Dr. M, a new graduate, was presented with a 5-month-old female DSH kitten for a new patient appointment and follow up ovariohysterectomy (OHE) procedure. Dr. M performed a thorough physical exam, discussed the patient’s history and vaccination status with the client, and submitted preanesthetic bloodwork/testing - complete blood count (CBC), serum biochemistry profile (CHEM), and urinalysis (UA); all of which were within normal limits. Dr. M performed the OHE without any identified complications and the patient was discharged home the same day – alert, active, and eating and drinking.
Two days later, the client took the kitten to the emergency clinic with a complaint of lethargy, vomiting, and straining to urinate for 24 hours. On intake exam, the ER DVM palpated and documented a firm, distended bladder, and subsequent abdominal radiographs revealed the same. CBC/CHEM bloodwork and UA revealed a metabolic acidosis, hyperkalemia, and azotemia. Attempts to manually express the bladder were unsuccessful, as was the insertion of a urinary catheter to attempt to flush and relieve the obstruction and empty the bladder. Given the kitten’s history and recent surgery, lab results, and urgency of the situation with guarded prognosis, the DVM at the emergency clinic performed an abdominal exploratory surgery. The exploratory revealed the uterine horns were wrapped around the neck of the bladder, resulting in a urinary outflow obstruction. Despite relieving the obstruction and recovering from surgery, the kitten died the following day. Dr. M was notified of the surgical error, and subsequently reported a “notice of potential claim” to their professional liability carrier.
OHE
complications are the #1 reported professional liability claim. Why? Because it
is the procedure that is most commonly performed. Surgical complications are a
possibility in any procedure, but safe practices, basic prevention techniques,
and early recognition of problems can minimize risk. The most common
complications of OHE are hemorrhage, pain, swelling, and surgical dehiscence,
but can also include concerns regarding ovarian remnants and the uterine stump,
as well as inadvertent puncture, laceration, or ligation of a ureter or other
adjacent anatomy.
Feline, canine, porcine, equine, and ruminate species possess a bicornuate uterus, which consists of two uterine horns and a uterine body. The uterine horns travel from the ovaries in a caudal direction and join to form the uterine body which lies between the colon and the bladder. When performing an OHE, is important to ensure the uterine body is exteriorized to avoid trauma to the ureters by the clamps or ligature and to make sure the uterine horns are not wrapped around the bladder neck.
Any anatomy can
pose a potential risk if not appropriately identified or treated with care. The
best way to manage complications of OHE is to avoid them through patience and
simple, consistent techniques. Consistency and focus when performing these
techniques of abdominal entry, ligation, and body wall closure can avoid most
complications. When complications occur, they must be addressed using sound
surgical principles, and often, with immediate action. While the wrapping of
the uterine horns around the neck of the bladder resulting in a urinary outflow
obstruction is a rare but serious complication of OHE, most surgeons experience
significant hemorrhage from a uterine stump at least once in their career. It’s
important to isolate and visualize each pedicle every time an OHE is performed
until they can be consistently identified quickly. If a pedicle tears or a
ligature becomes loose or slips off, that is not the time to learn how to find
them quickly! Knowing your anatomy and techniques for performing safe and
simple OHE procedures will drastically reduce complications and incidence of
potential future professional liability claims and board complaints.
Sources:
PubMed: Complications of ovariohysterectomy procedures performed in 1880 dogs https://pubmed.ncbi.nlm.nih.gov/25323211/
dvm360: Preventing and managing spay/neuter complications https://www.dvm360.com/view/preventing-and-managing-spayneuter-complications-proceedings
Clinician’s Brief: Top 5 Complications of Gonadectomy https://www.cliniciansbrief.com/article/top-5-complications-gonadectomy?utm_medium=CB&utm_source=social&utm_campaign=Facebook&fbclid=IwAR2tdBfb-lbVJh39Rg_JXYLPtUF7dNyod08E-GL1EuPYXaCjKwCypy1y3jE