Mo.'"'t.<o.

l of
EQJ)INE
FIE LD
SURGERY
of
ECWINE
FI E LD
SURGERY
David A. Wilson, DVM
Associate Professor, Equine Surgery
Department of Veterinary,Medicine and Surgery
University of Missouri
Columbia, Missouri
Joanne Kramer, DVM
Clinical Assistant Professor, Equine Surgery
Department of Veterinary Medicine and Surgery
University of Missouri
Columbia, Missouri
Gheorghe M. Constantinescu, DVM, PhD., Dr.h.c.
Professpr, Anatomy
DepartrnentofBiomedical Sciences
Ul'liversity of Missouri
Columbia, Missouri
CHAPTER 1
Introduction
David A. Wilson
"Chance favors the prepared mind."
Louis Pasteur
This book is written for practitioners and veteri -
nary students attracted to and interested in equine
surgery. Procedures are described and illustrated
that can be performed in the field or basic prac-
tice settings, require a minimum of additional
equipment or assistance, generally take less than I
hour of anesthesia, and do not involve entering a
body cavity or joint. Although the procedures
described in this book can be donf in the field by
any qualified veterinarian, it is not the intention
of this book to be the sole source of preparation
or reference for the new or relatively inexperi-
enced equine practitioner.
Performing surgery in the field has the poten-
tial to be very rewarding but also the potential
to be very unrewarding. If the procedure goes
according to plan, the experience can be great.
However, as with many things involving horses,
there is a seemingly almost unlimited opportunity
for fail ure. Preparation is the key to minimizing
these opportunities for failure. A thorough under-
standin g of the presenting problem, indicated
surgical procedure, relevant anatomy, available
facilities, equipment, and assistance, client expec-
tations, and individual patient characteristics are
important; these factors must be evaluated when
considering surgery in the field.
With any surgical procedure, it is the responsi-
bility of the surgeon to be thoroughly familiar
with the pertinent anatomy as well as the poten-
tial deviations from normal expected in health
2
and disease. Swelling and trauma can significantly
alter the anatomy such that previously well -
understood structures may be difficult to identify
and in unexpected locations.
Once the anatomy is understood, the specific
surgical procedure should be thoroughly reviewed.
The surgeon should get in the habit of reviewing
every procedure prior to performing the surgery to
refresh the surgeon's memory of the specifics of the
surgery. Equine practitioners are exposed to a wide
range of disorders but do not often see many of
anyone particular disorder. Therefore, it may be
months or years between specific surgeries, and a
procedure that was once very familiar may seem
completely foreign after the first skin incision. Sur-
gical procedures should be practiced on cadaver
specimens prior to performing them for the first
time on a client's animal. Practice surgeries on
cadaver specimens to review the pertinent normal
anatomy, confi rm the landmarks for the approach,
and identify potentially difficult portions of the
procedure and to develop familiarity with the
particular instrument needs for the proposed
surgery.
Practitioners or new graduates wanting to
become more familiar with these procedures
should consider working with or visiting an expe-
rienced practitioner. In addition, many continu-
ing education opportunities are available that
provide in-depth reviews of these and similar pro-
cedures. In particular, the annual meetings of the
American College of Veterinary Surgeons and the
American Association of Equine Practitioners are
good sources of current surgical information.
CLIENT COMMUNICATION
Client communication is probably the most
important factor in preventing misunderstand-
ings and addressing problems when things do
not go well. The owner (or trainer) should be
informed of the options for therapy, costs, prog-
nosis, potential complications and consequences,
anticipated outcome, and recommendations prior
to surgery. Ideally, this conversation should be
with the person who will actually pay the bill and
with the person responsible for the horse's care.
However, in many insta nces in equine practke,
the person paying the bill may not be available.
Keeping good written notes of conversations
and estimates and providing written discharge
instructions concerning aftercare is essential. Ali
communications should be as realistic and honest
as possible. Clients must be warned of the poten-
tial complications and expected outcome. General
complications such as the development of rhab-
domyolysis or coliti s seen in horses stressed by
transportation, anesthesia, and surgery should be
communicated to the owner when appropriate.
The specific complications associated with the
procedure to be performed should also be dis-
cussed. However, overstating the difficulty of the
recommended surgery or the gravity of the poten-
tial consequences to minimize client expectations
is inappropriate.
INSURANCE
When contemplating surgery on an insured horse,
the veterinarian should be aware that it is the
client's responsibility to inform the insurance
company of a pending surgical procedure, partic-
ularly for an elective procedure. which is the case
for most procedures covered in this book. The
veterinarian may choose to contact the insurance
company, but it is the client's responsibility. The
insurance company will then make a decision
about whether to cover the animal for the p r o c e ~
dure. These deliberations are between the owner
and the company, but the veterinarian may be
drawn into the process when decisions regarding
treatment options, prognosis, and euthanasia are
considered. Because of potential conflict s of inter-
est, guidelines for those si tuations are available
from the American Association of Equine Practi -
tioners Equine Insurance Committee.
l
Introduction 3
DECISION FOR SURGERY
The decision to perform surgery on a specific case
can be difficult. Is the surgery necessary? What are
the best- and worst-case scenarios for a present-
ing problem or specific procedure? The decision
is complicated by adding the field scenario into
the equation. The temperament of the horse, the
potential surgical environment (i.e., facilities,
terrain, weather, etc.), the availability of needed
equipment, the availabil ity of trained assistants,
the expectations of the client, the skill of the
surgeon, and the ability to handl e unforeseen
developments aU enter into the decision. Certainly
many clients have excellent facilities; however,
there are other clients with facilities where field
surgery may be a greater adventure than anyone
needs. After considering the factors for a given cir-
cumstance, the surgeon must decide whether to
perform a particular procedure.
PATIENT EVALUATION
A thorough history should be gathered on all
horses presented for elective surgery. Previous
treatments, responses to treatment, potential ad-
verse reactions to previously administered med-
ications, and the genetic background (e.g., the
potential for developing hyperkalemic periodic
paralysis) should all be reviewed.
A thorough physical examination should be
performed, concentrating on the rest of the
animal prior to focusing on the potential reason
for surgery. Blood should be submitted for evalu-
ation including a complete blood cell count or at
least a packed cell volume and total protein deter-
mination prior to the time of the surgery. Serum
chemistry evaluations are desirable but are not
always necessary for elective procedures. If the
horse's physical condition or laboratory values
are abnormal , elective procedures should be
postponed.
PATIENT PREPARATION PRIOR TO SURGERY
For most elective procedures, feed should be with-
held about 6 hOllrs prior to surgery. Water should
be allowed ad libitum. Withholding feed for up
to 72 hours can be tolerated for elective proce-
dures. However, it should be recognized and
4 PRESURGICAL PREPARATION AND ASSESSMENT
communicated to the owner that withholding
feed will alter gastrointestinal flora and predispose
the horse to colitis.
Tetanus vaccination status of the patient
should be assessed and, if necessary, a tetanus
booster should be administered. If the patient has
never received tetanus toxoid and the surgery is
an elective procedure, the procedure should be
delayed until appropriate tetanus prophylaxis is
established. Patients that have not received tetanus
toxoid within the past 6 months, but are on a con-
tinuing immuni zation program, should receive a
tetanus booster.
Prophylactic and therapeutic antibiotics
should be judiciously administered. When indi-
cated, antibiotics should be administered imme-
diately prior to surgery at the correct dosage and
for the correct amount of time but should be dis-
continued as soon as possible after surgery.
When possible, the surgical site should be
clipped (size 40 clipper blades) and prepped
before (within 2 hours) induction. Over smooth
areas, the hair may be shaved with a disposable
razor. A wide area surrounding the anticipated
surgery site should be clipped and scrubbed in
order to be prepared for the unanticipated need
to expand the surgical site.
Immediately prior to the operation, the pro-
posed surgical site should undergo a surgical
scrub consisting of at least 5 minutes' exposure
to either povidone-iodine 7.5% surgical scrub
(Betadine surgical scrub) or chlorhexidine glu-
conate 4% antimicrobial skin cleanser (Hibiclens;
Zeneca Pharmaceuticals Inc. , Wilmington, Del.).
The final surgical preparation consists of alter-
nating 70% alcohol or isotonic saline rinse with
the surgical scrub using aseptic technique. Rinsing
with saline or 70% isopropyl alcohol does not make
a difference in the antimicrobial effect of povidone-
iodine; however, alcohol reduces the residual effect
and antiseptic quality of chlorhexidine.'
REFERENCES
I. American Association of Equine Practitioners: The
veterillary role ill equille insurallce, Lexington, Ky,
2000, AAEP.
2. Stashak TS: Selected factors that affect wound
healing. In Stashak TS, editor: Equine wound mall-
agement, Philadelphia, 1991, Lea & Febiger.
CHAPTER 2

Surgical Instruments
David A. Wilson
This chapter serves as a reference for the various
surgical instruments referred to throughout the
book. The equine surgeon should become famil-
iar with the instruments, how they handle, what
procedures they should and should not be used
for, and when they should be used. Usi ng the right
instrument at the right time is essential to good
surgical technique. Selecting the appropriate
instrument ensures minimal trauma to tissues
and that the procedure will be performed in the
least amount of time with the least harm to the
patient. Handling the instruments in practice
cadaver or laboratory settings is essential to
become proficient enough to handle them effec-
tively in surgical situations.
INSTRUMENTS
Scalpel blades used for the No.3 scalpel handle are
sizes 10, II , 12, and 15 (Figure 2-1). Scalpel blade
sizes 20, 21, and 22 are made for the No.4 scalpel
handle (Figure 2-2). The No. 10 blade on a No.3
Bard-Parker handle is used for most equine sur-
gical procedures. However, the No. 11 and No. 15
blades are useful when very precise or small inci-
sions are required. The sharp tip on both the No.
II and No. 12 blades is useful for lancing
abscesses. Typically, the scalpel handle is held
between the thumb and the third and fourth
fingers, with the index finger placed over the back
of the handle to apply pressure on the blade.
When using the No. II and No. 15 blades, the
5
scalpel handle is usually held in a "pencil -gri p"
fashion to allow for finer motor control. The No.
4 handle and its associated blades are used for
larger areas where precision is not a major
concern.
Scissors
Many types of scissors are available depending on
the job to be performed. These include scissors
designed to cut various types of tissue and scis-
sors designed to cut suture, wire, or bandage
material. Operating scissors are classified accord-
ing to the shape of the tips, for example, sharp-
sharp, sharp-blunt, and blunt-blunt (Figure 2-3).
When using the appropri ate scissors, the tip of the
scissors is used to cut tissue, the tip or body is used
to cut sutures) and the heel is used to cut wire.
Metzenbaum scissors are relatively delicate and
are made for precise dissection, whereas Mayo
scissors are made for tissues wi th more substance.
Mayo and Metzenbaum scissors are availabl e with
straight or curved blades. The straight blades are
designed for working close to the surface of the
wound, and the curved scissors are used for
working deeper in the wound (Figure 2-4). For
blunt dissection, the closed tips of the scissors are
inserted into the ti ssue and then opened to spread
the tissue. Tissue scissors should not be used to
cut suture or wire.
Bandage scissors are designed with angled
blades, and the lower blade has a small "button"
tip to protect the underlying structures and
6 PRESURGICAL PREPARATION AND ASSESSMENT
to allow easy entry under bandage material
(Figure 2-5) . If bandage scissors are used against
contaminated wounds, the scissors should be
sterilized after use to prevent transfer of infec-
tion.
10 11
12
128 15
15C
Figure 2 ~ 1 Scalpel blades that fit the No.3 Bard-
Parker handle. (Reprinted with permission from Miltex
Instrument Company, Bethpage, N.Y., 2004. )
,
,
,
I
)
20 23
"
A B
Figure 2·2 A, Bard-Parker No.4 handle. B, Va rious
shapes of scalpel blades that fit the No.4 scalpel handle.
(Reprinted with permission from Miltex Instrument
Company. Bethpage. N.Y .• 2004. )
Needle Holders
The two primary types of needle holders used in
large animal practice are the Mayo-Hegar and
Olsen-Hegar needle holders (Figure 2-6). The
Olsen-Hegar needle holders have a suture-cutting
scissors built into the jaws, enabling the surgeon to
cut suture without reaching for the suture-cutting
scissors. A variety of other options for needle
holders are available depending on the preference
of the surgeon and the size of needle being held.
Thumb Forceps
Thumb fo rceps are used for graspi ng and holding
tissues (Figure 2-7). Typically, the forceps are
held in a "pencil" grip. Many types are available,
and the selecti on is based on the type of tissue
involved. Toothed fo rceps are commonl y llsed for
stabilization of tissue such as skin, fascia, or
muscle while suturing. Theoretically, the presence
of teeth on these forceps makes the grip required
to hold the tissue less forceful than if there were
no teeth, resulting in less tissue trauma. Forceps
are often classified based on the number of inter-
locking teeth on each head. For example 1 x 2
indicates there are two teeth on one side of the
fo rceps and one on the other. The higher-number
teeth are generally used for more robust tissues.
Nontoothed forceps generally have ridges or
grooves on the surface of the tip and are used for
grasping visceral and serosal or adventitial tissues
as the lack of teeth decreases the likelihood of
puncture.
Hemostatic Forceps
Hemostatic forceps are primarily used to clamp
the ends of vessels to establish hemostasis. Hal stead
mosquito forceps are used for clamping smaiJ
vessels (Figure 2-8, A). Kelly forceps are used for
clampi ng larger vessels and as a grasping forceps
to hold tissue or stay sutures for manipulation
Figure 2-3 Operating scissors. ( From
Sonsthagen TF: Veterinary illstrllll1ellts alld
equipmel1t: a pocket guide, St Louis, 2006,
Elsevier Inc.)
Sharp/sharp Sharplblunt BlunVbluntSharp/sharp Sharplblunt Blunt/blunt
straight straight straight curved curved curved
A B c
Figure 2-4 A. Straight Mayo scissors. S, Curved
Mayo scissors. C, Curved Metzenbaum scissors.
(Reprinted with permission from Miltex Instrument
Company. Bethpage. N.Y .• 2004.)
Figure 2-5 Lister bandage scissors. (From
Sonsthagen TF: Veter;'lary imtrulllents and equipment:
a pocket gil ide, St Louis, 2006, Elsevier Inc. )
Figure 2-8 A, Halstead mos-
quito forceps. B, Kell y forceps.
C. Crile forceps. (Reprinted with
permission from Miltex Instru-
ment Company. Bethpage, N.Y.,
2004.)
Yo
A
Surgicailnstruments 7
A B
Figure 2-6 A, Mayo- Hegar needle holders. B, Olsen-
Hegar needle holders. (Reprinted wi th permission from
Miltex Instrument Company, Bethpage. N.Y., 2004. )
~
"
• •
VI W
••
!
Yo
,.
r;;

2
@
<i!>
,
A B c
Figure 2-7 Forceps. A. Brown-Adson forceps. B.
Tissue forceps. C, Adson fo rceps. (Reprinted with per-
mission from Miltex Instrument Company, Bethpage,
N.Y .• 2004. )
Yo
B c
8 PRESURGICAL PREPARATION AND ASSESSMENT
(Figure 2-8, B). When curved forceps are used,
they should be applied such that the tip of the
forceps is pointing upward.
Grasping Forceps
A variety of forceps with a ratchet device built into
the handle are used to grasp. retract, or stabilize
larger portions of tissue. Allis tissue forceps are
probably one of the more common graspillg
forceps (Figure 2-9). They have opposing edges
with short teeth and relatively long "arms" and are
used to grasp fasc ia, subcutaneous tissue, skin.
tendon, etc. Because of their short teeth and
Figure 2-9 Al lis forceps. (Reprinted with permiss ion
from Miltex Instrument Company, Bethpage. N.Y.,
2004. )
i ~
I
.....
A B c D
potential for trauma, they should not be used on
skin or viscera intended to remain with the
patient. Sponge forceps are used to hold gauze or
other sponges to blot tissues dry from blood or
other fluid during dissection (Figure 2-10).
Retractors
Retractors are essential for the display of deep
tissues during an operation. They may be hand-
held or self-retracting. The retractors work by
placing a blade in front of tissues that would oth-
erwise reduce the visibility of the operative field
(Figures 2-11 to 2-13). Great care must be taken
Figure 2·10 Forester sponge-holding forceps. (From
Sonsthagen TF: Veterinary iflStrtlmellts alld equipmelll:
a pocket guide, St Louis. 2006, Elsevier Inc.)
!
E
Figure 2-11 Finger-held retractors.
A, Senn retractor. B, Mathieu retractor.
C, Meyerding finger retractor with
various blades for gripping (shown ver-
ti cally). D, Farabeuf retractor. E, Parker
retractor. (Reprinted with permiss ion
from Miltex Instrument Company,
Bethpage, N.Y., 2004. )
f
I ~
10
b
B
o
o
c
,


.-
D
Surgical Instruments

• •

9
Figure 2-12 Hand-held retractors. A, Army-Navy retractor. B, Hohmann retractor wi th two different blades.
C, Meyerding retractor. D, Ribbon maUeable retractor. (Reprinted with permission from Miltex Instrument Company,
Bethpage, N.Y .. 2004.)
to ensure that damage is not caused to the struc-
tures being retracted.
General Pack for Field Surgery
Box 2- J lists the contents of a typical general pack
for fi eld surgery. Throughout the remainder of
the book, only the instruments needed in addi-
tion to these are listed in the description of the
procedure.
INSTRUMENT PREPARATION
Most of the procedures described in this book
are classified as "clean" elective surgical proce-
dures. Therefore, the instruments used should
be wrapped and sterilized. Before sterilization,
instruments are thoroughly cleaned, paying
particular attention to box locks, hinges, and
serrations, and disassembling instruments with
multiple components. Common sterili zation
techniques include autoclaving, gas sterilization,
plasma sterili zation, and cold sterilization. Auto-
c1aving, a technique using moist heat from steam,
is the sterilization method of choice for preparing
instruments for aseptic surgery. An indicator is
placed in the pack with the instruments and
should be checked by the surgeon to confirm the
sterility of the instruments. The high heat and
humidity effectively sterilize most instruments,
but some surgi cal instruments and equipment
with delicate or heat-sensitive components cannot
endure such an environment.
Gas sterilization using ethylene oxide is used
for instruments that may be damaged by the heat
of autoclaving. However, ethylene oxide produces
noxious fumes that require special venting and
Figure 2-13 Self-retaini ng retractors. A, Weitlaner
retractors. B, Gelpi retractors.
A
B
10 P RESURGICAL PREPARATION AND ASSESSMENT
BOX 2-1
Contents of a Typical General Pack
for Field Surgery
4 Towel clamps
2 Needle holders (Mayo-Hegar or Olsen-Hegar)
I Brown-Adson thumb forceps
I Rat tooth forceps (2 x 3 or I x 2)
2 Straight mosquito forceps (straight or curved)
2 Kelly forceps (straight or curved)
1 Suture scissors
I Curved Metzenbaum scissors
I Curved Mayo scissors
I Straight Mayo scissors
2 Carma It or Oschsner forceps
I NO.3 scalpel handle
30 Gauze sponges
I Hand towel
Other Useful Equipment
Battery-operated headlight or other light source
Knee pads
Glue to help hold drapes in place
Ropes to assist in limb positioning
Small fold-up camping table on which to place
instruments
Towels
extensive aerati on for at least 14 hours before the
pi ece of equipment can be used again.
Hydrogen peroxide gas plasma is the latest tech-
nique for low-temperature «50°C), low-moisture
sterilization of sensitive surgical products. 1t is
suited for sterilizing heat- and moisture-sensi tive
instruments and instruments with sharp edges.
Major advantages of thi s technique include a ster-
ilizati on time as short as 55 m i n u t ~ s and the pro-
duction of no toxic residuals requiring aeration to
comply with Occupational Safety and Health
Admi nistrati on (OSHA) safety regulations.
Cold (chemi cal) sterilization, using a product
such as glutaraldehyde, provides a hi gh level of
disinfection but does not achieve sterili zation.
Minimum immersion time for disinfection with
glutaraldehyde is approximately 45 minutes. Cold
sterilization is commonl y used by the large animal
surgeon for a second or third surgery of the day
when other methods of sterili zation are not avail -
able. Solutions used for cold steril ization can be
very irritating to tissues. Therefore, care should be
taken to thoroughly rinse or immerse the instru-
ments in sterile saline before use to avoid
potential ti ssue damage. Specifi c sterilization
protocols can be developed for your practice by
consulting further references and manufacturers'
recommendati ons.1.
2
REFERENCES
l. Freeman DE: Sterili zation and antiseptics. In Auer
JA, Stick l A, editors: Equine surgery, ed 2, Philadel-
phia, 1999, WB Saunders.
2. Southwood LL, Baxter GM: Instrument steril ization,
skin prepa rati on, and wound management, Vet Ciill
N Am Equine Pract 12: 173, 1996.
CHAPTER 3
Wound Closure
David A. Wilson
The princi ples of wound closure are similar
whether closing a surgical incision or a laceration.
Primary closure relies on a clean field, with clean
and viable wound margins and skin edges for
closure. When presented with a naturally occur-
ring wound, there are many factors to
but the primary objectives are to preserve the life
of the patient, to determine the extent of the
wound, and to prevent or minimize infection.
A minor wound should not divert attention
from more serious problems, such as hemorrhagic
shock, exhaustion, or cerebral contusion associ-
ated with head injuries. Thus, a quick assessment
of the wound should be followed by a thorough
physical examination and acquisi tion of pertinent
vital signs. After initial stabilization and control of
bleeding, attention should be directed at deter-
mining the extent of the wound and returning the
patient to a normal functional and cosmetic status
with the shortest delay possible.
Wounds should be thoroughly evaluated to
determine their extent. Wounds over synovial
st ructures such as joints or tendon sheaths are
common in horses, and the involvement of these
structures is often unrecognized. Tendons and lig-
aments, vessels and nerves, and the eyes, sinuses,
thorax, and abdomen are other structures com-
monly involved in equine wounds. Thinking in
three dimensions and understanding the three-
dimensional anatomy of the involved structures
will help the practitioner to recognize the poten-
t ial extent of the injuries and to better prepare the
owner for the potential problems associated with
the wound.
11
WOUND PREPARATION
The objective in wound preparation is to reduce
the contamination of a wound and to obtain a
"clean" field. Infection is the most important
factor in delaying wound healing. Infections are
classified as primary, in which the contamination
occurs at the time of injury, or secondary, in
which the contamination occurs through the
suture line or through other portals (i.e. , drai.ns,
fistulas).
Before wound preparation, the wou nd should
be protected by placing sterile, water-sol uble
lubricating jelly or sterile moist gauze sponges
into the wound. A wide area of hair around the
wound should be clipped. To prevent hair from
falling into the wound, the hair may be dampened
with water or lightl y coated with a sterile, water-
soluble lubricating jelly. Sponges used to pack the
wound should be discarded and replaced by new
ones after each stage of preparation. The wound
bed itself should be gently cleansed with antisep-
tic soap and steril e gauze sponges, followed by
copious lavage to neutralize the detergent base
of the antiseptic. The clipped area should be
scrubbed at least three times with antiseptic soap
and rinsed between scrubs with sterile 0.9% saline
solution.
Antiseptics for Skin Preparation
The two most commonly used surgical scrubs
for skin preparation are povidone-iodine and
12 PRESURGICAL PREPARATION AND ASSESSMENT
chlorhexidine. Although uncommon, one disad-
vantage of povidone-iodine is a skin reaction,
which seems to be more frequent after clipping,
scrubbing, rinsing with 70% alcohol, spraying
with povidone-iodine solution, and bandaging.
Detergent forms of chlorhexidine should not be
used around the eye) because exposure may lead
to corneal edema and bulbous keratopathy.l-J
The mechanical effect of scrubbing the wound
with these antiseptic soaps is helpful in removing
debris and reducing bacterial concentration at the
wound surface. A marked delay in wound healing
occurs if the soap is not thoroughly rinsed from
the wound. Additionally, even though these anti-
septics are effective, much of the bacterial popu-
lation in the skin resides in protected hair follicles)
sebaceous glands) and crevices in the lipid coat of
the superfi cial epithelium.
WOUND LAVAGE
Bacteria adhere to the wound surface by an elec-
trostatic charge. Lavage cleans the wound of
debris and reduces the bacterial numbers, inflam-
matory mediators, and substances that potentiate
infection. In addition, lavage stimulates periph-
eral microcirculation through its gentle massag-
ing action, which may favor the formation of
granulation tissue. Lavage is easy to perform,
requires no special equipment, is cost effective,
and is well tolerated by most patients.
Lavage solutions are most effective when deliv-
ered by a fluid jet of at least S psi: Pressures of
10 to IS psi are approximately SO% effective in
removing substances that potentiate infection and
adherent bacteria from a wound.
s
Although this
pressure cannot be achieved by gravity flow or
lavage with a bulb syringe, adequate pulsatile
pressure can be attained by forcefully expressing
lavage solutions from a 35- or 60-mL syringe
through an IS-gauge needle or by using a spray
bottle or a WaterPik. The WaterPik delivers 40 to
50mL/min at 10 to 15 psi at the low-intermediate
setti ng and is effective for heavily contaminated
wounds. Care must be taken not to drive conta-
minants deeper into the wound or inadvertently
separate loose fascial planes.
The ideal lavage solution should be sterile, iso-
tonic, normothermic, nontoxic, and compatible
with antibi otic or disinfectant medications that
may be added. Isotonic crystalloids, such as
-
normal saline or lactated Ringer's solution, meet
these criteria and are the most commonly used
solutions. Tap water is often used initially to
reduce gross contamination in heavily contami -
nated wounds. In these cases, subsequent lavage
with sterile isotonic fluid may help restore tissue
normotonicity and reduce edema.
Wound lavage should also be considered for
closed wounds. The advantages of flushing a
closed wound include the dilution and mobiliza-
tion of exudates and the delivery of medication.
The disadvantages are that bacteria can be readily
introduced into the wound and dead space may
be created or expanded.
WOUND DEBRIDEMENT
The goal of debridement is to obtain fresh, clean
wound margins and skin edges for primary closure
and to remove contaminated tissues and foreign
material so that wound healing can progress effi-
ciently during second-intention healing.
Debridement involves the removal of dead or
damaged tissue, foreign bodies, and bacteria that
compromise local defense mechanisms. Liberal
removal of contaminated fascia, fat, and muscle
and careful retenti on of bone, tendons, nerves,
and major vessels are important. Fascia, fat, and
muscle all have excellent blood supply and
provide excellent media for the growth of conta-
minating organisms. Although skeletal muscle is
not replaced, there are usually sufficient remain-
ing muscle fibers or alternative muscle groups
available to make up for the loss. Small pieces of
bone that have lost their blood supply should be
removed.
Surgical Debridement
Surgical debridement may be accompl ished in a
variety of ways (en bloc, layered, or staged). En
bloc resection is probably the most effective
method of surgical debridement but may result in
the loss of some viable tissue. With this technique,
the entire wound is excised at its niargi ns such
that all wounded and contaminated tissue is
removed. This method is primarily reserved for
draining tracts and areas where significant tissue
loss can occur without consequence. With layered
debridement, tissue removal is started at the most
superficial tissue layer and is continued into the
depths of the wound. This systematic approach
helps to prevent contamination of deeper tissues
with debris from more superficial layers as
debridement progresses and preserves viable
tissue. Staged debridement is a method of layered
debridement that minimizes tissue loss. In most
equine distal limb wounds, where tissue is at a
premium, staged debridement is used over a
number of days to avoid inadvertent removal of
viable tissue. When performing staged debride-
ment, the two governing criteria are color and
attachment. White, tan, black, and green tissues,
as well as those that are poorly attached, should
be debrided. Tissues that are pink to dark pur-
ple and well attached should be left in place.
Non-surgical methods of wound debridement
include chemical or enzymatic debridement, laser
debridement, bandaging techniques, or biosur-
gical therapy. These techniques are discussed
elsewhere.
6
WOUND CLOSURE
Priorities during wound closure are to limit in-
fection or contamination, minimize skin loss, and
exert the least amount of tension possible on the
suture line. Ideally, wounds are managed by
primary closure. Wounds most amenable to
primary closure include those of the head and
upper body, flap wounds with a good blood supply,
and recent minimally contaminated wounds of the
extremities. Wounds with considerable skin loss, or
severe contamination or infection, should not be
closed initially. These may be closed later using
delayed primary or secondary closure techniques
or allowed to heal by second intention.
Primary closure, leading to first-intention
healing, is performed after surgery or soon after
injury. Ideally, primary closure is performed
during the golden period. The golden period
relates to the time required for multiplying bacte-
ria to reach an infective level, considered to be 10
6
organisms per gram of tissue. Theoretically, this
time period is 6 hours. In actuality, this may be
longer in clean wounds and considerably shorter
in severely contaminated wounds. Primary clo-
sure is best used for fresh, minimally contam-
inated wounds with a good blood supply without
involvement of vital structures.
Delayed primary closure is performed 3 to 5 days
<lfter iniurv when h r of 'nfi ia
Wound Closure 13
controUed by the inflammatory and debridement
phases of healing but prior to granulation tissue
formation. Delayed primary closure is best used
for contaminated, contused, or swollen wounds
and for those involving a synovial struct ure. It is
particularly useful in distal limb wounds, where
contamination is a frequent problem.
Delayed secondary closure is performed more
than 5 days after injury, once granulation tissue
has begun to form. As with delayed primary
closure, delayed secondary closure is used after
several days of therapeutic care for contaminated
wounds with compromised blood supply. At
the time of closure, the granulation tissue is
removed to allow apposition of skin edges. This
may result in significant dead space or oozing of
blood and serum. Drains may be necessary to
minimize the accumulation of serum within the
wound.
Second-intention healing consists of fibropla-
sia followed by wound contraction and epithel ial-
ization. Indications for second-intention healing
include severe contamination or infection, con-
siderable skin loss, excessive skin tension that pre-
cludes primary closure, and unavoidable motion
like that occurring in the pectoral and gluteal
regions. Second-intention healing is best used for
wounds not over a joint surface, those with an
adequate vascular supply to the underlying soft
tissues, and those with sufficient mobile skin to
allow wound contraction.
SUTURE MATERIAL
Suture material selection should be based on the
biologic and physical properties of the suture, the
wound environment, and the tissue response to
the suture (Table 3-1). The characteristics of the
ideal suture include good handling quality; good
knot security; adequate tensile strength; lack of
allergenic, electrolytic, capillary, or carcinogenic
properties; minimal tissue reaction; no adverse
effect s on a wound in the presence of infection;
easily sterili zed; economical; and absorption soon
after the suture has served its purpose.
The suture material with the best handling
characteristics is silk, which, with respect to
handling, sets the standard by which all other
suture materials are compared. Generally, the
braided, multifil ament synthetic sutures have
• •
1 r ) n m -
TABLE 3-1
Characteristics of Commonly Used Suture Materials
TRADE
GENERIC NAME NAME FILAMENT SOURCE
Absorbable
Polyglactin 910 Vicrylt Multi Glycolic-lactic acid
polymer
Polyglycolic acid Dexon
f
Multi Glycolic acid
Polydioxanone PDS li t Mono Polydioxanone
polymer
Polyglyconate Maxon
t
Mono Glycolic acid-
polytrimethylene
carbonate
Poliglecaprone 25 Monocrylt Mono Copolymers of
epsilon-
caprolactone
and glycolide
Chromic catgut Multi Submucosa of
ovine intestine
or serosa of
bovine intestine
PERCENT
LOSS OF
TENSILE
STRENGTH
14
DAYS
35-50
35-60
15-25
30
70
21
DAYS
60-80
65-90
30-40
45
100
Variable
COMPLETE FOREIGN
ABSORPTION MODE OF BODY
( DAYS) DEGRADATION RESPONSE
60-70 Hydrolysis Slight
120 Hydrolysis Slight
180 Hydrolysis Slight
180 Hydrolysis Slight
110 Hydrolysis Slight
90+ Enzymatic Inflammatory
No. OF
THROWS
FOR GOOD
KNOT
SECURITY*
3
3
4
4
5
3
SIZE-
STRENGTH
RATIO
Good to
excellent
Good to
excellent
Excellent
Excellent
Excellent
Poor
-
...
"0
"
m
~
C
"
" - ()
>
r
"0
"
m
~
"
~
-
o
z
>
z
o
>
~
~
rn
~
~
• m
Z
-;

Nonabsorbable
Silk Multi Raw silk spun by
silk worm
Polymerized Supramid or Multi Polyamide strands
caprolactum Braunamid enclosed in a
polyamide
sheath
Stainless steel Mono Chromium nickel
molybdenum
Polyester Mersilene' Multi Synthetic resin
polymers
(extruded)
Nylon Ethi lon' Mono Polyamide
filament
(extruded)
Polypropylene Prolene' Mono Polymerized
polyolefin
hydrocarbons
(extruded)
,. An additional throw is recommended for continuous patterns.
tEthicon, Inc, Somerville. N.J.
:j:Davis & Geck, Inc, American Cyanamid Co, Manati, Puerto Rico.
NA, not appli cable.
>80% in Variable Proteolysis
8 days
NA NA NA
NA NA NA
NA NA NA
30% in NA Chemical
2 years degradation
NA NA NA
Moderate 3
Moderate 5
Inert 2
Moderate 5
Minimal 4
Minimal 3

Poor
Good
Excellent
Excellent
Good
Fair to good
~
~
~
0.
n
:.
~
;;;
-
'"
16 PRESURGICAL PREPARATION AND A SSESSMENT
ment sutures. Stainless steel has the worst han-
dling properties.
The number of throws necessary to secure a
square knot vari es with the size and type of suture
material. In general, multifilament sutures have
better knot security than do monofilament
sutures. Stainless steel has the best knot securi ty.
Also, the small er the suture, the more secure is
the knot. For example, No. 2-0 polyglycolic acid
suture material has better knot security than does
No. 2 polyglycolic acid suture material.
The suture material should be as strong as the
tissue in which it is placed. Skin and fascia are rel-
atively strong, whereas fat and muscle are rela-
tively weak. In traumatic wounds, the tissue
immediately surrounding the wound may be
compromised. Therefore, the wound margins
should be debrided, if possibl e, to clean healthy
tissue and the sutures should be placed back from
the wound margins to ensure that the sutures are
placed in the healthiest tissue. The strength of a
sutured wound is usually dependent on both the
tissue's ability to hold suture and the tensile
strength of the suture material. With healthy
tissue, the initial strength of the sutured wound is
dependent on the strength of the sut ure; however,
by 3 to 4 days, the repaired tissue starts to increase
in strength.
All suture materials potentiate infection by
acting as foreign bodies when placed in contami-
nated wounds. Monofilament sutures are the least
reactive and can withstand wound contamination
better than can multifilament sut ures of the same
material. Multifilament sutures exhibit capillarity,
a wicklike action that allows bacteria to move
along the suture strand. Nat ural materials (e.g.,
catgut, silk, cotton, linen, collagen) are generally
considered the most reactive, are weaker, and have
a variable rate of absorption.
Synthetic absorbable sutures, such as polygly-
colic acid, polyglactin 910, polydioxanone, poly-
glyconate, and polyglecaprone, have the distinct
advantage of being absorbed at a constant rate by
hydrolysis. Additionally, monofilament sutures
are less reactive than twisted or braided materials.
Synthetic nonabsorbable sutures, such as nylon,
polypropylene, and polyfilament polyamide, are
generally less reactive than absorbable sutures.
Polyfilament polyamide has characteristics that
make it the least desirable synthetic no nab-
sorbable suture, such as losing 15% to 20% of
its strength when wet and being associated
with an increased incidence of suture sinus tract
formation.
1
SUTURE PLACEMENT AND PATTERNS
The placement of sutures affects wound healing.
Sutures should be placed such that they just
appose the wound edges. Loosely approximated
wounds are st ronger at 7, 10, and 21 days after
surgery than are wounds tightly secured with
sutures,S possibly because overtightening disrupts
the microvascuJar circulation to the wound edges.
Wound edges weaken over time because of colla-
gen lysis; therefore, sutures should be placed at
least 0.5 em from the margins. Additionally, al-
though more sutures improve initial strength,
the increased number of sutures compromises
blood supply to the wound edges and stimulates
an excessive tissue reaction and subsequentl y
increases infection rate. Deep sutures should be
placed only in fascial planes, tendons, and liga-
ments, because additional deep sutures are gener-
ally ineffective and cause excessive tissue reaction.
The suture pattern also can affect wound
healing. Although the simple continuous pattern
is the easiest to apply and provides the most
uniform support, its design leads to reduced
microcirculation to the wound margins and a
single break resuJts in failure of the entire line.
Comparatively, a simple interrupted pattern leads
to less edema, does not exert a negative impact on
the microcirculation, and encourages greater
wound tensile strength after 5 and 10 days,'
although these positive effects are attenuated at
later times.
9
'
13
The disadvantages of interrupted
patterns compared with conti nuous patterns
include the use of more suture material and
increased placement time. Interrupted suture pat-
terns should be used when impaired healing is
anticipated and excessive tension is present.
Simple interrupted suture patterns cause less
inflammation than vertical mattress and far-near-
near-far patterns because of relatively less suture
material in the incision line and fewer skin
penetrations.
Suture patterns may be divided based on
whether they are appositional or serve as tension
suture patterns. Simple interrupted, simple con-
tinuous, Ford interlocking, cruciate, and subcuta-
neous or subcuticular patterns are classified as
appositional suture patterns (Figures 3-1 to 3-5).

Figure 3-1 Simple interrupted pattern.
Figure 3-3 A and B, Ford interlock-
ing pattern.
.
A
Figure 3-4 Interrupted cruciate pattern.
Wound Closure 17
__
Figure 3-2 Simple continuous pattern.
B
The ver tical and horizontal mattress patterns and
the near-far-far-near or far-near-near-far or other
combination suture patterns are classified as
tension suture patterns (Figures 3-6 to 3-10).
They are often used in conjunction with apposi-
tional suture patterns to combine the benefits of
both (see Figure 3-9) .
Simple Interrupted and Continuous Patterns
The simple interrupted suture pattern provides
secure, anatomic closure with precise suture
tension (see Figure 3-1).lt is easy to apply and the
skin retains the ability to expand between the
sutures. The simple continuous suture pattern is
used in tissues that are elastic and are not subject
18 PRESURGICAL PREPARATION AND ASSESSMENT

Figure 3-5 Subcutaneous pattern illustrating the
direction of suture placement in both the beginning
and end of the pattern.
A
B

Figure 3-6 A, Interrupted horizontal mattress
pattern. B. Horizontal mattress suture pattern wi th bol-
sters used as a tension suture pattern.
to significant tension (see Figure 3-2). It provides
good apposition and an airtight or watertight seal.
Bites in the wound edges are made at right angles
to the edges of the wound. Excess tension causes
puckering and strangulation of the skin.
Horizontal Mattress Pattern
The interrupted horizontal mattress pattern can
be everting or appositional depending on the
depth of suture placement and dista nce from the
wound edges (see Figure 3-6) . The pattern is good
for large skin wounds, for wounds with increased
tension, and in conjunction with pieces of rubber
I
I
Figure 3-7 Continuous hor izontal mattress suture
pattern. Used as a tension suture, slight everting
pattern.
A
B
,
,
-
- -
- -
Figure 3-8 A and B, Interrupted verti cal mattress
pattern.
tubing or buttons to act as a tension suture.
Because of the placement of this pattern, the
sut ures have a tendency to reduce the blood
supply to the wound edges. The continuous hor-
izontal mattress pattern provides necessary
tension for wound edge approximation without
applying tension to the wound edge itself (see
Figure 3-7) . It is often used as a tension-relieving
suture for the wound edge.
Vertical Mattress Pattern
The interrupted vertical mattress pattern can also
be everting or appositional depending on the
depth of suture placement and distance from the
wound edges (see Figure 3-8). It is stronger in
tissues under tension and less compromising to
I
Figure 3 ~ 9 A and B, Com-
bined vert ical mattress tension
suture and simple interrupted
appositional sut ure patterns.
C, Combination of vertical mat-
tress sutures with bolsters and A
simpl e interrupted apposit ional
sutures to close incisions under
tension.
,
Figure 3 ~ lOA and B, Near-far-far-near
tension suture pattern. C and 0 , Far-near-
near-far tension suture pattern.
"
A
B
blood supply to the wound margins than inter-
rupted horizontal mattress sutures. The verti cal
mattress suture pattern can be used for concur-
rent closure of skin and subcutis to eliminate dead
space.
Wound Closure 19
,.
,,,-:
v ' c
--
B
c
D
Other Tension Patterns
The nea r-far-far- near, fa r- near-near-far, and other
vari ati ons are tension suture patterns occasionally
used in equine surgery (see Figure 3- 10). They
20 PRESURGICAL PREPARATION AND ASSESSMENT
have been shown to be excellent tension sutures;
however they are time consuming to insert. In one
retrospective study, an increased incisional infec-
tion rate was associated with closure of the linea
alba using a near-far-far-near suture pattern.
14
Subcutaneous or Subcuticular Patterns
Subcutaneous or subcuticular suture patterns are
used to close the subcutaneous or subcuticular
ti ssue pri or to skin closure. Subcuticular patterns
can also be used in place of a typical ski n closure
pattern (see Figure 3-5). The first part of the
suture pattern is placed by starting approximately
8 to 10mm from the apex of the incision in the
subcutaneous tissue, directing the needle toward
the apex of the incision, and emerging in either
the subcutis or subcutaneous tissue depending on
the pattern desired. The second bite of the suture
starts at the apex and emerges approximately 8 to
10mm from the apex in the subcutaneous tissue.
The knot is then tied and thus is "buried." The
third bite of the suture is superficial to the knot
and closer to the apex of the incision to effectively
reinforce burying the knot. The remainder of the
suture pattern is pl aced somewhat similar to a
continuous horizontal mattress pattern, with the
needle crossing the incision at right angles or
slightly "behind" where the previous suture
emerged. A knot similar to the start is placed at
the end of the incision. The last two bites start in
the subcutaneous tissue and the needle is directed
toward the apex and somewhat more superficial.
The last bite starts with the needle reversed at the
same level of emergence as the previous bite,
directing the needle toward the subcutaneous
tissue about 8 to 10 mm from the apex. The knot
is tied and the free end of the suture is cut. The
needle is passed into the subcutaneous tissue at
the level of the knot, emerging through the skin
about 10 to 15 mm perpendicular to the incision
li ne. The needle and suture are then pulled tight
to help bury the knot, and the suture is cut at the
skin level.
Securing sutures is most commonl y performed
using instrument ties. However, every surgeon
should be able to use one- and two-hand ti e tech-
niques to secure sutures. The ability to use these
techniques gives the surgeon signifi cant flexibility
to apply secure ligatures and sutures in various
situations where the use of instrument ties is
problematic. Ideally, the surgeon should be able to
use either right or left one-hand ties to take full
advantage of their utility.
TISSUE ADHESIVES
Various tissue adhesives, such as cyanoacrylates,
collagen gelati n, and fibrin glue, are used for
primary wound closure.1
5
,16 Advantages include
rapid and painless application, hemostatic and
bacteriostatic properties, the provision of a
water-resistant protective coating, no need for
suture removal, and an acceptable cosmetic
result. " It is generally thought that tissue adhe-
sives may have some benefits in small incisions or
wounds in which primary suture closure is indi -
cated, whereas larger wounds are unlikely to
benefit from tissue adhesives. Wounds healing by
second intention may benefit from tissue adhesive
sprays after a healthy granulation tissue bed has
formed.
16
DEAD SPACE
Dead space allows the seepage and accumulation
of blood and serum in a warm and moist envi-
ronment that is ideal for bacterial proliferation,
thus encouraging infect ion. Dead space may be
dealt with by layered wound closure when ade-
quate tissue is available, by compression bandages,
by drainage, or by suture obliteration,17 although
the latter may promote wound infection in con-
taminated wounds. Walking sutures can be used
to advance a skin flap over the wound bed at the
same time the dead space is eliminated (Figure
3- 11). A stent or tie-over bandage can be used to
help obliterate dead space in wounds in which cir-
cumferential bandaging is not possible. This type
of bandage protects the wound and may provide
relief to the primary suture line as well as direct
pressure over areas of dead space (see Figure
25-12).
DRAINS
Drains are used when a large dead space remains
after suture closure or there is sufficient tissue
damage so that continued seepage of fluids is
expected. Drains can be therapeutic to remove
existing fluid accumulation or prophylactic to
-
-
,

,
• -
A
,-
-'
"
-
,
Wound Closure 21
B

C 0
Figure 3-11 A-D, Use of walking sutures placed in the subcutaneous tissue to close large defects in skin.
Figure 3-12 A, Insertion of the
Jackson-Pratt negative suction drain
using a trocar at a site ventral to the
incision line. B, Jackson-Pratt negative
suction drain in place to provide con-
tinuous suction to remove exudate and
fluid from the incision or wound site.
Note use of three-way stopcock. 60-mL
syringe. and needle placed through
plunger to maintain suction.
A
ensure against fluid accumulation. Drains must be
maintained in a sterile environment to decrease
the chance of secondary infection. They should
traverse the wound from a proximal to distal ori-
entat ion, adjacent to but not directly underlying
the suture line, and should exit from a sepa rate
incision adjacent to the wound edges to minimize
B
41 e "?/<At;, ,"f;, ."'" ...... _>
the chances of retrograde infection. Drains should
be sutured proximally and at the exit point.
Drains are classified as active or passive. Active
drains are closed suction drains that function by
negative pressure to suction out excess fluid or air
(Figure 3- 12). Passive drains, including Penrose
drains or other forms of rubber or polyethylene
22 PRESURGICAL PREPARATION AND ASSESSMENT
,
Figure 3-13 Partial closure of subcutaneous tissue
over Penrose drain. Drain sutured in place (arrow) and
exits the site distal to the incision or wound site to avoid
the primary incision line.
tubing, funct ion by gravity or pressure differen-
tials (Figure 3-13). The ideal drain is inert, soft,
smooth, nonreactive, and radiopaque. The disad-
vantages of drains include the potential introduc-
tion of bacteria or foreign bodies into the wound,
the care involved to maintain patency, and the
potential irritation and resultant scar tissue and
adhesion formation that may occur as the result
of a foreign body reaction. Drains should be
removed after 2 to 3 days, when infection is con-
trolled, or if they are not functioning effectively.
Ideally, wound drainage is expected to change
from an exudate to a transudate, and the quantity
is expected to graduaUy diminish to negligible
levels during the 2- to 3-day period.
MANAGEMENT OF SKIN TENSION
Excess tension on a primary suture line is l.ikely to
complicate healing via local ischemia, cutting out
of sutures, and wound disruption. Methods to
decrease tension on the primary suture line
include undermining the surrounding skin, pro-
viding relief incisions, and the use of tension
suture patterns. Although excessive undermining
is deleterious, undermining up to 4 cm from the
wound edge on distal limb wounds has not been
Figure 3-14 Previously repaired pastern laceration
showi ng evidence of skin necrosis secondary to b a n ~
dages applied over tension suture supports. Three
hor izontal mattress sutures had been placed with
polyethylene supports 2 weeks previously.
associated with complications.!8 Rel ief incisions
away fr0111 the wound margins can sometimes
decrease tension. The relief incisions may be
closed after the primary incision is closed or left
to heal by second intention.
Tension suture patterns used to reduce the
tension on the primary suture line are placed well
back from the wound margins so that the blood
supply is not compromised. Once the tension
sutures are in place, the primary inci sion line is
sutured to appose the wound edges. Widely placed
vertical mattress sutures, with or without support
using buttons, gauze, or rubber or polyethyl ene
tubing, are effective in reducing tension on the
primary suture line. Other tension suture patterns
incl ude horizontal mattress, far-near-near-far,
and far-far- near-near patterns. Tension sutures
with supports are used in regions that cannot be
effectively bandaged (e.g., upper body, neck),
whereas no supports are used under bandages or
casts, because pressure on the supports may cause
tissue necrosis (Figure 3-14) . Tension sutures are
removed in 4 to 10 days, depending on the
appearance of the wound. Staggered removal is
preferred, removing half of the sutures initially
and the remaining half later.
REFERENCES
I. Hamill MB, Osato MS, Wilhelmus KR: Experimen-
tal evaluation of chlorhexidine gl uconate for ocular
antisepsis, Antimicrobial Agef/ts Chemother 26:793,
1984.
2. Phinney RD, Mondino BJ, Hofbauer JD, et al:
Corneal edema related to accidenta1 Hibiclens
exposure, Alii J Ophtha/mol 106:210, 1988.
3. Nasser RE: The ocular danger of Hibiclens (chlor-
hexidine), Pfost Recomtr Surg 89:164, 1992.
4. Baxter GM: Wounds and wound healing. In
Colahan PT, Mayhew IG, Merritt AM, Moore lN,
editors: Equine medicine alld slIrgery, ed 5, St Louis,
1999, Mosby.
5. Stashak TS: Selected factors that affect wound
healing. In Stashak TS, editor: Eqlline IVOUlld mall-
agement, Philadel phia, 1991, Lea & Febiger.
6. Wilson DA: Principles of early wound manage-
ment, Vet elill N Alii Equine Pmct 21:45, 2005.
7. Stashak TS: Selection of suture materials and suture
patterns for wound closure. In Stashak TS, editor:
Equine wound management, Philadelphia, 1991, Lea
& Febiger.
8. Brunius U, Ahren C: Healing of skin incisions
during reduced tension of the wound area. A ten-
siometric and histologic study in the rat, Acta Chir
Scalld 135:383, 1969.
9. Fingland RB. Layton Cl, Kennedy GA, et al: A com-
parison of simple conti nuous versus simple inter-
rupted suture pattern for tracheal anastomosis after
large-segment tracheal resection in dogs, Vet SlIrg
24:320, 1995.
10. Kirpensteijn 1. Maarschalkerweerd RJ. van der Gaag
I, et al: Comparison of three closure methods and
Wound Closure 23
two absorbable suture materials for closure of
jejunal enterotomy incisions in healthy dogs, Vet Q
23:67, 2001.
II. Magee AA. Gal uppo LD: Comparison of incisional
bursting strength of simple continuous and inver-
ted cruciate suture patterns in the equine linea alba,
Vet Su'g 28:442, 1999.
12. Van Hoogmoed L, Snyder JR, Stover SM, et a1: In
vitro biomechanical comparison of the strength
of the linea alba of the llama, using two suture
patterns, Am J Vet Res 57:938, 1996.
13. Weisman DL, Smeak DD, Birchard SJ, et al: Com-
parison of a continuous suture pattern with a
simple interrupted pattern for enteric closure in
dogs and cats: 83 cases (1991-1997), ] Alii Vet Med
Assoc 21 4:1 507,1999.
14. Kobluk eN, Ducharm NC, Lumsden JH, et a1:
Factors affecting incisional complication rates asso-
ciated with colic surgery in horses: 78 cases ( 1983-
1985). ] Alii Vet Med Assoc 195:639, 1989.
15. Blackford J. Shires M, Goble D, et al: The use of
N-butyl cyanoacrylate in the treatment of open leg
wounds in the horse, Proc Am Assoc Equille Pract
32:349, 1986.
16. Bello TR: Practical t reatment of body and open leg
wounds of horses with bovine collagen, biosyn-
thetic wound dressing and cyanoacrylate, J Eqllille
Vet Sci 22: 157, 2002.
17. Trotter GW: Techniques of wound closure, Vet Clil1
N AII1 Equine Pmct 5:499, 1989.
18. Bail ey lV, Jacobs KA: The mesh expansion method
of suturing wounds on the legs of horses, Vet Slirg
12:78,1983.
-
CHAPTER 4
Emergency Management of the Fracture Patient
Gal Kelmer
INDICATIONS
Unstable appendicular skeleton fractures.
EQUIPMENT
Bandaging material includes uniform layered
cotton padding, elasti c gauze, elastic adhesive,
inelastic tape, and wound dressing materials.
Splints can be made from any lightweight rigid
material. PVC (polyvinyl chloride) pipe, 8 to
10 cm in diameter and of 4- to 8-mm wall thick-
ness, sectioned longitudinally into thirds makes
an excellent, inexpensive, readily available splint-
ing material. The sharp edges of the splint may be
rounded and should be wrapped with tightly
taped padding. Other acceptable splinting mate-
rials include wooden splints,S to 20 cm wide and
10 to 20mm thick, and aluminum or concrete
reinforcement rods, 12 to 16 mm in diameter, cut
to length (Figure 4-1).
POSITIONING AND PREPARATION
All emergency fracture stabilization should be
done with the horse in a standing position while
providing analgesia and mild to moderate seda-
tion. Recovery from general anesthesia can chal-
lenge even an ideal fracture repair by the ap-
plication of extreme forces to the horse's limb.
Thus, general anesthesia should be avoided unless
absolutely necessary. !
24
INITIAL EVALUATION AND TREATMENT
Prompt and proper fracture stabilization in the
horse can make the difference between death and
an athletic future. A horse with a fractured, unsta-
ble limb can rapidly induce further trauma that
will markedly decrease the chance for successful
repair and survival. The goal of the initial treat-
ment and stabil ization is to prevent further
trauma. Such trauma may result in eburnation of
fracture ends, further fragmentation and fracture
displacement, damage to neurovascular struc-
tures, skin penetration leading to an open frac-
ture, and additional soft tissue damage. 1·6
Initial assessment of the injured horse inclu-
des evaluating the systemic condition, specifically
hydration status and cardiovascular function, the
bone involved, and the stabil ity of the bony
column, and determining whether the fracture is
open or closed. Typically, the horse will be sys-
temically stable and will benefit from immediate
stabilization of the injured limb. Analgesia and
sedation of the fractured horse are important in
order to relieve anxiety and alleviate pain, thereby
minimizing further self-inflicted damage to the
injured limb. Phenylbutazone (4.4 mg/kg N ) is
beneficial for both its analgesic and anti-inflam-
matory properties. Additional analgesia and seda-
tion can be achieved using detomidine (0.01 to
0.02 mg/kg NIIM) with or without butorphanol
(0.01 to 0.04 mg/kg IM). Use caution when
administering these sedatives and analgesic agents,
so as not to render the horse ataxic. Horses with
these fractures may be dehydrated and hypo-
volemic and thus can be profoundly affected by
these agents. If there is skin penetration of the
injured limb, even if distant from the apparent
fracture. broad-spectrum antibiotics (e.g., gen-
tamicin 6.6 mg/kg IV and potassium penicillin
22,000 Ju/kg IV, or gentamicin and procaine
penicillin 22,000 IV/kg 1M, or cefazolin II mglkg
IV) should be administered. In a markedly dehy-
drated horse, administration of aminoglycosides
(e.g., gentamicin) and nonsteroidal antiinflamma-
tory drugs (NSAIDs) (Le., phenylbutazone) should
be postponed until adequate hydration is achieved
via intravenous fluid administration. The horse
should be current on tetanus vaccination.
Limb Stabilization
Immediately after initial assessment of the patient
and the affected limb, external coaptation should
-
- \
Figure 4-1 Bandaging and splinting equipment.
Emergency Management of the Fracture Patient 25
be applied. Splinting can be done well with simple
equipment in field situations when attention is
given ~ o proper technique.
7
,B
Radiographs can be taken either following
stabilization or later at the referral facility. The
basic method of stabilization is a splint applied
over a bandage to decrease interfragmentary
movement and to significantly alleviate anxiety.
The specific mode of immobilization differs along
the limb according to the locally predominant
biomechanical forces. Both forelimbs and hind
limbs can be divided into the following four func-
tional sections.
l
.
s
Section 1 is the most distal fore-
limb or hind limb segment between the coronary
band and the distal quarter of the metacarpus or
metatarsus. Section 2 in the forelimb extends
from distal metacarpus to distal radius, while in
the hind limb it includes middle and proximal
metatarsal fractures. Section 3 in the forelimb
comprises diaphyseal and proximal radial frac-
tures, while in the hind limb it includes tarsal
and tibial fractures. Section 4 in the forelimb
consists of fractures of the ulna, humerus, and
scapula, while in the hind limb it includes proxi-
mal tibial physis and femur fractures . Appropriate
stabilization techniques for the previously des-
cribed sections of both forelimbs and hind limbs
are described next.
Section 1
The most distal forelimb or hind limb segment
is between the coronary band and the distal quar-
ter of the metacarpus or metatarsus ( Figure 4-2).
Dorsopalmar or dorsoplantar bending is the prin-
Section 4
3
Figure 4-2 Dividing the limbs
into four functional sections. Each
section is stabilized in a different
technique according to the local gov-
erning biomechanical forces.
Section 3 ---
Section 2 - --
f- Section 2
Section 1 ----
Section 1
26 PRESURGI CAL PREPARATION AND ASSESSMENT
dpal force and is best counteracted by applying
a dorsal splint-cast combination over a light band-
age extending from the ground to just below the
carpus. The bandage is applied with the distal limb
straight and the splint applied to align the dorsal
cortices. The splint is taped tightly with the carpus
held in flexion. The tape material should be
nonelastic, such as duct tape or white tape to
prevent unwanted motion between the splint and
the limb (Figure 4-3). Fiberglass cast material may
be applied over the taped splint to increase rigidity.
In the hind limb, the same principles hold but the
splint is applied to the plantar aspect with ti,e
metatarsophalangeal (fetlock) joint in slight flexion
(Figure 4-4).
Figure 4-3 Section 1 forelimb fracture, distal thi rd
metacarpus to distal interphalangeal joint region, sta-
bilized using a dorsal splint-cast combination over a
light bandage.
Figure 4-4 Section 1 hind limb fracture, distal third
metatarsus to distal interphalangeal joint region, stabi-
li zed using a plantar splint-cast combination over a light
bandage.
Section 2
Forelimb fractures, from distal third metacarpus
to distal radius, should be stabil ized with a Robert
Jones bandage applied from the ground to the
humeroradial joint (elbow) (see Figure 4-2). The
bandage should include multiple layers of padd-
ing and each padding layer is tightened with
elastic gauze. Padding can be made with rolled or
layered cotton. Each padding layer should be
about 2 to 3 em thick with the total bandaged
diameter approximately three times the limb's
diameter. It is crucial that the bandage is uniform
in shape and tight enough to achieve maximum
stability and rigidity of the splinted limb while
avoiding excessive focal skin pressure. Palmar and
lateral splints that extend from the ground to the
elbow should be appli ed. Splints should be taped
as tight as possible over the bandage, using a gen-
erous amount of nonelastic adhesive material
such as duct tape (Figure 4-5).
Middle and proximal third metatarsal fractures
(see Figure 4-2) should be bandaged from the
ground to the level of the stifle. In the hind limb,
the bandage should be less extensive to facilitate
splint application. Plantar and lateral splints
should be applied from the ground to the level of
the calcaneal tuber. The lateral splint may extend
to the level of the stifle for more proximal frac-
tures. Splinting material and application manner
are similar to those previously described (Figure
4-6) .
Figure 4-5 Sect ion 2 forelimb fracture, distal radius
to distal metacarpal region, stabilized using paJmar and
lateral splints over a heavy Robert Jones bandage.
Figure 4-6 Section 2 hind limb fracture, third
metatarsal bone, stabi li zed using plantar and lateral
splints over a moderate Robert Jones bandage.
Section 3
Diaphyseal and proximal radial fractures should
be stabilized with a Robert Jones bandage aug-
mented with caudal and lateral splints applied as
for section 2 with the exception that the lateral
splint extends proximally to lie against the lateral
aspect of the shoulder (see Figure 4-2). The prox-
imal extension of the splint is essential because
of minimal soft tissue protection over the medial
aspect of the radius. The splint prevents abduc-
tion of the distal limb and penetration of the skin
by the fractured bone ends at the medial aspect of
the fracture line (Figure 4-7). Tarsal and tibial
fractures are especially difficult to immobilize
because of the reciprocal apparatus (see Figure 4-
2). A Robert Jones bandage is applied as for
section 2) but in this case the bandage should
extend to the level of the patella with the splint
preventing slippage. The splint should extend
proximally to lie against the lateral thigh and hip
and prevent skin penetration by fracture bone
ends from limb abduction. Ideally, a lightweight
metal splint or steel concrete reinforcement rod
shaped to the hock and stifle angulations and bent
back upon itself is used as the lateral portion of a
Schroeder-Thomas splint. Cast material can be
wrapped around the bent rod fo r additional
strength (Figure 4-8). Alternatively, the splint can
be made of a wide (20 em) wooden board (Figure
4-9). In all options, the splint is incorporated into
Emergency Management of the Fracture Patient 27
Figure 4-7 Section 3 forelimb, diaphyseal and prox-
imal radial fractu res, stabilized using similar bandage
and palmar splint as for section 2 fractures. Here the
lateral splint is extended to lie against the lateral aspect
of the shoulder and prevent limb abduction.
Figure 4·8 Section 3 hind limb, tibia, and tarsal frac-
tures, stabilized using lateral splint over a moderate
Robert Jones bandage. The splint is made of a speci fi-
cally bent aluminum rod enforced with synthetic cast
mater ial and extending proximally to lie against the
thigh and hip to prevent limb abduction.
I
28 PRESURGICAL PREPARATION AND ASSESSMENT
Figure 4-9 Section 3 hind limb, tibia, and tarsal frac-
tures, stabilized using a lateral splint over a moderate
Robert Jones bandage. The spl int is made of a broad
wooden board extended proximall y to lie against the
thigh to prevent limb abduction.
the coaptat ion as tightly as possible with liberal
use of inelast ic tape.
Section 4
Fractures of the ulna. humerus, and scapula are
unstable as a result of loss of the triceps function,
which precludes use of the limb (see Figure 4-
2). A light bandage from the ground to the elbow
combined with a caudal spl int spanning the
carpus to lock the carpus in extension will enable
weight bearing on a limb affected with an ulnar
fracture (Figure 4-10). Splinting cannot aid prox-
imal tibial physeal and femur fract ures (see Figure
4-2). Heavy coaptation may actually cause further
damage by increasing the fulcrum to distract the
fragment and potentiaUy open a closed proximal
tibial fracture.
PREPARATION FOR REFERRAL
In most cases, it is advisable to discuss referral and
surgical opt ions with the client only after the
patient is relatively calm and the limb is properly
stabilized. The nearest surgical facility should be
contacted and consulted prior to transporting the
horse. Euthanasia is definitely indicated in certain
situations such as an open comminuted tibial
fracture in an adult size horse.
5
However, in most
Figure 4-10 Section 4 forelimb fractures disabling
the triceps apparatus such as olecranon fractures. A
caudal splint over a light bandage is applied in order to
lock the carpus in extension and by that aid in control
and use of the limb.
cases, initial stabilization of the limb and the
patient and consultation with the nearest surgical
facility will provide the best servi ce to the horse
and the client. The horse should be transported in
a confined area with minimal space for body
movement and adequate room for head motion
and foot placement to aid in balance. A horse with
an injured forelimb should face backward and a
horse with a hind limb injury should face forward
so as to prevent additional stress on the injured
limb during emergency stops. Providing dist rac-
tion for the ride in the form of a small amount of
hay is recommended.
2
COMPLICATIONS
Improper splinting such as using one thick
padding layer without intermittent tightening
with elastic gauze or a very heavy splint improp-
erly secured to the limb can actually increase the
amount of damage to the fractured limb.
4

s
EXPECTED OUTCOME
The prognosis depends on the horse's weight and
temperament, the specific bone involved and the
location of the fracture within the bone, the frac-
I
ture configuration, and the availability of a well-
equipped surgical facil ity. The goal of initial sta-
bilization is to ensure that the horse reaches the
referral center in the best possible condition,
while minimizing additional injuries to soft tissue
and fractured bones during transportation.
I
,2,s
ALTERNATIVE PROCEDURES
A commercially available manufactured metal
splint, "Kimzey Leg Saver" (Kimzey Welding
Works, Woodland, Calif.), provides adequate sta-
bilization for section 1 fractures in both forelimbs
and hind limbs. Care should be taken to ade-
quately cushion the most proximal aspect of the
Figure 4·11 An alternative way to stabili ze section 1
fractures and luxations is by use of a commercially
available manufactured metal splint. the "Leg Saver" by
Kimzey. (Courtesy Kimzey Welding Works. Woodland,
Calif.)
Emergency Management of the Fracture Patient 29
splint (Figure 4- 11 ). The splint provides a quick
and easily applied support; however, it may
provide less rigid support than a tightly placed
splint-cast combination,l ,2
COMMENTS
Joint luxations present similar to traumatic unsta-
ble fractures and warrant immediate stabilization
following the same described principles.
REFERENCES
I. Bramlage LR: Current concepts of emergency first
aid treatment and transportation of equine fracture
patients, Camp Cant Educ 5:S564, 1983.
2. Bramlage LR: First aid and transportation of frac-
ture patients. In Nixon AJ, editor: Equine fracture
repair, Philadelphia, 1996, WB Saunders.
3. Young DR, Kobluk CN: Diseases of bone. In Kobluk
CN, Ames TR, Geor R], editors: The horse: diseases
and clinical management, Philadelphia, 1995, WB
Saunders.
4. Auer JA, Bramlage LR: Emergency care and trans-
portation of the fracture patient. In Colahan PT,
Mayhew IG, Merritt AM, Moore lN, editors: Equine
medicine and SlIrgery, ed 5, St Louis, 1999, Mosby.
5. Bramlage LR: Emergency first aid treatment
and transportation of equine fracture patients. In
Auer lA, Stick JA, editors: Equine surgery, ed 2,
Philadelphia, 1999, WB Saunders.
6. McIlwraith CW, Orsini ]A: Musculoskeletal system.
In Orsini JA, Divers T], editors: MalUml of equine
emergencies: treatment and procedllres, ed 2, Phil-
adelphia, 2003, WB Saunders.
7. Walmsley J: Emergency management of fractures in
horses, In Practice 21:122, 1999.
8. Whitton RC: Temporary splinting of fractures. In
Rose RJ, Hodgson DR, editors: Manual of equille
practice, ed 2, Philadelphia, 2000, WB Saunders.
CHAPTER 5
Field Anesthesia
Keith R. Branson
Equine field surgery requires portable anesthesia.
This factor makes it difficult to use inhalation
anesthesia. Fortunately) most of the patients un-
dergoing surgical procedures in the field are rela-
tively healthy and require minimal supportive
care while under anesthesia. Adequate) safe anes-
thesia is still required) however) because regard-
less of your surgical skills) a successful outcome
also requires successful anesthesia. This chapter
includes a discussion of the physiologic effects of
the drugs commonly used for injectable anesthe-
sia) how these drugs are used, and a brief discus-
sion of supportive care measures and induction
methods. In addition, a brief discussion of caudal
epidural anesthesia and epidural catheter place-
ment is included.
TRANQUILIZERS AND a,-AGONISTS
None of the injectable general anesthetics possess
all the properties needed to produce good anes-
thesia when used alone. For that reason other
drugs are administered in conjunction with the
general anesthetics. Tranquilizers and a 2-agonists
are commonly used for their sedative, analgesic,
and muscle relaxant properties.
Acepromazine
Acepromazine is the most commonly used mem-
ber of the phenothiazine family of tranquilizers.
Members of this group of drugs are known
for their sedative effects) but they also possess
30
antiemetic and antihistaminic effects. The central
sedation seen with the phenothiazine tranquiliz-
ers is due to their antagonism of dopamine at cen-
trally located receptors. In general) increasing the
dose above that needed for sedation will only
result in an increase in duration of tranquilization
and increased undesirable side effects. I Further
increases in dose may even result in excitement.
Acepromazine produces a decrease in arterial
blood pressure caused by a peripheral al-adreno-
receptor antagonism.
2
Because of this a
l
antago-
nism) a mixed adrenoreceptor agonist) such as
epinephrine) can have a more dramatic hypoten-
sive effect since its vasodilatory ~ effects will be
more pronounced. In addition) acepromazine has
an antiarrhythmic effect on the heart, most likely
from an a-adrenoreceptor antagonism in the
heart.
3
,4 Minimal respiratory depression) other
than a slight decrease in the respiratory rate) is
associated with the use of acepromazine alone) and
it does decrease the animal's ability to thermoregu-
late. '" Early reports of priapism and flaccid penile
paralysis in stallions and geldings given acepro-
mazine have led to hesitance to use this drug in stal-
lions and geldings.
8
-
lo
Some practitioners think
that acepromazine is still a useful sedative for use
in male horses) and if used) it should be adminis-
tered intramuscularly (1M) and at the lowest effec-
tive dose.
1l
There is a dose-dependent decrease in
the hematocrit attributed to sequestration of ery-
throcytes in the spleen.
lo
.
n
Acepromazin e is highly
protein bound and has an elimination half-life of
longer than 3 hours. 10 It undergoes hepatic metabo-
lism to form inactive metabolites.
When used alone, the dose for acepromazine
ranges from 0.02 to 0.09 mg/kg administered
intravenously (IV) and 0.03 to 0.05 mg/kg 1M.
Acepromazine is rarely used alone when sedation
and chemical restraint for standing surgical proce-
dures are desired, since it has no analgesic proper-
ties. In addition, time to onset can be highly
variable and the overall degree of sedation is hard
to predict.
a,-Agonists
Xylazine is one of the most widely used sedative-
analgesics in veterinary medicine. Unfortunately,
it also has significant undesirable cardiovascular
effects since it is a nonspecific a-adrenoreceptor
agonist. It was thought that if agents that were
more specific for the centrally located <X2-
adrenoreceptol's could be developed, the periph-
eral effects would be minimized. Detomidine is
more specific for or adrenoreceptors but its car-
diovascular effects are very similar to those of
xylazine when equipotent doses are compared.
The initial response of the peripheral vasculature
is vasoconstriction. Although there may be differ-
el1Ces in the venous and arterial responses, an
obvious increase in peripheral vascular resistance
and an accompanying increase in arterial blood
pressure occur.
l3
·
15
This is especially evident if the
drug is given intravenously. These agents also have
significant central sympatholytic and parasympa-
thomimetic effects, which result in a decrease in
cardiac output. A decrease in heart rate occurs
both as a result of the central effects and as a
response to the initial vasoconstriction-induced
hypertension.
l3
·
l s
In additi on to bradycardia, atri -
oventricular conduction disturbances increase
following (X2-agonist administration.
14
.
16
This group
of drugs routinely causes some decrease in the res-
piratory rate with little effect on PaC0
2
; however, a
decrease in Pa02 is routinely observed at the doses
needed to produce sedation. 15,16
A transient increase in UriJle output is seen
after the administration of u 2-agOnlsts.17. 18 Concern
exists that especially xylazine, may
cause abortion in pregnant mares, but there is
little evidence of this effect. However, intrauterine
pressure is increased after the administration of
most uz-agonists.
19
Both xylazine and detomidine
undergo hepatic metabolism with rapid excretion
of the metabolites in the urine.
20
-
B
When used alone, the usual dose for xylazine
is 0.3 to 1 mg/kg IV and 1 to 2 mg/kg 1M.
Field Anesthesia 31
Lower doses are often used as an analgesic in
colic patients. The detomidine dose is 0.01 to
0.04 mg/kg IV 01' I M when used alone, and, as
with xylazine, lower doses of detomidine can be
used as an analgesic. Detomidine has a longer
duration of sedation than xylazine (approxi-
mately 45 and 30 minutes, respectivelyL and the
sedation produced lasts longer than the analgesia.
When these agents are used with opioids, the Ur
agonist dose is reduced. These combinations are
discussed in a later section of this chapter.
Two other selective u
2
-adrenoreceptor agonists
are used in horses-romifidine and medeto-
midine. Both have physiologic effects similar
to xylazine a nd detomidine.
15
,24 A dose of romm-
dine 0.08 mg/kg IV is equivalent to approximately
1 mg/kg of xylazine or 0.02 mg/kg of detomidine.
Detomidine, at least at higher doses, produces
sedation of longer duration than romifidine
but romifidine appears to produce slightly less
ataxia.
25
,26 Medetomidine is an u 2-agonist ap-
proved for use in dogs. Its use in horses has
been limited, but it appears a dose of 0.0075
mg/kg will produce adequate sedat ion of a
duration longer than that normally seen with
xylazine but shorter than that seen with detomi-
dine.
15
,27
One advantage of the uragonists is the avail-
ability of specific antagonists to reverse their
effects. The most commonly used antagonists are
tolazoline, yohimbine, and atipamezole, with tola-
zoIine being the least specific antagonist for the
uradrenoreceptor and atipamezole being the
most specific.
28
Because of tolazoline's relative
lack of (X2 specificity, its use is sometimes associ-
ated with significant clinical signs as a result of the
antagonism of endogenous adrenergic substances.
These signs can include diarrhea, abdominal pain,
and hypotension caused by vasodHation.
28
The
use of the agonist atipamezole has been evaluated
as part of a lameness examination after light
sedation with detomidine (0.01 mg/kg). 29 Admin-
istration of atipamezole reversed most of the
sedation-related stride changes, but some differ-
ences were still evident. In general, the dose of
antagonist is determined by the agonist dose and
the specific agonist used. This relationship is a
reflection of the relative affinity the agonist and
antagonist have for the receptors. In general, 4 mg
of tolazoline is needed to adequately reverse 1 mg
of xylazine, and 10 mg of atipamezole is needed
to reverse 1 mg of detomidine.
28
.
3o
The time inter-
val since administration of the agonist should also
I
32 PRESURGICAL PREPARATION AND ASSESSMENT
be considered when determining the dose of
antagonist to administer. If in doubt, it is certainly
appropriate to titrate the antagonist dose to
produce the desired degree of reversal.
Benzodiazepines
The benzodiazepines are used primarily for their
muscle relaxant effects. In addition, they provide
some sedation, although their sedative effects
are minimal in horses. They are also used to
treat seizures. The benzodiazepines function by
enhancing the effect of y-aminobutyric acid
(GABA), an inhibitory neurotransmitter. This
results in sedation by depression of the limbic
system and in muscle relaxation by inhibition of
internuncial neurons within the spinal cord.
11
Limited data are available on the physiologic effects
of the benzodiazepines in horses, but the cardio-
vascular effects are minimal in most species.
ll

ll

n
Three benzodiazepines are currently in use in
equine anesthesia diazepam, midazolam, and
zolazepam. Zolazepam is part of a fixed drug
product, Telazol (Fort Dodge Animal Health),
which is a combination of zolazepam and tileta-
mine, a dissociative anesthetic that is discussed
further in the dissociative anesthetic section later
in this chapter. Diazepam is supplied in a propy-
lene glycol vehicle that makes intramuscular
injection painful and the rate of absorption from
the injection si te variable. Midazolam is water
soluble and well absorbed after intramuscular
injection.
32
All of the benzodiazepines appear to
undergo hepatic metabolism with the metabolites
excreted in the urine. Some of the metabol ites of
diazepam appear to have a significant pharmaco-
logic effect. 32,33 Because these drugs are rarely used
alone, the commonly used doses are included in
the later section on anesthetic combinati ons.
Guaifenesin
Guaifenesin, also known as glyceryl guaiacolate
(GG), is used for its muscle relaxant properties at
the internuncial neurons in the spinal cord. The
cardiovascular and respiratory effects of guaifen-
esin are minimal when the commonJy recom-
mended clinical doses are used. It is usually
suppli ed as a sterile powder that is dissolved to
form a 5% or 10% solution of guaifenesin. A 5%
solution is commonly dissolved in a 5% glucose
solution to minimize hemolysis after administra-
tion.
34
A 10% solution of guaifenesin in sterile
water also produces minimal hemolysis.
35
Less
concentrated solutions are less likely to cause
phlebitis or thrombus formation.
36
Perivascular
administration of guaifenesin can result in severe
tissue damage. If the solution is allowed to cool
substantially below room temperature, the guaife-
nesin will precipitate out of the sol ution. It can be
redissolved by warming the solution. Guaifenesin
undergoes hepatic metabolism and the metabo-
lites are excreted in the urine.
37
Accumulation of
metabolites, such as catechol, can lead to signs of
toxicity, including muscle stiffness, tremors, and
dyspnea. Guaifenesin is rarely used alone but is
usually combined with an injectable anesthetic
agent such as a barbiturate or a dissociative anes-
thetic such as ketamine.
OPIOIDS
Opioids are potent analgesics; unfortunately, they
often produce excitement when administered by
themselves to horses. This is especially true of the
full opioid agonists. The development of opioids
that are agonists at only some opioid receptors has
made the use of opioids in the horse easier and
more effect ive. Opioid receptors are commonly
classified as mu ( ~ ) , kappa (K), and delta (0)
receptors. Mu receptor activation is generally
associated with profound analgesia as well as with
some of the undesirable opioid effects such as
bradycardia. hypoventilation. and excitement.
Kappa receptor activation produces anal gesia that
is not as intense as that associated with mu recep-
tor act ivation but is also associated with fewer
undesirable effects. Delta receptors are primarily
thought to modulate mu receptor activity and
produce analgesia. In general, the opioids have
minimal cardiovascular and respiratory effects.
Small increases in heart rate, blood pressure, and
cardiac output were observed after full agonists
were admi nistered, probably from the excitatory
effects of these drugs in the horses studied.
38
The
nonselective full agonists such as morphine and
fentanyl have a very narrow margin between the
analgesic and the excitatory dose, especially in
pain-free animals.
39
It is important to differenti-
ate the behavioral effects of opioids in pain-free
horses, such as those often used in research
studies, and their effects in clinically painful
horses. In a study of the peri operative use of 1110r-
phine in painful horses, minimal behavioral ef-
fects were seen.
40
Kappa agonists such as butor-
phanol also produce some excitement but the
effect is somewhat less than that seen when mu
agonists such as morphine are administered.
41
,42
Butorphanol has been administered as a continu-
ous infusion to maintain analgesia at a loading
dose of 0.018 mglkg IV and then a continuous
infusion at 0.0237 mglkglhr'3 Another opioid
that has seen limited use in horses, but has many
desirable characteristks, is buprenorphine. When
combined with detomidine, buprenorphine has
provided good analgesia and sedation for stand-
ing procedures.
44
Transdermal delivery systems
have provided an additional route of admin-
istration for opioids. Fentanyl is commonly
administered in this manner (Duragesic; Janssen
Pharmaceutical Products) to a variety of species.
This delivery route has been studied in horses, and
it was determined that two 10-mg (100 ~ g l h r )
patches provided plasma levels of fentanyl that
should provide analgesia. Eight to IS hours was
required to reach peak plasma levels and patches
needed to be replaced at 48-hour intervals to
maintain the desired plasma concentrations.
45
No
significant undesirable effects were noted in this
st udy.
INJECTABLE ANESTHETICS
None of the available injectable general anesthet-
ics provide all of the actions of an ideal anesthetic.
Therefore, when used clinically they are almost
always combined with other drugs.
Ketamine
Ketamine is a dissociative anesthetic. Patients
receiving ketamine appear to be in a cataleptic
state while still maintaining many reflexes. The
higher centers, the cerebral cortex, are dissociated
from somat ic input. The site of action of keta-
mine is centrally located N-methyl-D-aspartate
(NMDA) receptors. In addition, some of the
analgesia produced by ketamine may be due to
interaction with opioid receptors.
46
Ketamine
undergoes hepatic metabolism with urinary ex-
cretion of the metabolites. Some of the metabo-
lites have pharmacologic activity.47 The analgesic
properti es of ketamine are somewhat controver-
sial; however, many stucUes show a significant
Field Anesthesia 33
analgesic effect.
48
.
s1
Some evidence exists that sub-
anesthetic doses produce minimal analgesia.
52

s4
The cardiovascular effects of ketamine must be
separated into its indirect central effect and its
direct peripheral effect. The central effect is an
overall increase in sympathetic tone resulting in
mild increases in heart rate, arterial blood pres-
sure, and cardiac output. It does, however, have a
mild direct depressant effect on myocardial con-
tractiIity.46.55 Little respiratory depression is seen
at cl ini cal doses although a slight increase in res-
piratory rate and decrease in tidal volume are
sometimes observed. Ketamine produces minimal
muscl e relaxation. Because of its poor muscle
relaxant effects and tonic-clonic limb spasms, it is
not used alone in veterinary anesthesia.
Tiletamine
Telazol is a proprietary mixture with equal con-
centrations of zolazepam, a benzodiazepam, and
tiletamine, a dissociative anesthetic. It is distrib-
uted as a dry powder that is reconstituted prior to
use. Tiletamine is somewhat more potent than
ketamine and has a slightly longer duration of
action. Its cardiovascular, respiratory, and anes-
thetic effects are similar to those of ketamine.
S6
Even though Telazol contains a tranquili zer as well
as a dissociative anesthetic, it is not commonly
used alone in equine anesthesia.
Thiopental
Thiopental is an ultra-short-acting thiobarbitu-
rate. It produces rapid unconsciousness after
intravenous injection. Recovery is a result of
redistribution of the drug from the brain to other
ti ssues in the body. Initially, the drug is redistrib-
uted to muscle and other nonfatty tissues with
moderate blood flow. The ultimate site of redis-
tribution is poorly perfused adipose tissue but, at
the time of recovery from anesthesia, the major-
ity of the drug resides in moderately perfused
tissues. Ultimately, it undergoes hepatic metabo-
lism. If thiopental is administered for prolonged
periods and then discontinued, the primary
factors associated with the termination of anes-
thesia are both redistribution into fat and hepatic
metabolism. These are slower than redistribution
into moderately perfused tissues. The site of
action for barbiturates has been shown to be
on the GABA receptor.
46
Barbiturates enhance
34 PRESURGICAL PREPARATION AND ASSESSMENT
the inhibitory effect of this neurotransmitter by
decreasing the rate of its dissociation from its
receptor and directly increasing the duration of
GABA-associated chloride channel opening. It has
no analgesic effects at subanesthetic doses. Its car-
diovascular effects are a mild peripheral vasodila-
tion (primarily venous) and a decrease in cardiac
contractility.46 A concurrent increase in heart rate
often occurs. Although thiopental can be used
alone to produce equine anesthesia, the quality of
recovery is poor.57 For this reason, it is commonly
used with other agents.
Propofol
Propofol is a phenolic compound that is chemi-
cally unrelated to thiopental , but the clinical and
physiologic effects are very similar. One signifi-
cant difference is the rapid hepatic metabolism
of propofol. 58 This combination of redistribution
and rapid metabolism results in rapid recovery
even after long periods of administration. Cur-
rently its cost precludes frequent use as an equine
anesthetic agent, although use may increase in the
future. It is used after premedication with a tran-
quilizer.
STANDING SEDATION AND RESTRAINT
COMBINATIONS
Many minor surgical and diagnostic procedures
are done without general anesthesia. In some
cases, a tranquilizer or alone is ade-
quate. In most cases, however, the combination of
a tranquilizer or cx2-agonist with an opioid pro-
vides superior sedation, analgesia, and restraint.
Many combinations are used, and the doses
withi n t11ese combinations are variable. The
attending veterinarian should use his or her judg-
ment as to the precise dose to use. One rule to
remember is that you can always give more drug
if needed but it is difficult to remove a drug from
the animal once it has been administered. Table
5- 1 lists the commonly used drugs and their
doses, as welJ as some specific comments.
It is important to remember that no matter
which drugs are selected to sedate a horse,
several other factors are important for successful
sedation.
I. The horse should be caLn when the drugs are
ad min istered.
2. After the drugs are administered, they should
be allowed to have an effect. It is important to
wait 5 to 15 minutes after IV administration
and 15 to 30 minutes after 1M admi nistration
for the drugs to have their full effect.
3. If a tranquilizer or <Xragent alone is not effec-
tive, it is usually best to add an opioid rather
than to give more of the initial drug.
For long procedures, it is sometimes easier to
administer a continuous infusion of detomidine
rather than to administer additional doses during
the procedure. This is especially useful during
Japaroscopic procedures. After initial sedation
with detomidine and butorphanol or detomidine
and buprenorphine, an infusion of detomidine is
administered at the rate ofO.IIlg/kg/min (0.0001
mg/kg/min) ..... A 450-kg horse would therefore
require 27 mg of detomidine/hr. Alternatively, an
initial detomidine infusion rate of 0.6 J.lglkglmin
can be used. The detomidine infusion rate is then
decreased by half every 15 minutes.
59
Xylazine can
also be given by infusion at the rate of 0.55
mg/kg/hr.60 Tn addition to the infusion, local
anesthetics should be used at the surgery site. Con-
stant infusions are often superior to intermittent
admi nistration in that the quality of sedat ion is
more uniform and there is usually less ataxia since
the peaks in plasma drug levels are eliminated.
INJECTABLE GENERAL ANESTHESIA
There is no ideal general anesthetic; therefore,
combinations of drugs are used to produce
general anesthesia. When combining drugs, it is
important to select drugs that have complemen-
tary effects. In addition, the duration of action of
the drugs must be considered as welJ as their
undesirable side effects. When the combination of
xylazi ne and ketamine is analyzed, it is evident
that ketamine provides the anesthesia as well
as some analgesia but is lacking in muscle relax-
ation and would cause rough inductions if used
alone. The addition of xylazine adds muscle relax-
ation as well as more analgesia and sedati on to
smooth the induction. Thei r durations of action
are complementary as well. Xylazme produces
approximately 30 minutes of sedation so the
recovery from ketami ne is generally smooth but
the sedation after anesthesia is not prolonged. The
addition of butorphanol or a benzodiazepine adds
more analgesia-sedation or muscle relaxation-
Field Anesthesia 35

TABLE 5-1
Drugs Commonly Used for Standing Sedation in Horses
DRUG(S)
Single Drugs
Acepromazine
Xylaline
Detomidine
Romifidine
DOSE ( IN MG/KG) (ALL CAN
BE GIVEN IV OR 1M)
0.04-0.08
0.3-1
0.Ql-0.04
0.04-0.12
Drug Combinations'"
Acepromaline 0.05
Morphine 0.1-0.2
Acepromazine 0.05
Butorphanol 0.025-0.05
Xylaline 0.25-1
Butorphanol 0.01-0.05
Detomidine 0005-0.Q2
Butorphanol 0.01-0.05
Detomidine 0.01
Buprenorphine 0.006
Romifidine 0.04-0.08
Butorphanol 0.01-0.05
COMMENTS
1. May cause penile paralysis
2. Variable time to onset
1. Higher doses may cause ataxia
2. Sedation lasts longer than analgesia
3. Approximately 30-minute duration
1. Higher doses may cause ataxia
2. 60- to 90-minute duration
1. May cause less ataxia than xylazine or detomidine
2. 60- to 90-minute duration
1. May cause penile paralysis
2. Variable time to onset
1. May cause penile paralysis
2. Variable time to onset
"Note: Use of the higher doses of both drugs often results in ataxia.
sedation, respectively. Tn addition, if a local an-
esthetic can be used to desensitize the surgical
site, the general anesthetic requirements are often
decreased.
a,-Agonist-Dissociative Combinations
Xylazine and ketamine are commonly used
together for short general anesthesia. Xylazine
(l.l mg/kg IV) is administered, and then after the
horse is sedate (usually about 5 minutes) keta-
mine is admi nistered (2.2 to 2.75 mg/kg IV).6l·'"
This will usually provide approximately I 0 minutes
of light general anesthesia. Mules and donkeys do
not respond adequately to this combination and
may not even become recumbent if the lower ket-
amine dose is used."·66 Butorphanol (0.02 mg/kg)
can be administered with xylazine to enhance
analgesia and sedation, and will slightly prolong
the anesthesia. A benzodiazepine can also be
administered IV prior to ketamine to enhance
muscle relaxation. Diazepam or midazolam can
be used at the dose of 0.06 mg/kg. In draft horses,
the doses of the drugs are decreased by 10% to
20%? If the duration of anesthesia needs to be
extended) one half of the original dose of xylazine
and ketamine can be administered together IV.
Detomidine or romifidine can also be used as a
preanesthetic prior to ketamine anesthesia.
68
.
70
The doses used are detomidine (0.02 mg/kg IV),
or romifidine (0.08 to 0.12 mg/kg IV), followed by
ketamine (2 to 2.2 mg/kg IV). Because of the
longer duration of action of these drugs, if addi-
tional time is needed, a half dose of ketamine
only should be administered. Butorphanol or a
benzodiazepine could also be used with these
combinations.
)
,
36 PRESURGICAL PREPARATION AND ASSESSMENT
a , -Agonists can be combined with Telazol.
The a,-agonist should be administered first and
Telazol is administered only after the horse is
sedate. Xylazine (1.1 mg/kg IV) can be combined
with Telazol (1.65 mg/kg IV) to produce general
anesthesia of approximately 20 to 30 minutes.
62
,71
Alternatively, detomidine can be used. Detomi-
dine at doses of 0.02 mg/kg or 0.04 mg/kg IV
followed by Telazol (2 mg/kg IV) produced ap-
proximately 25 and 30 minutes of anesthesia,
respectively." Xylazine (0.44 mg/kg IV) can be
followed by a mixture ofTelazol dissolved in deto-
midine and ketamine to produce recumbency of
approximately 40 minutes" A 500-mg bottle of
Telazol is dissolved in 4 mL of 100 mg/mL keta-
mine and 1 mL of 10 mg/mL detomidine. Three
milliliters of the mixture per 450 kg of body
weight is the recommended dose.
a,-Agonist-Dissociative-Guaifenesin
Combinations
The combination of guaifenesin, ketamine, and
xylazine (GKX), or "t riple drip:' has been used for
many years in equine anesthesia. This combina-
tion was first described as an induction comb ina-
tion
73
and later as a maintenance anesthetic. ?4
When used as a maintenance anesthetic, 0.5
mg/mL of xylazine and 1 or 2 mg/mL of ketamine
are added to a 5% solution of. guaifenesin in
dextrose. One liter of 5% guaifenesin would have
5 mL of 100 mg/mL xylazine and 10 or 20 mL of
100 mg/mL ketamine added. It should always be
administered through a catheter because extravas-
cular guaifenesin can cause severe tissue damage.
In addition, the vein used for administering the
anesthetic should not be occluded so blood can
flow freely to allow distribution of the drug and
prevent thrombophl ebitis. Triple drip can be used
as an induction agent in horses sedated with
xylaxine.
74
More commonly, however, it is used as
a maintenance anesthetic following induction
with xylazine and ketamine as described earlier in
this section. It is infused at a rate that produces
the desired level of anesthesia, but the mainte-
nance infusion rate is usually 2.2 to 2.75 mLlkg/hr
(approximately 1 mLllb/hr)."'·"·" The higher con-
centration of ketamine allows slightly slower
infusion rates for longer procedures. This is an
appropriate anesthetic technique for up to 90
minutes in healthy horses. If the recovery is pro-
longed, tolazoline can be used to antagonize the
sedative effects of xylazine. 75 If the recovery is pro-
longed and the horse is unable to get up but does
not appear sedate, fluids should be administered
in an attempt to improve excretion of the drugs
and their metabolites.
Detomidine can be used with guaifenesin and
ketamine after induction with detomidine and
ketamine.
76
,77 The preparation used contains ket-
amine (2 mg/mL) and detomidine (0.02 mg/mL)
in 10% guaifenesin administered at approxi-
mately 1 mLlkg/hr. If 5% guaifenesin is used, the
ketarnine and detomidine concentrations should
each be reduced by one half (l mg/mL and 0.01
mg/mL, respectively). The infusion rate for the
less concentrated mixture is 2 mLlkg/hr.
Romifidine with guaifenesin and ketamine has
been used as a maintenance anesthetic following
induction with romifidine and ketamine.
78
The
induction dose is 0.1 mg/kg of romifidine IV fol-
lowed by 2.2 mg/kg of ketamine IV. The mainte-
nance infusion consists of an initial bolus of 50
mg/kg of guaifenesi n followed by IV infusion of
romifidine (0.0825 mg/kg/hr), ketamine (6.6 mg/
kg/hr ), and guaifenesin (l00 mg/kg/hr). After 30
minutes, the guaifenesin infusion rate is decreased
50%.
Thiopental-Guaifenesin Combinations
The use of guaifenesin with thiopental allows the
use of a lower dose of thiopental and usually pro-
duces better recovery than the use of thiopental
alone. Induction is usually preceded by the
administration of an such as xylazine
or detomidine. Both thiopental and guaifenes in
will cause tissue damage. Therefore, it is essential
thi s mixture be administered via an indwelling IV
catheter located in a vessel with good blood flow.
A 14-gauge or larger catheter is recommended to
allow the rapid administration of the thiopental-
guaifenesin mixture. To administer this mixture,
2g of thiopental is added to 1 L of 5% guaifen-
esin.
64
This mixture is then administered IV as
rapidly as possible until the horse is recumbent.
To speed induction, 1 additional gram of thiopen-
tal can be administered IV as the horse begins to
relax. If drug administration is stopped after the
horse is recumbent, the duration of anesthesia
will be 10 to 20 minutes. Additional anesthesia
time can be produced by continuing the infusion
to effect. The typical infusion rate will be approx-
imately 1.5 mLlkg/min." If more than 1 L of the
mixture is to be used, the second liter should only
contain 1 g of thiopental (l mg/mL). Total anes-
thesia time with this mixture should be limited to
30 minutes or less. After short anesthetic periods,
recovery from this mixture is usually quiet and
uneventful.
MONITORING HORSES WHILE UNDER
INJECTABLE GENERAL ANESTHESIA
In general, sophisticated monitoring equipment is
not used during field anesthesia. Efforts should be
made to ensure adequate circulatory and respira-
tory function.
79
This can be as simple as palpating
the pulse, observing chest wall movement, and
observing mucous membrane color. Normal
horses will have a pulse rate between 25 and 50
beats per minute and a respiratory rate of 6 to 12
breaths per minute.
Anesthetic depth is determined by assessing
the palpebral and corneal reflexes and watching
for the presence of nystagmus. Horses under
injectable general anesthesia will appear to be at a
lighter plane of anesthesia than those under
inhalation anesthesia. The corneal and palpebral
reflexes should be present. Also, the character of
breathing will often change as the depth of anes-
thesia decreases. Commonly, deep "sighs" and
intermittent breath holding will occur at a light
level of anesthesia. Usually, if nystagmus is
present, the depth of anesthesia is inadequate
unless the procedure is almost complete. If anes-
thesia is being maintained by an infusion, the rate
of the infusion can be increased if deeper anes-
thesia is needed. When the horse is very light, a
small bolus (0. 1 to 0.5 mLlkg) of the infusion can
be rapidly administered. During anesthesia with
an (X2-agonist-ci issociative combination, an addi-
tional dose of (X2-agonist -dissociative or dissocia-
tive alone can be administered. The usual dose is
half of the induction dose.
SUPPORTIVE CARE FOR HORSES WHILE
UNDER INJECTABLE GENERAL ANESTHESIA
Because patients undergoing surgical procedures
in the field are usually relatively healthy and
support facilities are limited, intensive supportive
care is usually not administered. An ocular lubri-
cant or ocular antibiotic ointment (without
steroids) should be placed in both eyes to prevent
corneal drying and there should be nothing near
the eye that could rub on the cornea. Covering the
Field Anesthesia 37
eyes with a towel will protect the eyes somewhat
and eliminate visual stimulation of the patient.
The surface the horse is placed on should be
smooth and can be padded if padding is availabl e.
It is important to minimize the time spent
positioning the patient for short procedures
since limiting anesthesia time usually results in
better recovery. Proper positioning of the patient
will limit the potential for myopathi es and
neuropathies.
When in lateral recumbency, the lower front
leg should be pulled as far rostral as possible to
eliminate pressure on the brachial plexus and
associated blood vessels. The halter should also be
removed to prevent facial nerve damage on the
down side. Positioning of the lower hind limb is
not as critical , but it is commonly puUed forward
as well to decrease pressure on the medial mus-
culature. Both the front and hind upper limbs
should be supported in a position parallel with
the ground. Horses positioned in dorsal recum-
bency should have their head and neck positioned
in a natural position to ensure a patent airway.
The legs should be allowed to assume a natural ,
semi -fl exed position. Unless necessary for the pro-
cedure, the hind limbs should not be kept in an
extended position.
Fluid therapy is not commonly administered
to equine patients undergoing short field proce-
dures but is appropriate if indicated. Ally balanced
crystalloid solution such as 0.9% saline or lactated
Ringer's solution can be administered at a rate
of 5 mL/kglhr to maintain vascular volume and
promote tissue perfusion. Any significant blood
loss can be treated by administering 3 mL of crys-
talloid fluid for each milliliter of estimated blood
loss. In healthy animals, this is usually adequate
therapy for blood losses of up to 10% of the
blood volume. Ideally any preexisting dehydration
should be corrected prior to anesthesia. If this is
not possible, the fluid deficit can be replaced while
under anesthesia. The fluid deficit is commonly
estimated by multiplying the perceived amount of
dehydration (in percent) and the animal's weight
(in kilograms) to determine the deficit (in liters).
A 450-kg animal that is 5% dehydrated would
need 22.5 L to replace its deficit (0 .. 05 x 450 kg =
22.5 L).
Under field conditions, intubation is not essen-
tial for the equine patient. It does protect the
airway from occlusion and allow mechanical ven-
tilation if needed. It would certainly be beneficial
to at least have an endotracheal tube available.
I
I
, I
38 PRESURGICAL PREPARATION AND ASSESSMENT
Oxygen supplementation can easily be done in
the field using a portable E oxygen tank, regula-
tor, and flowmeter. A full E tank will hold approx-
imately 650 L of oxygen. The oxygen can be
administered via a nasal insufflation line at a flow
rate of 5 to 10LImin. Oxygen can also be supple-
mented using an E tank and a demand valve. The
demand valve is attached to an endotracheal tube
and can be used in two ways. If the horse is breath-
ing spontaneously, the demand valve is auto-
maticall y triggered during inspiration and the
inspired air is supplemented with oxygen. Alter-
natively, if the horse is not breathing well sponta-
neously, the demand valve can be manually
triggered to start the oxygen flow. Once an ade-
quate volume has been delivered, which is deter-
mined by watching the chest excursion, the trigger
is released and the horse passively exhales. The
demand valve must have a high maxi mum flow
and have an adaptor to allow it to be attached to
an equine endotracheal tube. Some demand
valves designed for human use do not have an
adequate peak flow rate. The flow rate should be
in excess of 150 Llmin. At least one demand valve
has both the required flow rate and necessary
adaptors for equine use (Equine Demand Valve;
JD Medical, Phoenix Ariz.).
INDUCTION AND RECOVERY FOR
INJECTABLE FIELD ANESTHESIA
Induction
Before administering any anesthetic drugs, a
quick physical examination should be performed.
Any obvious health problems or injuries should
be brought to the attention of the owner or agent
and their effect on anesthesia discussed. The
risk of anesthetic and surgical complications
should be discussed and made clear to the owner
as well. In a comprehensive survey of almost
42,000 equine anesthetic cases, the overall death
rate (excl uding colic surgeries) was 2.4%.80 This
included horses that died or were euthanized. If
only the horses undergoing injectable anesthesia
were evaluated, the death rate dropped to 0.3%.
Although this may seem to be a big positive for
injectable anesthesia, one must realize these were
generally healthy horses undergoing short proce-
dures with anticipated high success rates.
A level area free of obstacles should be selected
for the procedure. An open grass-covered area is
ideal. The horse should be fitted with the correct
size nylon halter and a sturdy lead rope should be
available. If an az-agonist-dissociative combina-
tion is used, the horse can easily be induced by one
person. After administration of the dissociative
agent, the handler maintains control of the head.
Generally, the horse will lean back and the handler
may have to hold the head down to keep the horse
from going over backward. Alternatively, the
handler can stand at the shoulder of the horse and
move the horse in a circle around him. One hand
should be on the horse's shoulder and the other
holding the lead rope close to the horse's head. As
the dissociative agent takes effect, the rear end of
the horse will usually swing away from the
handler. He or she should be on the side of the
patient that is to be up once the horse is anes-
thetized if it is to be positioned in lateral recum-
bency. As the horse goes down, the handler can
step toward the head and control its fall by
holding onto the lead rope. If a guaifenesin
mixture is used for induction, it is difficult to hold
the horse and the drug container. A second person
is needed to manage the drug bottle as the horse
is going down. If several assistants are available,
an alternative method can be used. One person
should be at the head holding the lead rope and a
second person should hold the tail. If the horse is
nervous, the person holding the tail should wait
until the horse is almost ready to go down before
grabbing it, recognizing that the horse may still
kick. Two additional assistants are at the horse's
shoulders. As the horse begins to relax, the assis-
tants on the head and tail pull in opposite direc-
tions and down. The assistants on the shoulders
attempt to keep the horse from falling sideways.
This should allow the horse to go down into a
sternal position, and it can then be rolled onto
either side.
Recovery
Recovery after short injectable anesthesia is usu-
ally relatively smooth. If the horse was nervous
and excited during induction, the recovery may be
less than optimal. IdeaLly during recovery, the
horse will move into a sternal position, wait a few
minutes, and then stand uneventfully. Covering
the horse's eyes with a towel often will help keep
the horse from trying to get up before it is ready.
In addition, it is important to keep the surround-
ings as quiet as possible during recovery. A sudden
loud noise may arouse the horse before it is able
to stand. If the horse is trying to get up but is
unable to remain standing, a small dose of
xylazine (0.2 to 0.4 mglkg IV) may calm the ani-
mal and provide a quieter recovery. Some practi-
tioners advocate holding the horse down until it is
able to get up, and this may be of benefit. It is best
done by kneeling on the horse's neck at the dorsal
aspect and holding the head to keep the horse from
swinging it up. Once the horse's attempts to get up
have become more vigorous, the head can be
released and the horse allowed to stand. After it is
standing, it is important to try and steady the horse
to keep it from stumbling around and injuring
itself. If it is standing but very Wlstable, a second
person holding the tail may be of benefit.
EPIDURAL ANESTHESIA AND ANALGESIA
Epidural anesthesia is an excell ent method of pro-
viding desensitization to the tail and perineal
region of the standing horse. Local anesthetics
traditionally have been used, but more recently
other drugs such as opioids and ur agonists have
been used separately or with local anesthetics to
improve the desensitization provided by local an-
esthetics or provide long-term pain control.
Anatomy
The spinal cord and meninges usually end in the
sacrum. Epidural injections are usually performed
at the sacrococcygeal or first intercoccygeal joint.
Either location is acceptable, and the injection site
can generally be determined by moving the tail up
and down and palpating for the most proximal
movable joint. The depth of the soft tissue over
the first intercoccygeal space is 3.5 to 8 cm.
Bl
The
nerves desensitized by the injection of a local
anesthetic in this area include the caudal and 52
to S5 sacral spinal nerves. These provide nerve
fibers making up the pudendal, middle rectal , and
cau-dal rectal nerves. The S2 nerve also con-
tributes motor innervation to most of the hind
limb, and blockade of this nerve may cause hind
limb ataxia. For this reason, it is important to limit
the vol ume oflocal anesthetic injected because the
volume injected will determine the rostral extent
of the blockade.
Technique
After the hair is clipped, suitably cleaned, and dis-
infected, the sacrococcygeal or first intercoccygeal
Field Anesthesia 39
joint is located by moving the tail up and down
and palpating for flexion. Once the joint has been
located, 2 mL of a local anesthetic such as 2% li-
docaine can be injected into the superficial tissues
over the joint. An 18- or 20-gauge 2.5- inch (6.4-
em) spinal needle is used to access the epidural
space. In large or heavily muscled horses, a 3.5-
inch (8.9-cm) needle may be needed, and in many
horses, a standard 1.5-inch (3.75-cm) hypodermic
needle will be adequate (Figure 5-1). The needle
is introduced perpendicular to the skin directly
over the center of the space on the midline. As the
needle is advanced and the epidural space is
entered, a loss of resistance will be felt. If the tip
of the needle strikes the floor of the canal, it
should be withdrawn slightly. There should be no
resistance to the injection of fluid or air at this
point. An alternative method of determining
when the epidural space is entered is called the
"hanging drop" technique. After the needle has
been advanced through the skin and into the soft
tissue overlying the intervertebral foramen, the
stylet is removed (if present) and a small amount
of sali ne or local anesthetic is instilled into the
hub of the needle. As the tip of the needle pene-
trates the ligamentum flavum. the fluid runs
down the needle into the epidural space and the
fluid in the hub disappears.
If repeated epidural injections are to be made,
an epidural catheter can be placed to make this
more convenient. Several commercial epidural
catheter kits that are suitable for equi ne use are
available. The needle insertion technique is the
same as described above but a different needle is
Figure 5-1 A sagittal section through the sacrococ-
cygeal region of an equine cadaver showing the needle
placement for a caudal epidural injection. The upright
needle is 2.5 inches long and the more caudally inserted
needle is 3.5 inches in length. The horse weighed
approximately 500 kg when alive.
I
40 PRESURGICAL PREPARATION AND ASSESSMENT
used. A Touhy needle with a slightly curved tip
allows easier placement of the catheter. After
the needle is in place, the catheter is advanced
through the needle and cranially into the epidural
space. The opening on the needle should be ori-
ented cranially. and this can be checked while the
needle is in the animal by observing the notch on
the hub of the needle. This notch will be over
the opening at the distal end of the needle. The
catheter should be advanced 5 to 10 cm cranially.
If local anesthetics are to be injected, this distance
should be shorter, only 2 to 4 cm, to prevent an
impairment of motor innervation to the hind
limbs. Once the catheter is in place, the needle is
withdrawn and the injection hub is attached to
the catheter per the manufacturer's instructions.
The catheter is then secured to the horse, and the
injection hub and site of entry of the catheter
through the skin are covered. It is important to
secure the catheter in such a way that prevents
kinking or accidental removal. The catheter
should be flushed daily if no therapeutic injec-
tions are performed.
Epidural Drugs
Classically, local anesthetics have been used for
epidural anesthesia. They provide complete de-
sensitization and can affect motor innervation
as well. The dose of local anesthetic is based to a
large extent on volume. The greater the volume of
drug injected into the epidural space. the farther
rostral the drug will have an effect. More recently,
uragonists and opioids have been used alone or
in conj unction with local anesthetics to prolong
anesthetic effects and provide long-term analgesia
without the loss of motor function. Additionally.
the analgesic effects of opioids extend farther ros-
trally than the sacrococcygeal region and can
provide analgesia for hind limb and even abdom-
inal pain.
82

83
A volume of 5 to 7 mL of local anes-
thetic is commonly used for a 4S0-kg horse. The
local anesthetics most commonly used in the
United States are 2% lidocaine, 2% mepivacaine,
and 0.5% bupivacaine. The duration of effect can
be variable. but lidocaine will typically provide 30
to 60 minutes of desensiti zation. Mepivacaine can
provide 90 to 120 minutes of desensitization,
and bupivacaine can produce up to 4 hours of
desensitization. The addition of epinephrine
(\ :100.000) will prolong the duration. The onset
of blockade after local anesthetic inj ection may
take up to 20 minutes. The opioid most com-
monly used for epidural injection is morphine;
the dose usually used is 0.1 mglkg." This dose can
provide analgesia without any motor effects for up
to 18 hours. Commercial preservative-free mor-
phine preparations are available that should be
used if possibl e. especially if multiple injections
are to be performed. Unfortunately. the currently
available preservative-free preparations are so
dilute, the volume required is too large to be prac-
tical. When the more concentrated morphine
preparations are used, they should be diluted to a
total volume of 10 mL with 0.9% sterile saline.
Xylazine can be administered epidurally by itself
or with other drugs. It appears to have some weak
local anesthetic effects that are not reversed by Cl
2
-
antagonists as well as analgesic effects produced
by adrenergic receptors in the spinal cord. The
usual dose is 0.17 mglkg" The author often adds
I mL of 100 mglmL xylazine to 4 mL of 2% lido-
caine to be used for caudal epidural injection in a
4S0-kg horse.
REFERENCES
I. Tobin T, Ballard S: Pharmacological review-the
phenothiazine tranquilizers, J Equine Med Surg
3:460. 1979.
2. Walker M, Geiser 0: Effects of acetylpromazine on
the hemodynamics of the equine metatarsal artery,
as determined by two-dimensional real-time and
pulsed Doppler ultrasonography, Am J Vet Res
47:1075.1986.
3. Muir WW, Werner LL, Hamli n RL: Effects of
xylazine and acetyl promazine upon induced ven-
tricular fibrillation in dogs anesthetized with thi-
amylal and halothane. Alii J Vet Res 36: 1299. 1975.
4. Maze M. Hayward E. Gaba DM: Alpha I-ad-
renergic blockade raises epinephrine-arrhythmia
threshold in halothane-anesthetized dogs in a
dose-dependent fashion, Anesthesiology 63:611,
2004.
5. Geiser DR: Chemical restraint and analgesia in the
horse, Vet Clin N Am Equine Pmct 6:495, 1990.
6. Marroum Pl. Webb AI. Aeschbacher G, et 31: Phar-
macokinetics and pharmacodynamics of acepro-
mazine in horses, Am J Vet Res 55:1428,1994.
7. Parry BW. Anderson GA, Gay CC: Hypotension in
the horse induced by acepromazine m31eate, AI/st
Vet J 59:148.1982.
8. Jones RS: Penile paralysis in stallions. J Am Vet Med
Assoc 149:124. 1966.
9. Lucke IN, Sansom J: Penile erection in the horse
after acepromazine, Vet Rec 104:2 1, 1979.
10. Ballard S, Shults T. Kownacki AA, et al: The phar-
macokinetics. pharmacological responses and
behavioral effects of acepromazine in the horse,
J Vet Phannacol Tiler 5:21, 1982.
11. Principles of sedation, analgesia and premedica-
tion. In Hall LW, Clarke KW. Tr im eM, editors:
Veterinary Ql1aesthesia, ed 10, St Louis, 200 I, WB
Saunders.
12. Gillespie JR, Schalm CW, Tyler WS: Hematologic
response of the horse to general anesthesia: a
review and new data. Proceedings of the First
International Symposium on Equine Hematology
Michigan State University, East Lans ing. Mich.,
490, 1975.
13. Bloor BC, Schmeling WT: Cardiovascular effects of
alpha2-adrenoreceptors. Allaest" Pharmacal Rev
1:246, 1993.
14. Sarazan RD, Starke WA. Krause GF. et al: Cardio-
vascular effects of detomidine, a new alpha 2-
adrenoceptor agonist, in the conscious pony, ] Vet
Pharmacol Ther 12:378, 1989.
15. Yamashita K, Tsubakishita S, Futaok S, et al: Car-
diovascular effects of medetomidine, detomidine
and xylazine in horses,] Vet Med Sci 62:1025, 2000.
16. Wagner AE, Muir WW III , Hinchcliff K\V: Cardio-
vascular effects of xylazine and detomidine in
horses, Am ] Vet Res 52:651, 1991.
17. Nunez E, Steffey EP, Ocampo L, et al: Effects of
alpha2-adrenergic receptor agonists on urine pro-
duction in horses deprived of food and water, Am
J Vet Res 65: 1342, 2004.
18. Thurmon ]C, Steffey EP, Zink1 ]G, et al: Xylazine
causes transient dose-related hyperglycemia and
increased urine volumes in mares, Am ] Vet Res
45:224, 1984.
19. Schatzmann U, Jossfck H, Stauffer IL, et al: Effects
of alpha 2-agonists on intrauterine pressure and
sedation in horses: comparison between detomi-
dine, romifi dine and xylazine. Zentralbl Veter;l1-
armed A 41:523, 1994.
20. Spyridaki MH, Lyris E, Georgoulakis I, et al: Deter-
mination of xylazine and its metabolites by GC-MS
in equine urine for dopi ng analysis, ] Pharm
Biollled A,wl 35: 107, 2004.
21. Salonen }S, Suoli nna EM: Metabolism of detomi-
dine in the rat. I. Compar ison of 3H-labell ed
metabolites for med in vitro and in vivo, Eur ] Drug
Metab Pharmacokiflet 13: 53, 1988.
22. Salonen JS, Vaha-Vahe T, Vainio 0, et al: Single-
dose pharmacokinetics of detomidine in the horse
and cow,] Vet PllQrmacol Ther 12:65, 1989.
23. Mudib AE, Chui YC, Young LM, et al: Characteri-
zation of metabolites of xylazi ne produced in vivo
and in vitro by LC/MS/MS and by GC/MS, Drug
Metab Dispos 20:840, 1992.
24. Freeman SL, Bowen 1M, Bettschar t-Wolfensberger
R, et al: Cardiovascular effects of romifidine in the
standing horse, Res Vet Sci 72: 123, 2002.
Field Anesthesia 41
25. England GC, Clarke K\V, Goossens L: A comparison
of the sedative effects of three alpha 2-adrenoceptor
agonists (romifidine, detomidine and xylazine) in
the horse,] Vet PllQrmacol Ther 15:194, 1992.
26. Hamm D, Turchi P, }ochle W: Sedative and an-
algesic effects of detomidine and romifidine in
horses, Vet Rec 136:324, 1995.
27. Hobo 5, Aida H, Yoshida K: Assessment of the seda-
tive effect of medetomidine and determination of
its optimal dose in thoroughbred horses,] Vet Med
Sci 57:507, 1995.
28. Tranquilli WJ, Maze M: Clinical pharmacology an d
use of alpha2-adrenergic agonists in veterinary
anaesthesia, Allaesth Pharmacol Rei' 1:297, 1993.
29. Buchner HH, Kubber P, Zohmann E, et aJ: Sedation
and antisedation as tools in equine lameness exam-
ination, Equine Vet] SuppI30:227, 1999.
30. Kollias-Baker CA, Court MH, Williams LL: Influ-
ence of yohimbine and tolazoline on the cardiovas-
cular, respiratory, and sedative effects of xylazine in
the horse,] Vet Pharmacol Titer 16:350, 1993.
31. Corn ick-Seahorn JL, Seahorn TL: Cardiopul-
monary and behavioral effects of midazolam Hel
and reversal with flumazenil in pony foal s,
Proceedings of the 22nd Annual Meeting of the
American College of Veterinary Anesthesiologists,
Phoenix, Ariz., 17,2004.
32. Stoelting RK: Benzodiazepines. In Stoelting RK,
editor: Pharmacology and physiology i/1 anesthetic
practice, ed 3, Ph iladelphia, 1999, Lippincott Raven.
33. Marland A, Sarkar P, Leavitt R: The uri nary elimi-
nation profiles of diazepam and its metabolites,
nordiazepam, temazepam, and oxazepam, in the
equine after a 10-mg intramuscular dose, ] Anal
ToxicoI23:29, 1999.
34. Wall R, Muir WW III: Hemolytic potential of
guaifenesin in cattle. Comell Vet 80:209, 1990.
35. Grandy }L, McDonell WN: Evaluation of concen-
trated solutions of guaifenesin for equine a n e s t h e ~
sia,] Am Vet Med Assoc 176:619, 1980.
36. Herschl MA, Tr im CM, Mahaffey EA: Effects of 5%
and 10% guaifenesin infusion on equine vascular
endothelium, Vet SlIrg 21 :494, 1992.
37. Davis LE, WolffWA: Pharmacokinetics and metab-
olism of glyceryl guaiacolate in ponies, Alii ] Vet Res
31:469, 1970.
38. Muir WW, Skarda RT, Sheehan WC: Cardiopul-
monary effects of narcotic agonists and a partial
agonist in horses, Am / Vet Res 39: 1632, 1978.
39. Amadon RS, Craig AH: The actions of morphine
on the horse. Preliminary studies: diacetyl mor-
phine (heroin), dihydrodesoxymorphine-D (deso-
morphine) and dihydroterocodine,] Am Vet Med
Assoc91:674,1937.
40. Mircica E, Clutton RE, Kyles KW, et a1: Problems
associated with perioperative morphine in horses:
a retrospective case analysis, Vet AnaestIT Allalg
30: 147,2003.
1
II
42 PRESURGICAL PREPARATION AND ASSESSMENT
41. Kamerling $, Weckman T, Donahoe J. et al: Dose
related effects of the kappa agonist U-50, 488H on
behaviour, nociception and autonomic response in
the horse, Eqlline Vet J 20: 114, 1988.
42. Nolan AM, Besley W, Reid ]. et al: The effects of
butorphanol on locomotor activity in ponies: a
preli minary study, J Vet Pllarmacol Ther 17:323,
1994.
43. Sellon DC, Monroe VL. Roberts Me, et al: Phar-
macokinetics and adverse effects of butorphanol
administered by single intravenous injection or
continuous intravenous infusion in horses, Am J
Vet Res 62: 183, 200 I.
44. van Dijk P, Lankveld DP, Rijkenhuizen AB, et a1:
Hormonal, metabolic and physiological effects
of laparoscopic surger y using a detomidine-
buprenorphine combination in standing horses,
Vet Allaestll Allnlg 30:72, 2003.
45. Maxwell LK, Thomasy SM, 510vis N, et al: Phar-
macokinetics of fentanyl followi ng intravenous and
transdermal administration in horses, Equine Vet'
35:484, 2003.
46. Reves ]G, Glass PSA, Lubarsky DA, et al: Intra-
venous nonopioid anesthetics. In Miller RD,
editor: Miller's anesthesia, ed 6, Philadel phia, 2005,
Churchill Livingstone.
47. Chang T, Glazko AJ: Biotransformati on and dispo-
sition of ketamine, i nt Anesthesiol eli" 12:157.
1974.
48. Rogers R, Wise RG, Pai nter OJ, et al: An investiga-
tion to dissociate the analgesic and anesthetic
properties of ketamine using functional magne-
tic resonance imaging, Allest/lesiology 100:292,
2004.
49. Kapfer S, Alfonsi p, Guignard B. et al: Nefopam and
ketamine comparably enhance postoperative anal-
gesia. Anesth Allnlg toO: 169, 2005.
50. Edrich T, Friedrich AD, Eltzschig HK, et al: Keta-
mine for long-term sedat ion and analges ia of a
burn patient, All estlt Analg 99:893, 2004.
51. Ozyalcin NS, Yuce! A, Camlica H, et al: Effect of
pre-emptive ketamine on sensory changes and
postoperative pain after thoracotomy: comparison
of epidural and intramuscular routes, Br , Annesth

93:356, 2004.
52. Katz J, Schmid R, Snijde!aar OG, et al: Pre-emptive
analgesia using intravenous fenta nyl plus low-dose
ketamine for radical prostatectomy under general
anesthesia does not produce short-ter m or long-
term reduct ions in pain or analgesic use, Pain
110: 707,2004.
53. Van Elst raete AC, Lebrun T, Sandefo I, et al: Keta-
mine does not decrease postoperative pain after
remifentanil-based anaesthesia for tonsillectomy in
adults, Acta AI/aesthesiol Scnlld 48: 756, 2004.
54. Hocking G, Cousins MJ: Ketamine in chronic pain
management: an evidence-based review, Allesth
AI/alg 97: 1730, 2003.
55. General pharmacology of the injectable agents used
in anaesthesia. In Hall LW, Clarke KW, Trim CM,
editors: Veterinary anaesthesia, ed to, St Louis,
2001, WS Saunders.
56. Wilson RP, Zagon IS, Larach DR, et al: Cardiovas-
cular and respi ratory effects of tiletaminezola-
zepam, Pharmacol Biochem Belwv 44: I , 1993.
57. Taylor PM: The stress response to anaesthesia in
ponies: barbiturate anaesthesia, Equine Vet} 22:307,
1990.
58. Simons Pj, Cockshott !D, Douglas Ej, et al:
Species differences in blood profiles, metabolism
and excretion of Cl4-propofol after intravenous
dosing to rat, dog and rabbit, Xenobiotica 21: 1243,
1991.
59. Wilson DV, Bohart GV, Evans AT, et al: Retrospec-
t ive analysis of detomidine infusion for standi ng
chemical restraint in 5 I horses, Vet Anaesth Analg
29:54, 2002.
60. Anaesthesia of the horse. In Hall LW, Clarke KW,
Trim CM, editors: Veterinary anaesthesia, ed 10, St
Louis, 2001 , WB Saunders.
61. Hall LW, Taylor PM: Clinical trial of xylazi ne with
ketamine in equi ne anaesthesia, Vet Rec 108:489,
1981.
62. Lin HC, Branson KR, Thurmon JC, et al: Ketamine,
Te!azol, xylazine and detomidine. A comparative
anesthetic drug combinations study in ponies, Acta
Vet Scalld 33: 109, 1992.
63. Muir WW, Skarda RT, Milne OW: Evaluation of
xylazine and ketamine hydrochloride for anesthe-
sia in horses, Am J Vet Res 38: 195, 1977.
64. Muir WW III , Lerche P, Robertson JT, et al: Com-
parison of four drug combinations for total intra-
venous anesthesia of horses undergoing surgical
removal of an abdominal testis, J Am Vet Med Assoc
217:869, 2000.
65. Matthews NS, Taylor T5, Skrobarcek CL, et al: A
comparison of injectable anaesthetic regimens in
mules, Eqllille Vet' SlIppl 34, 1992.
66. Matthews NS, Taylor TS: Anesthetic management
of donkeys and mules. In Steffey EP, editor: Recellt
advances in allesthetic mallagement of large domes-
tic animals, Ithaca, N.Y., 2000, International Veteri-
nary Information Service (www.ivis.org).
67. Olson KN: Anesthesia for laryngoplasty with or
without sacculectomy in 85 draft horses: compari -
son with 322 Thoroughbreds, Vet Arwestl, Analg
29:97, 2002.
68. Freeman SL, Bowen 1M, Bettschart-Wolfensberger
R, et al: Cardiopulmonary effects of romifidine and
detomidine used as premedicants for ketaminel
halothane anaesthesia in ponies, Vet Rec 147:535,
2000.
69. Kerr CL, McDonell WN, Young SS: Cardiopul-
monary effects of romifidine/ketamine or xylazinel
ketami ne when used for short duration anesthesia
in the horse, Call' Vet Res 68:274, 2004.
70. Taylor PM, Bennett Re, Brearley Je, et al: Com-
parison of detomidine and romifidine as premed-
icants before ketamine and halothane anesthesia in
horses undergoing elective surgery, Am J Vet Res
62:359,200!.
71. Hubbell JA, Bednarski RM. Muir WW: Xylazine
and tiletamine-zolazepam anesthesia in horses, Am
J Vet Res 50:737, 1989.
72. Muir WW III , Gadawski JE, Grosenbaugh DA: Car-
diorespiratory effects of a tiletamine/zolazepam-
ketamine-detomidine combination in horses, Am J
Vet Res 60: 770, 1999.
73. Muir WW, Skarda RT, Sheehan W: Evaluation of
xyiazine, guaifenesin, and ketamine hydrochloride
for restraint in horses, Alii J Vet Res 39:1274, 1978.
74. Greene SA, Thurmon le, Tranquilli WJ. et al: Car-
diopuJmonary effects of continuous intravenous
infus ion of guai fenesin, ketamine, and xylazine in
ponies, Am J Vet Res 47:2364, 1986.
75. Lin HC, Wallace SS, Robbins RL, et a1: A case
report on the use of guaifenesin-ketamine-xylazine
anesthesia for equine dystocia, Cornell Vet 84: 61,
1994.
76. Taylor PM, Luna SP, Sear JW, et al: Total intra-
venous anaesthesia in ponies using detomidine,
ketamine and guaiphenesin: pharmacokinetics,
cardiopulmonary and endocrine effects, Res Vet Sci
59: 17, 1995.
77. van Dijk P: Intravenous anaesthesia in horses
by guaiphenesin-ketamine-detomidine infusion:
some effects, Vet Q 16(suppI 2):SI22, 1994.
Field Anesthesia 43
78. McMurphy RM, Young LE, Marlin Dj, et a1:
Comparison of the cardiopulmonary effects of
anesthesia maintained by continuous infusion of
romifidi ne, guaifenesin, and ketamine with anes-
thesia maintai ned by inhalation of halothane in
horses, Am J Vet Res 63: 1655, 2002.
79. American Coll ege of Veterinary Anesthesiology:
Suggestions fo r monitoring anestheti zed veterinary
patients, J Am Vet Med Assoc 206:936, 1995.
80. Johnston GM, Eastment JK, Wood JLN, et al: The
Confide ntial Enqui ry into Perioperati ve Equine
Fatalities (CEPEF): mortality results of Phases I
and 2, Vet Afwesth AI/alg 29:159,2002.
81. Hall LW: Spi nal analgesia. In Hall LW, editor:
Wright's veterillary aI/aesthesia alld allalgesia,
London, 197 1, Balliere and Tindall.
82. Robinson EP: Preferential derma to mal analgesic
effects of epidurally-administered morphine in
horses. In Bryden 0 1, editor: Animal paill alld its
control, Sydney, 1994, University of Sydney.
83. Natalini CC, Robinson EP: Evaluation of the anal-
gesia effects of epidurally administered morphone,
alfentinil. butorphanol, tramadol, and U50488H in
horses. Am J Vet Res 61:1579, 2000.
84. Grubb TL, Riebold TW, Huber MJ: Comparison
of lidocaine, xylazine and xylazinellidocaine for
caudal epidural analgesia in horses, J Am Vet Med
Assoc201:1 187, 1992.
1MB URGERIES
45
Chapter 6
Periosteal Transection and Elevation
Rick D. Howard
INDICATIONS
Performed alone for the treatment of angular
limb deformities in foals with mild to moderate
deformity or in combination with transphyseal
bridging for foals with more severe deformities.
Most commonly used for treatment of carpal
valgus and tarsal valgus but also for varus or
valgus deformities of the metacarpophalangeal or
metatarsophalangeal joints.
EQUIPMENT
A hooked surgical blade and periosteal elevator.
POSITIONING
Dorsal recumbency is preferred for bilateral
procedures or when performed concurrent with
transphyseal bridging. Lateral recumbency is pre-
ferred for unilateral cases or for bilateral cases
(with rolling) not requiring concurrent trallsphy-
seal bridging.
ANATOMY
The surgical approach for treatment of carpal
valgus is over the distolateral aspect of the radius
just proximal to the distal radial physis (Figure
6-1). The vertical skin incision is positioned
46
between the common and lateral digital extensor
tendons, a site with minimal soft tissue overlying
the radius. The surgical approach for treatment of
tarsal valgus is over the lateral malleolus of the
tibia just proximal to the distal tibial physis
(Figure 6-2). The vertical skin incision is posi-
tioned either just cranial or caudal to the lateral
digital extensor tendon. The surgical approach for
treatment of metatarsophalangeal or metacar-
pophalangeal angular limb deformities is on the
concave side of the limb using an approach just
proximal to the distal physis of the 3rd metacar-
pal bone or the 3rd metatarsal bone. Periosteal
transection and elevation to augment growth at
the proximal physis of the first phalanx through
an approach just distal to the proximal physis of
the 1st phalanx may be indicated in certain
cases.
PROCEDURE
Periosteal transection and elevation is performed
on the lateral aspect of the limb for treatment of
valgus deformities and on the medial aspect of the
limb for the treatment of varus deformities. A 3-
to 4-cm vertical incision is made in the skin and
subcutaneous tissues parallel to the long axis
of the bone beginning I to 2 cm proximal to the
physis and extending proximally. The incision is
carried to the level of the periosteum. Curved
hemostatic forceps are used to bluntly dissect
between the periosteum and overlying soft tissues
extending from the distal aspect of the incision in

1-
Site of
surgical ___ -1',
approach
Figure 6-1 Incision site for periosteal transection
on the lateral aspect of the left forelimb between the
common (1) and lateral (2) digital extensor tendons
starting at the level of the distal radial physis and
extending proximal 3 to 4 em.
I
Figure 6-2 Incision site for periosteal transection
on the lateral aspect of the left tibia on either side
(dotted lines) of the lateral digital extensor tendon (1)
starting at the level of the distal tibial physis and extend-
ing proximal 3 to 4 em.
the cranial and caudal planes. The subcutaneous
tissues and tendons are elevated with curved
hemostatic forceps. A No. 12 hooked scalpel blade
is used to transect the periosteum along the lateral
hemicircumference of the bone. When performed
for treatment of carpal valgus, the rudimentary
cartilaginous ulna should also be transected using
a No. 10 scalpel blade. When ossified, as is typical
Periosteal Transection and Elevation 47
Figure 6-3 Occasionally, a rudimentary cartilagi-
nous ulna is noted, which should be transected using a
No. 10 scalpel blade. When ossified, as is typical in older
foals. a segmental ulnar ostectomy should be performed

uSing rongeurs.
Figure 6-4 The periosteum is initially transected
along the lateral hemicircumference of the bone. The
periosteum is then incised longitudinally extending
proximally 3 to 4 em from and connecti ng with the hor-
izontal periosteal transection. The resulting paired tri-
angular shaped flaps of periosteum are elevated with a
periosteal elevator.
in older foals, a segmental ulnar ostectomy should
be performed using rongeurs (Figure 6-3) . The
periosteum is then incised longitudinally extend-
ing proximally 3 to 4 em from and connecting
with the horizontal periosteal transection. The
resulting paired triangular shaped flaps of per-
iosteum are elevated with a periosteal elevator
(Figure 6-4). The subcutaneous tissues are sutured
with absorbable material in a simple continuous
pattern, and the skin is sutured closed with intra-
dermal sutures or with simple interrupted sutures
of No. 3-0 nonabsorbable monofilament suture
material. The wound is bandaged routinely .

48 LIMB SURGERIES
POSTOPERATIVE CARE
Postoperative Care
Bandaging: Postoperatively, the surgical site is
maintained under a bandage for 10 to 14 days.
Suture Removal: If skin sutures are placed, they
should be removed after 10 to 14 days.
Exercise: The foal is strictly confined to a stall for
10 to 14 days. Exercise restriction is instituted
postoperatively to reduce trauma to the asym-
metrically loaded physis and cuboidal bones and
is considered an essential component of the ther-
apeutic plan during postoperative convalescence.
The duration and degree of exercise restriction
are dependent on the age of the foal and the
severity of the angular limb deformity; however,
strenuous exercise should not be allowed until the
angular limb deformity has been corrected.
Other: The hooves should be trimmed to achieve
balance and the foal maintained on a nutritionally
balanced diet.
EXPECTED OUTCOME
The expected degree of correction is proportional
to the amount of growth expected to occur at the
affected physis during the 6 to 8 weeks following
surgery. It is considered that after this amount of
time no further benefit is derived from periosteal
transection and elevation. In cases where partial
but inadequate correction is achieved, repeated
surgery may be warranted provided adequate
growth potential remains. In contrast to the
transphyseal bridge procedure, overcorrection of
the angular limb deformity is not a complication
of periosteal transection and elevation.
COMPLICATIONS
Complications include incomplete correction of
the angular limb deformity, incisional dehiscence,
and development of arthropathy as sequelae to
the damage induced by asymmetric loading of the
cuboidal bones during weight bearing.
ALTERNATIVE PROCEDURES
An alternative technique to the open technique as
described involves performing periosteal transec-
tion and elevation using a blind approach through
a I-em-length skin incision. Using the blind tech-
nique, the surgical wounds are allowed to heal by
second intention under a bandage. The primary
advantages of the technique are the decreased sur-
gical time and decreased incisional complications.
Postoperative care is essentially as described for
the open technique for periosteal transection and
elevation.
COMMENTS
The differential diagnoses for angular limb defor-
mities in foals include intercarpal or intertarsal
ligament laxity, crushed carpal or tarsal bones,
distal radial or tibial physeal dysplasia, and physeal
trauma resulting in premature closure of the
physis. Preoperative radiographs are important to
confirm the source of the angular limb deformity
and to determine if surgical manipulation of the
growth plate is indicated for treatment of the defor-
mity. Dorsopalmar (plantar) and lateral medial
radiographic views of the affected area will gener-
ally confirm the source of the angular deformity.
Periosteal transection and elevation is best
indicated for deformities associated with physeal
dysplasia. Periosteal transection and elevation
requires a functioning physis to be effective. If the
physis is crushed, as occurs with Salter-Harris
type V or VI fractures, the procedure will not be
effective because the physis is unable to respond.
Angular limb deformities may also be associ-
ated with the metaphysis or diaphysis of long
bones; typically the third metacarpal or metatarsal
bones. These deformities are usually congenital
and their repair is beyond the scope of this book.
Since its introduction into equine surgery in
1980, periosteal transection and elevation has
been widely accepted as an effective method for
augmentation of axial limb growth in the treat-
ment of angular limb deformities. 1.2 The effec-
tiveness of the procedure has been questioned.
The results of a study on the efficacy of periosteal
transection and elevation for the treatment of
experimentally induced carpal valgus indicated
foals treated with stall confinement and hoof
trimming alone or with the addition of periosteal
transection and elevation demonstrated a similar
correction in angular limb deformity. 3 Although
the results were significant, it is important to note
that the transphyseal bridge model for carpal
valgus used in that study may be an inadequate

ld approach through
Jsing the blind tech-
:e allowed to heal by
ndage. The primary
re the decreased SUf-
lonal complications.
Ily as described for
teal transection and
limb defor-
or intertarsal
tarsal bones.
pP"tSla, and physeal
closure of the
are important to
limb deformity
ianipullati', In of the
of the defor-
lateral medial
area will gener-
deformi ty.
elevat,,' 'n is best
with physeal
and elevation
effective. If the
Salter-Harris
will not be
to respond.
also be associ-
of long
or metatarsal
indicated
and hoof
In'''' ,n'to note
for carpaJ
an inadequate
model for naturally occurring carpaJ valgus
and that extrapolation of the results to naturally
occurring disease may be inappropriate.
REFERENCES
1. Auer JA, Martens RJ: Angular limb deformities in
young foals, Proc Am Assoc Equine Pract 26:81, 1980.
Periosteal Transection and Elevation 49
2. Auer JA, Martens RJ. Williams EH: Periosteal tran-
section for correction of angular limb deformities in
foals. J Am Vet Med Assoc 181 :459. 1982.
3. Read EK, Read MR, Townsend HG, et al: Effect of
hemi -circumferential periosteal transection and ele-
vation in foals with experimentally induced angular
limb deformities. ] Am Vet Med Assoc 221 :536,2002.
CHAPTER 7
Transphyseal Bridging
Rick D. Howard
INDICATIONS
Transphyseal bridging is performed alone or
in combination with periosteal transection and
elevation for the treatment of angular limb de·
formities associated with the carpus, tarsus, meta-
carpophalangeal, or metatarsophalangeal joints
in young foals «3 months of age) with severe
angular limb deformity or in foals with clinically
significant deformity after the potential for rapid
growth has passed: 2 months for the distal 3rd
metacarpal) 3rd metatarsal, and proximal 1st
phalangeal physes; 4 months for the distal tibial
physis; and 6 months for the distal radial physis.' ·2
EQUIPMENT
An AO-ASIF 4.5-mm or 5.5-mm screw set, instru-
mentation for placement and removal of screws,
and orthopedic wire are required. Alternatively,
self-tapping screws may be used, reducing the
required orthopedic equipment to a drill, an
appropriate-size drill bit, screwdriver, self-tapping
screws, and orthopedic wire. Equipment for ob-
taining intraoperative radiographs is also neces-
sary.
POSITIONING
Dorsal recumbency is preferred for bilateral pro-
cedures or when performed concurrently with
50
periosteal transection and elevation. Lateral re-
cumbency is used for unilateral cases not requir-
ing periosteal transection and elevation.
ANATOMY
Regardless of the technique used, transphyseal
bridging requires the placement of an orthopedic
implant in the epiphysis of the operated bone. The
surgeon should become famili ar with the size and
contour of the epiphyses of commonly operated
bones to avoid inadvertent damage to the articu-
lar surfaces of the adjacent joint. Because of the
irregular shape and narrow proximal-to-distal
dimension of the distal tibial epiphysis, radi-
ographic guidance is essential to avoid the risk of
errant placement of the implant into the tibio-
tarsal joint. Radiographic confirmation of correct
screw placement is recommended for transphy-
seal bridging at all locations.
PROCEDURE
Transphyseal bridging is performed on the medial
aspect of the limb for the treatment of valgus
deformities and on the lateral aspect of the limb
for the treatment of varus deformities. Periopera-
tive antibiotics are administered, the foal is anes-
thetized and positioned, and the surgical site is
prepared aseptically for surgery. A curvilinear
incision is made in the skin and subcutaneous
tissues oriented along the long axis of the radius

':,L '---- Epiphysis
Figure 7-1 A curvili near incision (dotted lille) is
made over the medial aspect of the left distal radial
physis oriented along the long axis of the radius, begin-
ning at the level of the radiocarpal joint and extending
toward the diaphysis of the bone for exposure of the
epiphysis, the physis, and 2 to 3 em of the metaphysis.
beginning at the level of the radiocarpal joint and
extending toward the diaphysis of the bone for
exposure of the epiphysis, the physis, and 2 to 3
cm of the metaphysis (Figure 7-1). The soft tissues
are bluntly dissected and retracted. Then 22-gauge
I.S-inch needles are placed into the radiocarpal
joint space and the physis. A I-em incision is
made with a scalpel through the collateral liga-
ment midway between the needles for placement
of the epiphyseal screw (Figure 7-2). Using radi-
ographic guidance for screw placement and ori-
entation, a 3.2-mm pilot hole is drilled, measured,
and tapped for placement of a 4.5-mm screw. As
a general rul e, the epiphyseal screw is placed
roughly parall el to the physis, except in the distal
tibial physis, where a shorter screw is used and the
screw mll st be angled from distal to proximal to
avoid entering the tibiotarsal joint. A 40-mm-
length cortical screw is inserted into the epiphysis
and incompletely tightened. A I-em incision is
made in the periosteum over the metaphysis at a
site approximately 2 to 3 cm from the physis. The
periosteum is elevated, and a 4.5-mm 40-mm-
length cortical screw is similarly placed in the
Transphyseal Bridging 51
.
Figure 7-2 Hypodermic needle in position to iden-
tify the distal radial physis. Two screws are placed per-
pendicular to the long axis of the bone approximately
I to 2 em proximal and distal to the physis.
Figure 7-1 A figure of eight wire (IS-gauge ortho-
pedic wire) is placed around the heads of the screws and
tightened using a wire hvister or pliers.

Figure 7-4 A second figure of eight wire is placed
and ti ghtened as described and the wire twists are bent
against the bone toward the adjacent joint.
metaphysis and tightened incompletely. A figure
of eight wi re (lS-gauge orthopedic wire) is placed
around the heads of the screws and tightened
using a wire twister or pliers (Figure 7-3). A
second figure of eight wire is placed and tightened
as described, and the wire twists are bent against
the bone toward the adjacent joint (Figure 7-4).

,
52 LIMB SURGERIES
The screws are tightened with a screwdriver until
the heads are flush with the soft tissues, taking
care not to tighten the screws excessively as this
will cause the wires to become dislodged over the
screw heads. Tightening the screws places addi-
tional tension on the figure of eight wires as the
bevel of the screw head engages the wires. The
subcutaneous tissues are sutured with absorbable
material in a simple continuous pattern, taking
care to cover as much of the implant as possible.
The skin is sutured with simple interrupted sutures
of No. 3-0 nonabsorbable monofilament suture
material. The wound is bandaged routinely, and a
thin cotton padded outer wrap is placed to reduce
external trauma to the surgical sites.
POSTOPERATIVE CARE
An essential component of the postoperative care
is the timely removal of the transphyseal bridge
implants. Client education is a key component of
successful case management. Clients should be
instructed that the implants must be removed
when the deformity has corrected or just prior
to complete correction. In contrast to periosteal
transection and elevation, overcorrection of the
angular limb deformity occurs if timely removal
of implants is neglected. In cases where bilateral
transphyseal bridging is performed, the removal
of implants may need to be performed on sepa-
rate occasions to allow adequate correction for
each limb. Although implant removal may be
achieved in some foals using sedation and local
anesthesia, general anesthesia greatly facilitates
the procedure and is indicated for most cases.
Following routine aseptic preparation, the
position of the screw heads is identified by
probing with a hypodermic needle and a stab inci-
sion is made down to each screw head. A mos-
quito hemostatic forceps is used to retract the soft
tissues while a screwdriver is manipulated and
firmly seated into the screw head and used to
remove each screw. A sturdy curved hemostatic
forceps placed through the stab incision over the
metaphyseal screw is used to hook the loops of the
figure of eight wires for extraction by firm trac-
tion. The skin incisions are sutured and the sur-
gical site bandaged for 10 to 14 days until the
sutures are removed.
Postoperative Care
Bandaging: The surgical site is maintained un-
der a bandage until skin sutures are removed at
10 to 14 days.
Exercise Restrictions: Postoperatively, the foal
should be strictly confined to a stall. Exercise
restriction is instituted postoperatively to reduce
trauma to the asymmetrically loaded physis and
cuboidal bones and is considered an essential
component of the therapeutic plan during post-
operative convalescence. The duration and degree
of exercise restriction are dependent on the age
of the foal and the severity of the angular limb
deformity; however, strenuous exercise should not
be allowed until the angular limb deformity has
been corrected.
Suture Removal: Skin sutures are removed at
10 to 14 days.
other: The hooves should be trimmed to achieve
balance and the foal maintained on a nutritionally
balanced diet.
EXPECTED OUTCOME
The expected amount and rate of axial correction
are proportional to the growth potential of the
affected physis and are dependent on the age of
the patient and the physis affected. Typically, rapid
correction of the angular limb deformity occurs
in young foals) while slower, but steady, correction
is anticipated fo r the older patient.
Swelling, inflammation, and scar tissue formation
at the surgical site of the implants are common
but typically become less apparent once the limb
has straightened and resolve once the implants
have been removed. The development of infection
may result in subcutaneous abscess or skin inci -
sion dehiscence and in some cases necessitates
premature removal of the surgical implants. The
most serious potential complication is overcor-
rection of the angular limb deformity. The gravity
of this complication should not be underempha-
sized; for example, a mild carpal valgus is typically
only a cosmetic impairment compared with the

I
potentially severe performance-limiting conse-
quences of a carpal varus deformity that may
result from delayed removal of transphyseal
bridge implants. Timely removal of implants is
essential to reduce the frequency of this compli-
cation.
ALTERNATIVE PROCEDURES
An alternative to the open technique as described
involves performing the surgery through stab
incisions made over the location of each screw
site.
2
The soft tissues between the screw holes are
bluntly undermined with mosquito hemostatic
forceps forming a tunnel for passage of the
figure of eight wires. Postoperative care is as
described for the open technique for transphyseal
bridging.
An alternative to screws and wires for
transphyseal bridging is the use of orthopedic
staples, initially described in 1963.
3
Staples have
the advantage of being easier and quicker to
place and have a low complication rate.
4
Two
sizes of staples are commercially available: 22 x
22 mm (Zimaloy Epiphyseal Staple; Zimmer, Inc.,
Warsaw, Ind.) and 29 x 22 mm (Blount E.S.;
Stryker, Kalamazoo, Mich.). Disadvantages of sta-
ples include the lack of compression across the
growth plate in the early postoperative period and
the limited flexibility in placement caused by the
fixed leg length of the staple.
Another alternative is the recently described
technique for the placement of a single transphy-
seal screw for transphyseal bridging.s The de-
scribed technique involves the placement of a
single fully threaded screw at an oblique angle in
lag fashion from the medial malleolus, across the
physis and into the metaphysis of the tibia. The
approach to the medial malleolus is via a stab inci-
sion and is associated with minimal soft tissue
dissection. Advantages cited for this technique
include reduced need for soft tissue dissection,
improved cosmetic result, and reduced risk of
infection. Although the authors indicate they had
used this procedure in the treatment of carpal
valgus, the current report was limited to treat-
ment of tarsal valgus in 4- to 12-month-old
horses. In this report of 11 cases, the tarsal valgus
resolved and the cosmetic result was considered
excellent.
5
We have used this method for correc-
.tion of carpal valgus in foals. In the carpus, the
Transphyseal Bridging 53
Figure 7-5 Dorsopalmar radiograph of the carpus
with a single 4.S-mm cortical bone screw placed across
the distal radial physis as an alternative for transphyseal
bridging.
screw can be placed distal to proximal or proxi-
mal to distal as shown in Figure 7-5.
COMMENTS
The primary advantage of transphyseal bridging
compared with periosteal transection and eleva-
tion is the more consistent response achieved even
in severely deformed or older patients. Unless the
physis is damaged on the side opposite the side
bridged or the physis is too mature to respond,
correction will occur. The disadvantages of the
procedure include increased time and cost of
the procedure, the increased risk of infection, the
increased likelihood of a less-than-satisfactory
cosmetic appearance, the requirement for more
special equipment, the possibility of overcorrec-
tion, and the need for a second surgery to remove
the implants to avoid overcorrection.
. The differential diagnoses for angular limb
deformities in foals include intercarpal or inter-
tarsal ligament laxity, crushed carpal or tarsal
bones, distal radial or tibial physeal dysplasia, and
physeal trauma resulting in premature closure of
the physis. In addition, angular limb deformities
may also be associated with the metaphysis or dia-
physis of long bones, typically the third metacarpal

I
54 LI MB SURGERIES
or metatarsal bones. These metaphyseal or dia-
physeal deformities are usually congenital, and
their repai r is beyond the scope of this book.
Preoperative radiographs are important to
confi rm the source of the angular limb deformity
and to determi ne if surgical manipulation of the
growth plate is indicated for treatment of the
deformity. Dorsopalmar (plantar) and lateral
medial radiographic views of the affected area
will generally confi rm the source of the angular
deformity.
Transphyseal bridging requires a functioning
physis to be effective and is best indicated for
deformities associated with physeal dysplasia. If
the physi s is crushed, as occurs in Salter-Harris
type V or VI fractures, transphyseal bridging will
not be effect ive because of the inability of the con-
tralateral side of the physis to respond. If the
origin of the deformity is associated with the
joint (e.g., crushed carpal bones), transphyseal
bridging can cosmetically straighten the external
appearance of the limb, but the internal misalign-
ment may result in degenerative joint disease and
lameness.
Transphyseal bridging may also be used in
concert with periosteal transection and elevation
in foals with severe deformities, as the two proce-
dures are performed on opposite sides of the limb.
There is no objective evidence indicating the com-
bi nati on results in better or faster correction of
the deformity.
REFERENCES
I. Fretz PB, Cyubaluk NF, Pharr jW: Quant itative anal-
ysis of long bone growth in the horse, Am f Vet Res
45: 1602, 1984.
2. Auer JA: AnguJar limb deformities. In Auer l A, Stick
lA, editors: Equine surgery, ed 2, Philadelphia, 1999,
WB Saunders.
3. Heinze CD: Epiphyseal stapling, Proc Am Assoc
Equine Pmct 9:203, 1963.
4. Hunt Rl: Management of angular deformities, Proc
Am Assoc Equine Pmct 46: 128, 2000.
5. Witte S, Thorpe PE, Hunt RJ, et al: A lag-screw tech-
nique for bridgi ng of the medial aspect of the distal
tibial physis in horses. f Am Vet Med Assoc 225: 158 1,
2004.

CHAPTER 8
Distal Limb Perfusion
Joanne Kramer
INDICATIONS
Infection of bone and soft tissues in the distal limb
(Figure 8- 1).
EQUIPMENT
A cannulated screw with an appropriately sized
drill bit and tap or commercially available
intraosseous infusion needles are needed for
intraosseous perfusion (Figu re 8-2) . A 20- to
26-gauge I -inch catheter is necessary fo r intra-
venous perfusion. For both techniques, an
Esmarch bandage or pneumatic tourniquet and
the selected anti biotic diluted in 60 mL of normal
saline are necessary.
POSITIONING AND PREPARATION
The limb should be clipped and prepared for
aseptic surgery. Care should be taken to isolate
open, infected sites from the perfusion entry site.
Depending on the nature of the horse, the proce-
dure can be performed with the horse standing or
under general anesthesia. For intraosseous perfu-
sion, the initial procedure is often performed
under general anesthesia and follow-up proce-
dures are performed standin g. Standing proce-
dures require sedation and regional anesthesia
above the area to be perfused.
55
ANATOMY
Regional perfusion delivers anti biotic into the
venous system by intraosseous or intravenous
infusion. With pressure, the perfusate distends
the venous vasculature, allowing the perfusate
to enter tissue wi th intact venous vasculature.
Antibiotics then enter ischemic tissue and exu-
dates via increased hydrostatic pressure in cap-
il lar ies and diffusion across a concentration
gradient.
'
,2 During regional perfusion, the timing
of anti biotic del ivery to the tissues is expected to
follow a similar pattern to that observed follow-
ing contrast medium. Shortly after intravenous
injection, contrast is in both the venous and arter-
ial systems; 15 minutes after injection. contrast
has started to diffuse into adjacent soft ti ssues;
and 30 minutes after inj ection, contrast is pri-
marily in the adjacent soft tissues' (Figure 8-3).
PROCEDURE
Selected Antibiotics
Antibi otics must be approved for intravenous
administration. Concentration-dependent antibi-
oti cs such as gentamicin and amikacin are com-
monly used, but other antibiotics may be used as
well. Ideally, antibioti c choice is guided by culture
and sensi tivity results. Because such high tissue
concentrations ca n be achieved locally with small
doses of antibiotic, antibiotics that are cost-
prohibitive to use systemically can be used. In
56 LIMB SURGERIES
Figure 8-1 A horse with a chronic distal limb infec-
tion.
Figure 8-2 Cannulated 4-mm scre"1 with a nut and
adapter welded to the head.
Figure 8-3 Contrast distribution 5 minutes after
injection into the palmar digital vein in the distal
pastern region.
reports, 125 to 1000 mg of amikacin or gentam-
icin per perfusion has been used.
3
-
6
For other
antibiotics, the systemic dose or less is used.
Exsanguination
Exsanguination of blood from the distal limb
is recommended before perfusion of the tissues.
Placement of the intravenous catheter is easier
before exsanguination. Placement of the bone
screw can be done easily before or after ex-
sanguination. For exsanguination, an Esmarch
bandage is applied to the limb from the hoof to
the distal cannon bone and secured tightly at the
proximal end to prevent loss of the perfusate into
the systemic circulation. A pneumatic tourniquet
can also be applied at the proximal end of the
Esmarch bandage to prevent loss of the perfusate.
After applying the tourniquet or securing the
Esmarch bandage at the proximal end, the distal
portion of the bandage is unwrapped (Figure
8-4). In cases with extensive cellulitis, application
of an Esmarch bandage is not recommended
because of the risk of forcing bacteria from the
B
A
Figure 8-4 A. A pneumatic tourniquet is applied at
the proximal end of the Esmarch bandage to prevent
loss of the perfusate. B. The distal portion of the
bandage is then unwrapped.
interstitial fluid into the lymphatic system. ? In
these cases, a tourniquet is applied to the distal
metacarpus without prior Esmarch bandage ap-
plication.
Intravenous Perfusion
A 20- to 26-gauge I-inch catheter is placed in the
palmar vei n at the level of or just distal to the
sesamoid bones. The catheter and extension set
Figure 8-5 A 20- to 26-gauge i-inch catheter is
placed in the pal mar digital vein at the level of or just
distal to the sesamoid bones. The catheter and exten-
sion set are then gl ued and taped into place. The
selected antibiotic diluted in 60 mL of saline is injected
slowly using a small syri nge. Because of the pressure
needed to deliver the antibiotic, a three-way stop-cock
is used to allow the dil uted antibiotic to be delivered
with a small syringe.
Distal Limb Perfusion 57
are then glued and taped into place. The selected
antibiotic diluted in 60mL of saline is injected
slowly using a small syringe. Because of the pres-
SUfe needed to deliver the antibiotic, we com-
monly use a three-way stop-cock to allow the
diluted antibiotic to be conveniently delivered
with a smail syringe (Figure 8-5). The tourniquet
is left in place for 30 minutes. After release of the
tourniquet, the catheter is removed and pressure
is applied to the puncture site for several minutes.
Intraosseous Perfusion
A stab incision is made in the proximal portio n of
the pastern midway between the lateral and dorsal
aspect. An appropriately sized drill bit is used
to create a pilot hole for the cannuJated screw
(Figure 8-6). The hole is tapped and the cannu-
lated screw is placed (Figure 8-7). The selected
ant ibiotic dil uted in 60 mL of normal sal ine is
then slowly injected using a three-way stop-cock
and small syringe. The tourniquet is left in place
for 30 minutes. After release of the tourniquet, the
screw is removed and the skin is closed with an
interrupted suture.
POSTOPERATIVE CARE
Postoperative Care
Bandaging: A sterile dressing is placed over the
incision or catheter site and a half limb bandage
is applied.
Exercise Restrictions: Stall rest with limited
activity is advised until the sepsis is resolved.
Medications: Systemic antibiotic therapy is con-
tinued as indicated by the underlying condition.
When the same antibiotic is given systemically as
is used in the perfusion, we omit one systemic
dose of the antibiotic on the day the perfusion is
performed. Tetanus prophylaxis is provided if nec-
essary.
Suture Removal: Skin sutures are removed 12
days postoperatively.
EXPECTED OUTCOME
Synovial structure and bone infections are diffi-
cult to treat and can have a poor outcome despite
aggressive treatment. Regional antibiotic perfu-
sion is an adjunctive therapy in the treatment of
I' I
58 LIMB SURGERIES
Drill bit
Cannulated
screw
Tap ~ P " " ,t.:1.,., .

Figure 8-6 A stab incision is made in the proximal portion of the pastern midway between the lateral and dorsal
aspect. An appropriately sized drill bit is used to create a pilot hole for the cannulated screw.
Figure 8-7 lntraosseous screw placement for perfu-
sion of the pastern and coffin joint region.
sepsis and does not replace systemic antibiotic
therapy, appropriate debridement, lavage, and
drainage. Because regional antibiotic perfusion
can achieve high tissue levels of antibiotics in
affected sites, it can improve the outcome. In one
study, the overall survival rate was 86% when
di stal limb perfusion was used in conjunction
with aggressive systemic and local therapy.8
COMPLICATIONS
Severe tissue irritation from the antibiotic perfu-
sion may occur but is rare. Partial thrombosis of
the vein used for perfusion may occur, especially
if used repeatedly. Complete thrombosis is un-
common.
ALTERNATIVE PROCEDURES
Regional perfusion can be performed in many
areas of the limb and has been described in the
tarsus, radius, and carpus.
9
,]O lntraosseous perfu-
sion can also be performed with a 14-gauge needle
placed through a 2-mm drill hole or the male end
of a Luer tip extension set placed through a 4-mm
hole, but sli ght inaccuracies in fit can result in
leakage of the perfusion solution. ]]
COMMENTS
In some st udies, intravenous perfusion techniques
have resulted in higher tissue levels of antibiotics
than intraosseous techniques.
4
,12 Bot h methods
produce much higher tissue levels than the
recommended peak serum concentrations. Intra-
venous perfusion requi res less equipment than
intraosseous perfusion but can be diffi cult to
perform in limbs with significant swell ing or in
veins that have had multiple perfusions. Sites for
intraosseolls perfusion can be used multiple times
after the original hole is drilled.
Additionally, a study comparing intraarticular
injection of gentamicin with regional
ous perfusion of gentamici n in normal horses
found the techniques produced similar bone
concentrations and that intraarticul ar inj ection
produced greater synovi al fluid concentrations
than regional intravenous perfusion.
13
In clinically
affected horses, the increased hydrostatic pressure
achieved in regional perfusion techniques may
result in better perfusion of capillaries obstructed
by debris or fibrin, but this has not been objec-
tivelyevaluated.
REFERENCES
1. Finsterbush A. Argaman M. Sacks T: Bone and joint
perfusion of antibiotics in the treatment of exper-
imental staphylococcal infection in rabbits, I Balle
loint SlIrg 52: 1424, 1970.
2. Finsterbush A, Wei nburg H: Venous perfusion of
the limb with antibiotics for osteomyel itis and
other chronic infecti ons, I Balle loint SlIrg Alii 54:
1227,1972.
3. Palmer SE, Hogan PM: How to perform regional
li mb perfusion in the standing horse, Proc Am Assoc
Eqllille Pmct 45: 124, 1999.
Distal limb Perfusion 59
4. Butt TD, Bailey lV, Dowling PM, et al: Comparison
of 2 tech niques for regional anti biotic delivery to
the equine forelimb: intraosseous perfusion vs.
intravenous perfusion, Call Vet I 42:617, 200 I.
5. Mattson 5, Boure L, Pearce 5: Intraosseous gen-
tamicin perfusion of the distal metacarpus in
standing horses, Vet Slirg 33(2): 180, 2004.
6. Werner LA, Hardy ], Bertone AL: Bone gentamici n
concentration after in tra-articuJar injection or
regional intravenous perfusion in the horse, Vet
Stlrg 32(6):559, 2003.
7. Orsini JA, Elce Y, Kraus B: Management of severely
infected wounds in the equine pati ent, Clill Tech Eq
Pmct 3(2):225,2004.
8. Santschi EM, Adams SB. Murphey ED: How to
perform equi ne intravenous digital perfusion, Proc
Am Assoc Equine Pract 44: 198, 1998.
9. Kettner NU, Parker lE, Watrous B1: lntraosseous
regional perfus ion for treatment of septic physiti s
in a t\'10 week old foal, J Am Vet Med Assoc
222(3):346,2003.
10. Whitehair KJ. Blevins WE, Fessler JF. et al: Regional
perfusion of the carpus for antibiotic delivery, Vet
SlIrg21 (4):279, 1992.
II. Ri chardson OW: Local anti microbial delivery in
equine orthopedics, Proc Am CoIl Vet SlIrgeollS Vet
Symp 13: 162,2003.
12. Scheuch BC, Va n Hoogmoed WD. Wilson JR, et al:
Comparison of intraosseous or intravenous infu-
sion for del ivery of amikacin sulfate to the tibio-
tarsal joint of horses, Am J Vet Res 63(3):374, 2002.
13. Werner LA. Hardy J. Bertone AL: Bone gentamici n
concentration after intra-articular or regional intra-
venous perfusion in the horse, Vet SlIrg 32(6}:559,
2003.
CHAPTER 9
Mid Metacarpal-Metatarsal Tendon Laceration Repair
Joanne Kramer
INDICATIONS
Treatment of flexor and extensor tendon lacera-
tions in the metacarpal or metatarsal region that
do not involve the digital sheath (Figure 9-1 ). Care
of lacerations involving the digital sheath requires
intensive management to treat synovial structure
sepsis and is discussed elsewhere
l
-
3
(Figure 9-2).
EQUIPMENT
Cast material and associated supplies are essentia1.
Recommended suture materials for tendon repair
include nylon, polydiaxone, and coated Kevlar
(FiberWire, Arthex, Naples, Fla.). Size No.2 or
larger suture material is used.
POSITIONING AND PREPARATION
The horse is positioned in lateral recumbency
with the affected limb positioned for access to the
laceration. The circumference of the limb should
be clipped and prepared asepti cally from at least
the fetlock to the mid carpal/tarsal region.
ANATOMY
The proximal extent of the digital tendon sheath
is in the distal third of the metacarpal-metatarsal
region. The distal end of the sheath lies just prox-
60
imal to the navicular bursa within the hoof
capsule. The distal end of the sheath and naviClI-
lar bursa are separated by the transverse lamina.
In the mid metacarpal-metatarsal region) the
cross section of the flexor and extensor tendons
varies from flat to circular (Figure 9-3).
ASSESSMENT AND SURGICAL PROCEDURES
Stabilization
A brief observation of the laceration and limb
position is made and the need for immediate
stabilization is determined. Elevation of the toe
indicates complete deep digital flexor tendon
laceration (Figure 9-4), and mild to moderate
dropping (hyperextension) of the fetlock suggests
superficial digital flexor tendon laceration or
partial disruption of the suspensory apparatus
(Figure 9-5). Severe hyperextension of the fetlock
suggests transection or complete disruption of
the suspensory apparatus (Figure 9-6). Buckling
forward at the fetlock or difficulty extending
the distal limb suggests common or long digital
extensor tendon rupture (Figure 9-7).
The need for stabil ization must be balanced
agai nst the need to determine the extent of the
wound and to offer owners who have economic
concerns a general prognosis before proceeding
with potentially costly procedures. Examination
of the injury can be performed with the limb
held up before stabilization is applied, but often
a detailed examination is not possible until the
Mid Metacarpal-Metatarsal Tendon laceration Repair 61
Figure 9·1 Flexor tendon laceration in the mid
metacarpal region proximal to the flexor tendon sheath.
Figure 9·2 Flexor tendon laceration in the palmar
pastern region involving the flexor tendon sheath.
Common digital extensor
tendon =-___ ......, .....
" i· ..
>, .
."
.. '
horse has been placed under anesthesia. Stabiliza-
tion should be applied before induction of anes-
thesia or transport. Flexor tendon lacerations,
whether complete or partial, require Kimzey
splint (Kimzey Welding Works, Woodland, Calif.)

application or similar support to reduce the
tension on the flexor tendons (Figure 9-8). Exten-
sor tendon lacerations can be stabilized in a
weight-bearing position by incorporating a PVC
or wood splint into the bandage along the dorsal
or palmar-plantar surface of the limb (Figure
9-9).
Synovial Structure Involvement
If the wound is near the digital sheath, involve-
ment of the sheath can be determined byasepti-
cally inserting a needle into the sheath at a site
distal from the wound and distending the sheath
with sterile saline. Involvement of the sheath is
confirmed if fluid is observed at the wound site.
Vascular Status
Laceration of the digital vein and artery may
accompany flexor tendon lacerations. In general,
despite significant laceration of the vasculature, it
is rare to have ischemic complications if only one
side of the vasculature is transected. Lacerations
involving both the lateral and medial vasculature
Long digital extensor
tendon--
MT III
~ ; ; : : = : : : = = : : : : ~ ~ e " l - Me II
II
A
Digital
check
Interosseous mel "" __
(suspensory lig.)
B
Figure 9·3 A, Transverse section through the middle metacarpal region. B, Transverse section through the middle
metatarsal region.
62 LIMB SURGERIES
Figure 9-4 Horse with a complete laceration of the
deep digital flexor tendon. The toe is elevated from the
ground, indicating hyperextension of the coffin joint.
Figure 9-5 Horse with a partial laceration of the
superficial digital flexor tendon showi ng mild fetlock
hyperextension.
risk ischemic compromise to the distal limb but
can also heal adequately. Unfortunately, a practi-
cal way of assessing the ability of collateral circu-
lation to provide adequate blood supply in the
future healing period is not available.
Wound Debridement and Repair
Removal of contaminated and devitalized tissue is
performed with layered debridement. In relatively
Figure 9-6 Horse recovering from suspensory liga-
ment disruption. Note the fetlock hyperextension.
Figure 9-7 Buckling forward of the fetlock seen with
long digital extensor tendon transection.
clean transections with potential for primary
closure, debridement should be as conservative
as possible. The wound should be lavaged ex-
tensively before, during, and after debridement
(Figure 9-10) . If closure is performed, gloves and
instruments are changed after debridement and
before closure.
If the free cut ends of the fl exor tendon are
cleanly transected and appear healthy, primary
repair should be performed to improve alignment
Mid Metacarpal-Metatarsal Tendon Laceration Repair 63
Figure 9-8 Kimzey splint support for a deep digital
flexor tendon laceration. An extended elevated heel
shoe has also been placed on the limb for support
during bandage changes.
Figure 9-9 PVC splint support for an extensor
tendon laceration.
and ea rl y strength of the repair.'" If the ends
of the fl exor tendon are extensively retracted)
swollen, or discolored or the wound appears to be
signifi cantly infected, the area should be debrided
and allowed to heal by second intention. In select
cases, delayed primary closure can be performed
with or without tendon suturing. All situations
require a minimum of 6 weeks of cast or splint
support. Partial flexor tendon lacerations can be
managed with wound closure and limb immobi-
Figure 9-10 Extensive lavage during the initial stages
of laceration repair.
lization without tendon suturing. If the laceration
involves greater than 75% of the cross-sectional
area of the tendon, tendon suturing may offer
simi lar benefits to repair of complete transec-
tions.
6
Many extensor tendon lacerations have a sig-
nificant degloving component and extensive soft
tissue trauma, which precludes reconstruction.
With appropriate wound care, these lacerations
can heal by second intention and often have
minimal functional impairment. Fibrosis between
the tendon ends eventually results in a mechani-
cal link between the tendon ends and, in many
cases, return of extensor function of the digit.
6
However, if the wound is amenable to primary
closure and the tendon ends are transected
cleanly, primary tendon repair is preferable.
Suture Patterns for Tendon Laceration Repair
Modified Far-Near-Near-Far Pattern
This pattern is the simplest pattern to perform,
and is best used in flat tendons. The needle is
placed perpendicular to and approximately 1.5 em
from the proximal tendon end for the initial far
bite. The needle then enters the distal tendon end
0.5 to 1 em from the end for a near bite in a posi-
tion sli ghtly axial to the far bite. It is then looped
back to the proximal end of the tendoll) and a near
bite is taken 0.5 to 1 em from the end in the same
plane as the previous near bite. The suture is then
brought to the distal end, and a far bite is taken in
the same plane as the initial far bite 1 to 1.5 em
from the end. The two far ends are then tied
(Figure 9-1 I).
64 LIMB SURGERIES
\
Figure 9-11 Modified far-near-near-far pattern.
Figure 9-12 Modified compound locking loop.
Modified Compound Locking Loop
This pattern is strong and works best in flat
tendons or ligaments. but it can also be used in
round tendons. A superficial transverse bite locks
around small groups of fibers to decrease pull-
through of larger vertical bites approximately 2
em from the tendon end. The pattern starts with
a superficial transverse bite about 1 em wide. A
vertical bite is then placed through both tendon
ends, and a similar transverse bite is taken in the
opposite tendon end. A vertical bite is then taken
from the distal tendon end to the proximal tendon
end and ti ed to the start of the first transverse bite.
A similar but wider locking loop is next placed
slightly closer to the tendon ends' (Figure 9-12).
Alternatively, both locking loops can be placed as
a continuous pattern.
4
Three-Loop Pulley
This pattern is strong and has less gap formation
than other repair patterns.
8
,9 It works best on
round tendons such as the deep digital flexor
tendon in the metacarpal region. The end result is
three loops equally dividing the cross-sectional
area of the tendon and intersect ing at 60-degree
Figure 9-13 Three-loop pulley.
angles. The initial loop is placed perpendicular to
the long axis of the tendon in a near-far pattern.
The second loop is placed in a plane 60 degrees
relative to the initial loop with bites taken similar
distances apart from each tendon end. The final
loop is placed in a far-near pattern 60 degrees
from the second loop (Figure 9-13).
POSTOPERATIVE CARE
Flexor Tendon Lacerations
No suture pattern or material provides the
strength required for flexor tendon function after
repair.
4
,9,10 Therefore, during the early stages of
tendon healing, the repair must be protected from
weight-bearing forces with cast application or
other external support. External support should
be provided for a minimum of 6 to 8 weeks fol-
lowing repair. After this period, support should be
gradually reduced. An elevated extended heel shoe
andlor splint should be provided for the follow-
ing 4 to 6 weeks. The optimal extent of heel ele-
vation required has not been determined, but the
initial hoof angle achieved is typically between 65
and 75 degrees. Heel elevation and extension are
then gradually reduced over the next 12 weeks to
adapt the tendon to increasing tension. Some
horses require long-term heel extension after
flexor tendon transection.
Repair of superficial digital flexor tendons in
the hind limb may benefit from Kimzey splint
application rather than half limb cast application.
Because hock flexion is normally accompanied by
fetlock flexion, tension in the superficial digital
flexor tendon is increased when a horse flexes its
hock but is constrained from fetlock flexion by a
half limb cast. The Kimzey splint supports the
Mid Metacarpal-Metatarsal Tendon Laceration Repair 65
limb in fetlock flexion. Disadvantages of the
Kimzey splint include prolonged immobilization
with the distal limb in flexion and the need
to keep the limb from bearing weight during
bandage changes. A full limb cast extending to the
proximal tibia will decrease strain on the superfi-
cial digital flexor tendon during repair by pre-
venting hock flexion, but generally, the risk of
complications with a full limb cast is not worth
the benefit when repairing superficial digital flexor
tendon lacerations in the metatarsal region.
Extensor Tendon Lacerations
In the early phases of extensor tendon healing, a
distal limb splint is recommended to support the
digit in extension. Often, the support of a bandage
is sufficient to prevent flexion, as some digital
extension is due to momentum as the limb swings
forward. If primary repair is performed, cast or
splint support should be provided for a minimum
of 4 weeks.
Contralateral Limb Support
Support should be provided for the opposite limb
to decrease the risk of contralateral limb lameness,
reduce edema, and elevate the contralateral limb
to a similar height as the casted limb. A support
bandage and foot elevation are often applied to
the contralateral limb, II In cases of severe injury,
support to the contralateral limb is essential to
decrease the chances of contralateral limb lamini-
tis. This can be provided in the form of frog and
caudal support, heel elevation, and decreased
breakover. Commercial shoes are available and
work well for this purpose (Redden Modified
Ultimate, Nanric Inc. , Versailles, Ky.).
EXPECTED OUTCOME
With optimal treatment, riding soundness occurs
in approximately 75% of extensor tendon lacera-
tions and 50% of flexor tendon lacerations.
'2
-
'4
Return to significant athletic activity has been
reported in 23% to 50% of flexor tendon lacera-
tions
12
·
'4
and 71 % of extensor tendon lacerations.
'2
COMPLICATIONS
Complications of extensor tendon lacerations
include wound infection, dehiscence, bone seques-
tra, excessive granulation tissue, stringhalt gait,
and fetlock contracture if the limb is chronically
flexed because of pain or inadequate extensor
tendon function. Wound infection, dehiscence,
sequestrum formation, and excessive granulation
tissue can be managed by local debridement
and wound therapy. Stringhalt development is
uncommonly seen after wounds in the proximal
dorsal metatarsal region and may require surgery
for treatment.
l s
Distal limb contracture can be
prevented by monitoring for adequate use of the
lower limb and splinting as needed.
Compli cations of flexor tendon lacerations
include dehiscence, wound infection, tendon
degeneration secondary to infection, inadequate
repair strength, vascular compromise to the lower
limb, cast complications, adhesions, contracture,
and contralateral limb laminitis. Dehiscence and
wound complications are managed by debride-
ment and second intention healing. Inadequate
repair strength is best prevented and managed by
adequate limb immobilization and a gradual
decrease in limb support. No direct treatment is
availabl e for vascular compromise. Cast compli-
cations are common but can be minimized by
careful daily monitoring of the cast and cast
changes as indicated. Contracture is a complex
probl em resulting from prolonged immobiliza-
tion or pain and healing with excessive surround-
ing scar tissue. Flexor tendon lacerations in
nonsheathed areas are less likely to have this
compli cation, and a gradually increasing exerci se
program improves most cases. Contralateral limb
laminitis is a severe complication. Appropriate
support of the contralateral limb and early aggres-
sive treatment for the primary problem can min-
imize its occurrence. Appropriate treatment for
contralateral limb laminitis includes corrective
shoeing, deep bedding, stall rest, analgesics and,
ideally, resolution of the primary problem.
ALTERNATIVE PROCEDURES
Annular ligament desmotomy may be indj cated
in some cases if superficial or deep digital
flexor tendon swell ing is impeded by the annular
ligament. Typically, this is performed several
weeks or even months after the tendon injury. A
limited case report suggests that annular ligament
desmotomy within 1 to 3 days after acute super-
ficial tendon rupture in racehorses may be
beneficial.
'6
66 LIMB SURGERIES
COMMENTS
Although the modified fa r-near-near-far sut ure
pattern is not as strong as the compound locking
loop or three-loop pulley patterns. it is simple to
perform and does not require extensive exposure
to perform. Placement of the near bites axial to
the far bites may decrease suture pull-out. It is
most usefuJ for superficial digital fl exor tendon
and extensor tendon repair.
REFERENCES
I. Bertone AL: Infectious tenosynovitis. Vet Cli,l N
Am Equille Pmcl 11:163, 1995.
2. Gaughn EM: Orthopedic wounds tendon and
tendon sheath, Proc Am Coil Vet Surgeolls Vet Symp
13: 167,2003.
3. Honnas eM, Schumacher J, Watkins JP, et aJ: Diag-
nosis and treatment of septic tenosynovitis in
horses, Comp COllt Educ 13:301, 199 1.
4. Bertone AL, Stashak TS, Smith FW, et al: A com-
parison of repair methods for gap healing in equine
flexor tendon, Vet SlIrg 19:254, 1990.
5. Jann HW, Good JK, Morgan SJ. et al: Healing of
t ransected equine superficial digital flexor tendons
with and without tenorrhaphy, Vet SUtg 21:40,
1992.
6. Bertone AL: Tendon lacerations. Vet Clill N Am
Equille Pmct 11:293,1995.
7. Watkins JP: Treatment principles of tendon disor-
ders. In Auer lA. Stick lA, editors: Equine surgery,
Philadelphia, 1999, WB Saunders.
8. Adair HS, Gobel DO, Rohrback BW: In vitro com-
pa rison of the locking loop and the three loop
pulley suture techniques in the repair of equine
flexor tendons, } Equille Vet Sci 9: 186, 1989.
9. Jann HW, Stein LE, Good JK: St rengt h characteris-
tics and failure modes of locking-loop and three-
loop pulley suture patterns in equine tendons, Vet
511rg 19: 18, 1990.
10. Lochner FK, Milne OW. Mills EJ, et al: In vivo and
in vitro measurement of tendon strain in the horse.
Alii VetJ Res 41:1929, 1980.
11. Hendrickson DA, Stokes M, Wittern C: Use of an
elevated boot to reduce contralateral support limb
complications secondary to cast appl ication, Proc
Am Assoc Equi1le Pmc 43: 149, 1997.
12. Belknap JK, Baxter GM, Nickels FA: Extensor
tendon laceration in horses: 50 cases (1982- 1988),
J Alii Vet Med Assoc 203:428, 1993.
13. Foland JW, Trotter GW, Stashak C, et al: Traumatic
injuries involving tendons of the distal limbs in
horses: a retrospective study of 55 cases, Equine Vet
J 23:422, 1991.
14. Taylor DS, Pascoe JR, Meagher OM. et al : Digital
flexor tendon lacerations in horses: 50 cases. ( 1975-
1990), J Am Vet Med Assoc 206:342, 1995.
15. Crabill MR, Honnas eM, Taylor DS. et al : String-
halt secondary to trauma to the dorsoproxi mal
region of the metatarsus in horses 10 cases ( 1986-
1991 ), J Am Vet Med Assoc 205:867,1994.
16. Mackay-Smith MP: How to surgically treat and
post-operatively rehabilitate acute athletic rupture
of superficial digital flexor tendon, Proc Am Assoc
Equine Pract 47:279.2001.
CHAPTER 10
Annular Ligament Desmotomy
Joanne Kramer
INDICATIONS
Annular ligament constriction caused by primary
annular ligament desmitis (Figure 10-1) and
annular ligament constriction secondary to ten-
donitis or sept ic tenosynovitis.
EQUIPMENT
Closed techniques are performed with a Mayo
scissors, bistoury knife, or groove director.
ANATOMY
The palmar-plantar annular ligament attaches on
the abaxial surfaces of the proximal sesamoid
bones and partially surrounds the tendon sheath
blending with its palmar-plantar wall and making
up the palmar-plantar wall of the fetlock canal
( Figure 10-2). The proximal and distal extent of
the palmar-plantar annular ligament can be esti-
mated by palpating the apex and base of the
sesamoid bones.
POSITIONING AND PREPARATION
The horse is positioned in lateral recumbency.
The circumference of the limb should be
clipped and prepared aseptically from the mid
metacarpus- metatarsus region distally.
67
PROCEDURE
Open Te(hnique
A 6- to 8-em skin incision is made over the lateral
aspect of the superficial digital flexor tendon
(SDFT) at the level of the palmar annular liga-
ment. The incision is made palmar to the neu-
rovascular bundle and should be just axial to the
palmar edge of the sesamoid bone' (see Figure 10-
2). A small incision is made in the proximal
border of the digital sheath or annular ligament,
and a groove director or forceps is passed under
the annular ligament to act as a guide for further
transection. The incision is continued through the
entire proximal annular ligament, being careful
not to damage the underlying tendons (Figure
10-3). The flexor tendons and exposed sheath
are examined for adhesions. If present, they are
resected. The tendon sheath is lavaged as required
by the primary probl em.
Subcutaneous tissues are closed with No. 2-0
absorbable suture in a continuous or interrupted
pattern. The skin is closed with an interr upted
pattern.
Closed Te(hnique
This is the preferred method if the tendons within
the fetlock ca nal do not need to be exposed. A 2-
cm incision is made through the ski n just proxi-
mal to the palmar annular ligament. The sheath is
entered through a similar or smaller incision, and
the distal extent of the annular ligament is defined
68 LIMB SURGERIES
Figure 10-1 Appearance of a limb with const riction
of the palmar annular ligament.
by passing a groove director or forceps under
the annular ligament and palpating the distal end
of the ligament (Figure 10-4). Care should be
taken to exclude the proximal digital annular lig-
ament. The annular ligament is then transected by
passing a bistoury knife underneath the ligament
and transecting the ligament (Figure 10-5, A, B)
or by passing the groove director underneath the
ligament to guide a scalpel blade' (Figure 10-5, C).
Care must be taken to not incise the skin if the
bistoury knife is used. Alternatively, the annular
ligament can be transected with scissors. A small
subcutaneous plane is created for I blade of the
scissors, and the annular ligament is transected by
closing the blades of a scissors passed so that one
blade of the scissors is deep to the annular liga-
ment and the other blade superficial to the liga-
ment in the subcutaneous plane created
2
(Figure
10-6). The tendon sheath can then be lavaged as
requited by the primary problem.
If the incision in the proximal tendon sheath is
large, it can be closed with No. 2-0 absorbable
suture. Subcutaneous tissues are closed with No.
2-0 absorbable suture. The skin is closed in an
interrupted pattern.
A
neurovascular
bundle
(the circle)
Site of
approach

• J.
. -
" .. i
, .
• •

..


• ,
B
- DDF tendon
Tendon
sheath
annular lig.
--.., SDF tendon
~ t ; . t : ~
Figure 10-2 The palmar-plantar annular ligament attaches on the abaxial surfaces of the proximal sesamoid bones
and partially surrounds the tendon sheath blending with its palmar-plantar wall and making up the palmar-plantar
wall of the fetlock canal. A. Lateral view. B, Cross section.

~ e . . . , . , . t ; ; . . t a . . . .
Figure 10-3 Transecti on of the annular ligament
using the open technique.
A
'1
\
\
\
B
Annular Ligament Desmotomy 69
Figure 10-4 Entrance into the digital sheath through
a small skin incision proximal to the palmar annular
ligament in a closed annular ligament resection. ArrolVs
show the approximate proximal and distal borders of
the pal mar annular ligament.
c
Figure 10-5 The 3nl1 uJar ligament is transected by A, passing a bistoury kni fe underneath the ligament, B, rotat-
ing the bistoury knife 90° so that the cutting edge is toward the ligament, and transecting the ligament, or C, passing
the groove director underneath the ligament to guide a scalpel blade.
70 LIMB SURGERIES
Figure 10-6 The annular ligament can also be
transected with scissors. A. A small subcutaneous
plane is created for one blade of the scissors, and
B, the annular ligament is transected by closing
the blades of a scissors passed so that one blade of
the scissors is deep to the annular ligament and
the other blade is superficial to the ligament in the
subcutaneous plane created.
POSTOPERATIVE CARE
Postoperative (are
A
Bandaging: A sterile dressing is placed over the
incision and a half limb bandage is applied. The
initial bandage is changed 24 hours after surgery.
Subsequent bandage changes are performed at 4-
to S-day intervals or more frequently if indicated.
Bandaging is applied for a minimum of 4 weeks
regardless of whether the open or closed technique
is performed.
Exercise Restridions: Stall rest is provided for 10
days, after which a gradual increase in daily hand-
walking is important to minimize adhesion forma-
tion. In cases without underlying tendon pathology,
light daily lunging at a trot or limited small paddock
turnout may be performed 3 weeks postoperatively.
Gradual return to work may begin in 6 weeks or as
indicated by the healing of any underlying tendon
• •
InJury.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and at
2.2 mg/kg BID for an additional 5 days. Further
EXPECTED OUTCOME
After desmotomy, the lower limb profile has
mild to moderate symmetrical enlargement
resulting from release of the constricting liga-
ment. This decreases over time, but it is rare
for a completely normal cosmetic appearance to
return. The prognosis for soundness is good for
cases with primary constriction or thickening of
the annular ligament. Cases with minor tendon
I ) \ \
.11 '
B
phenylbutazone therapy is dictated by underlying
tendon damage and the level of lameness present.
Antibiotic therapy is continued in cases with preex-
isting infection and in select cases where delayed
incisional healing is anticipated.
Suture Removal: Skin sutures are removed
12 days postoperatively.
Intrasynovial Medications: Intrasynovial so-
dium hyaluronate is a useful adjunctive therapy
in cases where adhesions have been transected
or a high level of inflarnmation is present within
the sheath. Although sodium hyaluronate has
been shown in an experimental adhesion model
to decrease adhesion formation and increase
hyaluronic acid content within the digital sheath,'
no products are specifically labeled for digital
sheath use. The author has used 20 to 40 mg
of sodium hyaluronate labeled for intraarticular
use at the time of surgery and 10 to 14 days
postoperatively.
lesions can also have a good prognosis, but exten-
sive tendon lesions or significant sheath adhesions
limit future soundness. The prognosis is guarded
for cases with septic tenosynovitis.
COMPLICATIONS
Complications include wound dehiscence, septic
tenosynovitis, synovial fistula formation, and
adhesions. Complications are rare following the
closed technique. The use of the open technique
increases the risk of complications, but with
appropriate postoperative care and monitoring,
complications are not common.
ALTERNATIVE PROCEDURES
Extrasynovial Transection
Performance of an annular ligament desmotomy
without entering the tendon sheath has been
described.
4
The technique relies on the presence of
a small extrasynovial space between the SDFT and
the palmar annular ligament_ A 2-cm skin incision
is centered between the proximal border of
the annular ligament and the ergot on palmar or
plantar midline. Sharp dissection is continued
through the subcutaneous tissues until the trans-
verse fibers of the annular ligament are identified.
Careful sharp dissection is conti nued through the
annular ligament until the division between the
annular ligament and longitudinal fibers of
the SDFT is identified through a 5-mm incision
in the annular ligament. Curved Kelly forceps are
directed through the incision in the annular liga-
ment to identify the dissection plane. The Kelly
forceps are opened several millimeters and a
No. 15 blade is used to inci se the ligament. The
forceps are advanced distally and then turned and
advanced proximally to allow complete incision of
the ligament. In most cases, the palmar axial
attachment of the fl exor sheath to the SDFT on
either side of midline can be seen in the surgical
field.
Desmoplasty
Desmoplasty of the annular ljgament has been
described in four horses with primary annular lig-
ament desmitis. s The procedure involves identify-
ing hypo echoic lesions in the annular ligament
Annular Ligament Desmotomy 71
and under ultrasound guidance, creating partial-
thickness incisions in the hypoechoi c regions with
a No. II blade.
Endoscopic Transection
Endoscopy of the digital sheath with guided
transection of the annular ligament has also been
described
6
-
s
and offers an improved prognosis for
horses with digital sheath pathology.
REFERENCES
1. Adams SB, Fessler JF: Palmar-plantar an nular liga-
ment division. In Adams SB, Fessler JF, editors: Atlas
of equifle Sl/rger)', Philadelphia, 2000, WB Saunders.
2. Turner AS, Mcllwraith CW: Sectioni ng of the
palmar or plantar annular ligament of the fetlock.
In Turner AS, Mcllwraith CW, editors: Techniques
ill large allimll( sllrgery, Philadelphia, 1989, Lea &
Febiger.
3. Gaughan EM, Nixon AJ, Krook LP, et al: Effects of
sodium hyaluronate on tendon healing and adhe-
sion for mation in horses, Am J Vet Res 52:764, 1991.
4. Hawkins DL, Churchill EA: Extrasynovial
palmar/ plantar an nular ligament desmotomy, Proc
Am Assoc Eqlline Pmc 44:210, 1998.
5. McGhee JD, White NA, Goodrich LR: Primary
desmitis of the palmar and plantar annular liga-
ments in horses: 25 cases ( 1990-2003), } Am Vet Med
Assoc 226:83, 2005.
6. Fortier LA, Nixon AJ, Ducharme NC, et al: Teno-
scopic examination and proximal annular ligament
desmotomy for treatment of equi ne complex digital
sheath tenosynovitis, Vet Surg 28:429, 1999.
7. Nixon AJ, Same AE, Ducharme NG: Endoscopic
assisted annular ligament release in horses, Vet Surg
22:501, 1993.
8. Wilderjans H, Boussauw S, Madder K, et al:
Tenosynovitis of the digital flexor tendon sheath and
annular ligament constriction syndrome caused by
longitudinal tears in the deep digital flexor tendon:
a clinical and surgical report of 17 cases in Warm-
blood horses, Equine Vet} 35:270, 2003.
CHAPTER 11
Lateral Digital Extensor Tenectomy
Joanne Kramer
INDICATION
Treatment of conventional stringhalt (Figure
11-1 ).
EQUIPMENT
Large Carmalt forceps are used for removi ng the
muscJ e tendon unit from the proximal incision.
ANATOMY
The lateral digital extensor muscle of the hind
limb ori ginates from the lateral collateral ligament
of the stifle and the adjacent region of the tibia
and fibula. It proceeds lateral to the long digital
extensor muscle and enters its tendon sheath in
the groove of the lateral malleolus of the tibia. In
this region, the tendon and sheath are covered by
extensive crural fascia and the distal extensor reti-
naculum of the tarsus. Just distal to the tarsus, the
lateral digital extensor tendon joins the long
digi tal extensor tendon (Figure 11-2).
POSITIONING AND PREPARATION
The procedure is performed with the horse under
general anesthesia in lateral recumbency with
the affected limb up or standing with sedation
and local anest hesia. When the procedure is
72
performed standing, local anesthetic is infiltrated
directly over and deep to the distal and proximal
skin incision sites. The lateral aspect of the mid to
distal tibi a and the proximal metatarsal region are
clipped and prepared aseptically.
PROCEDURE
A 3 ~ c m incision is made directly over the palpa-
ble lateral digital extensor tendon just proximal to
its junction with the long digital extensor tendon.
The tendon is elevated to the level of the incision.
A second lO-cm vertical ski n incision is made
directly over the lateral digital extensor starting at
the muscle tendon junction and extending proxi-
mally (Figure 11-3, A). Pulling on the isolated
lateral digital extensor tendon in the distal inci-
sion can be used to guide the exact location of the
proximal incision. The subcutaneous tissue and
fasciae are incised to expose the lateral digital
extensor muscle belly. Blunt di ssection and large
Carmalt forceps are used to el evate the muscle to
the level of the incision. A small amount of sharp
and blunt dissection is also used to free restrict-
ing tissue from the muscle tendon unit. The lateral
digital extensor tendon is then excised in the distal
incision (Figure 11 -3, B). The entire tendon is
then pulled through the proximal incision (Figure
11-3, C). This is the most difficult aspect of the
procedure and is best accomplished by placing
large forceps underneath the tendon of the lateral
digital extensor muscle and pulling proximally
and laterally. The muscle is then severed in the
I
Figure 11-1 Marked hyperflexion of the hock in a
horse with a stringhalt gait.
Tendon of long
digital extensor m.----l,
Digital
retinaculum
A
Tendon of lateral
digital extensor m.
lateral Digital Extensor Tenectomy 73
proximal portion of the incision so that at least 2
cm of muscle is removed (Figure 11-3, DJ. [f nec-
essary, the remaining muscle stump is cauterized
or Qversewn with absorbable suture material in a
Halstead or Cushing pattern. Some surgeons
believe the success rate of the surgery increases
with removal of more muscle, and in some cases
recurrence of stringhalt has been treated with
resection of an additional 3 to 4 inches of lateral
digital extensor muscle. 1,2 The crural fasciae are
then closed with a simple interrupted or
simple continuous pattern with No. 0 synthetic
absorbable suture material. Closure of the subcu-
taneous tissue is optional. The skin is closed with
No. 0 suture material in an interrupted or contin-
uous pattern of the surgeon's choice. The distal
incision requires closure of the skin only.
Long digital-
extensor m.
Lateral digital
extensor
Long digital
Lateral digital
extensor tendon

.-:;.. .
. .
~ :" . . . ~ ­
• •
· . - . , '. ~
• •

. -
- --
~ -{.

B
-
c
Figure 1 1 ~ 2 A, Location of the lateral digital extensor muscle and tendon with cross sections near B. the muscle-
tendon junctions and C. distal incision site.
74 LIMB SURGERIES
b
a
A c
B
o
~ _ ~ . 1 ! . ,
Figure 11-3 A, A 3-cm incision is made directly over the palpable lateral digital extensor tendon just proximal to
its junction with the long digital extensor tendon (aJ . A second lO-cm verti cal skin incision is made directly over the
lateral digital extensor starting at the muscle-tendon junction and extending proxi mally (b). B, The lateral digital
extensor tendon is excised in the distal incision. C. The entire tendon is pulled through the proximal incision. D, The
muscle is severed in the proximal portion of the incision so that at least 2 em of muscle is removed.
POSTOPERATIVE CARE
Postoperative Care
Bandaging: A sterile dressing is placed over the
incisions and a full limb bandage is placed from
the proximal tibia distally. The bandage is changed
as needed every 2 to 4 days and maintained until
the incisions have healed.
Exercise Restridions: Stall rest is required for
2 weeks and followed by small area turnout for 2
weeks.
Meditations: Phenylbutazone is administered at
4.4 mg/kg BID for 24 hours.
Suture Removal: Skin sutures are removed 12
days postoperatively.
EXPECTED OUTCOME
Although positive results from the surgery are
often dramatic and very rewarding) owners
should be forewarned that the results of the
surgery are variabl e and cannot be predicted.
Improvement, when present, may occur in the
immediate postoperative period or days to
months after the surgery.
2
COMPLICATIONS
Dehiscence of the incision may occur) especially if
a stringhalt gait persists in the earl y postoperative
period. Seroma or hematoma formation associ-
ated with the stump of the lateral digital extensor
muscle may also occur.
COMMENTS
Stringhalt is a gait abnormality characterized by
exaggerated hyperfl exion of one or both hind
limbs. Several forms have been described. The
Australian, or outbreak, form of stringhalt is bilat-
eral, occurs in groups of horses on pasture, and is
thought to be caused by a plant toxin. It has been
identified in Australia, New Zealand, and Califor-
nia.
3
,4 The Australian form and possibly other
forms of st ringhalt have been shown to have an
underlying neuTopathy.4,S
Conventional, or classic) stringhalt occurs
in individual horses and is typically unilateral.
The majority of conventional stringhalt cases have
no known initiating factors. Some cases are as-
sociated with trauma to the dorsal proximal
metatarsal region, with the suspected etiologies
being adhesion formation involving the lateral
digital extensor tendon and altered myotactic
response due to injury,6 Other causes of stringhalt
may be peripheral neuropathy associated with
neurologic disease such as equine protozoal
myelitis.
5
In one report, a stringhalt-like gait improved
after local anesthesia of the tarsometatarsal and
distal intertarsal joints and resolved after intraar-
ticular corticosteroid treatment.
7
The authors
have also observed stringhalt-like gaits in horses
with thin soles after trimming and horses with
hind limb laminitis. These horses have a normal
or significantly inlproved gait on soft footing or
after abaxial anesthesia.
When a horse is presented with a stringhalt-
like gait, a di etary history, neurologic exam, and
search for identifiable sources of pain should
be undertaken and treatment is based on these
results if indicated. Surgical treatment is generally
indicated for cases of stringhalt associated with
dorsal metatarsal trauma or horses with stringhalt
of unknown etiology. One author recommends
surgical treatment if t h ~ gait improves after local
anesthetic solution is injected into the lateral
digital extensor muscle.
s
With the exception of the stringhalt gait, many
cases will have an unremarkable history and din-
ical examination. The improvement in gait after
surgery is difficult to predict for individual cases,
,
lateral Digital Extensor Tenedo y 7S
but the authors have not seen ' diopathic cases
improve without surgery. In horses with stringhalt
secondary to dorsal metatarsal trauma, response
to treatment was reported in nine horses.
6
Of the
four horses treated with exercise, one resolved,
two improved, and one had no change in gait. Of
the five horses treated surgically, two resolved, two
had gait improvement, and one had no change in
gait.
REFERENCES
I. Turner AS, McJlwraith CW: Lateral digital extensor
tenotomy. In Turner AS, McIlwraith CW, editors:
Techl1iques ill large allima{ surgery, Philadelphia,
1989, Lea & Febiger.
2. Sullins KE: Lameness. Part X. The tarsus. In Stashak
TS, editor: Adam's lame/less in horses, Philadelphia,
2002, Lippincott, Will iams and Wilkins.
3. Adams SB, Fessler IF: Lateral digital extensor
myotenectomy for stringhalt. In Adams SB, Fessler
J F, editors: Atlas oj equine surgery, Philadelphia,
2000, WB Saunders.
4. Siocombe RF, Huntington PI, Fr iend SCE, et al:
Pathological aspects of Australian stringhalt, Eqllille
Vet/24:174,1992.
5. Valentine B: Mechanical lameness in the hindlimb.
In Ross MW, Dyson 5J, editors: Diag1l0sis a1ld man-
agement oj lame1less i1l the horse, St Louis, 2003, WB
Saunders.
6. Crabill MR, Honnas eM, Taylor OS, et al: Stringhalt
secondary to trauma to the dorsoproximal region of
the metatarsus in horses: 10 cases (1986- 1991), J Am
Vet Med Assoc 205:87,1994.
7. Hebert C, Jahl1 HW: Intra-articular corticosteroid
treatment for stringhalt in a Quarter horse a case
report, J EquinE Vet Sci 14:53, 1994.
8. Bennet SD: Lameness in the American Saddlebred
and other trotting breeds with collection. In Ross
MW, Dyson SJ, editors: Diagnosis and mallage-
ment of lameness ill the horse, St Louis, 2003, WB
Saunders.
CHAPTER 12
Medial Patellar Desmotomy
Joanne Kramer
INDICATIONS
Horses with persistent upward patellar fixation or
horses with continued intermittent upward patel-
lar fixation after appropriate conditioning and
maturation have been achieved (Figure 12-1).
EQUIPMENT
A blunt- tipped bistoury knife is used to transect
the medial patellar ligament.
POSITIONING AND PREPARATION
Surgery is performed with the horse standing. The
limb should be fully weight bearing with the stifle
extended. The tail should be wrapped and tied out
of the surgical field. The medial aspect of the stifle
region is clipped and prepared aseptically. Local
anesthetic is injected subcutaneously cranial and
deep to the medial patellar li gament.
ANATOMY
The medial patellar ligament inserts distally in a
groove on the proximal medial aspect of the tibial
tuberosity and proximally on the medial aspect of
the patella through the para patellar fibrocartilage.
Upward fixati on of the patella occurs if during
76
maximal stifle extension the fi brocartilage is ele-
vated and rotated over the medial trochlear ridge
of the femur' (Figure 12-2). The patella is released
when the patella is rotated laterally and elevated
slightly by the quadriceps to clear the medial
trochlear ridge. The locked and unlocked posi-
tions of the patella are shown in Figures 12-1
through 12-4.
PROCEDURE
With the limb fully weight bearing and the
stifle extended. a 2-cm vertical skin incision is
made just cranial to the distal part of the medial
patellar ligament (Figure 12-5) . Curved Kelly
forceps are advanced under the medi al patellar
ligament to create a plane of dissecti on deep to the
medial patellar ligament. Keeping close to the
medial patellar ligament and on its distal aspect,
a bistoury knife or Bard Parker handle with a new
No. 10 blade is advanced under the medial patel-
lar ligament with the cutting side facing distal.
When the tip of the blade or bistoury knife is pal-
pabl e on the caudal side of the medial patellar lig-
ament, the instrument is rotated 90 degrees and
the medial patellar ligament is severed (Figure 12-
6). When the ligament is transected, the stifle will
fl ex slightly. After transection. the aponeurotic
insertion of the sarto rius muscle is palpable just
caudal to location of the patellar ligament.
2
-
4
The
skin is closed with interrupted sutures.
..
-
-
- -
-
-..
- .;"1 ' T
Figure 12-1 A horse with upward fixation of the
patella. Note the extended stifl e and hock and flexed
distal limb.
Cartilaginous process
(parapatellar
fibrocartilage)
Medial
patellar
Figure 12-2 The locking mechanism.
Patellar
ligaments:
medial---:c-:-
Cartilaginous process
(parapatellar fibrocartilage) ..__--..
lateral-
Incision site
Medial Patellar Desmotomy 77
-
-
.
-

- .
-
-
-
Figure 12-3 Exaggerated flexion of the limb after
release of the patella.
-
-
-

-
.. r
-
Figure 12-4 Nor mal limb position at the start of the
next stance phase.
Figure 12-5 Location of the skin incision for
medial patellar desmotomy.
78 LIMB SURGERIES
Figure 1 2 ~ 6 Transection of the medial patellar liga-
ment with a bistoury knife.
Postoperative Care
Bandaging: None is practical or required in this

region.
Exercise Restridions: Stall rest with handwalk-
ing for 2 weeks followed by small paddock turnout
for a minimum of 90 days after the surgery.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for 24 hours.
Suture removal: Skin sutures are removed 12
days postoperatively.
EXPECTED OUTCOME
If rested extensively after surgery, most horses
have an uneventful recovery and return to their
intended use. A retrospective study supports a
high return to athletic activity with appropriate
case selection.
5
Fragmentation of the patella or
middle patellar ligament desmitis may occur in
some horses. If associated with lameness, frag-
mentation of the patella may require arthroscopic
treatment. 6,7
COMPLICATIONS
Surgical errors are rare but include entrance into
the femoropatellar joint capsule, severance of the
medial femorotibial or middle patellar ligament,
and incomplete transection of the medial patellar
ligament. If a blade is used for transection and is
not securely attached to the handle, it may detach
when being turned 90 degrees against the liga-
ment. Medial patellar ligament desmotomy may
predispose horses to distal fragmentation of the
patella from increased stress on the middle patel-
lar ligament.
6
,7 A case of apical fracture has also
been reported.
s
Extensive fibrosis or surgical site
swell ing may also develop and usually resolves
with extended rest but rarely results in lameness
or recurrent upward patellar fixation.
9
ALTERNATIVE PROCEDURES
A modification of the procedure performed under
general anesthesia that involves transection of the
aponeurosis of the gracilis and sartorius in addi-
tion to the medial patellar ligament transection
has been described. 1O This procedure may mini-
mize the risk of recurrent fixa tion.
Medial patellar ligament splitting has been
described as an alternative to medial patellar lig-
ament desmotomy.ll The procedure induces a
localized desmitis and thickening of the ligament
that theoretically makes locking the patella more
difficult. Using ultrasound guidance, percuta-
neous splitting of the proximal third of the medial
patellar ligament is performed. Advantages of the
procedure include a reported high success rate
with early return to work after surgery, and
reduced incidence of fragmentation of the patella
and middle patellar ligament desmitis.ll
Injections of counteri rritants into the medial
and middle patellar ligaments have been used as
a treatment for intermittent upward patellar
fixation and may work by creating fibrous tissue
that restricts stretching of the medial patellar
ligament.
12
,13
COMMENTS
In a horse with upward patellar fixation, the limb
is positioned with the stifle and hock held in
extension with the distal limb held in partial
fl exion (see Figure 12-1). Release of the limb often
occurs with a quick and exaggerated flexion (see
Figure 12-3) . Three situations have been
described.
2
Persistent fixat ion occurs when the
patella remains fixed for a prolonged period of
time, often requiring assistance or multipl e
attempts by the horse to release the patella. Inter-
mittent fixa tion occurs when the patella remai ns
fixed with the limb held in extension behind the
horse for several seconds and then is released
during a normal step. Momentary fixat ion occurs
when the patella temporarily fixes, causing a slight
delay in the start of protraction and a slightly
exaggerated flexion when the limb is released.
Conservative therapy should always be
attempted before surgical correction of upward
patellar fixation. Most cases of intermittent up-
ward patellar fixation occur in young horses
with poor quadriceps condition or in horses that
have had a period of extended stall rest. These
horses often respond to an exercise program that
increases the strength of the quadriceps and sur-
rounding musculature. Cases t hat are candidates
for surgery have intermittent upward patell ar fix-
ation despite adequate condi tioning programs or
have persistent locking that cannot be manually
released or recurs after release.2.4·6, '4
Although most cases of upward patellar
fixation are primary, upward pateUar fixation
can occur secondary to neurologic disease and to
stifle pathology and in horses with coxofemoral
joint luxation.
4
,'4.'7 If necessary, these conditions
should be ruled out before performing surgery.
Because of possible fragmentation of the distal
patella and middle patellar ligament desmitis after
desmotomy, the amount of postoperative rest has
been increased. The optimum rest period for
healing is not known. Current recommendations
vary and include 4 to 6 weeks if no signs of lame-
ness are present,S 2 to 3 months,9.'8 2 to 5 months,4
and 4 to 5 months.
6
REFERENCES
I. Dyce KM, Sack WO, Wensing CJG: The hindlimb
of the horse. In Dyce KM, Sack WO, Wensing CJG,
editors: Textbook of veterillary anatomy, Philadel -
phia, 1987, WB Saunders.
Medial Patellar Desmotomy 79
2. Adams S8, Fessler IF: Medial patellar desmotomy.
In Adams S8, Fessler JF, editors: Atlas of equine
surgery, Philadelphia, 2000, WB Saunders.
3. Jansson N: Treatment fo r upward fixat ion of the
patella in the horse by medial patella r des motomy
indications and complications. Equine Pract 18:24,
1996.
4. Walmsley JP: The sti fle. In Ross MW, Dyson 51,
editors: Diagllosis and mallagemem of lame1less in
the horse, Philadelphia, 2003, WB Saunders.
5. Bathe AP, O'Hara LK: A retrospective study of the
outcome of medial patellar ligament desmotomy in
49 horses, Proc Am Assoc Equine Pract 50:476, 2004.
6. Gibson K, Mcl lwraith CW, Parks RD, et al:
Producti on of patellar lesions by medial patellar
desmotomy in normal horses, Vet Surg 18:466,
1989.
7. Mcllwraith CW: Osteochondral fragmentation of
the distal aspect of the patella in horses, Equine Vet
]22:157,1990.
8. Riley CB, Yovich JV: Fracture of the apex of the
patella after medial patellar desmotomy in a horse,
Aust Vet J 68:37, 1991.
9. Dyson 51: Patellar injuries. In White NA, Moore TN
editors: Curreflt techniques ill equine surgery and
lameness, Philadelphia, 1998, WB Saunders.
10. Wright I: Ligaments associated wi th joi nts, Vet Ciin
N Am Equille Pract II :249, 1995.
11. Tribnar MA: Medial patellar ligament splitting for
the treatment of upward fixation of the patella in 7
equids, Vet Surg 3 1 :462, 2002.
12. Brown M: The effects of an injection of counterir-
ritant into the patellar ligament of ponies: applica-
tion to st ifle lameness, J Equine Vet Sci 3: 149, 1983.
13. van Hoogmoed LM, Agnew DW, Whitcomb MB, et
al: Ultrasonographic and histologic eval uation of
medial and middle patellar ligaments in exercised
horses followi ng injections with ethanolamine
oleate and 2% iodine in almond oil, Am J Vet Res
63:738, 2002.
14. Sullins KE: Lameness. Part XII. The stifle. In Stashak
TS, editor: Adam's lameness ill horses. Philadelphia.
2002, Lippincott Williams and Wilkins.
15. Black 18: The Western performance horse. In Ross
MW, Dyson SJ, editors: Diagllosis and management
of lameness ill the horse, Philadelphia, 2003, WB
Saunders.
16. Walmsley 1P: Medial desmotomy for upward fixa-
tion of the patella, Equine Vet Educ 6: 148, 1994.
17. Clegg PO, Butson RJ: Treatment of coxofemoral
joint luxation secondary to upward fixa tion of
the patella in a Shetland pony, Vet Rec 138: 134,
1996.
18. Latimer FG: Tarsus and stifle. In Hinchcliff KW.
Kaneps AI, Geor RJ, editors: Equille sports medicine
and surgery, New York, 2004, WB Saunders.
1 __________________________________________________________________ __
CHAPTER 13
Distal Check Ligament Desmotomy
Joanne Kramer
INDICATIONS
The primary indication for distal check li ga-
ment desmotomy is deep digital flexor tendon
(DDFT) contracture with coffin joint contrac-
ture (Figure 13- 1). It is also occasionally used in
the treatment of metacarpophalangeal fl exural
deformities and in the treatment of caudal foot
lameness with upright hoof wall or pastern con-
formation.
EQUIPMENT
Specialized instruments are not required for
this surgery. The foot should be trimmed
and examined for subsolar abscesses. Toe exten-
sions are applied in some cases to protect the
toe and to provide a lever arm during breakover
to gradually stretch the DDFT (Figures 13-2 and
13-3).
ANATOMY
The distal check ligament wraps around the
DDFT on the dorsal and lateral surface of the
DDFT and often forms a sli ght C shape around
the DDFT (Figure 13-4). The palmar vei n, artery,
and nerve lie close to the DDFT and distal check
ligament (see Figure 13-4). Care should be taken
to not exteriorize or transect these with the check
ligament.
80
POSITIONING AND PREPARATION
The horse is positioned in lateral recumbency
with the affected limb up. When both limbs are
affected, the distal check ligament on the down
side can be approached medially. Alternatively, the
horse may be positioned in dorsal recumbency
when the condition is bilateral. The ci rcumference
of the limb should be clipped and prepared asep-
tically from the fetlock to the mid carpal region.
PROCEDURE
A 6-cm skin incision is made near the distal end
of the proximal third of the metacarpus over the
DDFT (Figure 13-5). The approach can be per-
formed on the lateral or medial aspect of the limb.
The lateral approach is generally simpler and is
fa rther from the neurovascular bundle. The sub-
cutaneous tissues and palmar fascia are incised,
and the intersection between the distal check li g-
ament and DDFT is palpated or visualized (Figure
13-6). The intersection between the DDFT and
distal check ligament is usually found best by pal-
pation with fingers or the tip of an instrument.
Occasionally, it can be visualized. Because of the
C shape of the distal check ligament) it often
wraps around the DDFT such that the DDFT is
deep to the intersection of the superficial digital
flexor tendon and distal check ligament.
Blunt dissection between the distal check liga-
ment and DDFT with a curved Kelly forceps or
Figure 13-1 Deep digital flexor tendon contracture in the
left foreli mb.
Figure 13-2 A toe extension created by setti ng a larger
size shoe forward after trimming.
Figure 13-3 A toe extension created with acryli c hoof
material.
Distal Check ligament Desmotomy
.-

. ~ "
- ' .

-
" •
-

,. .
-
81


82

I
L IMB S URGER IES
Common tendon
sheath of SDF and DDF
Communicating
branch
,--- Interosseous --
medius
(suspensory lig.)
Lateral palmar v.a.
(palmar common
digital v. III)
Lateral palmar n'
palmar v.a.
palmar n.
SDF tendon
Communicating branch
Figure 1 3 ~ 4 Anatomy of the distal check ligament and palmar metacarpus.
\ / Site of
approach
I
Figure 13-5 Location of the ski n
incision for distal check ligament
desmotomy,
DDFtendon
''<-'- - Distal
check lig.

Figure 13-6 Ident ificatio n of the intersection be-
tween the distal check ligament and DDFT.
Figure 13-7 Intraoperative view of the exteriorized
check ligament.
-;lG>c.ot;..t(... .
Figure 13-8 Exteriorizat ion of the check ligament
with curved forceps.
Metzenbaum scissors is used to separate the struc-
tures and exteriorize the check ligament (Figure
13-7), To enable exteriorization of the entire
check ligament, it is helpful to dissect bluntly to
the far side of the tendon bundle with the curved
tips facing palmar and then rotate the ti p dorsally
when exteriorizing the check ligament (Figure
13-8).
Distal Check Ligament Desmotomy 83
DDF

Distal
check j
Figure 13-9 Transection of the distal check liga-
ment.
Figure 13-10 Gap for mation between the ends of
the check ligament after transection.
After confirming that the check ligament has
been exteriorized, the check ligament is transected
with a scalpel blade (Figure 13-9). Complete tran-
section is assessed by careful exami nation of the
transected ends and the gap between the ends of
the ligament when the foot is extended. A gap of
at least 1 em should be present. and the ends of
the check ligament should be visualized (Figure
13-10). If intact fibers of the check ligament
remain, these should be transected.
The palmar fascia and subcutaneous tissues are
closed with a simple continuous pattern using No.
2-0 absorbable suture material. The skin is closed
with a conti nuous or simple interrupted pattern
using No. 2-0 or No. 3-0 suture material.
84 LIMB SURGERIES
POSTOPERATIVE CARE
Postoperative Care
Bandaging: A sterile dressing is placed over the
incision and a half limb bandage is applied. The
bandage is changed every 3 to 4 days and the
limb is maintained in a bandage for 3 weeks.
Exercise Restrictions: Handwalking should be
introduced 5 days postoperatively and the time
period of handwalking gradually increased over
the following 3 weeks up to 30 to 45 minutes
twice daily. When controlled exercise is not possi-
ble, turnout in a small area is provided.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Continued
phenylbutazone administration at lower doses or
less frequent intervals may be necessary for pain
management.
Suture removal: Skin sutures are removed 12
days postoperatively.
Corrective Trimming
If not done preoperatively. the heels should be
trimmed or rasped to lower the hoof angle. In
some cases, toe extensions are used in the post-
operative peri od to increase tension on the DDFT
during breakover and to protect the toe from

excessive wear.
A large change in hoof angle subsequent to
surgery and corrective trimmi ng may cause sig-
nificant postoperative pain and subsequent con-
tractural reflex. In these cases, the foot can be
trimmed and a temporary heel elevation can be
placed on the foot (Figure 13-1 I). The elevat ion
Figure 13-11 Temporary heel elevation using acrylic.
is then gradually lowered over the first postoper-
ative week to allow for an adaptation period.
Dietary Modification
Rapid growth should be controlled to the extent
possible. Early weaning may be indicated in foals
of heavy lactating mares. High-energy diets
should be avoided. and there may be some benefit
to limiting feed intake to grass hay only for 30
days. I More commonly, growing weanlings are fed
a grass hay or grass-alfalfa mix hay-based diet
with concentrate rations of 0.5% body weight for
a 60-day period.
EXPECTED OUTCOME
Most horses with DDFT contracture improve dra-
mat ically with distal check ligament desmotomy,
corrective trimming or shoeing, and management
of controllabl e underlying factors. Younger horses
and those with deformities of less than 90 degrees
have the best prognosis.
2
-
s
The results for treat-
ment of metacarpophalangeal deformity vary. 2.3,6
In a single report of selected cases of caudal foot
lameness, results were good.
7
COMPLICATIONS
Complications include excessive scar tissue for-
mation and recurreflt contracture. The amount of
-
Figure 13-12 No ground contact at the heel in a
horse with deep digital flexor tendon contracture.
scar tissue formed may be partly related to the size
of gap between the ends of the check ligament
after transection. Excessive scar tissue formation
can be minimized by adequate hemostasis, careful
and minimal dissection during surgery, and
appropriate bandaging after surgery. Recurrent
contracture is usually due to inadequate hand-
walking during the recovery period, or persistent
pain from uncorrected underlying problems (e.g.,
severe developmental orthopedic disease, reCUf-
fent toe abscesses).
ALTERNATIVE PROCEDURES
Ultrasound Guided Transection
Ultrasound guided transection of the distal check
ligament has been described. " The technique is
technically more difficult than the traditional
technique but can be performed with the horse
standing.
Corrective Trimming and Shoeing
Mild cases of DDFT contracture often respond to
lowering the heels. The toe then acts as a fulcrum
and the weight of the foal forces the coffin joint
to extend.
9
In some cases treated conservatively,
lowering the heel alone results in continued pro-
gression of contracture. This is presumably due to
pain or damage in the dorsal lamina and third
phalanx secondary to abnormal weight-bearing
forces. This is particularly true when after trim-
ming, the heels do not contact the ground during
normal weight bearing (Figure 13-12). Select
cases of this type have been treated without
surgery by lowering the heel and applying a shoe
with a raised heel. The rational e behind this
approach is t hat it allows for decreased tension on
the DDFT while allowing the entire foot to be
trimmed and bear weight normally. to
COMMENTS
With DDFT contracture, excessive stress on the
toe causes widening of the white line, excessive
wear of the toe, and in some cases remodeling of
the tip of the third phalanx. Before surgery, the
foot should be checked carefully for subsolar
abscesses near the toe. If abscesses are present,
treatment is preferred before distal check ligament
Distal Check ligament Desmotomy 8S
desmotomy. II Radiographs are useful for evaluat-
ing the position and architecture of the third
phalanx.
Before proceeding with surgery, the horse
should be examined for sources of pain that are
contributing to the contracture through a pain
withdrawal reflex. In most cases, sources of pain
are related to physitis or foot pathology and are
treated in conjunction with distal check ligament
desmotomy. Rarely, other sources of pain such as
shoulder osteochondrosis are present and affect
the prognosis.
REFERENCES
1. Owens JM: Abnormal flerion of the corono-pedal
joint or "contracted tendons" in unweaned foals,
Equine Vet J 7:40, 1975.
2. Adams SB, Santschi EM: Management of congeni-
tal and acquired flexural deformities, Proc Am Assoc
Equille Pract 46: 117,2000.
3. Mc1lwraith CW, Fessler IF: Evaluation of inferior
check ligament desmotomy for treatment of
acquired flexor tendon contracture in the horse, J
Am Vet Med Assoc 172:293, 1978.
4. Stick lA, Nickels FA, Williams MA: Long-term
effects of desmotomy of the accessory ligament of
the deep digital flexor muscle in Standardbreds: 23
cases (1979-1989), J Am Vet Med Assac 200:1131,
1992.
5. Wagner PC, Grant BD, Kaneps AJ, et al: Long term
results of desmotomy of the accessory ligament of
the deep digital flexor tendon (distal check liga-
ment) in horses, J Am Vet Med Assoc 187:1351,
1985.
6. Blackwell RB: Response of acquired flexural defor-
mity of the metacarpophalangeal joint to desmo-
tomy of the inferior check ligament, Proc Am Assoc
Equine Pract 28:107,1982.
7. Turner TA, Rosenstein OS: Inferior check desmo-
tomy as a treatment for caudal hoof lameness, Proc
Am Assac Equine Pract 38: 157, 1992.
8. White NA: Ultrasound guided transection of the
accessory ligament of the deep digital flexor muscle
(distal check ligament desmotomy) in horses, Vet
Surg 24:373,1995.
9. Curtis SJ: Farriery in treatment of acquired
flexural deformities and a discussion on apply-
ing shoes to young horses, Equine Vet Ed 4: 193,
1992.
10. Redden RF: A method for treating club feet, Proc
Am Assoc Equine Pract 34:321, 1988.
11. Adams SB, Fessler JF: Distal check desmotomy. In
Adams SB, Fessler JF, editors: Atlas of equine
surgery, Philadel phia, 2000, WB Saunders.
••
CHAPTER 14
Proximal Check Ligament Desmotomy
Joanne Kramer
INDICATIONS
Proximal check ligament desmotomy is used in
the management of metacarpophalangeal flexural
deformities (Figures 14- 1 and 14-2) and in the
management of superficial digital fl exor ten-
donitis (Figure 14-3) .
EQUIPMENT
Gelpi or Weitlaner retractors, electrocautery, and
suction should be available for this procedure.
POSITIONING AND PREPARATION
The horse is positioned in lateral recumbency
with the affected side down. Bilateral cases are
repositioned after one limb is complete. Alterna-
tively, dorsal recumbency can be used when the
condition is bilateral. Dorsal recumbency has the
advantage of natural hemostasis, but access to
the surgical site is awkward. The circumference of
the limb should be clipped and prepared asepti-
cally from the carpus to the mid radial region.
ANATOMY
The proximal check ligament originates on
the caudomedial aspect of the radius, courses
obliquely, and inserts broadly on the medial
86
and cranial aspect of the superficial digital
flexor tendon at the musculotendinous junction
(Figures 14-4 and 14-5). From the lateral aspect,
the ligament lies adjacent to the proximal and
medial aspects of the carpal tendon sheath. From
the medial aspect, the ligament lies adj acent to,
and is fused with, the deep sheet of the fl exor reti-
naculum. To gain access to the proximal check lig-
ament from the medial aspect, the antebrachial
fascia must be incised where it is extended as the
superfi cial sheet of the flexor retinaculum. This
exposes the tendon of the fl exor carpi radialis
muscle, which is retracted caudally to expose the
ligament.
The fi bers of the proximal check ligament are
in two and deep.
The palmar carpal branch of the proximal
radial artery is the nutrient artery for the superfi -
cial digital flexor tendon (SDFT). It is exposed at
the proximal aspect of the ligament and runs in a
distolateral di.rection between the superficial and
deep layers of the proximal check ligament.
PROCEDURE
An 8- to l O-cm incision is made on the medial
aspect of the limb 1 cm caudal to the radius and
cranial to the cephalic vein. The incision starts 1
em proximal to the level of the distal physis and
extends proximally (see Figure 14-4). The subcu-
taneous tissues are incised and electrocautery is
used as needed to achieve hemostasis. The com-
municating branch of the proximal radial vein
Figure 14-1 Moderate superficial digital fl exor ten-
don contracture in both forelimbs.
Figure 14-2 Superficial digital flexor tendon con-
tracture with fetlock contracture in the left forelimb.
that perforates the antebrachial fascia and joins
the cephalic vein is ligated and transected. The
cephali c vei n is then retracted caudally (Figure 14-
6). The superficial sheet of flexor retinaculum and
the antebrachial fascia are incised to expose the
tendon and distal muscle belly of the flexor carpi
radialis. Gelpi or Weitlaner retractors are used to
retract the fl exor carpi radialis caudally (Figure
Proximal Check Ligament Desmotomy 87
Figure 14-3 Superficial digital fl exor tendonitis in
the left forelimb.
Site of
approach

Figure 14-4 Location of the incision for proximal
check li gament desmotomy.
14-7). The proximal check ligament is fused with
the deep sheet of flexor retinaculum. The fibers of
the ligament are generally oriented obliquely and
can be traced to the distal radius. Palpation and
blunt dissect ion are used to define the limits of the
proximal check ligament.
88 LIMB S URGERIES
The palmar carpal branch of the proximal
radial artery courses through the proximal margin
of the check ligament, and other small but deep
vessels can be found throughout the ligament.
When isolated and visualized, the proximal check
Figure 14-5 Intraoperative view of the proximal
check ligament (arrow),
Superficial of flexor retinaculum
ligament is carefully transected a small amount
at a time, taking care to avoid vessels coursing
through the ligament (Figure 14-8). Visualizing
the distal extent of the check ligament may require
transecting a small amount of the deep sheet
of the flexor retinaculum. When the excision is
complete, the muscle belly of the radial head of
the deep digital flexor tendon (DDFT) is visible
(Figure 14-9) . The carpal sheath may also be
visible in the distal portion of the incision (Figure
14-10). If the carpal sheath has been incised, the
area should be lavaged liberally. The area is
checked for bleeding before closure.
The incision in the superficial sheet of the
flexor retinaculum is closed with No. 2-0 or No.
o absorbable suture material in a continuous pat-
tern. The subcutaneous tissues are closed with No.
2-0 absorbable suture material. The ski n is closed
with an interrupted pattern using No. 2-0 suture
material (Figure 14-11).
fascia (a)
Deep communicating branch to the
proximal radial v. (b)
Cephalic v. (c)
Tendon sheath of flexor carpi
(cut) radiali s m.
Tendon
flexor carpi radialis m.
Figure 14-6 Ligation and transection of the communicating branch that perforates the antebrachial fascia. and
incision of the superfi cial sheet of retinaculum and tendon sheath of the fl exor carpi radialis.
Proximal Check Ligament Desmotomy 89
b (cut)
c
.
Figure 14-7 Retraction of the flexor carpi radialis caudally to expose the proximal check ligament fused with the
deep sheet of flexor retinaculum. a, Antebrachial fascia; b, cut end of the deep communicating branch to the proxi-
mal radial vein; c, proximal check ligament; d, tendon of fl exor carpi radialis muscle; e, tendon sheath of flexor carpi
radialis muscle;f, deep sheet of flexor retinaculum; g, superficial sheet of flexor retinaculum.
," (cut)
I > Layers of proximal check lig.
..
Figure 14-8 Transection of the proximal check ligament. a, Deep communicating branch to the proximal radial
vein; b, proximal radial artery (palmar carpal branch); c, deep sheet of flexor retinaculum; d, superficial sheet of flexor
retinaculum.
Figure 14-9 Visualization of the muscle belly of the
radial head of the deep digital flexor tendon (arrow)
after transection of the proximal check ligament.
,

SuperfiCial> L f
ayers 0
proximal
check lig.
c
Carpal

Figure 14-10 The carpal sheath exposed after tran-
section of the proximal check ligament. a, Superficial
sheet of fl exor retinaculwn; b, deep sheet of flexor reti-
naculum; c. proximal radial artery (palmar carpal
branch).
90 LIMB SURGERI ES
POSTOPERATIVE CARE
Postoperative care
Bandaging: A sterile dressing is placed over the
incision, and a pressure bandage is applied over
the incision site. The limb is then bandaged from
the incision site distally. The limb is kept bandaged
for 3 weeks and the bandage is changed every 3
to 4 days. For flexural deformities, polyvinyl chlo-
ride (PVC) splints may be necessary to prevent
the fetlock from buckling forward and to maintain
load on the flexor tendons.
Exercise Restrictions: The horse is stall rested
for 2 weeks without handwalking and then stall
rested with handwalking for the following 2 weeks.
Exercise is then gradually increased as indicated
by the primary problem.
Medications: Phenylbutazone is administered
at 4.4 mglkg BID for the initial 24 hours
and 2.2 mglkg BID for an additional 3 days. Con-
tinued phenylbutazone administration at lower
doses or less frequent intervals may be necessary
for pain management in flexural limb deformities.
Antibiotics are used preoperatively but generally
not continued in the postoperative period.
Suture Removal: Skin sutures are removed 12
days postoperatively.
Other: When contractural deformity is present,
the foot should be trimmed to as normal an angle
as possible. In mild cases, an elevated heel may
be beneficial to allow lengthening by a gradual
increase in load on the tendon. In severe cases,
a vertical bar shoe may be indicated.'
Figure 14-11 Closure of the superficial
retinaculum, subcutaneous tissue, and ski n.
EXPECTED OUTCOME
The prognosis is guarded for mild to moderate
metacarpophalangeal flexural deformities and
poor for severe deformities.2.3 When performed
for superficial digital flexor tendonitis, the prog-
nosis for a return to racing appears to be improved
for racehorses, with Standardbreds showing greater
improvement.
4
.
6
COMPLICATIONS
Seroma formation is the most common compli-
cation. Seromas should be left to resorb sponta-
neously. Seromas that continue to increase in size
can be aseptically aspirated or, rarely, treated by
drainage after postoperative days 12 through 14.7
Incisional or carpal sheath infections are possible
but not common. Increased strain on the sus-
pensory ligament after proximal check ligament
desmotomy may predispose to suspensory liga-
ment desmititis.
8
,9 Horses treated for metacar-
pophalangeal flexural deformities may not have
significant improvement with proximal check lig-
ament desmotomy alone and may require addi-
tional procedures.
ALTERNATIVE PROCEDURES
In horses with superficial fl exor tendon core le-
sions, percutaneous tendon splitting may improve
healing by draining hematomas or seromas asso-
ciated with the core lesion and creating a com-
munication between the tendon core and the
peritenon that promotes heal ing. The procedure
is often performed in conjunction with proximal
check ligament desmotomy.7,10
Tenoscopically assisted superior check liga-
ment desmotomy has also been described and
may offer the advantages of decreased incisional
complications and operative time,l1 ,12
Flexural limb deformities of the metacar-
pophalangeal joi nt will sometimes respond to
inferior check ligament desmotomy alone or
in combination with proximal check ligament
desmotomy. 2, 1l Fetlock fl exural deformities have
also been treated with superficial digital flexor
tenotomy.2
COMMENTS
Proximal check ligament desmotomy is more dif-
ficult than distal check ligament desmotomy. A
thorough understanding of the anatomy, careful
attention to hemostasis, and strict asepsis are
important for consistently good results.
Determining the most appropriate surgical
treatment for fetlock flexural deformities can be
difficult. For mild cases where the fetlock angle is
less than 180 degrees, the limb can be forced into
extension and the superficial and deep digital
fl exor tendons palpated. If the tautest structure is
the DDFT, distal check ligament desmotomy may
be beneficial. If the tautest structure is the SDFT
or the superficial and deep feel equally taut, prox-
imal check ligament desmotomy is then per-
formed. In moderate or severe cases where the
fetlock angle is greater than 180 degrees, both pro-
cedures are performed.
2
If response is not ade-
quate after transection of both check ligaments,
tenotomy of the SDFT is performed. As discussed
previously, severe cases have a poor prognosis for
correction because of joint capsule and suspen-
sory li gament contracture. These cases are candi-
dates for fetlock arthrodesis.
Several, but not ail, studies suggest that proxi-
mal check ligament desmotomy increases the like-
lihood of return to racing after superficial digital
flexor tendonitis.
4
-
6
,9 The reason for improvement
is not clearly understood but is likely related to the
functional lengthening of the superficial digital
flexor musculotendinous unit that occurs after
desmotomy. When the proximal check ligament is
Proximal Check ligament Desmotomy 91
intact, the majority of the load during weight
bearing is sustained by the tendon from the prox-
imal check ligament distally. Desmotomy is
thought to allow the muscle to assume a greater
portion of the load and contribute to the elastic-
ity of the entire unit.
14
The act ual strain in vitro
on the SDFT after proximal check ligament
desmotomy increases, but the elongation of the
musculotendinous unit also increases during load
application. 15 This elongation and recruitment of
muscle fibers may allow for increased elasticity in
the musculotendon unit compared with those
that heal without desmotomy. 14
REFERENCES
1. Auer ]A: Flexural deformities. In Aller JA, Stick lA,
editors: Equine surgery, ed 2, Philadelphia, 1999,
WB Saunders.
2. Adams S8, Santschi EM: Management of congeni-
tal and acquired fl exural deformities, Proc Am Assoc
Equine Pract 46: 117. 2000.
3. Kidd lA, Barr ARS: Flexural deformities in foals,
Equine Vet Edu, 14(6):311,2002.
4. Fulton Ie, Maclean AA, O'Reill y JL, et al: Superior
check ligament desmotomy for treatment of super-
ficial digital flexor tendonitis in Thoroughbred or
Standardbred horses, At/st Vet J 71:233, 1994.
5. Hawkins JF, Ross MW: Transection of the accessory
ligament of the superficial digital flexor muscle for
the treatment of superficial digital flexor tendonitis
in Standardbreds: 40 cases (1988- 1992), J Am Vet
Med Assoc 206(5):674, 1995.
6. Hogan PM, Bramlage LR: Transection of the acces-
sory ligament of the superficial digital flexor
tendon for treatment of tendonitis: long term
results in 61 standardbred racehorses horses ( 1985-
1992), Equine Vet J 27(3):22 1, 1995.
7. Adams SB, Fessler JF: Proximal check desmo-
tomy/Percutaneous tendon splitting. In Adams SB,
Fessler JF, editors: Atlas of equine surgery, Philadel-
phia, 2000, WB Saunders.
8. Alexander GR, Gibson KT, Day RE: Effects of supe-
rior check desmotomy on flexor tendon and sus-
pensory ligament strain in equine cadavers, Vet
Surg 30:522, 200 I.
9. Gibson KT, Burbdige HM, Pfeiffer DU: Super-
ficial digital flexor tendonitis in thoroughbred race
horses: outcome following non-surgical treatment
and superior check desmotomy, Aust Vet J 75:631,
1997.
10. Henni nger R, Bramlage L, Schneider R: Shor t term
effect of superior check ligament desmotomy and
percutaneous tendon splitting as treatment for
acute tendonitis, Proc Am Assoc Equine Pract
36:539, 1990.
92 LI MB SURGERIES
11. Kretzschmar BH, Desjardins MR: Clinical evalua-
tion of 49 tenoscopically assisted superior check
ligament desmotomies in 27 horses, Proc Am Assoc
Equine Pract 47:484, 2001.
12. Southwood LL, Stashak TS, Kainer RA: Desmo-
tomy of the accessory ligament of the superficial
digital flexor tendon in the horse with use of a
tenoscopic approach to the carpal sheath, Vet 5urg
28:99, 1999.
13. Blackwell RB: Response of acquired flexural defor-
mity of the metacarpophalangeal joint to desmo-
tomy of the inferior check ligament, Proc Am Assoc
Equine Pract 28: 107,1982.
14. Bramlage LR: Superior check desmotomy as a
treatment for superficial digital flexor tendonitis:
Initial report, Proc Am Assoc Equine Pract 32:365,
1986.
15. Shoemaker RS, Bertone AL, Mohammad LN, et al:
Desmotomy of the accessory ligament of the super-
ficial digital flexor muscle in equine cadaver limbs,
Vet SlIrg 20:245, 199L
CHAPTER 15
Distal Splint Bone Resection
Joanne Kramer
INDICATIONS
Fractures in the middle or distal third of the splint
bones with nonunion, excessive callus, sequestra,
or septic osteitis (Figure 15- 1).
Figure 15-1 Mid metatarsal splint bone fracture.
93
EQUIPMENT
A chisel or osteotome, bone rasp. and tourniquet
are used for this procedure.
ANATOMY
The distal aspect of the splint bone has rudimen-
tary attachments to the palmar/plantar fascia and
proximal ligament of the ergot (Figure 15-2). The
interosseous ligament attaches the splint bones to
the third metacarpal-metatarsal bone. In the hind
limb, the dorsal metatarsal artery lies between
metatarsal bones III and IV. The dorsal branch of
the ulnar nerve (lateral) and the palmar meta-
carpal or plantar metatarsal nerves (lateral and
medial) run in the area of the distal end of the
splint bone (see Figure 15-2).
POSITIONING AND PREPARATION
The horse should be placed in lateral recumbency
with the affected splint bone up or in dorsal
recumbency with the affected limb suspended.
The limb should be prepared and draped for full
circumferential access to the entire metacarpal!
metatarsal region.
PROCEDURE
A vertical incision is made directly over the
affected splint bone starting 4 em proximal to the
94 LIMB SURGERI ES
Interosseous Ii
Distal end of
lateral splint bone
Palmar
n. IV

Jig. 01 the
Lateral
extensor
Dorsal br.
of ulnar n.
ergot Lateral palmar a.v.
Interosseous digital a.v. III)
medius
(suspensory lig.) Lateral palmar n.
'-,''--- Distallig. of
the ergot
_ ..
Common digital
tendon

. .,
,
••••
-
Figure 15-2 Anatomy of the distal splint bone.
Interosseous medius m .
(suspensory lig.)
01 the ergot
Medial palmar a.v.
(palmar common
digital a.v. II)
Medial palmar n.
Within the digital
tendon sheath
Figure 15-3 Freeing the spl int bone from its distal
attachments.
fracture site and ending 2 cm distal to the distal
aspect of the splint bone. The distal end of the
splint bone is sli ghtly rounded and can usually be
palpated directly. If the region is significantly
swollen, the opposite splint bone can often be pal-
pated and used as a rough estimate of the distal
landmark. The incision is then deepened to the
level of, but not through. the periosteum. In severe
cases, extensive scar tissue is present surrounding
the splint bone. The distal end of the splint bone
is identified and sharp dissection used to free it
from its distal attachment to the palmar fascia and
proximal ligament of the ergot (Figure 15-3). The
end is then grasped with a towel clamp or forceps,
and a curved osteotome or chisel is used to
sever the attachments to the third metacarpal or
metatarsal bone (Figure 15-4). Care should be
taken to avoid damaging the dorsal metatarsal
artery in the pelvic limb, which may be difficult to
identify in cases with extensive fibrous tissue.
In some cases, the distal splint bone and frac-
tured portion can be freed past the fracture site
Figure 15-4 Severing the interosseous ligament
attaching the splint bone to the cannon bone.
~ t ; . . t ' ~
Figure 15-5 Amputation of the splint bone proxi-
mal to the fracture site with an osteotome.
for removal in one unit. The osteotome is used
2 em proximal to the affected area to create
the proximal amputation site (Figure 15-5) . The
splint bone and affected portion with its perios-
teum can then be removed as one unit (Figure 15-
6), Other cases may have extensive callus for-
mation, making removal in one unit from the
distal end difficult. These require removal of the
portion distal to the affected site, creation of the
proximal amputation site, and further dissection
to remove the remaining portion of affected bone.
All sequestra, surrounding mineralized tissue, and
Distal Splint Bone Resection 95
Figure 15-6 Removing the affected portion of splint
bone.
Figure 15-7 Using a bone rasp to smooth the edge
of the remaining proxi mal spli nt bone after excision of
the distal portion.
discolored tissue should be removed. The area is
then lavaged. The proximal aspect of the remain-
ing splint bone is tapered or smoothed with a
bone rasp to avoid leaving any sharp edges (Figure
15-7) .
Bleeding from the region can be controlled
as needed through the use of cautery, hemostat
appl ication, and occasionally ligation. Although
the region is generally very vascular, most bleed-
ing can be controlled by postoperative pressure
bandaging. Tourniquet application facilitates the
procedure.
The subcutaneous tissues are closed with a syn-
thetic absorbable suture material. If the amount
of dead space is extensive, a Penrose drain can be
pl aced before closure of the subcutaneous tissues.
Most cases can be managed without a drain. The
skin is closed with an interrupted pattern.
96 LI MB SURGERIES
POSTOPERATIVE CARE
Postoperative Care
Bandaging: A sterile dressing is placed over the
incision and a half limb bandage is placed and
changed the day following surgery. An inner pres-
sure bandage can be placed over the incision site
to control postoperative hemorrhage and swelling.
If placed, this should be removed the day follow-
ing surgery. The bandage is changed every 2 to 4
days for 3 weeks. If a drain has been placed, it
should be removed within 3 days or sooner if
drainage is minimal.
Exertise Restridions: Strict stall rest is advised
for the first 10 days followed by stall rest with
handwalking for the following 2 weeks. Return to
activity is then dependent on healing of the site
and the degree of any concurrent suspensory lig-
ament damage. In general, exercise is limited to
small-area turnout for at least 2 months postop-
eratively.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Further anti-
inflammatory use is dependent on concurrent
problems such as suspensory desmitis. Antibiotic
use and duration are dependent on the presence
of infection and ideally guided by culture results.
If a drain is placed, antibiotic therapy should be
continued 24 hours past removal of the drain.
Generally, if debridement is thorough, the need
for antibiotic therapy is minimal.
Suture Removal: Skin sutures are removed 12
days postoperatively.
EXPECTED OUTCOME
The prognosis for middle and distal splint bone
fract ures is exceUent. The prognosis for proximal
splint bone fractures is variable.
COMPLICATIONS
Seroma formation may occur especially if a large
amount of dead space was present during closure.
This is generally treated by continued bandaging
or, if persistent, by opening the distal end of the
incision. Dehiscence of the incision is possible,
especiall y if a seroma develops. Generally, this is
only partial dehiscence and can be allowed to heal
by second intention. Excessive bone reaction near
the amputated portion of the splint bone is
unlikely but may require additional rest, antiin-
flammatory therapy, and possibly fur ther surgical
removal.
ALTERNATIVE PROCEDURES
Segmental ostectomy of the affected portion of
the splint bone leaving the proximal and distal
segments intact has been described as an alterna-
tive to resection of the entire splint bone distal to
the fracture. Results were good in the 17 cases
described.
l
COMMENTS
Minimally displaced fractures will often heal ade-
quately with conservative management.
2
-
4
Frac-
tures in the proximal third of the splint bone may
require internal fixation or complete removal of
metatarsal bone IV.,·6 Amputation of the splint
bone in the proximal one fourth of the splint bone
potentially destabilizes the remaining portion of
the splint bone and is not recommended without
consideration of internal fixation of the remain-
ing proximal fragment. If the proximal fragment
is stable) some open proximal fractures may be
managed by debridement without disturbi ng the
proximal or distal segment attachments.
2

4
,7
Distal splint bone fractures are often associated
with hyperextension injuries or suspensory liga-
ment desmitis.
8
.
9
These conditions should be as-
sessed preoperatively and may dictate postopera-
tive therapy. Fractures in the middle third of the
splint bone are generally a result of trauma and
are more likely to be associated with infecti on or
sequestrum formation.
REFERENCES
1. Jenson PW, Gaughan EM, Lillich JD, et al: Segmen-
tal ostectomy of the second and fourth metacarpal
and metatarsal bones in horses: 17 cases (1993-
2002),1 AII1 Vet Med Assoc 224(2):271, 2004.
2. Adams SB, Fessler JF: Excision of distal splint bone
fractures. In Adams SB, Fessler JF, editors: Atlas of
equine surgery, Philadelphia, 2000, WB Saunders.
3. Dyson SJ; The metacarpal region. In Ross MW,
Dyson SJ, editors; Diagllosis and management of
lamelless in the horse, St Louis, 2003, WB Saunders.
4. Jenson PW, Gaughn EM, Lillich JO, et a1: Spl int bone
disorders in horses, Camp COlIl Educfor the Pract Vet
25(5):383,2003.
5. Baxter GM, Doran RE. Allen 0: Complete excision
of a fractured fourth metatarsal bone in eight horses,
Vet SLlrg 21(4):273, 1992.
6. Peterson PR, Pascoe JR, Wheat JD: Surgical man-
agement of proximal splint bone fractures in the
horse, Vet SlIrg 16( 1): 13, 1987.
Distal Splint Bone Resection 97
7. Kidd 1: Management of splint bone fractures in the
horse, In Practice 25(7):388, 2003.
8. Bukowiecki CF, Bramlage LR, Gabel AA: In vitro
strength of the suspensory apparatus in training and
resting horses, Vet SlIrg 16(2): 126, 1987.
9. Verschooten F, Gasthuys F, De Moor A: Distal spl int
bone fractures in the horse: an experimental and
clinical study, Eqllille Vet] 16:532, 1984.
CHAPTER 16
Deep Digital Flexor Tenotomy
Joanne Kramer
INDICATIONS
Severe distal interphalangeal joint contracture or
severe laminitis with rotation of the third phalanx
(P3) (Figures 16-] and 16-2).
EQUIPMENT
A heel wedge is used during standing procedures.
Modified table knives or malleable retractors are
useful when isolati ng the tendon during transec-
tion' (Figure 16-3).
Figure 16-1 Severe deep digital flexor tendon
contracture.
98
POSITIONING AND PREPARATION
The procedure is most often performed with the
horse standing in adult horses with laminitis and
recumbent in foals with severe deep digital flexor
tendon (DDFT) contracture. When performed
with the horse standing, heel wedges are tem-
porarily placed on the horse to take tension off the
DDFT during the procedure. A high palmar-
palmar metacarpal nerve block or inverted-U
block is performed in the proximal metacarpal
region. The limb is clipped circumferentially and
prepared for aseptic surgery in the mid metacarpal
region. A sterile adhesive drape or short drapes
proximal and distal to the site are used.
Figure 16-2 Laminitis with rotation of the third
phalanx.
ANATOMY
The heads of the DDFT originate from the medial
epicondyle of the humerus, olecranon, and caudal
radius and insert as a single tendon on the palmar
surface of the third phalanx. Transecting the
DDFT eliminates the pull of the deep digital flexor
muscle on the coffin bone, reducing shearing
forces between the dorsal coffin bone and hoof
wall and essentially eliminating coffin joint
Figure 16-3 Bent table knives are useful during iso-
lation and transection of the deep digital fl exor tendon.
The curvature of the top instrument is greater than that
of the bottom instrument.
Common digital
extensor tendon
Lateral digital
extensor tendon
MC IV
Dorsal br.
ofulnarn.
Lateral palmar a.v.
(palmar common
digital a.v. III)
Lateral palmar n.
~ .

Deep Digital Flexor Tenotomy 99
flexion. The incision for mid metacarpal deep
digital flexor tenotomy is located above the prox-
imal extent of the digital flexor tendon sheath and
is typically below the distal check ligament inser-
tion. At this level. the neurovascular bundles lie
directly over and slightly dorsal to the DDFT. Care
must be taken to not exteriorize or transect these
with the tendon (Figure 16-4).
PROCEDURE
A 3-cm incision is made over the DDFT in the
middle third of the metacarpus, avoiding the
flexor tendon sheath, which extends proximally to
the level of the second and fourth metacarpal
bones (Figure 16-5). The palmar fascia is incised,
and blunt dissection is used to create a space
between the superficial digital flexor tendon and
the DDFT. A space is then created between the
DDFT and the suspensory ligament (interosseous
medius tendon). The bent knife with the larger
curvature is slid on the palmar surface of the
DDFT, and the bent knife with the smaller curva-
ture is slid on the dorsal surface of the DDFT until
the instruments overlap (Figure 16-6). Slight
. • I,. . •
", ' ....
• •
... . " ......
- - • • •
- '.
-
--

.'
MC II
Interosseous medial m.
(suspensory lig.)
Medial palmar a.v.
(palmar common
digital a.v. II)
Medial palmar n.
SDFT
Figure 16-4 Cross sectional anatomy of the deep digital flexor tendon and mid metacarpal region.
2
100 LIMB SURGERIES
i of
't-
a
:pproach
Figure 16-5 lncision location for deep digital flexor
tenotomy.
Figure 16-6 Isolation of the deep digital flexor
tendon.
overlapping of and tension on the instruments
bring the DDFT to, but not out of, the incision.
The DDFT is then transected with a No. JO blade
(Figure 16-7). I f the distal check ligament is
present at the level of the incision, it is isolated
and transected with the DDFT. After transection,
the heel elevation can be removed to check for
adequate gap formation between the tendon ends.
Closure of the subcutaneous tissue is optional.
Closure of the skin is performed with an inter-
rupted apposing or everting pattern using No.
2-0 monofilament suture material.
POSTOPERATIVE CARE
Postoperative Care
Bandaging: A sterile dressing is placed over the
incision and a half limb bandage is applied. The
limb should remain bandaged for 30 days, and
the bandage is changed every 5 to 7 days or more
frequently if needed.
Exerc:ise Restrictions: Horses with laminitis
should be rested as their condition indicates and
are not allowed significant turnout for a minimum
of 6 months. Foals with contracture can be allowed
turnout in a small area after I week, and the
amount of exercise allowed is gradually increased
over the next 60 days. Free choice turnout should
not be allowed for up to 6 rnonths.'
Medications: Phenylbutazone should be admin-
istered for a rninirnum of 5 days.
Suture Removal: Skin sutures are removed 12
days postoperatively.
Other: Continued corrective shoeing is an essen-
tial component of treatment. Surgery should not
be performed without considerations for postop-
erative corredive trimming and shoeing. Prin-
ciples of shoeing to reestablish the normal
relationship between the solar surface of P3 and
the sole following deep digital flexor tenotomy
have been described',' and are essential when
tenotomy is performed as a component of lamini-
tis treatment. Foals with severe fiexural deformi-
ties should be trimmed in a normal fashion. The
need for corrective shoeing in these cases
depends on the amount of release achieved after
tenotomy.
_
Figure 7 Transection of the deep digital flexor
tendon.
EXPECTED OUTCOME
Deep digital flexor tenotomy is a salvage proce-
dure, although some horses may become sound
for athletic activity. The intended goal should be
limited to an improvement in comfort level and
pasture soundness. Severe chronic cases of coffin
joint contracture may have such severe joint
capsule and surrounding tissue contracture that
limb position may not improve significantly after
tenotomy.5,6
The prognosis for horses with laminitis likely
depends on the condition of P3 and blood supply.
An improvement in pain, but not survival rate,
has been reported in horses with acute refractory
laminitis,7 In selected cases of chronic laminitis,
an improved prognosis for survival has been
reported.
s
COMPLICATIONS
Incisional dehiscence or drainage is rare. Sever-
ance of the palmar artery, vein, or nerve is possi-
ble and care must be taken that these structures
are not isolated with the DDFT. Pain following
tenotomy in foals with contracture may be signif-
icant because of stretching of the joint capsule and
soft tissue and can be managed with nonsteroidal
antiinflammatory medication. Occasionally, tem-
porary heel elevation is used to allow for a more
gradual change in foot conformation. Hyper-
extension of the coffin joint may occur and is
managed with heel extension and elevation.
Superficial digital flexor tendonitis may result
from the increased strain on the superfi cial digital
flexor tendon. Recurrent infection, abscessation,
and sequestration of P3 are associated with
chronic pain. If chronic pain persists, flexural
deformity of the metacarpophalangeal joint may
occur.
Deep Digital Flexor Tenotomy 101
ALTERNATIVE PROCEDURES
Tenotomy at the level of the mid pastern has been
described.
9
The procedure is performed under
general anesthesia. A vertical 3-cm midline in-
cision is made on the palmar aspect of the mid
pastern. The incision is continued through the
subcutaneous tissue and digital flexor tendon
sheath. Curved forceps are placed under the
tendon, and it is transected with a scal pel. The
incision in the tendon sheath is closed with No.
2-0 absorbable suture. The subcutaneous tissues
are closed with 2-0 absorbable suture and the skin
is closed in an interrupted pattern.
The DDFT can be isolated and elevated outside
the incision with curved forceps as has been tra-
ditionally described. to During standing surgery,
we prefer to use the modified table knives
described by Redden because the neurovascular
structures are easily protected from transection
without having to exteriorize the tendon. Because
of the anatomic location and peri tendinous
attachments, tenotomy at the level of the pastern
may provide greater release than tenotomy at the
mid metacarpal level. I I No difference in outcome
has been demonstrated between tlle two tech-
niques, and we prefer mid metacarpal tenotomy
because of the lack of tendon sheath in the mid
metacarpal region and the more proximal loca-
tion for standing surgery.
REFERENCES
I. Redden RF: Shoeing the laminitic horse. In Redden
RF, editor: Understanding laminitis, Lexington,
1998, The Blood Horse Inc.
2. Sullins KE: Standing musculoskeletal surgery. In
Bertone A, editor: Standing surgery in the horse,
Vet Clin N Am Equine Pract 7:687, 1991.
3. Nickels FA: Laminitis. In Ross MW, Dyson S1.
editors: Diagnosis mId management of lamelless in
the horse, Philadelphia, 2003, WB Saunders.
4. Redden RF: Shoeing the laminitic horse, Proc Am
Assoc Equine Pract 43:356, 1997.
5. Adams SB, Santschi EM: Management of congeni-
tal and acquired flexural deformities, Proc-Am Assoc
Equine Pract 46: 117, 2000.
\

I
102 LIMB SURGERIES
6. Mcllwraith CW, Fessler IF: Evaluation of inferior
check ligament desmotomy for treatment of
acquired flexor tendon contracture in the horse, J
Am Vet Med Assoc 172:293, 1978.
7. Hunt RJ, Allen DA, Baxter GM, et a1: Mid
metacarpal deep digital flexor tenotomy in the
management of refractory laminitis in horses, Vet
5urg 20:15,1991.
8. Eastman TG, Honnas eM, Hague BA: Deep digital
flexor tenotomy as treatment for chronic laminitis
in horses: 37 cases, Proe Am Assoc Eqllille Pmct
44:265, 1998.
9. Allen 0, White NA, Foerner 1F, et al: Surgical
management of chronic laminitis in horses: 13
cases (1983-1985), ] Am Vet Med Assoc 189:1604,
1986.
10. Adams S8, Fessler JF: Deep digital flexor tenotomy.
In Adams 5B, Fessler JF, editors: Atlas of eqllille
surgery. Philadelphia, 2000, WB Saunders.
11. Hunt Rl: Laminitis. In Ross MW, Dyson 5J, editors:
Diagllosis and management of lameness ;n tlte horse,
Philadelphia, 2003, WB Saunders.
CHAPTER 17
Semitendinosus Tenotomy and Myotomy
Joanne Kramer
INDICATIONS
Treatment of gait abnormalities secondary to
fibrosis or ossificat ion of the semitendinosus
muscle (fi brotic myopathy).
EQUIPMENT
No special equipment is required for tenotomy. A
blunt-tipped bistoury is useful for the myotomy
procedure.
ANATOMY
The semitendinosus muscle originates from the
transverse processes of the first and second caudal
vertebrae, the sacrosciatic ligament, and the
ventral surface of the ischiatic tuberosity. It inserts
on the tibial crest, crural fascia proper, and cal-
caneal tuberosity. The tendon of insertion on the
medial aspect of the proximal tibia is transected
in the tenotomy procedure. The myotomy proce-
dure involves transecting muscle fibers at the
distal extent of the fibrotic region and is typically
performed on the caudal aspect of the limb just
proximal to the musculotendinous junction.
POSITIONING AND PREPARATION
The semitendinosus tenotomy procedure is per-
formed with the horse in lateral recumbency with
103
the affected limb positioned down. The myotomy
procedure is performed with the horse standing
with local anesthesia and sedation.
PROCEDURE
Semitendinosus Tenotomy
Palpation of the proximal medial tibial region
usually reveals the location of the horizontally ori-
ented tendon of insertion. Generally, the tendon
is about four fingers' width distal to the proximal
tibia. The distal end of the tibial crest can also be
used as a proximal to distal guide. An 8-cl11 verti-
cal incision is made over the tendon caudal to the
medial saphenous vein. The incision is extended
through the subcutaneous tissues and the dense
crural fascia to expose the tendon. Curved forceps
are passed underneath the tendon, and the tendon
is transected (Figure 17-1). The fascial layer is
closed with an interrupted or continuous pattern
using synthetic absorbable suture material.
The subcutaneous tissue is closed with a continu-
ous pattern using synthetic absorbable suture
material. The skin is closed in an interrupted
pattern.
Semitendinosus Myotomy
Infiltration of local anesthetic is performed in
an inverted-U pattern surrounding and distal
to the most taut palpable area of fibrosis . A 6-cm
vertical incision is made over the caudal aspect
104 LIMB SURGERIES
A
Tendon of
semitendinosus m.
I
Saphenous a. and n.
and medial
saphenous v.
___ Incision line
Figure 17-1 Location (A) and incision (B) of the semitendinosus tendon of insertion on the proximal tibia
of the semitendinosus muscle beginning at the
distal extent of the fibrosis and extending
distally. Blunt dissection is used to deepen the
incision to the level of palpable fibrosis. A blllnt-
tipped bistoury is used to transect the muscle
or tendon attachments at the distal extent of the
fibrotic area (Figure 17-2). Taut vertical fibrotic
bands that appear to limit cranial movement
when the limb is pulled forward by an assistant
are transected.! The horse is then walked several
steps to judge the effect of the release. If necessary,
the procedure is repeated until the gait improves
or until the entire area distal to the fibrosis has
been transected. The incision is lavaged copiously
with sterile saline and packed with sterile roll
gauze. Partial closure of the skin is performed and
the remainder of the incision is left to heal by
second intention. Alternatively, a Penrose drain
can be placed and the incision closed primarily.
When other muscles such as the semimembra-
nosus or biceps femoris are involved, a similar
myotomy procedure can be performed.
POSTOPERATIVE CARE
Postoperative Care
Bandaging: If myotomy is performed, the gauze
packing is changed the following day and
removed in 2 days.
Exercise Restrictions: Stall rest with light hand-
walking is advised for the first 2 weeks, followed
by gradually increasing exercise. Full turnout is
allowed 6 weeks following surgery.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 5 days. Antibiotic
therapy is continued until 24 hours after drain or
packing removal. Horses should receive a tetanus
toxoid booster if it has been longer than 6 months
since the previous vaccination.
Suture Removal: Skin sutures are removed 12
days postoperatively.
B
-----Bistoury
knife
Semitendinosus Tenotomy and Myotomy 105
~ 09 ......... , , ~ . . : t : u . . . -
Fibrotic
region
Fibrous
bands
Figure 17-2 The use of a bistoury knife to transect restr ictive scar tissue on the distal aspect of the affected

region.
EXPECTED OUTCOME
Reported cases treated with tenotomy have had
good results, but only a small number of cases
have been reported.
2
,3 Horses with mild scarring
often improve considerably with tenotomy, and
the procedure has minimal complications. In the
author's opinion, horses with more severe fibrosis
generally require myotomy fo r improvement and
have a higher likel ihood of recurrence. In one
report, 75% of horses treated with myotomy had
75% or greater improvement in gait. At approxi-
mately 2-year foll ow- up, one third of these horses
had some recurrence of gait restriction. Some
horses with some recurrence of restriction were
abl e to perform at their intended level. 4 Horses
with fibrosis confined to the semi tendinosus
muscle have a better outcome than those with
additional fibrosis in the biceps femoris or semi-
membranosus muscles.
s
In cases where muscles
other than the semitendinosus are involved, tran-
section of fibrosis in the involved muscle may be
beneficial. 1.6
COMPLICATIONS
Dehiscence, seroma formation, and infection are
possible but not common if the tenotomy only is
performed. If myotomy is performed, the likel i-
hood of these compli cations increases. Extensive
postoperative fibrosis may result in recurrence of
the gait abnormal ity.
ALTERNATIVE PROCEDURES
Transect ion of the semitendinosus muscl e's in-
sertion on the calcaneal tuber has also been
described for cases where a taut band is palpable.
The limb is protracted during surgery after
tenotomy of the tibial insertion. If a taut band
is palpable over the calcaneal tuber insertion, it is
transected through an incision caudal and distal
to the first incision.
2

7
Complete removal of the area of fibrosis and a
4-cm portion of tendon has also been described.
8
,9
The procedure can be effective, but a high inci-
106 LIMB SURGERIES
dence of complications probably caused by the
extensive dissection required and large remaining
dead space has been reported. Additionally, recur-
rence in gait restriction secondary to fibrotic
heali ng is likely. I,1O
COMMENTS
Fibrotic myopathy is commonly a result of trauma
to the semitendinosus muscle with subsequent
inflammation, hematoma formation, and fibrosis
or ossification. Involvement of the semimembra-
nosus, biceps femoris, and gracil is muscles is also
possible. In cases where the inciting injury was
observed, the hind limb has been caught cranially
and underneath the horse or slipped forward
excessively during sLiding stops. It has been
reported after intramuscular injections.
2
.
s
,1O Two
congenital cases and three cases associated with
peripheral neuropathy have been reported.
2ol1
The gait associated with fibrotic myopathy is
likely caused by an effective shortening of the
semitendinosus muscle and adhesions between
the semitendinosus muscle and biceps femoris
or semimembranosus muscles. This functional
shortening limits protraction of the hindlimb and
results in the limb being retracted just before
ground contact and contacting the ground in a
pronounced vertical slapping motion. The abnor-
mality is most easily observed at a walk. The gait
restriction appears to be primarily mechanical
and not directly associated with pain.
REFERENCES
I. Irwin DHG, Howell DW: Fibrotic myopathy,
hematomas and scar tissue in the gaskin area of the
thoroughbred, J South African Vet Assoc 52:65,
1981.
2. Bramlage LR, Reed SM, Embertson RM: Semi-
tendinosus tenotomy for treatment of fibrotic
myopathy in the horse, } Am Vet Med Assoc 186:565,
1985.
3. Pickersgill CH, Kriz N, Malikides N: Surgical t reat-
ment of semitendinosus fibrotic myopathy in an
endurance horse management, complications
and outcome, Equine Vet Educ 12:242, 2000.
4. Magee AA, Vatistas NJ: Standi ng semitendinosus
myotomy for the t reatment of fibrotic myopathy
in 39 horses, Proc Am Assoc Equine Pract 44:263,
1998.
5. Villamandos RG, Santisteban JR, Avila I: Tenotomy
of the tibial insertion of the semitendinosus muscle
of two horses with fibrotic myopathy, Vet Rec
126:67,1995.
6. Dabareiner RM, Schmitz DG, Honnas eM, et al:
Gracilis muscle injury as a cause of lameness in two
horses, ] Am Vet Med Assoc 224:1630, 2004.
7. Adams SB, Fessler JF: Semitendinosus tenotomy for
fibrotic myopathy. In Adams SB, Fessler JF, editors:
Atlas of equine surgery, Philadelphia, 2000, WB
Saunders.
8. Adams OR: Fibrotic myopathy in the hindlegs of
horses, J Am Vet Med Assoc 139: 1 089, 1961.
9. Sullins KE: Lameness. Part XlII: the femur. In
Stashak TS, editor: Adam's lameness in horses,
Philadelphia, 2002, Lippincott, Williams & Wilkins.
10. Turner AS, Trotter GW: Fibrotic myopathy in the
horse, } Am Vet Med Assoc 184:335, 1984.
II. Valentine BA, Rouselle SD, Sams AE, et al: Dener-
vation atrophy in three horses with fibrotic myopa-
thy, J Am Vet Med Assoc 205:332, 1994.
CHAPTER 18

Palmar-Plantar Digital Neurectomy
Joanne Kramer
INDICATIONS
Chronic lameness that improves significantly after
palmar/ plantar digital anesthesia and has not
improved with alternative treatment options.
Typical indications include selected cases of nav-
icular disease, navicular bone fractures, wing frac-
tures of the third phalanx, idiopathic heel pain,
and palmar-plantar foot injuries (Figure 18-1).
EQUIPMENT
Specialized instruments are not required for the
guillotine or Black's method of neurectomy.
Perineural capping requires Gerald or similar
smooth-tipped forceps (Figure 18-2) .
POSITIONING AND PREPARATION
This surgery can be performed with the horse
standing or under general anesthesia. Maintaining
sterile and atraumatic technique is more difficult
during standing surgery because of the proximity
of the ground and inadvertent limb movement.
Standing surgery is performed with the horse
under sedation with local anesthetic over the
palmar digital nerves at the level of the sesamoid
bones. Peripheral anesthesia is also beneficial
when the surgery is performed under general
anesthesia.
Horses under general anesthesia are pl aced in
lateral or dorsal recumbency. When bilateral
107
surgery is performed, the lateral side of the upper
forelimb and the medial side of the lower forelimb
are operated on initially. The horse is then rolled
onto the opposite side and the procedures are
repeated. Alternatively, the horse can be placed in
dorsal recumbency with the limbs extended or
fl exed on the sternum.
When possible, surgery time is decreased by
having two surgeons operate simultaneously. The
circumference of the limb should be clipped and
prepared aseptically from the fetlock distally.
ANATOMY
The palmar-plantar branch of the palmar-plantar
digital neurovascular bundl e lies in the space
between the palmar/plantar border of the pastern
and the abaxial border of the deep digital flexor
tendon (DDFT). The nerve is just palmar/plantar
to the artery and is found just deep to the liga-
ment of the ergot. The presence of small accessory
nerve branches varies; when present, they often lie
palmar/plantar and deep to the ligament of the
ergot.
PROCEDURE
A 3-cm skin incision is made over the abaxial
border of the DDFT in the mid to distal pastern
region (Figure 18-3, A) . The incision is extended
carefully through the subcutaneous ti ssue. Blunt
dissection is used to isolate the palmar digital

Figure 18-1 Preoperative image of a horse with nav-
icular disease. Note the typical pointing stance of the
left forelimb.
A
o
Site of
approach
1
Figure 18-2 Gerald forceps used when performing
perineural capping.
of digital cushion
B
c
.-.--1
E
.. _, __
Figure 18-1 A, Incision location for pal mar digital neurectomy. B, Location of the palmar digital nerve in relation
to surrounding structures. C, Palpation of longitudinal fibers when the nerve is stretched over a smooth instrument.
OJ Crimped appearance of the nerve after it has been released. E, Transection of the palmar digital nerve. 1, Palmar
digital nerve; 2, palmar digital vein; 3, palmar digital artery; 4, ligament of the ergot.
nerve (Figure 18-3, B) . Identification of the nerve
is confirmed by its appearance (smooth, white,
and glistening), by the crimped appearance of the
nerve after it has been stretched and released, and
by palpating longitudinal fibers when the nerve is
stretched over the smooth portion of an instru-
ment (Figures 18-3, C and D). When isolation of
the nerve is confirmed, a 2- to 3-cm section of the
nerve is freed from the surrounding tissues. The
nerve is stretched, and the proximal end is tran-
sected sharply with a new blade as proximal as
possible. The distal portion is then transected
sharply (Figure 18-3, E). The surgical site is eval-
uated for accessory nerve branches. If identified,
they are transected in a similar manner. Subcuta-
neous closure is optional. The skin is closed with
a continuous or interrupted pattern using No.
2-0 suture material.
POSTOPERATIVE CARE
Postoperative Care
Bandaging: A sterile dressing is placed over the
incisions, and a limited-pressure bandage is
applied over the incision sites using folded gauze
sponges and 3-inch Elasticon. A half limb bandage
is then applied. The initial bandage is changed 24
hours after surgery and replaced without the pres-
sure bandage. Subsequent bandage changes are
performed at 4- to 5-day intervals or more fre-
quently if indicated. Bandaging is applied for a
minimum of 3 weeks.
Exercise Restridions: Stall rest is provided
for 4 weeks. After 10 days, handwalking is al-
lowed. After 4 weeks, the horse may resume
normal activity.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the first 24 hours and 2.2
mg/kg BID for an additional 5 days.
Suture Removal: Skin sutures are removed 12
days postoperatively.
Other: When performed for navicular disease,
corrective shoeing to decrease the biomechanical
forces on the navicular bone should be continued.
The bottom of the foot should be checked daily
for puncture wounds, or the horse should be shod
with pads.
EXPECTED OUTCOME
Reported soundness rates 1 year after palmar
digital neurectomy are 74%1 and 77%.2 After 2
Palmar-Plantar Digital Neurectomy 109
years, the reported soundness rate is 63%. I
Reasons for lameness vary and may be directly
related to surgical complications, reinnervation,
or secondary lameness in the limb.
COMPLICATIONS
Progression of the underlying problem may occur.
In severe cases of navicular disease, progression
can result in DDFT rupture or navicular bone
fracture. To decrease the incidence of these com-
plications, we generally avoid performing neurec-
tomy in horses with erosion of the flexor cortex of
the navicular bone or extremely large medullary
cavity cysts (Figure 18-4). If neurectomy is per-
formed in horses with flexor cortex lesions, the
horse should be shod with moderate to significant
heel elevation and activity should be limited. In
all cases of navicular disease, corrective shoeing
for navicular disease should be continued postop-
eratively.
Undetected foot abscesses may occur from lack
of sensation, and the foot should be examined
daily for evidence of puncture. Reinnervation can
occur within months of the surgery, and treat-
ment options are limited to repeat neurectomy
at a more proximal location. Neurectomy above
the dorsal branch of the palmar digital nerve
is not recommended. Painful neuroma formation
is somewhat unpredictable.
3
Its occurrence is
thought to increase when excessive inflammation
Figure 18-4 Horse with large medullary cavity cyst.
This horse is at increased risk for deep navicular bone
fracture following neurectomy.
110 LI MB SURGERIES
occurs. This may be related to performing surgery
too soon after diagnostic anesthesia, traumatic
surgical technique, excessive postoperative move-
ment, or incisional site problems. Ideall y, surgery
should not be perfo rmed for a minimum of
2 weeks after diagnostic anesthesia of the palmar
digital nerve. Surgical technique and handling of
the nerve should be as atraumatic as possible,
and excessive dissection minimized. Adequate
postoperative rest and proper bandaging tech-
niques should be emphasized to the owner. Loss
of the hoof wall as a result of ischemia is a rare
but possible complication. Reasons for its occur-
rence are not well understood.
4
ALTERNATIVE PROCEDURES
Black's Technique
Thi s method of neurectomy allows for removal of
a longer section of nerve, decreasing the cha nces
of accessory nerve branch innervation to the
region. The proximal nerve endin g may also lie
deeper in the incision, potentially decreasing the
incidence of neuroma formation.
5
A 2-cm skin inci sion is made over the abaxial
border of the DDFT just above the medi al or
lateral cartilage of the third phalanx in the distal
pastern region. The inci sion is extended carefully
through the subcutaneous tissue. Blunt dissection
is used to isolate the palmar digital nerve. Identi-
fi cation of the nerve is confirmed by crimping of
the nerve after it has been stretched and released
and palpating longitudinal fibers when the nerve
is stretched over the smooth portion of an instru-
ment. Closed Kelly forceps are placed below the
nerve, and traction is appl ied to identify the loca-
tion of the nerve in the proximal pastern region.
A 2-cm incision is made in the proximal pastern
region distal to the base of the proximal sesamoid
bone directly over the nerve being held in trac-
ti on. The nerve is isolated in this region, and trac-
tion is applied to the proximal and distal ends to
ensure the same nerve is exposed through both
incisions (Figure 18-5). A new scalpel blade is
then used to transect the nerve as proximal as pos-
sibl e through the upper incision. Traction is
applied to the distal end of the nerve in the distal
incision, and a 6- to 8-cm portion of nerve is
stripped through the incision (Figure 18-6) . The
exposed nerve is then severed as distally as possi-
ble, and the skin is closed routinely (Figure 18-7).
Figure 18-5 Exposure of the palmar digital nerve in
the proximal and distal incisions used in Black's
method of neurectomy.
Figure 18-6 The nerve has been transected proxi-
mally and pulled through the distal incision in Black's
method of neurectomy.
Figure 18-7 Two-day postoperative view of the inci-
sions used in Black's method of neurectomy.
Perineural Capping
Perineural capping of the proximal nerve end may
be performed in an attempt to decrease painful
neuroma formation. } Controlled studies with
high case numbers are lacking, but if the tech-
nique can be performed atraumatically it is likely
beneficial. The palmar digital nerve is isolated and
exposed as for the guillotine technique. The distal
end of the nerve is severed. The end of the prox-
imal nerve is grasped with hemostats, and Gerald
or similar dressing forceps are used to free the
combined epineurium and perineurium (per-
ineural sleeve) from the nerve (Figure 18-8, A
and B). After freeing of the perineural sleeve, the
proximal end of the nerve is sharply transected. If
sufficient nerve length is available, two partial
incisions in the nerve can be made before tran-
seeting the nerve. The purpose of these incisions
is to slow axon regeneration and allow increased
time for the perineural capping seal.
3
After nerve
transection) the edge of the perineural sleeve is
grasped and pulled over the nerve (Figure 18-8,
e) . The perineural sleeve is closed with one or two
interrupted sutures using 4-0 absorbable suture.
Subcutaneous and skin closures are routine.
Other techniques for neurectomy have been
described, including a method of tunneling the
proximal nerve end into bone and the use of a
carbon dioxide laser to perform neurectomy) and
they appear to have good success rates.
6
,7
COMMENTS
Careful selection of cases should be performed.
Significant improvement in lameness after palmar
digital anesthesia is important, as well as an owner
who understands potential complications and will
provide excellent short- and long-term postoper-
ative management. A variety of techniques for
neurectomy are available, but no single technique
has proven to be superior. Atraumatic technique
and adequate postoperative rest are the essential
components of all techniques. Although potential
complications of neurectomy dictate limited use
of the procedure) palmar digital neurectomy can
offer significant pain relief and return to athletic
function in horses that have not responded to
other treatment options.
Palmar-Plantar Digital Neurectomy III
A
B
C
Figure 18-8 Perineural capping on a cadaver limb.
A. The nerve ending is grasped with hemostats, and
smooth-tipped forceps are used to strip the perineural
sleeve proximally. B, The perineural sleeve has been
stripped proximally, and the nerve is exposed. C, After
severing the exposed nerve, the nerve ending retracts
proximally within the perineural sleeve. The perineural
sleeve is then closed with No. 4-0 suture material.
112 LIMB SURGERI ES
REFERENCES
I. Jackman BR, Baxter GM, Doran RE. et al: Palmar
digital neurectomy in horses: 57 cases (1984-1990).
Vet Su'g 22:285, 1993.
2. Matthews S, Dart A, Dowling B: Palmar digital
neurectomy in 24 horses using the guillotine tech-
nique, Aust Vet} 81 :402, 2003.
3. Evans LH: Procedures used to prevent painful neu-
romas, Proc Am Assoc Equine Pmct 16: 103. 1970.
4. Taylor TS, Vaughan IT: Effects of denervation of the
digit of the horse,} Am Vet Med Assoc 177: 1 033, 1980.
5. Black J8: Palmar digital neurectomy: an alternative
surgical approach, Proc Am Assoc Equine Pmct
38:429, 1992.
6. Harris JM, Kermedy MA: Modified posterior digital
neurectomy for management of chronic heel pai n in
horses, Proc Am Assoc Equine Pract 45:99, 1999.
7. Haugland LM, Collier MA. Panciera RJ. et al: Effect
of C02 laser neurectomy on neuroma formation
and axonal regeneration. Proc Am Assoc Eqllille Pmct
39:229, 1993.

CHAPTER 19
Cast Application
Joanne Kramer
INDICATIONS
Casts provide mechanical support and physical
protection for fractures, luxations, and tendon
and ligament injuries. Casts also provide physical
protection and soft tissue immobilization for
wounds and are commonly used to facilitate
wound healing.
EQUIPMENT
Fiberglass casting material, cast padding, syn-
thetic stockinette, orthopedic felt, and acrylic are
used (Figure 19-1). A variety of fiberglass casting
material is available. J,2 We commonly use Delta
Lite "S."*
POSITIONING AND PREPARATION
Most casts are applied under general anesthesia
with the affected limb uppermost. Standing
application is possible but increases the risk of a
poorly fitting cast due to movement. Half limb
and distal limb casts are put on with the horse
under general anesthesia. Foot casts and some
forelimb distal limb casts are put on with the
horse standing with the affected limb held up by
an assistant.
"Delta-Lite "$"; Johnson & Johnson, Raynham, Mass.
113
CAST APPLICATION
Preparation
The li mb should be clean and the foot trimmed
normally. A sterile dressing is applied over inci-
sions or wounds. A double layer of stocki nette is
applied to the region of limb to be cast (Figure 19-
2). The stockinette should conform to the limb
and not be allowed to wrinkle. Orthopedic felt is
applied at the proximal limit of the cast (Figure
19-3).
Limb Positioning and Handling
The limb is generally cast in a weight-bearing
position. Exceptions include fl exor tendon lacera-
tions, where the limb may be cast in a slightly
flexed position. The hind limb is often cast in
slight flexion to decrease tension on the superfi- .
cial digital flexor tendon from the reciprocal
apparatus when the stifle and hock flex. If traction
is required, wires may be placed through the hoof
wall and used with a steel bar to apply traction.
Wires may also be useful to maintain foot posi-
tion while casting. When handling the limb
during cast application, the limb should be held
only at the foot and above the cast. Pressure on
the cast material during the curing process can
create focal pressure points that lead to cast sores
or areas of stress concentration.
-
114 LIMB SURGERIES
Figure 19-1 Supplies used in cast application. From
left to right, stockinette, orthopedic felt, foam cast
padding, and fiberglass casting material.
Figure 19-2 Applying a double layer of stockinette.
Figure 19-3 Orthopedic felt applied at the a n t i c i ~
pated proximal limit of the cast.
Handling of Cast Material
The strength of a cast depends on the thickness of
the cast and the bonding between the individual
layers of cast tape. The polyurethane resin i.n the
casting tape starts to cure when immersed in
" , ,
'>
$ ; II!
'" ..
Figure 19-4 A cast where all layers have cured
simultaneously.
Figure 19-5 A cast where individual layers of cast
material have cured separately. The result is a weak cast
prone to break.
water. Specific directions for handling vary with
each manufacturer. Generally, the cast material is
immersed in water at room temperature (68° to
77° F, 20° to 25° C) and squeezed four to five times
while immersed, before application. Cast material
curing time can be slowed slightly by exposing the
material to cooler water for a shorter time period.
As cast material cures, it stiffens to provide rigid
support. AlI layers of the cast should cure simul -
taneously to provide adequate strength. Once cast
application is begun, subsequent layers of cast
tape must be applied rapidly to avoid individual
layers of cast material stiffening before becoming
bonded to the surrounding layers (Figures 19-4
and 19-5).
Application of Cast Material
A layer of cast padding is applied before the cast
material is applied to ensure even contact between
Figure 19-6 Foam padding applied before fiberglass
casting tape is applied.
the cast and the limb and to protect the skin from
the fiberglass material. A variety of materials are
available for cast padding.1 A water-curable foam
padding>!- is commonly used and appears to de-
crease cast sores' (Figure 19-6). The foam padding
should be set on the limb with only minimal
tension. The cast material should be applied with
only enough tension to avoid wrinkling. Each
turn should be overlapped by half a tape width.
The tension used when applying the cast material
can be increased gradually as the number oflayers
in the cast increases. For most fiberglass cast
materials, the horse should be maintained in
recumbency for 20 minutes after cast application
to allow for curing.
Half Limb Cast
A doubl e layer of stockinette is rolled from the
foot to above the carpus or tarsus and held in
place with towel clamps. The stockinette should
fit snugly and be stretched to avoid wrinkles. A 2-
inch-wide felt strip is then placed over the
metacarpal-metatarsal bones at the proximal limit
of the cast, which should be 2 em distal to the
ca rpal or tarsal joint. Custom support foam or
other cast padding material is applied starting
proximally and working distally, with special
attention paid to adequately cover the coronary
band. This is immediately followed by a layer of
2- to 3-inch-wide casting material. The initial
2- to 3-inch layer allows better contouring of the
cast material to the limb but has decreased
"Custom Support Foam; 3M Animal Health Care Prod-
ucts, St. Paul, Minn.
Cast Application 115
Figure 19-7 Applying fiberglass casting material.
Figure 19-8 Incorporation of a heel wedge into the
bottom of the cast. A partial roll of casting tape has been
incorporated into the heel (left) and acrylic applied to
provide an even weight bearing surface (right).
strength compared with wider casting tape. Four-
inch-wide cast tape should be used for subsequent
layers (Figure 19-7). Cast material should be
applied with only enough tension to avoid wrin-
kling and with each turn overlapped by half a tape
width. Before the last layer of cast material is
applied, the stockinette is folded down and held
in place by the last cast layer. Adhesive tape is used
to seal the proximal end of the cast. The entire
length of cast should be covered in five to eight
layers of tape.' Generally, five or six rolls of casting
tape are used in a hal f limb cast. Casts providing
mechanical support for severe orthopedic injuries
require more layers than do casts providing soft
tissue support for wound healing. A heel wedge
should be placed so that the toe and heel of the
cast are level when the limb is directly under the
horse (Figure 19-8). Acrylic or other durable
material is applied to the bottom of the cast to
prevent wear (Figure 19-9).
116 LI MB SURGERIES
Figure 19-9 Applying acrylic to protect the bottom
of the cast from excess ive wear.
Figure 19-10 Applying a dist.l limb cast.
Distal Limb Cast
Thi s cast terminates at the proximal pastern,
allowi ng fet lock flexion and extension (Figure 19-
10). Distal limb casts are most commonl y used in
the treatment of heel bulb and distal pastern and
coronary band lacerations.
5
,6 The palmar-plantar
aspect of the cast is slightly shorter than the
dorsal aspect of the cast to all ow for fetlock exten-
sion. Stockinette is applied and felt padding is
placed around the proximal aspect of the first
phalanx. The limb is cast in a weight-bearing posi-
tion. Cast padding and 2- or 3-inch cast material
is used to allow for adequate contouring. Acrylic
is placed on the bottom of the foot to decrease
wear. The heel is not typically elevated. Deter-
mining the optimal weight-bearing position of
the fetlock is difficult and is best assessed when
the cast has cured and the limb is bearing weight.
In some cases, the cast may have to be trimmed
back slightly if it appears to impinge on the fetlock
Figure 19-11 A foot cast used to protect hoof wall
injuries or aid in third phalanx fracture stabili zation.
joint dorsally or the proximal sesamoid bones
palmarly or plantarl y.'
Foot Cast
Foot casts terminate just below the coronary band
on the hoof wall (Figure 19- 11 ). They can be used
in the management of hoof wall injuries or coffin
bone fractures. ' Felt padding should be applied to
the heel bulb region. Two-inch casting material is
used to allow for adequate contouring. Acrylic is
placed on the bottom of the cast to decrease wear.
Bandage Cast
Bandage casts are used when frequent access to
the limb is desired or as reduced support in the
transiti on from a traditional half limb cast to ban-
daging. Two or three pieces of thin sheet cotton
are rolled around the limb and secured wi th
brown roll gauze. Vetrap* is then applied. The
foot is included in the wrap for increased immo-
bilization. Orthopedic felt is applied at the proxi-
mal limit of the cast. Applicati on of custom foam
support is recommended but optional. The cast is
then constructed wi th the desired amount of
casting tape (generally five or six rolls of 4-inch
casting tape). Acrylic is applied to protect the foot.
At the first required bandage change, the cast is
cut with an oscillati ng saw along the medial and
lateral or dorsal and palmar aspects. The bandage
is then changed, and the two halves are reapplied
and secured with duct tape.
s
*Vetrap; Animal Care Products, 3M Health Care, SI. Paul,
Minn.
A modification of this procedure is performed
when less immobilization is required or the ban-
dage cast is used as a transition to bandaging alone
after a half limb cast has been removed. The initial
layer of bandage material described earl ier is
placed without Vetrap, and a second identical layer
is placed over the initial layer and secured with an
elastic wrap. The cast is then constructed without
inclusion of the bottom of the foot and bivalved
at the first bandage change (Figure 19-12, A to C).
POSTOPERATIVE CARE
Posto erative care
Bandaging: A support bandage and foot eleva-
tion are often applied to the contralateral limb'
(Figure 19-13). In cases of severe injury, support
to the contralateral limb is essential to decrease
the risks of contralateral limb laminitis. This can be
provided in the form of frog and caudal support,
heel elevation, and decreased breakover. Com-
mercial shoes are available and work well for this
p u r p o s e ~
Exercise Restridions: Horses with casts should
be confined to a stall. After cast removal, exercise
must be gradually increased to avoid overloading
articular cartilage, bone, and soft tissues. The
longer the period of immobilization, the more
important and gradual is this reintroduction
period.
*Redden Modified Ultimate; Nanric Inc., Versailles, Ky.
A B
Cast Application 117
cast Removal
In adult horses, casts are generally removed or
replaced within 4 to 6 weeks. With very careful
monitoring, an adult horse showing no problems
may wear a cast up to 6 to 8 weeks. In young foals,
casts should be removed in 10 to 12 days. For
older foals, casts can be left in place for up to 3
weeks.
For orthopedic support, cast application is
often necessary for 8 weeks. For wound support,
cast application is required for 2 to 3 weeks.
Casts are removed with an oscillating cast
cutter and cast spreaders. The medial and lateral
sides of the entire length of the cast are cut full
thickness with an oscillating saw (Figure 19-14).
The cast spreaders are then inserted in the cut line
and the cast pried open (Figure 19-15). The
underlying stockinette is then cut, and the cast is
removed from the limb. When the oscillating saw
has penetrated the depth of the cast, a character-
istic "give" is felt. The cast cutters should not be
dragged back and forth along an area to be cut.
Even pressure should be applied without moving
the saw until the cast has penetrated the depth of
the cast. The cast cutters are then removed and
reinserted so that the previously cut area is over-
lapping halfway with the next area to be cut. Cast
spreaders should not be inserted until the entire
length of cast is cut. If the thickness of the cast is
symmetrical and the layers of casting tape have
cured in a one-layer cast, removal is straightfor-
C
Figure 19-12 A bandage cast used for transition to bandaging after traditional half li mb casting. A, The casting
material is placed over a double layer of bandage material. B, At the first desired bandage change, the bandage cast is
split into two halves. C, After the bandage is changed, the halves are supported with duct tape, allowing subsequent
bandage changes to be performed as needed.
118 LIMB SURGERI ES
ward. Special care should be taken over bony
prominences, joints, and the coronary band, as
these are the areas most likely to be injured with
the cast cutter.
Bandaging or splint application is indicated
after cast removal to prevent edema and to ease
Figure 19-13 Bandaging and elevation of the con-
tralateral limb.
Figure 19-14 Cast removal using an oscillating saw.
Figure 19-15 Aft er the entire cast has been split with
an oscillating saw. Cast spreaders are inserted to sepa-
rate the two halves of the cast.
the transition between cast support and normal
weight bearing. Foals often require temporary
heel extension after cast application because of
flexor tendon laxity (Figure 19-16).
Cast Monitoring
Casts must be monitored daily for the presence of
heat, discharge, pressure sores, and cracking.
Horses wearing casts should be monitored closely
for changes in the level of lameness present. Early
cast removal and replacement or reassessment are
indicated immediately if the cast has broken or
the horse has had a significant change in lameness
level.
COMPLICATIONS
Cast sores, disuse osteopenia, articular cartilage
softening, joint stiffness, tendon or ligament
laxity, or breakage of the cast may occur.
2

4

1O
,11
Pressure or friction sores generally occur at the
proximodorsal aspect of the thi rd metacarpal
bone, the proximoplantar aspect of the superficial
digital flexor tendon, and the pal mar/plantar
aspect of the sesamoid bones in hal f limb casts
(Figures 19-17 and 19-18). In distal limb casts,
pressure or fri ction sores are most common at the
proximopalmar aspect of the pastern. Foals and
thin-skinned horses are particularly susceptible to
cast sores. The degree of articular cartilage
atrophy and disuse osteopenia and laxity is likely
related to the length of cast immobilization and
to the use or lack of use of the limb during the
casting period. In foals, marked flexor tendon
Figure 19-16 Application of a heel extension to
provide fl exor tendon support in a foal with tendon
laxity secondary to cast application.
A B
Figure 19-17 Areas prone to cast sore development
when a half limb cast is worn.
Figure 19-18 Cast sores on the palmar aspect of the
fetlock.
laxity occurs within a short period of time. Prox-
imal sesamoid bone fracture secondary to disuse
osteopenia after hind limb cast application has
been reported in two horses.
12
Half-limb casts
ending too low can create stress concentration on
the metacarpal bone and risk fracture, especially
during recovery from anesthesia.
Breaking of the cast usually occurs at the level
of a moveable joint. Breakage is a result of inade-
quate cast material strength due to inadequate
thickness or inadequate curing (curing of two or
more individual layers). Broken casts need to be
removed immediately and replaced entirely.
Cast Application 119
Figure 19-19 Incorporation of a dorsal-palmar
splint to increase bending strength in a half limb
cast.
ALTERNATIVE PROCEDURES
Splints
During cast application, longitudinal splints of
cast material can be applied on the dorsal and
palmar aspect of the cast for additional strength.
The splints are applied after several layers of cast
material have been applied, and the final layers of
cast material are used to incorporate the splints
into the cast (Figure 19-19).
Preplaced Fetotomy Wires
Plastic-covered fetotomy wires can be prep laced
on the medial and lateral aspects of the limb
superficial to the cast padding but deep to the
casting tape. The cast is then removed by placing
handl es on the wire and using the wire to saw the
cast open on each side?
COMMENTS
Casts are only rarely used as the primary stabi-
lization method for fractures or luxations. More
often, casting is used as initial first aid stabiliza-
tion for the transport of horses with severe
orthopedic injuries. For more information on the
appropriate form of stabilization for specific
injuries, Chapter 4 on emergency stabilization of
orthopedic injuries should be consulted.
The benefits of cast application in wound
healing are often overlooked because of a per-
ceived increase in cost. We have found that the
120 LIMB SURGERIES
cost of frequent bandage changes is often similar
to the cost of initial casting and have had good
success with cast application as an aid to wound
heal ing. To minimize complications, the period of
cast application should be as short as possibl e. and
removal, reassessment, and replacement should
be performed if there is any question as to the
status of the underlying limb. Foals can develop
cast complications quickly because of their thin
skin, high activity level, and tendency toward
severe ligament laxity.
REFERENCES
1. Booth TM, Dart AJ. Watkins JP: Equine limb casts:
materials and methods, Comp Cant Educ Prac Vet
25:701.2003.
2. Murray RC, Oebowes RM: Casting techniques. In
Nixon AI, editor: Equine fracture repair, Philadel-
phia, 1996, WB Saunders.
3. Bramlage LR, Embertson RM, Libbey CJ: Resin
impregnated foam as a cast liner on the distal limb,
Proc Am Assoc Vet Pract 37:481,1991.
4. Riggs CM: Indications for and application of limb
casts in the mature horse, Equine Vet Educ 9:190,
1997.
5. Blackford JT, Latimer FG, Wan PY, et al: Treating
pastern and foot lacerations with a phalangeal cast,
Proc Am Assoc Equille Pmct 40:97.1994.
6. Booth TM, Knottenbelt DC: Distal limb casts
in equine wound management. Equine Vet Educ
11:273.1999.
7. Booth TM, Dart AI. Watkins JP: Equine limb casts:
materials and methods, Camp Cant Educ Pmct Vet
25:708.2003.
8. Hogan PM: How to make a bandage cast and indi-
cations for its use, Proc Am Assac Equine Pract
46: I SO. 2000.
9. Hendrickson DA, Stokes M, Wittern C: Use of an
elevated boot to reduce contralateral limb support
complications secondary to cast application, Proc
Am Assoc Equine Pmct 43: 149. 1997.
10. Ri chardson OW, Clark CC: Effects of shor t- term
cast immobilization on equine articular cartilage,
Am I Vet Res 54:449. 1993.
11. vanHarreveld PO, Lillich JD, Kawcak CE: Effects
of immobilization followed by remobilization
on mineral density, histomorphometri c features
and formation of the bones of the metacar-
pophalangeal joint in horses, Am / Vet Res 63:276,
2002.
12. Malone ED, Anderson BH, Turner TA: Proximal
sesamoid bone fracture following cast removal in
two horses, Equine Vet EdriC 9:185,1997.
EAD AND ECK URGERIES
121
CHAPTER 20
Intraoral Wire Fixation of Rostral Mandibular
and Maxillary Fractures
David A. Wilson
INDICATIONS
Fractures of the rostral mandible, maxi ll a, and
incisive bones that can be repaired with wire and!
or acrylic. Only fractures that can be readily
repaired with stainless steel wires are discussed.
EQUIPMENT
Stainless steel wire (16 or 18 gauge), needle
holders or pliers, wire cutters, acrylic, and drill. A
spool speculum or section of PVC tubing pl aced
between the cheek teeth improves access to the
oral cavity. Ideally, a nasotracheal tube is also
placed during the surgery to facilitate breathing.
POSITIONING AND PREPARATION
Simple fractures involving one to three incisors
can be repai red in the standing, sedated horse
with local anesthesia. Mental and infraorbital
nerve blocks provide effective regional anesthesia
in these cases. Alternatively, local anesthesia can
be used. Fractures involving the interdental space
are more commonly repaired under general anes-
thesia in either lateral or dorsal recumbency
depending on fracture configuration. Antibiotics
and nonsteroidal antiinflammatory agents are
administered prior to surgery. Ideally, a nasotra-
cheal tube is placed to protect the airway. The
mouth is rinsed with water to remove accumu-
122
lated feed material, and the area surrounding the
fracture site is scrubbed with povidone-iodine
soap and rinsed again. If a wire will be passed
around the premolars, stab incision sites are
clipped and prepared aseptically.
ANATOMY
The primary structures potentially involved in the
repair of these fractures are the maxilla, incisive
bone, incisive part of the mandible, incisors,
canine teeth, mental and infraorbital nerves,
intermandibular synchondrosis, and permanent
tooth roots. The permanent incisors, canines, and
premolars are formed from separate enamel
organs that are derived from lingual (medial )
extensions of the dental laminae of the deciduous
teeth.
1
The permanent incisors erupt on the
lingual aspect of the deciduous incisors.
The mental nerve emerges from the mental
foramen on the rostrolateral aspect of the hori-
zontal ramus, approximately midway between the
second premolar and the third incisor. A small er
portion of the mental nerve continues rostral in a
smaller canal along with the vasculature of the
lower incisors. 1
PROCEDURE
Various methods have been described to repair
fractures of the rostral mandibl e and incisive
bone.'· " The first step of the surgery is thorough

Intraoral Wire Fixation of Rostral Mandibular and Maxillary Fractures 123
debridement of the fracture site. Remaining food
material, clotted blood, and bone fragments are
removed. A bone curette may be used to freshen
the edges of exposed bone, being careful to not
manipulate or damage exposed, unerupted per-
manent teeth. Completely detached or broken
teeth should be removed. However, loose decidu-
ous teeth are maintained if possible. These teeth
often survive better than expected and provide
stability, structure, and positioning for future
permanent tooth eruption. Fractures involving
alveoli can result in infectious periodontitis and
puipitis, necessitating removal of the tooth.
9
However, removal of the tooth should be delayed
until the fracture heals.
Fractures that involve four or fewer incisors
can be repaired with cerclage wire fixation tech-
niques. As a rule of thumb, wires should engage a
minimum of two teeth as the teeth immediately
adjacent to the fracture will not be very stable. A
minimum of two loops should be used to secure
a fracture fragment . Ideally, there should be
overlap of the wire loops to improve stabilization
(Figure 20-1). A 14-gauge hypodermic needle
with or without a 2-mm drill hole can be used to
guide the stainless steel wire (16 to 18 gauge [I-
to l.2-mm diameter]) through the interalveolar
spaces. In young horses, the 14-guage needle may
be used without prior drilling. The 14-guage
needle may also be used as a cannula after drilling
A B
to facilitate wire passage between the incisors. The
wires should be applied tightly by hand and
twisted one or two turns followed by additional
twisting using fencing pliers, needl e drivers, or the
equivalent, being careful not to overtighten the
wires and cause wire breakage. When necessary,
additional stabilization can be achieved by secur-
ing the corner incisor(s) to the exposed canine
if erupted or second or third premolar (Figures
20-2 and 20-4).
Incorporating the second premolar into the
fixation involves placing a tension band wire from
the incisors to the second premolar (Figure 20-3).
A stab incision is made through the cheek directly
over the space between the second and third
premolars. Hemorrhage is minimized by incising
through the skin and using blunt dissection to
separate underlying soft tissues. The buccal
mucosa is penetrated, and the drill bit with a pro-
tective drill guide is positioned between the
second and third premolars just ventral to the gin-
gival margin. The drill guide is left in place after
drilling between the teeth is completed to help
thread the wire through the drilled hole. The wire
is then pulled through the cheek and directed
rostral to be laced through the holes previously
made between the incisors. The wires spanning the
interdental space are twisted together to increase
compression at the fracture line. After tightening,
the ends of the wi res are bent flat and may be
c
"7J.p"...,,! ~ .. ( .,.
Figure 2 0 ~ 1 A. Using a hypodermic needle as a wire guide to help pass the wire between teeth. B. Second passage
of the wire using the hypodermic needle to help pass the wire. C, Wires in position to repair a rostral mandibular
fracture involving the first and second right incisors in a young horse without canine teeth. Note overlap of wire
loops, which reinforces the fixation.
....
124 HEAD AND NECK SURGERI ES
B
A '"
Figure 20·2 A. Rostral mandibular fracture involv-
ing the first left incisor and all three right incisors.
In older horses, the canines can be used to anchor the
stabilizing sutures. B. Note the "notch" in the cani ne to
help hold the wires in position (arrow).
A
B
covered with a small amount of acryl ic. In young,
rapidly growing horses, both sides of the mandible
should be included in the fixa tion to the premo-
lars to minimi ze the risk of developing disparate
mandibul ar growth or placi ng undue stress on the
symphysis.
Bilateral fractures in the interdental space with
displacement are often unstable and require more
than wire fixati on. In comminuted fractures of the
interdental space, the mandible tends to collapse
when the wires are ti ghtened. A buttress is needed
to maintain the mandible in position. Acryl ic
reinforcement of intraoral wiring can be used in
some of these fractures, resulting in a relatively
stable fixation.
12
Ideally, cold curing acrylic should
be used or the acrylic should be lavaged with
sali ne as the acrylic is curing.
A tension band wire is pl aced from the incisors
to the first or second cheek tooth as previously
described. After the wires are placed, an intraoral
splint is made by molding acrylic around the wires
and contouri ng it to fit the mouth from the
incisors to the second cheek tooth. The wires run
c
Figure 20-3 A. Positioning of drill through cheek between first and second cheek teeth fo r insertion of tension
band wi re for repair of rostral mandibular fract ure. B. Initial wire insertion to repair rostral mandibular fracture

involving the right incisors. In young horses. a 14- or 16-guage needle can be used to insert the wires between teeth.
In older ani mals, a small drill (about 2 mm) can be used to provide a path for the wire. C. Wires in place fo r repair
of a rostral mandibular fracture involving the right incisors in the absence of canine teeth. After the wires are tight-
ened, the ti ed ends should be folded over against the gum to minimize soft tissue irritation. A small amount of acryl ic
may be applied over the wire ties to minimize irritation .
Intraoral Wire Fixation of Rostral Mandibular and Maxillary Fractures 125
__ ...............
Figure 20-4 Comparison of technique to repair the
same fracture as Figure 20-3 showi ng how the fra cture
would be repaired if the cani nes were present.
through the acrylic and hold it into place. Addi-
tional strength can be gained by wiring the acrylic
to the mandible, incisors, or premolars. In frac-
tures that have minimal displacement or maintain
reduction easily, the acrylic may be formed to the
mouth first, allowed to harden, and then removed
prior to the insertion of wires. This allows
removal of sharp edges or excessive material with
a rasp or Dremel tool. Holes are then drilled into
the acrylic splint. and the splint is wired to the
mandible, premolars, and incisors.
POSTOPERATIVE CARE
Postoperative Care
Medications: Because these fractures are often
open, with significant contamination, broad-spec-
trum antibiotic therapy should be considered, but
it generally is not necessary beyond the first 3 to
5 postoperative days. Nonsteroidal antiinflamma-
tory drugs are typically administered for 1 to 3
days. Tetanus prophylaxis should be current.
Other: Horses generally return to a norrnal diet
immediately after surgery, but in some cases a
pelleted feed or gruel may be of benefit. The
mouth may be rinsed out at least twice daily for
the first week. Additionally, the horses should not
be allowed to graze for 2 to 4 weeks, and the
wires should be checked daily for breakage.
EXPECTED OUTCOME
Rostral fractures usually heal without
tion in 4 to 6 weeks, provided there is adequate
stabilization and permanent tooth buds are not
involved. Fractures involving the interdental space
may require a longer healing period. typically
8 weeks. In most cases, the wires can be removed
in the standing horse with minimal sedation.
COMPLICATIONS
Purulent drainage, bone sequestration. septic
osteitis, difficult mastication, unusual incisor
eruption, wire loosening. and fixation failure are
potential complications. Brachygnathism has also
been reported in three foals following repair of
bilateral fractures of the mandible.' In one study,
27% of horses experienced short-term complica-
tions.
5
Fortunately, although short-term compli-
cations may be common, the long-term prognosis
for functional and cosmetic outcome is favorable.
COMMENTS
Young, curious horses typically incur these frac-
tures when they try to free themselves after getting
their head or teeth caught. Delay or failure to
repair these fractures may result in malocclusion,
tooth loss, osteomyelitis, loss of function, and less
than optimal cosmesis.
5
Because the oral side of
the mandible and maxilla is the tension surface,
intraoral wire fixation provides strong, effective
fixation in many fracture configurations.
REFERENCES
1. Dixon PM: Dental anatomy. In Baker GJ, Easley J,
editors: Equille dell tis try, London, 1999, WB
Saunders.
2. Murch KM: Repair of bovine and equine mandibu-
lar fractures, Can Vet J 21:69, 1980.
3. Staton AL: Si mplified wiring procedure for frac-
tured jaw, Pulse 2:9, 1988.
4. DeBowes RM: Fractures of the mandible and
maxilla. In Nixon AJ. editor: Equine fracture repair,
Philadelphia, 1996, \rVB Saunders.
5. Henninger RW, Beard WL: Rostral mandibular and
maxillary fractures: repair by interdental wiring,
Proc Am Assoc Equine Pract 43: 136, 1997.
126 HEAD AND NECK SURGERIES
6. Steenhaut M: Surgical-treatment of dental prob-
lems and mandibuJar fractures in the horse, Vlaams
Diergeneeskundig TijdschriJt 67:23, 1998.
7. Martens A, Steenhaul M, Boel K. et al: Conserva-
tive and surgical treatment of mandibular and
maxillary fractures in 54 horses. Vlaams Dierge-
neeskundig Tijdschrift 68: 16. 1999.
8. Beard WL: The skull. maxilla. and mandible. In
Auer JA. Stick lA. editors: Equine surgery, ed 2,
Philadelphia, 1999, WB Saunders.
9. Crabill MR. Honn<1s CM: Mandibular and maxil -
lary fracture osteosynthesis. In Baker G], Easley
J. editors: Eqllille dentistry. London. 1999, WB
Saunders.
10. Henninger RW, Beard WL, Schneider RK, et al:
Fractures of the rostral portion of the mandible
and maxilla in horses: 89 cases (1979-1997), J Am
Vet Med Assoc 214:1648,1999.
11. Adams S8, Fessler JF: Repair of mandibular and
maxillary fractures In Adams S8, Fessler]F editors:
Atlas oj equine surgery, Philadelphia. 2000. WB
Saunders.
12. Peavey CL. Edwards RB, Escarcega A], el al: Fixa-
tion technique influences the monotonic properties
of equine mandibular fracture constructs, Vet Surg
32:350, 2003.

CHAPTER 21
Sinus Trephination
David A. Wilson
INDICATIONS
Sinus trephination can be performed for both
diagnostic and therapeutic purposes to confirm
the presence of purulent exudate; to obtain sirtus
contents for cytology, biopsy, or culture; and to
provide a portal for sinus irrigation or tooth
repulsion.
I
-
3
EQUIPMENT
A Steinmann intramedullary pin of 3/
W
or 1/4- inch
diameter or a trephine instrument is used for this
procedure.
POSITIONING AND PREPARATION
The procedure is performed in the standing,
sedate horse with local anesthesia.
3
-
s
The trephine
site is clipped and prepared for surgery. Instilla-
tion of local anesthesia should create a ski n bleb
and infiltrate the underlying periosteum.
ANATOMY
Important landmarks for defining the boundaries
of the sinuses and determining entrance portals
include the infraorbital canal, the faci al crest, the
facial tubercle, the orbit, and the nasolacrimal
duct. The course of the nasolacrimal duct can be
127
approximated by a line from the medial canthus
of the eye to the infraorbital canal. This line
should be avoided when creating entrance portals
to the sinuses. The location of the sinuses are illus-
trated in Figures 21-1 through 21-3 and the
approximate boundaries of the sinuses are
described below.'
Maxillary Sinuses
The dorsal boundary corresponds to a line drawn
caudad from the infraorbital foramen parallel to
the facial-crest . The ventral boundary varies with
the age of the horse. The last three or four cheek
tooth roots project into the ventral aspect of the
maxillary sinus to an extent that varies with age.
The rostral boundary is at the level of the infraor-
bital foramen, and the caudal border is at the level
of the ventral port ion of the orbit. The maxillary
sinus is divided into rostral and caudal portions by
an oblique septum, whose lateral margin is com-
monly about 5 cm caudal to the facial tubercle, but
can be quite variable (see Figure 21-1). The infra-
orbital canal separates the maxillary sinus into a
lateral bony compartment occupied by the roots
of the cheek teeth and a medial compartment
within the ventral concha! sinus.
Frontal Sinus
The frontal sinus is roughly triangular-shaped
with the base on midline. The right frontal sinus
is separated from the left sinus by a complete
septum. The rostral limit of the frontal sinus is at ~ " " - ......................... ~ - ..... ~ - - -
128 HEAD AND NECK SURGERIES
Infraorbital canal
Nasolacrimal
Rostral maxillary sinus Caudal maxillary sinus
~ t ; . 1 . ___
Figure 21-1 Lateral view of skull with bone removed over the frontal and maxillary sinuses. Note position of infra-
orbital canal and nasolacri mal duct (dotted lilies).
\
-+ Conchofrontal
Sinus
Infraorbital
canal
Caudal maxillary
Rostral maxillary
sinus
Facial
tubercle
'-- Nasolacri mal
duct
~ Q.,...,t;;;J.;.,..,......,
Figure 21-2 Overview of skull with bone removed
over the frontal and maxillary sinuses. Note relative
posi ti ons of infraorbital canal and nasolacrimal duct
(dotted lilles).
a point halfway between the infraorbital foramen
and the orbit at the approximate level of the fifth
cheek tooth. The caudal limit is at the level of the
caudal border of the orbit. The lateral extent is
near the level of the medial canthus. The medial
extent is on midline. In the horse, the dorsal
conchal sinus has an extensive communication
with the frontal si nus. and together they are com-
monly referred to as the conchofrontal sinus. The
rostral extent ofthe concha! sinus is at the level of
the facial tubercl e.
The caudal maxillary and frontal sinuses
communicate through a large frontal maxillary
opening and drain into the nasal cavity through
the nasomaxillary opening in the middle meatus.
The rostral maxillary sinus drains into the nasal
cavity through a separate opening in the middle
meatus.
PROCEDURE AND PREPARATION
Several sites are recommended for sinus trephina-
tion in the horse. The trephine portal for the
frontal sinus is 3 to 4 cm caudal to the most rostral
aspect of the frontal sinus and 3 to 4 cm lateral to
midline. The trephine portal for the caudal max-
illary sinus is 1 to 2 cm dorsal to the facial crest
and 7 to 8 cm caudal to the most rostral aspect of
the facial crest. The trephine portal for the cranial
maxillary sinus is J to 2 cm dorsal to the facial
crest and 3 to 4 em caudal to the facial tubercle.
As the septum dividing the maxiUary sinuses is
variable, these locations are guidelines only.
The infraorbital foramen and the levator
nasolabialis and levator labii maxillaris muscles
Dorsal conchal
Dorsal nasal concha
Ventral nasal
Rostral maxillary
Sinus Trephination 129
-0,-- Nasolacrimal duct
Infraorbital canal
Dorsal, middle, and
ventral nasal meatus
---'; '+----'t Palatine artery
, "
Figure 21-3 Transverse section through the skull at level of M2 (between the medial canthus and the facial
tubercle).
Concho-
frontal
Caudal
maxillary
Sinus
Rostral
i I
tubercle
Site of penetration
of intramedullary pin
Faci al
crest
Figure Identification of the limits of potential
trephine sites in the maxillary and frontal sinuses. The
diagonal dotted line is the approximate site of the
septum between the rostral and caudal maxillary

sinuses.
are palpable and should be avoided when creating
portals for the maxiJJary sinuses.
For diagnostic trephination, a I-em stab
incision is made through the skin and periosteum.
A Steinmann intramedullary pin is used to pene-
trate the bone. The pin should be positioned in
the chuck such that a maximum of 1/ 2 inch of the
pin length is protruding (Figure 21-4). The goal is
to penetrate the bone without damaging deeper
structures. Excess pin length protruding from the
handle of the pin chuck should be guarded to
protect the surgeon. This size portal provides
access for aspiration or for placement of a lavage
catheter, biopsy instruments, or a 4-111111 arthro-
scope for inspection of the sinuses.
Occasionally) there is a need for a larger portal
into the sinuses. Commercial trephine instru-
ments are available up to 2.5 cm in diameter)
which is large enough to allow digital palpation
of the sinuses if necessary. A circular incision)
slightly larger than the size of the trephine. is
made and the skin is discarded. Alternatively) a
cross-incision can be made through skin and
periosteum. The four resultant flaps are elevated ,
130 H EAD AND NECK SURGERIES
from the underlying bone to provide access for the
trephine instrument. The skin edges are elevated
from the trephine site to avoid binding the soft
tissues in the instrument as it is turned. The trocar
point of t he trephine should be extended to prop-
erly seat the saw blade. Once the saw blade is
seated, the trocar poi nt should be retracted to
minimize the risk of penetrating any underlying
structures. Oscillating rotations are used to cut
and ream out a circular plug of bone, with care
taken to control the instrument as the cut is
nearing completion to avoid damaging st ructures
within the sinus.
POSTOPERATIVE CARE
Postoperative therapy depends on the primary
problem. Sinus trephination is principally used
for diagnostic purposes and sinus irrigation. With
the except io n of primary sinusitis, most condi -
tions will require further surgical therapy once the
primary problem is determined. Portals can
remain open for 10 to 12 days to allow repeated
irrigation or entrance. Mild cellulitis surrounding
the portal site often develops, which can be
managed by cleaning the site at Jeast daiJy with
moistened gauze sponges.
EXPECTED OUTCOME
Even large trephine holes typically heal without
complicat ion in 3 to 4 weeks. Replacement bone
or fibrous tissue fill s the defect. A small depression
is often palpable, but not visible, once the hair
grows out. The long-term prognosis depends on
the primary problem.
COMPLICATIONS
The most common complication is hemorrhage.
The sinus mucosa is extremely vascular, and this
vascularity is increased in inflammatory condi -
tions. Generally, direct pressure will control the
bl eeding. Inadvertent penetration of structures
within the sinus can result in additional compli -
cations such as oronasal fi stula formation, bone
sequestration, hemorrhage, and death depending
on the structure penetrated. These severe compli -
cations can be virtually eliminated by controlling
the depth of penetrati on during the trephination
procedure.
ALTERNATIVE PROCEDURES
Endoscopic examination using arthroscopic
equipment allows visualizatio n of the caudal
maxillary and frontal sinuses through a frontal
sinus portal and of the sphenopalatine sinus
thro ugh a caudal maxillary sinus portaI.
7
- \O The
potential advantages of endoscopic examination
include the ability to obtain a more diagnostic
biopsy, the potential to treat minor problems, and
the abi lity to visualize a greater portion of the
respective sinuses. AJthough many disorders of
the si nuses can be addressed by sinus trephinatio n
with or without sinus endoscopy, several disor-
ders, such as resectio n or treatment of neoplastic
and nonneoplasti c growths, may require a
sinus bone flap surgery to properly address the
disorder.
11
COMMENTS
Speci fi c diseases of the sinuses include empyema,
sinusitis, tumors, and alveolar periostitis. Chronic,
unilateral purulent nasal discharge is the primary
sign associated with paranasal sinus empyema in
horses. Other clinical signs associated with disor-
ders of the si nuses include facial swelling and dis-
tortion and ocular di scharge.
REFERENCES
I. Merriam ]G: Field sinusotomy in the management
of chronic si nusiti s and alveolitis, Proc Am Assoc
Equine Pmct 39:235, 1993.
2. Worster AA, Hackett RP: Equine sinus endoscopy
usi ng a fl exible endoscope: diagnosis and treatment
of sinus disease in the standing sedated horse, Proc
Alii Assoc Equille Pmct 45:1 28 1999.
3. Adams SB, Fessler JF: Sinus trephination. In Adams
SB, Fessler JF, editors: Atlas of equil1e surgery.
Philadelphia, 2000, WB Saunders.
4. Ford TS: Standing surgery and procedures of the
head, Vet Ciin N Am Equille Pmct 7:583, 1991.
5. Schumacher J: Standing sinus surgery of the horse.
Proe ACVS Vet Sylltp 132,2004.
6. Gerard MP: Applied paranasal si nus anatomy. Proc,
ACVS Vet Sylllp 128, 2004.
7. Ohnesorge B, Stadler P: Minimal invasive and
conventional surgery of progressive ethmoidal
haematomas in horses, Tiemrztliche Praxis Ausgabe
Grosstiere Nlltztiere 29:219, 200 I.
8. Ohnesorge B, vonBorstei M, vonOppen T: Endo-
scopic therapy of progressive ethmoidal haematomas
in horses via sinus maxillary trepanation: case
reports, Pferdeheilkunde 20:316, 2004.
Sinus Trephination 131
9. Ruggles AJ. Ross MW, Freeman DE: Endoscopic
examination of nor mal paranasaJ sinuses in horses,
Vet SlIrg 20:418, 1991-
10. Ruggles A]. Ross MW, Freeman DE: Endoscopic
exami nation and treatment of paranasal sinus
disease in 16 horses, Vet Surg 22:508, 1993.
11. Hilbert B}, Little CB. Klein K. Thomas 18: Tumours
of the paranasal sinuses in 16 horses, AI/st Vet J
65:86, 1988.
CHAPTER 22
Tooth Repulsion
David A. Wilson
INDICATIONS
Repulsion is indicated for cheek teeth that cannot
be removed orally, teeth with broken crowns, or
fragmented teeth. '·' Although the techniques
described in this chapter are applicable to the first
five cheek teeth, repulsion in field or suboptimal
conditions is most practical for the rostral cheek
teeth. Improved extraction techniques and anes-
thetic protocols have expanded the capabil ity of
oral extraction of affected teeth. Oral extraction is
the preferred method of removal when possible
and practical.
J
,5-7
Specific indications for tooth removal include
retained deciduous teeth, interventional ortho-
dontics, severe periodontal disease, loose teeth,
supernumerary teeth, dental impactions, end-
odontic disease with secondary osteomyelitis,
severe disease or injury to the dental crown or
root, malocclusions, occlusal trauma, neoplasia,
biting discomfort, and sinus disease secondary to
dental disease.
s
The clinical signs associated with dental disease
are broad and typically include quidding, the
presence of a head tilt while eating, nasal dis-
charge, sinusitis, the presence of a chronic drain-
ing tract, headshaking, facial pain, excessive
sal ivation (ptyalism), anorexia or pica, and the
presence of long forage stems or whole grain in
the feces. Additional but less common clinical
signs include facial swelling or distortion, weight
loss, diarrhea, colic, reluctance to start eating, slow
or intermittent eating, difficulty in prehension,
choke, and epistaxis.
s
A thorough oral exam ina-
132
tion, including the use of a full-mouth speculum
with appropriate illumination, and a radiographic
examination are recommended if dental disorders
are suspected. Additionally, ultrasound, nuclear
scintigraphy, and computed tomography may be
useful to evaluate certain dental disorders.
9
EQUIPMENT
A dental punch and mallet are used for tooth
repulsion. A trephine or large bone rongeurs, or a
high-speed burr can be used to remove overlying
bone to access the tooth roots. Ideally, pre-
operative, intraoperative, and postoperative radi-
ographs should be taken to ensure identification
of the correct tooth, to assess the approach, to
evaluate the positioning of the dental punch, and
to check the tooth root socket for remaining frag-
ments after repulsion.
POSITIONING AND PREPARATION
The horse should be placed under general anes-
thesia in lateral recumbency with the affected
tooth up. If a mandibular tooth is affected, the
horse may be placed in lateral recumbency with
the affected tooth up or in dorsal recumbency.
ANATOMY
Pertinent structures to be aware of when consid-
ering tooth repulsion include the facial muscles,
facial crest, orbit, infraorbital canal, nasolacrimal
duct, frontal and cranial and caudal maxillary
sinuses, facial artery and venous plexus, parotid
salivary duct. and branches of the facial nerve
(Figure 22-1). The alveoli of the second and third
premolars (teeth numbered six and seven in the
Triadan system) and often the rostral aspect of the
fourth premolar (tooth 108 or 208 in the Triadan
system) are embedded in the maxillary bone.1O
The three molar tooth roots (9 through 11 in the
Triadan system) and part of the fourth premolar
in younger horses extend to a variable degree into
the maxillary sinus depending on the age of the
horse. In young horses, the large reserve crowns
virtually fill the sinus, whereas in the old horse
with shorter roots, the sinus becomes fairly large
(Figures 22-2 and 22-3). The caudal aspects of the
fourth premolar and the first molar lie in the
rostral maxillary sinus, and the second and third
molars li e in the caudal maxillary sinus. (See
Chapter 21 for a discussion on sinus trephination
and for a more detailed description of the rostral
levator anguli ",<U
Malaris ", ..
Angularis oculi a.v. ,
Zygomatic
Dorsal part of
lateral nasal m.
Dorsalis nasi
levator nasolabialis m.
Nasal diverticulum
levator labii
i m.
Depressor labii
inferioris m.
Tooth Repulsion 133
and caudal maxillary sinuses and their relation-
ship to the cheek teeth. ).
The upper cheek teeth usually have three
roots-two small lateral roots) and a larger medial
root (Figure 22-4). Occasionally four roots are
present. The lower cheek teeth have two roots
(with the exception ofM3, which has three roots),
one caudal and one rostral. The reserve crown and
roots of the rostral cheek teeth are roughly per-
pendicular. The reserve crown and roots of the
caudal three cheek teeth are curved caudally.
PROCEDURE
Selection of the surgery site is critical to success-
ful tooth repulsion. The surgery site is based on
the location of the tooth or teeth involved and
their curvature. The first two or three (depending
on the age of the horse) maxillary cheek teeth and
all of the mandibular teeth are directly accessible,
but tlle caudal three or four maxillary cheek teeth
-"set,,, Dorsal and vee,":
'" m. buccal brs. of
Parotid gland
Parotidoauricularis m.
Ventral
masseteric v.
~ _ - and masseteric
br. a.
Parotid duct
jugUlar v.
Depressor anguli oris m.
from cutaneous faciei m.
labial a.
Buccinator . Parotid duct a.v.
Figure 22·1 Lateral view of head with skin removed showing superficial structures.
I
-
134 H EAD AND N ECK SURGERIES
Figure 22-2 Radiograph of 8-year-old horse.
Figure 22-3 Radiograph of 12-year-old horse.
need to be accessed through the maxillary sinus.
The third upper molar is better accessed through
a frontal sinus trephination site to allow position-
ing of a dental punch through the frontomaxiilary
opening into the caudal-maxillary sinus II or a
combination of frontal and maxillary trephina-
tion sites.
12
Occasionally, a bone flap may be used
to provide greater exposure to the tooth roots. iJ
\
~ " _ ... .:J. .. __
A B
Figure 22-4 Lateral and ventral views of mandibu-
lar and maxillary cheek teeth showing differences in
root structure. A. maxillary tooth with three roots
(some have four roots); B. mandibular tooth with two
roots.
Ideally, radiographs are taken at various inter-
vals throughout the procedure to ensure accurate
placement of the surgical site, removal of a
minimal amount of bone over the affected tooth,
and accurate placement of the punch. Radi -
ographs provide an accurate method of placing
the punch along the sagittal plane but not in the
frontal plane. The teeth accessible through the
sinuses are usually more toward midline than
anticipated (see Figure 21-3). In young horses
with long tooth roots that virtually fili the sinuses,
a trephine site that is very close to the infraorbital
ca nal will be necessary.
After the appropriate surgery site has been
selected, a 5-cm skin incision is made. The bone
overlying the tooth roots is removed with eit her
rongeurs or a trephine (Figure 22-5). The punch
is seated with the mallet, and a hand is positioned
in the mouth over the affected tooth to detect
vi brations from the punch. Radiographs can be
taken at this point to verify accurate pl acement
and orientation of the punch. Once it is verifi ed
that the tooth being punched is the affected tooth,
several hard hits are generally required with the
mallet to loosen the tooth (Figure 22-6). The
Figure 22-5 Horse in lateral recumbency showing
trephination of the caudal maxillary sinus.
~ e . . .... .:t-,.. .
Figure 22-6 Dental punch in position to repulse the
left second maxillary molar.
rostral cheek teeth can often be removed intact.
Because of the limited space in the oral cavity, the
caudal cheek teeth may be too long to remove
intact. If this is the case, molar cutters or Gigli
wire can be used to decrease their length in order
to remove them completely.
Once removed, the tooth is examined carefully
for missing roots or fragments. The tooth root
socket is thoroughly explored to remove any
residual fragments oftooth or bone. This is a crit-
ical point of the surgery as many of the compli-
cations associated with this procedure are due to
bone or tooth sequestra.
In most cases, the tooth socket is filled with a
plug to prevent packing of feed material in the
tooth socket. Plugs can be made of a variety of
materials such as 4 x 4 gauze sponges, acrylic,
dental wax, or other material. 14 Acrylic plugs
should be inserted such that they do not extend
too deep into the socket, to facilitate ease of
removaL Generally, the socket should remain
packed for 2 to 3 weeks to allow formation of a
good granulation tissue bed in the tooth socket
Tooth Repulsion 135
that will be resistant to future infection. If t ~ e plug
does not come out on its own, the horse should
be sedated or anesthetized and the plug removed.
If gauze sponges are used for packing, the sponges
should be replaced every 2 to 3 days.
POSTOPERATIVE CARE
Postoperative Care
Exercise Restridions: The horse should be stall
rested for at least 2 weeks with controlled hand
walking only.
Medications: Broad-spectrum antibiotics are
recommended for 3 to 5 days. Further antibiotic
therapy may be indicated if infection of the tissues
surrounding the affected tooth is extensive. Non-
steroidal antiinflammatory drugs are recommen-
ded for 1 to 2 days.
Other: The mouth should be lavaged and the
surgery site cleaned daily. If an acrylic plug or
dental wax was placed at the time of surgery, it
should either be expelled on its own or removed
within 30 days of surgery. Following plug removal,
the surgery site is cleaned at least daily until the
wound is completely filled with granulation tissue.
EXPECTED OUTCOME
Owners should be forewarned that although post-
operative care is not technically difficult, it is
involved and may be necessary for extended
periods. Short-term complications are likely, but
the long-term prognosis for healing is good.
COMPLICATIONS
Complications from this procedure can be
divided into categories that include problems
associated with restraint or general anesthesia,
the extraction itself, wound healing, and long-
term complications.
5
,15, 16 Complications associated
with the extraction itself include hemorrhage,
removal of the wrong tooth, and damage to struc-
tures adjacent to the tooth being removed (i.e.,
palatine artery. sinuses, alveolar bone, jaw, adja-
cent teeth, nasolacrimal duct, parotid salivary
duct, and facial nerve).
Complications associated with wound healing
include wound dehiscence or persistent drainage
:
136 HEAD AND NECK SURGERIES
resulting from fistula formation, incomplete tooth
removal, bone sequestrum, infected tooth root
socket, packing breakdown, mucous membrane
healing prior to wound granulation, or the pres-
ence of a foreign body in the wound. Long-term
complications can be associated with an incorrect
initial diagnosis resulting in persistence of the
primary problem, removal of the wrong tooth, or
leaving behind a diseased tooth or tumor.
Therapy starts with exploration of the tooth
root socket under general anesthesia. Generally, a
bone or tooth root fragment is identified, and
removal typically results in rapid heal ing of the
surgery site. If bone or root fragments are not
identified, alveolar bone damage may be present.
Because the alveolar bone between cheek teeth is
relatively thin, damage to the alveolar bone may
expose the root of the adjacent tooth, which may
result in periodontal disease in the adjacent tooth.
Inadvertent removal or loss of the alveolar
plate can occur as a result of the original inflam-
matory process or during surgery. Removal of the
alveolar plate such that the cement surface of the
reserve crown of the adjacent tooth is exposed will
result in incomplete healing as granulation tissue
will not adhere to exposed cementum. Similarly,
aggressive curettage of the socket can result in
destruction of mesenchymal cells that would have
contributed to healing of the socket. Generally,
these errors will result in the development of
chronic draining tracts and periodontal disease
with the potential future need for removal of the
affected adjacent tooth.
Repulsion of a mandibular tooth may result in
a fractured mandible if the dental punch is posi-
tioned on the mandibl e rather than on the tooth
root or if the punch slides off the tooth root and
this redirection is not recognized by the surgeon.
This is a surprisingly easy complication if care is
not taken to correctly position the punch and
continually monitor its orientation. Fortunately,
unless the mucous membranes have been pene-
trated, these fractures can heal well following
removal of any small bone fragments.
Because of the orientation of the cheek teeth,
gaps created by tooth removal are gradually closed
by movement of the cheek teeth to fill the gap.
This movement creates another problem that will
require continued tooth care for the rest of the
horse's life. Tooth overgrowth can occur at either
the site of tooth removal or the first or last cheek
tooth of the opposing arcade.
ALTERNATIVE PROCEDURES
Several options exist for treatment of periapical
infections in horses. Medical therapy is limited to
the systemic administration of antibiotics and is
often ineffective. Ideally, the antibiotic therapy is
guided by bacterial culture and sensitivity results.
In the absence of bacterial culture results, we gen-
erally recommend long-term therapy (30 to 60
days) of a potentiated sulfonamide. Typically, the
drainage stops or at least diminishes during the
course of therapy, only to return shortly after
the antibiotics are discontinued. One publication
reported successful medical therapy in three of
five horses treated medically. 17
Occasionally lateral buccotomy and alveolar
plate removal are indicated for removal of teeth
with damaged crowns or teeth surrounded by
sclerotic bone that would make removal by con-
ventional oral extraction or repulsion difficult.!!
Additionally, the caudal mandibular cheek teeth
may be removed with this technique.
18
Lateral
buccotomy and alveolar bone plate removal are
more tedious and time consuming than oral
extraction or repul sion and therefore are not
practical in field situations. A thorough descrip-
tion of the technique is available elsewhere.
SJ
1
Ideally, endodontic therapy for periapical
infections in horses would allow for the tooth
to remain in place, thus avoiding many of the
complications associated with their removal.
Endodontic therapy requires special surgical
skills, knowledge, and equipment and is generally
a long general anesthetic procedure. The reported
long-term success rates have ranged frol11 44% to
81 %.1.19,20
An alternative procedure for periapical infec-
tions of the mandibular teeth has been re-
ported.
9
,21 Periapical curettage involves identifying
the affected area, removing the overlying cortical
and cancellous bone, and identifying the affected
alveolus. Using curettage and irrigation. infected
material is removed, with care taken to not disturb
the healthy root. The wounds are then left to heal
via second intention. Postoperative therapy con-
sists of removing the external serum crusting on
a daily basis and applying petrolatum to the skin
around the wound to prevent serum scalding. The
wounds are not flushed, and postoperative antibi -
otics and analgesics are recommended but not
required. The success rate has been reported to be
over 75%, but a large number of cases have
not been reported.
21
Those deemed unsuccessful
were subsequently treated successfully with tooth
repulsion. Periapical curettage appears to be a
reasonable option for resolving the periapical
infection and maintaining the mandibular tooth.
COMMENTS
The difficulty of and time required for dental
repulsion vary considerably. Repulsion of the
more caudal upper teeth because of their curved
roots and si nus involvement is technically more
difficult and requires additional surgical time and
intraoperative monitoring and more postopera-
tive care. Repulsion of teeth from older horses
with shorter reserve crowns is less difficult than
repulsion of teeth from young horses with exten-

Slve reserve crowns.
Simultaneous or preoperative loosening of the
affected tooth with molar spreaders and extrac-
tion forceps is beneficial and results in a shorter
and less traumati c repulsion.
Each tooth is independently and firmly
attached to the bony structure (alveolus) by the
periodontal ligament and gingiva. The periodon-
tal ligament consists of bundles of connective
tissue fibers that run in various directions from
the bone of the socket wall to the cement cover-
ing the reserve crowns and the tooth roots. The
gingiva has a mucous membrane surface with a
dense internal fibrous attachment to the perios-
teum and the peripheral cement of the tooth. Even
in cases with extensive periodontal disease, there
may be significant remaining gingival or peri-
odontal ligament attachments to make tooth
removal difficult, particularly in young horses
where the reserve crown may be as long as
8cm.
REFERENCES
1. Prichard MA. Hackett RP, Erb HN: Long term
outcome of tooth repulsion in horses. A retrospec-
tive study of 61 cases, Vet 5urg 21: 145,1992.
2. Schumacher J. Honnas eM: Dental surgery, Vet
Clill N Am Equine Pract 9:133,1993.
3. Dixon PM: Dental extraction and endodontic tech-
niques in horses, Comp COrl t Edltc Pmct Vet 19:628,
1997.
Tooth Repulsion 137
4. Gaughan EM: Dental surgery in horses, Vet Clill N
Am Equille Pract 14:381, 1998.
5. Easley J: Equine tooth removal (exodontia).
In Baker GJ, Easley J, editors: Equine dentistry,
London, 1999, WB Saunders.
6. Tremaine WH: Oral extraction of equine cheek
teeth, Equine Vet Educ 16:151, 2004.
7. Lowder MQ: Oral extraction of equine teeth, Camp
Cant Educ Pmct Vet 21:1150,1999.
8. Knottenbelt DC: The systemic effects of dental
disease. In Baker GJ, Easley J, editors: Equine den-
tistry, London, 1999, WB Saunders.
9. Gibbs C. Dental imaging. In Baker GJ, Easley
J, editors: Equine dentistry, London, 1999, WB
Saunders Co.
10. Dixon PM: Dental anatomy. In Baker GJ, Easley
J, editors: Equine Dentistry, London, 1999, WB
Saunders.
11. Lowder MQ: Tooth removal, reduction, and preser-
vation. In VVhite NA, Moore JM, editors: Currellt
techniques in equine surgery and lameness, Philadel-
phia, 1998, WB Saunders.
12. Boutros CP, Koenig JB: A combined frontal
and maxillary sinus approach for repulsion of the
third maxillary molar in a horse, Catl Vet J 42:286,
2001.
13. Hahn K, Kohl er L: Removal of upper cheek teeth of
the horse using bone flap technique, muscle trans-
position and alveolar closure, Tierarztliche Praxis
Allsgabe Grosstiere N'ltztiere 30:50, 2002.
14. Trostle 55, Juzwiak J5, 5antschi EM: How to use
antibiotic impregnated plaster of paris for alveolar
packing after tooth removal, Proc Am Assoc Equine
Pract 46: 180, 2000.
15. Lillich JD: Complications of dental surgery, Vet
Clin N Am Equine Pmct 14:399, 1998.
16. Pascoe JR: Complications of dental surgery, Proc
Am Assoc Equine Prnct 37:14 1, 1991.
17. Dixon PM, Tremaine WH, Pickles K, et al: Equi ne
dental disease. Part 4: a long-term study of 400
cases: apical infections of cheek teeth, Equine Vet J
32: 182, 2000.
18. Lane Gl: Equine dental extraction--repulsion vs
buccotomy: techniques and results. Proceedings
of the 5th World Veterinary Dental Congress,
Birmingham, 1997.
19. Lowder MQ: Diseases of the teeth. In Colahan PT,
Mayhew IG, Merritt AM, Moore IN, editors: Equine
medicine and surgery, ed 5, Philadelphia, 1999.
Mosby.
20. Baker GJ: Endodontic therapy. In Baker GI, Easley
J. editors: Equine dentistry. London, 1999, WB
Saunders.
21. Carmalt JL, Barber SM: Periapical curettage: an
alternative surgical approach to infected mandibu-
lar cheek teeth in horses, Vet Surg 33:267, 2004.
CHAPTER 23
Tracheotomy
David A. Wilson
INDICATIONS
Indications for tracheotomy are to establish an
emergency airway because of an upper airway
obstruction, or to relieve nasal or laryngeal
inflammation. Tracheotomy is a life-saving proce-
dure in the face of an upper respiratory obstruc-
tion. Tracheotomy is also used to "rest" an
inflamed upper respiratory tract. Tracheotomy
can also be used as a route for endotracheal intu-
bation for general anesthesia when nasot racheal
or orotracheal intubation limits access to the sur-
gical field.
EQUIPMENT
Tracheotomy tube and scalpel blade.
POSITIONING AND PREPARATION
Ideally, a wide area is clipped and routinely pre-
pared for aseptic surgery; however, in emergency
sit uations little preparation is dOf\e. The proce-
dure is ideally performed standing with the head
extended using local anesthesia. In an emergency
situation, a variety of positions are used. When
llsed as a route for endotracheal intubation, the
procedure is often performed in lateral recum-
bency after induction of anesthesia. Light seda-
tion may be necessary for fractious patients.
Draping is not necessary, but sterile instruments
and gloves are desirable.
138
ANATOMY
The paired muscle bellies of the sternomandib-
ularis, sternothyroideus. and sternohyoideus mus-
cles lie on the ventral aspect of the trachea and are
separated during the approach. The tracheal rings
are spaced closely together, but incision of the
annular ligament allows enough separation
to insert the tracheotomy tube without removal
of portions of the tracheal ring (Figures 23-1
through 23-5).
PROCEDURE
A 6- to 8-cm ventral midline incision is made
between the upper and middle thirds of the neck
in a region where the trachea is easily pal pable. In
cases where a permanent tracheostomy is antici-
pated or even a possibility, the tracheotomy site
should be caudal enough to allow space in the
cranial third of the neck for the subsequent tra-
cheostomy (Figure 23-6). Long incisions should
be avoided to improve the "fit" of the tracheotomy
tube.
The subcutaneous tissues are incised, and the
paired sternothyrohyoideus muscles are separated
on midline. Blunt dissection should be minimized
to decrease subcutaneous emphysema and seroma
formation. Two tracheal rings in the center of the
incision are identified, and a transverse stab inci-
sion is made between the two rings. The stab inci-
sion should completely penetrate the tracheal
,----- -----------

Figure 23-1 Ventral view of the neck with the skin
removed showi ng cutaneous colli muscles.
Figure 23-3 Ventral view of the neck with skin and
cutaneous coll i and sternomandibular is muscles removed.
Paired omohyoideus mm.
Sternohyoideus mm.
sternomandibulari s mm.
... .....t"(.I.<J .
Figure 23-2 Vent ral view of neck with ski n and cuta-
neous colli muscles removed.
Paired omohyoideus mm.
Left external jugular
Paired
sternothyrohyoideus mm.
Paired
sternomandibularis --\
mm. (cut)
140 HEAD AND NECK SURGERIES
Atlas (C1
Longus capitis
Common carotid a.
Sternomandibularis
Sternothyroideus
Omohyoideus and __
sternohyoi deus mm.
Cutaneous colli m. ----
Maxillary v.
-- Esophagus
--- Parotid gland
'---- Linguofacial v.
Trachea
....
Figure 23-4 Transverse section through cervical region at level of Cl.
Longus capitus
Sternomandibularis m.
Common carotid
Left external jugular v.
Sternothyroideus mm.
Sternohyoideus mm .. - -
Omohoideus m. - -
Cutaneous coll i
..... : .
Figure 23-5 Transverse section of the neck at the level of C4.
Tracheotomy
incision site + -
'e..<_.-". fC _ _
Figure 23-6 Incision site for tracheotomy.
Figure 23-7 View of the tracheotomy site just prior
to inserting self- retaining tracheotomy tube.
mucosa. A stab incision that is too shallow may
result in separation of the mucosa from the tra-
cheal ring, which will increase bleeding and may
lead to granuloma formation. The annul ar liga-
ment is incised from midl ine ] to 2 em in both
directions (about one third of the ci rcumference
of the lumen),
A tracheotomy tube is then placed (Figure 23-
7) . We prefer self- retaini ng tracheotomy tubes,
Tracheotomy 141
but care must be taken to make sure the second
flange of the tube does not dissect subcutaneously.
This complication can be avoided by careful posi-
tioning and palpation of the tube after pl acement.
The self-retaining tracheotomy tubes have the
advantage of not completely relying on the tra-
cheotomy tube for an open airway. Therefore,
if the tube becomes clogged, there remains a
residual, albeit compromised, airway. Collapse or
"kinking" of the tube is also avoided with the use
of self-retaining tracheotomy tubes.
POSTOPERATIVE CARE
Postoperative Care
Tracheotomy Tube Management: Trache-
otomy tubes require almost continuous mon-
itoring and management. The tubes and the
surrounding skin should be cleaned at least daily.
Scrubbing of the tracheotomy site should be
avoided. Exudate and blood clots should be
removed with a dry, sterile sponge, and the skin
surrounding the site should be cleaned. Extra
tubes should be immediately available.
Medications: Broad-spectrum antibiotics and
nonsteroidal antiinflammatory agents are generally
not necessary unless indicated for the treatment
of the underlying problem.
other: After removal of the tracheotomy tube, the
wound is allowed to heal by second intention with
daily cleaning. Cleaning of the wound during
closure is performed at least once daily or as
needed with moistened gauze sponges. Petrola-
tum (Vaseline) is applied to the skin surrounding
the surgery site to prevent scalding from the anti-
cipated drainage. Healing is generally complete in
2 to 3 weeks.
COMPLICATIONS
Fortunately, in horses there are few complications
associated with tracheotomy. Most complications
are associated with the primary problem rather
than the tracheotomy procedure. However, sub-
cutaneous emphysema, hemorrhage, and infl am-
mation are relatively common.
t
.} Minimizing soft
tissue dissection, avoiding separation of the
tracheal mucosa from the cartilage rings, and
avoiding tracheal ri ng trauma will minimize
these complicati ons. Rare complications include
-
142 H EAD AND NECK SURGERIES
tracheal stricture, granulomas, chondromas, and
pneumothorax.
I
-
4
REFERENCES
I. Turner AS, Mcllwraith CW: Tracheostomy. In
Turner AS, Mcl lwraith CW, editors: Techniques ill
large al/ill/al sllrgery, ed 2, Philadelphia, 1989, Lea &
Febiger.

2. Freeman DE: Standing surgery of the neck and
thorax, Vet Clin N Am Equille Pract 7:603, 199 1.
3. Adams S8, Fessler JF: Tracheotomy. In Adams S8,
Fessler JF, editors: Atlas of equille surgery. Philadel-
phia, 2000, WB Saunders.
4. Kelly G, Prendergast M, Skelly C, et al: Pneumot ho-
rax in a horse as a complication of tracheotomy,lrish
Vet J 56: 153. 2003.
CHAPTER 24
Tracheostomy
David A. Wilson
INDICATIONS
Tracheostomy is indicated for any permanent dis-
order of the larynx and upper trachea in which
airflow is impaired.
EQUIPMENT
No special equipment is required. Self-retaining
retractors and Rochester Carma!t forceps or
simil ar forceps are desirable.
POSITIONING AND PREPARATION
The surgery can be performed with the horse
standing with mild sedation and local anesthesia
or in dorsal recumbency under general anesthe-
sia. The head should be extended for either pro-
cedure. If the procedure is performed in dorsal
recumbency, care should be taken to position the
neck, head, and body without twisting or torquing
such that the skin incision is directly on midline
when the horse stands. The ventral cervical region
is clipped and prepared routinely for aseptic
surgery.
ANATOMY
The paired sternothyrohyoideus muscles originate
from manubrium sterni and extend on the ventral
143
aspect of the trachea. The smaller sternothy-
roideus inserts on the caudal border and abaxial
surface of the thyroid cartilage, and the larger
sternohyoideus continues on to insert on the
basihyoid bone. The paired omohyoideus muscles
originate from the subscapular fascia close to the
shoulder joint and join the sternohyoideus in the
prox.imal third of the neck. The trachea primarily
consists of from 48 to 60 hyaline cartilage rings.
These rings are ( -shaped and open dorsally, with
the ends connected by the transversely oriented
tracheal muscle, l
PROCEDURE
Several similar techniques have been described.
2

4
A 10- to 12-cm ventral midline incision is made
in the proximal third of the neck in a region where
the trachea is palpable (Figure 24-1). If a tra-
cheotomy has been performed previously, this site
should be avoided.
The cutaneous colli and subcutaneous tissues
are incised, and the paired sternothyrohyoideus
and omohyoideus muscles are identified. The
right and left sternothyrohyoideus muscles are
separated on midline and retracted laterally to
expose a section of three or four tracheal rings.
Sections of the paired sternothyrohyoideus
muscles as well as the most axial portions of the
omohyoideus muscles are clamped with an
angiotribe, straight Rochester-Pean or Rochester-
Carmalt forceps, transected, and excised at the
proximal and distal extent of the tracheostomy

144 HEAD AND NECK SURGERIES
Tracheostomy
incision site
Figure 24-1 Incision site for tracheostomy, just
caudal to the first tracheal ring.
A
B
c
site to minimi ze the tension on the tracheal
mucosa-skin junction during subsequent closure.
Bleeding is controlled with hemostat application
and or ligation if necessary. Subcutaneous tissue
may be sutured to the peritracheal fascia to
decrease dead space.
A midline and two paramedian incisions are
made 15 mm on each side of midline in the
exposed tracheal rings (Figures 24-2 and 24-3).
Care should be taken to start on midline and to
avoid incising the mucosa. The rectangular seg-
ments of tracheal cartilage that are created are
carefully dissected free of mucosa. The mucosa is
desensitized with topical application oflocal anes-
thetic solution and incised in a double-Y -pattern.
Stay sutures are placed to ali gn and prevent retrac-
tion of the mucosa. The mucosa is then apposed
to the skin using No. 2-0 PDS and a simple inter-
rupted pattern. Care should be taken to close all
gaps between mucosal edges or between mucosa
and skin. The remaining skin incision, proximal
D
Figure 24-2 Ventral view of the neck illustrat-
ing tracheostomy procedure. A, Dotted lines show-
ing proposed incision lines through tracheal
cartilage only. S, After incising through cartilage
and removal of the first fou r tracheal sections.
C, After removal of all tracheal sections. Dotted
line shows proposed double-Y incision in tracheal
mucosa. D, Finished tracheostomy showing tra-
cheal mucosa sutured to skin.
and distal to the created stoma, is apposed in an
interrupted pattern.
POSTOPERATIVE CARE
Postoperative Care
ExeKise Restriction: The horse should be con-
fined to a stall for 2 weeks with controlled hand-
walking only.
Medications: Broad-spectrum antibiotics and
nonsteroidal antiinflammatory agents are recom-
mended for 1 to 2 days.
Suture Removal: The sutures are removed in
10 to 14 days.
Other: The surgery site should be cleaned once
or twice daily until the sutures are removed and
once daily indefinitely.
EXPECTED OUTCOME
Tracheostomy sites generally heal with minimal
complications, but slight dehiscence may occur
and may require additional repair. Owners should
be warned that in some cases it may take as long
as 4 months for sufficient stoma healing to occur
before the required once or twice daily cleaning is
reduced to maintenance levels. The required long-
term maintenance varies from cleaning once
per day to less than once per month. Long-term
outcome of tracheostomy is generally favorable.
In one study, more than 90% of owners were
pleased with the resul ts (Figure 24-3).'
COMPLICATIONS
The most common complications include partial
dehiscence of the tracheal mucosa-skin suture
line, excessive inflammation, granulation tissue
formation, stricture, skin growth or apposition
over the tracheostomy site, and coughing. Long-
term complications include coughing during
exercise, stridor, and exercise-induced dyspnea.
4
Complications can be reduced if sufficient por-
tions of the paired sternothyrohyoideus and por-
tions of the omohyoideus muscles are removed,
the mucosa-to-ski n suture line is placed with little
to no tension, and care is taken to place sutures
sufficiently close together to eliminate all gaps
between mucosal edges or between mucosa and
skin. Stricture of the stoma size or insufficient
Tracheostomy 145
Figure 24-3 A, Immediate postoperative appearance
of tracheostomy. B, View 3 weeks after surgery.
stoma size can be repaired by enlargement of the
stoma, either by removing the ventral portion of
additional tracheal rings or by removing greater
portions of muscle to reduce the tension on the
tracheal mucosa-skin suture line. Removal of a
3 x 6-cm portion of skin over the stoma site to
decrease the chances of functi onal appositional
closure of the stoma site has also been described.)
Additionally, small elliptical portions of skin may
be taken out of either side of the stoma after it is
created to reduce the chances of functional appo-
sition. If partial dehiscence occurs, the granula-
tion tissue, if present, should be resected and
sutures placed to reattach the mucosa to skin.
Tracheostomy affects pulmonary defense
mechanisms by disruption of the mucociliary
escalator, reduced airway temperature control,
and altered humidification of inspired gases.
Horses with preexisting pulmonary disease may
experience an exacerbation of the existing disease
resulting from this reduction in pulmonary
defense mechanisms.
5
A
B
146 H EAD AND NECK SURGERIES
REFERENCES
I. Hare WeD: Equine respiratory system. In Getty R,
editor: Sisson alld GrossnulII's The anatomy of the
domestic arlima/s, ed 5, Philadelphia, 1975, WB
Saunders.
2. Shappell KK, Stick lA, Derksen FJ. et al: Permanent
tracheostomy in Equidae: 47 cases (1981-1986),
J Am Vet Med Assoc 192:939, 1988.
3. McClure SR, Taylor TS, Honnas eM, et al: Perma-
nent tracheostomy in standing horses: technique
and results, Vet Slirg 24:231. 1995.
4. Rakestraw PC, Eastman TG, Taylor TS, et al: Long
term outcome of horses undergoing permanent tra-
cheostomy: 42 cases, Proc Am Assoc Equine Pract
46:111,2000.
S. Murray JF: Tile normal hlllg: the basis for diagnosis
and treatmellt of pulmonary disease. ed 2, Philadel-
phia, 1986, WB Saunders.
CHAPTER 25
Surgical Treatment Options for Dorsal
Displacement of the Soft Palate
David A. Wilson
INDICATIONS
Dorsal displacement of the soft palate (DDSP)
causes temporary or intermittent exercise intoler-
ance. A number of factors potentially influence
soft palate position, and accordingly a variety of
procedures have been described for the treatment
of DDSP. Altering the head position, changing
tack, and using a "tongue-tie" or a figure-eight
noseband are a few of the conservative treatment
options that may help horses with DDSP and aid
in the diagnosis and determination of the cause of
the displacement. Various surgical procedures
have been described to treat DDSP, including
sternothyrohyoideus myectomy, sternothyroideus
tenectomy, staphylectomy, and epiglottic aug-
mentation.
1
'
13
Var ious combinations of the proce-
dures have also been described,14. !9 Also, various
laser procedures to either resect or cauterize the
soft palate, and a tie-forward procedure have been
recently described to address DDSP, IO,!2,13,!7,20
None of these procedures are very effective for
persistent DDSP because of the likely damage to
innervat ion of the soft palate and pharynx in
these cases.
EQUIPMENT
Rochester-Carmalt forceps, straight Rochester-
Pean forceps with longitudinal serrations, an
angiotribe or a similar instrument, and a Penrose
drain are used for the myectomy procedures. A
147
spay hook may be useful for the sternothyroideus
tenectomy procedure.
9
A Gelpi or Weitlaner
self- retaining retractor, Allis tissue forceps. long-
handl ed or right-angle scissors, and curved
sponge forceps are used fo r soft palate resection.
An Nd:YAG, CO" or diode laser may be used to
transect muscle or to perform the staphylectomy
or photothermoplasty procedures.
IO
,12.13,17,19
PREPARATION AND POSITIONING
Most procedures are best performed with the
horse under general anesthesia in dorsal recum-
bency and the head extended; however, with ·expe-
rience, they can be accomplished in the standing
sedated horse with local anesthesia.
Staphylectomy procedures require temporary
access to the lar ynx. This is typically accomplished
by using intravenous anesthesia. When an endo-
tracheal tube is used, it is removed for the portion
of the procedure requiring access to the larynx.
ANATOMY
The sternomandibularis originates fr om manu-
brium sterni , extends the entire length of the
neck, forming the ventral border of the jugular
furrow; and inserts on the caudal border of the
ramus of the mandible (see Fi gures 23-1 through
23-5) . At approximately the mid-cervical region,
the paired sternomandibularis muscle diverges
from midline, exposing the underlying paired

148 HEAD AND NECK SURGERIES
Mandibular inn.
Unguofacial v. --+---"
Parotid gland
Paired omohyoideus mm.
Paired sternohyoideus mm.
Paired sternomandibularis mm. -1-'1=
Figure 25-1 Ventral view of the head and rostral
neck with the skin and cutaneous colli muscle removed.
sternothyrohyoideus muscles. The paired ster-
nothyrohyoideus muscles originate from manu-
brium sterni and extend on the ventral aspect of
the trachea. The smalJer sternothyroideus inserts
on the caudal border and abaxial surface of the
thyroid cartilage. The larger sternohyoideus
muscle inserts on the basihyoid bone and the
lingual process of the hyoid bone (Figures 25- J
and 25-2), The paired omohyoideus muscles orig-
inate from the subscapular fascia close to the
shoulder joint and merge with the sternohyoideus
in the proximal third of the neck
Important landmarks for the laryngotomy
incision include the paired sternohyoideus
muscles overlying the larynx and the V-shaped
cricothyroid membrane, which lies between the
thyroid and cricoid cartilages.
PROCEDURE
Myectomy and Tenectomy Procedures
Sternothyrohyoideus Myectomy
This procedure can be performed in the standing
patient or under general anesthesia. A 6- to 8-cm-
Lingual process of ---+r'
basihyoid bone
Basihyoid bone
Thyroid cartilage
Paired
thyrohyoideus mm.
Cricothyroid _
membrane
Cricoid cartilage ~
Paired
sternothyroideus mm.
Figure 25-2 Ventral view of the larynx.
long incision is made through the anesthetized
skin on the ventral midline of the neck (Figure
25-3), The level of the caudal portion of the inci-
sion is at the level where the sternomandibularis
diverges from midline, exposing the paired ster-
nothyrohyoideus muscles, The rostral portion of
the incision is at the level of convergence of the
omohyoideus and sternohyoideus muscles. At this
mid-cervical region, the sternothyrohyoideus
muscles are well exposed and are relativel y free
from other structures.
The incision is continued through the subcu-
taneous tissue and the cutaneous coll i muscle. The
sternohyoideus muscle is then exposed and split
longitudinally on midline. The dissection contin-
ues laterall y along the trachea to the lateral
borders of the sternothyrohyoideus muscles, The
ventral surface of the muscles is then separated
from the cutaneous colli and sternomandibularis
muscles by scissors and blunt finger dissection.
The dissection should continue until a 5-cm lon-
gitudinal section of the paired muscle is under-
mined and separated from the surrounding
tissues. The combined sternothyrohyoideus mus-
cles are elevated from the wound and an approx-
imately 5-cm length of muscle is removed by
Incision site for
myectomy
Figure 25-3 Surgical approach for sternothyrohy-
oideus myectomy.
cross-clamping the muscles with Rochester-
Carmalt, straight Rochester-Pean, or similar forceps.
Mayo scissors, a scalpel blade, or a laser (Nd:YAG
or diode) can be used to cut the muscle and
remove the 5-c01 section of muscle between the
clamps. Electrocautery may also be used, but the
electrical stimulation causes significant muscle
contraction. The forceps are then removed from
the ends of the muscles and the muscles are
allowed to retract, leaving a large area of dead
space next to the trachea (Figure 25-4). Hemor-
rhage is usually negligible, but small bleeders may
be clamped with hemostats.
A Penrose drain may be placed and tunneled
through stab incisions, rostral and caudal to the
surgical inci sion (Figure 25-5). A three-layer
closure consisting of cutaneous colli muscles, sub-
cutaneous tissue,. and skin is performed. The cuta-
neous colli muscles and subcutaneous tissue are
closed in separate layers using an absorbable
monofilament suture material with a simple con-
tinuous suture pattern. The skin is closed with
suture and pattern of the surgeon's choice. We
typically use No. 2-0 nylon in a Ford's interlock-
ing pattern, or skin staples. Alternatively, the
Dorsal Displacement of the Soft Palate 149
Rostral
Omohyoideus m.
Sternohyoideus m. -+
Retracted
cut ends of the
sternohyoideus and
sternothyroideus
(smaller) mm.
Caudal
Figure 25-4 Intraoperative view of sternohyoidec-
tomy and sternothyroidectomy for DDSP.
Figure 25-5 Sutured ventral neck inCISion with
Penrose drai n in place emerging proximal and distal
(arrows) to the primary incision.
entire incision may be left to heal by second inten-
tion.
7
Compl ete healing with minimal scar for-
mation will occur within 2 to 3 weeks.
Sternothyrohyoideus and Omohyoideus
Myectomy
A variation of this procedure involves an incision
in the prox:imal third of the neck and partial
myectomy of the omohyoideus muscle (Figure
25-6). This procedure involves more dissection
than the sternothyrohyoideus myectomy and may
be slightly more likely to develop postoperative
seromas. The axial portion of the omohyoideus
muscles must be transected from their attach-
150 HEAD AND NECK SURGERIES
Sternothyroideus
Sternohyoideus
Figure 25-6 Intraoperative view of sternohyoidec-
tomy. sternothyroidectomy. and omohyoidectomy for
DDSP.
Sternothyroideus. m.
Omohyoideus m.
Figure 25-8 Close-up view of the sternothyroideus
musculotendinous section showing dotted lines where
resection will occur. The omohyoideus muscle is being
retracted.
Ceratohyoideus m.
Cricoid cartilage
Ceratohyoid
bone
Lingual process
,.,.,.
....-Cricothyroid lig.
Figure 25-7 Lateral view of
the larynx illustrating the inser-
tion of the sternothyroideus on
the thyroid cartilage. The omohy-
oideus muscle is being retracted.
of basihyoid bone c : ~ ~
ments to the sternohyoideus muscles. This proce-
dure is better performed with the patient under
general anesthesia because of the more extensive
dissection. although it can be accomplished in the
standing patient. This procedure has the advan-
tage of removing all of the caudaJ retractors of the
larynx.
Sternothyroideus Tenectomy and Sternohyoideus
Myectomy
Another variation of this procedure invol ves a
sternothyroideus tenectomy and sternohyoideus
myectomy. A 5-cl11 ventral mid-line skin incision
is made over the larynx and is extended caudally
to the level of the fi rst tracheal ring. The longitu-
dinal incision is extended through the paired ster-
nohyoideus muscles to expose the ventral aspect
of the larynx, the cricoid cartilage, and the crico-
tracheal space. The musculotendinous portion of
the sternothyroideus muscle is located at the level
of the cricoid cartilage. about 3 to 4 cm off
midline. The tendon is followed to its attachment
of
i of the omohyoi deus m.
sternothyroideus m.
on the caudal edge of the thyroid cartilage to
ensure that the correct structure is isolated. A spay
hook may be used to help isolate and exteriorize
the tendon' (Figure 25-7). A small vein often lies
adjacent to the tendon and should be avoided.
Forceps are placed across the muscular portion of
the sternothyroideus muscle. The tendon is tran-
sected, and a 2-cm portion of the muscle is
removed (Figure 25-8). The omohyoideus is
dissected from the sternohyoideus muscle. and a
5-cm section of sternohyoideus is then removed
(see Figure 25-6) .
Staphylectomy
A ventral midline laryngotomy is performed at
the level of the cricothyroid membrane. A to-cm
incision is made starting at the cranial border
of the thyroid cartilage and extending caudal to
the first tracheal ring (Figures 25-9 and 25- 10).
The incision is continued through the cutaneous
coUi muscles and subcutaneous tissue. The paired
sternohyoideus muscles are identified and sepa-
inn.
cartilage
oall ventricle
'hP"..,,-/-J.:........ .
Figure 25-9 View of the ventral throat region illus-
trating the relative position of the larynx in relation to
the mandible and the laryngeal ventricle in relation to
the cricothyroid membrane.
Incision site for
Figure 25-10 Surgical approach for laryngotomy
.
mClSlon.
Dorsal Displacement of the Soft Palate 151
rated longitudinally the length of the incision (see
Figure 25-1). A self-retaining retractor is inserted
between the muscle bellies to expose the fascia
overlying the cricothyroid membrane. Sharp dis-
section is continued through the fascia. A small
vein is often present within the fascia that is tran-
sected. Bleeding is controlled with either hemo-
stats or electrocautery. The exposed cricothyroid
membrane is palpated. The caudal border of the
thyroid cartilage and the cranial border of the
cricoid cartilage are identified. The laryngotomy
is then performed by placing the back of the
scalpel blade against the cricoid cartilage. An
initial stab incision is made into the laryngeal
lumen, and the incision is continued rostral to the
center of the thyroid cartilage. The self-retaining
retractors are then repositioned within the larynx.
The laryngeal lumen may be swabbed with a
gauze sponge that has been soaked with local
anesthetic solution (2% mepivacaine).
A finger or curved sponge forceps is inserted
into the larynx, over the epiglottis to displace the
caudal free edge of the soft palate into the airway.
If freeing the soft palate is difficult, the epiglottis
should be pushed ventral while lifting the head.
This action should displace the epiglottis and free
the caudal edge of the soft palate (Figure 25-11).
The free edge of the soft palate is then grasped
on midline with Allis tissue forceps. The forceps
should grasp approximately 5 to 8 mm of tissue.
The tissue is retracted to provide tension on the
caudal border of the palate. Long-handled or
right-angle scissors are then used to start a cut to
one side of the forceps and directed to the oppo-
site side. The tissue removed should taper to a
point and be about 2 cm in length (Figure 25-12).
The procedure is repeated on the opposite side.
The tissue removed should be crescent shaped:
wide at the center (about 6 to 10 mm) and taper-
ing to a point about 2 cm on either side of midline
(Figure 25-12, D). The laryngotomy incision is left
to heal by second intention.
Alternative Staphylectomy Procedures
Other surgeons have recommended removal of a
small notch of tissue at the caudal midline of the
soft palate.
6
For this procedure, Rochester or
equivalent forceps are used to grasp the soft palate
in the center of the caudal border) and Metzen-
baum scissors are used to cut around the tips of
the forceps. The size of ti ssue removed approxi-
mates an equilateral triangle with each side mea-
suring about 8 to 10 mm .

152 H EAD AND NECK SURGERIES
B
A
C
Figure 25-11 A, Once the incision has been made through the cricothyroid membrane, self- retai ning retractors
are placed to aid visual ization of the caudal aspect of the larynx. B, The soft palate is elevated from bel ow the epiglot-
tis and becomes visible within the larynx (arrow) . C, The free edge of the soft palate is then grasped on midline with
Allis tissue fo rceps.
B
A
o
Figure 25-12 A, The free
edge of the soft palate is retracted
caudally. B, Long-handled or
right angle scissors are used to
start a cut on midline directed
to the opposite side. The tissue
removed should taper to a poi nt
and be approximately 2 em in
length. C, The procedure is
repeated on the opposite side. D,
The tissue removed should be
wide at the center and taperi ng
a maximum of 10 mm to a point
approximately 2 em on either
side of midline.
Staphylectomy is often used in conjunction
with sternothyrohyoideus myectomy. A compos-
ite procedure has been described that includes a
ventriculectomy in addition to myectomy and
partial staphylectomy." Staphylectomy has also
been used in conjunction with epiglottic aug-
mentation for cases of flaccid epiglottis.
16
An alternative combination procedure has
been described and reviewed that combines a
sternothyroideus myectomy, small staphylectomy,
and caudal soft palate photothermoplasty.19 The
procedure is performed through a typicallaryn-
gotomy approach. Prior to penetrating the
cricothyroid membrane, both caudal margins of
the thyroid cartilage are exposed and the ster-
nothyroideus muscles are transected at their
musculotendinous junctions. The cricothyroid
membrane is then incised to expose the laryngeal
lumen. The caudal free edge of the soft palate is
grasped with Allis tissue forceps, and a CO, laser
is used (at a power setting of 35 Wand focused
spot size of 0.22 mm) to make several lines in a
sweeping motion through the oral mucosa of the
soft palate, parallel to and extending rostral 4 to
5 em from the caudal free margin of the palate.
A small (4 mm x 8 mm), semicircular section of
tissue is then sharply resected from the caudal free
margin of the soft palate. The cricothyroid mem-
brane is closed with polyglactin 910 in a simple
continuous pattern. The remaining layers are left
to heal by second intention.
Laser ablation of the caudal aspect of the soft
palate can also be performed in the standing
sedated horse using the Nd:YAG or diode laser or
electrocautery with endoscopic visualization in an
attempt to increase the rigidity of the palate. To
perform the procedure effectively, the palate must
be displaced during the procedure. Maintaining
thi s position can be difficult due to swallowing,
etc., in the conscious horse.
17
Tie-Forward Procedure
A tie-forward procedure has also been described
in which a suture is placed from the basihyoid
bone to each wing of the thyroid cartilage at the
insertion site of the sternothyroideus muscle.
ll
.
20
This suture maintains the larynx in a rostral and
slightly more dorsal position. Therefore, instead
of preventing caudal retraction of the larynx by
means of the myotomy-tenotomy procedures, the
"tie-forward" procedure maintains the larynx in a
fixed cranial position.
Dorsal Displacement of the Soft Palate 153
POSTOPERATIVE CARE

Postoperative Care for Myectomy and
Tenectomy Procedures
Exercise Restrictions: The horse should be
rested in a stall for at least 1 week with controlled
handwalking followed by return to normal exercise
over the next 2 to 3 weeks.
Medications: Perioperative therapy rnay consist
of antibiotics and nonsteroidal antiinflammatory
drugs. These generally do not need to be contin-
ued beyond the first postoperative day unless a
drain is in place.
Suture Removal: The sutures are removed in
10 to 14 days.
Other: A towel stent or neck bandage may be
applied over the incision site and maintained for
2 to 4 days after surgery (Figure 25-(3). The stent
or bandage protects the wound and provides
counterpressure to the wound to reduce edema,
hematoma, and seroma formation. The Penrose
drain should be removed in 2 to 3 days.
o
: \
,
,
,
, \
,
J
i
\lj
),"'-
Figure 25-13 Towel stent sutured in position for
sternohyoideus myectomy, sternothyroideus tenectomy
for either DDSP or modified ForsseU's procedure. The
stent is applied to protect the incision and to apply pres-
sure to the incision site to minimize postoperative
hematoma or seroma formation.
154 HEAD AND NECK SURGERIES
Postoperative Care for Staphylectomy
Procedures
Exercise Restrictions: The horse should be
rested in a stall with controlled handwalking only
for 2 weeks to allow the inflammation of the soft
palate to subside. The horse may then return to
its normal activity.
Medications: Broad-spectrum antibiotics and
nonsteroidal antiinflammatory drugs are adminis-
tered for 2 to 5 days depending on the amount
of postoperative drainage and local inflammation.
Suture Removal: Laryngotomy incisions may be
left to heal by second intention.
Other: The incision site is cleaned at least once
daily with moistened sterile sponges. Petrolatum
is applied around the incision to minimize
scalding.
EXPECTED OUTCOME
The incision should heal completely within 2 to
3 weeks with minimal scarring. Previous reports
have indicated a 50% to 85% chance for return to
normal activity following the various versions of
sternothyrohyoideus myectomy.2.4,15 The progno-
sis for horses with intermittent dorsal displace-
ment to return to normal activity following
staphylectomy is about 60%.4.1S.16 Combinations
of these procedures have been reported to
improve the prognosis.
15
.
19
Horses with persistent
DDSP or a hypoplastic epiglottis with DDSP have
a poor prognosis. In cases with a hypoplastic
epiglottis. a partial staphylectomy with or without
epiglottic augmentation may be a better surgical
option.
COMPLICATIONS
Following myectomy-tenectomy procedures. the
complications are few but can include seroma or
hematoma formation, incisional infections. and
reWliting of the severed ends of the muscles
through scar formation. Seromas and hematomas
are best treated by controlling bleeding at the time
of surgery, adequate counterpressure applied to
the wound postsurgery, and limiting exercise in
the immediate postoperative period. There may
be a cosmetic defect at the site of muscle resec-
tion. Staphylectomy complications include dys-
phagia if too much of the caudal palate is removed
and granulation ti ssue at the exposed edge of the
palate.
COMMENTS
DDSP is a common cause of poor performance in
racehorses. but it also occurs in other types of per-
formance horses. particularly those that have
exaggerated flexion at the poll during work. DDSP
is one of the common causes of noise at exercise
and the noise is typically characterized as a "gur-
gling" sound, generally loudest on expiration. It is
often a diagnosis by exclusion of other common
causes of noise at exercise or decreased perfor-
mance. Horses with DDSP often have signifi cant
Figure 25-14 A. Endoscopic view of normal equine
larynx. B. Endoscopic view of equine larynx with dorsal
displacement of the soft palate.
A
B
airway compromi se during exercise but can
recover quickly when the horse is allowed to
swallow to replace the palate in the correct posi-
tion. During clinical examination, the palate may
not displace unless specific conditions, such as the
type of tack used and the head posi tion used
during performance, can be duplicated. Unless the
specific condi tions are duplicated, the "noise"
reported by the owner or trainer will not be noted
and the airway will generall y appear completely
normal on endoscopic exami nation at rest or after
exercise {Figure 25- 14}. Endoscopic examination
while the horse is worki ng on a high-speed tread-
mill , ideally with the same tack and head position
that exist when the DDSP typically occurs, is fre-
quently the only way to directly make the diagno-
SiS.
21
DDSP may occur secondary to other airway
abnormalities that cause turbulent airflow, in-
creased negative airway pressure, or to signifi-
cant upper airway inflammat ion. These common
airway abnormali ties include laryngeal hemiple-
gia, epiglottic entrapment, guttural pouch dis-
orders, and pharyngeal lymphoid hyperplasia.
Therapy to address these potential primary prob-
lems is warranted before proceeding with any of
the surgical options discussed here.
REFERENCES
1. Mcllwraith CW, Turner S: Myectomy of the ster-
nohyoid, sternothyroid, and omohyoid muscles. In
Mcllwraith CW, Turner S, editors: Equine surgery
advallced techniques, Philadelphia, 1987. Lea &
Febiger.
2. Harrison rw, Raker CW: Sternothyrohyoideus
myectomy in horses: 17 cases (1984-1985), ] Am
Vet Med Asso, 193: 1299, 1988.
3. Shappell KK, Caron JP, Stick JA, et al: Staphylec-
tomy for treatment of dorsal displacement of the
soft palate in two foals, ] Am Vet Med Assoc
195:1395,1989.
4. Anderson ]D, Tulleners EP. Joh nston JK, et al: Ster-
nothyrohyoideus myectomy or staphylectomy for
treatment of intermittent dorsal displacement of
the soft palate in racehorses: 209 cases ( 1986-1991),
] Am Vet Med Assoc 206: 1909, 1995.
5. Duncan DW: Ret rospective study of 50 Thorough-
bred racehorses subjected to radical myectomy
surgery for treatment of dorsal displacement of the
soft palate, Proc Am Assoc Equil1e Pmct 43:237,
1997.
Dorsal Displacement of the Soft Palate 155
6. Llewe1.lyn HR. Petrowitz AB: Sternothyroideus
myotomy for the treatment of dorsal displacement
of the soft palate, Proc Am Assoc Equine Pract
43:239,1997.
7. Robertson JT: Dorsal displacement of the soft
palate. In White NA II , Moore IN, editors: Curre1lt
teclllliqlles ;11 equine surgery and lameness. Philadel-
ph ia, 1998, WE Saunders.
8. Holcombe SJ, Ducharme NG: Pharynx. In Auer JA,
Stick ]A, edi tors: Equine surgery. ed 2, Philadelphia.
1999, WE Saunders.
9. Adams SB, Fessler IF: Sternothyrohyoideus
myectomy. In Adams SB, Fessler JF, editors:
Atlas of equine sllrgery, Philadelphia, 2000. WB
Saunders.
10. JagerHauer K, Lutkefels E. Deegen E, et al: Experi-
mental study on transendoscopic laser surge ry of
dorsal displacement of the soft palate in horses,
Tierarztliche Praxis Ausgabe Grosstiere Nutztiere
31:18,2003.
11. Ducharme NG: Treatment considerations for
DDSP, Pro, ACVS Vet Symp 13:210, 2003.
12. Stick JA: Soft palate displacement: treatment
options, Proc ACVS Vet Symp 13: 189,2003.
13. Tate LP, Sweeney CL, Bowman KF, et al: Transendo-
scopic Nd:YAG laser surgery for treatment of
epiglottal entrapment and dorsaJ displacement
of the soft palate in the horse. Vet Surg 19:356,
1990.
14. O'Riell y JL, Beard WL, Renn TN, et al: Effect of
combined staphylectomy and laryngotomy on
upper airway mechanics in clinically normal
horses, Am ] Vet Res 58: 10 18, 1997.
15. BonenClark G, Bryant ], Hernandez J, et al:
Sternothyroideus tenectomy or sternothyroideus
tenectomy with staphylectomy for the treatment of
soft palate displacement, Proc Am Assoc Equine
Proct 45:85, 1999.
16. Adams SB, Fessler JF: Epiglottic augmentation and
staphylectomy. In Adams SB, Fessler JF, editors:
Atlas of equine surgery. Philadelphia, 2000, WB
Saunders.
17. Hogan PM, Palmer SE, Congelosi M: Transendo-
scopic laser cauterization of the soft palate as an
adjunctive treat ment for dorsal displacement in
the racehorse, Proc Am Assoc Equine Pract 48:228,
2002.
18. Barakzai SZ. Johnson VS, Bai rd DH. et al: Assess-
ment of the efficacy of composite surgery for the
treatment of dorsal displacement of the soft palate
in a group of 53 racing Thoroughbreds (1990-1996),
Eqllifle Vet J 36: 175, 2004.
19. Smith 11. Embertson RM: Sternothyroideus
Myotomy, staphylectomy, and oral caudal soft
palate photothermoplasty for treatmen t of dorsal
displacement of the soft palate in 102 Thorough-
bred racehorses, Vet SlIrg 34:5, 2005.

156 HEAD AND NECK SURGERIES
20. Ducharme NG, Hackett RP, Woodie JB, et al:
Investigations into the role of the thyrohyoid
muscles in the pathogenesis of dorsal displacement
of the soft palate in horses, Equille Vet J 35:258,
2003 .
21. Parente El, Marti n BB, Tulleners EP. et al. Dorsal
displacement of the soft palate in 92 horses during
high-speed t readmill examinati on (I993- 1998),
Vet Surg 31:507. 2002.
CHAPTER 26
Modified Forssell's Operation for Cribbing
David A. Wilson
INDICATIONS
The primary indication for this procedure is mod-
ification of cribbi ng behavior when nonsurgical
methods fail.
EQUIPMENT
Large Rochester-Carmalt, straight Rochester- Pean
or angiotribe forceps, and a Penrose drain are
used for thi s procedure. An Nd:YAG or diode laser
may be used to transect muscle.]
ANATOMY
The ventral branch of the accessory nerve (CNXl)
is located on the dorsomedial aspect of the ster-
nomandibularis and enters the muscle about 5 em
from the musculotendinous junction. The paired
sternothyrohyoideus muscles lie on the ventral
aspect of the trachea. The tendon of insertion of
the sternothyroideus muscle is on the caudal
border and abaxial surface of the thyroid cartilage
(see Figure 25-2) . The larger stemohyoideus mus-
cle continues on midline to insert on the basihy-
oid bone. The paired omohyoideus muscle merges
with the sternohyoideus muscle in the proximal
third of the neck (see Figures 23-2 to 23-5).
157
POSITIONING AND PREPARATION
This procedure is best performed under general
anesthesia with the horse in dorsal recumbency
and the head extended; however, with experience,
it can be accompli shed in the standing sedated
horse with local anesthesia. Transecting the ster-
nohyoideus at the attachment to the hyoid appa-
ratus is difficult in the standing horse. The ventral
cervical region is clipped and prepared for aseptic
surgery.
PROCEDURE
A 3D-em ventral midline incision is made starting
2 em rostral to the larynx at the basihyoid bone
and extending caudally (Figure 26-1). The ski n
is retracted laterally, and hemostasis is achieved
as needed in the subcutaneous tissue. A plane
of dissection is established between the omohy-
oideus and sternomandibularis muscles to expose
the medial aspect of sternomandibularis 5 em
caudal muscles to the musculotendinous junction.
The sternomandibularis muscle is gently retracted
and rolled slightly abaxial to expose the dorsal
medial aspect. The nerve can be located by palpa-
tion of a slight indentation in the musculature
where the nerve enters or by identifying the nerve
just caudal and ventral to a small arterial branch
supplying the sternomandibularis muscle (Figures
26-2 through 26-4). In most cases, a small amount
of fascia will need to be dissected from the ster-
158 HEAD AND NECK SURGERIES
Incision site
for modified
Forssell's
procedure
____
Figure 26-1 Incision site for modified Forssell's pro-
cedure. A 30-cm vent ral midli ne incision starts 2 em
rostral to the larynx at the basihyoid bone and extends
caudally.
....... t;;'""J-..... ....-.
Figure 26-2 Lateral view of neck illustrating the
approximate insertion site of the ventral branch of the
spinal accessory nerve as it traverses the axial surface of
the sternomandibularis muscles (dotted lilies) prior to
entering the muscle belly approximately 5 em caudal to
the musculotendinous junction.
nomandibularis muscle to expose the nerve.
Cont raction of the sterno mandibular is muscle
and flexion of the head are observed when the
nerve is pinched with hemostats. A 5- to 1O-C111
section of nerve is exposed using blunt dissection
and removed (Figure 26-5) . A sternohyoideus

Figure 26-3 The sternomandibularis muscle is
retracted laterally exposing the insertion of the ventral
branch of the spinal accessory nerve. In most cases, a
small amount of fascia covers the nerve and wili need
to be dissected off to expose the nerve.
e.r .... ;t;;
Figure 26-4 The insertion of the spinal accessory
nerve is best identified by palpation for a depression on
the axial border of the sternomandibulari s muscles.
myectomy and a sternothyroideus tenectomy
are then performed as described in Chapter 25.
Additionally, when performing myectomy for
cribbing behavior, a portion of the omohyoideus
is removed and the sternohyoideus and omohy-
oideus are ideally transected rostral to the ventral
aspect of the larynx.
Figure 26-5 Once the spinal accessory
nerve is identified, it can be bluntly dissected
free from the muscle to expose a 5- to lO-em
section of the nerve to be removed.
Modified Forssell's Operation for Cribbing 159
Ventral
POSTOPERATIVE CARE
Postoperative Care
Exer<ise Restridions: The horse should be
confined to a stall for 2 weeks with controlled
handwalking only.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 2 days. Broad-spec-
trum antibiotic therapy is indicated until 24 hours
after drain removal.
Suture Removal: Sutures are removed 12 to 14
days after surgery.
Stent Removal: The stent is typically removed
2 days after surgery.
Drain Removal: The Penrose drain is removed
2 to 5 days after surgery depending on the
amount of drainage.
Dther: In the event that hematomas or seromas
occur, they should be managed conservatively.
COMPLICATIONS
The most common compli cation is failure to
resolve the behavioral abnormaUty.2-8 Factors that
may help to minimize recurrence of the cribbing
behavior include excising the muscle belly cranial
enough to prevent scar tissue from facilitating
ret raction of the larynx and instituting envi ron-
mental and behavioral changes. Other complica-
ti ons include seroma or hematoma formation and
incisional infecti ons. Seromas and hematomas are
best treated by controlli ng bleeding at the time of

accessory n.
Sternohyoideus m.
surgery, applying adequate counterpressure to the
wound postsurgery, and limiting exercise in the
immediate postoperative period. The long-term
consequences of the incisional complications are
minimal. These incisions can heal very well by
second intention if necessary. Therefore, even
with complete dehiscence, the inci sions heal with
very littl e scar formation. A cosmetic defect may
be present at the site of muscle resection, partic-
ularly if the muscles are resected in the mid-
cervical region.
EXPECTED OUTCOME
Reported success rates using the modified Fors-
sell's procedure range from 50% to 100%.1-3.6
Many horses undergoing this procedure show
various levels of cribbing following surgery. For-
tunately, most just apply their teeth to a flat object,
such as the top of a post or fence, but do not grasp
as they did prior to surgery and do not flex the
neck or make gulpi ng noises as they did prior to
surgery. Success has been attributed to transecting
the sternohyoideus and omohyoideus rostral to
the ventral aspect of the larynx. This success may
occur because the entire insertion of the omohy-
oideus is removed. If a more caudal transection is
performed, it is difficult to include all of the omo-
hyoideus. Additionally, remaining rostral portions
of the sternohyoideus muscle may establish some
adherence to the surrounding tissues and regain
some retraction function. Cosmesis is generally
very good, particularly if the muscle transections
are as far proximal and distal as recommended.
Muscle resections in the mid cervical region may
160 HEAD AND NECK SURGERIES
result in visual "steps" on the ventral aspect of the
neck where the muscle becomes reattached to the
fascia overl ying the ventral trachea.
ALTERNATIVE PROCEDURES
Nonsurgical methods to modify cribbing behav-
ior include moving the horse to a pasture or
increasing the frequency of turnout, applying
noxious agents to the surfaces used for cribbing,
providing the horse with a companion such as
another horse, a goat, or a pony, the application
of cribbing straps, the use of electric shock collars,
acupuncture, J and the use of opioid antagonists in
an attempt to block the pleasurable sensation
caused by the cribbing and wind-sucking activity.?
REFERENCES
I. Delacalle J, Burba OJ, Tetens J, et a1: Nd:YAG laser-
assisted modified Forssell's procedure for treatment
of cribbing in horses, Vet SlIrg 31 :111, 2002.
2. Greet TR: Windsucking treated by myectomy and
neurectomy, Equine Vet J 14:299, 1982.
3. Turner AS, White N, Ismay J: Modified Forssell's
operation for crib-biting in the horse, J Am Vet Med
Asso, 184:309, 1984.
4. Mcllwraith CW, Turner AS: Myectomy of the ster-
nohyoid, sternothyroid, and omohyoid muscles. In
Mdlwraith CW, Turner AS: Equine surgery adva1/ced
tecillliqlles, Philadelphia, 1987, Lea & Febiger.
5. Fjeldborg I: Results of surgical management of crib-
bing by neurectomy and myectomy, Eqllille Pract
7:34, 1993.
6. Schofield WL, MulvilJe JP: Assessment of the modi -
fied Forssell's procedure for the treatment of oral
stereotypes in 10 horses. Vet Rec 142:572, 1998.
7. Adams S8: Biology and treatment of specific muscle
disorders. In Auer JA, Stick JA, editors: Equille
surgery, ed 2,. Philadelphia, 1999, WB Saunders.
8. Adams SB, Fessler JF: Modified Forssell's operation
for cribbing. In Adams SB, Fessler IF, editors:
Atlas of equine surgery, Philadelphia, 2000, WB
Saunders.
9. Oodam NH, Shuster L, Court MH, et al: Investiga-
tion into the use of narcotic antagonists in the treat-
ment of a stereotypic behavior pattern (crib-biting)
in the horse, Am J Vet Res 48:311,1987.
..... PHTHALMIC URGERIES
161
CHAPTER 27
Nasolacrimal Flush
Laurence E. Galle
INDICATIONS
Catheterization and flushing of the nasolacrimal
duct is indicated to confirm or rule out naso-
lacrimal obstruction as a cause for epiphora,
mucoid, or mucopurulent discharge. Flushing of
the nasolacrimal duct may also be a therapeutic
procedure in that it call dislodge small foreign
bodies or purulent debris that obstruct the flow
of tears through the duct. ! If an obstruction is
diagnosed within the nasolacrimal system, dacry-
ocystorhinography can be performed to deter-
mine the anatomic location of the obstruction
by the injection of radiopaque contrast media
through the catheter.
2
EQUIPMENT
A 5-Fr male urinary catheter or polyethylene
tubing is needed for nasolacrimal catheterization.
A 3-mL syringe, %- inch 25-gauge needle, and
local anesthetic are needed if local anesthesia or
akinesia is to be used to facilitate placement of the
catheter. If the catheter is to be sutured into place,
a No. 10 Bard-Parker blade, needle drivers, general
operating scissors, and No. 2-0 or No. 3-0 mono-
filament non absorbable suture are also needed.
POSITIONING AND PREPARATION
Nasolacrimal catheterization is typically per-
formed with standing sedation. Local anesthesia
162
or akinesia of the eyelids and nares may facilitate
insertion of the catheter.
ANATOMY
The structures of the nasolacrimal system are
divided into secretory and drainage components.
The tearfi lm is a trilaminar fluid secreted by the
lacrimal gland, third eyelid gland, conj unctival
goblet cell s, and meibomian glands. The tearfilm
is drained from the eye through the dorsal and
ventral puncta into the dorsal and ventral canali-
culi (Figure 27-1). The canaliculi merge ventro-
medial to the medial canthus and form the
lacrimal sac, a dilation of the proximal naso-
lacrimal duct that lies within the lacrimal fossa of
the lacrimal bone. The nasolacrimal duct passes
medially through the maxillary bone and contin-
ues rostrally through the soft tissues of the nares
to the opening or orifice of the duct. This opening
is located on the fl oor of the nasal cavity approx-
imately 5 to 7 cm from the opening of the nares
near the mucocutaneous junction (Figure 27-2).
The nasolacrimal duct is approximately 4 to 5 mm
in diameter and is narrowed proximally as it
passes through the maxillary bone. l,3·s
PROCEDURE AND PREPARATION
The openi ng of the nasolacri mal duct is located
on the floor of the vestibulum of the nasal cavity,
and a 5-Fr male urinary catheter is placed into
lacrimal punctum
'-----Ventrallacrimal
punctum
Nasolacrimal Flush 163
Nasolacrimal sac ----,
Nasolacrimal --'---
duct
Figure 27-1
lacrimal duct.
Schematic illustrating the anatomy of the dorsal and ventral puncta, nasolacrimal sac, and naso-
/
Figure 27-2 Nasolacrimal punctum in the vest i-
bulum.
the ostium and advanced gently in a retrograde
manner, I Using the index finger, gentle pressure is
applied over the opening to «sea!" it around the
catheter. Patency of the nasolacrimal system can
be tested by injecting 15 to 20 mL of sterile saline
through the catheter. Patency of the dorsal and
ventral puncta at the medial canthus is individu-
ally determined by alternately applying digital
pressure over each canaliculus.
Alternatively, the nasolacrimal system can be
catheterized in an antegrade manner from the
dorsal punctum.
6
The surgeon should first use
appropriate local anesthesia or akinesia of the
eyelids, topical anesthesia of the cornea, and seda-
tion. The catheter is inserted into the dorsal
punct um and is flushed with sterile saline. The
ventral canaliculus should be occluded with
digital pressure to ensure flushing of the naso-
lacrimal duct to its opening (Figure 27-3).
The nasolacrimal catheter can also be tem-
porarily sutured in place to provide patency of the
nasolacrimal system while treating an obstruc-
tion. If the surgeon intends to suture the naso-
lacrimal catheter in place, then local anesthesia of
the dorsal or lateral nasal wall adjacent to the
nares should be injected prior to placing the tube.
A stab incision is then made through the anes-
thetized area using a No. 10 Bard-Parker scalpel.
The nasolacrimal catheter is inserted retrograde as
described above and is advanced to the naso-
lacrimal sac. The free end of the catheter is
inserted from inside the nasal cavity through the
164 OPHTHALMIC SURGERIES
Figure 27-1 Catheter placed in the dorsal punctum
demonstrati ng the use of digital pressure to obstruct
the ventral canalicul us.
stab incision and exits dorsally or dorsolaterally
along the face. The catheter is sutured in place
adjacent to the opening of the duct with two
simple-i nterrupted No. 3-0 monofilament non-
absorbable sutures. Additional sutures are placed
along the face to secure the catheter
7
(Figure
27-4).
POSTOPERATIVE CARE
Postoperative Care
Medications: If obstruction of the nasolacrimal
duct is diagnosed, then flush material is submit-
ted for bacterial culture and susceptibility, the
results of which should direct antibiotic use.
Antimicrobial therapy should be continued for at
least 14 days.
other: Nasolacrimal catheters that are sutured
in place to maintain patency of the duct during
treatment should remain in place for at least 2 to
3 weeks.' Topical antimicrobial therapy should be
continued until the catheter is removed.
COMPLICATIONS
Congenital ostium malformation or scarring of
the nasolacrimal duct or puncta may prevent
~ - ' ( ; . " - ' ' ' -
Figure 27-4 Nasolacrimal catheter sutured in place
to treat nasolacrimal obstruction.
catheterization. Catheters that exit the dorsal or
ventral puncta and are sutured in place have the
potential to rub the cornea and cause corneal
ul ceration. Care should be taken to avoid contact
of the catheter or sutures/with the cornea.
REFERENCES
1. Moore C: Eyelid and nasolacrimal disease, Vet Clill
N Alii Equine Pract 8:499, 1992.
2. St rubbe D, Gelatt KN: Opht hal mic examination and
diagnostic procedures. In Gelatt KN, editor: Veteri-
nary ophthalmology, ed 3, Philadelphia, 1999, Lip-
pincott Williams & Wilkins.
3. Cooley PL Normal equine ocular anatomy and eye
examination, Vet Clin N Alii Equine Pmct 8:427,
1992.
4. Carastro SM: Equine ocular anatomy and oph- .
thalmic examination, Vet Clill N Am Equille Pmct
20:285, 2004.
5. Samuelson D: Ophthalmic anatomy. In Gelatt KN,
editor: Veterinary ophthalmology, ed 3, Philadelphia,
1999, Lippincott Williams & Wilkins.
6. Slatter D: Lacrimal system. In Slatter D, editor:
Fundamel1tals of veteri1lary ophthalmology, ed 3,
Philadel phia, 2001, WB Saunders.
7. Brook D: Use of an indwelling nasolacrimal cannula
for t he administration of medication to the eye,
Eqlline Vet] (Suppl ) 2:135, 1983.
CHAPTER 28
Inferomedial Subpalpebral Lavage Tube Placement
Laurence E. Galle
INDICATIONS
A sub palpebral lavage tube is indicated to facili-
tate the administration of topical ophthalmic
solutions,l .6
EQUIPMENT
Needle drivers) general operating scissors. 12-
gauge trocar, and one sterile silicone sub palpebral
lavage tube device approximately 90 em long with
a I-em-diameter footplate are needed
2
.
3
(Figure
28-1). The sub palpebral lavage tube device may be
purchased from commercial sources or manufac·
tured by the surgeon from appropriate materials.
POSITIONING AND PREPARATION
Subpalpebral lavage tubes can be placed in
sedated patients using appropriate nerve blocks
to provide eyelid akinesia and sensory anesthesia
including topical corneal anesthesia.
ANATOMY
Ventromedial subpalpebrallavage tube placement
requires knowledge of the lower eyelid, medial
canthus, third eyelid, and orbital rim. The poste·
rior surface of the ventral eyelid is the palpebral
165
conjunctiva. The palpebral conjunctiva is firmly
adherent to the eyelid at the eyelid margin and
becomes loosely attached toward the conjunctival
fornix. In the ventral aspect of the medial canthus,
the conjunctiva in the fornix: reflects onto the
anterior surface of the third eyelid. The conj unc-
tiva of the third eyelid again reflects into a fornix
on its posterior surface before becoming associ-
ated with the globe as it becomes the bulbar
conj unctiva' (Figure 28-2). The inferomedial sub-
palpebral lavage tube will be positioned such that
its footplate is in the inferomedial conjunctival
fornix between the ventral eyelid and the third
eyel id.'
PROCEDURE
The surgeon should ensure patency of the sub-
palpebral lavage tube prior to attempting to insert
it into the patient. The tip of a 12-gauge trocar
is directed deep into the conjunctival fornix
between the ventral eyelid and third eyelid. The
index finger is used to guide the trocar and
prevent injury of the globe with the trocar (Figure
28-3). The trocar is advanced through the con-
junctival fornix and through the skin ventral to
the medial canthus. A stainless steel thimble may
be used to advance the trocar, and needle drivers
may be placed adjacent to the exit site of the trocar
through the skin to provide counterpressure to
facilitate trocar placement. The free end of the
subpalpebral lavage tube is inserted externally
[
166 OPHTHALMIC SURGERIES
Figure 28·1 Footplate of lavage tube.
Tarsal
plate ---;-
Cilia
Tarsal
glands --:::::::::::
Skin'
Orbicularis
oculi m.
lavage tube
in
conjunctiva
_ev,lIor palpebrae
m.
conjunctiva
Semilunar fold
I tertia,
third eyelid)
,
Figure 28-2 Schematic of eyelid anatomy.
into the trocar from the conjunctival fornix. The
tubing is advanced until it is visualized in the tip
of the trocar and the trocar and tubing are then
advanced through the skin, leaving the subpalpe-
brallavage tube in the ventral eyelid as the trocar
is removed. The surgeon advances the subpalpe-
bral lavage tube until the circular footplate is
secure aga inst palpebral conjunctiva. Prior to
suturing the lavage tube into place, a 20-gauge
Luer stub adapter with attached injection port is
inserted into the free end of the lavage tube and
patency is again tested by injecting saline or fluo-
rescein through the lavage tube. Short strips
of duct tape or porous medical grade tape are
secured to the lavage tube adjacent to the exit site
through the ventral eyelid, between the eyes, and
Figure 28-3 Finger guiding trOCilr.

Figure 28-4 Horse's head with lavage tube in place.
adjacent to the ipsi lateral ear. These tabs of tape
are then sutured in place using two No. 2-0
monofilament nylon simple interrupted sutures
per tab of tape to secure the lavage tube to the
patient (Figure 28-4).
POSTOPERATIVE CARE
Postoperative Care
Protection: A protective eye cup is recommended
to prevent self-trauma and failure of the lavage
tube.
Other: The tube and footplate should be tested
daily for patency; the blunt-tipped Luer adapter is
a common site for failure with leaking of the tube
and may need to be replaced if worn. Tubes
leaking from sites rostral to the ears will need to
be replaced with a new lavage tube. Tape tabs and
sutures should be inspected for loosening and
should be resutured if necessary.'·5
Medication: Only 0.1 mL of medication is nec-
essary for injection through the lavage tube. The
dose of medication is advanced through the
lavage tube by slowly injecting approximately 1 mL
of air through the tube using a tuberculin syringe.'
COMPLICATIONS
Ocular complications of subpalpebrallavage tube
placement include displacement of the footplate
from the conjunctival fornix, corneal ulceration,
swelling of the ventral eyelid, and loss of the foot-
plate within the eyelid. Nonocular complicati ons
include leakage or loss of the injection port, need
Inferomedial Subpalpebral Lavage Tube Placement 167
for resuturi ng of tape tabs, and tearing or break-
age of the lavage tube system.
3
,5 The most fre-
quently reported complications of inferomedial
lavage systems are displacement of the footplate
from the conj unctival fornix (18%) and need for
resuturing of tape tabs (14%). '
REFERENCES
1. Brooks DE: Equine ophthalmology. In Gelatt KN,
editor: Veterinary ophthalmology, ed 3, Philadelphia,
1999, Lippincott, Williams & Wilkins.
2. Miller TR: Principles of therapeutics, Vet Clin N Am
Equille Pract 8:479, 1992.
3. Gi uliano EA, Maggs DJ, Moore CP, et al: Inferome-
dial placement of a single-entry subpalpebral lavage
tube for treatment of equine eye disease, Vet Opll-
t/In/mo/ 3: 153, 2000.
4. Frauenfelder H, McJlwraith W: Placement of a sub-
palpebral catheter in a standing horse, Vet Med Small
Arl;m c/irl 74:724, 1979.
5. Sweeney CR, Russel l GE: Complications associated
wi th use of a one-hole subpalpebrallavage system in
horses: 150 cases (1977-1996), , Am Vet Med Assoc
2 11 :127 1,1997.
6. Gelatt KN: Postoperati ve subpalpebral medicat ions
in horses and dogs, Vet Med 62:1165,1967.
7. Samuelson D: Ophthalmic anatomy. In Gelatt KN,
editor: Veterillary ophthalmology, ed 3, Philadelphia,
1999, Lippincott, Williams & Wilkins.
CHAPTER 29
Eyelid Laceration Repair
Laurence E. Galle
INDICATIONS
Simple traumatic eyelid lacerations can be
repaired with simple, multilayer suturing tech-
niques. If, however, defects are excessively large
with significant loss of eyelid tissue from devital-
ization or necrosis, advanced blepharoplastic tech-
niques may be required.
1
,2
EQUIPMENT
General surgical pack, Derf needle drivers, Bishop-
Harmon tissue forceps, Stevens tenotomy scissors.
POSITIONING
Although some minor lacerations may be repaired
with standing sedation-anesthesia and appropri-
ate local anesthesia-akinesia, general anesthesia
with the patient in lateral recumbency is recom-
mended for most eyelid lacerations. 1.3
ANATOMY
The four major layers of the eyelid, from external
to internal, are skin, orbicularis oculi muscle,
fibrous tarsal plate, and conjunctiva
4

S
(see Figure
28-2).
168
PROCEDURE AND PREPARATION
The surgical site is cleaned of debris with gentle
lavage with saline or a 1 :50 dilution of povidone-
iodine solution. Necrotic tissue is identified and
debrided, leaving as much viable eyelid tissue as
possible.J,6 If the laceration involves the lacrimal
canaliculus near the medial canthus, then tempo-
rary cannulation of the affected canaliculus prior
to suturing is necessary to align the lacerated ends
of the canaliculus during suturing. I.' Subconjunc-
tival connective tissue is closed using No. 3-0
or No. 4-0 absorbable simple horizontal mattress
sutures. The first sut ure should be placed adjacent
to the eyelid margin to provide optimal eyelid
margin apposition, and subsequent sutures are
placed toward the apex of the incision. Eyelid
lacerations should be repaired with a minimum
of two suture layers (i.e., subconjunctival sutures
and skin sutures); however, excessive tension
across the laceration or significantly compro-
mised eyelids may require an additional suture
pattern or a temporary tarsorrhaphy.1 Skin clo-
sure is performed with No. 3-0 monofilament
nylon suture. The first skin suture to be placed is
a figure-of-eight suture within the eyelid margin
to provide optimal eyelid margin apposition
2

3
(Figure 29-1). The remainder of the skin is closed
in a simple interrupted pattern.
A B
C 0
'ii"-,,, . ; t ~ • . _
Figure 29-1 Schematic demonstrating A, B, subcon-
junctival closure and C, figure-of-eight suture at eyelid
margin. D, The reminder of the skin laceration is closed
in a simple interrupted pattern.
POSTOPERATIVE CARE
Postoperative Care
Medications: Systemic and topical broad-spec-
trum antibiotics are used initially pending culture
and susceptibility of the affected area, and tetanus
prophylaxis should be given. Appropriate antibi-
otics are continued for 7 days. Nonsteroidal anti-
inflammatory therapy is necessary for a minimum
of 3 days.
other: Cold compresses should be applied post-
operatively to combat inflammation and edema.
Protedion: Protective eye cups are recom-
mended to prevent self-trauma.
2
,3
Eyelid laceration Repair 169
COMPLICATIONS
The most frequent complication of eyelid lacera-
tion repair is wound dehiscence. This is most
commonly a result of single-layer closure, but it
may also occur as a result of devitalized wound
edges or excessive tension across the surgical site.
If wound dehiscence occurs, a second surgical
repair with debridement and suturing is recom-
mended to prevent eyelid margin defects and
to reduce the potential for corneal abrasion or
ulceration.
Some patients may develop a notch-like defect
of the eyelid. Slich defects, if significant, can cause
abnormal tearfilm distribution, and corneal irri-
tation or ulceration. Minor defects of the eyel id
margin may be left alone if they do not adversely
affect the corneal surface; more significant defects,
however, require additional blepharoplastic tech-
niques to correct or remove the defect. These
eyelid margin defects are most easily prevented by
two-layer closure and an appropriately placed
figure-of-eight suture at the eyelid margin.'
REFERENCES
1. Brooks DE, Wolf D: Ocular trauma in the horse,
Equille Vet J (Suppl ) 2:1 41,1983.
2. Millichamp NJ: Ocular trauma, Vet Clin N Am
Eqllille Pract 8:521,1992.
3. Moore CP: Eyelid and nasolacrimal disease, Vet Clin
N Am Equine 8:499, 1992.
4. Samuelson D: Ophthalmic anatomy. In Gelatt KN,
editors: Veterinary ophthalmology, ed 3, Philadel-
phia, 1999, Lippincott, Williams & Wilki ns.
5. Cooley PL: Normal equine ocular anatomy and eye
exami nation, Vet Cli ll N Am Equine Pract 8:427,
1992.
6. Moore CP, Constantinescu GM: Surgery of the
adnexa, Vet c/in N Am Small Allim Pract 27: J 0 I J,
1997.
7. Miller TR: Eyelids. In Auer lA, Stick JA, editors: Equine
surgery, ed 2, Philadelphia, 1999, WB Saunders.
CHAPTER 30
Enucleation-Transconjunctival and Transpalpebral
Laurence E. Galle
INDICATIONS
Enucleation is indicated when there is minilnaJ or
no chance for maintenance of vision and when
leaving the globe would result in continued
patient discomfort or leave the patient at risk of
systemic complications. Common indications
for enucleation include ruptured globes, intraoc-
ular neoplasia, panophthalmitis, and chronic
uveitis or glaucoma. 1,2 It is imperative that the
surgeon consider aU alternatives that might
otherwise retain a comfortable, visual eye prior
to performing an enucleation. The tran5-
conjunctival approach is preferred for optimal
cosmesis and minimal need for hemostasis. The
transpalpebral approach, with use of a complete
tarsorrhaphy prior to enucleation, is indicated for
contaminated or infectious ocular disorders
where reducing the potential of contaminating
the orbit with conjunctival microbial flora is
desired.
3
EQUIPMENT
A general surgical pack is appropriate for an enu-
cleation. Additional instrumentation that may
prove valuable includes suction, electrocautery,
Steven's tenotomy scissors, and Bishop-Harmon
tissue forceps.
170
PREPARATION AND POSITIONING
The patient should be placed in lateral recum-
bency under general anesthesia with the affected
eye up.
ANATOMY
Unlike carnivores, the equine globe is positioned
within a completely enclosed bony orbit ( Figure
30-1 ). Extraocular muscles, vascular supply, fat,
fascia, and the optic nerve form the orbital cone
as they converge to the posterior aspect of the
orbit. The orbital cone is completely enclosed
within a connective tissue fascial sheath called
Tenon's fascia, which merges anteriorly with the
sclera adjacent to the limbus. The conjunctiva is
firmly attached to the limbus, becomes more
elastic and loosely attached as it forms the con-
junctival fornix, and reflects onto the posterior
surface of the eyelids where it again becomes
firmly attached at the eyelid margin. The fibrous
tarsal plate of the eyelids is continuous with dense
connective tissue called the orbital septum that
inserts on the orbital rim.
4
,5
PROCEDURE
Transconjunctival Enucleation
A lateral canthotomy is performed with Metzen-
baum scissors to facilitate exposure of the globe.
Enucleation-Trans(onjunctival and Transpalpebral 171
Infratrochlear notch
Zygomatic process of
frontal bone
Zygomatic process of
temporal bone
Caudal lacrimal process
Fossa of lacrimal sac
r

<
I
I

Z
/
.,.-
Caudal alar foramen
Temporal process
of zygomatic bone
Figure 30-1 Schematic demonstrating the horse's bony orbi t.
Usi ng delicate toothed forceps, such as Bishop-
Harmon tissue forceps. the conjunctiva is gently
grasped adjacent to the limbus and tented, and the
conjunctiva is snipped approximately 2 mm from
the limbus with Steven's tenotomy scissors to
create an incision. A peritomy (360° conjunctival
incision adjacent to the limbus) is performed
using blunt and sharp dissection with Steven's
tenotomy scissors, leaving approximately 2 mm of
conjunctiva attached to the limbus for grasping
with forceps for globe manipulation (Figure 30-2,
A and B). The dense fibrous connective tissue
attachment of Tenon's fascia is grasped and
incised with tenotomy scissors. Tenon's capsule is
incised near its insertion over its circumference,
and the extraocular muscles and fascial attach-
ments are transected at their insertions using
curved Metzenbaum scissors or curved Steven's
tenotomy scissors. Avoiding rostral traction of the

globe, the optic nerve is isolated and clamped
approximately 4 to 5 mm caudal to the sclera.
Using curved Metzenbaum scissors or enuclea-
tion scissors, the optic nerve is transected
between the sclera and the clamp to leave approx-
imatel y 2 to 3 mill of optic nerve attached to the
enucleated globe. The conjunctiva, third eyelid,
and third eyelid gland are removed using Met-
zenbaum scissors. The eyelid margins are excised
from the eyelids approximately 4 mm from the
eyelid margin using Mayo scissors. Hemostasis
during removal of the conjunctiva and eyelid
margins is provided with hemostatic clamps
or electrocautery. The surgical site is closed in
three layers. A si mple continuous pattern of No.
3-0 absorbable suture is used to close the fascia
and connective tissue attached to the orbital rim
in a manner to create a diaphragm to minimize
concavity postoperatively. A simple continuous

172 OPHTHALMIC SURGERIES
A
B
c
Figure 30-2 A and B. Schematic demonstrating a
peritomy. C, Schematic demonstrating Allis tissue
forceps clamped to the eyelid margins and attached skin
to faci litate exposure during dissection for transpalpe-
bral enucleation.
pattern of No. 3-0 absorbable suture is placed
in the subcutaneous tissues. The skin is closed
with No. 3-0 nylon in a simple interrupted
pattern.
3
.
6
Transpalpebral Enucleation
A complete temporary tarsorrhaphy is performed
using No. 2-0 monofilament nylon in a simple
continuous pattern. An elliptical skin incision is
made around the palpebral fissure using a scalpel,
leaving approximately 5 mm of skin attached to
the eyelid margin. Allis tissue forceps may be
clamped to the eyelid margins and attached skin
to facilitate exposure during dissection (Figure
30-2, C). Blunt dissection should be used in a pos-
terior direction, being careful not to enter the con-
junctival cul-de-sacs. Caudal to the conjunctival
fornix, blunt dissection should be continued
toward the sclera until the sclera is exposed.
Extraocular muscle transection and optic nerve
transection should be performed as described in
the transconjunctival enucleation procedure.
Once the optic nerve has been transected, the
globe and attached conjunctiva, third eyelid, and
its gland are removed from the orbit. The surgical
site is closed in three layers as described for
transconjunctival enucleation.
3
,6
POSTOPERATIVE CARE
Postoperative Care
Protedion: A protective eyecup is used for 1
week postoperatively to prevent self-trauma.
Medications: Nonsteroidal antiinflammatory
drugs may be used from 3 to 7 days to minimize
associated discomfort and edema.'
Suture removal: Suture removal is r e c o m ~
mended in approximately 14 days.
COMPLICATIONS
Patients commonly exhibit significant periorbital
swelling and discomfort for 2 to 3 days postoper-
atively. This can be minimized through appropri-
ate intraoperative hemostasis and postoperative
antiinflammatory therapy.) Orbital cysts or
mucoceles may develop several weeks to months
postoperatively if the conjunctiva is not com-
pletely excised. Such cases require surgical explo-
ration and removal of remaining conj unctiva.
Because the nasolacrimal duct is not ligated and
is usually patent immediately postoperatively, it
is not uncommon to observe serosanguinous dis-
charge from the ipsilateral nares postoperatively.
This is not usually a complication but will often
worry an observant client who was not appro-
priately informed of this possibility prior to
discharge.
REFERENCES
I. Michau TM, Gilger BC: Cosmetic globe surgery in
the horse, Vet Ciin N Am Equine Pmct 20:467, 2004.
2. Brooks DE, Wolf D: Ocular trauma in the horse,
Eq"ille Vet] (Suppl ) 2:141,1983.
3. Brooks DE: Orbit. In Auer JA, Stick JA, editors:
Equille surgery, ed 2, Philadelphia, 1999, WB
Saunders.
4. Samuelson D: Ophthalmic anatomy. In Gelatt KN.
editor: Veterinary ophthalmology, ed 3, Philadelphia,
1999, Lippincott, Williams & Wilkins.
5. Cooley PL: Normal equine ocular anatomy and eye
examinatjon, Vet Ciill N Am Equine Pmc! 8:427,
1992.
6. Ramsey OT. Fox DB: Surgery of the orbit, Vet Clill
N Am Small Allim Pract 27: 1215, 1997 .
CHAPTER 31
Entropion
Laurence E. Galle
INDICATIONS
Equine entropion occurs most commonly in
neonates secondary to dehydration, septicemia, or
malnutrition. ]-4 Some breeds, however, may be
predisposed to congenital entropion or primary
anatomic entropion that is unrelated to systemic
illness.
5
Primary anatomic entropion and entro-
pion that occurs as a complication of systemic
illness are often exacerbated by pain and bleph-
arospasm, which results in spastic entropion.
Regardless of the etiology, entropion in the
neonate should be initially managed with tempo-
rary tacking sutures rather than a permanent sur-
gical procedure. The usefulness of such everting
sutures is twofold. For spasti c entropion, they
prevent corneal irritation and discomfort resul-
tant to cilia and hair of the eyelids contacting the
corneal surface, thus breaking the cycle of corneal
pain and blepharospasm. For secondary entro-
pion, the sutures maintain a more normal
anatomic relationship of the cornea and eyelids
while the underlying illnesses are resolved, If
entropion persists after repeated tacking suture
procedures have failed. then a permanent method
of correction, the Hotz-Celsus blepharoplasty
technique. may be necessary.4
EQUIPMENT
Bishop- Harmon tissue forceps, Derf needle
drivers, general operating scissors. and a No. 3-0
173
or No, 4-0 monofilament nylon or braided silk
suture are needed to place temporary tacking
sutures. In addition to these instruments, a No. 15
Bard-Parker scalpel blade on a No, 10 scalpel
handle and Steven's tenotomy scissors are needed
to perform a Hotz-Celsus bl epharoplasty,
PREPARATION AND POSITIONING
Tacking sutures are easily placed in sedated or
anesthetized patients using appropriate local
anesthesia-akinesia. Anesthesia or sedation, how-
ever, is often contraindicated in patients with
systemic illnesses that are frequently responsible
for entropion, The eyelids of most debilitated
neonates can be tacked with only local anesthesia
and aki nesia, and this is often performed with the
patients restrained in lateral recumbency. Hotz-
Celsus blepharoplasty is also performed with the
patient in lateral recumbency with the affected eye
upward, but this requires general anesthesia.
ANATOMY
The major layers of the eyelids, from external
to internal, are skin, orbicularis oculi muscle,
fibrous tarsal plate, and conjunctiva. The eyelids
are covered with hair to within 2 to 3 mm of the
eyelid margin, and well-developed cilia (eye-
lashes) are on the upper eyelid
6
,' (see Figure
28-2),
174 OPHTHALMIC SURGERI ES
Figure 31-1 Schematic of Lembert sutures placed in
eyelid.
PROCEDURE
Temporary Eyelid Tacking
Simple interrupted Lembert sutures are placed to
evert the affected eyelid margin. Lembert sutures
are placed in the eyelid skin such that the most
distal portion of the suture is approximately 3 mm
from the eyelid margin (Figure 31-1). The
number of Lembert sutures to be placed will vary
by the extent of entropion and the degree of
tension necessary to maintain eyelid eversion, but
a minimum of two or three Lembert sutures
should be placed.
Hotz-Celsus Blepharoplasty
The length of affected eyelid margin and amount
of inward rolling are estimated before the patient
is anesthetized or local anesthesia is injected. Hair
should be clipped and the surgical site prepared
for aseptic surgery. The surgeon removes a cres-
cent-shaped st rip of skin and underlying orbicu-
laris oculi muscle of the approximate shape and
size of the area affected by entropion.
s
An incision
is made through skin and underlying orbicularis
oculi muscle 3 mm from, and parallel to, the
affected eyelid margin, using a No. 15 scalpel
blade. A curvilinear incision is made proximal to,
and parallel to, the first incision, joining the ends
of the two incisions to create a crescent (Figure
A
B
c
D
Figure 31-2 Schematic of crescent-shaped skin
being removed and "bisecting" method of suture place-
ment to close Hotz-Celsus blepharoplasty.
31-2, A). One corner of the crescent is grasped
with Bishop-Harmon forceps, and the crescent of
skin and orbicularis oculi is excised sharply using
Steven's tenotomy scissors. Closure of the surgical
site should be with No. 4-0 monofi lament nylon
or braided silk in a simple interrupted pattern. To
ensure appropri ate alignment of the curvil inear
incisions, the fi rst suture should be placed in the
center of the incision, with subsequent sutures
placed such that they bisect the area remaining to
be sutured (Figure 31-2, B to D).
POSTOPERATIVE CARE
Postoperative Care
Protedion: A protective eye cup is recom-
mended for either surgical procedure unti l sutures
are removed to prevent rubbing of the surgical
site.
Suture Removal: Tacking sutures should be left
in place for 7 to 10 days but may "cut through"
the skin prior to this time. Hotz-eelsus blepharo-
plasty sutures should be removed in 14 days.
COMPLICATIONS
Care should be taken to prevent sti ff suture ends
of monofi lament nylon from maki ng contact with
the cornea as such contact will cause corneal
irritation and may precipitate corneal ulceration.
Overcorrection of entropion by removing too
much tissue may result in ectropion and exposure
keratitis. Therefore, the surgeon should err on the
side of removing less tissue if any doubt exists as
to the amount of tissue to be removed. Cl ient edu-
cation about the potential of overcorrection or the
need for a second Hotz-Celsus procedure if
undercorrected is imperative.
REFERENCES
1. Latimer C, Wyman M, Hamilton J: An ophthalmic
survey of the neonatal horse, Equine Vet J (Suppl)
2:9, 1983.
Entropion 175
2. Koch S, Cowles R, Schmidt G: Ocular disease in the
newborn horse: a preliminary report. } Equine 511rg
2: 167, 1978.
3. Gelatt KN: Congenital and acquired ophthalmic
disease in the foal, Anim Eye Res 1-2: 15, 1993.
4. Turner AG: Ocular conditions of neonatal foals, Vet
Clill N Am Equine Pract 20:429, 2004.
5. Munroe G, Barnett K: Congenital ocular disease in
the foal, Vet Clin N Am Large Anim Pmct 62:519,
1984.
6. Cooley PL: Normal equine ocular anatomy and
eye examination, Vet Clin N Am Equille Pmct 8:427,
1992.
7. Samuelson D: Ophthalmic anatomy. In: Ge1att KN,
editor: Veterinary opllthalmology, ed 3, Philadelphia,
1999, Lippincott, Williams & Wilkins.
8. Moore CP, Constantinescu GM: Surgery of the ad-
nexa, Vet Clin N Am S1IIall Anim Pmct 27:101 1,1997.
CHAPTER 32
Nerve Blocks for Ophthalmic Procedures: Lacrimal, Zygomatic,
Infratrochlear, Palpebral, and Supraorbital Nerve Blocks
Laurence E. Galle
INDICATIONS
The indications for the lacrimal, zygomatic. and
infratrochlear nerve blocks are to provide local
anesthesia to the dorsolateral, ventrolateral, and
ventromedial eyelids. These sensory nerve blocks
are primarily used for minor diagnostic or thera-
peutic procedures such as sub palpebral lavage
tube placement, conjunctival biopsy, or eyelid lac-
eration repair. These blocks do not provide aki-
nesia of the eyelids. [· 3
The supraorbital nerve block provides sensory
anesthesia of the dorsomedial two thirds of the
eyelid to facilitate examination or minor surgical
procedures. This block does not provide akinesia
of the eyelids.' -3
The palpebral nerve block is used to provide
eyelid akinesia for ophthalmic examination and to
facilitate diagnostic or minor surgical procedures.
It does not, however, provide sensory anesthesia
of the eyelids.
1
-
3
EQUIPMENT
A 5-mL syringe, 'Is-inch 25-gauge needle, and 2%
lidocaine.
PREPARATION AND POSITIONING
These procedures may be performed in restrained
patients but are facilitated by sedation.
176
ANATOMY
The lacrimal, zygomatic, infratrochlear, and
frontal nerves provide sensory innervation to the
eyelids of the horse. The lacrimal nerve innervates
the dorsolateral third of the eyelid, the zygomatic
nerve innervates the ventrolateral eyelid, the
infratrochlear nerve innervates the medial can-
thus and ventromedial aspect of the eyelids,
and the frontal nerve innervates the dorsomedial
two thirds of the eyelids (Figure 32- 1). The zygo-
matic nerve is a branch of the maxillary branch
of the trigeminal nerve (CN V), whereas the
lacrimal, infra trochlear, and frontal nerves are
branches of the ophthalmic branch of the trigem-
inal nerve.
1
.4 The lacrimal, zygomatic, and
infra trochlear nerves exit the orbit from beneath
the orbital rim adjacent to the areas they inner-
vate, whereas the frontal nerve exits the orbit with
the frontal artery and vein through the supraor-
bital foramen of the supraorbital process of the
frontal bone.
The palpebral nerve is a branch of the auricu-
lopalpebral branch of the fac ial nerve (CN VII)
and innervates the orbicularis oculi muscle. The
palpebral nerve is most easily palpated as it crosses
the dorsal border of the zygomatic arch' (Figure
32-2) .
PROCEDURE
The lacrimal nerve block is performed by palpat-
ing the dorsolateral orbital rim_ Using a 25-gauge
Infra-
trochlear n.
n.
Figure 32-1 Schematic demonstrating innervation
of the eyelids by the lacrimal, zygomatic, frontal and
infratrochlear nerves.
Nerve Blocks for Ophthalmic Procedures 177
needle, inject 3 to 5 mL of 2% lidocaine along the
lateral third of the orbital rim. The zygomatic
nerve block is performed in the same manner, but
along the ventrolateral third of the orbital rim.
The infratrochlear nerve is blocked by injecting 2
to 3 mL of 2% lidocaine over a notch palpated
along the ventromedial aspect of the orbital

nm.
The supraorbital foramen is located by grasp-
ing the rostral and caudal borders of the supraor-
bital process of the frontal bone usi ng the thumb
and middle fingers. Moving the thumb and
middle finger medially as the process widens, the
index finger is used to palpate the depression of
the supraorbital foramen approximately hal fway
between the middle finger and thumb. A 25-gauge
needle is passed subcutaneously to the opening of
the supraorbital foramen or into the supraorbi-
Figure 32-2 Schematic demonstrating palpebral nerve anatomy in relati onship to the zygomatic arch and orbital
rim. F, Frontal; J, infra trochlear; L, lacrimal; Z, zygomatic.
=
178 OPHTHALMIC SURGERIES
tal foramen and 2 to 3 mL of 2% lidocaine are
injected.
l
The palpebral nerve is located by palpation
along the dorsal aspect of the zygomatic arch with
the index finger. A 25-gauge needle is inserted
through the skin adj acent to the nerve as it crosses
the zygomatic arch, and 1 to 5 mL of 2% lidocaine
are injected subcutaneously. The injection si te
should be gently massaged for 2 to 3 minutes.
Resulting eyelid akinesia may last 45 minutes to 1
hour. I
COMPLICATIONS
Inserting the needle directly into the supraorbital
foramen for frontal nerve block is preferred
by some clinicians but has the potential hazards
of intravascular injection and breaking off the
needle within the foramen in fractious patients.
Surgical exploration to remove the needle is nec-
essary if this latter complication occurs.
REFERENCES
1. Strubbe DT. Gelatt KN: Ophthalmic examination
and diagnostic procedures. In Gelatt KN. editor: Vet-
erinary ophthalmology, ed 3, Philadelphia, 1999, Lip-
pincott, Williams & Wilkins.
2. Cooley PL: Normal equine ocular anatomy and eye
examination, Vet Clill N Am Equine Pract 8:427,
1992.
3. Carastro SM: Equine ocular anatomy and oph-
thalmic examination, Vet Clill N AII1 Equine Pract
20:285, 2004.
4. Samuelson D: Ophthalmic anatomy. In Gelatt KN.
editor: Veterinary ophthalmology, ed 3, Philadelphia,
1999, Lippincott, Williams & Wilkins.

. I , ~
1


CHAPTER 33
Temporary Tarsorrhaphy
Laurence E. Galle
INDICATIONS
A temporary tarsorrhaphy is performed to pro-
vide temporary decreased exposure of the globe,
protection of the cornea, or both. ]-3 It is most
often used to protect an ulcerated cornea but may
also be used to maximize eyelid closure when
excessive corneal exposure is likely (e.g., facial
nerve [eN VII] paralysis- paresis).'"
EQUIPMENT
Derf needle drivers, Bishop-Harmon ophthalmic
forceps, and general operating scissors are neces-
sary for this procedure.
PREPARATION AND POSITIONING
This procedure is most easily performed using
general anesthesia with the patient in lateral
recumbency. It can be performed, however, in a
standing pati ent with heavy sedation and appro-
priate nerve blocks to obtain eyelid akinesia and
sensory anesthesia.
ANATOMY
A thorough understanding of eyelid anatomy is
imperative for appropriate suture placement in a
temporary tarsorrhaphy. The major layers of the
179
eyelids are composed of skin) muscle, a fibrous
tarsal plate, and conjunctiva from the external to
internal surfaces. The meibomian glands are
buried within the distal end of the fibrous con-
nective tissue tarsal plate wi th openings in the
eyelid margin. Well-developed cilia (eyelashes) are
on the upper eyelid
6
(see Figure 28-2).
PROCEDURE
The skin of the dorsal eyelid is grasped with
forceps, and a simple horizontal mattress suture
of No. 2-0 or No. 3-0 monofilament nylon is
placed using a curved cutti ng needle. The suture
pattern is started 5 mOl from the dorsal eyel id
margin, and the needle shouJd be inserted down
to, but not through, the fibrous tarsal plate. The
needle should be advanced such that it exits the
eyelid margin slightly anterior to the meibomian
gland orifices. The horizontal mattress suture
crosses the palpebral fissure, is inserted into the
ventral eyelid margin slightly anterior to the mei-
bomian gland orifices, and should exit the eyel id
skin approximately 5 mm from the eyelid. This
completes half of the mattress sut ure. The hori-
zontal mattress suture is completed by placing the
suture from the ventral to dorsal eyelid using the
same depth of Suture placement as in the first half
of the suture placement. The number and spacing
of the hori zontal mattress sutures are determined
by the surgeon.
7
.
S
Stents may be used to minimize
cutting of the suture into the eyelid.
8
The eyelids
may be completely closed with this technique, or
180 OPHTHALMIC SURGERIES
only a portion of the palpebral fi ssure may be
dosed to cover a localized lesion. In either case,
the sutures are temporary.
POSTOPERATIVE CARE
Postoperative Care
Protedion and Cleaning: The eye should be
covered with a protective eye cup to prevent
rubbing. The cup should be cleaned daily, and the
tarsorrhaphy should be inspected for potential
complications.
Suture Removal: The palpebral fissure will
begin to "gap" open to expose the sutures, usually
in 7 to 10 days. This exposed suture may rub the
cornea and could lead to corneal ulceration. The
sutures should be removed or replaced when
gapping begins to occur.
COMPLICATIONS
If the mattress sutures are placed too shallow
withi n the eyelid or exit too far anteri or to the
meibomian glands, the inverting nature of the
suture pattern may cause the eyelid margins to
rub the cornea (i. e., entropion). If the sutures are
placed too deep (e.g., through the conjunctival
surface), the suture material may contact the
cornea. Either situation predisposes the pati ent to
corneal ulceration, and such sutures should be
removed or replaced immediately. As noted for
postoperative care, the palpebral fissure may
begin to "gap" as early as 7 days postoperatively;
tarsorrhaphies that are "gapped" should be
removed or replaced to prevent ulceration.
REFERENCES
1. Miller TR: Principles of therapeutics, Vet Clin N Am
Equine 8:479,1992.
2. Andrew SE, Brooks DE, Biros D1, et al: Posterior
lamellar keratoplasty for treatment of deep stromal
abscesses in nine horses, Vet Ophthalmol 3:99, 2000.
3. Brooks DE: Equine ophthalmology. In Gelatt KN,
editor: Veterirlary ophthalmology, ed 3, Philadelphia,
1999, Lippincott , Williams & Wilkins.
4. Slatter D, Hanson S, deLahunta A: Neurooph-
thalmology. In Slatter D, edi tor: Fundamelltals of
veterinary ophthalmology, ed 3, Philadelphia, 2001,
WB Saunders.
5. Millichamp N1: Ocular trauma, Vet Cli n N Am
Equine 8:521, 1992.
6. Samuelson D: Ophthalmic anatomy. In Gelati KN.
editor: Veterinary ophthalmology. ed 3. Philadelphia.
1999, Lippincott. Will iams & Wilkins.
7. Slatter D: Principles of ophthalmic surgery. In Slatter
D, editor: FUrldamentafs of veterillary oplltllalll1ology,
ed 3, Philadelphia, 2001, WB Saunders.
8. Miller TR: Eyelids. In Auer 1. Stick J, editors: Equine
surgery, ed 2. Philadelphia, 1999, WB Saunders.
ALE ROGENITAL
URGERIES
181
CHAPTER 35
Cryptorchid Castration
Joanne Kramer
INDICATIONS
Cryptorchid castration is performed to prevent
breeding and to modify behavior.
EQUIPMENT
Emasculators are used to crush and sever the
spermatic cord. White's modified, Serra, and
Reimer emasculators are commonly used. All ca n
be used effectively; we commonl y use Serra emas-
culators. Sponge forceps can be used to evert the
vaginal process.
POSITIONING AND PREPARATION
Cryptorchid castration is performed with the horse
in dorsal recumbency under general anesthesia.
ANATOMY
Normal testicular descent involves enlargement
and then regression of the gubernaculum, a mes-
enchymal condensation within the genital fold
connected to the developing testes. This enlarge-
ment of the gubernaculum extends through the
vaginal ring and inguinal canal and is invaded by
an extension of peritoneal lining forming the
vaginal process. During the process of testi cular
descent, the gubernaculum differentiates into the
196
proper li gament, the ligament of the tail of the
epididymis, and the scrotal ligament (inguinal
extension of the gubernaculum).1 Cryptorchid
surgery is based on the identi ficati on of one or
more of these structures and the use of these
structures to locate the retained testicle.
The retained testicle may be within the
inguinal ca nal or within the abdomen. Complete
abdominal cryptorchids have the epididymis and
testicle within the abdomen. Incomplete or partial
abdominal cryptorchids have the tail of the epi-
didymis within the inguinal canal and the testes
within the abdomen (Figure 35-1). For complete
or incomplete abdominal cryptorchids. the prox-
imity of the testicle to the vaginal ri ng varies
depending on the length of the li gament of the tail
of the epididymis and proper ligament.
PROCEDURE
The cryptorchid testicle is removed first. A IO-cm
skin incision is made over the superficial inguinal
ring (Figure 35-2). Electrocautery is used if nec-
essary to control subcutaneous bleeding. The
depth of the incision is extended by palpating the
deep inguinal ring through the subcutaneous
tissues and inguinal canal with the index finger of
both hands and then spreading the tissues in one
layer. Dissecting bluntly is important because of
the superfi cial caudal epigastric vessels that li e
lateral to the incision. Dissecting the deeper
tissues in one layer keeps the surgical field simpler
and makes it easier to identify the ingui nal exten-
Cryptorchid Castration 197
A B c
>
Figure 3 5 ~ 1 Three different positions of a retained testicle (cryptorchidism). A. Inguinal retention within the
inguinal canal. B. Incomplete or partial abdominal retention. C. Complete abdominal retention.
Superficial iguinal
>
Figure 35-2 Location of the superficial inguinal
ring. Straight dotted line indicates the cranial border of
the pubis.
-
Figure 35-3 Schematic view of the inguinal exten-
sion of the gubernaculum.
sion of the gubernaculum or the vaginal process
(Figures 35-3 and 35-4).
[f the testicle is inguinal, it will be identified at
this point and can be removed using emasculation
(Figure 35-5). The vaginal tunic should be opened
to confirm the presence of a testicle. Incomplete
Figure 35-4 The inguinal extension of the guber-
naculum (small arrow) has been used to locate the
vaginal process (large arrow) in a cryptorchid.
abdominal cryptorchids will have only the epi-
didymis present in the vaginal tuni c, and with
gentle traction and occasional enlargement of
the vaginal ring, the testicle can be found and
removed. It is important that the descended tail of
the epididymis not be mistaken for a small testi-
cle and removed without removal of the abdom-
inal testicle (Figures 35-6 and 35-7).
Noninvasive Inguinal Approach
If the testicle is abdominal, the cranial medial
aspect of the superficial inguinal ring is searched
for the inguinal extension of the gubernaculwn
198 MALE UROGENITAL SURGERIES
A Figure 35-6 The taiJ of the epididymis exposed in an
B
Figure 35-5 A, First view of an inguinal testicle
(arrow). B, An inguinal t.esticle after exteriori zation
(arrow).
(scrotal ligament).2 The ingui nal extension of the
gubernaculum is palpable as a fi brous band such
that when tension is placed on it, it ca n be
observed to descend into the inguinal canal. The
size of the inguinal extension of the gubernacu-
lum varies but is generally less than 1 cm. Light
traction on the inguinal extension of the guber-
naculum and blunt dissection to loosen tissue
around the structure in the inguinal ca nal result
in exposure of the vaginal process (see Figures 35-
3 and 35-4). The vaginal process is then incised,
and the epididymis or ligament of the tai l of the
epididymis is used to retr ieve the testicle from the
abdomen.
incomplete abdomi nal cryptorchid.
Figure 35-7 After identifi cation of the tail of the
epididymis in Figure 35-6, traction on a long proper
ligament resulted in exteriori zation of the abdomi nal
testicle.
if the inguinal extension of the gubernaculum
is not located, the vaginal process can often be
fo und by palpat ing a thin cordlike structure in the
depression of the deep inguinal ring and by placing
a curved sponge forceps in the deep inguinal ri ng
and carefully everting the vaginal process
M
(Figure
35-8) . Opening the vaginal process reveals the lig-
ament of the tail of the epididymis, which ca n be
used to find the epididymis and testicle. In some
cases the vaginal ring must be enlarged to all ow
the testes to be exteriorized. This can be done
manually with a finger or with Metzenbaum

SCissors.
process
of the tait
;$f epididymis
fig. of the
tail of the epididymis
. (i"t
<'!', Y ' f-: .&-
:J • .o::-_, .....
Figure 35-8 Schemat ic view of eversion of the
vaginal ring with sponge forceps
A
Cryptorchid Castration 199
The testicle is removed by emasculation or lig-
ation and transection. Some testicles will not be
able to be exteriorized sufficiently to effectively
apply emasculators and will require ligation. If the
vaginal ring has been opened or is wider than one
finger width) the superficial inguinal ring should
be closed with No.2 or 3 synthetic absorbable
suture material in an interrupted pattern. Further
closure of the subcutaneous tissues and skin is
optionaL
Modified Parainguinal Approach
This approach can be used when the location of
the testicle is known to be abdominal or when the
noninvasive method has been attempted but the
vaginal process not located.
5
A lO-cm skin inci-
sion is made 2 cm parallel to the medial border of
the superficial inguinal ring beginning 3 to 4 cm
cranial to the cranial extent of the ring (Figure 35-
9, A). A 4-cm incision is made into the aponeu-
c
Lig. of the tail of
B
Tail of epididymis
Proper lig. of testis
Figure 35-9 Modified para inguinal approach for removing an abdominal testicle. A, Tncision in the aponeurosis
of the external abdominal oblique. B, Schematic view of sweeping the deep inguinal ring for testicular attachments.
C, Closure of the aponeurosis of the external abdominal oblique.

200 MALE U ROGENITAL SURGERIES
rosis of the external abdominal oblique muscl e.
This incision should be 1 to 2 cm medial to the
superfici al inguinal ri ng and centered over the
cranial aspect of the ring. The index and middle
fi nger are inserted through this incision and
bluntly through the internal abdominal oblique,
transverse fascia, and peri toneum and into the
peritoneal cavity. The area of the deep inguinal
ring is swept with the finger for either the epi -
didymi s, ductus deferens, proper ligament, or li g-
ament of the tail of the epididymis (Figure 35-9,
B). Once one of these attachments is exteriorized,
traction is used to exteriori ze the testicl e from the
abdomen. The testicle is removed by emasculation
or ligation and transecti on.
The aponeurosis of the external abdomi nal
obl ique muscle is closed with No. 2 or 3 synthetic
absorbable suture material (Figure 35-9, C). The
skin and subcutaneous tissue are closed with No.
2-0 absorbable synthetic suture material.
POSTOPERATIVE CARE
Postoperative Care
Exercise Reslridions: All horses should be stall
rested for 24 hours. Further restriction of activity
depends on the approach used and the antici-
pated incisional healing. Horses that undergo a
noninvasive approach with minimal dilation of the
vaginal ring can be allowed turnout after the initial
24 hours of stall rest and can return to use in 2
weeks. When the superficial ring has been closed,
horses should have stall rest for 24 hours followed
by 1 week of handwalking and 2 weeks of small-
paddock turnout. When the abdomen has been
entered through a limited parainguinal approach,
horses should have stall rest for 24 hours followed
by 3 weeks of small -paddock turnout.
Medications: Horses should receive a tetanus
toxoid booster if it has been longer than 6 months
since the previous vaccination. Phenylbutazone
(4.4 mg/kg BID) therapy is provided for 24 hours.
Antibiotic therapy is case dependent but typically
is given only perioperatively.
other: Recently gelded horses should be isolated
from mares for a minimum of 2 days and prefer-
ably up to 1 week after castration.
E X P ~ C T E D OUTCOME
Cryptorchid castrations vary in the difficulty and
time required to perform. In general, the time
requi red or level of difficulty cannot be pre-
dicted preoperatively. Many inguinal cryptorchids
requi re li ttle more than routine castrations. Some
abdomi nal cryptorchids require significant time,
careful exploration, and closure. Best results come
when the surgeon is prepared for either situat ion.
COMPLICATIONS
Complications are similar to those discussed for
routine castration. When invasive procedures are
necessary, the risk of incisional problems and
eventration is greater than for routine castration.
Addit ionally, if significant tissue trauma and
manipulation occur during explorat ion for
abdomi nal testicles, adhesion formation near the
inguinal ring may cause colic. Using noninvasive
approaches when possible and enteri ng the
abdomen through approaches that can be closed
di rectly (e.g., the modified parainguinal incision)
decrease the ri sk of incisional compli cations and
event rati on. Rarely, greatly enl arged testicles, ter-
atomas, or cystic testicles are identi fi ed and
require removal through an enlarged incision.
Monorchidism is rare but possible. If a
retained testicl e is not identified after a thorough
search, two opti ons are available. The horse can
be referred for further surgery, preferably
laparoscopy, or the descended testicl e can be
removed and hormonal testi ng carried out to
confi rm the absence of testicular tissue.
ALTERNATIVE PROCEDURES
Alternati ve procedures for removing cryptorchid
testicl es include invasive inguinal , suprapubic
paramedian, and fl ank approaches. The invasive
inguinal approach involves entering the abdomen
through the inguinal canal. This procedure ca n
extensively disrupt the deep inguinal ring and
vagi nal ri ng, whi ch cannot be closed directl y.
Therefore, the authors prefer the parai nguinal
approach to the invasive inguinal approach.
Suprapubic paramedian laparotomy has been well
described and is preferred by some authors.
6
.
7
With the exception of laparoscopic approaches,
cryptorchid castration is not routinely performed
through a flank approach.
Laparoscopy is a safe and effective way to iden-
tify and remove abdominal cryptorchid testicles.
Advantages include performing the procedure
through small incisions with secure closure, ease
of locating the testicle, and the ability to examine
both sides of the abdomen when the side of the
retained testicle is unknown. Disadvantages
include expense of the equipment and the need to
learn a specialized technique.
COMMENTS
Geldi ngs that present with stallion-like behavior
should have serum testosterone measurements
before and 30 to 120 minutes after the adminis-
tration of at least 6000 IV human chorionic
gonadotropi n (HCG) intravenously to determine
if testicular tissue is present. Geldings have serum
testosterone levels of less than 40 pglml. Cryp-
torchids have serum concentrations of greater
than 100 pg/mL' Horses younger than 18 months
or horses tested during winter may respond
poorly to HCG and may need to have an addi-
tional sample tested 24 hours after HCG admin-
istration or be retested when older or during the
spring.9 Previous surgical exploration often makes
identification of surgical landmarks difficult, and
when the side of cryptorchidism is not known,
surgery can be prolonged. In these situations,
laparoscopic exploration of the abdomen is the
recommended approach.
Left cryptorchid testicles are more likely to be
abdominal, whereas right cryptorchid testicles are
more likely to be inguinal.!O Rectal examination of
the inguinal region may also be useful in deter-
mining the location of the testicle. Horses with
abdominal testicles will have a small or indis-
cernible inguinal ring. A larger ring with evidence
Cryptorchfd Cdstration 20 J
of the ductus deferens entering the canal indicates
the horse is an incomplete abdominal cryp-
torchid, is an inguinal cryptorchid, or has a
descended scrotal testicle.
4
Decision to perform
diagnostic rectal examination is based on the size
and temperament of the horse and the anticipated
surgical approach. Bilateral cryptorchidi sm occurs
in up to 15% of cryptorchid horses. These cases
may have inguinal, incomplete abdominal, or
abdominal retenti on.
9
REFERENCES
I. Dyce KM, Sack WO, Wensing C1G: The urogenital
apparatus. In Dyce KM, Sack WO, Wensing CJG,
editors: Textbook of veterillary allatomy, Philadel-
phia, 2002, WB Saunders.
2. Valdez H, Taylor TS, McLaughlin SA, Martin TM:
Abdominal cryptorchidectomy in the horse using
inguinal extension of the gubernaculum testis,] Am
Vet Med Assac 174: litO, 1979.
3. Adams OR: An improved method of diagnosis and
castration of cryptorchid horses, ] Am Vet Med
Assac 145:439, 1964.
4. Adams SB, Fessler IF: Noninvasive inguinal cryp-
torchidectomy. In Adams S8, Fessler JF, editors:
Atlas of eqlline surgery, Philadelphia, 2000, WB
Saunders.
5. Wilson OG, Reinertson EL: A modified parain-
guinal approach fo r cryptorchidectomy in horses.
An evaluation in 107 horses, Vet 5urg 16:1, 1987.
6. Bladon B: Surgical management of cryptorchidism
in the horse, In Practice 24: 126, 2002.
7. Cox J: A surgical approach to the cryptorchid
horse, III Practice 10:11, 1988.
8. COX JE: Cryptorchid castration. In McKinnon AO,
Voss lL, editors: Equine reproductioll, Philadelphia,
1993, Lea & Febiger.
9. Mueller EPO: Cryptorchidism. In Wolfe OF, Moll
DH, editors: Large animal Ilrogellital surgery.
Philadelphia, 1999, Williams & Wilkins.
10. Stickle RL, Fessler JF: Retrospective study of 350
cases of equi ne cryptorchidism,] Am Vet Med Assoc
172:343, 1978.
CHAPTER 36
Circumcision
Joanne Kramer
INDICATIONS
Circumcision is indicated for removal of neoplas-
tic tissue, granulomas. or other masses from the
sheath (Figure 36- 1), It is also indicated for
removal of preputial scar tissue that prevents
penile retraction or extension.
EQUIPMENT
A tourniquet is optional.
POSITIONING AND PREPARATION
The horse is positioned in dorsal recumbency
under general anesthesia. The penis is extended,
and the prepuce and shaft of penis are prepared
for aseptic surgery.
ANATOMY
The prepuce has two infoldings, which allow for
retraction of the penis into the preputial cavity.
The first of these infoldings is the external fold of
the prepuce consisting of the external lamina,
preputial ostium, and internal lamina. The
second infolding is the preputial fold consisting
of the outer lamina of the preputial fold, the
preputial ring, and the inner lamina of the
preputial fold (Figure 36-2), Circumcision can be
202
performed when lesions are located anywhere
from the internal lamina of the external fold to the
inner lamina of the preputial fold.
PROCEDURE
Two parallel circumferential incisions are made
around the prepuce proximal and distal to the
affected region (Figure 36-3), A plane of dissec-
tion is established deeper than the affected tissue
but superficial to the deep fascia of the penis, The
enti re region between the circumferential inci-
sions is undermined and removed by creating a
longitudinal incision between the circumferential
incisions (Figure 36-4). Subcutaneous vessels may
require ligation. If a tourniquet has been used, it
Figure 36-1
prepuce. This
, , ,
Ci rcumCISion.
Squamous cell carcinoma involving the
lesion was removed successfully by
ring Outer
Urethral
Preputial
ostium
Fossa glandis
-
Preputial
fold
Outer
lamina
lamina
Preputial
ring
--------------
External preputial lamina
¥ • " oJ
Circumcision 203
Figure 36-2 A, External aspect of the penis and prepuce. S, Median section through the penis inside of the prepuce.
Figure 36-3 Circumferential incisions lIsed for removal of a lesion involving the prepuce.
A
B
204 MALE U ROGENITAL SURGERIES
Figure 1 6 ~ 4 Intraoperative view before a longitudi-
nal incision (dotted IiI/e) is created between the hori-
zontal incisions to complete the removal of a squamous
cell carcinoma lesion during ci rcumcision.
Figure 36-5 Multiple-layer closure after ci rcumci-
.
slon.
should be rel eased at this point and the area
checked carefully before closure. Simple superfi-
cial resecti ons can be closed in one layer wi th an
interrupted pattern that apposes the remaining
epithelium. Resection of larger amounts of
prepuce or resections with greater depth need to
be closed in layers using short runs of continuous
suture patterns with absorbable suture in the
deeper layers and an interrupted pattern in the
epithelium' (Figures 36-5 and 36-6). Care should
be taken to maintain alignment during closure.
Figure 3 6 ~ 6 Intraoperative view after closure during
a ci rcumcision procedure.
POSTOPERATIVE CARE
Postoperative Care
Exercise Restridions: Exercise is limited to
handwal king or small-paddock turnout for 2
weeks. Light daily exercise is important to mini-
mize edema formation. Stall ions should be iso-
lated from rnares for 3 to 4 weeks.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Antibiotic
therapy is given preoperatively and for 3 to 5 days
postoperatively. Horses should receive a tetanus
toxoid booster if it has been longer than 6 months
since the previous vaccination.
Suture Removal: Sutures used are absorbable
but can be removed 12 days postoperatively.
EXPECTED OUTCOME
The most common reason for circumcision is
removal of squamous ceU ca rcinoma lesions
involving the prepuce. If the extent of neoplasia is
limited and confined to the preputial tissues and
wide surgical margins are taken, the prognosis for
survival without recurrence appears to be good.
2
COMPLICATIONS
Edema commonly develops and generall y resolves
with time and low-grade exercise. Recurrence of
squamous cell carcinoma lesions is possi ble.
Dehiscence of the incision ca n be managed by
second-intenti on heal ing. but extensive dehis-
cence may cause stricture and require further
resection.
ALTERNATIVE PROCEDURES
Laser excision of neoplastic tissues of the prepuce
has been described and has the advantages of
increased hemostasis and abl ation of the underl y-
ing tumor bed.) Surgical excision has been com-
bi ned with topical 5-fluorouracil and cisplatin
Circumcision 205
injection in a limited number of cases and has had
good reported success.
4

S
REFERENCES
1. Allen DA: Conditions of the penis and prepuce. In
Wolfe DF, Moll HD, editors: Large allimal urogenital
surgery, Philadelphia, 1999. Williams & Wilkins.
2. Mair TS, Walmsley JP, Phillips Tl: Surgical treatment
of 45 horses affected by squamous cell carcinoma of
the penis and prepuce, Equine Vet J 32:406, 2000.
3. Palmer SE: Use of lasers in urogenital surgery. In
Wolfe DF, Moll HO, editors: Large animal urogenital
surgery, Philadelphia, 1999, Williams & Wilki ns.
4. Fortier LA, MacHarg MA: Topical use of 5 fluo-
rouracil for treatment of squamous cell carcinoma
of the external genitalia of horses: 11 cases, J Am Vet
Med Assoc 295: 1183, 1994.
5. Theon AP. Pascoe JR, Meagher DM: Peri-operative
intratumoral administration of cisplatin for t reat-
ment of cutaneous tumors in equids, J Am Vet Med
Assoc 205: 1170, 1994.
==
CHAPTER 37
Penile Amputation
Joanne Kramer
INDICATIONS
Neoplastic lesions (primarily squamous cell carci-
noma) and other masses involving the shaft of the
penis (Figure 37-1), permanent penile paralysis,
paraphimosis, or priapism.
EQUIPMENT
A tourniquet and urinary catheter are required for
this procedure.
POSITIONING AND PREPARATION
The horse is positioned in dorsal recumbency
under general anesthesia. The penis is extended
and maintained in extension using gauze or
umbilical tape around the glans. The penis,
prepuce, and caudal abdomen in the area where
the penis is extended should be prepared for
aseptic surgery. A urinary catheter is placed before
surgery to facilitate identification of the urethra
during surgery.
ANATOMY
The urethra is located on the most ventral aspect
of the penis and palpable if a urinary catheter has
been placed. The urethra is surrounded by the
corpus spongiosum penis. The corpus caver-
206
nosum penis surrounded by the tunica albuginea
is the largest vascula r space. The primary blood
vessels (the dorsal arteries and veins of the penis)
encountered in penile amputation are on the
dorsal aspect of the penis between the deep fascia
and the tunica albuginea. The veins on the dorsal
aspect of the penis and the cross-sectional
anatomy of the peni s are shown in Figure 37-2.
PROCEDURE
WilHam's technique is commonly used and is well
described. ! A triangular skin incision is made on
Figure 3 7 ~ 1 Extensive melanoma on the distal shaft
of the penis.
Dorsal
A
Obturator
External
pudendal v.
Penile Amputation 207
Internal
pudendal v.
Bulbospongiosus m.
v. of penis
m.
Body of penis
Cranial v. of
penis
\----4---
B
r - - - - - - 5 - - - - - - ~ ·
r---------
6
-------+
c
~ ~ ~ ~ ~ , . . . ---Dorsal process of glans penis ----'
5
6
D
-«'{ P.->vot;.J:<c, . >
Figure 37-2 A, Anatomy of the penis with transverse sections that extend through the B, glans penis, C, cranial
penis, and D. caudal penis. 1, Retractor penis muscle; 2, bulbospongiosus muscle; 3, urethra; 4, corpus spongiosum
penis; 5, albugi nea; 6, corpus cavernosum penis.
the ventral aspect of the penis proximal to the
intended site of amputation (Figures 37·3 and 37·
4). The base of the triangle is distal and about 3
em wide. The sides of the triangle are 4 to 5 em
long. This incision is continued through the sub-
cutaneous tissue. The skin and underlying tissues
are discarded.
A longitudinal incision is made the length of
the tr iangle between the retractor peni s muscles,
through the corpus spongiosum penis, and into
the lumen of the urethra (Figure 37·5) . The sides
of the urethra are sutured to the skin edges
with a simple interrupted pattern using No. 2-0
absorbable monofilament suture material (Figure
37-6). When the amputation is performed in the
more proximal portions of the penis, it may be
helpful to close the subcutaneous tissue to the
tissue just deep to the urethral mucosa before
closure of the mucosal epitheli um to the skin.
Closure of this layer decreases tension on the ure-
208 MALE UROGENITAL SURGEIUES
Figure 37-3 Triangular skin incision used in
William's technique for amputation.
Figure 37-4 Intraoperative view of the triangular
skin incision used in WilJiam's technique for amputa-
tion.
Figure 37-5 A longitudinal incision is made into the
lumen of the urethra.
thral mucosa) minimizes dead space) and helps
control hemorrhage from the corpus spongio-
sum. When this layer is closed) a simple continu-
ous pattern with absorbable suture material is
used.
The penis is then transected at the base of the
tr ia ngle in an oblique manner so that the dorsal
aspect of the penis is slightly longer than the
ventral aspect (Figure 37-7). Branches of the
dorsal artery and veins of the penis are ligated.
The tunica albuginea is closed over the corpus
Figure 37-6 The sides of the incised urethra are
sutured to the epithelium using an interrupted pattern.
I
~ r ; C.f " ~
Figure 37-7 The base of the penis is transected so that
the dorsal aspect is slightly longer than the ventral aspect.
Figure 37-8 The tunica albuginea is closed to com-
press the corpus cavernosum.
cavernosum to compress the vascular spaces using
a simple interrupted pattern with No. 0 or No.1
absorbable suture (Figure 37-8). The fi rst suture
is placed on midline, and the subsequent sutures
bisect the halves (Figure 37-9). The sutures should
be closely spaced. Generally) seven or eight sutures
are used. Blood loss from the corpus cavernosum
can be extensive) and this seal should be checked
carefully after release of the tourniquet.
The subcutaneous tissue deep to the skin is
closed to the tissue just deep to the urethral
Figure 37-9 Intraoperative view of the initial suture
placed to close the corpus cavernosum.
mucosa in a simple continuous pattern with
absorbable suture material. The urethral mucosa
is then closed to the skin at the base of the trian-
gle in a simple interrupted or simple continuous
pattern using No. 2-0 monofilament absorbable
suture material (Figures 37-10 and 37-11).
POSTOPERATIVE CARE
Postoperative Care
Exercise Restrictions: Stall rest with handwalk-
ing should be provided for 10 days, followed by
small-area turnout for 10 days.
Medications: Phenylbutazone is administered at
4.4 mg/kg BID for the initial 24 hours and 2.2
mg/kg BID for an additional 3 days. Antibiotic
therapy is given perioperatively and for 3 to 5 days
postoperatively. Horses should receive a tetanus
toxoid booster if it has been longer than 6 months
since the previous vaccination.
Suture Removal: Sutures are absorbable but
can be removed 12 days postoperatively.
Other: Amputation is not usually performed on
stallions because of potential incisional problems.
Ideally, stallions should be gelded several weeks
before surgery. If the procedure is performed on
a stallion, exposure to mares should be avoided
for 4 weeks. Artificial collection will be necessary
when breeding is resumed.
EXPECTED OUTCOME
With appropriate
associated with the
hemostasis,
surgery are
complications
not common.
Penile Amputation 209
Figure 17-10 Final appearance after performing
William's technique.
Figure 37-11 Intraoperative view of final appear-
ance after performing William's technique.
Recurrence or metastasis of squamous cell carci-
noma is a significant problem, and owners should
be forewarned of this . Reported survival rates for
squamous cell carcinoma include a 60% to 71%
survival rate of longer than 1 year.
2
,3 Involvement
of the urethra decreases the prognosis; one study
shows only a 30% IS-month survival rate when
urethral tissue was involved.
2
COMPLICATIONS
Hemorrhage, dehiscence, urethral stricture,
minor swelling, and recurrence or metastasis of
neoplastic lesions are possible. Mild incisional
hemorrhage during urination may be common
during the first 2 to 3 days postoperatively.1.4 Per-
sistent bleeding or hemorrhage that is dissecting
into the incision line should be controlled surgi-
210 MALE UROGENITAL SURGERI ES
cally.4 Minor dehi scence of the sut ure line usuall y
results in adequate healing by second intention.
More extensive dehiscence may result in urethral
stri ct ure. Recurrence or metastasis of neoplastic
lesions carries a poor prognosis and requires
further surgery.
ALTERNATIVE PROCEDURES
Alternative techniques for amputation have been
described and include Scott's and Vinsot's tech-
niques.l ,s In Scott's technique, a full circumferen-
tial incision is made at the intended site of
resection. Dissection is carried down to but not
into the urethra. Approximately 4 to 6 em of
urethra is freed distal to the site of peniJ e ampu-
tation. This is the most difficult aspect of the
entire procedure, because the wall of the urethra
is intimately associ ated with the corpus spongio-
sum. The vascular spaces of the corpus caver-
nosum are closed by apposing the tunica
albuginea with simple interrupted sutures using
No. 0 or 1 absorbable suture material. The ure-
thral stump is separated into three tri angular por-
tions, folded back, and sutured to the epithelium.'
Advantages and disadvantages of this technique
are simil ar to those for William's technique.
With Vinsot's technique, a triangul ar portion
of epithelium and underl ying tissue with the base
proximal to the apex is removed. A modification
of this procedure performed in standing horses
involves making a longitudinal incision directly to
the urethra.' A non absorbable ci rcumfe rentiallig-
ature is placed around the penis, and the penis is
transected distal to the ligature. After longitudinal
incision, the urethral mucosa is sutured to the
skin as previously described. The penile stump is
allowed to heal by second intention. The advan-
tages of this technique are the decreased surgery
time and the potential to perform the procedure
standing. The disadvantage of this technique is
the tendency for strict ure formati on and the
potential for inadequate hemostasis. '
COMMENTS
Amputation in the distal portion of the penis is
considerably less complicated than in the more
proximal portions. In the proximal portions, the
diameter of the penis is larger and the redundant
tissue of the prepuce must be dealt with, which
increases surgical and anestheti c time. In cases of
squamous cell carcinoma, every attempt must be
made to assess the horse for evidence of metasta-
sis and to identify small satell ite lesions elsewhere
on the penis or prepuce. For horses with lesions
too proximal to amputate or requiring preputial
ablation and inguinal lymph node removal , more
involved procedures have been described.
6

s
REFERENCES
I. Schumacher J: The penis and prepuce. In Auer JA,
Stick JA, editors: Equille surgery, Philadelphia, 1999,
WB Saunders.
2. Howarth S, Lucke VM, Pearson H: Squamous cell
carcinoma of the equine external genitalia: a review
and assessment of penile amputation and urethros-
tomy as a surgical lreatment, Equine Vet J 23:53,
1991.
3. Mair 1'S, Walmsley JP, Phill ips TJ: Surgical treat-
ment of 45 horses affected by squamous cell carci-
noma of the penis and prepuce, Equine Vet J 32:406,
2000.
4. Adams S8, Fessler 1F: Penile amputation. In Adams
S8, Fessler JF, editors: Atlas of eqlline surgery,
Philadelphia, 2000, WB Saunders.
5. Scott EA: A technique for amputation of the equine
penis, J Am Vet Med Assoc 168: 1048, 1976.
6. Archer DC, Edwa rds GB: En bloc resection of
the penis in five geldings, Equine Vet Edllc J 6: 12,
2004.
7. Dol es J, Williams JW, Yarbrough TB: Penile amputa-
tion and sheath ablation in the horse, Vet 5urg
30:327,200l.
8. Markel MD, Wheat JD, Jones K: Genital neoplasms
treated by en bloc resection and penile retroversion
in horses: 10 cases (I977- 1986),J Am Vet Med Assoc
192: 396, 1988.
CHAPTER 38
Perineal Urethrotomy in Males
Gal Kelmer
INDICATIONS
Treatment of urolithiasis involving the bladder
and urethra, urethral rents causing hemospermia
in stallions and hematuria in geldings, and tem-
porary urine diversio n for urethral obstr uctive
lesions, such as hematoma, neoplasia (e.g.) squa-
mOllS cell carcinoma), o r parasitic granuloma
(e.g., habronemiasis).1.)
EQUIPMENT
A mal e urinary catheter is helpful fo r urethra iden-
tificat ion during surgery. When using urethro-
tomy to treat urolithiasis, special equipment such
as a custom-made lithotrite may be necessary.
PREPARATION AND POSITIONING
The horse should be standing in stocks with the
use of systemic sedation and epidural analge-
sia. An alternative to epidural anesthesia is an
inverted-V block using local anesthetic. Manual
emptying of feces from the rectum is followed by
dipping, tail wrapping, and surgical preparation
of the perineal region.
ANATOMY
The male pelvic urethra is about 12 cm long and
tapers in diameter from 3 em near the prostate to
211
1.5 em in the uret hral isthmus and penile urethra.
The urethralis muscle envelops the pelvic uret hra.
The corpus spongiosum penis surrounds the
urethra, and the bulbospongio511s muscle lies
caudal to the pelvic urethra and becomes ventral
to the penil e urethra distally. The symmetrical
retractor peni s muscle covers the
sus and lies beneath the subcutaneous tissue at the
perineal region.
PROCEDURE
A vertical incision starts 4 to 6 cm distal to the
anus and extends ventrally for 8 to 10 cm through
the median raphae skin and subcutaneous tissue
(Figure 38-1). The incision should not extend
ventral to the ischium in order to prevent urine
spraying on the limbs and subsequent scald for-
mation. The retractor penis muscles are separated
on midline and reflected laterally (Figure 38-2) .
The bulbospongiosus muscle is exposed and
incised. Hemorrhage is expected, at this stage,
and is controlled by applying light pressure using
surgical gauze. The incision continues through
the corpus spongiosum penis and the urethral
wall. Urethral lumen entry is verified by visualiz-
ing and palpating the urinary catheter (Figure
38-3). The catheter helps to prevent both acci-
dental deviation from midline and penetration of
the cranial urethral wall .
104
212 MALE U ROGENITAL SURGERIES
Figure 38-1 View of the hi nd quarters of a gelding.
The interrupted line depicts the approach for perineal
urethrotomy.
-
Figure 38-2 Intraoperative view, showing perineal
urethrotomy of a gelding with a uri nary catheter in
place. The illustration depicts the incision through the
skin and subcutaneous tissue and between the retrac-
tor penis muscles. The deep layer shown at the center
of the incision is the bulbospongiosus muscle.
A
B
Figure 38-3 A, Postoperative view of perineal ure-
throtomy in a geldi ng. At the center of the incision the
uri nary catheter is visible within the urethral lumen. 8,
Close-up view of a completed perineal urethrostomy.
The second layer of suture is shown depicting simple
interrupted sutures between the urethral mucosa and
the perineal skin.
POSTOPERATIVE CARE
Postoperative Care
Protection and Cleaning: The surgery site
should be kept clean, and petrolatum jelly is applied
to the perineal region and the medial aspect of both
upper hind limbs to prevent urine sCilld.
Medications: Broad-spectrum systemic antibi-
otics and nonsteroidal anti inflammatory medication
such as phenylbutazone are given perioperatively
for 3 to 5 days.
Exercise Restrictions: Stallions need to avoid
sexual activity for 4 to 6 weeks.
Dietary Modifications: Adding salt to the feed,
at 1
0
/0 of the horse's diet, may encourage drink-
ing and aid in preventing recurrence of urolithia-
sis.
5
other: Hemorrhage should be monitored for the
fi rst 24 hours. Dripping of blood from the incision
and terminal hematuria are expected for up to 2
weeks postoperatively.
EXPECTED OUTCOME
Cystic urolithiasis carries a favorable prognosis,
but owners should be forewarned about the pos-
sibility of recurrence.
6
.
8
Urethral urolithiasis can
be treated successfully if diagnosis and treatment
are performed early, thus avoiding urethral
obstruction and bladder rupture. The success of
urethrotomy for treatment of other urinary
obstructive lesions depends primarily on the
nature and extent of the lesion.
COMPLICATIONS
Excessive bleeding in the form of a continuous
stream of blood warrants intervention. Applica-
tion of light pressure with gauze or cold packing
for 10 to 15 minutes is usually sufficient. However,
if significant bleeding persists, surgical explo-
ration is indicated. If the corpus cavernosum
penis is the source of bleeding, suturing the tunica
albuginea is indicated for prompt, effective hemo-
stasis. Urine scald is a common sequel that can
generally be avoided by keeping the distal end of
the incision proximal to the ischial arch. Scald
should be cleansed, and affected areas should be
treated with silver-sulfadiazine cream, zinc-oxide,
or other nonirritating cream-ointment on a daily
basis. Unilateral urine scald caused by asymmet-
ric urine flow may be eliminated by applying
sutures at the contralateral side of the urethro-
tomy in an attempt to redirect the urine stream
straight caudally. Stricture formation can gener-
ally be prevented by careful attention to tech-
nique, making one straight incision of adequate
length. Recurrence of urolithiasis may be
more common following urethrotomy than with
laparocystotomy due to incomplete fragment
removal.
9
Other reported complications include
rectal or urethral damage, orchitis, peritonitis,
incontinence. and bladder rupture.
9
ALTERNATIVE PROCEDURES
Urethral rents can be treated by perineal release
incision. The procedure is identical to that of per-
ineal urethrotomy but avoids entering the ure-
thral lumen. The incision through the corpus
spongiosulll penis presumably provides a tem-
porary alternative route for the blood, while
allowing the urethral rent to heal by second
intention. 3. \0
Perineal Urethrotomy in Males 213
Urethrostomy for permanent urine diversion is
created by a two-layer closure over the above
described urethrotomy (see Figure 38-3 B). Ini-
tially, a hemostatic layer is performed by suturing
the bulbospongiosus muscles and the corpus spon-
giosum penis, using No. 3-0 synthetic absorbable
suture, in a simple continuous pattern. The
second layer is performed in a simple interrupted
pattern, using No. 2-0 polypropylene, connecting
the urethral mucosa to the perineal skin. Meticu-
lous, tensionless apposition of the mucosa to the
skin is crucial to prevent dehiscence and lateral
urine diversion causing scald formation. ],2
Laparocystotomy is an effective method for
cystic calculi removal. The primary disadvantage
is the need for general anesthesia. The primary
advantages are reduced trauma to the bladder and
urethra and decreased recurrence rate from com-
plete calculi removal and the less traumatic nature
of the procedure.
5
,9
Laparoscopy has also been used for cystic
calculi removal. The procedure necessitates
general anesthesia, special equipment, and expe-
rience with the technique. However, it enables
excellent visualization and access to the bladder. II
COMMENTS
As a treatment for urolithiasis, urethrotomy can
be performed for retrieving small uroliths or
crushing larger ones using a lithotrite.
l
Most
cystic calculi are large enough that they must be
crushed or broken into smaller pieces to allow
removal through a urethrotomy incision. This can
result in a long and somewhat traumatic proce-
dure. Other, less traumatic, options for eliminat-
ing uroliths via urethrotomy include laser (e.g. ,
pulsed-dye) and electrohydraulic lithotripsy.'-'
Performing the urethrotomy 24 to 48 hours before
lithotripsy may provide for better visualization
with less hemorrhage. Following calculi fragmen-
tation, thorough bladder irrigation is indicated
and may be repeated postoperatively to decrease
recurrence and prevent cystitis.
REFERENCES
1. van Harreveld PO, Gaughan EM. Lillich JO:
Urethral surgery in horses, Camp Cant Educ Pract
Vet 20;739, 1998.
2. Lillich JO, OeBowes RM: Urethra. In Aller JA, Stick
JA, editors: Eqllille 5l11gery, ed 2, Philadelphia, 1999,
WB Saunders.
214 MALE UROGENITAL SURGERIES
3. Schumacher J, Schumacher J: Surgical management
of urolithiasis in the equine male. In Wolfe OF, Moll
HO, editors: Large animal urogenital surgery, ed 2,
Baltimore, 1998, Williams & Wilkins.
4. Adams SB, Fessler JF: Perineal urethrotomy and
removal of cystic calculi In Adams SB, Fessler 1F,
editors: Atlas of equine surgery. Philadelphia, 2000,
WB Saunders.
5. Schumacher J, Schumacher J, Schmitz 0: Macro-
scopic haematuria of horses. Equine Vet Edllc 4:255,
2002.
6. Howard RD, Pleasant RS, May KA: Pulsed dye laser
lithotripsy: treatment for urolithiasis in 2 geldings.
J Am Vet Med Assoc 212:1600.1998.
7. Judy CEo Galuppo LD: Endoscopic-assisted disrup-
tion of urinary calculi using a holmium:YAG laser
in standing horses, Vet Surg 31 :245, 2002.
8. Eustace RA, Hunt 1M: Electrohydraulic lithotripsy
for the treatment of cystic calculi in tvvo geldings,
Equine Vet J 20:221. 1988.
9. Laverty S, Pascoe JR, Ling GV, et al: Urolithiasis in
68 horses, Vet Surg 2 J :56. 1992.
10. Schumacher T, Varner DO, Schmitz DG, et al:
Urethral defects in geldings with hematuria and
stallions with hemospermia, Vet Surg 24:250, 1995.
11. Ragle CA: Laparoscopic removal of cystic calculi in
10 horses. In Fischer AT, editor: Equi1/e diagllostic
and surgical laparoscopy, Philadelphia, 2002, WB
Saunders.
EMALE ROGENITAL
URGERIES
215
CHAPTER 39
Caslick's Procedure (Vulvoplasty)
John C. Janicek
INDICATION
Pneumovagina resulting from abnormal perineal
conformation.
EQUIPMENT
No special equipment is required.
POSITIONING AND PREPARATION
The mare is restrained standing in a stock or
backed into a stall doorway. The tail is held out of
the way by an assistant or wrapped and tied
forward. Following aseptic preparation of the per-
ineal region, local anestheti c ( 15 to 20 mL lIsing a
22-gauge needle) is infiltrated along the vulvar
labial mucocutaneous margin (Figure 39- 1),
Excessive local anesthetic infiltration should be
avoided to prevent distortion of the mucocuta-
neous margins.!
PROCEDURE
Beginning at the level of the ischiatic tuber and
extending to the dorsal commissure, a thin band
of mucosa approximately 3 to 5 mm wide is
excised from each side of the vulva along the
mucocutaneous margin
2
(Figure 39-2). The
exact length of tissue removed depends on the
216
mare's conformation.) To reduce the likelihood of
removing an excessive width of mucosa, thumb
forceps may be used to apply downward tension
on the band of excised mucosa. Excessive mucosal
removal results in excessive scar tissue forma-
tion, making future easlick's procedures more
diffi cult.,,4
Once the mucosa has been excised, the exposed
surfaces are apposed beginning at the dorsal COI11-
'<l r f " J ~ . c ~ _
Figure 39-1 Infiltration oflocal anesthetic along the
vulvar mucocutaneous margin.
/
(
\
......
Figure 39-2 Excision of vulvar mucosa along the
mucocutaneous junction using scissors.
I
'9 •. i. .. _. _
Figure 39-3 Apposition of vulvar mucosa
Ford interlocking pattern.

usmg a
missure with No. 0 non absorbable suture using a
continuous pattern. Simple continuous or Ford
interlocking patterns are commonly used (Figure
39-3). A single "breeding stitch" may also be
placed just distal to the suture line with No. I non-
absorbable suture material using a loose single
interrupted suture to protect the repair during
assisted live cover or artificial insemination
(Figure 39-4). The "breeding stitch" should not be
so ventral that it prevents urination or assisted live
cover breeding. A «breeding stitch" should not
be placed in mares in which pasture breeding is
intended.
(aslick's Procedure (Vulvoplasty) 217
'<jj -
Figure 39-4 Addition of a "breeding stitch" just
distal to the Caslick suture line.
POSTOPERATIVE CARE
Postoperative Care
Medications: Antibiotic and antiinflammatory
therapies are generally not necessary.
Suture Removal: Sutures should be removed
10 to 14 days after surgery.
other: No exercise restrictions are necessary.
Prior to foaling (3 to 5 days), an episiotomy
should be performed to minimize perineal da-
mage during parturition.
EXPECTED OUTCOME
Resoluti on of pneumovagina is likely followi ng a
Casl ick's procedure in mares with normal to
mildly abnormal perineal conformation. Mares
with moderate to severe abnormal perineal con-
formation or persistent pneumovagina may
require perineal body reconstruction.
COMPLICATIONS
Minimal compl ications are associated with this
procedure; however, dehiscence and suture si nus
tract development are possible. Excessive ventral
closure may result in urovagina. Unpredictable
vulvar tearing may occur if episiotomy is not per-
formed before parturition.
218 FEMALE UROGENITAL SURGERIES
COMMENTS
For maximum reproductive funct ion, the dorsal
commissure of the vulva should extend no more
than 4 to 5 cm dorsal to the ischiatic tuber,
meaning that approximately two thirds of the
vulvar cleft is below the ischiatic tuber.4 The
vulvar labiae should be oriented vertically with a
cranial-to-caudal slope of no more than 10 de-
grees from vertical.
s
A distance of more than 4 cm
between the dorsal commissure of the vulva
and the ischiatic tuber and/or an angle of more
than 10 degrees in the declination of the vulvar
labiae is associated with poor perineal conforma-
tion and increases the likelihood of pneu-
movagina.
s
Variations in perineal conformation
have many causes, including inherent conforma-
tion, poor physical condition, and age. A flat
croup, elevated tail set, under-developed vulvar
labiae, and sunken anus all contribute to faulty
perineal conformation.
s
Poor physical condition
intensifies the problem and can result in abnor-
mal conformation in mares with otherwise
normal conformation. Improving the physical
condition of these mares results in improved p e r ~
ineal conformation. With age and repeated foal-
ings, the vulva lengthens and vulva conformation
becomes more horizontal relative to the pelvic
brinl because of general organ and muscle relax-
ation in the pelvic region.
4
REFERENCES
I. Anasari MM: The Caslick's operation in mares,
Comp Cont Edllc Vet 5:s107, 1983.
2. Beard W: Standing urogenital surgery, Vet Clill N Am
Equine Pmct 7:669, 1991.
3. Turner AS, McI lwrath CW: Techniques ill large
allimai surgery, ed 2, Philadelphia, 1989, Lea &
Febiger.
4. Trotter GW, McKinnon AO: Surgery for abnormal
vulvar and perineal conformation in the mare, Vet
Clill N Am Equine Pmct 4:389, 1988.
5. Easley J: External perineal conformation. In McKin-
non AO, Voss JL, editors: Equi/le reprodllction,
Philadelphia, 1993, Lea & Febiger.

CHAPTER 40
Perineal Body Reconstruction (Episioplasty)
John C. Janicek
INDICATION
Pneumovagina or persistent endometritis follow-
ing easlick's procedure.
EQUIPMENT
No special equipment is required.
PREPARATION AND POSITIONING
The mare is restrained standing in a stock, and the
procedure is performed with either epidural or
local perineal body anesthesia, and sedation if
necessary. Once anesthesia is confirmed. the tail
is wrapped and securely retracted. Fecal material is
removed from the rectum. The perineal region is
then rinsed and aseptically prepared. Sterile saline
is used instead of alcohol to remove antiseptic
soaps, because alcohol may cause excessive irrita-
tion.
PROCEDURE
Vulvar retraction is maintained with towel clamps
or stay sutures positioned lateral to the dorsal
vulvar commissure. In this procedure, triangular
areas of mucosa are removed from the perineal
body. An incision is made along the vulvar muco-
cutaneous margin of both labiae beginning at the
dorsal commissure, extending to the desired
ventral limit. I The ventral limit of the incision is
subjectively chosen by determining the amount of
219
tissue required to develop a dorsal commissure
that will provide an adequate vaginal seal. The
length required is typically 4 to 6 em. The incision
is then extended dorsocranially until the cranial
portion terminates on the dorsal midline at the
vestibulovaginal junction (Figure 40-1). The tri-
angular mucosal flaps are then resected from both
sides of the vestibule. The resultant exposed sub-
mucosa forms a right-angled triangle with the
right angle located along the dorsal commissure
of the vulva' (Figure 40-2) .
Closure of the ventral vestibular mucosal
margins is performed cranial to caudal with No. 2-
o absorbable suture in a simple continuous pattern
2
(Figure 40-3). Deeper submucosal tissues are
apposed with No. 2-0 absorbable suture using a
simple interrupted pattern. Caslick's procedure is
performed to appose the vulvar opening (Figure
40-4).
POSTOPERATIVE CARE
Postoperative Care
Exercise Restrictions: Small-paddock turnout
should be maintained for 14 days.
Medications: Broad-spectrum antibiotics are
administered for 7 to 10 days. A nonsteroidal anti-
inflammatory agent is administered for 3 to 5
days.
Suture Removal: Caslick's sutures are removed
10 to 14 days after surgery.
Other: Sexual rest for 4 to 6 weeks is recom-
mended. Prior to foaling (3 to 5 days), an epi-
siotomy should be performed to prevent perineal
damage during parturition.
220 FEMALE UROGENITAL SURGERIES
/
Figure 40-1 Proposed area of vestibular
mucosa to be removed (dotted lilies) for
perineal body reconstruction.
Figure 40-2 Caudolateral view of proposed area of
vest ibular mucosa to be removed (dotted lines) for perineal
body reconstruction.
Figure 40-3 Cranial-to-caudal cl osure of
the ventral vestibular mucosa
simpl e continuous pattern.
• •
margin usmg a
.
I
Figure 40-4 easlick's procedure is performed to
oversew the submucosal perineal tissues and appose the
vulvar lips.
EXPECTED OUTCOME
Adequate reconstruction of the mare's perineal
region alleviates pneumovagina in most cases of
Perineal Body Reconstruction (Episioplasty) 221
moderate to severely abnormal perineal confor-
mation. Occasionally, pneumovagina does not
resolve following Caslick's procedure or perineal
body reconstruction. In these cases, perineal body
transection may be warranted.
2
COMPLICATIONS
Minimal complications are associated with this
procedure; however, dehiscence and suture sinus
tract development are possible. Excessive ventral
closure may result in urovagina. Unpredictable
vulvar tearing may occur if episiotomy is not per-
formed before parturition.
REFERENCES
I. Beard W: Standing urogenital surgery, Vet Clill N Am
Equille Pract 7:669,1991.
2. Trotter GW, McKinnon AO: Surgery for abnormal
vulvar and perineal conformation in the mare, Vet
CliIl N Am Equine Pract 4:389, 1988.
CHAPTER 41
Urethral Extension (Urethroplasty)
John C. Janicek
INDICATIONS
Urine pooling, urovagina.
EQUIPMENT
Long-handled instruments and a 30-Fr Foley
catheter are required. Self-retaining retractors
(vaginal spatula. Balfour. modified Finochietto)
and a good light source (floor lamps. headlamp.
or fiberoptic lights) are useful but not necessary.
PREPARATION AND POSITIONING
The mare is restrained standing in a stock, and
surgery is performed following epidural anesthe-
sia, and sedation if necessary. Once anesthesia is
confirmed, the tail is wrapped and securely
retracted. Fecal material is removed from the
rectum. The perineal region is rinsed, followed
by cleansing of the vaginal lumen with a dilute
povidine-iodine solution. The perineal region is
then asepticall y prepared, with care taken to not
use alcohol, as it may cause excessive irritation.
PROCEDURE
Various repair techniques are described. The goal
of all techniques is to create a mucosal tunnel
222
extending from the urethral orifice to near the
mucocutaneous junction so that urine enters the
vagina caudal to the brim of the pelvis. allowing
gravity to assist in voiding urine. In all techniques,
it is important to place the first suture cranial to
the urethral orifice to minimize the risk of fistula
formation and to appose the dissected tissue
shelves with minimal tension. Adequate visualiza-
tion is achieved by use of a vaginal spatula posi-
tioned along the dorsal aspect of the vaginal
lumen along with ventrolateral placement of
towel clamps in the vulvar labiae. Retraction may
also be provided using Balfour or modified
Finochietto retractors.
Monin Te(hnique
This technique involves caudal translocation of
the transverse urethral fold
l
,2 and is recom-
mended only in cases with mild perineal confor-
mational abnormalities. The major limitation of
this technique is the inability to extend the ure-
tlual opening as far caudally as can be done with
other techniques, which is necessary in mares with
moderate to severe perineal conformational
abnonnalities.
The transverse urethral fold is grasped with
Allis tissue forceps 1 cm abaxial to each side of
midline and retracted approximately 5 cm cau-
dally. The lateral aspect of the transverse urethral
fold is split horizontally and the incision is
extended along the corresponding ventrolateral
vaginal wall (Figure 41-1). The transverse urethral
fold is sutured to the vaginal floor in the retracted
Figure 41-1 The transverse urethral fold is caudally
retracted. On the right side, an incision has been made
through the transverse urethral fold and corresponding
ventrolateral vaginal wall. On the left side, a dot'ted line
indicates the proposed incision line.
position with No. 2-0 absorbable suture using a
two-layer pattern. The ventral layer is apposed
using a Connell pattern, and the dorsal layer is
apposed using a horizontal mattress pattern
(Figure 41-2). A simple interrupted suture should
be placed at the caudalmost aspect of the two
. ..
InCISions.
Brown Technique
This is the most common urethral extension tech-
nique used.
3
Correction of urovagina in mares
caused by severe perineal conformation abnor-
malities can be achieved with this technique by
extending the urethral opening far caudally.
However, mares with vaginal scars or vaginal
mucosa atrophy are not good candidates fo r this
technique because of increased tissue tension.
3
A 30-Fr Foley catheter is placed in the urinary
bladder and the cuff is inflated. The transverse
urethral fold is split horizontally, and the mucosal
incision is extended caudally along the left and
Urethral Extension (Urethroplasty) 223
'\
\
A
B
Figure 41-2 A, The right side of the transverse ure-
th ral fold and corresponding ventrolateral vaginal wall
are split horizontally in an interrupted manner. Arrows
indicate the direction of tissue mobilization. The left
side of the transverse urethral fold has been sutured to
the corresponding ventrolateral vaginal wall . B, Close-
up view of a two-layer closure. The ventral layer is
apposed using a Connell pattern, and the dorsal layer is
apposed using a continuous horizontal mattress
pattern.
right vaginal walls to a point approximately 3 cm
cranial to the vulvar labiae (Figure 41-3). Under-
mining of the ventral and dorsal mucosal layers is
performed to decrease tension. The ventral mu-
cosal layer is closed with No. 2-0 absorbable su-
ture using a Connell pattern, everting the tissue
ventrally (Figure 41-4). Submucosal tissue is
closed with No. 2-0 absorbable suture using a
simple continuous pattern (Figure 41-5). Finally,
the dorsal mucosal layer is everted dorsally with
No. 2-0 absorbable suture using a continuous
horizontal mattress pattern (Figure 41-6).
Shires Technique
Although simple and efficient, this technique
4
is
limited in that it may be used only in mares that
have redundant vestibular folds that may be
pulled together to form a tunnel without the need
for dissecting and undermining tissue flaps to
form a shelf.'
224 FEMALE UROGENITAL SURGERIES
Figure 41-3 Horizontal splitting of the transverse
urethral fol d and caudal extension of the vaginal
mucosa incision (dotted line) along the left and right
vaginal walls.
Figure 41-4 Inversion of the ventral mucosal layer
using a Connell pattern.
Figure 41-5 Submucosal tissue closure using a
simple continuous pattern.
A
B
Figure 41-6 A, Eversion of the dorsal mucosal layer
using a continuous horizontal mattress pattern. B, Close-
up view of the completed three-layer closure.
A 30-Fr Foley catheter is placed in the urinary
bladder and the cuff is inflated. Before any inci -
sion is made, two lines of the ventral vaginal
mucosa are dorsall y everted and sutured over the
Foley catheter with No. 0 absorbable suture using
an interrupted horizontal mattress pattern,
leaving adequate mucosa to allow excision and
further suturing (Figure 41-7). Suture placement
is continued caudally to approximately 2 em
crani al to the vulvar labiae. The two lines of dor-
sall y everted mucosa are excised to create four
fresh-cut edges of vaginal mucosa (Figure 41-8).
These debrided edges are then apposed with
Figure 41-7 Dorsal eversion of ventral vaginal
mucosa over 30-Fr Foley catheter and sutured using an
interrupted horizontal mattress pattern.
Figure 41-8 Excision of dorsally everted vaginal
mucosa, creati ng four fresh-cut edges of vaginal
mucosa.
Urethral Extension (Urethroplasty) 225
No. 2-0 absorbable suture usi ng a simple contin-
uous pattern (Figure 41-9) .
McKinnon Technique
Correction of urovagina in mares caused by severe
perineal conformation abnormal ities can be
accomplished with thi s techni que
5
,6 by providing
a wide, long, and strong urethral extension. This
technique is recommended when the urethra
opening needs to be extended far caudally and
increased tissue tension is present. Minimal tissue
tension is exerted on the completed tunnel. Ini-
tially, a steep learni ng curve for this tech nique is
encountered, but it can be easily performed with
experience. In addition, disruption of the blood
supply should be avoided during the tissue flap
dissection.
A 3D-Fr Foley catheter is placed in the urinary
bladder and the cuff is inflated. The caudal border
of the transverse urethral fold is grasped on
midline with All is tissue forceps and retracted
caudally. A hori zontal mucosal incision is made 2
to 4 cm cranial to the caudal edge of the trans-
verse urethral fold extending slightly dorsocau-
dally along the left and right vaginal wal ls (Figure
41-10). This incision should end at the vulvar
labia half to two thirds of the di stance between the
vaginal fl oor and vaginal roof. The transverse ure-
thral fold and vaginal wall mucosal tissues are
undermi ned so that the free tissue flaps are
reflected caudall y and axially, respectively. Dis-
section of transverse urethral fold tissue should
Figure 41-9 Apposition of freshly debrided mucosal
edges usi ng a simple continuous pattern.
226 FEMALE UROGENITAL SURGERIES
Figure 41-10 Caudal retraction of the transverse
urethral fold allowing an incision to be made into the
transverse urethral fold. The proposed incision is
shown with dotted lines. The incision should end at the
vulvar labia half to two thirds of the distance between
the vaginal floor and roof.
allow 3 to 6 em of caudal reflection, while the
vaginal wall tissues are reflected past midline
without tension (Figure 41-11) . The final config-
uration is in the shape of a Y, with the base of the
Y caudaL Beginning at the right cranial junction
of the transverse fold and vaginal wall incision,
reflected tissues are apposed with No. 2-0 ab-
sorbable suture using a Connell pattern, endi ng
at the midpoint of the transverse urethral fold
reflection (Figure 41-12). The second suture line
is performed on the left side in the same manner,
cont inuing caudally ending at the caudal edge of
reflected vaginal wall (Figure 41-13). It is impor-
tant to maintain minimal suture tension on the
suture line and invert all tissue edges. Exposed
submucosal tissues created dorsally by transverse
fold and vaginal mucosal dissection are allowed to
heal by second intention.
When indicated, a Caslick's procedure is per-
formed after all urethroplasty techniques.
> ; t . S ~ ;1;.. ~ •
Figure 41-11 Caudal reflection of the transverse
urethral fold and axial reflection of the vaginal wall
mucosa after dissection.
1¥,S .. ; ( ~ .
Figure 41-12 The reflected transverse urethral fold
and vaginal wall are apposed using a Connell pattern
beginning at their cranial junctions.



,

,
,
Figure 41-13 The second suture line begins on the
opposite side in the same manner, continuing caudally
ending at the caudal edge of the vagina walL The com-
pleted urethral extension is in the shape of a Y, with the
base of the Y pointing caudal.
POSTOPERATIVE CARE
Postoperative Care
Exercise Restridions: Small-paddock turnout
should be maintained for 30 days.
Medications: Broad-spectrum antibiotics are
administered for 7 to 10 days. A nonsteroidal anti-
infiammatory agent is administered for 3 to 5 days.
Catheter Removal: Mares should be monitored
closely to determine their ability to urinate ade-
quately. The Foley catheter is removed within 3
days postoperatively.
Other: The reproductive tract should not be
examined for 2 to 4 weeks after surgery, and
the mare should have 45 to 60 days of sexual
rest.
EXPECTED OUTCOME
Primary healing is reported to occur in appro-
ximately 85% to 89% of urethroplasty proce-
Urethral Extension (Urethroplasty) 227
dures.
3

S
Short-term complications such as dehis-
cence or fistula formation are reported to occur in
11 % to 15% of all described techniques.'" When
complications arise, subsequent surgeries are essen-
tial to improve the chances for complete healing.
Postoperative conception rates are reported to be
64% to 92% within 1 year postoperatively.3's Recur-
rence of urovagina is uncommon, unless a signifi-
cant change in perineal conformation occurs.
COMPLICATIONS
Suture dehiscence and fistula development along
the suture line are the most common complica-
tions. Fistula development is most commonly
observed at the junction of the transverse urethral
fold and vaginal wall reflexion. These complica-
tions can be avoided by precise dissection, metic-
ulous suture placement, and reduced tension
on apposed tissues. If a fistula develops, an
attempt to repair the fistula should be pursued to
minimize the risk of endometriti s, persistent
urovagina, and infertility.
Leaving the indwelling urinary catheter in
place for longer than 3 days may result in cystitis.
If cystitis does occur, the catheter is removed, the
urine is cultured, and appropriate antimicrobials
are administered until bacteria are no longer
isolated.}
REFERENCES
I. Beard W: Standing urogenital surgery, Vet Clill N Am
Equine Pmct 7:669,1991.
2. Baird AN: Surgical management of urovagina in the
mare, Southwest Vet 38:36,1987.
3. Brown MP, Colahan PT, Hawkins DL: Urethral
extension for treatment of urine pooling in mares, ]
Am Vet Med Assoc 173: 1005, 1978.
4. Shires GM, Kaneps AJ: A practical and simple surgi-
cal technique for repair of urine pooling in the mare,
Proc Am Assoc Eqllil'le Pract 32:51, 1986.
5. McKinnon AO, Belden JO: A urethral extension
technique to correct urine pooling (vesicovaginal
reflux) in mares, J Am Vet Med Assoc 192:647,1988.
6. Easley JK: Diagnosis and treatment of vesicovaginal
reflux in the mare, Vet Clin N Am Equine Pmct 4:407,
1988.
CHAPTER 42
Third-Degree Perineal Laceration Repair
John C. Janicek
INDICATIONS
Dystocia, traumatic breeding, or conversion of a
rectovaginal fistula into a third-degree perineal
laceration for subsequent repair.
EQUIPMENT
Long handled instruments and monofilament
absorbable suture materials are required. Self-
retaining retractors (Balfour, modified Finochietto)
and a good light source (floor lamps, headlamp, or
fiberoptic lights) are useful but not required.
PREPARATION AND POSITIONING
Surgery is delayed for 4 to 6 weeks following the
laceration to allow wound contraction and inflam-
mation to subside. Delaying surgery for this period
allows the wowld edges to strengthen and become
clearly defined before repair is attempted. A gruel
or pasture diet is fed 3 to 5 days prior to surgery,
and the mare is fasted 1 day before surgery.
The mare is restrained standing in a stock, and
surgery is performed following epidural anesthe-
sia, and sedation if necessary. Once anesthesia is
confirmed, the tail is wrapped and securely
retracted. Fecal material is removed from the
rectum and vagina. The perineal region is rinsed,
foll owed by cleansing of the rectal and vaginal
lumens with a dilute povidone-iodine solution.
The perineal region is then aseptically prepared.
228
The preparation solution should be rinsed with
sterile saline, not alcohol, as alcohol may cause
excessive irritation.
PROCEDURE
One- and two-stage repair techniques are
described. A one-stage repair is preferred;
however, a two-stage repair should be performed
if excessive tension is present during surgery. No
distinct advantage or disadvantage exists between
techniques. Principles for all techniques include
initial creation of rectal and vaginal shelves,
minimal tissue tension, and maintaining a soft
manure consistency after surgery. All repair tech-
niques close the defect from cranial to caudal.
Modification of the techniques can be performed
based on surgeon preference.
Towel clamps or retention sutures are posi-
tioned along the dorsolateral and ventrolateral
aspects of the laceration to provide exposure. The
cranial extent of the laceration is extended
approxi mately 3 cm, creating a rectal and vaginal
shelf. Dissection is continued laterally and cau-
dally along the scar tissue line into the submucosa
until the tissue flaps created can be apposed on
midline without tension (Figure 42-1). Both
mucosal surfaces are dissected 2 cm or more.
One-Stage Repair
Goetz Technique
Using No.1 absorbable suture, a six-bite pattern
is used to close the rectovaginal shelf.l The sut ure
------------------------------------------------------------...............
,
Figure 42-1 Surgical dissection of a third-degree
peri neal laceration prior to surgical repair. The recto-
vaginal shelf is reflected with the proposed incision line
(dotted lille) shown.
pattern begins within the vaginal lumen, allowing
the knot to be secured within the vaginal lumen
(Figure 42-2). Sutures are positioned approxi-
mately 1 em apart; the suture pattern includes the
vaginal mucosa but does not penetrate the rectal
mucosa. The vaginal mucosa is closed over the
newly created rectovaginal shelf with No. 0
absorbable sut ure using a continuous horizontal
mattress pattern. The rectal mucosa is left to heal
by second intention. Closure of the rectovaginal
shelf and vagi nal mucosa should extend to the
cutaneous perineum. Caslick's procedure is then
performed to appose the vulvar opening.
Modified Goetz Technique
The vaginal mucosa is inverted into the vaginal
lumen with No. 0 absorbable suture using a
Connell or Lembert patter n.
2
-
4
This suture pattern
is continued caudally to reconstruct the cranial
half of the defect and then tied but not cut. Using
No. I absorbabl e suture, purse-string sutures are
used to close the rectovaginal shelf (Figure 42-3).
Sutures are positioned approximately 1 cm apart
and should not pass through the vaginal or rectal
mucosa. Once the cranial half of the rectovaginal
Third-Degree Perineal Laceration Repair 229
Figure 42-2 The rectovaginal shelf is closed with a
six-bite pattern. The pattern should begin and end in
the vagi nal lumen without penetrating the rectal
mucosa.
Figure 42-3 The vaginal mucosa is inverted into the
vaginal lumen using a Connell pattern and the recto-
vaginal shelf is closed using a purse-string pattern.
shelf is reconstructed, closure of the vaginal
mucosa is completed. followed by closure of the
remaining caudal half of the rectovaginal shelf.
The rectal mucosa is everted into the rectal
lumen with No. 0 absorbable suture using a

230 FEMALE UROGENITAL SURGERIES
Cushing or Lembert pattern (Figure 42-4).
Closure of the rectovaginal shelf and mucosal sur-
faces should extend to the cutaneous perineum. A
Caslick's procedure is then performed to appose
the vulvar opening.
Semitransverse Closure Technique
Small marker incisions are made at the ventral
aspect of the perineal body along the left and right
mucocutaneous junctions
5
; these markers will be
used as the ventrocaudal points of the triangle
used to construct the perineal body. The scar
tissue mucosal junction along the rectovaginal
shelf is incised longitudinally and divided in its
entirety. Rectal and vaginal mucosae are under-
mined approximately 7 to 10 cm from the recto-
vaginal shelf. Beginning approximately 4 cm
cranial to the external anal sphincter, a mucosal
incision is made from the lateral edge of the rec-
tovaginal shelf ventrocaudally toward the original
marker incision. A triangle-shaped section of
mucosa is excised; the exposed triangular section
of submucosa will form the perineal body when
sutured. The center of the rectovaginal shelf is
grasped with Allis tissue forceps, pulling the shelf
caudally to the cranial border of the proposed
perineal body. The final configuration is in the
shape of a Y, with the base of the Y pointing
caudal. Beginning at the deepest corner on the
right side, the rectovaginal shelf is reconstructed
with No. 2 absorbable suture using a simple
-
/
J1t-_ ;f. •.•. r . - ~ .... _
Figure 42-4 The rectal mucosa is everted into the
rectal lumen using a Cushing pattern.
continuous pattern ending at the center of the
shelf. The left side is closed in the same manner.
Rectal and vaginal mucosa surfaces should not be
penetrated.
Perineal body reconstruction begins at the
caudal edge of the newly formed rectovaginal
shelf and is continued caudally. The first suture
incorporates the caudal end of the newly formed
rectovaginal shelf and the right and left sides of
the perineal body. The dorsal portion of the per-
ineal body is closed first with No. 2 absorbable
suture using a Cushing pattern. Incorporation of
the rectal, vaginal, or anal mucosa should be
avoided during closure. The remainder of the
perineal tissue is closed with No. 2-0 absorbable
suture using a simple interrupted pattern.
Caslick's procedure is performed to appose the
perineal skin and vulvar opening.
Two-Stage Repair
Aanes Technique
The vaginal mucosa is inverted into the vaginal
lumen with No. 0 absorbable suture using a
Connell or Lembert pattern.
6
,7 This suture pattern
is continued caudally to reconstruct the cranial
half of the defect and then tied but not cut. Using
No.1 absorbable suture, purse-string sutures are
used to close the rectovaginal shelf (see Figure
42-3). Sutures are positioned approximately 1 cm
apart, avoiding the vaginal and rectal mucosa. If
an excessive amount of tension or dead space is
present, partial tightening of the purse-string
sutures along with sagittally oriented simple inter-
rupted sutures will help obliterate dead space
(Figure 42-5). Once the cranial half of the recto-
vaginal shelf is reconstructed, closure of the
vaginal mucosa is completed, followed by closure
of the remaining caudal half of the rectovaginal
shelf. Optionally, the rectal mucosa may be
inverted into the rectal lumen with No. 2-0
absorbable suture using a Cushing or Lembert
pattern. Closure of the rectovaginal shelf is COI1-
tinued to the level of the cutaneous perineum.
Closure of the perineal body is performed 3 to
4 weeks after the first surgery if the rectovestibu-
lar shelf is completely healed. If dehiscence occurs
or a fistula is present, the first stage must be
repeated. Local anesthesia of the perineal body or
epidural anesthesia is used. Closure of the per-
ineal body is performed as described in the per-
ineal body reconstruction technique (see Chapter
40). A triangular section of the vestibular mucosa
,
,
,
A
Figure 4 2 ~ 5 A, Suture pattern placement in the
cranial area of a third-degree perineal laceration repair
when excessive loss of tissue or thick, inelastic connec-
tive tissue is present. When the purse-string suture is
tightened, tension on the connective tissue produces a
transverse ridge in the rectal submucosa that reduces
the diameter and elast icity of the rectum.
c
Figure 42-5 C, Sagittally oriented simple inter-
rupted sutures are then placed from rectal submucosa
to vaginal submucosa to obliterate dead space.
Third-Degree Perineal Laceration Repair
231
B
Figure 42-5 B, To prevent this complication, the
purse-string suture is tied before the ridge starts to
form.
D
"'$i.e- .(_ ... £(#..,., ,
Figure 42-5 D, Tissues are approximated without
excessive tension. Several of these purse-string sutures
with their associated simple interrupted sutures may be
necessary in mares that have suffered excessive tissue
loss or that have developed excessive fibrosis.
232 FEMALE UROGENITAL SURGERIES
is reflected ventrall y and removed from each side.
with the triangle apex pointing cranially and the
base along the mucocutaneous junction of the
perineum (Figure 42-6). Closure of the ventral
vestibular mucosaJ margins should be performed
in a cranial-to-caudal manner with No. 2-0 ab-
(
A

, ,
sorbable suture in a simple continuous pattern
(Figure 42-7). Deep perineal tissues should be
apposed with No. 2-0 absorbable suture using a
simple interrupted pattern. Perineal ski n is
apposed with No. 0 nonabsorbable suture using
Ford interlocking pattern (Figure 42-8).
B
Figure 42-6 A, Proposed area of vestibular
Illllcosa to be removed (dotted lilies) for perineal
body reconst ruction. B. Caudolateral view of pro-
posed area of vestibular mucosa to be removed
(dotted lilies) for perineal body reconstruction.
Figure 42-7 Cranial-to-caudal closure of the
ventral vestibular mucosa margin using a simple con-
tinuous pattern .
Figure 42-8 Apposition of submucosal perineal
tissue is shown using a ser ies of simpl e cont inuous
patterns. Casli ck's procedure is performed to oversew
the submucosal perineal tissues and appose the vulvar
lips.
POSTOPERATIVE CARE
Postoperative (are
Exercise Restrictions: Small-paddock turnout
should be maintained for 30 days.
Medications: Broad-spectrum antibiotics are
administered for 7 to 10 days. A nonsteroidal anti-
infiammatory agent is administered for 3 to 5
days.
Suture Removal: Perineal and Caslick's sutures
should be removed 10 to 14 days after surgery.
Dietary Modifications: Free-choice access to
grass, a gruel diet, or both should be provided for
30 days, with gradual return to normal diet. Occa-
sionally, mineral oil may be added to the diet to
maintain a soft manure consistency.
Other: Sexual rest is recommended until the fol-
lowing breeding season.
EXPECTED OUTCOME
Primary healing is reported to occur in approxi-
matel y 75% to 90% of repaired third-degree per-
ineal lacerations.
2
-
7
Short-term complicat ions
Third-Degree Perineal laceration Repair 233
such as dehiscence or fi stula formation are
reported to occur in 12% to 24% of all surgical
repairs. 2,4,6,7 Subsequent surgeries are essential
when complications arise to improve the chances
for complete healing. Concept ion rates are
reported to be 75% to 92% within 1 year after
surgery.2.4,6,7 Third-degree lacerations recur in 5%
to 50% of foal ing mares due to the inelasticity of
the resultant scar t.i ssue.
2
-
4
,6.7
COMPLICATIONS
Suture dehiscence and subsequent fi stula devel -
opment are possibl e. These complications can be
avoided by precise dissection, adequate tissue pur-
chases) and reduced tension on apposed tissues.
Fistula formation may result in fa ilure to conceive
due to endomet ritis) pneumovagi na) or contin-
ued fecal contamination of the vaginal lumen.
Urovagina may be a consequence of the mare)s
natural perineal conformation or the result of
altering the perineal confo rmation during a rec-
tovaginal fist ula repair and can be addressed with
a urethroplasty procedure.
2
Mares should be
monitored closely during subsequent foa lings
because the fibrous tissue from the repair may
reduce the el asticity of the birth canal and predis-
pose the mare to additional birthing trauma.
7
As
the sutures are progressively placed in the caudal
tissues) care must be taken to avoid narrowing of
the rectal lumen) which will predi spose the mare
to tenesmus and constipation.
COMMENTS
Epidural anesthesia is occasionally insufficient for
some rectovaginal procedures. Local anestheti c
techniques have been developed to ei ther supple-
ment or replace epidural anesthesia. The perineal
area can be desensitized by infiltrating local anes-
thetic laterally between the rectum and the pelvi s.
A needle long enough to extend approximately 1
inch cranial of the area to be desensiti zed should
be used. One hand is inserted into the rectum and
the needle is inserted through the skin at the 9 to
10 o'clock position lateral to the rectum. The
needle is then advanced parall el to the rectum in
the loose connective tissue lateral to the rect um.
Twenty to 40 mL of local anesthetic are injected
as the needle is withdrawn. The procedure is then
234 FEMALE UROGENITAL SURGERIES
Pudendal n.
Caudal rectal n.
e;" (>,..-.-t;" .1.-"", ____
Figure 42-9 Illustration for performing subsacral anesthesia in the horse. The left hand is placed in the rectum to
identify the ventral sacral foramina and a needle is inserted on midline a third of the distance from the anus to the
base of the tail, directed toward the foramen identified by the left hand.
repeated on the other side at the 2 to 3 o'clock
position.
Another technique of subsacral anesthesia has
been described. The tail is wrapped and retracted
dorsally. One hand is inserted into the rectum to
locate the sacral promontory. The hand is drawn
back along the sacrum 2 to 3 em from midline to
locate the ventral sacral foramina. By counting
back, the third ventral foramen (exit of the
pudendal nerve) is found. The index or middle
finger remains on this point (Figure 42-9) . With
the other hand a needle (LIp to 6 inches in length)
with a short beveled point is inserted on midline
a third of the distance from the anus to the tail
base, and directed toward the ventral sacral
foramen. A syringe is attached to the needle and
approximately 20 mL of anesthetic solution is
injected. The syringe is removed and the needle
withdrawn 5 to 6 em until the point reaches the
fourth sacral foramen (exit of the caudal rectal
nerve) and 20 mL of anesthetic solution is like-
wise injected. The entire procedure is repeated on
the other side so that a total of 80 mL of anaes-
thetic is required. Within 5 to 20 minutes areas
desensitized by this block include the perirectal
region, the entire caudal region overlying the
semitendinosus and semimembranosus muscles,
and most of the perineum excluding the vulva and
the area immediately surrounding the vulva. In
males, the penis and retractor penis muscles will
be desensitized.
8
REFERENCES
I. Beard W: Standing urogenital surgery, Vet c/in N Am
Equine Pract 7:669, 1991.
2. Belk nap JK, Nickels FA: A one-stage repair of third-
degree perineal lacerations and rectovestibular fistu-
lae in 17 mares, Vet Surg 21 :378, 1992.
3. Stjck1e RL, Fessler JF, Adams SB: A si ngle-stage tech-
nique for repai r of rectovestibular lacerations in the
mare, Vet SlIrg 8:25, 1979.
4. O'Reilly JL, Maslean AA, Lowis TC: Repair of third-
degree perineal laceration by a modified Goetz tech-
nique in twenty mares, Equille Vet J 10:2, 1998.
5. Phillips TN, Foerner JJ: Semitransverse closu re tech-
nique for repair of perineal lacerations in the mare,
Proc Am Assoc Equine Pract 44: 191, 1998.
6. Aanes WA: Surgical management of foaling injuries,
Vet Clill N Am Equine Pract 4:417, 1988.
7. Colbern GT, Aanes WA, Stashak TS: Surgical man-
agement of perineal lacerations and rectovestibular
fi stulae in the mare: a retrospective study of 47 cases,
] Alii Vet Med Assoc 186:265. 1985.
Third-Degree Perineal l aceration Repair 235
8. Popescu P, Paraipan V, Nicolescu V: Anestezia sub-
sacrala 1a taur si la cal. Probleme ZootelJl/ice SI Vet-
erillare Of. 3:46, 1958. In Westhues M, Fritsch R:
Anilllal allaesthesia, Vol. 1, p. 180, Edinburgh and
London, 1964, Oliver and Boyd. ("Local Anaeste-
sia" translated from German by A.D.Weaver)
CHAPTER 43
Rectovaginal Fistula Repair
John C. Janicek
INDICATIONS
Dystocia. traumatic breeding, or unsuccessful
third-degree perineal laceration repair resulting in
rectovaginal fi stula formation.
EQUIPMENT
Long-handled instruments and monofilament
absorbable suture material s are required. An SO-
degree scalpel handle is hel pful for the direct
repair technique described. Self-retaining retrac-
tors (Balfour, modified Finochietto) and a good
li ght source (floor lamps) headlamp, or fiberoptic
lights) are useful but not required.
PREPARATION AND POSITIONING
Surgery is delayed fo r 4 to 6 weeks following
fi stula formation to allow wound contraction and
inflammation to subside. Delaying surgery for this
period allows the wound edges to strengthen and
become clearly defined before repair is attempted.
A gruel or pasture diet is red 3 to 5 days prior to
surgery, and the mare is fasted 1 day before
surgery.
The repair can be performed with the horse
standing or under general anesthesia. For stand-
ing procedures, the mare is restrained in a stock,
and surgery is performed folJowing epidural anes-
thesia) and sedation if necessary. Once anesthesia
236
is confirmed) the tail is wrapped and securel y
retracted. Fecal material is removed from the
rectum and vagina. The perineal region is rinsed,
followed by cleansing of the rectu m and vagina
with a dilute povidine-iodine solution. The per-
ineal region is then aseptically prepared. The
preparation solution should be rinsed wi th sterile
saline) not alcohol) as alcohol may cause excessive
irritation.
PROCEDURE
Various repair techniques are described. Princi -
ples for all techniques include complete debride-
ment of the fi stul a margin, minimal tension on
the repair, and maintaining a soft manure consis-
tency after surgery. Modi fi cation of the techniques
can be performed based on surgeon preference.
Direct Repair
Fistulas up to 10 em have been repaired using this
technique. I This technique preserves the perineal
body and anal sphincter) resulting in good
primary healing and minimal swell ing and pain
after surgery. Complete fistula margin debride-
ment, which can be diffi cult in craniall y located
fistulas) is the major limitation of the direct repair.
The anal sphincter is dilated with self- retaining
retractors or by placing umbili cal tape through the
anal sphincter 2 cm lateral to each side of dorsal
midline and securing the tape around the base of
the tail. Towel clamps or retention sutures are
positioned along the ventrolateral aspect of the
sphincter fo r retraction if self-retaining retractors
are not used (Figure 1). The fistula margin is
incised circumferentially (Figure 43-2), exposing
the submucosal tissue and incised edges of the
rectal and vaginal mucosae (Figure Taking
large, closely spaced to bites, the
Figure 43-1 Dilat ion of the anal sphincter using
umbilical tape secured around the base of the tail and
ventrolateral positioning of towel clamps allows good
visualization of the rectovaginal fistula.
--
v
Redovaginal Fistula Repair 237
submucosa is apposed transversely with No. 1
absorbable suture using a si mple interrupted
pattern. The submucosal sutures should be pre-
placed beginning in the lateral aspects of the
fi stula and tightened after all sutures have been
preplaced. Care should be taken to avoid purchase
of the rectaJ and vaginal mucosa within these bites
(Figure The rectal mucosa is then apposed
transversely with No. 0 absorbable suture using a
continuous horizontal mattress pattern (Figure
43-5), Closure of the vagi nal mucosa is optional.
Schiinfelder Technique
FistuJas up to 6 em have been repaired with this
technique.
2
As long as principles of fl ap develop-
..
•• l'4"-
Figure 43-3 Exposure of fresh submucosal tissue
and incised edges of the rectal and vaginal mucosae,
Figure 43-2 Circumferential inci-
sion of the fi stula using an 3D-degree
scalpel handle.

238 FEMALE UROGENITAL SURGERI ES
A B
~ ~ ~ ... ~ . -
Figure 43-4 A, Preplacement of submucosal suture
pattern in a transverse direction beginning in the
corners of the fistula using a simple interrupted pattern.
B, Sagittal cross section of submucosa suture place-
ment. Avoid penetrating the rectal and vaginal
mucosae.
A
B
~ ~ . - ~ ­
Figure 43-5 A, Transverse apposition of the rectal
mucosa using a continuous horizontal mattress pattern.
B, Sagittal cross section of rectal mucosa suture place-
ment.
ment are respected, this technique avoids exces-
sive tension on wound closure and minimizes
swelli ng and pain after surgery.
Following full-thickness fistula debridement, a
U-shaped vaginal tissue (mucosa and submucosa)
pedicle flap is made from the lateral vaginal wall
closest to the fistula (Figure 43-6). The base of the
flap should be as wide as the fistula and at least
two-thirds the length of the flap. The flap length
should provide sufficient length to achieve rota-
tional transfer to cover the fistula without tension
on the flap. The base of the flap should be I to 2
~ ~ ~ . l > " -
Figure 43-6 Transverse cross section of a dorsally
based U-shaped vaginal tissue flap originating from the
lateral vaginal waU.
mm from the fistula margin. Once the flap is
rotated, the vaginal mucosa faces dorsally into the
rectum and its margins should extend at least 2
mm beyond the fistula margin (Figure 43-7). The
flap is circumferentially secured to the edges of
the fistula with No. 0 absorbable suture using a
simple interrupted pattern. The rectal mucosa
should not be penetrated when securi ng the flap
to the fistula margin. Closure of the rectal mucosa
is not required.
Bemis Technique
This technique can be used to repair large fistu-
las.'" Caudally located fi stulas can be easily and
efficiently repaired, leaving the caudal rectum and
anal sphincter intact. The major limitations of this
technique are reduced exposure and difficult
closure of large cranially located fistulas. Addi-
tionally, increased scar tissue formation in the
perineal region may compromise the elastic
nature of the dorsal vaginal region.
An 8- to lO-cm transverse perineal incision is
made equidistant from the ventral surface of the
anal sphincter and the dorsal commissure of the
I
Figure 43-7 Transverse cross section of a vagi nal
tissue fla p rotated into position so that the vaginal
mucosa is facing dorsally and its margins are at least
2 mm beyond the fi stul a margin. The flap is circurn-
ferentially secured to the edges of the fistula using a
simple interrupted pattern.
vulva. Dissection is continued cranially in a hori-
zontal plane through the perineal body and rec-
tovagi nal shelf, attempting to separate the fi stula
into two equal-thickness fistulas (rectal and
vagi nal) (Figure 43-8). The rectal and vaginal
mucosae are circwnferentiaUy dissected approxi-
mately 2 to 3 em from the underlying tissue sur-
rounding the fistul a. Avoiding the rectal mucosa)
the rectal fistula is transversely closed with No.1
absorbable suture using an interrupted Lembert
pattern. The sutures are preplaced begi nning in
the lateral aspects of the fistula and tightened after
all have been prep laced. The vaginal fistula is then
longitudinally closed with No. I absorbabl e suture
using an interrupted Lembert pattern. The sutures
are preplaced beginning in the rostral and ca udal
aspects of the fi stula and tightened after all have
been preplaced (Figure 43-9). After both fistulas
have been closed) the remaining tissue surround-
ing and caudal to the fi stulas is closed with No. 0
absorbable suture using a simple interrupted
pattern. The transverse perineal skin incision can
be left to heal by second intention or primarily
closed with No. 2-0 nonabsorbable suture using a
simple interrupted pattern. The rectal mucosa is
transversely apposed with No. 0 absorbable suture
Redovaginal Fistula Repair 239
/
-.;;.e ...... l.J' u -
Figure 43-8 Complete horizontal dissection
between the ventral surface of the anal sphincter and
dorsal commissure of the vulva extendi ng through the
fistula to create rectal and vaginal shelves. The dotted
lines indicate proposed areas of dissection.
using a continuous horizontal mattress pattern.
The vaginal mucosa is longitudinally or trans-
versely apposed with No. 0 absorbable suture
using a continuous horizontal mattress pattern.
Huber Technique
This technique is a combination of the Bemis and
conversion to third-degree laceration techniques
that can be used to repair large fistulas.
5
.
6
Longi -
tudinal divi sion of the vaginal shelf provides
exceUent exposure and surgical access for suture
placement. Healthy tension-absorbing rectal
tissues located between the fistula and perineum
are preserved) and broad) generous shelves of
perirectal and perivaginal tissues are created.
An 8- to lO-cm transverse perineal incision is
made equidistant from the ventral surface of the
anal sphincter and the dorsal commissure of the
vulva. Dissection is continued cranially in a hori-
zontal plane through the perineal body and rec-
tovaginal shelf) attempting to separate the fistula
into two equal -thi ckness fistulas (rectal and
vaginal) (see Fi gure 43-8) . The rectal and vaginal
mucosae are circumferentiaUy dissected approxi-
240 FEMALE UROGENiTAL SURGERIES
-
Figure 43-9 After dissection, the rectal fistula is
transversely closed and the vagi nal fistula is longitudi-
nally closed using an interrupted Lembert pattern.
Suture preplacement should begin in the lateral and
cranial aspects, respectively, of each fistula. Submucosal
tissue surrounding and caudal to the fistula is closed
using a simple interrupted pattern. The perineal skin
incision can be left to heal by second intention or pri-
marily closed using a simple interrupted pattern.
mately 2 to 3 em from the underlying tissue sur-
rounding the fist ula.
A longitudinal midline incision is made
through the vaginal shelf from the fi stul a caudally
to the exterior (Figure 43- 1 0) . The vaginal mucosa
is inverted toward the vagi nal lumen with No. 0
absorbable suture using a Connell pattern. This
suture pattern is continued caudally to recon-
struct the cranial half of the defect and then tied
but not cut. If desired, the rectal mucosa is trans-
versely apposed from the vagin al side with No. 0
absorbable suture using a Connell pattern from
the vaginal side. The rectovaginal shelf is closed
with No. 1 absorbable suture using a six-bite
purse-st ring pattern. Successive bites are taken in
the rectal submucosa, lateral perivaginal tissue,
and vaginal submucosa on each side with the knot
ti ed deep to the rectal mucosa (Figure 43-11 ).
~ e - " " t . - . t . ~ ...... ~ ­
Figure 43-10 Appearance of the surgical area after
a longitudinal midline incision is made through the
vaginal shelf.
Figure 43-11 Vaginal mucosa inversion towards the
vaginal lumen using a Connell pattern. A six-bite purse-
string pattern is lIsed to close and el iminate dead space
between the rectal and vaginal shelves.
Sutures are positioned approximately 1 em apart,
avoiding the vaginal and rectal mucosa. Once the
cranial half of the rectovaginal shelf is recon-
structed, closure of the vaginal mucosa is com-
pleted, foll owed by closure of the remaining
caudal half of the rectovaginal shelf. The trans-
verse perineal ski n incision is closed with No. 2-0
nonabsorbable suture usi ng a simple interrupted
pattern. If indicated, easlick's procedure is per-
formed to appose the vulvar openi ng.
Klug Technique
Fistulas up to 6 em have been repaired using this
technique.
7
The KIug technique provides good
visualization, a durable and stable closure, and
good first-time heal ing success rate without dis-
rupting the integr ity of the anal sphincter. Repair-
ing a large fi stula using this technique should be
attempted with caution. Tissue mobilization is
difficult in large fistula repairs and may requi re an
alternative repair method. Cranially located fist u-
las shouJd not be repaired with this technique
because of inadequate visualization and limi ted
working room.
Beginning at the caudal edge of the fistula, an
incision approximately 1 cm in depth is made
through the vaginal mucosa and submucosa
extendi ng caudally to the dorsal commissure of
the vulva ( Figure 43-12). The vaginal mucosa
caudal to the fistula is dissected approximately 2
em and ventrally reflected. The cranial and lateral
aspects of the fi stula are then horizontally split
through the li ne of scar tissue and separated into
rectal and vaginal shelves (Figure 43-13). Dissec-
ti on of the rectal and vaginal shelves should
extend approximately 2 to 3 cm lateral and cranial
to the fi stula. Sl ight caudal traction is applied to
the cra nial vaginal shelf, and an interrupted vest-
over-pants pattern using No.1 absorbable suture
is used to close the fi stula (Fi gure 43- 14). The
cranial vaginal shelf provides the ventral layer,
while the caudal rectal shelf provides the dorsal
layer of the repair. A shelf overlap of at least 2 cm
should be obtained (Figure 43-15). The remain-
ing vaginal submucosa should be apposed with
No. 0 absorbable suture using a simple inter-
rupted pattern. The reflected vaginal mucosa
should be apposed with No. 2-0 absorbable suture
usi ng a continuous horizontal mattress pattern.
The rectal mucosa is allowed to heal by second
intention.
Redovaginal Fistula Repair 241

A
, ,
)
B

Figure 43-12 A, An incisi on (dotted lilies) approxi -
mately 1 em deep is made through the vaginal mucosa
and submucosa beginning at the caudal edge of the
fistula and extended to the dorsal commissure of the
vulva. Essentially, a second-degree per ineallaceratiol1 is
created. B, Sagittal cross section indicating the length
and depth of the incision (dotted lille) made through
the dorsal vaginal mucosa and submucosa.
Conversion to Third-Degree Perineal laceration
When fi stulas have large diameters or are located
very cranial or if minimal perineal tissue is
present, conversion into a third-degree perineal
laceration and subsequent repair is often recom-
mended. Third-degree perineal laceration conver-
sion is initiated by incising from the caudal
margin of the fi stula through the perineal ti ssues,
anal sphincter, and dorsal vulvar commissure.
Repair of third-degree lacerations is discussed in
Chapter 42.
242 FEMALE UROGENITAL SURGERIES
A
--J
B
Figure 43
w
13 A, Followi ng creation of a second-
degree perineal laceration, the dorsal vaginal mucosa
caudal to the fi stula is dissected 2 em and ventrally
reflected. B, Sagittal cross section of the ventrally
reflected vaginal mucosa. The dotted title depicts hori-
zontal dissection through the cranial and lateral aspects
of the fistula, allowing separation of the fi stula into
rectal and vaginal shelves.
POSTOPERATIVE CARE
Postoperative Care
Exercise Restrictions: Small-pen turnout should
be maintained for 30 days.
Medications: Broad-spectrurn antibiotics are
administered for 7 to 10 days. A nonsteroidal anti-
infiammatory agent is administered for 3 to 5 days.
Suture Removal: Perineal and Caslick's sutures
should be removed 10 to 14 days after surgery.
Dietary Modifications: Free-choice access to
grass, a gruel diet, or both should be provided for
30 days, with gradual return to normal diet. Occa-
sionally, mineral oil may be added to the diet to
maintain a soft manure consistency.
other: Sexual rest is recommended until the fol-
lowing breeding season.
A
B
Figure 43
w
14 A, Vest-over-pants (dotted line) is used
to close the fistula. The first two sutures are placed
through the cranial aspect of the vagi nal shelf and the
caudal edge of the rectal shelf. B, Sagittal cross section
indicating caudal traction of the vaginal shelf so that at
least 2 em of tissue overlap is obtained.
EXPECTED OUTCOME
Primary healing is reported to occur in approxi-
mately 65% to 100% of repaired rectovaginal
fist ulas.l-l
O
Short-term complications such as de-
hiscence or fistula formation are reported to occur
in 6% to 35% of all surgical repairs. '·
'o
Subsequent
surgeries are essenti al when complications arise to
improve the chances for complete healing_ Post-
operative conception rates are reported to be 33%
to 92% within I-year postoperatively?,S-9 Recur-
rence of rectovaginal fi stulas and third-degree
perineal lacerations during subsequent foalings
are reported in 8% to 10% of mares as a result of
stress on inel astic tissues secondary to excessive
scar tissue deposition.
A
B
Figure 43-15 A, Closure of the fistula. B, Sagittal
cross section of suture placement for closure of the
fistula.
COMPLICATIONS
Suture dehiscence and subsequent fistula devel-
opment are possible. These complications can be
minimized by precise dissection, adequate tissue
purchases, and reduced tension on apposed
tissues. Fistula recurrence may result in failure to
conceive due to endometritis, pneumovagina, or
continued fecal contamination of the vaginal
lumen. Urovagina may be a consequence of the
Rectovaginal Fistula Repair 243
mare's natural perineal conformation or the result
of altering the perineal conformation during a
rectovaginal fistula repair, and may be addressed
with a urethroplasty procedure.' Mares should be
monitored closely during subsequent foalings
because fibrous tissue may reduce the elasticity of
the birth canal and predispose the mare to addi-
tional birthing trauma.
s
As the sutures are pro-
gressively placed in the caudal tissues, care must
be taken to avoid narrowing of the rectal lumen,
which will predispose the mare to tenesmus and
const ipation.
REFERENCES
1. Adams S, Benker F, Brandenburg T: Direct rec-
tovestibular fistula repair in five mares, Proc Am
Assoc Equine Pmct 42:156,1996.
2. Schonfelder AM, Sobiraj A: A vaginal mucosal
pedicle flap technique for repair of rectovaginal
fistula in mares, Vet Surg 33:517, 2004.
3. Aanes WA: Surgical management of foaling
injuries, Vet eli" N Am Equine Pract 4:417, 1988.
4. Beard W: Standing urogenital surgery, Vet Clin N
Am Equine Pract 7:669,1991.
5. Huber MJ: Modified technique for single stage rec-
tovestibular fistula closure in three mares, Equine
Vet J 30:82, 1998.
6. Schofield WL: Surgical repair of rectovaginallacer-
ations and fistulae in 20 mares, Irish Vet J 51 :468,
1998.
7. Klug E, Almdida-Sampaio AlS, Aupperle H: Repair
of the rectovaginal fistula in the mare a new sur-
gical approach, Pferdeheilktmde 17:600,2001.
8. Colbern GT, Aanes WA, Stashak TS: Surgical man-
agement of perineal lacerations and rectovestibular
fi stulae in the mare: a retrospective study of 47
cases, J Am Vet Med Assoc 186:265, 1985.
9. Belknap lK, Nickels FA: A one-stage repair of third-
degree perineal lacerations and rectovestibular fis-
tulae in 17 mares, Vet Slirg 21:378, 1992.
10. Hilbert J: Surgical repair of recto-vaginal fistulae in
mares, Aust Vet J 57:85, 1981.
IMITED BDOMINAL
URGERIES
245
CHAPTER 44
Inguinal Herniorrhaphy
David A. Wilson
INDICATIONS
Repair of congenital inguinal hernias is indicated
for hernias that have not resolved by 3 to 6 months
of age, for hernias that are gradually increasing in
size, or in cases in which owners request elective
repair.' -4 Foals with large herni as that have rup-
tured into the subcutaneous space or exhibit
clinical signs of abdominal pain should not be
repaired in the field because of the difficulty in
reducing these hernias and the potential need for
abdominal exploration.
EQUIPMENT
No special equipment is requi red.
PREPARATION AND POSITIONING
The horse is placed under general anesthesia and
positioned in dorsal recumbency. Preoperative
administration of antibiotics (e.g., penicillin and
gentamicin) and nonsteroidal antiinflammatory
agents are recommended. The caudoventral ab-
domen is clipped and prepared for aseptic
surgery, with care taken to not damage or irritate
the sensitive inguinal skin. Aggressive scrubbing
and the use of alcohol should be avoided. Sterile
saline should be used to ensure complete removal
of any surgical soap. If there is any concern that
the reduction may be prolonged, the bladder
should be catheterized to minimize urine conta-
mination of the surgery site.
246
ANATOMY
The primary structures involved in congenital
inguinal hernia repair are the superficial and deep
inguinal rings, the inguinal canal , the vaginal
tunic and vaginal ring, the testicles, and the in-
testine within the hernial sac. The superficial
inguinal ring is formed by a slit in the aponeuro-
sis of the external abdominal oblique. Its lateral
border continues as the femoral fascia, which is
the medial fascia of the thigh. The deep inguinal
ring is formed by the internal abdominal oblique
muscle and arcus inguinalis (inguinal ligament).
The inguinal canal is a potential space between the
deep and superficial inguinal rings. The vaginal
tunic is an evagination of peritoneum that encases
the testicle and spermatic cord. The vaginal ring,
a transition between the peritoneum and the
vaginal tunic, is a thickened ring that plays the role
of a limiting barrier against indirect herniation.
PROCEDURE
Congenital inguinal hernias in the foal are gener-
ally classified as indirect inguinal hernias in that
the intestines pass through an intact vaginal ring
and are usually contained within the vaginal canal
and cavity (the virtual space between the parietal
and visceral layers of the vaginal tunic) (Figure
44-1 ). The approach is directly over the affected
inguinal canal. A 10-cm incision is made centered
over the superficial inguinal ring, starting at its
cranial margi n and extending caudal to the
Small
Testicle

Figure 44-1 Indirect inguinal hernia viewed from
the abdomen, and skin cut away from scrotum showing
intestine and testicle within the scrotum.
scrotum. Intestine is typically noted within the
vaginal tunic. Occasionally, the parietal vaginal
tunic or peritoneum in the region of the vaginal
ring tears and the intestine is directly under the
skin. Ruptures of the tunic or peritoneum can be
very large and are an indication that surgical
repair is indicated (Figure 44-2). The skin of very
young foals is thin. Stretching and thinning of the
skin can lead to blood supply disruption, ischemic
necrosis, and subsequent sloughing of the skin.
If the vaginal tunic is intact, a combination of
blunt and sharp dissection is used to free the tunic
and internal spermatic fascia from the external
spermatic fascia. The vaginal tunic and testicle are
twisted in order to "milk" the intestine back into
the abdominal cavity (Figure 44-3). A transfixa-
tion suture is then placed. while maintaining the
twist, within the inguinal canal. The testicle and
tunics are then emasculated distal to the ligature.
For ruptures of the vaginal tunic, the tear is
identified and the intestines are replaced into the

abdomen. "Last-out, first-in" is the guideline for
feeding the loops of bowel back in the abdomen.
This may require enlargement of the vaginal ring
depending on the condition of the intestine. Care
should be taken to not inadvertently disrupt the
delicate intestinal mesentery. The testicle and
tunic are then emasculated in a routine manner.
Inguinal Herniorrhaphy 247
Vaginal tunic
and testicle
Figure 44-2 Direct inguinal hernia showing in-
testines outside the abdomen next to the vaginal tunic
containing the testicle.
__ . -
Figure 44-3 For indirect inguinal hernias. the
vaginal tunic can be tvvisted, starting at the testicle and
tvvisting the vaginal tunic to force the intestines into the
abdomen.
The superficial inguinal ring is then closed
with preplaced absorbable sutures (Figure 44-4) .
A simple interrupted or cruciate pattern using No.
1 or No.2 absorbable monofilament suture mate-
rial is recommended for closure of the superficial
inguinal ring. Use of a blunt-point hernia needle
(The Torrington Company, Torrington, Conn.)
reduces the risk of inadvertently penetrating the
large vessels in the surgical field. The sutures
248 L I MITED ABDOMINAL SURGERIES
~ t . . . . , t - ... ~ . ~ -
Figure 44-4 Prep laced sutures in the superfici al
inguinal ring to close inguinal hernia.
should be placed at varying distances from the
edges of the ring to avoid creating excessive
tension in one fascial plane. The subcutaneous
tissues and skin may then be closed with
absorbabl e sutures. Passive drains may be consid-
ered in the presence oflarge dead spaces. Alterna-
tively, the subcutaneous tissues and skin may be
left open to heal by second intention, particularly
in cases with extensive preoperative subcutaneous
dissection, a large amount of dead space, or com-
promised integrity of the overlying skin.
POSTOPERATIVE CARE
Postoperative Care
Exercise Restrictions: The foal should be
rested in a stall or small paddock for at least 2
weeks prior to returning to unrestricted pasture
turnout or turnout with other foals.
Medications: Broad-spedrum antibiotics and non-
steroidal antiinflammatory agents are generally not
necessary. However, the presence of complicating
fadors may alter this decision. Tetanus prophylaxis
should be current. In most cases, adequate antibod-
ies to tetanus will be achieved by passive transfer via
colostrum from an appropriately vaccinated mare.
other: If placed, drains should be removed within
2 days. Drainage from the drains or from the sui>-
cutaneous tissues of open incisions rnay cause
scalding of the skin between the legs. The skin
surrounding the incision and between the legs
should be coated with petroleum jelly to minimize
this scalding.
EXPECTED OUTCOME
Edema of the incision site and prepuce may be
extensive but generally resolves with conservative
therapy. In uncomplicated and elective cases, re-
covery is usually st raightforward and uneventful.
COMPLICATIONS
The prevalence of complications is low. Seroma
formation is probably the most common compli -
cation.
s
Failure to resect devitalized bowel is prob-
ably the most serious complication.
6
This can be
avoided by careful evaluation of the intestine with
or without exploratory celiotomy to evaluate the
intestines. In neonates, exploratory celiotomy has
the added advantage of being able to remove the
umbilical remnants to reduce the incidence of
septicemia. If there is preoperative concern about
the systemic health of the foal, the viability of the
intestine, or the anticipated length or difficulty of
the procedure, the repair should be performed at
an equine surgical facility, where potential com-
plications can be readily addressed.
Uncommon complications include incisional
infections, wound dehiscence with evisceration,
intestinal prolapse, paralytic ileus, bronchopneu-
monia, abdominal adhesions, peritonitis, and
colic. In an unpublished review of inguinal hernia
repair by the author, the incidence of complica-
tions following repair was 13% (4 of 31 cases). [n
the only published report identified, the survival
rate following inguinal herniorrhaphy was only
50%.'
ALTERNATIVE PROCEDURES
Laparoscopic techniques have been developed to
repair readily reducible inguinal hernias and pos-
sibly salvage the affected testicle.' "
COMMENTS
Congenital inguinal hernias occur primarily in
mal es. Most resolve spontaneously by 3 to 6
months of age. The cause of congenital inguinal
hernias is unknown. but a hereditary predisposi-
ti on may exist and it is generally agreed that cas-
tration should accompany the hernia repai r.
Development of the hernia is likely related to
increased abdominal pressure and large vaginal
rings. In the perinatal period the vaginal rings are
large to allow the testicles to descend into the
scrotum, but normally contract to less than 2 em
during the first 2 weeks of life. Increased abdomi-
nal pressure during parturition may force the
small intestines into the inguinal canal or scrotum
as the foal passes through the birth canal. Strain-
ing to pass meconium may also increase abdomi-
nal pressure and increase the likelihood for
intestines to pass into the inguinal canal. Occa-
sionally. the parietal vagi nal tunic or the peri -
toneum in the vagi nal ring region tears, and the
intestines migrate subcutaneously under the skin.
Individual intestinal loops may be seen under the
skin.
Foals with inguinal hernia(s) generally present
with non pai nful swelli ng or enlargement of the
scrotum or inguinal region. Usually the hernias
are reducible, do not cause any clinical signs such
as colic, and resolve within a few days to a few
months. Conservative therapy including daily
monitoring and fr equent reduction of the hernia
is recommended until the vaginal rings close
down and the hernia resolves. There is some
concern that foals treated conservatively for
inguinal hernias may be predisposed to evisce-
ration following castrat ion. Therefore, owners
should be aware of this potential complication
and instructed to inform their veterinarian at the
time of cast ration. Additionally, the presence of a
Inguinal Herniorrhaphy 249
congenital inguinal hernia should be recorded in
the medical record to remind the veterinarian of
this potential compl ication.
REFERENCES
I. Spurlock GH, Robertson JT: Congenital ingui nal
hernias associated with a rent in the common
vaginal tunic in five foals, J Am Vet Med Assoc
193:1087,1988.
2. Hance SR, DeBowes RM, Clem MF, et al: Umbilical,
inguinal, and ventral hernias in horses, Comp Cont
Educ Pmct Vet 12:862, 1990.
3. Gaughan EM: Inguinal hernias in horses, Comp Cont
Edllc Pract Vet 20:1057, 1998.
4. Dietz 0, Richter W: Etiology, earl y symptoms and
treatment of equine inguinal hernia. Praktische
Tierarzt 83:712, 2002.
5. Adams SB, Fessler JF: Neonatal inguinal herniorrha-
phy. [n Adams SB, Fessler JF, editors: Atlas of equine
SLlrgery, Philadelphia, 2000, WB Saunders.
6. van der Velden MA: Ruptured inguinal hernia in
new born colt foals: a review of 51 cases, Equine Vet
J 20: 178,1988.
7. Klohnen A, Wilson DG: Laparoscopic repair of
scrotal hernia in 2 foals, Vet Surg 25:414, 1996.
8. Marien T, van Hoeck F, Adriaenssen A, et al: Laparo-
scopic testis-sparing herni orrhaphy: a new approach
for congenital inguinal hernia repair in the foa l,
Equine Vet Educ 13:32, 200 I.
9. Boure LP: Laparoscopic surgical techniques in foa ls,
Proc ACVS Vet Symp 13:31,2003.
CHAPTER 45
Umbilical Herniorrhaphy
David A. Wilson
INDICATIONS
Uncomplicated congenital umbilical hernias that
have persisted until 5 to 6 months of age) gradu-
ally enlarged over time, or failed to respond
to conservative therapy,l Complications may
develop in congenital umbilical hernias, which
can significantly increase the complexity and
expense of repair. One report has shown a com-
plication rate of 8.8%.2 Hernia repair before these
complications develop is desirable.
EQUIPMENT
No special equipment is required fo r surgical
repair of umbilical hernias.
PREPARATION AND POSITIONING
The surgery is performed with the horse under
general anesthesia in dorsal recumbency. The
ventral abdomen is clipped, prepared, and draped
for aseptic surgery. In males, the bladder may be
catheterized in males and the prepuce closed with
towel clamps or suture to minimize urine conta-
mination of the surgery site.
ANATOMY
An umbilical hernia consists of a midline defect
in the body wall and an outpouehing of the skin
250
with a peritoneal lining (hernial sac). The hernial
sac generally contains small intestine.
PROCEDURE
Closed Herniorrhaphy
An approximately lO-em fusiform incision is cen-
tered over the umbilicus. Generally) intestine will
be palpable within the hernial sac and the hernia
can be readily reduced. The incision is continued
through the subcutaneous tissue with care taken
to not penetrate the hernial sac. The skin and sub-
cutaneous tissues are dissected from the hernial
sac (Figure 45-1). At the attachment of the
umbilicus, the hernial sac can be very thin and is
easily penetrated. 1f the sac is penetrated, the
defect in the sac is closed with No. 2-0 absorbable
suture material.
The hernial sac is then inverted into the
abdomen (Figure 45-2). Absorbable sutures (No.
I or No.2 depending on the size of the foal) are
placed in the fi brous hernial ring, with care taken
to not incorporate intestine into the suture line
(Figures 45-3 and 45-4). The specific suture
pattern for closure of the hernial ring is left to the
discretion of the surgeon. Simple interrupted,
cruciate, and far-near-near-far patterns are com-
monly used.
The advantages of the closed method of repair
are the relative ease of the procedure and the
reduced risk of postoperative peritonitis or evis-
ceration. Disadvantages include not being able to
thoroughly assess the contents of the hernial sac,
Umbilical Herniorrhaphy 251
A
B
Figure 1 A, Sharp dissection of skin from hernial sac. S, The hernial sac and overlying skin are held before
removal of skin from sac.
__
Figure 45-2 After removal of skin from the hernial
sac and before closure, the sac is inverted into the
abdomen.
Figure 45-1 The fi rst bite of closure inserts the
needle into the edge of the fibrous hernial ring and
inverted hernial sac.

Figure 45-4 The hernial sac is inverted into the
abdomen and the thickened fibrous ring (arrow) is
closed.
the potential for incorporation of intestine in the
sutllre line, and, in large hernial sacs (larger than
a tennis ball). the potential for ischemic necrosis
of the hernial sac and subsequent aseptic peri-
tonitis. The closed technique is indicated for
repair of most uncomplicated hernias.
Open Herniorrhaphy
The approach for the open technique is similar
to the closed technique until the hernial sac is
252 LIMITED ABDOMI NAL SURGERIES
exposed. At this point, the hernial sac is resected
to the level of the fibrous ring of the hernia.
Careful palpation of the hernial ring will identify
a thinned triangular area on the cranial and
caudal borders of the ring with the fibrous por-
tions of the linea alba in a fusiform shape (Figure
45-5). The tissue within this triangular area may
be removed.
Closure of the abdominal wall consists of
appositional absorbable sutures (No.1 or No.2
depending on the size of the foal). The suture pat-
terns are similar to those recommended for the
closed technique. The vest-over-pants or Mayo
mattress suture pattern is not recommended
because the pattern tends to excessively focus or
increase the tension of the suture line rather than
simply closing the space between the fibrous por-
tions of the herni al ring.3
The only significant advantage of the open
technique is the ability to assess the contents of
the hernial sac. The disadvantages of the open
technique are the slightly increased risk of post-
operative evisceration) abdominal adhesions, and
,
,
Palpable border
of defect in linea alba
,

,- Hernial sac

A
Figure 4 5 ~ 5 A, Careful palpation of the hernial ring
will identify a thinned triangular area on the cranial and
caudal borders of the ring with the fibrous portions of
the linea alba in a fusiform shape. B, The tissue within
this triangular area (black arrow) may be removed along
with the fibrous tissue forming the base of the triangle
(white arrow), in an open herniorrhaphy, Dotted line
indicates the line of incision,
peritonitis. The open technique is indicated for
repair of large hernias) irreducible hernias, or
hernias complicated by enterocutaneous fistula.
The subcutaneous tissue and skin are closed
similarly for both open and closed techniques.
The suture material and patterns are left to the
surgeon's preference. We use No. 2-0 polydiox-
anone, polyglactin 910, or poli glecaprone. A sub-
cuticular layer in the skin rather than traditional
skin closure or the use of absorbable sutures in the
skin eliminates the need for suture removal.
POSTOPERATIVE CARE
Postoperative Care
Exercise Restridions: The foal should be
rested in a stall or small paddock for at least 4
weeks prior to returning to unrestricted pasture
turnout or turnout with other foals. The incision
line should be palpated and examined for ade-
quate healing before unrestricted exercise is
allowed.
Medications: If the procedure is uncomplicated,
only preoperative antibiotics and anti-inflammatory
agents are indicated. Tetanus prophylaxis should
be current.
Suture Removal: Nonabsorbable sutures should
be removed in 10 to 14 days.
EXPECTED OUTCOME
If the margins of the body wall defect are carefully
identified during surgery and adequate ti ssue
bites are obtained using strong nonreactive suture
material, closed and open herni a repairs have a
high success rate. Mild periincisional edema is
common during the first postoperative week.
COMPLICATIONS
Reported complication rates for either surgical
hernia repai r or the clamp technique have been
reported to be between 7% and 19%. 4,5 Seroma
formation is probably the most common compli-
cation associated with both surgical techniques
and generally occurs as a result of inadequate
closure of subcutaneous dead space. Hematomas
may also occur if inadequate hemostasis occurred
during surgery. Generally, hematomas and
seromas regress on their own and require no
,
I
\
specific therapy. However, seroma and hematoma
formation may progress to subcutaneous infec-
tion, which can be determined by the presence of
focal tenderness, persistent inflammation, and
moisture or discharge at the suture sites. Sub-
cutaneous infections are treated with warm com-
presses and systemic antibiotic therapy. If not
resolved by 10 to 14 days postsurgery, ultrasonog-
raphy may be used to identify subcutaneous
abscesses and needle aspiration or lancing of the
abscesses considered. Uncommon complications
associated with the open technique include evis-
ceration, abdominal adhesions, and peritonitis.
ALTERNATIVE PROCEDURES
The advantages of hernial clamping or the appli-
cation of elastrator rings have been reported to be
ease of application and cost. 1,5,6 The primary dis-
advantage of hernial clamping is the risk of incor-
porating gut into the clamp and inadequate
fibrosis of the abdominal wall defect. The proce-
dure should be done under general anesthesia
with the foal in dorsal recumbency. Clamping is
recommended only for hernias that are uncom-
plicated, easily reducible, and less than 8 em in
length. Additionally, the hernial sac should be
easily palpable to ensure there are no contents
within the sac when applying the clamp. Some
surgeons believe that clamping is easier in females
than in males as the prepuce can get in the way
in males. In males, the smallest possible clamp
should be selected and carefully padded to prevent
injury to the foal's sheath.'
COMMENTS
Umbilical hernias are a common congenital defect
in young horses. Females are twice as likely as
males to have the defect.7 Many hernias are small
and will resolve with time or with more c o n s e r ~
vative measures such as manual daily reduction,
the application of a truss, or umbilical clamps.l
Umbilical hernias generally require surgery if they
persist until 5 to 6 months of age, if they gradu-
ally enlarge over time, or if they fail to respond to
conservative therapy. Most hernias are uncompli-
cated and reducible. Some (8% to 10%) sustain
complications that are life threatening and
Umbilical Herniorrhaphy 253
mandate emergency surgery. 2,8,9 Hernias that
suddenly increase in size, become edematous
or painful, or are associated with depression or
colic warrant urgent clinical evaluation and
exploratory surgery. Hernias that exhibit these
signs are not amenable to field surgery, and the
horse should be referred to an appropriate surgi-
cal facility. Careful evaluation of the umbilical
masses by palpation and ultrasonography will
help to differentiate complicated umbilical
hernias from the uncomplicated, reducible
hernias.
The goals of surgical repair of an umbilical
hernia are obliteration of the hernial sac and
repair of the defect in the abdominal wall. Alter-
natives to surgical repair of hernias include the
application of hernial clamps or elastrator rings
and the injection of irritating substances around
the base of the hernial sac. These alternatives are
usually successful in obliterating the hernial sac
but do not directly repair the defect in the abdom-
inal wall.
REFERENCES
1. Adams SB, Fessler 1F: Umbilical herniorrhaphy. In
Adams S8, Fessler JF, editors: Atlas of equine surgery,
Phil adelphia, 2000, WB Saunders.
2. Freeman DE, Orsini 1A, Harrison TW, et al: Compli-
cations of umbilical hernias in horses: 13 cases
(1972- 1986), JAm Vet Med Assoc 192:804,1988.
3. Orsini JA: Management of umbilical hernias in the
horse: treatment options and potential complica-
tions, Eqllil1e Vet Educ 9:7,1997.
4. Wilson DA, Baker G1, Boero MJ: Complications of
celiotomy incisions in horses, Vet SlIrg 24:506, 1995.
5. Riley CB, Cruz AM, Bailey ]V, et al: Comparison of
herniorrhaphy versus clamping of umbilical hernias
in horses: a retrospective study of 93 cases (1982-
1994), Can Vet J 37:295, 1996.
6. Greenwood RES, Dugdale OJ: Treatment of umbili-
cal hernias in foals with elastrator rings, Equine Vet
Educ 5: 113, 1993.
7. Freeman DE. Spencer PA: Evaluation of age, breed,
and gender as risk factors for umbilical hernia in
horses of a hospital population, Am J Vet Res 52:637,
1991.
8. Steckel RR, Nugent MA: Parietal hernia in a horse,
] Am Vet Med Assac 182:818, 1983.
9. Markel MD, Pascoe JR, Sams AE: Strangulated
umbilical hernias in horses: 13 cases ( 1974-1985),
] Am Vet Med Assoc 190:692, 1987.
INDEX
2-0 monofilament nonabsorbable sutures, 162
2-0 PDS, usage, 144
3-0 nonabsorbable monofilament suture material, 52,
162. See also Simple-interrupted 3-0
monofil ament non absorbable sutures
4.S-mm cortical bone screw, dorsopal mar radiograph.
See Carpus
IS-gauge orthopedic wire, usage, 5 1-52, 51 f
20-gauge I-inch catheter, 55
placement. See Palmar vein
22-gauge I-inch catheter, 55
placement. See Palmar vein
3D-em ventral midline incision, 158f
30-Pr Foley catheter, placement, 223, 225
60-mL syringe, usage, 21£
A
Aanes technique. See Third-degree perineal laceration

repair
Abcessation. See P3
Abdominal cryptorchid, 198f. See also Incomplete
abdominal cryptorchids
Abdominal retention, 197f
Abdominal testicle
exteriorization, 198f
removal, modified para inguinal approach, 199f
Abduction, prevention. See Limbs
Acepromazine, usage, 30-31, 35t
Acrylic hoof material, usage. See Toe
Adhesives. See Tissue
Adson forceps, 7f. See also Browll-Adson forceps
Albuginea, 207f
Allis forceps, 8f
Allis tissue forceps
schematic,l72f
usage. See Soft palate
Alpha
2
agonists (a ragonists), 30-32
advantage, 31-32
dissociative combinations, 35-36
dissociative-guaifenesin combinations, 36
Aminoglycosides, administration, 25
Analgesia. See Epidural analgesia
Anal sphincter
dilation, umbilical tape (usage), 237f
ventral surface, horizontal dissection, 239f
Anesthesia. See Epidural anesthesia; Field anesthesia;
Injectable general anesthesia
induction/recovery. See Injectable field anesthesia
Page numbers followed by t indicate table; f, figure.
255
Anesthetic depth, 37
Anesthetics. See Injectable anesthetics
Angiotribe forceps, 157
Angular limb deformity, 50, 52
differential diagnoses, 53
origin, 54
Annular ligament
constriction. See Palmar annular ligament
incision. See Proximal annular ligament
proximal border, incision, 69f
transection, 69f
scissors, usage, 70f
Annular ligament desmotomy
anatomy, 67
bandaging,'lO
complications,70-7l
equipment, usage, 67
exercise restriction, 70
indications, 67
intrasynovial medications, 70
medications, 70
outcome, expectation, 70
positioning, 67
postoperative care, 70
preparation, 67
procedure, 67 -68
al ternatives, 71
closed technique, 67-68
open technique, 67
references, 71
suture removal, 70
Antebrachial fascia, perforation, 88f
Antibiotics, usage. See Distal li mb perfusion
Antiseptics, usage. See Skin preparation
Arcus inguinal is, 183f
Army-Navy retractor, 9f
Articular cartil age atrophy, degree, 118
B
Balfour self-retai ning retractor, 222, 236
Bandage cast, 116-117
splitting, 117f
usage, 116-117, 117f
Bandages
application, 28f. See also Tension suture
change, 11 7f
material, casting material (placement),
117f
usage. See Robert Jones bandage
Bandage scissors. See Lister bandage scissors
design, 5-6

256 I NDEX
Bandaging
equipment, 25f
indication, 118
Bard-Parker blade. See No. 10 Bard-Parker
blade
Bard Parker handle, No. JO blade (usage), 76
Bard-Parker No.4 handle, 6£
Basi lhyoid bone, 148f, 158f
lingual process, 148f
Battery-operated headlight, inclusion, lOb
Belpharospasm, 173
Bemis technique. See Rectovaginal fistula repair
Bent table knives, usefulness, 99f
Benzodiazepines, 32
Betadine surgical scr ub, 4
Bilateral fractures. See Interdental space
Biomechanical forces, 25f
Bishop-Harmon tissue forceps, 170, 171
Bistoury knife
No. 10 blade, usage, 76
passage, 68, 69f
usage, lOS£. See also Medial patellar ligament
transecti on
Black's method. See Neurectomy
Black's technique, 110
Blades. See Scalpel blades
Bleeding, control, 95
Blepharoplasty. See Hotz-Celsus blepharoplasty
Blunt dissection, usage, 172
Blunt-tipped bistoury. usage. 104
Body reconstruction. See Perineal body
reconstruction
Bolsters
incl usion. See Verti cal mattress sutures
usage. See Tension suture
Bone
amputation. See Spl int bone
diaphysis. 51
fracture, risk (increase). See Deep navicular bone
fr acture
lateral hemicircumference, 47f
rasp. usage, 95f
resection. See Distal splint bone resection
sequestrati on, 125
Bony orbit, schematic. 171 f
Bradycardia, 31
Breakage. result. 119
Breeding stitch
addition. See Caslick suture li ne
ventrality. avoidance. 217
Bridging. See Transphyseal bridging
Broad-spectrum antibiotics, 25
Brown-Adson fo rceps. 7£
Brown-Adson thumb forceps, inclusion, lOb
Brown technique. See Urethral extension
Bulbospongiosus muscl e, 207f, 212f
Bupivacaine. usage. 40
Butorphanol
administration, 35
Butorphanol (Contirmed)
sedation, 34
usage, 24, 35t
(
Canaliculus, lacerated ends (alignment), 166
Canines
notch, presence, 124f
presence, 125£
usage, 124f
Cannulated 4-mm screw, wing nut/adapter (welding),
56f
Cannulated screw, usage, 57, 58f
Carbon dioxide laser, usage, 147
Carmalt forceps. inclusion. lOb
Carotid artery, 140f
Carpus, 4.5-mm corti cal bone screw (dorsopal mar
radiograph), 53f
Car tilaginous ulna, presence, 47f
Caslick's procedure (vulvoplasty). See Urethroplasty
techniques
comments, 217-2 18
complications, 217
difficulty, 216
equipment, usage, 216
indications, 216
medications, 217
outcome. expectation, 217
performing, 22lf, 233f
positioning, 216
postoperative care, 217
preparation, 216
procedure, 216-217
references, 218
suture removal, 217
Caslick suture line, breeding stitch (addition), 2I7f
Cast application, 113-117
acrylic, application, 116f
bandagi ng, 117
comments, 11 9-120
complications, 11 8-119
equipment, usage, 113
exercise restrictions, 117
indications, 113
limb position ing/handling, 113
positioning, 113
postoperative care, 117- 118
preparation, 113
procedure, alternatives, 119
references, 120
supplies, 114£
Casting mater ial, placement. See Bandages
Casting tape, partial roll, Iisf
Cast layers
separate curing, 114f
simultaneous cur ing, 114f
Cast material
application, 114-115
handli ng, 114
Cast proximal limit, orthopedic felt (application)
I 14f
Castration. See Cryptorchid castration
anatomy, 184
closed technique, 184- 185
technique, 184f
colic, complication, 192
comments, 193- 194
complications, 189- 192
cranial inguinal approach, 193
emasculators, application. See Closed castration
equipment. usage, 182
exercise restricti ons, ] 88
exteriorization, maintenance. See Modified closed
castration
hemorrhage (excess), complication, 190
hydrocele
complication, 192
formation. See Postcastration
indications, 182
infecti on, complication, 190
intestinal eventration, complication, 191
medications, 188
modified closed technique, 184
performing, l8Sf
omental prolapse, complication, 190-191
open technique, 185
performing, 187f
outcome, expectation, 189
penile damage, complication, 192
peritonitis, complication, 190
persistent stallion-like behavior, complication, 191-
192
positioning, 182-183
postoperati ve care, 188
preparation, 182-183
primary closure, 193
procedure, 184-188
alternatives, 192-193
references, 194- 195
special circumstances, 185- 188
swelling, complication, 189
techniques. See Half-cl osed castration techniques
Cast removal, oscill ating saw (usage), 1I 8f
Casts. See Bandage cast; Distal limb; Foot cast; Half
limb cast
monitorin g, 118
removal , 117-118
Cast sores. See Fetlock
Catheter
placement. See Dorsal punctum
recommendation, 36
removal. See Urethral extension
suture. See Nasolacrimal catheter
usage. See Sesamoid bones
Caudal epidural injection, needle placement, 39f
Caudal maxillary sinus, 128f, 129f
communication, 128
trephination, 135f
Caudal penis, 207f
Cefazolin, 25
Index 257
Celiotomy, advantage. See Exploratory celiotomy
Cephalic vein, 87
Cervical region (C1), transverse section, 140f
Check ligament. See Distal check ligament
desmotomy. See Distal check ligament desmotomy;
Proximal check ligament desmotomy
ends, gap formation, 83f
exteriorization, curved forceps (usage), 83f
Cheek, drill positioning, 124f
Cheek teeth
lateral view. See Mandi bular cheek teeth; Maxillary
cheek teeth
orientation, 136
tension band wire, insertion, 124f
Chromic catgut, characteristics, 14t
Chronic distal limb infection, 56f
Circumcision
anatomy, 202
complications, 205
equipment, usage, 202
exercise restrictions, 204
indications, 202
medications, 204
multiple-layer closure, 204f
outcome, expectation, 204-205
positioning, 202
postoperative care, 204
preparation, 202
procedure, 202-204
al ternatives, 205
cl osure, intraoperative view, 204f
references, 205
suture removal, 204
Client communication, 3
Clipper blades (size 40), 4
Closed castration, emasculators (application), 185f
Closed herniorrhaphy, 250-251
Closed technique. See Annular ligament desmotomy;
Castration
Coffin joint
hyperextension, 62£
region (perfus ion), intraosseous screw placement,
58f
Cold (chemical) sterilization, usage, 10
Colic, complication. See Castration
Collateral ligament, 51
Collum glandis, 203f
Communicating branch, 82f
ligation/transection, S8f
Compound locking loop. See Modified compound
locking loop
Conchofrontal sinus, 128f, 129£
Congenital entropion, 173
Conj unctiva, grasping, 171
Connell pattern, usage, 223f, 229. See also Cranial
junctions; No. 0 absorbable suture; Vagi nal
mucosa; Ventral mucosal layer
258 I NDEX
Conti nuous horizontal mattress suture pattern, ISf
Contralateral limb
bandaging/elevation,IISf
support, 65
Corneal pain, 173
Corona glandis, 203f
Corpus cavernosum
blood loss, 208
compression, 208f
initial suture, intraoperative view, 209f
Corpus cavernosum penis, 207f
bleeding, source, 213
Corpus spongiosum penis. 207f
incision, 207
Cor rective shoeing, 85
Corrective trimming, 85. See also Distal check
ligament desmotomy
Counterirritants, injections, 78
Cranial ingui nal approach. See Castration
Cranial junctions, Connell pattern (usage), 226£
Cranial penis. 207f
Crescent-shaped skin. removal (schematic), 174£
Cribbing, modified ForsseU's operation
anatomy, 157
complications, 159
drain removal, 159
equipment, usage, 157
exercise rest riction, 159
indications, 157
medications, 159
outcome, expectation, 159-160
positioning, 157
postoperative care, 159
preparation, 157
procedure, 157-158
alternatives, 160
references, 160
stent removal, 159
suture removal , 159
Cricoid cartilage. 148f
Cricothyroid membrane, 148f
incision, 152f
laryngeal ventricle, relation, 15lf
Crile forceps, 7f
Cross- clamping, usage, 148- 149
Cryptorch id cast rati on
anatomy, 196
comments, 20 I
compl ications, 200
equipment, usage, 196
exercise restrictions, 200
indications, 196
medications, 200
modified paraingui nal approach, 199-200
noninvasive ingui nal approach, 197-199
outcome, expectation, 200
positioning, 196
postoperative care, 200
Cryptorchid castration (Continued)
preparation, 196
procedure, 196-200
alternatives, 200-201
references, 201
Cryptorchid testicle, removal, 196
Curved forceps, usage, 8. See also Check ligament
Curved Mayo scissors, 7f
inclusion, lOb
Curved Metzenbaum scissors, 7f
inclusion, 1 Db
usage, 171
Curved sponge forceps, usage, 151
Curvilinear incision. See Left distal radial physis
Cushing pattern, 73
usage, 230f
Cutaneous colli muscles, 139f
removal, 148f
Cutaneous colli tissues, 143
D
DDFT. See Deep digital flexor tendon
DDSP. See Soft palate
Dead space. usage, 20
Debrided mucosal edges (apposition), simple
continuous pattern, 225f
Deep digital flexor tendon (DDFT), 80, 82f
3-cl11 incision, 99, 107
abaxial border, 107
contract ure, 84f, 98. See also Left fo relimb
improvement, 84
mi ldness, 85
cross-sectional anatomy, 99f
heads, 99
intersection. identification. See Distal check
ligament
isolation, 99f, 100f
laceration, 62f
Kimzey splint support. 63f
lateral border, 110
radial head, 88
muscle beliy, visual ization, 89f
severe contracture, 98f
t ransection, 99f, 10 I f
Deep digital flexor tenotomy
anatomy, 99
bandaging, 100
commen ts, 101
compl ications, 101
equipment, usage, 98
exercise restrictions, 100
incision location, IOOf
indications, 98
medications, 100
outcome, expectation, 10 1
positioning, 98
postoperat ive care. 100
preparation, 98
,
,
Deep digital flexor tenotomy (Continued)
procedure, 99-100
alternatives, 101
references, 101-102
suture removal, 100
Deep inguinal r ing. sweeping (schematic view), 199£
Deep navicular bone fracture, risk (increase), l09f
Delayed primary closure, 13
Delayed secondary closure. 13
Dental punch, position, 135f
Desmoplasty, 71
Desmotomy. See Annular ligament desmotomy;
Medial patellar ligament desmotomy
Detomidine
doses, 35
sedation, 34
usage. 24, 35t, 36
Diagnostic trephination, 129
Diaphyseal fracture. See Section 3 diaphyseal fracture
Diaphyseal radial fracture, 27
Dietary modification. See Distal check ligament
desmotomy
Digital cushion, fascia, 108f
Digital extensor retinaculum, 73f
Digital extensor tenectomy. See Lateral digitaJ extensor
tenectomy
Digital extensor transection. See Long digital extensor
tendon transection
Digital flexor tendon
laceration. See Deep digital flexor tendon laceration
partial laceration. See Superficial digital flexor
tendon
Digital flexor tenotomy. See Deep digital flexor
tenotomy
Digital neurectomy. See Palmar-plantar digital
neurectomy
Digital sheath
entrance, skin incision (usage), 69f
proximal border, incision, 69f
Diode laser, usage, 147, 153, 157
Direct repair. See Rectovaginal fistula repair
Dissociative combinations. See Alpha
2
agonists
Dissociative-guaifenesin combinations. See Alpha2
agonists
Distal attachment, spl int bone (freeing), 94f
Distal check ligament
anatomy, 82f
DDFT intersection. identification. 83f
transection, 83f
Distal check ligament desmotomy
anatomy, 80
bandaging, 84
comments. 85
complications, 84-85
corrective trimmi ng. 84
dietary modification. 84
equipment, usage. 80
exercise restrictions, 84
Index
Distal check ligament desmotomy (Continued)
indications, 80
medications, 84
outcome, expectation, 84
positioning, 80
postoperative care, 84
preparation, 80
procedure. 80, 83
alternative, 85
references. 85
skin incision. location, 82f
suture removal, 84
Distal incision site, 73f
Distal interphalangeal joint region, 26f
Distal limb
cast, 116
application. 116f
usage, 116
extension, 77f
infection. See Chronic distal limb infection
Distal limb perfusion
anatomy, 55
antibiotics, usage, 55-56
bandaging. 57
comments, 58-59
complications. 58
equipment, usage, 55
exercise restriction, 57
exsanguination, 56-57
indications, 55
medications. 57
outcome, expectation, 57-58
positioning, 55
preparation, 55
procedure. 55-57
alternatives, 58
references, 59
suture removal , 57
Distal pastern region, palmar digital vein injection
(contrast),56f
Distal radial physis. 47f
dorsopalmar radiograph, 53f
identification, hypodermic needle (usage), 5lf
Distal splint bone anatomy, 94f
Distal splint bone fractures, 96
Distal splint bone resection
bandaging, 96
comments, 96
complications, 96
equipment, usage. 93
exercise restrictions, 96
indications, 93
medications, 96
outcome, expectation, 96
positioning, 93
preparation, 93
procedure. 93-95
alternatives, 96
259
260 INDEX
Distal splint bone resection (Cofltinued)
references, 96-97
suture removal, 96
Distal third metacar pus, 26f
Distal third metatarsus, 26f
Distal tibial epiphysis, proximal-to-distal dimension,
50
Disuse osteopenia, degree, 118
Dorsal conchal sin us, 129f
Dorsal displacement, surgical treatment options. See
Soft palate
Dorsal displacement of the soft palate. See Soft
palate
Dorsal layer, apposition (contin uous horizontal
mattress pattern, usage), 223f
Dorsally based V-shaped vaginal tissue flap, t ransverse
cross-secti on, 238f
Dorsal mucosal layer (eversion), continuous
horizontal mattress pattern (usage), 224f
Dorsal nasal concha, 129f
Dorsal nasal meatus, 129f
Dorsal-palmar splint, incorporation, 119f
Dorsal puncta, anatomy (schematic), 163f
Dorsal punctum, catheter (placement), 164f
Dorsal splint cast combin ation, usage, 26f
Dorsopalmar radiograph. See Carpus; Distal radial
physis
Double-Y incision. See Tracheal mucosa
Double-Y pattern, 144
Down testicle, castration, 182
Drains
classificati on, 21-22
removal. See Cribbing
usage, 20-21
Dr ill bit, usage, 58f
Dr ugs
combinations, 35t
usage. See Single drugs; Standing sedation
Duct tape, usage, 117f
Ductus deferens, 183f
Duragesic, 33
E
Edema, formation, 189f
Eight wire, figure (placement), 51 f
Electric shock collars, usage, 160
Electrocautery, 170
Elevation. See Periosteal transection/elevation
Emasculator. See Modified White's emasculator;
Reimer emasculator; Serra emasculator
application. See Closed cast ration; Open castration;
Spermatic cord
Endoscopic transaction, 71
Entropion
anatomy, 173
complications, 174- 175
equipment, usage, 173
indications, 173
Entropion (Continued)
positioning, 173
postoperative care, 174
preparation, 173
procedure, 174
protection, 174
references, 175
suture removal, 174
Enucleation. See Transconj unctival enucleation;
Transpalpebral enucleation
Epididymis
ligament tail
cutting. See Open cast ration
disruption, 187f
long proper ligament, traction, 198f
tail, exposure, 198f
Epidural analgesia, 39-40
anatomy, 39
technique, 29-40
Epidural anesthesia, 39-40
anatomy, 39
technique, 39-40
Epidural drugs, usage, 40
Epidural injection, 39
needle placement. See Caudal epidural injection
repetition, 39-40
Epiglottis, 152f
Epinephr ine, addition, 40
Episioplasty. See Perineal body reconstruction
Epitheli um, urethral sutures (interrupted pattern),
208f
Ergot, 94f
ligament, 108f
Esmarch bandage (proximal end), pneumatic
tourniquet (application), 56f
Esophagus, 140f
Ethylene oxide, usage, 10
Euthanasia, indication, 28
Eventration. See Castration; Inguinal hernia-
eventration
Evosions, 119f
Exploratory celiotomy, advantage, 248
Exsanguination. See Distal limb perfusion
Extensor tendon lacerations, 63, 65
PVC splint support, 63f
Extensor tenectomy. See Lateral digital extensor
tenectomy
Exteriorized check ligament, intraoperati ve view, 83f
External abdominal oblique, aponeurosis
closure, 199f
incision, 199f
External inguinal ring, sutures (preplacement ), 248
External spermatic fascia, st ri pping, 184f
Extrasynovial transection, 71
Exudate, removal. See Incision site; Wounds
Eyelid
anatomy, schematic, 166f
innervation, schematic, 177f
Eyelid (Colltinued)
Lembert sutures, placement schematic, 174£

margin
figure-of-eight suture, schematic, 169f
subjunctival closure, schematic, 169f
tacking. See Temporary eyelid tacking
Eyelid laceration repair
anatomy, 168
complications, 169
equipment, usage, 168
indications, 168
medications, 169
positioning, 168
postoperative care, 169
preparation, 168
procedure, 168
protection, 169
references, 169
F
Facial crest, 127
rostral end, 129f
Facial nerve
auriculopalpebral branch, 176
CN VII paralysis-paresis, 179
Farabeuf ret ractor, 8f
Far- near-near-far suture patterns. See Modified
far-near-near- far suture pattern
Far-near-near-far tension suture patterns, 19f
Fascia, coverage, 158f
Fetlock
buckling, 62f
canal, palmar-plantar wall, 68f
contracture. See Left forelimb
hyperextension, 60, 62f
palmar aspect, cast sores, 119£
Fetotomy wires, preplacement. See Plastic-covered
fetotomy wires
Fiberglass casting
material
application, 115f
usage, 11 4f
tape, application, 11 5f
Fiberglass cast material, 26
FiberWire, 60
Fibrous tarsal plate, 179
Field anest hesia, 30
inductionlrecovery. See Injectable field anesthesia
references, 40-43
Field surgery, general pack, 9
contents, lOb
Figure-of-eight suture, schematic. See Eyelid
Finger-held retractors, 8f
Finger sponge forceps, usage, 151
Finger traction. See Tunic
First-intention healing, 13
Fistula repai r. See Rectovaginal fistula repair
Flaccid epiglottis, 151
Flexion, exaggeration. See Limbs
Flexor carpi radialis
caudal retraction, 89f
muscle, tendon sheath, 89f
Index 261
retinaculum, superficial sheet (incision), BSf
tendon sheath, superficial sheet (incision), SSf
Flexor retinacul um
closure, 88
deep sheet, 89f
superficial sheet, 89£
Flexor tendon
free cut ends, 62-63
lacerations, 64-65. See also Mid metacarpal region;
Palmar pastern region
sheath, proximal, 61f
support, IISf
Flexor tenotomy. See Deep digi tal flexor tenotomy
Fluid therapy, 37
Foam cast padding, usage, 114£
Foam padding, appl ication, 11 5f
Foley catheter, usage. See Ventral vaginal mucosa
Foot cast, JI6
usage, 11 M
Foot cysts, detection, 109
Forceps, 7f. See also Adson forceps; Allis forceps;
Brown-Adson forceps; Crile forceps; Forester
sponge-holding forceps; Grasping forceps;
Halstead mosquito forceps; Hemostatic forceps;
Kelly forceps; Thumb forceps; Tissue
inclusion. See Brown-Adson thumb forceps;
Carmalt forceps; Oschsner forceps; St raight
mosqui to forceps
passage, 69f
usage. See Check ligament; Perineural sleeve;
Vaginal ring eversion
Ford's interlocking pattern, 17f. See also Vulvar
mucosa
Forel imbs
fract ure, 26. See also Section 1 foreli mb fr acture;
Section 2 forel imb fract ure; Section 3 forel imb
fractures; Section 4 forelimb fractures
moderate SDFT contracture, 87f
SDP tendonitis. See Left forelimb
Forester sponge-holding forceps, 8f
Forssell's operation, modification. See Cribbing
Fossa gland is, 203f
Fract ure patient
comments, 29
complications, 28
emergency management, 24
references, 29
equipment, usage, 24
indications, 24
initial evaluation/treat ment, 24-28
outcome, expectation, 28-29
positioning/preparation, 24
procedures, alternatives, 29
referral, preparation, 28
262 INDEX
Frontal sinus Heel (Contil/Lled)
communication. 128
trephine sites, limits (identification), 129f
G
Gamma-aminoblltyr ic acid (GABA). 32
GABA-associated chloride channel opening, 34
receptor, 33
Gas sterilization, 10
Gauze sponges, inclusion. lOb
Gelding
hind quarters, view, 212f
per ineal urethrotomy
intra-operative view, 212f
postoperative view. 212f
Gelpi retractors, 9f
usage, 87
Gelpi self-retai ning retractors, 147
General anesthesia. See Injectable general anesthesia
Gentamicin, 25
Gerald forceps, usage, 107. See also Perineural capping
GG. See Glyceryl gllaiacolate
GKX. See Guaifenesin ketamine xylazine
Glans penis, 207f
Glyceryl guaiacolate (GG), 32
Granulation tissue formation. 145
Graspi ng forceps, 8
Groove director, passage, 69f
Guai fenesin, 32
10% solution, 32
combi nations. See Alpha2 agonists; Thiopental -
guaifenesin combinations
Guaifenesi n ketamine xylazine (GKX) combination,
36
Gubernaculum
inguinal extension, usage, 197f
testis. inguinal extension (schematic view). 197£
Guillotine technique. III
H
Half-closed castration techniques, 184
Half limb cast, 115
areas, soreness, 119f
casti ng tape, usage, 115
strength. increase, 119f
Half limb cast ing, 117f
Halstead mosquito forceps. 7f
Halstead pattern, 73
Hand-held ret ractors, 9f
Hanging drop technique, 39
Hay- net. recommendation, 28
HCG. See Human chorionic gonadotropin
Head
lateral view. 133f
lavage tube, placement. 166f
ventral view, 148f
Heel
elevation, 64. 84
acrylic, usage. See Temporary heel elevation
extension, 64
appUcation, 118f
ground contact, absence, 84f
wedge. incorporation, 115£
Hematocrit, dose-dependent decrease, 30
Hemorrhage, excess, 189f
complication. See Castration
Hemostasis, provision, 171-172
Hemostat ic forceps, 6, 8
Hemostats, usage. See Nerve ending
Hernia-eventration. See Inguinal hernia-event ration
Hernial ring, palpation, 252f
Hernial sac
abdominal inversion, 25 1 f
inversion, 250
needle, insertion, 251 f
skin dissection, 25 1 f
Herniorrhaphy. See Closed herniorrhaphy; Inguinal
herniorrhaphy; Open herniorrhaphy; Umbilical
herniorrhaphy
H ibiclens. 4
Hind limb fracture. See Section 1 hind limb fracture;
Section 2 hind limb fracture; Section 3 hind limb
fracture
Hock
extension, 77f
hyperflexion. 73f
Hohmann retractor, blades (inclusion), 9f
Hoof angle. change, 84
Hor izontal mattress pattern. See Suture
Hor izontal mattress sutures
pattern, 28f
placement, polyethylene supports, 22f
Horizontal periosteal transection. connection. 47f
Hotz-Celsus blepharoplasty, 173, 174
suture placement. bisecting method. 174f
Huber technique. See Rectovaginal fistula repair
Human chorionic gonadotropin (HCG).
administration, 191
Hydrocele
complication. See Castration
formatio n. See Postcastration
Hydrogen peroxide gas plasma, usage. 10
Hydrolysis, constant rate, 16
Hyperflexion. See Hock
Hypodermic needle
I
usage. See Distal radial physis
wire guide, 123f
Incision Line
avoidance. See Primary incision line
ventral site, trocar usage, 21 f
Incision site. See Periosteal transection
distal site, drain, 22£
exudate, removal, 21£
,


I
Incisors
fractures, 123
involvement. See Rostral mandibular fractures
Incomplete abdominal cryptorchids, 197
Indirect inguinal hernia, 247f
abdominal view, 247f
i nduction, 38. See also Injectable field anesthesia
Infection, complication. See Castration
Inferomedial subpalpebrallavage tube placement
anatomy, 165
complications, 167
equipment. usage, 165
indications, 165
medications, 167
positioning, 165
postoperati ve care, 167
preparation, 165
procedure, 165- 166
protection, 167
references, 167
Infraorbital canal, 129f
positi on, 128f
relati ve positions, t28f
Infraorbital nerve, blockage, 177
Infra trochlear nerve blocks
anatomy, 176
complications, 178
equipment, usage, 176
indications, 176
positioning, 176
preparation, 176
procedure, 176-178
references, 178
Inguinal canal, inguinal retention, 197f
Inguinal hernia. See Direct inguinal hernia
abdominal view. See Indirect inguinal hernia
closure, 248£
Inguinal hernia-eventration, 186, 188
Inguinal herniorrhaphy
anatomy, 246
comments, 248-249
complications, 248
equipment, usage, 246
exercise restrictions, 248
indications, 246
medications, 248
outcome, expectation, 248
positioning, 246
postoperative care, 248
preparation, 246
procedure, 246-248
al ternatives, 248
references, 249
Inguinal testicle
exteriorization, view, 198f
view, 198f
Injectable anesthetics, 33-34
Injectable field anesthesia, inductionlrecovery, 38-39
Inj ectable general anesthesia, 34-37
supportive care, 37-38
usage. See Patient
Injury, initial assessment, 24
Index 263
Instruments. See Surgical instruments
Insurance, communication, 3
Interdental space, bilateral fractures, 124
Internal abdominal oblique muscle, 183f
Internal inguinal region, postcastration adhesion
formation, 192
Internal spermatic fascia, 183f
Interosseus ligament, 94f
severing, 95f
Interosseus medius, 94f
Interrupted cruciate pattern, 17f
Interrupted horizontal matt ress pattern, 18f
Interrupted Lembert pattern, usage. See Vaginal fi stula
Interrupted vertical mattress pattern, 18-19, 18f
Intestinal eventration, complication, 191
Intestine
exposure, 191
milking, 247
Intramuscular injections, 106
Intraoral wire fixation. See Rostral mandibular
fractures; Rostral maxillary fractures
Intraosseous perfusion, 57
Intraosseous screw placement. See Coffin joint;
Pastern
Intrasynovial medications. See Annular ligament
desmotomy
Intravenous perfusion, 57
Intubation, usage, 37
Ischatic tuberosity, 103
J
Jackson-Pratt negati ve suction drain
insertion, 21£
placement, 21 f
K
Kappa agonists, 33
Kappa receptor activation, 32
Kelly forceps, 7f
usage, 6, 8
Ketamine, 33. See also Guaifenesin ketamine xylazine
half dose, 35
Kevlar, 60
Kimzey Leg Saver, 29
Kimzey Splint, 61
disadvantages, 65
Kimzey splint support. See Deep digital flexor tendon
Kl ug technique. See Rectovaginal fistula repair
Knee pads, inclusion, lOb
l
Lacerations. See Extensor tendon lacerations; Flexor
tendon lacerations
conversion. See Third-degree perineal laceration
264 INDEX
Lacerations. See Extensor tendon lacerations; Flexor
tendon lacerations (Conti nued)
repair. See Eyelid laceration repair; Mid
metacarpal-metatarsal tendon laceration
repair; Third-degree perineallaceration repair
lavage, 63f
skin necrosis, evidence. See Pastern laceration
Lacrimal nerve blocks
anatomy, 176
complications, 178
equipment, usage, 176
indicati ons, 176
positioning, 176
preparation, 176
procedure, 176-178
references, 178
Laminitis, 98f
Laparocystotomy, 213
Laparoscopy, 213
Large cords, separation/ligation, 185-188
Laryngeal ventr icle, relation. See Cricothyroid
membrane
Laryngotomy, surgical approach, ISH
Larynx
lateral view, 150f
ventral view, 148f
Lateral digital extensor, IO-cm vertical skin incision, 74f
Lateral digi tal extensor muscle, location, 73f
Lateral digital extensor tendon, 47f, 73f
location, 73f
pull ing, 72
Lateral digital extensor tenectomy
anatomy, 72
bandaging, 74
comments, 74-75
complications, 74
equipment, usage, 72
exercise restriction, 74
indication, 72
medications, 74
outcome, expectation, 74
positi oning, 72
postoperative care, 74
preparation, 72
procedure, 72-73
references, 75
suture removal, 74
Lateral recumbency, 37, 135f
Lateral splints
extension,27f
usage, 27f
Lavage solutions, effecti veness, 12
Lavage tube
footplate, 166f
placement. See Head; Inferomedial subpalpebral
lavage tube placement
Laxity. See Ligament
degree, 118
Left distal radial physis, medial aspect (curvilinear
incision), 51£
Left forelimb
DDFT contracture, 81£
fetlock contracture, 87f
lateral aspect, 47f
pointing stance, 108f
SDFT contracture, 87f
SDF tendonitis, 87f
Left j ugular vein, 139f
Left second maxillary molar, repulsing, 135f
Left tibia, lateral aspect, 47f
Leg Saver, usage, 29f
Lembert pattern, usage, 230
Lembert sutures
number, variation, 174
placement schematic. See Eyelid
Lidocaine, usage, 40
Ligament
desmotomy. See Annular ligament desmotomy;
Distal check ligament desmotomy; Medial
pateUar ligament desmotomy
laxity, 11 9
Limbs
abduction, prevention, 27f, 28f
appearance, 68f
cast. See Distal limb; Half li mb cast
flexion, exaggeration, 77f
functional sections, divis ion, 25f
perfusion. See Distal limb perfusion
perineural capping, Illf
position, stance phase, 77f
positioning, ropes (usage), lab
Limb stabilization, 25-28
section 1,25-26
section 2, 26
secti on 3, 27-28
section 4, 28
Limb support. See Contralateral li mb support
Linea, closure, 251 f
Lister bandage scissors, 7f
Locking loop. See Modified compound locking loop
Locking mechanism, 77f
Long digi tal extensor tendon, 73f
transection, 62f
Long-handled instruments, requirement, 236
Long-handled scissors, usage, 152f
Longitudinal fibers, palpation, 108f
M
Males, perineal urethrotomy
anatomy, 211
cleaning, 212
comments, 213
complications, 213
dietary modifications, 212
equipment, usage, 21 I
exercise restrictions, 212

Males, perineal urethrotomy (Continlled)
indications, 21 1
medications, 212
outcome, expectation, 213
positioning. 21t
postoperative care, 212
preparation, 211
procedure. 21 1-212
alternatives, 213
protection, 212
references. 213-214
Mandibular cheek teeth, lateral view, 134f
Mandibular fractures, intraoral wire fixation. See
Rostral mandibular fractures
Mandibular tooth, repulsion, 136
Mastication, difficulty, 125
Mathieu retractor, 8f
Mattress patterns. See Interrupted horizontal mattress
pattern; Inter rupted vert ical matt ress pattern;
Suture
Matt ress suture pattern. See Conti nuous horizontal
mattress suture pattern; Horizontal mattress
suture pattern
Maxillary cheek teeth, lateral view, l34f
Maxillary fractures, intraoral wire fixation. See Rostral
maxillary fractures
Maxillary sinus, trephi ne sites limits (identification),
129f
Maxillary vein, 140f
Mayo- Hegar needle holders, 7f
McKinnon technique. See Urethral extension
Medial canthus, 129f
Medial patellar ligament desmotomy
anatomy, 76
bandaging, 78
comments, 78-79
complications, 78
equipment, usage, 76
exercise restrictions, 78
indications, 76
medications, 78
outcome, expectation, 78
positioning, 76
postoperative care, 78
preparation, 76
procedu re, 76
alternatives, 78
references, 79
ski n incision, location, 77f
suture removal , 78
Medial patellar ligament transection, bistoury knife
(usagel,78f
Median raphe, removal, 192, 193f
Medullary cavity cyst, 109£
Mepivacaine, usage, 40
Mesofuniculus, ligament tail (disr uption), 187£
Mesorchium, window (creation), 186f
Metal splints, usage, 29f
Index 265
Metzenbaum scissors, usage, 83
Meyerding finger retractor, blades (i nclusion), 8f
Meyerdi ng retractor, 9f
Middle metacarpal region, transverse section, 6lf
Middle metatarsal fractu res, 26
Middle metatarsal region, transverse section, 61f
Middle nasal meatus, 129f
Midline incisions. 144
Mid metacarpal-metatarsal tendon laceration repai r
anatomy. 60
assessment, 60-64
comments, 66
compl ications, 65
equipment, usage, 60
indications, 60
outcome, expectation, 65
positioning, 60
postoperative care, 64-65
preparation, 60
procedures, alternatives, 65
references, 66
stabilization, 60-61
surgical proced ures, 60-64
synovial structure, involvement, 6 1
vascular status, 61-62
wounds, debr idement/repair, 62-63
Mid metacarpal region
cross-sectional anatomy, 99f
flexor tendon laceration, 61 f
Mid metatarsal spli nt bone fracture, 93f
Moderate SDFT contracture. See Forelimbs
Modified closed castration, exteriorization
(maintenance),186f
Modified closed technique. See Castration
Modified compound locking loop. 64, 64f
Modified far- near-near-far pattern, 64f
Modifi ed far- near- near-far suture pattern, 63
Modified Finochietto self-retai ning retractor, 222, 236
Modified Forssell's operation. See Cr ibbing
Modified Forssell's procedure, 152f
incision site. t 58f
Modified Goetz technique. See Third-degree perineal
laceration repair
Modified parainguinal approach. See Cryptorchid
castration
Modified White's emasculator, 182£
Monin technique. See Urethral extension
Monofilament absorbable suture materials,
requirements, 236
Monorchidism, rarity, 200
Morphine, usage, 35t
Mosquito hemostatic forceps, usage, 52
Mucocutaneous junction, 217f
Mucosal edges (appositi on), simpl e continuous
pattern. See Debrided mucosal edges
Muscles
severing, 74£
view, 133f
266 INDEX
Muscle-tendon junctions, 73f, 74f
Musculotendinous junction, 158f
Myectomy. See Omohyoideus myectomy;
N
Sternothyrohyoideus myectomy
exercise restrictions. 153
medicati ons, 153
procedures, 148- 153
postoperative care, 153
suture removal, 153
Nasolacrimal catheter
suture, 164f
usage, 163
Nasolacrimal catheterizati on, 162
Nasolacrimal duct, 129f
anatomy, schematic, 163f
position, 128f
relative position, 128f
Nasolacrimal flush
anatomy, 162
complications, 164
equipment, usage, 162
indications, 162
medications, 164
positioning, 162
postoperative care, 164
preparation, 162-164
procedure, 162- 164
references, 164
Nasolacr imal obstruction, treatment, 164f
Nasolacrimal sac, anatomy (schematic), 163f
Nasolacr imal system, catheterization, 163
Navicular disease, preoperative image, 108f
Nd:YAG laser, llsage, 147, 153. 157
Near-far-far-near tension suture patterns, 19f
usage, 20
Neck
C4, transverse section, 140f
lateral view. IsSf
vent ral views, 139f, 144f
Needle holders. 6. See also Mayo-Hegar needle
holders; Olsen-Hegar needle holders
inclusion, lOb
types, 6
Needle placement. See Caudal epidural injection'
Negative suction drain, insertion. See Jackson- Pratt
negative suction drain
Nerve blocks. See Infratrochlear nerve blocks;
Lacrimal nerve blocks; Ophthalmic procedures;
Palmar-palmar metacarpal nerve block; Palpebral
nerve blocks; Supraorbital nerve blocks;
Zygomatic nerve blocks
Nerve ending (grasping), hemostats (usage), III f
Neurectomy, Black's method, 107, II0f
No. 0 absorbable suture, ConneU pattern (usage),
240
No.2 synthetic absorbable suture material. usage,
200
No.3 scalpel handle, inclusion, lOb
No.3 synthetic absorbable suture mater ial, usage,
200
No.4 scal pel handle, scalpel blades (shapes), 6f
No. 10 Bard- Parker blade, 162
No. 10 scalpel blade, usage, 47
No. 12 hooked scalpel blade, usage, 47
Non invas ive inguinal approach. See Cryptorchid
castration
Nonsteroidal inflammatory drugs (NSAIDs),
25
NSAIDs. See Nonsteroidal inflammatory drugs
Nucleat ion, indications, 170
Nylon. characteristics. 1St
o
Ocular lubricant, usage, 37
Olecranon fract ures, 28f
Olsen-Hegar needle holders, 7f
Omental prolapse, complication. See Castration
Omohyoidectomy
intraoperative view, 149f
usage. See DDSP
Omohyoideus dissection, 150
Omohyoideus muscle, retraction. 150f
Omohyoideus myectomy, 149-150
One-stage repair. See Third-degree perineal laceration

repair
Open castrati on
emasculators. application, 187f
epididymis, ligament tail (cutting), 187f
tunic, removal, ISSf
Open herniorrhaphy, 251-252
usage, 252f
Open technique. See Annular ligament desmotomy;
Castration
Operating scissors, 6f
classification,S
Ophthalmic procedures, nerve blocks
anatomy, 176
complications, 178
equipment, usage, 176
indications, 176
positioning, 176
preparation, 176
procedure, 176- 178
references, 178
Opioids, 32-33
Orbital rim, 177f
Orchitis, 213
Orthopedic felt
appl ication. See Cast proximal limit
usage, 114f
Orthopedic support, 117
Oschsner forceps, inclusion, l Ob

Oscillating saw
removal. See Cast removal
usage, 117
Oxygen supplementation, 38
p
P3, abscessation/sequestration, 10 1
Palmar annular ligament
constriction, 68f
proximal incision. 69f
Palmar digital artery, 108f
Palmar digital nerve
distal incision, 110f
exposure, proximal/distal incisions, I 1 Of
incision, postoperative view, 110
location, 108f
transection, 108f, 110£
Palmar digital vein, I08f
injection, contrast. See Distal pastern region
Palmar fascia . closure, 83
Palmar metacarpus, anatomy, 82f
Palmar-palmar metacarpal nerve block, 98
Palmar pastern region, flexor tendon laceration, 61 f
Palmar-plantar annular ligament, 68f
Palmar-plantar digital neurectomy
anatomy, 107
bandagi ng, 109
comments, III
compli cations, 109-110
equipment, usage, 107
exercise restrictions, 109
indications, 107
medicat ions, 109
outcome, expectati on, 109
positioning. 107
postoperative care, 109
preparation. 107
procedure, 107. 109
alternatives. 110-111
references, 112
suture removal. 109
Palmar-plantar wall See Fetlock
Palmar vein, 20-gauge/22-gauge I-inch catheter
(placement), 57f
Palpable lateral digital extensor tendon, 3-cm incision.
74f
Palpebral conj unctiva, 166
Palpebral nerve anatomy, schematic. 177f
Palpebral nerve blocks
anatomy. 176
complications. 178
equipment. usage, 176
indications. 176
positioning, 176
preparation, 176
procedure, 176-178
references, 178
Paramedian incisions, 144
Parietal lamina. 183£
Parker retractor, 8f
Parotid duct, 133f
Passive drains, 21-22
Pastern
Index 267
proximal portion, stab incision, 58f

regIOn
flexor tendon laceration. See Palmar pastern
.
regiOn
perfusion, intraosseous screw placement,
58f
Pastern laceration (previously repaired), skin necrosis
(evidence),22f
Patella
fragmentation, 78
rel ease. 77f
upward fixatio n, 77f
PateUar ligament desmotomy. See Medial patellar
ligament desmotomy
Patient
emergency management. See Fracture
patient
evaluation, 3
monitoring. injectable general anesthesia (usage).
37
preparation. See Surgery
Penile amputation
anatomy, 206
comments, 210
complications. 209-210
equipment. usage, 206
exercise restrictions, 209
indi cations, 206
medications, 209
outcome, expectation, 209
positioni ng, 206
postoperative care, 209
preparation, 206
procedure, 206-209
alternatives, 210
references. 210
suture removal, 209
William's technique, triangular skin incision,
208f
appearance, 209f
intraoperative view, 208f, 209f
Penile damage, complication. See Castration
Penis
anatomy, 207f
base, transection, 208f
distal shaft, melanoma. 206f
external aspect, 203f
free part, 203f
median section, 203f
transection, 208
transverse section, 207f
268 I NDEX
Penrose drain, 22f
placement, 149
usage, 21-22
Perfusate loss, prevention, 56f
Perfusion. See Distal limb perfusion; Intraosseous
perfusion; Intravenous perfusion
Perineal body reconstruction (episiopJasty)
complications, 221
equipment. usage, 2 19
exercise restrictions. 219
indication, 219
medications, 219
outcome, expectation, 22 1
positioning, 219
postoperative care, 219
preparation, 219
procedure, 219
references, 22 1
suture removal, 219
Perineal laceration repair. See Third-degree perineal
laceration repair
Perineal urethrotomy. See Males
completion, close-up view, 212f
postoperative view. See Gelding
Perineural capping, Ill. See also Limbs
Gerald forceps, usage, I08f
requirement, 107
Perineural sleeve
closure, III
str ippi ng, 111£
smooth-tipped forceps, usage, III f
Periosteal elevator, usage. See Periosteum
Periosteal transection, incision site, 47f
Periosteal transection/elevation
anatomy, 46
comments, 48-49
complications, 48
equipment, usage, 46
exercise restriction, 48
indi cations, 46
introduction, 48-49
outcomes, expectation, 48
positioning, 46
postoperative care, 48
procedure, 46-47
alternatives, 48
references, 49
suture removal, 48
Periosteum
transection,47f
triangular shaped flaps (elevation), periosteal
elevator (usage) , 47f
Per itomy, schematic, 172f
Peritonitis. 213
complication. See Cast ration
Persistent stallion-like behavior, complication. See
Castration
Phenylbutazone, 25
Plantar splints
cast combination, usage, 26f
usage,27f
Plastic-covered fetotomy wires, preplacement, 11 9
Plugs, composition, 135
Plunger, needle placement, 21 f
Pneumatic tourniquet, application. See Esmarch
bandage
Poliglecaprone 25, characteristics, 14t
Polydioxanone, 16
characteristics, 14t
Polyester, characteristics, 1St
Polyethylene supports. See Horizontal mattress sutures
Polyglactin 910, 16
characteristics. I4t
Polyglacti n acid, characteristics, 14t
Polyglecaprone. 16
Polyglycolic acid, 16
Polyglyconate, 16
characteristics, 14t
Polymerized caprolact um, characteristics. 1St
Polypropylene, characteristics, 1St
Polyvinyl chloride (PVC)
splint support. See Extensor tendon lacerations
tubing, placement. 122
usage, 24
Postcastration
adhesion formation, impact, 192f
hydrocele, for mation. 192f
Postoperative hematoma, minimi zation, 153f
Potassium penicillin, 25
Preoperative radi ographs, 54
Prepuce
circumferential incisions, 202
external aspect. 203f
involvement. See Squamous cell carci noma
lesion removal, ci rcumferential incisions, 203f
median section, 203f
Preputial ring, 203f
Primary anatomi c entropion, 173
Primary closure, 13
Primary incision line, avoidance, 22f
Primary suture line, excess tension. 22
Propofo!' 34
Proximal amputation site. 9S
Proximal annular ligament. 67
incision. 69f
Proximal check ligament
intraoperative view, 88f
transection. 89f
Proximal check ligament desmotomy
anatomy, 86
bandaging, 90
comments, 91
complications. 90
equipment, usage, 86
exercise restrictions. 90
incision, location, 98f

Proximal check ligament desmotomy (Colltillued)
indications, 86
medications, 90
outcome, expectation, 90
positioning, 86
postoperative care, 90
preparation, 86
procedure, 86-88
alternatives, 90-91
references, 91-92
suture removal, 90
Proximal metatarsal fractures, 26
Proximal radial artery, palmar carpal branch, 89f
Proximal radial fracture, 27. See also Section 3
proximal radial fracture
Proximal radial vein, deep communicating branch, 89f
Proximal sesamoid bones, abaxial surfaces, 68f
Proximal splint bone, edge (removal), 95f
Proximal tendon sheath, incision, 68
Proximal tibia
insertion, 104f
medial aspect, 103
Pul leys. See Three-loop pulley
Purse-stri ng pattern
tightening, 231 f
usage. See Rectovaginal shelf
Purse-st ring suture, simple interrupted suture
(association),23 1f
PVc. See Polyvinyl chloride
R
Rad ial fract ure. See Section 3 proximal radial fracture
Radiographs, 134f
Recovery. 38-39. See also Injectable field anesthesia
Rectal damage, 213
Rectal fis tula, transverse closure, 240f
Rectal lumen, 230f
Rectal mucosa
inversion, 230f
transverse apposition, 238f
Rectal shelf
creation, 239f
vaginal shelf, dead space (elimination), 241 f
Rectovaginal fi stula
circumferential incision, 80-degree scalpel handle
(usage),237f
cl osure, 243f
sut ure placement, sagittal cross-section, 243f
vest-over-pants, usage, 242f
cranial/lateral aspects, horizontal dissection, 242f
margin, 239f
submucosal sutures pattern, preplacement, 238f
visualization, 237f
Rectovaginal fistu la repair
Bemi s technique, 238-239
complications, 243
dietary modifications, 242
direct repair, 236-237
Index 269
Rectovaginal fi stula repair (Continued)
equipment, usage, 236
exercise restrictions, 242
Huber technique, 239-24 1
indications, 236
Kl ug technique, 241-242
medications, 242
outcome, expectation, 242
positioning, 236
postoperati ve care, 242
preparation, 236
procedure, 236-242
references, 243
Schonfelder technique, 237-238
suture removal, 242
Rectovaginal shelf, closure
purse-stri ng pattern, usage, 229f
six-bite pattern. usage, 229f
Rectum (elasticity), reduction (problem), 23 1 f
Rei mer emasculator, 183f
Repulsion. See Tooth repulsion
Restraint, combi nations. See Standi ng sedat ion
Restrictive scar tissue. transection, lOSf
Retained testicle, location, 197f
Retractor peni s muscle, 207f
Retractors, 8-9. See also Army-Navy retractor;
Farabeuf retractor; Finger- held ret ractors; Gelpi
ret ractors; Hand-held retractors; Mathi eu
retractor; Meyerdi ng retractor; Ribbon mall eable
retractor; Self- retaining ret ractors; Senn
retractor; Weitlaner
retractors
blades, inclusion. See Hohmann ret ractor;
Myerding finger ret ractor
Ribbon malleable retractor, 9f
Right angle scissors, usage, 152f
Robert Jones bandage, usage, 27f, 28f
Rochester-Carmalt forceps, 147, 157
Rochester-Pean forceps, 147, 157
Romifidine, usage, 35t, 36
Rongeurs, usage, 134. See also Segmental ulnar
ostectomy
Rostral mandibular fractures
incisor involvement, J 24f
repair, 124f
techniques, comparison, 125f
wire posi ti oni ng, 123f
Rostral mandibular fractures, intraoral wire fixat ion
anatomy, 122
comments, 125
complications, 125
equipment, usage, 122
indications, 122
med ications, 125
outcome, expectation, 125
positi oning, 122
postoperati ve care, 125
preparation, 122
i
270 I NDEX
Rost ral mandibular fract ures, intraoral wi re fixation
(Continued)
procedure, 122- 125
references, 125-126
Rost ral maxillary sinus, 128f, 129f
Rostral neck, ventral view, 148f
5
Sacrococcygeal region, sagittal section. 39f
Scalpel blades, 6f
guidance. 69f
shapes. See No.4 scalpel handle
usage,S
Scalpel handle
inclusion. See No.3 scalpel handle
scalpel blades. shapes. See No.4 scalpel handle
Scar tissue, presence, 94
Schonfelder technique. See Rectovaginal fi stula repair
Schrodeder-Thomas splint, usage. 27
Scissors. 5-6. See also Curved Mayo scissors; Curved
Metzenbaum scissors; Lister bandage scissors;
Operating scissors; Straight Mayo scissors
inclusion. See Suture
Scrotal ligament, 198
Scrotal region/sheath
postoperative appearance, 189f
postoperative swelli ng, 189f, 190f
SDF. See Superficial digital flexor
SOFT. See Superficial digital flexor tendon
Secondary ent ropion, 173
Second-degree perineal laceration, 242f
Second-intention healing, 13
Second premolar. involvement, 123
Section 1 forel imb fracture, 26£
Section 1 fractures. stabilization, 29f
Section 1 hind limb fracture, 26£
Section 2 forelimb fracture. 26f
Secti on 2 fractu res, 27f
Section 2 hind limb fracture, 27f
Section 3 diaphyseal fracture, 27f
Section 3 forelimb fractures, 27f
Sect ion 3 hind li mb fracture. 27f. 28f
Section 3 proximal radial fracture, 27f
Section 3 tarsal fracture, 28f
Section 3 tibia fracture, 28f
Section 4 foreli mb fractures, 28f
Sedation
achievement, 24
restraint, combinations. See Standing sedation
Segmental ulnar ostectomy (performing), rongeurs
(usage),47f
Self-retaining retractors, 9f, 222, 236
placement, 15lf
Self- retai ning tracheotomy tube, insertion, 141 f
Semitendinosus myotomy, 103- 104
bandaging, 104f
exercise restri ct ions. 104f
medications, 104f
Semitend inosus myotomy (ColltiITJ.led)
references, 106
suture removal, 104f
Semitendinosus tendon, location/i ncision, 104f
Semitendinosus tenotomy, t03
bandaging, 104
exercise restrictions, 104
medications, 104
references, 106
suture removal, 104
Semitendinosus tenotomy/myotomy
anatomy, 103
comments, 106
complicati ons, lOS
equipment, usage, 103
indications, 103
outcome, expectation, 105
positioni ng, 103
postoperative care, 104
preparation, 103
procedure, t03-J 04
alternatives, 105- 106
Semi transverse closure technique. See Third-degree
perineal laceration repair
Senn ret ractor, 8f
Septic tenosynovitis, 70
Sequest ration. See Bone; P3
Seroma formation, 190f
minimization, 153f
Serra emasculator, 183f
Sesamoid bones
abaxial surfaces. See Proximal sesamoid bones
catheter, usage, 57f
Shires technique. See Urethral extension
Shoe, setting, 81£
Shoeing. See Corrective shoeing
Silk, characteristics, 13, 1St
Silver-sulfadiazine cream, 213
Si mple conti nuous pattern, 17f
Simple-interrupted 3-0 monofilament nonabsorbable
sutures, 164
Simpl e interrupted appositional suture patterns,
combination. See Vertical mattress sutures;
Vertical mattress tension suture
Simple interrupted pattern. 17f
Single drugs, usage. 35t
Sinus trephinati on
anatomy. 127- 128
comments, 130
complications, 130
equipment, usage, 127
indications, 127
outcome, expectation, 130
positioning, 127
postoperative care, 130
preparation, 127, 128-130
procedure. 128-130
alternatives. 130
--------------------------------............................ ...............
Sinus trephination (Continued)
references, 130-131
Six-bite pattern, usage. See Rectovaginal shelf
Skin
closure. 90f
performing. 168
defects, closure, 21 f
necrosis, evidence. See Pastern laceration
preparation, antiseptics (usage), 11-12
tension, management. 22
Ski n incision, 69, 184£
depiction, 212f
enl argement, 185
locati on. See Distal check ligament desmotomy;
Medial patellar ligament desmotomy
Skull
lateral view, 128f
overview, 128f
transverse section, 129£
Small intestine, adhesion formation (excess), 192f
Smooth-tipped forceps, usage. See Perineural sleeve
Soft palate
elevation, IS2f
free edge, retraction, 152f
grasping, AJlis tissue forceps (usage), 152f
Soft palate, dorsal displacement (DDSP), 153f
impact, 154
omohyoidectomy, usage, 149f
sternohyoidectomy, usage, 149
Soft palate, dorsal displacement (surgical treatment
options) (DDSP)
anatomy, 147-148
comments, 154-155
cornplkations. 154
equipment, usage, 147
indications, 147
outcome, expectation, 154
positioning. 147
postoperative care, 153
preparation, 147
procedure, 148-153
references, 155- 156
Soft tissue dissection, 53
Spastic entropion, 173
Spermatic cord, 183f
emasculation, 187f
emasculators, application, 184f
musculofibrous portion, emasculation, 185f, 188f
separation, 185f
vascular portion, emasculation, 185f, 188f
Spinal accessory nerve
identification, 159f
insertion, 158f
ventral branch, insertion, 158f
Spl int bone
amputation, 95f
freeing. See Distal attachment
removal, 95f
Index 271
Splint bone (Contill/led)
resection. See Distal splint bone resection
Spl inting equipment, 25f
Spl ints
application, indication, 118
cast combination, usage. See Dorsal splint cast
combination; Plantar splints
extension. See Lateral splints
usage. See Lateral splints
Sponge forceps, usage. See Vaginal ring eversion
Squamous cell carcinoma
incisions, intraoperative view, 204f
prepuce, involvement, 202f
Stabilization. See Mid metacarpal-metatarsal tendon
laceration repair
Stab incision, 149. See also Pastern
shallowness, 141
Stainless steel, characteristics, 1St
Stance phase. See Limbs
Standing sedation
drugs, usage, 35t
restraint combinations, 34
Staphylectomy, 150-151
exercise restrictions, 153
medications, 153
procedures
alternatives, 151-153
postoperative care. 153
suture removal, 153
Steel concrete reinforcement rod, usage, 27
Stent bandage. usage, 20
Stent removal. See Cribbing
Sternohyoidectomy
intraoperative view, 149f
usage. See DDSP
Sternomandibularis muscle
axial surface, 158f
removal, 139f
retraction, 158f
Sternothyrohyoideus muscles, separation, 138
Sternothyrohyoideus myectomy, 148- 150.
IS3f
surgical approach, 149f
Sternothyrohyoideus tenectomy. ISO, 153f
Sternothyroidectomy, intraoperative view,
149f
Sternothyroideus
insertion. See Thyroid cartilage
inserts, usage, 148
musculotendinous section, view, 150f
Steven's tenotomy scissors, 170
Sti fl e, extension, 77
Stockinette
double layer, 115
application, 114f
usage, 114f
Straight Mayo scissors, 7f
inclusion. lOb
272 INDEX
Straight mosquito forceps, inclusion, lOb
Stringhalt gait, 73f, 75
St ringhalt-like gait, 75
Subcutaneous patterns. See Suture
Subcutaneous plane, creat ion, 70f
Subcutaneous tissue
closure, 83, 90f
option, 73
incision, 143, 212f
partial closure, 22f
walking sutures, usage, 21 f
Subcuticular patterns. See Suture
Subjunctival closure, schematic. See Eyelid
Submucosal perineal tiss ue
apposition,221f
simple continuous patterns, usage, 233f
oversewing, 221 f
Submucosal sutures pattern, preplacement. See
Rectovaginal fistu la
Submucosal tissue
closure, 223
simple continuous pattern, usage, 224f
exposure, 237f
Submucosa suture placement, sagittal cross, 238f
Subsacral anesthesia, performing, 234f
Suction drain, insertion. See Jackson-Pratt negative
suction drain
Superficial digital flexor (SDF) tendonitis, 90. See also
Left forelimb
Superficial digital fl exor tendon (SDFT), 82f
contracture. See Forelimbs; Left foreli mb
extrasynovial space, 71
lateral aspect, 67
partial laceration, 62f
repair, 64
tens ion, decrease, 113
in vitro strain, 91
Superficial inguinal ring
location, 197f
medial border, 199
Superficial retinaculum, closure, 90f
Superficial structures, view, 133f
Supraorbital foramen, location, 177-178
Supraorbital nerve blocks
anatomy, 176
compl ications, 178
equipment, usage, 176
indicati ons, 176
positioning, 176
preparation, 176
procedure, 176- 178
references, 178
Surgery
decision, 3
general pack. See Field surgery
patient preparation, 3-4
Surgical dissection. See Third-degree perineal
laceration
Surgical instruments, 5-9
preparation, 9-10
references, 10
Surgical procedures. See Mid metacarpal- metatarsal
tendon laceration repair
Surgical treatment options. See Soft palate
Suspensory ligament disruption, recovery, 62f
Suture
continuous patterns, 17-18
horizontal mattress pattern, 18
materials
characteristics, 14t-15t
usage, 13, 16
patterns. See Conti nuous horizontal matt ress suture
pattern; Ford's interlocking pattern;
Horizontal mattress sutures; Interrupted
cruciate pattern; Modified far-near-near-far
suture pattern; Simple continuous pattern;
Simple interrupted pattern; Tendon lacerations
bolsters, usage. See Tension suture
combination. See Vertical mattress sutures;
Verti cal mattress tension suture
impact, 16
placement, bisecti ng method. See Hotz-Celsus
blepharoplasty
placement/patterns, 16-20
scissors, inclusion, lOb
securing, 20
simple interrupted patterns, 17·18
subcutaneous patterns, 18f, 20
subcuticular patterns, 20
tension patterns, 19-20
usage. See Tension suture
vertical mattress pattern, 18-19
Swelling, complication. See Castration
Synovial structure, involvement. See Mid
metacarpal-metatarsal tendon laceration
.
repair
Synthetic absorbable sutures, 16
T
Tap, usage, 58f
Tape tabs, restructuring, 167
Tarsal fracture. See Section 3 tarsal fracture
Tarsorrhaphy. See Temporary tarsorrhaphy
TeJazol, 32
Temporary eyelid tacking, 174
Temporary heel elevation, acrylic (usage), 84f
Temporary tarsorrhaphy
anatomy, 179
cleaning, 180
complications, 180
equipment, usage, 179
indications, 179
positioni ng, 179
postoperative care, 180
preparation, 179
procedure, 179-180
Temporary tarsor rhaphy (Coll tilllled)
protection, 180
references, 180
suture removal, 180
Tendon lacerations. See Extensor tendon lacerations;
Flexor tendon
Kimzey splint support. See Deep digital flexor
tendon
repair. See Mid metacarpal- metatarsal tendon
laceration repair
suture patterns, 63-64
Tendon sheath, 68f
proximal. See Flexor tendon
Tenectomy. See Lateral digital extensor tenectomy;
Sternothyrohyoideus tenectomy
procedures, 148-153
postoperative care, 153
Tension-absorbing rectal tissues, 239
Tension band wire
insertion. See Cheek teeth
placement, 124- 125
Tension patterns. See Suture
Tension suture
patterns. See Far-near-near-far tension suture
patterns; Near-far-far-near tension suture
patterns
bolsters, usage, 18f
usage, 22
supports, bandages (application), 22f
usage, 18f
Testicle
anatomy, 3184f
exposure, 184f
exteriorization. See Abdominal testicle; Ingui nal
testicle
location. See Retained testicle
prolapsing. 187f
removal. 199
modified parai nguinal approach. See Abdominal
testicle
Testicular attachments, identification, 199f
Thiobarbi turate, 33
Thiopental. 33-34
Thiopental-guaifenesin combinations, 36-37
Thi rd-degree laceration, occurrence, 233
Third-degree perineal lacerati on
conversion, 24 1
references, 234-235
surgical dissection. 229f
Third-degree peri neal laceration repair
Aanes technique, 230-232
comments. 233- 234
complications, 233
cranial area, suture pattern placement, 23lf
dietary modifi cations. 233
equipment. usage, 228
exercise restrictions. 233
indications, 228
Index 273
Third-degree permeallaceration repair (Conti l/lled)
medi cations, 233
modified Goetz technique. 229-230
one-stage repair, 228-230
outcome, expectation, 233
posit ioni ng. 228
postoperative care, 233
preparation. 228
procedure, 228-232
semitransverse closure technique, 230
suture removal, 233
two-stage repair, 230-232
Third metacarpal-metatarsal bone, 93
Third metatarsal bone, 27f
Third phalanx
fracture stabilization, 116f
rotation, 98f
Three-layer closure. close-up view, 224f
Three-loop pulley. 64. 64f
Three-way stopcock, usage, 21f. 57f
Throat region. view. See Ventral throat region
Thumb forceps. 6
Thyroid carti lage. 148f
sternothyroideus, insertion, 150f
Tibia fractu re. See Section 3 tibia fracture
Tibiotarsal joint, entering, 51
Tie-forward procedure, 153
Tie-over bandage, 20
Tiletamine, 33
Tissue
adhesives, 20
forceps. 7f
mobilization. direction, 223f
removal . 62
walking sutures, usage. See Subcutaneous
tissue
Toe
elevation. 62f
extension, creation, 8lf
acrylic hoof material. usage, 81 f
Tooth removal, 132
Tooth repulsion. See Mandibular tooth
anatomy, 132-133
comments, 137
compl ications, 135- 136
equipment, llsage, 132
exercise restrictions, 135
indications, 132
medications. 135
outcome, expectation, 135
positi oni ng, 132
postoperati ve care. 135
preparation. 132
procedure, 133-135
alternatives. 136-137
references, 137
Touhy needle, usage, 40
Tourniquet. application. See Esmarch bandage
274 INDEX
Towel clamps
inclusion, lOb
--
ventrolateral positioning, 237f
Towel stent, suture, 153f
Tracheal cartilage, incision lines, 144f
Tracheal muc6sa, double-Y incision,
144£
Tracheal mucosa-skin suture line, 145
Tracheal sections. removal, 144f
Tracheostomy
anatomy, 143
completion, 144f
complications, 145
equipment. usage, 143
exercise restri ction, 145
incision site, 144f
indications, 143
medications, 145
outcome, expectation. 145
positioning, 143
postoperative care, 145
preparation, 143
procedure. 143-145
neck. ventral view, 144f
references. 145
site. apposition. 145
suture removal, 145
Tracheotomy
anatomy. 138
complications. 141-142
equipment. usage. 138
incision site, 141 f
indications, 138
medications. 141
positioning, 138
postoperative care. 141
preparation, 138
procedure, 138, 141
references, 142
si te. view. 141 f
tube
fit . 138
management, 141
Tranqui lizers, usage, 30-32
Transconj unctival enucleation
anatomy, 170
complications, 172
equipment, usage, 170
indications, 170
medications, 172
positioning, 170
postoperative care, 172
preparation, 170
procedure, 170- 172
protection, 172
references, 172
suture removal, 172
Transdermal delivery systems. 33
Transection. See Extrasynovial transection; Periosteal
transection/elevation; Ultrasound guided
transection
Transpalpebral enucleation
anatomy, 170
approach. 172f
complications, 172
equipment, usage, 170
indications, 170
medications, 172
positioning. 170
postoperative care, 172
preparation. 170
procedure, 170, 172
protection, 172
references, 172
suture removal, 172
Transphyseal bridging
alternative, 53f
anatomy, 50
bandaging. 52
comments, 53-54
complications, 52-53
equipment, usage, 50
exercise restrictions, 52
indications, 50
olLtcomes, expectation, 52
positioning, 50
postoperative care, 52
procedure, SO-52
alternati ves, 53
references. 54
suture removal, 52
Transphyseallag-screw, S3
Transverse urethral fold
caudal reflection, 226f
caudal retraction, 223f, 226f
horizontal splitting, 224f
incision. 223f. 226f
mucosa (stri p), excision, 223f
suture. See Ventrolateral vaginal wall
vaginal wall, apposition, 226f
Trephination. See Diagnostic trephination; Sinus
trephinati on
Trephines
sites, limits (identification). See Frontal sin us;
Maxillary sinus
usage. 134
Triceps apparatus, disabling, 28f
Trigeminal nerve, maxillary branch, 176
Triple drip. usage. 36
Trocar
fi nger guidance, 166f
point, retraction, 130
usage. See Incision line
Tuber calcis, insertion, 105
Tunic
cranial aspect, incision, 185f
Tunic (Continued)
exteriorization, finger traction, l8Sf
incision, 187f
removal. See Open castration
usage, 186f
Tunica albuginea, 206
closure, 20Sf
Two-layer closure, close-up view, 223f
Two-stage repair. See Third-degree perineal laceration
.
repair
u
Ultrasound guided transection, 85
Umbilical herniorrhaphy
anatomy, 250
comments, 253
complications, 252-253
equipment, usage, 250
exercise restrictions, 252f
indications, 250
medications, 252f
outcome, expectation, 252
positioning, 250
postoperative care, 252
preparation, 250
procedure, 250-252
alternatives, 253
references, 253
suture removal, 252f
Umbilical tape, usage. See Anal sphincter
Urethra, 207f
involvement, 209
lumen, vertical incision, 207, 208f
sides, suture, 208f
Urethral damage, 213
Urethral extension (urethroplasty)
Brown technique, 223
catheter removal, 227f
complications, 227
equipment, usage, 222
exercise restrictions, 227
indications, 222
McKinnon technique. 225-226
medications, 227
Monin technique, 222-223
outcome, expectation, 227
positioning, 222
postoperative care, 227
preparation, 222
procedure, 222-226
references, 227
Shires technique, 223, 225
Urethral mucosa, perineal ski n (simple interrupted
sutures), 212f
Urethral process, 203f
Uret hral sinus, 203f
Urethroplasty techniques, Caslick's procedure, 226
Urethrostomy, 213
Urine output, transient increase, 31
Urolithiasis. 213
V
Vaginal canal. 183f
Index 275
Vaginal fistula, longitudinal closure (i nterrupted
Lembert pattern, usage), 240f
Vaginal floor/roof, distance, 225
Vaginal lumen, pattern. 229f
Vaginal mucosa
dissection, 242f
dorsal eversion, excision, 22Sf
incision, caudal extension, 224f
inversion, Connell pattern (usage), 229f, 241f
Vaginal process
location, 197f
opening, 198
Vaginal ring eversion (schematic), sponge fo rceps
(usagel, 199f
Vaginal shelf
creation, 239f
dead space, elimination. See Rectal shelf
longitudinal midline incision, surgical area
(appearance),240f
Vaginal spatula, 222
Vaginal tissue flap (rotation), transverse cross-section,
239f
Vaginal tuni c, twisting, 247f
Vaginal wall
mucosa, axial reflection, 226f
suture line, 227f
Vascular status. See Mid metacarpal- metatarsal tendon
laceration repair
Ventral branch, insertion. See Spinal accessory nerve
Ventral canal iculus, obstruction, 164f
Ventral midline skin incision, 150
Ventral mucosal layer (inversion), Connell pattern
(usagel , 224f
Ventral nasal concha, 129f
Ventral nasal meatus, 129f
Ventral puncta, anatomy (schematic), 161 f
Ventral throat region, view, 151£
Ventral vagi nal mucosa (dorsal eversion), 30-Fr Foley
catheter (usage), 225f
Ventral vestibular mucosa margin
closure, 219
cranial -to-caudal closure, simple conti nuous
pattern (usage), 220f, 232f
Ventrolateral vaginal wall
incision, 223f
transverse urethral fold, suture, 223f
Ventromedial subpalpebrallavage tube placement,
165
Vertical bites, 64
Vertical mattress pattern. See Suture
Vertical mattress sutures (bolster inclusion), simple
interrupted appositional sutures (combination),
19f
276 INDEX
Vertical mattress tension suture, simple interrupted
appos itional suture patterns (combination), 19f
Vertical skin incision. See Lateral digital extensor
Vestibular mucosa, removal (proposed area), 220f,
232f
caudolateral view, 220£, 232£
Vestibulum, nasolacrimal punctum, 163£
Vest-over-pants, usage. See Rectovaginal fi stula
Vetrap, appl ication, 11 6
Visceral lami na, 183£
Vulvar labia, incision (ending), 226£
Vulvar Li ps
apposition, 22 1 f, 233f
towel clamps, 222
Vulvar mucocataneous margin, local anesthetic
(infiltration),2 16f
Vulvar mucosa
apposition, Ford interlocking pattern (usage),
217f
excision, scissors (usage), 217f
Vul voplasty. See e asl ick's procedure
w
Walking sutures, usage. See Subcutaneous tissue
Weight bearing surface, 115f
Weitlaner retractors, 9f
usage, 87
Weitlaner sel f- retaining retractors, 147
Will iam's technique
triangular skin incision. See Penile amputation
usage, 206-207
Wi re guide. See Hypodermic needle
Wire positioning. See Rostral mandibular fractures
Wi re twists, bending, 51 f
Wounds
x
closure, II , 13
references, 23
debridement, 12-13. See also Mid metacarpal-
metatarsal tendon laceration repair
lavage, 12
consideration, 12
preparation, 11 - 12
repair. See Mid metacarpal- metatarsal tendon
laceration repai r
scrubbing, mechanical effect, 12
site
distal site, drain, 2lf
exudate, removal, 21 f
Xylazi ne. See Guaifenesin ketamine xylazine
addition, 34
usage, 3 1, 35t
z
Zimaloy Epiphyseal Staple, 53
Zolazepam, 32
concentrations, 33
Zygomatic arch, 177f
Zygomatic nerve blocks
anatomy, 176
complications, 178
equipment, usage, 176
indications, 176
positioning, 176
preparation, 176
procedure, 176- 178
references, 178

Sign up to vote on this title
UsefulNot useful