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Wednesday, September 23, 2015

Double-Checking A Spay

Last week I performed a routine spay on an English bulldog.  She was in heat, so the uterus was a bit bigger than normal.   Vets don't like doing surgery on dogs in estrus because the vessels and uterus are larger, increasing the risk of bleeding and other complications.  However, most of us with good surgical experience will still do it, adding a charge to account for the extra time and materials (sponges and suture) it will take.  Over my career I've spayed plenty of dogs who were in heat and never had any serious problems.  But last week's spay came close.

The surgery was routine, but nearing the end I noticed some excessive bleeding.  I extended my incision and saw that one of the pedicles (the part we remove the ovaries from) was bleeding.  This happens sometimes, even with good, experienced surgeons.  We know that this isn't a huge problem, and is just a matter of re-clamping the tissue and putting more suture around the vessels.  As scary as it may sound for a pet owner, this is a relatively routine complication and is taken care of pretty easily by the vet before closing the abdomen.

So I identified the "bleeder", finished removing the uterus, and then stood there and waited.  Whenever I have an unexpected bleeder I wait several minutes after ligating it to see if there is any further leakage that I have to fix.  I'll use gauze to remove any mild capillary seeping and check for bleeding several times.  When I am convinced that there is nothing abnormal I'll proceed to close the abdomen, as I did in this case.  Everything was routine from that point on.

Until time for her to go home.

I had finished her surgery early in the morning so I had told the client to pick up in the early afternoon.  When we got her out to remove her IV catheter and take final vital signs I noticed a decent amount of bleeding from the incision.  This can sometimes happen when a subcutaneous vessel bleeds and is rarely a concern.  Typically it will stop quickly.  Unfortunately this dog's didn't.  In fact, as I pushed on the abdomen the bleeding became heavier and faster.  It was clear to me that this didn't appear to be a simple small skin vessel, and there was a very real risk that there was more internal bleeding that was now leaking through the incision.

So I did the right thing.  When the owner came to pick up we still had three hours left in the day.  We told the client that we needed to observe her longer and I had my associate take my next few appointments.  I immediately got the dog back under anesthesia and went in to look for the bleeding.  I didn't want to have to do that for multiple reasons, such as increased anesthesia risks, a higher possibility of infection, further tissue trauma, and just the time it would take.  But this had happened because of a surgery we did, and I didn't want the pet to end up at the emergency clinic that night or even bleed to death.  I took responsibility and went back in to find what was bleeding.

Here's where I was surprised.  There was a slight amount of bleeding at the incision, likely from a subcutaneous vessel or the muscle wall.  However, inside the abdomen there was no blood.  In a case like this where a major vessel may have slipped out of the suture, I would have expected a pool of blood in the belly.  But that was not the case.  I spent some time looking around, identified the surgery locations, and verified that the sutures were all still in place and tight.  I was puzzled because there was no apparent source of the heavy bleeding I had noticed just a few minutes prior.  I triple-checked, then stood back for a full five minutes waiting for blood to accumulate.  Nothing happened.  So I finally closed her back up.

The next couple of hours were pretty standard for a second post-op recovery.  There was no further bleeding and she recovered normally.  I saw her today for a recheck, and she was doing just fine.

It was a weird case because I never identified the source of the bleeding that had worried me enough to go back in on a second surgery.  Honestly, looking back I could have just placed a pressure bandage around her abdomen and she would have been fine.  But at the time I didn't know that and I don't regret my decision one tiny bit.

4 comments:

  1. I haven't had this happen to me before, but I feel your pain! You did right by that patient, never doubt your judgement. I've heard of this happening and sometimes they get sent to ER for ON care. I imagine this could be scary for an owner, but only because they don't really understand that a spay is MAJOR surgery. It sure would be nice if we had ultrasound readily available.

    ReplyDelete
    Replies
    1. I agree, Krissy! A quick ultrasound probe would have told me that there was no internal bleeding.

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  2. I'm glad you went back in. You did the responsible thing, something I'd expect from my own vet. :)

    Roberta

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  3. I wish you were our vet. You obviously love your job and have the highest ethics.

    ReplyDelete

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