Breaking down the suspensory ligament

Wendy Blount, DVM
Tricks of the Trade
Reducing Spay-Neuter Time
Marvin Mackie, DVM – Quick Spay
James Wright, DVM, MPH, ACPVM
Dr. Sara White
Dr. Bob Judd, ABVP
BOD, ASV; Spay ASAP Inc.
Judd Veterinary Clinic
Dr. Karla Brestle
Dr. Philip Bushby, ACVS
Medical Director, Humane Alliance
Mississippi State CVM
Dr. Mark Bohling, ACVS
Brenda Griffin, ACVIM
University of Tennessee CVM
University of Florida CVM
I Feel the Need
for Speed!
• Speed per se is not the desired goal
• Efficiency is the goal and not the same as speed
• Efficiency is elimination of all unnecessary tissue
handling and any wasted motion
• Experienced surgeons who are very fast are not
necessarily rushing, they just make very few
“false moves.”
• Less tissue handling means less trauma and less
pain for the patient
Halsted’s Principles of Surgical Technique
• Gentle tissue handling
• Strict asepsis
• Meticulous hemostasis
• Elimination of dead space in the surgical
• Suspensory ligament - suspends the ovary from
the dorsal wall of the abdominal cavity, and
continues in the broad ligament to suspend uterus
• Broad ligament – peritoneum and fat lateral to
uterine body
• Proper ligament – tethers the ovary to the uterus,
containing the uterine tube
• Pedicle – usually refers to the ovarian or testicular
vessels and vas deferens
• Stump – usually refers to the uterine stump
Rate Limiting Steps to Spay-Neuter
• Finding the linea alba
• Finding the uterus
• Breaking down the suspensory ligament
• Finding a dropped pedicle or stump
• Waiting for light anesthesia to become
surgical again
• Waiting for the next patient
Finding the linea alba
• Overweight – excess subcutaneous fat
• Lactation (flank approach)
• Cats – herringbone meeting of left and right
rectus rather than linea alba
Finding the linea alba
Cat Video (0:06)
Finding the uterus
• Visual – requires largest incision
• Spay hook – smallest incision
– More likely to cause trauma than your finger in
the hands of an inexperienced surgeon
– the spay hook has no sensory nerve endings
• Finger sweep – big enough to get your finger
with uterus out.
Finding the uterus
• Full bladders, full colons and increased intra-abdominal
fat are my greatest obstacles
– Technicians gently express the bladder prior to prepping
– Tech trained to “leave it” if to much pressure is required
– It is possible to rupture the urinary bladder with manual
– Sometimes excessive manual pressure is not perceived to
be used
– If manual expression can’t be done safely, intra-operative
expression or even cystocentesis can help
Finding the uterus
• Finding the uterus quickly not only minimizes
surgery time, but also minimizes tissue
handling trauma.
• When I have to hunt for the uterus, I usually
give an extra intra-operative pain injection IM.
– Butorphanol, buprenorphine, morphine
– NSAID on recovery
Finding the uterus
• Spay hook sweep (0:36)
Finding the uterus
• Spay hook sweep
Cat Video (0:48)
Finding the uterus
• Finger sweep (0:11)
Finding the uterus
• Finger sweep (0:21)
Three Clamp Technique (2:43)
Three Clamp Technique
• Need big clamps for big dogs – I like
– We have only one in most spay packs, and open 2
more for big fat spays. We have 8 extra.
• Need small clamps for cats and small dogs
– Large clamps can tear small pedicles
– 4 small clamps and 2 mosquitos in each pack
• Good quality clamps prevent letting loose.
Three Clamp Technique
• 1 click on the first clamp, 1 cm proximal to
the ovary
• 2 clicks on the second clamp half way
between the first clamp and the ovary.
– always place your thumb and forefinger around the
ovary when you apply clamp 2 to avoid clamping or
cutting the ovary.
• 3 clicks on the third clamp on the proper
Breaking down the suspensory ligament
to get good exposure
• avoid “catchage”
– Slipped ligatures and pain
– Check for catchage by running your finger around the
ligature before you release it into the abdomen
• plenty of “tissue tag” above and beyond your ligature
to prevent a slipped ligature
• Plenty of room to use the 3 clamp technique if you like
• Avoid disrupting the ovary when you sharply dissect
the pedicle away
Breaking down the suspensory ligament
to get good exposure
• Sometimes stretching the ligament is fine for
• If the ovary does not retract back into the
abdomen when you set it on the drape, your
exposure is fine
• Some break it down from cranially and some
from the proper ligament window toward cranial
– In either case, the artery is avoided
Breaking down the suspensory ligament
to get good exposure (1:03)
Breaking down the suspensory ligament
to get good exposure - techniques
• strum with the fingers
• cut with blade or scissors
• Combination – nick then strum
• break down with hemostats
Breaking down the suspensory ligament (0:37)
Breaking down the suspensory ligament (0:16)
Breaking down the suspensory ligament
Cat Video (0:18)
Pregnant Cat Video (0:17)
Kitten Video (0:05)
Bertha the
100 lb Pit Bull
Bertha the
100 lb Pit Bull
Challenges spaying overweight dogs
• Incision Placement
• Finding the linea
• Finding the uterus
• Grease control and getting ligatures tight
when lots of fat is in the pedicle
• Dealing with the broad ligament
• Closing the linea (BCS 9/9)
Bertha the
100 lb Pit Bull
Incision Placement
• More important in large dogs because the
reproductive tract is longer
• Especially important in deep chested dogs where
distance between incision and dorsal attachment
of suspensory ligament is longest
• 1-2 cm caudal to the umbilicus
• Extend back 3-4 cm
• Extend caudally as needed to exteriorize an
enlarged uterus or the uterine body
Bertha the
100 lb Pit Bull
Incision Extension
• Bluntly with hemostats or dull edges of the
scissors if <1cm extension (cat video)
• With blade and thumb forceps (next video)
• Cutting with Mayo scissors, while elevating
the ventrum
Bertha the
Finding the linea (0:27)
100 lb Pit Bull
Bertha the
100 lb Pit Bull
Finding the uterus
• In my hands, finger sweep works much better than
spay hook for fat dogs.
• Have to make incision that big to get the uterus out
• If all else fails, extend the incision caudally and
exteriorize the bladder to expose the uterine body or
stump found between the colon and bladder.
• occasionally a uterine horn can seem to be trapped
beneath a very full colon – look there if not found in
the usual place.
Bertha the
100 lb Pit Bull
Grease control
• sterile huck towel in the pack to wipe grease off
your gloves as needed
• If it’s really bad and you can no longer grips the
suture material without slipping, change your
gloves for a fresh start
• Use Miller’s Knot for fat dog pedicles & stumps
– Fat cats don’t seem to carry much fat in their
ovarian pedicles
Bertha the
Miller’s Knot (0:45)
100 lb Pit Bull
Bertha the
100 lb Pit Bull
Miller’s Knot
• 2 passes around the pedicle increases surface area of
the ligature pressure
• Reduces tendency of ligature to cut tissue
• Particularly useful for large or edematous uteri
• Elevating the suture ends as you tighten helps to
tighten both loops equally
Cat Video (1:15)
Bertha the
100 lb Pit Bull
2 Clamp Technique for Fat/Enlarged Uterus
• Do not clamp the uterus prior to ligation
– To do so on an enlarged uterus risks transecting it with
the clamp prior to ligation
– It can retract under the pelvis
• Better exposure by breaking down broad ligament
• Place clamps after ligation
• Preserve 1 cm tag of tissue on the uterine stump
Bertha the
100 lb Pit Bull
2 Clamp Technique for Fat/Enlarged Uterus (0:45)
Bertha the
100 lb Pit Bull
Should uterine arteries be ligated separately?
• Almost all experts in HQHVSN say it’s not
• There is a post on the ASV listserve several times
yearly about problems with not ligating separately
Massive bruising on the abdomen, usually a cat
2-3 days after OHE
Occasionally the hemorrhage is fatal the first night
The uterine artery slips caudally beneath the ligature
and there is retroperitoneal bleeding which seeps out
the inguinal ring into the SC tissues
Bertha the
100 lb Pit Bull
Dealing with the broad ligament (0:20)
Bertha the
100 lb Pit Bull
Dealing with the broad ligament
Self Tie of Cat Broad Ligament (0:40)
• Watch using a scalpel blade with no handle on it
• Especially if you place your blade on the drape
Bertha the
Dealing with the broad ligament
100 lb Pit Bull
Bertha the
Dealing with the broad ligament
100 lb Pit Bull
Bertha the
100 lb Pit Bull
Dealing with the broad ligament
• Break down the broad ligament
– Better access to the uterine arteries for ligation
– Allows exteriorization of the uterine body (cat video)
• Use Rochester-Carmalts to crush and tear broad ligament
rather than breaking down manually – 3 clicks
• Easier to tear the suspensory ligament with less tissue
• Ligate if needed – encircling or Miller’s.
• Pedicle tie does not work well in my hands for fat dogs.
Bertha the
100 lb Pit Bull
Closing the linea
• Place one interrupted suture in the center with
a surgeon’s knot to keep fat from erupting out
every time Bertha breathes
• This is probably more important when closing
obese dogs with longer incisions
– Dropped stumps or pedicles
– Multiple adhesions
– Exploratory to confirm spay
Bertha the
100 lb Pit Bull
Closing the linea
• Continuous or interrupted????
– Apposition and seal better with continuous
– Interrupted provides back-up for suture or knot
– Cruciate rather than simple interrupted cuts knot
number by half
• Suture reaction is greatest at the knots
• Knot tying takes a little more time
Bertha the
100 lb Pit Bull
Closing the linea
• Bites at least 5-10mm from edge of rectus
• Suture ears at least 3-4mm
• 4-6 throws per knot
• Avoid crushing tissue with the first two throws
– Impedes healing
– Causes animals to lick and chew at suture line
Bertha the
Closing the linea (0:54)
100 lb Pit Bull
Ovarian Pedicle Ties
• don’t work well on animals with lots of fat in the pedicle.
• can often do a pedicle tie in even fat cats.
• Leave 4-5mm tissue tag beyond the hemostat to establish
clamp security
Pedicle Tie Female Cat (0:14)
Pedicle Tie Pregnant Cat (0:27)
• Same techniques used for testicular pedicles in routine and
cryptorchid castrations in cats and puppies
Dogs of
Preventing scrotal hematoma
• Meticulous hemostasis
– Avoid branches of the caudal superficial epigastric a.
Disposable JorVet handheld electrocautery
Epineprine:Lidocaine Splash
The socket is dry when I close, or I don’t close
Ligation of SC vessels only when needed
Reduced scrotal swelling from 2 in 100 to 2 in 1000
Dogs of
JorVet handheld electrocautery
-runs on two AA batteries
-2200o cautery and three
tips - $67.00
-2200o cautery - $36.00
- 1100o cautery - $29.00
-replaceable tips
-cautery lasts 4-6 months
Dogs of
Epi-Lido “Splash”
• Mix 1:9 epinephrine (1:1000) and 2% Lidocaine
• Getting the dilution backward can cause scrotal
necrosis if used as a true splash
• Apply 2cc of the mixture to a sterile 4x4
• Place the 4x4 into the scrotal sac for 30-60
seconds, and then remove
• Mackie uses 100% epinephrine for this
Dogs of
Epi-Lido “Splash” (1:57)
Dogs of
Open or closed?
• I do most of mine closed
– Strip the fascia away to have minimal connective tissue
around the ligation
– Run a hemostat along the cord
• If open, I do the Mackie modified open technique
– Ligate the spermatic cord and let it retract back in the
– Ligate the tunic and amputate most of it
Dogs of
Open or closed? (3:14)
Dogs of
What to do with the pendulous scrotum?
• A significant amount of contraction will occur
with time
• Not necessary to avoid scrotal swelling
• We offer scrotal ablation in older dogs for
cosmetic reasons for $20 extra
Skin Sutures or Not?
• Not necessary in most cases with intradermal closure
• Elected in high energy female dogs likely to chew
• Elected for very large incisions
– Alternatively, can do several segments of continuous for very large
• Elected if significant skin pathology
• Coming back for suture removal can be an issue for low cost
• I almost never put skin sutures in a dog castration
Burying the knot
• If the knot protrudes through the incision, it will likely need to
be removed with suture scissors
• Tie the knot with suture ends parallel to the incision
• Take a deep last bite prior to tying the knot
• Use an Aberdeen knot to reduce knot size
• Close SC and skin with a continuous for only one knot, when
incision is longer than can be closed with a cruciate or two
• Choose suture size that is not too large to reduce knot size
• “smurf” the knot just prior to applying glue to skin edges
Burying the knot
Aberdeen knot (1:32)
Burying the knot
Continuous SC and skin closure – single knot
• Only two throws in the first knot anchoring to rectus
• Tack to body wall by taking bites between the cruciate knots
in the linea
• Discussion about fetal euthanasia
• Example of tattoo ink placed in the incision
Continuous Closure (3:50)
Burying the knot
Smurf the knot (2:54)
• Don’t forget to trim the suture tag!
Incision Size – smaller really is better
• “incisions heal side to side”
• Other reasons to limit incision size to the minimum allowed to
exteriorize the reproductive organs
• Minimize instruments and fingers in the abdomen to minimize
tissue trauma, post-operative pain and adhesion formation
– Also limit exposure of abdominal contents to trauma
• Decrease likelihood of foreign bodies left in the abdomen
• Minimally invasive surgery for quicker recovery and lower
incidence of post-operative complication
• Larger incisions take longer to close and allow fewer
procedures each day
Transecting the pedicle before you ligate
• Scary at first – the pedicle is no longer tethered if the clamp
fails prior to ligation
• Bushby – “When you consider the increased tissue
manipulation necessary when ligating the pedicle prior to
transection, the risk of tearing the pedicle at the proximal
clamp is actually greater than a clamp slipping off”
– True IF you have good clamps
• 1-2-3 click technique minimizes risk of tear by proximal clamp
– 1 click on the proximal clamp
– 2 clicks on middle clamp
– 3 clicks on clamp on proper ligament
Transecting the pedicle before you ligate
• Preserving adequate tissue tag distal to clamp is key (1cm)
– Also makes the ligature more secure
– If you can’t do this, work on better ovarian exposure
• Incision placement cranial enough
• Break down suspensory ligament properly
• Remove the proximal clamp just prior to the final tightening of
the Miller’s knot
– Increases distance between the clamp and ligation by
reducing “spreading” of the pedicle by the closer clamp
• If you double ligate, try transecting after the first ligation
Tattoo and Glue
• Texas state law requires us to either microchip or tattoo
animals sterilized by releasing agencies
• Sec. 828.001. DEFINITIONS. Releasing agency - a public or
private animal pound, shelter, or humane organization. The
term does not include an individual who occasionally renders
humane assistance or shelter in the individual's home to a
dog or cat.
Tattoo and Glue
• Texas state law requires us to either microchip or tattoo animals
sterilized by releasing agencies
• (c) Identification markers. An animal sterilized under this section must
be identified by a microchip and/or a tattoo indicating that it has
been sterilized.
• (1) A new owner of an animal with a microchip shall be responsible
for providing information to the data base registry of the microchip
manufacturer indicating that the animal has been sterilized.
Tattoo and Glue
• Texas state law requires us to either microchip or tattoo animals sterilized by
releasing agencies
• (2) A tattoo must:
• (A) be placed on the inside of the animal's thigh near the abdomen or on the
caudal-ventral abdomen;
• (B) be imprinted with ink that is manufactured in the United States;
• (C) meet the standards of the federal Food and Drug Administration for
• (D) be of a contrasting color to the predominant color of the skin in which it
is tattooed; and
• (E) consist of the universal symbol for male or female overlain by a slash
through the circle to indicate sterilization.
Tattoo and Glue
• The required tattoo is almost never done
• green tattoo line on the ventral abdomen is the standard of care
• NOTE – ear tip is not a legal way of identifying TNRed cats in
• TNRed cats must be either microchipped or tattooed in addition
to ear tip
• Most tattoo parallel to the incision
• Some put tattoo ink in the incision
• It’s not uncommon for an owner or even a GP vet to think that
tattoo ink in the incision is gangrene
Tattoo and Glue (0:34)
Tattoo and Glue
Tattoo even tomcats on the ventral abdomen
Video incision is full thickness skin
I just score the skin so there is no need for glue
Blot the extra ink (peroxide) to prevent a temporary case of
“green tongue”
• Ketchum tattoo paste is a favorite (tube)
• Don’t get the roll-on kind – it gets contaminated with first use
• Apply with paper indicator strip of the back end of the scalpel
blade handle
Tattoo and Glue
• Take care to avoid getting glue in the subcutaneous tissues
• It causes a terrible foreign body reaction
– Delays healing
– Potentiates infection
• If you touch the glue to the animal’s skin change out the
application straw prior to the next patient
• Describe the tattoo in the discharge instructions
Tattoo and Glue
Minimizing Time Between Patients
• Often the rate limiting step to the number of procedures that
can be done each day
• Less than 2 minutes surgeon down time between surgeries
• Should be able to reglove, regown if needed, and start the
next one without rushing
• 2 minutes x 30 procedures = an hour of down time per day
• 5 minutes x 30 procedures = 2-1/2 hours down time per day
• 10 minutes – you might was well get the cot out
Minimizing Time Between Patients
• Learn at what point in the procedure to call for the next
– When I am ligating the first ovary
– A little more time to induce cats
– A little more time for a “Labdomen”
• Alternate spays with neuters
• 3 male cat neuters per surgery unit, unless infectious disease
• Go on the next one as soon as a neuter or group of neuters is
brought into the OR
Minimizing Time Between Patients
• Packs and gloves opened for the next patient during skin closure
• Careful communication – respond, “Heard!”
• Forms or travel sheets minimize writing (
– Circles and checks as much as possible
– Blanks to prompt information gathering
– Better yet, have a scribe for computer entry as you go
• Colored tag system
Green – pre-A exam completed, premedicated and ready for induction
Blue – needs vet exam prior to premedication and induction
Yellow – infectious disease, surgery at the end of the day
Red tag – surgery complete or canceled
Zeuterin (formerly Neutersol)
• “Esterilsol” in other countries
• Ark Naturals says infertility is “permanent and
irreversible” in 99.6% of dogs
• Approved only for dogs 3-10 months of age
• One uncontrolled study in Mexico on adults
• No studies assess fertility >12 months postinjection
• A very small number of dogs do show uptick in
fertility near the end of the 12 months
Zeuterin (formerly Neutersol)
• A very small number of dogs suffer scrotal rupture
with exposed testicle 1 week to 4 months postinjection
• “Oligospermia” is considered “infertile” in the FDA
approval studies
– <20 million sperm per ml
– Unlikely, but not impossible that these dogs could
successful breed
• Other uncommon adverse reactions include scrotal
draining tracts, erosions, self trauma, pain on
injection, and preputial swelling
Zeuterin (formerly Neutersol)
• All dogs have scrotal swelling which peaks at 48
hours post-injection
• 0.5-2% are fertile after injection
• 2-5% have adverse reactions requiring castration
• 5% euthanized for excessive testosterone driven
• Infertility occurs within 30 days
Zeuterin (formerly Neutersol)
• Example - 2,500 castrations per year
– 10-50 will remain fertile
– 50-125 will need to be castrated
• ACC&D - Potential for mild adverse injection site reactions
to progress to serious reactions in dogs that are not
properly supervised should be considered carefully.
• ACC&D recommends Esterilsol use be limited to dogs with
owners/caregivers that can provide appropriate care.
– Alliance for Contraception in Dogs and Cats
• Reasonable option when anesthesia potentially dangerous
Suture Size and Material
• Monosorb seems to break a little bit easier than PDS –
– may need one size larger for stumps and pedicles
– If you break the suture, grab one size up to try again
• Polysorb in my hands has poor knot security, as
compared to Vicryl and other similar generics.
• Suture size for closing the linea alba
No larger than 0 PDS for even the largest spays
3-0 PDS fewer suture reactions than 2-0 for cats
2-0 PDS for medium dogs
3-0 to close SC and skin
Suture Size and Material
• Swaged on more expensive than reel
• Less tissue trauma with swaged on
– Needle sharper
– No double thickness as suture loops through needle eye
– Don’t need thumb forceps for intradermal suturing
• Reels allow you to pick and choose different suture
types and sizes for the same surgery without waste
• Threading needles with reel suture takes more time
• Don’t cold pack suture pack leftovers – feline
retroviruses are transmitted with way
Patient Positioning
• Front legs pulled down to the side rather than over
the head can help for deep chested dogs
• Decreases traction on the ovarian pedicles via the
suspensory ligament
• Tables that “V” keep patients from tipping right and
• Crossing the front legs before tying can also help
with this in deep chested dogs
Patient Positioning (0:30)
Avoiding Dehiscence of the Abdominal Wall
• Avoid crushing tissue as you close the first two
throws of each knot
• Make sure you are closing the rectus sheath, not
subcutaneous tissues
• Take bites at least 5-10mm from the edge of the
• Knots are not properly tightened, or don’t have
enough throws
• The sheath, not the muscle tissue is the holding layer
Dealing with a Dropped Pedicle
• Extend the incision cranially to the manubrium
• Use the biological retractors to move organs out of the way to
caudal to each kidney
– Left pedicle dropped – reflect descending colon to the right
– Right pedicle dropped – reflect duodenum to the left
• Grasp the pedicle with 2 fingers to exteriorize, then clamp
• The ureter is just beneath the ovarian artery
– Using a clamp to grasp the pedicle can result in trauma to or ligating the
– Pooling hemorrhage can obstruct the normal view of the ureter
Tips for Cryptorchid Surgery
• Determine which side is cryptorchid by retropulsing
the normal testicle into its inguinal canal
• If testicle can be palpated, make an incision over
the testicle
• If not, make incision same as spay in the cat
• Paramedian incision along the cranial half of the
prepuce in the dog
– Find the vas deferens there and follow it to the testicle
Tips for Cryptorchid Surgery
• MIA cat testicles are more often in the inguinal
• Can be very difficult to dislodge
• Have an assistant put pressure upward on the
inguinal canal with a gloved hand from inside the
• This allows palpation of and incision over the
hidden testicle
– They can be very small in the cat
Why are these Techniques Different from those
taught in Vet School?
• These skills are for the experienced surgeon
• Those taught in vet school are for the inexperienced surgeon
– Larger incisions to compensate for infamiliarity with surgical anatomy
– Double ligation to compensate for poor knot security
– Ligation prior to transection to prevent a dropped pedicle due to
overmanipulation of the instruments or other poor technique
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