Prior to working in specialist practice, I was a general practitioner for over 10 years. I have seen most spey complications there are, including ureteral ligation resulting in a fistula between the ureter and the vagina leading to urinary incontinence (this became a published case report which I helped author). These are my tips; 1 - Take an extra minute to ensure you are approaching absolutely on midline. I am particular about the patient being completely straight in dorsal recumbency before I will start. For this to happen, everything from the head caudally needs to be straight. This ensures my midline incision is directly over the linear alba (this is the same for all abdominal approaches). I then sharp dissect (i.e. with the scalpel) down to midline and move the fat from side to side until I can clearly visualise the midline before making an approach (the scalpel itself can be useful for clearing away a little fat). Try to keep this to a minimum to avoid seroma formation (the other thing you can do to avoid seroma formation is handle your tissues gently). When you approach off-midline via the musculature you get more bleeding, and this takes time to address. Also constant ooze from the musculature into the abdomen during the procedure can make structures more difficult to visualise, and at the completion of the procedure, it can be hard to tell if the bleeding is from a bleeding stump or from ooze. 2 - I make my incision for cats more caudal than for dogs. Cat ovarian pedicles are more flexible and you can often stretch the pedicle further caudally. However, the uterine bifurcation tends to be more caudal (to access it, I would often pull my incision caudally to expose the bifurcation - don't pull on the uterus too firmly! – I did this once and was left with the uterus in my hands and the uterine stump disappeared into the abdomen - if this happens, don't worry it can be retrieved). In dogs, I make the incision more cranially as I find the opposite is true - ie. ovaries harder to expose, uterine bifurcation simpler to expose. When I became experienced at the procedure and was aiming for a 1cm incision, I made this incision just caudal to the umbilicus in dogs, and around 2cm caudal to the umbilicus in cats. 3 - Take an extra minute to apply hemostats/cauterise any small bleeders during your approach (as per Halsteds principles of accurate hemostasis). 4 – Exteriorising the uterus – hook fairly deep but don’t pull too hard. The uterus is easy to exteriorise when the hook is correctly located, and you shouldn’t need to pull on structures. If you are retrieving intestine, you are generally too cranial, if you are retrieving bladder you are not deep enough and if you are retrieving colon you are too deep. I found it easiest to aim fairly deep caudolaterally then hook back towards my incision. Again, you do not need to tug on anything to exteriorise the uterus! If you are struggling, lengthen your incision.
Especially in dogs, it is safest to hook with your finger. If you use a spey hook, be gentle and careful not to penetrate the spleen. 5 - In dogs, focus on your ability to stretch and snap the suspensory ligament. I would use my thumb nail through the glove and push towards the abdominal wall. Via palpation, I would push soft tissues away from the ligament so I was confident I was just tearing this ligament and not the ovarian vasculature (if you push it towards the abdomen and feel a solid band, you are unlikely to tear the ovarian vasculature). If you stretch/snap this ligament you can exteriorise the ovary adequately. 6 - Following on from point 5, take the time to expose the ovary adequately! You want to place your first clamp as far from the ovary as possible. If you are struggling, palpate again for any part of the suspensory ligament you may not have torn completely. You can palpate the edges of the ovary through the bursa. Do this every time so you can familiarise yourself with what this feels like, so you can ensure the entire ovary is removed. 7 - Always double ligate the ovarian and uterine stump. Your knot needs to be TIGHT. To learn how tight this needs to be, you possibly need to break your suture from pulling it too tight a few times!. The feeling you get on your first throw just before it breaks, is the tightness it needs to be. Place your second throw quickly before your first throw loosens (this is not as critical for a slip knot). Several knot-tying configurations have been investigated. I use a surgeons knot or a slip knot. The advantage of a slip knot, is that there is less urgency in the placement of the second throw (it doesn’t slip) and one study found it superior to a surgeons knot. 8 - Placing your ligature in the crush mark also helps with getting your ligature tight around the vessels. 9 - Use PDS suture. Do not use catgut. PDS is superior in every way and complications are expensive to the practice. 10 - Post ligation, palpate the ovary again. If you do this every single time, you will learn by palpation if you have removed the whole ovary. 11 - Count swabs. You really don't want to leave a swab in the abdomen. It is an extra 30 seconds.
Avoiding ureteral ligation; 12 - Ureteral ligation can really only occur if you become lost (not a criticism, we have all been there). In my view, vets tend to get lost when things start to go wrong e.g. there is a lot of bleeding, you are rushing, the anatomy is unclear due to the bleeding etc. If you follow the above tips in regards midline approach, accurate hemostasis, 2 x ligatures on the pedicle and exteriorisation of the anatomy, then this should be avoided. In addition, to avoid ureteral ligation, ensure you can visualise the entire uterus and uterine bifurcation, especially if you are unsure of what you are ligating. To hook the ureter, in conjunction with the uterus, would require some force - be gentle. If you exteriorise the uterine body on it's own, even if you have managed to hook a ureter, it should slip back into the abdomen as it is not attached to the uterus (take-home message = exteriorise adequately). Another tip is to clamp/tear the broad ligament away, allowing you to isolate the uterus with little other tissue in the way. You often don't need to ligate the broad ligament, as by the time you have ligated the uterine stump, time alone with your clamp has achieved adequate hemostasis here. 13 – During closure, use your needle or other instrument to push away all the subcutaneous tissue prior to every bite of the linea alba. The subcutaneous tissues can often appear very similarly to the linea alba. I have on multiple occasions seen vets (including myself as a new grad) sutured the subcutaneous tissues, which leads to the intestines saying 'hello' the next day. Use a simple continuous suture pattern for closure. 14 – It can help hugely to have an assistant. If there is any chance of getting someone to scrub for larger dog ovariohysterectomies for the difficult part of the procedure, it can be very valuable and save time (it can’t be looked at as wasted staff time, because it will save everyone’s time in the long-run, especially if a complication is avoided as this also involves staff time and practice money). 15 – Spey complications are common. It can be a difficult procedure. Do not be disheartened by a complication. I have had several. Take your time, learn the ‘feel’ of the tissues (turn on the proprioceptive part of your brain when performing the procedure) and lengthen your incision as needed. In summary, the tips I have are; 1 – Be fussy about patient positioning 2 – Make your incision more caudally in cats 3 – Use adequate hemostasis during your approach 4 – Aim your spey hook caudo-laterally then pull gently towards your incision 5 – Focus on snapping the suspensory ligament in dogs 6 – Take the time to exteriorise your ovary adequately 7 – Double ligate everything 8 - Place your ligatures in a crush mark 9 - Use PDS suture 10 - Post ligation, palpate the ovary again to ensure it is fully resected 11 - Count swabs 12 – Avoid ligating the ureter by adequately exposing the uterus and visualising the bifurcation 13 – Take care to suture the linea alba and not the subcutaneous tissues 14 – Consider an assistant, especially for large dogs 15 – Bounce back from complications