My surgery confidence has been improving. I have thus far met my goal of not vomiting before, during, or after any one of my surgeries. My nerves have decreased quite a bit, although I still have to occasionally quell some panic when I'm actually in surgery.
Last week I had a dog neuter (4 mo Chi from the humane society) and a dog spay (5 mo client-owned hound x). This week I did an 8 week old kitten spay on Monday, a 1 yo cat spay on Tuesday, and a 5-10 year old Chi X spay named Cheeto today (all from various humane societies). Here's my Monday kitten, Celine, who has already found a home:
Cheeto's spay today was by far my most harrowing surgery. I was pretty stressed out for my very first dog spay last week, but that stress was due more to never having done a spay before and general concerns about cutting open an abdomen and yanking out parts. Today's spay was stressful because things started going wrong.
First of all, the anesthesia left something to be desired. Our anesthetists are technician students from one of the local community colleges, and although they have all been through several semesters of classroom learning and are all very nice people, they have a wide range of technical abilities, experience with animals, and experience with anesthesia. Still, I don't fault them for any error or oversight because I know they are still learning and I can't help but think back just a few weeks to my own introduction to anesthesia as a junior.
So Cheeto was pre-medicated, had an IV catheter placed, and was induced into general anesthesia. At this point the tech student intubated her and we connected all of her monitoring devices and I clipped her and we moved her to surgery.
Fast forward to about 20 minutes after arrival in the surgical suite. I've just started cutting, and Cheeto just isn't doing well under anesthesia. Her CO2 level is high, her oxygen level is low, she seems lighter than she should be given the relatively high % of gas anesthetic she's on, and.... wait... do I smell isoflurane?
The supervising anesthesia tech came over to help the student with Cheeto's anesthesia, and quickly ascertained that the endotracheal tube placed in Cheeto's trachea was too small -- meaning that it was not big enough to create a complete seal in Cheeto's trachea, so she was breathing a mixture of anesthetic through the tube and room air around the tube.
Really the only solution for this problem is to place a bigger ET tube. So, with her guts poking out, lying on her back, Cheeto was successfully reintubated and the remainder of her anesthesia was relatively uneventful (except for some hypotension and bradycardia -- oh, and when she kept trying to wake up every time I pulled on her ovaries).
On my end of the surgery table, I found myself dealing with a large, flabby uterus surrounded by an incredible amount of slippery fat that would not stay out of my way. Once I finally had the first ovary dealt with, I had to go fishing for the second horn of the uterus. Having found Side #2, I started to gently break down the suspensory ligament connecting the ovary to the kidney (which is a tough structure that usually takes quite a bit of effort to tear) -- and the thing snapped almost immediately. Uh oh.
Okay, then, guess it's time to start tying off blood vessels! I placed my clamp below Cheeto's left ovary, and was halfway through my first ligature around her ovarian vessels when the tissue between my ligature and the clamp just tore -- with no warning at all. Commence msasive amounts of bleeding. (Okay, in retrospect, it probably wasn't that much bleeding. I'm sure the surgery instructor laughs to herself when we freak out about these things. But hey, I don't like seeing blood everywhere!)
Fortunately, the bleeding was coming from a vessel in Cheeto's uterus which I was about to remove anyway, so I was able to clamp it off. When I'd at last removed both ovaries and most of both uterine horns, there was still more blood in the abdomen than I liked to see, so I worried that something was still oozing. However, I took the advice of the surgery instructor ("Doesn't look like that much blood to me!") and just closed the abdomen.
We close the abdomen in dogs in 3 layers. The first and most important layer is through the body wall -- the muscles and connective tissue that sit on the bottom of the abdomen and are the strongest thing we can suture. The second layer is the subcutaneous tissues, which we suture together mainly to eliminate dead space where fluid can accumulate. Finally, we place a third line of suture within the skin, the idea being to be able to bring the skin edges together over the incision without any suture sticking out.
I've been working hard on my intradermal suturing (the third and final layer). On my first dog, I didn't start or end the suture line well but it closed okay in the middle, so I had to place skin sutures at both ends of my incision. On my second spay, the middle and last end of the incision closed great but I needed a skin suture at the first end. On my third spay, both ends closed great but I had some gapping in the middle. This time, everything closed well but my knot at the end of the intradermal suture line, which is supposed to end up buried under the skin, would not bury itself no matter what I tried. So, I avoided any skin sutures, but did have to use some tissue glue on top.
In my 4 spays, the thing I've found to be most difficult each time is actually cutting into the abdomen and finding the parts I want. The incision through the skin is easy -- but then underneath there can be a hugely variable quantity of fat and subcutaneous tissues before you get to the linea alba -- the connective tissue structure we want to cut through to get into the abdomen. It's just very difficult to know how deep you're going with your gradual incisions in the same general region, although I'd imagine it gets a lot easier with time.
Once you're in the abdomen and have access to the guts, the next thing you have to do is actually locate the uterus. (Well, first you should make sure the spleen is out of the way. The spleen likes to sit right beneath the linea alba that you cut through to get into the abdomen, and the spleen is easily angered if you cut or poke it.)
The body of the uterus (the part connected to the cervix) sits between the bladder and the colon in dogs and cats. So with a dog lying on her back in surgery, the organ closest to the surface we're cutting into is the bladder, with the uterine body beneath the bladder, and the colon even further down. The two horns of the uterus are semi-mobile, so there isn't one exact place you can go to find them. So we use an instrument called a spay hook to fish around till we find what we want.
And even when you "catch" something on your spay hook, it isn't all that easy to identify it. There's a whole lot of intestines in every animal's abdomen, and in some cases they look very similar to the uterus (at least to us beginning surgeons -- again, something else that probably gets much easier with experience). So I had one spay where I kept pulling up intestine after intestine after intestine, and since I didn't know for sure that it was intestine and not uterus, I had to try to follow it one way or the other to find the uterine body or the ovary. Conversely, I had a cat spay this week when I kept pulling up uterus over and over and pushing it back, thinking it was intestine, until finally my surgery instructor came over and said "...Why do you keep letting go of the uterus?"
I've found that once the uterus is located, everything is pretty straightforward from there, because it's all a matter of ligating and transecting the things you need to ligate and transect, then sewing everything back up and waking up the pooch or kitty. It just seems funny that it takes so much time and effort to (a) get into the abdomen and (b) find the organs we're actually looking for.
I do think I've gotten over the feeling that I'm not ready to do these kinds of surgeries. It's true that I'm not yet ready to do them on my own with no supervision or assistance, but as long as I can keep from panicking, I do feel comfortable handling most of the complications I might encounter. All of our surgery patients stay in the hospital overnight after surgery, so it's gratifying to see how great they look the next morning and to reassure yourself that no, they didn't bleed to death overnight.
With 2 weeks of surgery left (which will probably be 4-5 more surgeries), I'm hoping to get in a couple more neuters as well as however many more spays I can do. The scary thing is, after this rotation is over, I'm pretty much done with primary surgery experience except for my externship rotation in the spring at a high-volume, low-cost hospital. Yes, I'll be scrubbing into plenty of surgeries between now and then, but mostly to handle the suction tip, pass instruments to the clinician, or maintain traction on the leg they're trying to fix.
Ah well, I guess that's why they call it veterinary "practice"!
No comments:
Post a Comment