Large Ani. Sx- Equine Female Urogenital 2

wilsbach's version from 2015-11-09 05:23

Perineal lacerations 2

Question Answer
what is a recto-vaginal fistula, and what is the etiology of it?Tear is through vag all the way through rectal wall, but is not continued to outside of body like in 3rd degree laceration. This is a A birth related injury. A foals foot is forced through the dorsal vagina and into the rectum, Then Foot is pulled or pushed back into the vagina to continue the normal birth process. In time there is a marked wound contraction but a fistula routinely persists
when should you consider repairing a recto-vaginal fistual and what pre-op considerations?(same as for 3rd degree laceration, so). wait six weeks or, if the foal is alive, until it is weaned. Dietary considerations the same (soft stools, no straining)
Note about repair of LARGE recto-vaginal fistulas?Large fistulas or those that are six or more inches anterior to the vulva are usually best repaired by making an incision to produce a third degree laceration and then repairing that laceration
describe Technique for the repair of rectovaginal fistulousA horizontal incision is made midway between the anus and the dorsal aspect of the vulva Dissection is continued 2 cm cranial to the cranial edge of the fistula (through the wound margins)--> Interrupted Lembert sutures with the sutures placed in a sagittal direction are used to repair the defect in the rectum (These sutures are placed from the ventral side of the rectum, the knots are tied ventrally and the sutures don't penetrate the rectal mucosa). --> Simple interrupted sutures placed in a transverse direction are used to close the defect in the vagina. The space between the rectum in the vagina starting at the most cranial aspect is closed with simple opposing sutures ALTERNATE PHOTO DESCRIPTION:
explain the vaginal mucosal pedicle flap technique for repair of rectovaginal fistulas in mares

vaginal conditions: Injuries + urine pooling

Question Answer
how are vaginal contusions usually dealt with?usually resolve without complication
how are vaginal hematomas usually dealt with?may occasionally have to be drained
what are varices? how do you deal with them?bigass vericose veins in the vag. Occasionally need to be ligated or injected with a sclerosing agent to prevent continual hemorrhage
a possible complication of a vaginal laceration might be a pelvic abscess. This is usually associated with what, and how is this usually dealt with?Usually associated with persistent straining. Therapy requires adequate drainage
vaginal adhesions: 2D versus 3D?Two dimensional adhesions form a membranous partition (like a persistent hymen). Three dimensional adhesions have height, breadth and extend for a variable depth
how can you help prevent vaginal adhesions?ointments (At the first indication of the formations of adhesions daily dilation and medication to prevent development and to allow epithelialization of the injured surfaces is indicated)
how does one deal with 3 dimentional vaginal adhesions?Dissection must be performed from caudal to cranial to establish a pathway to the cervix and then the area dilated daily until epithelium covers the surfaces
vaginal injuries can lead to peritonitis. what are CS? how do you DX? what is TX?CS: temperature rise, Anxiety and depression, Mild colic, splinted abdomen, Hesitance to move. DX: Abdominocentesis will show high WBC, and a sp Gravity >1.017. TX: High levels of effective antibiotics, Drainage and flushing of the abdomen, Support - fluids, correction of acid base, serum
what is urine pooling? why is it a prob? what is the etiology of this?A pool of urine is present in the anterior vagina. Many think that this results in a marked decrease in conception. Seen most commonly in older mares in poor general condition
what is conservative management of urine pooling?Increase the general condition of the mare to increase vaginal fat
surgical management of urine pooling--> prep/dissection (more on specific techniques in other cards)standing mare- LA or epidural. flush vagina w/ gentle antiseptic. use balfour retractors and stay sutures on lips of vulva for visualization. Extend urethra caudally using the transverse fold and vaginal mucosa. (pic= transverse fold is A)
what are the 4 sx techniques for urovagina?(1) Monin technique (Vestibuloplasty) (2) Brown technique (3) McKinnon technique (4) Shires technique
how do you perform the monin technique to fix urovagina?Transverse fold is grasped and retracted caudally--> Free edge of the transverse fold is removed 2 cm lateral to the midline to the junction of the fold and the vaginal wall on both sides---> The transverse fold is pulled caudally. Incisions are made in the lateral sides of the vagina starting anteriorly at the junction of the transverse fold and the vagina--> The incised edge of the transverse fold is sutured to the incisions made in the lateral sides of the vagina - to pull the urethral orifice caudally
how do you perform the brown technique to fix urovagina? The free edge of the transverse fold is split into a dorsal and ventral layer with a scalpel--> Incisions are continued caudally from the junction of the transverse fold with the wall of the vagina to the vulva--> A continuous horizontal mattress suture is used to appose the ventral flaps of mucosa that were produced by the dissection (everting the cut edges into the tunnel that is produced)--> A continuous suture is used to appose the dorsal flaps of mucosa that were produced by the dissection (everting the cut edges into the vagina)
how do you perform the McKinnon technique to fix urovagina?The same as the Brown technique except only the most ventral layer of tissue is sutured, the dorsal tissues are allowed to heal by second intention
how do you perform shires technique to fix urovagina?A Foley catheter is placed in the bladder--> Interrupted mattress sutures are placed on each side of the catheter to pull the mucosa of the vagina up over the catheter and produce large ridges of mucosa over the catheter--> The everted edges of mucosa are removed with scissors to leave four cut edges of mucosa--> The cut edges of mucosa are sutured in two layers using a simple continuous suture pattern

prolapses of abdominal organs

Question Answer
If prolapse of the bladder occurs through the urethral orifice how do you dx and how do you manage it?DX: The surface of the prolapse is mucous membrane and the openings of the ureters can be identified. TX: epidural--> Thorough cleansing. Massage to relieve edema. Force the everted bladder through the urethral orifice. **you will need to make sure they don't continue to strain- can do this via Continuous epidural, or tracheotomy
if a prolapse of the bladder occurs through the vaginal wall, how do you DX? TX?DX: you will see there is a vaginal laceration is present and The serosal surface of the bladder is visible. TX: Epidural anesthesia--> Thorough cleansing--> Replace bladder in the abdomen--> Suture the laceration--> Antibiotics and abdominal flushing to control peritonitis
why might epidural+ sedation instead of just an epidural be necessary in uterine prolpase of mare? why is this so important to do?Some mares are extremely anxious when the uterus flaps on their rear legs. It is important to sedate and control the mare promptly because excessive trauma may result in rupture of uterine arteries
(uterine prolapse) endometrial hemorrhage is hard to control. what is the best way to control this kind of bleeding?The endometrium is so vascular that ligatures are of little value. Rapid return to normal position is the most effective means of endometrial hemorrhage control
describe the tx of a uterine prolapse in the mareEpidural anesthesia - sedation if necessary. Thoroughly clean uterus. Check carefully for uterine lacerations and repair, if present. Reduce edema via massage. Support the weight of the uterus, then have it Returned to normal position by forcing through the vulva and cervix (Start by applying pressure to the tissue that is close to the vulva and then work all of the prolapse through the vulva and cervix. If there are no uterine lacerations it is sometimes indicated to infuse dilute non irritating antiseptic solution into the uterus to force it back into proper position (the solution should then be siphoned out of the uterus) ). Inject oxytocin to stimulate contraction of the uterus and cervix - after repositioning
what do you NOT do when replacing a prolapsed uterus, and why?Do not use sutures in the vulva to prevent recurrence! a mare can apply enough pressure to tear out sutures in the vulva! Once the uterus has been placed through the cervix and the cervix is contracted the uterus will not prolapse
what can you do to prevent metritis after a uterine prolapse (why are we extra scared of metritis?)metritis is often the forerunner of laminitis! Consider daily infusion and siphoning of the uterus. Local and systemic antibiotics. Banamine (flunixin meglumine)
what is more common in mares- uterine or vaginal prolapse? UTERINE- vaginal prolapse seldom if ever occurs in mares
is there a genetic predisposition leading to weakness-->uterine prolapse?no

Cervical conditions

Question Answer
usual etiology of cervical conditions?Usually secondary to foaling or abortion--> severe stretching/tearing (embryotomy, extended labor, Occasionally damage occurs in a normal delivery)
cervical Loss of tone or ability to contract is usually because...Rupture or stretching of the musculature without involvement of the mucosa
if there is a cervical laceration which only involves the mucosa, what do you do?Those that involve only the mucosa require treatment to prevent adhesions
most cervical lacerations involve what area?Most involve only the segment of the cervix that projects into the vagina (Some involve the entire length of the cervix tho)
how do you tx a cervical laceration detected on post partum exam where only the mucosa is involved?Massage with antibiotic ointments to prevent adhesions
how do you tx a cervical laceration detected on post partum exam where muscular layer is involved?Manage to prevent adhesions (massage with ointments), and Delay repair for 30 to 60 days (may heal andd might not require sx).
what important thing is indicated you need to do prior to repair of post-partm cervical laceration?Complete uterine examination including biopsy is indicated prior to repair (Status of the endometrium is very important!!)
how do you tx Loss of tone of the cervix (no obvious muscular damage)?Purse string suture (not to effective)--> Reduce lumen to insemination pipette size. Use braided nonabsorbable suture. Incise the mucosa at 12 and six o'clock. Insert a buried suture. Suture must be cut prior to delivery
what is used for some relaxation of the cervix for tx of laceration?Isoxsuprine is used by some for relaxation
how do you tx Laceration involving the musculature of cervix (not post-partum, this was in a diff numbered section)(position and anesthesia: Standing with an epidural in stocks, or Standing with pudendal or paracervical blocks has been described, or General anesthesia, may allow better cervical retraction). Isoxsuprine is used by some for relaxation. Removal of a wedge of tissue and suture repair. This is difficult be aided by long bladed Balfour retractors, Shortened Caslick speculum, Long handled instruments, Head lamp, and Traction sutures on either side of the cervix. Closure: Ideal to close with three layers of absorbable suture (difficult tho). To prevent post operative adhesions, massage with abx ointment. Repair is tedious exasperating and requires patient cooperation
downside to repair of cervical lacerations involving the musculature? If successful and the mare becomes pregnant, the tear will probably recur at foaling