Fish Surgery
MichaelJ. Murray, DVM
As the number and value of captive fishes increases, so
too will the indications for surgical intervention by the
veterinarian. In general, the most difficult aspect of fish
surgery is the provision of adequate and safe anesthe-
sia, and several different anesthetic regimens are pro-
vided. Once one is familiar with the normal anatomy of
the piscine patient, the basic concepts of surgery pre-
vail, including appropriate surgical approach, hemosta-
sis, and gentle tissue manipulation. Specific surgical
procedures, celiotomy, liver biopsy, renal biopsy, and
laparoscopy are discussed. Finally, successful outcome
of a surgical manipulation often rests in the postoper-
ative management of the surgical patient. Suggestions
for appropriate postoperative management are also
discussed.
Copyright 2002, Elsevier Science (USA). All rights re-
served.
Key words: Fish, surgery, anesthesia, laparoscopy, ce-
liotomy, biopsy.
g g V o u can do that?" is probably one of the
At most c o m m o n l y e n c o u n t e r e d responses
to clinicians advocating a surgical m a n i p u l a t i o n
of a piscine patient. O n the surface, one should
not be terribly surprised at such a response;
however, one n e e d only look m o r e carefully at
the demographics associated with captive fish to
u n d e r s t a n d some of the driving forces b e h i n d
"pet" fish medicine. Although the exact num-
bers are difficult to ascertain, the results of the
2001 p e t ownership survey posted on the Amer-
ican Pet Product Manufacturers Association
Web site indicate that there are approximately
160 million pet fish. Many of these fish are dear
pets to their owners, a n d the h u m a n - a n i m a l
b o n d definitely influences the level of veterinary
care expected. As life support systems for captive
fish have i m p r o v e d and decreased in cost, b o t h
the value and longevity of m a n y specimens has
From the Monterey Bay Aquarium, Monterey, California.
Address correspondence to Michael J. Murray DVM, Monterey
Bay Aquarium, 886 Cannery Row, Monterey, CA 93940.
Copyright 2002, Elsevier Science (USA). All rights resemed.
1055-937X/02/1104-0007535.00/0
doi:10.1053/saep. 2002.126571
246 Seminars in Avian and Exotic Pet Medicine, Vol 11, No 4 (October), 2002: pp 246-257
increased. Public aquaria have increased in b o t h
n u m b e r and complexity and often exhibit fish
with substantial financial and genetic value. As a
result, advances in fish surgery have b e c o m e
commonplace.
A n u m b e r of excellent reviews of surgery in
the piscine patient have b e e n published recently
in the veterinary literature. 1,2 Much of the earli-
est work published was directed towards and
written by fish pathologists and biologists with
particular emphasis on diagnostic sample collec-
tion and transmitter implantation. ~-7 An a t t e m p t
will be m a d e within this review to present a m o r e
traditional veterinary a p p r o a c h to fish surgery
that includes discussion of anesthesia, patient
preparation, instrumentation, surgical proce-
dures, and postoperative m a n a g e m e n t .
Anesthesia
Debate still occurs regarding the ability of fish
to feel pain. W h e t h e r or not they feel pain, it is
i n c u m b e n t u p o n the veterinarian to err on the
side of caution, assume pain can be experi-
enced, and offer anesthesia during painful pro-
cedures (Table 1). T h e r e can be no doubt, how-
ever, regarding the often violent reaction that
fish have to noxious stimuli.
O n e must always recognize the potential for
idiosyncratic problems with anesthetics in fish.
For that reason, there are circumstances in
which painless procedures, such as skin scrap-
ings, may be carried out with gentle physical
restraint. This does not imply, however, that
physical restraint is appropriate for procedures
that may be painful to the fish.
Many elasmobranches are adequately sedated
following immersion in a water column that is
supersaturated with oxygen. Still other species
may be adequately immobilized by physically
holding t h e m in dorsal r e c u m b e n c y via a process
of tonic immobility. This practice should be
used with caution because some species may
experience adverse effects to e x t e n d e d periods
of tonic immobility.
 Fish SurgeU 247

Table 1. Anesthetic Doses p r o l o n g e d procedures a m e c h a n i s m for main-

Anesthetic Agent Dose taining respiratory support and acceptable anes-
thetic levels must be provided.
Inhalant anesthetics Inhalant anesthesia as described in this con-
Tricaine text may be maintained in one of t w o fashions.
methanesulfonate
Induction 100-200 mg/L In smaller specimens, a non-rebreathing system
Maintenance 50-100 mg/L may be used. Anesthetic- and oxygen-laden wa-
Eugenol ter appropriately p r e p a r e d for the fish may be
Induction 100-120 mg/L placed in a reservoir bag, such as an e x p e n d e d
Maintenance 40 mg/L IV bag. Anesthetic-laden water may then be de-
Injectable anesthetics
Ketamine livered via gravity flow through an appropriately
Teleost 66-68 mg/kg IM sized tube through the oral cavity directed over
Elasmobranch 12-20 mg/kg IM the gill filaments. Flow rates are easily controlled
Ketamine/ with clamps on the tubing. Water that accumu-
medetomidine lates may be drained into a n o t h e r reservoir but
Immobilization Ket, 1-2 mg/kg IM
Medet, 50-100 /xg/kg IM is not recycled over the fish's gills.
Reversal, In larger specimens a rebreathing system is
atipamezole 200/,g/kg IM r e c o m m e n d e d . A variety of anesthetic delivery
Ketamine/xylazine systems have b e e n described. In the author's
(sharks) experience, the design described by Lewbart
Ketamine 12-20 mg/kg IM
Xylazine 6 mg/kg IM and H a r m s is p r e f e r r e d and may be modified to
anesthetize large specimens (Fig 1). sq~ In this
Abbreviation: IM, intramuscularly. system, anesthetic-laden water is p u m p e d f r o m a
Table reprinted with permission,s
reservoir across the fish's gills f r o m where it
drains back into a reservoir for recirculation to
the patient. Such a system permits a p r o l o n g e d
Inhalant Anesthetics out-of-water p r o c e d u r e yet still maintains ade-
Not to be confused with the traditional inhal- quate respiratory support and anesthesia. It is
ant agents used in terrestrial animal anesthesia, i m p o r t a n t that the flow be directed over both
inhalants include those c o m p o u n d s added to gill arcades and in a n o r m o g r a d e fashion. Ret-
the water that sedate or anesthetize the fish. rograde flow may c o m p r o m i s e the n o r m a l
Although a n u m b e r of c o m p o u n d s have b e e n counter-current m e c h a n i s m of the gills and may
' e m p l o y e d in the past, the most c o m m o n l y used actually h a r m the structures.
agents currently in use are tricaine methanesul-
fonate (MS-222 or Finquel; Argent Chemical
Laboratories, R e d m o n d , WA) and eugenol.
Both c o m p o u n d s are readily available and have
b e e n evaluated for b o t h efficacy and safety.
Generally, fish are initially placed in an induc-
tion c h a m b e r that contains the p r o p e r levels of
anesthetic, with the a p p r o p r i a t e temperature,
pH, a n d oxygen levels, and is large e n o u g h to
prevent excessive struggling but not so large as
to p e r m i t concussive injury. Once the fish
reaches an a p p r o p r i a t e level of anesthesia, it
may be r e m o v e d f r o m the induction c h a m b e r
for out-of-water procedures.
For p r o c e d u r e s that are expected to be
shorter in duration, such as gill or fin biopsies,
Figure 1. Piscine rebreathing anesthetic system. A
no further chemical restraint may be required. side port off the power head (white arrow) is used to
In general, the time that the fish is held out of provide a trickle of water to keep the fish moist (black
water should be less than 5 minutes, s In m o r e arrow). Reprinted with permission. 1~
248 Michaelf Murray
Despite the a p p a r e n t "bullet-proof' nature of
these systems, there are areas of concern. First,
one must be ever cautious of water quality. Pro-
longed p r o c e d u r e s may result in water that be-
comes increasingly c o n t a m i n a t e d with nitroge-
nous waste. Additionally, one should be certain
that adequate gas exchange is occurring at the
water's surface. In some circumstances it may be
necessary to percolate oxygen t h r o u g h the anes-
thetic reservoir. In most cases, a dissolved oxy-
gen concentration of 6-10 p p m is adequate since
p r o l o n g e d exposure to high oxygen levels may
be d a m a g i n g to the respiratory system (the
gills). Finally, such a system has limits to varying
the "anesthetic setting." O n e may modify the
anesthetic concentration of the reservoir by add-
ing a known concentration of anesthetic or a
known volume of clean water to the system to
either raise or lower the anesthetic concentra-
tion, respectively. Mternatives to such manipula-
tions include multiple reservoirs of varying con-
centration or the use of an alternating system of
anesthetic provision at a steady level, followed by
use of anesthetic-free water when the anesthetic
d e p t h becomes excessive.
Tricaine Methanesulfonate (MS-222)
MS-222 is probably the most c o m m o n l y used
fish anesthetic at this time. It is a water-soluble
benzocaine derivative that is FDA-approved for
use in food fish that require a 21-day withdrawal
time. In aqueous solution, tricaine is acidic, with
a p H of nearly 3.0. T h e r e f o r e buffering is nec-
essary, typically with sodium bicarbonate, espe-
cially in freshwater systems. Marine systems typ-
ically contain adequate i n h e r e n t buffering, but
the p H should always be evaluated before the
induction of fish with MS-222.
Tricaine is generally recognized to cause hyp-
oxia, hypercapnia, and acidosis. 11 Secondary to
these effects hyperglycemia and elevations of
potassium, magnesium, hemoglobin, and he-
matocrit may also be noted. An increase in uri-
nary o u t p u t a n d subsequent electrolyte loss may
be n o t e d for up to a week postanesthetic, lz
It is r e c o m m e n d e d that an aqueous stock so-
lution (10 g i n / L ) of MS-222 be p r e p a r e d for
dosing anesthetic systems. Such stock solutions
are unstable in light, necessitating storage in
dark containers, and can be refrigerated or fro-
zen for increased shelf life. Because of the acidic
nature of the solution, buffering of anesthetic
systems should occur just before their use on
fish. An oily residue n o t e d on the surface of the
stock solution indicates that desulfonation has
occurred and that the solution has lost potency
and should be replaced.
As a general guideline, MS-222 induction is
carried out at concentrations of 100-200 m g / L .
Anesthetic m a i n t e n a n c e may then be accom-
plished at 50-100 m g / L . It is imperative that the
clinician develops a familiarity with the effects of
the agent u p o n the species in question. Varying
degrees of sensitivity to MS-222 have been ob-
served, and margins of safety may vary depend-
ing u p o n the water-quality parameters. In most
cases, the rate of recovery is directly related to
the length of anesthesia, anesthetic depth, and
water quality. O n e would typically anticipate
rapid recovery of less than 15 minutes in shorter
procedures and p r o l o n g e d recover?, periods
(hours) in procedures of a longer duration.
Eugenol (Clove Oil)
T h e phenolic c o m p o u n d eugenol is the active
ingredient in clove oil, which has long b e e n
advocated as a safe and effective anesthetic by
fish hobbyists and commercial fish farmers. 1~
Because eugenol is not water-soluble, it must be
diluted in 95% ethanol before use. Generally, it
is diluted 1:10 in 95% ethanol to p r o d u c e a stock
solution of 100 m g / m L . A concentration of 100-
120 m g / L is generally used for induction, 40
m g / L for maintenance.
W h e n c o m p a r e d with MS-222, both com-
pounds were f o u n d to contribute to hypoxemia,
hypercapnia, acidosis, and hyperglycemia. 11 Eu-
genol typically results in a m o r e rapid induction
and a m o r e p r o l o n g e d recovery period than MS-
222. Eugenol has a m o r e narrow range of safety
and may in fact cause respiratory failure at
higher doses. As with MS-222 one must be cog-
nizant of the idiosyncratic reactions to eugenol,
such as the cardiorespiratory depression and
death n o t e d anecdotally with Acanthuridae
(tangs and doctorfish). 1
Injectable Anesthetics
T h e r e are circumstances in which inhalation
anesthesia is inappropriate for use. It may not be
possible to provide anesthetic induction cham-
 JFish Surgery
bers for very large specimens. Some species such
as Scombridae do n o t tolerate confinement, a n d
"capture" of individuals in large aquaria may
preclude induction with tricaine or eugenol. In
those instances, parenteral administration of
agents may be indicated.
Intramuscular injections are typically given in
the dorsolateral musculature dorsal to the lat-
eral line. Although intramuscular injections are
not the ideal m e t h o d , they may be necessary,
particularly when injection with a pole syringe or
Hawaiian sling is necessary in larger aquaria.
W h e n administering intramuscularly, a deep in-
jection may aid in minimizing the retrograde
drainage of the material f r o m the injection site.
If possible, the needle should be directed crani-
ally to minimize d a m a g e to the integument.
Ketamine
An injectable, short-acting, dissociative anes-
thetic agent, ketamine hydrochloride is rarely
used alone, but rather in combination with
other agents, such as the ~-agonists m e d e t o m i -
dine or xylazine hydrochloride. In most teleost
fish, a relatively high dose is required for immo-
bilization and therefore is often used as an "in-
duction" agent. Elasmobranchs are typically
m u c h m o r e sensitive to the effects of ketamine
and may require addition of an o~-agonist for
adequate sedation, s
Propofol
T h e intravenous sedative/hypnotic agent
p r o p o f o l has some potential use as an anesthetic
despite its obvious limitation as an intravenous-
only c o m p o u n d . O f particular interest is its ap-
plication in tonically immobilized fish such as
elasmobranchs. It has several advantages when
used, including rapid, s m o o t h induction, rela-
tively short duration of effect, and n o n c u m u l a -
tive effects. It has b e e n used in sharks at a dose
of 2.5 m g / k g administered intravenously over a
30-second period into the caudal vein. TM Follow-
ing administration, righting reflex is lost within
5 minutes and returns in approximately 75 min-
utes.
Anesthetic Monitoring
As in traditional surgery, anesthetic monitor-
ing in fish is as i m p o r t a n t as any o t h e r aspect of
249
the procedure. O n e may attribute a series of
stages, planes, and descriptions to the events
that occur as the fish proceeds f r o m its n o r m a l
state to the deepest state of anesthesia--sedation
followed by narcosis a n d finally anesthesia. 12
Care should be taken to prevent iatrogenic in-
jury to the fish as it passes t h r o u g h the excitabil-
ity phase of anesthesia. During this period, the
fish may swim erratically and may even a t t e m p t
to leap f r o m the induction chamber. An exces-
sive anesthetic time or dose results in medullary
collapse and respiratory arrest followed by car-
diac arrest.
For p r o c e d u r e s involving minimal time
a n d / o r pain, a state of d e e p narcosis is typically
adequate. At this level the fish does not r e s p o n d
to positional changes, has a nearly n o r m a l respi-
ratory rate, shows no a t t e m p t to right itself, but
may d e m o n s t r a t e some reactivity to strong stim-
uli. In a plane of surgical anesthesia, there is a
total loss of reactivity, and the respiratory a n d
cardiac rates are very slow but strong.
Several parameters are generally m o n i t o r e d
in an effort to gauge anesthetic level (Table 2).
Respiratory rate, as evidenced by opercular
movements, is probably the most important.
Others include jaw tone, reaction to postural
changes, muscle tone, and reaction to painful
stimuli.
T h e r e has b e e n little success to date in the use
of pulse oximetry in fish anesthesia; however, a
Doppler-flow p r o b e over the heart may be useful
in d e t e r m i n i n g heart rates. 8
Patient Preparation and
Instrumentation
As in any surgical procedure, presurgical
p r e p a r a t i o n should e n h a n c e the patient's ability
to survive the p r o c e d u r e a n d return to normal
function quickly. Presurgical m a n a g e m e n t of
the piscine patient is no different (see Table 3).
If possible, underlying aberrations in the pa-
tient's water quality, temperature, and so on
should be corrected in an effort to m a k e a m o r e
stress-tolerant anesthetic and surgical candidate.
Attempts should be m a d e to minimize prean-
esthetic stress on the fish. Fish that are "relaxed"
tend to p r o c e e d t h r o u g h anesthetic induction
m o r e smoothly than those that b e c o m e excited.
Food should be withheld for at least 1 feeding
cycle to decrease b o t h nitrogenous waste prod-
250 Michael J. Murray

Table 2. Anesthetic Stages in Fish

Stage Plane Parameter Observed Effect
I Sedation
Light Equilibrium Normal
Muscle tone Normal
Respiratory rate Normal
Cardiac rate Not determined
Reaction to stimuli Slight loss

Deep Equilibrium Normal

Muscle tone Slight decrease
Respiratory rate Slight decrease
Cardiac rate Not determined
Reaction to stimuli Lost, still reacts to postural changes
II Narcosis
Light Equilibrium Loss, weak response to postural changes
Muscle tone Decreased
Respiratory rate Increased, excitatory phase
Cardiac rate Not determined
Reaction to stimuli Excitement phase, increased

Deep Equilibrium Loss, no response to postural changes

Muscle tone Decreased
Respiratory rate Normal
Cardiac rate Normal
Reaction to stimuli Reaction to strong stimuli
Suitable for minor sampling, biopsy
III Anesthesia
Light Equilibrium Loss, no response to postural changes
Muscle tone Loss
Respiratory rate Decreased
Cardiac rate Decreased
Reaction to stimuli Respond to deep pressure
Suitable for minor surgery

Surgical Equilibrium Loss

Muscle tone Loss
Respiratory rate Very low
Cardiac rate Slow
Reaction to stimuli Total loss of reactivity
Surgical plane of anesthesia
IV Medullary Collapse
Equilibrium Loss
Muscle tone Flaccid
Respiratory rate Total loss of gill movement, apnea
Cardiac rate Cardiac arrest follows resp arrest
Reaction to stimuli None
Suitable for euthanasia ONLY!
Reprinted with permission. 12

u c t b u i l d - u p a n d t h e p a r t i c u l a t e l o a d to t h e wa- t a n e o u s infections. U s i n g plastic bags o r l a t e x

t e r c o l u m n , w h i c h m a y c l o g t h e gill rakers.
O n e c a n n o t o v e r s t a t e t h e i m p o r t a n c e o f gen-
tle h a n d l i n g o f t h e fish p a t i e n t . R o u g h h a n d l i n g ,
especially in abrasive nets, will r e s u l t in t h e loss
o f excessive a m o u n t s o f t h e s u r f a c e p r o t e c t i v e
m u c u s a n d p r e d i s p o s e t h e fish to s e c o n d a r y cu-
e x a m gloves ( f r o m w h i c h t h e p o w d e r has b e e n
r i n s e d ) in t h e ' h a n d l i n g p r o c e s s will m i n i m i z e
this d a m a g e .
O n c e t h e fish has b e e n suitably a n e s t h e t i z e d ,
it m a y b e p l a c e d in a s u i t a b l e s u p p o r t s t r u c t u r e
for the procedure. Any material that contacts
 Fish Surgery
Table 3. Considerations for Fish Surgery
Preoperative Water quality
Minimize stress
Withhold food for 1 feeding cycle
Gentle handling
Intraoperative Minimal skin preparation
Pull scales individually
Keep skin moist
Monofilament suture
Postoperative Recovery tank
Resuscitation
Increased oxygen saturation
Minimize stress
Analgesics
Antibiotics
the fish's skin, such as the foam in V-troughs,
must be moistened before introducing the ani-
mal. It is often helpful to cover the fish's eyes as
an aid to the anesthetic effects. When out-of-
water surgery is being carried out, the skin must
be kept moist t h r o u g h o u t the procedure. A va-
riety of devices, including turkey basters, sy-
ringes, and 1V bags may be used for this main-
tenance technique.
Although there should be some form of pre-
surgical preparation of the entry site, it should
minimally disrupt the protective functions of the
skin and mucus layer. In most instances, a cot-
ton-tipped applicator moistened with sterile sa-
line may be used to reduce the surface contam-
ination. If antiseptics truly are indicated, they
should be quite dilute, 1:20 povidone-iodine or
1:40 chlorhexidine being r e c o m m e n d e d . 1 Alco-
hols should never be used because they tend to
damage the skin. For fish with large scales, the
scales should be gently removed individually
along the incision line. Fine-scaled fish, such as
the salmonids, n e e d not have scales removed.
Clear plastic drapes are generally advocated
for fish surgery. They tend to isolate the surgical
site for aseptic procedures and help to keep the
surrounding skin moist by reducing evaporation
(Fig 2). A ring of p e t r o l e u m jelly a r o u n d the
incision area is typically adequate for adhesion
of the drape to the fish's skin.
A n u m b e r of suture materials have been ad-
vocated for use in fish. It is important to recog-
nize that between mammals and fish the absorb-
ability and reactivity of many materials is not the
same. Many synthetic "absorbable" suture mate-
251
rials have been recovered from the coelom years
following surgical procedures. This prolonged
retention time suggests that a monofilament su-
ture may be preferable to decrease the possibil-
ity of secondary infection associated with the
wick-like effect of braided materials. Studies of
reactivity and incision-healing time also tend to
favor monofilament materials, with the greatest
reactivity and longest healing time found to be
with polyglactin 910, and the least and shortest
with monofilament nylon and polydioxanone.m5
For the vast majority of surgical cases involv-
ing fish, the instrumentation necessary is already
present within the typical veterinary clinic. Some
form of magnification is often necessary, partic-
ularly with smaller patients. Similarly, ophthal-
mic or microsurgical instrumentation may be
indicated. Self-retaining retractors such as Gel-
pi's are often helpful in coelomic procedures.
An appropriately sized osteotome may be re-
quired should pelvic girdle osteotomy be re-
quired in large specimens.
Surgical Procedures
In general, surgical manipulation of the fish is
little different from that of terrestrial verte-
brates. The basic surgical axioms apply: know
the anatomy; control hemorrhage; use a gentle
touch when manipulating tissue; and, if you
d o n ' t know what it is, d o n ' t cut it. The most
problematic of these axioms is knowledge of the
Figure 2. Celiotomy in a starry flounder (Platichthys
steUatus). Note the clear plastic drape used to isolate
the surgical site, the retractor employed for maximum
exposure, and the multicentric neoplasm of uncertain
origin.
252 Michael J. Murray

anatomy. Although fish do tend to follow a rel-
atively well-conserved vertebrate anatomic pat-
tern, there is t r e m e n d o u s variation in the spe-
cific a n a t o m y across piscine taxa. It is therefore
i n c u m b e n t u p o n the practitioner to gain a thor-
ough knowledge of the anatomy t h r o u g h post
m o r t e m examinations of similar specimens and
reviews of a p p r o p r i a t e a n a t o m y texts.
Historically, most of the surgical references to
fish have involved either the implantation of
telemetry devices or the nonlethal collection of
biopsy specimens by non-veterinarians. Over the
past decade, in large part due to the pioneering
work by Lewbart, Harms, Noga, Stoskopf, and
others, a variety of surgical procedures have
b e e n d o c u m e n t e d in the veterinary litera-
ture. 1,~,9,16q9 It is beyond the scope of this m a n u -
script to review each of the published references
to piscine surgery. Instead, the reader is directed
to cited references to specific surgical proce-
dures for m o r e detailed information.
Surgery of the Integument
A large n u m b e r of the fish surgeries carried
out in private veterinary practices involve the
removal of cutaneous masses. In m a n y cases,
these masses are in fact neoplastic. O n e may use
a c o m b i n a t i o n of radiosurgery a n d cold steel in
attempts to remove these masses. In most cases a
wide margin of tissue should be removed. Be-
cause of the fish's tightly a d h e r e n t skin a n d min-
imal subcutis, closure of these skin defects is
often impossible. Therefore, second-intention
healing is generally necessary. Topical antimi-
crobials, such as silver sulfadiazine cream, ,nay
be used postoperatively. Larger defects may be
associated with e x u b e r a n t loss of fluid and elec-
trolytes, the effects of which may be partially
mitigated by increasing the salinity of the water
system to 1-3 g / L (in freshwater systems).1
removal of foreign bodies, and the p e r f o r m a n c e
of minimally invasive surgical techniques (Fig
3) .20
As with any other species, laparoscopy should
be carried out using aseptic technique. T h e typ-
ical insertion points for laparoscopy are deter-
m i n e d by the anticipated anatomic "target" as
well as the anatomy of the fish u n d e r consider-
ation (Fig 4, 5). T h e tightly packed, relatively
fusiform shape of most fish precludes adequate
visualization without some f o r m of abdominal
distension (Fig 6, 7). Traditional insufflation
with carbon dioxide gas is the p r e f e r r e d tech-
nique; however, the author has used r o o m air in
n u m e r o u s cases without incident.
A Veress needle is typically used for insuffla-
tion into the peritoneal (or coelomic) cavity. It
has a spring-loaded blunt o b t u r a t o r that is de-
pressed and moves out of the way as the needle
passes t h r o u g h tissue, yet it springs into place to
protect the viscera once a cavity has b e e n en-
tered. T h e needle may be introduced at a 45 ~
angle n e a r the targeted entry point (Fig 8). It is
often preferable to make a small stab incision
t h r o u g h the skin to facilitate p l a c e m e n t of the
needle. As the needle is advanced into the coe-
lomic cavity, a discernible "pop" will be felt. It is
exceptionally i m p o r t a n t to advance the needle
carefully to prevent iatrogenic t r a u m a to viscera
(Fig 9).

Laparoscopy
Although the use of endoscopy in fish is not a
novel idea, the recent introduction into most
veterinary clinics of quality, rigid, rod-lens sys-
tems has m a d e its use m o r e practical. T h e indi-
cations for laparoscopy in fishes m i r r o r those
described for o t h e r species: sex identification in
Figure 3. Collection of liver biopsy specimens from
m o n o m o r p h i c or juvenile specimens, manage- the liver (arrow) in the leopard shark (Triakis semifas-
m e n t of reproduction, examination of coelomic ciata) is generally not associated with substantial hem-
viscera and collection of diagnostic specimens, orrhage.
 Fish Surgery
Figure 4. With a more lateral approach, the cranial
aspect of the swim bladder (SB) is visible adjacent to
the liver (L) in this Pacific mackerel (Scomberjaponi-
s ,
Once the needle is in place within the coe-
lom, the cavity may be insufflated to a pressure
of 10 m m Hg. The needle may then be removed
from the pressurized coelom. The 45 ~ tunneling
t h r o u g h the body wall tends to prevent excessive
loss of pressure. A trocar and sleeve may then be
placed t h r o u g h the track created by the Veress
needle. Again, caution must be exercised as this
sleeve is placed. With the trocar removed, an
appropriately sized rigid telescope may be in-
serted.
Figure 6. A panoramic view of the coelom of a rock-
fish (Sebastes spp) in dorsal recumbency. The liver is
the dominant organ (white arrow) in this view. Large
quantities of abdominal fat (black arrow), commonly
encountered in captive specimens, are also promi-
nent.
253
Figure ~. Pyloric ceca (arrow) in Pacific mackerel
(Scomberjaponicus) are also present in salmonid fishes.
In cases requiring multiple puncture ap-
proaches, a second trocar/sleeve may be intro-
duced. Should this be necessary, it is recom-
m e n d e d that the entry point be planned to ac-
c o m m o d a t e anatomy in conjunction with the
need to triangulate between the second port, the
telescope, and the target organ. Initial violation
of the skin may be made with a scalpel blade,
and a partial thickness dissection t h r o u g h the
body wall made with fine mosquito forceps. The
final placement of the second trocar/sleeve
should be visualized with the telescope.
At the completion of the laparoscopic proce-
dure, as m u c h gas as possible should be removed
from the body cavity with digital manipulation
Figure 7. The tightly compacted visceral mass (larger
black arrow) in the koi is difficult to manipulate en-
doscopically. One typically sees multiple tendrils of
connective tissue (white arrow) spanning the space
between the viscera and the body wall and ribs (small
black arrow)
254 Michael J. Murray
Figure 8. Veress needle (white arrow) inserted on the
midline near the pectoral fins of a leopard shark
(Triakis semifasciata). In this instance, a second portal
of entry is being made caudally. Anesthesia is being
delivered via the clear tube inserted in the shark's
mouth.
and pressure. The skin defects may then be
closed routinely. Any residual gas r e m a i n i n g
within the coelom should be absorbed relatively
rapidly over several days. In those cases, aquar-
ium furniture should be placed in the recovery
tanks to allow the fish to "wedge" itself to main-
tain a comfortable posture for itself within the
water column.
Celiotomy
In most cases, the surgical a p p r o a c h to the
coelom of the fish is t h r o u g h a ventral midline
incision. T h e incision extends f r o m the caudal
aspect of the pectoral girdle to approximately 1
cm cranial to the vent, d e p e n d i n g u p o n the size
of the fish. 1 Should additional exposure be re-
quired, an osteotomy of the pectoral girdle may
be carried out either with an o s t e o t o m e in larger
specimens or simply with blade/scissors in
smaller ones. T h e ventral midline may be fur-
ther e x t e n d e d laterally if necessary. Use of self-
retaining retractors such as Gelpi's is often nec-
essary for g o o d exposure to coelomic viscera.
As previously indicated, a large body of pub-
lished information is available regarding the col-
lection of biopsy specimens using nonlethal
techniques, especially in sahnon fishes. O n e
such technique is a lateral a p p r o a c h to the liver. 7
Access to the liver is m a d e through an incision
m a d e just caudal to the o p e r c u l u m and dorsal to
the pectoral fin (Fig 10). In most cases, an inci-
sion length of 5-7 cm provides adequate expo-
sure to the lateral aspect of the liver.
A similar technique for exposure of the dor-
sally placed kidney has also b e e n described. 7 In
this instance the incision is started midway be-
tween the lateral line and the left pelvic fin with
care taken not to incise across the lateral line.
T h e incision is then continued caudally and ven-
trally to a p o i n t midway between the vent and
the caudal b o r d e r of the pelvic fin. With blunt
dissection, retraction, and compression of the
swim bladder, the caudal aspect of the left kid-
ney may be exposed (Fig 11). T h e caudal pole of
the swim bladder may n e e d to be teased away
f r o m its a t t a c h m e n t to the kidney; however, such
dissection should be conservative. A Backhaus
towel clamp may be used to hold a sterilized
stainless steel washer, which may then be placed
u p o n the swim bladder as an aid in compres-
sion/retraction. W h e n carrying out renal biop-
sies, one should a t t e m p t to collect small samples
and recognize (and avoid if possible) the opis-
t h o n e p h r i c ducts draining the kidneys.
Closure of the body wall is typically straight-
forward. D e p e n d i n g u p o n the size of the fish
and the thickness of the body wall, either a
single- or a double-layer closure may be used. In
the first case, b o t h the skin and muscle are in-
c o r p o r a t e d in the closure. Skin and muscle are
closed separately in the double-layer technique
(Fig 12). T h e suture pattern employed is depen-
d e n t u p o n personal preference. A continuous
Figure 9. Veress needle in place within the coelom of
a rockfish (&bastes spp). The arrow points to the
beveled edge of the sharp needle, which is protected
by the retractable trocar once the needle enters the
body cavity.
 Fish Surgery
Figure 10. With retractors,
the liver (white arrow) and
stomach (black arrow) are
easily approached in the
black rockfish (&bastes melan-
ops) .
p a t t e r n is a d e q u a t e in m o s t cases, b u t inter-
r u p t e d sutures are similarly successful. Surgical
staples have b e e n used successfully in b o t h fresh-
water a n d m a r i n e species. T h e n a t u r e o f fish
skin is such that p r o p e r p l a c e m e n t o f staples is
difficult, a n d surgical staples are t h e r e f o r e n o t
often used.
Despite references to the contrary, the use o f
cyanoacrylate adhesives is n o t r e c o m m e n d e d ,
since they often incite a severe dermatitis. 9 In
addition, incisions closed with cyanoacrylate ad-
Figure 11. A caudal, lateral approach to the coelom
exposes the compressed swim bladder (SB), abdomi-
nal fat bodies (F), a loop of small intestine (SI), and
the caudal pole of the kidney (K) in the black rockfish
( S&astes melanops).
255
hesives have a h i g h e r i n c i d e n c e o f d e h i s c e n c e
than those closed with sutures. 91 This is n o t sur-
prising because c u t a n e o u s g o b l e t cells p r o d u c e
mucus, the p r e s e n c e o f which a d j a c e n t to the
incision site u n d e r m i n e s a n d elevates the adhe-
sive, resulting in dehiscence.
Postoperative Management
Recovery f r o m an anesthetic p r o c e d u r e may
be a p r o t r a c t e d event, particularly w h e n inject-
Figure 12. Closure of a celiotomy incision in the
starry flounder (Platichthys steUatus). The right hand
aspect of the figure demonstrates the closure of the
body wall, and the left side demonstrates skin closure;
each is done in separate layers.
256 Michael J. Murray
able agents are used (see Table 3). In the case of
inhalant anesthesia, it is r e c o m m e n d e d that the
"anesthetic setting" be t u r n e d down towards the
e n d of a p r o c e d u r e that has b e e n either lengthy
or has involved greater anesthetic depth. This
may be accomplished by either diluting the con-
centration of anesthetic in the reservoir or by
changing the over-the-gills infusion to a m b i e n t
water.
Postanesthetic fish should be p e r m i t t e d to
recover totally in a recovery tank that is not its
p r i m a r y enclosure. This tank should be free of
obstacles or furniture that may injure or entan-
gle the patient. Obviously, the water-quality pa-
rameters should be a p p r o p r i a t e and consistent
with those f o u n d in the fish's primary tank. T h e
fish should be gently restrained as it is placed in
its recovery tank. Water flow should be directed
into the patient's oral cavity to facilitate resusci-
tation as the gills are perfused. O n e may n e e d to
physically p r o p e l the fish fotavard to accomplish
this perfusion for some specimens. T h e fish
should not be pulled backwards because this
dramatically decreases respiratory efficiency and
may d a m a g e the gill filaments.
As the fish regains consciousness, there is an
increase in jaw tone and opercular movements.
Caution should be practiced a r o u n d the oral
cavity of fish with potentially dangerous teeth
because jaw tone and biting may occur before
the return of opercular movements. Once
strong respiratory m o v e m e n t s are detected, the
fish should be released into the water column,
even though it may not have regained its n o r m a l
posture. T h e fish should be allowed to recover in
a dimly lit, quiet area to minimize stress and to
facilitate a m o r e gentle recovery period. T h e
recovery f r o m some anesthetic agents may be
rather violent a n d involve uncontrolled swim-
m i n g a n d even porpoising in the tank. Obvi-
ously, ways of preventing injury should be con-
sidered.
Some anecdotal evidence suggests that hypox-
emia may be somewhat persistent following MS-
222 or eugenol anesthesia in freshwater fish. 22
For this reason ensuring adequate or even
slightly elevated oxygen saturation of recover
systems may be advantageous. O n e must bear in
mind, however, that p r o l o n g e d exposure to dra-
matically elevated levels of oxygen may result in
damage to gill filaments.
T h e r e is an ongoing debate as to the ability of
fish to experience pain. As a result, the indica-
tion for postoperative analgesia is also debat-
able. Despite the uncertainty, it seems appropri-
ate that the clinician should err on the side of
the patient and administer analgesics in those
cases for which postoperative pain m a n a g e m e n t
would be a p p r o p r i a t e in o t h e r species. W h e n
administered before cessation of anesthesia, bu-
t o r p h a n o l (0.4 m g / k g intramuscularly or subcu-
taneously) produces no untoward effects. In
fact, b u t o r p h a n o l - t r e a t e d koi r e t u r n e d to nor-
mal swimming and began eating sooner than koi
given a placebo. 23
As in m a m m a l i a n patients, the administration
of postoperative antibiotics is controversial. It is
agreed, however, that antibiotics are not a pan-
acea for p o o r surgical technique. Because most
piscine surgical techniques are not truly aseptic
as a consequence of limited skin preparation,
some prophylactic antibiotic administration is
probably justified. Generally, a single adminis-
tration of a broad-spectrum antibiotic such as
amikacin, enrofloxacin, or ceftazidime is ade-
quate. O n e must bear in m i n d that most antimi-
crobials are not a p p r o v e d for use in "food fish,"
and therefore only a p p r o v e d products should be
used in those specimens that may ultimately be
c o n s u m e d by h u m a n s (eg, oxytetracycline hy-
drochloride, 10 m g / k g intramuscularly). 1 O n e
may also apply a thin layer of a povidone-iodine
o i n t m e n t to the incision site to discourage the
growth of fungi as healing proceeds. 1
T h e r e m a i n d e r of the recovery period should
be relatively straightforward. Postoperative anti-
biotics or analgesics should be continued as in-
dicated. Water quality p a r a m e t e r s within the re-
covery area should be m o n i t o r e d and main-
tained. T h e elevated oxygen saturation of the
system may be gradually r e d u c e d over time as
well. O n e should not overlook the potentially
detrimental effects of "exposure" in a recovery
tank. Many fish benefit f r o m the provision of
adequate hiding places and visual security once
they have recovered f r o m the effects of the an-
esthetic.
As the n u m b e r s and the value of captive fish
increase, the potential indications for surgical
intervention in fish will increase. Although the
c o n c e p t of "out-of-water" surgery in this g r o u p of
animals may be initially intimidating, fish are
actually excellent surgical candidates. T h e clini-
 Fish Surgery
clan m u s t b e aware o f t h e intricacies o f fish
anesthesia and anesthetic monitoring, however.
That, coupled with a sound knowledge of the
patient's anatomy, should allow the practitioner
to a p p r o a c h fish surgery with a minimum of
trepidation.
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