhesions between the A double suture of 7 metric polyester suture
repositioned arytenoid cartilage and the thyroid (Ethibond) on a half-circle needle is placed through
cartilage. the muscular process. This is made easier if the
Some horses will cough post-operatively clue to arytenoid cartilage is grasped with a pair of towel
the inhalation of food since the lateral fixation of clips to elevate the process (Fig. 2.63).
the arytenoicl impairs the protective mechanism of A tunnel is created with a pair of forceps under
50 SECTION 2/SURGERY OF THE HEAD AND NECK
Arytenoid
cartilage
r· /. -~
Thyroid
/tit4P' cartilage
Fig. 2.61. The horse is placed in right lateral recumbency with the
Skin incision head and neck extended. A 12-cm incision is made immediately
ventral to the linguofacial vein and the underlying omohyoideus
muscle is identified.
the cricopharyngeus muscle, and fascia is removed

from the dorsal caudal portion of the cricoid carti-
lage to expose its most axial aspect. The double
suture is divided so as to produce two separate
sutures and one end of each suture is passed under
the cricopharyngeus muscle (Fig. 2.64). The notch
immediately adjacent to the dorsal midline of the
larynx is palpated to indicate the correct placement Cricopharyngeus m.
of the sutures in the cricoicl cartilage. The tip of the
needle is inserted behind the cricoid in the region
of this notch and the needle is carefully advanced
submucosally to penetrate the cricoid cartilage 1 .5
cm rostral to its caudal border. The second suture
is then placed r cm lateral to the first and both are
tied under moderate tension (Fig. 2.65).
Thyropharyngeus m.
The thyropharyngeus and cricopharyngeus
muscles are co-apted with a simple continuous Fig. 2.62. The fascia! septum between the thyropharyngeus and cricopharyngeus
suture of 3 metric synthetic absorbable suture and muscles is divided with scissors to expose the muscular process of the arytenoid cartilage.
the fascia and subcutaneous tissues are closed simi-
larly. The skin is closed with interrupted sutures of Muscular
nylon. process of
arytenoid
cartilage
Fig. 2.63. The arytcnoid cartilage is elevated with a pair of towel clips and a double
suture of braided polyester is placed through the muscular process.
THE NECK 51
Cricopharyngeus
m.
Fig. 2.65. Both sutures arc passed through the cricoid cartilage
and tied.
Fig. 2.64. The loop is cut and the needle removed. The
double suture is passed under the cricopharyngeus
muscle.
Cricoid
cartilage Cricothyroid membrane
DEVOCALIZATION - DOG
Thyroid cartilage
Removal of the vocal cords in the dog reduces its
bark to a low and husky noise but the vocal
cords regenerate very rapidly resulting in a partial
recovery within weeks and an almost complete
recovery in 6 months. The surgery should only
(a)
be performed in exceptional circumstances and
the reader should be aware of possible ethical
implications.
To devocalize a dog it is necessary to remove
completely all the vibrating structures within the
larynx responsible for voice production. This en-
tails removing the ventricular and vocal folds with
parts of the underlying cuneiform and arytenoicl
carti !ages. (b)
An attempt may be made to remove these struc-
tures per os using a biopsy punch or scissors but the Fig. 2.66. (a) Right side of a sagittal section of the larynx as seen following laryngotomy.
Note how the ventricular fold and part of the cuneiform cartilage arc situated under the
only satisfactory procedure is to perform a laryn-
vocal fold. (b) The ventricular fold with part of the cuneiform cartilage and the vocal
gotomy and dissect them out (Fig. 2.66). fold with part of the arytcnoid cartilage, as indicated by the dotted lines. arc removed by
With the dog in dorsal recumbency a midline diathermy.
skin incision is made extending from the basihyoid
bone to the cricoicl cartilage. The underlying
sternohyoideus muscle is divided and separated to
expose the cricothyroid ligament and thyroid complete before the laryngeal opening is closed
cartilage. The cricothyroid ligament is incised using interrupted sutures of synthetic absorbable
throughout its length and the incision continued suture material. The sternohyoideus muscle and
through the body of the thyroid cartilage. A small skin are co-apted in the customary manner.
self-retaining retractor is inserted which enables Although this method does not completely devocal-
the laryngeal cavity to be completely visualized. ize clogs its results are better than those achieved
Care must be taken to ensure that haemostasis is by removing the vocal cords.
52 SECTION 2/suRGERY OF THE HEAD AND NECK
Parotid
gland
Rostral
sublingual
gland
Submandibular
gland
11
I
Internal
maxillary vein Caudal
sublingual
.1 illlllilll l il l l l l l l llllil l l gland
External External maxillary vein

jugular vein
Fig. 2.67. Note the position of the submandibular salivary gland located between the external and internal maxillary
veins and its intimate relationship with the caudal sublingual salivary gland.
Capsule of
SALIVARY RETENTION submandibular
CYSTS - DOG Parotido-auricularis m. gland
These cysts develop as painless fluctuating swellings

in either the submandibular or cervical region of the
neck or sublingually where they are called ranulae.
They are generally the result of saliva leaking from
a ruptured sublingual gland or duct, or, more
rarely, from the submandibular gland. The escap-
ing saliva accumulates under the tongue in the
submandibular region or in the dependent part of
the neck where it stimulates a local tissue reaction
which leads to the development of an organized
cyst wall (mucocoele).
The removal of the entire sublingual/mandibular
complex is recommended since it is difficult to
separate the caudal portion of the sublingual gland
from the submandibular gland (Fig. 2.67). Fig. 2.68. The dog is placed in lateral recumbcncy with
The dog is positioned in lateral recumbency with the affected side uppermost and its head and neck
a sandbag under the neck and the head rotated so extended. A skin incision 7.5-10 cm long is made from
the angular process of the mandible to the point of the V
that the cyst is uppermost (Figs 2.68-2.71). Follow- formed by the union of the external jugular vein with the
ing removal of the salivary gland complex the in- internal and external maxillary veins. The underlying
cision is closed by co-apting the parotido-auricularis parotido-auricularis muscle is incised to expose the
muscle with interrupted sutures of synthetic absorb- capsule of the mandibular gland.
able suture material and the skin is repaired in the
customary manner. The mucocoele is drained by a
stab incision. It is rarely necessary to debride or
remove the sac lining.
It is not always obvious on which side of the
neck the affected glands are located. If so the
gland may be located by opening the cyst and
tracing the sinus back to the gland.
THE NECK 53
Submandibular Sublingual gland

gland posterior portion
Submandibular
gland
Fig. 2. 70. The freed glands arc brought out of the incision and the rostral portion of
the sublingual gland separated by blunt dissection using scissors.
Fig. 2.69. The capsule is incised and the submandibular
and caudal portion of the sublingual gland is freed by
blunt dissection.
Sublingual
gland-rostral
portion
TRACHEOTOMY - HORSE
The operation of tracheotomy is performed to Fig. 2. 71. When the rostral portion of the sublingual gland has been entirely freed, its
insert either a temporary or permanent trache- extremity is seized with artery forceps. It is then drawn back to expose the ducts which
arc tied off and the attachments severed to complete the removal of the glands.
otomy tube. Temporary tracheotomy is employed
to provide an airway for the relief of an acute high
obstruction. The latter is employed when perma-
nent obstructions are present such as ossification of
the larynx, neoplasms, a fractured tracheal ring or
as a substitute for laryngeal ventriculectomy
to relieve the effects of paralysis of the intrin-
sic muscles of the larynx when a quick result is
required.
The operation is satisfactorily performed with
the horse standing under sedation and local anal-
gesia (Figs 2.72-2.75). Under sedation the horse
lowers its head and it is necessary to have an
assistant supporting its jaw to obtain satisfactory
exposure of the site.
The tube is composed of four parts, a lower and
upper, a central cylindrical portion and a plug,
securely held together by small thumbscrews
(Fig. 2.76). Each part is introduced separately in
its proper order.
Fig. 2.72. The correct site for inserting a permanent tracheotomy tube is in the midlinc
For the first few days post operation, there is of the ventral aspect of the neck at the upper and middle thirds. This site is clear of the
considerable mucous discharge and the tube has to harness and leaves room for repeating the operation lower down should stenosis of the
be removed daily for cleaning. Once the local trachea occur.
54 S EC TI O N 2 f S U R G ER Y O F TH E H EA D AND N EC K
Cartilaginous
ring
Fig. 2.73. A longitudinal skin incision 5.0-6.5 cm in length is made in the midline of the neck. This exposes the
sternothyrohyoideus muscle, which is divided and retracted to expose the trachea.
Fig. 2.75. The blade of the scalpel is inserted through the

annular ligament and the upper ring partly severed. The
disc of cartilage to be removed is then seized securely
with Kocher forceps and a circular incision is continued
through the cartilage to complete its removal.
inflammation has subsided the tube can be cleaned

in situ and need only be removed at IO- 14 day
intervals.
Fig. 2.74. A semi-disc of cartilage is removed from two When in the stable the tube is kept closed by its
adjacent tracheal rings. This leaves a strip of each ring
intact and prevents the rings from collapsing. The size of
plug to prevent dust, etc. entering the trachea, and
the disc to be removed is gauged by using the plug of the care must be taken to ensure there is no place
tube as a guide. It is important to use a solid scalpel to against which it can be rubbed. If the top half of a
remove the cartilaginous disc as the tip of a fine loose box door is kept open then a grill should be
detachable blade can easily snap off and disappear down put up to prevent the horse getting his head over
the trachea.
the lower half. A horse should never be turned out
to grass wearing a tube.
THE NECK 55
Fig. 2.76. Jones' tracheotomy tube. This is the standard permanent self-retaining Fig. 2.77. Temporary or emergency tracheotomy tube
tracheotomy tube and is available in the following sizes: for a horse. The trachea is exposed in the manner
described but instead of removing a disc of cartilage from
Size Bore (mm) Neck (mm) two adjacent rings an intertracheal annular ligament is
divided transversely and the flange of the tube inserted
25 25 between the two tracheal rings. It is retained in position
2 28.5 28.5 with tape tied around the neck.
3 12 32
4 35 35
TRACHEOTOMY DOG Sterno-

hyoideus m.
It is sometimes necessary to perform a temporary
tracheotomy (Figs 2.78-2.79) in the dog to provide
an emergency airway for a high obstruction or in
Fig. 2.78. The dog is restrained in dorsal
the treatment of intrapulmonary haemorrhage or
recumbency with its head and neck fully
pulmonary oedema in which the tidal volume has extended. A longitudinal and midline skin
been reduced to that approximating the physiologi- incision 2.5-4.0 cm in length is extended
cal dead space. It also enables the bronchial tree to caudally from just below the cricoid cartilage
be aspirated of mucus and secretions, which is not · of the larynx. The underlying sternohyoideus
muscle is divided and retracted to expose the
possible via the larynx.
trachea.
The tube is retained in situ with a tape tied
around the neck and has to be cleaned out two or
three times daily. When the tube is removed the
flap of trachea is repositioned and the overlying
muscle and skin closed in the usual manner. The
edges of the flap and of the trachea rapidly adhere
and prevent stenosis of the lumen.
Fig. 2.79. The tracheotomy is Fig. 2.80. A plastic tracheotomy tube. This
performed by severing two or three type, moulded in transparent non-toxic PVC, is
tracheal rings and reflecting a very suitable for dogs and is obtainable in sizes
complete section of the trachea. ranging from French Gauge 16 to 42 (9-22 mm
external diameter).
SECTION 2/SURGERY OF THE HEAD AND NECK
just behind the point where it passes under the

OPERATION FOR WINDSUCKING
maxillary vein and extended caudally for 15 cm.
AND CRIB-BITING (FORSELL'S
The muscle is then separated from the fascia by
OPERATION) - HORSE
blunt dissection and when it has been completely
Windsucking and crib-biting can be alleviated and separated, tension is applied and it is severed
often permanently cured by resecting 15 cm of about 2.5 cm cranial to the point where it disap-
each pair of the sternohyoideus and omohyoideus, pears under the maxillary vein. The severed muscle
sternothyroideus and sternocephalicus muscles is then reflected about 15 cm and removed together
from near their cranial insertions (Fig. 2.81 ). with the fascia, but two points deserve attention:
The operation is performed with the horse in (a) a large artery enters towards the centre of this
dorsal recumbency, its neck extended and with its muscle and requires to be ligated; and (b) a branch
head resting at an angle of 30°. If the head is from the carotid artery enters the muscle 3.5-5 cm
excessively extended it may stretch the recurrent
laryngeal nerve and it also makes dissection more
difficult.
A midline longitudinal skin incision is com-
menced just caudally to the body of the hyoid
bone and extended caudally for 25-35 cm to expose
the muscles of the neck (Fig. 2.82). First the sterno- Oesophagus
hyoideus and omohyoideus muscles are divided Vagus nerve
15 cm caudal to the angle of the jaw, dissected Carotid a rterv-====:ltJ.;;~~:::=:..;;;;..,;~~
forward and resected near their insertions. This Jugular vein ---~to
exposes the sternothyroideus, a small flat muscle
lying on the trachea, which is divided 15 cm from Trachea Sternocephalicus
its insertion, dissected forward off the trachea and Sternothyroideus
resected at its insertion. Next the sternocephalicus
is resected as it disappears under the parotid gland
Sternohyoideus
and submaxillary vein. This muscle is enclosed in a
sheath of fascia which is incised longitudinally from Fig. 2.81. Cross-section of the horse's neck at the third cervical vertebra.
Sternothyroideus
m.
-~=
'-'-fr---- Omohyoideus
m.
Stump of '--'+i-"-'-'-'----Plane of dissection to

omohyoideus ---..,,.,-+-1.lil- locate spinal accessory
m. nerve
,-+s+--Sternocephalicus
m.
+;-~-- Sternohyoideus
m.
Fig. 2.82. The ventral aspect of the neck of the horse showing the sites of transection of the sternothyroideus and
sternocephalicus muscles (dashed lines).
THE NECK 57
to the point where it disappears under the sub- tomy can be performed after myectomy of the
maxillary vein and so particular care must be taken omohyoid and sternothyrohyoideus muscles, the
when it is divided. nerve is easier to identify before the surgical field
Although haemorrhage during the operation is has become obscured by blood. A plane of dis-
minimal it should be meticulously controlled by section is established on the medial side of the
forcipressure or diathermy to minimize seroma sternocephalicus muscle about 5 cm caudal to its
formation. A z.y-cm diameter Penrose drain is musculo-tendinous junction. By carefully rotating
inserted at both extremities of the wound or, the muscle laterally, the nerve is identified on its
alternatively a continuous suction drain may be dorsomedial aspect (Fig. 2.82). Gentle pressure on
employed. Closure of the wound consists of a the nerve with forceps evokes sudden contraction
simple continuous suture in the subcutaneous tissue of the muscle. Curved haemostats are placed under
with synthetic absorbable material and horizontal the nerve which is separated from the underlying
mattress sutures of nylon in the skin. A stent muscle using two fingers, allowing at least 12 cm to
bandage sutured over the length of the incision be removed. The procedure is repeated on the
helps to eliminate dead space. This is removed 4 other side.
days post-operatively and the drainage tubes after
3-7 days.
CANNULATING THE CAROTID
The not inconsiderable mass of muscle removed,
ARTERY - DOG
inevitably results in some disfigurement. A modifi-
cation of the technique in which the sternocepha- Blood for transfusion is obtained from the jugular
lieus muscle, the largest and most powerful muscle vein of the donor unless exsanguination is practised,
involved in cribbing is denervated rather than when the carotid artery is cannulated. The carotid
resected, improves the cosmetic result without artery has also to be cannulated for cerebral
reducing the overall success rate. The sternocepha- angiography. The procedure is shown in Figs 2.83-
lieus muscle is innervated by the ventral branch of 2.86.
the spinal accessory nerve. Although the neurec-
Oesophagus
Jugular vein
Fig. 2.83. With the dog in right lateral recumbency a longitudinal skin incision is made dorsal to and parallel with the
jugular furrow. The line of cleavage between the stcrnocephalicus and stcrnohyoideus muscle is located and the muscles
separated by blunt dissection co expose the left common carotid artery and left vago-sympathctic nerve trunk lying
between the trachea and oesophagus.
Fig. 2.84. The left common carotid artery is freed by

blunt dissection, ligated cranially and clamped caudally
with a bulldog clip. A ligature is placed around the artery Fig. 2.86. Method of cannulating the artery. (a) V-
and left untied. shaped opening produced by cutting the artery with
scissors. (b) The end of the cannula is bevelled. To insert
the cannula into the lumen of the vessel the point of the
bevelled end is inserted under flap. (c) The cannula is
inserted until it encounters the clamp and then retained
in position by tying the ligature previously laid. Finally,
the clamp is released.
Fig. 2.85. The artery is picked up with dissecting forceps

and partially severed with scissors to fashion a V-shapcd
opening.
The mandible
FRACTURE OF THE HORIZONTAL
RAMUS - DOG
Many methods have been advocated for immobiliz-

111111111111
I 11111' '11111111111111111
ing fractures of the horizontal ram us. These include
fixation with a bone plate or transfixion by an
intramedullary pin but in the majority of cases the
easiest and most effective method is to immobilize
incision
-
Line of skin
r----_ ::,,'":r;
--
""y
... ·.
~I
1mn
is
,PI
~I Fracture of
ram us
the fracture with a wire suture supported by inter-
dental wiring (Figs 2.87-2.90). If this method is
11111111111111 1111111111] I I I"I
111111111
1
I ,[
impractical clue to loose, broken or missing teeth
then fixation with a bone plate is an alternative
Fig. 2.87. The dog is placed in dorsal rccumbcncy with
method (Fig. 2.91 ). its head and neck fully extended and the skin is incised
A fracture of the ram us is invariably complicated along the ventral border of the ramus.
by torn gums and mucous membranes. These are
sutured using 2 metric synthetic absorbable suture
material. Post operation, particular attention must
be paid to mouth hygiene and to the control of
infection.
THE MANDIBLE 59
Buccinator m. Facial vein
Fig. 2.88. The fracture site is exposed by reflecting the buccinator muscle and facial vein medially.
Fig. 2.89. Using a 1.5-mm drill, two holes are drilled through the ramus one on each side of the fracture, making sure
they arc placed below the alveoli of the adjacent teeth.
Fig. 2.90. A length of wire is passed through the drill

holes, the fracture reduced and then immobilized by
twisting tight the ends of the wire. The twisted portion is
then cut off short and the end pressed flat against the Fig. 2.91. In many cases a bone plate and screws
lateral aspect of the ramus. With the dog turned on its provides more stable immobilization. A 2.7-mm dynamic
side the immobilized fracture is further supported by compression plate is suitable for most sizes of dogs.
wiring together the two teeth adjacent to the fracture.
An external fixator consistmg of multiple

FRACTURE OF THE
percutaneous pins joined by a 'sausage' of methyl-
SYMPHYSIS - CAT
methacrylate is a cheap and versatile method of
repairing many mandibular fractures (Fig. 2.92). This is a very common fracture in the cat and is
Perfect reduction of all of the fractured fragments best treated by encircling the symphysis with a wire
is not important provided dental occlusion is suture (Fig. 2.93).
achieved. Healing should be established in about 3 weeks
when the wire is removed. A similar fracture in the
dog is treated in like manner.
Symphysis
Mucous membrane
Fig. 2.93. Using a full-curved round-bodied needle, a

monofilamcnt wire suture is passed beneath the mucous
Fig. 2.92. An acrylic external fixator. The jaws are
membrane ventral to the incisors, and then around the
closed and two or more Kirschner wires arc inserted
symphysis behind the incisors, before being twisted tight
percutaneously into each major fracture segment. The
and cut off.
ends of the wires arc pushed through wide-bore
polythene tubing which is then filled with methylmeth-
acrylate. The acrylic is prepared by mixing liquid
monomer with a powdered polymer. It sets within a few
minutes by an exothermic reaction.
Section 3
Abdominal Surgery
Laparotomy
In the dog it is normal practice to carry out lapar-
DOG
otomy through the linea alba or by variations of
this simple approach (Fig. 3.1 ). This is well toler-
Linea alba incision
ated by the patient and gives an excellent surgical
exposure to all the abdominal viscera. Careful dissection through the fibrous linea alba
During recent years it has become common allows an almost bloodless laparotomy incision.
practice to enter the abdomen of the horse through The incision may be closed by a single layer of
the linea alba; an incision which allows excellent interrupted sutures. Alternatively, a continuous
surgical exposure, reduces post-operative tissue suture is simple and quick.
reaction and eliminates the possibility of unsightly To carry out a cranial laparotomy through the
scarring of the sublumbar fossa. linea alba it is necessary to trim the fatty falciform
In the larger domestic animals, however,
incisions near the lower abdomen are subjected to
considerable pressure from the weight of the over-
lying abdominal contents, and wound breakdown
is likely to be complicated by a massive prolapse of
viscera. For this reason, laparotomy is commonly
carried out through a flank incision. As the ox does
not tolerate lateral recumbency for any length of
time clue to ruminal tympany, this, together with
the placid temperament of the cow, has led to
major abdominal surgery being carried out on
the standing animal under regional analgesia.
Although there are advantages with this procedure,
one must bear in mind that the flank incision (a)
considerably reduces the surgical exposure and
makes manipulation of the large abdominal viscera
very exhausting. Nor is it possible to block all
sensory nervous pathways from the abdominal
viscera by the commonly used techniques of
regional analgesia.
Anatomical considerations
The anatomical distribution of the abdominal

muscles follows a common pattern, with only minor
species modifications. The external and internal
oblique abdominal muscles, and the transverse
abdominal muscle all arise as muscle masses each
forming a broad fibrous tendon of insertion or
aponeurosis. The aponeuroses of the two oblique
{b) Rectus abdominis m.
muscles fuse at the linea alba external to the flat
1, External oblique rn,
muscle mass of the rectus abdominis muscle, and 2. Internal oblique m.
together form the external sheath of the rectus. 3. Transversus rn,
The aponeurosis of the transversus muscle forms 4. Peritoneum
the internal sheath of the rectus muscle. It fuses at Fig. 3.1. The abdominal wall of the dog may be opened
the linea alba deep to the rectus abdominis, surgically from xiphisternum to pubic brim, but this is
together with the peritoneum. rarely if ever necessary. Operations on the diaphragm,
stomach, spleen and small intestine are normally carried
out through an incision anterior to the umbilicus
(cranial laparotomy, a), whereas hysterectomy,
cystotomy and surgery of the rectum and colon require
an incision between the umbilicus and pubic brim (caudal
laparotomy, b).
64 S EC TIO N 3 / A B D O M I N A L S U R G E RY
ligament which lies in the midline and extends

Ventral midline incision
from the umbilicus forward between the central
lobes of the liver. The linea alba approach is the most versatile and is
now used almost universally for colic surgery. It is
also the approach favoured by most surgeons for
Rectus-splitting or paramedianincision
Caesarean section and ovariectomy in the mare.
This can be conveniently used for both cranial and A short exploratory incision in the central mid-
caudal laparotomies. The incision is made parallel line can be extended in either direction to ac-
to the linea alba through the external and internal commodate any problem encountered. For colic
sheaths and the substance of the rectus abdominis surgery an initial skin incision, 20 cm long, is made
muscle. Surgical trauma is not excessive as the commencing at the umbilicus and extending
fibres of the rectus muscle run in the direction of cranially. Separation of the subcutaneous fat and
the incision, but haemorrhage is often consider- connective tissue for a centimetre or so on either
able and must be carefully controlled. Closure is side facilitates closure of the linea alba later.
effected by a continuous suture in the internal The incision in the linea alba, which is only a few
rectus sheath and the peritoneum, then by a layer millimetres wide, is made carefully and precisely
of interrupted sutures in the external rectus sheath. commencing at the umbilicus where the exact mid-
line can be identified even when the abdomen is
very distended. The underlying retroperitoneal fat,
Rectus reflection
which may be several centimetres thick, is divided
This may again be used for a cranial or caudal exposing the thin peritoneum which is opened
laparotomy and if correctly carried out is almost along the length of the round ligament of the liver.
bloodless. The external rectus sheath is incised Midline incisions heal more slowly than para-
parallel to and about I cm away from the linea median or flank incisions because of the relative
alba to expose the rectus muscle. The rectus sheath lack of vasculature of the linea alba. Improved
is blunt-dissected away from the rectus muscle anaesthetic and surgical techniques and reliable
towards the midline until the medial edge of the suture materials allow reconstruction to be ac-
rectus muscle is exposed along the required length. complished quickly and easily with only minimal
The edge of the rectus muscle is then lifted away risk of herniation and evisceration even in the
from the internal sheath, which is opened about biggest horses. A wide variety of suture techniques
5 mm away from and parallel to the linea alba. and materials have been used.
Closure is effected by a continuous suture in the The peritoneum is thin and tears easily but pro-
internal sheath and peritoneum, and interrupted viding adequate decompression of bowel has been
or continuous sutures in the external sheath. carried out, it can be sutured using a continuous
suture of 3 metric polyglycolic acid or polyglactin
910. Experimental and clinical experience has shown
HORSE
that no detrimental effects result if the peritoneum
Laparotomy is now widely practised in the horse is left unsutured. The linea alba is closed using a
and includes operations to correct disorders of the continuous suture of 5 metric coated polyglactin or
alimentary tract, surgery of the abdominally placed 5 metric polyglycolic acid doubled (Fig. 3.2a). In
genital organs and surgery of the urinary bladder. extremely large or muscular horses, or when con-
In addition to allowing access to the organ on siderable tension is required to approximate the
which surgery is contemplated, the laparotomy edges of the incision the far and near suture pat-
incision must fulfil other requirements. tern is useful (Fig. 3.2b). Non-absorbable, coated
The site of the incision and the materials and braided polyester suture material may be used.
methods used to close it, must be able to withstand The subcutaneous tissue is closed with a continu-
the great stresses and strains to which it will be ous suture of 3.5 metric polyglactin and the skin
subjected, e.g. when the patient regains its feet with a continuous mattress suture of 8 metric
after surgery. The incision should be simple to sheathed multifilament polyamide. Although the
perform, produce minimal damage to the abdomi- use of continuous suture patterns and absorbable
nal wall and should heal without impairment of materials would appear, theoretically at least, to
function. be risky, it has proved a reliable method and has
A variety of approaches are employed, the most the advantage of significant saving in time (this
important being: ventral midline, ventral para- may be critical in colic cases) and a reduced inci-
median and flank. dence of sinus formation.
LAPAROTOMY 65
Fig. 3.2. (a) The linca alba is closed using a continuous suture of 5 metric coated polyglactin or 5 metric polyglycolic acid
doubled. (b) When considerable tension is required to close the incision the linea may be repaired with a far and near
suture pattern.
Muscle fibres
of rectus abdominis m.
External rectus sheath
Fig. 3.3. After incision of the skin, the cutaneous trunci muscle and the abdominal tunic, the external sheath of the
rcctus is incised.
from the xiphoid as far back as the entrance to the

Paramedian incisions
sheath. Made further caudally, the incision should
Paramedian incisions (Figs 3.3-3.6) are most use- be angled slightly medially at its caudal end because
ful to gain access to the caudal abdomen in the the fibres are converging on the linea alba.
male horse for cryptorchidectomy, cystotomy and Closure is effected by a continuous suture in the
repair of a ruptured bladder. peritoneum and transversus fascia, which is often
The skin incision is made along the line of the difficult if the retroperitoneal fat layer is very
fibres of the rectus abdominis muscle and is there- thick. The fascia of the external sheath is closed
fore parallel to the midline, if made anywhere with interrupted sutures.
66 S EC TI O N 3 / ABDOMI NAL S U R G E RY
Cut edge of rectus

abdominis m.
Internal rectus sheath

(transverse fascia)
Fig. 3.4. The rectus muscle is gently split longitudinally in the direction of its fibres by blunt dissection to expose the
internal rectus sheath. This allows the vessels which traverse the incision to be recognized and ligated before they arc
cut.
External rectus sheath
Fat layer
covering peritoneum
Fig. 3.5. The internal sheath of the rcctus is opened to expose the layer of fat which covers the peritoneum.
Peritoneum
Fat
Fig. 3.6. The peritoneum is carefully 'tented' to avoid damage to the underlying viscera, and opened with scissors.
Absorbable sutures of polyglycolic acid, polyglactin or polydioxanone are used for all layers other than skin.
This type of muscle-splitting flank incision is

Flank incision
sometimes referred to as a 'grid-iron' incision, and
The paralumbar fossa in the horse is very small has the advantages of causing the minimum of
and this site allows only enough room for manual surgical trauma, and once traction is removed from
exploration, with little or no visualization of each muscle layer the wound tends to be self
abdominal contents. Therefore, it is more common closing. It is usual to close the peritoneum and the
to make the incision lower in the flank (Figs overlying fat layer with a continuous suture. Inter-
3.7-3. IO). rupted sutures are placed in the internal and exter-
LAPAROTOMY 67
Apo neurosis
of the external
oblique m.
Internal
Fold of oblique m.
right flank
Transversus m.
Fig. 3.7. A vertical incision is made through the skin and

cutaneous trunci muscle. The incision extends from just
cranial to the external angle of the ileum down to the
fold of the flank to expose the aponeurosis of the external
oblique muscle. This avoids the danger of cutting the
lateral border of the rectus abdominis muscle, and its
adjacent posterior abdominal artery.
Fig. 3.9. The fibres of the internal oblique arc split and retracted to expose the
aponcurosis of the transvcrsus muscle whose fibres tend to run in the vertical plane.
Internal
oblique m.
Fat
Peritoneum
Fig. 3.8. The aponeurosis of the external oblique muscle

is opened in the vertical plane to expose the thick origin Fig. 3. IO. The transversus aponeurosis is split to reveal the layer of fat covering the
of the internal oblique muscle, whose fibres are inclined peritoneum. This is not usually as thick as in the lower abdomen, but must be 'tented'
in a cranio-vcntral direction. and opened with care.
68 S EC TI O N 3/ A B DOM I N A L S U R G E RY
nal oblique muscles and the skin is closed separately the horse, and flank laparotomy may be carried
incorporating the cutaneous trunci muscle. out either cranially for rumenotomy or caudally
This approach has been used for cryptorchi- either for Caesarean section or to rectify a displaced
dectomy and ovariectomy and should be employed abomasum. Both of these incisions should be mod-
in colic cases should a repeat laparotomy be necess- elled on the 'grid-iron' technique as described for
ary more than 4 days after the initial operation. the horse, with the following anatomical variations.
Access to a viscus located near the roof of the I The cranial incision will pass through the thick
abdomen sometimes necessitates removal of the muscular origin of the external oblique, whereas
17th and/or t Sth rib. Splenectomy, nephrectomy the underlying internal oblique in this region is
and total resection of the caecum are performed only an aponeurosis. If the incision is high in the
using this approach. sublumbar fossa it will pass through the muscular
The technique of rib resection is as described for origin of the transverse muscle, which lower down
the dog (Section 7). blends into an aponeurosis in which may be seen
In some horses with a more caudal attachment the lumbar segmental nerves.
of the diaphragm, removal of the 17th rib may 2 Caudal laparotomy just cranial to the external
result in the thoracic cavity being opened but this angle of the ileum is anatomically the same as
presents no problem providing the margin of the described for a flank laparotomy in the horse,
diaphragm is included in the sutures used to close except that there is no fat layer in the cow between
the deepest layer of the incision. the transversus fascia and the peritoneum.
3 When closing both of these incisions the perito-
neum and transversus fascia should be closed
CATTLE
together with a continuous suture. The other
The sublumbar fossa of the ox is wider than that of muscle layers are co-apted by interrupted sutures.
Gastro-intestinal surgery
dilatation of the dog's stomach led to a tendency
DOG
for the stomach to rotate around the fixed point of
The high acid content in the stomach of the dog the cardia , and numerous clinical observers have
enables it to digest relatively large pieces of meat shown that this rotation is invariably 270° in a
which are swallowed after a minimum of chewing clockwise direction, as viewed from the abdominal
and often include large pieces of bone. This pre- cavity looking cranially.
disposes to the ingestion of large and undigestable Whereas simple dilatation causes extreme dis-
'foreign bodies', which will often lie in the stomach comfort and respiratory embarrassment, torsion of
for long periods of time without giving rise to the stomach causes profound cardiovascular
symptoms. If they cause gastritis bylocal irritation, changes due to the virtual complete occlusion of
or pass into the pyloric area of the stomach they the venous return from the gastro-intestinal tract.
then stimulate vomiting and other signs suggestive It is therefore vitally important to differentiate
of obstruction. Whilst it is difficult to palpate a dilatation from torsion.
foreign body in the stomach, it can usually be The immediate action of the clinician must be to
demonstrated radiographically. pass a stomach tube. If this enters the stomach
through the cardia it not only relieves the dilatation
but also shows that no torsion is present. In cases
Gastric dilatation and torsion
of simple dilatation it is important to drain the
This condition is most frequently seen in the larger stomach of its contents, if necessary rotating the
breeds of dog, and usually follows soon after inges- dog in its long axis several times in order to release
tion of a large meal. The condition is characterized all the possible residual pockets of gas and ingesta.
by rapid abdominal distension, accompanied by This drainage procedure should be repeated fre-
signs of acute discomfort and frequent attempts at quently during the first 24 hours to guard against
vomiting, which are usually unproductive. Exper- the recurrence of the dilatation.
imental work carried out on cadavers showed that If it proves impossible to insinuate the stomach
GAST RO - I NT ES TI N A L S U R G ER Y 69
tube through the cardia, then the distension must

be relieved as a matter of urgency. In cases of
extreme distress, where respiratory and circulatory
collapse are imminent, the distension can be re-
lieved by trocharization of the stomach through
the abdominal wall just caudal to the costal arch
in the lower right flank. The trochar will enter the
dilated fundus of the stomach, which following a
clockwise torsion will be lying in the right epigas-
trium. Emptying the stomach by paracentesis, fol-
lowed by warm saline lavage, sometimes leads to
spontaneous resolution of the torsion and is con-
firmed by the ability to pass the stomach tube
through the cardia.
An alternative method of decompression is tem-
porary gastrostomy performed under local anal-
gesia. This is a more time-consuming technique
but has the advantage over trocharization that
there is less likelihood of peritonitis developing. A
5-cm grid incision is made through the previously Fig. 3.11. Roberts' forceps arc pushed through the abdominal wall ventral to the tip of
the 13th rib. The exit hole in the skin is situated dorsally and is of a smaller diameter
desensitized abdominal wall 2 cm behind and than the catheter which is to be used.
parallel to the right costal arch. The distended
stomach wall is picked up and anchored by two
temporary stay sutures before stitching it to the
edge of the skin wound with a continuous suture of
a synthetic absorbable suture. The stomach wall
Purse-string
is incised within the sutured area and its edges suture in
oversewn to control bleeding. The stomach can pyloric antrum
now be emptied and lavaged with warm saline with
little risk of contaminating the abdominal cavity.
After 24 hours of drainage a laparotomy is per-
formed to excise the gastrostomy and repair the
stomach wall.
If decompression fails to relieve the torsion it is Foley -----1
necessary to reposition the stomach surgically. In catheter
the past this has been done via a laparotomy as an
emergency procedure. However, such surgery was
invariably carried out on a severely shocked patient
and, in spite of vigorous transfusion, the mortality
rate was unacceptedly high. It is wiser to defer
surgery until the animal is fit for general anaes-
thesia. This generally means maintaining decom-
pression for 24 hours while cardiovascular and Fig. 3.12. The Foley catheter is pulled through the abdominal wall. A purse-string
respiratory function improve. suture of non-absorbable material is placed in the pyloric antrum and a small incision
made within it.
Tube gastrostomy and gastropexy is the surgical
procedure of choice to reposition the rotated
stomach. This technique can also be used to pre-
vent recurrence of the torsion at a later date. The and the linea alba. A small incision is made in the
dog is placed in dorsal recumbency and a midline skin to permit the points of the forceps to exit
laparotomy performed. Roberts' forceps are (Fig. 3. I 1 ). The end of a 26 French gauge Foley
pushed through the parietal peritoneum and catheter is grasped by the forceps and pulled into
musculature of the abdominal wall of the right the abdomen. The catheter is passed through the
paracostal region near the tip of the 13th rib. The greater omentum of the stomach and through an
points of the forceps are directed dorsally so as to incision in a previously placed purse-string suture
emerge half-way between the vertebral column in the pyloric antrum. This suture is placed two-
70 SECTION 3 / ABDOMINAL SURGERY
thirds of the way from the fundus to the pylorus

and should be of non-absorbable material such as
polypropylene (Fig. 3. 12).
The balloon of the Foley catheter is inflated with
saline and the purse-string suture tightened around
its body. The inflated catheter is pulled up so that
the stomach lies against the abdominal wall and
the two are sutured together with interrupted non-
absorbable sutures. A purse-string suture is placed Purse-string
in the skin around the Foley catheter (Fig. 3. 13) suture in skin
and the laparotomy incision closed in the usual
way. Stomach wall
sutured to
The abdomen is bandaged to prevent the clog abdominal wall
from interfering with the catheter. This must be
left in situ for at least 5 clays to minimize the
development of peritonitis. Before withdrawing Fig. 3. 13. The Foley catheter is introduced into the stomach and its balloon inflated with
saline. Traction is applied to the inflated catheter to appose the stomach and adjacent
the catheter the balloon is deflated and the purse-
body wall. A series of gastropcxy sutures of silk or polypropylene arc placed to anchor
string skin suture is removed. The gastrostomy the gastric wall to the peritoneum, taking care not to put the needle through the inflated
heals by granulation within a few days, during balloon. A purse-string suture is placed in the skin around the Foley catheter.
which time the area is kept clean and bandaged.
The significance of delayed gastric emptying in
the aetiology of the gastric dilatation/torsion com-
plex is unclear but it is recommended that pyloric Bowel
clamp
myotomy (see Fig. 3. 17) is performed as a pro-
phylactic measure. In contrast, there is no indi-
cation for splenectomy unless the organ is infarctecl.
Gastrotomy
The stomach is approached through a caudal lapar-
otomy incision to the left of the linea alba. The
foreign body is readily palpable through the intact
stomach wall and can be manipulated into the Fig. 3.14. The exposed portion of stomach is carefully packed off with moist and warm
fundus of the stomach which is then drawn up to isolation towels to avoid peritoneal contamination. The stomach wall is opened by
the incision by gentle traction. The portion of cutting down onto the foreign body which is immobilized by gripping it through the
stomach containing the foreign body is isolated by stomach wall. It will be noted that the mucous membrane of the stomach is extremely
vascular and is freely movable owing to the very loose texture of the subrnucous
means of a bowel clamp (Figs 3.14-3.16).
connective tissue. After removing the foreign body the stomach wall is closed in two
layers.
Mucous membrane Bowel clamp
Fig. 3.15. The mucous membrane is closed by a continuous mattress suture of 2 metric
synthetic absorbablc material which not only co-apts the edge of the incision but also has
a haemostatic effect. If haemorrhage from the mucous membrane is not controlled a
large submucous haematoma may form which can lead to complete disruption of the
gastrotomy incision.
GASTRO-INTESTINAL SURGERY 71
Interrupted Lembert inversion sutures
Fig. 3.16. The muscle layer is closed by interrupted sutures which invert the wound edges and bring the peritoneal
surfaces into apposition, thus ensuring rapid adhesion of the superficial muscle layer.
Pyloric stcnosis
This condition is either congenital or acquired. It
may be caused either by spasm of the sphincter or
hypertrophy of the pyloric musculature both of
Submucosa
which interfere with the passage of food from the protruding through
stomach into the duodenum. This leads to retention incision of
of food in the stomach giving rise to gastric dila- the pylorus
tation which is accompanied by vomiting. This is
often very forceful in nature and is referred to as
'projectile vomiting'.
Acquired hypertrophic pyloric stenosis appears
to be most frequent in young Boxer clogs. Both the
congenital and acquired conditions are benign in
nature and respond to surgical correction.
The operation of choice is pyloric myotomy using
Pyloric antrum
the Freclet- Ramstedt technique which aims to
divide the encircling pyloric musculature and Fig. 3.17. Once the pylorus is adequately exposed an
thus to relieve the obstruction to the pyloric canal incision is made transversely across the complete depth
(Fig. 3.17). The area is exposed through a cranial of the pyloric sphincter. extending 1-2 cm in either
direction, to expose the submucous layer which should
laparotomy to the right of the miclline. The thick-
not be cut. If the technique is carried out correctly the
ened pylorus is readily palpable but is relatively submucosa will protrude through the incision, which is
immobile, being fixed by the hepatoduodenal left unsuturcd, thus relieving the obstruction to the
ligament, and care must be taken when applying pyloric canal. Should the submucous layer be
traction to avoid damage to the common bile duct. inadvertently opened, it must be accurately sutured to
avoid leakage of ingcsta into the abdominal cavity.
An alternative technique is to insert the fore-
finger into the pyloric canal through a small gas-
trotomy incision. Once the pyloric sphincter is
completely divided the lack of resistance is appreci-
ated by the examining finger. pylorus and pyloric antrum the most satisfactory
treatment is by gastro-jejunostomy (partial gas-
trectomy) (Fig. 3. 18). Whilst this re-routing
Gastro-jejunostomy
of ingesta from the stomach direct into the je-
Some cases of pyloric obstruction are neoplastic junum does have its disadvantages, it is generally a
and will not therefore be relieved by simple more satisfactory technique than a direct gastro-
myotomy. In cases where the lesion involves the cluodenostomy following resection of the pylorus.
72 S EC TI O N 3/ A B DO M I N A L S U R G E RY
Common
bile duct
Stomach
Pancreas
Duodenum
Root of
mesentery
Jejunum
Fig. 3.18. The affected pylorus and pyloric antrum arc rcscctcd, avoiding damage to the common bile duct. The
proximal end of the duodenum is ovcrscwn , and starting at the lesser curvature, the defect in the fundus of the stomach
is closed, until a stoma is left on the greater curvature which approximates in size to the lumen of the jejunum. This
stoma is then anastomosed to the conveniently adjacent jejunum by an end-to-side anastomosis, so that food leaving the
stomach passes into the jejunum direct, and receives bile and pancreatic secretions from the duodenum. The arrows
indicate the direction of peristalsis.
Intestinal obstruction Obstruction
Enterotomy
Foreign bodies which pass through the pylorus into

the duodenum often become held up in their pass- Bowel
age through the small intestine and cause intestinal clamp
obstruction. This is an extremely serious condition
and unless it can be quickly relieved death is the
inevitable end result. It must be remembered that
during normal digestion the fluid and electrolytes
which are secreted into the intestine from the
duodenum and pancreas are mostly reabsorbed in
the lower small intestine, so that the loss of these
constituents in the faeces is minimal. In the average
animal this turnover of fluid represents about 2.5
times the plasma volume in 24 hours, and thus any
interference with the normal cycle as occurs in
intestinal obstruction will rapidly lead to extreme
Fig. 3.19. Locate the obstruction, milk the ingesta away
dehydration. An obstruction that occurs high in
from the foreign body and apply bowel clamps to the
the small intestine completely prevents this cycle intestine just above and below the site of obstruction in
of reabsorption and therefore produces a far more order to avoid spillage of intestinal contents when the
rapid and dangerous syndrome than an obstruction bowel wall is opened. The intestine proximal to the
which occurs low in the terminal ileum, but both obstruction is invariably distended with fluid which
continues to be secreted into the bowel lumen after the
will end fatally if they are not relieved. In addition,
obstruction has occurred. Ideally the foreign body should
the loss of electrolyte occasioned by vomiting be manipulated distally into a piece of undevitalized
further aggravates the dehydration and also gives bowel before the incision is made, but this is not always
rise to a metabolic acidosis. It is not difficult to possible.
G AST RO - I NT ES Tl N A L S U R G ER Y 73
I I
Fig. 3.20. Cut through the wall of the intestine onto the
foreign body and remove it. Fig. 3.21. Aspirate any intestinal contents and close the
incision with an inversion suture which penetrates the full
thickness of the intestinal wall, using an atraurnatic
needle with 2 metric synthetic absorbable suture
appreciate that any case of intestinal obstruction material.
requires a careful pre-operative assessment and
that surgery should never be undertaken until
replacement has been made of the lost fluid and
electrolyte, and the pH has been restored to
normal. In the majority of cases the condition
can be cured by enterotomy, in which the bowel
wall is opened and the foreign body removed
(Figs 3.19-3.21 ), but this should only be attempted
after adequate preparation of the patient.
Enterectomy
In cases where intestinal obstruction has occurred
and there has been delay in seeking treatment, the
bowel wall adjacent to the foreign body undergoes
ischaemic necrosis and may actually perforate. In
these circumstances it becomes necessary to excise
the segment of necrotic intestine and to anastomose
the free ends (Figs 3.22-3.29). In the majority of
cases the necessity for enterectomy will be obvious
due to the devitalized nature of the obstructed
Fig. 3.22. The site of resection is isolated by bowel
bowel wall, but it must be remembered that the
clamps and the mesenteric blood supply to the
intestinal wall has remarkable powers of recovery, devitalized area is isolated and ligated.
and enterectomy is never undertaken without due
consideration. In cases in which the intestinal wall
will not support sutures without tearing, it is almost
certain that the tissue is too devitalized to undergo
repair, and therefore enterectomy rather than
enterotomy must be performed.
Intussusception is also a frequent indication for
enterectomy. The intussuscepted bowel can usually
be reduced until the last 2-3 cm when it invariably
tears. The technique of making a longitudinal in-
cision through the muscle coat to relieve pressure
and overcome tearing during the final stage of
reduction has not proved successful in the authors'
hands.
The amount of bowel removed is dependent Fig. 3.23. The damaged section of bowel is removed
partly on the macroscopic damage and partly on together with the immediately adjacent mescntcry.
74 SECTION 3/ ABDOMINAL SURGERY
Fig. 3.24. After resection there is often a marked

difference in the lumen of the two ends of the bowel and
the smaller piece must be trimmed off at an angle to
reduce the disparity.
Mesenterie
border
Fig. 3.25. The two open ends of bowel arc held side by ·
side by bowel clamps and arc sutured together by a single
mattress-type stitch, which is tied so that the knot lies
within the lumen of the intestine. leaving at least 15 cm of
synthetic absorbablc suture material free on the encl
which is not attached to the atraumatic needle.
Atraumatie
needle
Fig. 3.26. The suture material not attached to the

atraumatic needle must now be threaded onto a needle
and drawn through the intestinal wall so that it lies
outside the bowel lumen. Closure is carried out using the
atraumatic needle and a through-and-through stitch until
it is no longer possible to continue stitching with the
intestinal ends held side by side.
Fig. 3.27. The bowel ends arc now rotated until they lie
in continuity and the suturing is continued making
certain that the needle penetrates the whole thickness of
the bowel wall with each stitch.
Fig. 3.28. Once the anastomosis is completed the two

ends of suture material arc tied. The bowel clamps arc
removed and ingcsta is squeezed from proximal to distal
bowel across the anastomosis to test both its patency and
integrity. Alternatively. simple interrupted appositional
sutures allow for easier tissue approximation and less Fig. 3.29. The tear in the mcscntcry is carefully closed
constriction at the anastomosis site. with 2 metric synthetic absorbable suture material.
the distribution of the mesenteric blood supply.

It is essential to make the resection at a point
where a major mesenteric vessel lies adjacent to
the intestinal wall.
(a)
An alternative approach to intestinal anastomosis
is to employ a simple approximating type of suture
pattern such as the simple interrupted appositional
suture. This suture is passed through all the layers
of the bowel and tied without crushing them. It
requires accurate and a traumatic placement of the
sutures so that the two ends of the bowel are
closely apposed without being under tension, but (b)
permits more rapid mucosal healing.
Whichever technique is employed, the anasto-
mosis site should be wrapped with omentum to
encourage healing.
HORSE
(c)
Side-to-side anastomosis is necessary in horses with
chronic, slowly occlusive lesions of the small intes-
tine which result in a great disparity between the
diameters of the intestine proximal and distal to
the lesion. Some surgeons prefer to use sicle-to-
sicle routinely for all small intestinal anastomoses.
After closure of the two ends of the intestine by
a double inverting suture, the two ends are laid (d)
alongside one another so that they overlap by
JO cm. They are united near their mesenteric
border with a continuous over-and-over suture of
3 metric polyglycolic acid (Fig. 3.3oa).
The lumen of each segment is opened by a
longitudinal incision 8 cm long extending as close
to the blind ends as possible (Fig. 3.3oa).
The lumena of the bowel are united using a
Connell suture of 3 metric polyglycolic acid (Fig.
3.3ob-d).
Finally the closure is completed by continuing
the over-and-over serosal suture to its origin where Fig. 3.30. (a) The two ends of the intestine arc closed by
it is tied. The overlapped mesentery is sutured with a double inverting suture and overlapped. They arc
joined by a continuous over-and-over suture and their
a row of interrupted sutures along each free edge
lumcna opened. The two incisions should extend as close
(Fig. 3.3oe). to the blind ends of the segments as possible. (b-d) The
lumena of the bowel arc united using a Connell suture of
3 metric polyglycolic acid. (c) The closure is completed
lleocaecal and jejunocaecal anastomosis by continuing the first over-and-over continuous suture
back to its origin where it is tied.
The ileum is frequently the site of small intestinal
obstruction in the horse. The terminal portion of
the ileum is inaccessible via a ventral midline
incision making resection and end-to-end anas-
tomosis at that level technically very difficult if not The necrotic intestine is resectecl and the end is
impossible. closed with an inversion suture. The jejunum is
To overcome this problem and the limited blood now placed between the dorsal and medial bands
supply at the ileum, side-to-side jejunocaecal anas- of the caecum with its closed encl pointing towards
tomosis is now used routinely (Fig. 3.31 ). the base of the caecum. The anastomosis is carried
76 SECTION 3/ ABDOMINAL SURGERY
Fig. 3.31. To overcome the problem of poor access to

the terminal ileum. a side-to-side jcjunocaccal
anastomosis is performed. The ileum is incised and its Fig. 3.33. Site of left cranial flank incision for
ends closed with an inverting suture. A side-to-side rumcntorny.
jcjunocaccal anastomosis is then performed. as in Fig.
3.30. The blind end of the jejunum must point to the base
of the caecum. The defect in the mcsentcry is closed to
prevent other portions of bowel becoming trapped. CATTLE
Rumenotomy
Rumenotomy is indicated either for the relief of

rumenal impaction, or as an approach to the exam-
ination of the reticulum and its contents. The left
dorsal sac of the rumen lies conveniently adjacent
to the left sublumbar fossa and can be easily
exposed through a cranial flank incision (Fig. 3.33).
This approach is well tolerated in the standing
animal using paravertebral analgesia or the less
specific techniques of local analgesia of the sub-
lumbar fossa. To avoid the danger of peritoneal
contamination from spilled ingesta once the
rumenal wall is opened, at one time it was common
practice to suture the rumenal wall to the edge of
the incised peritoneum before it was opened, or
Fig. 3.32. Side-to-side anastomosis of the jejunum to the
caecum bypassing the terminal ileum. The anastomosis is as an alternative the rumenal wall was 'tented'
performed as in Fig. 3.30. through the abdominal incision by means of stay
sutures and held by two or more assistants. Both of
these techniques had their disadvantages, but have
largely been overcome by a set of instruments
designed by McLintock, which consist of a rubber
out as previously described for side-to-side covered hook, a reinforced rubber sleeve, and a
anastomosis. large adjustable clamp (Figs 3.34-3.36).
The mesenteric defect is closed by suturing the
cut edge of the jejuna! mesentery to that of the
ileum and to the ileocaecal fold.
A modification of this technique, in which the
ileum is anastomosecl side-to-side to the caecum,
without resection, can be used to bypass non-
strangulating obstructions of the terminal ileum
caused by hypertrophy or ileal-ileal intussus-
ceptions (Fig. 3.32).
GAST RO - I N TES TI N A L S U R G ER Y 77
Rumen wall
Abdominal
wall
Rubber sleeve
cavity
Rumen wall
held outside the incision
by rubber ring
Fig. 3.34. Once the abdominal wall is opened, the rumenal wall is grasped and an
incision approximately 12 cm long is made in the left dorsal sac. The rubber-covered
hook is inserted into the upper commissure of the incision to hold it until the sleeve is
inserted. This rubber sleeve is reinforced at one end by a flexible but firm rubber ring,
which enables the sleeve to be compressed, but which immediately springs open when Fig. 3.35. Following the necessary exploratory
the compression is removed. This ring is compressed and inserted into the rumenal procedures, the cuff must be removed before the
incision, and once released it expands to firmly grip the walls of the incision. The sleeve rumenal incision can be sutured. The clamp that is used
and adjacent rumen arc then manipulated through the abdominal incision, so that the to hold the rumen during closure consists of a hinged
ring holds a portion of rumen firmly against the body wall, and prevents peritoneal metal frame which incorporates two soft rubber rollers
soilage. The rumen and reticulum may then be explored by inserting the hand and arm along each arm. The jaws of the clamp arc opened and
through the cuff. insinuated between the ring of the rubber cuff and the
abdominal wall. Once the clamp is in position the rubber
cuff can be removed, and the clamp then seals the rumen
against spillage of its contents, and at the same time
holds the rumen in a convenient position for suturing,
free of tension.
Pouch of
rumen
exteriorized
by clamp
Fig. 3.36. The rumen is closed by a continuous inversion
suture of 4 metric synthetic absorbable suture material
and this layer is reinforced by a layer of interrupted
inversion sutures. The clamp is then removed and the
abdominal wall closed.
78 SECTlON 3f ABDOMINAL SURGERY
Left displacement of the abomasum

The abomasum normally lies on the abdominal
floor slightly to the right of the midline. Its greater
curvature gives attachment to the superficial part
of the greater omentum which arises from the left
longitudinal groove of the rumen. In left-sided
abomasal displacement (LDA) the abomasum be- Rumen
comes trapped between the left side of the rumen
and the left abdominal wall, and this in turn leads
to a change in position of the omasum and a Duodenum
Superficial
downward displacement of the duodenum me- part of
greater
diated through the omental attachment between omentum
the lesser curvature of the abomasum and the
duodenum.
The prime objectives of any surgical methods of Abomasum
correction of LDA should be to restore it to its
normal position, after reducing its size if necessary,
and to stabilize it in this position to prevent recur-
rence. A variety of techniques carried out in the Fig. 3.37. The normal relationship of the rumen and
standing or recumbent animal is commonly used. abomasum. The rumen occupies the majority of the left
There is little significant difference between the side of the abdominal cavity, but its ventral sac extends
success rates reported for the different techniques, to the right of the midline. The superficial part of the
greater omentum extends from the left groove of the
consequently the method employed will largely
rumen ventrally around the ventral sac and inserts partly
depend on the surgeon's experience and prefer- onto the greater curvature of the abomasum, and partly
ence, and on the facilities and assistance available along the second or horizontal portion of the duodenum.
at the time. It is beyond the scope of this book to
give a detailed description of all these techniques.
Standing techniques
These may be carried out via left or right, or both
left and right, flank incisions.
Left-side Right-side
Bilateral flank approach. This has the disadvantage operator operator
of requiring two operators working through
incisions in the right and left flanks respectively
(Figs 3.37-3.39), but it has several advantages,
particularly for those who have little or no experi- Abomasum
ence of the surgical correction of LDA. Identifi-
cation of the abomasum is made easy for the
operator on the right side; decompression of the Fig. 3.38. The abomasum is reduced by the left-side
abomasum by pressure or tapping with a needle operator exerting downward pressure on the abomasum
by means of the hand and forearm in order to avoid
can be safely accomplished and any adhesion penetrating the wall, remembering that the abornasurn
between the abomasum and left abdominal wall must pass beneath the ventral sac of the rumen.
may be assessed and a decision made whether or Difficulty may be experienced by the right-side operator
not to break them clown. in identifying the abornasum. He must largely rely on
being 'handed' a piece of abomasum underneath the
rumen by his colleague on the left side.
Right flank approach. Once the operator is The final reduction from the left to right usually occurs
familiar with the bilateral technique, he or she can quite suddenly, and this can be judged as complete when
change to a right paralumbar technique thereby the great orncntum , between the left rumenal groove and
dispensing with the need for a second surgeon the greater curvature of the abomasum, can be seen lying
(Fig. 3-40). When this single flank approach is closely applied to the ventral rumenal sac.
adopted, replacement of the abomasum is facili-
tated by evacuating the gas using a 16-gauge needle
G AST RO - I NT EST I N A L S U R G ER Y 79
Fold of omentum
incorporated in
the closure of
the right flank
incision
Fig. 3.39. The abomasum is anchored by incorporating a

fold of greater omentum, 3 cm from the pylorus, in the
continuous suture used to close the transvcrsalis muscle
and peritoneum. Chromic catgut is preferred for this (a)
suture because it is less likely than polyglycolic acid to cut
through the omentum and also creates a greater degree
of reaction thereby enhancing the adhesion between the
omentum and the parietal peritoneum.
F~;:,,.;;;o.;:.:-- Greater curvature

of abomasum
on a long length of sterile tubing. This is taken
around the caudal aspect of the rumen and inserted
through the greater curvature of the abomasum. (b)
Once the abomasum is significantly reduced in
Fig. 3.40. (a) Site of incision in the right flank for surgery to correct left displacement of
size, the needle is withdrawn and replacement and the abomasum. Although the pylorus can be identified by palpation due to its indurated
fixation are carried out as previously described. nature, a simpler method is to grasp the relatively thin caudal part of the greater
omen tum just cranial to the abdominal incision and gently withdraw it, hand-over-hand,
until the pylorus appears at the incision. The omentum will be seen to contain
Recumbent technique progressively more fat as its attachment to the abomasum is approached. (b) The pylorus
can be identified as an apparently blind pouch separated from the thinner-walled
A right paramedian approach is performed with duodenum by a narrow band of fat which covers its lateral surface.
the cow cast and restrained in dorsal recumbency.
The use of xylazine sedation and local infiltration
has now largely superseded general anaesthesia for
this operation. The abdomen is entered via a
i y-cm incision running parallel to, and TO cm from, the standing animal via a right flank paracostal
the midline starting just behind the xiphisternum incision starting 15 cm below the lumbar transverse
(Fig. 3.41). processes. Care should be taken to avoid accidental
perforation of the grossly distended abomasum
which lies in close contact with the peritoneum.
Right dilatation and torsion of the abomasum
Evacuation of gas from the dorsal part of the
Torsion of the abornasum, an abdominal catas- abomasum by needle suction produces sufficient
trophe, is preceded by a period of milder illness relaxation to enable it to be grasped and brought
corresponding to the progressive dilatation of the to the incision. After insertion of a purse-string
organ. The mechanical movements involved are suture, a z-cm diameter tube is introduced to allow
not fully understood. Clockwise and anticlockwise partial evacuation of the abomasum of several
rotat~~~ viewed tr~'!1Jhe}g~'i11avi-~~~ni~_~iri~ed, litres of foul-smelling fluid contents (Fig. 3.43).
while in othe'r cases the initial movement is a 180° After removal of the drainage tube the suture is
anticlockwise rotation viewed from behind which tied and oversewn.
is followed by a similar rotation viewed from the If the direction of the torsion can be determined,
right (Fig. 3.42). it is corrected by counter-rotation using the palm
Surgery to correct the torsion is carried out in of the hand and the forearm. In cases where the
80 S EC TI O N 3/ ABDOMINAL S U R G E RY
Greater omentum
3 cm from greater
curvature of
abomasum incorporated
in closure of deep
layer of abdominal
incision
Fig. 3.41. With the animal lying on its back the ventral sac of the rumen falls away from the abdominal floor and thus it
docs not impede manipulation and drainage of the displaced abomasum. The abomasum is anchored in its correct
position by incorporating greater omen tum 3 cm from the greater curvature in the abdominal incision as the peritoneum
and sheath of the rcctus arc sutured. Six metric chromic catgut is used for this purpose, while the remainder of the
closure is carried out using 5 metric polyglycolic acid.
180° anticlockwise 180° anticlockwise

torsion viewed from torsion viewed from
behind the right
Fig. 3.42. Torsion of the abomasum. Om, omcntum; P, pylorus.
nature of the torsion is not immediately apparent, 0.9 per cent saline ( 10-30 litres) is necessary to
correction is achieved by trial and error and is correct the severe hypochloraernia, hypokalaemia
often signalled by the sound of fluid passing into and alkalosis resulting from the massive seques-
the duodenum which now appears at the abdominal tration of fluid in the abomasum.
incision as a distended tube running dorsally and The prognosis is favourable if the abomasurn is
cranially. Further confirmation that the abomasum seen to contract vigorously after it is decompressed.
is in its correct position can be obtained by checking However-if it remains flaccid, impaction frequently
its relationship to the omasurn and by identifying develops within a few days because of irreversible
the pylorus in its normal position. damage to the ventral vagus nerve supply at the
In order to reduce the risk of recurrence of the site of the torsion. In the authors' opinion per-
torsion, the greater omentum adjacent to the forming a pyloromyotomy at the time of the initial
pylorus is anchored to the abdominal wall. surgery does not prevent the impaction from
Supportive therapy in the form of intravenous developing.
180° anticlockwise torsion

_i--------
1
of abomasum
''
Fig. 3.43. Partial evacuation of the abomasum by release

of the gas from its dorsal part provides sufficient
relaxation to enable it to be grasped and brought to the
surface.
Semipermanent rumenalfistula
A semipermanent fistula provides a simple but
(
effective means of treating calves with chronic
recurrent ruminal tympany. It is also of value in
cattle with tetanus where it provides a means of
administering food and water as well as allowing
gas to escape.
The site for the operation is the left sublumbar
fossa at the point of maximum distension. A vertical
incision IO cm long is made through all the layers
of the abdominal wall to expose the rumen which is
sutured to the peritoneum and aponeurosis of the
transversalis muscle in an oval fashion using a
continuous suture (Fig. 3.44). A vertical incision is
made into the lumen of the rumen within this area Fig. 3.44. Site for vertical incision through all layers of the abdominal wall for a
and the margin folded back and sutured to the semipermanent rumenal fistula. The rumen is first sutured to the peritoneum and
aponeurosis of the transversalis muscle in an oval fashion, before it is incised vertically.
skin.
The cut edges arc then sutured to the skin.
Alternatively, the abdominal incision can be
made in grid-iron fashion, splitting each layer along
the direction of its fibres. A pouch of rumen is
brought through the incision, sutured to the skin
alone using a number of mattress sutures and
opened by removing a portion of its wall (Fig.
)K (
3.45). The natural tendency for the incisions in the
various layers to close when there is no tension on
the abdominal wall acts as a valve reducing leakage
of rumen contents but allowing any gas which
builds up to escape.
Fig. 3.45. Site for grid-iron incision for a semipermanent rumenal fistula. A pouch of
rumen is brought through the incision and sutured to the skin with a number of mattress
sutures. The fistula is created by removing a portion of the rumenal wall.
82 SECTION 3 / ABDOMINAL SURGERY
Branches of
SPLENECTOMY - DOG splenic artery and vein
The spleen lies parallel to the greater curvature of

the stomach in the left hyogastric region, and is
supported by the gastrosplenic omentum which
runs from the greater curvature of the stomach to
invest the spleen. It is a mobile structure and can
readily be exteriorized through a left cranial lapar-
otomy incision (Fig. 3.46). The major blood supply
is from the splenic artery which is a branch of the
coeliac artery. The splenic vein drains into the
gastrosplenic vein. The splenic artery runs in the
fatty gastrosplenic omentum and then divides into
numerous splenic branches which enter the sub-
stance of the spleen along the longitudinal hilus.
Gastrosplenic omentum
Fig. 3.46. Splcncctomy is not a difficult operation, but requires patience and careful
haemostasis. The rather complex vascular structure necessitates the identification and
separate ligation of the numerous splenic branches before they can be divided.
Section 4
Surgery of the
Genito-urinary System
Castration
During embryonic development, the testicle arises there is a danger of intestine escaping through the
retroperitoneally from the gonadal ridge, and re- inguinal canal resulting in an intestinal prolapse.
ceives its excretory duct system (epididymis and
vas deferens) from the remnants of the meso-
Closed technique
nephric (Wolffian) duct. It migrates from the dorsal
aspect of the abdominal cavity into the scrotum This technique involves cutting through the scrotal
due to the pull of the inguinal ligament of the skin and exposing the testicle, complete in the
mesonephros (gubernaculum) which is attached to unopened tunica vaginalis. The neck of the tunica
the tail of the epididymis. The scrotum is lined by vaginalis is then either ligated and severed, or
the tunica vaginalis, a direct outpouching of the removed by means of an emasculator (Fig. 4.1 ).
peritoneum through the inguinal canal, and so for This technique involves blunt dissection and, under
the testicle to descend retroperitoneally into the
scrotum it is necessary for it to push a double fold
of the tunica vaginalis into the lumen of the scrotal
sac. The testicle thus lies within the lumen of the
tunica vaginalis enclosed in the tunica vaginalis
reflexa, and these two serous layers (often referred
to as 'the coverings') are joined at the tail of the
epididymis by the remains of the gubernaculum,
the so-called 'attached portion'. This structure is of
significance when considering the techniques of
castration.
Haemostasis is an important aspect of castration,
and may be considered under three headings.
I Haemostasis by traction. This relies upon rapid
blood clotting due to the elastic recoil of the artery

wall, which is exacerbated when the artery is torn
rather than cut. This is an effective method, but Fig. 4.1. The cmasculator.
should be limited to very young animals.
2 By ligature. This is the most effective method
but in the field it raises problems of asepsis and is

usually confined to castration carried out under
hospital conditions.
3 By emasculator, In this method the cord is sev-
ered by an instrument which at the same time
crushes the cord tissue proximal to the cut end,
and thus encourages natural clotting, similar to the
effects of traction. A good emasculator is very
efficient and easy to use, but is not so reliable as a
ligature.
Open technique
In this method all the tissues of the scrotum and

tunica vaginalis are incised and the testicle and
spermatic cord are removed without their cover-
ings. This method is easily carried out under field
conditions, and may be used in the standing colt or
bull, under local analgesia. The main disadvantage
is that it opens the tunica vaginalis and thus makes
Fig. 4.2. The Burdizzo. Note that one jaw of the
a potential connection between the peritoneal cav- Burdizzo is extended laterally so that it overlaps at each
ity and the outside. This means that if an undetected end (the cord stop). This is to prevent the spcrmatic cord
weakness exists in the form of an incipient hernia slipping from between the jaws when they arc closed.
85
86 S EC Tl O N 4/ G E N lT O - U RI N A RY S Y ST EM
(b)
(a)
Fig. 4.3. The Elastrator: (a) closed, and (b) open.
field conditions, potential contamination of the

HORSE
scrotal area. It does not involve opening the tunica
vaginalis and thus avoids the very real danger of
Open technique
intestinal prolapse. It is the method that is used to
castrate any animal with an actual or suspected
scrotal hernia (see Section 6).
'Bloodless' castration
This method is suitable for use in cattle and sheep,

both of which have pendulous scrotums. It involves
the use of an instrument which will crush the
spermatic cord without opening the scrotum, and
this eliminates, to a very great extent, the dangers
of post-operative sepsis. In cattle and sheep, the
Burdizzo bloodless castrator is used (Fig. 4.2),
whereas in young lambs, it is popular to apply a
tight elastic band around the neck of the scrotum,
using an Elastrator (Fig. 4.3). The pressure of the
elastic band causes as ischaemic necrosis of the
neck of the scrotum and its contents, all of which
separate and drop off after 10- 14 days.
Fig. 4-4- The testicle is grasped through the scrotal wall,

so that it is firmly immobilized and the scrotal skin is
tightly stretched. The scrotum is opened by a single, firm
incision which penetrates the skin, the tunica vaginalis
and the testicle.
CASTRATION 87
Epididymis
__ Tail of
epididymis
Vascular -~TI~SS!sW
part of
spermatic
cord Non-vascular
part of
Attached spermatic
portion cord
Fig. 4.6. The attached portion together with the vas

Tunica dcferens is separated from the cranial vascular portion
vaginalis
of the spcrmatic cord by blunt dissection.
Fig. 4.5. The opened tunica vaginalis retracts to expose

the testicle. except for the single area of attachment
which unites the tail of the cpididyrnis to the tunica
vaginalis by means of the vestigial gubcrnaculum.
Emasculator
severing the Fig. 4.8. The vascular portion of the spcrrnatic cord is
non-vascular
portion also severed with an cmasculator , which should be held
tightly clamped to the severed vascular portion for at
least 30 seconds in order to ensure adequate haemostasis.
It should then be opened sharply, to avoid interference
with the crushed vascular tissue.
Fig. 4.7. The attached portion is severed with an

cmasculator. This reduces post-operative haemorrhage
from small blood vessels in the vas dcfcrcns.
88 S EC Tl O N 4 / G EN ITO - U R IN A RY S Y STE M
Tail of
epididymis
Cremaster
Fig. 4.9. The skin of the scrotum is opened without muscle
incising the tunica vaginalis.
Fig. 4.10. The testicle within the unopened tunica

vaginalis is separated from the scrotal sac by blunt
dissection. The insertion of the cremaster muscle into the
tunica vaginalis is seen on its caudo-latcral surface.
DOG
Open technique using a ligature
See Figs 4.12-4.15. Complications of prescrotal

castration include haemorrhage from scrotal tissue
and bruising of the scrotum. These may be reduced
or eliminated by ablation of the scrotum at the
time of castration.
Fig. 4.11. The spermatic cord, together with the tunica
vaginalis and cremastcr muscle, is severed by using an
emasculator as close to the inguinal canal as possible.
Closed technique
See Figs 4.9-4. 11.
It is customary to leave the scrotal incisions un-

sutured to allow drainage, following both the open
or closed techniques, but this is a matter of personal
preference. In cases of actual, or suspected scrotal
Fig. 4.12. The testicle is pushed forwards so that it can
hernia, it is normal practice first to obliterate the be exposed by a midline skin incision cranial to the
neck of the cord with 4 metric synthetic absorbable scrotum. This allows both testicles to be removed
suture material before severing the cord with an through the same incision and lessens the possibility of
emasculator. See Section 6 which deals with the post-operative interference by the dog.
treatment of scrotal hernia.
CASTRATION 89
CALF
Castration by Burdizzo
The calf is restrained against a wall with its tail

held vertically. The spermatic cord is palpated,
and the scrotal neck is held between the finger and
thumb so that the cord is firmly anchored in a fold
of scrotal skin. The Burdizzo is applied to the fold
of the scrotal skin and the underlying spermatic
cord, and the jaws of the instrument are closed
(Figs 4. 16-4. 17).
Fig. 4.13. The skin and tunica vaginalis arc opened by a This is repeated on the same side below the
single incision. original crushed area. It is important to ensure that
the minimum amount of scrotal skin is included in
the crush and great care must be taken to ensure
that the cord is included in the crushed tissues,
otherwise the operation will be a failure, and
this may not be noticed until several weeks have
elapsed.
Care must also be taken to avoid the crush
marks in the scrotal neck coalescing in the midline,
otherwise there is the danger that the scrotum will
slough.
Fig. 4.14. The 'attached portion' of the tunica vaginalis

is severed.
Spermatic cord
anchored in a
fold of the
scrotal neck
Fig. 4.16. The spermatic cord is palpated, and the scrotal

neck is held between finger and thumb so that the cord is
firmly anchored in a fold of scrotal skin.
Fig. 4.15. The tunica vaginalis retracts, the exposed

spcrrnatic cord is clamped and ligated, and severed above
the ligature. The pre-scrotal incision is closed with
interrupted sutures.
90 S EC TI ON 4f G EN ITO - U RI N A RY SYSTEM
Elastrator
ring fully
extended
Fig. 4.18. Traction is gently applied to the scrotum after

making certain that both testicles arc within the scrotal
Fig. 4.17. The Burdizzo is applied to the fold of scrotal sac. The Elastrator jaws arc opened by closing the
skin and the underlying spcrmatic cord, and the jaws of handles and the stretched rubber ring is manipulated
the instrument are dosed. onto the neck of thc·scrotum.
LAMB
Castration by Elastrator
When using the Burdizzo and Elastrator (Figs
4.18-4.19), great care must be taken to avoid
damage to the sigmoid flexure of the penis. Should
this happen, the urethra may be irreparably
damaged, leading to death from urethral obstruc-
tion or necessitating an ischial urethrostomy or
amputation of the penis to enable the damaged
area to be by-passed (see Figs 4.75-4.76).
RIG CASTRATION
Fig. 4.19. The Elastrator is released and removed, so
(CRYPTORCHIDECTOMY) that the rubber ring tightly encircles the scrotal neck.
Partial or complete retention of the testicle within
either the abdominal cavity or the inguinal canal is
encountered in all animals, but its incidence is for handling and normal work. The type of reten-
highest in the horse. This is predisposed by the tion falls into three categories:
remarkable growth of the equine fetal gonad be- I Abdominal, in which the testicle and its complete
tween 4 and 9 months of gestation, which in the duct system are retained in the abdominal cavity.
case of the male fetus, makes the gonad too large 2 Partial abdominal, in which the tail of the epi-
to negotiate the inguinal canal until shrinkage didyrnis.is drawn into the inguinal canal by the pull
occurs late in gestation. If the reduction in size of of the gubernaculum, but the testicle remains
the gonad does not coincide with the period of within the abdominal cavity adjacent to the internal
resorption and shortening of the gubernaculum, inguinal ring.
then some degree of retention occurs. Although 3 Inguinal, in which the testicle is located within
the undescended gonad is incapable of spermato- the inguinal canal or just inside the external ingui-
genesis, it still elaborates male sex hormone, and nal ring but has not descended completely into the
so the rig or cryptorchid horse develops male be- scrotum.
havioural characteristics which makes it unsuitable This pattern of retention dictates a standard
CAST RA TlON 91
procedure which should be adopted in all cases in Tailof epididymis

which a retained testicle is suspected.
The horse is restrained on its back under general
anaesthesia. The scrotal skin is tented by tissue
forceps and incised with scissors. In this way it is
possible to avoid injury to the large veins which
run in the subcuticular tissues. The subscrotal con-
nective tissue is broken down by blunt dissection,
and the inguinal canal is located cranio-lateral to
-------Body of
the scrotum. It is easily recognized as it offers no
epididymis
resistance to blunt dissection and the fingers readily
enter the external ring. If the testicle is in the
inguinal canal it is either visible or palpable, and
should be grasped by tissue forceps and drawn out
of the canal, when it can be removed by an ernascu-
lator or any method of choice. Not every horse
that is suspected of being a cryptorchid has a Fig. 4.20. Partial abdominal retention.
retained testis. The owner of a horse bought as a
gelding may suspect that the animal is a cryptorchid
if it has an intractable disposition, or shows interest
in a mare which is in oestrus. In the past if the
surgical history of the horse was unknown, it was
necessary to explore the inguinal canals in order to
eliminate the possibility of a retained testicle. If
the horse had already been satisfactorily castrated,
the remains of the spermatic cord would be found
either adherent to the scrotal skin or to the side of
the external inguinal ring. It can be readily recog-
nized by the presence of the cremaster muscle
emerging from the inguinal canal and blending
with the cord tissue.
The need for such surgery has been eliminated
by the introduction of a diagnostic laboratory test
for cryptorchidism. Measurement of testosterone
levels in blood just prior to, and from 40 minutes
to 2 hours of administering 6000 i.u. of human
chorionic gonadotrophin (HCG) intravenously, or Fig. 4.21. Parapreputial incision.
alternatively, measurement of oestrone sulphate in
a single sample (provided the animal is over 3
years of age and is not a donkey) will allow the
animal which has not had both testes removed to cases and those with complete abdominal retention
be identified. in which careful exploration of the inguinal canal
If the testicle cannot be readily palpated within fails to locate anything, this approach is abandoned
the inguinal canal then it is necessary to carefully and preparation made to open the abdominal cavity
explore the depths of the canal. In partial abdomi- through a parapreputial (paramedian) incision
nal rigs the tail of the epididymis, enclosed in a (Fig. 4.21).
small vaginal sac, is palpable and should be grasped Once the abdomen is opened the testis which is
with forceps so that gentle traction can be applied. usually small and flabby, is often found adjacent to
On incising the vaginal sac it will be seen to contain the caudal canthus of the internal inguinal ring.
only the tail and body of the epididymis together If it cannot be palpated, then search should com-
with the vas deferens (Fig. 4.20). These structures mence systematically by locating the vas deferens
must not be mistaken for a small testis. Further as it enters the prostatic urethra at the neck of the
traction on the epididymis will usually draw the bladder, and then tracing this forwards until the
testis into the canal but in some cases it is too large tail of the epididymis and testis are located. One of
to pass through the internal inguinal ring. In these the most important factors in accurate localization
92 S EC Tl O N 4 / G EN ITO - U R I N A RY S Y STEM
Fig. 4.22. The testis is removed using an emasculator.
Fig. 4.23. The ram is positioned on its back, and the hair
clipped from the abdominal wall. Local or general
of the testis is recognition of the flabby nature of anaesthesia may be used.
the majority of the abdominal testes. Once grasped,
the testis is brought out through the incision and
removed using an emasculator (Fig. 4.22). It is not
always possible to exteriorize completely the epi-
didymis through the laparotomy incision and in
these cases the emasculator should merely be ap-
plied as high up as possible. In cases of bilateral
abdominal retention both testes can be found and
removed through a single abdominal incision.
Rarely, the abdominally retained testis may be
abnormally large because it is teratomatous. In its
cystic form the testis can be reduced in size quickly
and simply by aspiration of its fluid contents. This
is not possible in the case of firm teratomas which
Skin
require a larger than normal incision for their incision
removal. into neck
of scrotum
VASECTOMY - RAM
The presence of a ram is known to stimulate the

onset of oestrus in a flock of ewes during the early
stages of the breeding season. Modern methods of
sheep husbandry, particularly those related to the
artificial control of oestrus by the use of progesta-
Fig. 4.24. The spcrmatic cord is located above the
gens, aim at the synchronization of oestrus in a
testicle, and an incision made through the skin to expose
flock in order to obtain a compact lambing period the glistening tunica vaginalis.
in the spring. Vasectomized rams are commonly
used to detect early oestrus in ewes, which are then
synchronized and served by fertile rams.
Vasectomy renders the ram infertile by obliter-
ating a portion of the vas deferens, but does not
make it impotent (Figs 4.23-4.25).
CASTRATION 93
--- Vas
deferens
Pampiniform
venous
plexus
Removing a
section of
vas deferens
between clamps
Fig. 4.25. The tunic is opened, taking great care to avoid damage to the large venous pampiniform plexus. The vas
deferens is recognized as a hard, non-pulsating white tube. It is easily separated from the other tissues of the cord, after
which it is double clamped, and a segment at least 2.5 cm long removed from between the clamps. It is not essential to
close the tunica vaginalis, and the incision is adequately closed by a series of interrupted sutures in the skin.
OVARIECTOMY - MARE
The indications for ovariectomy in the mare are

limited. Unilateral ovariectomy is indicated for the
removal of an ovarian tumour. Bilateral ovari-
ectomy is sometimes carried out in an attempt to
improve the temperament of a vicious mare, but
the results are by no means encouraging and various
reports indicate that improvement is only likely to
occur in mares that become vicious when in oestrus
or in animals which recently have acquired Fig. 4.26. The ecraseur.
nymphomaniacal symptoms.
Ovariectomy may be carried out through a flank
or a midline incision (Section 3, p. 64). The flank ap- The ovary is located and brought to the incision.
proach makes removal of a lower ovary extremely Normal-sized or small ovaries can be removed
difficult, due to the short length of the mesovarium, solely using an ecraseur (Fig. 4.26). It is important
and the authors favour a midline approach for that the ecraseur is tightened slowly by an assistant
either unilateral or bilateral ovariectomy. In ad- while the surgeon ensures that bowel or omentum
dition to the ease of approach to both ovaries does not become trapped between the chain and
through a midline incision, the mare is not left with the ovarian pedicle. The pedicle should not be
an unsightly scar in the flank. stretched while the ecraseur is tightened or haemo-
The mare is fully starved for 24 hours to reduce stasis may be inadequate.
the bowel contents. With the mare placed in dorsal In the case of large granulosa cell tumours of the
recumbency a midline incision is made extending ovary, it is helpful to reduce the size of the pedicle
from the mammary gland caudally, to as far forward by ligating the blood vessels nearest the uterine
as is necessary. horn, reserving the ecraseur for the major vessels.
94 S EC TI O N 4/ G EN ITO - U RI N A RY S Y STE M
OVARIOHYSTERECTOMY - BITCH
Ovariectomy on its own is an uncommon operation

in the bitch, and it is invariably combined with
removal of the uterus, i.e. ovariohysterectomy.
The operation is performed either to neuter the
animal in order to avoid the twice yearly oestrus Ligature tied
cycle, or for the removal of a diseased uterus into the area
crushed by
affected with cystic hyperplastic endometritis or lower crushing
pyometritis. clamp Ovary
The neutering operation, which is normally per-
formed on a young animal, should carry a negligible
risk. Technical difficulties arise from an almost
universal tendency to attempt the operation
through too small an incision, and the use of
various forms of non-absorbable ligature material
within the abdominal cavity which give rise to
Severing ovarian pedicle between
chronic fistulae discharging in the flank from a site ligature and upper clamp
below the external angle of the ilium.
The operation for pyometritis, on the other Fig. 4.27. The pcdiclc containing the ovarian vessels is double clamped and a synthetic
absorbable ligature threaded below the lower clamp, which is removed as the ligature is
hand, often requires extensive treatment for fluid
tightened so that the suture material tics into the crushed tissue. The pediclc is severed
imbalance before surgery may be safely under- between the ligature and the ovary. The second clamp is left attached to the ovarian
taken, but the technique for either operation is pedicle to prevent "back-bleeding' from the anastomosis to the uterine artery.
basically the same, and will be considered under a
common pattern (Figs 4.27-4.32).
A caudal laparotomy incision is made, extending
from the pelvic brim to a point just cranial to the
umbilicus. The ovarian blood supply in the bitch is
homologous to the testicular blood supply in the
male, and each ovary receives its arterial supply
direct from the aorta. The uterus is supplied by the
uterine artery, which is a branch of the internal
iliac artery. The uterine artery runs close to the
lateral vaginal wall and at the level of the cervix it
enters the broad ligament, through which it runs
almost parallel to the uterine horn until it reaches
the ovarian extremity, where it anastomoses with
the ovarian artery. Ovariohysterectomy therefore
entails the control of haemorrhage from both the
Ligature in Uterine
ovarian and the uterine arteries before excision of broad ligament body
the ovary and the uterine horns.
Fig. 4.28. The broad ligament is detached from its
The right uterine horn and ovary are exposed by
connection to the cervix, taking care to avoid tearing the
elevating the duodenum towards the midline, uterine artery and vein. A synthetic absorbablc ligature
thereby using the mesoduodenum as a retractor. is tied across the base of the broad ligament.
The left uterine horn and ovary are similarly
exposed by retracting the descending colon.
The right ovary is exposed by gentle traction on
its suspensory ligament. The ovarian artery and even with maximum abdominal relaxation. The
the tortuous ovarian vein are identified as they run procedure is greatly simplified by the use of the
through the cranial border of the broad ligament, curved gallbladder forceps as illustrated ( Geary
and a small hole is made in the broad ligament Grant cholecystectomy forceps).
behind the ovarian vessels, to make an ovarian This procedure is then repeated on the left ovary
pedicle. and broad ligament, so that both ovaries and
Ligation of the ovarian blood vessels is always uterine horns are free, but still attached to the
difficult, as the ovaries cannot be easily exposed, cervix and vagina.
CASTRATION 95
Amputation
of uterus
Severing the broad ligament

between ligature and clamp
Fig. 4.29. The broad ligament is clamped on the uterine

Fig. 4.31. The cranial vagina is double clamped above
side, and divided between the clamp and the ligature.
the ligatures, and transected as close as possible to the
lower clamp.
Ligature
encircling
uterine artery
and vein on
one side
Inverted
end of
vaginal
stump
Fig. 4.30. The cervix and vagina arc exposed by Fig. 4.32. The clamp may be overscwn using the
reflecting the uterine horns caudally. A synthetic Parker- Kerr technique. A continuous synthetic
absorbablc ligature is applied to the uterine artery and absorbablc suture is inserted across the crushed end of
vein on either side, below the level of the cervix. the stump by picking up a small piece of tissue below the
clamp on one side, and then alternating progressively so
that the loop of suture material between each stitch loops
over the jaws of the clamp. The clamp is then slightly
opened to release the crushed tissue, and as it is
withdrawn, each end of the suture material is gently
pulled. This has the effect of inverting the crushed tissue
and sealing the stump. On a small stump, the ends of the
inversion suture are tied together, but in a large stump it
is advisable to stitch back across the inverted stump so
that the suture ends are adjacent before tying them.
96 SECTION 4f GEN ITO-URINARY SYSTEM
OV ARIOHYSTERECTOMY - CAT
This operation (Figs 4.33-4.35) is usually carried

out through a small incision in the left sublumbar
fossa. The cat is restrained on its right side, under
general anaesthesia, and fully extended by tapes
placed on its front and hind legs. The urinary
bladder should be emptied by manual pressure,
and it is not facetious to suggest that a check
should be made to ascertain that the cat is female.
The site of the incision is mid-flank, below and
slightly cranial to the external angle of the ilium. It
is important to check this landmark, which can be
confused with the great trochanter of the femur.
The uterine horn is sometimes seen lying adjac-
ent to the incision, but in most cases it must be
found. This is easily accomplished by identifying
the sublumbar fat, and then gently drawing it out
of the incision and at the same time displacing it Fig. 4.33. (a) The skin below the external angle of the
upward when the uterine horn will be drawn into ilium is incised and a portion of subcutaneous fat
the incision. The sublumbar fat is solid and dark in removed. (b) The thin aponeurosis of the external
oblique is split, and the thick internal oblique is nicked
colour, whereas the omental fat is thin, lace-like in with a scalpel. (c) The nick is enlarged with forceps
consistency and highly vascular. making certain that the thin peritoneum is also incluclccl.
This produces a small, almost self-closing, grid-iron
incision.
Fig. 4.34. (a) The uterine horn is drawn through the Fig. 4.35. (a-b) The operation is completed by double
incision and the thin broad ligament is broken down. clamping the cranial vagina, and ligating into the crush
Further traction will expose the ovary. (b) The ovarian of the lower clamp. Clamping the cranial vagina in the
pedicle is double clamped. In a young cat the pedicle is mature cat may result in complete amputation, as the
broken by traction. In a mature cat, or one that is near tissue tends to be rather friable. In these circumstances
the beginning or end of oestrus, it is safer to ligate the the cranial vagina should be transfixed and ligated,
pedicle as described in the bitch. (c) The lower uterine without prior crushing. (c) Closure is made with simple
horn is picked up at its junction with the uterine body by interrupted sutures in the internal oblique muscle, and
traction on the detached horn. The ovary is drawn into occasionally two to three sutures in the aponeurosis of
the incision, but this is slightly more difficult and requires the external oblique. (cl) The skin is closed with
greater traction than was necessary for the upper ovary. interrupted nylon sutures.
Caesarean section
BITCH
The delivery of a litter of puppies by Caesarean Gravid uterus
exteriorized
section is extremely well tolerated in the bitch (Figs and packed off
4.36-4.40), and carries less hazard to both bitch
and puppies than does a prolonged vaginal delivery
using forceps. Subsequent fertility is unimpaired,
and therefore the operation should be considered
during the early stage of dystocia , and not put off
as a last desperate measure when all else has failed.
It is normal to open the abdomen through a linea
alba incision in order to avoid damage to the active
and highly vascular mammary tissue.
The procedure of removing puppy fetal mem- Fig. 4.36. The gravid uterus is lifted outside the abdominal cavity. This relieves
branes is continued until all have been delivered. It respiratory embarrassment due to pressure on the diaphragm, and allows adequate
packing off of the abdominal cavity.
is important to check that no fetus has been over-
looked, especially in the larger breeds which often
have numerous puppies in a litter. Incision into uterine body with
Once the uterus is empty, an ecbolic such as protrusion of fetal membranes
ergometrine is injected into the bitch, preferably
by the intravenous route, in order to stimulate
rapid and effective uterine involution. The uterine
incision is closed with a continuous synthetic
absorbable inversion suture.
Fetal resuscitation
Normal birth is a traumatic episode in the life of

the fetus, whereas delivery by Caesarean section is
relatively atraumatic. In cases of prolonged labour
necessitating Caesarean section, however, the fetus
is frequently hypoxic and may show respiratory
Fig. 4.37. The uterus is opened at the uterine body, and the fetal membranes of the first
depression due to the effect of the anaesthetic
puppy usually protrude through the incision.
drugs that were necessary for the Caesarean oper-
ation. All these factors may add up to the need for
fetal resuscitation after surgical delivery. This falls
into three distinct categories.
I Ensure an open airway. Always hold the new-
born puppy in a head-down position to promote
drainage. If necessary, apply suction to the naso-
pharynx by means of a fine catheter attached to a
sucker.
2 Ensure adequate warmth.
3 Stimulate the circulation by vigorous skin mass- Clamps on
the umbilical
age and by rhythmical movements of the limbs. cord
The new-born puppy in need of resuscitation is
limp and shows feeble and intermittent attempts to
breathe. Simple resuscitation methods ensure that
the respiratory tree is unobstructed and provide
the stimulus that is necessary to encourage the new
pulmonary circulation and to initiate normal respir- Fig. 4.38. The membranes are ruptured and the puppy delivered. The umbilical cord is
ation. Providing that there is a regular pulse, re- double clamped, and cut between the clamps. The puppy should be handed to an
suscitation should be continued until the puppy is assistant and held head downwards to allow drainage from the pulmonary tree.
97
98 S EC TI ON 4/ G EN ITO - U RI N ARY S Y STEM
crying vigorously, and making purposeful limb

movements. An early check should be made to
eliminate the presence of common congenital ab-
normalities, e.g. cleft palate and imperforate anus.
CATTLE
The cow is monotocous, normally carrying one calf

to full term, and thus the problem confronting the
obstetrician in cattle practice is different from that
of the bitch, in which the lives of a whole litter of
Withdrawing the fetal membranes
puppies may be in jeopardy. The large size of the
cow makes vaginal manipulation easier than it is in Fig. 4.39. The fetal membranes are removed by traction and twisting of the clamp.
the bitch, and the decision for Caesarean section is
only reached after a thorough vaginal examination
has eliminated the possibility of vaginal delivery.
In addition, fertility following Caesarean section in
cattle is considerably reduced compared with that Local area of
uterine
following vaginal delivery so that the operation involution
Fetal
tends to be performed at a relatively late stage of membranes
labour, when more conventional means of delivery of next puppy
have failed.
The operation is frequently carried out in the
standing cow under regional analgesia but other
Placental zone
operators prefer the animal to be recumbent, in of fetal
which case it is restrained by sedation which is membranes
reinforced by regional analgesia.
The technique for both methods is similar.
Laparotomy is carried out through a vertical or
oblique left flank incision extending from 15 cm Fig. 4.40. The fetal membranes consist of the thickened zonary placenta, usually stained
below the external angle of the ilium, down to the green, and the thin transparent allanto-chorion and amnion. In a healthy uterus, the
level of the fold of the flank (Fig. 4-41). All the uterine wall rapidly retracts in the area from which the puppy has been removed.
muscle layers are incised along the same direction
as the initial skin incision.
If possible, the uterus should be drawn up to the
incision before it is opened, but in many instances suture of the Cushing pattern and, if deemed
the weight of the gravid uterus· will make this necessary, oversewn. It is advisable to commence
impossible and it must be incised blindly within the suturing from the cervical end of the incision as
abdominal cavity. A Roberts' embryotomy knife is this portion tends to retract quite quickly as the
ideal for this purpose in that it can be carried safely uterus involutes. The fetal membranes are fre-
in the palm of the hand across the peritoneal cavity quently impossible to detach during the operation
without risk of damage to the viscera. and, if so, should be left to be voided through the
The incision should be made along the greater vagina.
curvature of the pregnant horn, not too close to
the tip of the uterine horn and well away from the
Special considerations
body of the uterus. If the calf is in cranial presen-
tation to the vagina, the uterus is incised from the
Monster calves
point of the calf's hocks which are readily identifi-
able, distally to just above the fetlock. Each leg in Schistosoma reflexus is the most common fetal
turn can now be flexed and brought out through monster encountered in cattle. Although most are
the incision. smaller than normal calves, the extensor tendon
Once the fetus is delivered, the uterus may be contracture of the limbs can complicate delivery.
lifted through the abdominal incision to facilitate However, provided each limb in turn is carefully
closure. This is carried out with 4 metric synthetic manipulated, taking care to cup the foot in the palm
absorbable suture material using an inversion of the hand to avoid damage to the uterine wall,
CYSTOTOMY 99
these calves can usually be delivered through a External angle

standard-sized incision. An obstetrical hook ap- of ilium
plied across the vertebral column of the monster is
an effective way of applying traction to a Schisto-
some calf in cephalo-caudal presentation to the
vagina.
Abdominal~~~~~--1c++-J-~-H
Irreducible uterine torsion incision
Owing to the large uterus and oedema of its wall,
which makes it unusually friable, it is usually
necessary to remove the calf before the torsion is
corrected.
Uterine
Emphysematous fetus incision
Delivery of a dead, emphysematous calf by
Caesarean section frequently results in contami- Fig. 4.41. Caesarean section in the cow. Note the
nation of the peritoneal cavity with large volumes relative positions of the abdominal and uterine incisions.
of highly toxic uterine fluid. Rapid absorption by
the peritoneum results in severe toxic shock and
death within a few hours of surgery. ent, or if haemorrhage occurs as it is being peeled
Attempts may be made to minimize the contami- away, it should be left in situ. However, it is
nation by employing a low flank incision (lateral to necessary to detach it for a distance of 3-5 cm to
the mammary vein but below the fold of the flank) enable a continuous interlocking stitch to be in-
which allows access to the smaller, ovarian end of serted around the margin of the incision. This
the horn. However, some contamination is inevi- prevents the mucosa from retracting and any haem-
table. Lavage of the peritoneal cavity with several orrhage from the numerous submucosal vessels is
litres of warm Hartrnann's solution containing anti- controlled. The uterine incision is now closed with
biotic which are then siphoned off, is often success- a double layer of Cushing sutures using 4 metric
ful in preventing toxaemia. Debridement of the polyglycolic acid.
abdominal incision is necessary if the muscle layers
are contaminated with fetal hair, placenta, etc.
EWE
The technique of Caesarean section in the sheep is

MARE
the same as that described for the cow. The much
A ventral midline incision, commencing just cranial smaller size of the sheep makes it easy to exteriorize
to the udder, is now the standard approach in the the uterus before opening it to deliver the fetus.
mare. Location and delivery of the part of the Twin pregnancies are common in the sheep, and
uterus overlying the foal's hocks usually presents an incision made in the uterine body will enable
no difficulty. If the placenta is clearly separating, it both fetuses to be delivered through the same
can be carefully removed, but if it is firmly adher- hysterotomy incision.
Cystotomy
the bladder is gradually moved in a cranial direction
DOG
by the enlarging prostate, so that the complete
The urinary bladder lies within the abdominal cav- bladder eventually lies within the abdominal cavity.
ity just cranial to the pelvic inlet. Its exact size The bladder is invested in a layer of visceral perito-
depends upon the amount of urine that it contains, neum, and is supported by three double folds of
and in cases of prostatic enlargement, the neck of peritoneum. The ventral fold or middle umbilical
100 SECTION 4/ GENITO-URINARY SYSTEM
ligament is reflected from the ventral surface of the Urinary calculus

bladder to the ventral midline of the abdominal
wall, and it contains the remnants of the embryonic
allantoic stalk or urachus. The two lateral umbilical
ligaments are reflected from the lateral walls of the
bladder to the lateral pelvic walls and extend
cranially to the umbilicus. They contain the
remnants of the embryonic umbilical arteries,
which were branches of the internal iliac arteries.
The commonest indications for cystotomy are
either for the removal of bladder calculi or for the
excision of localized tumours of the bladder wall.
In the female, the bladder is exposed by a simple
caudal laparotomy incision, but in the male, this Fig. 4.42. The bladder is lifted through the incision and
the peritoneal cavity is carefully protected by adequate
incision must be made parallel to the prepuce, and
abdominal packs before the bladder is opened. If
of necessity involves transection branches of the possible, the dorsal aspect of the bladder should be
external pudenda! artery and vein. These are large chosen for the cystotomy incision.
vessels and must be carefully ligated. The interrup-
tion of local venous drainage frequently leads to
considerable venous congestion, and swelling of
the parapreputial area during the post-operative
period is inevitable.
Following cystotomy (Figs 4.42-4.45) the
bladder is washed out with sterile saline, in order
to remove the inevitable blood clots.
It is important that the clog should be given the
opportunity to empty its bladder at about 6 hours
after the operation, and that this should be noted
on its case notes. Post-operative retention of urine
will lead to leakage and eventual rupture of the
suture line, which can be avoided by catheterization
if urinary retention develops.
Wound breakdown is also more likely if sutures
Fig. 4.43. After removal of the calculi or excision of the
of polyglycolic acid arc used as this material is
bladder wall, the thick mucous membrane is closed by a
clegraclecl by the urine. continuous suture of 2 metric synthetic absorbable suture
material.
Fig. 4.44. The type of suture employed to close the Fig. 4.45. The detrusor muscle of the bladder is closed
mucous membrane should be a continuous mattress by a series of simple interrupted sutures using a synthetic
suture which everts the edges of the mucous membrane absorbable suture other than polyglycolic acid, varying in
away from the lumen of the bladder. This is done to size from 2 to 3.5 metric depending upon the size of the
avoid raw edges of the mucous membrane protruding dog.
into the bladder lumen, where they can act as a focus for
the laying down of further cystic calculi.
URETHRAL OBSTRUCTION IOI
defects of the bladder wall, rather than traumatic

HORSE
ruptures are seen.
Cystotomy . is sometimes necessary in the male The foal is usually presented for surgery between
horse to remove a cystic calculus. The calculus the 3rd and 5th day of life by which time the
which is usually composed of calcium carbonate peritoneal cavity contains several gallons of urine.
has a very rough irregular surface which causes There is a moderately severe metabolic acidosis, a
intense irritation to the bladder mucosa. marked hyponatraemia and hypochloraemia and,
The approach is via a right caudal paramedian most significantly, a marked hyperkalaemia.
incision as close to the pubic brim as possible. The As much as possible of the urine should be
bladder is located within the pelvis and steady removed by paracentesis prior to induction of
traction has to be applied to it for several minutes anaesthesia using halothane/oxygen administered
before it can be brought up to the abdominal via an intranasal tube. Following endotracheal intu-
incision. Stay sutures of umbilical tape inserted bation anaesthesia is maintained on a semi-closed
either side of its apex allows further traction to be circuit. A solution of 0.9 per cent NaCl is adminis-
applied. After packing off the abdominal cavity tered by intravenous drip to correct the electrolyte
with swabs, the bladder is incised on its dorsal imbalance. A catheter is introduced into the
aspect and carefully peeled away from the surface urethra and advanced to the level of the ischial
of the calculus which is then removed. Small frag- arch.
ments of calculus frequently break off during this The surgical approach is via a suprapubic para-
process and these, and all debris in the bladder, medial incision as previously described. As much
should be removed by lavage and suction to mini- as possible of the remaining urine is removed by
mize the risk of further calculi forming. Closure of suction to facilitate close examination of the blad-
the bladder should be in two layers using 3 or der which is brought to the abdominal incision
3.5 metric synthetic absorbable suture material. without difficulty. Close scrutiny is necessary to
The first layer should be a simple continuous determine the extent of the tear which is usually on
pattern; the second, a continuous inverting Cushing the dorsal aspect of the bladder, particularly when
or Lembert suture. it extends caudally along the body. The catheter is
now advanced into the bladder but not far enough
to impinge on its apex before the tear is closed with
a double inverting Cushing suture of 3 metric
REPAIR OF RUPTURED
synthetic absorbable suture material. The perito-
BLADDER - FOAL
neal cavity is lavaged with warm saline solution
Rupture of the bladder is not uncommon in new- prior to closure of the abdominal incision. The
born foals and occurs almost exclusively in colt catheter is sutured to the penis near the urethral
foals. The cause of the condition is unknown, orifice and a finger of a surgical glove, with a small
although it is believed that strong forceful abdomi- hole at its apex, is taped to the end of the catheter
nal contractions at the time of parturition are the to act as a one-way valve. The catheter is removed
major contributory factor. Occasionally congenital 48 hours later.
Urethral obstruction
The urethra in all species of male animals under- In the dog, the terminal portion of the urethra
goes a sharp change of direction at the ischial arch, runs beneath a longitudinal groove in the os penis,
where it emerges from the caudal floor of the and this is the commonest site at which urethral
pelvis and runs forward under the abdominal wall. obstruction occurs in this species (Fig. 4.46).
At the ischial arch, the urethra becomes invested The urethra at the ischial arch is relatively deeply
in the ischiocavernosus and bulbocavernosus buried in tissue, whereasbehind the os penis it is
muscles. This combination of a change in direction quite superficial. Note the relationship of the low
together with the muscular reinforcement predis- urethrotomy incision to the scrotum and testicles.
poses the ischial arch as a site for obstruction by
small calculi that are washed out of the bladder.
I02 SECTION 4/ GENITO-URINARY SYSTEM
Fig. 4.46. The sites of obstruction in the dog at the ischial arch and behind the os penis (after Miller et al. (1979)
Anatomy of the Dog, W.B. Saunders, Philadelphia).
DOG
Low urethrotomy
The symptoms of acute urethral obstruction in the

dog soon become obvious. Numerous unsuccessful
attempts at urination are followed by signs of
discomfort and vomiting. Abdominal palpation will
reveal a grossly distended rock-hard bladder. The
common site of obstruction is behind the os penis,
and this can readily be confirmed by passing a
Scrotum Site of incision Metal sound
metal sound down the urethra. This will meet
resistance at the site of obstruction, and give a very Fig. 4.47. Under general anaesthesia, the dog is positioned on its back, and a probe is
real impression of metal striking against stone. In inserted into the urethra as far as possible. The base of the penis is gripped with the left
hand, and an incision is made through the skin and the underlying urethra, to expose the
the majority of cases the obstruction can be re- calculi.
moved by a low urethrotomy, which involves open-
ing the urethra between the caudal aspect of the
os penis and the scrotum (Figs 4.47-4.48). It
must be remembered that urethral obstruction
quickly leads to uraemia, and although this
is normally reversible once the obstruction is
removed, at the time of operation the dog is highly Urethral
susceptible to the effect of barbiturate narcosis. calculi
These drugs should be used with care, and at
minimal dose rate, in uraemic animals. Tip of
Releasing the grip of the left hand will result in metal sound
considerable haemorrhage from the edges of the
cut urethra, and once all the calculi are removed,
there may be a rush of blood-stained urine from
the bladder. A catheter should be passed into the Fig. 4.48. The edges of the wound are held with tissue forceps and the calculi are
bladder to ensure that no more calculi are present, removed under direct vision.
~-
URETHRAL OBSTRUCTION 103
and the bladder should be washed out with sterile

saline until the washings are no longer blood- Urethrotomy
incision
stained.
The urethrotomy incision is not sutured. For up
to 7 days post operation there is invariably haemor- Vascular bed
rhage from the incision each time the dog urinates, of the corpus
or even if it becomes excited. This will cease as the
wound slowly heals, which is normally complete in §~~~~-Insertion of
3-4 weeks. The proximity of the low urethrotomy bulbo-and
ischiocavernosus
incision to the scrotum predisposes to scrotal infec- muscles
tion, and care must be taken to avoid contamination
of the scrotal sac with urine, giving rise to orchitis. Cut end of retractor
penis muscle
High urethrotomy
If the urethra is obstructed by a calculus that
Stitched
cannot be removed through a low urethrotomy u reth rostomy
incision, then it is necessary to open the urethra
just below the ischial arch by carrying out a high
urethrotomy. At this point, the urethra is not a
superficial structure, but is invested in the insertions
of the bulbo- and ischiocavernosus muscles. In
addition the urethra lies embedded in the highly
vascular corpus cavernosum of the penis. This con- Fig. 4.49. The urethrostomy is established midway
tains numerous vascular sinuses supplied by the in- between the anus and the scrotum.
ternal pudenda! artery and these have to be incised
before the urethra can be exposed and opened. In
cases where it is possible to introduce a catheter
into the urethra, the lumen of the urethra may be is most likely to occur, namely, the ischial arch
identified by palpation. However, in cases where and the area just proximal to the os penis. In ad-
the urethra is obstructed and will not permit the dition, the pelvic urethra proximal to the ureth-
passage of a catheter then it is often extremely diffi- rostomy is widely dilatable and will allow the
cult to locate the urethral lumen due to the intensity passage of small stones which may subsequently
of the haemorrhage from the corpus cavernosum. be washed out of the bladder. The operation does
Once the urethra is located and opened, and the not render the animal incontinent, but urine scald-
obstructing calculus removed, a catheter should be ing of the perineum or scrotum is a potential
passed into the bladder in order to ensure the free complication.
passage of urine, and the bladder should be washed The sutures should either be of 2 metric synthetic
out with sterile saline. It is not usual to suture the absorbable material or preferably I .5 metric blood-
urethrotomy incision, which will gradually heal vessel silk. Although in many cases a direct suture
over a period of 3-4 weeks. can be made between the edges of the urethra and
the skin, the procedure is simplified by removing a
wedge of the ischio- and bulbocavernosus muscles
Urethrostomy
from either side of the urethral incision. This
In dogs which show a tendency to repeated attacks reduces the bulk of tissue and facilitates suturing
of urethral obstruction, urethrostomy offers the urethra to the skin, but it does, of necessity,
best chance of relief. Two urethrostomy sites are increase the problem of haemostasis, as both of
possible. these muscle masses are well supplied with blood.
A high urethrostomy is in essence the same oper- The preferred urethrostomy site is at the scro-
ation as a high urethrotomy, but having opened tum. This has the advantage of permitting relatively
the urethra longitudinally, its cut edges are sutured easy access to the urethra since it is superficial at
to the skin edges, so that after healing a perma- this point. It also has a wide diameter at this level
. nent stoma is created in the urethra at the ischial and there is less risk of stenosis. However, cas-
arch (Fig. 4.49). By this means, a by-pass is estab- tration and scrotal ablation must be performed
lished which avoids the two areas where obstruction prior to suturing the urethral mucosa to the skin.
104 SECTION 4/ GENITO-URINARY SYSTEM
CAT
Urethral obstruction in the cat is complicated both
by the nature of the obstructing material which
commonly consists of magnesium ammonium phos-
phate crystals held together in a colloidal 'matrix
plug', and also by the length and narrow lumen of
the male cat urethra. Many cases can be managed
medically, but in cases of recurrent obstruc-
tion long-term relief can only be achieved by the
surgical elimination of the narrow penile urethra
and the construction of an ischial urethrostomy
(Figs 4.50-4.55).
The use of a catheter in the new stoma should be
avoided as it may promote stricture formation, and
the cat should be given shredded newspaper rather
than litter in its litter tray in the immediate post-
operative period.
Fig. 4.51. The penis is dissected free of the subcutaneous

fat and connective tissue down to its attachment to the
ischial arch. Each ischiocavemosus muscle is isolated and
clamped for a short period before it is divided.
Fig. 4.50. A purse-string suture is inserted around the lschial

arch
anus, and the urethra is catheterized. The cat is
positioned in ventral recumbency with its hind legs tied
over the end of the table and the tail pulled upward and
forward. The skin incision encircles the prepuce and
scrotum.
Fig. 4.52. After severing the ischiocavemosus muscles,

the penis is completely freed from its attachments to the
ischial arch.
URETHRAL OBSTRUCTION I05
Fig. 4.53. The urethra is split longitudinally to expose Fig. 4.55. The lower end of the penis is amputated, and
the urethral catheter. the remaining severed edge of the urethra is sutured to
the skin.
Fig. 4.56. In cattle and sheep and to a lesser extent the

goat, urethral obstruction occurs at the sigmoid flexure of
Fig. 4.54. The upper cut urethral margins are sutured to the penis. The sigmoid flexure may also be damaged
the skin, using 2 metric synthetic absorbable suture during bloodless castration, giving rise to acute urethral
material or blood-vessel silk with a cutting atraumatic
obstruction. (After Oehme & Tillman (1965) J. Am. Vet.
needle.
Med. Assoc. 147, 1331.)
tomy, or by amputation of the penis above the

OTHER DOMESTIC SPECIES
sigmoid flexure. It must, of course, be emphasized
The relatively long narrow urethra in those species that these are life-saving procedures and are nor-
with a sigmoid flexure (Fig. 4.56) makes catheter- mally carried out merely to allow the animals to
ization extremely difficult. In the ram or wether, recover sufficiently from the effects of obstructive
obstruction to the vermiform urethral extension uraemia so that they may be sent for casualty
(Fig. 4.57) can often be cleared by manually 'milk- slaughter. Urethral obstruction in the breeding
ing' the appendage, or if this fails by amputation of male animal is a most serious condition, and
the urethral appendage. urethrotomy or amputation will curtail the animal's
Obstruction at the sigmoid flexure is normally ability for natural service.
treated either by a high urethrotomy or urethros-
I06 SECTION 4/ GENITO-URINARY SYSTEM
Urethrostomy
Urethrostomy is most commonly performed in

steers because of obstruction by urethral calculi
or much more rarely due to accidental inclusion
mmmtt+-Vermiform
of the urethra in the jaws of a Burdizzo during extension of
castration. Rupture of the urethra leading to sub- urethra
cutaneous infiltration of urine along the ventral
abdomen, or less frequently rupture of the bladder,
may have occurred due to delay in diagnosis of the Fig. 4.57. In the ram, the vermiform extension of the urethra is a very common site of
obstruction. urethral obstruction (after Sisson & Grossman (1975) The Anatomy of the Domestic
Urethrostomy is performed as a salvage oper- Animal, 5th edn, W.B. Saunders, Philadelphia).
ation to provide an alternative outlet for urine
until the animal is fit for slaughter.
Anaesthesia
The surgical procedure is performed under caudal W,.--l.A~-- Site of incision caudal to
epidural anaesthesia with the animal standing or the remains of the
cast in dorsal recumbency. Although the urethros- scrotum
tomy can be performed at several sites a distal
approach at the level of the distal sigmoid flexure
has much to commend it in that it allows easy
Fig. 4.58. Site of incision caudal to the remains of
identification of the penis and allows the urethros- the scrotum.
tomy to be sited in such a way that urine is directed
away from the medial aspect of the limbs reducing
the risk of scalding.
A IO-cm vertical incision is made over the sig-
moid flexure of the penis where it can be palpated
immediately caudal to the remnants of the scrotum,
(Fig. 4.58).
The penis is deeper than one would anticipate
and blunt dissection has to extend through sub-
cutaneous adipose tissue and between the paired
retractor penis muscle before the firm fibrous penis
is located. Gentle traction will allow part of the
penis to be withdrawn through the skin incision
(Fig. 4.59). It may be possible to palpate the Fig. 4.59. Part of the penis is withdrawn by
calculus and remove it through a small incision on gentle traction.
the ventral aspect of the penis. If there is no
urethral necrosis the urethra may be sutured after
checking, by passing a catheter proximally and dis-
tally, that the urethra is patent. However, in most
cases there is usually extensive damage at the site.
The penis is transected to leave an 8-12-cm
stump protruding from the dorsal commissure of
the skin incision (Fig. 4.60). The dorsal arteries
and vein are ligated. The urethra is readily ident-
Urethra
ified and is opened for a distance of 4 - 5 cm
(Fig. 4.61). The stump of the penis is directed Corpus
caudoventral so that it projects slightly from the spongiosum
skin incision to which it is anchored with a suture Corpus
which passes through the tunica albuginea and the cavernosus
corpus cavernosus. It is important that the. stump
should be of sufficient length so that there is no Fig. 4.6o. The penis is transected and spatulated.
AMPUTATION OF THE PENIS I07
Urethra
Cut edge
of urethra
/~'::-'----_,,,,,- Suture anchoring

Corpus penis to the skin
cavernosus
Fig. 4.61. The stump of the penis is anchored to the skin on either side in such a way that Fig. 4.62. The urethral mucosa and the edge of the
it protrudes slightly. corpus spongiosus are sutured to the skin on both sides.
infolding of skin because of excessive tension. The is a very serious condition and unless diagnosed
cut edge of the urethra is now sutured to the edge and treated very early, will curtail the animal's
of the skin incisions on each side {Fig. 4.62). ability for natural service.
Urethral obstruction in the breeding male animal
Amputation of the penis

Amputation of the penis in any species presents 1 ---Site of
two major problems: ~ amputation
I
· 1 The control of haemorrhage. I
2 The prevention of subsequent urethral stenosis.
HORSE
Malignant growths of the penis are not uncommon
in the ageing gelding. These growths are mostly
carcinomas affecting the glans penis. Many of these Catheter Urethral Tourniquet
mucosa
animals are kept purely as pets, and as the tumour
rarely metastasizes, amputation of the penis (Figs Fig. 4.63. A tourniquet is applied to the penis after the
4.63-4.65) is a justifiable and successful means of insertion of a urethral catheter. An incision is made in
the lower midline of the penis, through the corpus
removing the growth and the associated objection-
cavernosum to expose the catheter and a length of
able preputial discharges. urethra.
Fig. 4.64. The edge of the urethral mucous membrane is

sutured to the integument of the penis, commencing on
the cranio-lateral aspect of the incision, and continuing
back to the caudal commissure and then forward again
on the contralateral side ..
108 SECTION 4 /GEN ITO-URINARY SYSTEM
Fig. 4.66
Carcinoma on
preputial
ring
Corpus cavernosus
Fig. 4.65. The penis is amputated through the corpus

spongiosum, and the amputated portion is slipped
forward along the catheter. The tourniquet is carefully
loosened and major bleeding vessels are picked up and
ligated. The cranial urethral mucous membrane is
sutured to the remainder of the integument, the sutures
penetrating the corpus spongiosum so that additionally
they are haemostatic in effect. The tourniquet is removed
gradually in order to check any uncontrolled bleeding.
Fig. 4.68
Reefing procedure Fig. 4.66. Two circumferential incisions, proximal and distal to the lesion.
Fig. 4.67. A third longitudinal incision connects the two. The integument is dissected
It is not uncommon for further neoplasms to away from the underlying tissues.
be present on the preputial ring. Thes~ can be Fig. 4.68. The two cut edges are apposed with sutures.
removed successfully by employing a reefing
A---A
procedure.
Parallel circumferential incisions are made
through the integument distally and proximally to
the lesions (Fig. 4.66). The integument between
the incisions is carefully dissected away avoiding
damage to the large vessels which lie outside the
tunica albuginea of the penis (Fig. 4.67). Bleeding
points are identified and ligated after release of the
tourniquet. The cut edges of the integument are
approximated with interrupted sutures of synthetic
absorbable suture material (Fig. 4.68).
DOG Fig. 4.69. The urethra is catheterized and the penis is snared with a tourniquet. With the
patient in dorsal recumbency the os penis is palpated. A pointed knife blade is thrust
Amputation of the penis in the dog (Figs 4.69- through the soft tissue of the penis keeping the blade in contact with the edge of the os
4. 74) is indicated as a treatment for neoplasia. It penis. An incision is then made in an cranio-lateral direction on both sides of the penis in
may also be necessary in cases of trauma which order to create two flaps of corpus spongiosum, and to expose the urethra.
have caused irrevocable damage to the penis,
particularly when the os penis is involved. The
presence of the os penis complicates the technique
of amputation, particularly as the urethra lies in a
groove on the ventral aspect of the bone. It is also
important to guard against urethral stenosis.
Fig. 4.70. The soft tissue of the corpus spongiosum is dissected free from the os penis,
and the catheterized urethra is carefully dissected from the groove in the os penis. Theos
penis is then severed with bone forceps as far back as possible.
AMPUTATION OF THE PENIS 109
Fig. 4.71. The urethra is transected as far forward as possible, in order to

leave a length of urethra still containing the urinary catheter.
..' I
I
I
I
' Fig. 4.74. The tourniquet is partially

'': ~ released in order to pick up any major
Fig. 4.73. The edges of the split urethra bleeding vessels. The cranial edge of the
Fig. 4.72. The urethral remnant is split longitudinally on are sutured to the ventral edges of the · urethra is then sutured to the remainder
its ventral surface in order to produce a splayed end. flaps of the corpus spongiosum. of the corpus spongiosum.
RAM
An incision is made through the skin in the midline
below the anus. The penis is located by blunt
dissection, freed from the surrounding connective
tissue, and is then transected above the sigmoid
flexure (Fig. 4.75). The dorsal artery of the penis is Corpus
ligated with a single suture (Fig. 4.76). cavernosum
Urethra
Corpus
spongiosum
Non-absorbable
suture
Dorsal artery of penis
Fig. 4.76. The suture applies pressure to the corpus

Fig. 4.75. The transected stump of the penis is sutured to spongiosum and so controls haemorrhage without
the skin, allowing 3 cm to protrude (after Oehme & interfering with urination (after Oehme & Tillman (1965)
Tillman (1965) J. Am. Vet. Med. Assoc. 147, 1331). J. Am. Vet. Med. Assoc. 147, 1331).
Ureteral ectopia
Ureteral ectopia is a congenital anomaly which The bladder is exposed by a posterior laparotomy
results in urinary incontinence. Clinical signs are incision and the course of the ureters is traced
usually seen in bitches and the incontinence may distally from the kidneys. The ectopic ureter may
be continual or intermittent. The diagnosis is con- be re-implanted by one of three techniques, de-
firmed by intravenous excretory urography, com- pending upon its position.
bined with pneumocystography.
The ectopic ureters generally enter the neck of
Intravesical technique
the bladder, urethra, uterus or vagina and the
ectopia may be unilateral or bilateral. On occasions I An incision is made in the ventral bladder wall
the ureter may empty into the bladder, yet con- and continued to the trigone area (Fig. 4.77a-c).
tinue to run within the bladder wall and drain The stoma of each ureter is examined. If the ureter
distally beyond the trigone. Hydro-ureter, with or enters the serosal surface of the bladder in the
without hydronephrosis, frequently occurs and normal position, but then runs intramurally beyond
may be associated with urinary tract infection. The the trigone, a new stoma is created and the distal
ectopic ureter is usually amenable to surgical re- portion of the ureter is ligated.
implantation into the bladder. 2 If the ureter by-passes the bladder it is tran-
Incised edge of
bladder mucosa
Incised ectopic
ureter
Ectopic ureter
running intramurally
Incised edge of
bladder musosa
Ureter ligated with

~;::,+--- Intramural non-absorbable suture
ectopic ureter
(b)
(a)
Fig. 4.77. (a) A ventral cystotomy is performed and the

ectopic ureter is identified running within the bladder
1,~;f
wall. (b) A small ellipse of mucosa overlying the ectopic
,~ii~t ureter is removed and the ureter is incised longitudinally.
A second mucosa! incision is made just distal to the first,
through which the ureter is ligated with a non-absorbable
suture. Care should be taken to ensure that the entire
!~! ! !
ureter is included in this ligature. (c) The new stoma is
completed by suturing the edges of the ureter and
\'.\[f;'.;(~ll!1iiM1:I::rs@tJ{ff!ff}f bladder mucosa with a series of interrupted sutures of

1.5 metric synthetic absorbable suture material. The
(c) distal mucosa! incision is closed with similar sutures.
IIO
URETERAL ECTOPIA III
Mucosal defect
in bladder wall
Edge of ureter
Ventral
bladder wall
(b)
"'""";;.;...:.....,,.;-....- Forceps pushed
intramurally through
the mucosal defect
created at the
re-implantation site
~·--~~- "''-::...-=
~"l:iij'~~~-<:~~wt-:r:!}~\~~~·~&f-
'. . ;!~~~ii~~~~:
(a)
Fig. 4.78. (a) A ventral cystotomy is performed and an ellipse of mucosa excised at the site of re-implantation. The tips
of a pair of mosquito forceps are pushed intramurally for a distance approximately three times the diameter of the
ureter which is to be transplanted. The serosa of the bladder is incised over the point of the forceps' exit and the end of
the ureter is pulled through the tunnel. The end of the ureter is then spatulated. (b) The implantation is completed by
suturing the edges of the ureter to the edges of the mucosa! defect with interrupted sutures of 1 .5 metric synthetic
absorbable suture material. The three corners of the ureter are sutured initially to ensure a reasonable fit.
Extravesical technique
sected, the distal portion ligated and the free end
re-implanted (Fig. 4.78). A small ellipse of mucosa The transected end of the ureter is spatulated as
is first excised at the proposed re-implantation site before but the submucosal tunnel is created through
on the dorsal wall of the bladder. The tips of a pair two serosal incisions, thereby obviating the need
of mosquito forceps are then passed through this for a cystotomy (Fig. 4.79). A mucosa) ellipse
defect and tunnelled intramurally for a distance is excised at the site of re-implantation and the
approximately three times the diameter of the splayed end of the ureter sutured to its edges with
ectopic ureter. A serosal incision is made over the interrupted sutures of r .5 metric synthetic absorb-
point of the forceps' exit and the ureter is pulled able suture material. Finally, the serosal defect is
through the tunnel. The splayed end of the ureter closed with similar sutures.
is sutured to the edges of the mucosa) defect with The bladder is catheterized post-operatively
interrupted sutures of 1.5 metric synthetic absorb- and the remaining management is similar to the
able suture material. intravesical techniques.
A Foley catheter is inserted in the bladder before If one of the kidneys is severely diseased it is
the cystotomy incision is closed; Urinary output is advisable to perform a ureteronephrectomy. It is
monitored post-operatively and a mild diuresis is vital to first establish the presence of a second
established for the first few hours following surgery. kidney and that it is functioning adequately.
II2 SECTION 4/ GENITO-URINARY SYSTEM
'------- Ventral surface

of bladder
t;(!
~. ,.
::;;::,; .
:.-.:,·:·: .
(a)
Fig. 4.79. (a) An incision is made in the bladder serosa at the proposed re-
implantation site. The tips of a pair of mosquito forceps are passed
through the serosal defect and pushed submucosally for a distance
approximately three times the diameter of the ureter. The serosa is incised
over the point of the forceps' exit and the splayed end of the ureter is
grasped. (b) An ellipse of bladder mucosa is excised, corresponding in size
to the splayed end of the ureter. The edges of the ureter and the vesical
mucosa are sutured with interrupted sutures of 1 .5 metric synthetic
absorbable suture material. Care should be taken not to twist or kink the
ureter. (c) The serosal defect is closed with interrupted sutures taking care
not to occlude the ureter.
Section 5
Surgery of the
Mammary Gland and Teat
Mammary neoplasia
Neoplasia of the mammary tissue is the commonest to insert a series of interrupted subcuticular absorb-
neoplasm in the bitch. In many cases the condition able sutures, before the skin is closed with mono-
is present for several years as a small, pea-like filament nylon. The post-operative congestion that
nodule which tends to be overlooked by both is inevitable may be dispersed more rapidly if the
owner and veterinarian until it suddenly increases bitch is given regular controlled exercise during the
rapidly in size. This increase is often associated immediate post-operative period.
with the stimulus of oestrus, and the rapid growth Radical mastectomies are necessary when there
of the neoplasm often coincides with the develop- are tumours of multiple glands or they may be
ment of metastatic lesions which spread via the performed prophylactically in the younger, rela-
lymphatics to the local lymph nodes, or by the tively fit, bitch. The more mammary tissue that is
cardiovascular system to the liver and lungs. Surgi- removed, the less there is in which new tumours
cal excision is the treatment of choice although the can develop. There is no value in performing an
optimal amount of tissue to be removed is still ovariohysterectomy to reduce the incidence of
debatable. recurrence.
Regional mastectomies are based upon the ana- A local mastectomy can be used to remove
tomical distribution of the lymphatic and venous tumours of a single breast rather than performing a
drainage. The lymphatic drainage of the three regional procedure. An elliptical incision is made
pectoral glands is towards the axillary lymph node around the affected gland and the mammary tissue
while the drainage of the two inguinal glands is of that gland is removed down to the body wall.
towards the inguinal lymph node (Fig. 5.1). It is Alternatively, lumpectomy, removal of just the
probable that an indefinite lymphatic link exists
between the third pectoral and the first inguinal
gland. It is also probable that the third pectoral
gland drains forwards through the second and first
pectoral glands, and that the first inguinal mam-
mary gland drains through the second one.
Regional mastectomies may either be radical or Pectoral
d -~-'\ ... . . Inguinal
modified radical procedures (Table 5. I). Both en- 1, ,:,. )
\~~./
2;'_ e)
·· ..... 1<~) 2(0)
tail elliptical incisions around the relevant mam-
mary tissue down to the body wall (Fig. 5.2).
In both procedures the inguinal lymph node is
generally removed while the axillary node is left
in situ. The importance of removing or leaving the
lymph nodes is unclear and the reason for leaving
the axillary node is that it is difficult surgically to
remove. In contrast, it is difficult to excise the fifth
inguinal mammary gland without removing part or
all of the inguinal lymph node.
Axillary lymph node Superficial inguinal lumph node
If inguinal glands are affected on both sides,
then all the inguinal mammary tissue is removed, Fig. 5.1. The lymphatic drainage of the three pectoral
including the intervening skin in the midline. If this mammary glands is towards the axillary lymph node. The
drainage of the two inguinal mammary glands is toward
intervening skin is left, it will frequently slough as
the inguinal lymph node.
it is almost certainly deprived of the majority of its
blood supply in a bilateral mastectomy. However,
in cases of bilateral neoplasia involving the pectoral
mammary glands, it is neither necessary nor desir- Table 5.1. Glands removed in radical and modified radical mastectomies
able to remove the intervening skin. Radical
Tumour Modified radical
Radical mastectomies of necessity involve the
removal of large quantities of skin, and this fre- Gland I Remove gland I Remove gland 1, 2, 3
quently leads to undesirable tension on the skin 2 I, 2 I, 2, 3
. edges in order to co-apt them. It is important that 3 I, 2, 3 1,2,3,4,5

4 4,5 3, 4, 5
the tension of mastectomy wounds is taken by the
5 4,5 3, 4, 5
subcuticular fascia, and to this end it is necessary
IIS
II6 SECTION 5 / MAMMARY GLAND AND TEAT
tumour tissue, can be performed. This approach

may be preferable in older bitches, especially when __________ ;:_:_~lijjljjllililllllllllllllllllllllll
the volume of the tumour is small. ,.,- - .... ,,~='"""'
,,"" ,, .,,,---......
,, (al ., ~.-, .,Q-~ (A'\,,/ •. -. · (bl.· ... ,,
-, ...... ~ ~ ~ .,.;'x,, [.. G)::::.;'\ '0)·, ,,
'
---------------
---- ,.....
-~--------------~--~ ~~,
_, . ..... _.
l'
,,' '·-~). . (_jj) Ci). · .. .~;, {.-vG' ,;~',
, ... - (c) . ··- ...,
~-.._ ~------ ------

............... ~----------'.'.:-::-:;;-iiiim,nn'!!Tmim""
Fig. 5.2. (a) Modified regional mastectomy for neoplasia

in the third pectoral gland. (b) Modified regional
mastectomy for neoplasia in inguinal glands 4 or 5.
(c) Radical mastectomy for neoplasia in pectoral gland 3.
Teats
TEAT OBSTRUCTIONS Mid-teat obstructions
Apart from uncommon congenital teat obstructions Localized mid-teat obstructions, or 'peas' are oc-
in the cow, most forms of obstruction are acquired, casionally the result of localized neoplasia, but
and many are related to chronic trauma inflicted at more commonly arise from localized areas of
milking time due to faulty milking technique. This chronic inflammation, possibly involving the ac-
trauma predisposes to chronic localized infection, cessory glands which underlie the mucous mem-
and it is therefore important that in addition to brane lining the teat canal. Large lesions may
dealing with the obstructive lesion, the milking require open teat surgery during the dry period in
technique should be checked and steps taken order to remove them, but many are amenable to
to control chronic infection in order to prevent surgery through the streak canal, and may be
recurrence of the condition. removed by a papillotome (Figs 5.5-5.6).
Basal obstruction Apical obstruction

This condition is usually acquired during the dry Chronic inflammatory conditions involving the
period, and is predisposed by chronic inflammation apex of the teat and the streak canal frequently
and infection of the annular fold of mucous mem- lead to fibrosis and stenosis of the streak canal.
brane, which separates the mucous membrane of
the milk sinus from that of the teat canal. The
annular fold is normally kept patent during lac-
tation by the daily passage of milk, but chronic
inflammation of the annular fold leads to adhesions
developing during the dry period, so that after
calving, the affected teat canal cannot fill with milk
from the milk sinus. A Hudson's teat probe and
spiral can be used to clear the annular fold (Figs
5.3-5.4).
Post-operative antibiotic therapy of the teat
canal is essential, bearing in mind that the ad-
hesions in the annular fold are probably predis-
posed by chronic infection. Fig. 5.3. Hudson's teat spiral and probe.
TEATS II7
Milksinus
Teat----
canal
Streak---...;
canal
-e l
Fig. 5.4. The probe is carefully inserted into the teat canal and a small hole is made through the centre of the adherent
annular fold. The probe is withdrawn, and the teat spiral carefully inserted into the teat canal and insinuated through
the hole in the annular fold and up into the milk sinus. The end of the teat is grasped, and the adhesions in the annular
fold are broken down by a sharp downward pull on the spiral.
Fig. 5.6. Barrett's papillotome.
Affected animals become very difficult to milk

due to the stenosis, and are aptly named 'hard
milkers'. The condition may be relieved by longi-
tudinal incision of the fibrosed canal. This treat-
ment tends to be only palliative as the incision
eventually heals, accompanied by an insidious
recurrence of the stenosis.
Fig. 5.5. The papillotome is inserted into the teat canal.
The cutting surface of the papillotome is pressed against The beneficial effect of this procedure will be
the lesion by pressure of the fingers through the teat wall. prolonged if a teat dilator is inserted into the
Small pieces of the lesion are then 'eroded' by a streak canal after milking for 7 days, during which
rhythmical up and down movement of the cutting edge. period it · is advisable to administer prophylactic
intramammary antibiotics. McLean's knife may be
used to open the end of a teat which has been
severely crushed by a 'tread' injury (Figs 5.7-5.8).
It is also useful in some cases of udder injury in
which large blood clots collect in the teat canal,
ti
II8 SECTION 5 f MAMMARY GLAND AND TEAT
and which may prove impossible to milk out until

the streak canal has been enlarged.
TEAT LACERATIONS
These fall into three main categories.

I Flap wounds involving a V-shaped superficial
Fig. 5.7. McLean's knife. The blade is designed to cut on
insertion and withdrawal.
layer of the teat skin, and usually associated with
a self-inflicted 'tread' injury. The thin layer of de-
tached skin is deprived of its blood supply and
undergoes rapid necrosis, leaving a large raw area
which heals only slowly. In these cases the area
should be protected by a bactericidal emollient
cream, and covered with a non-stick, self-adhesive
dressing between milking.
2 Deep lacerations of the teat wall which do not
penetrate into the teat canal. These will invariably
heal if left unsutured, but in all cases the healing is
greatly accelerated if the edges of the wound are
cleaned and any bruised and devitalized tissue is
removed before co-apting the edges with simple
interrupted sutures of fine monofilament nylon.
3 Deep penetrating wounds into the teat canal,
through which milk escapes. These lacerations
must be sutured, otherwise milk will be lost con-
tinuously through the torn wall of the teat canal, 1 -0
and infection may readily become established. ..
Although in the past it has been customary not
to suture the mucosa! lining this can now be carried Fig. 5.8. The knife is thrust sharply up through the
out to advantage using very fine absorbable suture streak canal, after first cleaning the teat and distending
the teat canal with milk. Once in the teat canal, the knife
material and an atraumatic needle. The remainder
may be rotated through 90° before it is withdrawn to
of the teat wall is gently opposed using vertical produce a cruciate incision in the streak canal (see insert
mattress sutures of fine monofilament nylon A).
(Fig. 5.9).
Many penetrating teat lacerations are extremely
irregular in shape, and are not the ideal straight
tear as illustrated. In addition, the wound is rarely
caused by a sharp instrument and so the wound
edges contain bruised and potentially dead tissue
which will eventually slough. Although many teat
lacerations are successfully repaired by direct su-
ture, others fail to heal completely due either to
sloughing of devitalized tissue, or to the interfer-
ence that is unavoidable each time the cow is
milked. These small areas of breakdown rapidly
develop an organized lining and form a teat fistula.
Once a true fistula has formed it is unlikely to heal
until the lining is dissected out and the wound
sutured. This is best carried out after the cow is
dried off, so that the incision may be left to heal Fig. 5.9. Vertical mattress sutures of fine monofilament
undisturbed before the next lactation commences. nylon are inserted. These sutures are left untied until all
have been inserted, making certain that the deep part of
the stitch passes through the submucous tissue without
penetrating into the teat canal.
- . -~- .'; -- ..... ·· . ·.,... . ., ......

Section 6
Hernia and Rupture
A hernia is the protrusion of a viscus through a this defect a portion of abdominal viscus will pro-
physiological opening of the abdominal cavity, tude, pushing with it a pouch of peritoneum. Also
namely, the umbilical or the inguinal rings. These attached to the peritoneal sac may be found the
physiological openings normally close either before vestigial remnants of the umbilical vein (the falci-
or soon after birth, but in certain instances they form ligament), umbilical arteries (the round liga-
remain patent, allowing abdominal viscera to pass ments of the bladder) and the allantoic stalk (the
through the open ring. ventral ligament of the bladder).
In the case of the inguinal canal, in both the Surgically, a hernia consists of a ring, which is
male and female it is lined by the tunica vaginalis, either the umbilical or inguinal ring; a sac lined
which is an outpouching of the peritoneum and with peritoneum, and the contents which may be
thus the protruding viscus is contained within the omentum, broad ligament or a portion of uterus or
sac of the tunica vaginalis. In the female this gives small intestine. In its simplest terms, therefore,
rise to a swelling in the inguinal area, but in the surgical reduction involves returning the herniated
male the swelling usually progresses down into the contents into the abdominal cavity, obliterating
scrotum and is referred to as a scrotal hernia, the peritoneal sac and closing the ring with sutures
which is complicated by the presence of the testicle to prevent recurrence of the hernia. All hernias are
in the tunica vaginalis. areas of anatomical weakness and their successful
An umbilical hernia arises due to failure of the repair depends upon the tissues being permanently
linea alba to close around the stalk of the umbilical co-apted by sutures. It is therefore essential that all
cord, and in many cases this is predisposed by low hernias are repaired with non-absorbable suture
grade infection of the umbilical remnant. Through material.
Incarcerated hernia
When it is not possible to return the contents to the necessary to enlarge the hernia ring in order to free
abdominal cavity, because they are trapped in the the trapped contents. The umbilical ring may be
hernia sac by the ring, the hernia is said to be enlarged in a cranial or caudal direction, but the
incarcerated. If a portion of intestine, or less inguinal ring can only be enlarged in an cranio-
commonly uterus, becomes incarcerated there is a lateral direction, as its cranio-medial canthus is
grave danger that the blood supply to the trapped adjacent to the bony pelvic brim. Having freed the
viscus may be impaired and finally cut off, causing trapped contents, it is then necessary to remove
strangulation and necrosis of the trapped viscus, any devitalized tissue, possibly necessitating enter-
and giving rise to- a gr~ve surgical emergency. In ectomy or hysterectomy, before the hernial ring is
dealing with an incarcerated hernia, therefore, it is closed.
Umbilical hernia
Figures 6. 1-6.3 illustrate the standard procedure Figures 6.4-6.6 show an alternative procedure
for dealing with umbilical hernias. if the peritoneal sac cannot be maintained intact.
121
122 SECTION 6 f HERNIA AND RUPTURE
Fig. 6.1. The skin of the hernial sac is freed by an Fig. 6.3. Closure of the hernial ring is simplified if all the
elliptical incision, and the connective tissue is broken sutures are inserted and 'laid' before they are tied.
down by blunt dissection to expose the glistening
peritoneal sac and the ring where it emerges through the
abdominal wall. The skin remnant is detached from the
peritoneal sac, leaving the sac intact.
Fig. 6.4. The peritoneal sac may be inadvertently

opened when attempting to free it from the overlying
skin, or purposely opened in order to inspect the
contents.
Fig. 6.z. The intact hernial sac is invaginated through

the ring, and the edge held between the thumb and Ring
forefinger while the stitches are inserted. This ensures
that no abdominal viscera are inadvertently damaged by
the needle.
it.1~
'·. ·.
f
i
1.-
Fig. 6.5. The peritoneal sac is trimmed off down to the

\,
fJ
j
level of the ring. ,
\.P
l,
'I
lf
'
j' L
UMBILICAL HERNIA 123
Fig. 6.6. The ring is closed by a series of simple interrupted sutures of non-absorbable suture material. It is easier if the
sutures are 'laid', i.e. each suture is inserted but is left untied until all the sutures are in position. This overcomes the
danger of accidentally incorporating a loop of intestine in the suture line. It is most important that the sutures are placed
well away from the edge of the hernial ring, to ensure that they are co-apting strong tissue. The skin is closed by
monofilament nylon.
Internal
rectus
sheath
Fig. 6.7. When using polypropylene mesh to repair a hernia it is best to suture it between the peritoneum and the
internal rectus sheath.
When the hernial ring is large and its edges thick cavity as previously described (Figs 6.1-6.2). The
and rounded, it may be difficult if not impossible to intact peritoneum is reflected peripherally from
bring them into apposition. In these cases, bridging the deep fascia) sheath of the rectus muscle for
the defect with a prosthetic material in the form of 1-2 cm. The mesh is cut so that it overlaps the
a mesh provides a simple and very effective alter- margin of the ring by the same amount. At least
native method of treatment. Polypropylene mesh eight sutures are preplaced around the margin of
has proved to be the most useful of the variety of the mesh (Fig. 6.7). The two ends of each suture
synthetic materials which have been used for this are taken in turn through the margin of the hernial
purpose in animals. ring from inside outwards and tied, thereby drawing
The mesh is best placed in an extraperitoneal the mesh between the muscle and the peritoneum.
position between the internal rectus sheath and the The subcutaneous tissue and skin are then carefully
peritoneum where it has a greater mechanical ad- apposed over the mesh.
vantage than if it is placed overlying the defect. A similar technique can be employed to repair
The sac is isolated and returned to the abdominal incisional and traumatic flank hernias.
Inguinal hernia
Inguinal hernia in the female
In both the female and the male, an inguinal
hernia should be approached by an incision over-
Tunica vaginalis
lying the external inguinal ring (Figs 6.8-6.u). In twisted to reduce
the female this is best accomplished by an incision contents
medial to the inguinal mammary tissue, whereas in
the male the incision should be over the inguinal
ring, and parallel to the fold of the flank. Kocher forceps
at base of
hernial sac
Fig. 6.10. A ligature of non-absorbable material is

placed below the Kocher forceps, and is tied into the
crushed tissue. The sac above the ligature is cut off.
Tunica
vaginalis
containing
contents
of hernia
:!!::..---'"'--.;,_- Ligature tied

into crushed
neck of
hernial sac
Fig. 6.9. The contents of the sac are returned to the

abdominal cavity by twisting the sac, the base of which is
Fig. 6.8. The skin is incised over the inguinal ring. then clamped with Kocher forceps.
The hernial sac is dissected free by blunt dissection and
gripped at its apex by a pair of forceps.
Ligated sac Sutures closing

external inguinal ring
Fig. 6.11. The external inguinal ring is closed by

interrupted sutures, burying the ligated pedicle of the
hernial sac.
124
INGUINAL HERNIA 125
Inguinal (scrotal) hernia in the male
Any hernia is a possible hereditary weakness, and

it is not desirable to breed from an animal so
affected. It is therefore normal practice to combine
castration with scrotal herniotomy (Figs 6.12-
6. 14), although this is not an essential part of the
operation, which, if necessary, can be carried out
without sacrificing the testicle.
Testicle
gripped
through
sac
Fig. 6.13. This diagram illustrates the relationship of the

testicle and spermatic cord to the hernial contents.
Contents
inside sac
Sac twisted
and clamped
Fig. 6.12. The skin is incised over the inguinal ring, and
the hernial sac is dissected free from its attachment to the
scrotum. The testicle is held through the wall of the
tunica vaginalis.
Fig. 6.14. The contents are reduced into the abdominal

cavity by twisting the sac, but maintaining a hold on the
testicle through the sac wall. Once the contents are
reduced, the base of the sac is crushed by Kocher
forceps, including the spermatic cord. The sac is then
ligated, and cut off above the ligature, so that both the
sac and the testicle are removed. The inguinal ring.is then
oversewn, as shown in Fig. 6. r 1.
Rupture
A rupture is a tear in the abdominal wall, or in the not arise following laparotomy to the same extent
anatomical boundaries of the abdominal cavity, as they do following thoracotomy.
i.e. the diaphragm and the pelvic diaphragm. It is 4 Intrathoracic adhesions are extremely uncom-
not related to a physiological opening and is not mon. If they do occur, they can usually be safely
congenital in origin, but it is always associated with broken down through an abdominal approach, and
violent trauma or with prolonged subacute trauma. only in very exceptional cases is it necessary to
Unlike a hernia, the contents of a rupture are not resort to thoracotomy to relieve them.
enclosed within a sac of unbroken peritoneum, and s Laparotomy allows an examination to be made
therefore adhesions between the contents and the of the abdominal viscera, which are frequently
rupture sac are a common complication and add damaged at the time of the diaphragmatic rupture.
greatly to the difficulty of repair. It is not proposed No matter which surgical approach is used,
to consider the treatment of traumatic tears in the successful repair is in large measure an anaesthetic
abdominal wall, which are normally repaired by
the application of standard surgical principles.
Each case is different and requires individual Tissue forceps co-apting Gosset
modification. tear in diaphragm retractor
Rupture of the diaphragm and rupture of the
pelvic diaphragm are two conditions which call
for rather special skill, and being comparatively
common are dealt with in some detail.
RUPTURE OF THE DIAPHRAGM
Any violent trauma, often associated with a car

accident or a fall, may lead to rupture of the
diaphragm. In the majority of cases the tear occurs Liver
in the central membranous portion of the dia-
phragm, and spreads radially to its attachment
with the costal arch, and may then tear this attach-
ment for variable distances. The majority of tears,
therefore, tend to be triangular.
In animals which survive this initial trauma, the
abdominal contents move forward into the pleural Abdominal pack
cavity giving rise to lung collapse in direct pro-
Fig. 6.15. The tear in the diaphragm is located, and the
portion to the volume of migrating viscera. edges are temporarily held together by tissue forceps.
Dyspnoea is therefore the most common presenting
symptom, as respiration is impaired partly by lung
collapse and partly by the loss of the diaphragm as
an integral part of the mechanics of respiration.
The surgical approach to the repair of the rup-
tured diaphragm is a matter of controversy, but the
authors are in no doubt that this condition is most
effectively dealt with through a cranial lapar-
otomy. They justify this approach against repair
through a thoracotomy incision for the following
reasons.
I Laparotomy gives a 360° approach to the dia- Fig. 6.16. The tear is sutured using either simple
phragm, whereas a thoracotomy only offers a 180° interrupted or mattress sutures of a non-absorbable
approach unless one is prepared to tear through suture material. It is often helpful to lay the last suture
and leave it untied until the anaesthetist fully inflates the
the mediastinum.
lungs (A). This tends partially to eliminate the surgical
2 Laparotomy is a more familiar technique to the pneumothorax, but it is by no means absolute, as the
general surgeon than is a thoracotomy. initial closure of the tear in the diaphragm is rarely
3 Problems of acute post-operative discomfort do completely airtight.
126
RUPTURE 127
problem, and calls for close co-operation between ing an apparently successful repair.due to failure to
the surgeon and anaesthetist. An animal with a eliminate the surgical pneumothorax.
ruptured diaphragm is suffering from a variable
degree of general hypoxia, which may precipitate a
PERINEAL RUPTURE - DOG
cardiac arrest on anaesthetic induction. For this
reason we do not induce anaesthesia .in cases of This arises in the mature male dog due to a de-
ruptured diaphragm until the surgeon is scrubbed generation of the muscles· of the pelvic diaphragm
for surgery, so that in the event of an emergency (Fig .. 6.17), which support the lateral walls of the
arising during induction he or she can rapidly open rectum, and seal the pelvic inlet from the abdomi-
the abdomen and take whatever remedial steps are nal cavity.
necessary. The aetiology of this condition is not clear. Many
Following induction, a cranial laparotomy in- factors have been implicated including tenesmus,
cision is made lateral to the linea alba, avoiding congenital weakness, prostatic hypertrophy and
the underlying falciform ligament. The incision hormonal imbalances.
should extend from the xiphisternum to beyond The levator ani and coccygeus muscles tend to
the umbilicus. Once the abdomen is opened the overlie and support each other, but there is a weak
incision should be held apart by retractors and the point between the levator ani and the sphincter ani
abdominal viscera removed as quickly as po_ssible internus, and it is at this point that the rupture
from the pleural cavity in order to relieve respir- first occurs (Fig. 6. 18). This is readily differentiated
atory embarrassment due to lung collapse. from a neoplastic enlargement by rectal examin-
The tear in the diaphragm is located and the ation. Neoplasms are space-occupying, whereas in
edges are temporarily held. together by tissue for- perinea! rupture the examining finger readily enters
ceps before being sutured (Figs 6.15-6.16). the rectal sacculation.
Following inspection of the abdominal viscera to The accumulation of faecal matter in the saccu-
check for any additional damage, the abdominal lation increases the tenesmus, which often forces
wall is closed. It must be emphasized that it is the prostate gland back into the pelvic inlet, and in
essential to aspirate both pleural cavities by means extreme cases will cause the bladder to become
of a plastic intrapleural catheter connected to a retroverted into the pelvis, causing acute urinary
sucker and underwater seal (see pp. 132-3) fol- obstruction. Surgical treatment, therefore, should
lowing abdominal closure. Animals can die follow- not be delayed, and is based upon accurate recon-
Perinea! artery and nerve
Fig. 6.17. The pelvic diaphragm consists of the coccygeus (1) and the levator ani muscles (2). Fibres of the levator ani
blend with the sphincter ani i11ternus (3). The floor of the pelvis is covered by the obturator internus muscle (4).
I28 SECTION 6/ HERNIA AND RUPTURE
struction of the pelvic diaphragm. The authors

consider that castration should be an integral part '''lllllllllllllllllllllllllllll~lllllllllllllllll/11111111111111111
of the surgical procedure, as it offers the only
effective long-term treatment for prostatic
hypertrophy.
After anaesthetic induction, the rectum and rec-
tal sacculation should be emptied of faeces, and a
purse-string suture inserted around the anus. The
dog is then placed in dorsal recumbency and cas-
trated before repairing the perinea! rupture. The Perinea! artery
animal is repositioned in ventral recumbency, with and nerve
displaced
its hind legs strapped over the end of the operating by rectal
table and the tail pulled upward and forward. The sacculation
table should have a head-down tilt to enable the
pelvic contents to be reduced into the abdomen.
The rupture is approached through an incision
starting at the base of the tail, curving around the
anus and ending above the scrotum in the midline. Fig. 6.18. Once the rectum is deprived of local support due to the rupture, there is a
The rupture sac contains blood-stained fluid, loose tendency for faecal matter to force the rectum through the muscle defect to produce a
connective tissue and fat, and occasionally the rectal sacculation (5) which is clinically recognizable by a swelling in the ischiorectal
fossa. The displacement of the perinea! artery and nerve makes them liable to damage
prostate gland and prostatic cysts are found. The
during the early stages of surgical exposure of the rupture sac. Care must be taken to
contents are pushed forward and the rectum and preserve these structures particularly when a bilateral repair has to be undertaken. ( I -4
sphincter ani are recognized medially, whereas the as in Fig. 6.17.)
remnants of the pelvic diaphragm may be seen
sloping forward laterally, or more frequently are
only appreciated by palpation. The floor of the
defect is formed by the obturator internus muscle,
and the perinea! artery and nerve must be recog-
nized as they cross the defect low down in the edge
of a fold of connective tissue.
The muscles are sutured together as shown in Hiatus in suture line
to allow passage of
Fig. 6.19, with a hiatus in the suture line which perinea! artery and
allows the passage of the perinea! artery and nerve, nerve
both of which supply the anal ring. This suturing
must be accurate, and is made easier if the stitches 3 o'clock
are first inserted and 'laid' and then finally are all
tied in succession. Non-absorbable material is used.
This suture line is then reinforced by dissecting
the subcutaneous fascia away from the excess skin
flap lateral to the incision, back to the line at which
the excess skin is to be cut off, and then stitching
the edge of the fascia to the sphincter ani, caudal
to the first row of sutures.
The skin is closed and the purse-string suture
removed from the anus. If the lesion is bilateral it
is normai practice to repair the worst side and to
allow 4-6 weeks before repair of the second side.
Fig. 6.19. Starting at the top of the defect, the levator ani muscle (2) is sutured to the
In bilateral cases it is important to avoid damage to cranial border of the sphincter ani muscle (3), and these sutures are continued round the
the perinea! nerve, otherwise faecal incontinence 'clock face' until at 3 o'clock the forward slope of the levator ani muscle makes it
may occur. necessary to complete the closure by stitching the obturator internus muscle (4) to the
sphincter ani. Alternatively, rather than suturing the obturator internus muscle from
3 o'clock to 6 o'clock, the repair can be strengthened by transecting its tendon of
insertion from the ischium, elevating the muscle and suturing into the cranial border of
the sphincter ani muscle. Although the coccygeus muscle (1) forms part of the pelvic
diaphragm, it is only involved in the closure when the Ievator ani has become too
degenerate to support sutures.
Section 7
Thoracic Surgery
Thoracotomy
LATERAL APPROACH - DOG Periosteum
A thoracotomy incision is always restricted on

either side by the presence of a rib, and this limits
the amount of exposure that may be obtained,
even with the use of a rib retractor. The incision
must therefore be accurately placed in relation to
the area of the chest that is to be explored and this
can only be decided by an accurate pre-operative
assessment of the lesion by radiography. A simple
thoracotomy incision may be made by cutting
through the intercostal muscles, but this produces
a very limited exposure and often proves difficult
to close. Better exposure is achieved by the sub-
periosteal resection of a rib (Figs 7.1-7.5). It is
possible to locate the correct rib for resection by
first palpating the last rib, and then counting
numerically backwards until the correct rib is pal- Fig. 7.1. The skin and muscles overlying the selected rib
pated. If the skin over the rib is then scratched are incised so that the rib is exposed. Haemostasis must
with a scalpel it is easier to identify after the be meticulous. The periosteum of the rib is incised along
patient is draped. its length, and dissected free from the underlying bone.
Periosteal
stripper
Periosteal
bed of rib
Fig. 7.3. The rib is then severed at each extremity and

lifted out of its periosteal bed.
Fig. 7 .2. Once a short section of rib has been completely

freed from its periosteum a periosteal stripper is inserted
below the rib. By carefully running the stripper along the
length of the rib it is possible to strip the periosteal
covering along its length down to the costochondral
junction.
131
132 SECTION 7 f THORACIC SURGERY
Periosteum and pleura Rib retractor
Lung
Lung Pericardium
Fig. 7.4. The periosteum and pleura are opened with
scissors, carefully avoiding damage to the underlying
lung tissue.
Fig. 7,5· The thoracotomy incision is then 'spread' and

held open by means of a rib retractor.
which in most cases will already have been inserted

Surgical closure
in the skin but left untied.
Before the thoracotomy incision can be closed it is If it is considered that further chest aspiration
essential to eliminate the surgical pneumothorax is necessary, the chest drainage tube is disconnected
by means of an intrapleural drainage tube con- from the underwater seal, having first occluded
nected to an underwater seal (Figs 7.6-7.7). the tubing by a gate clamp, reinforced by doubling
The pleura and periosteal layer should be closed over the tubing and securing it with adhesive plas-
by a continuous suture to produce an airtight seal. ter. This occlusion must be absolute because if the
The superficial muscle layers may be closed by chest drain is inadvertently opened so that the
either continuous or interrupted sutures. pleural cavity is in direct contact with the atmos-
phere, then a massive pneumothorax will result
which may well prove fatal. The occluded tube is
Management of the chest drain
then lightly bandaged to the patient's body in such
Once an airtight closure of the chest wall has been a way that it cannot become displaced or be inter-
achieved, air will be sucked out of the pleural fered with. If further chest aspiration is necessary,
cavity as indicated by a stream of bubbles from the the chest drain must be reconnected to the under-
plastic tube beneath the surface of the water, and water seal before the gate clamp and adhesive
bubbles will continue to flow until the surgical plaster are removed. This method of underwater
pneumothorax has been eliminated and the lungs seal drainage will also remove any fluid which may
fully re-expanded. accumulate within the pleural cavity.
At this stage the water level in the plasti_<; tubing
will rise indicating a negative pressure within the
MEDIAN STERNOTOMY - DOG
pleural cavity, and this level will rise and fall
slightly at inspiration and expiration. Once a satis- An alternative thoracotomy approach involves
factory negative pressure has been achieved with splitting the sternum (Fig. 7.8). This approach
minimal respiratory swing the pleural drainage provides good exposure of the thoracic contents
tube is removed by traction, and the small skin but has the disadvantage that the heart presses on
incision closed by a simple purse-string suture the great vessels and reduces cardiac output.
THORACOTOMY 133
~--- From patient
To sucker
Fig. 7.6. With the chest still open a small skin incision is Underwater - Suction-
made high in the chest wall at either one or two seal bottle limiting
intercostal spaces in front or behind the thoracotomy bottle
incision. A pair of Kocher forceps is inserted into the
skin incision and then thrust through the thickness of
the chest wall (I). The jaws of the forceps are opened
Fig. 7.7. The free end of the drainage tube is attached
and the drainage tube is grasped and drawn out through
to the underwater seal which in turn is connected to a
the thickness of the chest wall and skin. The end of the
mechanical sucker. In order to limit excessive suction, a
drainage tube which remains in the pleural cavity should
suction-limiting bottle may be interposed between the
have a 'kettle-spout' end and one side hole (ra) and this
water seal and the sucker. The water seal must be at least
should be positioned to lie just within the pleural cavity
1.2 m below the level of the dog.
(2). The drainage tube is then anchored to the skin with a
suture, avoiding penetrating the tubing or transfixing it in
any way as this may give rise to an air leak. A second,
purse-string, suture is laid to close the skin incision when
the tube is removed.
The dog is placed in dorsal recumbency and the

skin is incised from the manubrium to the xiphis-
ternum. The incision is continued through the
subcutaneous tissues and fascia down to the ster- Sternebrum
nebrae. Starting at the xiphoid cartilage, the ster- split and
retracted
nebrae are split with an osteotome or oscillating
saw, taking care to remain in the midline. If the
first one or two sternebrae can be left intact, the
ensuing closure will be more stable.
The sternotomy is closed with sutures of mono-
filament stainless steel wire taken around each split
sternebra. The overlying soft tissues and skin are
co-apted in the usual manner. A chest drain is
inserted before closure. Fig. 7.8. The sternebrae have been split from the
xiphoid cartilage to the manubrium. The internal
thoracic vessels course on either side of the midline and
should be avoided.
134 SECTION 7 / THORACIC SURGERY
Dorsal branch of left

vagus nerve
Mediastinal
pleura
Bone gripped
by forceps
Surgical
pack
Bone in the
lumen of the
oesophagus
Diaphragm
Fig. 7.10. The oesophagus is opened with care to avoid
damage to the branches of the vagus and the obstructing
bone is removed with forceps.
Ventral branch
of left vagus
nerve
Fig. 7.9. Following thoracotomy the lung is gently retracted towards the hilum and
packed away from the operation site. The bone is readily visible through the
oesophageal wall, as are the dorsal and ventral branches of the left vagus nerve which
run above and below the oesophagus as it penetrates the oesophageal hiatus in the
diaphragm.
bone is frequently in an advanced state of putrefac-

OESOPHAGEAL OBSTRUCTION -
tion and the oesophagus also contains decomposing
DOG
ingesta. It must be emphasized that bleeding from
Oesophageal obstruction in the dog is commonly the oesophageal wall must be controlled before
caused by swallowing an irregular-shaped bone. It closure is commenced. The oesophagus is liberally
then becomes held up either where the oesophagus supplied by the broncho-oesophageal artery and
passes close to the right side of the aortic arch at fatal haemorrhage can occur if a major branch is
the base of the heart or, more frequently in the cut, particularly if this occurs in an area where
low pressure zone between the heart and the dia- pressure necrosis has largely destroyed the elastic
phragm. In the majority of cases it is possible to retractile wall of the artery.
remove the bone by means of an oesophagoscope
and crocodile forceps. In cases where the bone has
Closure of the oesophagus
been in situ for several days and its sharp pro-
jections have eroded into the oesophageal mucous Unlike the intestine, the oesophagus is not covered
membrane, it may prove very hazardous to attempt with a layer of serous membrane and therefore
a forced extraction by endoscopy due to the danger surgical closure must be particularly thorough
of tearing the oesophageal wall. In such cases it is (Figs 7.II-7.12). This is often made difficult by
usual to remove the bone through a transthoracic devitalized areas of tissue caused by local pressure
oesophagotomy, resecting the left fifth rib to ap- necrosis from the sharp edges of the obstructing
proach the aortic arch and the left eighth rib to bone.
approach the oesophagus immediately in front of A single layer closure using simple interrupted
the diaphragm (Figs 7.9-7.10). oppositional sutures is a satisfactory alternative. In
Care must be taken to protect the pleural cavity this case, the sutures should be pre-placed before
from contamination by careful packing off, as the being tied.
THORACOTOMY 135
Continuous
suture in
mucous
membrane Interrupted sutures
in muscle coats
Fig. 7.12. The muscular coats of the oesophagus are

closed by a single layer of interrupted sutures. On
completion, the pleural cavity is checked to make certain
Fig. 7.11. Continuous horizontal mattress suture in that all packs have been removed, a chest drain is
mucous membrane using a synthetic absorbable suture inserted and the routine thoracotomy closure carried out.
material.
vascular ring where it causes gross dilatation. Most

VASCULAR RING OBSTRUCTION
of this retained food is eventually regurgitated,
OF THE OESOPHAGUS - DOG
although this is frequently mistaken for vomiting
Oesophageal obstruction can also be caused by a by the owner of the puppy. The presence of a
developmental anomaly of the great vessels of the vascular ring obstruction has a characteristic radio-
chest (Figs 7.13-7.16). The condition produces graphic appearance and unless oesophageal dila-
clinical symptoms when the affected puppy is tation is very severe, in the majority of cases the
weaned onto solid food. This can only pass through vascular ring is amenable to surgical division
the vascular ring with difficulty and so most of it is (Figs 7.17-7.18).
retained within the oesophagus, cranial to the
-----Carotid
left 3rd arch
Left 4th arch
Left
subclavian
Left 6th arch

forming ductus :.~~:~
Pulmonary arteriosus
artery Alternative origin
of left subclavian
Fig. 7.13. A simplified diagram of the normal aortic arch complex
shows that the arch of the aorta develops from the fourth left Fig. 7.14. The commonest departure from the normal pattern
embryonic aortic arch, and the pulmonary artery from the sixth involves the development of the fourth right aortic arch into the
embryonic aortic arch, which during intrauterine life maintains a definitive aorta, while the ductus arteriosus makes contact with this
patent connection with the left fourth aortic arch in order to by-pass dextro-aorta by utilizing the remnants of the left fourth arch. Once
the lungs. This vessel, the ductus arteriosus, rapidly closes in the the ductus arteriosus closes and contracts, the oesophagus is trapped
neonatal animal but persists throughout life as the fibrous in a vascular ring composed of the base of the heart, the dextro-aorta
ligamentum arteriosum. and the ligamentum arteriosum.
136 SECTION 7 / THORACIC SURGERY
Aorta partially obscured

by oesophagus
Ligamentum
arteriosum
Left
subclavian Vena
azygos
Pulmonary
artery
Sigmoid
oesophageal
dilatation
Double aortic arch Oesophageal
constriction
Fig. 7.15. Less commonly, both of the primitive fourth
aortic arches may persist. Fig. 7.17. A left thoracotomy at the level of the fourth
rib will expose the vascular ring (Fig. 7.18). After gently
retracting the left apical lung lobe the mediastinal pleura
is broken down with care to avoid damage to the
adjacent thoracic duct, and the vascular ring may be
identified at the caudal end of the oesophageal dilatation.
The ligamentum arteriosum is dissected free of the
oesophagus by blunt dissection and ligated close to its
aortic and pulmonary artery connections before it is
divided. The oesophagus should be freed by blunt
dissection and then dilated by means of a blunt sound,
inserted into the puppy's mouth by an assistant, which is
then guided with care through the obstructed area,
making certain that the site of obstruction is well dilated.
Dextro-ao rta
Left
subclavian
Right subclavian artery
arising distally Ligamentum
arteriosum
Fig. 7.16. The right subclavian artery may arise from the
distal instead of the proximal root and gives rise to
oesophageal obstruction. Aortic arch
Pulmonary
artery
Fig. 7.18. Oesophagus removed to show the complete

vascular ring.
THORACOTOMY I37
Aorta
Ductus
arteriosus
(b) (c)
Left vagus
nerve
Fig. 7.19. (a) The mediastinal pleura is incised dorsal to the left vagus nerve and
retracted. (b) A double loop of umbilical tape is passed behind the aorta. The ends of
the tape are gently drawn in front of and behind the ductus, thereby obviating the
necessity to dissect blindly behind it. (c) The double loop is cut to make two ligatures to
tie around the ductus. The ligature nearest the aorta should be tied first. The ductus
(a) should not be divided but the ligatures should be placed as widely apart as possible.
will result in unacceptably high pressures in the

PATENT DUCTUS ARTERIOSUS -
pulmonary circulation.
DOG
The aim of surgery is to ligate the patent ductus
The ductus arteriosus normally closes within the and prevent blood flowing from the aorta to the
first few days of life and becomes a fibrous band. pulmonary artery. Access is achieved by removing
Failure to close allows blood to pass between the the left fourth rib and retracting the cranial and
aorta and pulmonary artery. The flow is usually middle lung lobes. The mediastinal pleura is incised
towards the pulmonary artery, thereby causing parallel and dorsal to the left vagus nerve and both
over-circulation of the lungs. Flow through the are retracted ventrally to expose the ductus.
ductus in this direction causes turbulence and a Blunt dissection cranial and caudal to a long
typical continuous (machinery) murmur is heard ductus is relatively easy compared to those cases
over the left third intercostal space. The increase where the vessel is short and wedge shaped. In
in the pressure in the pulmonary vessels, left atrium some cases dissection is facilitated by elevating the
and left ventricle may result in dilatation of these aorta distal to the ductus with a length of umbilical
structures and the dog eventually suffers from left- tape. The ductus is occluded with two ligatures of
sided congestive heart failure. Ligation of the similar material. These are passed behind the aorta
patent ductus arteriosus should be performed as and their ends grasped by forceps gently introduced
soon as possible to prevent the above changes in front of, and behind the ductus. This avoids
(Fig. 7.19). dissecting behind the fragile ductus and reduces
Occasionally, when the pulmonary pressure is the likelihood of tearing it. The aortic end of the
greater than the systemic pressure, the flow within ductus is ligated first and the ends of the ligature
the ductus will reverse and unoxygenated blood are left uncut so that gentle traction can be applied
enters the aorta. Since the pressure difference while the second ligature is tightened. The distance
between the two sides is much less, and the flow is between the two ligatures should be as great as
more laminar, the murmur may be absent. The possible. The ductus should not be divided since
dog may experience severe exercise intolerance there is always a possibility that the ligatures may
and cyanosis may be noted. Surgery is contra- slip.
indicated in these cases since ligation of the ductus
138 SECTION 7f THORACIC SURGERY
stage the blood supply to the affected lung lobe

LOBECTOMY - DOG
must be identified and ligated (Figs 7.20-7.21).
Lobectomy is indicated for the extirpation of dis- The second stage involves the excision of the lobe
ease conditions which are limited to a discrete area by transection of the bronchus and surgical closure
of lung tissue such as early bronchiectasis or a of the bronchial stump (Figs 7.22-7.23).
localized primary neoplasm, or to cases of trauma In the dog, all lobes of the lung are separated by
which involve gross laceration of lung tissue. The distinct fissures apart from the left cranial and
operation falls into two separate stages. In the first middle lobes which are fused over a transverse
Surgical
pack
Fig. 7.21. The vessel is then divided between the

Branch of ligatures.
pulmonary
artery
Curved forceps used to draw

ligature under vessel ·
Fig. 7.20. The pulmonary artery and vein are dissected free from the bronchus by
careful blunt dissection, remembering that the major vessels of the pulmonary tree are
thin walled and easily torn, so they must be handled with considerable care. Two
ligatures are passed around each vessel.
Lung lobe to be
removed
Cut end
of bronchus
after
amputation
of lung lobe
Note that no tissue
Crushing clamp has been crushed
around bronchus
Fig. 7.22. Once the bronchus is free of its attendant blood vessels it is occluded by a crushing clamp placed dose to the
lung parenchyma and as far as possible from the junction with the main bronchus. Two stay sutures of monofilament
nylon are then inserted into the wall of the bronchus as close as possible to the junction with the main bronchus, using a
round-bodied needle.
THORACOTOMY 139
distance of approximately 2.5 cm from the ver- All sutures laid and tied
tebral border to the fissure between the two lobes. in bronchial stump
The main pulmonary vessels follow the distribution
of the bronchial tree and are therefore recognized
by first identifying the bronchus supplying the
diseased or traumatized lung lobe.
Normal chest closure is carried out, but as most
lobectomies are followed by a mild pleural effusion
it is usual to blank off the chest drain and to leave Bronchial stump
it bandaged to the patient's chest, as previously after closure
described. Subsequent aspirations may then be
carried out and in most cases the chest drain can be
removed after 12 hours. It should be remembered
Fig. 7.23. The lobe is amputated by dividing the bronchus between the stay sutures and
that if a breakdown in the bronchial stump is going the crushing clamp with a scalpel, taking particular care to avoid damaging the bronchial
to occur, the fifth post-operative day is the most wall, as the cartilage rings are very prone to undergo necrosis which will result in a
critical and any increasing dyspnoea at this time slough of the bronchial stump and a resultant pneumothorax. The open bronchial stump
may indicate a bronchial leak. In some cases this is aspirated free of blood and mucus and is closed by a series of carefully placed sutures
of monofilament nylon, which are all tied but are left uncut until it is certain that there is
will seal spontaneously providing that continuous
no air leak from the occluded bronchus.
chest aspiration can be applied, but the majority
require a re-suture of the bronchial stump.
The space that is left following lobectomy is
obliterated mainly by an expansion of the adjacent
lung lobe, often accompanied by an elevation of
the diaphragm on the affected side. Providing that
adequate lung re-expansion is achieved, the de-
formity that results will almost be obliterated.
Fig. 7.24. Instruments: (1) rib retractor; (2) rib periosteal stripper; (3) rib raspatory;
(4) rib-cutting shears.
Section 8
Ophthalmic Surgery
In all ophthalmic surgery a precise technique and
exact suturing are _essential. Some special instru-
ments (Figs 8.36-8.43, see pp. 152-4), needles
and suture materials are required and without them
this branch of surgery should not be attempted. All
operations to be described are best performed
under general anaesthesia. Pre-operative prep-
aration varies with each individual operation but
all procedures require shaving the peri-orbital area,
trimming the eyelashes, and applying a 1 per cent
aqueous solution of iodine to the skin. Post
operation the eye is left uncovered but to prevent
self-inflicted injury the ipsilateral front foot is
bandaged.
Fig. 8.1. For ophthalmic surgery the patient is positioned in lateral recumbency with a
sandbag placed under the nose to keep it and the eye horizontal.
Eyelids
ENTROPION
The simplest and most satisfactory method of
treating entropion in the dog is to remove an
elliptical piece of skin parallel to the edge of the
eyelid together with the underlying orbicularis
muscle (Figs 8.2-8.4). The exact amount of skin
to be removed varies with each individual and
should be assessed prior to anaesthesia.
It must be realized that success in this operation
will depend on the degree of out-turning of the
eyelid that is achieved and this depends not only
on the width of the piece of skin removed but also
on the depth of tissue removed and the closeness
of the first incision to the margin of the eyelid.
ECTROPION
This condition is the outward turning of the lower
eyelid and is the opposite to entropion. It is cor- Fig. 8.2. A scalpel is used to make the first incision.
Looseness of the eyelid makes this incision difficult but
rected by shortening the lid either by femoving a
the tissue can be satisfactorily tensed by putting the end
wedge of eyelid at the outer canthus in a manner of a finger underneath the lid.
similar to that described for removing an eyelid
tumour (see Figs 8.6-8.9) or by performing a
V-Y plasty (see Section 12, Fig. 12.2b) with the
arms of the V embracing the extremities of the out-
turning of the lid.
143
I44 SECTION 8 / OPHTHALMIC SURGERY
lr'~~~;.::~r
~~ ..
Fig. 8.3. Scissors will be found more satisfactory than a Fig. 8.5. A typical carcinoma of the eyelid which is infiltrating the
scalpel for removing the piece of skin particularly when it deeper tissues. The most satisfactory method of removing these
is of irregular shape due to an uneven in-turning of the neoplasms is by excising a V-shaped wedge of eyelid.
lid.
Fig. 84 The incision is closed with a series of Fig. 8.6. The wedge of eyelid, in which the neoplasm is included,
interrupted sutures using I metric braided nylon on a is removed with scissors. The two incisions are made through the
small full-curved needle (Lanes's curved No. 1). The whole thickness of normal eyelid and conjunctiva.
edges of the skin are just brought into apposition, the
knot tied tightly and pulled away from the edge of the
eyelid. If these simple measures are not practised then,
due to constant movement of the eyelid, the sutures
become loose and wound breakdown occurs.
protruding portion is removed then the growth

EYELID TUMOUR
rapidly recurs.
Neoplasms, such as papillomas and sebaceous
adenomas occurring on the margin of the eyelid
DISTICHIASIS
are removed by simple excision, and haemorrhage
is controlled by electrocautery. Neoplasms such as The supernumerary eyelashes are treated either
squamous and basal cell carcinomas which infiltrate by simple removal with cilia forceps or electro-
the deeper tissues must be removed by radical epilation.
excision (Figs 8.5-8.9). If only the superficial or
NICTITATING MEMBRANE 145
Fig. 8.7. A good deep wedge of tissue is Fig. 8.8. The wound is closed by simple Fig. 8.9. Care must be taken to ensure that
removed from the point where the incisions interrupted sutures using I metric braided the edges of the incision, especially the
meet well below the margin of the eyelid. nylon. Each suture is placed deep into the palpebral margin, are brought into perfect
This type of wedge resection ensures that eyelid tissues but not through to the apposition.
there will be little distortion following conjunctiva! surface.
repair.
Nictitating membrane
REMOVAL OF THE NICTIT ANS NICTITA TING MEMBRANE USED
GLAND (HARDERIAN GLAND) AS A CONJUNCTIVAL FLAP
Surgical excision of the nictitans gland is indicated The nictitating membrane can be used as a most
in cases of prolapse or chronic inflammation of the satisfactory conjunctiva! flap to protect and support
gland (Figs 8. I0-8. 11). Haemorrhage is controlled the cornea in cases of wounds and ulcers (Fig.
either by injection of o. 1 per cent adrenaline sol- 8.12). There is no tendency for any.adhesions to
ution into the base of the nictitating membrane or form between it and the corneal lesion.
instilling a few drops topically.
Fig. 8.10. The nictitans gland is exposed by seizing the edge of Fig. 8.11. The gland is picked up with forceps and dissected free,
the nictitating membrane with two pairs of Allis forceps and starting at the base of the nictitating membrane, taking care not to
everting it. The conjunctiva over the gland is then incised. injure the cartilaginous plate of the nictitating membrane. After
removal of the gland, the conjunctiva is just smoothed back into
place. No suturing is necessary.
146 SECTION 8/ OPHTHALMIC SURGERY
Fig. 8.12. Each suture is first passed through the fleshy

ridge of tissue on the free edge of the nictitating
membrane and then through a thick piece of bulbar
conjunctiva by picking it up and elevating it from the
globe with dissecting forceps. Three or four interrupted
sutures, using I metric braided nylon, are required to
pull the nictitating membrane across the cornea and
anchor it to the bulbar conjunctiva. Sutures should be
left in for about I week.
Cornea
PAROTID DUCT TRANSPOSITION
Transposition of the parotid duct is indicated in

some instances in dogs suffering from keratocon-
junctivitis sicca. Some dogs may be managed
medically with the use of artificial tears or pilo-
carpine, but others require transposition of the
parotid duct to enable the secretion of the parotid
gland to replace normal tear production.
The parotid gland lies at the base of the ear and
its duct runs rostrally under the superficial fascia
close to the masseter muscle. It opens at a small
papilla on the buccal mucosa opposite the third or
fourth upper cheek tooth.
Prior to surgery, the function of the gland and Fig. 8.13. A piece of 3 metric monofilament nylon is
the patency of its duct should be checked by threaded through the papilla of the parotid duct opposite
placing a drop of atropine on the tongue, drying the third or fourth upper cheek tooth.
the area around the papilla and noting whether it
becomes moist again.
A piece of 3 metric monofilament nylon is
threaded through the papilla at the commencement
of surgery to facilitate identification of the duct
(Fig. 8.13). This lies midway between the dorsal
and ventral branches of the facial nerve and can be
mistaken for either of these structures.
The rest of the procedure is shown in Figs 8. 14-
8.15.
CORNEA 147
Facial vein
Parotid duct
. ;. :,~-~
Facial nerve
1r-tt~f;_~
Site of skin
incision
Fig. 8.14. (a) A skin incision is made over the parotid duct and the dissection continued through the platysma muscle.
(b) The duct is freed from the underlying masseter muscle by blunt dissection to the point where it enters the cheek. The
dissection is completed by incising a disc of buccal mucosa, 6 or 7 mm in diameter, from around the papilla.
Fig. 8.15. A subcutaneous tunnel is made with a pair of

mosquito forceps from the lateral angle of the ventral
conjunctiva! fornix. The forceps are used to grasp the
mucosa! disc and to pull it through to the conjunctiva!
sac. The disc is secured with six to eight interrupted
sutures of I metric synthetic absorbable suture material
placed around its periphery and the defect in the buccal
mucosa is closed with two to three interrupted sutures of
2 metric synthetic absorbable suture material. The sub-
cutaneous tissues are closed with a continuous suture
of 3 metric synthetic absorbable suture material and the
skin co-apted in the usual manner.
DERMOID REMOVAL
See Figs 8.16-8.19.
Fig. 8.16. A corneal or conjunctiva! dermoid is a fleshy, hairy and

often pigmented congenital defect. It is usually located on the cornea
adjacent to the Iimbus towards the outer canthus.
~
148 SECTION 8/ OPHTHALMIC SURGERY
I
I
Fig. 8.18. The dermoid is held with dissecting forceps

and, starting at the corneal edge, dissected off the cornea
back towards the limbus with a Tooke's knife.
Fig. 8.17. Removal of a corneal dermoid requires a good

exposure which is obtained by inserting an eye speculum.
Fig. 8.19. Using fine scissors the dermoid is removed by

severing its connection with the conjunctiva just behind
the limbus.
lntraocular surgery
A major factor in intraocular surgery is the method
LENS EXTRACTION
by which the eye is entered and repaired. Incising
the cornea is a quick and bloodless method-but
Stage I: Opening the eye
healing is slow and leaves a scar. Entry via a
lirnbal-based conjunctiva! flap and scleral incision See Figs 8.20-8.24.
is the method preferred and although it is more
complicated, and haemorrhage has to be con-
trolled, healing is satisfactory and no post-operative
scar persists.
Extraction of the cataractous lens is made easier
when the pupil is dilated and this is obtained by
installing I per cent atropine into the eye for 2 or 3
days before surgery.
INTRAOCULAR SURGERY 149
Fig. 8.20. An eye speculum is inserted and a lateral Fig. 8.23. The puncture is made anterior to the iris which
canthotomy performed using straight scissors. is extremely vascular and great care must be taken to
ensure that it is not damaged.
Fig. 8.21. The bulbar conjunctiva is incised, about 4 mm Fig. 8.24. The incision is extended using corneal spring
behind the limbus, and then using small sharp pointed scissors. Care must be taken that the blade of the scissors
scissors is dissected from the underlying sclera to form a in the anterior chamber is in front of the iris before each
conjunctiva! flap, which is reflected onto the cornea. cut is made otherwise there is a grave danger of damage
to the iris with considerable haemorrhage.
Fig. 8,22. The anterior chamber is entered by puncturing

the sclera with a paracentesis needle inserted just behind
the limbus.
150 SECTION 8 / OPHTHALMIC SURGERY
Fig. 8.25: The lens is removed by applying gentle Fig. 8.26. Immediately the Jens protrudes through the
pressure at the inferior Jimbus using an expressor hook. incision in the sclera it is picked up with fine fixation
The Iuxated lens has a posterior attachment to the forceps and extracted.
vitreous which must be cut with scissors prior to removal
to prevent vitreous loss.
Stage II: Removing the dislocated lens

For removing a cataractous lens extracapsular
extraction is recommended (Figs 8.25-8.26). By
this method the zonule and posterior capsule are
preserved intact thus preventing the loss of any
vitreous. A large circular piece of the anterior
capsule is torn away following its rupture with a
cystitome and the contents of the lens removed as Fig. 8.27. (a) The scleral incision is closed with a series
for a subluxated lens. When the lens substance is of interrupted sutures using Barraquer virgin silk on a
soft it is removed with a vectis. Jameson Evan's 8-mm corneal needle. (b) The
conjunctiva! flap is repositioned covering the sutures in
the sclera and sutured to the bulbar conjunctiva with a
Stage ID: Repairing the scleral incision few interrupted sutures as for the scleral incision. (c) The
canthotomy is repaired with interrupted sutures using
See Fig. 8.27. r metric braided nylon.
Surgery of eye trauma

buckling of the cornea care must be taken to place
WOUNDS OF THE CORNEA
the sutures at right angles to the edges and just far
Lacerations of the cornea with collapse of the enough apart and tied with just sufficient tension
anterior chamber require suturing (Fig. 8.28). to prevent the escape of aqueous humour.
The anterior chamber is cleared of all blood clot Reformation of the anterior chamber is rapidly
and foreign material by irrigation with a solution of established following suturing but some surgeons
sterile normal saline. The edges of the cornea are practice injecting normal saline solution or an air
approximated with interrupted sutures using plain bubble to ascertain that the suture line is leak
collagen I metric material with an 8-mm spatulated proof and to prevent the development of anterior
1/4 circle needle attached. The sutures must not synechia.
penetrate the thickness of the cornea. To ensure Post operation it is necessary to instil atropine
accurate approximation of the edges any protruding solution daily and an antibiotic 4~hourly. The
iris is repositioned or excised if infected. To prevent sutures are removed after about IO days.
J
SURGERY OF EYE TRAUMA 151
(a)
(b)
(c)
Fig. 8.28. Repair of wounds of the cornea. ( a) Sutures must not penetrate the thickness of the cornea. (b) Edges
approximated using interrupted sutures of plain collagen 1 metric with 8-mm spatulated needle attached. (c) Completed
suturing.
Fig. 8.29. The eyelids are sutured together with a

continuous suture of fine braided nylon.
Fig. 8.31. With continual traction on the eyeball and

taking care not to incise the conjunctiva the retrobulbar
tissues are dissected free and the extraocular muscles are
severed as close to the globe as possible. This is
continued until the retractor oculi muscle is exposed.
Fig. 8.30. An elliptical incision is made around the

margins of the eyelids through the skin and eyelid muscle
down to the palpebral conjunctiva.
ENUCLEA TION OF THE EYEBALL

. Enucleation is indicated in cases of gross injury,
panophthalmitis, irreducible prolapse . and neo-
plasia. The operation comprises removing the
eyeball together with the bulbar and palpebral Fig. 8.32. The retractor oculi muscle and the enclosed
artery, vein and nerve are clamped with either curved
conjunctiva and the nictitating membrane
artery or gall bladder forceps. The eye is then removed
(Figs 8.29-8.35). by severing the tissues above the forceps.
Fig. 8.34. To occlude the dead space in the orbit the

Fig. 8.33. Haemorrhage from the artery and vein is retrobulbar tissues and extraocular muscles are drawn
controlled by placing a suture, using 3 metric synthetic together with a few 3 metric synthetic absorbable
absorbable suture material, below the forceps. sutures. This procedure controls haemorrhage and
obviates the necessity for packing the cavity.
In the dog this elliptical incision can be made

remote from the edge of the eyelids but in the
horse the skin is closely adherent to the underlying
bone and unless the incision is made close to the
eyelid margins it will be difficult to co-apt the skin
edges at the end of the operation.
Fig. 8.35. The skin incision is closed with interrupted

sutures of monofilament nylon, and protected by
oversewing a gauze pad.
Ophthalmic instruments
Fig. 8.36. An eye speculum.

OPHTHALMIC INSTRUMENTS 153
Fig. 8.37. A needle holder.
Fig. 8.38. Corneal scissors.
Fig. 8.39. Intracapsular forceps.
Fig. 8.40. An iris repositor.
Fig. 8.41. A lens expressor.

Fig. 8.42. A vectis.
Fig. 8.43. Tooke's knife.

Section 9
Neurosurgery
Nerve suture
Tissues without motor function or sensation are a
serious disability and therefore all severed nerves
must be repaired by primary suture, even when
infection is present (Fig. 9.1).
(a)
Fig. 9.1. (a) Identify the nerve and remove the cut end,
with a sharp scalpel, through normal tissue. (b) Co-apt
the neurolemma with a series of interrupted sutures,
using I metric blood-vessel silk on an atraumatic needle.
(c) Correct alignment of the nerve ends. (d) Incorrect
alignment of the nerve ends due to axial rotation. This
can be reduced by matching the blood vessels in the
neurolemma. (c) Correct (d) Incorrect
Neurectomy - horse
Neurectomy is the excision of a portion of a nerve, With the fetlock joint in extension a skin incision
and is employed in the horse to treat incurable 4 cm long is made along the dorsal edge of the
lameness. Cutting the sensory nerve supply from deep digital flexor tendon, extending from just
a painful pathological lesion alleviates pain and below the level of the distal extremity of the small
enables the horse's working life to be prolonged
for a limited period.
Neurectomies can be performed under local anal-
gesia, but it is recommended that these operations
should be performed with the horse recumbent
Metacarpal vein----- Palmar nerve
and under general anaesthesia. Suspensory ligament Metacarpal artery
Digital nerve
PALMAR NEURECTOMY Dorsal branch of

Tendon of deep
digital nerve
Neurectomy of the medial and lateral palmar ""- digital flexor m.
Pal mar branch of
nerves deprives all structures below the fetlock of digital nerve
sensation. Midway between the knee and fetlock
joint the medial palmar nerve gives off a communi- Digital artery
---- Ligament of ergot
cating branch which passes obliquely down over
the flexor tendons to join the lateral palmar nerve
just above the distal extremity of the fourth meta-
carpal bone. When performing a neurectomy of
the lateral palmar nerve care must be taken to
sever it distal to its junction with this communi-
cating branch from the medial palmar nerve. At
the fetlock the medial and lateral palmar nerves
Fig. 9.2. The anatomical arrangement of the nerves,
are called the medial and lateral digital nerves and blood vessels, tendons and ligaments of the distal leg of
each divides into two branches, the dorsal branch the horse. Site A is used for palmar neurectomy and site
and the palmar branch of the digital nerves. B for digital neurectomy.
157
--~
·-~~
158 SECTION 9 f NEUROSURGERY
metacarpal bone to a point level with the apex of

the sesamoid bone. A common mistake is to make
the incision dorsal to the tendon, i.e. in the de-
pression between the tendon and the suspensory
ligament. The deep fascia is incised the length of
the incision and the edges separated, when the
nerve should be distinctly seen (Fig. 9.3). If not
seen the nerve can be brought into view by applying
digital pressure to the tendon of the deep digital
flexor muscle on the opposite side of the leg.
The skin and fascia are closed together with
interrupted sutures, using monofilament nylon.
The horse is turned over and palmar neurectomy
performed on the opposite side.
DIGITAL NEURECTOMY
Fig. 9.3. (a) The nerve is identified by its longitudinal
Neurectomy of the palmar branch of the medial striation and dissected free from the surrounding
and lateral digital nerve desensitizes the caudal structures. It is then clamped with artery forceps at the
portion of the foot. The nerve lies immediately proximal extremity of the incision, retracted distally and
palmar to the medial/lateral digital artery and the severed transversely with a scalpel. (b) The distal
extremity of the nerve is then twisted up on the artery
depression between the deep digital flexor tendon forceps, retracted proximally and severed in like manner,
and the palmar border of the first phalanx. ensuring that at least 4 cm of nerve are removed.
With the fetlock joint in extension draw a finger
up the depression between the deep digital flexor
tendon and the palmar border of the first phalanx
until the base of the sesamoid bone is palpated.
From this point make an oblique skin incision 4 cm Near the middle of the first phalanx the nerve is
long directed distally to cross this depression. crossed obliquely by the ligament of the ergot,
Incise the fascia the length of the incision, sep- which in appearance is similar to the nerve. It will
arate the edges by dissection and isolate the nerve be seen if the incision is placed too low, but can be
which will be found lying parallel and immediately differentiated from the nerve because it is more
palmar to the digital artery. The nerve is recog- superficially placed, broader, flatter and inelastic,
nized and neurectomy performed in the manner as and when clamped with artery forceps does not
described for high palmar neurectomy. provoke a reflex movement of the limb.
Cervical spine
FENESTRATION OF A CERVICAL
INTERVERTEBRAL DISC - DOG
111111111111/lll:''IIIIIII 1111111111
This operation consists of making a small hole in
i---
-----
Position of the
L
the anulus fibrosus which permits the escape of
---- skin incision
the nucleus pulposus, or enables it to be scooped
out (Figs 9.4-9.9). It does not provide access to
the spinal cord itself, therefore it is not possible to
remove extruded disc material from the vertebral
canal. Accordingly, fenestration is not an appro-
priate procedure for dogs with significant neuro- 1111111111111. .iil l 11111111111111
logical defects, but it may be used where pain is the Fig. 94 The dog is placed in dorsal recumbency with its
only clinical sign associated with a prolapsed inter- head and neck extended. Exposure is improved by
vertebral disc. placing a sandbag under the neck.
CERVICAL SPINE 159
Sternocephalicus m.
Sternohyoideus m.
Fig. 9.5. A longitudinal midline skin incision is made between the larynx and the manubrium. The skin is reflected to
expose the underlying stemocephalicus and stemohyoideus muscles.
Sternohyoideus m.
Fig. 9.6. The stemohyoideus muscle is incised the length of the skin incision and retracted to expose the trachea.
Trachea
Oesophagus
Longus colli m.
Carotid artery Vago-sympathetic

trunk
Fig. 9.7. By blunt dissection the oesophagus, carotid artery and vago-sympathetic trunk are exposed and retracted to
reveal the underlying longus colli muscle.
160 SECTION 9 / NEUROSURGERY
lntervertebral
disc
Ventral process
of cervical
vertebra
Carotid artery
Ventral Ventral longitudinal

longitudinal ligament
Vago-sympathetic ligament
trunk Fig. 9.9. Fenestration is performed by cutting a hole in
the ventral longitudinal ligament and the underlying
anulus fibrosus with a sharp pointed scalpel (blade
Longus colli m.
No. II). The nucleus pulposus either escapes or can be
scooped out.
Fig. 9.8. The longus colli muscle is divided longitudinally, and retracted to expose the
ventral longitudinal ligament of the cervical vertebrae. This enables the ventral
processes of the cervical vertebrae to be palpated and allows the exact position of any
intervertebral disc to be accurately located.
If the nucleus pulposus is completely removed canal, thereby relieving pressure on the spinal cord.
then no further protrusions of the fenestrated disc The surgical approach is similar to that described
can occur, but after operation it is not uncommon for a cervical fenestration. Following division and
for a protrusion to develop in the adjacent discs, retraction of the longus colli muscle, the relevant
and therefore it is customary to fenestrate them at intervertebral disc is identified and fenestrated.
the same time as a preventive measure, although Bone is then removed from either side of the disc,
they may appear to be quite normal. using a high speed mechanical burr, to create a slot
The operation is completed by co-apting the in the midline of the vertebral bodies (Fig. 9.10).
longus colli muscle with a synthetic absorbable The slot is carefully deepened until the spinal cord
suture in a simple continuous pattern. The struc- is exposed. The width of the slot should not exceed
tures of the neck are returned to their normal pos- one-third of the width of the vertebra. Too wide a
ition and the sternohyoideus and sternocephalicus slot results in penetration of the vertebral sinuses
muscles are sutured separately using a similar su- and severe haemorrhage. The length of the slot
ture pattern and material. Subcutaneous dead should be approximately one-third the length of
space is occluded by a subcuticular suture and the each vertebral body, although due to the angle of
skin closed with a continuous suture. the intervertebral disc the length of the slot in the
rostral vertebra should exceed that of the caudal
vertebra (Fig. 9.11).
DECOMPRESSION OF THE
Haemorrhage mayeither arise from the vertebral
CERVICAL SPINAL CORD BY A
sinuses or from the cancellous bone. The former
VENTRAL SLOT - DOG
should be controlled by packing the slot with hae-
This operation involves cutting a slot in the bodies mostatic gelatin sponge; the latter may be con-
of two adjacent cervical vertebrae and their associ- trolled with bone wax.
ated intervertebral disc. This enables any prolapsed The closure of the tissues is similar to that de-
disc material to be retrieved from the vertebral scribed for cervical fenestration.
CERVICAL SPINE 161
-:>'iii"..,..-+- Slot cut in adjacent vertebrae

to expose the spinal cord
lntervertebral disc
Fig. 9.10. To remove disc material from the cervical vertebral canal it is necessary to perform a ventral slot. The slot is
cut with a mechanical burr through the outer cortical bone of the vertebrae and continued through the soft cancellous
bone of their bodies. When the inner cortical bone layer is reached, extreme caution is required. The decompression is
completed by carefully removing the periosteum of the inner cortical bone and the underlying dorsal longitudinal
ligament from the floor of the vertebral canal with a scalpel.
Disc material
causing cord
compression
Fig. 9.11. The dog's head is to the left. Due to the slope of the intervertebral disc spaces more bone is removed from
the rostral vertebra than the caudal one. The extruded materal may be removed with a small curette or dental scraper.
may result in forelimb hypermetria, quadriparesis

STABILIZATION OF THE
or even quadriplegia.
CERVICAL VERTEBRAE - DOG
The condition is treated by arthrodesis of the
Instability of the cervical vertebrae, or spondyloli- affected intervertebral joints. The intervertebral
thesis, is one cause ofthe 'Wobbler syndrome'. disc spaces are fenestrated, the adjacent vertebral
The fifth, six and seventh vertebrae are generally endplates are curetted and the vertebrae stabilized
involved, although the site of compression must be by screwing them together (Fig. 9.12). To encour-
confirmed by myelography. The dynamic com- age early arthrodesis, the disc spaces are packed
pression produced by the abnormal cranial tilting with cancellous bone taken from a suitable site
of any or all of these vertebrae results in hindlimb ( the proximal humerus is readily accessible and
proprioceptive defects. More severe compression usually used).
The vertebrae are stabilized with 3.5-mm cortical Ventral aspect of

or 4.0-mm cancellous screws. The length of screw cervical vertebrae
is determined by measurements taken from a pre-
operative radiograph of the lateral cervical spine.
DISTRACTION-FUSION OF THE
CERVICAL VERTEBRAE - DOG
In the older dog, spondylolisthesis may be com-
plicated by disc disease secondary to vertebral
instability. In some of these cases it is necessary to
decompress the spinal cord by performing a ventral
slot (see Figs 9.10 and 9.II).
In other cases, where myelography indicates Fig. 9.12. Stabilization of the cervical vertebrae with
cord compression can be relieved by traction on screws through their vertebral bodies. The intervening
disc spaces are fenestrated and packed with cancellous
the cervical spine, a distraction-fusion technique
bone to encourage arthrodesis.
is indicated. Following a ventral approach the
affected disc space is fenestrated and anulus re-
moved from the vertebral end plates. The vertebrae
are distracted and held apart with a metal washer
{Fig. 9.13), held in place with a screw placed
through the adjacent vertebral bodies. The remain-
der of the disc space is packed with autogenous
cancellous bone to promote fusion of the joint.
The washer frequently causes collapse of the
adjacent vertebral end plates. If this occurs slowly,
it is often of little clinical consequence. However,
early collapse frequently results in a marked de-
terioration in the dog's neurological status.
Fig. 9.13. Distraction-fusion of the cervical spine.
ATLANTO-AXIAL SUBLUXA TION -
DOG
Atlanto-axial subluxation is occasionally seen in
toy breeds of dogs and is characterized by com-
pression of the cervical spinal cord. Dogs generally
have pain and motor dysfunction ranging from
fore- or hindlimb paresis to quadriplegia.
The luxation can be reduced and the vertebrae
stabilized with a heavy suture of non-absorbable
monofilament material passed under the dorsal
arch of the atlas and through holes drilled through
the dorsal spine of the atlas (Fig. 9.14). Care
should be taken not to flex the neck too much
during surgery since this may provoke respiratory
arrest.
As an alternative to dorsal stabilization, it is poss-
ible to stabilize the vertebrae ventrally by placing
two screws, one either side of the midline, across
the atlanto-axial articulation. This is technically
. more demanding, but if arthrodesis can be achieved,
long-term stability is improved.
THORACOLUMBAR SPINE 163
Polypropylene suture
being drawn under the
neural arch of the atlas
by a fine wire loop
Fig. 9.14. Dorsal stabilization of an atlanto-axial subluxation. After the loop of suture
material has been drawn under the neural arch of the atlas (a), it is cut and the ends
(a) threaded through holes drilled in the axis. The suture is knotted as in (b).
Thoracolumbar spine
HEMILAMINECTOMY OF THE
1111111111111111111111111111111111111111111111111111111111111111 Position of skin
THORACOLUMBAR VERTEBRAE incision
- DOG 111,~~111111.
This operation (Figs 9.15-9.20) consists of remov-

~
~
' I
ing the articular facets of two adjacent vertebrae,

together with a portion of their ipsilateral wall, to
/11~/ll lfJi· I 1111
11111111111111111111111Jllllllllll1IIIIIII /1111111111111111
expose the spinal cord. This decompresses the
spinal cord and enables any extruded disc material Fig. 9.15. The dog is placed in sternal recumbency with a sandbag under its abdomen to
to be removed from the vertebral canal. obtain a degree of kyphosis. To permit sufficient muscle retraction the dorsal midline
skin incision must extend at least two vertebrae cranial and caudal to the intervertebr~l
disc to be exposed.
Subcutaneous fat Lumbodorsal fascia
lnterspinous
ligament
Spinous Cranial articular Longissimus dorsi m.

process process
Fig. 9.16. The subcutaneous fat is incised and dissected free from the underlying
lumbodorsal fascia, which is incised the length of the skin incision. The supraspinous
ligament is incised around and between the apices of the spinous processes and the
longissimus dorsi muscle is separated from them by blunt dissection.
Dorsal spine
Spinous process
Cranial
articular facet
Multifidus m.
Fig. 9.17. The cranial articular facets are exposed by

dissecting them free of and retracting the multifidus
muscle.
Fig. 9.18. Hemilaminectomy is performed by cutting off

the articular facets with bone ronguers.
Fig. 9.19. The base of the articular facets is removed and Fig. 9.20. Completion of the hemilaminectomy. The
the intervertebral foramen is enlarged with ronguers. epidural fat is carefully removed, the underlying spinal
The foramen can be opened a little by lifting the caudal cord is carefully elevated and any extruded disc material
vertebrae with a towel clip attached to its dorsal spine. is removed. The disc may be fenestrated if considered
necessary.
Tibial neurectomy - calves

Spastic paresis is a progressive condition character- third overlies the lateral head of the gastrocnemius
ized by contraction of the gastrocnemius and re- muscle.
lated tendons and muscle bellies leading to severe After incising the skin and underlying gluteal
overextension of the hock. fascia, the groove in the biceps femoris is identified
Tibial neurectomy is .carried out under general and the heads (Fig. 9.21b) are exposed by blunt
anaesthesia. The site of the 15-20-cm incision is dissection and separated with a wound retractor.
on the lateral aspect of the thigh in the groove The peroneal nerve which is approximately 8 mm
between the two heads of the biceps femoris muscle wide can be seen on the lateral surface of the
(Fig. 9.2i:a). This can be seen clearly in the standing lateral head of the gastronernius muscle. The tibial
animal but is much less obvious in the recumbent nerve lies in the adipose tissue associated with the
patient. The incision is made so that its distal one- popliteal lymph node. Careful blunt dissection will
TIBIAL NEURECTOMY - CALVES 165
enable the nerve to be located without damaging

the blood vessels in this area. The nerve, which is
as broad as the peroneal nerve, will be seen passing
between the medial and lateral heads of the gastroc-
nemius muscle. Its identity can be confirmed by
observing a sharp contraction of the muscle when
gentle pressure is applied to the nerve with a pair
of haemostats.
A 3-cm segment of the nerve is removed (Fig.
9.21c). The incisions in the biceps femoris and
gluteal fascia are closed with interrupted and con-
tinuous sutures, respectively, and the skin with
interrupted sutures. Limited exercise is encouraged
(a)
for the first few weeks after surgery.
The operation is usually free from complications
in animals of relatively low weight but rupture
of the gastrocnemius can occur I - 5 days post-
operatively in heavy cattle. In these larger animals
partial neurectomy is advocated in which only the
bundles of the tibial nerve which supply the gastro-
cnemius muscle (identified by electric stimulation)
are cut. Sites of
incision
Peroneal
nerve Tibial
nerve
(b) (c)
Fig. 9.:21. Site of tibial neurectomy (for details see text).

····················-····------ ------
Section 10
Orthopaedic Surgery
Arthrotomy and the internal fixation of fractures
have become safe and established practices due to
the control of infection by antibiotics and a better
understanding of the reaction of tissue to the metals
implanted. However, it must still be remembered
Fig. 10.1. 6.5-mm cancellous bone screw. Diameter of
that operations involving bone and joints require a
thread 6.5 mm; diameter of core 3.2 mm; diameter of
more precise aseptic technique than similar oper- shaft 4.5 mm.
ations upon soft tissues. The use of inert metals
and antibiotics in no way reduces the necessity for
sound surgical techniques but rather provides an
additional safeguard and a means of supplementing
the natural resistance of the patient.
It is the authors' practice in all operations below
the elbow and stifle joints in the horse and in
selected cases in the dog to obtain a bloodless field
Fig. 10.2. Corticalscrew, Diameter of thread 4.5 mm;
by forcing the blood from the limb with a rubber diameter of core 3.2 mm.
bandage and then applying a tourniquet. At the
completion of the operation rather than releasing
the tourniquet and ligating the bleeding vessels, a
pressure pad and bandage are applied before the
tourniquet is removed. The pressure bandage is ASIF screws are available in two types: cortical
left on for 24-48 hours. screws for use in cortical bone and cancellous
In order to minimize such complications as screws for use in the less dense cancellous bone
muscle atrophy, joint stiffness and disuse osteo- (Figs 10.1-10.2). The cancellous screw has a
porosis following fracture repair, it is important to deeper, more open thread which is designed to
achieve early weight bearing on the injured limb. have better purchase in the softer trabecular bone
This requires accurate reduction and rigid internal of the metaphyses and epiphyses. Both types of
fixation of the fractured bones. screw have a rounded end and therefore a thread
To achieve an early return to function of an has to be cut with a bone tap before they are
injured limb following a fracture, the Association inserted. The advantage of pre-cutting the thread
for the Study of Internal Fixation (ASIF) advocates is that the full depth of the threads of the screw
rigid internal fixation using compression and has grip the bone. In contrast, self-tapping screws
designed bone screws and plates for this purpose. impact bone chips as they are driven into the bone
Compression, per se, does not stimulate osteogen- and only the tips of their threads provide purchase
esis, but by eliminating micromovement, callus on the bone. They are, therefore, more likely to
formation is reduced to a minimum and healing pull out.
occurs by creeping substitution. This is called When using cortical screws, the size of the bone
primary bone union. tap corresponds to the outside diameter of the
The ASIF system permits repair of a much wider screw. These are available with diameters of 5.5,
range of fractures than was previously possible, 4.-5, 3.5, 2.7, 2.0, or 1.5 mm. The corresponding
due in part to an improved understanding of the drill bit sizes are 4.0, 3.2, 2.5, 2.0, 1.5 and I.I mm
biomechanics of fracture repair and in part to a respectively.
greater variety of specially designed implants. Cancellous screws may be fully threaded or par-
A number of techniques have been devised to tially threaded. They are available as 3.5, 4.0 and
create compression at a fracture site and the reader 6.5-mm diameter screws. The drill bit size for the
is encouraged to consult G.E. Fackelman and threaded hole corresponds to the core diameter of
D.M. Nunamaker (1982) Manual of Internal the screw and is 2.0 mm for the 3.5-mm screw,
Fixation in the Horse and W.O. Brinker et al. 2.5 mm for the 4.0-mm and 3.2 mm for the 6.5-mm
(1984) Manual of Internal Fixation in Small screw.
Animals for further details (see Bibliography). A partially threaded cancellous screw may be
Some of these techniques can be applied using used as a lag screw provided the non-threaded
'conventional' implants, such as interfragmentary shaft crosses the fracture line. These screws are
compression using a lag screw and the application recommended for fractures of trabecular bone.
of a tension band wire.
170 SECTION IO/ ORTHOPAEDIC SURGERY
INTERFRAGMENTARY
COMPRESSION USING
LAG SCREWS
The principle of the lag screw is that the threads
only bite in the distal fragment so that the fragments
are pulled together. This effect can be achieved by
using a partially threaded cancellous screw or a
fully threaded cortical screw where the proximal
fragment is overdrilled. In each case static inter-
fragmentary compression is produced.
Using a cancellous bone screw
See Fig. 10.3.
Fig. 10.4. Lag screw fixation using a 4.5-mm cortical screw. (a) Drill the near cortex
with a 4.5-mm drill using a 4.5-mm tap sleeve. (b) Insert a drill sleeve, with an external
diameter of 4.5 mm and an internal diameter of 3.2 mm, into the hole until it meets the
opposite cortex. (c) The far cortex is drilled usinga 3.2-mm drill bit. (d) The length of
screw required is measured with a depth gauge. (e) The far cortex is tapped out using a
Fig. 10.3. The lag effect obtained with a partially 4.5-mm cortical tap. (f) A countersink is cut in the near cortex for the head of the screw.
threaded cancellous bone screw. Note that the shaft (g) Drive in a cortical screw.
crosses the fracture line and only the thread takes hold in
the far fragment.
Using a cortical screw

This screw has a full length thread and will act as a
lag screw provided it can obtain a hold in the far
cortex. This requires a larger hole to be drilled in
the near cortex than the far cortex, which has to be
tapped. The large hole is called the 'gliding hole'
and the small hole the 'pilot hole'.
The gliding hole must be the same diameter as the
outside diameter of the screw and the pilot hole is
tapped with a bone tap of equal size (Fig. 10.4).
A single cortical screw inserted at right angles to
the axis of the long bone prevents the fragments
moving under axial compression (Fig. 10.5). To (b)
create maximum interfragmentary compression,
Fig. 10.5. (a) Screw inserted at right angles to the
the screw should be placed at right angles to the fracture line. Under axial compression, movement may
fracture. In practice, the screw is often inserted occur. (b) Screw inserted at right angles to the axis of the
along the line that bisects these two angles. long bone. Under axial compression there is greater
resistance to movement.
INTERFRAGMENTARY
COMPRESSION USING THE
TENSION BAND PRINCIPLE
forces by using the tension band principle. This
Tensile forces acting at a fracture site can be type of compression is termed dynamic com-
counteracted and converted into compressive pression since it relies upon muscular forces to
INTRODUCTION I7I
create the compressive effect. A tension band may

either be a bone plate (Fig. 10.6) or a figure-of-
eight wire. In both cases they must be applied to
the tensile side of the bone.
AXIAL COMPRESSION USING A

BONE PLATE
A plate with round holes can be used as a com-
pression plate by employing a tension device (Fig.
10.7). This round hole plate has now been largely
superceded by the dynamic compression plate which
has oval holes. By inserting the screw at one end of
the oval hole, i.e. eccentrically, the plate is placed (a) (b) (c)
under tension as the conical head of the screw
engages the plate (Fig. 10.8). This obviates the Fig. 10.6. The principle of a tension band plate.
(a) Transverse fracture of a long bone under axial
need for the tension device.
compression. Note the effect of the tension forces on the
convex side. (b) A plate applied to the concave side does
not overcome the tension as the plate is under bending
stresses, this results in metal fatigue and the plate
breaking. (c) A plate applied to the convex side
counteracts all tension forces and provides rigid internal
fixation.
Fig. 10.7. Using the tension device and a 4.5-mm round hole bone plate. (a) A 3.2-mm hole is drilled r cm from the
fracture line. The 4.5-mm thread is tapped, the fracture reduced, a bone plate applied and held in position with a
4.5-mm screw. While retaining the reduction with the bone-holding forceps a hole is drilled r8 mm from the end of the
plate using the special drill sleeve, a 3.2-mm drill bit and the 4.5-mm thread tapped out.
(b) The hook of the tension device is inserted and engaged in the horizontal slot in the end hole of the plate and the
tension device fixed to the bone with a 4.5-mm screw. The nut on the tension device is now tightened until a satisfactory
reduction is attained.
(c) The remaining screws are driven into the first fragment using the drill guide, a 3.2-mm drill bit
and tapping the 4.5-mm thread.
(d) The tension device is now tightened, using an open-ended wrench, until full compression and rigid fixation is
attained. The reduction is checked and the remaining screws inserted. Finally the tension device is removed and the last
4.5-mm screw inserted in the hole of the plate occupied by the screw fixing the tension device.
~-------.!!
(a) (b)
Fig. 10.8. Using a 4.5-mm dynamic compression plate. (a) A 3.2-mm hole is drilled I cm from the fracture line. The
4.5-mm thread is tapped, the plate applied and the first cortical screw driven until its head just touches the plate. The
fracture is reduced and an assistant pulls on the plate with a hook to engage the oval hole firmly against the screw. The
second hole is now drilled eccentrically on the opposite side of the fracture and the thread tapped.
(b) The second screw is now driven and tightened, followed by tightening the first screw. Because the screws are
placed eccentrically, tightening will press the conical head of the screw down against the edge of the oval hole thus
forcing the fragments together and compressing them. The remaining screws are inserted in the centre of each oval hole.
Thoracic limb - horse
Elbow
FRACTURE OF THE OLECRANON
In most fractures of the olecranon the attachment
of the triceps brachii to the summit of the bone
causes separation of the fragments.
These fractures should be treated by open re-
duction and fixation using a tension-band plate
applied to the caudal aspect of the bone
(Fig. 10.9).
Surgery is performed with the horse in lateral
recumbency with the affected leg uppermost. The
fracture is approached by a curved skin incision
over the caudo-lateral aspect of the point of the
elbow and extending to the lower third of the
ulna. The common digital extensor and the ulnaris
lateralis muscles are separated by blunt dissection
to expose the fracture site.
Fig. 10.9. Fracture of the ulna repaired with a 3.5-mm

dynamic compression plate applied- as a tension-band
plate.
Carpus
cussive forces by confining the foal to a large pen.
ANGULAR DEFORMITIES OF THE
If very definite improvement is not apparent within
CARPUS - FOAL 4-6 weeks, surgery is advisable. This may be
Angular limb deformities resulting from unequal directed at retarding maturation and calcification
physeal growth are quite common in foals. The of endochondral ossification on the more active
most frequent location is the carpal joint where side of the physis by temporarily bridging it with
valgus deformity - outward deviation of the distal staples, or screws and a figure-of-eight tension
limb - predominates. Varus deformity, in which band wire. Alternatively, growth may be stimulated
the distal limb is deviated towards the midline, is on the less active side by horizontal transection of
much less common as are fetlock varus and tarsal the periosteum and periosteal stripping.
valgus deformities.
Conservative therapy is successful in correcting
Transphyseal bridging
most of the angular deformities. This should in-
clude trimming the hooves to remove the fulcrum See Figs IO.IO-IO.II.
effect caused by a long toe and reduction of con-
(al
Fig. IO.IO. (a) In cases of valgus deformity affecting the carpus, the distal growth plate of the radius is exposed by a
6-8-cm curvilinear skin incision over the point of maximum convexity on the medial aspect and its exact location
delineated using a hypodermic needle.
(b) Using staples: the size of staple selected varies with individual foals and is determined by reference to the
preoperative radiographs. The staples are held in a special staple inserter, centred on the hypodermic needle and
inserted at right angles to the growth plate. They are driven into the bone using an orthopaedic hammer until the body
of the staple lies flat against the periosteum. Two staples are sufficient, one placed medially and the other cranio-
medially. Their position should be checked by radiography before skin closure. Removal of the staples once the leg is
straight is achieved by incising the skin and overlying fibrous tissue and prising them out using a staple elevator or old
orthopaedic chisel.
173
174 SECTION IO f ORTHOPAEDIC SURGERY
Fig. 10.11. Using screws and cerclage wire: (a) A 3.2-mm hole is drilled to a depth of about 40 mm in the distal radial
epiphysis parallel to the plane of the growth plate and radiocarpal joint. An intra-operative radiograph should be taken
at this point to ensure that the drill does not endanger the physis or radiocarpal joint. The hole is then tapped using an
ASIF 4.5-mm tap. A 4.5-mm cortical screw 32-38 mm in length is inserted and tightened to a point where the head still
protrudes from the collateral ligament. A second screw is inserted in the metaphyseal region in a similar manner to the
first.
(b) A figure-of-eight (1.2 mm) wire loop is placed around the heads of the screws. Additional tension is then brought
about in the wire by alternatively tightening the screws. The subcutaneous tissues are carefully opposed to ensure that
the implants are covered before closing the skin.
This technique has the advantages of applying more immediate compression at the growth plate, producing less
fibrous reaction at the site and allowing easier removal of the implant. However, there does not appear to be any
significant reduction in the time taken for the limb to straighten compared to that when staples are used.
chisel, allowed to fall back into place and is left

Hemicircumferential transection of
unsutured (Fig. ro.rzb). The operation is com-
the periosteum
pleted by closing the subcutaneous connective
Stimulating growth on the concave side of the tissue with a continuous suture of 3 metric syn-
growth plate by hemicircumferential transection thetic absorbable suture material and the skin
and elevation of the periosteum offers a much with a subcuticular suture of the same material
simpler but equally effective method of correcting (Fig. IO. 12c).
angular deformities. In foals with very severe angulations, simul-
The growth plate is identified with a needle. A taneous transphyseal bridging on the convex side,
curvilinear incision 6 cm long is made commencing and periosteal elevation on the concave side, will
just below the physis and extending proximally. bring about a more rapid correction of the deform-
The subcutaneous connective tissue is incised and ity. This is of particular importance in varus de-
reflected exposing the periosteum which is incised formity of the fetlock joint which carries a much
parallel to, and approximately 1-2 cm proximal to less favourable prognosis than angular deformities
the growth plate extending to the cranial and caudal of the carpus because of early closure of the distal
borders of the radius. A vertical incision 4-5 cm metacarpal or metatarsal growth plate. Clinical
long is made creating an inverted T (Fig. ro.rza). experience has shown that to be successful, correc-
The triangular portion of periosteum on either tive surgery must be carried out in these cases
side is elevated from the underlying bone with a before the foal is 2 months of age.
THORACIC LIMB - HORSE/ CARPUS 175
FRACTURE OF THE
CARPAL BONES
1----+---+-- Inverted T-shaped
incision on lateral The bones most frequently fractured are the radial,
aspect, 2.5 cm above intermediate and third carpal bones. Slab frac-
growth plate
tures must be-immobilized by a lag screw, where-
as in smaller chip fractures the bone fragment(s)
must be removed. This can be effected through
an arthotomy incision or via arthroscopy. In
either case the subchondral bone defect should be
curetted to make a smooth surface. In chronic
cases excrescences of cartilage and bone may de-
velop along the joint edges and these also must be
removed with rongeurs.
Carpal arthrotomy
The horse is restrained in lateral recumbency with
Periosteum the affected leg ventral .so that the carpus can be
exposed from the medial aspect.
Figures IO. 13-10. 15 show the procedure for
removing a chip fracture from the proximal border
of the third carpal bone.
Slab fractures of the carpus are most commonly
associated with the third carpal bone. Thin slabs of
23 gauge -------'~
hypodermic bone which only involve the dorsal edge of the
needle joint surface are best removed as the area of
identifying
growth plate weight bearing surface that is lost is minimal and of
little consequence.
(b)
Carpal fascia
lntercarpal
joint space
(cl
Fig. 10.12. Hemicircumferential transection of the

periosteum (for details see text).
Fig. 10.13. Removal of a chip fracture from the proximal border of the third carpal
bone. On the dorso-medial aspect of the carpus the skin is incised to form a flap between
the tendons of extensor carpii radialis and the common digital extensor muscles. The
underlying fascia and joint capsule are incised longitudinally between these tendons to
expose the radial and third carpal bones. A medial view of the right carpus is shown.
Radial carpal
bone
Carpal
fascia
Fig. 10.15. The carpus is extended and the incision closed by co-apting the fascia and
joint capsule together with a series of interrupted synthetic absorbable sutures. It is an
advantage to lay the sutures individually before tying them. The skin flap is replaced and
retained in position with mattress sutures using monofilament nylon.
Fragment Third carpal
of bone bone
Fig. 10.14. The carpus is flexed which opens the

intercarpal articulation. The fascia and joint capsule are attain this the following points require attention:
retracted. This permits the edges of the intercarpal I The operation must not be delayed more than
articulations to be examined and enables the fragment to 5-7 days because new tissue growth will prevent
be dissected free. Any excrescences are removed with
accurate reduction and result in an articular defect.
rongeurs and the area is curetted to create a smooth
surface. 2 The slab of bone moves proximally and it cannot
be accurately replaced unless the carpus is flexed.
3 The slab of bone must be immobilized with a lag
On the other hand thick slabs of bone must be screw to obtain compression of the fracture. The
accurately replaced, repositioned and immobilized screw should be inserted in the centre of the slab
with a lag screw if the normal weight bearing area and at right angles to the fracture plane. Counter-
of the joint is to be maintained (Figs IO. 16- 10. 17). sinking the screw head reduces the chances of
It is essential that the slab of bone is accurately splitting the slab during tightening but care must
positioned and the joint surface is congruent. To be taken not to overtighten the screw.
Radial carpal bone
Joint space
Reflected skin
flap
Reflected flap
of fascia and
joint capsule
Dorsal aspect of slab of bone

which is detached from the third
carpal bone and has risen
proximally
Fig. 10.16. Repair of a slab fracture of the third carpal bone. A skin flap is formed as in Fig. 10. 13 and the underlying
fascia and joint capsule are incised to expose the fracture.
THORACIC LIMB - HORSE/ METACARPUS 177
The incision is closed by replacing the reflected

fascia and co-apting it and the joint capsule with a
series of interrupted synthetic absorbable sutures
which are laid individually before tying them. The Exposed articular
skin flap is replaced and sutured with mattress surface of
radial carpal
sutures using monofilament nylon. bone
Carpal arthroscopy
Two portals of entry are required for the arthro-
scopic removal of chip fractures from the radio-
carpal or the intercarpal joint. In either case the
instrument portal is placed nearest the fragment Fracture line showing
and the arthroscope portal is situated on the op- accurate reduction
of fragments
posite side of the joint. The lateral portal is situated
between the tendons of the extensor carpii radialis
and the common digital extensor muscles, while
the medial portal is medial to the extensor carpii
radialis tendon. Care should be taken not to dam-
age the tendon sheaths when making the stab
incisions through the skin. Fig. 10.17. With the carpus flexed the gap between the slab of bone and the third carpal
The fragment is identified with a probe, 'before bone is cleared of all blood clot and detritus. By flexing the carpus the fragment moves
grasping it with a pair of forceps and freeing it with distally and can be accurately repositioned. The fragment is then immobilized and firmly
compressed in position with a 3.5-mm cortical lag screw.
a twisting action. Intracapsular fragments and non-
articular osteophytes are normally left in situ. The
skin incisions are closed with simple interrupted
sutures of monofilament nylon.
Metacarpus
FRACTURE OF A SPLINT BONE Suspensory ligament
Although a splint bone may be fractured at any
point throughout its length the most common site
is the distal extremity of the medial splint bone of a
thoracic limb. If there is marked displacement with
non-union or healing is accompanied by excessive
new bone formation which impinges on the sus-
pensory ligament or flexor tendons then the splint
bone should be removed. Since the splint bone is
an integral and weight bearing bone of the carpus
it should not be totally removed but as much as
possible of its proximal extremity preserved.
Small metacarpal Large metacarpal
or splint bone bone
Removal of a medial splint bone
Fig. 10.18. The skin is incised tile length of, and parallel with, the caudal border of the
The horse is restrained in lateral recumbency with splint bone. It is then reflected to reveal the caudal and medial aspect of the large
the affected leg ventral (Figs 10.18-10.22). metacarpal bone, the splint bone and the suspensory ligament.
Fig. 10.19. The fascia along the caudal aspect of the splint bone is incised and the Fig. 10.20. With a hack-saw blade the splint bone,
suspensory ligament dissected free and retracted to expose the whole length of the splint proximal to the fracture, is sawn through at an oblique
bone. angle. This results in the development of new bone
between the cut surface and the metacarpal bone instead
of the formation of an exostosis.
Osteotome
Fig. 10.21. The splint bone is separated from the metacarpal bone by breaking down the
interosseous attachments with an osteotome and gently lifting it free. The splint bone
should not be severed or freed with a chisel and hammer. The blows can result in a
fissure fracture of the metacarpal bone which becomes a complete or even open fracture
as the horse takes weight on the leg when getting up.
Suspensory
ligament
·""-..._____ Proximal extr.emity

of splint bone
Fascia
Fig. 10.22. The incision is closed by co-apting the fascia to the edge of the suspensory
ligament with a series of interrupted sutures using synthetic absorbable suture material
and the skin with interrupted sutures Mmonofilament nylon.
recumbency with the affected leg ventral (Figs

Removal of a 'splint'
10.23-10.26).
When a medial splint is very large and continually An exostosis involving either of the two small
being struck by the opposite foot, the only remedy metacarpal or splint bones (metacarpal bones II
is its removal. The horse is restrained in lateral and IV) is colloquially referred to as a 'splint'.
THORACIC LIMB - HORSE/ METACARPUS 179
Thin layer of
connective tissue
overlying
periosteum
Fig. 10.23. The skin is incised longitudinally over the

splint and reflected to expose a thin layer of connective
tissue and periosteum ..
Splint
)
Fig. 10.24. The connective tissue and periosteum are
incised longitudinally the length of the splint and
reflected from the bone using a periosteal elevator. ~
Reflected
periosteum
Fig. 10.25. Using a bone chisel and mallet the splint is

excised and fashioned level with the small and large
metacarpal bones.
Fig. 10.26. The periosteum and connective tissue are

co-apted using a continuous suture of 3 metric synthetic
absorbable material and the skin with interrupted sutures
of monofilament nylon.
Fetlock joint
FRACTURE OF A PROXIMAL Tendon of deep digital flexor m.
SESAMOID BONE
Fracture of a proximal sesamoid bone is most
frequently seen in racehorses. Following conserva-
tive methods of treatment many horses become
sound but this improvement is short lived as the
horse invariably goes lame during training or when
Suspensory
raced. The most common fracture is of the apex of ligament
the bone and this is treated by the removal of the
bone fragment. In such cases, up to a third of the
proximal end of the bone can be removed with
good results (Figs 10.27-10.32).
Transverse fractures of the middle and lower
third of a proximal sesamoid bone may be treated
by an open reduction and immobilization with a
lag screw, or the fracture plane may be packed
with cancellous bone (Figs 10.33-10.34). Fig. 10.27. A skin incision is made some 7.5 cm long
The incision is closed by co-apting the collateral from just below the button of the splint bone parallel
ligament with mattress sutures using fine synthetic with the palmar border of the metacarpal bone to the
base of the fractured sesamoid bone. The skin is reflected
absorbable suture material and the subcutaneous
to expose the palmar border of the metacarpal bone,
tissues and skin in the customary manner. suspensory ligament and edge of the tendon of the deep
digital flexor. The figure shows the lateral aspect of the
left fetlock joint.
Suspensory
ligament
)fffj
,;/fWJ@_
/]f!\f,M Flexor surface
':f' .,&"1"~ of proximal
sesamoid bone
Apex of proximal
sesamoid bone
Line of
fracture
Fig. 10.29. The apex of the sesamoid bone is dissected

free from its attachment to the intersesamoidean
ligament.
Metacarpal bone Metacarpo-

phalangeal
articulation
Fig. 10.28. The fascia between the metacarpal bone and suspensory ligament is incised
and the incision extended distally to meet the collateral ligament of the fetlock joint.
This exposes the joint capsule which is incised in like manner. The fetlock joint is now
flexed and the suspensory ligament retracted to bring into view the apex and flexor
surface of the sesamoid bone.
180
THORACIC LIMB - HORSE/ FETLOCK JOINT 181
Bone
chisel
Fig. 10.30. The apex is separated along the fracture line

with a bone chisel or osteotome.
Fig. 10.33. With the horse recumbent and lying so that

the fractured sesamoid bone is uppermost, the fracture is
exposed by a longitudinal skin incision just dorsal to the
plantar artery. The skin edges are reflected to expose the
plantar artery, vein and nerve which are retracted in a
plantar direction. The base of the sesamoid bone is then
Gouge exposed by dividing the collateral ligament transversely
and freeing the attachments of the deep sesamoidean
ligaments by blunt dissection. This enables the bone to
be firmly held in bone-holding forceps and a hole drilled
from the posterior border of its base, directed slightly
obliquely towards the apex.
Fig. 10.31. The apex is finally separated from all its
attachments with a gouge and removed.
Fig. 10.32. The wound is closed by co-apting the joint

capsule and fascia with interrupted sutures using
synthetic absorbable suture material and the skin with
Fig. 10.34. A lag screw is then driven which pulls the two
halves of the bone tightly together.
Phalanges
complete or incomplete, sagittal or spiral and
FRACTURE OF THE
may involve both articular surfaces of the bone
FIRST PHALANX
(Figs 10.35-10.36).
Fractures of the first phalanx commonly occur in Chip fractures of the dorsal edge of the proximal
the front leg and range from simple fractures with surface of the first phalanx result in intermittent
little displacement or chip fractures of the dorsal lameness and are treated by the removal of the
edge of the proximal articular surface to grossly detached piece of bone. This is best performed
comminuted fractures. Simple fractures may be arthroscopically but may be successfully achieved
via a dorsal arthrotomy (Figs 10.37-10-40).
Fractures of the second phalanx are rare. Frac-
tures of the third phalanx are not uncommon and
non-articular fractures have a good prognosis when
treated conservatively by rest and fitting a bar shoe
with heel clips to prevent expansion of the foot
when weight is taken. Intra-articular fractures in
horses under 3 years of age can be satisfactorily
---Extensor branch of treated on the same lines but in older horses the
the suspensory
fracture requires to be immobilized with an ASIF
ligament
cortical lag screw. Careful preparation is necessary
to reduce contamination during surgery and it is
advisable to soak the foot in strong iodine solution
for 48 hours before wrapping it in a sterile adhesive
plastic drape.
An area of horn is removed with a 13.5-mm drill
Fig. 10.35. Immobilization of a split pastern. Non- bit and the fracture immobilized with a 4.5-mm
displaced fractures can be immobilized with two, three or cortical lag screw. The screw should not impinge
possibly four, lag screws inserted through stab incisions,
using the extensor branch of the suspensory ligament as a
landmark. The screws are placed at right angles to the
fracture line and parallel with the articular surfaces. The
proximal fragment is overdrilled when using cortical Tendon of
screws to achieve compression at the fracture site. common
digital
extensorrn.
Joint
capsule
Fig. 10.37. A longitudinal skin incision is made over the

Fig. 10.36. Immobilization of a spiral fracture of the first dorsal aspect of the fetlock joint parallel with, and
phalanx. The lag screws must be placed at right angles to medial to, the tendon of the common digital extensor. By
the fracture plane to ensure adequate compression. This careful dissection the tendon is separated from the
requires careful planning and a thorough pre-operative underlying joint capsule and retracted. The figure shows
radiographic examination. the dorsal aspect of the left fetlock joint.
THORACIC LIMB - HORSE/ PHALANGES 183
on the sensitive laminae on the opposite side of the

hoof and should be removed as soon as healing is
complete. Distal end of
Complete transverse fractures which do not metacarpal bone
extend beyond I cm from the tip of the extensor
process respond well to the removal of the detached
piece of bone (Figs 10-41-10.42). Proximal end of
The incision is closed by co-apting the tendon first phalanx
and joint capsule together with interrupted sutures
using synthetic absorbable suture material and the
skin in the customary manner.
Joint capsule
Fig. 10.38. The joint capsule is incised and its

attachments to the dorsal and proximal surface of the
first phalanx dissected free.
Chip fracture
?~111'.Q~Ml'J~r-- Surface from

which chip of bone
Gouge has been removed
Fig. 10.40. The joint capsule is closed with interrupted

Fig. 10.39. Slight flexion of the fetlock joint provides sutures using synthetic absorbable suture material. The
adequate exposure for the examination of the joint and extensor tendon is repositioned and the skin incision
removal of the fragment of bone using either a gouge or closed with interrupted sutures using monofilament
bone-nibbling forceps. nylon.
Distal articular surface, Fracture of

Tendon of common second phalanx extensor process,
digital extensor m. third phalanx
Fig. 10.41. A longitudinal and midline incision is made from the pastern joint and Fig. 10.42. The edges of the incised tendon are forcibly
extended distally through the coronary corium to the wall of the hoof. The skin edges are retracted and its attachments to the extensor process
retracted to expose the expanded portion of the tendon of the common digital extensor dissected free. This enables the fragment of bone to be
which is incised together with the joint capsule. detached with a gouge and removed.
The foot
OPERATION FOR SANDCRACK
A sandcrack is a fissure in the wall of the hoof and
treatment is directed to removing the pressure at
the free extremity and to immobilizing the edges of
the crack (Fig. 10.43).
The grooves must be cut to the depth of the
white zone if they are to relieve pressure on and
immobilize the edges of the sandcrack effectively,
and it is a matter of choice whether a hoof saw, hot
iron or drawing knife is used to fashion them. The
bearing surface of the wall immediately under a
complete crack must be pared away to prevent any
pressure at this point from the shoe.
(al (iii)
(bl
(al (iv) (cl

THORACIC LIMB - HORSE f THE FOOT 185
can heal by granulation. The time-honoured

GROOVING THE WALL
method of attaining these ideals necessitated re-
A number of techniques are employed to obtain moval of a section of the horn and reflecting a flap
expansion at the heels and to relieve pressure of the coronary corium and skin. This established
within the foot. The method of grooving the wall free drainage but the development of a false
shown in Fig. I0.44 is both simple and effective. quarter. The great advance in controlling infection
has led to less drastic methods to effect a cure.
The operation (Fig. I0.45) should be performed
OPERATION FOR QUITTOR
under general anaesthesia and with a tourniquet to
Necrosis of a lateral cartilage is termed 'a quittor' control haemorrhage. Post operation the wound is
and is characterized by one or more sinuses dis- packed with vaseline gauze and dressed every 2-3
charging at the coronet. days. Healing is by granulation which may become
Treatment is directed towards removal of all exuberant and have to be controlled by cauteriz-
necrotic and diseased tissue, the provision of drain- ation to enable the skin edges to unite.
age and the control of infection so that the wound
Elliptical skin incision
Lateral cartilage
Coronet
Fig. 10.44. With the foot resting on a tripod three or four

parallel grooves arc cut at 2-cm intervals from the
coronet to the bearing surface. These grooves arc placed
on both the medial and lateral aspects of the heels,
extend down to the white line and each is 0.5 cm wide. Fig. 10.45. An elliptical piece of skin above the coronet,
They arc easily fashioned using a drawing knife and if the which includes the discharging sinus or sinuses. is
wall is very hard it can be softened by cold water removed to expose the cartilage. The edges of the wound
footbaths for I hour twice daily for 2-3 days. arc retracted, all necrotic cartilage dissected free and a
thorough dcbridcmcnt of the surrounding tissues carried
out.
Fig. 10.43. (Opposite). (a) Immobilizing the edges of a deep sandcrack using a standard horseshoe nail: (i) After paring
the edges of the sandcrack a special tool, heated to a dull red heat, is used to fashion a bed for the nail on either side of
the sandcrack. If only one nail is required then the beds arc sited just above the centre of the sandcrack with the inner
edge of the bed about 6 mm from the edge of the sandcrack. If two nails arc used then the proximal one is inserted
12 mm below the coronet and the other 18 mm below it. (ii) A horseshoe nail, slightly bent on flat, is driven across the
sandcrack and driven home using the point of a buffer as a punch. (iii) The point of the nail is turned over and cut off
with pincers. (iv) The turned over end of the nail is tapped into position while the head of the nail is kept in position
with the end of a handle of the pincers. (v) Procedure completed, the edges of a deep sandcrack arc immobilized with a
horseshoe nail.
Due to the comparative thinness and flat surface of the horn at the quarters, deep sandcracks cannot be satisfactorily
immobilized using either clips or horseshoe nails. These methods arc only suitable for toe sandcracks.
(b) Superficial and incomplete: Two grooves arc cut from the coronet in the form of a V to meet at the lower limit of
the crack.
(c) Superficial and complete: Two parallel grooves arc cut, one on each side of the crack, from the coronet to the
bearing surface.
Thoracic limb - dog
DRAPING A LEG FOR SURGERY
Fig. 10.46. After the leg has been

clipped it is held by a tape, disinfected
and a sterile towel is placed beneath it.
Fig. 10.47. A second towel is placed on

top of the first towel with its upper edge
resting just distal to the proposed
incision and the leg lowered onto the
towel.
Fig. 10.48. The extremity of the leg is

wrapped in the second towel which is
retained in position with towel clips.
This permits the leg to be manipulated
during surgery without any risk of
contamination.
186
THORACIC LIMB - DOG 187
Fig. 10.49. A laparotomy sheet, with a

rectangular hole in the centre, is placed
over the leg and unfolded.
Fig. 10.50. The hole is positioned with

its upper edge resting just proximal to
the operation site and retained with a
towel clip at each extremity.
Fig. 10.51. The lower edge of the hole

is folded over to complete the isolation
of the operation site and retained with
two towel clips.
Shoulder joint
CA UDO-LATERAL APPROACH
The caudo-lateral approach (Figs 10.52- 10.55) to

the shoulder is frequently used to remove osteo-
chondritis dissecans lesions from the caudal aspect
of the humeral head. The joint is irrigated with
saline and the joint capsule co-apted with horizon-
tal mattress sutures of 3 metric absorbable suture
material. The muscles are repositioned and sutured
to their tendon insertions using horizontal mattress
sutures of similar material. The subcutaneous tissue
and skin are closed in the usual manner.
Fig. 10.52. To perform an arthrotorny of the left

shoulder joint, the dog is placed in lateral recumbency
with the affected leg uppermost. A slightly curved skin
incision is made which extends from a point just proximal
and caudal to the acromion process of the scapula down
to the upper third of the humerus.
lnfraspinatus m.
Severed attachment ----

of deltoid m. to Teres minor m.
acromion process
of scapula
Spino us head of
deltoid m.
Reflected acromial
head of
deltoid m.
Fig. 10.53. The acromial head of the deltoid muscle is separated by blunt dissection, severed about I cm from its
attachment to the acromion process and reflected ventrally. This exposes the tendons of the infraspinatus and teres
minor muscles crossing the lateral aspect of the shoulder joint. Alternatively, the spinous and acromial heads of the
deltoid muscle may be retracted with Gelpi retractors without severing the acromial head.
188
THORACIC LIMB - DOG f SHOULDER JOINT 189
lnfraspinatus m. Teres minor m.
Osteochondritic (a)
lesion
Head of humerus
Fig. 10.54. The tendons of insertion of the infraspinatus and teres minor muscles are
severed about I cm from their attachments to the greater tuberosity and reflected to
expose the joint capsule. The more experienced surgeon will reflect these muscles by
placing a pair of Gelpi retractors between them, rather than transecting them. The
thickened joint capsule is incised transversely midway between its points of attachment
(b)
to ensure that adequate tissue is left on either side for repair. At the caudal extremity of
the incision, care must be taken not to damage the branches of the circumflex artery and Fig. 10.55. The caudal articular surface of the humeral
vein or axillary nerve. head can now be inspected but to obtain satisfactory
exposure of the lesion it is generally necessary to extend
the joint and rotate the head of the humerus laterally.
The loosely attached flap of cartilage is lifted off with
dressing forceps (a), any attached areas being broken
down with an osteotome. The exposed subchondral bone
is then curetted and any cartilage not firmly attached at
the periphery of the lesion is removed likewise (b).
DIS LOCATION OF THE Omotrans-

lnfraspinatus m.
versarius m.
SHOULDER JOINT
Dislocation of the shoulder joint is most frequently
lateral and alil.ho11gh easily reduced by a closed
reduction it remains unstable. If redislocation
occurs then an open reduction and stabilization of
the joint is necessary (Figs 10.56-10.61). Greater
tuberosity Deltoideus m.
of humerus
Brachle-
cephalicus m.
Fig. 10.56. The shoulder joint is approached from the lateral aspect by a curved skin
incision which extends from the upper third of the spine of the scapula down over the
greater tuberosity of the humerus and terminates towards the middle of the humerus.
The skin edges are reflected and the brachiocephalicus and deltoideus muscles separated
to expose the lateral aspect of the proximal extremity of the humerus.
Spine of
scapula
Supraspinatus m.
lnfraspinatus m.
Acromion
Deltoideus m.
Deltoideus m.
Fig. 10.58. The ventral surface of the deltoideus muscle

is freed carefully by blunt dissection to conserve its
attachment to both the acromion and humerus.
Fig. 10.57. The attachments of the omotransversarius, supraspinatus and infraspinatus
muscles to the spine of the scapula are separated and the muscles retracted to expose the
acromion.
Lateral ridge of
Fig. 10.59. A tunnel is drilled, using a 3-mm twist drill, greater tuberosity
transversely through the spine and close to the blade of
the scapula approximately r.5-2.0 cm from the
acromion.
Fig. 10.6o. A tunnel is drilled obliquely through the

proximal extremity of the humerus from a point about
r.5 cm below the crest of the greater tuberosity to
emerge through the lateral ridge.
Fig. 10.61. (Left). A length of o.6-cm nylon tape is

passed up the humeral tunnel, under the attachment of
the deltoideus muscle, through the hole in the scapular
spine and brought down under itself. Finally the ends of
the tape are pulled sufficiently tight to stabilize the joint
and tied. The muscles are repositioned and the
subcutaneous fascia closed with a continuous suture of
synthetic absorbable suture material. The skin is
co-apted with interrupted sutures of monofilament
nylon.
Humerus
FRACTURE OF THE
HUMERAL SHAFT
Brachiocephalicus m. Deltoideus m.
Overriding fractures of the shaft of the humerus are
virtually impossible to reduce by closed methods
or to immobilize by external fixation. Following an
open reduction the fracture may either be repaired
Lateral head
with an intramedullary pin or a bone plate and of triceps m.
screws.
Repair with an intermedullary pin

The intramedullary pin selected is of a diameter Cephalic
equal to the medullary cavity at its narrowest point vein
and of a length which extends from the cranio-
lateral extremity of the greater tuberosity to just
above the supratrochlear foramen. When the frac- Fig. 10.62. The skin is incised on the cranio-lateral aspect of the limb along a line joining
ture involves the distal third of the shaft, a smaller the greater tuberosity and epicondyle. The skin is reflected to expose the brachio-
diameter pin should be selected and driven into the cephalicus, deltoideus and lateral head of the triceps muscle and the cephalic vein.
medial condyle of the distal humerus. The figure shows the left thoracic limb.
Figures 10.62-10.65 show the procedure for
repairing a fracture with an intermedullary pin.
The pin is finally aligned and pushed into the
cancellous bone of the distal fragment (Fig. 10.65).
Brachialis m. Lateral
. head of
: triceps m.
Steinmann -----".<',~
pin
Jacob's ------.~
chuck
Fig. 10.63. The lateral head of the triceps and the brachialis muscle are separated along
their line of cleavage and retracted to expose the lateral aspect of the shaft of the
humerus. In fractures of the distal extremity, care must be taken to identify the radial Fig. 10.64. The proximal fragment is firmly held by
nerve. bone-holding forceps and the intramedullary pin, fitted
in a Jacob's chuck, is passed up the medullary cavity and
rotated through the cancellous bone until the point
emerges on the cranio-lateral surface of the greater
tuberosity and lies subcutaneously. The overlying skin is
incised and the pin extruded a further 5.0-7.5 cm.
,
i
The fracture site is held securely in bone-holding

forceps to prevent its disruption while the pin is
broken off. The point at which the pin is to be
broken off is determined from pre-operation radio-
graphs and the site is prepared by sawing com-
pletely around and through about two-thirds its
thickness.
The muscles and skin are co-apted in the usual
manner.
Repair with a bone plate and screws Screw end of

Steinmann pin
The shortness and curvature of the humeral shaft
makes contouring a bone plate to its lateral aspect
difficult and time consuming. Thus the fracture is
best treated by performing an open reduction and
Bone-holding
fixation with a bone plate and screws on the medi- forceps
al aspect of the limb (Figs rn.66- 10.67).
The muscles and skin are co-apted in the usual
manner. Fig. 10.65. The chuck is removed and attached to the protruding proximal end of the
intramedullary pin. The pin is then carefully drawn up the proximal fragment using a
rotary movement, until the point is protruding just beyond the fracture line. With the
distal fragment held iii bone-holding forceps and the intramedullary pin used to
manipulate the proximal fragment, the fracture is reduced and the protruding point of
the intramedullary pin manoeuvred into the medullary cavity of the distal fragment.
Final alignment is made and the pin pushed into the cancellous bone of the distal
fragment until the point comes to rest just above the supratrochlear foramen. The use of
a screw-ended pin was previously thought to improve pin stability, but this is doubtful
and the pin may fracture if it is subjected to bending forces at its threaded/non-threaded
junction.
Fig. 10.66. The dog is placed in lateral recumbency with the affected left leg lowermost.
To obtain adequate exposure of the distal and medial aspects of the shaft of the humerus
the dog's thorax requires to be slightly rotated upwards and the limb pulled at right Fig. 10.67. Cranio-caudal view of a distal fracture of the
angles to the vertebral column and retained under traction. A longitudinal skin incision shaft of the humerus. Note the position of the distal
is made from the distal third of the humerus to the elbow joint. The biceps brachii and screws. Care must be taken when selecting the site for
medial head of the triceps muscle are divided along their line of cleavage, between the driving them that they do not enter the supratrochlear
branches of the cephalic vein, to expose the fracture. The fracture is reduced by foramen, thereby obstructing the anconeal process of
manipulation and immobilized with a bone plate with at least two screws on either side the olecranon and preventing normal extension of the
of the fracture line. , elbow joint.
Elbow joint
UNUNITED ANCONEAL PROCESS
Failure of the anconeal process to unite with the
olecranon results in intermittent lameness which
becomes permanent as an osteoarthritis develops.
This condition is treated by removing the detached Anconeal
or displaced piece of bone (Figs 10.68-10.72). process
Humerus
Oiecranon
Radius Lateral epicondyle

of humerus showing
Ulna osteoarthritic changes
Fig. 10.70. The fascia, anconeus muscle and joint

capsule are incised, and, with the joint flexed, are
retracted to expose the lateral epicondyle of the humerus
and the ununited anconeal process.
Fig. 10.68. The dog is positioned in lateral recumbency

with the affected leg uppermost and supported on a
sandbag. The joint is exposed via a curved skin incision
extending from the distal and posterior extremity of the
humerus to the upper third of the ulna.
Anconeal
process
· Subcutaneous fascia
and underlying
anconeus m.
Fig. 10.71. The anconeal process is removed by

separating it along its line of fusion using a gouge or
osteotome and severing any caudal attachments to the
joint capsule with scissors.
Fig. 10.69. The edges of the skin are reflected. The

lateral epicondyle of the humerus and the anconeus
muscle lie under the subcutaneous fascia.
193
Pronator teres m.
overlying medial
Flexor carpi---';,-1;','1 collateral ligament
radialis m.
*-"* Subcutaneous Medial humeral
fascia condyle
~~--Site of osteochondritis
Articular ---~ dissecans lesion
surface of the
proximal ulna Head of radius
Anconeus m. Site of ununited

coronoid process
Fig. 10.72. The incision is closed by co-apting the edges

of the anconeus muscle with interrupted sutures of Fig. 10.73. Exposure of the medial aspect of a left elbow. A skin incision is made from
absorbable synthetic material. The subcutaneous fascia is the lower third of the humerus, extending over the medial epicondyle of the humerus to
closed with a continuous suture of similar material and terminate at the upper third of the radius. The incision is continued through the fascia
the skin closed in the usual manner. overlying the superficial digital flexor, flex or carpi radialis and pron a tor teres muscles.
The latter two muscles are separated by blunt dissection and retracted with Gelpi
retractors. The joint capsule is incised and the Gelpi retractors repositioned. The joint is
then flexed and the coronoid process or articular flap on the medial humeral condyle
removed with a gouge.
The incision is closed by co-apting the joint capsule with simple interrupted sutures of
synthetic absorbable suture material. The overlying fascia and subcutaneous tissues are
closed with continuous sutures of similar material and the skin in the customary manner.
Post operation it is advisable to support the elbow joint in a bandage for 7-10 days.
UNUNITED CORONOID PROCESS
AND OSTEOCHONDRITIS
DISSECANS OF THE FRACTURE OF THE
MEDIAL HUMERAL CONDYLE LATERAL HUMERAL CONDYLE
An ununited or fragmented coronoid process and The lateral condyle has a comparatively frail neck
osteochondritis dissecans of the medial humeral of bone which curves laterally away from the main
condyle are common causes of elbow lameness in shaft and is weakened on its medial aspect by the
young, rapidly growing large dogs. If surgery is supratrochlear foramen. Any stress which causes a
required, the treatment in both cases is to expose fracture of the lateral condyle deprives the trochlea
the medial aspect of the elbow joint and remove of its lateral support, and it fractures through the
the osteochondral fragments (Fig. 10.73). The dog supratrochlear foramen. The condyle is displaced
is restrained in lateral recumbency, lying on the and normal function of the joint can only be
affected leg, with a sandbag placed under the restored by open reduction and fixation.
elbow. To obtain satisfactory exposure the elbow
must be flexed and the carpus inwardly rotated,
Repair with a transfixion screw
using the sandbag as a fulcrum.
In most cases a muscle splitting approach can be Open reduction and fixation using a transfixion
used but if additional exposure is required the screw is shown in Figs 10.74-10.80. Closure of the
medial collateral ligament can be transected, with wound is effected by replacing the muscles and
or without transection of the pronator teres muscle. co-apting them with interrupted sutures of synthetic
Any transected structures must be carefully sutured absorbable material and the skin in the usual
when the arthrotomy is repaired. manner.
THORACIC LIMB - DOG f ELBOW JOINT 195
Fig. 10.74. The dog is positioned in dorsal recumbency

with the leg drawn forwards. The joint is approached by
a longitudinal skin incision over the point of the elbow.
Anconeus m. Olecranon
Lateral
epicondyle
of humerus
Fig. 10.76. The detached epicondyle is isolated by

severing the attachments of the anconeus muscle.
Lateral ep.icondyle of humerus

Anconeal process
Fractured
Fig. 10.75. The skin is reflected medially and laterally to trochlea
expose disrupted subcuticular tissue and antebrachial
fascia. Beneath can be identified the olecranon,
· anconeus muscle and loose lateral epicondyle.
Fractures of the lateral condyle which are under

24 hours old may be repaired by closed reduction,
immobilizing them with a lag screw placed through Extensor--------:::
a stab incision. carpi radialis m.
It is helpful in these cases to hold the recon-
structed trochlea in position with a retaining clamp
(Figs 10.81-10.82). The clamp acts as a drill guide
which ensures that the drill hole passes centrally Fig. 10.77. The attachments of the extensor carpi
radialis muscle are severed. This permits the detached
through the trochlea and allows the screw to epicondyle to be freely manipulated while remaining
be driven without disturbing the reconstructed attached to the radius by the lateral digital extensor and
trochlea. extensor carpi ulnaris muscles.
Fractured trochlea Anconeal process
Lateral
supracondyloid
ridge
Fig. 10.78. The detached epicondyle is rotated to expose the fractured trochlea and held
in Frosch bone-holding forceps while a hole is drilled through the centre of the trochlea
using a standard 4.0-mm twist drill.
Lateral epicondyle
Lateral
supracondyloid
ridge
Fig. 10.79. The detached epicondyle is accurately reduced and using the drill hole as a
guide, a hole is drilled through the medial trochlea.
Drill hole,
medial trochlea
Lateral supracondyloid ridge
Fig. 10.So. A 4.4-mm transfixion screw is driven through the displaced epicondyle until
its point just emerges. The epicondyle is now accurately reduced by inserting the point of
the screw into the drill hole of the medial trochlea. Final alignment is made and the
screw driven through the medial trochlea to obtain good immobilization. During the
final tightening of the screw, care must be taken to ensure that the alignment of the
supracondyloid ridge is not disrupted. Provided the non-threaded portion of the screw
crosses the fracture plane, compression is produced at the fracture site as the screw is
tightened.
THORACIC LIMB - DOG f ELBOW JOINT 197
..;;;;;;;iiiilf
(b)
Fig. 10.81. Components of the retaining clamp. (a) Retaining clamp with adjusting Fig. 10.82. Clamp in position to retain a detached medial
screw which is hollow to take the screwdriver and screw. (b) Sleeve which fits into the epieondyle. Note that the clamp requires to be slightly
adjusting screw of the retaining clamp and acts as the drill guide. angulated to drill the trochlea along its true medio-lateral
axis.
Repair with ASIF screws using the

lag screw principle
The fracture is reduced and immobilized with
condylar clamps (Fig. 10.83a). Interfragmentary
compression is achieved either with a fully threaded Condylar -----0""-""
clamp
cortical screw or a partially threaded cancellous
screw (Fig. ro.Sjb,c). To counteract rotational Site for insertion
forces it may be necessary to drive an additional of screw
Kirschner wire up the lateral condyle.
Medial
Lateral ---~; condyle
condyle
Fig. 10.83. (a) The fracture is reduced and immobilized with pointed reduction forceps
or condylar clamps. (b) Repair with a fully threaded cortical screw. The lateral condyle
is overdrilled so the screw is free to slide through this part of the bone before it grips
the medial condyle. (c) Repair with a partially threaded cancellous screw. The shank
of the screw is of a smaller diameter than the threaded portion, thus creating
compression as the screw is tightened.
Shaft
of humerus
Medial
condyle Medial
condyle
Lateral
condyle
Point of
transfixion
screw
Supratrochlear
fora men
Fig. 10.84. A typical intercondylar fracture of the distal

extremity of the humerus. The condyles are separated
and detached from the shaft of the humerus. Repair is
carried out in two stages: (i) repairing the fractured
trochlea by joining the two condyles, and (ii) anchoring Fig. 10.86. The medial condyle is held in Frosch bone-
the strong medial condyle to the shaft. holding forceps and a hole drilled down its long axis to
emerge at the origin of the flexors of the carpus and
digits.
Rush pin
Transfixion
screw
Transfixion
screw
Fig. 10.85. The elbow joint is exposed as described for

Rush pin
repair of a fractured lateral condyle (Figs 10.74-10.77).
When exposing the medial condyle by separating the
attachments of the tensor fascia antebrachii, the median
nerve which crosses the elbow in front of the medial Fig. 10.87. The supracondylar fracture is reduced and
condyle and the ulnar nerve which passes over the medial immobilized with a Rush pin. The pin is inserted through
condyle must be identified, dissected free and drawn the medial condyle to enter the medullary cavity of the
aside. The displaced condyles are repositioned and humerus and driven home until the hooked end engages
united with a transfixion screw. To ensure that a firm the distal end of the medial condyle. This is satisfactory
union is established· the neck of the transfixion screw for small dogs but larger dogs require plate fixation.
must engage the medial condyle. (a) Medial view, and (b) cranial view.
INTERCONDYLAR FRACTURE Repair using a bone plate

OF THE HUMERUS
The fracture is most easily exposed by a caudal
A similar but greater stress than that which causes approach and osteotomy of the olecranon
a fracture of the lateral condyle results in both the (Fig. 10.88). The triceps muscle is reflected
medial and lateral condyles being sheared from proximally and the intercondylar fracture repaired
their attachment to the diaphysis. This gives rise to with a lag screw. The supracondylar fracture is
an intercondylar fracture which is commonly re- reduced and immobilized with a plate applied
ferred to as a T or Y fracture. to the caudal aspect of the medial condyle
(Fig. 10.89). In giant breed dogs, a second plate
can be applied to the caudal aspect of the lateral
Repair using a lag screw and Rush pin
condyle. The osteotomized olecranon is repaired
See Figs 10.84-10.87. using a tension band technique (see Fig. 10.92).
THORACIC LIMB - DOG f RADIUS AND ULNA 199
Median nerve
Fig. 10.89. The intercondylar fracture is repaired with a

lag screw and the medial condyle immobilized with a
Fig. 10.88. Osteotomy of the olecranon. Care must be taken to avoid the median nerve bone plate applied to its caudal aspect.
which is cranial to the osteotomy.
Radius and ulna

FRACTURE OF THE OLECRANON
Anconeus m.
The most common site of fracture is at the lower
end of the semilunar notch. Due to the pull of the
triceps muscle, reduction of the fracture cannot be
maintained except by internal fixation using the Extensor carpi
tension band principle. Either two intramedullary ulnaris m.
pins and a figure-of-eight wire, or a bone plate and
screws can be used (Figs 10.90-10.93).
FRACTURE OF THE RADIUS

AND ULNA
Complete and overriding fractures of the radius

and ulna are extremely difficult to reduce and align Flexor carpi
ulnaris m.
accurately by closed methods. Unless accurate
reduction and alignment are attained together with
rigid immobilization, mal-union and non-unions
can result. For these reasons, and because it is
essential that a dog's radius should be in perfect
alignment, these fractures are most .satisfactorily
treated by an open reduction and internal fixation
with a bone plate and screws.
,To ensure that an accurate alignment of the leg Fig. 10;90. The dog is placed in lateral recumbency with the affected leg uppermost.
The fracture is exposed by a caudo-lateral skin incision extending from above the point
is· obtained it is necessary to be able to see and
of the elbow to some s cm distal to the fracture. The extensor carpi ulnaris and flexor
manipulate the forepaw. Disinfection of the digits carpi ulnaris muscles are separated and retracted to expose the fracture site and the
is essential to prevent contamination of the surgical lateral surface of the olecranon and ulna.
Tendon of insertion
of triceps rn.
Olecranon
"-----Wire threaded
through ulna
Fig. 10.91. A small tunnel is drilled through the olecranon distal to the fracture and a
length of wire threaded through it. The fracture is reduced and a small intramedullary
pin or Kirschner wire is drilled from the point of the olecranon distally.
-,---- Tendon of triceps rn.
Kirschner wire
Figure-of-eight
tension band wire
Fig. 10.92. A second pin is driven parallel to the first. Fig. 10.93. An alternative technique, particularly
The stainless steel wire is taken around the pins and applicable when fractures are comminuted, is to
tightened as shown. The loop enables both sides of the immobilize the fracture with a laterally applied bone
wire to be tightened independently. The ends of the pins plate.
are bent over, cut short and rotated so that they finish
flush with the tendon of the triceps.
THORACIC LIMB - DOG/ RADIUS AND ULNA 201
Fig. 10.94. The leg is held in tissue forceps, disinfected'in the usual way, Fig. 10.95. The nylon bag is tied in position with a tape and the leg
a drape placed beneath it and a nylon bag put over the digits. draped by passing it through a hole in a laparotomy sheet.
field. This presents difficulties and whatever

method is employed it is not without its disadvan-
tages, but the problem can be overcome by putting
the disinfected foot into a sterile nylon autoclave
Extensor carpi--~",:, Common digital
bag (Figs 10.94- rn.95). extensor m.
radialis m.
The radius is approached from the cranial aspect
by a midline skin incision and its shaft exposed
(Fig. ro.co). The fractured ends are isolated
Lateral digital
and freed by blunt dissection and realigned (Fig. extensor m.
I0.97).
FRACTURE OF DISTAL
EXTREMITY OF THE RADIUS
Fractures of the distal extremity of the radius are
difficult to immobilize with a standard bone plate if
the distal fragment is small. In the smaller breeds
non-union is a frequent complication and the frac-
Abductor
tures are best repaired with ASIF miniplates or pollicis longus m.
special T plates. If these are unavailable they can
be treated with an intramedullary pin inserted
via the antebrachio-carpal joint (Figs 10.98-
IO.IOI). In either instance, packing the fracture
site with cancellous bone is advised. Fig. 10.96. The radius is approached from the cranial aspect by a midline skin incision
The incision is closed with the joint extended. extending from just below the elbow to a little above the carpus. The skin is reflected
and the cephalic vein isolated and retracted medially. The shaft of the radius is exposed
The joint capsule and fascia are co-apted with a by separating the extensor carpi radialis and common digital extensor muscles along
continuous suture using synthetic absorbable suture their line of cleavage. Isolation and freeing the fractured ends by blunt dissection
material, the tendons are repositioned and the presents little difficulty.
Tendon of
common digital
extensor m.
(a)
Tendons of
extensor carpi
radialis m.
(b)
(cl
Fig. 10.98. The distal extremity of the radius is exposed

(d) by a longitudinal skin incision over the cranial aspect of
the carpus extending from the lower third of the radius to
Fig. 10.97. ,Reduction of an overriding fracture can be the proximal extremity of the metacarpus.
difficult especially if it is of several days standing and
accompanied by muscle contracture. This is easily
overcome by elevating the two ends (b), fitting them
together (c) and pressing them back into normal
alignment ( d).
Tendons of
extensor carpi
radialis m.
Fracture
Tendon of
common
digital
extensor m.
Distal
extremity Distal
of radius extremity
of radius Radial
carpal bone
Fig. 10.100. An intramedullary pin is inserted via the

distal articular surface of the radius. In some cases it is
helpful first to drill a hole before inserting the pin.
Fig. 10.99. The tendons of the extensor carpi radialis

and common digital extensor are separated along their
line of cleavage and retracted. The fractured ends are
freed by blunt dissection, reduced and aligned. The
fascia and joint capsule are incised and the antebrachio-
carpal joint flexed to expose the articular surfaces.
THORACIC LIMB - DOG f RADIUS AND ULNA 203
Tendon of lateral digital extensor m.
Extensor pollicis longus m.

,,._____ Abductor pollicis longus m.
•l:~~~i!~~flljj~l--- Deep digital flexor m.

O.~~~..""l:H++HttHtl--- Extensor carpi ulnaris m.
(a)
Blade of
oscillating
saw
Fig. 10.101. The pin is driven half to two-thirds up the

medullary cavity of the radius. It is then withdrawn,
o.5 cm cut off and driven home flush with or below the
surface of the articular cartilage.
skin closed in the usual manner. Post operation

the joint is supported in a cast until healing is
(b)
established.
Fig. 10.102. (a) A longitudinal skin incision is made along the palpable lateral border
THORACIC LIMB DEFORMITIES of the shaft of the ulna. The lateral digital extensor and extensor carpi ulnaris muscles
are separated by blunt dissection to expose the shaft of the ulna which is isolated by
For a dog to develop normally the radius and ulna freeing the attachments of the abductor pollicis muscle. (b) Using an oscillating saw a
must grow in unison. In the larger breeds of dogs, 1.5-2-cm section of the ulna is removed. Care must be taken that no periosteum
deformities of their legs often develop during remains as this stimulates healing and leads to rapid bridging of the gap which is not the
purpose of the resection.
their period of rapid growth.
Premature closure of the distal ulnar growth
plate, while the radius continues to grow at its
normal rate, has a 'bow-string' effect, and is fol-
lowed by a cranial bowing of the radius with lateral
deviation of the foot. This deformity can be cor-
rected by removing 1.5-2 cm of the middle of the
shaft of the ulna (Figs 10.102-10.103).
In severe cases, it is necessary to prevent further
growth of the medial aspect of the radial distal (a)
growth plate by stapling (Fig. 10.104).
Segmental ulnar ostectomy and transepiphyseal
stapling is best performed before the dog is
6 months old, so as to capitalize on its remaining
growth potential. Significant straightening of the
limb is unlikely after this age.
Cuneiform osteotomy
A mal-union fracture of the radius and ulna with
(b)
gross distortion or an uncorrected growth deformity
can be realigned by a cuneiform osteotomy (Figs
Fig .. 10.103. (a) Haemorrhage from the exposed medullary cavity of the gap in the ulna
10.105-10.106).
is considerable and can be controlled by plugging it with absorbable gelatin sponge.
(b) The resection is protected by co-apting over it the lateral digital extensor and
extensor carpi ulnaris muscles with a continuous suture and the skin is then sutured in
the usual manner.
Fig. 10.1()4. As a rule one staple bridging the growth Fig. 10.105. The dog is supported in ventral recum-
plate on the medial aspect is adequate but if considered bency, an Esmarch 's bandage and toumiq uet applied
necessary a second staple can be placed cranio-medially. and the leg supported on an extension board. The leg is
Care must be taken in locating the exact position of the prepared in the usual manner, a nylon bag tied over the
growth plate with a needle, as the notch X can easily be foot and the limb draped by passing it through the hole in
mistaken for it. It is always advisable to check a laparotomy sheet. This enables the leg to be freely
radiologically that the staples are correctly positioned. manipulated during the operation.
(For details of the technique of inserting staples see
Fig. JO.IO.)
(a) (b) (c) (d)
Fig. 10.196. (a) The cranial shaft of the radius is exposed as described (see Fig. 10.98) and the individual tendons
dissected free. A wedge of bone is removed from the radius at the point of maximum curvature using an osteotorne, and
the ulna is severed with bone-cutting forceps. If available, an oscillating saw will make these osteotomies quicker and
less traumatic.
During these procedures care must be taken to conserve the blood supply to the foot. Also it should be noted that the
radius cannot be aligned until the ulna is divided. When cutting the wedge it is an advantage to make the distal saw-cut
parallel to the antebrachio-carpal joint and to angulate the proximal saw-cut to fashion the size of the wedge to be
removed.
(b) The radius is aligned and immobilized with a bone plate and screws. This operation results in some shortening of
the leg which is directly related to the size of wedge removed.
(c-d) The size of the osteotomy to be performed can be accurately predetermined by making a tracing of the
outline of the deformed bone from radiographs taken pre-operatively, cutting it out, and then folding it over at the point
of maximum curvature to produce a straight bone.
- -·····--·--- ----·--·-······-----.-·--·---·--··--··----~-····--··--··------·- ----·------···--····-·· ---------------··-·-~-------·---·-·---- ---·---------
Carpus
FRACTURE OF THE
ACCESSORY CARPAL BONE
A small chip fracture of the ventral border of the
accessory carpal bone is a relatively common injury
in Greyhounds. If the chip is small it should be Transverse--------
carpal ligament
excised carefully (Figs IO. I07- IO. I09). Larger slab
fractures should be immobilized with a r.y-mm
screw. Abductor digiti quinti m.
Ligament between
accessory carpal bone
and fifth metacarpal bone
Fig. 10.108. The ligament and digiti quinti muscle are

Transverse separated along their line of cleavage and the incision
carpal extended to sever the carpal transverse ligament.
ligament
Abductor
digiti quinti m.
Fracture of
accessory
carpal bone
Ligament between
accessorycarpal bone
and fifth metacarpal bone
Fig. 10.107. A skin mcision approximately 4 cm long is

made obliquely across the lateral aspect of the accessory
carpal bone and the skin edges reflected to expose the
carpal transverse ligament, the ligament between the
accessory carpal bone and the fifth metacarpal bone and
the abductor digiti quinti muscle.
Fig. 10.109. The ligament and muscle are retracted and

their attachments to the accessory carpal bone dissected
free to expose the ventral border of the bone. The
detached piece of bone is dissected free and any bony
projections are removed with bone-nibbling forceps and
the incision closed in the usual manner.
205
Phalanges
SUBLUXA TION OF THE PROXIMAL Dorsal
INTERPHALANGEAL JOINT sesamoid
Distal extremity
This injury is especially common in Greyhounds. It of first phalanx
may vary from a Type I sprain associated with
stretching or tearing of one collateral ligament to a
Type III sprain with rupture of both collateral Tendon of
ligaments, with or without avulsion chip. fractures. common digital
Type I sprains should be supported in a padded extensor m.
bandage for 3 - 4 weeks and the nail trimmed to
reduce leverage on the affected joint. In Type II
luxations, one of the collateral ligaments is com-
pletely severed and must be repaired with hori-
zontal mattress sutures of non-absorbable material
or polydioxanone. The joint should be supported
for 6 weeks post-operatively. Type II luxations Fig. IO.no. The joint is exposed by a longitudinal skin incision over its dorsal aspect.
which remain as persistently painful joints and The tendon of the digital extensor muscle together with the sesamoid bone is freed and
Type III sprains may be treated by amputation of held to one side.
the digit or arthrodesis of the affected joint
(Figs IO.IIO-IO.II3).
The articular surfaces are debrided and the joint
immobilized in a normal standing position with a
horizontal mattress suture of stainless steel wire.
Additional stability can be attained by using a
small bone plate applied to the dorsal aspect of the
phalanges or with a Kirschner wire inserted across
the joint.
Proximal articular
Arthrodesis of the proximal interphalangeal joint surface of
second phalanx
See Figs 10.uo-10.u2.
Fig. IO.III. The joint is flexed and the articular cartilage curetted off the ends of the
bones.
Fig. IO.II:z. Using a r.y-mm drill the distal extremity of the first phalanx and the proximal extremity of the second
phalanx are drilled transversely so that the drill enters and emerges at the points of origin and insertion of the collateral
ligaments respectively. A monofilament stainless steel wire is threaded through the holes and then, with the joint in the
normal standing position, twisted tightly. The twisted end is cut off short and pressed flat against the lateral aspect of the
second phalanx. The extensor tendon_ and sesamoid bone are repositioned and the skin closed in the usual manner.
206
-·----··-···---·-···------- ----~ -- ----~--~----·-------- ------~ -- - ---~-- --- ----------~-
PELVIC LIMB - HORSE/ STIFLE JOINT 207
Arthrodesis using a Kirschner wire

Both the methods described for arthrodesing this
joint have their advocates. In practice, the wire
suture tends to break before arthrodesis is estab-
lished but the Kirschner wire although it is tech-
nically more difficult to insert, provides better
immobilization ,of the joint (Fig. 10.II3). Further
strength can be provided by employing a figure-of-
eight tension band wire over the dorsal aspect of Fig. 10.113. Kirschner
wire used to immobilize
the joint.
the proximal
interphalangeal joint.
............................................................................................
Pelvic limb - horse
n
!
Stifle joint
UPWARD FIXATION OF
I
M
i
___ Patella
THE PATELLA
1
i.
Intermittent upward fixation of the patella occurs Accessory V

cartilage
in all types of horses of all ages but more especially
of patella li
in ponies and young stock. When the stifle joint is
Ii
extended the patella rides upwards on the trochlea
Lateral
and slips over its rim (Fig. IO. II4). This results in a patellar
temporary fixation which is followed almost ligament
Medial
immediately by release of the patella. patellar
The operation most frequently performed to al- ligament
. Middle
leviate this condition is desmotomy of the medial patellar
patellar ligament. It is designed to release the ligament
tension on the accessory cartilage and to prevent it
hooking over the trochlea. Relief is obtained by Tibial
either severing or resecting 1.5-2.5 cm of the tuberosity
medial patellar ligament.
It is customary to perform the operation with the
horse standing under local analgesia. The ligament
is located by palpation and a stab incision is made
through the skin and underlying fascia just medial
to its midpoint. Through this incision a tenotome Fig. 10.114. The medial patellar ligament is an extension
is passed on flat, under the medial ligament and of the .accessory cartilage of the patella. The cartilage
then turned on edge to sever it. The authors becomes hooked over the medial trochlea of the femur
during upward fixation. The figure shows a cranial
prefer, however, to expose the ligament with the
view of the left stifle joint.
horse under general anaesthesia, and remove a
1.5-2.5-cm section of its length (Fig. 10.II5).
frequently affects the lateral trochlear ridge of the
distal femur. The results of conservative treatment
OSTEOCHONDRITIS DISSECANS
are generally poor and entail a rest of at least
In the horse, osteochondritis dissecans most 6 months before the result can be assessed. Surgical
(a) (b) (c)
Fig. 10.115. The horse is placed in dorsal recumbency and the hind leg extended. Using the tibial tuberosity as a
landmark the medial patellar ligament is located by palpation. (a) A skin incision 4-5 cm long is made parallel with
the medial edge of the ligament and midway between the tibial tuberosity and the accessory cartilage of the patella. This
exposes the underlying fascia. (b) The fascia is incised and the medial patellar ligament is picked up with a tenaculum
and brought out through the incision. (c) The ligament is divided and 1.5-2.5 cm removed. If this does not result in the
normal free movement of the patella when the stifle joint is flexed and extended, then it is necessary to incise the
aponeurosis of the gracilis and sartorius muscles which blend with the medial patellar ligament, at the midpoint of the
incision to the depth of 1 .5 cm. The incision is closed by co-apting the fascia and skin with three or four interrupted
sutures of synthetic absorbable suture material and monofilament nylon respectively.
treatment is the method of choice; the majority of

CYST OF THE MEDIAL FEMORAL
cases return to normal work.
CONDYLE
With the horse in lateral recumbency, and
the affected leg uppermost and extended, an Horses treated conservatively with 6 months rest
arthrotomy of the femoropatellar joint is per- result in recovery in approximately 50 per cent of
formed, between the lateral and middle patellar cases. Surgical treatment is indicated in those cases
ligaments, to expose the lateral trochlear ridge.
A skin incision, IO- 12 cm in length is made
extending from the base of the patella between the
lateral and middle patellar ligaments to the tibial
crest. The superficial and deep fascia is next incised
to expose the cranial fat pad. This is either incised
likewise or an eliptical portion removed to expose
the joint capsule which is then incised to expose
the lateral trochlear ridge. --+-- Medial ridge
Any detached pieces or fragments of cartilage of trochlea
are removed and the lesion curetted leaving it with
a smooth cartilaginous edge. If the crater is not
Medial condyle '---- Medial patellar
haemorrhagic then four to six holes (2 mm dia- of femur ligament
meter) should be drilled into the underlying can-
cellous bone to promote vascularization. Medial meniscus
Prior to closure, the joint is flushed with isotonic
saline solution. The arthrotomy is closed by co-
apting the joint capsule and the edge of the fat pad Medial femoro-
tibial ligament
with a continuous suture and the superficial and
deep fascia together with interrupted sutures using
a 4 metric synthetic absorbable suture material,
and the skin with mattress sutures using mono-
filament nylon. The incision is protected by over-
sewing a gauze pad.
Post-operatively, the horse should be rested for
Fig. 10.116. A longitudinal slightly curved skin incision, approximately 15 cm in length,
3 months before being returned gradually to work. is made between the medial femorotibial ligament and the medial straight patellar
ligament. The incision is continued through the connective tissue and fascia to expose
the joint capsule, which is then incised longitudinally.
PELVIC LIMB - HORSE/ STIFLE JOINT 209
which are severely lame when first examined and

those which remain lame after conservative
treatment.
Treatment comprises a medial arthrotomy of i.,
the femorotibial joint, removing the inverted
cartilage from around the opening of the cyst, and Articular surface of
curetting the cyst to remove its lining and any medial condyle
Opening of cyst
detritus (Figs IO.I16-10.u7). This is followed by
packing the cavity firmly with an autogenous can- Medial patellar ----iR Middle patellar
ligament ligament
cellous bone graft obtained from the contralateral
tuber coxae. In approximately 60 per cent of cases
the cavity is subsequently filled with either normal Medial meniscus
bone or a mixed fibrocancellous bone, the cyst
opening is obliterated by fibrocartilage and a normal
functioning joint is re-established.
The operation is performed under general
anaesthesia with the horse lying on its side with the
affected leg ventral and the uppermost leg extended
forwards.
Packing the cyst Fig. 10.117. The medial femorotibial and medial patellar ligaments are retracted and
the joint slowly flexed to bring the opening of the cyst into view and positioned for
Pieces of cancellous bone are firmly packed into curettage and packing.
the cavity, using a punch, until it is completely
filled without encroaching on the edges of the
surrounding articular cartilage.
The incision is closed by co-apting the joint contralateral tuber coxae {Figs 10.n8-10.II9). A
capsule with a continuous suture and the fascia 10- 12-cm incision is made along the middle of the
with interrupted sutures using 3 metric synthetic quadrangular mass forming the tuber coxae. The
absorbable material; and: the skin with mattress subcutaneous tissues are incised and the fat either
sutures of monofllament nylon. reflected or removed to expose the periosteum.
The incision is closed by co-apting the periosteum
and subcutaneous tissues with a continuous suture
Obtaining the autogenous cancellous bone g.Faft
using 3 metric synthetic absorbable material and the
The cancellous bone graft is obtained from the skin with mattress sutures of monofilament nylon.
Fig. 10.118. The periosteum is incised longitudinally and Fig. 10.119. A rectangular piece of cortical bone,
reflected with a periosteal elevator. measuring 1.5 x 3.0 cm is removed with an osteotome to
expose the underlying cancellous bone, pieces of which
are removed with a gouge and immediately wrapped in a
blood-soaked swab.
Hock joint
BONE SPAVIN DISEASE
Bone spavin is a degenerative joint disease of the
'low motion' joints of the hock, usually involving
the distal intertarsal and tarso-metatarsal joints.
Occasionally the proximal intertarsal joints are
involved.
Non-surgical treatment in the form of exercise
with or without the use of non-steroidal anti-
inflammatory drugs can result in spontaneous bony
ankylosis of the joints and remission of the
lameness. This is unpredictable, however, and may
take a long time.
Distal intertarsal
Arthrodesis of the distal intertarsal and tarso- joint ---~
metatarsal joints is an alternative method of treat- Tarsometatarsal ---
ment which is indicated in cases in which the joint
degenerative joint disease changes are character-
ized by osteolysis with no, or only minimal,
periosteal reaction. The principle of the procedure
is the surgical destruction of approximately 6o per
cent of the opposing articular surfaces thereby Fig. 10.120. (a) Medial aspect of the hock, and (b) 1-4: drill tracks.
inducing a rigid ankylosis.
The operation is performed under general
anaesthesia with the horse in lateral recumbency
and the affected leg undermost. The joint or joints not cause the animal undue discomfort. Approxi-
to be drilled are located on the cranio-medial mately 75 per cent of horses return to soundness
aspect of the hock just caudal to the saphenous 5- IO months after surgery.
vein using 23 gauge hypodermic needles; correct
positioning being checked radiographically. A
STRING HALT
5-cm vertical skin incision is made exposing the
cunean tendon from which a 2-cm section is Stringhalt is an involuntary flexion of one or both
removed. Drilling of the distal intertarsal joint is hind legs during progression. The aetiology is un-
commenced through a stab incision in the ligaments known but in many cases the condition can be
and joint capsule, using a 3.5-mm bit, preferably in relieved by removing 15-18 cm of the tendon of
a hand drill. The direction of this first track is the lateral digital extensor (Fig. I0.121).
checked radiographically soon after it is begun to The operation is performed with the horse in
ensure it is along the plane of the joint. If found to lateral recumbency and the affected leg uppermost.
be correct, it is used as a guide for all subsequent A longitudinal skin incision on line with the point
drill tracks. Depending on the size of the horse, of the hock and 7. 5- IO cm in length is made along
three to four tracks, radiating from the original the muscle belly of the lateral digital extensor. The
drill hole (Fig. 10.120) are sufficient to destroy the underlying layer of thick fascia is incised to expose
required amount of articular cartilage. Care should the muscle which is isolated by blunt dissection.
be taken to avoid excessive drilling which can lead The identity of the muscle is confirmed by pulling
to joint instability and much greater post-operative on it and noting movement at its distal attachment
discomfort. The procedure is repeated on the to the tendon of the long digital extensor. Next the
tarsometatarsal joint if this is involved also. After tendon of the lateral digital extensor is exposed by
removing any bone debris by flushing with sterile a 2.5-cm skin incision just proximal to its junction
saline, the wound is closed in two layers. Parenteral with the tendon of the long digital extensor. It is
antibiotics and oral phenylbutazone are admin- isolated by blunt dissection and severed. Finally,
istered for 5 days post-operatively. The horse is traction is applied to the proximal portion and the
confined to a box for 1 month, with walking exercise severed tendon pulled up through the incision. The
in hand during the second 2 weeks. Thereafter tendon is then severed proximally together with
exercise is progressively increased provided it does 7.5-10 cm of muscle belly.
2IO
~-··
l,
!
PELVIC LIMB - DOG/ PELVIS 211

I:
r:
In some cases extraction of the tendon is difficult Deep digital flexor m.

due to adhesions where it crosses the hock and
Lateral digital extensor m.
they have to be broken down. ;:j
h
After removal of the tendon the fascia at the Long digital extensor m.
proximal incision is co-apted with a continuous i!!
suture using 3 metric synthetic absorbable material !I
and then both skin incisions with interrupted I
sutures using monofilament nylon. It is important
that the horse is given walking exercise; which is
gradually increased, from the day following
operation to prevent the formation of adhesions
during wound healing.
Lateral digital Tenectomy

extensor tendon of the lateral
digital extensor
:r---- Site of distal

incision
Fig. IO.IZI. Lateral aspect of the right hock. Note the proximal and distal sites for
performing tenectomy of the lateral digital extensor.
Pelvic limb - dog
Pelvis
Fracture of the pelvis is a relatively common sequel
to road accidents. In the absence of serious nerve screw
injury which may cause either hind leg paralysis or
bladder dysfunction, the majority of dogs with
pelvic injuries make remarkably good recoveries in Bone-----
spite of very extensive bone damage. plate
In certain cases where there is gross bone dis-
: placement, particularly when the fractures are spine
bilateral or the acetabulum is involved, open
reduction and internal fixation is necessary (Fig. ·
10.122). The surgical exposure of the ilium is along
the long axis of its ventral border, incising the
aponeurosis of the tensor fascia Iata ventrally and
the sartorius muscle cranially. The exposure is ~--lntramedullary
continued by subperiosteal elevation and dorsal pin
reflection of the middle and deep gluteal muscles. Fig. 10.122. Some common fractures of the pelvis in the dog which, when accompanied
Exposure of the acetabulum is best performed by by gross bone displacement, are most satisfactorily treated by open reduction and
osteotomy of the great trochanter. The osteo- fixation by the methods indicated.
tomized portion is subsequently repaired with a lag fully contoured bone plate. An ASIF reconstruc-
screw or tension band wire. tion plate is ideal since it can be contoured in three
Fixation may be achieved by the use of trans- planes.
fixion and lag screws, or by the application of small Most pelvic fractures cause a reduction in the
bone plates. Ischial fractures may be immobilized size of the pelvic inlet, and this must be borne in
by means of an intramedullary pin inserted at the mind when dealing with the condition in the
ischial tuberosity and lodged in the ischiatic spine. breeding bitch.
Acetabular fractures are best repaired with a care-
Hip joint
AMPUTATION OF THE
FEMORAL HEAD
Excision arthroplasty is frequently employed in the

treatment of fractures of the femoral neck, osteo-
arthritis and ischaemic necrosis of the femoral
head. A false joint is established which, especially
in small dogs, functions most efficiently.
A number of methods are practised to expose
the hip joint but in the authors' experience the
cranio-lateral approach has much to commend it
(Figs 10.123-10.129). This method provides a good
exposure, enabling the joint capsule to be accu-
rately co-apted to ensure the formation of a satis-
factory false joint.
The joint capsule is co-apted with horizontal
mattress sutures using absorbable synthetic suture
material. The tenotomized portion of the deep
gluteal muscle is similarly repaired, followed by
co-aptation of the biceps femoris and the tensor
fascia lata by a continuous suture. The skin incision Fig. 10.123. To expose the right hip joint the dog is
is closed in the usual manner. restrained in lateral recumbency with the affected hip
joint uppermost. The joint is exposed by a curved skin
incision commencing from a point 2.5-5.0 cm above the
greater trochanter and extending distally along the line of
the femur to terminate at its upper third.
PELVIC LIMB DOG/ HIP JOINT 213
Superficial ti
gluteal m. !!
i
Middle gluteal m. i
11
Ii
:.11
Biceps 11
femoris m. Tensor fascia

11.1
lata m.
I'
Iii
:I
;1
,,
;1
Ii
I!
Fig. 10.124. The skin edges are retracted and the I
subcutaneous fat separated to expose the superficial i
gluteal muscle, tensor fascia lata and biceps femoris
muscle in the right hind leg. I,
,.1·11
'[,I
i!
'i
!JI
,1,
!,[
jl,
.I
Superficial gluteal m.
I
1,1
Biceps i'
femoris m.
Vast us
lateralis m. Site of partial
tenotomy of
deep gluteal m.
Fig. 10.125. The tensor fascia lata is incised along its

attachment to the biceps femoris muscle and both are
retracted. The tendon of the deep gluteal muscle is
partially tenotomized.
Incised joint capsule
Femoral head
Vastus lateralis m.
Fig. 10.126. The superficial and middle gluteal muscles are retracted dorsally and the Fig. 10.127. The vastus lateralis muscle is reflected from
vastus lateralis is retracted caudally. The joint capsule is incised about two-thirds of the its origin on the lateral aspect of the proximal femur with
way around the circumference of the acetabulum and some o. 3 cm from its attachment to a periosteal elevator to expose the femoral neck.
the rim. The stifle is externally rotated through 90° so that the femoral head is
disarticulated. It may be necessary to divide the teres ligament with curved scissors in
order to achieve this.
Joint
capsule
Fig. 10.128. Direction of osteotomy of the femoral neck. Fig. 10.129. The joint capsule is closed with two or three
The osteotome or saw is directed distally to the lesser mattress sutures using synthetic absorbable suture
trochanter. material. All the sutures are laid before tying them.
PELVIC LIMB - DOG f HIP JOINT 215
·~·- .....
····.... ~
... •I Pectineus m .
./ \ Sartorius m. -~~
Femoral artery -~~
Adductor m.
- I Femoral vein
I 1111111111111111111111111111111111111111111111~~11
Fig. 10.130. Site of skin incision for exposing the
pectineus muscle of the right leg. The dog is placed in
dorsal recumbency with the affected leg abducted to
expose the medial aspect of the thigh.
Fig. 10.131. A skin incision is made along the length of

the pectineus muscle and reflected to expose from
PECTINECTOMY cranially to caudally the sartorius muscle, the femoral
artery and vein, the pectineus muscle and the adductor
Resection of the pectineus muscle (Figs IO. 130- muscle.
10.32) is employed for the treatment of hip dys-
plasia. It reduces the tension and improves
abduction and extension of the joint but does not
allay the progressive development of osteoarthritic
changes.
The subcutaneous tissues are co-apted with a
continuous suture using 3 metric synthetic
absorbable suture material and the skin with inter-
rupted sutures using monofilament nylon.
TRIPLE PELVIC OSTEOTOMY
Triple pelvic osteotomy is used to improve joint

congruency in skeletally immature dogs with sub-
luxation of their femoral heads due to hip dysplasia.
The acetabular portion of the pelvis is isolated by
osteotomy of the pubis, ischium and ilium and
rotated to improve the dorsal cover of the femoral
head (Fig. IO. 133). Fig. 10.132. Using blunt dissection and with due care
The pubis is exposed by performing a pee- not to injure the femoral artery or vein the pectineus
tinectomy (Figs IO. 130- 132) and sectioned with muscle is separated from its neighbours. Experience has
shown that satisfactory results are obtained by simply
an osteotome. A portion of the pubic bone may be
resecting 4-5 cm of its central portion:
removed, but if the osteotomy is made
close to the medial face of the acetabulum this is
generally unnecessary. ilium, elevating the middle gluteal muscle from
The dog is then placed in lateral recumbency its ventral attachment to the tensor fascia lata.
and the ischium exposed by subperiosteally The ileum is osteotomized at right angles to the
elevating the internal obturator and the semi- long axis of the pelvis with an oscillating saw or
membranosus and quadratus femoris muscles from osteotome, freeing the acetabular portion of the
its dorsal and ventral surfaces respectively. An pelvis. (Fig 10.133b). This is rotated to increase
embryotomy wire is carefully passed through the the dorsal cover of the femoral head and im-
obturator foramen to section the ischium. mobilized with a pre-contoured bone plate (Fig.
A lateral approach is made to the wing of the ro.rjjc). This plate is twisted around its long axis
to match the angle required to rotate the acetabulum

sufficiently to eliminate dorsal subluxation of the
femoral head.
Post-operatively, the dog is restricted to lead
exercise until the osteotomies have healed.
SUBTROCHANTERIC FEMORAL
OSTEOTOMY
An alternative technique for improving joint

congruency in dysplastic dogs is a subtrochanteric
femoral osteotomy. This is indicated where the
angles of inclination and anteversion of the femoral
neck are increased producing coxa valgus. The
inclination angle is the angle that the femoral neck
makes with the diaphysis when the femur is viewed
in a standard ventrodorsal radiographic projection
of the pelvis with the femora extended and parallel Fig. 10.133. (a) Hemipelvis with dysplastic hip joint. (b) Osteotomies of the ilium,
and the stifles vertical. The normal angle is approxi- pubis and ischium permit rotation of the acetabular segment. (c) The ilia! osteotomy is
immobilized with a pre-contoured bone plate.
mately 145°. The angle of anteversion is the angle
that the femoral neck makes with the diaphysis
in the horizontal plane. This can be established
trigonometrically from measurements taken from
ventrodorsal and lateral radiographs of the pelvis
and femur.
A subtrochanteric femoral osteotomy involves
removal of a wedge of bone from the medial aspect
of the femur {Fig. IO. 134a) so as to create varisation
of the femoral neck. The osteotomy is immobilized
(J
with an ASIF double hook plate (Fig. ro.rjac)
Q)
which provides a very secure three point anchorage
in the greater trochanter. Careful pre-planning is n
required to determine the size of the wedge and
the osteotomy angle. The optimum post-surgical (])
inclination angle is about 135°. ()
o
(a) (b) (c)
DISLOCATION OF THE HIP JOINT
Dislocation 'of the hip joint is very common in the Fig. 10.134. (a) Wedge removed from the medialaspect of the femur. (b) Osteotomy
repaired with double hook plate (c).
dog. In the majority of cases, provided the aceta-
bulum and femoral head are not dysplastic, a closed
reduction by direct traction is satisfactory but if
this fails, or if dislocation persistently recurs after behind the acetabular fossa by means of a 'toggle
repeated reductions then it is necessary to perform pin'.
an open reduction with fixation {Figs IO. 135- The hip joint is exposed by the method described
rn.138). · (see Figs I0.124-rn.126). The acetabulum is care-
To retain the head of the femur in the acetabulum fully inspected and any blood clot, granulation
the ruptured ligamentum teres is replaced by a tissue and remnants of the joint capsule or liga-
prosthesis of braided nylon which is anchored mentum teres removed.
PELVIC LIMB - DOG/ HIP JOINT 217
Acetabular
fossa
Greater Head of
trochanter femur
Fig. 10.136. (a) Using a larger drill bit, a hole is drilled through the centre of the
acetabular fossa and care taken that the point only just penetrates into the pelvic cavity
and does not injure the underlying organs. (b) A 'toggle pin' of slightly smaller diameter
than the hole drilled and threaded with braided nylon is inserted into the hole. (Braided
nylon: dogs under 15 kg, size 3.5 metric; over 15 kg, size 5 metric.) (c) With a fine probe
the toggle pin is pushed through the drill hole until it lies free in the pelvic cavity. The
braided nylon is then tensed to bring the toggle pin flush against the medial surface of the
Fig. 10.135. A hole is drilled down the neck of the femur acetabulum.
from the point of origin of the ligamentum teres, i.e. the
fovea capitis, to emerge at the base of the greater
trochanter.
Deep
gluteal m.
Suture being passed

through small hole drilled
through base of
greater trochanter
Greater
trochanter
Fig. 10.137. The ends of the braided nylon are threaded

through the drill hole in the femoral neck. The head of
the femur is repositioned in the acetabulum and the
braided nylon pulled taut.
Fig. 10.138. The ends of the braided nylon are tensed to ensure that the head of the
femur fits into the acetabulum before passing each end in opposite directions through a
hole drilled across the base of the greater trochanter, and securely tying it to its fellow.
Femur
FRACTURE OF THE
FEMORAL SHAFT
Fractures of the shaft of the femur are the most Fascia lata
common of all fractures encountered in the dog. Biceps
femoris m.
Owing to the large and powerful muscle groups
surrounding the shaft it is impossible to perform
effectively a closed reduction or attain external
immobilization. The majority of cases are treated
Vastus
by intramedullary fixation, but if the medullary lateralis m.
cavity is excessively wide, the shaft has a marked
curvature, or the fracture is grossly comminuted
then internal fixation with a bone plate is the
method of choice.
Exposure of the fracture is shown in Figs IO. 139-
10.141.
Figures 10.142-10.146 depict a Venables bone
plate since these are still widely used. They are
neither as strong or versatile as ASIF dynamic
compression plates, nor do they permit axial com-
pression as depicted in Fig. rn.8. Nevertheless, Fig. 10.140. The skin edges are reflected to expose the
fascia lata, which is incised along the line of its
provided a plate of adequate size is applied cor-
attachment to the biceps femoris to reveal the vastus
rectly it will provide a rigid form of internal fixation. lateralis muscle.
Finally, the incision is closed with interrupted
sutures (Figs I0.147-10.148).
Vastus Biceps
lateralis m. femoris m.
Fig. 10.139. To expose the lateral aspect of the shaft of

the femur the dog is placed in lateral recumbency with
the affected leg uppermost. The skin is incised practically Fig. 10.141. The vastus lateralis and biceps femoris
the whole length of the femur, along the line joining muscles are separated by blunt dissection and retracted
the greater trochanter and the cranial aspect of the stifle to expose the fracture. Blood clots and any detached
joint. fragments of bone are removed from the site of fracture.
218
PELVIC LIMB - DOG/ FEMUR 219
Depth gauge
Lawman's
bone clamp
Venable
bone plate
Fig. 10.144. A screw depth gauge is used to determine

accurately the length of screw required. The hooked end
is passed down through both drill holes to engage on the
outside of the distal cortex, and the adjustable sleeve is
Fig. 10.142. The fractured ends of the bone are freed of muscle attachments and the fixed against the proximal cortex. The gauge is removed,
fracture reduced and aligned. Following reduction, the bone plate is carefully positioned and the length of screw required read off from the scale
on the lateral surface of the shaft and retained in position with a bone clamp. A or the screw can be measured against the protruding end.
Lawman's self-retaining bone clamp is depicted here. The diameter of the shaft of a long bone varies con-
siderably throughout its length, so all screws have to
be individually selected after measuring each drill hole ..
Standard
twist drill
__,. Sleeve of
screwdriver
Sherman
screw
Fig. 10.143. A hole is drilled at right angles to the shaft Fig. 10.145. A standard 3.5-mm Sherman type
of the bone and through both cortices with a 2.8-mm orthopaedic screw is driven. The second screw to be
twist drill using a hole in the plate as a guide. Care must driven on either side of the fracture fixes the plate in
be taken that the drill does not come in contact with the position.
plate as this results in the transfer of metallic particles
which leads to corrosion and tissue reaction.
220 SECTION. IO/ ORTHOPAEDIC SURGERY
Stille type
bone-holding forceps
\(\)......... .
7:·. ·.
:·~-~\: ·:: . ~
Biceps
femoris m.
Fig. 10.146. If a Lawman's self-retaining bone clamp

cannot be satisfactorily employed then the bone plate can Fig. 10.147. At the distal extremity of the incision the vastus lateralis muscle is retained
generally be held in position with Stille type bone- in position under the biceps femoris muscle with one or two interrupted sutures.
holding forceps.
Fig. 10.149. The dog is positioned in lateral recumbency

with the affected leg uppermost. The site is exposed via a
parapatellar skin incision which extends from the distal
third of the femur to the proximal third of the tibia.
Fig. 10.148. The fascia lata and fascia of the biceps femoris muscle are co-apted with
authors find that a small bone plate attached to the

FRACTURES OF THE
lateral surface maintains perfect alignment and
DISTAL FEMUR
immobilization of the supracondylar fracture
In young dogs a fracture of the distal epiphysis (Figs 10.149-10.153).
of the femur, and in adult dogs a supracondylar Distal femoral physeal fractures should not be
fracture, are not uncommon. In both cases the bridged with a bone plate and most of these frac-
condyles rotate caudally and the distal extremity of tures can be repaired very successfully with crossed
the shaft is displaced cranially. Kirschner wires or small intramedullary pins. All
In these cases an open reduction and fixation implants should be removed as soon as healing is
are essential. Numerous methods have been rec- complete so as not to create a growth deformity.
ommended to immobilize these fractures but the
PEL VIC LIMB - DOG/ FEMUR 221
Vastus
lateralis m.
Shaft
of femur
Trochlea
Biceps
femoris m.
Fig. 10.150. The vastus lateralis and biceps femoris muscles are separated along their
line of cleavage and the incision is extended distally through the fascia of the Fig. 10.152. A three-holed bone plate is fixed on the
femoropatellar joint and joint capsule. The distal extremity of the shaft of the femur and lateral aspect by driving two screws into the distal end of
the detached epiphysis are isolated by blunt dissection. the shaft and one through the condyles. If the fracture
involves the physis, it should be repaired with small
intramedullary pins or crossed Kirschner wires and the
implants removed in 4-6 weeks so that they do not
interfere with normal growth.
Distal
femoral
epiphysis Fascia lata and
fascia of stifle joint
Fig. 10.153. It is important when closing the incision to

Fascia ensure the patella has been accurately repositioned in the
lata trochlea groove and securely retained in position by
co-apting the fascia and joint capsule opposite the patella
with mattress sutures using synthetic absorbable suture
material.
Fig. 10.151. With the shaft of the femur held in Stille type bone-holding forceps and the
detached epiphysis in Frosch bone-holding forceps the bones are aligned, brought into
contact and the fracture reduced by extending the joint.
Stifle joint
RUPTURE OF THE
CRANIAL CRUCIATE LIGAMENT 111111111111111111111111111111111111111111111111111111111111111111111111
Rupture of the cranial cruciate ligament results in

a mechanical instability of the joint, which is fol- '--'1 11111111111111
lowed by degenerative osteoarthritis. The object
of treatment is to stabilize the joint. This is --11111111111111111
attained by replacing the ruptured ligament with a
prosthesis.
111111111111111111111111111111111111111~11111111111111111111
Site of skin incision_/

Patsaama's technique to expose the right
stifle joint
Many modifications of Patsaama's original method
have been suggested but in all cases the prosthesis Fig. 10.154. The dog is positioned in dorsal recumbency
is inserted through femoral and tibial bone tunnels with the affected leg extended and resting on a sandbag.
and anchored at either end. Figures IO. 154- 10. 164
depict skin being used as the prosthesis.
To ensure that the skin prosthesis crosses the Lateral Patella Tibial tuberosity
trochlear
intercondyloid fossa in the position originally condyle
occupied by the intact cranial cruciate ligament it is
necessary to drill two holes. They are referred to as lnfrapatellar
the femoral and tibial tunnels, respectively, and it pad of fat
is essential they emerge in the intercondyloid fossa
at the exact points of attachment of the ligament. Fascia of
stifle joint
Fig. 10.155. The stifle joint is approached from the lateral aspect by a parapatellar
skin incision extending from the lower third of the femur to the upper third of the tibia.
This exposes the underlying fascia which is incised together with the joint capsule to
open the joint.
lnfrapatellar
pad of fat
Fig. 10.156. The patella is dislocated medially to expose the trochlea and infrapatellar
pad of fat.
222
PELVIC LIMB - DOG/ STIFLE JOINT 223
Joint capsule
and fascia of
stifle joint
Fig. 10.157. The femoral tunnel is drilled from just

above the origin of the lateral collateral ligament. It
emerges on the medial surface of the lateral condyle at
the point of attachment of the cranial cruciate ligament.
Tibial tuberosity
Tibial
crest
Femoral
tunnel
Fig. 10.158. With the stifle joint in maximum flexion the

tibial tunnel is drilled from the intercondyloid fossa to
emerge towards the distal extremity of the tibial crest.
Tibial tunnel
Femoral
tunnel
Fig. 10.16o. The skin is passed through the femoral and

tibial tunnels by twisting it up and attaching a length of
monofilament wire to one end. The wire is first passed
through the femoral tunnel and the skin pulled through.
Fig. 10.159. The skin transplant is cut the length of and parallel with the edge of the The wire is then continued down the tibial tunnel
incision. Its width varies from 3 mm for small dogs to 5 IIlIIl for large dogs. followed by the skin.
Joint capsule
and fascia
of stifle joint
Fig. 10.161. The patella is repositioned in the trochlea.

The skin transplant at the femoral tunnel is anchored by
suturing it to the joint capsule and fascia with two
mattress sutures using monofilament nylon. Any excess
of skin is cut off.
Fig. 10.162. The stifle is extended. The skin transplant

Sutures fixing skin graft Skin graft replacing is pulled tight and its end reflected back over the tibial
to joint capsule and cranial cruciate ligament crest and attached to the fascia with two mattress sutures
fascia of joint using monofilament nylon.
Fig. 10.163. The joint capsule and fascia are co-apted

with mattress sutures and the skin incision is closed with
Fig. 10.164. To protect the wound a gauze pad can be oversewn.
'Over the top' technique

An alternative technique, the so-called 'over the
Incision in lateral fascia
top' technique, was described by Arnoczky, This extending into straight
involves fashioning the prosthesis from the medial patellar ligament
fascia of the stifle and the· medial third of the
Fig. 10.165. A lateral parapatellar
straight patellar ligament (including a quadrant of skin incision is continued through
the patella). iThe distal end of the prosthesis the subcutaneous fascia to expose
remains attached to the tibia and the free end is the lateral fascia of the stifle and
passed through the joint to emerge over the lateral the straight patellar ligament. An
incision is made in the lateral third
femoral condyle proximal to the lateral fabella. It
of the straight patellar ligament
is pulled taut and anchored to the dense femoro- and continued proximally into the
fabellar ligament and adjacent periosteum of the lateral fascia. The total length of
femur. The advantages of this technique over the incision is two to three times
Patsaama's method are the lack of bone tunnels on the length of the straight patellar
ligament and there should be
which the prosthesis may fray, the graft retains a
sufficient fascia left lateral· to the
vascular supply from its distal attachment and it is patella to enable the joint to be
sounder biomechanically. closed securely.
Numerous variations of Arnoczky's original
technique are employed. In the authors' experi-
ence the procedure shown in Figs 10.165-10.169
provides satisfactory results.
Graft of lateral fascia

and lateral third of
Biceps straight patellar
femoris ligament
m.
Fig. 10.166. A second incision is made parallel to the

first so that a graft I .o- 1 .5 cm in width is created. It is
left attached distally. The joint capsule is then incised
along a similar line.
Graft passer with graft

threaded through its
slotted end
Joint capsule
and lateral
fascia
Fig. 10.167. The patella is luxated medially and the joint flexed.
A graft passer is inserted within the joint and pushed through
the caudo-lateral aspect of the joint capsule, through the dense
femorofabellar ligament, so that it emerges between the femoral
condyles lateral to the caudal cruciate ligament. The free end of
the graft is threaded through the graft passer.
Lateral fascia
Fig. 10.168. The graft is pulled taut and anchored with

doubled 3.5-mm monofilament nylon to the adjacent Fig. 10.169. The joint capsule is closed with cruciate
dense fascia and the periosteum of the lateral femoral mattress sutures of synthetic absorbable material. The
condyle. lateral fascia is repaired with horizontal mattress sutures
of similar material and subcutaneous tissues and skin are
routinely closed.
PELVIC LIMB ...:..... DOG/ STIFLE JOINT 227
Patella
Sartorius m.
.
1111-..-....~ Tibial
tuberosity
Fascia
Medial
collateral Medial
ligament meniscus
lnfrapatellar
pad of fat
Fig. 10.171. The underlying sartorius muscle and fascia

are incised the length of the incision and retracted. The
remnants of the collateral ligament are isolated by
dissection and their origins exposed.
Fig. 10.170. To replace a ruptured medial collateral
ligament the dog is placed in lateral recumbency with the
affected leg ventral. The ligament is exposed via a lightly
-----,
ll
curved parapatellar skin incision which extends from the
lower third of the femur to the upper third of the tibia.
I
RUPTURE OF A COLLATERAL ---.J
LIGAMENT OF THE
FEMOROTIBIAL JOINT
The collateral ligaments may be either torn from
their insertions or ruptured. These injuries inter-
fere with the normal stability of the joint, and
cannot be treated either by external immobilization
or by repair of the torn ligament. Replacement of
the collateral ligament with wire is a practical
method of treatment (Figs 10.170-10.172).
In most cases the wire breaks, but by the time
this occurs considerable peri-articular fibrous tissue
has been laid down which adequately stabilizes the
joint, and unless the ends of the broken wire cause Fig. 10.172. A rz-mm standard Sherman screw is
inserted into the condyle of the femur at the point of
irritation or pain, it need not be removed.
origin of the ligament and a second screw just below the
medial condyle of the tibia. These two screws are then
joined by a strand of monofilament wire (0.8-1.0 mm)
placed around them in the manner of a figure-of-eight.
To stabilize the joint effectively the wire has to be drawn
just tight enough to permit only 80 per cent of the normal
range of flexion and extension.
Tibial Patellar ligament

tuberosity
Patella
Fig. 10.173. A longitudinal skin incision is made over the cranial aspect of the stifle joint extending from the distal
extremity of the femur to the upper third of the tibia. The skin is reflected to both sides and the underlying connective
tissue is incised to expose the patella, patellar ligament and tibial tuberosity.
DISLOCATION OF THE PATELLA Patella
The commonest cause of medial dislocation of the

patella, either permanent or intermittent, is a
congenital defect. It may be due to a curvature of
the distal extremity of the femur, medial displace-
ment of the tibial tuberosity or abnormalities of Tibial
tuberosity
the trochlea. The object of treatment is to retain
the patella in the trochlea and this is attained by
either transplanting the tibial tuberosity to re-align
the pull of the quadriceps, patella and patellar
ligament, by fashioning a new trochlea or by per-
forming a capsulectomy. Mild cases may be
corrected by a capsulectomy but the majority
require the tibial tuberosity to be transplanted
laterally and reinforced with a capsulectomy.
Fig. 10.174. An incision 2.5-5 cm in length is made through the fascia and joint capsule
In severe cases these measures may have to be just lateral to the patella. This forms the base line for the removal of an elliptical
combined with fashioning a new trochlea. In these segment. This incision is closed with mattress sutures using synthetic absorbable suture
cases the patella is invariably flat and must be material. The first .suture is placed opposite the middle of the patella and pulled tight.
trimmed to shape to fit into the depth of the An attempt is then made to push the patella medially. If this succeeds the elliptical
reconstructed trochlea. incision is enlarged until manual dislocation is not possible. Then closure is completed.
Capsulectomy
The dog is restrained in dorsal recumbency with This incision is closed as described then the original
the affected leg extended and resting on a sandbag. incision is closed by first co-apting the subcutaneous
First, a skin incision is made (Fig. 10.173) and the tissues with interrupted sutures using synthetic
skin reflected so a second incision can be made absorbable material and then the skin in the usual
through the fascia and joint capsule (Fig. 10.174). manner.
Tibial tuberosity Patella Tibial Tibial

crest tuberosity
Fig. 10.178. The tibial tuberosity together with the

Fig. 10.175. The patellar ligament is isolated by passing
patellar ligament is sawn off with a hack-saw blade.
the blade of a scalpel beneath it and severing the fascia!
attachments between the patella and the tibial
tuberosity.
Cranial tibial ism.
Fig. 10.179. Two saw-cuts are made to remove the tibial

tuberosity: one parallel with the tuberosity and the other
placed distal and at right angles to the tuberosity.
Fig. 10.176. The attachment of the cranial tibialis muscle
to the tibial crest is incised.
Fig. 10.177. The cranial tibialis muscle is separated from

the tibial crest by blunt dissection.
Fig. 10.18o. A niche is gouged out of the proximo-lateral

Lateral transposition of the tibial tuberosity aspect of the tibia to form a bed for the transplant.
The patella, patellar ligament and tibial tuberosity
are exposed as described (see Fig. 10.173). The
procedure is shown in Figs 10.175-10.182.
After completing the transplant the stability of
the patella is tested. If it can still be dislocated
medially then in addition a capsulectomy is
performed.
..
I
I
------· I
I
.
I
1;;,7.:
1°=·
I 31
I
.,
I
I
Fig. 10.181. (r) The tibial tuberosity is reflected, held securely on a swab, and two holes drilled through it, 0.3-0.5 cm
apart, with a r.y-mm twist drill. (2) With the same size drill two holes are drilled transversely through the proximal
aspect of the tibial crest in a latero-medial direction. (3) A strand of monofilament stainless steel wire (size o.8- r .o mm)
is threaded through the holes in the tibial tuberosity.
Fig. 10.182. The tibial tuberosity is

transplanted by rotating it through 90° and
passing the wires through the holes in the tibia.
It is then fitted into the prepared bed by
pulling the wires tight and twisting up the
ends. The twisted end is cut off to leave about
0.3-0.5 cm which is pressed flat against the
bone.
Tibia
EPIPHYSEAL SEPARATION OF FRACTURE OF THE
THE TIBIAL TUBEROSITY TIBIAL SHAFT
Efficient joint function is not re-established unless Fractures of the shaft of the tibia are invariably
the detached tibial tuberosity is reduced. An open overriding and often open. A closed reduction is
reduction and fixation with two Kirschner wires difficult and, owing to the shape of the leg, casts
and a figure-of-eight tension band wire is rec- provide inadequate support. These cases may be
ommended (Figs IO. I 83 - 10. 185). treated by open reduction and internal fixation
The implants should be removed as soon as with a bone plate applied to the caudo-medial
healing is established. It is particularly important aspect of the shaft.
to remove the figure-of-eight wire so as not to Although there are disadvantages inherent in
interfere with normal growth. the use of an intramedullary pin, many cases are
PELVIC LIMB - DOG/ TIBIA 231
Tibial crest Figure-of-eight

tension band wire
Cranial Bed of
tibialis m. detached tibial Fig. 10.185. The detached tuberosity is carefully
crest repositioned and immobilized with two Kirschner wires
and a figure-of-eight tension band wire.
Fig. 10.183. The detached tibial tuberosity is exposed via
a longitudinal skin incision extending from the patella to
the upper third of the tibia.
Cranial
tibialis m.
Long digital
flexor m.
Fig. 10.184. After displacement, the epiphyseal breach
rapidly fills with granulation tissue. To reduce the tibial Medial branch
tuberosity accurately it is necessary to remove this tissue ofsaphenous
carefully. vein
Oblique fracture
Tendon of
peroneus
tertius
satisfactorily treated by this method. The pin
should be driven in in a normograde fashion, i.e.
started on the cranial aspect of the tibial tuberosity,
driven distally through the proximal fragment, the
fracture site and into the distal fragment. This
ensures the proximal end of the pin does not enter
the stifle joint. Additional rotational stability can
often be provided with cerclage wires, especially
when the fracture is oblique or spiral (Figs IO. 186-
10.187).
The subcutaneous tissue is co-apted with inter-
rupted sutures of synthetic absorbable material
and the skin sutured in the usual manner. Fig. 10.186. The shaft of the tibia is exposed via a skin
incision along its medial aspect. The subcutaneous tissues
have to be incised and dissected off the shaft to expose
the fracture effectively.
(a) (b)
Fig. 10.187. (a) Immobilization of an oblique fracture

with an intramedullary pin tends to push the edges of the
fracture apart. (b) The edges of the fracture are brought
together and a satisfactory reduction maintained by
placing one or two cerclage wire loops around the bone.
SEPARATION OF THE DISTAL

EPIPHYSIS OF THE TIBIA Fig. 10.188. The displaced epiphysis is reduced and the
fracture immobilized with two Kirschner wires.
In these cases the shaft of the tibia is displaced
cranially, and is treated by an open reduction and
fixation with two Kirschner wires {Fig. IO. 188).
Hock joint
DIS LOCATION OF THE
TALOCRURAL JOINT
Dislocations of the talocrural joint occur in both Distal

the dog .and cat. If it remains stable following a extremity
closed reduction it is immobilized in a cast but if it of tibia
redislocates then it is necessary to perform an
internal fixation and replace the torn collateral Medial
ligaments (Figs rn.189-rn.190). collateral
The incision is closed in the usual manner and ligament
the joint supported in a cast. The wire sutures are
left in situ indefinitely. In some cases they break,
but by the time this occurs considerable peri- Tibial
tarsal
articular fibrous tissue has been laid down which bone
adequately stabilizes the joint, and unless the ends
of a broken wire cause irritation or pain it need not
be removed.
Fig. 10.189. The tarsus is approached from the cranio-
medial aspect by a slightly curved skin incision extending
from the lower third of the tibia to the upper end of
the metatarsal bones. The medial collateral ligament has
a short and long component and generally both must
be replaced.
PELVIC LIMB - DOG/ HOCK JOINT 233
Fig. 10.191. The fracture is exposed via a skin incision

on the plantaro-lateral aspect of the hock joint which
extends from just above the tuber calcis to the
mid-tarsus.
Fig. 10.190. Position of the screws and figure-of-eight
wires to replace the short and long medial collateral
ligaments of the talocrural joint.
Tuber calcis
-4----Tendon of
superficial digital
flexor m.
Fig. 10.192. The tendon of the superficial digital flexor

muscle is dissected from the bone and retracted.
Fig. 10.193. The fracture is immobilized with two

Kirschner wires and a figure-of-eight wire.
the pull of the Achilles tendon. The distractive

FRACTURE OF THE TUBER
force of the Achilles tendon must be counteracted
CALCIS OF THE CALCANEUS
with a figure-of-eight tension band wire on the
It is impossible to maintain an accurate reduction plantar aspect of the tuber calcis to avoid the
of the calcaneus without internal fixation due to development of a non-union (Figs IO. 191 - IO. 193).
234 SECTION I O / 0 RT HO PAE DIC SU R GERY
..... ··'
Fig. 10.194. The dorsal slab is drilled with a 2.7-mm drill

through a drill sleeve. Drilling ceases when the drill bit reaches
the fracture plane.
FRACTURE OF THE CENTRAL

TARSAL BONE
Fractures of the central tarsal bone are common in

the Greyhound and may vary from a fissure with
no displacement or dorsal extrusion of a fragment,
to a comminuted fracture with collapse of the
joint. A displaced dorsal fragment is treated by
replacing the fragment and retaining it in position
with a lag screw (Figs IO. 194- IO. 197) followed by
support in a cast.
Fig. 10.195. The body of the central tarsal bone is drilled

with a z.o-mm drill through a drill insert and the depth of
the hole measured.
Fig. 10.196. Threads are cut into the body of the bone
with 2.7-mm bone tap.
PELVIC LIMB - DOG/ HOCK JOINT 235
Calcaneus
Tendon of the
superficial digital
flexor m.
---,+---- Fourth tarsal bone
Fig. 10.197. A 2.7-mm screw of appropriate length is

inserted. The fracture is compressed as the screw
is tightened. Fig. 10.198. The articular surfaces of the calcaneo-
quartal joint are drilled and curetted so as to destroy
them.
SUBLUXA TION OF THE

PROXIMAL INTERTARSAL JOINT
Rupture of the plantar ligament causes collapse of
the tarsus with resulting hyperflexion of the hock
when weight is taken. Closed reduction followed
by external fixation provides immediate stabil-
ization but when the cast is removed and weight
;..------ Figure-of-eight
taken a degree of hyperflexion inevitably ensues tension band wire
which prevents normal joint function. Arthrodesis
of the calcaneo-quartal joint is the only way to
return the dog to satisfactory locomotor efficiency
(Figs 10.198-rn.199).
Fig. 10.199. A transverse hole is drilled with a I .5-mm

drill bit through the plantar process of the fourth tarsal
bone and a length of stainless steel wire threaded through
it. A second tunnel is drilled through the calcaneus
approximately one-third of its length from its proximal
end and a second piece of stainless steel wire inserted.
The proximal intertarsal subluxation is reduced and a
drill hole is started on the proximal surface of the tuber
calcis. The fibres of the Achilles tendon are divided
longitudinally in order that the drill bit is unimpeded.
The drill is directed down the medullary canal of the
calcaneus and across the calcaneo-quartal joint. The drill
is removed and a small Steinmann pin is driven down its
track and countersunk below the surface of the tuber
calcis. The two pieces of wire are twisted in a figure-of-
eight so as to form a tension band on the plantar aspect of
the joint.
Orthopaedic instruments
In bone surgery, plates, screws, pins and wire are
used. Few metals can be left in the body without
causing a severe tissue reaction but three have
been found satisfactory for surgical implants. First,
(a) .;.•..• .•
,_
,
..
,,
stainless steel of -the SMO or EAN58J variety

(b)
which is an austinitic stainless steel containing
about 18 per cent chromium, 8 per cent nickel, and
2-4 per cent molybdenum. Secondly, vitallium or
vinertia, a non-ferrous alloy containing 65 per cent Fig. 10.200. Regular (a) and broad (b) 3.5-mm dynamic compression plates.
cobalt, 30 per cent chromium, and 3 per cent
molybdenum and thirdly, titanium, an element
which is very light.
The choice of metal for bone plates, screws, etc.
is very much a matter of personal preference. The
authors have found the stainless steel implants to
be entirely satisfactory, being inert in tissues, cor-
rosion resistant and having the necessary mechan-
ical strength.
Different metals should not be used in contact
with one another. A stainless steel bone plate
should not be held in place with vitallium screws
(d) ••••••••••••••••••••
as electrolytic and chemical reactions will cause
corrosion of the implants. This results in local Fig. 10.201. Some special ASIF plates: (a) a double hook plate; (b) a T plate; (c) a
tissue reaction which may be followed by wound reconstruction plate; and ( d) a veterinary cuttable plate.
breakdown or the non-union of a fracture.
BONE PLATES
Bone plates are designed to provide maximum

strength with minimal dimensions and are con-
toured slightly to accommodate the curvature of
the bone. Three variations are in common use:
(i) compression plates, of which there are many
sizes and variations (Figs I0.200-rn.201), (ii) the
Venable bone plate, and (iii) the Sherman plate.
Fig. 10.202. Venable bone plate. This plate has no constrictions between the screw holes
Compression plates and is relatively strong. For this reason it is the most satisfactory bone plate for general
veterinary orthopaedics when ASIF plates are unavailable. They are obtainable in eight
ASIF dynamic compression plates range from the lengths from 38 mm to 127 mm.
broad 18-hole 4.5 mm to the three-hole 2-mm
miniplate. The holes are elliptical so that when
Length (mm) Holes
eccentrically placed screws are tightened the bone
moves relative to the plate and the fracture line is
38* 4
compressed. 45* 4
A wide variety of special plates is available in 64 4
the ASIF system making these plates very versatile. 76 4
90 4
102 6
Non-compression plates Il4 6
127 8
See Figs rn.202-rn.205.
Note. These bone plates are drilled and countersunk to
accept 4-.mm bone screws with the exception of the plates
marked (*) which take a 3.6-mm screw.
ORTHOPAEDIC INSTRUMENTS 237
Fig. 10.203. Sherman bone plate. The shape of this plate

is not conducive to strength, and it has therefore only a
limited application in veterinary orthopaedics. It is
obtainable in lengths from 25.4 mm to 140 mm and is
drilled and countersunk to accept 4-mm screws,
Fig. 10.204. Eggers contact splint. Basically a bone plate but with slots in place of the normal screw holes. It is designed
to assist the longitudinal muscle pull and pressure of weight bearing to maintain the fractured ends in close contact. It is
obtainable in lengths from 38 mm to 127 mm. The slot accepts a 4-mm screw.
Fig. 10.205. Heavy duty bone plate. This plate is 4.8 mm thick and obtainable with either screw holes or slots to the
following lengths: 150 mm, 180 mm and 205 mm. It is drilled and countersunk to accept 4-mm bone screws. This plate is
useful for the fixation of fractures in large dogs.
screw. If the drill hole is too large it reduces the

BONE SCREWS
holding power of the screw and if too small the
bone tends to split.
Sherman screws
Sherman screws have either fine or coarse threads

and the screw slot may be either the plain slot, the
Phillip's recessed head or the cross slot. The threads
extend the full length of the screw to enable
purchase to be obtained on both cortices of the
Fig. 10.207. Transfixion screw. This is a partially
bone. The maximum holding power of the screw is
threaded self-tapping screw and is used for drawing
obtained when the size of the drill hole is approxi- together two bone fragments. The length of the smooth
mately 85 per cent of the outside diameter of the shaft near the head enables the loose fragment to be
drawn up against the fixed or larger fragment. It is
obtainable in the following sizes:
Diameter (mm) Lengths (mm)

Fig. 10.206. Sherman bone screw ( coarse thread 20
threads per inch (t.p.i.) with plain slot). This is a 4.4 44.5, 51.0, 57.0, 63.5, 70.0, 76.0
standard orthopaedic screw, and is self-tapping, with a
truncated end. It is obtainable in the following sizes:
Recommended sizes of twist drills to be used for various
screws:
Screw, outside Drills, outside
2.8 9.5, 12.7, 15.9, 19.0, 22.2, diameter (mm) diameter (mm)
25.4, 28.5, 31.5, 35.0, 38.0
Transfixion screw 4.4 4.0
3.6 and 4.0 (20 t.p.i.) 9.5, 12.7, 15.9, 19.0, 22.2,
25.4, 28.5, 31.5, 35.0, 38.0, Sherman screw 2.8 2.3
41.5, 44.5, 47.5, 51.0, 57.0, 3.6 2.8
63.5, 70.0, 76.0 4.0 3.2
Fig. 10.208. Screw depth gauge. Used to determine the length of screw needed to penetrate a bone. The hooked end of
the gauge is inserted into the drilled hole and hooked over the distal bone surface. The sleeve is then pushed against the
bone or bone plate, fixed in position by tightening the screw and the gauge withdrawn. The calibrations on the stem
indicate the length of screw required.
Fig. 10.209. Screwdriver with holding sleeve. This combination facilitates the driving of screws which are firmly locked
to the end of the sleeve. This dispenses with supporting the screw in screw-holding forceps or with the fingers. When the
screw is three-quarters driven the sleeve is removed and the screw driven home in the usual manner.
ASIF bone screws

This screw (Fig. 10.210) is used in cortical bone. It
has a round end and therefore requires a precut
thread to be cut in the bone with a bone tap.
Diameter (mm) Lengths (mm) Drill bit size (mm) Tap size (mm)
1.5 6-20 I.I 1.5

2.0 6-24 1.5 2.0
2.7 6-40 2.0 2.7
3.5 10-IIO 2.5 3.5
4.5 14-IIO 3.2 4.5 Fig. 10.210. ASIF cortical bone screw.
5.5 24-100 4.0 5.5
Cancellous bone screw

This screw (Fig. 10.2u) is used in cancellous bone
and has deeper threads.
Diameter (mm) Lengths (mm) Drill bit size (mm) Tap size (mm)
10-60 2.0 3.5

10-50 2.5
30-IIO 3.2 6.5
Fig. 10.2n. ASIF cancellous bone
screw.
DRILLS
ASIF bone drills

ASIF bone drills have a quickfit locking system
which enables a rapid change of drill bit.
Bone taps (Fig. 10.212) are used to cut a thread
in the bone when using screws that are not self-
tapping. This enables the thread of the screw to
match the thread in the bone and improves its pull- Fig. 10.212. ASIF bone tap.
out strength.
A countersink (Fig. 10.213) increases the area of
contact between the screwhead and bone, thus
spreading the force over a greater area.
Tap guides (Fig. 10.214) protect the soft tissues
from the sharp threads of the bone taps. They also
discourage lateral movement of the tap as it cuts
through the bone.
Drill sleeves (Fig. 10.215) fit within the larger
gliding hole and ensure the smaller thread or pilot
hole is drilled in exactly the same direction. A
4.5-mm drill sleeve has a 4.5-mm outer diameter
and 3.2-mm inner diameter.
Fig. 10.213. ASIF countersink.
Fig. 10.214. Tap guide.
Fig. 10.215. Drill sleeve.
Fig. 10.216. Screwdriver for hexagonal socket heads.

Most ASIF screws have hexagonal heads but different
sizes require a different sized screwdriver.
240 SECTION IO/ ORTHOPAEDIC SURG.ERY
Otherdrills
See Figs rn.217-10.219.
Fig. 10.217. Drills. Bone drills are made from either stainless steel or vitallium.
Stainless steel twist drills are obtained in the following sizes:
Length (mm) Diameters (mm)
76 and 127 I.6, 2.0, 2.4, 2.8, 3.2, 3.6, 4.0,

4.4, 4.8, 6.3
Fig. 10.218. Pistol-grip hand drill with Jacob's chuck. This drill has a two-to-one gear
ratio and is cannulated its entire length to accommodate Steinmann pins and long-shank
drills up to a 6.3-mm diameter.
Fig. 10.219. Cortex reamer. Used for boring holes by hand and is especially useful for
starting a hole prior to drilling.
ORTHOPAEDIC INSTRUMENTS
INTRAMEDULLARY PINS
AND NAILS
A variety of intramedullary pins and nails (Figs Fig. 10.220. Steinmann pin. This pin is the standard veterinary intramedullary pin. It is
10.220-10.223) are used for the internal fixation round in cross-section and pointed at both ends so that it can be inserted via the fracture
of fractures. The most suitable metal for this type site. The pins are obtainable in the following sizes:
of implant is stainless steel. To secure satisfactory
immobilization the pin must impact the medullary Diameter (mm) Lengths (mm)
cavity.
1.6, 2.0, 2.4, 2.8, 3.2, 3.6, 4.0, 4.8, 6.4, 8.o 127, 150, 180,205,230,255,280,305
Fig. 10.221. Rush intramedullary pin. This pin is round in cross-section, has a 'sledge-
runner' tip at one end, and a hook at the other to grip the cortex at the point of insertion.
It is inserted at an oblique angle at the side of the bone and when it's 'sledge-runner' tip
strikes the opposite cortex it does not penetrate it but is deflected and runs along the
medullary cavity. It does not immobilize a fracture by impacting the medullary cavity
but rather by the spring-like action obtained by opposing point pressures within the
medullary cavity. It is obtainable in the following sizes:
2.4 25- 102 (in 6-mm increments)

3.0 102-256 (in 13-mm increments)
4.8 203-355 (in 19-mm increments)
6.o 280-432 (in 19-mm increments)
Fig. 10.222. Kuntscher nail. This nail is fluted and in cross-section either clover-leaf-
shaped or V-shaped to enhance its grip in cancellous bone and to control rotation. The
V-shaped nail is the type generally used in veterinary orthopaedics. It has a rounded
point and a hole at the other end to engage the extraction hook. It is inserted by being
driven into the medullary cavity via the extremity of the bone. It is obtainable in the
following sizes:
6 and 8 140, 16o, 180, 200, 240, 250, 260,

270, 280, 300, 320, 340
Fig. 10.223. (Right). Kirschner wire. This may be

described as a very fine Steinmann pin. It may be
obtained in stainless steel or vitallium. The former is
supplied in the following sizes:
o.8, 1. 1 and 1.5 6.25, 7.5, 8.75, 10.0, 22.5, 25.0,

30.0
ORTHOPAEDIC WIRES
See Figs 10.224- 10.226.
--
Fig. 10.225. Wire-holding forceps. These forceps are

shaped and designed for gripping and manipulating wire.
Fig. 10.224. Cerclage wire. Fragments of bone can be

held together with suture wire either passed through a
drill hole in each fragment or by a circumferential wire
loop. The ends of the wire are held in wire-holding
forceps, pulled tight and secured by twisting them
together, and then cutting off the twisted end with wire-
cutting forceps and pressing the stump flat against the
bone.
Stainless steel cerclage wire (monofilament) is
obtainable in four sizes (0.8-1.5 mm diameter).
Suture wire is made from either stainless steel or
tantalum and may be obtained either as a single strand
(monofilament) or with several strands either twisted or Fig. 10.226. Suture-wire scissors.
braided (multifilament). Although the multifilament wire
is less likely to kink and is more flexible, it is the
monofilament stainless steel suture wire that is in general
use in orthopaedics.
Stainless steel suture wire is available from 1.5 to 9
metric with a variety of swaged-on needles.
BONE-CUTTING INSTRUMENTS
See Figs 10.227-10.231.
Fig. 10.227. Chisel. Is bevelled on one side only and

used for cutting or shaping bone. It is obtainable in the
following widths: 6, 8, IO, 12, 15, 20, 25 and 3omm.
Fig. 10.228. Gouge. Is used for cutting out a groove or

hollow in a bone. It is obtainable in the following widths:
6, 8, IO, 12, 15, 20, 25 and 3omm.
Fig. 10.229. Osteotome. May be described as a special type of chisel and is used for dividing bone. The edges are
bevelled equally o l-ioth sides. It is obtainable in the following widths: 6, 8, IO, 12, 15, 20, 25 and 30 mm.
Fig. 10.230. Liston's bone-cutting forceps. The standard type of bone-cutting forceps, which are obtainable with either
straight or curved jaws.
BONE-HOLDING INSTRUMENT
See Fig. 10.232.
Fig. 10.232. Frosch's bone-holding forceps. A very

useful pattern of forceps for holding and manipulating
small bones.
Fig. 10.231. Luer bone-nibbling forceps. Powerful

double-action forceps designed for removing small pieces
of hard compact bone.
Section 11
Amputations
'I•.
i
.
I
I~
I
JIu
·.t
I
t
Amputation of a limb
Many small dogs and cats live normal and active
lives after amputation of either a front or a hind
leg, whereas farm animals and the larger breeds of
dog are severely handicapped by the loss of a limb.
When planning an amputation it is not necessary to
fashion a stump suitable for fitting a prosthesis,
and one should therefore aim to produce a short
stump which will not unbalance the animal or
cause it any encumbrance. The usual site to ampu-
tate a front leg is through the middle of the humer-
us, or for a hind leg through the middle of the
femur. Forequarter amputation, removing · the
scapula and the humerus in their entirity, may be
required in the management of some tumours.
Similarly, the hindlimbs may, on occasion, be dis-
articulated at the hip joint.
Fig. 11.1. The dog is placed in lateral recumbcncy with the affected leg uppermost,
AMPUTATION OF THE resting on a sandbag. The distal extremity of the leg is draped in the customary manner
THORACIC LIMB - DOG and passed through the opening of a laparotomy sheet to permit ease of manipulation
during surgery.
Left thoracic limb
See Figs 1 1. 1 - 1 1.9.
Triceps
brachii m.
Cephalic
vein
Extensor
carpi
radialis m.
Brachio- ""''";,':.,":-,,-','-- Distal

cephalicus limit
m. of skin
incision
Fig. 11.2. A semicircular skin incision is made on the

lateral aspect of the limb extending from a line through
the middle of the humerus down to the elbow joint. The
leg is then abducted and the incision joined by a
corresponding incision on the medial aspect. The skin
flap is reflected on the lateral aspect to expose the long
and lateral heads of the triceps brachii muscle, the
brachiocephalicus muscle and the cephalic vein, which is
ligated.
247
248 S EC TIO N I I / A M PUT A TIO N S
Triceps brachii m. Biceps brachii m.
Triceps
Brachialis m. brachii m.
Superficial
radial nerve ---;=---===~t!i
Ulnar nerve Brachia! vein Brachia! artery
Fig. 11.5. The leg is elevated and the skin flap on the
medial aspect reflected to expose the biceps brachii
muscle, the brachia! artery and vein which are ligated
Fig. 11.3. The common tendon of insertion of the triceps brachii is severed, and the and the ulnar nerve which is severed proximally.
muscle mass reflected proximally to expose the brachialis muscle where it curves around
the lower third of the humerus and the superficial radial nerve which is severed
proximally.
Brachialis m. Shaft of humerus Brachia!

artery and vein
Ulnar
nerve
Biceps
brachii m.
Brachio-
cephalicus
m.
Biceps
brachii m.
Fig. 11.6. The biceps brachii muscle is severed just

proximal to where it divides to be inserted onto the
radius and ulna and is reflected. The leg can now be
amputated by sawing through the shaft of the humerus
using a hack-saw blade.
Fig. 11.4. The brachialis and brachiocephalicus muscles arc severed and reflected to
expose the lateral aspect of the shaft of the humerus.
AMPUTATION OF A LIMB 249
Triceps
Brachiocephalicus m. Brachialis m. brachii m.
Fig. I I. 7. The ends of the severed muscles arc sutured

together with interrupted synthetic absorbablc sutures,
to form a protective muscle pad over the stump of the
humerus. The brachialis and biceps brachii muscles arc
first sutured together over the stump and then the
brachiocephalicus and triceps brachii muscles. Biceps brachii m.
Brachiocephalicus m. Triceps brachii m.
Fig. 11.8. After the ends of the muscles have been

sutured together care must be taken to ensure that their
edges are also co-apted.
Fig. 11.9. The skin flaps arc co-apted with interrupted

mattress sutures using rnonofilament nylon.
250 SECTION I If AMPUTATIONS
AMPUTATION OF THE
PEL VIC LIMB - DOG
The leg is draped and positioned in the same

manner as described for the thoracic limb.
Left pelvic limb
See Figs. 11.10-11.13. Quadriceps

femoris m.
Biceps
femoris
Sartorius m. m.
Fig. II.IO. A semicircular skin incision is made on the

lateral aspect of the hind leg, extending from a line
through the lower third of the thigh down to the stifle
joint. The leg is then abducted and the incision joined by Line of
a corresponding incision on the medial aspect. The skin incision
of the
flap is reflected on the lateral aspect to expose the fascia lata
sartorius, quadriceps femoris, biceps femoris muscles
and the fascia lata. The fascia lata is incised along the
length of its attachment to the biceps femoris muscle.
Quadriceps
femoris m.
Sartorius m.
Biceps
Distal femoris m.
caudal
femoral
artery
Line of incision of
aponeurosis of biceps
femoris m.
Fig. II.II. The quadriceps femoris and biceps femoris muscles are separated by blunt dissection to expose the lateral
aspect of the femur. The tendon of insertion of the quadriceps femoris muscle and the cranial belly of the sartorius
muscle are severed proximal to the patella and reflected to expose the lateral aspect of the femur arid the distal caudal
femoral artery, which is ligated.
AMPUTATION OF A LIMB 251
Semimembranosus m.
Shaft
of femur ---:,;,c+,~~:":--Wii+I--",
Semitendinosus m.
Sciatic nerve
Popliteal artery
Fig. I I. 12. The aponeurosis of insertion of the biceps femoris is incised transversely and the muscle reflected to expose
the poplitcal artery, the sciatic nerve and the adductor, scmimcmbranosus and semitcndinosus muscles. The popliteal
artery is ligated and the sciatic nerve divided proximally.
Sartorius m.
Semimem-
branosus m.
7'7"~i,,-- FemoraI
artery
and vein
Semitendin-
Saphenous
osus m.
nerve
Fig. 11.13. The leg is elevated and the skin flap on the medial aspect reflected to expose the caudal belly of the
sartorius and the gracilis muscle. These muscles are severed and reflected to expose the femoral artery and vein which
are ligated and the saphenous nerve which is divided proximally. Also exposed are the semimcmbranosus and
semitendinosus muscles which arc severed together with the underlying adductor muscle to expose completely the shaft
of the femur. The leg can now be amputated by sawing through the shaft of the femur using a hack-saw blade and the
operation completed in the manner described for amputating the thoracic limb.
Amputation of digits
The amputation of a digit or phalanx does not cartilage is removed from the distal end of the first
seriously interfere with the locomotor efficiency of phalanx using a scalpel or curette. Any necrotic
the animal. Many dogs which have had a digit tissue is removed by sharp dissection, and the stump
amputated continue to perform satisfactorily on of the deep flexor tendon and its synovial sheath
the race-track and in other sports, and farm animals are examined for evidence of infection.
remain as economic units within the herd or flock. The operation is completed by packing the
wound with a non-adhesive dressing and a cotton
wool pad. The foot is enclosed in cotton wool and
AMPUTATION OF A
a cotton bandage, and finally Elastoplast is applied
DIGIT - CATTLE
as a pressure bandage to control haemorrhage.
The most common indication for amputation of
the digit is infection of the coronopedal joint which
is most frequently a sequel to solar ulceration or
white line abscessation at the sole-heel junction.
Infection of the flexor tendon sheath and discharg-
ing sinuses above the coronary band may be further
complications. Gross trauma to the digit and infec-
tion of the pastern joint are much less common
indications for amputation.
The aim is to remove all necrotic and infected
tissue. Provided this is achieved, the patient will be
walking on the remaining digit within a few days
and healing will be rapid.
The cow is cast and placed in lateral recumbency
with the affected digit uppermost. Alternatively
the operation may be performed with the cow
standing if one of the crushes specifically designed
for foot trimming is available, because these pro-
vide support for the animal and enable the limb to
be adequately immobilized. Anaesthesia can be
achieved simply and effectively using an intra-
venous regional nerve block. Fig. 11.14. An incision is made with a scalpel 0.5 cm
Amputation (Figs I I. 14- I I. 16) may be carried above the coronary band. It is continued through all
structures down to the underlying bone and continued in
out above or below the proximal interphalangeal like manner to encircle the digit.
joint by sawing through the first or second phalanges
respectively, or by disarticulation of that joint
which is the method preferred by the authors.
The incision is made 0.5 cm above the coronary
band and is continued through all the tissues to the
underlying bone and continued in like manner to
encircle the digit.
The second phalanx is exposed on its lateral
aspect and the dissection is continued upwards to
the proximal interphalangeal joint which is located Pastern joint
I .5 cm above the initial skin incision. Escape of
synovial fluid indicates that the joint has been

reached.
The joint is disarticulated by continuing the in-
cision around the joint thereby transecting the
extensor tendon cranially, the flexor tendon cau-
dally and the medial collateral ligament. This is Fig. 11.15. The second phalanx is exposed by separating
made easier by manipulating the digit. the surrounding reactionary fibrous tissue from it with an
Once the digit has been removed, the articular orthopaedic chisel.
252
AMPUTATION OF DIGITS 253
Distal articular
surface of first phalanx
Deep flexor tendon
Deep flexor tendon

sheath
Curette to remove
articular cartilage First
metacarpal
bone
Fig. 11.16. The distal limb is disarticulated at the
proximal interphalangeal joint and the articular cartilage
of the distal surface of the first phalanx is curetted. Any
necrotic tissue within the deep flexor tendon sheath must
be excised before the stump is bandaged.
The stump is checked for any evidence of infec-

Fig. 11.17. An elliptical skin incision is made to encircle the digit (1) and the
tion 4 days post-operatively and the dressing is subcutaneous tissue dissected free to expose the first metacarpal bone and proximal
renewed. Provided there are no complications, phalanx (2).
further dressings are not required.
AMPUTATION OF FIRST DIGIT First metacarpal bone

OR DEW CLAW - DOG
In the thoracic limb the first digit has two phalanges

and articulates with the first metacarpal bone
whereas in the pelvic limb it is attached to the
metatarsal bone by fibrous tissue.
It is customary to remove the first digit, when
the puppy is 2-4 days old, with a pair of curved Proximal
phalanx
scissors. Haemorrhage is controlled by digital
pressure or the application of a styptic and the
wound left to heal by granulation.
If the first digit has not been removed at this
early age it is advisable to leave the dog until it is
over 3 months of age and perform a radical oper-
ation (Figs 11.17-11.20). Fig. 11.18. The digit is retracted distally. The proximal phalanx and distal extremity of
the first metacarpal bone are freed by dissection from the underlying tissues. This
dissection exposes the digital artery and vein which are picked up with artery forceps and
ligated.
254 SECTION I I/ AMPUTATIONS
Stump of first
metacarpal bone
Fig. 11.20. The incision is closed by co-apting the skin

and subcutaneous tissues with a series of interrupted
First metacarpo-phalangeal joint sutures using monofilament nylon. The wound is
protected with a 'non-stick' dressing, cotton wool pad
Fig. 11.19. The digit is amputated by severing the first and bandages.
metacarpal bone with bone-cutting forceps.
moved the dog will go lame after exercise because

AMPUTATION OF DISTAL
the pad provides insufficient protection against
PHALANX - DOG
concussion. If they are removed the end of the
The success of this operation depends on the bone receives no direct concussion as it is protected
removal of the condyles of the second phalanx with a covering of fibrous tissue and does not come
(Figs 11.21-11.23). If the condyles are not re- into direct contact with the pad.
Fig. 11.22. The condyles of the second phalanx arc

removed with bone-cutting forceps.
Condyle second phalanx
Fig. 11.21. The nail is held in maximum flexion, a stab

incision is made at right angles to the digit and as close to
the base of the nail as possible, through the skin,
subcutaneous tissues and into the distal interphalangeal
joint. The incision is then extended to meet the pad on
either side. The distal phalanx is completely
disarticulated and removed by incising the skin on the
ventral surface in close proximity to the pad.
AMPUTATION OF DIGITS 255
Fig. 11.25. The horn is split with bone-eutting forceps

and separated from the ungual process.
Fig. 11.23. The pad is sutured to the skin with three or

four interrupted sutures using monofilament nylon. The
wound is protected with a 'non-stick' dressing. A small
tampon of cotton wool is placed in each interdigital space
and the whole foot enclosed in a cotton wool pad and
bandage.
REMOVAL OF A CLAW - DOG

Fig. 11.26. Each section of split horn is seized with
When a dog turns or corners at speed it pivots on artery forceps and carefully eased away from the ungual
its claws. This action puts considerable stress on crest of the third phalanx and the ventral surface of the
corium.
the interphalangeal joints. The removal of a claw is
a method employed to relieve pressure on injured
interphalangeal joints (Figs 11.24-11.27).
Fig. 11.27. The ungual process is removed with bone-

cutting forceps, as close to the ungual crest as possible,
and the surface lightly cauterized with silver nitrate.
Fig. 11.24. The dorsal surface of the claw is levelled by

shaving away the horn with a scalpel.
Amputation of a tail (docking)
Docking is practised in all animals as a method of
treating gross injuries and neoplasia of the tail.
Docking of lambs' tails is routinely employed.
DOG
Docking of dogs' tails may be required for medical
reasons. The dog is placed in ventral recumbency
and its tail clipped and prepared for surgery. A
tourniquet is applied at the base of the tail. The
skin is incised dorsally and ventrally to create two
elliptical skin flaps. The ventral and lateral coc- Fig. II .28. A tourniquet is applied at the base of the tail
cygeal arteries are ligated or cauterized and the tail and the skin incised so that two elliptical skin flaps arc
removed by disarticulation of the intercoccygeal fashioned, one dorsal and one ventral.
joint proximal to the apex of the skin incision
(Figs II .28-11.32).
The end of the coccygeal vertebra is protected
by suturing any available soft tissue and closing the
skin with a series of interrupted mattress sutures.
Fig. 11.29. The proximal skin flaps arc reflected to

expose the intercoccygeal joint proximal to the apex of
the incision.
Lateral
coccygeal
artery
lntervertebral
fibrocartilage
Fig. II .30. The tail is removed by disarticulation and th€

coccygeal artery and lateral coccygeal arteries picked up
and ligated.
AMPUTATION OF A TAIL 257
lntervertebral
fibroca rti I age
Lateral
coccygeal artery
and vein
Coccygeal
artery and vein
Fig. 11.31. Cross-section representation of the tail at

point of disarticulation. Note the positions of the
coccygeal arteries.
Fig. 1 r .33. The correct method of holding and

restraining a lamb for docking.
Fig. 11.32. The end of the coccygeal vertebra is

protected and the wound closed by co-apting the skin
flaps with interrupted mattress sutures.
LAMB
Lambs are generally docked when a few days old

using the 'rubber ring' method (Figs I I .33- Ir .34).
The contraction of the rubber ring produces a
pressure necrosis of the underlying tissues which
results in the tail separating in 10- 12 days. It
causes little discomfort, no haemorrhage ensues,
sepsis is rare and the stump heals by granulation.
Fig. 11.34. The rubber ring is affixed with the aid of an

Elastrator instrument and is adjusted to lie just distal to
the caudal fold. Care should be taken not to weaken the
contraction of the ring by over-stretching it.
Section 12
Miscellaneous Procedures
Repair of accidental skin wounds
Many accidental skin wounds are irregular and
infected, with the skin edges either bruised or
devitalized so that primary union is impossible. d<-
-T-1-1-1-l-<'
x/
Bruised and infected tissue tends to slough, leaving ~x
an area which eventually heals slowly by granu-
lation. This often leaves a large scar, devoid of (a)
hair, which gradually contracts giving rise to un-
sightly contraction lines. I\
A
I \
Provided excessive amounts of skin have not I
I•\
\
I \
been lost, these skin wounds can often be closed by I
I
I \
\
\
I \
direct suture, which avoids the lengthy process of ,' ", ,~-...
healing by granulation and the subsequent un- '-----------~
sightly scarring. Even in cases where sloughing is (b)
anticipated suturing should be attempted, as inevi-
tably a limited amount of primary union will take
place, leaving less tissue to heal by granulation.
In cases with considerable local tissue damage, it -H-H-l-l-1-l-
is sometimes necessary to carry out extensive
wound debridement, and then to wait until healing
(c)
by granulation is well established before attempting
wound closure. During this process the skin edges Fig. 12.1. Methods of closing irregular wounds by skin excision and direct suture.
become adherent to the underlying granulating
tissue, and so lose their elasticity. Therefore, before
attempting to co-apt the skin edges, it is essential
,
..
\
to free them from the underlying tissue and to I \
!"'
I \
undermine the skin for some distance around the I

I
' T'
wound edges in order to produce the maximum
I
I • I T
I
I , I
I
skin mobility. It is equally important to ensure that '' \
\
,,l +
the granulating surface is healthy, free from infec- (a)
tion and below the level of the surrounding skin. In
many wounds with irregular edges and skin retrac-
--'-<
tion it is not possible to co-apt the skin edges by T'
I
direct suture without first removing the exuberant

granulation tissue and excising and undermining
+
..J-
the surrounding skin (Fig. 12.1). (b) +

When dealing with extensive skin wounds which
Fig. 12.2. (a) Closure by double counter-incision. The skin between the defect and the
cannot be closed by direct suture, the edges of the counter-incision is undermined. In many cases, after co-apting the edges of the defect it
defect may be relieved of tension by counter- is then possible to suture together the edges of the counter-incisions, but if not they are
incision (Fig. 12.2). left to heal by granulation. (b) Closure by a single counter-incision. The skin between
the defect and the counter-incision is undermined, and after co-apting the defect the
counter-incision is closed by Y-plasty.
Tendon injuries
Ruptures and wounds of tendons are most fre- cation of the damage to the underlying tendon.
quently encountered in the horse and dog. All skin The digital flexor tendons are the tendons most
wounds in the vicinity of tendons must be carefully frequently involved. Any wound on the caudal
explored as the size of the wound gives no indi- aspect of the limb below the carpus or hock must
261
262 SECTION I 2 / MISCELLANEOUS PROCEDURES
be viewed with the utmost concern. Little alteration

will be seen in limb posture if the damage is limited
to the superficial digital flexor tendon, but if the
deep digital flexor is also severed, characteristic
lifting of the toe is evident when weight is borne on
the leg. When the suspensory or distal sesamoidean
ligaments are damaged there will be marked sinking
of the fetlock. The wounds are often grossly con-
taminated with involvement of the tendon sheath.
Carbon fibre
TENDON REPAIR prosthesis
bridging gap
Under general anaesthesia an extensive area above between the
tendon ends
and below the wound is prepared for aseptic sur-
gery. A long skin incision is frequently necessary
to expose the ends of the tendons which may have
retracted a considerable distance. Before attempt-
ing to repair the tendon all frayed avascular and (a) (b)
contaminated tissue must be removed and the ends
Fig. 12.3. Repair of deficit in flexor tendons using carbon or polyester fibre prosthesis.
trimmed back until normal tendon tissue is ex-
(a) By suture with absorbable synthetic material to the surface of the tendon. (b) By
posed. When the damage has been caused by a implantation into .t-shapcd incisions into the tendon and suture.
sharp object, such as glass, the amount of tendon
which has to be removed is minimal making it
feasible to join the ends by suturing using a strong
non-irritating suture material such as stainless steel.
However, traumatic severence of the digital flexors best sutured using a variation of the Ford inter-
in the horse by over-reach wounds when the animal locking suture (Fig. 12.6).
is moving at speed frequently results in severe
fraying of the tendon ends. In these cases the
INFERIOR CHECK LIGAMENT
considerable gap which is left between the ends of
DESMOTOMY
the tendon when all the irreparable tissue has been
removed must be bridged by using a prosthetic Severe contraction of the deep flexor tendon in
material which will act as a scaffold for neontendon foals which does not respond to manual stretching,
formation. Twisted or plaited carbon fibre and paring down of the heel, and extension of the toe,
polyester fibre have been used successfully for this can be treated successfully by desmotomy of the
purpose. The fibre is embedded in T-shaped inferior check ligament.
incisions in the two ends of the tendon and With the patient in lateral recumbency under
anchored with interrupted sutures of absorbable general anaesthesia, the check ligament is ap-
synthetic material (Fig. 12.3). The paratendon and proached from the lateral or medial aspect in the
subcutaneous tissues are closed separately in a proximal third of the metacarpus (Fig. 12.7a).
simple continuous pattern and the skin with simple Identification of the ligament is facilitated by the
interrupted sutures. The wound is dressed with use of an Esmarch bandage. The skin, subcutis and
sterile gauze and the leg is cast in a slightly flexed deep fascia are incised along the cranial border of
position up to the level of the carpus or tarsus for the deep flexor tendon (Fig. 12.7b). The groove
7- ro weeks. In the horse, following removal of between the check ligament and the deep flexor
the cast continuing support for the healing tendon tendon is identified allowing the ligament to be
is provided by a shoe with extended branches. isolated with dissecting scissors and transected (Fig.
12.7c). Fascia and skin are sutured with absorbable
suture material and an elastic bandage applied
TENDON SUTURE
from coronet to carpus. Some improvement in the
Numerous suture patterns exist for the repair of position of the foot is evident immediately post-
tendons but the following three will be found suit- operatively but daily exercise on a hard surface is
able for most occasions. Round tendons may be necessary to complete the stretching of the muscle-
sutured using a locking loop pattern (Fig. 12-4) or tendon unit. This process is helped by shortening
a triple pulley suture (Fig. 12.5). Flat tendons are the heel and applying a shoe with an extended toe.
TENDON INJURIES 263
Fig. 12.6. Ford interlocking suture for flat tendons.
Fig. 12.4. Locking loop suture for round tendons. This

suture is placed in the order shown.
Deep digital
flexor tendon
Inferior check __;;;;~~,._
ligament
(a)
(c)
(b)
Fig. 12.7. Identification and isolation of subcarpal check ligament from the deep digital
flexor tendon.
Fig. 12.5. Triple pulley suture for round tendons. This is

a stronger suture pattern then the locking loop.
Prolapse of the rectum
This condition occurs in all species, but is most Outer layer
common in the pig. In the majority of cases there is Inner layer
no obvious cause for the condition, and providing
that there is no irreversible damage to the prolapsed
rectum, it can easily be replaced and maintained in
•
position by means of a purse-string suture placed
around the anus.
If, however, the prolapse has been present for
some time, then an intense venous congestion of
the prolapsed viscus will occur. In addition, the -------------Line of
amputation
congested and devitalized tissue may become
traumatized to such a degree that amputation offers
the only hope for successful treatment (Fig. 12.8).
Before attempting amputation, it is necessary to
pass a probe between the prolapse and the anal (b)
ring in order to ascertain that one is dealing with a
rectal prolapse, and not with the terminal portion
of a piece of intussuscepted small intestine.
Fig. 12.8. ( a) In order to prevent the inner portion of the

prolapse retracting into the abdominal cavity after
amputation, a stay suture should be inserted into each
quadrant through all layers of the prolapse, using strong
suture material of any type. (b) The rectum is amputated
distal to the stay sutures, and any bleeding vessels picked
up and ligated. The outer and inner layers of the
amputated rectum are then sutured together, using
interrupted sutures of a suitable size synthetic absorbable
material. (c) The stay sutures are removed and the stump
returned through the anus. A purse-string suture is
inserted around the anal ring, and tied just tight enough
to prevent a further prolapse, yet allowing sufficient
room for defecation. It should be removed 48 hours
later.
Excision of anal sacs - dog

The anal sacs lie on the ventrolateral aspect of the most suitable for this purpose. These have a rela-
anus, deep to the external anal sphincter muscle, tively short 'pot life' but long enough to enable the
and their ducts open on the mucocutaneous border material to be injected into the sac through its
of the rectum. They are adequately supplied with excretory duct. After setting, the plastic remains
blood from both the caudal rectal and the perinea! rubber-like in texture and allows easy identification
arteries (Fig. 12.9). of the anal sacs. To excise the anal sacs the skin is
In order to ensure the complete removal of the incised over them on either side of the anal opening.
anal sac it is common practice to outline the sac By blunt dissection the sac is freed, the duct iso-
with a variety of packing materials. These vary lated, ligated with 3 metric synthetic absorbable
from cotton wool, wax, to plaster-of-Paris, but suture material and removed. Due to the extensive
modern dental impression plastics are probably the blood supply, haemostasis must be of a high stan-
CASLICK'S OPERATION FOR PNEUMOVAGINA - MARE 265
External anal sphincter m.
Anal sac
Rectum
Anal
sphincter
Internal
pudenda!
artery
Fig. 12.9. The blood supply to the anal sac of the dog.
dard, and care must be taken to obliterate the dead tinuous 2 metric synthetic absorbable suture before
space created by removal of the sac with a con- suturing the skin.
Caslick's operation for pneumovagina - mare

In a mare of normal conformation, the caudal part
of the vagina acts as a valve which prevents the
aspiration of air and bacterial contaminants into Rectum
the genital tract (Fig. 12. ro). This valve effect may
be destroyed by injury to the perineum at foaling,
or impaired by defects in conformation which may
be either congenital, or acquired with age. The
aspiration of air and bacteria into the vagina leads
to vaginitis and cervicitis, and is a serious cause of
infertility in mares, particularly of Thoroughbreds.
Pelvic floor
Fig. 12.10. (a) Diagrammatic representation of the (a) y
Bladder
normal vaginal seal. The angle of the line x-y is
approximately 80° and the upper commissurc of the vulva
is level with the floor of the pelvis, producing a valvular
scat against the aspiration of air and bacteria into the
anterior vagina. (b) Cranial retraction of the anus
causes a forward tilting of the vulva. and draws the upper
commissurc of the vulva above the level of the pelvic
floor, thus destroying the valvular scat. ( c) A thin strip of
tissue on either side of the mucocutaneous junction of
the upper commissurc of the vulva is dissected away to
just below the level of the pelvic floor. (cl) The raw
surfaces are held together by sutures or metal clips until
heating is complete. Y (c) (d)
266 SECTION I 2/ MISCELLANEOUS PROCEDURES
In his discussion of the causes of pneumovagina commissure of the vulva to just below the level of
in the mare, Caslick stated, 'To have a normal con- the pelvic floor, which would re-establish the vulva!
striction between the vulva and vagina, the mare seal and thus eliminate the pneumovagina.
should have what one might term an ideal vulva. It Within a few weeks, vaginal swabs will reveal a
should lie at an angle of about 80°, and the union normal bacterial flora. The sutured upper com-
of the upper commissure should extend below the missure of the vulva may split during service and
floor of the pelvic girdle.' He went on to suggest parturition, and in both cases will require
that a simple remedy to the condition of pneu- resuturing.
movagina would be to suture together the upper
Perinea! reconstruction - mare

Tearing of the upper commissure of the vulva
during the violent second stage of labour in the
mare may rapidly progress to splitting of both the
perineum and the anal sphincter, resulting in a
third-degree perinea! laceration with the formation
of a recto-vaginal fistula (Fig. 12. 11). This not only
leads to faecal contamination of the vagina, but by
destroying the natural seal of the posterior vagina
also allows air to be aspirated into the vagina.
Early attempts to repair this very serious injury
aimed at reconstructing both the roof of the vagina Fig. 12.12. A strip of vaginal mucous membrane is
and the floor of the rectum at a single operation. dissected free from the V-shaped shelf of connective
They were frequently unsuccessful due mainly to tissue which demarcates the remains of the vaginal roof
the dry and bulky faecal bolus in the mare which and the rectal floor. This creates a strip of raw tissue on
either side of the defect.
overstretched and eventually tore open the suture
lines. In view of this it was suggested by W.A.
Aanes that the repair should be carried out in two
stages (Figs 12.12-12.15):
I To repair the vaginal roof which would function
at the same time as the floor of the rectum. No
attempt was to be made to close the anal sphincter.
Fig. 12.13. The raw edges are drawn together by a series

of interrupted sutures preferably of non-absorbable
material. Insertion of these sutures is commenced at the
cranial end of the defect, gradually working backwards
until the roof of the vagina is closed to the level of the
perineum. The free edges of vaginal mucous membrane
are drawn together by a continuous synthetic absorbable
suture, which is inserted simultaneously with the
This closure creates a roof to the vagina, which in turn
acts as the floor of the rectum, preventing faecal
Fig. 12.11. Third-degree laceration of the perineum. contamination of the vagina. The perineum and anal
Schematic section through the rectum, vagina and sphincter are left open in order to allow the easy passage
perinea! body. The arrow indicates the passage of faeces of faeces during the healing period. The mare will,
from rectum to vagina. however, continue to aspirate air into the vagina.
CRYOTHERAPY 267
Fig. n.14. A strip of tissue is cut from the

Fig. 12.15. The perineum is reconstructed by suturing
mucocutaneous border of the upper commissure of the
together the raw edges using the same principles as that
vulva and from the perinea! scar tissue. Note that the
devised by Caslick (Fig. 12.10).
lower margin of the strip extends below the floor of the
pelvis, to ensure the reconstruction of the posterior
vaginal seal.
2 To reconstruct the vaginal seal and the perineum recto-vaginal tear are completely healed and all
by using a modification of Caslick's operation (see potentially necrotic tissue has sloughed. This means
p. 265). a period of 3-6 weeks following the injury. The
In order to ensure success, the first stage of the second procedure is normally carried out within
operation is not attempted until the edges of the IO- 14 days of the first.
Cryotherapy
The principle of cryotherapy is to produce tissue
necrosis by freezing. The efficacy of the treatment
depends partly upon the type of tissue to be frozen,
but more significantly upon the type of freezing
technique and the cryogen used. There are two
major techniques, freezing with a cryoprobe or
with a spray. Cryoprobes are suitable for small
areas but where large masses or regions require
freezing it is advisable to use a spray.
The cryogens in common use are gaseous nitrous
oxide and liquid nitrogen. The former can only be
delivered through a probe whereas liquid nitrogen
can be used either as a probe or spray. Liquid
nitrogen also possesses the advantage of being a
much colder, and therefore more potent, cryogen.
It has a boiling point of -196°C which permits rapid
cooling of tissues. It is necessary to produce tissue
temperatures of approximately -30°C in order to
achieve adequate destruction and the best results
are obtained by freezing the tissues rapidly and
allowing them to thaw slowly. In practice, a double
freeze-thaw cycle is employed to ensure effective
destruction.
Nitrous oxide machines are designed to be Fig. 12.16. Tissue temperature monitoring device
attached to anaesthetic nitrous oxide bottles. These together with tissue probes.
are readily available and wastage is minimal. Liquid
268 SECTION I 2 / MISCELLANEOUS PROCEDURES
nitrogen is now also readily available and can be

stored for extended periods in modern dewars.
There is still some loss during storage due to
evaporation but recent advances in the design of
holding containers have largely overcome this
problem.
Cryoprobes may be used in a number of ways.
Contact freezing, as its name implies, entails freez-
ing the tissue by applying the probe to its surface.
Stab freezing can be performed by incising into the
area to be frozen and inserting the probe into
its centre. This is particularly suitable for solid
masses. Large areas or big tumours may either be
debulked surgically before freezing, or overlapping
iceballs must be created to cover the entire region.
Whatever technique is employed, it is necessary to
obtain adhesion between the probe and the area
before freezing is effective. This is not a problem
where the surface of the area is moist but on
occasions cryoadhesion must be improved by the
application of a water-soluble jelly. Freezing with
a spray technique is slightly less controlled but
much less time-consuming and more efficient.
Spray-cones are available which concentrate the
cryogen to a given area and increase its effect. Fig. 12.17. Crojet unit (CryoTech Ltd, Ripley, UK) with
Following freezing, the tissues within the iceball a variety of probes. These are interchangeable with
will either slough, or form a dry, leathery eschar different sized spray attachments.
which slowly detaches from the underlying tissues.
Although the process of sloughing may produce an removal of surface tumours in all species, especially
ugly and often offensive wound, the process is sarcoids in horses, the removal of some tumours of
painless to the patient as the local nerve endings the oropharynx, the treatment of chronic infective
are destroyed within the iceball. Once sloughing is lesions such as anal furunculosis, as a cryoneurec-
complete the area will heal by granulation tissue tomy technique, for disbudding of goats, for
and produce relatively small amounts of scar tissue. the removal of anal sacs and for many other
Cryotherapy is commonly employed for the procedures.
Bibliography
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Handbook of Small Animal Orthopaedics and Fracture Saunders, Philadelphia.
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Index
Page numbers in italic refer to holding instruments 243 cataract 148, 149, 150
figures plates 171, 172, 218, 236, 237 catgut
primary union 169 chromic 20
abdominal muscles, anatomy 63 screws 169, 237-8 plain 19-20
abdominal surgery 63-82 bone spavin disease 210 catheterization of the bladder 12
abomasum braided nylon sutures 21 cattle
left displacement 78-9, Bo Burdizzo 85, 89, 90 amputation of a digit 252-3
right dilatation and torsion burr 48, 49 Caesarean section 98-9
79-80, 81 dehorning 45-6
amputation gastro-intestinal surgery 76-81
cattle, digit 252-3 Caesarean section laparotomy 63, 68
dog bitch 97-8 teat laceration u8
claw 255 cow 98-9 teat obstruction u6-18
dew claw 253, 254 ewe 99 urethral obstruction 106-7
distal phalanx 254, 255 mare 99 see also calf
femoral head 212, u3-14 calcaneus, fracture of tuber calcis central tarsal bone, fracture 234,
pelvic limb 250- 1 233 235
tail 256, 257 calf central venous pressure (CVP)
thoracic limb 247-9 castration 89, 90 measurement 12- 13
lamb, tail 257 disbudding 44-5 normal in the dog 13
anal sacs, excision 264-5 emphysematous 99 cerclage wire 242
antibacterial agents 15 monster 98-9 cervical spinal cord, decompression
aortic arch, developmental tibial neurectomy 164-5 16o, 161
anomalies 135-6 cancellous bone screw 169, 238 cervical vertebrae
artery forceps 18, 19 as lag screw 170 distraction-fusion 162
arthroscopy, carpal 177 canine teeth extraction, dog 43 fenestration 158-60
aseptic techniques 14-15 cannulae for intravenous infusion stabilization 161-2
in orthopaedic surgery 169 12 chest drain 132, 133
ASIF bone drills 239 capsulectomy 228 chisel 242
ASIF bone screws 169, 170, 238 carbon fibre in tendon repair 262 coccygeus muscle 127, 128
ASIF bone tap 239 carotid artery cannulation, collagen sutures 20
ASIF countersink 239 dog 57, 58 conjunctiva) dermoid 147-8
ASIF dynamic compression bone carpus cornea
plates 171, 172, 236 dog dermoid removal 147-8
atlanto-axial subluxation, dorsal accessory carpal bone fracture parotid duct transposition 146,
stabilization 162, 163 205 147
aural resection, dog 30-2, 33 angular deformities in the wound repair 150, 151
puppy 203, 204 corneal scissors 153
Barrett's papillotome u6, II7 horse cortex reamer 240
bistouries 16 angular deformities in the cortical bone screw 169, 238
bitch foal 173-4, 175 as lag screw 170
Caesarean section 97-8 arthrotomy 175-7 counter-incision 261
mastectomy n5-16 fracture 175-7 cranial cruciate ligament rupture
ovariohysterectomy 94, 95 cartilage knife 16 222
ureteral ectopia 110- 11, II2 Caslick's operation for 'over the top' technique 225,
bladder pneumovagina 265-6 226
catheterization 12 castration 85 Patsaama's technique 222,
rupture in the foal 101 bloodless 86 223-4, 225
blood, estimation of intra-operative calf 89, 90 crib-biting 56-7
loss to closed technique 85-6 Cryojet unit 268
blood vessels, tying off 17, 18 dog 88, 89 cryotherapy 267-8
blunt dissection 15-16 horse 86-8 cryptorchidectomy 90-2
bone lamb 90 CVP see central venous pressure
autogenous cancellous graft 209 open technique 85 cystotomy
cutting instruments 242-3 rig 90-2 dog 99-100
drills 239, 240 cat horse 101
fracture dislocation of talocrural joint
axial compression with bone 232, 233 deep digital flexor tendon injury
plate 171, 172 mandibular fracture 6o 262
interfragmentary compression opening the facial sinuses 36, 37 dehorning 45-6
170, 171 ovariohystercctomy 96 dehydration
see also specific bones and split palate 42 assessment 12- 13
joints urethral obstruction 104, ro5 in intestinal obstruction 72 -3
272 INDEX
dermoid, corneal/conjunctiva! ecraseur 93 Foley self-retaining catheter 12

147-8 cctropion 143 forceps
devocalization 51 Eggers .contact splint 237 artery 18, 19
diaphragmatic rupture 126-7 Elastrator 86, 90 dissecting 17, 18
diathermy 17, 18 elbow joint Frosch's bone-holding 243
diathermy unit 11 dog glove-stretching 49
digital flexor tendon injury 261 -2 fracture of the lateral humeral intracapsular 153
digital neurcctomy 158 condylc 194-7 knot tying with 25
disbudding 44-5 intcrcondylar humeral fracture Liston's bone-cutting 243
dissecting forceps 17, 18 197-8, 199 Luer bone-nibbling 243
dissection 15- 16 ostcochondritis dissccans of wire-holding 242
instruments 16-17, 18 medial humeral condylc Forsell's operation 56-7
distal intertarsal joint, arthrodesis 194 Fredet+Rarnstcdt technique 71
210 ununitcd anconcal process frontal sinus opening and drainage,
distichiasis 144 193, 194 horse 33, 34, 35
docking ununitcd coronoid process Frosch's bone-holding forceps 243
dog 256, 257 194
lamb 257 horse, olccranon fracture 172
dog emasculator 85 gastrectomy, partial 71, 72
amputation entercctomy, dog 73, 74, 75 gastro-intestinal surgery
dew claw 253, 254 enterotomy, dog 72-3 cattle 76-81
distal phalanx 254, 255 cntropion 143, 144 dog 68-75
pelvic limb 250- 1 cnucleation 151-2 horse 75-6
tail 256, 257 epididymis 85 gastro-jejunostorny, dog 71, 72
thoracic limb 247-9 Esmarch's bandage 204 gastropexy, dog 69-70
anal sac excision 264-5 ewe, Caesarean section 99 gastrotomy, dog 70, 71
aural resection 30-2, 33 exsanguination of a limb 13, 14, temporary 69
carotid artery cannulation 57, 169 tube 69-70
58 eye speculum 152 genito-urinary surgery 85-112
claw removal 255 eye trauma 150-2 glove-stretching forceps 49
cystotomy 99- 100 eyeball, enuclcation 151-2 gloves, sterile 7-8
dcvocalization 51 eyelid gouge 242
docking of tail 256, 257 surgery on 143-4, 145 gown, sterile 3, 6
enucleation 152 tumours 144, 145 grid-iron incision 66
exposing the nasal cavities 39, gubernaculum 85
40-1
extraction of teeth 42-4 facial sinuses opening
fenestration of cervical disc cat 36, 37 hacmatocrit 12
158-6o horse 33-6 haematoma, car 29
gastro-intestinal surgery 68-75 facial surgery 33-41 haemostasis 13- 14, 17- 18, 19
laparotomy 15, 63-4 falciform ligament 121 in castration 85
mandibular fracture 58, 59 fcmorotibial joint Harderian gland, removal 145
neurosurgery 158-64 dislocation of patella 228-9, head surgery 29-60
oesophageal obstruction 230 heavy duty bone plate 237
134-5, 136 rupture of collateral ligaments hemilaminectomy 163, 164
ophthalmic surgery 143-52 227 hernia 121
orthopaedic surgery rupture of cranial cruciatc incarcerated I21
pelvic limb 2 JI -35 ligament 222-5, 226 inguinal 121, 124-5
thoracic limb 186-207 femur scrotal 121, 125
patent duetus arteriosus 137 dog umbilical 121-3
penile amputation 108, 109 amputation of femoral head hip joint, dog
perinea! rupture 127-8 212, 213-14 amputation of femoral head
salivary retention cysts 52, 53 distal fracture 220, 22I 212, 213-14
splenectomy 82 shaft fracture 218, 219-20 dislocation 216, 217
thoracic surgery 131-9 subtrochanteric osteotomy pectinectomy 215
tonsillectomy 41, 42 216 subtrochanteric femoral
tracheotomy 55 horse, cyst of medial condylc osteotomy 216
urethral obstruction 101, 102-3 208-9 triple pelvic osteotomy 215- 16
see also bitch fenestration of cervical disc hock joint
drill sleeve 239 158-60 dog
drills 239, 240 fetlock joint dislocation of talocrural
ductus arteriosus 135 proximal sesamoid bone fracture joint 232, 233
patent 137 180, 181 fracture of central tarsal
Dunhill artery forceps 19 varus deformity 173, 174 bone 234, 235
fluid loss estimation 12-13 fracture of tuber calcis of
fluid therapy, pre-operative calcancus 233
car 11-12 subluxation of proximal
dog foal intertarsal joint 235
lateral wall resection 30, angular deformities of carpus horse
31-2 173-4, 175 bone spavin disease 210
vertical canal ablation 32, 33 bladder rupture JOI stringhalt 210-11
haematoma 29 inferior check ligament hoof
split 29, JO desmotomy 262, 263 grooving wall of 185
INDEX 273
sandcrack 184 Kirschner wire 207, 232, 241 neurectomy

horse knot tying 24, 25 calf, tibial 164-5
castration 86-8 Kocher's artery forceps 19 horse
cryptorchidectomy 90-2 Kuntscher nail 241 digital 158
cystotomy 101 palrnar 157-8
enucleation 152 neurosurgery 157-65
Forsell's operation 56-7 lag screw 169, 170 nictitans gland removal 145
gastro-intestinal surgery 75-6 lamb nictitating membrane as
laparotomy 63, 64-8 castration 90 conjunctiva! flap 145, 146
laryngeal ventriculectomy 46, docking of tail 257 nylon sutures 20- I
47-9 laparotomy 63
laryngoplasty 49-50, 51 anatomical considerations 63
neurectomy 157-8 cattle 63, 68
opening the facial sinuses 33-6 obturator internus muscle 127,
dog 15, 63-4
orthopaedic surgery horse 63, 64-8 128
pelvic limb 207- I I in repair of diaphragmatic oesophagotomy, transthoracic 134
thoracic limb 172-85 rupture 126-7 oesophagus
penile amputation 107-8 laryngeal retractor 47, 49 obstruction 134, 135
repulsion of the teeth 37, 38, 39 laryngeal ventriculectomy, horse surgical closure 134, 135
tendon injuries 261 -3 vascular ring obstruction I 35,
46, 47-9
tracheotomy 53-4, 55 laryngoplasty, horse 49-50, 51 136
see also foal; mare lateral digital extensor tendon, olecranon fracture
Hudson's teat probe and tencctomy 210-11 dog 199, 200
left displacement of the abomasum horse 172
spiral II6, II7
omohyoideus muscle resection
humerus, dog (LOA) 78-9, 80
fracture of lateral condylc lens 56-7
operating theatre routine and
194-7 expressor I 53
layout 3-11
fracture of shaft 191-2 extraction 148, 149, 150
ophthalmic surgery 143-52
intercondylar fracture 198, 199 levator ani muscle 127, 128
instruments 152-4
osteochondritis dissecans of ligamentum arteriosum 135
limb oral surgery 41 -4
medial condyle 194
orthopaedic surgery
hydro-ureter 110 amputation 247-51
dog
exsanguination 13, 14, 169
Liston's bone-cutting forceps 243 pelvic limb 2u-35
lobectomy 138-9 thoracic limb 186-207
ileocaecal anastomosis 75-6 Lowrnan's bone clamp 219 horse
incision 15, 16 pelvic limb 207- 11
Luer bone-nibbling forceps 243
grid-iron 66 thoracic limb 172-85
instruments 16-17 implants 236-8, 242
in laparotomy 63-8 instruments 236-43
Mcl.ean's knife 117, n8
inferior check ligament desmotomy techniques 169-71
mammary neoplasia 115-16
262, 263 mandible orthopaedic wire 242
inferior maxillary sinus opening and osteochondritis dissecans
cat, fracture of symphysis 60
drainage, horse 34, 35-6 dog, fracture of horizontal dog 194
instrument trolley horse 207-9
ramus 58, 59
position IO osteotome 243
external fixation 60
preparation 3, 4 mare ovariectomy, mare 93
instruments ovariohysterectomy
Caesarean section 99
controlling haemorrhage 18, 19 bitch 94, 95
Caslick's operation for
incision and dissection 16- 17, cat 96
pneumovagina 265-6
I8 'over the top' technique 225, 226
ovariectomy 93
ophthalmic surgery 152-4
perinea) reconstruction 266-7
orthopaedic surgery 236-43
mastectomy 115-16
thoracic surgery 139
Mayo scissors 17 packed cell volume 12
see also specific instruments
Mayo table 9, IO palate, split 42
intcrvcrtcbral disc
medial patellar ligament palmar neurectomy 157-8
cervical, fenestration 158-60
desmotomy 207, 208 papillotome 116, I 17
thoracolumbar,
median sternotomy 132-3 Parker- Kerr technique 95
hcmilaminectomy 163, 164
mesonephric duct 85 parotid duct transposition I 46,
intestinal anastomosis 74, 75-6
metal wire sutures 21 147
intestinal obstruction, dog 72-5
Metzenbaum scissors 17 partial gastrectomy, dog 71, 72
intracapsular forceps 153
monofilament nylon sutures 20- 1 patella
intramedullary pins/nails 241
mucocoele 52 dog, dislocation 228-9, 230
intraocular surgery 148-50
multifilament polyamide sutures horse, upward fixation 207, 208
intrapleural drainage 132, 133
21 patent ductus arteriosus 137
intravenous infusion 1 I - 12
patient preparation 11- 15, 186-7
intussusception 73
Patsaarna's technique 222, 223-4,
iris repositor 153
nasal cavity exposure, dog 39, _225
40-I pectinectomy 215
neck surgery 46-58 pelvic diaphragm rupture 127-8
jejunocaecal anastomosis 75-6 needle 21-2 pelvis, dog
Jones' tracheotomy tube 55 holder 153 fracture 211 -12
jugular venepuncture 11- 12 nerve suture 157 triple osteotomy 215-16
274 INDEX
penile amputation rumenotomy 76, 77 horse

dog I08, Io<) rupture 126 osteochondritis dissecans
horse 107-8 diaphragm 126-7 207-9
ram 109 perinea! 127-8 upward fixation of patella
perineum Rush pin 241 207, 208
reconstruction in the mare stomach dilatation and torsion,
266-7 dog 68-70
rupture in the dog 127-8 stringhalt 2w- 11
periosteum, hemicircumferential salivary retention cysts, dog 52, subtrochanteric femoral osteotomy
transection 174, 175 53 216
personnel, preparation 3-8 sublingual gland excision, dog suction machine, portable 10
phalanges , 52, 53 superficial digital flexor tendon
dog, subluxation of proximal submandibular gland excision, injury 262
interphalangeal joint dog 52, 53 superior maxillary sinus opening
206-7 sandcrack 184 and drainage, horse 34, 35
horse, fractures 182-3 scalpel 16, 17 surgeon's knot 24, 25
pig, rectal prolapse 264 schistosoma reflexus 98-9 surgical approach 15-25
plasma proteins 12 scissors surgical diathermy unit I 1
pneumovagina, Caslick's operation corneal 153 surgical gut 19
265-6 Mayo 17 surgical principles 3-25
poll 44-6 Metzenbaum 17 suture materials 19
polydioxanone sutures 20 suture 24 absorbable 19-20
polyester suture-wire 242 non-absorbable 20- I
fibre in tendon repair 262 screw depth gauge 238 use in hernias 121
sutures 21 screwdriver 238, 239 wire 242
polyglactin 9w sutures 20 scrotal hernia 88 suture needles 21-2
polyglycolic acid sutures 20 scrotum 85 suture scissors 24
polypropylene scrubbing up 3, 5-6 suture-wire scissors 242
mesh in hernia repair 123 sheep see ewe; lamb; ram; wether sutures
sutures 21 Sherman bone plate 236, 237 continuous 22, 23
premedication 11 Sherman bone screw 237 inversion 23, 24
primary bone union 169 shoulder joint, dog mattress horizontal 22-3
prostatic hypertrophy 127-8 caudo-lateral approach 188, r89 mattress vertical 23
proximal interphalangeal joint, dislocation 189, rgo nerve 157
subluxation 206-7 silk sutures 20 removal 23-4
proximal intertarsal joint, skin simple/interrupted 22
subluxation 235 accidental wound repair 261 tendon 262, 263
proximal sesamoid bone fracture preparation 14-15 swab-rack to
180, r8r spastic paresis 164
pulmonaryvessels r38, 139 Spencer Wells artery forceps 19 talocrural joint dislocation, dog/cat
puncture incision 16 sphincter ani internus muscle 127 232, 233
puppy, resuscitation 97-8 spinal cord decompression, cervical tantalum sutures 21, 242
pyloric myotomy, dog 70, 71 16o, 161 tap sleeve 239
pyloric stenosis, dog 71 splenectomy, dog 82 tarsometatarsal joint, arthrodesis
'splint' 178 210
splint bone teat
quittor 185 fracture 177, 178 fistula 118
removal 178, 179 laceration - II 8
split palate, cat 42 obstruction u6-18
radius, dog spondylolithesis 161 -2 teeth
cranial bowing 203, 204 stab incision 16 dog, extraction 42-4
cuneiform osteotomy 203, 204 stainless steel horse, repulsion 37, 38, 39
distal extremity fracture 201 -3 implants 236 tendon
shaft fracture 199, 200, 201 sutures 21, 242 injuries 261-2
ram staples 173, 203-4 repair 262
penile amputation 109 starvation, pre-operative II suture 262, 263
urethral obstruction 105 Steinmann pin 241 tenotomy knife 16
vasectomy 92, 93 sternocephalicus muscle tension band 170, 17r
rectal prolapse 264 denervation 57 testicles
recto-vaginal fistula, mare 266 resection 56-7 development 85
reef knot 24, 25 sternohyoideus muscle resection retention 90-2
reefing procedure 108 56-7 thoracic surgery 131-9
retaining clamp 197 sternothyroideus muscle resection thoracolumbar vertebrae,
rib-cutting shears 139 56-7 hemilaminectomy 163, r64
rib periosteal stripper 139 sternotomy 132-3 thoracotomy 131-2, 133
rib raspatory 139 stifle joint tibia, dog
rib retractor r39 dog epiphyseal separation of
ribs, resection 68, 131, r32 dislocation of patella 228-9, tuberosity 230, 23 t
roaring 46 230 fracture of the shaft 230- 1, 232
round ligament of the bladder rupture of collateral ligaments lateral transposition of tuberosity
121 227 229, 230
rumenal fistula, semipermanent rupture of cranial cruciate separation of distal epiphysis
81 ligament 222-5, 226 232
INDEX 275
tibial neurectomy 164-5 upper carnassial tooth extraction, ventral ligament of the bladder
titanium implants 236 dog 44 121
tonsillectomy, dog 41, 42 ureteral ectopia IIO- II, II2 vertebrae
Tooke's knife 154 urethral obstruction 101 cervical
tourniquet 13-14 cat 104, 105 distraction-fusion 162
tracheotomy cattle 106-7 fenestration 158-60
dog 55 dog IOI, 102-3 stabilization 161 -2
horse 53- 4, 55 sheep 105 thoracolumbar,
tracheotomy tubes 55 urethrostomy hemilaminectomy 163, 164
transfixing ligature 17- 18, 19 cat 104, 105 vitallium implants 236
transfixion screw 237 cattle 106-7 vomiting, projectile 71
transphyseal bridging 173-4, dog 103
203-4 urethrotorny, dog 102-3
trephine 33 urine output measurement 12 wether, urethral obstruction 105
trephining 33, 34 whistling 46
to open facial sinuses in the windsucking 56-7
horse 34-5 valgus deformity wire, orthopaedic 242
to repulse teeth in the horse 37, foal 173 wire-holding forceps 242
38, 39 _ puppy 203-4 wobbler syndrome 161-2
triple pelvic osteotomy 215- 16 varus deformity, foal 173 Wolffian duct 85
tunica vaginalis 85, I 2 I vas deferens 85 wounds
vasectomy, ram 92, 93 accidental 261
vectis 154 closure 18-25
ulna, fracture in the dog 199, 200, Venable bone plate 218, 219-20,
201 236

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An Atlas of

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FORMERLY READER IN ANIMAL SURGERY

DEPARTMENT OF CLINICAL VETERINARY MEDICINE

DEPARTMENT OF CLINICAL VETERINARY MEDICINE

PROFESSOR OF EQUINE STUDIES

DEPARTMENT OF VETERINARY CLINICAL SCIENCE

UNIVERSITY VETERINARY FIELD STATION

Set by Setrite Typesetters, Hong Kong

PREFACE TO THIRD EDITION vii

PREFACE TO FIRST EDITION viii

1 GENERAL SURGICAL PRINCIPLES .r

2 SURGERY OF THE HEAD AND NECK 27

4 SURGERY OF THE GENITO-URINARY

5 SURGERY .OF THE MAMMARY GLAND II3

6 HERNIA AND RUPTURE II9

7 THORACIC SURGERY 129

12 MISCELLANEOUS PROCEDURES 259

The best way of learning to perform an operation is to assist or watch

Operating theatre routine

If trolleys are prepared for a series of operations it

Care must be taken when scrubbing-up to ensure

Putting on a sterile gown

As it is impossible to render the hands completely Fig. 1.2. Using Cheatle

Fig. 1.10. The sterile towel for drying the

Fig. 1.13. Correct method of putting on a sterile gown:

Fig. 1. II. Correct method of drying the hand and

Putting on sterile gloves

The principle of putting on sterile gloves ensures

Fig. 1.15. The right-hand glove is picked up with the left

risk of contamination caused by touching the wrist

Hand towel drum

The theatre nurse having prepared the instrument

Fig. 1.23. Mayo table with instruments for immediate

Fig. 1.24. Arrangement of instrument trolley

Fig. 1.25. Swab-rack. It is necessary to have a system to check the

Preparing the patient

therapy in animals. The carefully tapered end of all

Estimation of fluid loss

increased in cases of dehydration.

(a) (b) (c)

Fig. 1.31. The front leg of a dog being cxsanguinatcd by

blood vessels are conserved, but if severed they

Fig. 1.34. (Righi) Dog positioned for a laparotomy. The clipped

Fig. 1.37. The skin is tensed by the operator using the

Fig. 1.41. Two large muscles can be separated or their

blunt dissection which is used to separate connec-

INSTRUMENTS FOR INCISION

These are probably the oldest instruments in

There is a large variety of shapes and sizes of

The best method of preventing a ligature from

its surrounding tissues or when occluding a uterine

Instruments for controlling haemorrhage

Artery forceps are designed for preventing and

A surgical incision inflicts the minimum of trauma

(a) (b) (c)

securely together with sutures, union will occur in

Fig. 1.48. (a) Spencer Wells artery forceps are the

Collagen sutures Non-absorbable sutures

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