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EMERGENCY AVIAN SURGERY

Jeffrey R. Jenkins, DVM, ABVP-Avian

Variations between birds and mammals make avian surgery an

exercise in preparedness and exactness. Preparation starts long before
the surgery, especially here, in education. Learning the distinctions of
avian anatomy and physiology and the hazards of avian anesthesia and
surgery is the first step toward successful avian surgery in the critical
patient. Avian surgery requires exactness because the small body size
and the increased metabolic rate of birds may magnify errors of tech-
nique and judgment. Surgery on patients less than 2 kg falls into the
realm of microsurgery, and the equipment and techniques of microsur-
gery should be followed with these patients. In this article we review
some of the more important anatomic and physiologic differences and
how they effect the choices to be made by the surgeon. Further, we
review special equipment that should be available for the avian surgeon,
and then last we review several techniques that may be required by the
critical avian patient. Many surgeries are associated with or are the
desired therapy resulting from a critical or an emergency situation. The
actual procedures are too numerous to list here; however, the foundation
of these surgeries involve the techniques described above.
Birds are highly specialized and highly intelligent animals. The
integument of birds is thin, delicate, and essentially glandless. It has
little attachment to underlying muscles; however, it may be tightly
adhered to bone, especially in the areas of the digits and feet. The body
(contour and covert) feathers of most birds grow in tracts (pterylae)
separated by areas without feathers (apteria). Feathers may be easily
and safely plucked from most species if pulled in the direction of their
growth. The large flight feathers, remiges and retrices, are attached with

From the Avian and Exotic Animal Hospital, San Diego, California

VETERINARY CLINICS OF NORTH AMERICA: EXOTIC ANIMAL PRACTICE

VOLUME 1 • NUMBER 1 • SEPTEMBER 1998 43

44 JENKINS

Table 1. AIR SACS OF VARIOUS SPECIES OF BIRDS

Cranial Caudal
Species Number Cervical Clavicular Thoracic Thoracic Abdominal

Dom. Fowl 8 2 2 2

Stork 11 1 2 2 4 2
Loon 10 0 4 2 4 2
Songbirds 7 2 1 clav-thoracic 2 2
Turkey 7 1 cerv-clav 2 2 0 2
Psittacine 9 1 1 2 2 2

highly developed and strong feather muscles and ligaments, making

their removal difficult and painful.

SEROSAL ANATOMY

An understanding of the serosal anatomy of the avian patient is

important when considering any surgery invading a body cavity. Enter-
ing the bird's coelom may breach air sacs and pleural and peritoneal
spaces. The typical bird has 16 coelomic cavities, including pulmonary
air sacs (8), pleural cavities (2), pericardial cavity (I), and peritoneal
cavities (5). Air sacs may be divided into pulmonary, pharyngeal tra-
cheal, and cervicocephalic. The pulmonary air sacs in most pet birds
include paired cervical, cranial thoracic, caudal thoracic and abdominal,
and two pair of clavicular, making 12 air sacs in total. Variations from
this most basic configuration are listed in Table 1. The caudal thoracic
and abdominal air sacs receive fresh air from the trachea. The cervical,
clavicular, and cranial thoracic air sacs receive air that has passed
through the lung. The exact function of the remaining air sacs and
pharyngeal-tracheal or cervicocephalic systems is not relevant to our
discussion but should be reviewed by the practitioner. They are reviewed
in detail in texts of avian anatomy and morphology.1
There are eight cavities of the coelomic cavity as listed in Table 2.
Five are peritoneal cavities formed by peritoneal partitions and are not
represented in mammals. The remaining three are pleural and pericardial
and are formed as in mammals. The four hepatic and the intestinal
peritoneal cavities are formed by five sheets of peritoneum, which form

Table 2. PERITONEAL AND PLEURAL CAVITIES OF BIRDS

Left ventral hepatic peritoneal cavity Intestinal peritoneal cavity

Right ventral hepatic peritoneal cavity Left pleural cavity
Left dorsal hepatic peritoneal cavity Right pleural cavity
Right dorsal hepatic peritoneal cavity Pericardial cavity

Adapted from King AS, McLelland: Coelomic cavities. In Birds: Their Structure and Function.
Bailliere Tindal, 1984, p 79.
 EMERGENCY AVIAN SURGERY 45

partitions within the coelomic cavity. As with mammals, the combined

dorsal and ventral mesentery makes up a prominent partition. It forms
a continuous vertical sheet from the dorsal to the ventral body wall as
far caudal as the ventriculus then continues only as the dorsal mesentery.
The left and right posthepatic septum are two double-layered sheets that
extend craniocaudally from the last two thoracic vertebrae to the caudal
wall of the peritoneal cavity to unite at the midline. The ventriculus is
situated between the two layers of the left sheet. The right and the left
hepatic ligaments are perpendicular to the ventral mesentery and cranial
to the posthepatic septum, extending from the visceral peritoneum cov-
ering the liver to the oblique septum, which originates at the parietal
peritoneum and parallels the visceral peritoneum. The hepatic ligaments
suspend the liver and separate the ventral and the dorsal compartments
of the hepatic peritoneal cavities on either side. The intestinal peritoneal
cavity is single and is formed on the midline between the left and the
right hepatic cavities, from the liver to the vent, and surrounds the gut.
The right and the left ventral hepatic peritoneal cavities extend along
the lateroventral body wall from the liver to the caudal body wall,
ventral to the intestinal peritoneal cavity. The right and the left dorsal
hepatic peritoneal cavities are small and located dorsal and cranial in
the abdomen and are separated by the dorsal and the ventral mesentery
as it suspends the proventriculus. The craniodorsal region of the left
liver lobe and the right liver lobe project into left and right cavities,
respectively, but nothing else is suspended within them. The right cavity
is blind, but the left cavity connects with the intestinal peritoneal cavity.
Good illustrations of these cavities may be found in the text by King
and McLelland. 1
Practical applications of the above include knowing that when plac-
ing an abdominal breathing tube, the airway is most often introduced
into the left abdominal air sac. From this location the caudal aspect of
the lung and the left primary bronchus may be accessed. If you are
surgically sexing a bird, the endoscope is introduced into this cavity
then advanced through the air sac into the intestinal peritoneal cavity to
view the gonad. Egg peritonitis thus occurs within the intestinal perito-
neal cavity. To lift the proventriculus and ventriculus into the abdominal
incision when performing a gastrotomy, you often need to first break
down the left sheet of the posthepatic septum and perhaps the ventral
mesentery. It is also important to know that the caudal thoracic and
abdominal air sac fill the coelomic cavity, and celiotomy is impossible
without opening these airways. This has a profound effect on both
inhalant anesthetics and heat loss during celiotomy.
The stomach of birds is divided into a cranial proventriculus (glandu-
lar portion) and a caudal ventriculus (the gizzard, or muscular stomach),
separated by an isthmus or intermediate zone and ending in a pylorus.
Carnivorous birds utilize the stomach as much for storage of food as for
digestion and often have a large thin-walled, saclike stomach with little
distinction between the various divisions of the organ. Parrots, as well
as insectivorous, herbivorous, and granivorous birds have a ventriculus
46 JENKINS

that is heavily muscled with a well-demarcated isthmus in the intermedi-

ate zone. In these species, the proventriculus is composed of gastric
glands, and in some species, it is lined with papillae that project into
the lumen. 2 The body of the proventriculus has poor ability to hold
sutures and tears easily when sutured. The ventriculus of most species
of birds has a very thick muscle wall that aids in the mastication of
ingested foods. When performing a gastrototomy, the ventriculus may
be handled and used to hold stay sutures that elevate the intermediate
zone into the surgical area. When entering the lumen of the stomach
there are glandular, acidic secretions lost at the time an incision is
made; these secretions must be controlled. This is best managed with a
combination of adequate isolation and packing and the judicious use
of suction.
The female reproductive tract is a common source of problems and
hence a common site for emergency surgery (Fig. 1). In most birds, only
the left side of the bird's reproductive tract is functional. The left ovary
produces large follicles that ovulate into a well-developed oviduct. A
complex system within the oviduct sequentially adds membranes, albu-
men, and shell to the egg as it passes through the oviduct into the cloaca
and is eventually laid. Metabolic problems, trauma to the oviduct, poor
nutrition, repeated laying, and abnormal hormonal cycles as well as
infection and problems of environment lead to failure of this system.

Figure 1. Ventral view of female reproductive tract with follicles of ovary at top of illustration
and vent at the bottom. Note ventral ligament that gathers oviduct and dorsal ligament.
(Adapted from King AS, McLelland: Birds: Their Structure and Function. Baillh3re Tindall,
London, 1984, p 147.)
 EMERGENCY AVIAN SURGERY 47

INSTRUMENTATION AND EQUIPMENT

Although avian surgery may be performed with conventional surgi-

cal instrumentation found in the small-animal or surgical referral prac-
tice, there are more appropriate tools. The standard size forceps, scissors,
and needle holders are gross and cumbersome in small patients. Even
some microsurgical instruments may seem too large in patients under
200 g. The instruments recommended for major surgical procedures
include four pairs of micro-Halstead mosquito hemostatic forceps (two
curved, two straight); four pairs of larger hemostatic forceps, such as
baby Mixter (two curved, two straight); one pair of straight, serrated, or
deBakey micro-Ads on forceps (no teeth); one pair of fine-toothed Adson
forceps; curved and straight jewelers forceps; extra delicate Olsen-Hegar
Needle holders with 1.2-mm smooth or ultrafine serrated jaws; modified
Castroviejo needle holders with curved, smooth jaws and without a
lock; one pair of curved iris scissors; one pair of spring-handled dis-
secting scissors; one pair of adventitia scissors; and a no. 7 scalpel
blade handle.
In all but the largest patients, magnification of some type is advised.
Only with magnification is it possible to identify specific bleeding vessels
and, in conjunction with appropriate hemostasis, control hemorrhage.
High-quality magnifying lou pes (SurgiTel, General Scientific Corpora-
tion, Ann Arbor, MI) with a power ranging from 2.75 X to 5 X have
proved to be the best mix of magnification, working comfort, and conve-
nience. The author prefers loupes with a 20- to 24-in focal distance and
a wide field of view and deep focal depth such as those referenced
above. Some authors have advocated the use of an operating microscope.
The disadvantage of working under the operating microscope is that of
time. Even a skilled microsurgeon may take twice as much time using a
scope as compared with using a loupe.
An important aspect of microsurgery is illumination. The author
recommends a coaxial halogen light (SurgiTel Halogen Light, General
Scientific Corporation, Ann Arbor, MI) that produces 500- to 1000-ft
candles (5375 to 10,750 lux) at the working surface. Coaxial illumination
provides a shadow-free, high-contrast working area. Too low or too
bright a light source causes eye strain, decreases contrast, and blanches
the colors of tissues. A halogen desk lamp works well as a supplemental
light source as well as a source of radiant heat.
Electrosurgery (radiosurgery) can significantly reduce surgery time
and reduce blood loss. This is an obvious advantage in avian surgery.
The principals and techniques of electrosurgery in avian surgery are
comprehensively reviewed elsewhere; however, a few significant aspects
should be mentioned. The significant difference between the skin of
birds and of mammals affects the choice and the use of electrosurgical
units and electrodes. The author prefers the Elman Surgitron Unit (El-
man Surgitron, Elman International Manufacturing, Inc., Hewlett, NY)
because the greatly refined frequency reduces tissue damage and maxi-
mizes control. Birds have a comparably thin skin and little subcutaneous
48 JENKINS

tissues. A fine-tip electrode, when used on bird tissues, requires a higher

electro surgical setting as compared with thicker, wetter mammalian
tissues. However, when a vessel is encountered at this setting, the
electrode has a tendency to cut rather than coagulate. This requires a
second effort to coagulate the vessel with a potential for greater damage
to the vessel and surrounding tissue. The author recommends the use
of a bipolar electrode for coagulation. The close relationship of the
indifferent lead (one side of the forceps) and the broad surface area
allow for dispersion of the current, and a lower-energy setting may be
used to coagulate the bleeding vessel by a tissue-welding technique. The
Harrison-tip bipolar electrode (Elman International Manufacturing, Inc.,
Hewlett, NY) is a sharp-tipped bipolar forceps modified by placing a
45° bend in one tip, 1 to 2 mm from the end, and by allowing the forceps
to be used for the electrosection of tissues. This gives a great degree of
control, but at the cost of greater tissue damage.

Special Equipment

Finding an instrument that provided adequate retraction for avian

coelomic surgery was a challenge for the author. Our favorite is a plastic
ring retractor that uses hooks attached to elastic cords (Lone Star Medical
Products, Inc., Houston, TX). Another favorite is the Heiss blunt retractor
(Heiss Blunt Retractor No. 17011-10, Fine Science Tools, Foster City, CA).
This retractor combines quick and effortless application, small size, good
strength, and adequate spread. The blade extends only 6.5 mm with a
minimal 3.3-mm hook, reducing the likelihood of tangling suture. Other
acceptable retractors are small AIm retractors with short blunt teeth
(Weiss Blunt Mini Retractor No. 17008-07, Fine Science Tools, Foster
City, CA).
Procedures in which ligation may be difficult or contraindicated
may more easily be performed with hemostatic clips (Weck Hemoclip,
Solvay Animal Health, Inc., Mendota Heights, MN). The clips are easily
applied, relatively inexpensive, and available in three sizes. Sterile appli-
cators work well for absorbing blood or fluids from the surgical field.
Synthetic sponges in the shape of spears (Weck-Cell Surgical Spears,
Solvay Animal Health, Inc., Mendota Heights, MN) absorb fluids faster
and in greater quantity. The spear point sponges also give a greater
degree of control when working with magnification. Absorbable gelatin
sponges (Gelfoam, Vpjohn, Kalamazoo, MI) can be life saving in situa-
tions where the origin of hemorrhage cannot be controlled. The author
has not experienced any complication from the use of this product in
numerous patients.

Presurgical Conditioning

Surgery for the emergency or the critical patient does not negate
presurgical conditioning. What conditioning is indicated must be deter-
 EMERGEN CY AVIAN SURGERY 49

mined by the procedure to be performed and the status of the patient at

the time it is presented. A patient in good condition presented for a
simple laceration may need little, if any, treatment, whereas a small
species presented for treatment of egg retention or surgical treatment of
egg peritonitis may need intensive care before surgery. Fluid therapy,
blood transfusion, antibiotics, and preanesthetic medications may be
indicated.
Blood transfusion is indicated before the initiation of surgery in
patients that have a hematocrit less than 15% (where surgery cannot be
postponed) or in patients in which a significant volume of hemorrhage
is expected to occur (as with large coelomic mass removal from species
under 60 g body weight). Birds with a hematocrit above 55% should
receive fluids before surgery. Birds with serum total solids below 3.0 are
reported to have a guarded prognosis for recovery from surgery.
The author recommends fasting avian surgical patients for no more
than a few hours before surgery. The purpose here is only to empty the
crop of its contents. The effects of negative energy on survivability are
not well studied in avian patients; however, clinical experience would
indicate that birds fasted for significant periods have an increased num-
ber of complications at surgery. Regurgitation and aspiration have not
proved to be a problem with this approach.

Postsurgery Care

Postsurgical care greatly affects the ultimate outcome of the proce-

dure. Monitoring and support of body temperature, blood volume, and
hydration should continue until those parameters have returned to nor-
mal. The monitoring and treatment of pain is an area that has had only
superficial examination. Avian patients deserve the same care in this
area as would mammalian patients. Butorphanol at a dose of 0.1 to 0.2
mg/kg 1M every 4 to 6 hours, buprenorphine at 0.03 to 0.05 mg/kg 1M
every 12 hours or as needed, has worked well in the author's practice;
however, there is much to be learned about this subject.

Skin-Incision or Radio-Surgical Techniques

The location for the skin incision should be chosen so as to have

minimal effect on feathers and feather tracts and to avoid the blood
supply to major feathers. Using a monopolar tip, the clinician incises the
skin in a single paint brushlike stroke. The skin is lifted with atraumatic
thumb forceps to create a fold in the tissue perpendicular to the incision.
Using the Harrison bipolar forceps, lightly close the tips of the forceps
on this fold at the point where the incision is to be made and activated.
The indifferent pole of the electrode may then be introduced into this
small slit and extended to the limit of the intended incision in one
direction. The tips are closed, and the power is activated as they are
50 JENKINS

drawn along the line of the incision. This creates the opening and
provides hemostasis for all but the most stubborn of vessels. The same
operation is repeated to the opposite limit of the intended incision. The
same technique may be utilized to incise the lower body wall or other
delicate structures where control is important.

Suture Patterns

Suture patterns used in general and microsurgery apply to most

avian surgery. Most psittacine birds simply delicately preen the ends of
the sutures, which is a problem only if knots are not securely tied. This
allows the use of continuous suture patterns in tissues where they may
be vulnerable in other species.

Laparotomy Approaches

The most useful approach to the abdomen is the lateral approach.

The bird is most often positioned in right lateral recumbency with the
left leg retracted and the incision made in the left side (Fig. 2). Feathers
are plucked from the left side, from midbreast to the dorsal body contour
feather tract and axilla to vent. The skin is prepared in a routine fashion
and draped with a self-adhesive drape. The skin incision is made from

/'

Figure 2. Left lateral surgical approach to the bird's coelom. Bird is placed in lateral
recumbency with the wings and left leg restrained dorsally.
 EMERGENCY AVIAN SURGERY 51

the proximal end of the pubic bone to the sixth rib dorsal to the uncinate
process. The left leg may now be further retracted. A branch of the right
femoral artery that extends perpendicular and ventral to the hip joint
must be identified and ligated. An incision is made through the midlat-
erallower body wall musculature parallel and dorsal to the skin incision.
The musculature must be elevated from the underlying coelomic struc-
tures and the incision made with great care and control to protect
underlying structures. The incision is continued through the seventh
and eighth rib. In species larger than cockatiels and small conures, a
section of the ribs may need to be removed or bisected and reflected
for adequate visualization and sufficient exposure when performing
proventriculotomy (gastrotomy) and hysterectomy or when removing
ovarian or testicular masses. Care must be taken not to lacerate the lung
tissue; it may be carefully reflected if needed. The intercostal vessel of
larger species, especially in the most proximal portion of the rib, may
be substantial and may require individual treatment with the bipolar
electrode to prevent or control hemorrhage. A Heiss or other retractor is
applied. Closure is accomplished by placing tension sutures from the
lower body wall musculature to the sixth rib (if the seventh and eighth
have been removed) with 4-0 monofilament synthetic or 4-0 nylon su-
ture. The remainder of the lower body wall musculature and the skin
incision may be closed with 6-0 monofilament or braided synthetic su-
ture.
Another popular approach, the horizontal or transverse, offers good
exposure to a large area of the abdomen. The bird is restrained in dorsal
recumbency, and the feathers of the ventral feather tracts are plucked
from the vent to midbreast. A transverse incision is made in the skin
halfway between the caudal end of the sternum and the vent. The
incision may be extended to the lateral body wall if needed. The lower
body wall muscles are lifted and carefully incised. Closure is accom-
plished in two layers with 4-0 to 6-0 absorbable synthetic suture in a
continuous or interrupted pattern.
The traditional midline approach gives poor visibility to the major-
ity of the coelom. Its usefulness is limited to surgery on the duodenal
and jejunal intestine and keyhole biopsy of the liver, pancreas, and
ventriculus. The approach is made more valuable by extending the
incision laterally along the costal border and/ or along the pubis bone
on one or both sides, creating one or two flaps (Fig. 3). A midline
incision is made and then extended along the ventral aspect of the keel
leaving 2 to 3 mm of lower body wall musculature and muscle sheath
to close the incision. The flap may be extended along the pubis on one
or both sides in a similar fashion. Closure is similar to that for the
transverse approach. These approaches provide the best exposure to
midcoelomic masses, uterine masses, and generalized coelomic diseases
such as egg peritonitis. Care should be taken to limit the size and area
of tissue exposed, the amount of air-sac disruption and the minimum
amount needed to accomplish the surgical task.
Surgery of the crop is most commonly indicated for the removal of
52 JENKINS

\ ~/
I
c o
Figure 3. A, Midline surgical approaches to the ventral coelom . The incision may be
extended along the costal margin (B) and along the pubis (C) to create a flap on one or
both sides (D) of the initial incision to give better access and viability.

foreign bodies and the repair of fistulas that are the results of bums in
hand-fed baby birds. The patient should be anesthetized and intubated
to prevent aspiration of crop contents. Positioning the patient with the
head elevated helps to keep fluids from entering the oral cavity. When-
 EMERGENCY AVIAN SURGERY 53

ever possible, foreign bodies should be retrieved with a blunt, atraumatic

forceps passed from the oral cavity, or the offending object may be
gently massaged up the cervical esophagus into the oral cavity. If inglu-
votomy is required, a skin incision large enough to remove the foreign
object is made over the left lateral portion of the crop. This area is chosen
to avoid large vessels and minimize complications with introduction of
feeding tubes postsurgically. Stay sutures are placed in the crop and an
incision is made one half to one third the size of the skin incision. The
crop is closed with 4-0 to 6-0 synthetic absorbable suture. Burns, re-
sulting from the feeding of hot formula, often result in fistulas, and, in
some cases, significant loss of crop tissue. Damaged skin and crop tissues
must be debrided and sutured separately. The crop is extremely elastic
and appears to heal remarkably well. Placement of a catheter before the
debridement and repair of these lesions aids in the identification of the
crop lumen. Losses of large areas of skin in a burn may require der-
moplasty techniques to close. Closure by secondary intention is possible.

FOREIGN BODY RECOVERY

It is not uncommon for pet birds to be presented with foreign bodies

in the crop. With luck these may be removed blindly before they pass
into the thoracic esophagus. When palpable in the crop, many foreign
bodies may be retrieved per os with a pair of alligator forceps. With the
bird anesthetized, the clinician inserts an endotracheal tube. This is an
important step because retrieval of the foreign material may obstruct the
glottal opening. A pair of blunt alligator forceps are carefully passed
into the crop. The foreign body is palpated and held with one hand and
passed into the open jaws of the forceps. Attention must be paid to the
crop so as not to cause damage during the procedure.
On occasion, foreign objects may be removed from the proventricu-
lus or ventriculus through the oral cavity. Ferrous objects may often be
retrieved with a small magnet attached to the end of a flexible catheter.16
In large species, both flexible and rigid endoscopy equipment may be
used to retrieve foreign bodies.

Proventriculotomy

Proventriculotomy is most commonly indicated for the removal of

foreign objects or toxins not retrievable with a rigid or flexible endoscope
from the proventriculus or ventriculus. Although the technique has been
described, ventriculotomy is generally avoided owing to its greater
vascularity, and its thick walls are difficult to close with an inverted
pattern. A lateral approach is made as described above. Adequate expo-
sure is important to visualize the suspending membranes and to avoid
the vessels of the proventriculus along its greater curvature. The suspen-
sory ligaments must be bluntly dissected, and stay sutures of 3-0 or
54 JENKINS

larger must be placed into the wall of the ventriculus to elevate the
intermediate zone between the proventriculus and ventriculus into the
surgical site. It may be secured with atraumatic forceps attached to the
serosal surface of the ventriculus or by tying the stay sutures to the ribs
at the margin of the incision in the abdominal wall. Stay sutures should
not be placed in the proventriculus. Moistened gauze is used to pack off
and contain any gastric contents that may spill. A stab incision is made
at an avascular area of the isthmus or intermediate zone between the
proventriculus and the ventriculus and extended proximally with scis-
sors. Suction should be ready and should be used to control leakage.
The ventriculus and proventriculus may be explored with blunt forceps.
Harrison recommends the use of a large-bore suction tube and high
volume suction along with aggressive irrigation to empty the stomach
of its contents. Closure of the proventriculus is accomplished with 4-0
to 8-0 synthetic monofilament absorbable suture in a continuous Cushing
pattern. Any spilled stomach contents are carefully removed and the
organs returned to their normal position. No attempt is made to repair
the suspensory ligaments. Closure is as described above.

Enterotomy and Surgery of the Intestine

Enterotomy is an uncommon procedure and usually the result of

trauma to the intestine or accidents at surgery, and it carries a guarded
to grave prognosis. Midline, flap, or transverse approaches may be
appropriate. Magnification and microsurgical instruments and tech-
niques are required. Damaged vessels must be carefully ligated. Anasto-
mosis of the intestine is performed with 6-0 to 10-0 suture with a taper-
point needle (the author prefers a 1/4 circle) and a simple oppositional
technique. Six to eight sutures are typically placed as with vessel anasto-
mosis.

Surgery of the Female Reproductive Tract

Surgery of the female reproductive tract is indicated in cases of egg-

laying-related disorders, egg binding, damage to the uterus, abnormal
egg production, biopsy or culture of the oviduct, egg peritonitis, or as a
sterilization procedure to stop egg laying. A lateral or ventral midline
or flap approach may be chosen, depending on which end of the repro-
ductive tract possesses the problem. Egg binding in birds is most often
a result of problems with calcium metabolism. When presented for egg
binding, calcium levels must be addressed before any anesthesia or
surgical manipulation. Egg-bound birds are often presented with pro-
lapse of the oviductal tissues. In these cases, the distal uterine tissues
have been forced through their cloacal openings into the cloaca and, in
come cases, prolapsed through the vent. It is not uncommon for there
to be a partial volvulus of the oviduct leaving the uterus, making
 EMERGENCY AVIAN SURGERY 55

identification of the luminal opening difficult or impossible. Further,

exposed uterine tissues quickly dry and become necrotic within 30 to 60
minutes of exposure. In cases in which the lumen cannot be identified,
an incision may be made in a nonvascular area of the organ, the egg
gently removed, and the incision closed with 6-0 to 8-0 absorbable suture
and an atraumatic needle with a simple continuous pattern. Necrotic
tissue should be excised and vital tissues sutured if the condition of the
patient permits. With critical or moribund patients, the tissues should
be returned to the cloaca, and surgical correction of the damaged uterus
should be postponed until a more favorable condition is achieved. If an
egg, eggs, or egg fragments are left in the distal oviduct, laparotomy
may be indicated. Incision over the egg easily produces the egg, and the
incision is sutured as described above. Before closing, the distal oviduct
and caudal coelom should be thoroughly examined.
Recurrent egg binding and other chronic or recurrent egg-related
problems are indicated for hysterectomy. The left lateral approach is
utilized. Adequate exposure and visualization is very important. The
incision through the coelomic wall should be made as far dorsal as
possible without the left leg interfering with the exposure. Preparation
is greatly enhanced by the use of a retractor with a short blade, which
does not extend into the coelom and is of a small size (and the widest
possible spread) so as to not be in the way of other instruments outside
the coelom. The ovary may be visualized with retraction of the proven-
triculus laterally and ventrally, and the ventral suspensory ligament of
the proventriculus teased away (Fig. 4). The uterus should be examined
and followed throughout its length before the clinician begins the hyster-
ectomy. Bluntly dissecting the ventral ligament allows the removal of
the bends and folds of the uterus. The infundibulum may then be
bluntly dissected from the ovary with a bipolar electrode. The ovarian
artery is encountered at the base of the infundibulum and must be
ligated with #10 hemostatic clips. A series of three #25 hemostatic clips
are placed at the junction of the uterus and the vagina at the vaginal
sphincter. The dorsal ligament may now be carefully dissected with the
bipolar electrode. Small branches of the ovarian artery should be cauter-
ized with the bipolar electrode or ligated with #10 hemostatic clips.
Closure is as described for the lateral approach.

Air-Sac Intubation

There are several situations in which intubation of an air sac may

be advantageous. These include airway obstructions and procedures
such as surgery or diagnostic tests involving the upper airway. It also
includes surgery of the oral pharynx in which intubation of the glottis
may interfere with the procedure. The tube is most often placed into the
left abdominal air sac because of its relatively greater size, although right
abdominal and cervical air sacs may be used. 14 The bird is positioned in
dorsal or right lateral recumbency and the location for the tube is chosen
56 JENKINS

Figure 4. Hysterectomy of a Senegal parrot. In these two views, cranial and lateral to the
incision (A) and cranial to the incision (B), the parrot is positioned in lateral recumbency.
The left leg is seen in the top of the photos. A lateral celiotomy was performed and a Heiss
Retractor placed. The two microhemostat forceps are attached to the ventral ligament of
the oviduct.

so that it does not interfere with or is occluded by the legs if the tube is
to be left in place in the conscious bird. Most often the tube is placed
just lateral to the ventriculus and medial to the thigh. This places the tip
of the tube in the left abdominal air sac. If the situation permits, the
area is prepared for sterile surgery and a small skin incision is made at
the location of the tube placement. Hemostats or blunt scissors are used
to dissect bluntly through the body wall. A visual inspection is made of
the area deep to the incision to assure a clear area for placement of the
tube. A sterile, shortened endotracheal tube or modified, soft-rubber
 EM ERGENCY AVIAN SURGERY 57

feeding tube is inserted through the hole, and the tube is checked for
patency. A butterfly of tape is placed on the tube and the sutures placed
to attach the tube to the body wall. The tube may now be attached to
the anesthesia machine.

Pharyngostomy Tube Placement

A pharyngostomy tube is indicated in situations in which the crop

needs to be bypassed when feeding an avian patient. This would include
burns or trauma to the crop for which there is significant loss of crop
tissue. The bird is anesthetized and intubated, then placed in lateral
recumbency. An area over the cervical esophagus is prepared for sterile
surgery. In most larger species, a 14-French catheter is chosen because
the inside diameter of the catheter is very close to the outside diameter
of a Luer-tip syringe. For small species under 80 to 100 g, a smaller-
feeding or nasogastric tube can be used and then fitted with a blunt-tip
syringe needle. The catheter is passed into the crop through the oral
cavity and manipulated down the thoracic esophagus and into the
proventriculus. A 1.5-cm incision is made over the tube at the area
prepared over the cervical esophagus, and a loop of the tube 4 to 6 cm
long is pulled through the incision. The tube is cut, allowing the remain-
der to be removed from the mouth. A suture may be placed to reduce
the size of the hole in the esophagus and the skin is closed around the
tube with a 4-0 to 6-0 absorbable suture. The tube is attached to the skin
with adhesive tape and cotton-cast padding covered with an nonadhe-
sive elastic-type bandage (Vetrap Bandaging Tape, 3M Animal Care
Products, St. Paul, MN). The catheter is flushed clean and capped with
a make adapter between uses. The volume of food that can be adminis-
tered into the stomach is much less than that which may be placed into
the crop.

Catheter Duodenostomy

A technique for needle catheter duodenostomy and duodenal ali-

mentation of birds has been described.1 ? The bird is positioned in dorsal
recumbency and prepared for sterile surgery. A 2- to 3-cm incision is
made on the midline from the keel and extended caudally. The duodenal
loop of intestine is identified by the presence of the duodenal arm of the
pancreas between the descending and the ascending segments. A needle-
over-tubing-type of indwelling jugular catheter of 17 to 20 gauge is used
for the duodenal catheter. The needle is placed through the abdominal
wall and then into the descending duodenum. The catheter is advanced
into the ascending duodenum and the needle is withdrawn. One suture
of 5-0 polypropylene is placed between the body wall and the duodenum
at the point of catheter placement. A second suture is placed, securing
the catheter to the outside of the abdomen, with a Chinese-finger snare
58 JENKINS

technique in which a simple interrupted suture is placed and then the

suture ends are tied around the catheter three or four times. The catheter
is flushed to assure patency.
The catheter is routed behind the leg and the wing and finally
attached at the base of the neck with one or more sutures. If medical-
grade tubing is used, it may be routed through a tunnel under the skin
to emerge at the same location. The catheter is capped with a male
adapter and flushed again. The catheter is removed when the Chinese-
finger snare suture is cut and gentle traction is applied to the catheter.

CONCLUSION

Avian surgery is an exercise of preparedness; this is never so true a

statement as in emergency and critical-care situations. The veterinarian
must be prepared through education of avian anatomy, physiology, and
avian surgical techniques; the clinician must also prepare the surgical
suite by the addition of appropriate equipment and supplies. The tech-
niques used in avian surgery are significantly different from those used
in larger species and require microsurgical techniques.
Before initiating a surgical procedure, the patient must be evaluated
and, in many cases, prepared or preconditioned. Only rarely is surgery
such an emergency that the prognosis would not be improved by ready-
ing the patient. Many surgeries are associated with or are the desired
therapy resulting from a critical or an emergency situation. The actual
procedures are too numerous to list here; however, the foundation of
these surgeries involves the techniques described above.

References

1. King AS, McLelland: Coelomic cavities. In Birds: Their Structure and Function. Bailliere
Tindal, 1984
2. King AS, McLelland: Digestive systems. In Birds: Their Structure and Function. Bailliere
Tindal, 1984

Address reprint requests to

Jeffrey R. Jenkins, DVM
Avian and Exotic Animal Hospital
2317 Hotel Circle South, Suite C
San Diego, CA 92108-3310