Friday June 14, 2013

I share my surgical experience with regards to the removal of a bladder stone from an old poodle and to provide a benchmark to enhance the standard of care by younger vets at Toa Payoh Vets.

KPI FOR SURGERY
How long it takes to remove one bladder stone from a poodle?

Poodle, 10 years, 4.1 kg 38.8 C. Dog was panting but owner said this was normal behaviour of excitement. Urinated blood yesterday, incontinent and now had abdominal distension the size of a small mango, indicating a much swollen bladder with difficulty in peeing.

Had antibiotics for past 7 days. Blood in urine. Dark red cloudy urine. Dog's abdomen distended on arrival. Anti-spasomodic injection and antibiotics enabled dog to pee and on surgery, bladder was empty but swollen with 8 mm wall (normal bladder is around 3 mm)  

2 packets of sutures 3/0 absorbable Polysorb, 3/0 nylon for skin

A: Injection of Induction Drugs  2.50 pm
B:  Isoflurane gas first given:     2.55 pm
C: Isoflurane gas stopped:         3.39 pm
D: First skin incision:                3.11 pm
E: Completion of skin stitching   3.41 pm

E-D = 30 minutes for a vet with 40 years of experience. 
E-A = 51 minutes
C-B = 44 minutes of isoflurane gas + oxygen used.

ANAESTHESIA
1. Domitor + Ketamine 0.1 + 0.11 ml IV in 3 ml of saline
2. Dog intubated 5 minutes after Dom + Ketamine IV. She was intubated a few times but seemed not to be breathing the isoflurane. Barked twice. Eyes blinking. I did not want to waste time to mask and intubate as this is an old dog and every second counts towards her survival rate. I decided to use gas mask which was excellent anaesthesia from 3% maximum for maintenance.

SURGERY
1. I palpated the empty bladder with stone. In female dog, I do not catherise unless necessary.
2. I incised where the bladder was located. Spread out the SC fat, linea alba cut and pop out the empty bladder.
3. I turned the bladder backwards, exposing the dorsal part of the apex.
4. Incised 1 cm. Popped out the stone which would be slightly >1 cm across.
5. My assistant flushed bladder with saline. I squeezed out any remaining debris or crystals, known to be struvites.
6. A urinary catheter passed from inside bladder to outside the vulva to dislodge any stones if present in the urethra.
7. I suture the 8-mm thick submucosa first with a layer of inverting sutures, parallel to incision.
8. At one end, I anchored the artery forceps and proceeded to suture a similar continuous inverting suture layer to the other end from bladder serosa and mucosa. "Suturing is similar to Caesarean section uterus," I said to Dr Daniel. I used 3/0 Polysorb sutures and throw 5 knots/tie.
9. "Some vets inject saline into the bladder of the female dog after suturing to see if there is a leak," I said to Dr Daniel. "I don't do it as the closure is tight with two layers." He took a video.
10. Closure of the linea alba (simple interrupted & continuous overlay).
11. Skin - horizontal mattress x 3 with 3/0 nylon.
12. There was some profuse bleeding post -op.  "Probably the bigger artery from the caudal epigastric blood vessel," I said. After bandaging, the bleeding stopped.
 

POST OP
The dog vomited twice, yellow gastric juice some 15 minutes after surgery, but seemed OK. "Barking non-stop before surgery," I said to the owner who visited. The dog sprang onto him as if she did not have any major op. Still barking non-stop as at 7.35 pm when I recorded this case. Incredible. The owner is advised to give the S/D diet but the dog did not like it. There are still small stones inside the left kidney and S/D may dissolve them. But the dog would not eat the S/D. "Give 10% mixed with home-cooked food and increase daily," I said. "It is important to avoid kidney stone operation!"  

An unusual old dog so active 2 hours post op. Compared to the overweight Jack Russell who is drinking lots of water and depressed, lying down 2 days after 10 small bladder stone removal surgery. He would stand up when the owner came.

UPDATE ON THE ABOVE-MENTIONED POODLE WITH BLADDER & KIDNEY STONES ON JUN 18, 2013
I phoned the owner. He said the poodle had started to eat more and was more active. The bruised redness of the belly area had moved to the thigh. I asked him to WhatsApp the images to me. The advantage of the patient going home on the 2nd day of surgery is home nursing and lower medical costs. The disadvantage is the dog cannot be crated and running around at home movement causes wound breakdown or infection
 

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UPDATE ON THE JACK RUSSELL WITH 10 SMALL BLADDER STONES ON SUNDAY JUNE 16, 2013
The dog returned to Toa Payoh Vets on Saturday June 15, 2013, on the 2nd day after surgery as she was fit. The other Jack Russell, on 3 bottles of IV drip was more active and barked on Saturday, much to the joy of the owners. He was drinking and drinking a lot of water of Friday lying on his chest and looking lethargic. He would walk when taken out but preferred to lie down for the last two days..