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SOFT TISSUE SURGERY

Update on
Ovariohysterectomy
Jacob M. Shivley, DVM, MS
Philip A. Bushby, DVM, MS, DACVS
Wilson Cooper Brookshire, DVM, MS, DACVPM (Epidemiology)
Kimberly Woodruff, DVM, MS, DACVPM (Epidemiology)
Mississippi State University College of Veterinary Medicine

The most commonly performed surgical many practicing veterinarians use, a traditional
procedures in small animal practices in the midline celiotomy approach for OVH.2 The
United States are for reproductive sterilization incision is often one-third to one-half the length
(spay/neuter).1 Surgical sterilization of the female of the distance between the umbilicus and pubis
dog and cat is commonly accomplished via and can be extended in patients with ovaries or a
ovariohysterectomy (OVH). In addition to uterine body that are difficult to exteriorize
sterilization, OVH significantly reduces the (e.g., obese or deep-chested dogs). Traditional
incidence of mammary gland tumors and is OVH techniques include digital strumming of
indicated for diseases such as pyometra, cysts, the suspensory ligament, triple clamping of the
and ovarian/uterine neoplasia. An analysis of the ovarian pedicle, and double ligation of the
veterinary medical literature reveals 4 commonly ovarian pedicles and uterine body. Closure is
used sterilization techniques—traditional midline, often depicted as a standard 3-layer closure.
laparoscopic, flank, and ovariectomy—which will
be highlighted in this update. Often missing from
surgical textbooks, student teaching, and scholarly Laparoscopic Approach
articles are discussions on efficient techniques that Laparoscopic OVH has been established
can be used when performing OVH. The authors as an alternative to the traditional midline
highlight several efficient techniques and other approach and may have advantages
helpful methods that can be used during OVH. (e.g., reduced postoperative pain, reduced
infection rate, and improved visualization of
anatomy). Potential disadvantages include the
REVIEW OF TRADITIONAL AND requirement for specialized equipment and
MODERN OVH TECHNIQUES training as well as the lengthy surgical times.
Surgeons must also overcome the lack of
Traditional Midline Approach depth perception when performing procedures
Veterinary students are commonly taught, and while visualizing a 2-dimensional screen.3

THE VALUE OF TIME

Use of efficient surgical techniques during an
ovariohysterectomy should prove beneficial for the
patient, surgeon, and veterinary business alike.

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A variety of specific techniques, which differ in number limited data have shown that pain scores for cats tend
and location of ports, have been described. However, to be higher among those that underwent flank OVH
most commonly used is the 3 median-portal approach. than among those that underwent midline celiotomy.10
Pedicle hemostasis can be accomplished by using
bipolar/ultrasonic sealing devices, pre-tied ligature For flank OVH, the patient is positioned in left lateral
loops, extracorporeal sutures, hemoclips, and recumbency, a dorsal-ventral incision is made in the
electrocautery. Vessel sealing devices are associated with right flank, subcutaneous tissue is excised, and muscle
less postoperative hemorrhage and shorter surgical fibers of the external abdominal oblique and internal
times;4 however, vessel sealing devices should not be abdominal oblique muscles are bluntly separated. The
used for uterine bodies ≥9 mm due to low uterine peritoneum is incised or bluntly punctured. After the
bursting pressure.5 Laparoscopic OVH outcomes have abdominal cavity has been entered, the right uterine
yet to be compared (by randomized controlled trials) horn is located and the OVH is performed in a manner
with outcomes of efficient surgical techniques that use identical to that of a ventral midline OVH. Apposition
short incisions and have succinct surgical times. The of the internal abdominal oblique muscle, the external
use of laparoscopic approaches should be carefully abdominal oblique muscle, subcutaneous tissue, and
weighed against use of efficient techniques, in which an skin is recommended. The flank spay technique in dogs
efficient open celiotomy can be performed with is reportedly similar to that in cats, but its use in dogs
incision lengths of 1 to 4 cm, and total surgical times is uncommon.11
of 5 to 11 minutes, in cats and dogs respectively.6,7

Ovariectomy
Ovariectomy is the surgical removal of both ovaries
while leaving the uterine tissue intact. When performed
properly, both ovariectomy and OVH result in
Laparoscopic OVH outcomes permanent sterilization. The data vary with regard to
have yet to be compared length of surgical incision, surgical time, and potential
(by randomized controlled for postoperative complications.12,13 In terms of risk,
several recent articles have indicated that risk for
trials) with outcomes of pyometra after ovariectomy or OVH is near zero if all
efficient surgical techniques of the ovarian tissue is removed. Because pyometra is
hormonally dependent, removing the ovaries almost
that use short incisions and completely removes the chance of postoperative
have succinct surgical times. pyometra.14,15

Also, uterine neoplasia after ovariectomy has been

reported, albeit rarely.16 Given conflicting evidence that
one procedure is easier or better for the patient than
the other, and given the existence of rare reports of
Flank OVH neoplasia, surgeons should use their best judgment
In the United States, the standard approach for OVH when deciding if an ovariectomy is indicated.
of the cat is through a ventral midline incision;
however, in other countries, veterinarians prefer a flank
approach. The flank approach has been recommended EFFICIENT OVH TECHNIQUES
for cats with mammary hyperplasia, nursing queens, Use of efficient surgical techniques benefits the patient
and feral cats. One obvious advantage is that the and the veterinary business alike. In both human and
incision avoids mammary tissue. Another advantage is veterinary medicine, increased surgical times have been
that for feral cats, the risk for evisceration in the case of associated with increased risk for anesthetic
dehiscence is less and the surgical wound can be complications and surgical wound infections.17-19
observed without handling the animal.8 One
disadvantage of flank OVH is that for Siamese and Decreased surgical times should lead to faster recovery
Burmese cats, the fur may grow back a different color.9 and return to function for the patient. Therefore,
Postoperative pain has been a matter of debate, but keeping duration of surgery and anesthesia to a

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minimum is imperative. Techniques to accomplish this recumbency) and laparoscopic OVH (tilted table).
can include creating shorter incisions, adopting Traditionally, the patient’s forelimbs are secured by
efficient ovarian pedicle disruption and ligation pulling them as far cranially as possible. In the authors’
techniques, and using more efficient suture patterns. experience (approximately 80,000 spay/neuter surgeries
performed over the past 15 years), positioning the
From a business standpoint, more-efficient surgeries patient’s forelimbs caudally, lateral to the patient’s
should decrease costs. A recent study found that use of thorax, is advantageous (FIGURE 1). There are several
the pedicle tie procedure in cats decreased surgical time ways to accomplish this positioning, but using a simple
by 2 minutes compared with double-ligation of the device created from bending aluminum splint rods
ovarian pedicles with suture ligature.6 Another study enables efficient placement and ease of disinfection
argued that sharply transecting the suspensory ligament (FIGURE 2). This position improves efficiency by
reduces time by 1.1 minutes per animal and could add minimizing abdominal body wall tension, improving
up to a substantial savings of time and resources suspensory ligament exposure, and allowing for shorter
(anesthetic drug costs and surgeon compensation).7 incisions and reduced tissue handling.
Were a clinic to perform 4000 OVHs in a year and
simply apply the 2 efficient techniques mentioned here,
206 hours could be saved, enabling the surgeon to Incision Length and Placement
complete more surgeries or see more appointments. OVH is more efficient when performed through an
appropriately placed small incision. In general, the
longer the spay incision, the more time it takes to close.
Patient Positioning The proper location of the spay incision is predicated
OVH is typically performed with the patient in dorsal on which reproductive structures are more difficult to
recumbency. Exceptions include flank spays (left lateral exteriorize and should vary accordingly. In cats, the
uterine body is more caudally situated in the abdomen
than it is in dogs; therefore, the abdominal midline
incision in cats should be situated more caudally. It has
been the authors’ experience that in dogs, the ovaries
are the most difficult structure to exteriorize, and it was
found that a more cranial incision in dogs facilitates
exteriorizing the ovaries and disrupting the suspensory
ligaments. The incision for puppies (5 months or
younger) is located midway between that of a cat and
an adult dog.

FIGURE 2. Various sizes of bent splint rods used to position

patients’ forelimbs in a caudal and lateral position, thereby
relaxing the abdominal body wall and easing the sharp
FIGURE 1. Caudally positioned forelimbs for OVH in a puppy. transection of suspensory ligaments.

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A For cats and kittens, the incision should be centered at

the midpoint between the umbilicus and the cranial
brim of the pubis (0.5 to 1.5 cm long) (FIGURE 3A).
Its length is usually no more than a third (usually less)
of the length from the umbilicus to the cranial brim of
the pubis. The skin incision for an adult dog is typically
just caudal to the umbilicus (2 to 4 cm long)
(FIGURE 3B). It is a third of the length or less from
umbilicus to cranial brim of the pubis. For a puppy, the
caudal-most aspect of the skin incision should be at the
midpoint between the umbilicus and the cranial brim
of the pubis (1 to 2 cm long) and is usually a fourth of
the length or less from umbilicus to cranial brim of the
B pubis (FIGURE 3C AND D).

Disrupting the Suspensory Ligament

Veterinary students have traditionally been taught to
digitally strum the suspensory ligament until it
stretches or tears away from the peritoneum.20 However,
a recent randomized controlled trial demonstrated the
safety and efficiency of sharp transection of the
suspensory ligament.7 This technique saves time and
provides less nociceptive input to the patient. In larger
adult dogs with strong suspensory ligaments,
depending on surgeon hand strength, sharp transection
C may be the only way to disrupt the ligament. Sharp
transection enables the surgeon to visualize the tissue to

D
cat spay incision

adult dog spay incision

puppy spay incision

Head × Pubis
FIGURE 4. Sharp transection. To perform, place a Kelly
Umbilicus
hemostatic forcep on the proper ligament, palm the forcep
with the nondominant hand, and apply upward traction
on the suspensory ligament. The index finger is situated
down the tensed suspensory ligament, causing the ovarian
FIGURE 3. OVH incision placement and length in (A) pedicle to lie on the caudal aspect of the index finger
cat, (B) adult dog, and (C) puppy. Incision (black line); (black arrow) and the suspensory ligament to become
umbilicus (blue arrow); cranial brim of the pubis (yellow separated from the ovarian pedicle and lie on the cranial
arrow). (D) Efficient OVH incision length and placement for aspect of the index finger (yellow arrow). Sharp transection
cat, adult dog, puppy. May vary with species, age, and body is performed in the visualized zone of transection
condition. (yellow arrow).

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be transected instead of blindly ripping tissue away obese, or pregnant animals. A recent prospective study
from the body wall (FIGURE 4). reported no perioperative complications after ligation
of canine ovarian pedicles with a single ligature.7

Ligatures
Veterinary students are also often taught to tie multiple Pedicle Tie
ligatures per structure, using square and surgeon knots. The pedicle tie is an instrument self-tie used to ligate
However, recent publications have demonstrated the ovarian vessels in the cat during OVH.6,23 It is similar
excellence of 2-pass binding knots.21,22 After a surgeon to the cord tie frequently used to ligate spermatic cords
has mastered appropriate knot security with these in the castration of cats and puppies. For a pedicle tie,
binding knots, placing one excellent ligature per the ovarian vessels are wrapped around a mosquito
structure can increase efficiency, lower the cost for hemostat and a knot is tied by using the vessels
suture material used, and decrease the amount of themselves (FIGURE 5). The knot should be gently
foreign material placed in the abdomen. For dogs, tightened before the hemostat is released.23 The absence
single ligation with a strangle knot or other appropriate of fat and increased elasticity in the feline ovarian
2-pass binding knot can provide proper hemostasis for pedicle allows isolation and placement of a secure knot.
most ovarian pedicles and uterine bodies encountered The pedicle tie can be safely and effectively performed
during OVH. Exceptions may include giant breed, in any female domestic cat, regardless of body size or

A B

C D

FIGURE 5. Pedicle tie. To perform the pedicle tie, place a straight mosquito hemostat on the proper ligament. Sharply transect the
suspensory ligament and fenestrate the broad ligament caudal to the ovarian vessels. With the ovary pulled toward the surgeon,
the surgeon’s dominant hand is supinated and the tip of a curved hemostat is crossed over the vessels (A) and placed into the
hole in the broad ligament behind the ovarian vessels. With the hemostat closed, the surgeon’s hand is then pronated in order to
“scoop” under the ovarian pedicle and prepare for the counterclockwise twist (B). The tip of the hemostat is then directed above
the vessels, and the hemostat is rotated counterclockwise until the hemostat faces the surgeon. This action causes the ovarian
vessels to be wrapped around the hemostat. The hemostat should then be opened and used to clamp the ovarian vessels (C). Cut
the ovarian vessels between the hemostat and the ovary, gently push the tissue off the end of the hemostat, and gently tighten to
secure the knot (D).

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reproductive status. In a study of approximately 2000 decrease the amount of time associated with closure.
cats involving pedicle tie use during OVH, only 1 These incisions can often be closed with 1 to 2 cruciate
incident of postoperative ovarian vessel hemorrhage sutures in the body wall and 1 to 2 buried simple
occurred (complication rate of 0.023%).6 However, the interrupted sutures that incorporate the subcutaneous
pedicle tie should not be used for OVH of the dog. tissue and skin together (FIGURE 6).

Longer incisions often used for OVH of the adult dog

Closure (3 to 4 cm) and extended incisions may be more
Much of the surgical time associated with a routine efficiently closed with a “continuous-continuous”
OVH is spent closing the incision. Learning to perform pattern (FIGURE 7). To create this pattern, the external
OVH through smaller incisions (2 cm or less), rectus sheath should be closed in a standard simple
especially in cats, puppies, and small adult dogs, will continuous pattern from the surgeon’s dominant hand
toward the nondominant hand. Remember that the
function of the body wall closure is apposition, not
A ligation.

SUMMARY
OVH has found its place as one of the most commonly
performed surgical procedures in veterinary medicine.
The surgeon should choose specific surgical techniques
according to skill, surgical equipment available, and
technical efficiency, all while being mindful of what is
best for the patient. An awareness and use of efficient
surgical techniques should prove beneficial for the
patient, surgeon, and veterinary business alike.
B

References
1. Greenfield CL, Johnson AL, Schaeffer DJ. Frequency of use of various
procedures, skills, and areas of knowledge among veterinarians in
private small animal exclusive or predominant practice and proficiency
expected of new veterinary school graduates. JAVMA
2004;224(11):1780–1787.
2. Kennedy KC, Tamburello KR, Hardie RJ. Peri-operative morbidity
associated with ovariohysterectomy performed as part of a third-year
veterinary surgical-training program. J Vet Med Educ
2011;38(4):408–413.
3. Levi O, Kass PH, Lee LY, et al. Comparison of the ability of veterinary
medical students to perform laparoscopic versus conventional open
ovariectomy on live dogs. JAVMA 2015;247(11):1279–1288.
C 4. Mayhew PD, Brown DC. Comparison of three techniques for ovarian
pedicle hemostasis during laparoscopic-assisted ovariohysterectomy.
Vet Surg 2007;36(6):541–547.
5. Barrera JS, Monnet E. Effectiveness of a bipolar vessel sealant
device for sealing uterine horns and bodies from dogs. Am J Vet Res
2012;73(2):302–305.
6. Miller KP, Rekers W, Ellis K, et al. Pedicle ties provide a rapid and safe
method for feline ovariohysterectomy. J Feline Med Surg
2016;18(2):160–164.
7. Shivley JM, Richardson JM, Woodruff KA, et al. Sharp transection of
the suspensory ligament as an alternative to digital strumming during
canine ovariohysterectomy. Vet Surg 2019;48(2):216–221.
8. Levy J. Feral cat management. In: Miller L, Zawistowski S, eds. Shelter
Medicine for Veterinarians and Staff. Ames, IA: Blackwell Publishing;
2004:377–388.
9. Yates D, Goetz U. Flank or midline ovariohysterectomy in the cat?
FIGURE 6. Buried simple interrupted closures for incisions
Companion Animal 2016;21:89–94.
that are 2 cm or less. Note how the closure incorporates
both the subcutaneous tissue and skin together (A AND B), 10. Burrow R, Wawra E, Pinchbeck G, et al. Prospective evaluation of
postoperative pain in cats undergoing ovariohysterectomy by a
forming a secure, cosmetic closure (C).
midline or flank approach. Vet Rec 2006;158(19):657–661.

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A B C

D E F

G H I

FIGURE 7. The “continuous-continuous” pattern for use in incisions that are 3 cm or longer. (A) To ensure knot security, each body
wall knot should have a minimum of 6 throws. The first 2 throws should be only tight enough to snuggly appose the body wall,
followed by 4 tight throws to secure the knot. (B AND C) Without cutting the loop away from the second body wall knot (instead,
cut only one side of the loop to create a longer tag), move directly to a continuous pattern in the subcutaneous tissue, moving
from the nondominant hand toward the dominant hand. (D) After the end of the incision is reached and the dead space is closed,
proceed directly into a subcuticular pattern, without tying a knot in the subcutaneous layer. (E) The subcuticular pattern is now
moving from the dominant hand toward the nondominant hand. (F AND G) At the end of the subcuticular pattern, a “deep strand”
is created by taking a bite of dermis in a superficial-to-deep direction. (H) This strand can now be tied back to the initial tag kept
from the external rectus sheath closure. (I) This efficient closure apposes 3 layers of tissue with only 3 total knots.

11. Reece J, Nimesh M, Wyllie R, et al. Description and evaluation of a 18. Haley RW, Culver DH, Morgan WM, et al. Identifying patients at high
right flank, mini-laparotomy approach to canine ovariohysterectomy. risk of surgical wound infection: a simple multivariate index of patient
Vet Rec 2012;171(10):248–248. susceptibility and wound contamination. Am J Epidemiol
12. Tallant A, Ambros B, Freire C, Sakals S. Comparison of intraoperative 1985;121(2):206–215.
and postoperative pain during canine ovariohysterectomy and 19. Burrow R, Batchelor D, Cripps P. Complications observed during
ovariectomy. Can Vet J 2016;57(7):741–746. and after ovariohysterectomy of 142 bitches at a veterinary teaching
13. Swaffield MJ, Molloy SL, Lipscomb VJ. Prospective comparison of hospital. Vet Rec 2005;157(26):829–833.
perioperative wound and pain score parameters in cats undergoing 20. Hill LN, Smeak DD. Suspensory ligament rupture technique during
flank vs midline ovariectomy. J Feline Med Surg 2019;22(2):168-177. ovariohysterectomy in small animals. Compend Contin Educ Vet
14. Kayla M, Michelle A, Philipp D, Jeffrey J. Outcome of laparoscopic 2010;32(6):E1-7.
ovariectomy and laparoscopic-assisted ovariohysterectomy in dogs: 21. Smeak DD, Hazenfield KM. Creating a leak-proof ligature with
278 cases (2003-2013). JAVMA 2017;251(4):443-450. confidence, part 1: overview of ligation & surgical binding knots.
15. Boursier JF, Bassanino J, Leperlier D. Effectiveness of a bipolar vessel todaysveterinarypractice.com/creating-a-leak-proof-ligature-with-
sealant device for ovariohysterectomy in cats with pyometra. J Feline confidence-part-1-overview-of-ligation-surgical-binding-knots.
Med Surg 2018;20(12):1119-1123. Accessed January 2020.

16. Conversy B, Freulon AL, Graille M. Focal uterine T-cell lymphoma in an 22. Hazenfield KM, Smeak DD. In vitro holding security of six friction knots
ovariectomized cat. JAVMA 2017;251(9):1059-1063. used as a first throw in the creation of a vascular ligation. JAVMA
2014;245(5):571–7.
17. Nicholson M, Beal M, Shofer F, Brown DC. Epidemiologic evaluation
of postoperative wound infection in clean-contaminated wounds: a 23. Bushby P. Surgical techniques for spay/neuter. In: Miller L, Zawistowski
retrospective study of 239 dogs and cats. Vet Surg S, eds. Shelter Medicine for Veterinarians and Staff. 2nd ed. Ames, IA:
Wiley-Blackwell; 2013:625–645.
2002;31(6):577–581.

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Become an
Animal
Jacob M. Shivley
Dr. Shivley obtained his DVM degree from
Mississippi State University College of
Veterinary Medicine in 2008, followed by

Advocate
a rotating internship. He then completed a
surgical internship at Wheat Ridge Animal
Hospital in Wheat Ridge, Colo. After 3 years
in small animal practice, he returned to MSU

Today!
as faculty of the shelter medicine program.
In 2019, he obtained his master’s degree
with an emphasis on teaching and learning.
His interests include veterinary medical
education and HQHVSN techniques. He is
passionate about songwriting and worship
music and is the worship pastor at his church.

Philip A. Bushby
Dr. Bushby, a 1972 graduate of the University
of Illinois College of Veterinary Medicine,
is a board-certified surgeon who has
served on the MSU faculty for 42 years. He
established the MSU CVM shelter program
and is a frequent speaker on efficient spay/
neuter techniques. He was a member of
the organizing committee for the shelter
medicine specialty board, received the
ASPCA Henry Berg Award in 2008, the
AVMA Animal Welfare Award in 2012, and
the Association of Shelter Veterinarians
Meritorious Service Award in 2015.

Wilson Cooper Brookshire

Dr. Brookshire is a 2010 graduate of the MSU
CVM. After 5 years of companion animal
practice in Germantown, Tenn., he joined
the faculty of MSU. He is a diplomate of the
ACVPM as well as the ACVPM Epidemiology
Specialty. He holds a master’s degree
in population medicine from MSU and a
graduate certificate in shelter medicine from
the University of Florida. He is a member of
the AVMA Committee on Antimicrobials and
is the 2020 Mississippi Veterinary Medical
Association Young Veterinarian of the Year.

Kimberly Woodruff
Dr. Woodruff obtained her DVM degree
from MSU in 2008. She completed a 1-year
shelter medicine internship, followed by a
3-year shelter medicine residency in 2012,
at which time she joined the faculty at MSU.
She became a diplomate of the ACVPM in
2016 and was board certified in veterinary
epidemiology in 2017. Her interests include
disease control, shelter epidemiology, and
teaching HQHVSN in the curriculum at MSU.

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