Avoiding ureteral trauma at female desexing + steps for a dropped pedicle Part 1
This is one of the complications vets are most concerned about, so I wanted to address it.
Ureteral damage is rare, and if the uterus and ovaries are exteriorised prior to ligation then it is VERY unlikely you are tying off a ureter. The most common time iatrogenic damage occurs is when you have dropped an ovarian pedicle. If you drop a pedicle, follow these steps:
- Don't panic, it takes a very long time for a dog to bleed out via an ovarian pedicle. You have time.
- Count swabs (just kidding, you have already done this at the start! and now you are thanking your past self)
- Pack the pedicle with a swab
- Lengthen your incision
- If at all possible, get an assistant to scrub so you have an extra pair of hands to retract
- Get good exposure to the caudal kidney region. Use your baskets (see last weeks post for a video explanation of this technique).
- Remove the swabs and excess blood. Swab away the blood in the region. I like to attempt to raise the pedicle with forceps (the pedicle being the vessel surrounded by fat). Once you have raised it away from tissue below, place a curved hemostat with tips facing upwards. If bleeding stops then you have correctly identified the pedicle.
Do not blindly pull and ligate down in this region as that is often when iatrogenic ureteral trauma occurs. If in doubt, clamp with fingers first. Exposure is the KEY.
Inadvertent ureteral ligation can also occur at the bladder end, generally when a uterine pedicle is dropped. Emptying the urinary bladder prior to surgery helps to reduce the risk of this. The empty bladder moves the bladder and ureters caudally and they are tucked safely under the pelvis away from the uterus. This also improves visualisation of the stump if dropped. If dropped, follow the same principles as above.
Do not use multifilament non-absorbable suture or catgut in the abdomen or around the pedicles as they can lead to granulomas/adhesions that later obstruct the ureters.
A recap -
Avoid ureteral trauma by:
- emptying bladder pre desexing
- having a good system for a dropped pedicle (feel free to put mine on your theatre wall)
- Always get good exposure over aiming for a small incision if things are going wrong
- Never blindly ligate a structure. Adequate exposure with retraction, assistance and lots of swabs should ensure you don't.
- Use appropriate suture material for ligating pedicles e.g. 2-0/3-0 PDS depending on animal size.
Finally, an interesting case: The ureter in this case was ligated along with the uterine stump. A fistula then formed between the ureter to the stump. Prior to our neoureterocystostomy (i.e. new entry for ureter into bladder) she was continuously dribbling urine via her vagina. This complication completely resolved post surgery. Yay!
I hope these tips help. Remember not to panic if you drop an ovarian stump. I have dropped many, but have always easily found them with my baskets and then just continued on with my day :)
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