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Compendium August 2008 (Vol 30, No 8)

Editorial — Spaying: One Technique No Longer Fits All

by Elizabeth Hardie, DVM, PhD, DACVS

    I have taught veterinary students how to spay dogs and cats for more than 20 years. Like most US veterinarians, the technique I learned (and now teach) is ovariohysterectomy using an open midline approach. This teaching prepares my students to begin their veterinary careers knowing one method for performing one of the most common veterinary surgical procedures. However, it is only a beginning. The controversies and complex decision-making surrounding spaying continue to increase. Good clients often want to discuss the pros and cons of spaying, the best age at which to spay, the best technique to be used, and the details of pain control. Because the size and breed of the animal can affect these decisions, "one discussion fits all" no longer applies. This issue of Compendium introduces a new series, Surgical Views, which is designed to highlight different surgical procedures. In the first article, Drs. Gower and Mayhew discuss laparoscopic ovariohysterectomy, which is one of the options for performing a spay.

    The pros and cons of spaying and the best age at which to spay were recently reviewed in great detail by Dr. Margaret Root Kustriz.1 The charts in this article are invaluable in helping to guide clients. What has received less widespread attention is the discussion about the best technique for performing a spay. Midline versus flank approach, ovariohysterectomy versus ovariectomy, open versus laparoscopic technique, suture versus clip versus laser versus bipolar cautery versus harmonic scalpel for hemorrhage control, use of incisional local anesthetic versus sole use of systemic analgesics≥the choices are dizzying. Many veterinarians become comfortable with one technique and tend to recommend that technique. Increased knowledge and comfort with various options allows the veterinarian to help the client choose the technique that is best for the individual patient.

    Midline versus flank approach: The midline approach allows easy access to both ovaries and both uterine horns. The incision can be extended if uterine abnormalities are encountered. However, if dehiscence occurs, evisceration readily follows. The flank approach avoids an incision that disrupts mammary tissue in lactating animals or animals with mammary gland hyperplasia. The approach takes longer to learn than a midline approach but, once learned, provides direct access to the ipsilateral ovary. Ovariohysterectomy can often be performed faster with a flank approach than with a midline approach, particularly in cats, and if dehiscence occurs, evisceration is rare. The flank approach is best reserved for animals with a thin, narrow body type in which no uterine abnormalities are suspected.

    Ovariohysterectomy versus ovariectomy: Ovariohysterectomy is the surgery of choice for animals in which uterine abnormalities are suspected and for animals that are at risk of exposure to progestins after surgery. Ovariectomy may be performed on animals in which no uterine abnormalities are present. Practitioners should be aware that increasing numbers of students are being trained to perform ovariectomy, rather than ovariohysterectomy, in young animals that are undergoing gonadectomy before the first estrus.

    Open versus laparoscopic technique: Open techniques can be performed with standard surgical instruments and sutures, while laparoscopic techniques require a laparoscope and laparoscopic instruments. Many laparoscopic techniques use specialized devices for hemorrhage control. Initial studies comparing open and laparoscopic techniques found that laparoscopic procedures were less painful but took longer and had more complications than did open procedures. As veterinarians have become comfortable with minimally invasive surgery techniques and with the use of laparoscopes that allow a single surgeon to perform the technique, laparoscopic techniques are becoming fast and routine. Laparoscopic techniques are particularly indicated for large, deep-chested dogs at risk of gastric dilatation-volvulus because laparoscopically assisted prophylactic gastropexy is easily performed at the same time as gonadectomy. Open techniques may be more appropriate for animals with uterine abnormalities. Laparoscopic techniques are more technically challenging in small dogs and cats, in which small scopes and instruments may be needed. The cost of open techniques is less than that of laparoscopic techniques.

    Techniques for hemorrhage control: Sutures, metal clips, bipolar electrocoagulation, harmonic scalpels, Nd:YAG lasers, and bipolar electrosurgical and cutting forceps have all been shown to provide satisfactory hemorrhage control during laparoscopic ovariectomy or ovariohysterectomy. Direct comparisons of bipolar electrosurgical and cutting forceps (which simultaneously seal and cut blood vessels) with Nd:YAG lasers, sutures, or metal clips found these devices to be economical and effective.

    Techniques for pain control: NSAIDs, opioids, and tramadol have been shown to provide pain relief after ovariohysterectomy. Combining NSAIDs and opioids has not been shown to provide increased pain control compared with preoperative use of either class of drugs alone. However, many practitioners use opioids for immediate pain control and then dispense NSAIDs or tramadol for home use. Incisional (with or without peritoneal) injection of bupivacaine has also been shown to reduce pain after ovariohysterectomy. Flank incisions are more tender than midline incisions (presumably because of the muscle dissection), and incisional bupivacaine injection might be particularly indicated in these patients.

    Every new technique has a learning curve but, once mastered, provides new options for your patients. Each animal deserves the least painful, most complication-free spay experience that the profession can offer.

    Suggested Reading

    Howe LM. Surgical methods of contraception and sterilization. Theriogenology 2006;66:500-509.

    Mayhew PD, Brown DC. Comparison of three techniques for ovarian pedicle hemostasis during laparoscopic-assisted ovariohysterectomy. Vet Surg 2007;36:541-547.

    Shih AC, Robertson S, Isaza N, et al. Comparison between analgesic effects of buprenorphine, carprofen and buprenorphine with carprofen for canine ovariohysterectomy. Vet Anaesth Analg 2008;35:69-79.

    Van Goethem B, Schaeffers-Okkens A, Kirpensteijn J. Making a rational choice between ovariectomy and ovariohysterectomy in the dog: a discussion of the benefits of either technique. Vet Surg 2006;35:136-143.

    Downloadable PDF

    1. Root Kustriz MV. Determining the optimal age for gonadectomy of dogs and cats. JAVMA 2007;231:1665-1675.

    References »

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