Small Animal/Exotics 20TH ANNIVERSARY Compendium July 1999

Highlights and Horizons in

Soft Tissue Surgery
Gary W. Ellison, DVM, MS, Diplomate ACVS
Professor and Service Chief, Small Animal Surgery
University of Florida
Gainesville, Florida

he past two decades were truly a

T golden age in the specialty of small

animal soft tissue surgery. Countless
talented surgeons invented, evaluated, and mastered myriad new techniques that
have allowed practitioners to treat conditions previously considered untreatable;
these techniques were often surprisingly successful, resulting in a better quality
of life for patients. The advances have been so numerous that adequate individu-
al recognition is not possible in a short overview of this type. In my opinion,
however, the most significant advances have occurred in the areas of pain man-
agement; oncologic, reconstructive, and abdominal surgery; alternative teaching
methods; and prepubertal gonadectomy.

Pain Management
Before 1979, little thought was given to postoperative pain management in Gary W. Ellison, DVM, MS
small animals. Methods for alleviating postoperative pain were popularized dur-
ing the past 20 years, including topical anesthetic nerve blocks and body cavity tomy and maxillectomy techniques
infusions, epidural opiate administration, injectable and oral nonsteroidal antiin- with excellent cosmetic and function-
flammatory drugs, and transdermal fentanyl patch application.1,2 In the 1990s, al results. Axial skeletal neoplasias,
Hardie and Kyles helped pioneer the development of point systems for more ob- such as osteosarcoma and chondro-
jective pain analysis in small animals and advocated pre- and intraoperative (pre- sarcoma of the face, ribs, and pelvis,
emptive) treatment for pain.1 Preemptive treatment reduced vocalization, aggres- were successfully managed using
sion, restlessness, and/or social withdrawal in animals experiencing pain as well maxillectomy, thoracoplasty, and
as the doses of analgesic and sedative drugs needed to control pain postoperative- hemipelvectomy techniques, respec-
ly.2 Research also showed that pain peaked within 24 hours after minor elective tively. Large soft tissue tumors of the
procedures, whereas more invasive surgical procedures (e.g., thoracotomies, am- thorax and trunk were resected, and
putation) required pain control for 72 hours or longer.1,2 defects were successfully repaired us-
ing prosthetic mesh. Dogs with ap-
Oncologic Surgery pendicular osteosarcoma received
The landmark work of Withrow3 and Salisbury4 in the early 1980s demon- limb-salvage procedures and often
strated how to remove “nonresectable” oral tumors via progressive mandibulec- outlived animals in which amputa-

ENDIU 1979 1980 1983 1984 1987

MP 1980 1983
First successful Axial pattern First Open

1985 19 Clinical feline

M’

20th

CO

portosystemic flaps for mandibulectomy peritoneal renal transplantation

1981
S

shunt ligation reconstructive and drainage is introduced

1 9 7

ANNIVERSARY
9 - 1
9 9 9

1979 is performed surgery are

introduced
maxillectomy
1982
techniques for
oral neoplasia are
performed

1984
for septic
peritonitis is
first described
First description of free
microvascular skin
transfers for wound
reconstruction is
published
19
 Compendium July 1999
tion alone was performed. The use of
lasers in veterinary surgery was also
instituted; carbon dioxide, neodymi-
um-yttrium-aluminum-garnet, and
argon lasers were used for the re-
moval of cutaneous tumors, treat-
ment of perianal fistulas, and treat-
ment of glaucoma, respectively.5
Reconstructive Surgery
Large wound defects are now com-
monly closed with innovative local
transposition flaps and free-tissue
transfers. Pavletic was able to transfer
large vascularized segments of skin in
single stages without the necessity of
a secondary procedure6; during the
1980s and 1990s, at least 11 of these
axial pattern flaps were described.
Because direct cutaneous flaps could
not reach all areas of the body, sever-
al veterinary microsurgeons trans-
ferred cutaneous or myocutaneous
free flaps to distant recipient sites,
usually over joint surfaces or distal
extremities with shear-type injuries.7
Severe distal degloving injuries were
treated by using segments of existing
digital pads to reconstruct weight-
bearing metatarsal and metacarpal
pads, allowing salvage of limbs that
previously would have been ampu-
tated.8
Abdominal Surgery
Major advances have been made
during the past 20 years in under-
standing gastric dilatation-volvulus
(GDV). Free-radical scavengers were
used to reduce gastric ischemia.9 Epi-
demiologic work by Glickman dem-
onstrated a genetic predisposition
toward GDV in Great Danes and
Irish setters with a high thoracic or
abdominal height:width ratio.10 Dogs
fed once daily were reportedly twice
98719901992 1990
1995
Surgical lasers are
1991
Prepubertal gonadectomy
1998
first used in in dogs is
1991
veterinary medicine first described
1994
19891993 1997
986
20TH ANNIVERSARY
as likely to develop GDV compared
with those fed twice daily.10 Many
successful surgical techniques were
developed for the prevention of
GDV, including circumcostal (Fal-
lah), incisional (McCoy), belt-loop
(Whitney), and ventral midline
(Meyer-Lindenburg) gastropexy.11
The first descriptions of subtotal
colectomy for surgical management
of idiopathic megacolon (IM) in cats
were provided by Bright and Rosen
in the early 1980s. This procedure
remains popular for cats with medi-
cally refractory cases of IM. Open
peritoneal drainage was studied by
several surgeons in the mid-1980s
and is now commonly used to treat
severe septic peritonitis in small ani-
mals. White and Williams described
an efficacious prostatic omentaliza-
tion technique for managing recur-
rent prostatic abscesses and cysts that
gave better results than did previous-
ly described techniques.12
In 1979, portosystemic shunts in
dogs and cats were introduced by
Breznock, who later described the
anatomic categories of shunts, ex-
plained the pathophysiology and
medical management of the disease,
and established the guidelines for
portal pressures during ligation.13 A
slow occlusion device was subse-
quently used by Vogt and Krawinkel
in 1993 that lowered the morbidity
associated with partial portosystemic
shunt occlusion.
The first successful feline renal
transplants were reported by Gregory
and Gourley in 1987. Since these
initial transplants, morbidity and
mortality associated with renal trans-
plantation in cats has been greatly re-
duced. There are currently at least six
centers in the United States that per-
1993
First use of gradual
1994–Present
Comprehensive pain
occlusion ring for
portosystemic shunts developed in
small animals
Synthetic models for
instruction of psychomotor
skills are developed
Small Animal/Exotics
OWNERS’ OUTLOOK
■ Anything for Love. The increasing
value owners are placing on their
pets’ companionship is evident
by the amount of money they are
willing to spend on veterinary care
to keep them healthy. In just 5
years—from 1991 to 1996—
annual spending on veterinary
care for cats and dogs rose from
$7 to $11 billion.a
■ The Wave of the Future? As
owners demand more advanced
and specialized care for their pets,
the veterinary profession has
needed to adjust accordingly.
In 1985, there were only 2261
veterinary specialists in the United
States; today, 6293 veterinarians
specialize in an ever-growing
number of fields.a
a
According to the American Veterinary
Medical Association.
form this sophisticated procedure,
with many patients having good to
excellent results.
In 1995, Matthews and Sukhiani
made a significant contribution in
the management of perianal fistulas
with the disclosure that cyclosporine
was effective in improving lesions in
almost 100% of dogs treated, elimi-
nating the need for surgery in half of
the patients.
Alternative Teaching Methods
In the early 1990s, in response to
increased attention to the ethical use
of animals in veterinary curricula,
psychomotor skills laboratories were
implemented to develop students’
technical skills in the laboratory be-
fore working on live animals and
cadavers were substituted for live an-
imals when possible. Several educa-
1997
Risk factors for gastric
control is dilatation-volvulus are
first described
1999
Compendium July 1999 20TH ANNIVERSARY
tors developed simulated models for vessel ligation, hollow
organ closure, and skin and subcutaneous closure.14 Stud-
ies comparing the technical skills of students using live-an-
imal versus simulated models and cadavers indicated that
the technical abilities of the groups were similar.15
Prepubertal Gonadectomy
The effect of prepubertal gonadectomy was studied by
Salmeri, Stubbs, and Bloomberg throughout the late
1980s and early 1990s.16,17 This invaluable work showed
that ovariohysterectomy and gonadectomy before 16
weeks of age is safe in dogs and cats, thereby enhancing pet
population control in North America.16,17
What the Future Holds
Traditional small animal soft tissue surgery as we know
it today will play less of a role in the future. Noninvasive
laparoscopic removal of gallbladders, removal of bladder
stones, spay and neuter techniques, and removal of certain
types of abdominal tumors will be more common. Cold
scalpels will likely be replaced by harmonic scalpels, which
greatly reduce hemorrhage while having a minimal effect
on tissue healing. Surgical laser units will become less cost-
ly and thus more common in veterinary practices. Multi-
specialty practices that provide the latest in surgical proce-
dures, radiation therapy, internal medicine, and intensive
care will continue to proliferate in medium-sized to larger
metropolitan areas, making advanced veterinary care more
logistically available for clients. In the area of organ trans-
plantation, we will see clinical liver, pancreas, intestine,
and even lung transplantation in cats and possibly dogs.
Surgical success rates for various types of neoplasias will
improve using new adjunctive therapies, including gene
and immunomodulating therapy.
Veterinary curricula will rely less on live-animal proce-
dures and more on fabricated models for teaching. Live-
animal research will become more limited because of in-
creasingly stringent animal-use guidelines; therefore, more
techniques and procedures will be applied directly from
Small Animal/Exotics
human studies without prior animal trials. Despite these
hurdles, the next 20 years will be an exciting and dynamic
time in soft tissue surgery.
References
1. Hardie EM, Kyles AE: Pain management in the small animal patient,
in Bojrab MJ (ed): Current Techniques in Small Animal Surgery, ed 4.
Philadelphia, Williams & Wilkins, 1998, pp 3–17.
2. Hansen BD: Analgesic therapy. Compend Contin Educ Pract Vet
16(7):868–875, 1994.
3. Withrow SJ, Holmberg DL: Mandibulectomy in the treatment of
oral cancer. JAAHA 19:273–286, 1983.
4. Salisbury SK, Richardson DC, Lantz GC: Partial maxillectomy and
premaxillectomy in the treatment of oral neoplasia in the dog and
cat. Vet Surg 15:16–26, 1986.
5. Bartels KE: Laser surgery, in Bojrab MJ (ed): Current Techniques in
Small Animal Surgery, ed 4. Philadelphia, Williams & Wilkins, 1998,
pp 45–52.
6. Pavletic MM: Caudal superficial epigastric arterial pedicle grafts in
the dog. Vet Surg 9:103, 1980.
7. Fowler JD, Miller CW, Bowen V, et al: Transfer of free vascular cu-
taneous flaps by microvascular anastomosis: Results in six dogs. Vet
Surg 16:446–450, 1987.
8. Swaim SF, Bradley DM, Steiss JE, et al: Free segmental paw pad
grafts in dogs. Am J Vet Res 54:2161–2170, 1993.
9. Lantz GC, Badlak SF, Hiles MC, Arkin TE: Treatment of reperfu-
sion injury in dogs with experimentally induced gastric dilatation-
volvulus. Am J Vet Res 53(9):1594–1598, 1992.
10. Glickman LT, Glickman NW, Sohellenberg DB, et al: Multiple risk
factors for the gastric dilatation-volvulus syndrome in dogs: A practi-
tioner/owner case-control study. JAAHA 33(3):197–204, 1997.
11. Ellison GW: Gastric dilatation volvulus—Surgical prevention. Vet
Clin North Am Small Anim Pract 23(3):513–530, 1993.
12. White RAS, Williams JM: Intra-capsular prostatic omentalization: A
new technique for management of prostatic abscessation. Vet Surg
24:390–395, 1995.
13. Breznock EM: Surgical manipulation of portosystemic shunts in
dogs. JAVMA 174:819, 1979.
14. Greenfield CL, Johnson AL, Arends MW: Development of
parenchymal abdominal organ models for use in teaching veterinary
soft tissue surgery. Vet Surg 22:357–362, 1993.
15. Carpenter LG, Piermattei DL, Salman MD, et al: A comparison of
surgical training with live anesthetized dogs and cadavers. Vet Surg
20:373–378, 1991.
16. Salmeri KR, Bloomberg MS, Scruggs SL, et al: Gonadectomy in im-
mature dogs: Effects on skeletal, physical, and behavioral develop-
ment. JAVMA 198:1193–1203, 1991.
17. Stubbs WP, Bloomberg MS, Scruggs SL, et al: Effects of prepubertal
gonadectomy on physical and behavioral development in cats.
JAVMA 11:1864–1871, 1996.