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Small Animal/Exotics 20TH ANNIVERSARY Compendium July 1999

Highlights and Horizons in


Soft Tissue Surgery
Gary W. Ellison, DVM, MS, Diplomate ACVS
Professor and Service Chief, Small Animal Surgery
University of Florida
Gainesville, Florida

he past two decades were truly a

T golden age in the specialty of small


animal soft tissue surgery. Countless
talented surgeons invented, evaluated, and mastered myriad new techniques that
have allowed practitioners to treat conditions previously considered untreatable;
these techniques were often surprisingly successful, resulting in a better quality
of life for patients. The advances have been so numerous that adequate individu-
al recognition is not possible in a short overview of this type. In my opinion,
however, the most significant advances have occurred in the areas of pain man-
agement; oncologic, reconstructive, and abdominal surgery; alternative teaching
methods; and prepubertal gonadectomy.

Pain Management
Before 1979, little thought was given to postoperative pain management in Gary W. Ellison, DVM, MS
small animals. Methods for alleviating postoperative pain were popularized dur-
ing the past 20 years, including topical anesthetic nerve blocks and body cavity tomy and maxillectomy techniques
infusions, epidural opiate administration, injectable and oral nonsteroidal antiin- with excellent cosmetic and function-
flammatory drugs, and transdermal fentanyl patch application.1,2 In the 1990s, al results. Axial skeletal neoplasias,
Hardie and Kyles helped pioneer the development of point systems for more ob- such as osteosarcoma and chondro-
jective pain analysis in small animals and advocated pre- and intraoperative (pre- sarcoma of the face, ribs, and pelvis,
emptive) treatment for pain.1 Preemptive treatment reduced vocalization, aggres- were successfully managed using
sion, restlessness, and/or social withdrawal in animals experiencing pain as well maxillectomy, thoracoplasty, and
as the doses of analgesic and sedative drugs needed to control pain postoperative- hemipelvectomy techniques, respec-
ly.2 Research also showed that pain peaked within 24 hours after minor elective tively. Large soft tissue tumors of the
procedures, whereas more invasive surgical procedures (e.g., thoracotomies, am- thorax and trunk were resected, and
putation) required pain control for 72 hours or longer.1,2 defects were successfully repaired us-
ing prosthetic mesh. Dogs with ap-
Oncologic Surgery pendicular osteosarcoma received
The landmark work of Withrow3 and Salisbury4 in the early 1980s demon- limb-salvage procedures and often
strated how to remove “nonresectable” oral tumors via progressive mandibulec- outlived animals in which amputa-

ENDIU 1979 1980 1983 1984 1987


MP 1980 1983
First successful Axial pattern First Open

1985 19 Clinical feline


M’

20th
 CO

portosystemic flaps for mandibulectomy peritoneal renal transplantation

1981
S

shunt ligation reconstructive and drainage is introduced

1 9 7

ANNIVERSARY
9 - 1
9 9 9

1979 is performed surgery are


introduced
maxillectomy
1982
techniques for
oral neoplasia are
performed

1984
for septic
peritonitis is
first described
First description of free
microvascular skin
transfers for wound
reconstruction is
published
19
Compendium July 1999 20TH ANNIVERSARY Small Animal/Exotics

tion alone was performed. The use of as likely to develop GDV compared OWNERS’ OUTLOOK
lasers in veterinary surgery was also with those fed twice daily.10 Many
instituted; carbon dioxide, neodymi- successful surgical techniques were ■ Anything for Love. The increasing
um-yttrium-aluminum-garnet, and developed for the prevention of value owners are placing on their
argon lasers were used for the re- GDV, including circumcostal (Fal- pets’ companionship is evident
moval of cutaneous tumors, treat- lah), incisional (McCoy), belt-loop by the amount of money they are
ment of perianal fistulas, and treat- (Whitney), and ventral midline willing to spend on veterinary care
ment of glaucoma, respectively.5 (Meyer-Lindenburg) gastropexy.11 to keep them healthy. In just 5
years—from 1991 to 1996—
The first descriptions of subtotal
annual spending on veterinary
Reconstructive Surgery colectomy for surgical management care for cats and dogs rose from
Large wound defects are now com- of idiopathic megacolon (IM) in cats $7 to $11 billion.a
monly closed with innovative local were provided by Bright and Rosen ■ The Wave of the Future? As
transposition flaps and free-tissue in the early 1980s. This procedure owners demand more advanced
transfers. Pavletic was able to transfer remains popular for cats with medi- and specialized care for their pets,
large vascularized segments of skin in cally refractory cases of IM. Open the veterinary profession has
single stages without the necessity of peritoneal drainage was studied by needed to adjust accordingly.
a secondary procedure6; during the several surgeons in the mid-1980s In 1985, there were only 2261
1980s and 1990s, at least 11 of these and is now commonly used to treat veterinary specialists in the United
axial pattern flaps were described. severe septic peritonitis in small ani- States; today, 6293 veterinarians
specialize in an ever-growing
Because direct cutaneous flaps could mals. White and Williams described
number of fields.a
not reach all areas of the body, sever- an efficacious prostatic omentaliza- a
al veterinary microsurgeons trans- tion technique for managing recur- According to the American Veterinary
Medical Association.
ferred cutaneous or myocutaneous rent prostatic abscesses and cysts that
free flaps to distant recipient sites, gave better results than did previous-
usually over joint surfaces or distal ly described techniques.12 form this sophisticated procedure,
extremities with shear-type injuries.7 In 1979, portosystemic shunts in with many patients having good to
Severe distal degloving injuries were dogs and cats were introduced by excellent results.
treated by using segments of existing Breznock, who later described the In 1995, Matthews and Sukhiani
digital pads to reconstruct weight- anatomic categories of shunts, ex- made a significant contribution in
bearing metatarsal and metacarpal plained the pathophysiology and the management of perianal fistulas
pads, allowing salvage of limbs that medical management of the disease, with the disclosure that cyclosporine
previously would have been ampu- and established the guidelines for was effective in improving lesions in
tated.8 portal pressures during ligation.13 A almost 100% of dogs treated, elimi-
slow occlusion device was subse- nating the need for surgery in half of
Abdominal Surgery quently used by Vogt and Krawinkel the patients.
Major advances have been made in 1993 that lowered the morbidity
during the past 20 years in under- associated with partial portosystemic Alternative Teaching Methods
standing gastric dilatation-volvulus shunt occlusion. In the early 1990s, in response to
(GDV). Free-radical scavengers were The first successful feline renal increased attention to the ethical use
used to reduce gastric ischemia.9 Epi- transplants were reported by Gregory of animals in veterinary curricula,
demiologic work by Glickman dem- and Gourley in 1987. Since these psychomotor skills laboratories were
onstrated a genetic predisposition initial transplants, morbidity and implemented to develop students’
toward GDV in Great Danes and mortality associated with renal trans- technical skills in the laboratory be-
Irish setters with a high thoracic or plantation in cats has been greatly re- fore working on live animals and
abdominal height:width ratio.10 Dogs duced. There are currently at least six cadavers were substituted for live an-
fed once daily were reportedly twice centers in the United States that per- imals when possible. Several educa-

98719901992 1990

1995
Surgical lasers are
1991
Prepubertal gonadectomy
1993
First use of gradual
1994–Present
Comprehensive pain
1997
Risk factors for gastric

1998
first used in in dogs is occlusion ring for control is dilatation-volvulus are

1991
veterinary medicine first described portosystemic shunts developed in first described

1994
19891993 1997
small animals

1999
Synthetic models for
986 instruction of psychomotor
skills are developed
Compendium July 1999 20TH ANNIVERSARY Small Animal/Exotics

tors developed simulated models for vessel ligation, hollow human studies without prior animal trials. Despite these
organ closure, and skin and subcutaneous closure.14 Stud- hurdles, the next 20 years will be an exciting and dynamic
ies comparing the technical skills of students using live-an- time in soft tissue surgery.
imal versus simulated models and cadavers indicated that References
the technical abilities of the groups were similar.15 1. Hardie EM, Kyles AE: Pain management in the small animal patient,
in Bojrab MJ (ed): Current Techniques in Small Animal Surgery, ed 4.
Prepubertal Gonadectomy Philadelphia, Williams & Wilkins, 1998, pp 3–17.
2. Hansen BD: Analgesic therapy. Compend Contin Educ Pract Vet
The effect of prepubertal gonadectomy was studied by 16(7):868–875, 1994.
Salmeri, Stubbs, and Bloomberg throughout the late 3. Withrow SJ, Holmberg DL: Mandibulectomy in the treatment of
1980s and early 1990s.16,17 This invaluable work showed oral cancer. JAAHA 19:273–286, 1983.
4. Salisbury SK, Richardson DC, Lantz GC: Partial maxillectomy and
that ovariohysterectomy and gonadectomy before 16 premaxillectomy in the treatment of oral neoplasia in the dog and
weeks of age is safe in dogs and cats, thereby enhancing pet cat. Vet Surg 15:16–26, 1986.
population control in North America.16,17 5. Bartels KE: Laser surgery, in Bojrab MJ (ed): Current Techniques in
Small Animal Surgery, ed 4. Philadelphia, Williams & Wilkins, 1998,
pp 45–52.
What the Future Holds 6. Pavletic MM: Caudal superficial epigastric arterial pedicle grafts in
Traditional small animal soft tissue surgery as we know the dog. Vet Surg 9:103, 1980.
it today will play less of a role in the future. Noninvasive 7. Fowler JD, Miller CW, Bowen V, et al: Transfer of free vascular cu-
taneous flaps by microvascular anastomosis: Results in six dogs. Vet
laparoscopic removal of gallbladders, removal of bladder Surg 16:446–450, 1987.
stones, spay and neuter techniques, and removal of certain 8. Swaim SF, Bradley DM, Steiss JE, et al: Free segmental paw pad
types of abdominal tumors will be more common. Cold grafts in dogs. Am J Vet Res 54:2161–2170, 1993.
9. Lantz GC, Badlak SF, Hiles MC, Arkin TE: Treatment of reperfu-
scalpels will likely be replaced by harmonic scalpels, which sion injury in dogs with experimentally induced gastric dilatation-
greatly reduce hemorrhage while having a minimal effect volvulus. Am J Vet Res 53(9):1594–1598, 1992.
on tissue healing. Surgical laser units will become less cost- 10. Glickman LT, Glickman NW, Sohellenberg DB, et al: Multiple risk
ly and thus more common in veterinary practices. Multi- factors for the gastric dilatation-volvulus syndrome in dogs: A practi-
tioner/owner case-control study. JAAHA 33(3):197–204, 1997.
specialty practices that provide the latest in surgical proce- 11. Ellison GW: Gastric dilatation volvulus—Surgical prevention. Vet
dures, radiation therapy, internal medicine, and intensive Clin North Am Small Anim Pract 23(3):513–530, 1993.
care will continue to proliferate in medium-sized to larger 12. White RAS, Williams JM: Intra-capsular prostatic omentalization: A
new technique for management of prostatic abscessation. Vet Surg
metropolitan areas, making advanced veterinary care more 24:390–395, 1995.
logistically available for clients. In the area of organ trans- 13. Breznock EM: Surgical manipulation of portosystemic shunts in
plantation, we will see clinical liver, pancreas, intestine, dogs. JAVMA 174:819, 1979.
14. Greenfield CL, Johnson AL, Arends MW: Development of
and even lung transplantation in cats and possibly dogs. parenchymal abdominal organ models for use in teaching veterinary
Surgical success rates for various types of neoplasias will soft tissue surgery. Vet Surg 22:357–362, 1993.
improve using new adjunctive therapies, including gene 15. Carpenter LG, Piermattei DL, Salman MD, et al: A comparison of
surgical training with live anesthetized dogs and cadavers. Vet Surg
and immunomodulating therapy. 20:373–378, 1991.
Veterinary curricula will rely less on live-animal proce- 16. Salmeri KR, Bloomberg MS, Scruggs SL, et al: Gonadectomy in im-
dures and more on fabricated models for teaching. Live- mature dogs: Effects on skeletal, physical, and behavioral develop-
animal research will become more limited because of in- ment. JAVMA 198:1193–1203, 1991.
17. Stubbs WP, Bloomberg MS, Scruggs SL, et al: Effects of prepubertal
creasingly stringent animal-use guidelines; therefore, more gonadectomy on physical and behavioral development in cats.
techniques and procedures will be applied directly from JAVMA 11:1864–1871, 1996.