Complications in Equine Surgery

COMPLICATIONSIN EQUINESURGERY
COMPLICATIONSINEQUINESURGERY
Edited by
LuisM.Rubio-Martinez
and
DeanA.Hendrickson
This edition first published 2021
© 2021 by John Wiley & Sons, Inc
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Library of Congress Cataloging•in•Publication Data

[Names: Rubio Martinez, Luis M., editor. | Hendrickson, Dean A., editor.
Title: Complications in equine surgery / edited by Luis M. Rubio Martinez,
Dean A. Hendrickson.
Description: Hoboken, NJ : Wiley-Blackwell, 2021. | Includes
bibliographical references and index.
Identifiers: LCCN 2020025496 (print) | LCCN 2020025497 (ebook) | ISBN
9781119190073 (hardback) | ISBN 9781119190080 (adobe pdf) | ISBN
9781119190158 (epub)
Subjects: MESH: Horse Diseases–surgery | Intraoperative
Complications–veterinary | Postoperative Complications–veterinary |
Horses–surgery | Surgery, Veterinary–methods
Classification: LCC SF951 (print) | LCC SF951 (ebook) | NLM SF 951 | DDC
636.1/089–dc23
LC record available at https://lccn.loc.gov/2020025496
LC ebook record available at https://lccn.loc.gov/2020025497]
Cover Design: Wiley
Cover Images: courtesy of Sussex Equine Hospital, Tanya Bricker, Dean Hendrickson
Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
Dedicated to Eva, Marcos, and Olivia, for their love, patience, and support.
Luis M. Rubio•Martinez
Dedicated to Amy for her love, patience, and continued support of my crazy endeavors.
Dean A. Hendrickson
vii
Contents
Foreword xi
Preface xiii
Acknowledgements xv
List of Contributors xvi
1 Surgical Complications 1
Luis M. Rubio-Martinez and Dean A. Hendrickson
2 Complications of Parenteral Administration of Drugs 10

Julie E. Dechant
3 Complications of Intravascular Injection and Catheterization 16

Julie E. Dechant
4 Complications of Endoscopy 25
Julie E. Dechant
5 Complications of Nasogastric Intubation 29

Julie E. Dechant
6 Complications of Fluid Therapy 36

Angelika Schoster and Henry Stämpfli
7 Complications Associated with Hemorrhage 57

Margaret C. Mudge
8 Complications of Blood Transfusion 64

Margaret C. Mudge
9 Complications Associated with Sutures 70

Ian F. Devick and Dean A. Hendrickson
10 Complications of Bone Graft Harvesting, Handling, and Implantation 79

Lynn Pezzanite and Laurie R. Goodrich
11 Complications of Cryosurgery 87
Ann Martens
12 Complications of Laser Surgery 95

Kenneth E. Sullins
viii Contents
13 Complications of Systemic Analgesic Drugs 109

Maria Amengual-Vila and Eva Rioja Garcia
14 Complications of Loco-Regional Anesthesia 118

Eva Rioja Garcia
15 Complications of Sedative and Anesthesia Medications 135

Rachel C. Hector and Khursheed Mama
16 Complications During Recovery from General Anesthesia 154

Alexander Valverde
17 Complications Associated with Surgical Site Infections 168

Denis Verwilghen and J. Scott Weese
18 Complications of Reconstructive Surgery 196

Jacintha M. Wilmink and Debra C. Archer
19 Complications of Excessive Granulation Tissue 204

Jacintha M. Wilmink and Debra C. Archer
20 Complications of Skin Neoplasia 212

Debra Archer and Jacintha M. Wilmink
21 Complications of Skin Grafting 222

Debra C. Archer and Jacintha M. Wilmink
22 Complications of Oral and Salivary Gland Surgery 233

Patrick Martin Dixon and Richard J.M. Reardon
23 Complications of Esophageal Surgery 254

Louise L. Southwood
24 Complications of Stomach Surgery 265

Louise L. Southwood
25 Complications of Splenic Surgery 272

Eileen Sullivan Hackett
26 Complications of Abdominal Approaches 279

Shauna P. Lawless and Eileen Sullivan Hackett
27 Complications of the Intraoperative Colic Patient 291

Anje G. Bauck and David E. Freeman
28 Complications of the Postoperative Colic Patient 310

Louise L. Southwood
29 Complications of Surgery of the Rectum and Anus 374

Michael A. Spirito
Contents ix
30 Complications of Abdominal Surgery: Incisional Hernia 378

John P. Caron
31 Complications of Equine Laparoscopy 391

Donna L. Shettko and Dean A. Hendrickson
32 Complications of Endoscopic Laser Surgery 404

Jan F. Hawkins
33 Complications Following Surgery of the Equine Nasal Passages and Paranasal Sinuses 413
Lynn Pezzanite and Jeremiah T. Easley
34 Complications of Pharynx Surgery 427

Norm G. Ducharme and Fabrice Rossignol
35 Complications of Larynx Surgery 438

Fabrice Rossignol and Norm G. Ducharme
36 Complications of Surgery for Diseases of the Guttural Pouch 468

Anje G. Bauck and David E. Freeman
37 Complications of Equine Tracheal Surgery 488

John Peroni
38 Complications of Equine Thoracic Surgery 491

John Peroni
39 Complications of Testicular Surgery 498

James Schumacher and Thomas O’Brien
40 Complications of Penile and Preputial Surgery 522

41 Complications of Ovarian and Uterine Surgery 532

42 Complications of Vulvar, Vestibular, Vaginal, and Cervical Surgery 550

43 Complications of Urinary Surgery 571

Sara K.T. Steward and Luis M. Rubio-Martinez
44 Complications of Diagnostic Tests for Lameness 583

Ellen R. Singer
45 Complications of Synovial Endoscopic Surgery (Arthroscopy, Tenoscopy, Bursoscopy) 601

Troy N. Trumble and Michael C. Maher
46 Complications of Equine Orthopedic Surgery 629

Kyla F. Ortved and Dean W. Richardson
x Contents
47 Complications of Surgery of the Equine Foot 667

Britta S. Leise
48 Complications of Surgical Correction of Angular Limb Deformities 683

Robert Hunt and Amy M. Buck
49 Complications of Surgical Correction of Flexural Limb Deformities 694

Belinda Black and James R. Vasey
50 Complications of Splint Bone Fractures 718

Timothy Lescun
51 Complications of Craniomaxillary and Mandible Fractures 730

Timothy Lescun
52 Complications of Tendon Surgery 739

Roger K.W. Smith
53 Complications of Muscle Surgery 757

Brad Nelson
54 Complications of Regenerative Medicine 769

Ashlee E. Watts
55 Complications of Osseous Cyst-Like Lesions 774

Ashlee E. Watts
56 Complications of Equine Ophthalmic Surgery 779

Kate S. Freeman and Dennis E. Brooks
57 Complications of Diagnostic Procedures of the Nervous System 815

Laura Johnstone
58 Complications of Anterior Cervical Fusion 826

Barrie DonLeo Grant
59 Complications of Surgery for Impingement of Dorsal Spinous Processes 833

Luis M. Rubio-Martinez
60 Complications of Peripheral Nerve Surgery 843

Yvonne A. Elce
Index 855
xi
Foreword
When I was invited to write this foreword to the book communication and thorough documentation will help
Complications in Equine Surgery, Dr. J.D. Wheat’s (R.I.P.) avoid litigation or, at the very least, prepare for it. The art of
wise insight at the outset of my equine surgery residency communication will help the experienced surgeon navi-
immediately came to mind. He was then an internationally gate these knotty situations, and junior surgeons and resi-
renowned equine surgeon at the University of California, dents should listen well and consult and learn from more
Davis, and a man of few, but often “powerful” words! I had experienced colleagues. Talking to a colleague about the
a case that developed a wound infection after the place- surgical error [1] may also help to reduce the emotional
ment of an implant following an eye enucleation. A col- burden incurred by the surgeon implicated.
league passed by and encouragingly piped up that it never The word complication is derived from the Latin word
happened to their cases! Dr Wheat’s retort was: “If it didn’t complicare for a fold, the opposite to smooth – the desired
happen, it is because you never did enough!” outcome following a surgical intervention. F.D. Roosevelt’s
The editors, Luis Rubio-Martinez and Dean Henrickson, statement “A smooth sea never made a skilled sailor” is fit-
are to be commended for tackling this challenging, impor- ting for surgery and surgeons! The words complication and
tant surgical topic. They are experienced and internationally adverse event, although they have different meanings, are
renowned equine surgeons and appropriate leaders for this often used interchangeably. Adverse events have been
tome. They have lined up an impressive team of knowledge- defined as “an unintended injury or complication resulting
able equine surgeons from all over the world, with pertinent in prolonged length of hospital stay, disability at the time of
expertise to address the plethora of complications that may discharge, or death caused by healthcare management and
arise following equine surgical interventions. not by the patients’ underlying disease” [2]. Adverse events
Complications are, unfortunately, part and parcel of our may cause preventable equine patient harm, prolong hospi-
surgical discipline. Indeed, they are perhaps one of the most talization, and increase costs. It is interesting that most
challenging parts of our working lives. Paradoxically, a lack of adverse events in human hospitals are associated with
exposure during residency training can leave less experienced surgery [3]. Furthermore, surgeons should note that non-
surgeons feeling ill-equipped to deal with them. A variety of operative management errors were more frequent than errors
emotional responses are triggered when surgical complica- in surgical techniques and included monitoring, incorrect or
tions arise. Depending on experience, these may include feel- delayed treatment, diagnostic error. or delay [4]. Complications
ings of failure, guilt, shame, anxiety, or embarrassment. For may be a consequence of an adverse event, but an adverse
some, a natural instinct is “fight or flight,” while others choose event may occur without complication.
to “bury their head in the sand,” or worst of all – blame others. Careful surgical planning (patient, surgical theatre, and
Although the equine surgical patient may be harmed and the equipment) and communication with the surgical team,
first victim of a surgical technical error, the surgeon may also intraoperative technique, and perhaps most important,
be the second victim in emotional terms [1], particularly non-operative management, should keep complications to
when serious complications arise. a minimum.
It is usually a humbling experience that we should learn Unfortunately, evidence-based information on complica-
from. The ideal approach when complications arise is to tions in equine surgery is not always available, as some of
accurately diagnose the nature of the problem, analyze the the equine surgical complications are extremely rare and
cause, treat it to the best of our ability using an evidence- treatment depends on the creativity and experience of the
based approach, and learn from it. Rapid disclosure of attending surgeon at the time. This is often the real-life
adverse events to the horse owner with good professional situation!
xii Foreword
Future efforts to improve patient safety should target junior surgeons, to provide guidance on decision-making
research on the leading causes of potentially preventable in challenging cases. It will provide access to the experi-
equine patient surgical harm, identified from collected ence of many expert surgeons. Niels Bohr stated that “an
data on the frequency, severity, and preventability of expert is a person who has made all possible mistakes in a
adverse events. The Clavien-Dindo classification of surgi- small field!” Hopefully, this body of work will inspire and
cal complications, now widely employed in human sur- pave the way for new research studies on this topic to move
gery, or variations thereof, would be a useful tool for this important surgical field forward.
grading complications in future equine studies [5].
A text book addressing this subject is timely, unique, and Professor Sheila Laverty MVB DACVS DECVS.
fills an important niche and will be an invaluable and com- Faculty of Veterinary Medicine, University of Montreal,
forting “go-to” resource, particularly for less experienced St. Hyacinthe, Canada
References
1 Wu, A. (2000). Medical error: the second victim. The doctor events among hospital patients in Canada. J.A.M.C. 170:
who makes mistakes needs help too. B.M.J. 320 (7237): 1678–1686.
726–727. 4 Anderson, O., Davis, R., Hanna, G.B., et al. (2013). Surgical
2 Brennan, T.A., Leape, L.L., Laird, N.M., et al. (1991). adverse events: A systematic review. Am. J. Surg. 206 (2):
Incidence of adverse events and negligence in hospitalized 253–262.
patients. Results of the Harvard Medical Practice Study I. 5 Dindo, D., Demartines, N., and Clavien, P.A. (2004).
N. Engl. J. Med. 324: 370–376. Classification of surgical complications: a new proposal
3 Baker, G.R., Norton, P.G., Flintoft, V., et al. (2004). The with evaluation in a cohort of 6,336 patients and results of
Canadian adverse events study: the incidence of adverse a survey. Ann. Surg. 240 (2): 205–213.
xiii
Preface
As surgeons we read and learn with enthusiasm about surgi- for residents when they are questioned by their mentors
cal treatments and techniques and enjoy performing those about unexpected signs, possible complications, reasons,
on our patients aiming to achieve a successful outcome for and how those could have been prevented and be treated at
them. That successful outcome is the result of many factors the time. The stress also extends to client communication, as
including good knowledge and technique, mentorship, the effect of those complications on the outcome of that par-
interaction with peers, experience and, of course, the avail- ticular patient may not be readily described in the scientific
ability of evidence-based literature and resources. literature. All these bumps along the way can be referred to
Publications in the form of textbooks and journals play a as complications that jeopardize the well-desired successful
central role in our individual training and progression, and outcome for our patients. Although we will not be able to
will remain as key in the further evolvement of equine sur- save all patients, the science to accurately predict, diagnose,
gery and formation of new equine surgeons. As residents we and manage complications, in addition to training and expe-
feel thrilled and enormously satisfied when we observe how rience, hopefully give the surgeon the ability to adapt to
application of those surgical treatments translates into sur- those less-than-ideal situations while providing the means
vival of our patients. It is with great satisfaction when as sur- to achieve the best successful outcome for that patient.
geons we remove gloves, gown and mask at the end of a The editors are delighted to present this new textbook
surgical procedure that has been completed effectively. The Complications in Equine Surgery. The original idea of this
satisfaction is bigger when the patient gets discharged from project came from one of the editors (LRM) during his
the hospital and increases further when we learn from own- early years as a surgery resident and young equine sur-
ers, trainers or referring veterinarians that the patient has geon. In 2014, LRM and DAH started with the design of
successfully returned to their previous or intended use. the project and in 2015 Wiley Blackwell came on board.
However, as surgeons we all learn that many hurdles are to After another 6 years we are finally seeing the project
be cleared in the pre-, intra-, and postoperative periods to completed. The aim of this project was to gather relevant
reach that successful outcome. On occasions, there are and important information to increase awareness, literacy,
unforeseen circumstances or factors that we may not be able and evidence on the prevention, identification, and man-
to control or that escape our individual experience. agement of complications commonly associated with
We all have experienced surgeries that do not go according diagnostic and surgical procedures performed on equine
to plan, despite having cautiously read and memorized all patients. Literature resources of this kind are common
steps of the surgical procedures. Not uncommonly, we and abundant in human medicine but limited in equine
encounter individual variations, intraoperative incidents or surgery, and veterinary medicine in general. The editors
situations that may escape the standard descriptions in the present this textbook in a format that markedly differs
literature. Surgical steps may be carefully followed without from other equine and veterinary textbooks. Complications
guarantee that they will translate into results as described in are the mainstay of the chapters, which are divided into a
textbooks or papers. In the postoperative period, we are vigi- number of sections including definition, risk factors, diag-
lant of our patients hoping for a steady recovery to hospital nosis, prevention, and treatment. This textbook is not only
discharge and successful return to previous use. We monitor aimed at equine surgery residents and surgeons, but also
our patients closely with special attention to detect early to all those equine clinicians that very often and carefully
signs that may alert us to occurrence of complications or take care of the patients in their pre- and postoperative
deviation from the uneventful recovery path. This represents times. We trust that all of you will find this textbook
a source of stress for the responsible clinician and especially useful.
xiv Preface
This project has only been possible thanks to the excel- reports, small case series, or limited notes in publications.
lent editorial team at Wiley, and the invaluable, hard work We trust this textbook will strive for the further development
of many authors who have contributed chapters to this and building-up of evidence-based information in the field
textbook. We have endeavored to include a long list of of complications in equine surgery, aiming to contribute to
worldwide experts in different areas of equine surgery. An the equine surgeons’ education and success, as well as the
emphasis has been made to include references, even welfare of our equine patients.
though these may sometimes be limited to single case Luis M. Rubio-Martinez
Dean A. Hendrickson
xv
Acknowledgements
The editors of this textbook would like to thank: ● To all our colleagues in our careers (colleagues, mentors,
peer clinicians, residents, and interns), as well as all
● All the staff at Wiley, especially Skye Loyd and Melissa
those equine patients that during the years have gifted us
Hammer, for believing in the project initially and for all
with our experiences, successes, and under-successes.
their invaluable hard work during the journey and mak-
All those experiences have improved our knowledge and
ing this project a reality. Thank you for your priceless
skills and hopefully made us better surgeons.
guidance, dedication, and patience.
● And finally, special thanks to our families for their
● All our colleagues who have contributed to this textbook
understanding and unconditional support, despite the
and made this project happen. Thank you for your time,
many evenings and holidays when they did not get our
effort, and patience in this long endeavor that finally has
attention.
reached its destination.
xvi
Listof Contributors
Maria Amengual-Vila, DVM, DECVAA, MRCVS Julie E. Dechant, DVM, MS, DACVS, DACVECC
Clinical Anesthetist Professor of Clinical Equine Surgical Emergency and
Highcroft Veterinary Referrals Critical Care
Witchurch, Bristol Department of Surgical and Radiological Sciences
United Kingdom School of Veterinary Medicine
University of California–Davis
Debra C. Archer, BVMS, PhD CertES(soft tissue), DECVS, Davis, CA
FRCVS, FHEA
Professor in Equine Surgery Ian F. Devick, DVM, MS, DACVS-LA
Institute of Veterinary Clinical Studies Associate Veterinarian
University of Liverpool Weatherford Equine Medical Center
Liverpool Weatherford, TX
United Kingdom
Anje G. Bauck, DVM, DACVS-LA Padraic Martin Dixon, MVB, PhD, FRCVS,
Clinical Assistant Professor DEVDC(Equine)
Department of Large Animal Clinical Sciences Professor of Equine Surgery
College of Veterinary Medicine Division of Veterinary Clinical Studies
University of Florida The Royal (Dick) School of Veterinary Studies
Gainesville, FL Midlothian
Scotland
Belinda Black, BSc, BVMS, DVSc DACVS-LA
Equine Surgeon Norm G. Ducharme, DVM, MSc, DACVS
Murray Veterinary Services James Law Professor of Surgery
West Coolup Cornell University Hospital for Animals (CUHA)
Western Australia College of Veterinary Medicine
Cornell University, Ithaca NY
Dennis E. Brooks, DVM, PhD, DACVO
Professor Emeritus Jeremiah T. Easley, DVM, DACVS
University of Florida Assistant Professor
Gainesville, FL Department of Clinical Sciences
College of Veterinary Medicine and Biomedical Sciences
Amy M. Buck, MS, DVM
Colorado State University
Hagyard Equine Medical Institute
Fort Collins, CO
Lexington, KY
John P. Caron MVSc, DVM, DACVS Yvonne A. Elce, DVM, DACVS

Professor Equine Surgery Lead of the Equine Hospital
Department of Large Animal Clinical Sciences Langford Vets Equine Hospital
Michigan State University Langford, Bristol
East Lansing, MI United Kingdom
ist of Contrieutors xvii
David E. Freeman, MVB, PhD, DACVS Laura Johnstone, BVSc, MVSc, DACVIM (LAIM)
Appleton Professor in Equine Surgery Cromwell
Large Animal Clinical Sciences New Zealand
College of Veterinary Medicine
University of Florida
Shauna P. Lawless, MVB
Gainesville, FL
Resident – Equine Surgery and Lameness
Kate S. Freeman, MEM, DVM, DACVO Department of Clinical Sciences
Affiliate Faculty of Ophthalmology Colorado State University
Colorado State University Fort Collins, CO
Fort Collins, CO
Britta S. Leise, DVM, PhD, DACVS-LA
Laurie R. Goodrich, DVM, PhD, DACVS
Associate Professor of Equine Surgery
Professor of Orthopedics
Department of Veterinary Clinical Sciences
Department of Clinical Sciences
Louisiana State University, School of Veterinary
Medicine
Fort Collins, CO
Baton Rouge, LA
Barrie DonLeo Grant, DVM, MS, DACVS, MRCVS
Equine Consultant Timothy B. Lescun, BVSc (Hons), MS, PhD, DACVS
Bonsall, CA Associate Professor of Large Animal Surgery
Department of Veterinary Clinical Sciences,
Eileen Sullivan Hackett, DVM, PhD, DACVS, DACVECC
Purdue University College of Veterinary Medicine
ACVS
West Lafayette, IN
Associate Professor Equine Surgery and Critical Care
Colorado State University Michael C. Maher, DVM, DACVS-LA
Fort Collins, CO Staff Surgeon
Brandon Equine Medical Center
Jan F. Hawkins, DVM, DACVS Brandon, FL
Professor of Large Animal Surgery
Department of Veterinary Clinical Sciences
Purdue University Khursheed Mama, DVM, DACVAA
West Lafayette, IN Professor, Anesthesiology
Rachel C. Hector, DVM, MS, DACVAA Colorado State University
Department of Clinical Sciences Fort Collins, CO
Clinical Instructor, Anesthesia
Ann Martens, DVM, PhD, DECVS
Fort Collins, CO
Professor of Large Animal Surgery
Dean A. Hendrickson, DVM, MS, DACVS Department of Surgery and Anesthesiology of
Professor of Surgery Domestic Animals
Department of Clinical Sciences Faculty of Veterinary Medicine
College of Veterinary Medicine and Biomedical Sciences Ghent University
Colorado State University Merelbeke, Belgium
Fort Collins, CO
Margaret C. Mudge, VMD, DACVS, DACVECC
Robert J. Hunt, DVM, MS, DACVS Department of Veterinary Clinical Sciences
Hagyard Equine Medical Institute The Ohio State University
Lexington, KY Columbus, OH
xviii ist of Contrieutors
Brad Nelson, DVM, MS, PhD, DACVS-LA Eva Rioja Garcia, DVM, DVSc, PhD, DACVAA, DECVAA,
Assistant Professor, Equine Surgery MRCVS
Principal Investigator, Preclinical Surgical Research Clinical Director of Anaesthesia and Analgesia
Laboratory Optivet Referrals
Department of Clinical Sciences Havant, Hampshire
College of Veterinary Medicine and Biomedical Sciences United Kingdom
Fort Collins, CO Fabrice Rossignol, DVM, DECVS
Equine Clinic Grosbois
Thomas O’Brien, MVB, DACVS-LA Boissy Saint Leger
Fethard Equine Hospital, France
Kilknockin
Luis M. Rubio-Martínez, DVM, DVSc, PhD, DACVS, DECVS,
County Tipperary
DACVSMR, MRCVS
Ireland
Sussex Equine Hospital, Ashington, West
Sussex, United Kingdom
Kyla F. Ortved, DVM, PhD, DACVS, DACVSMR
CVet Ltd. Equine Surgery and Orthopedics,
Assistant Professor of Large Animal Surgery
United Kingdom
Department of Clinical Studies
New Bolton Center, School of Veterinary Medicine,
Angelika Schoster, Dr.med.vet, DVSc, PhD, DVSc,
University of Pennsylvania
DACVIM, DECEIM
Kennett Square, PA
Clinic for Equine Internal Medicine
University of Zurich
Lynn Pezzanite, DVM, MS, DACVS
Switzerland
Post-doctoral Fellow/PhD Student
Department of Clinical Sciences and Translational James Schumacher, DVM, MS, DACVS, MRCVS
Medicine Institute Department of Large Animal Clinical Sciences
College of Veterinary Medicine and Biomedical Sciences College of Veterinary Medicine University of Tennessee
Colorado State University Knoxville, Tennessee
Fort Collins, CO
Donna L. Shettko, DVM, MSN, DACVS
John Peroni, DVM, MS, DACVS Western University of Health Sciences
Professor of Surgery Pomona, CA
Department of Large Animal Medicine
Ellen R. Singer, BA, DVM, DVSc, DACVS, DECVS, FRCVS
Veterinary Medical Center
Director, E Singer Equine Orthopaedics and Surgery Ltd.
University of Georgia
Neston, Cheshire
Athens, GA
United Kingdom
Richard J.M. Reardon, BVetMed (hons), MVM, PhD, FHEA, Roger K. W. Smith, MA, VetMB, PhD, DEO, FHEA, ECVDI
CertES(orth.), DECVS, DEVDC(equine), MRCVS LAassoc, DECVSMR, DECVS, FRCVS
Senior Lecturer in Equine Surgery Professor of Equine Orthopedics
The Royal (Dick) School of Veterinary Studies Department of Clinical Sciences and Services
University of Edinburgh The Royal Veterinary College
Easter Bush, Midlothian Hatfield, Hertfordshire
Scotland United Kingdom
Dean W. Richardson, DVM, DACVS Louise L. Southwood, BVSc, PhD, DACVS, DACVECC
Charles W. Raker Professor of Equine Surgery Professor, Large Animal Emergency & Critical Care
Chief, Large Animal Surgery Department of Clinical Studies New Bolton Center
New Bolton Center, School of Veterinary Medicine, School of Veterinary Medicine
University of Pennsylvania University of Pennsylvania
Kennett Square, PA Philadelphia, PA
ist of Contrieutors xix
Michael A. Spirito, DVM James R. Vasey, BVSc, FANZCVSc

Davidson Surgery Center Goulburn Valley Equine Hospital
Hagyard Equine Institute Congupna, Victoria
Lexington, KY Australia
Henry Stämpfli, DVM, Dr.Med.Vet., DACVIM Denis Verwilghen, DVM, MSc, PhD, DES, DECVS
Professor Retired Associate Professor in Equine Surgery
Large Animal Medicine, Clinical Studies Head of the Camden Equine Centre
Ontario Veterinary College School of Veterinary Science – Faculty of Science
University of Guelph University of Sydney
Guelph, Ontario Australia
Canada
Ashlee E. Watts, DVM, PhD, DACVS
Sara K.T. Steward, DVM Associate Professor
Equine Surgery Resident Department of Large Animal Clinical Sciences
Veterinary Teaching Hospital Texas A&M University
Department of Clinical Sciences College Station, TX
Fort Collins, CO J. Scott Weese, DVM, DVSc, DACVIM
Department of Pathobiology
Kenneth E. Sullins, DVM, MS, DACVS Ontario Veterinary College
Professor of Equine Surgery University of Guelph
College of Veterinary Medicine Guelph, Ontario
Midwestern University Canada
Glendale, AZ
Jacintha M. Wilmink, DVM, PhD, DRNVA
Troy N. Trumble, DVM, PhD WOUMAREC (Wound Management and
Associate Professor Reconstruction in Horses)
Veterinary Population Medicine Department Wageningen
University of Minnesota The Netherlands
College of Veterinary Medicine
St. Paul, MN
Alexander Valverde, DVM, DVSc, DACVAA

Associate Professor
Department of Clinical Studies
Ontario Veterinary College
University of Guelph
Guelph, Ontario
Canada
1
Surgical Complications
Luis M. Rubio-Martinez DVM, DVSc, PhD, DACVS, DECVS, DACVSMR, MRCVS1 and
Dean A. Hendrickson DVM, MS, DACVS2
1
Sussex Equine Hospital, Ashington, West Sussex, United Kingdom and CVet Ltd. Equine Surgery and Orthopedics, United Kingdom
2
College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
Overview but are defined according to a time period. A 30-day period

after the surgical procedure, either during or after hospi-
The term “surgical complication” is frequently used in the talization, has been used in human medicine [2].
medical profession, but its definition in the medical litera- All surgical procedures are associated with a degree of risk
ture has been inconsistent over the years. The World and the benefits of any procedure need to be weighed against
Journal of Surgery defines “surgical complication” as “any any potential complications so that the clinician and the
undesirable, unintended, and direct results of an operation patient or animal owner can make a balanced and informed
affecting the patient that would not have occurred had the decision. This discussion should also cover complementary
operation gone as well as could reasonably be hoped” [1]. techniques that augment results to optimize physical, occu-
This definition suggests that a surgical complication is pational and societal goals [3]. In veterinary medicine, own-
dependent on the surgical skill of the surgeon, the facilities ers’ expectations, engagement and commitment, animal
and equipment available and the condition of the patient. welfare and economics need also to be balanced.
Surgical complications can be classified into patient-
related complications (related to patient-specific charac-
istof ComplicationsAssociated
L teristics, rather than to a procedural error), and
with Surgery: practitioner-related complications (arising from errors
that directly lead to undesirable and unintended results
● Morbidity and mortality affecting the patient, but also as a result of a faulty tech-
● Surgical checklists nique) [3]. Although surgical errors may be frequently
● Perioperative consequences of surgical trauma linked to complications, some errors may not result in
● Metabolic and nutritional effects complications.
● Neuroendocrine Recognition of errors and complications provide unique
● Systemic inflammatory response instances to learn from and to work toward avoiding or pre-
● Pain venting their re-occurrence [4]. To maximize this process
● Impact of host factors and comorbid conditions the following practitioner’s goals have been defined in
human medicine [3, 5]:
“Surgical complications,” otherwise referred to as “opera-
tive complications,” are not restricted to the time window 1) Minimize errors by applying an appropriate surgical
of the surgical procedure itself but comprise both intra- technique.
and postoperative complications [2]. The duration of sur- 2) Identify and manage errors in a timely manner and in a
gery defines the time window for intraoperative way that would prevent ensuing complications.
complications; meanwhile, postoperative complications 3) Identify and manage complications in a timely manner
are not restricted to those occurring during hospitalization and appropriately.
Complications in Equine Surgery, First Edition. Edited by Luis M. Rubio-Martinez and Dean A. Hendrickson.
© 2021 John Wiley & Sons, Inc. Published 2021 by John Wiley & Sons, Inc.
2 Surgical Complications
4) Identify and consider patient-related complications in undergoing major surgery; [12] however, the association
the decision-making process, so that they can be antici- between general postoperative morbidity and long-term
pated, prevented or managed correctly. outcome or functionality is not well established [9]. This
stems from the inconsistent reporting of morbidity in rela-
It is not uncommon for clinicians to adopt routines that pre-
tion to definition, type and criteria, which leads to a lack of
vent and manage complications on the basis of personal
reliability in the recording of complications data [9].
experience. However, in some cases this may be associated
Surgical mortality is a concrete universal outcome meas-
with “making the same mistakes with increasing confi-
ure, but unlike morbidity, mortality recording has tradi-
dence over an impressive number of years” [6]. In human
tionally been inconsistent as a result of variable duration of
medicine, standards of expected outcomes for groups of
hospitalization, follow-up information, and number of sur-
patients require evidence-based practice, making seniority
gical procedures performed during the same hospitaliza-
and individual experience less important [7]. Evidence-based
tion period or different hospitalization periods [10].
literature in this area has quickly developed over the last
Evidence-based knowledge on complications has rapidly
decades, and several textbooks and journals dedicated to
evolved and continues to do so in human medicine. The
surgical complications are available in the human field. The
Morbidity and Mortality Conferences (MMCs) were estab-
application of an evidence-based approach for prevention,
lished in the beginning of the 20th century at the
identification and management of surgical complications
Massachusetts General Hospital in Boston [13], with the
should result in a reduction in mistakes in the clinical deci-
aim to improve the quality and safety of human health-
sion-making process. In addition, it will also identify areas
care [14]. The MMCs have become a requirement for all
on which further research is warranted.
human medicine surgical training programs in high-risk
specialties such as surgery, anesthesia, intensive care and
oncology, being a key factor in the accreditation of human
Morbidityand Mortality hospitals [15]. These conferences are associated with
improvements in healthcare quality and patient safety
Morbidity (from Latin morbidus, meaning sick, unhealthy) is through analysis of failures [15]. To further improve the
a diseased state, disability, or poor health due to any cause effectiveness of these MMCs, additional structured frame-
[8]. Surgical morbidity relates to those morbid states that are works such as the Physician Peer Review have been imple-
related to a surgical procedure performed on a patient. mented, enabling surgeons to review and evaluate peer
Although traditionally defined by the presence or absence of surgeons’ results and take corrective actions [16, 17]. These
specific postoperative complications, surgical morbidity rep- systems aim to improve competencies, protect patients
resents any clinically significant, non-fatal, adverse outcome from harm and assist institutions in their evaluations of
associated with a surgical procedure [9]. Morbidity can be surgical outcomes, with the ultimate goal of improvement
divided into local (associated with operation site, e.g. wound of patient outcome through implementation of measures
dehiscence) or general (related to any operation, e.g. acute to identify and prevent operative complications.
renal failure). It can also be subdivided based on timely In 1991, Copeland et al. developed the “Physiological
occurrence as intraoperative or postoperative; the latter being and Operative Severity Score for the numeration of
further considered as immediate, early, late or long-term, Mortality and morbidity (POSSUM)” as a representative
although these are based on arbitrary time thresholds [9]. method for evaluating the result of surgery in patients [18].
These categories overlap and are closely interconnected, as This system includes a physiological score and an opera-
for example a specific, local complication such as surgical site tion severity score to calculate individual risk for morbidity
infection may have general or systemic effects such as and mortality. Classification systems for perioperative
pyrexia, inappetence and motor dysfunction, which are not complications (such as the Clavien–Dindo classification)
procedure specific [9]. have been developed [19] and application of these systems
Surgical mortality is any death regardless of cause, occur- has confirmed their prediction of morbidity and mortality
ring: (1) within 30 days after surgery in or out of the hospi- rates in humans [20]. Over the last few years, equine stud-
tal; or (2) after 30 days during the same hospitalization ies have focused on identification of prognostic factors,
period subsequent to the operation [10, 11]. In patients mainly associated with mortality, in patients suffering from
undergoing more than one surgical procedure during a sin- certain conditions or undergoing specific surgical proce-
gle hospitalization, mortality is assigned to the first opera- dures. From those studies, risks factors have been identi-
tion during hospitalization [10]. fied which provide useful information during the
In human medicine, postoperative morbidity has been decision-making process between veterinarian and horse
shown to have a significant effect on mortality in patients owner. However, inconsistent definitions, limited
etaeolic and Nutritional ffects 3
populations and diverse management regimes often limit the degree of stress response as there is no single variable
universal conclusions. Adaptations of POSSUM-like strate- or combination thereof that define stress in a consistent
gies to the equine surgical field warrant consideration. manner. A combination of variables encompassing all
involved pathways, and even variables related to other
body systems susceptible to stress-related consequences
Surgical Checklists such as the reproductive system, should be included to
define the short- and long-term effects of stress [28]. The
The Safety Checklist was developed by Dr. Atul Gawande pathways involved are totally interrelated and difficult to
with the intention of improving outcomes, team dynamics separate, but for the purpose of this review the stress
and patient safety in an intensive care unit of a human hos- response in the surgical patient will be divided into four
pital [21]. Based on their successful implementation, in sections: metabolic/nutritional effects, neuroendocrine
2008 the World Health Organization (WHO) instituted the consequences, inflammatory response, and pain.
Surgical Safety Checklist (SSC) as a global initiative to
improve surgical safety of human patients. Since then,
SSCs have become standard practice in human hospitals Metabolicand NutritionalEffects
and are slowly being implemented in veterinary hospitals.
These checklists cover introduction of surgical and anes- In the 1930s, Cuthbertson described the body’s post-trau-
thetic teams, identification of patient, consent, procedure matic response as an immediate “ebb” or shock phase fol-
to be performed, anatomical location, estimated duration lowed by the flow phase [29]. The short-lived (24–48 h) ebb
of surgery, availability of equipment, and potential compli- phase is characterized by reductions in blood pressure, car-
cations among others. Use of SSCs has assisted in preven- diac output, body temperature and oxygen consumption,
tion of potential safety hazards and errors in the operating and when associated with hemorrhage, hypoperfusion and
room, and improved safety and communication among lactic acidosis, depending on the severity. The latter flow
operating staff [22–24]. Their implementation has been phase is characterized by hypermetabolism, increased car-
associated with reduced morbidity, length of in-hospital diac outputs, increased urinary nitrogen losses, altered glu-
stay and mortality [25]. Sustained use of SSCs seems to be cose metabolism and accelerated tissue catabolism.
discipline-specific and is more successful when physicians The nutritional status of the human surgical patient is
are actively engaged and leading implementation [26]. In well recognized as a factor associated with morbidity and
addition, implementation of SSCs did not negatively mortality [30, 31]. Malnourished patients show a reduction
impact the operating room efficiency, whilst reducing over- in survival, immune function, wound healing and gastroin-
all disposable costs, in a large multispecialty tertiary care testinal functions, and associated prolonged hospitaliza-
human hospital [27]. tion and increased infection [32, 33]. Preoperative fasting,
anesthesia, surgery and disease all contribute to the stress
hypermetabolic response. Stimulation of the sympathetic
Perioperative Consequences nervous system causes release of catecholamines, an
to SurgicalTrauma increase in oxygen delivery and consumption at the tissue
level, and a rise in body temperature. As a consequence,
Any surgical procedure is associated with some degree of the resting energy expenditure increases. Individual assess-
tissue trauma, which results in a stress response by the ment of resting energy expenditure has become an integral
patient’s body. This stress response follows the same path- part of the management of the human surgical patient.
ways as that after accidental trauma or disease; however, Providing adequate perioperative nutritional support is
the magnitude of the stress response will vary with the standard of care in humans, as malnutrition or overfeeding
severity of the stimulus. The patient’s condition, severity of are associated with poorer outcome [34]. Horses undergo-
disease, anesthesia and surgical procedure will all contrib- ing surgery are subject to variable preoperative fasting
ute to the stimulus of a stress response. Healthy patients times, and colic patients may undergo prolonged food and
undergoing elective minor surgery may not sustain any sig- even water restriction perioperatively. However, standard
nificant effects, but patients with severe trauma or critical assessment of the nutritional status of the equine patient is
illness can enter prolonged catabolic states with notable not common, and nutritional support is often limited to
consequences to morbidity and mortality. intravenous and/or oral fluids with electrolytes. Other
The stress response is multifactorial and governed by nutrients such as glucose, aminoacids and lipids are less
inflammatory, metabolic, neurohormonal and immuno- frequently incorporated in the form of either enteral or par-
logic pathways. As a consequence, it is difficult to categorize enteral nutrition. [35].
The healthy adult horse can tolerate food deprivation, can lead to use of adenosine triphosphate and creatinine
commonly referred to as simple starvation or pure protein phosphate as energy sources and production of lactate,
or calorie malnutrition (PPCM), for 24–72 hours with min- which can extend into the recovery period [43, 44].
imal systemic consequences [36]. In this situation, healthy Because of decreased venous drainage from the muscle,
humans sustain neuroendocrine changes leading to a increased muscle lactate is not paralleled by the lower
lower metabolic rate and resting energy expenditure. This plasma lactate during anesthesia and increases in plasma
is associated with decreased blood glucose, insulin, lactate and potassium extend into the recovery period [42,
increased glucagon and down-regulation of catechola- 44–46]. These metabolic changes can be apparent in
mines. Initial hepatic glycogenolysis and gluconeogenesis healthy horses, especially in the heavy patient and pro-
followed by use of fat stores maintain normal blood glu- longed anesthesia, but changes are more pronounced and
cose values and survival, while lean tissue (protein) is commonly recognized in prolonged anesthetics and ill
spared. horses such as colic cases [43, 46].
Energy demands are increased in patients with a prior Nutritional supplementation will reverse catabolic pro-
history of malnutrition, increased metabolic rate (i.e. cesses during simple starvation; however, it will not com-
young growing animals), underlying metabolic abnormali- pletely reverse those during metabolic stress, which will
ties, sepsis, severe trauma, or underweight animals at remain as long as tissue injury persists. Nutritional support
higher risk of stress response. The effect of fasting on of the critically ill patient aims to minimize the severity of
stressed catabolic patients is a hypermetabolic state with protein loss and morbidity associated with the disease. The
increased resting energy expenditure. This is the result of goal should be to re-institute food intake as soon as possi-
the catecholamine release by the stimulated sympathetic ble and if that is not possible, consider nutritional support.
nervous system and the inflammatory cytokines released at Nutritional support can be provided in the form of enteral
the site of injury, inflammation, disease or surgery [37, 38]. or parenteral nutrition. The enteral route is always pre-
The magnitude of this hypermetabolic state relates to the ferred as it provides a trophic stimulus for the gastrointes-
severity of the disease or trauma. Stimulation and/or tinal tract and has a protective effect against bacterial
release of corticotrophin, cortisol, epinephrine, growth translocation across the intestinal wall [47]. Early enteral
hormone and glucagon result in an increased resting meta- nutrition (initiated within 48 h after surgery) significantly
bolic rate characterized by insulin resistance, increased decreased morbidity and length in critically ill human
glucocorticoid secretion, gluconeogenesis, dysregulation patients [48], and lessened the hypermetabolic and cata-
of glycemia, lipolysis, proteolysis, nitrogen loss and rapid bolic responses to injury in human and animals [49]. When
malnutrition [39]. Blood triglycerides should be moni- the enteral route is not available, parenteral nutrition can
tored, and appropriate nutritional support instituted in be used in the form of partial (most commonly) or total
horses at risk of developing hyperlipemia such as obese parenteral nutrition. Although there is a paucity of pub-
animals (especially miniature horses and donkeys), lactat- lished studies, there are some reports of clinical applica-
ing mares, and horses suffering from Cushing’s syndrome tion of enteral and parenteral nutrition in foals and adult
or equine metabolic syndrome. horses, from which some guidelines can be obtained [35,
The response to an elective surgical procedure will be 47, 48, 50–55]. Parenteral nutrition is not exempt of com-
more limited in a healthy than in a critically ill patient or a plications and, therefore, close monitoring of patients
patient with severe trauma. However, an increase in meta- receiving it is required [52, 55, 56]. A clinical nutrition
bolic rate occurs postoperatively in humans after simple counselling service has recently been pioneered at a refer-
elective surgery [40]. Anesthesia and midline abdominal ral equine hospital [57].
exploratory laparotomy increased the postoperative caloric
demand in healthy horses by 10% in experimental condi-
tions [41]. Increased demands in critically ill equine Neuroendocrine
patients are expected to be higher but have not been quan-
tified to the editors’ knowledge. Surgical patients undergo a sympathetic nervous system
Due to the patient’s size and weight, local changes in response with activation of adrenocortical axis and release
muscle metabolism can also be substantial in the recum- of catecholamines, cortisol and glucagon. The degree of
bent horse under general anesthesia. Physical compres- surgical trauma will determine the magnitude of this endo-
sion of muscle groups is associated with restricted local crine response, with redistribution of blood flow to pre-
blood perfusion and an increased demand for energy serve important organs, splenic contraction to increase
through anaerobic metabolism in the muscle [42]. This blood volume, mobilization of resources to provide sub-
Systemic Inflammatory Response 5
strates such as glucose and fatty acids, and activation of the glyceride and glucose concentrations and activities of liver
immune system in more severe cases [58, 59]. enzymes such as GGT, AST, AP and SDH, whereas plasma
General anesthesia itself is associated with a stress ammonia was expected to remain within normal limits
response characterized by sympathetic output in healthy [72–74]. This may indicate hepatocellular injury in equine
horses [45]. Inhalation anesthesia increased adrenocorti- colic patients but could otherwise be associated with
cotropic hormone and cortisol release in healthy horses [60, underlying diseases, transient bile duct obstruction, vascu-
61], and even in glycerol and non-esterified fatty acids in lar compromise of the liver, or ascending infection from
prolonged anesthesia in healthy horses [45]. On the con- intestinal contents into the liver [72, 74, 75]. Increased TG
trary, total intravenous anesthesia seemed to cause a lesser values have the potential to progress organ damage [76],
stress response than gas anesthesia, although duration of and were in fact negatively associated with survival [72];
anesthesia and other factors have important effects [62]. however, a return of TG to normal values was observed at
Fasting, re-feeding and anesthetic drugs (i.e. α2-agonists) the time of re-feeding in most horses [72]. Elevated bile
affect insulin regulation and therefore different drug com- acid concentrations at admission were associated with
binations, and induction and anesthetic protocols contrib- decreased survival in colic patients, although increased
ute to large variability of the hyperglycemic response and bile acid can also be the result of prolonged fasting (>3
circulating levels of these stress markers in the equine days) [72].
patient [63-65]. Hypothermia is another factor that occurs during sur-
Laparoscopic surgery under standing sedation and local gery, which in humans has been associated with an adren-
anesthesia produced increased cortisol and non-esterified ergic response [77]. A decrease in the mean core body
fatty acids plasma levels in horses [66]. Minor elective sur- temperature occurs in horses during standing laparoscopy
gery under general anesthesia (skin sarcoid removal or and horses under general anesthesia with or without sur-
laryngeal surgery) produced minor changes in blood glu- gery [45, 78, 79], but the effects of hypothermia on the
cose, lactate or plasma non-esterified fatty acid (NEFA) stress response in horses are unknown.
values, beyond those caused by anesthesia [63]. Equine In conclusion, the stress response to anesthesia and sur-
patients undergoing elective arthroscopic surgery showed gery is multifactorial, with pain, tissue perfusion and
transient hyperglycemia and increased beta-endorphin energy availability being important determinants of stress.
and cortisol [67]. Cortisol response in people undergoing Differences in fasting period, anesthetic protocol, length of
surgery correlates with surgical trauma and is higher in anesthesia, anesthetic protocol, surgical procedure, surgi-
abdominal than other minor surgeries [68, 69]. Similarly, a cal trauma, and systemic condition of the patient will have
1.6-fold [67] versus a 10-fold [70] increase in plasma corti- definite effects on the type and magnitude of stress mark-
sol was observed in horses undergoing arthroscopy or ers such as glycaemia, and plasma insulin, cortisol and
abdominal surgery, respectively. Horses with acute colic NEFA in horses [67], as has been shown in humans.
showed only a mild increase in plasma cortisol intraopera-
tively, but already had much higher preoperative cortisol
levels, which indicates that the stress response in these SystemicInflammatoryResponse
patients may be already nearing or at maximum level
before undergoing surgery [71]. Postoperative return to All surgery leads to systemic inflammatory response syn-
baseline of cortisol levels correlates with surgical trauma, drome (SIRS). The majority of information is found in the
being faster after elective arthroscopy than elective abdom- human literature. It is assumed that similar effects can be
inal surgery [64]. This return was longest in colic cases found in the equine patient. The inflammatory response
(~60 h) compared with 24 hours in the non-colic group [71]. consists of hormonal, metabolic and immunological com-
Sustained increased levels of cortisol in the postoperative ponents. The more severe the surgical insult, the more
period may also reflect response to pain or further trauma severe the inflammatory response [80]. The hormonal
in this time period [70]. response is characterized by various stress hormones. In
Surveillance of metabolic and endocrine changes in peri- people, adrenaline and cortisol levels are increased in the
operative equine patients is limited. A recent report inves- face of surgery, as are glucagon, growth hormone, aldoster-
tigating the metabolic and hepatic changes in 32 surgical one and antidiuretic hormone. The extent of surgical
adult colic patients, revealed that hepatic dysfunction, trauma correlates well with the levels of ACTH and corti-
hepatobiliary disease and alterations in metabolism are sol [81]. If patients develop postoperative complications,
common in equine colic patients [72]. Surgical colic other abnormalities can occur. In people, critically ill
patients showed increased levels of bile acids, bilirubin, tri- patients can have a cortisol deficiency. High dose therapy
with glucocorticosteroids has been associated with plex and difficult to determine. Consequently, endocrine
increased mortality, while low doses may have beneficial measures may not be accurate indicators of pain alone. It is
effects by increasing their response to noradrenaline [82]. also difficult to separate the inflammatory process
The metabolism is decreased in the first few hours after associated with surgery and surgical complications from
surgery. However, this is soon followed by a catabolic and the pain response associated with surgery and surgical
hypermetabolic phase. This phase is characterized by break complications. The measurement of equine pain is proba-
down of skeletal muscle and fat [83]. Oxygen delivery to bly best accomplished with multidimensional pain
the tissues is important during this hypermetabolic phase. scales [88]. The Horse Grimace Scale has been recently
The body reacts by vasodilating, increasing the heart rate, described and is easy to use and has a high reliability
increasing cardiac output, and increasing the respiratory between observers [89].
rate [84]. A leukocytosis occurs in the peripheral blood and
granulocytes and macrophages accumulate in the dam-
aged tissues [85]. Many pro-inflammatory cytokines are I mpactof HostFactorsand Comorbid
released leading to inflammation. The amount of cytokine Conditions
release is well correlated with both the magnitude and
duration of surgery and the risk of postoperative complica- Blood loss impairs the body’s ability to deliver oxygen to
tions. If the initial pro-inflammatory response is exagger- the tissues and oxygen delivery to the tissues is important
ated, sever systemic inflammatory response syndrome may during injury [84]. Lack of oxygen impairs the body’s abil-
occur. ity to heal. Diagnosing blood loss in the horse can be chal-
lenging due to the large reservoir of red blood cells stored
in the spleen. Splenic contraction can maintain packed cell
Pain volume and total protein in the acute stages of hemor-
rhage [90]. Fluid volume expansion can actually reduce the
Surgical procedures will lead to a pain response. It is well effectiveness of oxygen delivery, making blood transfu-
supported that the more invasive a procedure is, the more sions an important aspect of improving oxygen delivery.
pain the patient will experience. Horses are typically stoic Pituitary pars intermedia dysfunction is thought to
animals when it comes to exhibiting pain. It is thought that impair corneal wound healing in horses [91]. There also
they mask signs of pain from predators, including humans, appears to be an association between PPID and degenera-
to minimize possible predation [86]. In one study, it was tive suspensory ligament desmitis [92]. It seems reasonable
determined that horses undergoing surgery paid decreased then that horses with PPID may have difficulty in healing.
attention toward novel objects and decreased responsive- This should be considered when operating on horses with
ness to auditory signals [87]. The relationship between PPID.
pain, behavioral distress and physiological stress is com-
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53 Krause, J.B. and McKenzie, H.C. 3rd. (2007). Parenteral
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55 Lopes, M.A. and White, N.A. 2nd. (2002). Parenteral
41 Cruz, A.M., Cote, N., McDonell, W.N. et al. (2006).
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43 Edner, A., Essen-Gustavsson, B., and Nyman, G. (2005). nutrition counselling service in the veterinary hospital:
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44 Edner, A., Nyman, G., and Essen-Gustavsson, B. (2002). metabolism. Br. J. Anaesth. 45 (3): 237–243.
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46 Edner, A.H., Essen-Gustavsson, B., and Nyman, G.C. halothane or isoflurane anaesthesa after induction with
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10
Complicationsof ParenteralAdministrationof Drugs

Julie E. Dechant DVM, MS, DACVS, DACVECC
School of Veterinary Medicine, University of California–Davis, Davis, California
Overview The skin overlying the proposed injection site should be

clean; however, there is no consensus if topical disinfection
Parenteral administration refers to the administration of with alcohol reduces the risk of bacterial inoculation [1, 2].
drugs by a route other than the oral route. This would include For a full-sized horse, a 1.5” needle should be used to allow
intravascular, intramuscular, subcutaneous, intradermal, for deep penetration into the muscle and it is prudent to use
intra-synovial, and epidural routes of administration. a larger-sized needle (18–19 gauge), because smaller needles
Intravascular and epidural injections will be discussed in sub- can break off in the muscle if the patient resists the injection.
sequent chapters. Subcutaneous and intra-dermal routes of In most circumstances, it is best to place the needle in the
administration have a low risk of complications and will not muscle without the syringe and then attach the syringe to the
be reviewed in this chapter. This chapter will focus on compli- hub of the needle. The syringe should be aspirated to ensure
cations of intramuscular and intra-synovial injections. no contamination of the site with blood before injecting the
medication, because many intramuscularly administered
medications are not compatible with intravenous injection
istof ComplicationsAssociatedwith
L (e.g. procaine penicillin) or would have a different dosage if
theParenteralAdministrationof Drugs: administered by the intravenous route (e.g. sedatives) [1, 2].
Ideally, no more than 10 ml should be injected at one site; the
● Intramuscular administration needle is redirected if larger volumes are administered [1, 2].
● Anatomical and procedural considerations
● Local muscle reaction: from mild inflammation to
abscess formation ocalMuscleReaction:From Mild
L
● Clostridial myonecrosis Inflammationto AbscessFormation
● Intra-synovial administration
● Post-injection synovitis and lameness Definition Local muscle inflammatory reactions are
● Medication errors characterized by swelling and soreness after intramuscular
injection of a substance. Severe local inflammations with
IntramuscularAdministration infection show local accumulation of purulent material
(abscess).
Anatomicaland ProceduralConsiderations
Risk Factors
The most common muscle groups used for intramuscular ● The cervical and pectoral muscles appear to be more pre-
injection are the cervical (trapezius), pectoral, gluteal, and disposed to muscle soreness, likely because these are
caudal thigh (semimembranosus, semitendinosus) mus- smaller muscle groups compared to the gluteal or semi-
cles [1, 2]. Most veterinarians do not advocate use of the membranosus/semitendinosus muscles.
gluteal muscles, because this site provides poor drainage if ● Repeated injection into the same location.
any septic complications develop after injection [2]. ● Some types of vaccines are anecdotally associated with a
Injection technique requires identification of local anat- higher risk of injection site abscesses. Certain medica-
omy and recognition of topical landmarks. tions, typically acidic formulations or those with
Clostridial Myonecrosis 11
non-aqueous carriers (gentamicin, tetracyclines, enro- referred to as clostridial myositis, malignant edema, or
floxacin, flunixin, phenylbutazone, etc.) are associated clostridial cellulitis [4].
with increased tissue reactivity.
Risk Factors Clostridial myonecrosis can develop after any
Pathogenesis Local swelling and soreness are common intramuscular injection, and has been reported after
complications, especially after repeated or large volume flunixin meglumine (most commonly), dipyrone, Vitamin
administrations or administration of irritating medications [2]. B with or without iron, tripellennamine, dexamethasone,
Abscess formation is a less common complication following furosemide, vaccines, among others [4–6].
intramuscular injection [1, 2] but may occur if the local
Pathogenesis All of these syndromes are referencing
inflammatory response is severe or if the injection site has
necrotizing soft tissue infections with Clostridium perfringens,
been contaminated with bacteria. Abscesses may form even
Clostridium septicum, Clostridium chauvoei, and Clostridial
after intramuscular antimicrobial administration.
sporogenes that develop after intramuscular injections or
muscular trauma [5]. It is not known if these infections result
Prevention Maximize aseptic technique for intramuscular
from inoculation of clostridial spores at the time of injection
injection or use alternate routes of administration for
or injury, or if these spores are quiescent within the tissue
medication, if available. Rotation of injection sites is
and they germinate after a muscle injury creates a suitable
desired when frequent dosing is required and may delay
anaerobic environment [5, 6]. Proliferation of clostridial
development of muscle soreness by allowing time for the
organisms results in the production of extracellular enzymes
inflammation to resolve [2]. If a site becomes swollen or
and exotoxins, which propagate the local tissue injury and
sore, it should no longer be used for injection [2]. Some
progress to signs of systemic toxemia.
practitioners advocate to avoid the gluteal muscles as
this location is very difficult to drain if abscessation
Prevention Due to the variety of medications associated
develops [2].
with clostridial myonecrosis, it is difficult to eliminate the
risk; however, flunixin meglumine, B vitamins, and
Diagnosis Inflammation and/or soreness can be
tripellennamine appear higher risk and should be avoided.
appreciated as raised, hardened and/or painful areas
It would seem advisable to maximize aseptic techniques
during normal clinical examination of the area. Abscess
for intramuscular injection and use alternate routes of
formation should be considered if the local muscle swelling
administration for medication, if available.
appears severe or if the horse develops a fever.
Diagnosis Clinical signs of clostridial myonecrosis (colic,
Treatment Avoid use of that location for further injections lethargy, inappetence, pyrexia, progressive localized painful,
and apply warm compresses for analgesia. Warm emphysematous swelling) develop within 48–72 hours of
compresses can also be used to help mature the abscess intramuscular injection [4–6]. Palpable subcutaneous
prior to establishing external drainage. In severe cases of emphysema in the affected muscle was present in 34 out of
muscle soreness, systemic non-steroidal anti-inflammatory 37 cases [4]. The emphysema is often rapidly progressive
treatment may be necessary. Drain abscess at a dependent along muscle planes and is associated with systemic signs of
location. The gluteal muscles are particularly difficult to fever, obtundation, and shock [4–6]. A presumptive
drain if abscessation develops. diagnosis can be based on a history of recent intramuscular
injection and local swelling, pain, and emphysema.
Expected Outcome Although most localized muscle Ultrasound is helpful in identifying emphysema within the
soreness or abscessation resolves without long-term deeper tissues. Treatment should not be delayed until there
consequence, fibrotic myopathy may develop after is a confirmed diagnosis, but presence of Gram-positive rods
intramuscular injection [3]. This may be an additional on Gram stain provides further support and anaerobic
consideration when administering intramuscular culture of Clostridia is confirmatory [5, 6].
medications to performance horses.
Treatment Aggressive treatment is necessary once
clostridial myonecrosis is suspected or confirmed.
Clostridial Myonecrosis Aggressive antimicrobial therapy should be instituted
promptly and continued for 10–14 days [5]. High-dose
Definition Clostridial myonecrosis is a rapidly progressing, intravenous penicillin should be started to treat the
necrotizing infection of muscle that is characterized by clostridial infection [5, 6]. Other antimicrobial agents have
severe local and systemic clinical signs [4–6]. It may also be been suggested but lack the same spectrum against
12 Complications of Parenteral Administration of rugs
Clostridia (ampicillin, cephalosporins, tetracyclines) or will infected tissue, concurrent systemic infection, and use
not attain high tissue concentrations (metronidazole) [6]. of immunosuppressive drugs [9, 10]
Intravenous fluid therapy is started to support the ○ In horses:
cardiovascular system. Non-steroidal anti-inflammatory ◼ Corticosteroids [11–13]
medication and other analgesic agents are administered, ◼ Polysulfated glycosaminoglycan or hyaluronic
and other treatments (fresh frozen plasma, platelet acid [11]
transfusion, etc.) may be given as needed [5]. Another ◼ Combination of corticosteroid-polysulfated
mainstay of treatment is surgical fenestration of the area to glycosaminoglycan [13]
allow drainage of the accumulated fluid and gas, ◼ Dexamethasone had higher risk than
debridement of necrotic tissue, and oxygenation of the betamethasone [12]
affected area [4–6]. Fenestration and debridement may ◼ Treating veterinarian [12, 13], >20 years in practice
need to be extended into previously unaffected areas on by the treating veterinarian [14]
subsequent days. If clostridial myonecrosis involves the ◼ Technical factors: <7-minute preparation time,
cervical muscles, it may be necessary to place a tracheostomy clipping the site, not using gloves, using the same
tube to secure the airway or a feeding tube for enteral needle to draw up medication and do the injection,
nutrition, because edema may progress cranially to cause and having someone other than the veterinarian
dyspnea and dysphagia. performing the procedure preparing the site [14].
Expected Outcome Prognosis for clostridial myonecrosis is Pathogenesis Post-injection flare is a chemical synovitis,
guarded to poor [4–6]. Horses may not survive despite presumably due to an inflammatory reaction to the
aggressive medical and surgical treatment. Owners should medication or substance within the medication. Developing
be warned that the recovery period may be protracted and an infection after intra-synovial injection is related to the
there will be extensive tissue loss in the affected area. amount and type of bacterial contamination and the type of
medication being administered. Some intra-synovial
medications potentiate infection to a greater degree than
Intra-SynovialAdministration other medications. For example, in an experimental study,
injection of 33 colony-forming units of Staphylococcus aureus
Intra-synovial medication may be used for diagnostic pur- with saline resulted in a synovial infection in 1 out of 8 horses,
poses (local anesthetic agents) or for therapeutic purposes whereas when 33 colony-forming units of S. aureus was
(anti-inflammatory medications, chrondroprotective injected with polysulfated glycosaminoglycan, hyaluronic
agents, or antimicrobial therapy). acid, or methylprednisolone acetate, synovial infection
developed in 8 out of 8, 4 out of 8, and 3 out of 8 of horses,
respectively [11]. In a different study, concurrent injection of
ost-InjectionSynovitis
P
125–250 mg amikacin with polysulfated glycosaminoglycan
and Lameness significantly reduced the risk of infection [15].
It is speculated that these intra-synovial medications
Definition A post-injection flare is an acute, non-septic
may potentiate infection by interfering with the normal
inflammatory response to the medication [7, 8]. Aside from
immune defenses of the joint. In two large-scale equine
the discomfort of the patient and the anxiety of the owner,
studies, the risk of septic synovitis after intra-synovial
the biggest concern related to a post-injection flare is
injection was 1 case per 1,087 injections [13] and 1 case per
differentiating it from septic synovitis. Septic synovitis is an
1,279 injections [12], which is much higher than the risk of
inflammatory response of the synovial cavity associated
post-injection septic synovitis in human medicine (1/10,000
with infection.
to 1/77,300) [9, 16].
Risk Factors Prevention Strict aseptic technique should be used any

● Substandard aseptic technique time a synovial structure is injected, including aseptic
● Post-injection flares: preparation of the site with disinfectant, use of single-use
○ Injected substance: corticosteroids, local anesthetics, vials, aseptic handling of medication, and performing the
hyaluronate, and polysulfated glycosaminoglycans injection with sterile gloves [17]. Research studies have
● Post-injection synovial sepsis: suggested that there is no need to clip hair from
○ In humans: failure of aseptic technique, experience of synoviocentesis sites [18, 19] and skin preparation times
practitioner, use of multi-dose vials, injection through of >2 minutes were recommended [19]; however, a survey
Medication Errors 13
of equine veterinarians suggested that not clipping and information about diagnosis and management of synovial
>7-minute preparation time was associated with reduced sepsis is covered in Chapter 45: Complications of Synovial
risk of infection [14]. Clipping may be beneficial if the Endoscopic Surgery.
area is soiled. The injection should be performed in a
clean, dry, non-dusty environment that is protected from Treatment A joint flare reaction is usually self-limiting but
wind [12]. may require systemic or topical anti-inflammatory
Concurrent administration of antibiotics with the intra- treatment [7, 8]. Lavage will hasten resolution of the post-
synovial medication is used by some veterinarians. Routine injection flare by removing inflammatory debris and any
use of antibiotics concurrent with intra-synovial medica- residual inciting medication, but adds expense and may
tion has not been shown to statistically alter the risk of reduce effectiveness of the original intra-synovial medication.
infection, likely because the incidence of infection in these However, given the severity of delaying treatment in septic
studies is low [12, 13]. Concurrent administration of anti- synovitis, it is prudent to proceed with lavage of the
biotics is recommended any time polysulfated glycosami- affected synovial structure and systemic and intra-
noglycans are injected intra-synovially [15]. Inclusion of synovial antimicrobial treatment if the two post-injection
antimicrobial agents should not replace strict aseptic tech- complications cannot be differentiated [7]. Septic synovitis of
nique, and has the potential to interfere with the efficacy of any cause is a life-threatening problem, and aggressive
the primary medication. treatment should be instituted immediately. Mainstays of
treatment are local and systemic administration of broad-
spectrum antimicrobial agents and lavage of the synovial
Diagnosis Non-septic inflammation or joint flare occurs
structure. It is worth emphasizing that antimicrobial selection
within several hours of the intra-synovial administration
should target staphylococci, which often have penicillinases.
and is characterized by synovial effusion and pain [7, 8].
In general, a post-injection flare will occur acutely (within
Expected Outcome Prognosis for recovery following joint
hours), will respond rapidly to anti-inflammatory
flare reaction is excellent. Prognosis following treatment of
medication, and does not persist beyond 1–2 days [7, 8].
post-injection septic synovitis is guarded, partially because
Signs of septic synovitis include localization of pain, heat,
the pre-existing joint pathology that prompted the intra-
and effusion in the injected synovial structure. Clinical
synovial injection may limit full recovery and partially
signs of septic synovitis typically occur within 2.5–4 days
because Staphylococcal infections have been associated
of injection, but may occur 1–19 days after injection [12,
with poorer outcomes and lower return to athletic activity
20]. Intra-synovial corticosteroid injections may delay
than other infections [23, 24].
recognition of the problem, because the anti-inflammatory
effect of the medication may suppress clinical signs.
Diagnosis should be supported by synoviocentesis with MedicationErrors
cytology and culture of the synovial fluid. Traditionally,
cytological findings of >30,000 total nucleated cells/μl, Definition Medical errors related to medications are
>80% neutrophils, and >4.0 g/dl total protein is supportive numerous, including overdosing, underdosing, using the
of the diagnosis [21, 22]. If intra-synovial corticosteroids wrong medication, and using the wrong formulation.
have been administered, infection may be associated with These will not be discussed here, but two types of
<10,000 total nucleated cell/μl [8]. Recent studies have medication errors will be highlighted. One is the wrong
used low cut-off values (<10,000 or even <5,000 cell/μl) as route of administration and the other is accidental injection
overall definition of sepsis (refer to Chapter 45: of a non-drug. One relatively common example of a wrong
Complications of Synovial Endoscopic Surgery, for further route error is the administration of procaine penicillin
information). Other markers of synovial infection, such as directly into the vascular system [26]. An example of
serum amyloid A, have recently been investigated (see administration of a non-drug is the inadvertent intravenous
Chapter 45: Complications of Synovial Endoscopic administration of mare’s milk in a neonatal foal [27].
Surgery). Culture is confirmatory of the diagnosis, but
treatment should proceed without waiting for culture Risk Factors
results, partially because of the disadvantage of delaying ● Inexperience and inattentiveness are common reasons
treatment and the low yield in obtaining positive culture for medication errors.
results in septic synovitis. In multiple studies, iatrogenic ● Repeated intramuscular injections may increase
infections of synovial structures appear to have a high vascularity of the site and increase the risk of venous
prevalence of staphylococci infections [23–25]. Further absorption of the administered drug.
14 Complications of Parenteral Administration of rugs
Pathogenesis Procaine penicillin must be administered by in the patient before injecting any medication are
intramuscular or subcutaneous injection, because those recommended but may be overlooked by inexperienced or
routes limit the systemic absorption of procaine. Most inattentive individuals [27].
commonly, procaine penicillin reactions occur when the
drug is administered by the correct intramuscular route, Diagnosis Severity of procaine reactions vary with amount
but the injection inadvertently results in the intravenous absorbed and individual variation [29]. Clinical signs range
absorption of a small amount of procaine [28]. Less from hyper-reactivity to seizures to death [26, 28, 29].
commonly, but more significantly, an inexperienced or Inadvertent intravenous administration of milk was
inattentive individual may directly inject procaine associated with acute signs of collapse and respiratory
penicillin intravenously. This is most likely to occur when distress, consistent with anaphylaxis. Peripheral pulses
there is an indwelling intravenous catheter, because of the were weak and mucous membranes were congested.
perceived convenience. Inadvertent intravenous
administration of mare’s milk has occurred when the Treatment Personnel should be moved away from the
intravenous catheter injection port was confused with the affected horse and the horse should be moved to a safe,
nasogastric feeding tube port, resulting in an acute quiet place (stall) and sedated, if possible [26]. External
anaphylactic reaction. stimulation should be minimized by reducing light and
sound. If seizure activity occurs, benzodiazepines and
Prevention In general, further administration of procaine phenobarbital may be administered, if safe to do so [26].
penicillin is discontinued after a procaine reaction occurs. The inadvertent administration of milk was treated by
Inadvertent, direct intravenous administration of procaine immediate removal of the contaminated intravenous
penicillin can be avoided by emphasizing that opaque catheter and aggressive supportive therapy, including
medications should not be administered intravenously epinephrine, corticosteroids, intravenous fluids,
(notable exceptions of propofol and lipid emulsions in antimicrobial therapy, and inotropic support.
selected circumstances) [26]. Important safeguards to
prevent confusion of intravenous and enteral access ports Expected outcome Horses typically recover from procaine
when multiple tubes and catheters are placed in patients reactions, but fatal reactions can occur. More commonly,
are to color-code enteral administration devices, labeling self-trauma may result from the hyper-excitability and
injections ports and enteral ports, and use of connections seizures. The foal with inadvertent intravenous
that are incompatible between enteral and intravenous administration of milk did recover with aggressive
ports [27]. Protocols to trace the tubing to the site of entry treatment and no long-term consequences were noted.
References
1 Lorello, O., Dallap Schaer, B., and Orsini, J.A. (2014). 7 Bertone, A.L. (2011). Noninfectious arthritis. In:
Medication administration and alternative methods of Diagnosis and Management of Lameness in the Horse, 2e
drug administration. In: Equine Emergencies: Procedures (M.W. Ross and S.J. Dyson), 687–690. St. Louis: Elsevier
and Treatments, 4e (ed. J.A. Orsini and Saunders.
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2 Stephens, J.O. (2008). Intramuscular injections. In: The Joint Disease in the Horse, 1e (C.W. McIlwraith and G.W.
Equine Hospital Manual, 1e (ed. K. Corley and J. Stephen), Trotter). 248–250. Philadelphia: WB Saunders.
13–15. Oxford: Blackwell Publishing, Inc. 9 Seror, P., Pluvinage, P., d’Andre, F.L. et al. (1999).
3 Turner, S. and Trotter, G.W. (1984). Fibrotic myopathy in Frequency of sepsis after local corticosteroid injection (an
the horse. J. Am. Vet. Med. Assoc. 184: 335–338. inquiry on 1,160,000 injections in rheumatological private
4 Peek, S.F., Semrad, S.D., and Perkins, G.A. (2003). practice in France). Rheumatol. 38: 1272–1274.
Clostridial myonecrosis in horses (37 cases 1985–2000). 10 Kaandorp, C.J., Van Schaardenburg, D., Krijnen, P. et al.
Equine Vet. J. 35: 86–92. (1995). Risk factors for septic arthritis in patients with
5 Peek, S.F. and Semrad, S.D. (2002). Clostridial myonecrosis joint disease. A prospective study. Arthritis. Rheu. 38:
in horses. Equine Vet. Educ. 14: 207–215. 1819–1835.
6 Jeanes, L.V., Magdesian, K.G., Madigan, J.E. et al. (2001). 11 Gustafson, S.B., McIlwraith, C.W., and Jones, R.L. (1989).
Clostridial myositis in horses. Compend. Contin. Educ. Comparison of the effect of polysulfated
Pract. Vet. 23: 577–587. glycosaminoglycan, corticosteroids, and sodium
References 15
hyaluronate in the potentiation of a subinfective dose of 20 Lapointe, J.M., Laverty, S., and Lavoie, J.P. (1992). Septic
Staphylococcus aureus in the midcarpal joint of horses. arthritis in 15 Standardbred racehorses after intra-
Am. J. Vet. Res. 50: 2014–2017. articular injection. Equine Vet. J. 24: 430–434.
12 Steel, C.M., Pannirselvam, R.R., and Anderson, G.A. 21 van Weeren, P.R. (2016). Septic arthritis. In: Joint
(2013). Risk of septic arthritic after intra-articular Disease in the Horse, 2e (C.W. McIlwraith, D.D. Frisbie,
medication: a study of 16,624 injections in C. Kawcak, et al. (eds), 91–104. St. Louis: Elsevier.
Thoroughbred racehorses. Aust. Vet. J. 91: 268–273. 22 Morton, A.J. (2005). Diagnosis and treatment of septic
13 Bohlin, A.M., Kristoffersen, M., and Toft, N. (2014). arthritis. Vet. Clin. N. Am. Equine Pract. 21: 627–649.
Infectious arthritis following intra-articular injection in 23 Walmsley, E.A., Anderson, G.A., Muurlink, M.A. et al.
horses not receiving prophylactic antibiotics: a (2011). Retrospective investigation of prognostic
retrospective cohort study of 2,833 medical records. indicators for adult horses with infection of a synovial
In: Proc. Am. Assoc. Equine Pract. 60: 255–256. structure. Aust. Vet. J. 89: 226–231.
14 Gillespie, C.C., Adams, S.B., and Moore, G.E. (2014). 24 Taylor, A.H., Mair, T.S., Smith, L.J. et al. (2010).
Joint injections in horses: current practices and factors Bacterial culture of septic synovial structures of horses:
associated with the risk of infection: a survey of does a positive bacterial culture influence prognosis?
veterinarians 2014 (abstr). Vet. Surg. 44: E53–E54. Equine Vet. J. 42: 213–218.
15 Gustafson, S.B., McIlwraith, C.W., Jones, R.L. et al. (1989). 25 Moore, R.M., Schneider, R.K., Kowalski, J. et al. (1992).
Further investigations into the potentiation of infection by Antimicrobial susceptibility of bacterial isolates from
intra-articular injection of polysulfated glycosaminoglycan 233 horses with musculoskeletal infection during
and the effect of filtration and intra-articular injection of 1979–1989. Equine Vet. J. 24: 450–456.
amikacin. Am. J. Vet. Res. 50: 2018–2022. 26 Divers, T.J. (2014). Appendix 4 – Adverse drug
16 von Essen, R. and Savolainen, H.A. (1989). Bacterial reactions, air emboli, and lightning strike. In: Equine
infection following intra-articular injection. Scan. J. Emergencies: Procedures and Treatments, 4e
Rheumatol. 18: 7–12. (J.A. Orsini and T.J. Divers), 812–816. St. Louis:
17 Goodrich, L.R. (2011). Principles of therapy for Elsevier Saunders.
lameness: intrasynovial. In: Adams and Stashak’s 27 Alcott, C.J. and Wong, D.M. (2010). Anaphylaxis and
Lameness in Horses, 6e (ed. G.M. Baxter), 964–970. systemic inflammatory response syndrome induced
Ames: Wiley-Blackwell. by inadvertent intravenous administration of mare’s
18 Hague, B.A., Honnas, C.M., Simpson, R.B. et al. (1997). milk in a neonatal foal. J. Vet. Emerg. Crit. Care. 20:
Evaluation of skin bacterial flora before and after aseptic 616–622.
preparation of clipped and nonclipped arthrocentesis 28 Nielsen, I.L., Jacobs, K.A., Huntington, P.J. et al. (1988).
sites in horses. Vet. Surg. 26: 121–125. Adverse reaction to procaine penicillin G in horses.
19 Zubrod, C.J., Farnsworth, K.D., and Oaks, J.L. (2004). Aust. Vet. J. 65: 181–185.
Evaluation of arthrocentesis site bacterial flora before and 29 Chapman, C.B., Courage, P., Nielsen, I.L. et al. (1992).
after 4 methods of preparation in horses with or without The role of procaine in adverse reactions to procaine
evidence of skin contamination. Vet. Surg. 33: 525–530. penicillin in horses. Aust. Vet. J. 69: 129–133.
16
Complicationsof IntravascularInjectionand Catheterization

Overview The left and right jugular veins are located in the jugular
furrows on either side of the neck. The jugular vein is in
Intravascular injection is commonly used to intermittently close association with the trachea on the ventromedial sur-
administer small volumes of medication to horses. face and the common carotid artery and vagosympathetic
Intravascular catheterization is employed to administer trunk on the dorsomedial surface [1]. The left jugular vein
large volumes or frequent administrations of medications, is also closely associated with the esophagus and the left
provide continuous administration of intravenous fluids, or recurrent laryngeal nerve, which are located dorsomedially
secure vascular access during situations when immediate to the vein [1]. Although venipuncture or catheterization
access is needed (i.e. anesthesia) or maintaining access is may occur at any site where the vein is visible, the carotid
problematic [1, 2]. Types of catheters most commonly used artery is closer to the jugular vein in the lower part of the
in equine practice are over-the-needle stylet catheters and neck.
over-the-wire catheters. With the exception of intra-arterial The recommended site for jugular venipuncture and
stem cell injections [3] or direct blood pressure monitoring, catheterization is the proximal third of the neck, because
intravascular catheterization and injection nearly always the omohyoideus muscle traverses between the jugular
involves the venous circulation. Complications may occur vein and the carotid artery, placing the jugular vein more
during catheter placement and venipuncture or while the superficially and increasing the separation between the
catheter is indwelling within the vessel. two vascular structures [1, 2]. Alternate sites for venous
access if the jugular vein is not patent or accessible include
the cephalic vein, the lateral thoracic vein, and the saphen-
L ous vein [1, 2]. These sites are less preferred because of
with IntravascularInjection reduced patient compliance during venipuncture or cathe-
and Catheterization terization (cephalic and saphenous), difficulty in visualiz-
ing the vein (lateral thoracic), and increased chance for
● Anatomic considerations occlusion or dislodgement of catheters (all sites) compared
● Perivascular swelling and inflammation to the jugular veins [1, 4].
● Intra-arterial injection or catheterization
● Catheter placement/dislodgement/patency
● Thrombophlebitis
● Intravascular foreign bodies erivascularSwelling
P
● Vascular air embolism/bleeding and Inflammation
AnatomicConsiderations Definition Perivascular swelling is localized swelling that

occurs at the site of intravascular injection, which may be a
The most commonly used site for intravenous injection minor blemish that does not obscure visualization of the
and catheterization in the horse is the external jugular vein vascular structure or it may be severe swelling that prevents
due to large vessel size and ease and convenience of access. further use of the site or causes associated tissue injury.
Perivascular S elling and Inflammation 17
Risk Factors Diagnosis Perivascular hematoma formation is recognized

● Un-cooperativeness of the patient by swelling that occurs at the injection site during or
● Inexperience of the person performing the procedure immediately after needle or catheter placement. Visibly
● Underlying coagulopathies progressing hematoma formation associated with jugular
● Injection of irritating substances, such as phenylbuta- venipuncture or catheterization is indicative of carotid
zone, guaifenesin, tetracyclines, etc. artery injury. Perivascular inflammatory reactions may be
differentiated from hematomas because they are more
delayed in onset, occurring minutes to hours after the
Pathogenesis Perivascular swelling may be caused by
injection. The swellings may be more diffuse and the vein
hematoma formation, inflammation of the tissues, or both.
may be thickened when palpated. Knowledge of recent
Perivascular swelling during intravascular injection or
administration of an irritating substance will be an
catheterization results from hematoma formation due to
important historical detail in differentiating this type of
trauma to the target vessel or adjacent vessels. The size and
reaction.
rate of hematoma formation will depend on the origin of
Perivascular injections may be recognized by the accu-
the bleeding (venous or arterial) and the size of the needle
mulation of injection fluid at the injection site. There may
or catheter being used. The second reason for perivascular
be increased resistance of flow to the intravascular injec-
swelling in the acute setting is a localized inflammatory
tion; however, if the injection is given through a catheter
response to the injection [1, 5, 6]. Perivascular inflammation
that is cracked and leaking at the insertion site, there may
is most commonly due to perivascular leakage of even
be no change in resistance. Horner’s syndrome (ipsilateral
miniscule amounts of an irritating medication, but rarely
ptosis, miosis, enophthalmos, protrusion of nictitating
may be caused by individual horses having a hypersensitivity
membrane, and localized sweating) may develop if the
to the silicone coating on most commercial hypodermic
vagosympathetic trunk is injured [7]. Signs of Horner’s
needles. If a highly irritating substance is inadvertently
syndrome are typically a transient reaction (self-resolving
given perivascularly, the local reaction may be so severe as
within 12–24 hours), but it may be permanent. Injury to
to cause necrosis and sloughing of tissues [6]. Irritation or
the left recurrent laryngeal nerve will result in left laryn-
inflammation of the vagosympathetic trunk or the left
geal hemiplegia [1]. This neurological deficit is typically
recurrent laryngeal nerve is an uncommon sequella to
not recognized at the time of venipuncture, because the
jugular venipuncture or catheterization, but is likely
signs are exercise intolerance and inspiratory stridor. Signs
related to the causes of perivascular inflammation and
of perivascular swelling may or may not be evident.
swelling.
Treatment Small hematomas will either self-resolve or
Prevention Hematoma formation may be minimized by resolve with digital pressure. Large, progressing hematomas,
excellent restraint of the patient, good lighting, clear especially those associated with carotid injury, require a
identification of associated anatomy, and sufficient padded pressure wrap being placed over the area for at least
experience with the procedure. Use of smaller gauge 20–30 minutes and selection of an alternate site for
needles or catheters will reduce the vascular trauma but venipuncture or catheterization. Perivascular inflammatory
may inhibit recognition of inadvertent arteriopuncture. reactions are best treated by avoiding further injection or
Perivascular administration of a highly irritating catheterization of that vessel until the swelling has
substance may be minimized or avoided by placing an completely resolved [8]. Local application of warm
intravenous catheter whenever an irritating substance compresses and topical anti-inflammatory agents
will be injected. A long (5.25”) catheter should be used (diclofenac, dimethylsulfoxide) are typically used to hasten
preferably over a short (3.5”) catheter to reduce risk of the resolution and prevent progression. If perivascular nerve
catheter being dislodged from the vein. The intravascular injury is noticed at the time of injection, treatment can
positioning of the catheter should be confirmed by include local and systemic anti-inflammatory medication.
aspirating blood or passively allowing blood to egress Oral administration of Vitamin E (10 iu/kg po q24hr) is
through an unclamped extension set prior to injection of thought to aid in neurologic healing. Knowledge that a
the medication. Although injury to the vagosympathetic highly irritating substance has been injected perivascularly
trunk may occur on either the left or right side, some will guide more aggressive treatment. At the very least, the
veterinarians endorse preference for the right jugular subcutaneous tissues in the area should be injected with
vein to avoid risking trauma to the left recurrent laryngeal saline or balanced electrolyte solution to help dilute the
nerve in performance horses [1]. irritant and the intravascular catheter should be removed
18 Complications of Intravascular Injection and Catheterization
from the associated vein [6]. Skin fenestration to allow injection in areas with adequate lighting. Use needles not
drainage or tissue debridement may be necessary if necrosis smaller than 18–20 gauge, although these calibers also
is evident. show weak or absent pulsations [9].
Expected Outcome Perivascular hematomas and mild

Diagnosis Accidental penetration of the artery is typically
inflammatory reactions will resolve without further
associated with pulsatile and projectile ejection of bright
treatment, although local application of warm compresses
red blood from the catheter or needle; however, projectile
and topical anti-inflammatory medications may speed
arterial blood is not always apparent [9, 10]. Smaller gauge
resolution. Severe inflammatory reactions may result in
(18–20 gage and smaller) needles are associated with weak
temporary or permanent loss of patency of the vein and
or absent pulsations [9]. Placement of the bevel against the
associated nerve function. Injury or inflammation of the
arterial wall or incomplete seating of the needle in the
vagosympathetic trunk or left recurrent laryngeal nerve is
vessel may also prevent forceful ejection of blood. The most
usually temporary, assuming there are no other clinical
serious consequence of arterial catheterization is injection
signs, but may be permanent, especially if there is severe
of medications into the arterial system. Intracarotid
associated, perivascular inflammation.
injections are the most severe and serious of these accidental
injections because of the typically immediate and violent
I ntra-ArterialInjectionor reactions by the patient. Clinical signs can range from
Catheterization disorientation to hyperexcitability to seizures and death.
Definition Accidental arterial penetration during Treatment If arterial puncture is recognized, the needle or
venipuncture or catheterization will result in a significant catheter should be removed and firm direct pressure
hematoma formation but no other consequences if quickly applied to the site immediately. Reactions to accidental
recognized. Administration of medications into the arterial intracarotid injections can be immediate and violent.
circulation is associated with severe and violent reactions Personnel and patient safety should be prioritized.
when it involves the cerebral circulation or may be Immediate treatment of accidental intracarotid injection
associated with arteriospasm and tissue necrosis if it includes sedation and/or anticonvulsive medications
involves a peripheral artery. (alpha-2 agonists, benzodiazepines, and phenobarbital)
and provision of neuroprotective treatments
Risk Factors (dimethylsulfoxide, corticosteroids, and mannitol) [10].
● Anatomical location: The common carotid
● Poor lighting Expected Outcome The severity of intracarotid injections
● Fractious or insufficiently restrained patient depends on the amount and type of medication administered.
● Inability or inexperience to recognize anatomic land- Oil-based formulations, such as phenylbutazone, are
marks, and accessing the vein in the lower part of the associated with fatal reactions [10]. Outcome may also be
neck [2] affected by injuries incurred subsequent to the injection (e.g.
● Use of smaller gauge needles head trauma, etc.). Although systemic reactions are not
pronounced with accidental injection of other arteries,
Pathogenesis The needle is advanced and placed into the
ischemia and necrosis of the tissues supplied by the artery
arterial lumen inadvertently and the solution injected. The
may occur if the artery thromboses.
common carotid artery is the most common artery to be
accidentally punctured, especially in the caudal two-thirds
of the neck, because of the close proximity of the carotid
atheter-Related:Difficultor
C
artery to the jugular vein and common use of the jugular
vein for venous access [1, 2]. Risk of inadvertent arterial
IncorrectPlacement,Dislodgement
injection or catheterization is less with the cephalic vein, and Lossof Patency
lateral thoracic vein, and saphenous veins, because there
Definition
are no adjacent arteries. Smaller gauge needles prevent
recognition of inadvertent arteriopuncture. ● Inability to advance catheter or guidewire is a technical
complication that can occur during placement of either
Prevention Adequate knowledge of anatomy is required; an over-the-needle stylet catheter or an over-the-wire
inject into the cranial aspect of the jugular vein whenever catheter.
possible. Adequately restrain the patient and perform ● Blockage, bending or removal of catheter.
hromeophleeitis 19
Risk Factors resistance to flow [8]. No flow, which persists despite

● Use of alternate venous access sites to jugular vein manipulation of the catheter, is caused by thrombus
(cephalic, lateral thoracic, saphenous) [2]. formation within the catheter.
● Type of catheter material: more pliable catheter materi-
als (polyurethane, silastic) can be compressed as they Treatment For stylet catheters, placement can be facilitated
traverse the skin. by advancing the stylet and catheter as a unit together into
● Foals are prone to removing the intravenous catheters the vein to overcome skin friction or past valve leaflets or by
from their dams. injecting sterile saline into the catheter as it is being
advanced to distend the vein. If the guidewire is verified to
Pathogenesis Inability to advance the catheter or guidewire be in the vein but cannot be advanced, options include
may be caused by friction from the skin against the catheter placement of the catheter in a different vein or more distally
(especially in thick skinned animals), perivascular in the vein or securing an over-the-wire catheter without
placement or inadequate seating of the stylet needle or inserting it to its full length (which is allowed by the catheter
guide needle into the vein, or obstruction by valve leaflets or clamp and fastener included in the kit). Catheter patency
changes in diameter or direction of the vein [1, 2]. Premature may be restored in some of these occluded catheters by
removal of a catheter results from a failure to adequately aspirating the thrombus from the catheter, if possible. It is
secure the catheter. The alternate catheter sites of the important to recognize that this may be an early sign of a
cephalic, lateral thoracic, and saphenous veins are prone to more serious problem, such as bending or breakage if the
premature removal because of increased mobility of these catheter is composed of stiff materials, or early signs of
areas and ability of the horse to bite at these sites [1, 4]. thrombophlebitis. Therefore, catheter removal should be
Even if a catheter is well sutured, some patients are highly considered in these cases and if the catheter is maintained,
adept at removing them, either through rubbing the neck or strategies should be used to reposition the catheter
scratching with a hind foot. Reasons for low flow may be (resuturing, catheter wraps or bandaging, maintaining the
due to kinking of the catheter under the skin or as the horse’s head in a more elevated position, etc.).
horse’s position changes or it may be caused by early
development of a thrombus at the catheter tip. Expected Outcome Use of an alternate site or replacement
of the catheter usually resolves the problem. In some cases,
Prevention To prevent premature catheter removal, it is hematoma, swelling, thrombophlebitis or infection at the
advisable to always securely suture in the intravascular site may develop.
catheters unless they are intended for very short-term use
and under predictable circumstances. Bandaging the
catheter site, use of a low-profile catheter (such as an over- Thrombophlebitis
the-wire catheter), and frequent monitoring may reduce
this complication but does not entirely prevent it. Catheter Definition Thrombophlebitis, defined as nonseptic or
patency can be assured by maintaining a continuous flow septic inflammation of the vein, is a common complication
of fluids through the intravascular catheter or regularly of indwelling intravascular catheters.
flushing or heparin locking the catheter if it is being used
infrequently. In general, flushing the catheter with Risk Factors
heparinized saline (2–10 iu/ml) every 6 hours is adequate ● Related to catheter placement: technique, duration of
in healthy horses, but more often may be prudent in catheterization, orientation of catheter relative to direc-
patients at higher risk for coagulopathies, such as colic tion of blood flow, and material, length, and diameter of
patients [1, 4, 8]. Catheters should be carefully inspected the catheter [1, 2, 4, 11]
and palpated every day with a gloved hand to determine if ● Type of intravenous fluids or medications being adminis-
the catheter is kinking under the skin. tered (e.g. nonsterile fluids, hyperosmolar fluids (paren-
teral nutrition, 50% dextrose, hypertonic saline),
Diagnosis Problems occur when the stylet catheter cannot undiluted irritating medications (chemotherapeutic
be advanced off the stylet needle into the vein or when the agents, phenylbutazone, amphotericin B, etc.))
guide wire cannot be passed through the needle. Trouble- ● Patient-related: critical illness, gastrointestinal disease,
shooting of this problem can be done by aspirating blood hypoproteinemia, and endotoxemia are independent
from the needle or stylet to verify that the tip of the needle risk factors for thrombophlebitis [11]. Patient coloniza-
or stylet is in the vein. Low flow through the catheter may tion with methicillin resistant staphylococcus is an anec-
be recognized by a catheter that is positional or has dotal risk factor.
● Catheter materials ranked in order of decreasing risk of venous drainage, associated veins may become dilated and
thrombosis are polypropylene > polyethylene > polyte- tissues may become edematous (i.e. facial and nasal edema
trafluoroethylene > silicone rubber > nylon > polyvinyl associated with jugular venous thrombosis) [1, 4, 16].
chloride > polyurethane > silastic [1, 2, 4, 12].
● Catheter size: Longer and larger diameter catheters Monitoring Ultrasound examination of the catheter site
are more inflammatory than short, narrow catheters and associated vein is most sensitive to detect early signs
[8, 12]. of thrombophlebitis, such as thickening of the vein and
● Catheter site handling: Catheter sites should be kept development of a thrombus on the catheter (Figure 3.2) [1,
clean from environmental contamination, secured, and 2, 4, 15]. The entire length of the catheter should be
maintained with aseptic technique. ultrasounded, because thrombi are often initiated at the
distal tip. Ultrasonographic evidence of thickening of the
Pathogenesis Development of thrombophlebitis is related vein is evident in at least 27% of catheterized veins
to the inflammatory and pro-coagulant environment maintained for at least 24 hours [15], although external
present within the catheterized vessel [11]. Catheter- clinical changes are seen in approximately 8–18% of colic
related factors (type, duration, contamination, instability), patients [17, 18].
patient-related factors (concurrent disease,
hypoproteinemia, endotoxemia, infection), and infusate
characteristics (hyperosmolar, acidic, microparticulate)
contribute to the degree of inflammation and coagulable
state within the vessel. Bacterial colonization is not always
associated with vascular changes [12, 13]; however, septic
thrombophlebitis is a serious complication.
Prevention Catheters should be placed and managed

aseptically, adequately stabilized, and kept clean and
protected from soiling or external trauma, with the caveat
that daily inspection should continue despite protective
wraps. Some clinicians advocate removal of all catheters after
48–72 hours and replacement in an alternate site if continued
use is needed [12]; however, signs of thrombophlebitis can
occur within 24 hours and repeated catheterization increases
the risk of thrombophlebitis. Administration of low- Figure 3.1 Photograph of a left jugular catheter insertion site
associated with nodular thickening and suppurative exudate.
molecular weight heparin (dalteparin) in colic patients was Source: Courtesy of Pablo Espinosa.
associated with less subclinical (ultrasonographic) changes
of thrombophlebitis than unfractionated heparin [14]. Non-
steroidal anti-inflammatory treatment was found to be
protective in another study [15]. Reduction in catheter flow
may be caused by early development of a thrombus at the
catheter tip.
Diagnosis Catheter sites should be closely monitored on at

least a daily basis for evidence of thickening or pain at the
insertion site or along the catheter [1, 2, 4, 8]. Clinical signs
of thrombophlebitis can occur within 24 hours and include
thickening at the insertion sites, local swelling, heat, cord-
like thickening of the vein, suppurative exudate
(Figure 3.1), pain on palpation, and if septic, may progress
to fever, obtundation, and systemic signs associated with Figure 3.2 Transverse ultrasound image of the jugular vein
septic embolization to distant sites [1, 2, 4, 11]. shown in Figure 3.1. Hyperechoic material was identified
Thrombophlebitis may also result in perivascular nerve superficial to the jugular vein (arrowhead). There was localized
thickening (arrows) of the jugular vein wall (perivasculitis). The
injury, such as Horner’s syndrome and left laryngeal jugular vein remained patent. Source: Courtesy of Pablo
hemiplegia. If thrombophlebitis results in occlusion of Espinosa.
Intravascular Foreign odies 21
Treatment If there are any signs of thrombophlebitis,

the catheter should be removed immediately and the
catheter should be cultured or saved for culture if any
concerns. Treatment should be instituted if there is local
swelling, pain, or inflammation, and includes warm
compresses and topical anti-inflammatory treatment
(dimethylsulfoxide or diclofenac). If signs of fever,
suppurative discharge, or cellulitis are present, then
systemic antimicrobial treatment is indicated and should
be guided by culture and sensitivity results. If
re-catheterization is necessary, the affected vein must not
be used and it is recommended to use another anatomic
site (i.e. do not use contralateral jugular vein, if possible,
because thrombophlebitis of both jugular veins can
impede venous drainage from the head). If
thrombophlebitis results in abscess formation or complete
occlusion of the vein (Figure 3.3), it may be necessary to Figure 3.3 Local abscessation of a jugular thrombophlebitis
with complete thrombosis of the right jugular vein at the level
surgically drain, resect, or reconstruct the vein [16, 19]. of the abscess and 10 cm caudally. Source: Courtesy of Pablo
Espinosa.
Expected Outcome Most cases of thrombophlebitis will
resolve uneventfully, but may require prolonged antimicrobial
therapy. Sequellae may include cosmetic blemish, permanent Pathogenesis Catheter fragmentation may occur during
occlusion of the affected vein, residual edema or varicosities placement of over-the needle stylet catheters if the catheter
in the area drained by the affected vein, and laryngeal is advanced and then retracted back over the stylet and the
hemiplegia. Septic embolization and dissemination of stylet pierces the side of the catheter [1]. Loss of the
infection to internal locations may occur and may be guidewire during placement of an over-the-wire catheter
associated with additional morbidity and mortality. using a Seldinger technique is not uncommon in human or
veterinary medicine [21, 22]. The most common reason for
IntravascularForeignBodies loss of the guidewire is not holding onto the guidewire at
all times that the wire is in the vein [22]. Catheters may be
Definition Needle emboli, catheter fragmentation, and accidentally transected when the sutures are being cut
loss of the guidewire are causes of intravascular foreign during catheter removal. Indwelling catheters may bend
bodies during catheter placement and/or management of and break (Figure 3.4), particularly if they are made of
indwelling catheters [1, 5, 8, 20]. more rigid material [1, 2, 20, 23]. In an experimental study
evaluating long-term jugular vein catheterization, 67% of
Risk Factors
● Use of small gauge (20 gauge or smaller) needles, inade-
quate restraint of a fractious patient, or manufacturer
defect. Risk factors for loss of guidewires identified in
human medicine and relevant to veterinary medicine are
inexperience in the technique or equipment, lack of ade-
quate supervision, distractions during catheter place-
ment, and high workload [21]. Patient restraint and
resistant during the procedure would be important in
equine settings.
● Catheter kinking and breakage should be considered for
any catheter type, especially as duration of catheteriza-
tion increases, and clinicians should be most alert to
failure in catheters made of stiffer materials (poly-
tetrafluoroethylene, polyethylene, polypropylene) and
Figure 3.4 Polyurethane catheter removed from a jugular vein
over-the-needle stylet catheters, because they have to be 48 hours after being placed. The catheter is seen to have
stiffer to allow insertion. multiple areas of bending and kinking. Source: Julie E. Dechant.
polytetrafluoroethylene catheters kinked, cracked or broke there is a defect in the catheter at or near the insertion site.
within 14 days, and 100% of polytetrafluoroethylene Intravascular foreign bodies should be localized by
catheters kinked and broke within 30 days [12]. In the radiographs starting at the site of penetration and
same study, none of the silicone rubber or polyurethane proceeding along the vein toward the thorax (Figure 3.5) [1,
catheters broke, even after 30 days of catheterization [12]. 20]. Ultrasound may be needed to evaluate the site of
Re-use of needles is a risk factor in breaking and causing insertion (although manipulation of the tissues makes
needle emboli in human intravenous drug abuse [24], but ultrasound less desirable than radiographs) or to evaluate if
re-use of hypodermic needles is ill-advised in veterinary the intravascular foreign body is in the heart [1, 20].
practice.
Treatment For any intravascular foreign bodies, immediate
Diagnosis Needle emboli can occur when the needle steps to be taken would be occlusion of the vein on the
breaks off the hub during placement (Figure 3.5). This will cardiac side of the insertion point to try to prevent migration
be recognized immediately because the hub and syringe into the heart and pulmonary vasculature [5]. Defective
will be free from the needle. Catheter fragmentation will catheters should be removed immediately. During removal,
not be recognized until the catheter is removed and found the vein should be occluded on the cardiac side of the vein
to be incomplete. Loss of the guidewire is typically so that any catheter fragments can be trapped at the site
recognized immediately in veterinary medicine [22]; and prevented from embolization [5]. If the intravascular
however, delayed recognition is common in human foreign body is accessible, it should be removed to prevent
medicine [21]. Catheter breakage is immediately evident if complications, assuming the risks of removal do not
it occurs at the time of catheter removal; however, if the outweigh the benefits [8, 20, 25]. Direct approaches can be
failure occurs in an indwelling catheter, it may not be made to the jugular vein, but this should be done under
recognized. During aspiration or injection of the catheter, general anesthesia with radiographic control to guide
any evidence that air bubbles are being aspirated or bubbling dissection. Endovascular retrieval is preferred in
under the skin during injection is strongly suggestive that humans [25]; however, horse size will be limiting to this
technique unless the patient is a foal or pony-sized or the
intravascular foreign body is located in the jugular vein or
cranial vena cava [20, 22]. In an experimental study, 5 out
of 6 horses with experimental catheter transection had the
transected catheter located in the proximal or distal
pulmonary arteries at necropsy 30 hours later [26].
Expected Outcome In general, it is believed that

intravascular foreign bodies located within the pulmonary
vasculature carry a low risk of complications [1, 8].
Vascular Air Embolism/Bleeding

Definition
● Vascular air embolism is the aspiration of a significant
amount of air from the environment into the vasculature
and the resulting systemic effects.
● Blood loss from a disconnected catheter port.
Risk Factors
● Large gauge, jugular vein catheters
● Catheters placed above heart level (for air embolism)
Figure 3.5 Lateral radiograph of the cranial cervical region
(cranial to the left of the image) in a horse that was referred for
treatment and removal of a needle fragment that broke off Pathogenesis Vascular air embolism may occur during
during attempted venipuncture of the left jugular vein. An catheter placement before the injection cap is attached to
intravenous catheter was placed in the contralateral (right) the catheter or it may occur after placement if the injection
jugular vein. The needle fragment was located medial to the
jugular vein in the cranial cervical region. Source: Courtesy of
cap or extension set becomes dislodged from the catheter.
the University of California, Davis Veterinary Medical Teaching Air may be passively aspirated into the catheter because of
Hospital Diagnostic Imaging Service. the negative pressure within the jugular vein when the
References 23
horse’s head is elevated. The total volume and rate of air injection cap or extension set from the catheter. The
aspiration are related to the development and severity of diagnosis may be supported by arterial blood gas analysis
clinical signs. Reportedly, up to 0.25 ml/kg body weight of and auscultation of a mill-wheel murmur [27–29].
air may be aspired in horses before clinical signs develop [6, Echocardiography can also be used to confirm the
27] Pulmonary edema results from the inflammatory diagnosis, but most cases are diagnosed presumptively [27–
response and vascular resistance induced by air in the 29]. Diagnosis of exsanguination from the catheter is
pulmonary microvasculature. Cardiac dysrhythmias or obvious due to the external blood loss.
neurological signs occur when the pulmonary vasculature
is saturated and air enters the systemic circulation and Treatment Treatment of vascular air embolism starts with
embolizes to the coronary or cerebral microvasculature or immediate replacement of the injection cap or extension
if air moves retrograde (cranially) in the jugular vein [1, set to prevent further aspiration of air. Nasal insufflation of
27–31]. Cardiovascular collapse can occur if a large air oxygen can help treat respiratory distress and can speed
embolus creates an air-lock in the right ventricle, reducing resorption of air emboli by changing pressure gradients to
cardiac output [29]. help diffusion of nitrogen out of the air bubbles and
Passive aspiration of air is not a significant concern with reducing their size [1, 29]. Pulmonary edema can be
catheters that are placed below heart level or in horses with managed with furosemide, corticosteroids, and non-
lowered head positions (hemorrhage would be a complica- steroidal anti-inflammatory drugs. Similarly, neurological
tion of dislodgement of injection caps or ports from these signs can be managed with anti-inflammatory (dimethyl
catheters). Blood loss from a disconnected catheter port is sulfoxide, corticosteroids, non-steroidal anti-inflammatory
rare, because most horses will clot before life-threatening drugs), neuroprotective (thiamine, Vitamin E) and anti-
amounts of blood are lost [1, 2]. convulsant (benzodiazepines, barbiturates) treatments, as
necessary [1, 30, 31].
Prevention Risk of vascular air embolism or blood loss Intravenous fluids should be administered if cardiovas-
following disconnection of catheter attachment can be cular compromise is evident, but they may exacerbate pul-
minimized by securing injection caps or extension sets monary or cerebral edema. The volume of blood loss may
with luer lock ports. Regular monitoring of horses with be significant in hypocoagulable patients or small-sized
indwelling catheters will minimize the length of time that patients [1, 2]. Treatment includes replacement of the
a catheter is disconnected. Theoretically, placement of injection port and administration of intravenous fluids or
catheters in the vein against the direction of blood flow (i.e. whole blood, if signs of hypovolemia are present or
up the jugular vein) would prevent air embolism, but severe [1].
would create additional problems (increased catheter
thrombosis, resistance to injection, and potential for Expected Outcome If recognized promptly and vascular air
exsanguination if catheter is disconnected) [31]. aspiration is limited, clinical signs can improve and horses
can return to normal after vascular air emboli. In one study,
Diagnosis Clinical signs of vascular air embolism are 19% of horses were euthanized or died subsequent to
tachycardia, tachypnea, muscle fasciculations, agitation, vascular air embolism [27–31]. Similarly, blood loss from a
respiratory distress and pulmonary edema and may include disconnected catheter was unlikely to be significant or
neurological signs and cardiovascular collapse [1, 27–31]. affect prognosis, unless the hemorrhage was not recognized
The signs may be attributed to vascular air embolism if or treated.
they occur in association with disconnection of the
References
1 Higgins, J. (2015). Preparation, supplies, and 3 Spriet, M., Trela, J.M., and Galuppo, L.D. (2015).
catheterization. In: Equine Fluid Therapy (ed. C.L. Fielding Ultrasound-guided injection of the median artery in the
and K.G. Magdesian), 127–141. Ames: John Wiley & Sons. standing sedated horse. Equine Vet. J. 47: 245–248.
2 Tan, R.H.H., Dart, A.J., and Dowling, B.A. (2003). Catheters: 4 Barakzai, S. and Chandler, K. (2003). Use of indwelling
a review of the selection, utilization and complications of intravenous catheters in the horse. In. Pract. 25:
catheters for peripheral venous access. Aust. Vet. 81: 136–139. 264–271.
5 Hardy, J. (2009). Venous and arterial catheterization and 18 Lankveld, D.P.K., Ensink, J.M., Dijk, P.V. et al. (2001).
fluid therapy. In: Equine Anesthesia: induction, Factors influencing the occurrence of thrombophlebitis
maintenance and recovery phases of anesthesia. In: after post-surgical long-term intravenous catheterization
Equine Anesthesia: Monitoring and Emergency Therapy, of colic horses: a study of 38 cases. J. Vet. Med. A. 48:
2e (ed. W.W. Muir and J.A.E. Hubbell), 131–148. St. 545–552.
Louis: Elsevier Saunders. 19 Rikjenhuizen, A.B. and van Swieten, H.A. (1998).
6 Muir, W.W. (1991). Complication: induction, Reconstruction of the jugular vein in horses with post
maintenance and recovery phases of anesthesia. In: thrombophlebitis stenosis using saphenous vein graft.
Equine Anesthesia: Monitoring and Emergency Therapy, Equine Vet. J. 30: 236–239.
1e (ed. W.W. Muir and J.A.E. Hubbell), 419–443. St. 20 Culp, W.T.N., Weisse, C., Berent, A.C. et al. (2008).
Louis: Mosby Year Book, Percutaneous endovascular retrieval of an intravascular
7 Sweeney, R.W. and Sweeney, C.R. (1984). Transient foreign body in five dogs, a goat, and a horse. J. Am. Vet.
Horner’s syndrome following routine intravenous injection Med. Assoc. 232: 1850–1856.
in two horses. J. Am. Vet. Med. Assoc. 185: 802–803. 21 Pokharel, K., Biswas, B.K., Tripathi, M. et al. (2015).
8 Lorello, O. and Orsini, J.A. (2014). Intravenous catheter Missed central venous guide wires: a systematic
placement. In: Equine Emergencies: Procedures and analysis of published case reports. Crit. Care Med. 42:
Treatments, 4e (ed. J.A. Orsini and T.J. Divers), 9–11. St. 1745–1756.
Louis: Elsevier Saunders. 22 Nannarone, S., Falchero, V., Gialletti, R. et al. (2013).
9 Gabel, A.A. and Koestner, A. (1963). The effects of Successful removal of a guidewire from the jugular vein
intracarotid artery injection of drugs in domestic animals. of a mature horse. Equine Vet. Educ. 25: 173–176.
J. Am. Vet. Med. Assoc. 142: 1397–1403.
23 Hoskinson, J.J., Wooten, P., and Evans, R. (1991).
10 Divers, T.J. (2014). Appendix 4 – Adverse drug reactions,
Nonsurgical removal of a catheter embolus from the
air emboli, and lightning strike. In: Equine Emergencies:
heart of a foal. J. Am. Vet. Med. Assoc. 199: 233–235.
Procedures and Treatments, 4e (ed. J.A. Orsini and T.J.
24 Kulaylat, M.N., Barakat, N., Stephan, R.N. et al. (1993).
Divers), 812–816. St. Louis: Elsevier Saunders
Embolization of illicit needle fragments. J. Emerg. Med.
11 Dolente, B.A., Beech, J., Lindborg, S. et al. (2005).
11: 403–408.
Evaluation of risk factors for developments of catheter-
25 Schechter, M.A., O’Brien, P.J., and Cox, M.W. (2013).
associated jugular thrombophlebitis in horses: 50 cases. J.
Retrieval of iatrogenic intravascular foreign bodies. J.
Am. Vet. Med. Assoc. 227: 113–1141.
Vasc. Surg. 57: 276–281.
12 Spurlock, S.L., Spurlock, G.H., Parker, G. et al. (1990).
Long-term jugular vein catheterization in horses. J. Am. 26 Scarratt, W.K., Pyle, R.L., Buechner-Maxwell, V. et al.
Vet. Med. Assoc. 196: 425–430. (1998). Transection of an intravenous catheter in six
13 Ettlinger, J.J., Palmer, J.E., and Benson, C. (1992). horses: effects and location of the catheter fragment. In:
Bacteria found on intravenous catheters removed from Proc. Am. Assoc. Equine Pract. 44: 294–295.
horses. Vet. Rec. 130: 248–249. 27 Parkinson, N.J., McKenzie, H.C., Barton, M.H. et al.
14 Fiege, K., Schwarzwald, C.C., and Bombeli, T. (2003). (2018). Catheter-associated venous air embolism in
Comparison of unfractioned and low molecular weight hospitalized horses: 32 cases. J. Vet. Intern. Med. 32:
heparin for prophylaxis of coagulopathies in 52 horses 805–814.
with colic: a randomized double-blind clinical trial. 28 Caporelli, F., McGowan, C.M., and Tulamo, R.M. (2009).
Equine Vet. J. 35: 506–513. Suspected venous air embolism in a Finnhorse. Equine
15 Geraghty, T.E., Love, S., Taylor, D.J. et al. (2009). Vet. Educ. 21: 85–88.
Assessment of subclinical venous catheter-related 29 Pellegrini-Masini, A., Rodriguez Hurtado, I., Stewart,
diseases in horses and associated risk factors. Vet. Rec. A.J., et al. (2009). Suspected venous air embolism in three
164: 227–231. horses. Equine Vet. Educ. 21: 79–84.
16 Russell, T.M., Kearney, C., and Pollock, P.J. (2010). 30 Holbrook, T.C., Dechant, J.E., and Crowson, C.L. (2007),
Surgical treatment of septic jugular thrombophlebitis in Suspected air embolism associated with post-anesthetic
nine horses. Vet. Surg. 39: 627–630. pulmonary edema and neurologic sequelae in a horse.
17 Mair, T.S. and Smith, L.J. (2005). Survival and Vet. Anesth. Anal. 34: 217–222.
complication rates in 399 horses undergoing surgical 31 Bradbury, L.A., Archer, D.C., Dugdale, A.H.A. et al.
treatment of colic. Part 2: short-term complications. (2005). Suspected venous air embolism in a horse. Vet.
Equine Vet. J. 37: 303–309. Rec. 156: 109–111.
25
Complicationsof Endoscopy
Overview Risk Factors

● Small-sized horses or foals
Endoscopy is performed using a flexible video-endoscope, ● Insufficient restraint
although rigid endoscopes may be used for certain surgical ● Unsedated patients
applications. The upper respiratory tract, larger airways of ● Restriction of the passageway to be scoped by luminal
the lower respiratory tract, proximal gastrointestinal tract masses or extraluminal swelling
(esophagus, stomach and proximal duodenum), caudal
intestinal tract (rectum and distal small colon), lower uri- Pathogenesis Similar to passage of a nasogastric tube,
nary tract (urethra, bladder and occasionally ureters), and there is the potential risk of epistaxis or other mucosal
uterus are commonly examined using endoscopy. This trauma. The severity of this injury is typically much less
chapter will review complications associated with endo- than for nasogastric intubation, because passage of the
scopic examination procedures, whereas surgical endo- endoscope is visually guided and directed and the
scopic procedures will be discussed separately. Similarly, endoscopes are generally narrower in diameter and more
complications associated with arthroscopy, tenoscopy, lap- pliable than most nasogastric tubes. Sources of epistaxis
aroscopy and thoracoscopy will be reviewed in their respec- would most likely include the nasal mucosa during
tive chapters. Complications can occur related to equipment endoscope advancement, because visualization would
damage, patient injury from the endoscope, and sequellae reduce the risk of traumatizing the nasal turbintate and
from insufflation. ethmoid turbinates. However, further advancement of the
endoscope into a more restricted space (guttural pouches,
esophagus) could result in inadvertent flexing of the scope
L into the turbinates. Advancement of the endoscope into
with Endoscopy the urethra, ureters, uterus, or caudal intestinal tract could
cause direct mucosal trauma in some cases.
● Epistaxis/mucosal trauma
● Equipment damage Prevention Use of intranasal phenylephrine, which causes
● Insufflation-related complications vasoconstriction of mucosal vessels, and application of
● Air embolism carbomethylcellulose lubricant, which reduces friction
between the endoscope and the passageways, may reduce
mucosal trauma and irritation in small patients or patients
Epistaxis/MucosalTrauma with restricted nasal passages.
Definition Epistaxis is the presence of hemorrhage exiting Treatment and Expected Outcome Most epistaxis and
the nares. Mucosal trauma includes bruising, abrasions, mucosal trauma complications associated with endoscopy
and lacerations which can occur during passage of the are self-limiting and do not need specific treatment. If
endoscopy into any hollow organ. severe epistaxis occurred, treatment could be applied
26 Complications of ndoscopy
similar to that described for epistaxis associated with

nasogastric intubation (see Chapter 5: Complications of
Nasogastric Intubation).
EquipmentDamage
Definition Crushing damage to the endoscope by mastication
Risk Factors
● Upper airway endoscopy or gastroscopy without endo-
scope protector
● Inexperience
● Oral endoscopy without a mouth speculum
Pathogenesis The most common damage is associated

with endoscopy of the nasopharynx due to retroflexion of
the endoscope into the oral cavity. Damage can occur at the
end of the endoscope if the leading edge retroflexes into
the oral cavity or it may occur in the body of the endoscope
if the scope does not advance through the cranial
esophageal sphincter and a loop of the endoscope
retroflexes into the oral cavity (Figure 4.1). This would be Figure 4.1 Photograph showing large segment (spanning the
most common when performing esophagoscopy and 160 cm to 205 cm gradations) of crushing and damage to a
gastroscopy, because of the intentional induction of a 3-meter gastroscope after a segment of the midbody of the
swallowing reflex to enter the esophagus and the long endoscope retroflexed into the oral cavity, where it was chewed
by the patient. Source: Julie E. Dechant.
length of the endoscope used for gastroscopy. Upper airway
endoscopy is not immune to oral retroflexion, although the
risk is much lower because the esophagus is not Insufflation-relatedComplications
intentionally entered. Use of the endoscope to evaluate the
oral cavity directly exposes the endoscopy to risk of damage Definition Insufflation is the directed administration of
by the teeth. The damage is caused by the horse chewing air through the endoscope to provide distension and
on the scope and the scope will be immediately visualization of collapsible hollow organs and can result in
non-functional. small intestinal volvulus or rupture of a hollow viscus.
Prevention This complication can be minimized by Risk factors

awareness of the risk of it occurring during gastroscopy ● None identified
and upper airway endoscopy. The person passing the ● Inattention during procedure
endoscopy controls the forward motion. This person
should be careful when advancing the endoscope until Pathogenesis These complications are likely the result of
confident in its location. Once seated in the esophagus, the effective creation of a one-way valve when performing
the person advancing the scope should make sure that endoscopy in long, narrow, tubular organs, whereby there
there is aboral advancement of the scope synchronous is no means for the insufflated air to escape and depressurize
with advancement of the endoscope into the nasal cavity. the system.
Alternatively, a larger diameter hollow tube can be Segmental jejunal volvulus has been described as a
positioned through the nasal cavity and into the complication after gastroscopy [2]. The incidence of jeju-
esophagus [1]. The gastroscope is then passed through this nal volvulus is low, with only 1–2 cases per year per insti-
tube, which prevents any resistance to passage and tution included in their study (0.3–3.2%/year) [2]. All of
retroflexion of the endoscope in the nasopharynx [1]. Oral the horses had gas distension of the affected small intes-
speculums must be used for any oral endoscopy procedures tine, which was presumed to be related to the gas insuffla-
and the scope should be protected by a rigid sheath when tion associated with gastroscopy. In the report of jejunal
in the mouth, if possible. volvulus, there was no apparent association with duration
Air Embolism 27
of gastroscopy, duration of feed withholding, or use of rupture is a hypothetical risk, but if it occurred, the
duodenoscopy. outcome would be poor due to difficulty in accessing the
Although bladder rupture has not been directly stomach for repair of the rupture and the spillage of gastric
described as a complication of cystoscopy in the literature, contents and subsequent peritonitis.
this author has observed a case in which prolonged ure-
throscopy and insufflation was used in an attempt to endo-
scopically remove a urethrolith [3]. The procedure resulted AirEmbolism
in retropulsion of the urethrolith into the bladder.
Subsequently, a perineal urethrotomy was performed to Definition One or more air bubbles get access to the
ensure patency of the urinary tract, but bladder rupture circulatory system, causing blockade of one or multiple
and uroperitoneum was diagnosed 12 hours later. It can- blood vessels.
not be proven that the urethroscopy caused the bladder
rupture, but this was seen as a potential cause for the Risk Factors (attributed to presumptive venous air embolism)
complication. ● Dorsal location of the urinary tract relative to the right
Gastric rupture has not been described in the equine ventricle
literature as a sequella of gastroscopy; however, gastric ● Presence of denuded epithelium
rupture has been described in a human patient during
diagnostic upper gastrointestinal endoscopy [4]. While Pathogenesi Urinary tract endoscopy was proposed to
this complication would be unlikely in most normal-sized cause venous air embolism in two cases reported in the
horses, it may be a potential complication in small literature [5–7]. Please refer to the vascular air embolism
patients. section in Chapter 3: Complications of Intravascular
Injection and Catheterization. Air was noted to be present
Prevention The authors of the jejunal volvulus case series within the renal pelvis during ultrasonographic examination
concluded that it is advisable to minimize the duration and performed 24 hours after the endoscopic procedure, which
amount of air insufflated into the duodenum, reduce the may suggest that air was absorbed through the renal
amount of sedatives administered, and to use suction to vasculature [6]. The dorsal location of the urinary tract
decompress the stomach after gastroscopy is completed [2]. relative to the right ventricle is suggested to create a pressure
Bladder rupture and hypothetical gastric rupture are gradient that favors the movement of air into the
presumed to be exceptionally rare occurrences. Therefore, vasculature [7]. This may be additionally facilitated by the
it is difficult to identify preventative measures. It may be presence of denuded epithelium, which could increase the
prudent to avoid prolonged cystoscopy, especially if the risk of air entering the bloodstream [5–7].
urethra is partially obstructed.
Prevention Prevention of venous air embolism during
Diagnosis Jejunal volvulus was diagnosed as the presence urinary tract endoscopy would include use of alternative
of severe colic signs requiring colic surgery within a few means to distend the urethra and bladder, such as saline
hours of the gastroscopy procedure. Gastric rupture solution or carbon dioxide gas, pre-oxygenation with 100%
(hypothetical) or bladder rupture could be identified as the oxygen, and anticoagulant therapy; however, the mucoid
loss of distension at the time of the endoscopic examination. and crystalline nature of equine urine makes the use of
In the proposed clinical case, bladder rupture was identified saline to distend the bladder impractical [6, 7]. These
as signs of uroperitoneum several hours later. precautions may be warranted in cases thought to be at
higher risk for venous air embolism, such as cases
Treatment All of these complications require emergency presenting for hematuria or severe cystitis cases with
exploratory celiotomy to diagnose and correct the problem. denuded mucosa [7].
Non-surgical methods to manage bladder rupture have
been described and may be a consideration in certain Diagnosis Refer to Chapter 3: Complications of
cases. Intravascular Injection and Catheterization.
Expected Outcome If treated promptly, the outcome Treatment The clinical signs and treatment of vascular air
following jejunal volvulus and bladder rupture would be embolism are described in detail as a complication of
expected to be good. If intestinal ischemia or peritonitis intravenous catheterization and readers are directed to that
occurs, the prognosis is much more guarded. Gastric chapter.
28 Complications of ndoscopy
Expected Outcome In the cases described in the literature, described in Gordon et al. [5] was euthanized following
and as described in Chapter 3, horses would be expected recovery from two occurrences of presumptive vascular
to recover and return to normal from this complication if air embolism, due to a poor prognosis for a malignant
recognized and insufflation was stopped. The horse lesion that prompted the cystoscopy.
References
1 Sykes, B.W. and Jokisalo, J.M. (2014). Rethinking equine 5 Gordon, E., Schlipf, J.W., Husby, K.A. et al. (2015). Two
gastric ulcer syndrome. Part 1: Terminology, clinical signs occurrences of presumptive venous air embolism in a
and diagnosis. Equine Vet. Educ. 26: 543–547. gelding during cystoscopy and perineal urethrotomy.
2 Bonilla, A.G., Hurcombe, S.D., Sweeney, R.W. et al. (2014). Equine Vet. Educ. doi: 10.1111/eve.12507.
Small intestinal segmental volvulus in horses after 6 Romagnoli, N., Rinnovati, R., Lukacs, R.M. et al. (2014).
gastroscopy: four cases (2011–2012). Equine Vet. Educ. 26: Suspected venous air embolism during urinary tract
141–145. endoscopy in a standing horse. Equine Vet. Educ. 26:
3 Kilcoyne, I. and Dechant, J.E. (2014). Complications 134–137.
associated with perineal urethrotomy in 27 equids. Vet. 7 Nolen-Walston, R. (2014). Venous air embolism during
Surg. 43: 691–696. cystoscopy in standing horses. Equine Vet. Educ. 26:
4 Wurm Johansson, G., Nemeth, A., Nielsen, J. et al. (2013). 138–140.
Gastric rupture as a rare complication in diagnostic upper
gastrointestinal endoscopy. Endoscopy. 45: E391.
29
Complicationsof NasogastricIntubation

● Inexperience, although hemorrhage may occur with
Nasogastric intubation is performed to check for gastric skillful intubation in a compliant horse
reflux, relieve gastric distension, or administer enteral flu- ● Non-compliant horse
ids, laxatives, or medications. Nasogastric intubation is
achieved by directing and maintaining the nasogastric tube Pathogenesis Epistaxis is the most common complication
into the ventral meatus of the nasal cavity, without trauma- from nasogastric intubation [1–3]. Hemorrhage can occur
tizing the nasal turbinates and the ethmoid turbinates. The when the respiratory mucosa, nasal turbinates, or ethmoid
tube is blindly manipulated within the nasopharynx to the turbinates are traumatized.
esophageal opening, avoiding the dorsal pharyngeal recess
and the salpingopharyngeal plica. Once in the esophagus, Prevention The risk of epistaxis may be minimized by
the nasogastric tube is gently advanced aborally to enter careful and gentle technique and assuring advancement of
the cardia of the stomach. tube into ventral nasal meatus using well-lubricated tubes
The blind manipulation and passage of the tube can that are in good condition and free of external defects or
result in trauma to the associated tissues along the intended roughening. Tube diameter should be selected to be an
pathway, and trauma to structures if the tube is misdi- appropriate size for the patient, with the dimensions of the
rected. Misplacement of the tube can result in further prob- ventral nasal meatus being most limiting. Although water
lems (fragmentation of the tube or administration of fluid often provides sufficient lubrication in most circumstances,
into the lungs) if not recognized. additional lubrication using carboxymethylcellulose or
lubricating gel at the end of the tube may reduce risk of
epistaxis in small patients, patients with dry or friable
L mucosa, or animals with restricted nasal passages. Pre-
with NasogastricIntubation emptive intranasal application of phenylephrine spray,
which causes local vasoconstriction of vessels within the
● Epistaxis nasal mucosa, may be of benefit. Patients should be
● Misplacement of tube adequately restrained, which may require use of a nose
● Esophageal/pharyngeal trauma twitch or sedation.
● Fragmentation of tube
● Administration of fluid into lungs Diagnosis Epistaxis occurs during placement or
● Sinusitis immediately after removing the nasogastric tube.
Treatment Mild elevation of the head may speed resolution

Epistaxis of bleeding, because lowering the head increases venous
congestion, which would delay hemostasis. Extreme
Definition Epistaxis is the presence of hemorrhage from elevation of the head should be avoided because it increases
the nares. the risk of aspiration and pneumonia [1]. Packing of the
30 Complications of Nasogastric Intueation
affected nasal cavity is an option, but the technique may

simply divert hemorrhage into the nasopharynx and not
reduce the volume of bleeding. Intranasal application of
phenylephrine or epinephrine may be useful in providing
local vasoconstriction; however, ongoing bleeding may
limit the amount and distribution of drug that is absorbed
by the nasal mucosa.
Expected Outcome Bleeding may be minor or more

significant, and is usually self-limiting [2]. In rare
circumstances, hemorrhage may be severe enough to
require blood transfusion and the administration of drugs
to promote coagulation and prevent fibrinolysis. It is
recommended that horses should not be anesthetized
while there is ongoing nasal hemorrhage, because the head
is generally positioned lower than the heart during
anesthesia, which would exacerbate hemorrhage, and the
cardiovascular consequence of ongoing blood loss is less
tolerated during the cardiovascular depressant effects of
most anesthetic drugs. Figure 5.1 Lateral radiograph of the pharyngeal region of a
miniature horse undergoing a positive contrast esophagogram
(black asterisks) showing the nasogastric tube coiled within the
Misplacementof Tube guttural pouch (white arrows). The nasogastric tube was
subsequently repositioned within the esophagus. The
intravenous catheter is labeled (white arrowhead).
Definition The tube is inadvertently misdirected into Source: University of California, Davis Veterinary Medical
tracheal lumen, guttural pouch or retroflexes at the back of Teaching Hospital Diagnostic Imaging Service.
the nasopharynx and enters the oral cavity, or exits out the
contralateral nostril while advancing the tube. tube retroflexing into the oropharynx. Misplacement of the
tube in the guttural pouch with subsequent perforation of
Risk Factors the medial compartment has been described [4].
● Uncooperative patients, inadequate restraint or assis-
tance, and inexperience with the procedure are predomi- Prevention Misdirection of the tube into the trachea can
nant risk factors. be minimized by flexing the horse’s head when the tube is
● Excessively pliable nasogastric tubes increase the risk of in the nasopharynx. Rotation of the tube by 180 degrees
misplacement or misdirection of the tube. after it has cleared the nasal passages may also be helpful.
● Smaller diameter tubes may increase the risk of mis- The tube can be marked with a permanent marker at the
placement of the tube within the guttural pouch distance from the nares to the pharynx/larynx to help judge
(Figure 5.1). the proximity of the indwelling tube to the larynx.
Retroflexion of the tube into the oral cavity may be
minimized by using a tube with sufficient rigidity to reduce
Pathogenesis Misplacement of the nasogastric tube is a abrupt bending of the tube. Tubes with areas of focal
common complication of nasogastric intubation. The weakness should be avoided. Sedation, especially with
esophageal opening is directly dorsal to the arytenoid detomidine [5], may relax the esophagus and aid passage of
cartilages of the larynx and it is relatively easy to enter the the tube; however, the horse may have a reduced swallowing
trachea, especially in horses that do not swallow or are reflex. Endoscopic guidance should be considered when
resisting the intubation procedure. Retroflexion of the tube smaller diameter nasogastric tubes are placed [4] or if
into the oral cavity can occur at the leading edge of the tube repeated attempts to pass the nasogastric tube have failed.
when trying to enter the esophagus. Alternatively, it may
happen along any part of the length of the tube if the Diagnosis Although horses may respond to intratracheal
esophagus spasms around the tube and prevents its placement of the nasogastric tube by coughing, some
advancement. Further efforts to advance the tube against horses may not exhibit a cough reflex. Absence of coughing
esophageal resistance results in the pharyngeal part of the does not guarantee correct placement of the nasogastric
sophagealyPharyngeal rauma 31
tube. Intratracheal positioning of the tube can be tube into the guttural pouch, it was described that initial
determined by lack of any resistance to advancement of the placement of a nasogastric tube was not able to be advanced
tube and free movement of air, if air is blown into the tube beyond the nasopharynx, although subsequent passage of
or suction is applied to the tube. The tube may be felt to be a larger diameter tube was successful. The horse developed
reverberating within the trachea if the trachea is gently signs of throatlatch swelling four hours later, which
shaken. More importantly, correct positioning of the tube prompted referral and identification of lesion with endos-
within the esophagus can be confirmed by palpating air copy, ultrasound and radiography [4].
boluses within the esophagus when air is blown into the
tube and negative pressure is obtained when suction is Treatment As long as intratracheal placement is
applied to the tube. Palpation or visualization of the tube recognized and corrected before any fluids or medications
within the cervical esophagus ensures correct positioning. are administered, there are minimal to no consequences.
If further confirmation is needed, a second individual can Erroneous administration of fluid or medication into the
auscultate for air bubbling into the stomach by listening lungs is discussed as a separate complication. Retraction of
over the left 14th intercostal space while air is blown into the orally misplaced tube corrects the misplacement;
the tube. however, the consequences range from abrasion of the tube
Location of small diameter feeding tubes, which may not to cracks or defects in the wall of the tube to complete
be easily palpable, can be confirmed with radiographs transection of the tube [5]. In the case report of guttural
(Figure 5.2). Retroflexion of the tube into the oral cavity pouch perforation as a complication of nasogastric
may be detected by recognizing that the horse is chewing intubation, the associated signs of pharyngeal swelling and
and recognizing that the chewing involves the tube. During cellulitis was treated with antibiotics, non-steroidal anti-
misdirection of the nasogastric tube into the contralateral inflammatory drugs, supportive fluid therapy, and feeding
nasal passage, there will be some resistance to passing the of pelleted mashes and soaked hay. Unfortunately, the
tube, but air will move freely in and out of the tube and it horse was euthanized several days later due to ulcerative,
cannot be localized in the trachea or esophagus. In the case necrotizing colitis [4].
report describing trauma secondary to misplacement of the
Expected Outcome If promptly recognized and corrected,
misplacement of the tube should not be considered a
complication. It is merely a consequence of blindly guiding
the tube into the esophagus. If misplacement of the tube is
not corrected promptly, it can be associated with life-
threatening complications if there is resulting tissue
trauma or infusion of medication into the lungs.
Esophageal/PharyngealTrauma
Definition Pharyngeal trauma ranges from mild bruising

to perforation of the dorsal pharyngeal wall. Esophageal
trauma can include ulcerations, linear lacerations, and
partial to full-thickness perforation of the wall at any point
along its length.
Risk Factors
● Prolonged durations or repeated intubations
● Horses that resist intubation by retching and contracting
Figure 5.2 Lateral radiograph of the thorax of a neonatal foal their cervical musculature may be at greater risk for
to document the position of the indwelling nasogastric feeding
tube. In this radiograph, the feeding tube is located within the complications
trachea and extending within a caudal bronchus and into the ● Smaller horse breeds [3]
dorsocaudal lung lobe. Correct esophageal positioning would be
evidenced by dorsal positioning of the feeding tube relative to Pathogenesis Mild pharyngeal trauma and bruising may
the trachea, especially at the carina (white arrowheads).
Source: University of California, Davis Veterinary Medical occur after nasogastric intubation. Pharyngeal perforation
Teaching Hospital Diagnostic Imaging Service. has also been described as a complication of nasogastric
intubation [7]. Ulceration or perforation of the esophagus antibiotic therapy is required because of the significant
is a documented complication of nasogastric intubation. In degree of contamination and extension of infection along
one study, the primary cause of esophageal perforations fascial planes. Nutritional and fluid support is a major
was traumatic nasogastric intubation [8]. In another study, challenge in these cases, because of the esophageal defect
esophageal ulceration or perforation was the predominant and the need for it to heal. The risks and benefits of
complication attributed to nasogastric intubation [3]. indwelling nasogastric tubes versus esophagostomy tubes
Pharyngeal and esophageal trauma can occur with a single need to be considered in each individual case [9].
intubation; however, prolonged durations or repeated
intubations appear to be associated with greater risk of Expected Outcome Prognosis for subclinical pharyngeal
complications [3]. trauma and bruising is excellent, whereas prognosis for
clinically evident pharyngeal trauma is guarded and
Prevention It is proposed that pharyngeal and esophageal depends on the ability to manage the cellulitis and avoid
trauma might be minimized by selecting smaller tube size associated complications, such as antimicrobial associated
and sedating horses with an alpha-2 agonist, such as colitis and laminitis [3, 7]. Prognosis for survival after
detomidine, to relax the esophagus [3]. It is important to esophageal ulceration is good, although stricture may
note that smaller tube size may increase the risk of certain occur with extensive or circumferential ulcerations.
misplacements and sedation may impede the swallowing Prognosis for esophageal perforations is guarded, because
reflex. The risk of prolonged intubations in horses with there is often a delay in treatment, resulting in extensive
persistent gastric reflux needs to be balanced against the cellulitis and tissue damage subsequent to the leakage of
risk of repeated, intermittent intubations. saliva and feed into the periesophageal tissues with
subsequent abscessation, mediastinitis, and tissue
Diagnosis In most cases, mild pharyngeal trauma and necrosis [8. 9].
bruising is subclinical and would only be recognized if the
horse undergoes endoscopic inspection of the nasopharynx.
Endoscopy was necessary to diagnose the pharyngeal Fragmentationof Tube
trauma after horses developed clinical signs of ptyalism,
dysphagia, bruxism, and coughing attributed to pharyngeal Definition Fragmentation of the tube refers to complete
trauma [3]. Clinical signs of esophageal trauma have been structural failure of the tube, resulting in discontinuity of
reported to be indistinguishable from pharyngeal the tube.
trauma [3]; however, other studies describe the concurrent
presence of fever, cervical swelling, and cellulitis when Risk Factors
esophageal perforation has occurred [8, 9]. In some ● Repeated use of tubes
perforation cases, the cellulitis and infection may travel ● Retroflexion into oral cavity
caudoventral along the fascial planes towards the ● Exposure to sunlight, chemical agents, or environmental
mediastinum. extremes
Endoscopy is helpful in identifying esophageal ulcera-
tions and perforations, although small perforations may be Pathogenesis Nasogastric tubes can fragment if they are
hidden within the esophageal folds in some cases [9]. In brittle, have defects, or become retroflexed into the oral
those situations, ancillary diagnostic tests, such as radiol- cavity. Nasogastric tubes can become brittle over time and
ogy and ultrasound, may be helpful to support the diagno- with repeated use, especially if exposed to sunlight,
sis and document the extent of cellulitis. chemical agents, or temperature extremes [10]. Tubes may
also fragment if a horse chews on a tube which retroflexes
Treatment Treatment of pharyngeal trauma and esophageal into the oral cavity [6]. These fragments may remain within
ulceration is antimicrobial therapy and anti-inflammatory the esophagus or stomach.
drugs to manage cellulitis, if present, and feeding of soft
feeds or mashes if the horse is dysphagic. Sucralfate may aid Prevention Nasogastric tubes should be frequently
in healing of esophageal ulcerations. Tracheostomy may be inspected to ensure that they are in good condition and
necessary if pharyngeal or peri-esophageal swelling causes without any defects or damage. Care should be taken to
upper respiratory tract obstruction. Surgical debridement of avoid oral retroflexion of nasogastric tubes and immediate
esophageal perforations is recommended to establish ventral correction, if it occurs. Awareness and prompt recognition
drainage and excise infected tissues. Broad spectrum of the problem may reduce the chance of complete
Administration of Fluid into ungs 33
transection of the tube. If the tube has been misdirected

into the oral cavity, it should be removed and inspected
for damage before continuing with nasogastric
intubation.
Diagnosis Once it is recognized that the tube is incomplete,

it is essential to immediately locate the position of the
fragmented segment of tube. This should include an oral
examination, because some fragments may be retrieved
orally [11]. If this is not successful, external palpation of
the neck, endoscopic examination of the esophagus and
stomach, and cervical and thoracic radiographs may locate
the fragment [6, 11]. Multiple fragments may be present, so
it is important that the entire tube is retrieved [10, 11].
Treatment Treatment requires removal of the fragmented

tube to prevent further gastrointestinal obstruction and Figure 5.3 Intraoperative photograph showing the removal of
trauma. The method of removal depends on the location of a large nasogastric tube fragment (1.3 cm diameter, 90 cm long)
the tube, available equipment, and the success of each through a full thickness enterotomy in the right dorsal colon.
technique. Manual extraction from the oral cavity can be This horse presented with acute signs of colic, but had no
known history of prior nasogastric intubation complications. It
performed if the tube is located in the oral cavity and is was presumed that the nasogastric tube fragment had been
facilitated by general anesthesia to allow safe and thorough acquired prior to the current ownership of the horse and did not
manual exploration [11]. Homemade or commercially cause problems until it migrated to the transverse colon and
available snares can be used to endoscopically snare and caused obstruction. Source: Courtesy of Isabelle Kilcoyne.
retrieve tube fragments, either using standing sedation or
general anesthesia [6, 10]. Surgical removal by esophagotomy pathology depends on the type and volume of fluid that
or gastrotomy has been used in selected cases when other enters the lung. There are several mechanisms by which
methods of retrieval were unsuccessful [6, 10]. nasogastric procedures can result in aspiration pneumonia.
First, the nasogastric tube may be misplaced into the
Expected Outcome If nasogastric tube fragments are not trachea by improper technique, inadequate restraint, or by
removed, it is likely that they may cause future intestinal impaired swallowing reflexes in obtunded patients
obstruction or injury and require emergency exploratory (Figure 5.1) [12]. Second, incomplete passage of the tube
celiotomy (Figure 5.3). into the stomach or esophageal intubation may allow
reflux of administered medication or fluid from the
esophagus and into the trachea [12]. Third, rapid
Administrationof FluidintoLungs administration or administration of a large volume of fluid
or medication into an already filled stomach can result in
Definition Aspiration pneumonia in this circumstance is esophageal reflux and aspiration of that reflux into the
caused by administration of enterally administered fluids lungs [12]. Fourth, failure to completely empty the tube,
or medication into the lung. failure to kink or occlude the tube while removing, or rapid
removal of the tube may allow any residual fluid or
Risk Factors medication within the tube to spill into the nasopharynx
● Improper technique where it can be aspirated [12].
● Inadequate restraint
● Incomplete passage into the stomach Prevention Prevention of inadvertent administration of
● Improper removal of the tube fluids into the lungs is an essential part of nasogastric
intubation procedures. Please refer to the section describing
Pathogenesis Administration of fluid into the lungs can be misplacement of nasogastric tubes for specific preventative
a consequence of misplacement of a tube into the trachea procedures. Careful attention to all precautions throughout
or it may result from spillage from a properly placed the nasogastric intubation procedure will help to minimize
nasogastric tube. The severity of the resulting pulmonary complications.
Diagnosis Development of respiratory distress immediately Sinusitis

following a nasogastric tube procedure is highly suggestive
of inadvertent pulmonary administration of fluid. Signs Definition Sinusitis is the accumulation of suppurative
may be delayed by a few days in cases with a small amount exudate within the paranasal sinuses of the horse and
of mineral oil aspiration. Diagnosis of contamination of the typically results in malodorous nasal discharge with or
lungs with mineral oil, also described as mineral oil-induced without pyrexia.
pneumonitis or lipoid pneumonia, is based on a history of
mineral oil administration, radiographic or ultrasonographic Risk Factors
evidence of pneumonia, and the identification of oil in ● Prolonged or repeated nasogastric intubation
tracheal wash or bronchoalveolar lavage samples [13–17]. ● Contamination of the nasal cavity with blood or gastro-
intestinal reflux, especially during general anesthe-
Treatment If a small amount of clean water is sia [18, 19].
inadvertently administered into the lungs, the horse ● Prolonged intubation is a significant risk factor in
should be placed on anti-inflammatory treatment and people [20]
antimicrobial therapy to prevent pneumonia [1].
Administration of larger volumes of fluid may require Pathogenesis Unilateral or bilateral sinusitis has been
additional supportive care, such as furosemide to treat described as a rare complication of nasogastric
pulmonary edema, bronchodilators, and intranasal oxygen intubation [18, 19]. Pathogenesis is assumed to be related
therapy. Inadvertent intratracheal administration of to overwhelming of normal sinus defense mechanisms by
certain medications (e.g. deworming drenches) [12] and impediment of normal sinus drainage (inflammation and
mineral oil [13, 15–19] may have fatal consequences, even swelling of mucosa secondary to indwelling tubes),
with aggressive treatment. These horses should be increased bacterial load (prolonged intubation, use of a
aggressively treated with antimicrobial therapy, anti- contaminated tube, or feed contamination of sinuses), or
inflammatory medications, bronchodilators, nebulization, propagation of bacterial growth (blood contamination).
and intra-nasal oxygen [13–17]. Repeated bronchoalveolar
lavage and lung lobectomy has been reported to be helpful Prevention Nasogastric tube-associated sinusitis may be
in people with mineral oil aspiration, but it has not been minimized by prophylactically lavaging the nasal passages
described in the equine case reports [16, 17]. There is one if they are contaminated with gastrointestinal reflux during
report of successful treatment of lipoid pneumonia, from colic surgery and by using clean, disinfected nasogastric
aspiration of mineral oil, in which dexamethasone tubes for as short a time as possible [18].
treatment was used [14]; however, other authors have
reported use of corticosteroids as part of their treatment Diagnosis Clinical signs are the development of suppurative
efforts in cases with unsuccessful outcomes [15]. nasal discharge and fever [18]. Radiographs of the paranasal
sinuses and endoscopy of the upper respiratory tract can
Expected Outcome A small amount of clean water localize the disease to the paranasal sinuses.
inadvertently administered into the lungs may be tolerated;
however, the horse should be placed on prophylactic Treatment Treat with systemic antimicrobial therapy and
treatment to prevent pneumonia [1]. In contrast, a small lavage of the affected sinuses via trephination. Sinusotomy
amount of mineral oil aspirated into the lungs in nearly via sinonasal flap may be necessary in selected cases.
invariably fatal [13–17].
Expected outcome Prognosis with appropriate treatment
should be good.
References
1 Fehr, J. (2013). Nasogastric intubation. In: Practical Guide 2 Lopes, M.A.F. (2003). Administration of enteral fluid
to Equine Colic (ed. L.L. Southwood), 38–44. Ames: John therapy: methods, composition of fluids and
Wiley & Sons, Inc. complications. Equine Vet. Educ. 15: 107–112.
References 35
3 Hardy, J., Stewart, R.H., Beard, W.L. et al. (1992). 12 Stauffer, B.D. (1982). Stomach intubation accidents. J.
Complications of nasogastric intubation in horses: Am. Vet. Med. Assoc. 181: 448.
nine cases (1987–1989). J. Am. Vet. Med. Assoc. 201: 13 Metcalfe, L., Cummins, C., Maischberger, E. et al. (2010).
483–486. Iatrogenic lipoid pneumonia in an adult horse. Irish Vet.
4 Gillen, A., Cuming, R., Schumacher, J. et al. (2015). J. 63: 303–306.
Guttural pouch perforation caused during nasogastric 14 Henninger, R.W., Hass, G.F., and Freshwater, A. (2006).
intubation. Equine Vet. Educ. 27: 398–402. Corticosteroid management of lipoid pneumonia in a
5 Wooldridge, A.A., Eades, S.C., Hosgood, G.L. et al. (2002). horse. Equine Vet. Educ. 18: 205–209.
Effects of treatment with oxytocin, xylazine butorphanol, 15 Bos, M., de Bosschere, H., Deprez, P. et al. (2002),
guaifenesin, acepromazine, and detomidine on Chemical identification of the (causative) lipids in a case
esophageal manometric pressure in conscious horses. of exogenous lipoid pneumonia in a horse. Equine Vet. J.
Am. J. Vet. Res. 63: 1738–1744. 34: 744–747.
6 Cribb, N.C., Kenney, D.G., and Reid-Burke, R. (2012). 16 Davis, J.L., Ramirez, S., Campbell, N. et al. (2001). Acute
Removal of a nasogastric tube fragment from the stomach and chronic mineral oil pneumonitis in two horses.
of a standing horse. Can. Vet. J. 53: 83–85. Equine Vet. Educ. 13: 230–234.
7 Rashmir-Raven, A.M., DeBowes, R.M., Gift, L.J. et al. 17 Scarratt, W.K., Moon, M.L., Sponenberg, D.P. et al. (1998).
(1991) What is your diagnosis? J. Am. Vet. Med. Assoc. Inappropriate administration of mineral oil resulting in
198: 1991–1992. lipoid pneumonia in three horses. Equine Vet. J. 30:
8 Craig, D.R., Shivy, D.R., Pankowski, R.L, et al. (1989). 85–88.
Esophageal disorders in 61 horses: results of nonsurgical 18 Nieto, J.E., Yamout, S., and Dechant, J.E. (2014). Sinusitis
and surgical management. Vet. Surg. 18: 432–438. associated with nasogastric intubation in 3 horses. Can.
9 Kruger, K. and, Davis, J.L. (2013). Management and Vet. J. 55: 554–558.
complications associated with treatment of cervical 19 Tremaine, W.H. and Dixon, P.M. (2001). A long-term
oesophageal perforations in horses. Equine Vet. Educ. 25: study of 277 cases of equine sinonasal disease.
247–255. Part 1: Details of horses, historical, clinical and
10 DiFranco, B., Schumacher, J., and Morris, D. (1992). ancillary diagnostic findings. Equine Vet. J. 33:
Removal of nasogastric tube fragments from three horses. 274–282.
J. Am. Vet. Med. Assoc. 201: 1035–1037. 20 Prabhakaran, S., Doraiswamy, V.A., Nagaraja, V. et al.
11 Baird, A.N. and True, C.K. (1989). Fragments of (2012). Nasoenteric tube complications. Scand. J. Surg.
nasogastric tubes as esophageal foreign bodies in two 101: 147–155.
horses. J. Am. Vet. Med. Assoc. 194: 1068–1070.
36
Complicationsof FluidTherapy
Angelika Schoster Dr.med.vet, DVSc, PhD, DVSc, DACVIM/DECEIM1 and
Henry Stämpfli DVM, Dr.med.vet, DACVIM2
1
Clinic for Equine Internal Medicine, University of Zurich, Switzerland
2
Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
L intracellular fluid compartment) and one-third is extracel-
with FluidTherapy lular (ECF, extracellular fluid compartment). ECF is com-
posed of interstitial and intravascular fluid (one-third of
● Fluid overload using crystalloid solutions body weight, ~8%) [1, 2]. Overhydration can have severe
● Complications associated with the type of crystalloid negative impacts on health and should be avoided.
fluid infused
– Sodium imbalance Definition Fluid overload occurs when the total body
– Potassium imbalance water is increased relative to the normal volume for a given
– Other electrolyte imbalances patient. Fluid overload is caused by administration of
– Complications due to administration of sodium bicarbonate excessive amounts of fluid or adequate amounts of fluid to
– Complications due to glucose/dextrose containing fluids a patient with impaired elimination, for example a patient
● Complications associated with intravascular plasma with decreased urine output due to renal compromise. This
administration condition is rare in adult horses with normal cardiac and
– Immunological reactions renal function.
– Non-immunogenic complications
– Serum hepatitis
Risk Factors
● Complications associated with administration of colloid
● Hypoproteinemia
therapy
● Renal failure, heart failure
● Complications of enteral fluid therapy
● Systemic inflammation
– Complications due to administration setup
● Blood product administration [3, 4]
– Complications due to volume of fluid used
– Complication due to type of fluid used
Pathogenesis If fluid plans are properly designed and
● Complications associated with administration of paren-
followed, this complication is rare. It may occur more
teral nutrition solutions
commonly in small patients (ponies and neonates) if the
– Catheter associated complications
weight is estimated, as the margin of safety is smaller in
– Metabolic aberrations
these patients.
– Complications due to withholding of enteral feeding
Starling’s law governs fluid shifts across capillary mem-
branes. Hydrostatic pressures maintain an outward pres-
sure, while oncotic forces aim to retain fluid in its respective
luidOverloadUsingCrystalloid
F compartment. Hydrostatic pressures are derived from body
Solutions water on either side of the capillary. If large amounts of
fluid are introduced into the intravascular space, hydro-
In healthy adult animals, the body is made of 60% of water. static pressure of the vasculature will increase. When the
Two-thirds of total body water is intracellular (ICF, hydrostatic pressure becomes high enough to overwhelm
Fluid Overload Using Crystalloid Solutions 37
counteracting forces in the interstitium, extravasation of Ongoing losses due to diarrhea or reflux should ideally
fluid occurs. In addition, the main oncotic force of the vas- be measured. If this is not possible, then losses can be esti-
culature, albumin, is often diluted in such situations. This mated. Maintenance fluid requirement is 2–3 ml/kg/h (50–
lowers oncotic pressure in the vasculature bed, thus further 75 ml/kg/day) in adult horses and 3–4 ml/kg/h in foals
promoting extravasation of fluid into the interstitium and (75–100ml/kg/day), who have a higher total tissue water
resulting in edema formation [5]. In horses with hypopro- amount.
teinemia (e.g. colitis, enteritis, colon torsion, post-perito- Additional fluid sources such as enteral fluids, or use of
neal lavage), the oncotic pressure of the vasculature is different fluids such as plasma, colloids, or parenteral
decreased even without prior dilution. In cases such as nutrition solution with their high osmolality, have to be
acute non-oliguric renal failure, extravasation of fluid due factored into the fluid equation. Once the desired amount
to high hydrostatic pressure can also occur in patients with of fluid for the next 24 hours is calculated it should be
normal protein levels. Clinical signs of over-hydration (see given as a continuous rate infusion (CRI). Ideally in all, but
Diagnosis below) become noticeable once the amount of certainly in smaller animals (ponies or foal), a fluid pump
total water exceeds a critical value, which is individually should be used.
different. The adequacy of fluid therapy should be monitored every
6–12 hours. The fluid plan should be adjusted accordingly
Prevention A fluid plan should be formulated for each every 12–24 hours. Monitoring parameters include hemato-
individual patient every 24 hours, taking into account crit and plasma proteins, serum creatinine and lactate.
dehydration, maintenance needs and ongoing losses. Care Serial measurements have to be performed, as single hema-
should be taken in animals with risk factors and response tocrit values can be influenced by splenic contractions and
should be monitored closely. The weight of the animal low protein concentrations can be due to primary hypopro-
should be measured if possible, not estimated, particularly teinemia rather than overhydration. Urine output is a good
in smaller horses (ponies, neonates). marker for hydration status. When adequate urine output
Before formulating a detailed fluid plan in severely hypo- (min, 1 mL/kg/h, approx. 500 mL/h or 12 L/day for a 500 kg
volemic patients, an initial resuscitation with a shock dose horse) occurs after initiation of fluid therapy and urine spe-
of a maximum of 90 ml/kg in bolus can be given. This cific gravity returns to normal (reference range 1,020–
amount can be administered safely in about 20–30 minutes 1,040), dehydration is likely resolved and fluid rates should
to a 500 kg horse. In high-risk patients, such as neonates, be reduced to cover maintenance and ongoing losses.
horses with suspected non-oliguric renal failure or horses Repeated weighing of the patient as an objective determina-
with severe systemic compromise or obvious signs of heart tion of adequate fluid administered has limited value. For
failure (distended jugular veins, jugular pulses, ventral instance, horses with colitis may accumulate fluid in the
edema, tachycardia, weak pulses), a more conservative colon, and gain weight rapidly while still being dehydrated.
approach is warranted and administration of 45–60 ml/kg Continuous daily weight gain should alert for fluid overload
over 30 minutes should be targeted initially. This should be in a horse with normal hydration status; however, severely
followed by slowly replacing the remainder of the deficit dehydrated horses usually appropriately gain weight. Other
over a 12–24 h period. Alternatively, hypertonic fluid (e.g. techniques providing a more accurate estimation of fluid
5–7% hypertonic saline, 4 ml/kg) can be used as an initial therapy include central venous pressure monitoring, bioim-
bolus followed by crystalloid fluid therapy (minimum of pedance analysis and pulse pressure variation [8–11]. These
5–10 times the amount of hypertonic saline techniques are not routinely used in practice and are usu-
administered). ally restricted to large referral or university hospitals.
A fluid deficit (dehydration or hypovolemia) can be
assessed via clinical data such as heart rate, capillary refill
Diagnosis Diagnosis of fluid overload is based on clinical
time, moistness of mucous membranes, and skin tent, as
signs and laboratory data. Acute fluid overload often leads to
well as laboratory data including hematocrit, plasma pro-
signs of pulmonary edema, while chronic fluid overload is
teins and creatinine [6, 7]. Anything less than 5% of fluid
often associated with signs of heart failure. Pulmonary edema
loss cannot be diagnosed clinically, whereas severe dehy-
leads to impaired oxygenation; clinical signs include
dration of around 12% may result in death. Dehydration in
tachypnea, tachycardia, coughing, respiratory distress, “wet”
percent (%) times body weight gives the amount of fluid in
lung sounds on auscultation and serous or frothy nasal
liters to be replaced over a specific time:
discharge (see Figure 6.1). Signs observed with chronic fluid
overload include lethargy, tachycardia, peripheral edema
Fluid deficit L %dehydration body weight kg formation on the ventral midline (see Figure 6.2), distal limbs,
38 Complications of Fluid herapy
Figure6.1 Frothy nasal discharge due to pulmonary edema Figure6.3 Chemosis as a consequence of fluid overload in a
from fluid overload in a horse. horse.
the sheath in geldings or the head when carried low, and Treatment options depend on severity of the case. If mild
rarely chemosis (see Figure 6.3). Additional signs seen can be signs of pulmonary (mild tachypnea but no signs of
restlessness, shivering, colic, ascites, pleural effusion, and respiratory distress or nasal discharge) or of cardiovascular
large amounts of urine voided. On laboratory analysis, impairment (mildly elevated heart rate but no overt signs
hematocrit and plasma proteins are often below normal of heart failure) are present and renal function is normal,
range. Arterial blood gas analysis can be performed to assess the kidneys are likely to excrete the excessive amounts of
oxygenation in patients with suspected pulmonary edema. fluid as long as no additional excessive fluid amount is
Blood pressure can be elevated. Other negative effects of fluid administered.
overload include interstitial tissue edema, gastrointestinal If severe clinical signs of pulmonary, cardiovascular or
motility disturbances, acute respiratory distress syndrome, any renal function impairment are present, additional
abdominal compartment syndrome, delayed wound healing treatments should be initiated.
and increased mortality [12, 13]. ● Discontinue or decrease administration of fluid,
depending on whether the underlying clinical problem
Treatment Once fluid overload is recognized, measures requires additional fluid therapy (e.g. electrolyte
should aim at reducing the total amount of body fluid. imbalances).
● Increase renal excretion of fluid: Furosemide 1–2 mg/kg
IV as a bolus. In case of severe pulmonary edema, up to
4 mg/kg.
● Drain excessive fluid from pleural and peritoneal spaces
if present.
● Reassess hydration status initially every 2–4 hours, later
every 6–12 hours, using the clinical and laboratory
parameters described above until hydration status is
normal.
Expected Outcome The outcome depends on the inciting

cause and underlying disease. If the inciting cause (such as
inadvertent over-administration to a healthy patient) can
be resolved, prognosis is good. If renal failure is the cause
for fluid overload, prognosis is poorer and guarded. Horses
with pulmonary edema can die within a short period of
Figure6.2 Ventral edema as a consequence of fluid overload time, or can recover fully depending on severity and
in a horse. initiation of treatment.
Complications Associated ith the ype of Crystalloid Fluid Infused 39
omplicationsAssociated
C Pathogenesis Changes in blood sodium concentrations
with the Typeof CrystalloidFluid are often due to underlying diseases or incorrect fluid
Infused therapy and result from abnormal water and sodium intake
or loss. Blood sodium is always in distribution equilibrium
with the total ECF. Abrupt changes in blood sodium
Fluid therapy can lead to acid–base and electrolyte imbal-
concentration cause shifts in the intracellular and
ances when given to a healthy animal, but also overcorrec-
interstitial fluid concentrations.
tions of pre-existing abnormalities can lead to severe side
In hyponatremia, water shifts from the extracellular fluid
effects if not performed correctly. Sodium and potassium
compartment intracellularly to maintain osmolal equality
mainly, but also chloride, calcium, magnesium and phos-
between the compartments. Water accumulation in brain
phor homeostasis, are important.
cells leads to cerebral swelling and neurological abnormali-
Many different crystalloid fluids are available commer-
ties. Hyponatremia is uncommon in horses, but can occur
cially, containing varying concentrations of different electro-
in association with diarrhea, bladder rupture, acute renal
lytes and base equivalents. Few formulations are currently
failure, and severe sweat losses and more rarely with exces-
available in 3–5 L bags, while 1 L bags usually are available
sive water consumption. Adrenal insufficiency and rhab-
but are often cost-prohibitive and cumbersome to be admin-
domyolysis are rare causes of hyponatremia [14–18].
istered to a normal sized horse. Depending on the country
In hypernatremia, osmolality of the extracellular fluid
and legislation, these fluids differ slightly in their composi-
increases. In acute cases, water shifts from the intracellular
tion. Every clinic/hospital/practitioner should attempt to get
fluid compartment extracellular to maintain osmolal
an overview of formulations available in his/her country for
equality between the compartments. Cerebral cell dehy-
administration to horses and should know content and con-
dration can lead to neurological signs. Hypernatremia is
centrations including osmolality of the fluids.
rare in horses.
Replacement fluid therapy should be considered sepa-
rately from maintenance fluid therapy, especially the type
Prevention
of fluid chosen. In general, replacement fluids (e.g. Lactated
● Monitor the amount of sodium administered via fluid
Ringer’s, isotonic saline, Normosol-RTM, Plasmalyte ATM)
therapy.
are very close to serum concentrations for sodium, chloride
● Sodium levels (in combination with other electrolytes)
and potassium, whereas maintenance fluids contain much
should be measured every 24–48 h during fluid therapy.
lower amounts of sodium and chloride and higher amounts
● In hypo- or hypernatremic animals, the rate and speed of
of potassium as well as other electrolytes and sometimes
correction is crucial to avoid complications.
glucose (e.g. Normosol MTM).
● If high or low sodium fluids are used, or correction of
SodiumImbalance existing hypo- or hypernatremia is performed, plasma
sodium concentrations should be measured every 12–24
Definition hours.
● Increased (hypernatremia) or decreased (hyponatremia) ● High risk patients (small patients, neonates undergoing
blood sodium levels (reference range: 139–147 mmol/L) abdominal or colon lavage with water) should have
● Acute (<24–48 h) and chronic (>40 h) conditions are blood sodium levels measured 1–2 hours after the
recognized procedure.
Risk Factors When replacement fluid therapy is administered to a nor-
● Administration of intravenous sodium-bicarbonate monatremic animal, a fluid containing concentrations of
(hypernatremia) sodium equal or close to plasma (~130–150 mmol/L) should
● Administration of hypertonic saline (hypernatremia) be used, e.g. Lactated Ringer’s solution (130 mmol/L). For
● Peritoneal lavage or colon lavage with water or low maintenance, solutions with lower sodium concentration
sodium fluids (hyponatremia) (~40 mmol/L) can be used. As these are not widely available
● Reflux and diarrhea (usually hyponatremia) in 3–5 L bags, replacement fluid is often used for mainte-
● Renal disease, interfering with sodium excretion (usu- nance as well. As long as renal function is adequate, the
ally hyponatremia, except if large amounts of sodium are increased sodium load is simply excreted by the kidney. In
administered when hypernatremia can occur) foals, or animals with impaired renal function, this should
● Small patients (neonates, ponies): these have a smaller be taken into account and a true maintenance solution con-
margin of safety (both) taining lower amounts of sodium and chloride (e.g.
● Pre-existing blood sodium abnormalities (both) Normosol-MTM Na 40 mmol/L) should be considered.
Diagnosis Diagnosis is based on clinical signs and blood used in animals with severe abnormalities, as this formula
sodium concentrations. Clinical signs occur only in moderate tended to underestimate the final serum sodium concentra-
to severe hyponatremia and include restlessness, focal and tions in humans with severe abnormalities [23].
general seizures and death. Clinical signs of acute In horses with chronic hyponatremia and dehydration,
hyponatremia occur in humans at concentrations of the following protocol can be attempted:
125 mmol/L [19], while concentrations as low as 110 mmol/L
● Administer an isotonic crystalloid (e.g. Lactated Ringer’s
can be without clinical signs in chronic hyponatremia [20].
Na 130 mmol/L or equivalent) at maintenance rate
The concentrations at which horses show clinical signs have
2–4 mL/kg/h.
not been experimentally determined; however, it is known
● Recheck sodium blood concentrations frequently (every
from case reports that foals with Na <100 mmol/L showed
2 h) and aim for a correction rate of 0.5 mmol/h. If the
severe signs [15, 16]. Signs of hypernatremia in horses are
correction is too fast, add sterile water to the infusion; if
unclear, but seizures are reported in humans.
the correction rate is too slow, switch to a crystalloid con-
Treatment For recommendations regarding treatment of taining more sodium (e.g. Normosol-Na 140 mmol/L,
hypo-and hypernatremia, the reader is referred to an NaCl 0.9% Na 154 mmol/L).
excellent review (Equine Fluid Therapy, 1st ed. Fielding, In hypernatremia, controversy exists over the type of
Magdesian eds, Wiley). fluid that should be used. In severely hypernatremic ani-
Acute hyponatremia (<24–48 h) can be corrected rap- mals, it might be feasible to start using saline (Na 154
idly, while long-standing hyponatremia (>48 h) has to be mmol/L), followed by Lactated Ringer solution (Na 130
corrected slowly. It is often difficult to determine the dura- mmol/L) and then switching to 5% dextrose in water (Na 0
tion of hyponatremia; if duration cannot be determined mmol/L) to avoid rapid correction of hypernatremia.
from history, underlying disease and clinical examination, In dehydrated hypernatremic animals, the following pro-
chronic hyponatremia should be assumed. tocol can be used:
For patients with acute hyponatremia displaying severe
signs of neurological side effects (seizures), hypertonic ● Use an isotonic or slightly hypertonic crystalloid fluid
saline can be used. The rate of correction is based on data (e.g. saline Na 154 mmol/L or Lactated Ringer solution
from humans, which showed that demyelinating syndrome Na 130 mmol/L) at 4 ml/kg/h.
was avoided when correction rates were limited to an Recheck sodium concentrations frequently (every 2 h)
increase of <12 mmol/L in 24 hours and <18 mmol/ in 48 and aim for a correction rate of 0.5 mmol/h. In severe
hours [21]. In equine practice, the most common formula- cases fluid might have to be spiked with hypertonic
tion of hypertonic saline is 7.2%. The concentration is not saline to achieve concentration approx. 20 mmol less
as important as the overall rate of sodium administered than the patient’s serum concentrations.
(slower rate for more concentrated solutions, faster rate for Once dehydration is resolved or in animals with normal
less concentrated). total body water, the following protocol can be followed:
● Administer NaCl (0.9%) 2 ml/kg over 10 minutes then
● Use a slightly hypotonic crystalloid fluid (e.g. 0.45%
recheck blood sodium concentrations.
saline Na 77 mmol/L or 5% dextrose in water 0 mmol/L)
Note that these patients will often also have hypochlo- at 4 ml/kg/h.
remia and metabolic acidosis due to decreased strong ion
difference. Sodium bicarbonate should not be used in these Expected Outcome
patients, as this will only supply sodium. ● Depends on severity
In chronic cases, the change of sodium concentration ● Animals can die from neurological side effects
should not exceed 0.5 mmol/h. The expected change in ● If treatment is instituted and the animal responds, full
sodium concentration when administering 1 L of fluid can recovery is possible
be determined using this formula [22]: ● Overzealous and quick correction of chronic hypona-
tremia can cause central pontine myelinolysis and per-
● Change in serum Na (mmol/L) = (Nainfusate/Napatient)/(kg manent neurological deficits
Body weight × 0.6) +1
PotassiumImbalance
Using this calculation, one can determine how many liters
are required to correct the abnormality and using the maxi- Definition Increased (hyperkalemia) or decreased
mum correction rate of 0.5 mmol/h, how quickly to admin- (hypokalemia) blood potassium levels outside the reference
ister the amount. A rather conservative approach should be range 3.1–4.1 mmol/L [24, 25]
Risk Factors (e.g. acute colitis and diarrhea) (500 kg horse, 30–50 g KCl
● Administration of potassium containing fluids PO q 12 h).
(hyperkalemia)
● Administration of low potassium fluids (>48 h, Diagnosis Diagnosis is based on clinical signs and
hypokalemia) determination of blood concentrations of potassium.
● Administration of Na-HCO3 (hypokalemia) Hyperkalemia is clinically more relevant than hypokalemia.
● Non-oliguric renal failure (hyperkalemia) Clinical signs of hypokalemia are not well documented in
● Pre-existing potassium abnormalities such as rhabdomy- horses and vary. Muscle weakness, diaphragmatic flutter,
olysis, ruptured bladder or hemolysis (hyperkalemia) and intestinal hypomotility have been described. Clinical
● Long-term administration of diuretics (azetazolamide, signs of hyperkalemia are mainly related to electrical
e.g. for HYPP, hypokalemia) conduction in the myocardium. Tall or peaked T-waves,
● Anorexia for several days (hypokalemia, total body defi- flattened P-waves and prolongations of the QRS complexes
cit of potassium) appear on ECG and can lead to asystole. Initial changes can
● Reflux or diarrhea (usually hypokalemia) be detected at serum potassium levels of 6.2 mmol/L, and
more pronounced and consistent signs are seen at serum
Pathogenesis Potassium is the most important intracellular
potassium concentrations of 7–8 mmol/L [26].
electrolyte, as more than 98% of the body potassium is
located intracellularly. Equine veterinarians are usually
Treatment General hydration status and all other
most interested in the extracellular amount of potassium.
electrolytes should be assessed, as abnormalities in blood
Potassium concentrations in blood are generally low and
potassium concentrations rarely occur alone. In
tightly maintained. Increases and decreases can occur
hypokalemia, the recommended potassium
rapidly. Small changes in serum potassium concentrations
supplementation in the administered fluids depends on
can lead to severe clinical signs that can be fatal. Potassium
serum potassium levels.
is important for cell membrane polarization. Abnormal
serum concentrations of potassium therefore lead to ● Serum K+ <2.5 mmol/L – substitute at 40 mmol/L
changes in cell membrane potential, which affects ● Serum K+ 2.5–3 mmol/L – substitute at 30 mmol/L
primarily muscle and heart cells. ● Serum K+ 3.0–3.5 mmol/L – substitute at 15–20 mmol/L
Prevention Monitor blood potassium levels q24–48 h while In mild hyperkalemia (5–7 mmol/L), potassium free flu-
administering fluid therapy. If a pre-existing potassium ids should be administered and potassium levels moni-
abnormality is present and being corrected, aim for more tored closely. If severe hyperkalemia (>7 mmol/L) is
frequent monitoring, every 6–12 hours. Fluids with adequate present and abnormalities are seen on ECG analysis, emer-
amounts of potassium should be administered. gency treatments should be instituted and include:
Replacement therapy can contain a potassium concen- ● Intravenous 23% calcium gluconate, 0.5 ml/kg, given
tration similar to equine plasma (e.g. Lactated Ringer’ solu- over 20 minutes diluted in isotonic IV fluids
tion K+: 5 mmol/L). Fluids with higher amounts of ● Intravenous dextrose 50%, 10 mg/kg/minutes, diluted to
potassium should not be used as replacement fluids as 5% (isotonic) in fluids and given over 30 minutes
inadvertent administration of potassium can cause severe ● Intravenous insulin, 0.1–0.2 IU/kg/h, diluted in fluids
signs of hyperkalemia. and given over 30 minutes
Maintenance fluids should contain higher amounts of
potassium (13–20 mmol/L), particularly if the horse is not Expected Outcome
eating to avoid hypokalemia. If available, a commercial ● Depends on severity.
maintenance solution (e.g. NormosolTM K+ 13 mmol/L) ● Animals can die from cardiac effects.
can be used; if unavailable, replacement fluids can be ● If treatment is instituted and the animal responds, full
spiked with potassium chloride (20 mmol/L). Note that recovery is possible.
adding 20 mmol/L of KCl to Lactated Ringer’s will result in
a total potassium concentration of 25 mmol/L, as LRS con-
OtherElectrolyteImbalances
tains 5 mmol/L of potassium. Maintenance fluid should
not be administered in volumes or rates higher than 2–4 Definition Abnormal blood concentrations of magnesium
ml/kg/day to avoid side effects due to potassium. (reference range 0.6–0.8 mmol/L), phosphorus (reference
Oral KCl administration assists in reestablishing body range 0.7–1.3 mmol/L) and calcium (reference range 2.9–
homeostasis of potassium in depleted anorexic horses 3.3 mmol/L). Ionized calcium is more relevant than total
calcium, as total calcium might be low due to hypoalbu- Risk Factors

minemia, whereas the concentration of ionized Ca is not ● Patients with chronic hyponatremia receiving sodium
affected by protein levels (ionized Ca reference range: 1.0– bicarbonate
1.7 mmol/L). ● Severely dehydrated animal with lactic acidosis receiving
sole administration of sodium bicarbonate to correct
Risk Factors metabolic acidosis
● Prolonged anorexia (low concentrations of all ● Patients with severe respiratory failure (hypercapnia,
electrolytes) pCO2 >60 mm Hg): administration of large amounts of
● Reflux and diarrhea sodium bicarbonate to these patients is believed to be
● Renal disease contraindicated
Pathogenesis Prolonged fluid therapy and/or anorexia, as Pathogenesis Once infused, the sodium increases the
well as various primary diseases (e.g. renal disease, strong ion difference and is shifting the equilibrium of the
diarrhea, reflux and sepsis), can lead to abnormal levels of bicarbonate dissociation toward HCO3, therefore in turn
calcium, phosphorus and magnesium. The reader is raising the pH concurrently with the sodium levels.
referred to a more comprehensive review for further details In chronic hyponatremia, intracellular sodium con-
(Torribio (2011) Vet. Clin. N. Am. Equine Pract; Stewart centrations have adapted and are similar to extracellu-
(2011) Vet. Clin. N. Am, Equine Pract,). lar (plasma) concentrations. When the plasma sodium
concentration is increased rapidly due to the adminis-
Prevention To avoid electrolyte depletion while on fluid tration of NaHCO3, the intracellular sodium concentra-
therapy, maintenance fluids should contain additional tion suddenly becomes lower than the plasma
electrolytes other than sodium, chloride and potassium. If concentration. As water follows solute, water is drawn
fluid therapy is anticipated for more than 48 hours, a from the brain cells to extracellular fluid (plasma),
maintenance solution should be used or electrolytes added causing osmotic demyelination syndrome (see also dis-
to the replacement fluid. When fluid therapy is administered cussion on sodium above).
for more than 48 hours, electrolyte concentrations should In severely dehydrated animals, the main acid–base dis-
be monitored daily, particularly in animals with diarrhea, turbance is metabolic acidosis as a result of lactate accu-
reflux or renal disease. mulation because of hypoperfusion. If NaHCO3 is
erroneously administered in an attempt to raise the pH,
Diagnosis Diagnosis is based on clinical signs and along with an inadequate amount of fluid administered,
measuring blood concentrations of electrolytes. hypoperfusion and metabolic acidosis due to lactate accu-
Hypocalcemia can lead to abnormal muscle contractions mulation persists. Acute hypernatremia can be caused if
evidenced by diaphragmatic flutter, intestinal hypomotility large amounts of NaHCO3 are infused in an attempt to
and weakness. Clinical signs of low phosphorus are rehydrate the animal with NaHCO3.
variable but can include weakness. Clinical signs of In the traditional approach to acid–base disturbance,
hypomagnesemia are variable but can include weakness. dissociation of HCO3 produces CO2, which then has to be
eliminated via the lungs. In patients with respiratory
Treatment The reader is referred to a more comprehensive compromise, elimination can be decreased and may lead
review for further details (Toribio et al. (2011) Vet. Clin. N. to respiratory acidosis. Following the physicochemical
Am.; Stewart (2011) Vet. Clin. N. Am.). approach to acid–base disturbance, CO2 is an independ-
ent variable and therefore not influenced by the concen-
ComplicationsDue to Administration tration of HCO3. Infusion of Na-HCO3 therefore does not
of SodiumBicarbonate lead to elevated pCO2 concentrations in the blood or
lungs. To err on the side of caution, administration of
Definition Sodium bicarbonate is a fluid containing equal
Na-HCO3 to patients with respiratory compromise should
amounts of sodium and bicarbonate ions and can be
be avoided.
indicated for correction of metabolic acidosis.
Administration can result in undesired side effects such as Prevention Determine acid–base and electrolyte status of
hypernatremia or respiratory distress, and if used in the patient and assess if Na-HCO3 is truly the fluid of choice.
wrong patients without concurrent administration of The origin of acidosis should be identified. In equine
isotonic fluids can result in worsening of the underlying medicine, the most common cause for metabolic acidosis is
acid–base abnormality. due to increased serum L lactate concentrations due to
hypovolemia and endotoxemia, and therefore Na-HCO3 is ComplicationsDue to Glucose-/Dextrose-

rarely indicated. These animals will benefit most from ContainingFluids
treatment of dehydration by administering replacement
therapy of isotonic crystalloid fluids. Definition Abnormal blood glucose levels (reference
The second-most common cause of metabolic acido- range: 3.7–6.7 mmol/L). The terms glucose and dextrose can
sis is electrolyte derangements. The underlying electro- be used interchangeably. Glucose exists as two isomers.
lyte derangements should be identified and corrected. L-glucose is the isomer circulating in the blood of animals
The most common causes of metabolic acidosis are and humans, while D-glucose (known as dextrose) is the
hyponatremia and hyperchloremia. Sodium bicarbo- isomer occurring widely in nature.
nate is therefore particularly useful in hyponatremic
hyperchloremic patients where large amounts of Risk Factors
sodium are needed without the addition of chloride. ● Neonates (hypoglycemia)
NaHCO3 is indicated if: ● Patients with metabolic disease are at high risk of hyper-
glycemia (Equine metabolic syndrome, pituitary pars
● Hyponatremia concurrent with hyperchloremia
intermedia dysfunction)
● pH <7.2
● Sepsis (both hypo- and hyperglycemia can occur)
If possible, an isotonic formulation (1.3%) of NaHCO3
should be administered: Pathogenesis Carbohydrate-containing solutions are
● Add 150 mmoL (13 g) of NaHCO3 to 1 L of sterile commonly used to provide additional energy as a simple
water means of parenteral nutrition. If administration of glucose
● Alternatively, 150 mmol/L can be added to Lactated exceeds the utilization by tissues, hyperglycemia ensues.
Ringer’s if sterile water is not available; note that this Animals with metabolic disease or sepsis have impaired
will result in a slightly hypertonic solution. There is no glucose uptake by cells due to insulin resistance contributing
problem with Ca chelation. to hyperglycemia. Hypoglycemia very rarely occurs in adult
horses. Neonates however, have low glucose storage
Calculate the deficit based on: capability and are at risk of hypoglycemia if glucose intake
● Deficit mmol/L NaHCO3 = BW × –BE × 0.3 (adults) or is reduced. In septic animals, particularly neonates, glucose
0.5 (foals <2 months) consumption by bacteria and increased cell demands due to
● Give half of the calculated amount over 30 min, the rest inflammatory mediators leads to hypoglycemia.
over 24 h
Prevention Recommendations are to maintain serum
Alternatively, oral NaHCO3 can be given 0.3–0.5 g/kg q glucose within narrow margins and avoid hypo- or
12–24 h. hyperglycemia [27]. To avoid hyperglycemia, glucose-
containing fluids should not be administered for initial
Diagnosis Repeat blood gas analysis should be performed large-volume fluid resuscitation. This can lead to profound
after administration of NaHCO3, every 6–12 hours, hyperglycemia with a diuretic effect causing massive
depending on severity of disease. Concentrations of pCO2 diuresis. If milk is withheld for more than 12 hours in
and sodium should be particularly closely monitored. neonatal foals, glucose-containing fluids should be
administered. In horses, it is reasonable to use a 2.5–5%
Treatment Immediately stop infusion of NaHCO3 if signs
dextrose-containing polyionic fluid as maintenance
or respiratory distress or tachypnea occur. Measure blood
therapy. Isotonic Glucose (5% glucose in water) should not
sodium levels and administer isotonic replacement fluids
be used as a general maintenance fluid due to the absence
(e.g. Lactated Ringer’s) at a rate slightly higher than
of electrolytes. This solution is useful for providing large
maintenance if Na levels are within normal limits;
amounts of water to patients with hyperosmolar syndrome
otherwise, follow recommendation in the paragraph on
but does have in vivo acidifying effects.
Sodium Imbalances.
If a fluid amount higher than the maintenance rate has
Expected Outcome The outcome depends on the severity of to be administered to a horse or foal to cover additional
the case. Animals can potentially die from respiratory losses or treat dehydration, it is often better to give a glu-
failure or worsening of acid–base and electrolyte cose-free polyionic crystalloid solution separately and to
abnormalities. If treatment is instituted and the animal add 50% dextrose as a separate infusion set using an infu-
responds, full recovery is usually observed. sion pump. In this way, the amount of glucose can be
titrated properly and separately from the amount of other omplicationsAssociated

C
fluids infused. Polyionic crystalloid glucose-free fluids with IntravascularPlasma
should always be given simultaneously through the same
Administration
catheter as the 50% dextrose, to dilute the hyperosmolar
solution and avoid endothelial injury. An infusion pump
Plasma transfusion has become part of the standard of care
should always be used for infusion of 50% dextrose to avoid
for critically ill adult horses and foals in equine hospitals.
glucose overload. The energy requirement in an adult
The most common indication in the peri-operative period
healthy horse is approximately 40 kcal/kg/day. A 5% dex-
is to achieve an increase in colloid osmotic pressure to treat
trose solution contains 0.17 kcal/mL. An infusion rate of 10
hypoproteinemia. This often occurs associated with gastro-
mL/kg/h would be required to provide the daily energy
intestinal disease in colic patients. Other indications for
requirement. This is a much higher rate than maintenance
surgical patients include presence of coagulopathies and
fluid requirements and potentially does result in fluid over-
foals with failure of transfer of passive immunity.
load. A 5% dextrose solution is therefore not adequate to
Homemade and commercial plasma from commercial
provide enough dextrose to cover the energy requirements
plasma banks are being used [28–30]. Complications asso-
of a horse long term.
ciated with administration of plasma include immuno-
A 50% dextrose solution contains 1.7 kcal/mL and can
genic and non-immunogenic reactions, serum hepatitis,
provide approx. 41 kcal/kg/day when used at 1 ml/kg/h
transmission of disease and septicemia due to bacterial
and may meet short-term energy requirements. It should
contamination. Severity or reactions range from mild urti-
be kept in mind that this form of parenteral nutrition does
caria to severe anaphylaxis with occasional death.
not cover amino acid (protein) needs. Some patients also
do not tolerate this amount of dextrose and respond with
hyperglycemia. Therefore, parenteral or partial parenteral
ImmunologicalReactions
nutrition with solutions containing carbohydrates, amino Definition Immunogenic transfusion reactions are
acids and lipids should be considered in adult horses where classified as acute or delayed. Acute reactions include
parenteral nutrition is required for >48–72 h (foals >24 h). hemolysis, non-hemolytic systemic fever reactions and
anaphylaxis. The only delayed immunologic transfusion
Diagnosis Clinical signs and blood glucose concentrations
reaction reported in veterinary medicine is post-transfusion
are used for diagnosis. Hyperglycemia has been shown to
purpura occurring in a previously blood transfused dog
be detrimental and causes increased morbidity and
with hemophilia.
mortality in human and equine patients. Clinical signs of
hyperglycemia only occur in chronic cases. Clinical signs
Risk Factors
of hyperglycemia are vague (reduced wound healing, etc.)
● Foals <7 days [31]
but polyuria and polydipsia can occur if glucosuria is
● Patients that have received multiple previous
present. Hypoglycemia can lead to weakness, and when
transfusions
severe to seizures.
● Multiparous mares
Treatment In patients with hyperglycemia, discontinue ● Hypernatremic animals
administration of glucose-containing fluids if possible. If
glucose-containing fluids are necessary as a form of Pathogenesis The immunogenicity of blood products
parenteral nutrition, insulin can be added to the fluid stems from proteins and from other cellular material not
regimen to decrease blood glucose. See later in this chapter completely removed during production. Generally
for further complications, monitoring and prevention of hemolytic transfusion reactions are the result of antibodies
hyperglycemia associated with the use of carbohydrate- in the recipient plasma reacting with the erythrocytes of
containing solutions as parenteral nutrition. the donor. These types of reaction should therefore not
occur if the plasma is free of red blood cells. Minor reactions
Expected Outcome can occur when antibodies present in the plasma of the
● Depends on severity. donor react with the red blood cells of the recipient. Non-
● Animals can potentially die from seizures in hypoglycemia. hemolytic febrile reactions are thought to occur due to
● Persistent hyperglycemia in human medicine has been asso- leukocyte antigens on transfused lymphocytes,
ciated with higher morbidity and poor outcomes overall. granulocytes or platelets and antibodies in previously
● If treatment is instituted and the animal responds, full sensitized recipients. Urticarial reactions are not well
recovery is possible. understood but are believed to occur due to proteins in the
Complications Associated ith Intravascular Plasma Administration 45
donor blood and antibodies in the recipient blood. There is time the horse should be continuously monitored for
usually not a specific antigen against which the recipient is signs of adverse reactions and a brief physical examina-
reacting. Systemic anaphylaxis is the most severe form, tion should be performed every 5 minutes. Parameters
which in humans is linked to IgA antibodies but unknown that should be monitored and should not increase during
in horses. Immunological transfusion reactions are that time include heart rate, respiratory rate and temper-
reported as <10% in horses [29, 31]. Plasma can also ature. The occurrence of respiratory distress, cardiac
contain large amounts of sodium, which could lead to arrhythmias, urticaria, muscle tremors, salivation and
clinically significant hypernatremia in small patients (e.g. coughing should also be monitored. If no reaction
neonates). occurs, the plasma can be administered faster.
Prevention Other
ype of plasma ● If multiple plasma transfusions are required within a
● It has been suggested that commercial plasma leads to short period of time, preferably plasma from the same
fewer adverse side effects than home-made plasma, donor should be used.
although this was not supported by a clinical study in a ● Heparin (2,000 IU/L) can be added to the thawed plasma
hospital setting [31]. to prevent blood clot formation during and after transfu-
● Method of plasma preparation could play a role in incision. The addition of heparin to plasma before transfu-
dence of adverse effects. Plasma prepared by gravity or sion has caused allergic reactions in humans. This has
centrifuge sedimentation contains a greater amount of not been proven in foals; however, all foals with adverse
cellular material compared to plasma obtained by plas- effects in one study had received plasma with added
mapheresis. Therefore, the latter preparation method heparin [31].
could potentially lead to a lower incidence of immuno-
logical reactions [30]. Plasmapheresis is well tolerated by Diagnosis Complications associated with plasma
horses and used for collection of plasma without compli- administration are most commonly recognized within the
cations but requires specialized equipment. first 15 minutes of the start of administration, but have
● Cross-matching before plasma transfusion would only been observed up to 48 hours post-transfusion. Clinical
be able to prevent hemolytic transfusion reactions, which signs of transfusion reactions include urticaria (see
are the result of antibodies in the recipient plasma react- Figure 6.4), anaphylaxis, pruritus, edema, tachypnea,
ing with the erythrocytes of the donor. This is a very rare tachycardia, pyrexia, colic, changes in mentation, muscle
occurrence. Cross matching before plasma transfusion is fasciculations, and evidence of hemolysis (hemolytic
rarely performed. plasma, hemoglobinuria). Signs of anaphylaxis usually
● Using blood products from a “universal donor” negative occur after transfusion of a few milliliters of plasma and
for Aa and Qa antigen can help prevent severe reactions. include colic, diarrhea, laryngeal edema, hypotension,
While horses have many different blood antigens, only
Aa and Qa are responsible for the majority of severe
hemolytic reactions.
● Plasma from geldings or maiden mares is preferred over
stallions and mares with prior pregnancies.
Administration of plasma
● Frozen plasma should be thawed at 30–37°C, in a water
bath prior to administration to avoid precipitation of pro-
teins which can occur when thawed at a higher tempera-
ture, (e.g. in a microwave).
● Plasma transfusions should be administered using a
blood administration set with a filter to reduce the num-
ber of clots transfused. Blood clots travel through the sys-
temic circulation and lead potentially to cardiac side
effects or pulmonary artery obstruction resulting in fatal
incidents.
● The plasma transfusion should be started at a rate of Figure6.4 Urticaria due to an immunological reaction after
0.3–0.5 mL/kg/ for the first 10–20 minutes. During this plasma transfusion in a horse.
shock, cardiac arrhythmias, cardiac arrest, and loss of should be free of equine infectious anemia and should be
consciousness [29, 31]. tested at least annually, depending on risk of exposure.
Treatment Stop transfusion immediately. Administer

SerumHepatitis
non-steroidal anti-inflammatory drug (flunixin
meglumine 1.1 mg/kg IV) and dexamethasone (0.05–0.1 Definition Acute hepatic necrosis (serum hepatitis,
mg/kg IV). Antihistamines (diphenhydramine 0.5–1 mg/ Theiler’s disease, post vaccination hepatitis) is a disease
kg IV) can be administered based on human associated with administration of biological products of
recommendations; however, their benefit has not been equine origin. Clinical manifestations of serum hepatitis
proven in horses. In severe cases of anaphylaxis, give usually occur with rapid onset 2–3 months (up to 6 months)
epinephrine (0.01–0.02 mL/kg IV). If the reaction was after administration of a biological product.
mild an attempt can be made to restart the plasma
transfusion at a slower rate. If signs of adverse effects Risk Factors Risk factors for developing serum hepatitis
return, the plasma transfusion has to be discontinued and after administration of tetanus antitoxin include pregnancy
the plasma discarded. If signs recur or signs are severe, or lactation. It is unknown whether this is also true for
use of plasma from a different donor (different lot number serum hepatitis following plasma transfusion [33].
in commercial plasma) may be attempted [31].
Pathogenesis Serum hepatitis has been reported after
Expected Outcome Most animals with immunogenic administration of plasma in horses [33]. The plasma was
reactions survive with appropriate treatment and reported to come from the same commercial source but
discontinuation of the plasma transfusion. Horses that from different batches. The incidence of serum hepatitis
show signs of anaphylaxis are at greatest risk of dying. following plasma administration was low (<0.4%) in one
study, although there is currently a lack of long-term
Non-ImmunogenicComplications follow-up reports after plasma transfusion [33]. However,
Bacterial contamination outbreaks after plasma transfusion have also been reported,
If plasma is homemade (harvested from plasma donors in- with morbidity rates ranging from 1% to 18% [34].
house) care has to be taken to maintain strict asepsis dur- The disease shares many similarities with human post
ing the procedure. Plasma should be frozen at –18°C or transfusion hepatitis, which was associated with administra-
lower within 8 hours post harvesting and stored for a maxi- tion of blood products before the detection of the Hepatitis B
mum of 1 year at a minimum of –20°C. Aseptic techniques and C viruses. Based on these observations an infectious
have to be followed during thawing and administration of agent has been suggested to play a role. Recently three mem-
both commercial and homemade plasma. Plasma should bers of the Flaviviridae, close relatives of the human hepaci-
be placed in an additional plastic bag to prevent contami- viruses, have been identified in horses (equine hepacivirus
nation of the infusion ports if they are exposed. Transfusion (EHVC), equine Pegivirus, and Theiler’s disease associated
should be completed after 4 hours to avoid bacterial con- virus, TDAV). The later has been associated with an outbreak
tamination. Plasma provides optimal culture conditions for of equine serum hepatitis [34]. The virus has since been
bacteria and once introduced they can proliferate quickly experimentally inoculated into healthy horses of which one
and cause sepsis in the recipient. Clinical signs, diagnosis developed elevated liver enzymes further strengthening the
and treatment of sepsis are not part of this chapter and the theory that TDAV might be a causative agent of Theiler’s dis-
reader is referred to other chapters or references. ease [34]. Equine hepacivirus has also been found in horses
with serum hepatitis and has been shown to cause clinical
ransmission of disease disease in experimentally infected horses [35]. Evidence is
There are reports that equine infectious anemia virus has mounting that Theiler’s disease is associated with equine
been transmitted through contaminated plasma products hepatotropic viruses potentially transmitted via contami-
in Germany and Italy [32]. It is possible that other blood- nated blood products.
borne diseases such as anaplasmosis, piroplasmosis,
Dourine (Trypanosoma cruzi) and others could be trans- Prevention Avoid unnecessary plasma transfusions (see
ferred via plasma transfusion; however, this has not been also complications of colloid use).
reported. USDA licensed plasma products are free of infec-
tious diseases. Other products (not licensed by the USDA) Diagnosis Clinical signs include lethargy, anorexia, pro-
are not regulated. If homemade plasma is used, donors found icterus, decreased gastrointestinal tract activity and
Complications Associated ith Administration of Colloid herapy 47
various nervous system signs due to hepatoencephalopathy generations with regard to morbidity, mortality, hemor-
and liver failure. Diagnosis is based on a history of admin- rhage and acute kidney injury.
istration of plasma or another biological product, elevated
Risk Factors The MW and pattern of substitution
liver enzymes, bile acids and bilirubin. Subclinical cases
with elevations of liver enzymes but without overt clinical determines the pharmacokinetics and pharmacodynamics
signs have also been reported. of the colloid but is also responsible for the severity of side
effects [37]. Currently, hetastarch, hexastarch, pentastarch
Treatment There is no specific treatment for Theiler’s and tetrastarch preparations are available on the market.
disease. Supportive treatment with intravenous fluids and
Pathogenesis In human medicine delayed onset pruritus,
treatment for hepatoencephalopathy can be attempted.
due to cutaneous deposition of HES in the dendritic cells of
Expected Outcome The mortality rate among symptomatic the skin (Langerhans cells), is reported in up to 54% of
horses ranges between 50% and 90%. patients and is refractory to treatment. Clinical pruritus
occurs usually several weeks after HES administration and
Circulatory overload may persist for 12–24 months. Side effects include acute
Circulatory overload is unlikely in the adult horse but does renal injury with underlying mechanisms being unclear.
occur in foals. For further information, see section on Osmotic nephrosis, altered oncotic forces in the glomerulus,
Circulatory Overload earlier in this chapter. lead to a change in glomerular filtration rates and a
decrease in reno-protective albumin have been discussed
Storage-associated changes as a potential cause [38–40]. Some studies have suggested
Clots or introduction of air into the bag may occur during that certain HES generations are associated with a higher
storage. A rare adverse event is venous air embolism [36]. risk for renal injury; however, a meta-analysis of these
studies in humans showed insufficient evidence to support
this [41]. Human clinical trials and meta-analysis have
C shown that the need for receiving renal replacement
with Administrationof Colloid therapy due to renal failure is higher in patients treated
Therapy with HES compared to other fluids, particularly in septic
patients [42, 43]. No side effects have been noted in the few
A colloid is a large (high molecular weight, MW) hydro- studies on colloid use in horses. A 10 mL/kg dose did not
philic molecule. Colloids do not freely permeate the capil- have a significant effect on serum creatinine, urine specific
lary membrane and remain in the vasculature bed where gravity, urine gammaglutamyltransferase (GGT), creatinine
they are responsible for plasma colloid oncotic (COP) pres- ratio and urine sediment examination in healthy
sure. Proteins, particularly albumin, are natural colloids. ponies [44]. Care has to be taken to extrapolate human data
Hydroxyethylstarch (HES) is the parent name of a group of to horses with signs of disease.
synthetic colloids. Other synthetic colloids include gelatins Dilutional coagulopathy, platelet dysfunction, and
and dextrans, which are not widely used and have been decreased concentration of von Willebrandt factor and fac-
mostly replaced by HES. There are different types (generator VIII have been reported in humans. The clinical signifi-
tions) of HES solutions available. They differ in concentra- cance of HES-induced coagulopathies is unclear [45]. Side
tion, MW, and molar substitution ratio and pattern of the effects are associated with the dose administered. The
hydroxyethyl molecules (C2/C6 ratio). administration of a single dose (25 mL/kg) is generally
accepted to be safe in humans and dogs. Incisional bleed-
Definition ing and bleeding into body cavities has occurred in dogs
● Volume overload treated with large doses of HES (>30 mL). Daily or weekly
● Coagulopathies hetastarch infusion over long periods did not result in sig-
● Acute kidney injury nificant coagulation abnormalities in humans [38]. Several
● Pro-inflammatory cytokine release studies have evaluated the effect of administration of HES
● Allergic reactions. Allergic reactions are very rare as the on coagulation times. A minimal effect on platelet count,
HES molecule is similar in structure to glycogen. The concentrations of von Willebrandt factor and factor VIII, as
side effects of HES are due to the cumulative effects of well as coagulation times, was noted after administration
therapy over several days, rather than a single 24-hour of 10 mL/kg HES to healthy horses in several studies [44,
dose. In human medicine there is currently not enough 46, 47]. Higher doses of HES (20 ml/kg) led to more changes
evidence to support a consistent difference between HES in equine platelet function and factor concentrations
compared to lower doses (10 mL/kg) [48]. The clinical sig- include volume resuscitation with smaller volumes of
nificance of these findings is not clear at this stage. fluid, shorter infusion times, longer intravascular duration
of infused fluids, maintenance of intravascular volume
Prevention Avoid unnecessary use of colloids. Over the despite low serum albumin concentrations, and reduced
past few years the use of hydroxyethyl starches in humans need for pressure medication during anesthesia.
has been associated with higher mortality rates and kidney The recommendations for use of HES in human medi-
injury. The Food and Drug Authority and European cine have drastically changed in the recent past. New
Medicine Agency (EMA) currently do not recommend the insights into physiology of fluid movements have ques-
use of colloids in critically ill adult men, including those tioned the benefit of an increased capillary COP.
with sepsis (www.fda.gov, www.ema.europa.eu). However, Additionally, HES administration has been associated with
the use of colloids is ]still recommended for specific more reports of side effects and increased mortality rates in
subgroups of patients, such as volume resuscitation for humans. Furthermore, several studies which initially
acute blood loss. described the beneficial effects of HES had to be withdrawn
Many of the side effects seen in humans have to date not due to a conflict of interest of the authors [51].
been observed in horses; however, adequately sized clinical There is little data on use of colloids in veterinary medi-
trials are missing. The extrapolation of human data to ani- cine, particularly horses. Treatment protocols differ from
mals has to be performed with caution, as there are differ- human medicine, with respect to dosage, product, MS ratio
ences in species physiology and treatment protocols. Acute and pattern, administration technique and concurrent
kidney injuries and significant bleeding have also not been fluid therapy. Extrapolation of data therefore has to be
observed in dogs and cats treated with HES. As there is a made with caution.
lack of additional therapeutic options in horses, the use of
HES is justifiable in selected cases. However, equine clini- omplicationsof EnteralFluid
C
cians should carefully weigh the necessity of colloid use in Therapy
horses. Horses with preexisting renal disease, coagulopa-
thies and sepsis should be especially carefully monitored Enteral fluid therapy is the administration of fluids into the
for side effects of HES infusions. gastrointestinal tract using a nasogastric tube or feeding
Colloids were widely used in human and veterinary tube. This technique is commonly used in human medi-
medicine over the last decades, as a means of increasing cine, as a natural way of administering fluids, and is rea-
COP. The Starling Landis equation described the forces sonably safe and cost effective. This is less commonly used
responsible for the fluid equilibrium between interstitium in horses but can be an effective method for providing large
and capillaries. The main factors are the capillary oncotic amounts of fluids to a horse, especially under field condi-
pressure (COP), the capillary hydrostatic pressure and the tions. Unfortunately lack of patient cooperation often lim-
hydrostatic pressure of the interstitium and the colloid its its use. Horses cannot usually be stimulated to drink
oncotic pressure of the interstitium [5]. Until recently, the excessive amounts of fluids and forced oral feeding can
COP was believed to counteract the outward movement of lead to aspiration pneumonia. The most practical route is
fluid from the vascular space and to be the main factor administration of fluids through a nasogastric tube. Less
responsible for maintaining intravascular fluid volume. common routes of administration include rectal enemas,
However, recently the no absorption rule has been added to or through fistulas in the large intestine. The former can
the traditional Starling equation, stating that net absorp- cause severe injury to the rectum and discomfort to the
tion back into the capillaries does not occur, even with horse and the latter is associated with complications due to
increased plasma COP. Administering a hyperoncotic fluid the surgery for fistulation, which is invasive and costly.
is therefore thought unlikely to increase the movement of
fluid from the interstitial space to the capillaries. The main
driving force for fluid shifts is thought to be the interstitial ComplicationsDue to AdministrationSetup
hydrostatic pressure [5], questioning the use of colloids. Definition Nasal trauma or aspiration pneumonia due to
In horses, colloids are used to expand plasma volume. inadvertent administration in the trachea/lungs
They are used in healthy horses undergoing anesthesia and
horses with disease resulting in decreased plasma oncotic Risk Factors
pressure. In prticular, animals with gastrointestinal disease ● Use of a large nasogastric tube
often suffer from hypoproteinemia and are being treated ● Use of a stiff nasogastric tube
with colloids to restore COP [46, 49, 50]. The benefits ● Inexperienced administrator
Complications of nteral Fluid herapy 49
Pathogenesis Mechanical trauma; inadvertent adminis- Expected Outcome Nasal trauma usually heals well over
tration of fluid or feed material in the trachea/lungs time; in rare cases necrosis of the conchae has occurred
(unpublished data). Prognosis for aspiration pneumonia
Prevention A small-bore tube can be used to reduce depends on severity; if sterile fluids only are used prognosis
trauma. Use a feeding tube with guidewire, which can be is good, if large amounts were administered into the lungs,
left in place for several days/weeks – if such a feeding tube prognosis can be guarded.
is used, the guidewire should be shorter than the tube to
avoid trauma from the tip of the wire. Lubricant should be
ComplicationsDue to Volumeof FluidUsed
placed on the tube before insertion. Insertion of the tube in
the trachea is common and needs to be avoided. Palpation Definition Overhydration and gastrointestinal rupture
of the ventral left neck region and trachea should be
performed to ensure correct placement. In some horses Risk Factors
(5%) the esophagus is transposed and runs along the right ● Small patients (ponies, neonates) where the capacity of
neck region, in which case this side of the neck has to be the stomach is overestimated
palpated. A cough reflex is not always elicited by incorrect ● Horses with reflux
placement, due to sedation or illness. Endoscopy or ● Horses with gastric impaction
radiography can also be used to assess correct placement of
the tube. While the tube is advanced in the esophagus, air Pathogenesis Similar to intravenous fluid therapy,
should be blown through the tube. This is important if a enteral fluid therapy can lead to overhydration.
small-bore tube is used to avoid retroflection of the tube. Experimental administration of large volumes (20 ml/
The tube should ideally end in the distal part of the kg/h) has been shown to lead to overhydration [52, 53].
esophagus rather than in the stomach. This prevents Systemic overhydration depends on the capacity of fluid
occlusion of the tube with solid ingesta. Large bore absorption from the gastrointestinal tract and it is
indwelling tubes in the stomach have also been shown to therefore less likely to occur compared to systemic
delay gastric emptying. The guidewire can be left in place intravenous fluid therapy. See earlier in this chapter for
or removed. If it is removed it should not be thrown out, as more details.
it might be needed for replacement of the tube. If the tube Horses have no capacity to vomit due to a strong external
is left indwelling it should be replaced every 24 hours in the sphincter at the cardia. Administration of large amounts of
opposite nostril (see Chapter 5: Complications of fluid with or without the addition of reflux, leads to overd-
Nasogastric Intubation). istension and rupture of the stomach. Colonic rupture is a
Diagnosis and clinical signs Diagnosis of nasal trauma is potential complication of enteral fluid therapy in man.
made based on clinical signs such as nasal discharge or Administration of fluid into the stomach leads to increased
bleeding and can be confirmed via endoscopy. Diagnosis of colonic motility through the gastro-colic reflex. In cases of
aspiration pneumonia due to inadvertent administration of severe impaction, this could lead to a colonic rupture.
enteral feeding into the trachea/lungs is based on clinical However, this has not been reported in horses [54, 55].
signs such as fever, coughing and nasal discharge. Endoscopy Cecal ruptures after enteral fluid therapy for cecal impac-
and cytology of a tracheal aspirate as well as thoracic tion have rarely been reported [56].
ultrasonography and radiography can aid in diagnosis.
Prevention Enteral fluids can be administered as a bolus
Treatment Nasal mucosal trauma will usually heal or as a continuous rate of infusion. If a bolus infusion is
without treatment. Discontinuation of nasogastric used, the maximum amount to be administered has to be
intubation or using the other nostril can also help. Anti- taken into account. The volume of the stomach of a 450 kg
inflammatories (flunixin meglumine 1.1.mg/kg q12 h IV) horse is approx. 8–15 L. Administration of more than 8 L is
and/or broad-spectrum antibiotics can be necessary in not recommended. Amounts have to be adjusted to body
severe cases. In case of aspiration pneumonia due to weight. If continuous rate infusion is chosen, the rate
inadvertent administration fluids into the trachea, general should be gradually increased from 5 ml/kg/h initially, to a
treatment principles for aspiration pneumonia should be maximum of 15 ml/kg/h, to avoid signs of abdominal
followed. These include anti-inflammatories (flunixin discomfort. The stomach needs to be assessed for reflux
meglumine 1.1.mg/kg q12 h IV) and broad-spectrum before administration. The horse’s reaction and vital
antibiotics (e.g. gentamicin 6.6 mg/kg q24 h IV and parameters should be checked during administration to
Na-penicillin 30,000 IU/kg q6 h IV). avoid over distention of the stomach.
Diagnosis and Clinical Signs If tachycardia, tachypnea or protein loss, decrease weight loss associated with catabolic
signs of colic occur, administration should be discontinued. patients, and booster immune function in patients where
If signs persist, a large bore nasogastric tube should be oral feeding is not possible.
placed to check for reflux. Parenteral nutrition is critical for provision of nutrients
when enteral feeding is not possible, for example patients
Treatment Discontinue enteral fluid therapy and empty with gastrointestinal disease, particularly after colic sur-
the stomach by nasogastric intubation. gery or esophageal diseases. Neonatal foals have little
reserve energy, therefore PN should be considered if feed
Expected Outcome If gastric distension is relieved on time, has to be withheld for >6 hours [58]. Adequate nutrition
the prognosis is good. If the stomach ruptures due to should particularly be evaluated and assessed in patients
volume overload, the prognosis is grave. with increased metabolic demands, such as in pregnant,
lactating and growing animals (foals), or in animals with
ComplicationDue to Typeof FluidUsed pre-existing metabolic diseases or severe illnesses (sepsis,
trauma) resulting in catabolism. Obese, over-conditioned
Definition Severe electrolyte abnormalities animals, donkeys, ponies and lactating mares are at a par-
ticular risk of hyperlipidemia, and nutritional support
Risk Factors should be instituted early to prevent this condition.
● Use of tap water (hyponatremia) [57] Complications associated with parenteral nutrition
● Custom-made electrolyte solutions with low sodium include catheter-associated complications, metabolic aber-
concentrations rations such as hyperglycemia, hyperlipidemia, electrolyte
abnormalities, protein intolerance and overfeeding [59,
Pathogenesis If large amounts of tap water are 60]. An additional aspect to consider is the detrimental
administered over a prolonged period of time, plasma effect on the gastrointestinal tract when oral feeding is
sodium concentrations will decrease due to dilution. withheld. Enterocytes need nutrients.
Inadvertent administration or false mixing of fluids and
electrolytes of fluids, e.g. 9% NaCl, can also lead to severe
hypernatremia and neurological signs. Additional Catheter-AssociatedComplications
electrolyte abnormalities reported after excessive doses See Chapter 3: Complications of Intravascular Injections
include hypomagnesemia and hypocalcemia [52]. and Catheterization.
Prevention If no abnormalities are present, a balanced
Definition Thrombophlebitis
isotonic solution containing sodium, chloride and
potassium similar to equine plasma should be chosen. Risk Factors
Osmolality should also be similar to equine plasma. ● Self-made solutions carry a higher risk of bacterial
Electrolytes should be monitored daily during enteral fluid contamination
administration or whenever the solution is changed. ● Use of small veins for parenteral nutrition
● Single lumen catheter used for all medication, fluid ther-
Treatment Discontinue or adjust the enteral fluid. apy and parenteral nutrition
Treatment depends on the electrolyte abnormality present;
see prior recommendations in this chapter. Pathogenesis Parenteral nutrition solutions are
hyperosmolar and can therefore lead to an increased risk of
Expected Outcome If signs are detected early and enteral thrombophlebitis, particularly when peripheral small veins
fluid therapy is adjusted, prognosis is good. are used. The nutrients in parenteral solution provide a
breeding environment for bacteria, leading to an increased
risk of catheter-associated sepsis/toxemia.
C
with Administrationof Parenteral Prevention Self-made solutions should be prepared
NutritionSolutions aseptically under a lamellar flow hood under aseptic
conditions. A sterile bag should be used and injection ports
Nutritional support is an important adjunct therapy in crit- should be wiped with alcohol to reduce bacterial
ically ill patients in equine medicine. Nutrition has been contamination. Dextrose and amino acids should be added
shown to improve wound healing, minimize muscle first followed by lipids to avoid lipids coming out of
Complications Associated ith Administration of Parenteral Nutrition Solutions 51
emulsion. Once compounded the solutions should be Pathogenesis Critically ill patients may have metabolic
refrigerated and used within 24 hours. Commercial abnormalities and endocrine dysfunction resulting in
solutions have a longer shelf-life (~2 years) and can be kept glucose intolerance and hyperglycemia. Hyperglycemia is
in stock. They are also less likely to become contaminated a common complication of parenteral nutrition, occurring
but are more costly than self-made solutions. Factors such in up to 65% of patients, depending on underlying
as pH, sunlight and addition of other solution can affect the disease [59, 62]. Animals with severe disease might not be
stability of the lipid emulsion. This can lead to lipid droplets able to hydrolyze lipids to the same extent as healthy
coalescing; the large lipid droplets cannot be cleared and animals due to a decrease in the activity of lipoprotein
could lead to lipid embolization of small vessels. lipase and therefore are at risk of developing hyperlipemia.
Initially, recommendations were to use large central
veins; however, due to the size of the jugular vein and its Prevention Energy requirements should be calculated
accessibility, this vein is commonly used and few complica- according to size, age, condition and metabolic stress.
tions have been reported in horses. The lumen of the cath- Overfeeding is fraught with complications and costly.
eter should be designated for parenteral nutrition only. If Maintenance requirements for an adult healthy horse
only one catheter can be placed, a double lumen catheter standing in a stall are approx. 33–40 kcal/kg/24 h. It is
can be used to allow for concurrent administration of med- unknown how disease states such as trauma, surgery or
ication and fluid therapy. Bags and tubing should be burn affect the caloric need. Providing between 25–65% of
changed every 24 hours to avoid contamination of bacteria. energy requirements has been shown to be optimal in
The bag and tubing should not be detached from the horse humans. Restricted intake is associated with decreased
during the day. If the horse has to be walked, the tubing inflammatory cytokines, improved metabolic profiles and
and bag should go with the horse. better survival compared with increased amounts of
calories [63]. The reader is referred to an excellent review
Diagnosis and Clinical Signs Clinical signs of thrombophle- for calculating and instituting caloric needs for parenteral
bitis are fever, heat and swelling around the catheter inser- nutrition [64].
tion or distal to the catheter insertion, distended jugular Commercially available PN solutions are available with
vein and reduced emptying or prolonged filling of the jugu- or without electrolytes. This should be taken into account
lar vein. Inflammatory parameters in the blood such as leu- when formulating a fluid plan and adjusting the rate of
kocytes, serum amyloid A and fibrinogen are often additional fluids given. Electrolytes including potassium,
elevated. sodium, chloride, calcium, magnesium and phosphorus
should be monitored every 24 hours to avoid complications.
Treatment Parenteral nutrition through the affected vein Administration of glucose and insulin can lead to decreased
has to be discontinued and the catheter removed. The levels of serum potassium levels. This should be taken into
reader is referred to Chapter 3: Complications of account when formulating a fluid plan. The amount of fluid
Intravascular Injection and Catheterization, for treatment provided with PN should be factored into overall fluid
and expected outcome of thrombophlebitis. amounts to prevent fluid overload. The reader is referred to
an excellent review for further information on composition
and preparation of self-made PN solutions [65].
MetabolicAberrations To avoid hyperglycemia, parenteral nutrition should be
administered with a pump to allow for continuous support.
Definition
All PN solutions contain large amounts of glucose, there-
● Inadequate or excessive energy provision
fore care should be taken when starting PN therapy. The
● Abnormalities is glucose homeostasis
initial flow rate should be calculated to provide 25–30% of
● Hypoproteinemia
the calculated daily requirement per hour. Blood and urine
● Electrolyte abnormalities
glucose concentrations should be monitored frequently
● Complications associated with parenteral nutrition-con-
during the first 24 hours (every 4–6 h). If blood glucose is
taining lipids include hyperlipidemia and hypertriglyc-
maintained between 4 and 10 mmol/L, and urine is nega-
eridemia [59, 61]
tive for glucose, the rate of administration can be increased
Risk Factors every 6–8 hours by 25%. If blood glucose levels rise and the
● Animals with existing hyperlipidemia are at risk for renal threshold is reached (appearance of glucose in urine)
worsening of the condition if lipid solutions are used administration should be decreased or discontinued.
● Animals with severe disease Alternatively, insulin can be administered as a bolus or CRI
to maintain normal glucose concentrations. The subcuta-

neous route is preferred over the intravenous route for
bolus dosing, as slower absorption occurs and variation in
blood glucose tends to be more moderate. A CRI is the pre-
ferred method of administration. There are different types
of insulin; the following doses apply to regular insulin.
Doses of insulin needed are often high as transient insulin
resistance is present in critically ill patients [62, 66, 67].
A starting point that is well tolerated is 0.07 IU/kg/h of
regular insulin [68] and is derived from a retrospective
study in foals [59]. Other authors describe much lower
starting doses of 0.0016 IU/kg [62]. Maximal effect is seen
after approx. 90–120 minutes of infusion and alterations to
dosing should therefore be made slowly and gradually. Figure6.5 Blood from a patient with severe hyperlipemia as a
Blood glucose concentrations should be monitored more consequence of reduced energy intake.
often when insulin is introduced (every 2–4 h) to prevent
hypo- or hyperglycemia. When insulin is administered as Solutions should be protected from direct sunlight to avoid
subcutaneous bolus doses, dramatic swings in blood glu- denaturation of proteins. Commercial aminoacid solutions
cose levels are often seen and changes in PN rate and insu- are usually hypertonic (up to 2,000 mosm/l) and safe infu-
lin doses should not be made simultaneously to avoid such sion rates with gradual increase and the use of infusion
swings. Increasing insulin doses by 50% is a reasonable pump need to be calculated individually.
approach when hyperglycemia persists. If hypoglycemia To avoid hyperlipidemia and its consequences, serum tri-
occurs, a bolus of 0.25–0.5 ml/kg 50% dextrose should be glycerides should be measured before initiation of lipid
administered over 2–3 minutes. Blood glucose should be containing PPN and monitored daily thereafter (reference
monitored every 30 minutes for the next 90 minutes to range 0.1–0.5 mmol/L). If hyperlipidemia and hypertri-
assess whether hypoglycemia recurs. Once a stable state of glyceridemia are not controlled, they can lead to hepatic
insulin and PN rate is reached, blood glucose monitoring lipidosis. Visual inspection for signs of lipemia (see
can be decreased to twice daily. If adequate calories cannot Figure 6.5) is not sensitive enough. The administration of
be provided through glucose-containing solutions due to lipid containing parenteral nutrition should be reduced or
persistent hyperglycemia, addition of lipids should be con- discontinued when triglycerides levels in blood increase
sidered. Addition of lipids provides essential fatty acids and above the reference range. Monitoring during PPN admin-
allows for provision of more calories without increasing istration should include regular assessments of serum and
the glucose load and decreases the risk of thrombophlebitis urine glucose, triglycerides, electrolytes and BUN as
as the solution becomes more iso-osmotic. explained above. Once stable levels are reached, once daily
To prevent hypoproteinemia, the following steps should monitoring is adequate. Additionally, respiratory function
be followed. If PN has to be administered for prolonged should be monitored with blood gas analysis, as glucose
periods of time (>48–72 h in adults, >24 h in foals), pro- administration leads to endogenous production of CO2.
teins should be added to glucose-only solutions to avoid Foals should also be weighed daily to ensure anabolic state
muscle wasting. Proteins provide essential and non-essen- and adequate weight gain. The catheter site should be
tial amino acids. The caloric benefit of amino acids is con- monitored four times daily for signs of thrombophlebitis.
troversial. Some authors recommend excluding the calories Parenteral nutrition should be discontinued gradually to
provided from amino acids from calculations to spare pro- avoid rebound hypoglycemia.
teins from anabolism. However, this could lead to underes-
Diagnosis and Clinical SignsClinical signs are vague and
timating the caloric content of a solution by 15–20% and
often masked by the underlying condition necessitating
could lead to overfeeding. Physiologically, it is more likely
parenteral nutrition. Blood glucose, protein, triglyceride
that calories are used as needed (for production of proteins
and cholesterol measurements need to be used for diagnosis.
and all other processes), and providing an overall correct
amount of calories is more useful than the concept of pro- Treatment
tein sparing [69]. Adequate protein provision should be ● Treatment of hyperglycemia: see above under Prevention
monitored through daily measurement of Blood Urea ● Treatment of hyperlipemia: discontinue lipid solution.
Nitrogen (BUN) and serum protein and serum albumin. Exogenous insulin therapy can be considered in severe
References 53
cases to stimulate the hormone sensitive lipase. In function and loss of mucosal integrity. Development of
high-risk patients such as ponies, donkeys and obese gastric ulcers also can occur.
individuals, as well as animals with pre-existing hyper-
triglyceridemia, administration of lipid-containing Risk Factors Foals are at particular risk of developing
solutions should be avoided. gastric ulcers.
● Treatment of electrolyte abnormalities: see earlier in this
chapter. Pathogenesis Enterocytes need food. Enteral feeding is
● Treatment of hypoproteinemia: adjustment of the paren- also less expensive, more physiological, improves immunity
teral solution to ensure that adequate amounts of amino including gastrointestinal immunity and is easier and safer.
acids are included. Neonatal foals that receive PPN or TPN without additional
enteral feeding are prone to development of gastric ulcers
Expected Outcome Hyperglycemia has been shown to be during that period and after re-feeding [70].
detrimental and to cause increased morbidity and mortality
in human and equine patients. Recommendations are to Prevention Some human studies suggest that the route of
maintain serum glucose concentrations within narrow administration is not as important as providing calories in
margins and avoid hypo- or hyperglycemia [27]. Outcome itself; recommendations are still to institute early use of
of hyperlipidemia depends on the severity but can be fatal. enteral nutrition if possible [82]. Current recommendations
Outcome of electrolyte abnormalities depends on severity of the American Society for Parenteral and Enteral
but is usually good. Outcome of hypoproteinemia and Nutrition are to avoid parenteral nutrition when the
muscle wasting depends on severity and the underlying gastrointestinal tract can tolerate enteral nutrition [83].
disease necessitating parenteral nutrition. Gastric protectants should be administered (0.5 mg/kg
Literature on parenteral nutrition in horses is mostly Omeprazol IV or 4.4 mg/kg omeprazole PO) to prevent
available in the form of case reports, retrospective case gastric ulcers in adult horses and foals. Sucralfate (12 mg/
series and conference proceedings [60, 62, 65, 67, 70–79]. kg PO q12 h) can be administered concurrently as mucosal
There are few controlled studies available [70, 76, 80, 81]. protectant. H2 receptor antagonists (ranitidine 6.6 mg/kg
Therefore, most information on application but also com- q8 h PO) can be administered instead of omeprazole if it is
plications of parenteral nutrition is extrapolated from unavailable or has proven to be ineffective in the
human medicine. This represents challenges as parenteral patient [84].
nutrition in humans differs from those in an equine setting
with regards to administration, types of fluid, duration of Diagnosis and Clinical Signs Clinical signs of gastric ulcers
therapy and metabolic side effects. include recurrent colic, salivation and bruxism.
Treatment Enteral feeding should be reintroduced

omplicationsDue to Withholding
C gradually. Some foals may also require help to develop
of EnteralFeeding normal nursing behavior after prolonged periods of being
off feed.
Definition Withholding of enteral nutrition and use of Expected outcome Outcome is largely dependent on the
parenteral nutrition leads to a decrease in gut mass and underlying disease. Gastric ulcers in foals can perforate
structural protein, decreased motility and digestive without prior clinical signs; in these cases prognosis is grave.
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57
ComplicationsAssociatedwith Hemorrhage
Margaret C. Mudge VMD DACVS, DACVECC
The Ohio State University, Columbus, Ohio
Overview ○ Coagulopathy (congenital or acquired)

○ Pre-existing bleeding (e.g. hemoabdomen, epistaxis)
Intra- and post-operative bleeding can occur with many with surgical procedures to explore the cause of
equine procedures. The difference between bleeding and bleeding
hemorrhage is generally based upon the severity of the ● Surgical/surgeon factors:
○ Technical failures (ligature slippage, poor choice of
blood loss. In many cases, hemorrhage can be predicted
based upon the location of the surgical procedure. This hemostatic device, lack of anatomic knowledge)
○ Long duration of surgery in a bleeding area (e.g. com-
chapter will discuss how to treat and prevent intra- and
post-operative hemorrhage. plex tumors, sinusotomy)
○ Inadvertent disruption of vasculature
○ Medications administered (e.g. hemodilution with

L intravenous fluids, anticoagulation with heparin)
with Hemorrhage
Pathogenesis Bleeding is part of almost every surgery, but
● Intraoperative hemorrhage is usually well controlled by the patient’s normal
○ Fluid therapy and blood transfusion mechanisms of hemostasis, along with surgical control of
○ Adjunctive systemic treatment
bleeding through pressure and ligation of vessels. The
● Postoperative hemorrhage initial response to disruption of a blood vessel is
vasoconstriction, followed by platelet activation, adhesion,
and aggregation. Activation of clotting factors is initiated
IntraoperativeHemorrhage by tissue factor, with the end result being a fibrin clot.
Platelet abnormalities, coagulation factor deficiencies, and
Definition Intraoperative hemorrhage is considered a excessive fibrinolysis can all result in abnormal or
complication if it is unexpected, severe enough to warrant uncontrolled bleeding.
a blood transfusion or leads to moderate/severe anemia, The correlation of coagulation profile findings and
obscures the surgical field, or puts the animal at risk of bleeding complications has been evaluated in dogs and cats
additional intraoperative or postoperative morbidity. Early after ultrasound-guided biopsies [1]. Bleeding complica-
consequences of hemorrhage include shock, anemia, and tions were seen in thrombocytopenic cases, and in cats
difficulty visualizing the surgical site. Late complications with prolonged aPTT and dogs with prolonged OSPT.
include seroma formation, surgical site infection, and Authors of a retrospective study in horses undergoing per-
delayed healing. cutaneous liver biopsy did not find a correlation between
bleeding complications and an abnormal coagulation pro-
Risk Factors file; however, only 3 horses (9% of monitored horses) had a
● Patient factors: decrease in packed cell volume (PCV) [2].
○ Highly vascular areas (e.g. tumor removal, gonadec- Hereditary hemostatic defects are uncommon in horses.
tomy, paranasal sinus surgery) Platelet dysfunction can occur secondary to Glanzmann
58 Complications Associated ith emorrhage
thromasthenia, a membrane glycoprotein defect that has

been described in a variety of breeds [3]. Von Willebrand
disease can also cause prolonged mucosal bleeding times.
Coagulation factor deficiencies, such as hemophilia A (fac-
tor VIII deficiency) have also been described and result in
prolonged bleeding times. Acquired hemostatic defects are
more common, and can be related to immune-mediated
destruction of platelets, liver disease, uremia, or bone mar-
row disease. Transient coagulopathies can occur in horses
with gastrointestinal disease or other critical illness, as
upregulation of inflammation leads to systemic activation
of coagulation [4].
There is limited information in the veterinary literature
regarding risk factors for surgical hemorrhage. There is
even less evidence for the efficacy of specific treatments or
preventative measures in reducing hemorrhage in veteri- Figure7.1 A horse is positioned in reverse Trendelenburg in
preparation for paranasal sinus surgery. Source: Margaret Mudge.
nary surgical procedures. Size has been shown to be a fac-
tor in ovariohysterectomy in dogs, with a 2% intraoperative
hemorrhage rate in dogs weighing less than 50 pounds and to surgeon skill, duration of surgery, or clinical judgment
79% hemorrhage rate in dogs of 50 pounds or more [5]. The with respect to the need for transfusion [13].
use of active suction drains has been reported as a potential
risk factor for postoperative hemorrhage in dogs, but this Prevention Coagulopathy is exceedingly uncommon in
has not been reported in horses [6]. otherwise healthy equine patients presenting for elective
Patient positioning has been shown to have a significant surgery. It would not be cost-effective to perform coagulation
effect on intraoperative blood loss in humans. Reverse testing on all patients undergoing major surgery, but a
Trendelenburg positioning for human patients undergoing thorough patient history, physical examination, and
endoscopic sinus surgery resulted in decreased blood loss consideration of any underlying disease can help direct
and improved visualization of the surgical field [7, 8]. Type further testing. The horse may have a history of excessive
of anesthesia has also been shown to have an effect on bleed- bleeding during elective surgery, such as castration, or there
ing during endoscopic sinus surgery in human patients, may be a history of hematomas or bleeding at venipuncture
with less bleeding under total intravenous anesthesia com- sites. Medications such as nonsteroidal anti-inflammatory
pared to inhalation anesthesia [9]. Although the effect of drugs (NSAIDs) may alter coagulation, although NSAIDs
positioning on blood loss has not been evaluated in horses, are commonly given prior to surgery in horses without
surgeons have observed decreased blood loss with standing clinical signs of excessive bleeding [14]. Herbal supplements
paranasal sinus surgery compared to recumbent surgery in have been shown to alter platelet function and coagulation
the horse [10]. Reverse Trendelenburg positioning has been in human patients. Commonly used mediations that
used by this author during recumbent paranasal sinus sur- increase the risk of bleeding include garlic, ginkgo biloba,
gery with a subjective decrease in blood loss (Figure 7.1). green tea, and fish oil [15].
The intravenous or topical administration of tranexamic Physical exam may reveal mucous membrane petechia-
acid during major human orthopedic surgery is associated tion, which should prompt a complete blood count, and
with a significant reduction in blood loss and units of blood potentially platelet function testing. Ideally, any anemia
transfused, without an increase in venous thromboembolic should be corrected before surgery, especially if blood loss
events [11]. Several topical hemostatic agents have been is anticipated. Although erythropoietin will increase red
evaluated for use in endoscopic sinus surgery, but none has blood cell production, the administration of recombinant
consistently reduced hemorrhage compared to no human erythropoietin has led to development of erythro-
treatment [12]. poietin antibodies and severe anemia in horses, so cannot
Surgeon experience may also be a factor in surgical hem- be recommended [16]. Delaying the surgery or administer-
orrhage. Involvement of a surgical resident in noncardiac ing whole blood or packed RBC transfusions are the best
surgeries on humans resulted in higher transfusion rates methods for correcting preoperative anemia.
(56–78% higher) compared to surgeries performed by an Clinicopathologic findings of hepatic failure (e.g. icterus,
attending surgeon without a resident. This may be related photosensitization, abnormal liver enzymes, increased
Intraoperative emorrhage 59
serum bile acids) should cause the clinician to delay sur- liters for a 500 kg horse). Acute normovolemic hemodilu-
gery, perform coagulation testing, and consider transfusion tion is another technique that could be considered when
with fresh frozen plasma. Horses with colic, especially with allogeneic blood is not available. This technique involves
obstructive surgical or inflammatory medical conditions, removal of the patient’s blood just before anesthesia with
frequently have clinicopathologic evidence of coagulopa- replacement of volume by crystalloid fluids [21].
thy with increased d-dimer and prolonged PT/PTT [17]. Human patients who require blood transfusion during
While there is no definitive treatment to prevent hemor- surgery have an increased risk of death, and are more likely
rhage in these horses, consideration should be given to to have septic and wound complications [22]. Hemorrhage
avoiding large volumes of synthetic colloids, and instead during trauma surgery carries a high risk of transfusion
treating with fresh frozen plasma if colloids are needed. and death, so in many cases, “damage control surgery” is
The surgeon should be prepared with appropriate hemo- advocated. An initial laparotomy is performed to control
static equipment. Surgical stapling devices such as the the damage (e.g. intestinal leakage, devitalized bowel,
LDS™ and electrothermal bipolar vessel-sealing device bleeding vessel), and packing with temporary closure are
(Ligasure™, Medtronic, Minneapolis, MN) can occlude performed until the patient is stable enough to undergo
vessels up to 7 mm in diameter [18]. Other stapling devices, definitive repair [23].
such as the TA™ staplers (Medtronic), can be used to com-
Diagnosis and Monitoring The diagnosis of intraoperative
press larger bundles of tissue. Electrocautery is effective for
hemorrhage is based on the volume of blood loss, along
vessels up to 2 mm diameter [19]. For distal limb surgeries,
with changes in vital signs (tachycardia, hypotension,
especially extensive wound or foot debridements, the use
prolonged capillary refill time) and decreasing PCV and
of a tourniquet should be considered to provide better
TS. Intraoperative blood loss is usually readily apparent,
visualization and limit blood loss Figure 7.2). Patient posi-
but can be overlooked if it is not collected and measured.
tioning should also be considered, for example, reverse-
Suction canister volume should be recorded, and PCV of
Trendelenburg or standing position for paranasal sinus
the fluid can be measured to determine the volume of
surgery.
blood lost. Careful monitoring under anesthesia is
Preparation for intraoperative hemorrhage also includes
necessary, as the heart rate and hematocrit may not change,
securing blood products or blood donor horses. In cases of
even with severe blood loss. Arterial blood pressure and
known red blood cell alloantibodies or previous transfu-
PaO2, along with mucous membrane color and capillary
sion reactions, preoperative autologous donation (PAD)
refill time, may be more accurate reflections of blood
should be considered [20]. PAD involves collecting the
loss [24]. Central venous pressure and blood lactate
patient’s blood 2–4 weeks prior to surgery. Approximately
concentration have also been shown to correlate with acute
15–20% of the patient’s blood volume can be collected (6–8
blood loss in standing, unsedated horses [25].
Treatment
Local treatment The initial response to intraoperative
hemorrhage should be to apply firm pressure to the bleed-
ing area. Direct mechanical pressure is a very effective way
to limit blood loss during and after surgery. If bleeding ves-
sels can be visualized, they should be clamped and ligated.
Collagen sponges, microfibrillar collagen, gelatin sponges,
oxidized regenerated cellulose, and bone wax are all topical
mechanical hemostatic agents that apply pressure to the
area of bleeding [26]. Topical thrombin and fibrin-based
sealants promote formation of fibrin clots, and are applied
onto the bleeding areas [27]. Surgical sealants such as poly-
ethylene glycol polymers are used as an adjunct for vascu-
lar reconstruction, but are quite expensive [28].
A tourniquet can be used on the distal limb in order to
improve visualization of transected vessels. In the case of
Figure7.2 A tourniquet is applied over the diffuse bleeding, such as after debridement of exuberant
metatarsophalangeal joint to limit blood loss and improve granulation tissue, pressure bandages can be used on the
visualization during surgery of the digit. Source: Courtesy of
Frank Nickels.
distal limb. If substantial bleeding is encountered during
paranasal sinus surgery, the sinus should be packed firmly mentation can be estimated to have lost approximately 30%
with gauze packing and the sinusotomy bone flap can be of its blood volume [25]. Up to half of the volume lost
temporarily stapled closed [29]. Chilled saline and topical should be replaced by a whole blood transfusion. In cases
vasoconstrictive agents such as epinephrine or phenyle- of normovolemic anemia, the following formula can be
phrine can also be used as topical adjuncts (alone or on used to estimate transfusion volume:
gauze packing) in sinus surgery to promote local vasocon- Blood transfusion volume (ml):
striction and reduce bleeding [30]. When blood loss from
Desired PCV Actual PCV
the paranasal sinuses cannot be controlled with direct Body weight kg 80 ml / kg .
pressure, temporary bilateral carotid artery occlusion can Donor PCV
be used to limit blood loss ([31].
One of the most important factors in limiting blood loss The target PCV will depend on whether the horse is at
is making a quick decision to limit blood loss and postpone risk of continued bleeding and whether there are any
the remainder of the surgery until bleeding is controlled. comorbidities that might decrease perfusion. This author
In the case of paranasal sinus surgery, the packing can be will typically target a PCV of 25%, although the total blood
removed during a standing procedure 24 to 48 hours later, transfusion volume will often be limited by how much
with reevaluation of the sinus and completion of the proce- blood the donor horse can give.
dure under better visualization. Donor horses are the most common source of blood for
transfusion, but autologous salvaged blood should also be
considered. Cell salvage devices can be used to collect blood
Fluid therapy and blood transfusion
from surgical sites or drains. Blood is suctioned from the sur-
Initial stabilization for acute blood loss is accomplished
gical site, filtered, centrifuged, washed, and returned to a
with intravenous crystalloid fluids. A starting point for
bag for reinfusion into the patient [35]. This technique has
resuscitation should be an initial bolus of approximately
been reported in canine patients, and could be used in
20 ml/kg. Overzealous resuscitation can result in further
equine patients if the equipment is available [36]. Blood can
bleeding due to an increase in blood pressure and dilution
be collected and transfused directly into the patient without
of clotting factors. The goals of fluid therapy should be to
processing, but the cell salvage system reduces contami-
bring the mean arterial blood pressure to within a range of
nants. A leukocyte depletion filter is needed when there may
60–70 mmHg, and maintain tissue perfusion [25]. Blood
be contamination of blood with neoplastic cells or bacteria.
lactate can be used to help determine response to fluid ther-
When blood is lost into a body cavity (hemothorax or
apy, with the aim to normalize lactate (<2 mmol/l) within
hemoabdomen), it can also be left to be reabsorbed by the
24 hours [32]. Synthetic colloids have been shown to cause
patient. The immediate hypovolemia must be addressed
platelet dysfunction and reduced von Willebrand factor and
with IV fluids, but the majority of shed blood may be reab-
factor VIII, and have been associated with increased blood
sorbed via lymphatics within 48 hours [37]. If PCV falls
loss during surgery in human patients [33]. In healthy
below 20% or the horse continues to have signs of shock
ponies treated with gelatin and hydroxyethyl starch,
despite fluid resuscitation, a blood transfusion may still be
hemodilution occurred but there were no clinically signifi-
needed. Allogeneic transfusion from a donor horse is most
cant effects on hemostasis [34]. Despite the lack of evidence
common, but collection of blood from the abdominal cav-
of adverse effects in horses, the use of synthetic colloids is
ity and reinfusion has also been reported [38].
not recommended in the acutely bleeding patient.
Blood transfusion is recommended for acute blood loss Adjunctive systemic treatment
of greater than 20% blood volume, especially if there are The mainstays of systemic treatment for acute hemorrhage
concerns about continued blood loss. Additional parame- are fluid therapy and blood transfusion. There are a num-
ters that indicate a need for transfusion include signs of ber of procoagulant medications that can also be used to
shock (heart rate >60/min, CRT >3 sec, cold extremities, enhance hemostasis in the horse [39]:
depressed mentation) despite adequate volume resuscita- ● Formalin – Proposed to enhance endothelial or platelet
tion, oxygen extraction ratio greater than 40%, lactate activation, reported dose of 10–100 ml of 10% formalin in
greater than 4 mmol/l, and acute hemorrhage with a PCV 1 L isotonic saline
less than 20%. ● Aminocaproic acid – Lysine derivative that inhibits fibrinol-
In acute blood loss situations, the volume of blood lost ysis by binding plasminogen activators and enhancing anti-
can be estimated based on the severity of shock. For exam- plasmin activity. The previously reported doses are 10–40
ple, a horse that is severely tachycardic with decreased mg/kg IV q6h slow in saline or 3.5 mg/kg/min for 15 min
pulse pressure, pale mucous membranes, and altered then 0.25 mg/kg/min constant rate infusion.
Postoperative emorrhage 61
● Tranexamic acid – Similar mechanism of action as amino- passage. Tachycardia, tachypnea, and pale mucous mem-
caproic acid; 5 g IV every 12 hours or 10 g PO every 6 hours branes may signal ongoing blood loss, and serial PCV/TS
● New research suggests that as little as 1/20 of the pub- can help to determine the severity of blood loss. TS should
lished doses of aminocaproic acid and tranexamic acid decrease within minutes to hours of blood loss, but PCV
may be effective in horses [40]. may remain normal even during terminal blood loss, due to
● Conjugated estrogens – May polymerize mucopolysac- the effects of splenic contraction [24]. Internal bleeding into
charides in vessel walls or decrease antithrombin activ- the abdomen or thorax may not be apparent until the horse
ity, 0.6 mg/kg IV every 24 hours begins to show signs of shock or discomfort. In a recent ret-
● Yunnan baiyao – Chinese herbal medication with dem- rospective study of postoperative abdominal hemorrhage,
onstrated hemostatic efficacy, possibly due to activation clinical signs included tachycardia, decreasing PCV/TP,
of platelets, enhanced expression of surface glycopro- abdominal discomfort, and incisional drainage. The hemo-
teins on platelets [41]. abdomen was confirmed by ultrasound or abdominocente-
sis [42]. Swirling, echogenic fluid is characteristic of
Expected Outcome The acute risks of intraoperative hemoabdomen, and abdominocentesis will confirm the
hemorrhage include rapid shock and death, particularly if diagnosis (Figure 7.3). Blood loss into the intestinal lumen
a large vessel is ruptured, such as a portal vein rupture can be more difficult to detect until it is passed in the feces.
during reduction of an epiploic foramen entrapment. Intraluminal blood loss should be suspected in horses that
There are no specific reports on intraoperative mortality have had an enterotomy or large colon resection, and that
due to hemorrhage in equine patients. have an acute, severe decrease in PCV along with tachycar-
dia and melena within 72 hours of surgery [43].
PostoperativeHemorrhage Treatment See “Fluid therapy and blood transfusion” and
“Adjunctive systemic treatment” sections above.
Definition Postoperative hemorrhage can occur immediately
after surgery or can be delayed by several days after surgery. Reoperation
Hemorrhage is most commonly from the surgical site, but can Reoperation is often the last resort for postoperative hem-
occur in distant areas if a coagulopathy has developed. orrhage, but should be considered early if there is unex-
pected postoperative hemorrhage and if there is a chance
Risk Factors Same as for intraoperative hemorrhage (see that a ligature may have slipped. A return to surgery may
above) be needed if the patient is deteriorating despite medical
therapy, although these patients are likely to be unstable
Pathogenesis The pathogenesis of postoperative hemor-
under anesthesia [44]. If bleeding was detected at surgery
rhage is the same as for intraoperative hemorrhage.
but was inaccessible, or if the source of bleeding is unlikely
Inadequate hemostasis may not be recognized at the time
of surgery, possibly due to lower blood pressure under
anesthesia, positioning (e.g. lower pressure in the distal
limb of a horse in dorsal recumbency), or a temporary clot
that becomes dislodged after surgery.
Prevention Same as for intraoperative hemorrhage (see

above)
Diagnosis and Monitoring Acute blood loss of 30% of blood

volume will result in cardiovascular shock due to
hypovolemia and reduced oxygen delivery to the tissues.
Signs of shock include tachycardia, tachypnea, prolonged
capillary refill time, cool extremities, depressed or anxious
mentation, and hypotension. In horses, splenic contraction
will increase the PCV, so the decrease in PCV will typically
lag behind the decrease in total solids (TS).
Figure7.3 Transabdominal ultrasound image showing cellular
Postoperative hemorrhage may be apparent if there is echogenic free fluid consistent with hemoabdomen. Source:
blood leaking from the surgical drain, incision, or nasal Courtesy of Teresa Burns.
to be accessible through the same surgical approach, an Expected Outcome Mortality in horses with hemorrhage after
alternate approach is indicated. For example, a hemoabdo- emergency celiotomy was reported to be 35%. Causes of death
men post-castration may be best treated through a standing were hemorrhagic shock, septic peritonitis, and adhesions [42].
laparoscopic approach [38]. In a report of post-castration complications, less than 2% of
In a case series at a level 1 human trauma center, reop- horses undergoing routine castration suffered from significant
eration for bleeding in trauma patients was prompted by hemorrhage. In all horses, bleeding occurred within 4 hours
direct signs, such as external bleeding or bleeding from of surgery, and all were treated by packing with sterile
drains, in 74% of patients. Indirect signs that led to reopera- laparotomy sponges which were removed at 24–48 hours.
tion included hemodynamic instability, decrease in hema- One horse received aminocaproic acid [45].
tocrit, and abdominal distention [44].
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64
Complicationsof BloodTransfusion
Margaret C. Mudge VMD,DACVS, DACVECC
The Ohio State University, Columbus, Ohio
Overview Immune Reactions

Blood transfusion can be a necessary treatment for intra- Hemolytic Transfusion Reactions
operative or postoperative hemorrhage, but transfusion of
Definition Acute hemolytic transfusion reactions can
blood products is not without risk. There are 8 recognized
involve destruction of red blood cells within 24 hours of
equine blood types with at least 30 different factors within
transfusion, and more often within several hours of
7 of these groups. There is no recognized “universal
transfusion. The hemolysis can involve the donor red blood
donor” and the incidence of adverse reactions to equine
cells (RBCs) or the recipient RBCs. Hemolysis can be
blood transfusion is much higher than the incidence for
intravascular or extravascular. Delayed hemolytic
human transfusions. The reported incidence of transfu-
transfusion reactions occur within 5 days of the transfusion.
sion reactions in horses transfused with whole blood or
pRBCs is 16%, with a 2% incidence of fatal anaphylactic
Risk Factors
reaction [1]. Immune reactions may involve recipient
● Incompatible blood types, especially in a horse that has
antibodies to donor red blood cell (RBC) antigens, donor
been previously transfused or exposed to a different blood
antibodies to recipient RBC antigens, or reactions to
type (e.g. broodmare) and has developed alloantibodies
plasma proteins, white blood cells, or platelets.
● Crossmatch-incompatible blood
Nonimmune reactions can occur when there is excessive
● Improper storage of blood products (non-immune
overall fluid volume administered or when blood is stored
reaction)
improperly. See Chapter 6: Complications of Fluid
Therapy, for information about complications associated
Pathogenesis Acute hemolytic reactions typically occur
with plasma administration.
when there is major incompatibility (donor RBCs and
recipient plasma), resulting in rapid destruction of the
transfused RBCs. Hemolysis of recipient red blood cells can
omplicationsAssociatedwith Blood
C occur if there are RBC antibodies in the donor plasma.
transfusion Delayed hemolytic reactions occur >24 hours after
transfusion, likely due to RBC antibody production shortly
● Immune reactions after transfusion. Clinical signs of acute hemolysis include
● Allergic and febrile reactions hemoglobinemia, hemoglobinuria, and anemia. In severe
● Transfusion-related acute lung injury cases, shock and cardiovascular collapse may occur. Clinical
● Nonimmune reactions signs with delayed hemolytic reaction are similar to those
● Transfusion-transmitted infections with acute hemolysis, although usually less severe. Acute
● RBC storage lesion renal failure may occur secondary to pigment nephropathy.
Allergic and Feerile eactions 65
Acute hemolytic transfusion reactions occur in approxi- Treatment Stop the transfusion if it is still in progress. Note
mately 1 out of 76,000 transfusions in humans [2]. In a ret- the adverse reaction in the medical record and discontinue
rospective study of blood transfusions in canine patients, any orders for further blood transfusion from that donor [7].
there was a complication rate of approximately 25%, with Signs of shock or hypotension should be treated with IV
hemolysis in 6% [3]. fluids. Crystalloid fluids should be continued to maintain
renal perfusion and reduce the risk of pigment nephropathy.
Prevention Ideally, all blood donors should be tested for If there is minor incompatibility (donor plasma and recipient
RBC antibodies, and blood typing should be used to find the RBCs), the red blood cells can be washed to remove the
optimal blood donor. Blood typing is not practical in an plasma fraction and blood transfusion may continue with
emergency situation, and due to the large number of blood careful monitoring. If the patient remains anemic and
types, an ideal donor may not be available. While anti-Aa requires additional blood transfusion, crossmatch is strongly
antibodies are thought to be the most immunogenic, anti-Ca recommended with new donors.
antibodies appear to be the most common in horses [4].
There is a stall-side test available (Alvedia, Limonest, France) Expected Outcome The expectations after blood transfusion
to detect Ca-positive horses, but Aa and Qa tests are not are for improved oxygenation of tissues. A decrease in
available. A complete crossmatch is recommended to heart rate, decrease in lactate, and increase in PCV are
determine donor-recipient incompatibility. reasonable expectations after transfusion, but the rise in
In an emergency, most horses can safely be given a blood PCV is not predictable. In a retrospective report of horses
transfusion without crossmatch, since they are unlikely to receiving blood transfusions, heart rate and respiratory rate
have preexisting RBC antibodies. A crossmatch is strongly improved significantly after transfusion, but PCV did not
recommended for horses that have previously been exposed increase significantly in horses with hemorrhagic anemia
to red blood cells either through blood transfusion or trans- receiving blood transfusions [1]. It is likely that these
placental exposure. The major crossmatch detects incom- horses were transfused during or soon after the episode of
patibility between the donor RBCs (RBC antigens) and the hemorrhage, so the pre-transfusion PCV may have been
recipient plasma (RBC antibodies). The minor crossmatch relatively high due to splenic contraction and incomplete
detects incompatibility between the recipient RBCs and volume resuscitation.
the donor plasma. Crossmatch can be performed by tradi- Acute hemolytic reactions can be severe and may lead to
tional tube incubation and microscopic evaluation to assess organ failure and death. If recognized early, outcome can
for agglutination. Ideally, complement should be added to be good, especially if a compatible donor is identified.
assess for hemolysis. Recently, a microgel assay and modi- Horses may develop RBC antibodies after transfusion,
fied rapid gel assay have been evaluated for use in without any clinical signs. These horses may develop acute
horses [5]. Crossmatch incompatibility is associated with hemolysis with subsequent transfusions, and broodmares
decreased RBC survival time as well as increased risk of may have RBC antibodies in their colostrum, leading to
febrile reaction [6]. neonatal isoerythrolysis in the foal [8].
If there is a history of transfusion reaction or if a cross-
match-compatible donor cannot be identified, autologous
transfusion options, such as preoperative autologous dona- Allergicand FebrileReactions
tion or cell salvage, should be considered (see Chapter 7:
Complications Associsted with Hemorrhage). Definition Febrile nonhemolytic transfusion reaction
(FNHTR) is a fever ( 1°C increase from baseline) that
Diagnosis and Monitoring Whole blood and packed RBC occurs within 4 hours of transfusion and that is not
transfusions should be monitored very closely during the associated with hemolysis or signs of allergic reaction.
first 10–20 minutes, checking temperature, heart rate, and
respirations. The transfusion should be slowed or stopped Risk Factors
if there are any signs of allergic reaction such as muscle ● Hypersensitivity to donor leukocytes
fasciculations, sweating, or urticaria. Signs of acute ● Crossmatch-incompatible blood
hemolytic reaction include a sudden decrease in packed ● In humans, blood product storage is associated with
cell volume (PCV), hemoglobinuria, hemoglobinemia, and accumulation of proinflammatory cytokines and FNHTR
systemic inflammatory response syndrome. Delayed
hemolytic reactions result in an unexpected decrease in Pathogenesis Fever and allergic reactions are the most
PCV more than 24 hours after transfusion. common complications of blood and plasma transfusion in
66 Complications of lood ransfusion
veterinary patients [1, 9]. Leukocytes in the transfused allergic reactions can usually be treated successfully.
blood may incite febrile reaction. Acute allergic reactions Anaphylactic reactions may be fatal.
can also occur, most often a type I immune-mediate
hypersensitivity to plasma components. In human patients,
febrile nonhemolytic reactions occur in 0.1–1.0% of
Transfusion-Related Acute
transfusions and incidence of allergic reaction is reported Lung Injury
at 1–3% [2]. In a retrospective study of blood transfusions
in canine patients, there was a complication rate of Definition Transfusion-related acute lung injury
approximately 25%, with fever (12%) and hemolysis (6%) (TRALI) is a new onset of bilateral pulmonary infiltrates
being the most common [3]. within 6 hours of transfusion. TRALI follows the criteria
for acute lung injury (ALI), defined as acute onset
Prevention In an experimental study with healthy horses, respiratory difficulty with evidence of pulmonary
crossmatch incompatibility was predictive of febrile capillary leakage, no evidence of left atrial hypertension,
reaction, so using crossmatch compatible blood should and PaO2/FiO2 of less than 300 mmHg [12]. TRALI is an
limit the risk of FNHTR [6]. Plasma proteins are thought to important cause of transfusion-related mortality in
be one stimulus allergic transfusion reactions, so washing humans. TRALI has been described in dogs but has not
the RBCs may reduce the risk of allergic reaction. This been reported in horses. Nonetheless, it is an important
author has used the technique of washing donor RBCs to potential adverse reaction to consider and include in the
eliminate an allergic reaction in a horse that had a moderate list of differential diagnoses for dyspnea or hypoxemia
allergic reaction to blood from multiple different after transfusion.
crossmatch-compatible donors. Leukoreduction has been
Risk Factors
shown to lower the risk of inflammatory reaction in an
● Leukocyte antibodies in the donor may react with leuko-
experimental study with healthy dogs, so this could also be
cyte antigens in the recipient, leading to sequestration
considered if a febrile reaction is noted [10]. Premedication
and activation of neutrophils in lung tissue.
with antihistamines has been shown to decrease the
● Activation of cytokines and lipids may also cause dam-
incidence of acute allergic reactions in dogs receiving
age to the pulmonary vascular endothelium.
transfusions [11].
● Activation of neutrophils related to infection, inflamma-
Diagnosis and Monitoring Clinical signs of allergic reaction tion, or trauma may be the “first hit” prior to the “second
can include urticaria, piloerection, facial swelling, and hit” of the transfusion.
fever. Severe anaphylactic allergic reactions will cause
hypotension and shock, and may cause death. FNHTR is Pathogenesis Activation of neutrophils (see above) leads
characterized by fever without other clinical signs. to damage to the pulmonary capillary endothelium, with
However, fever is also associated with acute hemolytic subsequent capillary leak. Priming of the neutrophils may
reaction, allergic reaction, and bacterial contamination, so occur from an initial event (e.g. trauma, surgery, infection).
careful investigation and close monitoring are warranted Activation of the neutrophils in the pulmonary endothelium
whenever fever is associated with transfusion. then occurs secondary to transfusion-related immune
stimulation.
Treatment Febrile reactions are usually self-limiting.
Treatment with antipyretics such as nonsteroidal anti- Prevention Leukocyte antibodies in donor blood can be
inflammatory drugs (e.g. flunixin meglumine, 1.1 mg/kg IV) reduced by processing whole blood into packed RBCs and
is indicated with high or symptomatic fevers. When in doubt, by washing RBCs.
the transfusion should be stopped while the cause of the
fever is investigated. Mild allergic reactions, such as urticaria, Diagnosis Clinical signs of TRALI include hypoxemia,
can be treated with antihistamines (e.g. diphenhydramine, cyanosis, tachypnea, and tachycardia, usually within 6
1.1 mg/kg IM) and temporary interruption of the transfusion. hours of transfusion. Volume overload, allergic reaction,
Any signs of anaphylactic reaction warrant immediate and systemic inflammatory response syndrome should also
discontinuation of the transfusion and treatment with be considered as differential diagnoses.
epinephrine (0.01–0.02 mg/kg IV).
Treatment Hypoxemic patients should be treated with
Expected Outcome FNHTR is usually self-limiting. There is supplemental oxygen. Conservative fluid therapy is
a risk of recurrence with subsequent transfusions. Mild indicated to reduce the risk of volume overload.
Transfusion-Transmitted Infections 67
Expected Outcome TRALI is usually self-limiting in are not underlying clinical conditions such as heart failure,
humans, with recovery in 48 to 96 hours, although renal failure, or sepsis.
mortality is reported as high as 25% [13]. The incidence of
TRALI in dogs appears to be low (3.7%) and not significantly
Transfusion-Transmitted Infections
different than the incidence of ALI in critically ill dogs that
have not received transfusions [14].
Definition Transfused blood may transmit infection due to
unrecognized donor infection or due to bacterial
overgrowth in the blood product.
Nonimmune Reactions
Risk Factors
Volume Overload
● Improper collection and storage of blood, including skin
Definition Volume overload, or transfusion-associated contamination during collection, refrigeration without
circulatory overload (TACO), is recognized when signs of strict temperature control, break in sterility during
respiratory distress and pulmonary edema occur after a warming or administration of blood
large volume transfusion. ● Blood-borne disease in donor horse
Risk Factors Pathogenesis Bacterial contamination can occur at many

● Large volume of whole blood given to normovolemic patient points during the collection, storage, and administration of
● Total dose (ml/kg) of blood products was a risk factor in blood products. Horses are most often transfused with
a study of dogs receiving packed RBC transfusions [15]. fresh whole blood, so the risk of substantial bacterial
● Large volume of crystalloid or colloid fluids adminis- contamination is low since the blood is not stored. Donor
tered in addition to blood transfusion horses may transmit viral, bacterial, and protozoal diseases,
● Preexisting conditions, such as heart failure and renal such as equine infectious anemia (EIA), piroplasmosis,
failure and equine parvovirus.
Pathogenesis Volume overload is uncommon in adult Prevention The USDA issues standards for equine plasma
horses receiving blood transfusions, but may occur with labelled for treatment of failure of passive transfer of
smaller patients such as miniature horses and foals [16]. immunity and treatment of specific diseases. These
Massive transfusion, defined as transfusion of one blood standards include testing plasma donors for EIA,
volume or more within 24 hours or 50% of one blood volume piroplasmosis, dourine, glanders, and brucellosis. The
within 3 hours, may lead to additional complications [17]. USDA recommends additional testing for equine viral
Massive transfusion can cause hypocalcemia associated arteritis, West Nile virus, and equine parvovirus. The USDA
with citrate toxicity. Liver failure has been reported in does not have regulatory oversight of whole blood or
neonatal foals receiving large volume transfusions to treat packed RBCs, but the guidelines for plasma donors are
neonatal isoerythrolysis, likely due to iron overload [18]. logical for blood donors as well. Blood donors should not
give blood if they are showing any signs of illness, including
Prevention Volume overload can be avoided with careful fever.
calculation of total fluid volume planned for treatment of The blood collection site (usually jugular vein) should be
the patient. In normovolemic patients, packed RBCs clipped and prepared with a surgical scrub, especially if
should be used, when available. blood will be stored. Sterile technique should be used with
needle or catheter placement and a closed collection sys-
Diagnosis Clinical signs include dyspnea and cyanosis. tem should be used to limit potential for bacterial contami-
Signs of pulmonary edema may be seen on thoracic nation. Stored blood should not be used if there are any
ultrasound or radiographs. signs of contamination or disruption of the bag. Do not
leave blood products at room temperature for more than
Treatment Discontinue the transfusion (if still in progress) 4–6 hours.
and administer supplemental oxygen. Furosemide (1.1 mg/
kg IV) should be administered as a diuretic. Diagnosis Bacterial contamination and production of
toxins may result in immediate clinical signs of systemic
Expected Outcome Prognosis is good if the condition is inflammatory response syndrome in the transfused patient.
recognized early and treated appropriately, assuming there Fever, tachypnea, and tachycardia can occur for a variety of
68 Complications of lood ransfusion
reasons during transfusion, and regardless of the suspected breakdown lead to an increase in potassium and lactate
cause, the transfusion should be stopped. Unfortunately, and a decrease in 2,3-DPG [20]. As the cell membrane
transmission of viral or protozoal disease will not be deteriorates, increased hemolysis can be detected and
immediately apparent, so prevention through donor testing hemoglobin microparticles are released. Large-volume
is strongly recommended. transfusion of stored blood can introduce high levels of
potassium and lactate.
Treatment The transfusion should be stopped if there are As storage time increases, post-transfusion viability of
any signs of reaction or suspicion of contamination. Any the RBCs decreases. The post-transfusion lifespan of
remaining donor blood can be cultured if bacterial equine autologous RBCs stored for 28 days was 59 days,
contamination is suspected. compared to a lifespan of 99 days for fresh, biotinylated
blood [21].
Expected Outcome Outcome will depend on the underlying
infection. In humans, approximately 10% of transfusion-
Prevention Fresh whole blood is most often used for
related deaths were due to transfusion-transmitted
equine transfusions, so “storage lesion” (hyperkalemia,
infections [19].
hyperlactatemia, decreased 2,3-DPG) is not usually a
concern. When collecting blood intended for storage, use
RBCStorageLesion CPDA-1 storage bags to support RBC viability. Use a
dedicated blood bank refrigerator at 4°C.
Definition The storage lesion refers to red blood cell and
Diagnosis and Monitoring Stored blood should be discarded
biochemical changes that occur during blood storage.
These include hemolysis, decreased red blood cell if hemolysis is evident, and storage of equine blood beyond
deformability, increased 2,3-diphosphoglycerate (DPG) 28 days is not recommended. Horses receiving stored blood
levels, increased potassium and lactate, and decreased should be monitored for hemolysis, hyperkalemia, and poor
glucose. tissue oxygenation, along with other transfusion reactions.
Treatment There is no specific treatment indicated for

Risk Factors
animals that receive older units of RBCs. The decrease in
● Long duration of storage. The RBCs continue to break 2,3-DPG is reversible, so the limitations of oxygen delivery
down throughout the storage period. should not be long-lasting. Additional blood transfusion
● Improper collection or storage. Collection into glass bot- may be needed if RBC viability has been severely
tles inactivates platelets and increases hemolysis. compromised by storage.
Improper storage solution will not support RBC metabo-
lism and will lead to more rapid RBC breakdown. Expected Outcome The biochemical and functional
changes that occur during RBC storage are similar across
Pathogenesis The morphologic and biochemical changes species. In dogs, age of the stored RBCs is associated with
in stored blood occur, even in storage solutions that provide the risk of transfusion-related hemolysis, but not with
dextrose and balance pH. Ongoing RBC metabolism and fever or mortality [3].
References
1 Hurcombe, S.D., Mudge, M.C., and Hinchcliff, K.W. 4 Bailey, E. (1982). Prevalence of anti-red blood cell
(2007). Clinical and clinicopathologic variables in adult antibodies in the serum and colostrum of mares and its
horses receiving blood transfusions: 31 cases (1999–2005). relationship to neonatal isoerythrolysis. Am. J. Vet. Res. 43
J. Am. Vet. Med. Assoc. 231 (2): 267–274. (11): 1917–1921.
2 Weinstein, R. (2012). Clinical Practice Guide on Red 5 Casenave, P., Leclere, M, Beauchamp, G. et al. (2019).
Blood Cell Transfusion. Washington, DC: American Modified stall-side crossmatch for transfusions in horses.
Society of Hematology. J. Vet. Intern. Med. May 18: 1–9 [Epub ahead of print].
3 Maglaras, C.H., Koenig, A., Bedard, D.L. et al. (2017). 6 Tomlinson, J.E., Taberner, R.C., Boston, S.D. et al. (2015).
Retrospective evaluation of the effect of red blood cell Survival time of cross-match incompatible red blood cells
product age on occurrence of acute transfusion-related in adult horses. J. Vet. Intern. Med. 29 (6): 1683–1688.
complications in dogs: 210 cases (2010–2012). J. Vet. 7 Tocci, L.J. (2010). Transfusion medicine in small animal
Emerg. Crit. Care. 27 (1): 108–120. practice. Vet. Clin. N. Am. Small Anim. Pract. 40: 485–494.
eferences 69
8 Wong, P.L., Nickel, L.S., Bowling, A.T. et al. (1986). 15 Holowaychuk, M.K., Leader, J.L., and Monteith, G.
Clinical survey of antibodies against red blood cells in (2014). Risk factors for transfusion-associated
horses after homologous blood transfusion. Am. J. Vet. complications and nonsurvival in dogs receiving packed
Res. 47: 2566–2571. red blood cell transfusions: 211 cases (2008–2011). J. Am.
9 Prittie, J.E. (2003). Tirggers for use, optimal dosing, and Vet. Med. Assoc. 244 (4): 431–437.
problems associated with red call transfusions. Vet. Clin. 16 Tennent-Brown, B. (2011). Plasma therapy in foals and
Small Anim. Pract. 33: 1261–1275. adult horses. Compendium. 33 (10): E1–E4.
10 McMichael, M.A., Smith, S.A., Galligan, A. et al. (2010). 17 Beer, K.S. and Thomer, A. (2019). Massive transfusion. In:
Effect of leukoreduction on transfusion-induced Textbook of Small Animal Emergency Medicine (ed. K.J.
inflammation in dogs. J. Vet. Intern. Med. 24 (5): Drobatz, K. Hopper, E. Rozanski, et al.), 1156–1160. John
1131–1137. Wiley & Sons.
11 Bruce, J.A., Kriese-Anderson, L., Bruce A.M. et al. (2015). 18 Polkes, A.C., Giguere, S., Lester, G.D. et al. (2008). Factors
Effect of premedication and other factors on the associated with outcome in foals with neonatal
occurrence of acute transfusion reactions in dogs. J. Vet. isoerythrolysis (72 cases, 1988–2003). J. Vet. Intern. Med.
Emerg. Crit. Care. 25 (5): 620–630. 22 (5): 1216–1222.
12 Wilkins, P.A., Otto, C.M., Baumgardner, J.E. et al. (2007). 19 U.S. Food and Drug Administration (2016). Fatalities
Acute lung injury and acute respiratory distress reported to FDA following blood collection and
syndromes in veterinary medicine: consensus definitions: transfusion: Annual summary for fiscal year 2016.
the Dorothy Russell Havemeyer Working Group on ALI Available at: www.fda.gov/media/111226/download.
and ARDS in Veterinary Medicine. J. Vet. Emerg. Crit. 20 Mudge, M.C., MacDonald, M.H., Owens, S.D. et al.
Care. 17 (4): 333–339. (2004). Comparison of 4 blood storage methods in a
13 Frazier, S.K., Higgins, J., Bugajski, A. et al. (2017). protocol for equine pre-operative autologous donation.
Adverse reactions to transfusion of blood products and Vet. Surg. 33 (5): 475–486.
best practices for prevention. Crit. Care Nurs. Clins. N. 21 Owens, S.D., Johns, J.L., Walker, N.J. et al. (2010). Use of
Am. 29: 271–290. an in vitro biotinylation technique for determination of
14 Thomovsky, E.J. and Bach, J. (2014). Incidence of acute posttransfusion survival of fresh and stored autologous
lung injury in dogs receiving transfusions. J. Am. Vet. red blood cells in Thoroughbreds. Am. J. Vet. Res. 71 (8):
Med. Assoc. 244 (2): 107–174. 960–966.
70
ComplicationsAssociatedwith Sutures
Ian F. Devick DVM, MS, DACVS-LA1 and Dean A. Hendrickson DVM, MS, DACVS2
1
Weatherford Equine Medical Center, Weatherford, Texas
2
Overview Suture-related complications include dehiscence, infec-

tion without dehiscence, tissue reaction, suture ligation
Suture serves as a fundamental part of veterinary surgery slippage, and suture cut-out. When specific to the alimen-
and is mainly used for tissue apposition of a wound/ tary, urogenital, respiratory, musculoskeletal, and ophthal-
incision and vessel ligation for hemostasis. The first known mologic systems, these complications will be discussed in
documented reference to suturing of a wound dates back to detail in the respective chapters. Suture cut-out as a com-
a papyrus from 1600 BC [1]. Obviously, since that time plication without incisional dehiscence can occur as a sep-
there has been enormous advances made in the arate complication in the realm of tendon repairs and
development of suture materials, resulting in a vast number certain upper airway procedures which are discussed in
of different suture materials and sizes available to their respective chapters.
veterinarians today.
Briefly, suture material is classified by degradation
behavior (absorbable vs. nonabsorbable), composition istof ComplicationsAssociated
L
(natural vs. synthetic), and structure (monofilament vs. with Sutures
multifilament) [2]. Degradation behavior, composition,
and structure along with suture surface characteristics and ● Dehiscence
suture size influence additional suture characteristics, ● Infection without dehiscence
including flexibility, elasticity, capillarity, memory, tensile ● Suture reactions
strength, knot holding capacity, and relative knot ● Ligature loop failure
security [2]. There is no one suture material that is ideal for
every situation and it is important for the veterinarian to
understand the advantages and disadvantages of the Dehiscence
different sutures physical and biological characteristics.
However, it is equally important to understand the wound/ Definition Wound or incisional dehiscence can be defined
incision location, tissue tension, contamination, vascular as separation of a previously apposed wound or incision.
supply, and the healing rate of the given tissues when Dehiscence may be superficial or deep and partial or
making the selection of an appropriate suture in the effort complete.
to decrease risk of suture-related complications [3]. The
cruciality of the proper surgical technique and the suture Risk Factors
pattern selection for the given wound/incision, along with ● Infection
pertinent peri-operative management (antibiotics, NSAIDs, ● Suture placement
bandaging, drain placement, immobilization, and ● Poor knotting technique
confinement) cannot be overstated in preventing wound ● Inappropriate suture material
and incisional suture complications [3]. ● Premature suture removal
Dehiscence 71
● Improper suture needle selection activity within 5 mm of the wound edges, leading to an
● Inadequate suture line tension increased risk of suture cut-through and dehiscence of the
● Excessive suture line tension wound [5].
● Dead space
● Suturing of nonviable tissue Poor knotting technique
● Inappropriate support and immobilization of a suture line A poor knot-tying technique can result in the knot untying
and wound dehiscence [5].
Pathogenesis
Infection Inappropriate suture material
All sutures produce a local tissue reaction to some degree, Selection of an inappropriate suture material with insuffi-
which increases the susceptibility to development of an cient tensile strength for the given tissues or that signifi-
incisional infection [4]. Infection can be the primary reason cantly decreases in tensile strength (resorption time) faster
causing dehiscence or can be a sequelae to dehiscence [5]. than tissue healing occurs for the respective tissue,
Bacteria release proteolytic enzymes that inhibit wound increases the risk of dehiscence [5]. Interactions between
healing, therefore inducing wound disruption and the suture material and tissue can alter the characteristics
dehiscence [5]. of the suture and lead to suture failure [9]. Barbed sutures
have been shown to increase the incidence of postoperative
● Tissue integrity and perfusion, local wound repair incisional dehiscence and erythema as wound
responses, and bacterial challenge, influence the complications [12].
presence of an infection of the suture line [6].
● Degree of bacterial contamination is a useful predictor of
Premature suture removal
incisional/wound infection potential [7].
Suture removal prior to appropriate wound healing may
● Improper wound cleansing with cytotoxic substances or
result in dehiscence [5].
overzealous scrubbing can result in unnecessary tissue
inflammation, edema, and necrosis, all leading to an
increased risk of incisional infection and dehiscence [8]. Improper suture needle selection
● Inadequate or traumatic debridement of necrotic, The type of needle and size in relation to the suture can
devitalized, heavily contaminated tissue and organic increase the risk of suture cut-through, especially when
debris increases risk of incisional infection and there is tension present or tissues are compromised [5].
dehiscence.
● Use of a larger suture size than necessary results in Inadequate suture line tension
unnecessary foreign material present within the wound/ Loosely placed sutures due to inadequate surgical tech-
incision, altering the tissue structure, weakening the nique or as a result of anticipated edema formation, as well
repair, and therefore decreasing the capacity to resist as a suture line placed in a region of already present edema,
infection [3, 9]. Physical and biochemical characteristics increases the risk of wound edge retraction and incisional
of the suture serve as an important factor in the initiation, gapping when the edema resolves [5].
severity, and persistence of incisional infections [4].
Bacteria have a higher affinity for braided suture Excessive suture line tension
compared to monofilament suture [4]. Removal of The use of excessive suture tension or use of an inappro-
bacteria by the body’s defense mechanism is slower with priate suture pattern for mild to moderate tension along a
braided suture [4]. The use of barbed sutures has been suture line to appose tissues can result in suture cut-
shown to increase the risk of incisional infections [10], through leading to dehiscence. Excessive suture tension
● Suture pattern choice can contribute to prolonged edema can affect the local blood flow, which increases the
and erythema from decrease in microvascular flow, inflammatory response resulting in tissue ischemia and
resulting in delayed healing, decreased incisional tensile pressure necrosis [3, 6, 7]. The use of suture stents or
strength, and risk of incisional complications [11]. quills in an attempt to diffuse the tension from the suture
to a larger surface area can also affect microvascular sup-
Suture placement ply and result in tissue pressure necrosis under the stent
Sutures that are placed too close to the wound margins risk or quill, especially when placed under a pressure bandage
suture cut-through due to an initial elevated collagenase or cast [3].
72 Complications Associated ith Sutures
Dead space general, this corresponds to fewer sutures in thicker skin

Dead space is created in some traumatic wounds where tis- and areas of low tension and more sutures in regions of thin
sues have been lost or dissection planes have been created. skin and higher tension [3]. Suture pattern choice can con-
Dead space is created surgically after tissue debridement, tribute to prolonged edema and erythema, such as with a
mass removal, or undermining has been performed to simple continuous suture pattern when compared to a sim-
relieve tension for the closure. As a result, seroma or hema- ple interrupted suture pattern [11]. This edema can result in
toma formation may manifest, increasing the risk of inci- delayed healing and risk of complications [11].
sional infection and possible dehiscence [4]. Physical and biological characteristics should be consid-
ered when selecting suture material and size, and the
Suturing of nonviable tissue The degree of tissue compromise suture material should be compatible with the tissue type
and viability of recently traumatized tissues can be difficult being sutured and the anticipated post-operative incisional
to predict. If a traumatic wound is closed too promptly, tension [5, 9]. The suture should be as strong as the normal
without allowing or anticipating the potential ensuing tissue through which it is placed [2, 3]. The rate of loss in
development of tissue necrosis to occur, the development of tensile strength of the suture material and the gain in
delayed necrosis may lead to dehiscence [5]. wound strength of the sutured tissues over time should
coincide {2, 3]. Monofilament suture material has the
Inappropriate support and immobilization of a suture advantages of low tissue drag and low tendency to foster
line infection [15]. There has been no beneficial effect in the
Excessive motion for any given suture line increases the use of antibiotic-coated suture material in preventing
risk of tension on the wound edges and possible suture-related complications [16].
dehiscence [5]. The repetitive motion of an incision causes Tension forces are converted to shear forces at the suture
chronic inflammation from microvascular, collagen knot, thus making the knot the weakest point of the suture
deposits, and epithelialization disruption [7]. However, loop [9]. Secure square knots are important in preventing
complete immobilization can result in disorganized new dehiscence and the appropriate number of throws for good
collagen and decreases incisional tensile strength [7]. knot security depends on the suture material characteristics
Inadequate support and/or immobilization of a suture line and the nature of the suture pattern (interrupted vs.
as well as inadequate confinement can have detrimental continuous) [3]. A surgeon’s throw is only indicated when
effects on the wound/incision healing process and result in needed to appose the tissues, otherwise it is contraindicated,
dehiscence. especially in deeper layers such as facial, subcutaneous,
organs, joint capsule, paratenon, etc. [3] Unnecessary
Prevention Effective apposition of the wound/incision throws on a knot or the use of a surgeon’s throw makes a
edges, atraumatic tissue handling, minimal disruption to bulkier knot and increases suture material within the
blood supply, appropriate suture pattern, material, needle, tissues, thus increasing the risk of delayed wound healing,
and placement are essential requirements for a positive pressure necrosis, suture extrusion, and infection [3, 17].
healing outcome [3, 5]. Adequate perioperative care is also Wound/incision location and the tissue layer being
an important factor in incisional healing and appropriate sutured will have important influence on the appropriate
use of antibiotics, NSAIDs, diagnostics, bandaging, and suture pattern indicated [3]. There is a wide variety of
confinement are important. Appropriate bandaging and suture patterns (interrupted vs. continuous, inverting vs.
NSAID uses can prevent excessive edema formation. It is everting, and tension sutures) and each have advantages
important to inflict the least amount of trauma achievable and disadvantage which must be considered when
to obtain the goal of the surgery [9]. determining an appropriate pattern for the given location,
The wound strength is more dependent on the tissue’s tension, and organ or tissue layer being sutured [3].
ability to hold the suture than on the given suture Interrupted sutures increase the amount of suture material
strength [2]. Suture placement from the wound edge is rec- in the wound/incision when buried and increase surgery
ommended an equal distance from the incision/wound time and cost [3]. Continuous patterns lack the ability to
edge as the thickness of the skin edge at that location [3]. vary tension along the suture line and knot or suture failure
Due to the normal inflammatory phase of healing, sutures can be catastrophic to the entire length of the apposed
should be placed at least 5 mm from the wound/incision tissues [3]. Also, simple continuous and horizontal suture
edge to prevent dehiscence [3]. Spacing between sutures is patterns can compromise the vascular supply to the wound/
variable, depending on wound/incision location and rela- incision edge resulting in increased inflammation and
tive local tension but it is advised to use the minimum num- edema formation [3, 11]. Depending on the wound/
ber of sutures necessary to achieve tissue apposition [3]. In incision location, inversion, eversion, or edge-to-edge may
Dehiscence 73
be advantageous. Inversion is advantageous in preventing Severely traumatized tissues or tissues suspected of

leakage in hollow viscera closure but also will reduce the blood supply loss should not be closed too soon and should
luminal diameter of viscera, which can lead to be closely monitored until viability is ensured [5]. In some
complications which are discussed in the respective circumstances it is recommended to suture the tissues
chapters. Slight eversion is recommended when there is a initially before viability is ensured, such as if it is over a
tendency for the skin edges to invert and the slight eversion joint or there is exposed cortical bone. An understanding
results in positive cosmetic outcome [3]. A continuous and acceptance of tissue necrosis and future partial
intradermal pattern results in the best cosmetic outcome dehiscence in these circumstances may be of more benefit
and does not require suture removal; however, there is a to overall healing and these expectations should be
potential for suture fistula formation if improper technique discussed in advance with the owner.
was used and the epidermis was included in the closure. Confinement should be used effectively to adequately
Incised wounds have limited tensile strength during the immobilize excessive motion. Confinement and exercise
inflammatory phase of wound healing and apposition is may range from a cross tied patient to stall confinement to
primarily achieved by the suture [9]. Excessive tension paddock turnout to pasture turnout, depending on the
placed on the suture line should be avoided, as the tissue’s surgery and postoperative time frame. Horses should be
ability to hold suture has more influence on the repair than introduced to exercise appropriately for the given surgical
the strength of the suture material itself [2, 3]. For wounds/ procedure performed and to allow for continued
incisions under tension it is discouraged to use a larger remodeling and strengthening of the incision.
suture size; instead it is recommended to increase the Incisional dressing and bandaging provide a barrier to
number of sutures and use of appropriate tension relieving environmental contamination but can also play a key role
sutures in the suture line [2, 3]. Other options of tension in decreasing motion of the surgical site. The location and
relieving techniques, such as undermining, walking surgical procedure performed will determine whether a
sutures, tension-relieving incisions, mesh expansion, tissue light bandage, compression bandage, stent bandage, or no
flaps or plasties, can be used to prevent occurrence of bandage is appropriate. In areas of high motion, such as
dehiscence from tension [3, 6, 7]. Staggered suture removal over a joint, casting or splinting may be considered
in areas of tension is also recommended to prevent necessary for that specific case [7].
incisional dehiscence [6]. Ensuring proper postoperative nutrition for the patient’s
Even the least reactive suture materials act as foreign metabolic needs will help prevent a delay in wound healing
material and decrease the ability of the wound to resist due to protein and vitamin deficiencies [7, 18].
infection, thus suture number, suture size, and number of Ensuring more focused or localized neoplastic treatment
knots should be minimized [3, 9]. However, there is usually with radiation therapy and protection of adjacent healthy
a variety of sutures that can be used with a favorable tissues is important in preventing unnecessary complica-
outcome in most situations, so surgeon preference can be tions with wound healing [19, 20].
considered in suture selection [9]. General recommendations are difficult to make based
Hematoma and seroma formation can be prevented by on the current literature, but in wounds with suspected
adequate intraoperative hemostasis, atraumatic surgical incomplete tumor resection, it has been thought to delay
technique, and closure of dead space created [5]. Drains intra-tumoral chemotherapy until wound healing has
should be placed intraoperatively if seroma formation is begun (7–14 days) to decrease the risk of dehiscence
anticipated [5]. As well adequate compression, bandaging [5, 21].
should occur in indicated areas to prevent hematoma or
seroma formation. Proper placement is essential and they Diagnosis Dehiscence can occur from the immediate
should not be used as a substitute for proper wound postoperative period up to several weeks after surgery.
cleansing, debridement, and lavaging [3]. Drains are not Dehiscence during the anesthetic recovery or soon after
benign, so close monitoring and aseptic technique during surgery can be a result of self-induced trauma or inadequate
bandage changes is important to prevent retrograde steps to immobilize the region, confine the patient, or
bacterial migration and excessive tissue irritation [3]. To relieve tension on the suture line as appropriate. Most
prevent complications associated with drains, they should commonly, incisional dehiscence will occur 4–5 days
be removed as soon as possible, such as when there is a postoperatively [5]. Clinical signs that may develop prior to
decrease in drainage or change from purulent or dehiscence include serosanguineous discharge or in the
serosanguinous to serous and non-odoriferous, and is case of an infection, a purulent odorous discharge. Tissue
typically at 2–4 days but varies depending on location and swelling, heat, and necrosis of the sutured tissue edges
wound environment [3]. along with pain to palpation may also be evident prior to
dehiscence. Dehiscence is diagnosed at the time where necessary, such as cross-tying, smaller stall confinement,
there is superficial or deep and partial or complete no hand-walking, etc.
separation of the previously sutured wound or incision. Partial dehiscence or intentional partial dehiscence, in
Identifying any primary cause for the dehiscence before the case when dependent sutures are removed to allow for
assuming it was a result of infection is important, since adequate drainage, can be managed with appropriate
with incisional disruption and dehiscence there is often wound care including cleansing, debridement, lavaging,
secondary infection present [5]. Clinical signs associated and appropriate wound dressings.
with incisional infections include incisional swelling, heat, Passive or active drains are incorporated to ensure
pain, and drainage of a purulent nature [13]. If there is a adequate drainage and obliteration of dead space if
suspected infection present, regardless of whether it was discharge, fluid, or gas build-up within the repair was
the primary cause or secondary to another cause, a deep suspected to have contributed to the dehiscence. Drains
swab should be obtained of the infected area after aseptic will function by channeling undesired discharge, fluid, gas,
preparation [6]. The swab is then submitted for aerobic and or debris and usually promotes faster healing and decreases
anaerobic bacteriological culture and sensitivity testing. In the chance of dehiscence reoccurring [3]. Incorporation of
some cases, a fungal culture is recommended. The degree a compression bandage when applicable will help with the
of bacterial contamination will help determine the most elimination of dead space.
appropriate wound management, thus qualitative and Common isolates from infected equine wounds include
quantitative cultures can be beneficial [7]. If a foreign body Streptococcus spp, Staphylococcus spp, Enterobacteriaceae,
and sequestra is the underlying cause of the dehiscence, it Pseudomonas spp, and anaerobes [6]. With the suspicion of
can be identified or ruled out with a number of diagnostics, infection of the suture line, a course of broad-spectrum
including manual exploration and probing, ultrasound, antibiotics and or regional limb perfusions are
contrast or plain radiographs, CT, or MRI of the wound [7]. recommended and initiated until culture and sensitivity
If self-mutilation was the cause of the dehiscence, it is results have been obtained. Delayed primary closure,
usually diagnosed through observation or evidence of a secondary closure, or second intention healing are
rough anesthetic recovery, rubbing, biting, or pawing [6]. recommended in cases where there is a presence of
Cytological or histopathological examination may be infection, necrotic or compromised tissue, or if additional
indicated to identify an underlying cause such as debridement is needed [5]. The degree of bacterial
neoplasia [5]. contamination, determined by qualitative and quantitative
culture, will help identify the most appropriate wound
Treatment Treatment will vary depending on the identified management [7]. Appropriate wound care and wound
cause of incisional dehiscence and whether it is a partial or dressings are essential and are dictated by the wound
completed dehiscence. Location, size, tissue viability, characteristics and phase of wound healing.
reason for the dehiscence, owner expectations and financial Sequesta formation may not be evident on radiographs
concerns will all play a critical role in how the dehisced until 3–4 weeks after injury [6, 7, 14]. Similarly, healing is
sutured line is treated. Examination of the dehisced delayed in most horses with foreign bodies present and are
incision and determination of cause is the first step in prone to dehiscence of the suture line and development of
determining a course of treatment. Early and meticulous a persistent draining tract [6, 14]. Prolonged medical
evaluation of the dehisced incision along with appropriate treatments are usually unsuccessful in resolving the
management using a combination of timely surgical and infection and the drainage returns once treatment is
medical treatments are used to promote the best healing discontinued. Complete removal of the fistulous tract,
outcome [6]. sequestrum and debridement of the underlying bone or
If there is no suspicion of infection then the dehisced removal of the foreign body usually results in a positive
sutures are removed, the wound cleansed, without the use outcome [6]. The dehisced incision may be managed by
of antiseptics, debrided, lavaged, and primary closure can primary closure or second intention healing [6]. In
be performed [5]. If excessive tension is suspected, dehisced cases not managed by closure, skin grafting can
additional steps are taken as needed, such as incorporating improve the cosmetic appearance [6, 7].
tension relieving suture patterns, walking sutures, or In the case of self-mutilation, applying cayenne pepper
tension relieving techniques such as tissue undermining, or similar substances on the outside of the bandage may
relief incisions, or plasties can be performed [7]. If excessive deter the behavior in some horses. Medicating with
motion is thought to be involved, increasing incisional tranquilizers or other calming agents may also be indicated
support through bandaging, splinting, or casting is in horses not tolerant of stall confinement. Different
recommended. In addition, stricter confinement may be bandaging techniques can be tried in certain cases, such as
Suture Reactions 75
with head surgeries where the use of a stockinette or reaction is most prominent at the knot site, since the knot
nothing in place of an Elastikon bandage may be more represents the major foreign body mass and density, and
beneficial for the outcome of the incision healing. causes the most mechanical trauma to the tissues [22].
Systemic diseases that could be playing a factor in
delayed wound healing and dehiscence should be Suture material
addressed, diagnosed, and treated accordingly. Both the physical (monofilament vs. multifilament) and
Incisions over areas of motion should be immobilized the chemical composition influence the reaction that takes
appropriately, depending on the predicted amount of place within the tissues [23]. Monofilament suture material
movement. This may be achieved with a bandage or a withstands contamination better than multifilament
splint or cast in certain circumstances [7]. suture material, while also having less tissue reactivity
properties [23, 24]. Multifilament material results in more
Expected Outcome The prognosis after treatment and/or tissue trauma and has more capillary action, which may
repair of a dehisced wound is usually good as long as the increase the potential for bacterial contamination [5].
initiating factors are recognized and eliminated. However, Although bacteria can adhere to any suture material,
outcome will be impacted by blood supply and location of multifilament suture surfaces tend to adhere to higher
the dehisced wound. Dehisced incisions that are left to heal numbers of bacteria when compared to monofilament
by second intention are at increased risk of decreased suture [4, 23]. Antibacterial-coated suture may be
cosmetic appearance (hairless scar formation) and tissue responsible for increased risk of development of incisional
strength, depending on size and location of the dehisced edema [16]. Chronic granulomatous or abscess formation
wound. Owners should be notified that financially the cost is a reaction that can occur secondary to suture material
of extended periods of proper wound dressings, bandaging, placement, which may result in a discharging sinus [9].
and recheck examinations required for wound healing by Surgical gut is a capillary multifilament suture that elicits a
second intention can easily exceed the cost of repairing the marked foreign body reaction when implanted in tissues
dehiscence via primary or secondary closure when because it is composed of collagen [23, 24]. In contrast,
indicated. synthetic monofilament absorbable sutures such as
polydioxanone, polyglyconate, and polyglecaprone 25 as
InfectionWithoutDehiscence well as synthetic multifilament absorbable sutures such as
polyglycolic acid and polyglactin 910, cause a mild
Surgical site and suture line infections can lead to wound inflammatory response characterized by the presence of
dehiscence as discussed earlier. However, suture-related macrophages and fibroblasts at the wound site [23, 24].
surgical site infections do not always lead to dehiscence, Alternatively, synthetic nonabsorbable sutures such as
although risk factors, diagnosis, treatment, and prevention nylon and polypropylene are biologically inert and cause
are similar to that of dehisced wounds due to infection. minimal tissue reaction [23, 24]. Steel is biologically inert
Details are discussed in Chapter 17: Complications and incites no inflammatory reaction, except for that
Associated with Surgical Site Infections. caused by inflexible suture ends [23, 24].
Inappropriately large suture

SutureReactions Using larger suture size than necessary results in unneces-
sary foreign material present within the wound/incision,
DefinitionSuture-related tissue reaction is a local
altering the tissue structure, causing excessive tissue reac-
inflammatory response induced by the suture material.
tion, weakening the incision line and therefore decreasing
Risk Factors the capacity to resist infection [3, 9]. Knot size depends on
● Suture material suture size and number of throws. Suture size is the princi-
● Inappropriately large suture ple influence on knot volume and tissue reactivity; an
● Excessive suture material increase in suture size increases tissue reaction more than
● Inappropriate suture technique adding an extra throw to a knot [22].
● Excessive tension
Excessive suture material
Pathogenesis Tissues react to all suture material regardless Suture material acts as a foreign body and induces a tissue
of the type of suture material used [9]. Excessive tissue reaction in the incisional line [25]. Inflammatory reactions
reaction to suture results in edema, tissue friability, and to sutures are most pronounced close to the knots because
subsequent suture failure [9]. Usually, the inflammatory they have the largest amount of foreign material [22].
Inappropriate suture technique culture and histopathological assessment [23]. Once the
The suturing technique and excessive and inappropriate problematic sutures have been removed, the wound can be
handling of the tissues and unnecessary needle sticks will closed with a more inert suture material or left to heal by
increase tissue inflammation and edema formation [23]. second intention, depending on the circumstances of the
Excessive tension can affect the local blood flow and case. Granulomatous or abscess formation, and suture
increase the inflammatory response resulting in tissue sinuses will usually heal without detrimental complication
ischemia and pressure necrosis [3, 7]. once the inciting suture is removed [9].
Expected Outcome
Prevention Appropriate surgical knowledge and technique
Tissue suture reactions can result in increased morbidity to
for the given suture(s) location is crucial in limiting the
the patient, prolonged wound healing time, decreased
occurrence of tissue reactions to sutures. Physical and
cosmetic appearance of the surgical site, and an increase in
biological characteristics of suture materials should be
the treatment costs. However, the prognosis is usually good
considered when selecting a suture material and size [5, 9].
after removal of the problematic suture(s) [9, 23].
Even the least reactive suture materials act as foreign
material, thus minimizing the amount of suture material
within the tissues without compromising the closure
LigatureLoopFailure
should be the objective in incisional closures [9]. Therefore,
Definition Ligation suture loops are commonly used for
decreasing the amount of suture material within the tissues
hemostasis of an isolated vessel, vascular pedicle, or other
is achieved by minimizing the number of sutures, using
structure and have the potential to fail via suture slippage
the smallest adequate suture size, having the fewest
or suture breaking.
number of knots achievable, keeping the number of throws
in a knot to a minimum, avoiding a surgeon’s throw when Risk Factors
possible, and not having excessively long suture tails [3, 9, ● Suture material
23]. Suture absorption time and the gain in wound strength ● Suture size
of the sutured tissues over time should coincide [2, 3]. ● Inappropriate ligation knotting
Monofilament suture material is recommended instead of ● Inappropriate ligation placement
multifilament if the circumstances allow [23]. ● Tissue bulk
Diagnosis Tissue reaction to suture material is usually Pathogenesis Suture material, ligation technique, number
diagnosed with observation of tissue edema or swelling of ligatures, and manipulation of the vessel or pedicle are
filled with clear fluid around an individual suture or entire all factors that should be considered when performing a
suture line [23]. Erythema in light-colored skin or heat and ligation [26]. Ligation knot slippage or breakage is a
pain to palpation are other clinical signs that can assist in significant contributor to ligation failure and occurrence is
the diagnosis of tissue suture reaction. There may also be likely underestimated [27].
present a draining tract to the skin if the suture reaction is
of deeper tissues [23]. Ultrasound is not usually needed for Suture material
the diagnosis but can be useful in identifying problematic The use of multifilament suture for laparoscopic ligating
suture fragments or segments. Suture reactions can also loops does not maintain the shape of the loop well due to
result in other observed incisional complications including low stiffness of the suture material and may result in
infection, wound disruption, and chronic sinus formation inadequate placement of the ligating loop [28, 29].
and it can be difficult to determine whether tissue suture Suture size
reaction or suture line infection were the initiating causes Selection of suture that is too small will result in suture
that disrupted wound healing. loop breakage, typically at the knot where suture tension
forces have been converted to shear forces, making the
Treatment Treatment of tissue reactions to suture will
knot the weakest point of the suture loop [9].
vary, depending on the degree of clinical signs. If the suture
reaction is mild, then typically no treatments are required. Inappropriate ligation knotting
For more advanced suture reactions or if the reaction does The square knot is used commonly for vessel ligation but,
not resolve within 1–2 weeks, then removal of the suture(s) however, performs poorly when compared to a slip knot,
or entire suture line is indicated. [23]. Samples of the modified transfixing ligature, or single-double other side
affected tissues should then be submitted for bacterial knot [26]. When using a square knot, it is dependent on
Ligature Loop Failure 77
there being no slippage of the first throw until the sec- Tissue bulk can be overcome by dividing it into smaller
ond throw has secured the knot [26]. Every knot type is sections (“divide and conquer method”) or multiple liga-
at risk of not providing appropriate vessel occlusion tures can be placed around a bulky structure to improve
and hemostasis if the surgical technique is not the hemostasis [26]. Clamping to crush the tissue and
sufficient. reduce its bulk, as well as “flashing” the clamp adjacent
to the ligature being placed, are additional techniques
Inappropriate ligation placement for improving vessel occlusion and ligature
Transection of the vessel/pedicle too close to the ligature security [26].
can result in ligature slippage [29].
Diagnosis Ligature loop failure can be observed
Tissue bulk intraoperatively under direct visualization or via
Tissue bulk of a pedicle or tissue surrounding a vessel can laparoscopy. Postoperatively, incisional swelling or
inhibit the ability to achieve adequate occlusion of the ves- hemorrhage from the incision line can develop. Ultrasound
sel and result in hemorrhage. and/or aspirate of the swelling are the most common
diagnostics used to differentiate a hematoma from seroma
Prevention The importance of meticulous and proper or edema formation. Diagnosis of hemorrhage into a body
placement of ligatures is essential for healing and cavity, such as pedicle ligation failure and development of
preventing surgical complications. Whether it is open a hemoperitoneum, are discussed in their respective
surgery or laparoscopy, ligatures are placed for the same chapters.
reasons; however, there may be differences in the
mechanics of the procedure [28]. Effective surgical
techniques when performing ligation and vessel occlusion Treatment When ligation failure occurs intraoperatively,
for hemostasis are essential in prevention of unnecessary the cause of the failure should be determined as to
hemorrhage [26]. whether it is ineffective occlusion (knot slippage), loop
Suture needs to be of sufficient size to withstand the ten- slippage, or suture breakage and measures used to
sile forces placed on the loop and shear forces at the knot. correct the failure. The use of ligating clips, staples,
Regardless of the knotting technique used, the use of electrocautery and other electrosurgical instrumentation
monofilament suture is recommended because it appears can be used in appropriate situations to provide
to be stronger and provides more efficient hemostasis then hemostasis after ligature failure [28, 29]. If there is
multifilament suture [30]. Monofilament suture is also hematoma formation then treatment options differ
advised for laparoscopic ligating loops because the shape depending on the degree and location. With mild
of the loop is usually maintained reasonably well by the hemorrhage and hematoma formation no treatment
increased stiffness [28, 29]. Ligature loops should be tied may be needed. For more significant hemorrhaging and
table-side rather than pre-tied and sterilized because steri- hematoma formation there are multiple treatment
lization can weaken the suture material and predispose to options. If there is active hemorrhaging then the incision
ligation failure [28]. A 4-S modified Roeder knot using may need to be opened and hemostasis achieved via
monofilament suture is recommended for maximal liga- intraoperative methods discussed. Alternatively,
ture loop strength [28]. compression or a compression bandage can be an
The performance of the single knot loop has been effective means of hemostasis and prevention of
shown to be biomechanically superior to a double knot hematoma formation.
loop in tensile breaking strength because with the single
knot loop the forces are equally divided over the whole Expected Outcome The prognosis is dependent on the
ligature, whereas with a double knot loop the two loops degree of hemorrhage but incisional vessel ligation
of the ligature will have different tensions after every failure usually has a good outcome once time has been
knot [27]. A transfixation ligature can be performed to allowed for the hematoma to resolve. However,
prevent slippage of the ligature; however, postoperative hematoma formation can increase morbidity to the
bleeding may still occur due to ligature failure of one of patient, prolong wound healing time, and can increase
the double knot loops [27]. Sliding knots have been treatment costs. Also, even mild hemorrhages can have
shown to be quicker and behave similar to or better than an impact on the safety and efficiency of a given
a surgeon’s knot in establishing hemostasis of procedure, as well as effect outcome, depending on the
arteries [30]. situation [28].
References
1 Mackenzie, D. (1973). The history of sutures. Med. Hist. for 14 and 28 days in phosphate buffered saline and
17 (2): 158–168. inflamed equine peritoneal fluid. Vet. Surg. 44 (6): 723–730.
2 Kümmerle, J.M. (2012). Suture materials and patterns. In: 18 Schroeder, D., Gillanders, L., Mahr, K. et al. (1991).
Equine Surgery, 4e (ed. J.A. Auer and J.A. Stick), 181–202. Effects of immediate postoperative enteral nutrition on
St. Louis, Elsevier. body composition, muscle function, and wound healing.
3 Céleste, C. (2008). Selection of suture materials, suture J. Paren. Ent. Nutr. 15 (4): 376–383.
patterns, and drains for wound closure. In: Equine 19 Haubner, F., Ohmann, E., Pohl, F. et al. (2012). Wound
Wound Management, 2e (ed. T.S. Stashak and C.L. healing after radiation therapy: review of the literature.
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4 Katz, S., Izhar, M., and Mirelman, D. (1981). Bacterial
20 Théon, A.P. and Pascoe, J.R. (1994). Iridium-192
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treatment results and prognostic factors in 115 horses.
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management and dermatologic surgery. Vet. Clin. N. Am. chemotherapy with cisplatin for cutaneous tumors in
Equine Pract. 24 (3): 66–696. equids: 573 cases (1995–2004). J. Am. Vet. Med. Assoc. 230
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79
10
Complicationsof BoneGraftHarvesting,Handling,and Implantation

Lynn Pezzanite DVM, MS DACVS1 and Laurie R. Goodrich DVM, PhD, DACVS2
1
Department of Clinical Sciences and Translational Medicine Institute, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO
2
Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
Overview pletely; 2) creeping substitution of cancellous bone involves

an appositional bone formation phase followed by a resorp-
Bone grafts are most frequently used in equine surgery to tive phase; and 3) cancellous grafts repair completely with
facilitate healing following long bone fracture, arthrodesis, time, while cortical grafts remain admixtures of necrotic
and comminuted phalangeal fractures [1]. Autogenous and viable bone [6]. All grafts are eventually replaced with
cancellous bone grafts are the most frequently used type of host tissue by a process called creeping substitution, which
graft in the equine patient [1, 2, 3]. Bone grafts may be cat- is defined as remodeling by osteoclastic resorption and
egorized according to their origin and location. Grafts may creation of new vascular channels with osteoblastic bone
be harvested and applied to a different site in the same formation [4, 5, 7].
individual (autograft), to a genetically different individual The successful integration of a bone graft depends on the
of the same species (allograft), or to a member of a different interaction of six factors: 1) host bed; 2) viability of the
species (xenograft). Grafts may be applied to an anatomi- bone graft; 3) volume of bone to be grafted; 4) growth factor
cally similar location (orthotopic) or different implantation activity of the host be; 5) metabolic activity index; and (6)
site (heterotopic). homostructural function of the bone graft [1, 8, 9]. The
In general, bone grafts serve the function of osteocon- condition of the host bed in terms of local blood flow, sta-
duction or osteoinduction, depending on the type of bility and bone marrow activity determines acceptance of
graft [1, 4]. Osteoconduction refers to the matrix of the the graft. Cancellous and vascularized corticocancellous
graft acting as a scaffold into which mesenchymal cells bone grafts are more viable and have greater rates of accept-
grow. Osteoinduction refers to a process through which ance in comparison to grafts with reduced vascularity.
signals are sent to influence new bone formation (osteo- Larger volumes of bone graft take longer to be incorporated
genesis) as a result of differentiation of mesenchymal into host tissue, and therefore have a greater likelihood for
cells or recruitment of viable osteoblasts and osteocytes development of complications such as nonunions or
on the surface of the bone graft. Bone morphogenetic fatigue failure. Proliferation of perivascular connective tis-
proteins (BMPs) are molecules found within bone mar- sue in the host bed, which facilitates osteogenesis, is
row and are responsible for signaling the differentiation induced by growth factor activity. The metabolic activity
of mesenchymal cells into cartilage and bone [5]. Their index (MAI) is correlated to the capacity of the host bed to
presence is thought to play an important role in this incorporate bone grafts and repair fractures. The MAI is
process. determined by heart rate, blood flow, metabolic rate, res-
Grafts may be composed of entirely cancellous or corti- piratory rate and body temperature. The MAI of horses has
cal bone, or a combination of both types. Cancellous bone not been determined, but is extrapolated from other spe-
grafts have been shown to have osteogenic, osteoinductive, cies [9]. The homostructural or support function of the
and osteoconductive properties [1, 5, 6]. Cancellous and bone graft influences incorporation of the bone graft.
cortical autografts differ histologically in three respects: 1) Complete incorporation of the graft into host tissue may
cancellous grafts revascularize more rapidly and com- take years [9].
80 Complications of one raft arvestingn, andlingn, and Implantation
L
with BoneGrafts
● Intraoperative Complications
● Reduced viability of graft
● Early Postoperative Complications
● Morbidity associated with incision at donor site
● Fracture at donor site
● Pneumothorax/hemothorax
● Late Postoperative Complications
● Suboptimal integration of bone graft
IntraoperativeComplications
ReducedViabilityof the Graft
Definition Reduced viability of the graft, defined as death

of cells within the graft itself, affects integration of the graft
into the host bed.
Figure10.1 Loosely arranged cancellous bone graft in

Risk Factors
blood-soaked sponge following collection from tuber coxae.
● Suboptimal handling of the graft
● Prolonged time between harvesting and implantation of The bone graft material should be lightly packed into the
the graft recipient site to allow for appropriate oxygenation of the
● Lack of a second surgical team to harvest the graft graft and to reduce mechanical damage to the cells [1, 10].
Osteogenesis occurs as a result of the activity of viable oste-
Pathogenesis Reduced viability of the graft results from a oblasts on the surface of the bone graft. Loosely arranged
combination of prolonged time between harvesting and bone grafts are more desirable due to the greater surface
implantation of the graft, dehydration or compaction of the area created, with more living cells available resulting in
graft, or exposure of the graft to air, saline-soaked sponges, greater osteogenic activity. Avoiding dehydration and com-
or antibiotics prior to implantation. Reduced cell survival paction of the bone graft results in a greater number of sur-
is attributed to a combination of mechanical damage, viving cells and improved viability of the graft [8].
desiccation, or osmotic challenge, depending upon the
circumstances [10, 11]. Diagnosis Reduced viability of the bone graft may
contribute to lack of incorporation of the graft into host
Prevention Cell survival may be maximized by several tissue, resulting in prolonged fracture repair or increased
techniques during harvesting and implantation. A separate rate of fracture repair failure. However, lack of viability of
surgical team in addition to the surgeons repairing the the graft itself may not be apparent unless infection of the
fracture is advantageous, in order to harvest the cancellous recipient site occurs or fracture repair failure occurs
bone graft while the surgical procedure is begun to reduce postoperatively as a result of implant fatigue. Diagnostic
lag time between harvesting and implantation. imaging (e.g. radiography, ultrasonography or CT) may be
It is recommended to have blood-soaked sponges ready utilized to recognize infection or fracture repair failure
to store the harvested bone or marrow following collection earlier if indicated based upon clinical signs.
and prior to implantation (Figure 10.1). Blood may be
obtained via intravenous catheter from the jugular or Monitoring
cephalic vein. Exposure of graft tissue to air, coverage with Monitoring for host acceptance of the graft involves moni-
saline-soaked sponges, or exposure of the graft tissues to toring for morbidity at the recipient site (e.g. infection) as
antibiotics during harvesting should be avoided. Aseptic well as clinical and radiographic evidence of bone healing.
technique during implantation is essential for successful Radiographic signs consistent with infection or lack of
incorporation of the graft. incorporation of the graft include evidence of malunion of
Early Postoperative Complications 81
the fracture site or lucency around the implants. Complete Utilization of the sternum as a graft donor site is associ-
integration of the bone graft into host tissue may take ated with minor complications, including peri-incisional
years [9]. Autogenous cancellous bone grafting enhances edema, serum exudate, and wound dehiscence due to the
and stimulates bone healing, and utilization of bone grafts ventral location and tension [16].
in long bone fracture repair should decrease fracture heal- Incisional dehiscence, which may result in osteomyelitis,
ing time and fracture repair failure as a result of implant is reported, particularly when the sternum and proximal
fatigue. tibia are used as donor sites due to tension and
location [13].
Treatment
Treatment following reduced viability of a bone graft is Prevention Location of the donor site is selected based
typically not necessary unless infection of the recipient upon the location of the surgical site and therefore
site occurs due to lack of adherence to aseptic technique. anesthetic recumbency selected, which dictates
Aggressive treatment of infection of the graft bed or frac- intraoperative access to the site and amount of graft
ture site is recommended, typically with a combination of material required. While multiple donor sites may supply
local and systemic antibiotic therapy. In addition, revi- an adequate quantity of bone graft material, each donor
sion of the fracture repair and local lavage may be site carries its own risks and benefits in terms of early
performed. postoperative sequellae. Donor site selection is made after
taking into account the known risks associated with each
Expectedoutcome
site as well as case specific factors such as location of the
Lack of incorporation of the bone graft may contribute to
lesion, soft tissue trauma or presence of decubital ulcers.
prolonged fracture repair as well as infection of the recipi-
Whenever possible, avoiding sites at greatest risk of
ent site if aseptic technique is not followed appropriately.
complication is recommended (Table 10.1).
In the event of persistent infection, removal of orthopedic
Adherence to aseptic technique is advised to reduce mor-
implants may be necessary following fracture repair and
bidity associated with the bone graft donor site incision. The
bone healing.
sternum and tibia have also been reported to be more prone
to dehiscence due to tension in these areas during anesthetic
recovery, and so avoidance of these sites as donor sites for
EarlyPostoperativeComplications
bone graft harvest may reduce incisional site complications.
MorbidityAssociatedwith IncisionatDonorSite
Diagnosis Incisional infection, seroma, or edema is
Definition The most common complications associated
diagnosed by clinical examination with evidence of
with the incision for bone graft harvest include incisional
drainage or swelling at the incision site.
infection, seroma, and drainage with peri-incisional
edema [3, 12–13]. Incisional dehiscence may result in Monitoring Monitor the graft donor incision site for
osteomyelitis, particularly when the sternum and proximal increased drainage, swelling or dehiscence that may
tibia are used as donor sites [13]. indicate seroma formation or infection. Complete
integration of the bone graft into host tissue may take
Risk factors Harvest site location years [9]. Autogenous cancellous bone grafting enhances
and stimulates bone healing, and utilization of bone grafts
Pathogenesis Case selection in the bone graft harvest site
in long bone fracture repair should decrease fracture repair
is important in minimizing complications. Several donor
failure as a result of implant fatigue.
sites for cancellous bone grafts in the horse have been
described, principally the tuber coxae, sternum, rib, Treatment Incisional infection or seroma at the donor site
proximal medial aspect of the tibia, and proximal humerus, may be treated successfully with facilitated drainage of the
each with its advantages and disadvantages, which are incision site and antimicrobial therapy.
summarized in Table 10.1 [3, 12, 14–17]. Similar amounts
of cancellous bone may be obtained from the sternum, Expected outcome Incisional complications, such as
tuber coxae, tibia and humerus, while the rib yields smaller incisional infection, seroma, and drainage with peri-
quantities in comparison [2, 17]. incisional edema or superficial incisional infection, are
Case-specific factors dictate intraoperative access to the usually self-limited and carry a good prognosis [3, 12, 13].
donor site, amount of graft material required, as well as Osteomyelitis is a more serious condition but usually
other case-specific factors including pre-existing soft tissue responds well to local debridement and antimicrobial
trauma or decubital ulcers [12, 16, 17]. therapy.
Table10.1 Summary of bone graft donor sites
DonorSite Advantages Disadvantages
Tuber coxae [2, 23, 17] ● Provide ample grafting material ● Time-consuming
● Good visualization for surgical approach ● Requires patient in lateral recumbency
● Low rate of postoperative incisional complications ● Decubital ulcers or soft tissue trauma over
● Remains the most commonly used donor site the tuber coxae may preclude its use
Sternum [16, 21, 37, 38, 39] ● Use in cases where patient in dorsal recumbency ● Risk of puncturing thoracic or pericardial
● Reduces risk of pathological fracture associated cavities exists
with harvesting from the tibia and humerus
● Absence of skin tension and dependency of this
location facilitates drainage if incisional infection
or dehiscence occur
● Cancellous bone obtained is equivalent in amount
and microscopic appearance to that obtained from
other sites such as the tuber coxae, proximal tibia,
and rib
● No instability or fractures of the sternum have been
reported, even when more than one sternebra is
accessed in order to obtain the desired amount of
cancellous bone
Tibia [12, 19] ● May be accessed with patient in dorsal or lateral ● Risk of pathologic fracture on anesthetic
recumbency recovery has been recognized
● Useful in cases where smaller amounts of graft
material (<50 ml) are required, such as in
arthrodeses, bone cysts or acute fractures
Humerus [3] ● Greater soft tissue coverage and muscular support ● Catastrophic fracture during recovery from
may reduce potential for incisional complications anesthesia
and help to dissipate torsional forces exerted on the ● Mild to moderate incisional swelling and
bone during recovery from general anesthesia edema
Rib [25] ● Bone obtained from transcortical rib biopsies was ● Pneumothorax or hemothorax
reported to be superior in quality to unicortical
biopsies in terms of histomorphometry
Fourth coccygeal vertebra [15] ● Provides large quantity of cancellous bone ● Use of this site requires tail amputation
● Accessible with the patient in dorsal or lateral
recumbency
Periosteum [15] ● Transplantation of periosteum as a source of ● Periosteum as an alternative donor source
osteoprogenitor cells may enhance bone healing as in bone grafting warrants further
donor tissue with good osteogenic properties investigation in vivo in the equine patient.
● Equine tibial periosteum was examined in vitro for
its osteogenic and osteoprogenitor characteristics
● Use of autogenous tibial periosteum in human
cartilage repair techniques reportedly did not result
in morbidity associated with donor site
FractureatDonorSite Pathogenesis Fracture of the humerus or tibia following

bone graft harvest is attributed to inappropriate torsional
Definition Catastrophic fracture during anesthetic
forces exerted on the bone during recovery from general
recovery has been reported when the graft is obtained from
anesthesia [3].
the tibia or humerus [3, 12, 18, 19].
Prevention The risk of pathologic fracture of the tibia on
Risk factors Utilization of the humerus or tibia as graft
anesthetic recovery has been recognized [19], and may be
donor sites [3, 12, 18, 19]
minimized with careful drill placement upon entering the
● Young horses are more at risk for tibial fracture [2] medullary cavity [12]. It has been suggested to use an
alternative donor site to the tibia, particularly in immature Pathogenesis Inadvertent puncture of the thoracic or
horses [2]. However, Boero et al. demonstrated that an pericardial cavities during bone marrow graft harvest from
approximately 1 cm diameter hole could be made in the the sternum or rib may result in hemothorax or
proximal medial aspect of the tibia at a point midway pneumothorax, leading to pulmonary collapse or
between the distal end of the groove for the middle patellar catastrophic cardiovascular event.
ligament and the caudal border of the bone from horses
weighing 350 to 450 kg [12]. Two adjacent 4.5-mm holes Prevention Examination upon necropsy has revealed that
were drilled, and the holes were joined and enlarged to the sternum of the equine patient contains between six and
approximately 1 cm in diameter to accommodate an 8.0- eight sternebrae. The preferred biopsy sites are the fourth
mm bone curette. This technique allowed for up to 55 ml of or fifth sternebrae of adult horses [21]. It is recommended
cancellous bone to be removed from the tibia without to use the more caudal sternebrae for several reasons [16].
significant decrease in the strength of the tibia, without The caudal sternebrae are covered by less muscle and
altering torsional load capacity, or increasing risk of have a thinner cartilaginous covering, are closer together,
pathological fracture [12]. and contain more cancellous bone per sternebra in com-
It is not recommended to utilize the humerus as a graft parison with the more cranial sternebrae. Familiarization
donor site due to concern that a defect of this size may cre- with the anatomy of this region is essential if sternum and
ate a stress riser resulting in catastrophic fracture of the ribs are to be used as donor sites for bone graft harvest.
humerus, which occurred in 1 out of 8 cases where a Utilization of a different donor site may result in less mor-
12-mm cortical defect was created using a drill in the lat- bidity to the patient.
eral proximal humerus [3].
Instability or pathologic fractures have not been reported Diagnosis Clinical signs result from damage to thoracic
following bone graft harvest from the tuber coxae or ster- structures, which may include pneumothorax, hemothorax,
num, and these donor sites may be used preferentially. as well as injury to the lungs, heart, or blood vessels, with
resultant respiratory distress. Clinical signs of
Diagnosis Catastrophic fracture of the humerus and tibia
pneumothorax include dyspnea, tachypnea, increased
secondary to bone graft harvest from these sites would
respiratory effort and cyanotic mucous membranes [22].
typically be apparent following anesthetic recovery from
Clinical signs of hemothorax are referable to hypovolemic
general anesthesia with significant lameness of the affected
shock, and include tachycardia, tachypnea, weak arterial
limb. Radiographic evaluation would confirm diagnosis of
pulses, pale mucous membranes, cold extremities,
catastrophic fracture of humerus or tibia following bone
respiratory distress, trembling, weakness, and sweating.
graft harvest.
Auscultation and percussion of the chest wall allow the
Monitoring Monitor for catastrophic breakdown or clinician to distinguish pneumothorax from hemothorax.
significant lameness of the affected limb following In patients with pneumothorax, lung sounds are absent
anesthetic recovery if the humerus or tibia were elected as with increased resonance percussed dorsally, while reduced
donor sites. Radiographic or ultrasonic evaluation would lung sounds ventrally and percussion of a fluid line are
confirm diagnosis of fracture. typical of hemothorax [22]. Thoracic radiography and
ultrasonography may aid in confirmation of pleural cavity
Treatment Pathological fracture of the humerus and tibia involvement.
following bone graft harvest would typically necessitate
euthanasia, depending on the age of the patient and Monitoring Diagnosis is made by clinical signs described
fracture configuration. and initial efforts are directed toward stabilization of the
Expected Outcome Euthanasia patient. Arterial blood gas sample may be performed and
analyzed to assess ventilation and gas exchange to dictate
Pneumothorax/Hemothorax further treatment. Shock may result in cases with
significant blood loss or respiratory compromise.
Definition Pneumothorax and hemothorax has been
reported when the sternum and ribs are used as donor
Treatment Emergency treatment of pneumothorax
sites [20].
focuses on stabilization of the patient by closure of thoracic
Risk factors Selection of rib or sternum as donor site for wounds and immediate removal of pleural air [22].
bone graft
● The wound is closed to reduce the severity of the pneu-
● Lack of familiarity with anatomy of region of donor site mothorax and the chest is sealed temporarily.
● Pleural air is removed by inserting a sterile teat cannula, and/or breach of aseptic technique) will have a negative
14-gauge catheter or thoracostomy tube into the dorsal effect on graft cell viability. Selection of the bone graft
aspect of the thorax at the 11th to 15th intercostal space. harvest site is chosen based upon quantity of graft material
Air is slowly removed using an extension set, three-way required, intraoperative access to donor site, and desire to
stopcock and 60-ml syringe. A one-way valve is attached minimize postoperative morbidity.
to allow continuous exiting flow of air upon initial Autogenous cancellous bone graft is used most com-
removal of pleural air and fluid. monly in the equine patient but graft rejection resulting in
● Oxygen supplementation is indicated in most cases of nonunion, fatigue fracture and implant failure has been
respiratory distress resulting from pneumothorax or reported [6], and rejection will be more likely with use of
hemothorax. Oxygen supplementation may be provided allo- or xenografts.
via nasal O2 insufflation at a flow rate of 15 L/min in The slow rate of fracture healing in the adult horse con-
adult horses [22]. tributes to poor overall survival rates for adult equine frac-
● Intra-tracheal oxygen administration increases the fracture patients. Adult horses often require 4 to 6 months or
tion of inspired oxygen and may help to speed the absorp- longer for complete fracture healing, in comparison to
tion of air from the pleural cavity in cases of canine patients, which may heal in 2 to 4 months [15, 23,
pneumothorax. 24]. See Chapter 46: Complications of Orthopedic Surgery,
● Emergency treatment of hemothorax focuses on restor- for further details. Instability at the fracture site as well as
ing intravascular fluid volume, cardiac output, and tissue early postoperative complications such as incisional infec-
perfusion. tion, dehiscence or osteomyelitis [3, 12, 13, 18, 25] will
● Draining blood from the pleural cavity may be indicated have a negative effect on graft survival.
to improve ventilation and perfusion matching and Utilization of bone grafts in long bone fracture repair
decrease intrapulmonary shunting of blood if the horse should contribute to decrease fracture-repair failure as a
demonstrates signs of respiratory distress. However, result of implant fatigue, improving prognosis for equine
leaving blood in the chest may actually inhibit bleeding, fracture patients. While autogenous cancellous bone graft-
and some of the red blood cells may autotransfuse [22]. ing enhances and stimulates bone healing, fatigue failure
of implants during the healing process continues to be a
Expected outcome Puncture of the thoracic or pericardial major postoperative complication in equine long bone frac-
cavity may result in pulmonary collapse or catastrophic ture repair [26, 28]. The osteogenic potential of equine
cardiovascular event. Euthanasia may be necessary if autogenous cancellous bone graft from various donor sites
emergency medical intervention is not sufficient to stabilize including tuber coxae, sternum, proximal tibial metaphy-
the patient. sis, and fourth coccygeal vertebrae has been investi-
gated [15]. During the early stages of bone healing, new
LatePostoperativeComplications bone formation at the fracture site may result from viable
graft cells or cells from the environment surrounding the
SuboptimalIntegrationof BoneGraft graft [6, 28, 29]. Therefore, transplantation of viable osteo-
genic cells in bone graft or donor tissue is critical to early
DefinitionPartial or total failure of the graft to survive and
bone healing [10, 28, 30, 31]. When the host environment is
to achieve osteogenesis, osteoinduction and/or
traumatized, as with most adult equine fractures, new
osteoconduction at the recipient site
bone formation is a product of osteogenic cells from the
graft bone that remain viable following
Risk factors
transplantation [29].
● Suboptimal handling of the graft
● Donor site selection Prevention Optimizing transplantation of tissue from a
● Use of allografts or xenogafts donor site to yield a greater number of viable osteogenic
● Instability at recipient site cells should lead to greater new bone formation [15].
● Morbidity at the recipient site Results of comparison of osteogenic potential of donor
● Fatigue failure of implants during healing in equine long sites revealed that the tuber coxae most consistently yielded
bone fracture repair viable osteogenic cells with an acceptable percentage of
osteoprogenitor cells, while the sternum and tibia were less
Pathogenesis Suboptimal handling techniques of the graft reliable in providing osteogenic cells [15]. Two additional
during harvest and implantation (prolonged harvest- donor sites have been examined; the fourth coccygeal
implantation time, exposure to air, saline, and antibiotics, vertebra and the tibial periosteum, were tissues with good
References 85
osteogenic potential, and may be considered when the Diagnosis Graft rejection may be recognized clinically as a
tuber coxae is not accessible or does not provide an non-union fracture, slow-healing fracture or fatigue
adequate amount quantity of cancellous bone. fracture. Histologically, evidence of an inflammatory
Autografts have greater osteogenic capacity in compari- process with callus bridging may be apparent.
son to either allograft or xenograft, and are the most com-
monly used type of bone graft in equine surgery [1, 32–34]. Monitoring Monitoring of graft acceptance in the recipient
The use of allografts would eliminate the need for a second site may be monitored indirectly with radiographic and
surgery to harvest the graft, thereby reducing morbidity clinical signs indicative of fracture healing. Adult horses
postoperatively. However, allogeneic bone demonstrates may require 4 to 6 months for complete fracture healing.
lower osteogenic capacity and therefore slower new bone
formation and may be subject to rejection by the recipient Treatment In cases where non-union fracture or graft
immune system. Bone allografts are subject to the same rejection result in prolonged fracture healing, further
immunologic factors as other tissue grafts [6]. The rejec- surgical intervention may be indicated, depending upon
tion of bone allograft is considered to be a primarily cellu- the fracture configuration and intended use of the patient.
lar immune response, although the humoral component of
the immune system may play a role as well. Host response Expected outcome Suboptimal or failure of
is related to antigen concentration and total dose. Rejection osteoconduction, osteoinduction, and osteogenesis
of bone allograft is observed clinically and histologically as processes induced by the graft will lead to instability and
an inflammatory process with callus bridging, nonunions, prolonged fracture healing. Graft rejection resulting in
and fatigue fractures [6]. The use of allogeneic bone has nonunion, fatigue fracture and implant failure has been
declined in human medicine due to concern over the pos- reported [6].The consequences will depend upon the
sibility of viral contamination of graft material and possi- location and condition that was being treated; unstable
ble transmission of disease to graft recipients [35]. long bone fractures will have a poor prognosis associated
Xenogenic bone is not generally considered useful as an with increased morbidity and mortality risk, while other
alternative to autogenous bone, as the antigenic response locations may be associated with prolonged healing and
elicited upon grafting results in failure of the graft in the site infection and/or suboptimal cosmetic outcome but
majority of cases [32]. Partial deproteination and defatting survival of the patient.
of xenograft have been shown to decrease the antigenic
response, but this process also removes the majority of
osteoinductive proteins [36].
References
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2 Bramlage, L.R. (1981). Autologous cancellous bone 8 Burchardt, H. (1989). Biology of cortical bone graft
grafting in the horse. Proc. Am. Assoc. Equine Pract. 27: incorporation. In: Bone Transplantation (ed. M. Aebi and
243–247. P. Regazzoni), 23. Berlin, Springer-Verlag.
3 Harriss, F.K., Galuppo, L.D., Decock, H.E.V. et al. (2004). 9 Urist, M.R. (1989). Introduction to update on allograft
Evaluation of a technique for collection of cancellous surgery. In: Bone Transplantation (ed. M. Aebi and P.
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Surg. 33: 293. 10 Bassett, C.A.L. (1972). Clinical implications of cell
4 Millis, D. and Martinez, S.A. (2003). Bone grafts. In: function in bone grafting. Clin. Orthop. Relat. Res. 87: 49.
Textbook of Small Animal Surgery, 3e (ed. D.H. Slatter), 11 Gray, J.C. and Elves, M.W. (1979). Early osteogenesis in
1875. Philadelphia: Saunders. compact bone isografts: a quantitative study of the
5 Marino, J.T. and Ziran, B.H. (2010). Use of solid and contributions of different graft cells. Calcif. Tissue Int. 29:
cancellous autologous bone graft for fractures and 225–237.
nonunions. Ortho. Clin. N. Am. 41: 15–26. 12 Boero, M.J., Schneider, J.E., Mosier, J.E. et al. (1989).
6 Burchardt, H. (1983). The biology of bone graft repair. Evaluation of the tibia as a source of autogenous
Clin. Orthop. 174: 28–42. cancellous bone in the horse. Vet. Surg. 18: 323.
13 Fackelman, G.E. and Auer, J.A. (2000). Bone graft biology 27 Nunamaker, D.M. (1996). Orthopedic implant failure. In:
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15 McDuffee, L.A. and Anderson. G.I. (2003). In vitro 29 Stevenson, S. (1999). Biology of bone grafts. Orthop. Clin.
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87
11
Complicationsof Cryosurgery
Ann Martens DVM, PhD, DECVS
Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
Overview The final result is coagulation necrosis which is charac-

terized by the formation of a necrotic eschar that gradually
The goal of cryosurgery is to destroy unwanted cells by detaches from the underlying granulation tissue starting
freezing, similar to the tissue injury that occurs in frostbite. from 7–10 days after cryosurgery. Complete sloughing
As the procedure does not involve a real “surgery,” a more takes approximately 2–4 weeks, but can also last up to 8
correct but less commonly used term would be weeks [13, 14]. The resulting wound heals by second inten-
cryoablation. tion. The final skin scar is often depigmented and partially
In equine medicine, cryosurgery was widespread in the hairless due to destruction of hair follicles and the highly
1980s and the technique was not only used for the treatment cold-sensitive melanocytes [4, 15, 16].
of tumors but also for cryoneurectomy and pain alleviation in The number of complications associated with cryosur-
a variety of orthopaedic diseases such as bone spavin, proxi- gery is rather limited as long as good cryosurgical equip-
mal suspensory desmitis and splint bone fractures [1, 2]. ment is available, the technique is applied correctly, and an
Nowadays, cryosurgery in horses is almost exclusively appropriate selection is made of lesions to which cryosur-
used for oncological applications, more specifically for the gery can be applied [15] (Table 11.1).
treatment of equine sarcoids and squamous cell carcino-
mas [3–7]. Non-oncological applications include the istof ComplicationsAssociated
L
destruction of the hair follicle in distichiasis [8] and the with Cryosurgery
management of patent urachus [9].
● Intraoperative complications
Cryosurgery can either be used as the sole treatment for
● Inadequate choice of cryosurgical equipment and
tumors, or as an adjunctive to surgical resection [4, 5]. Tissue
technique
injury arises from direct damage to the cell wall by intracel-
● “Run-off” of cryogen
lular ice-crystal formation during fast freezing followed by
● Early postoperative complications
recrystallization during the slow thawing phase [10], from
● Bleeding after cryosurgery
microcirculation failure after the thawing phase, [11] and
● Excessive local edema and pain
from post-thaw cell stress resulting in apoptosis [12].
● Excessive tissue necrosis
Maximal tissue destruction with freezing is obtained when 2
● Late postoperative complications
or 3 freeze–thaw cycles are performed [10].
● Tumor recurrence
Table11.1 Complications related to cryosurgery
Intraoperative Earlypostoperative Latepostoperative
Inadequate choice of cryosurgical equipment and Bleeding Recurrence of the lesion

technique
Run-off of cryogen Excessive edema
Excessive tissue necrosis
88 Complications of Cryosurgery
IntraoperativeComplications freezing and a “slow spontaneous” thawing. Tissue

temperatures of –30 to –40°C should be reached to ensure
InadequateChoiceof CryosurgicalEquipment tissue destruction and this should be monitored using
and Technique thermocouple needles (see Prevention below).
Definition Choice of a cryosurgical equipment and/or Prevention The choice of cryogen and cryosurgical
technique that do not allow sufficiently fast freezing of the equipment should be adequate for the size of lesion to
tumoral mass and may result in: ensure that the tumor can be frozen fast and sufficiently
● incomplete tumor destruction with local recurrence as a deep:
late postoperative complication ● Liquid nitrogen is the most powerfull cryogen (–196°C)
● excessive prolongation of the procedure for horses and is most commonly used in cryosurgery in horses.
treated under general anesthesia ● Hand-held instruments for gas-cooling with N2O are also
only suited to treat smaller lesions, even though the size

Risk Factors
of the tip can be adapted to the size of the lesion to be
● Thick tumors frozen.
● Tumors with a large base ● Copper probes or cotton tips immersed in liquid nitrogen
quickly warm up in contact with living tissue and do not

Pathogenesis Maximal tissue destruction is obtained by
allow deep freezing [13]. Their use is restricted to small
fast freezing and slow thawing. To ensure destruction of all and superficial lesions.
tumoral cells, the obtained tissue temperature should be ● Liquid nitrogen circulation probes should be large
low enough. The larger and thicker the tumoral mass is, enough to cover the entire lesion to assure a more or less
the longer it takes to obtain sufficiently low temperatures equal temperature distribution. In case the tumor base
in the entire lesion to ensure destruction. Although initial exceeds the size of the largest probe, cryosurgery should
experimental data suggested that a tissue temperature of be performed at multiple locations with an overlap of a
–20°C for 1 minute is adequate for tissue destruction [17], few millimeters. A contact gel assures good contact
other studies have shown that lower temperatures are often between the probe and lesion and the probe should stick
required to destroy tumor cells [18]. Biological susceptibility to the lesions once the freezing starts [13]. Air bubbles
to cryoablation varies according to the tumor type and between probe and tissue must be avoided as these have
moreover, not all cells within the tumor will be subjected to an insulating effect.
the same cooling and thawing temperatures and rates [19]. ● Spraying liquid nitrogen directly onto the tissue results
When a cold probe is applied to the tissue, a steep in much faster freezing compared to the use of probes
temperature gradient develops in the tissue. Whereas the held in contact with the tissue [13].
tissue close to the probe freezes very fast to very low ● Very fast freezing of larger lesions can also be obtained
temperatures, the tissue in the peripheral lesion cools by pouring the liquid nitrogen directly onto the lesion.
slowly and to a higher temperature, with a less destructive This requires the use of a cup to confine the liquid nitro-
effect. Therefore, the application of lower temperatures is gen to the lesion (see below).
advised. Recent studies in human medicine suggest that Besides a correct choice of cryogen and cryosurgical
exposure of cancer cells to low temperatures of –30°C to equipment, several measures can be taken to promote fast
–40°C for 1 minute using a double freeze-thaw protocol freezing and limit the duration of the procedure:
yields complete cell destruction [12, 18].
Although cryosurgery of superficial skin lesions can be ● Lesions that exceed the level of the surrounding tissues
performed under local analgesia in the standing sedated should be debulked. This decreases the tissue volume to
animal [13, 14], some locations (e.g. ventral abdomen, be frozen and helps achieving lower temperatures at a
inguinal region, ocular tumors, etc.), or tumor or patient high freezing speed [13, 14].
characteristics require general anaesthesia. When the cry- ● For lesions located close to vessels or in a well vascular-
oablation is seriously prolonged, there is a higher risk of ized area, the efficacy of freezing can be enhanced by the
anesthesia-related intra- and postoperative complications placement of a tourniquet (distal limbs) or a Chalazion
(hypoxia, myositis, nerve paralysis, etc.). clamp (eyelid) to temporarily slow down or stop the cir-
culation in the treated area [8, 16].
Diagnosis and monitoring Exact determination of the ● In cases of multiple tumors, time can be gained by freez-
correct speed of freezing and thawing is not possible and ing a second tumor during the slow thaw phase of a first
the surgeon should rely on achieving an “as fast as possible” tumor.
Intraoperative Complications 89
● Similarly, when a large tumor base needs to be frozen in Pathogenesis Application of cryogen by spray is less
consecutive areas, time can be gained by freezing a sec- precise than by probes and some technical experience is
ond zone during the slow thaw phase of a first zone. required to apply cryogen safely [21]. When the sprayed
● The slow thawing phase is the most time-consuming. liquid nitrogen comes into contact with the tissue, it
Nevertheless, it is not advised to speed up that phase of evaporates. However, when too much liquid nitrogen is
the cycle, for example by heating the probe or using a applied at any one time, it does not evaporate immediately
hair dryer. Indeed, the process of recrystallization result- and runs off the skin causing inadvertent frost lesions. This
ing in direct cellular damage mainly occurs during the complication is more likely to occur when treating large
slow thawing phase which is essential for cryosurgical lesions that require the application of more cryogen in
success. order to obtain rapid freezing of the entire lesion.
Finally, temperature should be monitored during the When liquid nitrogen is poured onto the tissues without
freezing process: a device to keep it in place, run-off is unavoidable.
The size and depth of the frostbite injury that occurs fol-
● Use thermocouple needles inside the lesion to make sure
lowing run-off depends on the amount that has been
–30 to –40°C is reached for 1 minute. In larger lesions,
spilled. However, full thickness skin lesions are unlikely to
multiple thermocouple needles should be placed and it is
occur.
more important to position them at the periphery of the
lesion compared to the center. Placement of the needle
Diagnosis Evident during the procedure as the cryogen
close to a blood vessel (heat source) can also influence
runs away from the desired area
the temperature measured [18].
● When thermocouple needles are not available or cannot
Prevention For spraying instruments, “cups” can be used
be placed safely, the tissue temperature should be esti-
to confine the cryogen to the lesion and prevent run-off.
mated as accurately as possible by:
The use of cups is essential when pouring liquid nitrogen
● Visual inspection of the formed ice-ball at the level of the
directly onto the lesion. Cups are commercially
cornea [5].
available [20] or can be custom-made from PVC-tubing or
● Inspection and palpation of the formed ice-ball at the
any other material (Figure 11.1). Different sizes should be
level of the skin [14]. Be aware that the outer edge of the
used, depending on the lesion to be treated. The use of a
palpable ice-ball only reaches a tissue temperature of
contact gel is advised to ensure that the entire cup fits well
0°C which is inadequate for cell destruction [20].
on the surrounding skin and sticks to the skin as soon as
● Ultrasonographic monitoring of the ice-ball. This is used
the liquid nitrogen is applied.
more commonly in human medicine (e.g. for cryother-
An alternative to the use of cups for spraying instru-
apy of the prostate and other internal organs). Frozen tis-
ments is to pack the surrounding area with vaseline-
sue has a hypoechoic appearance and the boundary
between frozen and unfrozen tissue shows as a white
hyperechoic rim (HER). At the border between the HER
and the hypoechoic frozen tissue, tissue temperature is
approximately –15°C. At the outer border of the HER,
tissue temperature is approximately 0°C [18].
Treatment If incomplete tumor destruction occurs,

treament of the postoperative recurrence may be required.
Expected Outcome Incomplete tumor destruction likely

results in recurrence postoperatively.
"Run-off "of Cryogen

Definition When the cryogen runs down from the site that
should be frozen
Figure11.1 A self-made PVC cup is used to confine the
Risk Factors sprayed liquid nitrogen to the lesion. Thermocouple needles
(arrowheads) are placed in the tissue to be frozen and the
● Use of a cryosurgical device that sprays liquid nitrogen underlying healthy tissue and a gel is used to ensure good
sealing between the cup and the surrounding healthy skin.
● Fast freezing by pouring liquid nitrogen onto the tissues Source: Ann Martens.
impregnated sponges or styrofoam to prevent run-off [16]. ● When treating lesions are resting directly over a large
This is more difficult compared to the use of cups as they superficial vein, the latter can be ligated proximally and
often do not seal perfectly to the surrounding normal tis- distally to prevent hemorrhage when the tissue
sue [14]. Open cell foams and gauze swabs should be sloughs [14].
avoided as they soak up the cryogen and become them- ● Contact probes should be allowed to detach spontane-
selves a cold sink producing damage which it was intended ously from the tissue during the thawing phase. Avulsion
to prevent [13]. of the probe can precipitate unnecessary bleeding
because of tissue tearing [1].
Treatment When run-off of cryogen is identified during ● A pressure bandage can be applied over the site for the
surgery, the frozen skin should be warmed up as quickly as first 24 hours to prevent hemorrhage [14].
possible (e.g. with a sponge soaked in warm water).
Rubbing is contraindicated as this worsens the skin
damage. Topical aloe vera cream or gel (antithromboxane) Treatment Management of postoperative bleeding consists
applied immediately after injury and in the follow-up in providing hemostasis, either by clamping and/or
period can help prevent local thrombosis and ischemia [22]. suturing the vessel or by applying a pressure bandage.
Expected outcome Most injuries are superficial and will Expected Outcome The prognosis is good because
heal uneventfully. In case of deep injury, hypo- or postoperative bleeding after cryosurgery is never
leukotrichia can result. life-threatening.
EarlyPostoperativeComplications ExcessiveLocalEdemaand Pain
BleedingafterCryosurgery
Definition The development of serious local swelling due
Definition Hemorrhage from the cryoablation site that is to excessive oedema formation at the site of cryosurgery
evident in the first 2–3 hours after surgery
Risk Factors
Risk Factors
● Tumoral masses with a (very) large base
● Tumors that require debulking to the level of the sur- ● Dependant antomical locations (ventral abdomen, chest,
rounding skin before freezing prepuce, etc.)
● Tumors from which a biopsy is taken prior to freezing
● Tumors located over a large superficial vein [14] Pathogenesis Local edema develops almost immediately
after thawing (Figures 11.2a, b) and results from the
Pathogenesis Limited bleeding after cryosurgery is normal vascular damage in the frozen tissue. It augments in the
in tumors that have been debulked or when a biopsy has next 24–48 hours with subsequent gradual resolution over
been taken, even if good hemostasis was obtaind prior to the following days (up to 1 week) [13]. This is more obvious
freezing. Bleeding results from vasodilation during the in dependant anatomical locations more prone to develop
thawing phase. It is commonly self-limiting, but can edema such as ventral abdomen, ventral chest, prepuce or
become objectionable to the owners [20]. distal limbs. Cryosurgery of limbal squamous cell
Excessive postoperative bleeding is a rare complication carcinomas also results in some corneal edema and corneo-
which could occur as a result of necrosis of the wall of an conjunctival inflammation [5]. This is considered to be
intact vessel that was frozen together with the tumor (e.g. normal.
saphenous vein for sarcoids on the inner aspect of the When treating very large tumors, the amount of tissue
thigh). The author has not experienced this complication necrosis after freezing can be very extensive, resulting in
yet, most likely because coagulation necrosis of the frozen excessive local swelling and associated pain. In some cases,
tissue also results in vessel thrombosis before rupture of local infections or lymfangitis may develop [13, 14].
the wall would occur. Ocular pain evident as blepharospasm and/or miosis has
been observed in 4 out of 10 horses treated with cryosur-
Diagnosis Obvious hemorrhage from the surgical site gery for limbal squamous cell carcinomas [5].
Prevention When tumors are debulked or a preoperative
biopsy is taken, care should be taken to achieve good Diagnosis and monitoring Obvious oedematous swelling at
hemostasis (e.g. using radiofrequency electrocoagulation). the site of cryosurgery
(a) (b)
Figure11.2 Equine sarcoid on the medial aspect of the right elbow of a horse before (a) and after (b) cryosurgery using a liquid
nitrogen circulation probe. The tumor has been debulked at the base and 1 freeze-thaw cycle has already been applied resulting in
pronounced edema, which will even increase after the second freeze-thaw cycle. This is not a complication but a normal biological
response after cryosurgery. Note the thermocouple needles inserted at the periphery of the lesion to ensure a sufficiently low
temperature. Source: Ann Martens.
Prevention Application of a compressive bandage accompanied by a yellowish exudate and a malodourous

immediately after cryosurgery will limit the development smell which disappears once all necrotic tissue has been
of oedema. This is recommended for cryosurgery of large fully rejected (Figure 11.3). This is a normal evolution after
masses at the level of the distal limbs but is technically cryosurgery. However, overly aggressive freezing results in
challenging or impossible at other locations (e.g. axilla, necrosis of too much healthy tissue and may damage vital
prepuce, inguinal region, chest, etc.). structures surrounding the tumor. This results in unwanted
tissue necrosis and sloughing of neighboring tissue, which
Treatment Excessive local swelling and pain can be is one of the most serious complications after cryosurgery.
managed by strong analgesic and anti-inflammatory
medication and the application of bandages at the distal
Prevention Tumors for which cryosurgery is feasible
limbs.
should be carefully selected by determining the risk of
Management of excessive ocular pain includes non-ste-
damaging important surrounding or underlying structures.
roidal anti-inflammatory medication and topical applica-
Thermocouple needles should be aplied into the tissues to
tion of 1% atropine [5].
be preserved around the lesion [13] and these tissues
Expected Outcome The oedema commonly resolves in 1 to
2 weeks.
ExcessiveTissueNecrosis
Definition Formation of too much tissue necrosis resulting
in undesired damage of underlying or surrounding tissue
and resulting in functional impairment
Risk Factors
● Cryosurgery without temperature control

● Tumors located over joints and tendons sheahs, or close
to the coronary band [14, 15]
● Cryosurgery of ocular lesions [14, 15]
Figure11.3 Sloughing of the cryonecrotic eschar 3 weeks after
cryosurgery of a sarcoid at the inner aspect of the right thigh,
Pathogenesis Necrosis and sloughing of the frozen tissue with the normal accompanying mucopurulent discharge. Source:
start from 7–10 days after cryosurgery and are commonly Ann Martens.
should not be cooled below 0 to –5°C. The risk of Treatment The necrotic tissue should be removed once it
inadvertent freezing of vessels at the edge of the lesion is is demarcated (2–4 weeks after cryosurgery) to support
relatively low as the circulating blood is a source of heat, second-intention wound healing. In the case of joint or
thus delaying the development of very low temperatures. sheath penetration, standard wound care should be
The use of cryosurgery has been discouraged for periocu- combined with repeated flushing of the synovial cavity and
lar sarcoids as they are commonly located on or very close the standard management of a septic synovitis [24].
to the eyelids, resulting in a high risk of excessive scarring However, the prognosis is very guarded because of the loss
of the eyelids and/or damage to the globe [23]. However, of synovial capsule as a result of tissue necrosis. When
cryosurgery for ocular squamous cell carcinoma’s can be globe perforation occurs as a result of cryosurgery,
performed safely if appropriate equipment and expertise enucleation is the only treatment option.
are available [5]. Over-freezing at that location is less likely
to occur with N2O (–89°C) compared to liquid Expected outcome Necrosis of the joint capsule can result
nitrogen [8]. in a penetrating intra-articular wound and subsequent
When using contact circulation probes for limbal squa- joint sepsis which can be extremely difficult to manage and
mous cell carcinomas, freezing occurs very fast and should may lead to the destruction of the horse [14, 16]. However,
be stopped when the frozen area exceeds 2–3 mm beyond even when the excessive slough of tissue does not result in
the visible tumor margins. Detachment of the probe is then joint penetration, extensive damage to the periarticular
needed to stop further cooling down of the tissues. This can tissues, fibrous reactions and osseous peri-articular new-
be achieved by applying 10–20 ml of saline solution at body bone formation may occur, resulting in functional
temperature to the eye [5]. Once the probe is detached, the impairment and/or osteoarthritis (Figure 11.4). Similarly,
tumor is further allowed to thaw slowly. necrosis of the tendon sheath wall can result in a
penetrating intrasynovial wound and sheath sepsis.
Diagnosis Diagnosis can commonly not be made within Cryosurgery of periocular sarcoids can result in loss of
the first days after cryosurgery and the presence of oedema the upper eyelid, unacceptable scarring of the eyelids, evis-
in the tissues to be preserved does not mean that they will ceration of the globe, and permanent loss of vision [14, 25].
become necrotic. It takes several days (at least 7–10) before Freezing of underlying nerves results in loss of nerve
demarcation of the necrotic tissue becomes evident and function, which can however be reversible. When periph-
before a correct diagnosis of the extent of undesired tissue eral nerves are frozen, the cellular components are
damage can be made. destroyed but the fibrous part of the epineurium remains
(a) (b)
Figure11.4 (a) Excessive tissue necrosis occurring at the dorsal aspect of the pastern 8 days after cryosurgery for an equine sarcoid.
The horse developed lymphangitis of the treated limbs in the first week after cryosurgery. On this picture, sloughing of a very large
portion of the skin of the dorsal pastern has started. The wound eventually healed after a skin grafting procedure performed 40 days
after the initial cryosurgery. Source: Ann Martens. (b) Lateromedial radiograph of the affected limb 7 months after cryosurgery.
Although no penetration of the pastern joint occurred, tissue necrosis resulted in the development of extensive peri-articular
new-bone formation and associated lameness. Source: Ann Martens.
Late Postoperative Complications 93
intact and will allow regeneration [13]. However, regenera- Pathogenesis Tumor recurrence occurs when the lesion
tion can also be incomplete [14]. has not been entirely and/or sufficiently frozen.
Freezing cortical bone causes cell destruction which To ensure destruction of all tumoral cells, the
reduces its strength. Spontaneous fractures have been obtained tissue temperature should be low enough
reported months after cryosurgery [15]. The author has over the entire volume of tumoral tissue (see
never experienced this complication, which might have Intraoperative Complication: Correct Cryosurgical
been more common at the time cryotherapy was still indi- Technique above).
cated for the treatment of bony disorders such as fractured Clinically, it has been shown that the risk of recurrence
splint bones [2]. of limbal squamous cell carcinomas after cryosurgery is
At locations with mainly underlying muscle, too exten- significantly influenced by the size of the initial tumor [5].
sive freezing mainly results in the sloughing of too large a However, in another study, no significant correlation
portion of the surrounding skin, subcutaneous tissue and between recurrence and tumor or patient characteristics
muscle, resulting in a large hole and a subsequent pro- was found [4].
longed healing by second intention (Figure 11.5).
Functional impairment is almost never an issue is these Diagnosis and monitoring Tumor regrowth usually takes
cases. several weeks to develop and initially it may be difficult
to differentiate new tumoral tissue from young irregular
granulation tissue in the cryosurgical wound healing by
LatePostoperativeComplications second intention. The definitive diagnosis of tumor
TumorRecurrence recurrence is made by histopathological analysis of a
tissue sample. For equine sarcoids treated by
Definition Regrowth of the tumor at the site that was
cryosurgery, diagnosis of recurrence is facilitated by
treated with cryosurgery
BPV-DNA analysis of a superficial swab of the suspected
Risk Factors tissue [26].
● Large tumors Prevention Correct choice of cryogen and cryosurgical

● Tumors with ill-delineated margins equipment to allow sufficient fast and deep freezing of the
● Size of initial tumor (squamous cell carcinoma) tumoral tissue (see above).
● Correct cryosurgical technique including the use of a
thermocouple needle to monitor tissue temperature
in and around the lesion (see above). To ensure freez-
ing of the entire tumor, an appropriate margin of vis-
ibly normal tissue should be included. In more than
70% of equine sarcoids, the surrounding normal skin
still contains BPV-DNA at 8 mm from the tumor bor-
der [27], making it advisable to include at least that
margin in the freezing process. For ocular squamous
cell carcinomas, a 2- to 3-mm margin has been
advised [5].
Treatment The cryosurgical procedure can be repeated

taking into account the above-mentioned preventive
measures. Several other tumor treatment modalities can be
applied, such as (laser) excision, chemotherapy, topical
treatments, and BCG vaccination.
Figure11.5 Very extensive slough of skin after cryosurgery of
an equine sarcoid at the level of the chest. The largest portion Expected outcome For equine sarcoids it should be kept
of the cryonecrotic eschar has already been excised and the in mind that recurrent tumors have been reported to have
formation of granulation tissue has started. At this location, this
is only a minor complication due to the absence of important
a lower response rate to further treatment modalities [4,
underlying structures. The wound will heal by second intention. 28], although this has not been confirmed in another
Source: Ann Martens. study [7].
References
1 Tate, L.P. and Evans, L.H. (1980). Cryoneurectomy in the 15 Fretz, P B. and Holmberg D.L. (1980). Sequelae to
horse. J. Am. Vet. Med. Assoc. 177: 423–426. cryosurgery. Vet. Clin. N. Am. Small Anim. Pract. 10:
2 McKibbin, L.S. and Paraschak, D.M. (1985). An 869–874.
investigation on the use of cryosurgery for treatment of 16 McConaghy, F.F., Davis, R.E., Reppas, G.P. et al. (1994).
bone spavin, splint and fractures splint bone injuries in Management of equine sarcoids: 1975–1993. N.Z. Vet. J.
Standardbred horses. Cryobiology. 22: 468–476. 42: 180–184.
3 Klein, W.R., Bras, G.E., Misdorp, W. et al. (1986). Equine
17 Cooper, I.S. (1964). Cryobiology as viewed by the surgeon.
sarcoid BCG immunotherapy compared to cryosurgery in
Cryobiology. 1: 44–51.
a prospective randomised trial. Canc. Immunol.
18 Baust J.G., Gage A.A., Bjerklund Johansen T.E. et al.
Immunother. 21: 133–140.
(2014). Mechanisms of cryoablation: clinical
4 Martens, A., De Moor, A., Vlaminck, L. et al. (2001).
consequences on malignant tumors. Cryobiology. 68:
Evaluation of excision, cryosurgery and local BCG
1–11.
vaccination for the treatment of equine sarcoids. 149:
665–669. 19 Baust, J.G. and Gage, A.A. (2005). The molecular basis of
5 Bosch, G. and Klein, W. (2005). Superficial keratectomy cryosurgery. B.J.U. Int. 95: 1187–1191.
and cryosurgery as therapy for limbal neoplasms in 13 20 Stick, J.A. (2012). Cryosurgery. In: Equine Surgery, 4e (ed.
horses. Vet. Ophthal. 8: 241–246. J.A. Auer and J.A. Stick), 161–165. Elsevier-Saunders.
6 Top, J.G.B., de Heer, N., Klein, W.R. et al. (2008). Penile 21 Featherstone, H.J., Renwick, P., Heinrich, C. et al. (2009).
and preputial squamous cell carcinoma in the horse: a Efficacy of lamellar resection, cryotherapy, and
retrospective study of treatment of 77 affected horses. adjunctive grafting for the treatment of caning limbal
Equine Vet. J. 40: 533–537. melanoma. Vet. Ophthal. 12 (Supp. 1): 65–72.
7 Haspeslagh, M., Vlaminck, L.E.M., and Martens, A.M. 22 Nizamoglu, M., Tan, A., Vickers, T. et al. (2016). Cold
(2016). Treatment of equine sarcoids in equids: 230 cases burn injuries in the UK: the 11-year experience of a
(2008–2013). J.A.V.M.A. 249: 311–318. tertiary burns centre. Burns Trauma. 4: 36.
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23 Marti, E., Lazary, S., Antczak, D.F. et al. (1993). Report of
nasolacrimal disease. In: Equine Ophthalmology, 2e (ed.
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Kryochirurgie versus Metakresolverödung. osseous infections. In: Equine Surgery, 4e (ed. J.A. Auer
Pferdeheilkunde. 24: 554–564. and K.A. Stick), 1190–1194. Elsevier-Saunders.
10 Gage, A.A. and Baust, J.G. (1998). Mechanisms of tissue 25 Knottenbelt, D.C. and Kelly, D.F. (2000). The diagnosis
injury in cryosurgery. Cryobiology. 37: 171–186. and treatment of periorbital sarcoid in the horse: 445
11 Hoffmann, N.E. and Bischof, J.C. (2002). The cryobiology cases from 1974 to 1999. Vet. Ophthal. 3: 169–191.
of cryosurgical injury. Urology. 60: 40–49. 26 Martens, A., De Moor, A., and Ducatelle, R. (2001). PCR
12 Robilotto, A.T., Baust, J.M., Van Buskirk, R.G. et al. detection of bovine papilloma virus DNA in superficial
(2013). Temperature-dependent activation of differential swabs and scrapins from equine sarcoids. Vet. J. 161:
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13 Lane, J.G. (1977). The treatment of equine sarcoids by (2001). PCR analysis of the surgical margins of equine
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95
12
Complicationsof LaserSurgery
Kenneth E. Sullins DVM, MS, DACVS
College of Veterinary Medicine, Midwestern University, Glendale, Arizona
Overview ● Gallium Aluminum Arsenide (GAA) Diode Laser

● Laser safety
LASER is an acronym for Light Amplification by Stimulated ● Specific complications of laser surgery in horses
Emission of Radiation. Excitation of a contained medium ● Patient Complications
(for which the laser is often named) produces coherent ● General surgery
electromagnetic radiation, light. A coherent beam remains ● Endoscopic Laser Surgery
intact almost indefinitely instead of diverging and can be ● Tarsal arthrodesis complications
manipulated by lenses. Lasers are typically monochro- ● Equipment Complications
matic (a single wavelength or “color”), which determines ● Summary
their specific tissue interaction [1].
Lasers expand surgical capabilities by facilitating mini-
mally invasive surgery and reaching areas that would oth- LaserPhysicsand TissueInteraction
erwise be completely inaccessible or by interacting with
tissue in ways impossible with conventional instruments. Surgical lasers produce a range of wavelengths (Figure 12.1)
Procedures previously requiring hospitalization, general with varying tissue interactions, the understanding of
anesthesia and prolonged convalescence may be accom- which is required to predict the laser’s effect upon tissue.
plished in an outpatient visit. However, lasers may not be Many surgical wavelengths are invisible. Interactions are
the most appropriate method for some procedures and the determined by the degree to which the tissue absorbs the
“fit” should not be forced. Surgical complications are mini- particular wavelength of laser energy (Figure 12.2). The
mized by a thorough understanding of anatomy, tissue more a tissue absorbs laser energy, the less it penetrates
response to injury, and surgical experience. Lasers add a into the tissue, thereby concentrating the surface effect.
substantial layer to each of these considerations. Mastering Whereas deeper penetration allows controlled coagulation
basic laser physics is required for safe and effective applica- (denaturation of protein) of a larger volume of tissue but
tion of surgical lasers. All too commonly, surgical lasers are may put associated deeper structures at risk of being
taken up as an experiment or “on the job” experience is injured. Complete lack of absorption of a wavelength by a
used to develop technique [2]. tissue allows complete passage affecting only a deeper
tissue. Interaction between laser light and a tissue that
preferentially absorbs that wavelength apart from sur-
rounding tissue, allowing selective coagulation/necrosis
L of that tissue, characterizes the principle of selective
with LaserSurgery photothermolysis [3–7].
The laser tissue effect is due to optical and thermal inter-
● Laser physics and tissue interaction actions [8]. Optical interaction is the result of true absorp-
● Lasers commonly used in veterinary surgery tion of electromagnetic energy and usually results in a
● Carbon Dioxide Laser thermal effect once absorbed by tissue. Depending upon
● Neodymium Yttrium Aluminum Garnet (Nd:YAG) Laser the amount, heat may “boil” the cytosol thereby vaporizing
96 Complications of aser Surgery
Electromagnetic Spectrum
(in nanometers)
Alexandrite Ho:YAG CO2

KTP GAA
Ruby Diode Er:YAG
Excimer Argon Dye Nd:YAG
Microwaves
577–630
190–390
488–514
10600
2940
1064
2100
x-rays TV and
532
694
755
980
cosmic rays radio
waves
UV VISIBLE
INFRARED
400 700
Figure12.1 Wavelengths of surgical lasers. Wavelengths in common veterinary use are in gray. The surgical lasers are generally not
in the visible range.
Light Absorption in Tissue

100,000
Ho:YAG 2,100 nm
10,000
Melanin
1,000
Absorption Coefficient
100 Hemoglobin Water

(per centimeter)
CO2 10,600 nm
10
1.0 Oxyhemoglobin
0.1 Nd:YAG 1064 nm

504 nm Dye
0.01 GAA Diode 980 nm
0.001
0.0001
0.2 1.0 3.0 10 20
Wavelength (Microns)
Figure12.2 Tissue absorption common surgical laser wavelengths. The visible spectrum is shown on the horizontal axis. The
near-infrared GAA Diode and Nd:YAG lasers are highly absorbed by dark pigment. However, note the increased absorption of the GAA
Diode laser on the water curve compared to the Nd:YAG laser. The Ho:YAG and CO2 lasers are both highly absorbed by water.
aser Physics and issue Interaction 97
the tissue into a smoke plume or simply denature tissue

proteins. When the optical interaction does not achieve the CO2 Laser @ 50 Watts
desired effect (e.g. Nd:YAG/GAA diode lasers on pale sur- 0.16 mm 2.0 mm 4.0 mm
faces), the irradiation is sometimes “artificially” converted
into heat by the delivery device before applying it to the
tissue, thereby causing the energy to be absorbed at the tip
of the fiber, producing heat and a profound surface effect
on the tissue while minimizing penetration to deeper
248,680 Watts/cm2 398 Watts/cm2
structures. Means to transform irradiation into heat include
blackening the tip of the bare quartz fiber or using a sap-
phire tip on a gas-cooled quartz fiber [2].
1,592 Watts/cm2
Lasers are rated by power, the rate at which they can
deliver energy. Power is expressed in watts (W) (1 W = 1
joule/second). Energy is measured in joules or calories (1 Figure12.4 Power density decreases with the square of the
joule = 0.24 calories). The total amount of energy delivered increase in spot size, which in turn increases with distance from
per unit area is fluence expressed in joules/cm2, which the surface. The beams depicted are all CO2 laser beams from
machines set to 50 W. The power densities shown below each
depends upon time of exposure as well as power density. demonstrate the profound reduction in tissue effect by
Power density (PD) (W/cm2) is a critically important value increasing spot size. Moving the handpiece away from the tissue
that expresses the amount of energy delivered per unit area increases spot size and decreases power density.
of tissue. Similar to water at a constant flow through a
hose, laser energy delivered through a wider aperture will
Delivering identical power density values over different
have a less profound effect than the same amount of laser
periods of time produces different results. If an acceptable
energy delivered through a narrower aperture (Figure 12.3).
full-thickness skin incision could be created with a 10-W
Power density is varied by adjusting the output of the laser,
laser beam delivered as a 0.4-mm spot size advanced along
by varying spot size of the laser beam on the tissue
the skin for 5 sec just penetrating the skin completely, dou-
(Figure 12.4), by changing the distance from the delivery
bling the rate of advancement (total time halved), the inci-
device to the tissue (Figure 12.5), or by changing the deliv-
sion would be shallower because the total laser energy
ery device. Power density varies with the square of the spot
(fluence) has been halved. Conversely, if the original time
size and is calculated by the following formula where s =
were doubled (advancement slowed), the depth of the inci-
spot size in mm, and W = power setting of the laser [2].
sion would increase beyond the skin and damaging collat-
2
PD W / cm 2 W/ 0.1s / 2 eral heating of adjacent skin would increase. Furthermore,
varying spot size or increasing distance from tissue dramat-
ically changes power density. Using a single power setting,
Power Density
FOCUS-Incisions
Vaporize@High Power
DEFOCUS-
Coagulate@Low Power
Figure12.3 Power density profoundly affects rate of tissue Figure12.5 CO2 laser handpiece with focusing lens. The stylus
effect and collateral heating of tissue. Both water hoses transmit indicates the point of maximum focus (power density) for
identical flows of water. The wider aperture of delivery in the incision. Slight increase of distance widens the spot size and
top image produces no mechanical effect on the flower, whereas tissue can still be vaporized. More distance from the tissue
the narrower aperture in the lower image produces a jet of further increases the spot size and reduces the effect on tissue
water that can disrupt the flower. Source: Kenneth E. Sullins. to coagulation.
the power density (tissue effect) can regress from focal inci- because it produces a zone of necrosis along the wound
sion/ablation (vaporization) to coagulation to negligible by margin. A small zone of necrosis has no effect on an open
simply moving the delivery device away from the tissue wound after resecting a mass, but it profoundly affects
surface. This is described further below under Carbon healing of a primarily sutured incision. Therefore, ade-
Dioxide Laser [2]. quate power density to incise quickly is critical to create a
The objectives of laser surgery fall broadly into three cat- precise incision with healthy adjacent tissue to achieve pri-
egories: incision/excision, ablation and coagulation of tis- mary wound healing [9]. Ablation also requires a relatively
sue. Which of these occurs depends upon power density high power density but laser energy is moved over a sur-
and absorption length of the laser, which in turn influence face to “paint” tissue away [2].
the rate of heat generation in tissue (Figure 12.6) [8]. With a small spot size, a single efficient pass across tissue
Incision/excision and ablation result in cell disruption and with adequate tension on the tissue, 5,000 W/cm2, is a min-
“vaporization” of tissue into smoke. Coagulation here imally sufficient power density to avoid collateral thermal
refers to denaturing of tissue proteins, which grossly necrosis (Figure 12.7) [10]. While learning, the tendency is
appears as blanching and tissue contraction [2]. to reduce the power setting and move tentatively or in mul-
Excision is simply incising or dissecting tissue, whereas tiple passes causing the laser to remain on the tissue longer
ablation refers to vaporization of tissue. An incision creates while increasing the width of the wound and collateral
tissue loss the width of the laser beam (usually 0.16 mm). heating. Incisions may dehisce due to thermal necrosis of
Highly concentrated laser energy (i.e. high-power density) the margins [11]. Experienced surgeons apply a signifi-
is required to efficiently cut tissue with minimal heating of cantly higher power density and work efficiently with a
surrounding tissue. Since laser energy has no mass (i.e. single pass of the laser (Table 12.1) [9]. A carbon dioxide
steel blade) to separate tissue, tension on tissue is abso- (CO2) laser in continuous mode at 50 W delivered with a
lutely required so the incised surfaces separate. Without 0.16-mm focused spot size yields a power density of 248,880
tension, excess heat will accumulate and the margins will W/cm2; a waveguide-delivered CO2 laser at 8 W through a
be jagged and eventually necrotic. Collateral heating of tis- 0.4-mm ceramic tip delivers approximately 6,300 W/cm2.
sue can be a substantial contribution to wound dehiscence, The former will produce an incision more efficiently, but
4
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Figure12.6 Absorption length of various wavelengths of surgical lasers in unpigmented skin. Wavelengths commonly used in
veterinary medicine are in dark gray; wavelengths (nm) are stated beside the names. The far-infrared Ho:YAG and CO2 lasers are highly
absorbed by water so penetrate minimally into skin, whereas the near-infrared Nd:YAG or GAA Diode lasers are absorbed more by the
darker pigments of the deeper layers [8].
aser Physics and issue Interaction 99
Reports of laser research should be examined closely to

LASER BEAM detect flawed methods [2]. Incisions created with the CO2
laser were reported to have reduced tensile strength upon
healing, with more necrosis and inflammation compared
to steel (scalpel) incisions, but the laser incisions were cre-
Smoke ated using a power density of 1,990 W/cm2 which resem-
plume
bles comparing a steel scalpel to a hobbyist’s wood burning
Laser set [11].
crater
Laser energy can be delivered to the tissue in a noncon-
tact or contact manner. As the term implies, with noncon-
Carbonization Area of tact delivery, nothing but the laser light touches the tissue,
thermal
thus imparting a purely optical interaction. Carbon dioxide
necrosis
Tissue laser energy is reflected by mirrors or down a highly pol-
ished waveguide and delivered in noncontact fashion.
Figure12.7 Range of tissue changes from laser beam. With Lasers delivered by quartz fibers (Nd:YAG and GAA diode
sufficient power density, a laser beam has a central area of
lasers) can deliver energy either way.
tissue vaporization/ablation shown by the crater in this drawing.
A layer of carbonization occurs when tissue that has been Laser energy is often delivered in continuous mode, i.e.
significantly heated cools to produce char. The area of thermal uniform throughout application of the energy to tissue;
necrosis is where tissue is heated beyond physiological limits some lasers have no other mode available. However, pulsed
and sloughs later. The goal of incisive surgery is to use adequate
modes tremendously increase efficiency and minimize col-
power density to create as little carbonization and thermal
necrosis as possible [10]. lateral heating of tissue. The principle is that spikes of laser
energy at 200 Hz increase power density substantially
should be moved quickly across the tissue to limit penetra- while the interruptions allow tissue to cool slightly, mini-
tion beyond the skin. The latter will produce an acceptable mizing diffusion of heat into adjacent tissues [12–14]. A
incision if tension is adequate to separate tissue and the CO2 laser in continuous mode at 50 W delivered with a
waveguide is passed once and quickly across the skin. The 0.16-mm focused spot size yields a power density of 248,880
skin defect will be 0.24 mm wider than the former with a W/cm2. In its pulsed mode, 400-W power spikes provide
perfect incision, which is clinically insignificant. intermittent power densities of 1,990,446 W/cm2 while
Table12.1 Common laser techniques and considerations [9].
Laser Description Capacity Accessories Preferenceforskinincision Comments
GAA Diode Quartz fiber 25–50 W 600 and 1,000 micron quartz 1,000 micron fiber sculpted 25 W is insufficient for
Laser delivery fibers down to approximately 600 noncontact vaporization
Handpiece to hold fibers micron at the tip 600 micron fiber too fragile
for general surgery. Excellent
for endoscopic surgery
Sterilize fibers for aseptic
procedures.
Nd:YAG Laser Quartz fiber 100 W Gas cooled Conical sapphire tip Gas cooled fiber excellent for
delivery noncontact ablation
CO2 Laser 125-mm focusing Minimum Computerized pattern 30–50 W pulsed mode. Sterilize handpiece and use
Articulated handpiece. 30 W scanner very useful for partial Better hemostasis in sterile sleeve for aseptic
Arm Delivery Minimum spot size thickness ablation of skin continuous mode if wound procedures
0.16 mm tumors or corneal tumors is to be left open
CO2 Laser 0.25–4.0mm (spot 15–40W Super pulse available No lens focus of laser beam.
Waveguide size) tips Power density varied with
Delivery distance, power setting or
changing diameter of tip
Laser Smoke Many brands Spare filters. Performance drops off
Evacuator available quickly when filter fills.
Sterilize hose for aseptic
procedures
producing identical total fluence (Figure 12.8). The tech- cornea or an ear. A computerized scanner considerably
nique depends upon the interval between laser exposure reduces this risk (see below) [2].
not exceeding the thermal relaxation time of the tissue, When 50 W of energy is administered through a 125-mm
which is the time required to cool 50% of the heat applied hand piece to focus through a lens to a 0.16-mm spot size,
without conducting heat to the surrounding tissue. By sup- the power density is 248,680 W/cm2, which incises skin
plying a second pulse before the tissue cools further, poten- with 0.1 mm of collateral tissue effect. The “incision” actu-
tial char is vaporized and tissue debris is evacuated as ally has removed tissue; the narrower the spot size, the
smoke or steam. This feature produces a cleaner skin inci- more natural the closure. Without changing settings, the
sion with less collateral thermal injury than from a con- hand piece can be retracted to defocus the laser beam to a
tinuous wave [15, 16]. The same principle applies to 2-mm spot (1,592 W/cm2) or a 4-mm spot (398 W/cm2),
ablating tissue/masses with a computerized scanner on a substantially changing the laser effect. The power density
CO2 laser. Pulsed mode should not be confused with simple changes with the square of the spot size (Figure 12.4). The
gaited mode, which simply turns the laser delivery off and surgeon must acquire the experience to achieve the spec-
on at specified intervals, which may be useful to prevent trum of incision, ablation or coagulation [2]. Hemostasis
overheating of the quartz fiber) [2]. during CO2 laser surgery is significant but less profound
than with lasers that penetrate tissue more deeply, even
though lack of penetration is one advantage of using this
asersCommonlyUsedin Veterinary
L laser. Hemorrhage from vessels 0.5 mm in diameter and
Surgery lymphatic drainage will largely be eliminated [17, 19];
larger vessels or visible lumens should be ligated [2].
CarbonDioxideLaser Carbon dioxide lasers transmit the energy by reflection
through mirrors in an articulating arm to a lens in the
The CO2 laser is the classic instrument of general sur- handpiece to focus the beam (Figure 12.9a). Some models
gery [9]. More CO2 lasers than any other wavelength are deliver the laser beam through a highly polished flexible
used in human or veterinary surgery [17]. With only opti- waveguide with a hand piece. Interchangeable tips instead
cal delivery, it has the convenience of having no fibers to of a lens determine spot size (Figure 12.9b). Carbon diox-
stock or maintain (Figure 12.9a). Tissue water absorbs the ide lasers are often equipped with pulsed modes (described
10,600 nm wavelength (far infrared (invisible) range) so above), making incisional surgery similar to that of a steel
completely that energy penetrates only 0.03 mm into tis- scalpel possible.
sue [17, 18]; however, persistent application will go deeper Some CO2 lasers can be fitted with semiflexible wave-
and deeper. The ability to precisely control the effect makes guides to access deeper surgical sites. Waveguides are actu-
the carbon dioxide laser safe for controlled application to ally tubes and are not as flexible as quartz fibers. Some
tissue overlying critical anatomic structures. Corneal squa- waveguides can be passed through the biopsy channel of
mous cell carcinoma can be ablated down to stroma with- some endoscopes, but they are fragile. Excessive bending
out a deeper effect. However, heat can be conducted into will reduce the laser energy or damage the waveguide lead-
normal tissue beyond the laser effect, which is of particular ing to a burn out; these should be kept relatively straight [2].
concern when applied to a thin structure such as the Computerized pattern scanners are accessories that
manipulate the focused (high-power density) laser beam
Pulsed across a preset scan size at a constant velocity to ablate tis-
Laser Continuous sue. Without a scanner, a slightly defocused beam is used
Laser
to create a manual crosshatch pattern to vaporize a surface
lesion, but char must be periodically scrubbed with a gauze
sponge to proceed. The manual technique is workable but
Laser generates more heat and is less uniform than with the
Power scanner (Figures 12.10 a–c). The difference between man-
(watts) ual delivery of a slightly defocused beam and computer
Time
scanning is that scanners deliver focused laser energy,
Figure12.8 Pulsed laser energy compared to continuous laser which ablates tissue completely. The beam moves away
energy. Pulsing higher power densities for short durations before collateral heating occurs and returns before the tis-
(vertical bars) produces a more efficient tissue effect with less
sue cools sufficiently for char to form; less heating of
collateral tissue heating compared to a continuous beam
(horizontal bar) emitting the same average power (fluence). The deeper tissue occurs. The surgeon must acquire the “feel”
tissue cools slightly between the pulses. of the scanner and keep it moving appropriately or it
asers Commonly Used in eterinary Surgery 101
(a) (b)
Figure12.9 (a) Typical higher-powered CO2 laser delivered through an articulated arm with a lens focusing handpiece. (b) Typical
CO2 laser delivered through a flexible waveguide and handpiece with variable aperture tips. Source: Courtesy of Aesculite, LLC,
Woodinville, WA 98072.
removes excessive tissue. The power settings should be discussion applies to both. Many Nd:YAG lasers have been
kept low until the proper technique is acquired. Since this replaced by the less expensive and more compact diode
is focused laser energy, reducing the power simply slows units. Nd:YAG lasers are generally sold with outputs up to
the rate of surgery and produces no detrimental effect [2]. 100 W, while diode lasers are most often in the 15–50 W
Equine general surgery holds many applications for the range. Higher power output is a reason why some continue
clean, efficient and safe CO2 laser [20–22]. Proper CO2 to use Nd:YAG lasers [2].
laser surgery produces much less thermal injury than elec- In their purely optical forms, these lasers are absorbed by
trosurgery [23], and tissue generally swells less than con- dark pigment such as melanin and hemoglobin and poorly
ventional surgery. Surgical dead space tends to fill less with absorbed by water (Figure 12.2). These wavelengths and
serum after laser dissection than with conventional surgi- any other delivered by quartz fiber can be used under
cal dissection [24]. However, surgical principles for closing water [9]. When the tissue is not obviously dark, the laser
dead space remain indicated [2, 9]. energy will convert to heat more slowly as it encounters
sufficient deeper pigment or protein, which may take sev-
eral seconds. That distance could be a few millimeters in
NeodymiumYttriumAluminumGarnet
pale skin or mucous membrane or longer in an eye if only
(Nd:YAG)and GalliumAluminumArsenide
cornea and clear aqueous or vitreous humor is encoun-
(GAA)DiodeLasers
tered. As tissue blackens, more laser energy is absorbed
The 1,064-nm Nd:YAG and 980-mn GAA diode laser wave- until black char accumulates and limits penetration. To
lengths behave almost identically in tissue, so the following continue, the char must be physically removed or time for
(a) (b) (c)
Figure12.10 (a) Preoperative image of large mixed sarcoid covering the scapular region of a horse. (b) Computerized scanner
attached to a CO2 laser performing a partial (skin) thickness ablation of the sarcoid shown in Figure 12.9a. The surface is even and
there is no char formation. The entire lesion will be treated. Leaving the dermis intact facilitates healing and minimizes chance of
recurrence. Topical fluorouracil was also used. (c) End result of lesion shown in Figures 14.9 a and b. Source: Kenneth E. Sullins.
tissue slough must be allowed [2]. All this occurs with con- stripped from the tip before use because it will burn. After
siderable potential tissue heat accumulation. stripping, the end is cleaved by scoring the quartz and frac-
Coagulation results in physical contraction of tissue, turing the fiber or cutting with scissors to yield a symmet-
which will slough during the ensuing several days if the ric circle from the aiming beam. A uniformly circular shape
protein has been denatured and the blood supply has been of the aimed beam indicates the coherence of the light
coagulated. Vascular stasis occurs when melanin-rich tis- emitting from the fiber, which is important for uniform
sues absorb the laser energy and conduct heat to the vascu- delivery of laser energy in a non-contact fashion. With nor-
lar endothelium where the coagulation cascade is activated. mal use, bare fibers gradually crystallize and burn out
In tissues with low melanin concentrations, hemostasis requiring cleaving back to a new area of the fiber, a con-
occurs when hemoglobin absorbs the laser energy and continuous process until they are too short to use. Bare quartz
ducts thermal energy to plasma protein [25, 26]. fibers are commonly available in diameters of 600–1,000
Deeply scattered laser energy can damage subsurface tis- microns [2].
sues such as nerves or vessels or coagulate darkly pig- Bare quartz fibers (Figure 12.11a) used in contact fash-
mented skin on the ear after passing through white ion and may be “sculpted” to a point to maximize the
cartilage of the pinna. Misdirected Nd:YAG laser energy in power density for incisive surgery. The sculpted tip burns
the pharynx can leave a horse dysphagic from damage to away rapidly leaving a fiber that is the same diameter as the
the pharyngeal branch of the vagus nerve, which lies deep entire fiber. The free beam (noncontact) effect of the fiber
to the dorsolateral pharyngeal wall. When deeper tissues returns when the tip wears out. Adequate power density
are at risk, a contact technique should be used with care for cutting is generally provided with a 600-micron fiber at
and the beam should be directed tangentially across the an output of 20 W. Larger diameter fibers require more
surface, and the integrity of the sculpted fiber or sapphire laser output or sculpting to maintain effective power den-
tip should be ensured (see below) [2]. sity for incision and may emit excess laser energy into the
Diode and Nd:YAG lasers are the instruments of choice deeper tissues at higher power settings. Sculpted
for equine endoscopic surgery because the energy is deliv- 1,000-micron fibers cut very well, and the sculpting will
ered through flexible quartz fibers, which can be inserted last for approximately one procedure. They are stiff enough
through the biopsy channels of video endoscopes. Two to have a real tissue feel but may have difficulty bending to
types of quartz fibers are in general use [2]. reach tissue during endoscopic surgery. Blackening the tip
The “bare” fiber is covered with a plastic coating similar of a bare fiber by firing it on a tongue depressor or, more
to insulation on an electrical wire. That plastic must be conveniently, with a black permanent marker, causes the
aser Safety 103
(a) (b) (c)
Figure12.11 (a) Bare quartz fibers (1,000-μ) for use with Nd:YAG or diode lasers. The fiber on the left is a plain cylindric tip for free
beam (non-contact) transmission of laser energy. The fiber on the right has been sculpted into a chisel point to increase power
density for contact laser surgery. Both ends eventually burn out requiring stripping back of the plastic coating and cleaving of the
quartz in a fresh site. Although possible to manually resculpt the tip, it is tedious and not as accurate as replacing the fiber. (b) A bare
quartz fiber is being blackened with a permanent marker. The black pigment absorbs the laser energy for an immediate effect on
tissue and limiting deeper penetration of laser energy. As the marker pigment burns off, the heat itself and tissue char blackens the
fiber continuing until the tip must be cleaved again. (c) Gas cooled fiber for use with Nd:YAG laser. The quartz fiber inside the plastic
tubing can transmit 50–100 W of energy without burning out, because the gas circulating in the tubing cools it. The ports in the tips
(inset) must remain clean for cooling to continue. The fiber can be used in non-contact fashion with the bare tip only or sapphire tips
of various types can be screwed onto the tip. Illustrated in the inset left to right are right-angle, conical and end-on sapphire tips. The
conical tips are used for incisions whereas the others are used for contact ablation of tissue. Source: Kenneth E. Sullins.
energy to be absorbed at the fiber tip so it cuts efficiently metal tip flares during burnout, it should be cut off the
(Figure 12.11b). Activating the laser only when the fiber is fiber before withdrawing the fiber from the endoscope or
in contact with tissue significantly prolongs the fiber life the metal edges could lacerate the biopsy channel in the
because tissue dissipates the heat. endoscope [2].
Noncontact application of laser energy requires rela-
tively high-power settings and high-power densities for an
adequate tissue effect. Smaller fibers transmitting 20–25 LaserSafety
watts can vaporize small areas but burn out very rapidly.
With higher outputs such as 50 watts, more tissue effect is American National Standard (ANSI) for Safe Use of Lasers
accomplished, but bare fibers still tend to overheat at these in Health Care Facilities Z136.3 is the authority for medical
levels. A fiber burning out inside an endoscope can badly laser safety in the United States. All surgical lasers are
damage the scope. Nd:YAG lasers that can be fitted with secured with a key lock and separate interlock required to
gas-cooled coaxial fibers contain a 600 μm (highest power operate the machine. A designated Laser Safety Officer
density possible) quartz fiber passed through a plastic tube responsible for lock security, warning signs during surgery,
that conveys cooling gas or liquid (Figure 12.11c). A metal and other required safety measures are advisable.
tip joins the two at the end of the fiber, enabling the fiber Appropriate eye protection is required for all surgical
to be used to deliver noncontact laser energy, or it can be laser wavelengths. Clear glass with protection from all
fitted with a sapphire tip for contact lasing. Compared to angles is adequate for the CO2 laser, but optical density rec-
the bare quartz fiber, higher powers can be transmitted ommendations are specific for the near-infrared and other
without burning out the fiber. Care must be taken not to wavelengths and should be followed for the specific laser.
touch tissue with the cooling port, because clogging will The patient’s eyes must be considered as well. Since surgi-
cause the fiber to burn out. If the fiber tip burns out, it cal lasers discussed here are not in the visible spectrum, a
must be refitted with a new tip or replaced [27]. If the low energy helium-neon laser aiming beam is used.
However, prolonged direct exposure, particularly to the heating of the skin margins that could lead to marginal
eye, can still cause damage. skin slough and incisional dehiscence. Carbon dioxide
All smoke generated from tissue should be evacuated lasers are the best choice for these types of general surgery
using a filtered laser smoke evacuator. In spite of reports because tissue can be precisely incised with almost no col-
that insignificant concentrations of bacteria become aero- lateral heating with appropriate instrument settings and
solized [28] and that horses are not adversely affected by surgical technique. The approximate appropriate power
routine upper airway laser surgery [29], there is sufficient density expecting primary healing for a skin incision is
evidence that infectious, carcinogenic and irritant material 5,000 W/cm2 [10].
is present in laser smoke [30, 31]. The vaporized debris and If either of these is in question, sutures set back from the
potentially viable cells or pathogens should not be inhaled skin margins 2–3 extra millimeters could help prevent
by humans or the patient. Surgical suction is inadequate dehiscence.
for this task because it is less efficient, and the suction lines The Nd:YAG /diode laser is not as precise as the CO2
will eventually foul. laser for skin incisions. The quartz fibers or sapphire tips
The surgical field should be protected by barriers. Towels produce more collateral heating of tissue. The power
or lap sponges soaked with sterile water or saline limit CO2 should be set high and the handpiece advanced in a single
laser energy from burning tissue off the field or drapes. Wet pass with skin tension separating the margins as it pro-
sponges should be held behind tissue that the laser could gresses. Tension relieving sutures provide some insurance
penetrate completely. Laser beams reflected from metallic against marginal necrosis of tissue. Noncontact delivery of
surgical instruments retain sufficient energy to affect tissue the Nd:YAG/diode laser produces too much collateral heat-
or personnel. Anodized or matte finished instruments to ing for reliable primary tissue healing and can risk subsur-
limit reflection can be purchased. face tissue.
Accelerants should be avoided. Saline should be used Either of the above lasers can be used for excision of
instead of alcohol for surgical prep. Heliox (oxygen diluted masses where skin margins are not a concern. However,
with helium) can be substituted for pure oxygen when the CO2 laser is more efficient for large masses and there
operating close to the airway with the horse under general are no fibers to wear out. Where important structures lie
anesthesia. If these few simple rules are followed, laser sur- deep close to the surgical site, the near infrared lasers
gery is as safe as any other surgery. should be restricted to contact delivery.
While all laser surgery removes some tissue along the
pecificComplicationsof Laser
S lines of incision/dissection, ablation/vaporization removes
all the target tissue by non-contact delivery of laser energy.
Surgeryin Horses
Masses ablated/vaporized are usually comparatively small
PatientComplications or they would have been excised. Examples include smaller
dermal melanomas, squamous cell carcinomas or similar
Definition Complications associated with the patient masses. Limited to noncontact delivery, the CO2 laser
secondary to laser use ablates tissue efficiently and safely, because it is highly
Risk Factors absorbed by water and tissue penetration is limited. Still,
surrounding tissue collateral heating should be minimized.
● Laser type The computerized scanner described earlier greatly
● Tissue type increases efficiency and reduces collateral heating.
● Length of deployment Nd:YAG/diode lasers efficiently ablate dark-colored soft
● Depth of laser penetration tissue masses but can still over penetrate to deeper tissue.
Contradicting the opening sentence, a spherical sapphire
Pathogenesis tip on a gas-cooled fiber of an Nd:YAG laser can be used to
General surgery perform “contact ablation” by “painting” the lesion away
General surgery using lasers consists of primary incisions, similar to a burr on bone. Importantly, the sapphire tip
excision of masses followed by primary closure or leaving largely limits the effect to the surface. Only heat is deliv-
the wound open for second intention healing, and abla- ered to the tissue so collateral heating must be watched but
tion/vaporization of tissue or masses also left open for sec- deeper penetration of laser energy will be limited.
ond intention healing. Incisions intended for primary
closure are sensitive in that skin margin viability must be Prevention Lesions on the inner pinna of the ear are good
preserved. Appropriate power density, rate of laser move- illustrations. A 4-mm sarcoid can easily be ablated with
ment and separating tissue tension prevents collateral either CO2 or near infrared lasers. The CO2 laser will
Specific Complications of aser Surgery in orses 105
efficiently ablate the mass (no matter what color it is) and
care must be taken not to overheat the underlying cartilage.
Noncontact Nd:YAG/diode lasers will also ablate the mass
but less efficiently and dark skin on the other side of the
ear can swell, slough or change color. Holding an ice pack
on the opposite side of the ear is a helpful safety measure.
Pooled liquefied fat can aerosolize causing a flash fire
due to the diesel effect. The surgical field should be kept
clean and dry with surgical suction and sponges [32].
If surgical sites are to be closed, the sutures should be
placed an additional 2–3 mm from the lased edge to reduce
the possibility of dehiscence.
Pathogenesis
ndoscopic aser Surgery
Endoscopic Laser Surgery is largely limited to Nd:YAG/ Figure12.12 Operating facility for standing endoscopic
diode lasers because the flexible quartz fibers can be surgery. The video endoscopic monitor faces the surgeon making
all the movements in the patient mimic those on the screen. The
inserted through the biopsy channel of the video endo- floor around the surgeon and assistants is free of cables or other
scope. Waveguides for CO2 lasers are improving but not debris. Source: Kenneth E. Sullins.
commonly in endoscopic use. Upper airway endoscopic
surgery is the most common equine application. Paramount
thick and the uterus is a quite thick muscular structure.
for these procedures is endoscopic surgical skill, the lack of
Aside from the decision as to whether the cysts should be
which can cause catastrophic patient complications.
treated, the Nd:YAG/diode lasers can be used endoscopi-
Arrangement of the surgical suite facilitates efficient
cally to ablate or excise the fluid-filled cysts. Some have
function, thereby preventing equipment and potential
“boiled” the interior fluid to “burst” the cyst. The author is
patient accidents. Cables, cords, suction line, vacuum hose,
unaware of complications except occasional hemorrhage,
foot switches, horse head supports and restraint devices
which should be controlled if it occurs. Insufflation is
clutter the area, thus offering every opportunity for misfire,
tripping, disconnecting equipment or otherwise contribut-
ing to bursts of mayhem. Systematic equipment placement
and a clean floor in front of the horse are mandatory
(Figure 12.12).
Inadvertent incision or “escaped” laser energy have pro-
duced seriously unfortunate patient complications. Non-
contact delivery of this wavelength has the real potential
for penetration beyond the pale pink mucous membrane to
injure underlying pharyngeal nerves or arytenoid cartilage.
Dysphagia or arytenoid chondritis (respectively) are seri-
ous complications. Contact incision/excision of tissue
(such as vocal fold and laryngeal saccule) is far safer, yet
the fiber should still be blackened and directed tangentially
to underlying tissues. Additionally, failure to strip the plas-
tic from the quartz fiber can result in flame outs when the
plastic burns.
In lieu of excising the laryngeal ventricle, some have per-
formed non-contact ablation/coagulation of ventricular
mucosa to stimulate closure. Any surviving mucosal cells
can produce enough mucus to cause a large mucocoele at
variable periods postoperatively (Figure 12.13) [2].
Endoscopic laser surgery has also been used to address
Figure12.13 Incomplete ventricular mucosal ablation left
uterine cysts and uroliths. Perforation of the hollow organ buried viable mucus-producing cells, resulting in a mucocoele
is always a potential; however, the equine bladder is rather that had to be surgically addressed. Source: Kenneth E. Sullins.
required to visualize the endometrium and cysts. Over- Riskfactors

insufflation can compress the cysts and make them diffi-
● Aged endoscope
cult to locate or manipulate. The author has seen no report
● Reuse of fibers
of air embolism or peritoneal insufflation from this proce-
● Acute flexing of the endoscope
dure but the potential should not be discounted and air
should always be evacuated after a procedure.
Lasers of different wavelengths than discussed here or Pathogenesis
other techniques are required to efficiently address equine Successful endoscopic laser surgery requires practice and
uroliths. The pulsed dye laser does work well but has attention to detail for patient and equipment safety. The
become largely unavailable. The Ho:YAG laser is used for videoendoscope itself is at risk of serious damage.
smaller uroliths in dogs and humans, but is extremely inef- Quartz fibers (Nd:YAG-Diode lasers) and waveguides
ficient for the larger equine stones. Endoscopic guidance (CO2 laser) can be relatively fragile and random laser
has successfully confined the laser energy to the urolith. energy escapes when they break. Carbon dioxide laser
The author has observed no complications directly related waveguides are highly polished semi-flexible tubes and
to either laser for lithotripsy. However, insufflation is generally not flexible enough to pass safely through an
required to access the stones and both lasers transmit a endoscopic biopsy channel. Inserted in other ways can also
constant flow of gas into the bladder. Air embolism during overstress the waveguide, so the author rarely uses the CO2
standing cystoscopy has been reported, although the horse laser in deep areas. The Nd:YAG and diode and some other
also had an intravenous catheter in place [33]. lasers are commonly delivered endoscopically through
much more flexible quartz fibers.
Prevention Care should be taken to minimize inadvertent
application of the laser fiber to normal tissues. Care should
Prevention
also be taken to minimize the hot laser fiber to touch
normal tissues. In a confined cavity, insufflation should be Adequate patient sedation is absolutely required. The
kept to a minimum to limit compression of cysts and to horse’s willingness to rest the extended head on a support
reduce the likelihood of penetrating the thin wall of the device is a good measure of adequate sedation that should
insufflated organ. prevent sudden movements that would risk equipment and
personnel. Most sedated horses tolerate the procedures
Pathogenesis very well.
However, quartz is a crystal that can break and should be
arsal arthrodesis complications
inspected before every procedure. Overbending/kinking or
The Nd:YAG/diode laser has been applied to “arthrodese”
stepping on the long fibers are common accidents that
the distal tarsal joints of horses with refractory distal tarsal
damage the fibers. After visual inspection, the room lights
osteoarthritis [34]. The laser fiber inserted into the joints
should be dimmed and with the aiming beam activated,
through a needle generates sufficient heat to boil the joint
the fiber should be bent in several directions in a bow shape
fluid, thereby incapacitating the sensory nerves in the
to evaluate for defects in the fiber. Focal or linear bright
fibrous joint capsule. The needle becomes extremely hot
lights along the fiber show cracks where light (and laser
and will burn the skin, possibly causing a significant
energy) can escape, causing damage to the interior of the
slough, which opens the joint.
biopsy channel and the workings of the endoscope leading
to expensive repairs (Figure 12.14a). Damaged fibers are
Prevention The skin and needle should be constantly
prone to burn out and can severely damage an endoscope
covered with gauze sponges soaked in frozen “slushy”
(Figure 12.14b). Bare quartz fibers should always be cleaved
sterile saline to avoid this complication. Furthermore,
and stripped for a new procedure. The fiber tips should be
inserting the needle/laser from the down side of a limb of a
clear and the aiming beam should go out the end of the
horse in lateral recumbency makes it very difficult to
fiber. Frosted or charred tips cause light to diffuse out of
maintain this freezing procedure on the limb.
the sides or not at all. Worn-out tips are inefficient and
brittle.
Once lased in the patient, the fiber tip remains hot for a
EquipmentComplications few seconds after the generator is turned off; the larger the
fiber, the longer it retains heat. By far the most common
Definition
endoscope accident is retraction of the hot fiber tip back
Complications associated with the laser equipment into the biopsy channel or lasing with the fiber tip too close
Reference 107
(a) (b)
Figure12.14 (a) Preoperative laser fiber inspection in a darkened room with the aimed beam turned on showing a fiber defect that
will certainly burn out and damage the endoscope. (b) Damaged quartz fibers that burn out in the endoscopic channel severely
damage the endoscope. Source: Kenneth E. Sullins.
to the end of the endoscope. Experience will teach the sur- aged, the tip should be cut off before bringing the fiber
geon the “proper” length of fiber to work with so tissue is back through the scope or the interior of the biopsy chan-
positively contacted while not risking the endoscope. nel can be damaged.
Surgeons must overcome the urge to suddenly retract the Fibers that fit too tightly in the biopsy channel are at risk
hot fiber if the horse moves or something is not exactly of overheating and burning out and damaging the interior
right. Working with sufficient fiber length past the end of of the endoscope. In general, 600–800-micron fibers fit
the videoendoscope also prevents melting the Teflon tub- well. Passing bare fibers through a Teflon tubing liner facil-
ing over the lens or spattering the lens with hot liquefied itates passage and protects the tip of the endoscope. Gas-
tissue. cooled fibers should pass through with no trouble.
Plastic coated gas cooled quartz fibers should be
inspected in the same manner as bare fibers and gas flow
through the tip should be verified. Occluded gas flow Summary
results in immediate burn out of the quartz fiber. If a sap-
phire tip is to be added to the gas cooled fiber, the threads Surgical lasers broaden and deepen surgical possibilities to
must be inspected so the energy goes out through the tip the advantage of patients and owners and new applications
and not the side. If, during lasing, the metal tip “blows” or continue to appear. As long as the surgeon understands
“flares up,” it is probably ruined and the metal will have laser physics and tissue interaction and exercises a few
become melted or deformed. The endoscope should be straightforward precautions, the results will be pleasing for
removed from the patient with the fiber in place. If dam- all involved.
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109
13
Complicationsof SystemicAnalgesicDrugs
Maria Amengual-Vila DVM, DECVAA, MRCVS1 and Eva Rioja Garcia DVM, DVSc, PhD, DACVAA, DECVAA,
MRCVS2
1
Highcroft Veterinary Referrals, Wirchurch, Bristol, UK
2
Optivet Referrals, Havant, Hampshire, UK
Overview Atrio-ventricular conduction blocks (AV blocks) occur

when the conduction through the AV node is slower than
Systemic analgesic medications are commonly used in the normal and are classified as first-, second- or third-degree
horse, and are encouraged for the majority of surgical con- depending on the degree of conduction abnormality.
ditions. There are many different agents available for use in Bradyarrhythmias are commonly associated to the
the horse. While they are commonly prescribed, the conse- administration of alpha-2 adrenergic agonists.
quences of extended use are not often considered. This Risk factors The severity of bradycardia is dependent on
chapter discusses the commonly-used analgesic agents and the route of administration of the alpha-2 adrenergic
the potential complications associated with their use. agonist, with a greater degree of bradycardia associated
with an intravenous compared to an intramuscular route.
● The severity and duration of bradycardic effect is depend-
istof Complicationsassociated
L ent on the drug administered, for example:
with systemicanalgesicdrugs
● Detomidine causes more prolonged cardiovascular
● Intra-op complications effects compared with medetomidine and xylazine [1].
– Bradyarrythmias ● Romifidine causes more prolonged cardiovascular effects
– Anaphylactoid reaction compared with detomidine and xylazine [2].
– Negative effect on recovery from general anesthesia ● Horses with a pre-existing high vagal tone may be more
○ Alpha-2 adrenergic agonists prone to severe bradyarrhythmias.
○ Ketamine
○ Lidocaine Pathogenesis Alpha-2 adrenergic agonists result in

● Post-op complications sedation, skeletal muscle relaxation and analgesia by
– Opioids – Excitement activating alpha-2 adrenergic receptors in the locus
– Ileus coeruleus and the spinal cord. They decrease the central
○ Alpha-2 adrenergic agonists
nervous system sympathetic output and peripheral
○ Opioids
sympathetic tone. Bradycardia is observed within 2 minutes
following an intravenous bolus and is initially caused by a
baroreceptor reflex in response to vasoconstriction and
Intra-OpComplications systemic hypertension caused by alpha-2b postsynaptic
receptor activation in vascular smooth muscle. Bradycardia
persists once the hypertension subsides due to the decrease
Bradyarrythmias
in sympathetic tone. Severe bradycardia due to increased
DefinitionBradycardia in horses is considered to be vagal tone and decrease sympathetic outflow predisposes
present when the heart rate is below 24 beats per minute. to the development of first- and second-degree AV block,
110 Complications of Systemic Analgesic rugs
and sometimes third-degree AV block. Bradycardia Treatment Normally it is not necessary to treat these
contributes to the marked decrease in cardiac output bradyarrhythmias unless the heart rate is dangerously low
observed following administration of these drugs. (i.e. life threatening).
A retrospective evaluation of detomidine infusion for The bradycardia and AV conduction disturbances caused
standing chemical restraint in 51 horses did not report any by alpha-2 adrenergic agonists can be antagonized with
complications associated with cardiovascular compro- alpha-2 adrenergic antagonists such as yohimbine or ati-
mise [3]. In the authors’ experience, the bradyarrhythmias pamezole. These antagonists will also counteract the
associated with the use of alpha-2 adrenergic agonists are desired sedation and analgesic effect from these drugs and
not clinically concerning in most horses. the cardiovascular effects may not be entirely reversed
when sedation is withdrawn.
The administration of anticholinergic drugs such as atro-
Prevention The administration of a combination of drugs
pine, glycopyrrolate or hyoscine-N-butylbromide, can be
(i.e. alpha-2 adrenergic agonist and opioid) reduces the
used to increase the heart rate without affecting the seda-
dose required to achieve the same desired effect, sedation
tion/analgesia. In cases of extreme bradycardia, the intra-
and analgesia, and therefore reduces the occurrence or
venous administration of an alpha-2 adrenergic antagonist
degree of adverse effects. It was observed in horses that the
agent, atropine and/or epinephrine (adrenaline), may be
administration of methadone, a pure mu opioid agonist, in
necessary.
combination with detomidine, reduced the duration of the
bradycardia and increased and prolonged the hypertension
Expected outcome Alpha-2 adrenergic agonists are
induced by detomidine [4].
extensively used in horses for sedation/analgesia purposes
The IV administration of an anticholinergic drug, such
with a very low incidence of complications. Healthy horses
as atropine, glycopyrrolate or hyoscine-N-butylbromide, 5
tolerate well their cardiovascular effects. Cardiovascularly
minutes before the alpha-2 adrenergic agonist drug, pre-
compromised and severely ill horses may not tolerate these
vents the decrease in heart rate without affecting the degree
cardiovascular depressant effects well and therefore they
of sedation/analgesia. However, these drugs induce a
should be avoided or very low doses used, while the animal
reduction in gastrointestinal motility through antimus-
is being closely monitored.
carinic effects on the intestinal M3 receptors and may
Severe bradyarrhythmia causes a severe decrease in car-
cause impaction-type colic. This effect is more pronounced
diac output, which may cause cardiovascular collapse. This
and of longer duration with atropine, and therefore this
is especially likely in horses with limited cardiovascular
drug is only used in emergency situations. Low dose of gly-
reserve capacity, such as hypovolemic animals. In these
copyrrolate [4, 5] or hyoscine [6] administered before or
cases, it is recommended to replace the intravascular vol-
after alpha-2 adrenergic agonists prevent or reverse the
ume before an alpha-2 adrenergic agonist agent is used.
bradycardia and cause shorter duration reduction in gas-
trointestinal motility compared with atropine. Hyoscine
may be alternatively administered intramuscularly 10 min-
AnaphylactoidReaction
utes before the alpha-2 adrenergic agonist to avoid the
marked increase in heart rate and systemic blood pressure Definition Anaphylactoid reactions produce a similar
associated with the IV administration [7]. Slow injection of clinical picture as true anaphylactic reactions, but are not
the drug while monitoring the horse for side effects (espe- mediated by IgE and occur through a direct non-immune
cially heart rate and blood pressure) should be performed, mediated release of histamine and other mediators from
especially in cardiovascularly compromised horses (i.e. mast cells and/or basophils.
colic) [8]. Risk factors Some opioid drugs (morphine and meperidine
[pethidine])
● Route, dose and rate of drug administration. The
Diagnosis Bradycardia occurs within minutes of drug
administration of a high dose of a rapid intravenous
administration and it can be easily detected palpating a
bolus of the drug leads to a greater histamine release
peripheral artery or with cardiac auscultation. The decrease
compared with lower doses administered as a constant
in heart rate may be mild and short lasting or severe and
rate infusion [9].
long lasting, depending on the administered drug, dose and
route. When second-degree AV blocks occur, an intermittent
irregular rhythm with missing beats is palpated or heard Pathogenesis Morphine and meperidine (pethidine),
on auscultation. These blocks can be diagnosed with an when injected intravenously, induce histamine release due
electrocardiogram. to mast-cell degranulation by a non-immunological
Intra-Op Complications 111
mechanism (non-IgE mediated) [10]. The most potent at epinephrine (adrenaline) should be immediately
causing this effect is meperidine (pethidine) [11]. administered as well as oxygen supplementation, while
The clinical consequences of an anaphylactoid reaction blood pressure, heart rate and oxygenation (pulse oximetry
are the same as those of a true anaphylactic reaction, most and/or blood gases) are being monitored.
commonly hypotension and tachycardia, but other effects
such as bronchoconstriction, pruritus, urticaria or cardio- Expected outcome Outcome should be good if supportive
vascular collapse may also occur (non-allergic treatment is instituted rapidly.
anaphylaxis).
A retrospective study of intraoperative administration of
morphine at doses of 0.1–0.17 mg/kg in horses found no NegativeEffecton Recoveryfrom General
significant increase in problems during or immediately Anesthesia
after anesthesia, which included no cardiovascular side Alpha-2 adrenergic agonists: excessive sedation and
effects when compared with a similar protocol without the ataxia
opioid [12]. However, a case report of two horses who
received intravenous meperidine, one sedated and one Definition
anesthetized, describes the occurrence of tachycardia and A normally functioning body can “sense” how its joints,
profuse sweating, which may have been due to an anaphy- muscles and tendons are moving, and where all the compo-
lactoid reaction [13]. Unfortunately, no blood pressure was nents of the body are in relation to each other. Ataxic
measured in these horses. Both horses recovered unevent- horses are those that are unable to control the rate, range or
fully from this reaction within 10 minutes. force of their movements, resulting in an inconsistent gait.
Prevention An alternative route of administration such as Risk Factors

intramuscular should be considered when drugs known to ● The degree of sedation ataxia is dependent on the route
cause histamine release are administered, especially and dose of alpha-2 adrenergic agonist administration.
meperidine. When morphine is administered intravenously,
it should be injected slowly while monitoring the horse for ● The administration of a high dose of a rapid intravenous
any possible side effects (especially heart rate and blood bolus of the drug leads to a longer recovery period and
pressure). the chance of ataxia if the horse tries to stand up at early
Previous administration of an anti-histaminic drug such stages.
as chlorphenamine or diphenhydramine, may be consid-
ered when these drugs are used in debilitated animals with Pathogenesis Alpha-2 adrenergic agonists act centrally
a reduced cardiovascular reserve. However, no problems causing sedation, analgesia and muscle relaxation. These
associated with the use of intravenous morphine at clinical effects are dose related up to a maximal point, after which
doses are usually observed in healthy horses [12] or horses increasing the dose further only increases the degree of
with colic (personal observation) and therefore the routine ataxia and lengthens the duration of the effects. Excessive
use of anti-histaminic drugs is not recommended as they ataxia due to excessive muscle relaxation may make it
may produce other unwanted effects (e.g. sedation). impossible to keep the horse standing. Excessive sedation
and ataxia in the recovery period could result in injuries or
Diagnosis Histamine release occurs within minutes of an unsuccessful recovery.
drug administration and the consequences appear quickly. The administration of xylazine, detomidine or romifi-
The first clinical signs of histamine release are hypotension dine to horses during the recovery period prolongs, but
and tachycardia, which may be mild and short lasting or improves the recovery from isoflurane anesthesia, making
severe, even causing cardiovascular collapse. These signs it smoother, free of excitation and ataxia with minimal car-
can be easily observed if the heart rate and blood pressure diopulmonary effects [14]. A study comparing the recovery
are being monitored (e.g. under general anesthesia), but in quality when xylazine or romifidine were administered
conscious horses they may go unnoticed. during the recovery period showed that a dose of 20
microg/kg of intravenous romifidine in healthy adult
Treatment Usually, treatment is not necessary. horses anesthetised with isoflurane for >1 hour, was asso-
Supportive treatment of hypotension includes the ciated with better recovery quality than a lower dose of
administration of intravenous fluids and/or vasoconstrictors romifidine or xylazine [15]. However, in a study of periop-
(e.g. phenylephrine). If the reaction is severe, causing erative morbidity and mortality in horses, sedation with an
bronchoconstriction and cardiovascular collapse, alpha-2 adrenergic agonist during recovery appeared to
show some association with improved recovery scores but, suffer injuries, which can range from minor wounds to
in the final model, it was found to be less important than fatal injuries leading to the euthanasia of the animal (e.g.
other factors [16]. fracture of a long bone).
Prevention When low doses of alpha-2 adrenergic agonists Ketamine: excitement and emergence hallucination
are used in the recovery period, they prolong the time of Definition Ketamine side effects include muscular
recumbency and improve the quality of recovery [14]. tremors, rigidity, involuntary limb movements, excitement,
However, if the dose is too high, they may cause excessive ataxia and hallucinations, which may lead to increased
ataxia. Romifidine causes a lower degree of ataxia morbidity and mortality during the recovery of horses [17].
compared with equipotent doses of xylazine and
detomidine [2]. Risk Factors
An alternative route of administration such as intramus-
● High plasma ketamine concentrations
cular may be considered as drugs are absorbed slowly and
● Length of the ketamine infusion. Accumulation of keta-
side effects, like ataxia, might be less dramatic.
mine and its metabolites can lead to prolonged recover-
An adequate dose for the weight of the patient should be
ies with poor quality [18].
used. If the horse has been on an intravenous infusion of
● Hepatic and renal disease can cause a delay in the metab-
any alpha-2 adrenergic agonist intraoperatively, the admin-
olism and excretion, respectively, of ketamine and its
istration of any more sedation for the recovery period
accumulation in plasma.
should be gauged carefully, as the residual amount of drug
after stopping the infusion may cause sufficient sedation
during this phase. Pathogenesis Ketamine is a dissociative anesthetic with
All alpha-2 adrenergic agonists increase diuresis, which actions on several receptors, but the antagonism of the
is of similar degree and duration among agents [2]; there- N-methyl-D-aspartate (NMDA) receptors in the central
fore, emptying the bladder at the end of the surgical proce- nervous system (CNS) is mainly responsible for its
dure before the recovery phase may improve comfort and anesthetic, analgesic, psychotomimetic and neuroprotective
prevent early attempts to stand up. effects. It is widely used in horses in combination with
benzodiazepines and/or alpha-2 adrenergic agonists as an
Diagnosis Horses recovering from general anesthesia induction agent and in total intravenous anesthesia,
present some degree of ataxia due to the residual effects of producing rapid and smooth induction with minimal
anesthetic drugs. Ataxia contributes to the uncoordinated cardiovascular depression and good analgesia.
and sometimes unsuccessful attempts to stand during this Intraoperative constant rate infusions (CRI) of ketamine
phase. Once standing, ataxic horses sway from side to side are used in equine anesthesia as part of the balanced
and sometimes fall back down. This contributes to the high anesthesia concept aiming to improve analgesia, reduce
mortality and morbidity observed in horses during the the amount of inhaled agent and preserve cardiovascular
recovery period. function [19].
It seems that recovery from ketamine anesthesia in the
Treatment Partial antagonism of the alpha-2 adrenergic horse depends on rapid redistribution of the drug from the
agonist, with yohimbine or atipamezole, can help to central compartment and this explains the abrupt recovery
improve the ataxia. However, if the horse is excessively from ketamine anesthesia often observed in the horse.
ataxic it may be dangerous for personnel to enter the The exact dose or circulating concentration of ketamine
recovery room. Moreover, if antagonized excessively this at which excitement or abnormal behavior occurs may vary
may cause excitement, which can also lead to fatalities between horses and has not been identified. Fielding
during the recovery. Keeping a quiet and dark environment et al. [29] concluded in their study that the use of subanes-
while the horse is recovering is essential to avoid early thetic doses of ketamine in standing horses up to 0.8 mg/
attempts to stand up, when the ataxia is more pronounced. kg/h for 6 hours did not cause signs of excitement, but an
analgesic effect was not obtained with the method of anal-
Expected outcome The ataxia seen in recovery due to gesic testing used.
sedation with alpha-2 adrenergic agonists is self-limited by
the metabolism of the drug. Xylazine produces the shortest Prevention The administration of a ketamine CRI
effects, lasting for about 15–20 minutes. intraoperatively for longer than 2 hours is not
Excessive sedation and ataxia may be responsible for recommended. Administration of ketamine CRIs in horses
morbidity and mortality during the recovery. Horses may with hepatic and/or renal disease should be avoided.
Postop complications 113
The administration of S-ketamine instead of racemic Prevention When using lidocaine as a CRI during
ketamine (R-/S- ketamine) decreases the adverse effects anesthesia, it is recommended to stop the infusion
observed during the recovery phase [20]. 30 minutes before the end of surgery to avoid ataxia during
The quality of recovery from anesthesia was better when the recovery period [24]. This study showed that using
an intravenous infusion of S-ketamine was used instead of intraoperative lidocaine as a CRI at a dose of 50 microg/kg/
racemic ketamine during isoflurane anesthesia in clinical min and discontinuing the CRI 30 minutes before the end
horses undergoing arthroscopy [20]. of surgery reduced the degree of ataxia during the recovery
period [24].
Diagnosis The presence of excitement in the recovery
period with nystagmus, ataxia, restlessness and hyper- Diagnosis Signs of neurotoxicity caused by lidocaine
reactivity to sound and noise. Sometimes “box-walling” include rapid eye blinking, ataxia, progressing to sedation,
has been described. muscle twitching, seizures and unconsciousness [21].
Tremors and signs of visual dysfunction, including staring
and inspecting the walls and floor closely, in some horses
Treatment If ketamine has been administered as a CRI
that received a CRI of lidocaine during anesthesia were
during anesthesia and the horse shows signs of excitement
observed [25].
early during the recovery phase, it is recommended to
sedate the horse with an alpha-2 adrenergic agonist. Treatment No specific treatment exists for lidocaine
Keeping the horse in a quiet and dark environment will neurotoxicity. The patients recover rapidly from the effects
avoid stimulation and early attempts to stand. of lidocaine after discontinuation due to its short terminal
half-life (40 min) in the horse [26].
Expected outcome With time the drug will be metabolized
and the horse will recover slowly from the side effects Expected outcome The outcome should be good if the
caused by the accumulation of ketamine and its metabolites. horse does not suffer from major injuries.
The outcome should be good if the horse does not suffer
from major injuries.
Postopcomplications
Lidocaine: ataxia and visual dysfunction
Definition Opioids:Excitement
Ataxia and alterations in behaviour related to visual dys- Definition Opioids can produce excitement, seen as box
function may be observed after overdosing with lido- walking, restlessness and dysphoria when administered
caine [21]. Horses show rapid and intermittent eye alone in pain-free horses.
blinking, anxiety and attempts to inspect closely located
objects. Risk Factors
Risk Factors ● Administration of high doses of opioids without the con-

current administration of a sedative drug
● Lidocaine administration until the end of anesthesia has ● Administration of opioids in pain-free horses
a significant negative effect on the degree of ataxia exhib-
ited by horses in the recovery period. Pathogenesis Horses possess a unique opioid receptor
● Liver disease can impair lidocaine metabolism and profile and density compared to other species and are
hepatic clearance, therefore it will not be metabolized sensitive to opioid-induced CNS stimulatory and locomotor
and so accumulates. effects. Excitement may result indirectly from increased
release of norepinephrine and dopamine. This may explain
Pathogenesis Lidocaine is a local anesthetic commonly the mechanism why noradrenergic and dopaminergic
used intravenously as a CRI as part of balanced anesthetic blocking drugs like phenothiazines suppress the opioid
protocols in equine anesthesia. The beneficial effects induced excitement [12]. However, increased locomotor
include analgesia and inhalational anaesthetic-sparing activity produced by opioids seems to be associated with
effect [22, 23]. However, lidocaine at high plasma opioid receptors. The propensity of an opioid analgesic to
concentrations can cause neurotoxicity and cardiotoxicity promote locomotion may be greater with mu (e.g.,
(see Chapter 14: Complications of Loco-Regional morphine) than with kappa agonists (e.g. butorphanol) [27].
Anesthesia). Kappa agonism more commonly causes ataxia and
staggering [28]. Opioids were studied in varying numbers Pathogenesis Alpha-2 adrenergic agonists decrease
of pain-free horses in one of the most commonly cited intestinal motility, which may predispose to ileus. Studies
references on opioid-induced locomotion in horses [32]. It in rats using clonidine showed that the activation of
is important to note that there is marked individual presynaptic alpha-2A subtype receptors was responsible
variation in responses. The median effective dose of for the slower motility [33]. In horses, xylazine-induced
morphine that causes an increase in locomotion activity in vasoconstriction of the cecal vasculature decreases arterial
pain-free animals is 0.91 mg/kg, which is considerably blood flow to the lateral cecal artery, decreasing normal
higher than the doses used clinically to produce local motility for up to 120 minutes with a full sedative
analgesia [30]. dose (1.1 mg/kg, IV) and for 30 minutes with a low dose
(0.275 mg/kg) [34].
Prevention Using appropriate clinical doses of opioids in The gastrointestinal effects of opioids may also predis-
combination with a sedative drug will prevent this pose to post-anesthetic colic or ileus. All opioids, including
excitement [30]. mu and kappa agonists, reduce gastrointestinal motil-
ity [30]. Morphine (0.5 and 1.0 mg/kg) and fentanyl (10 or
50 mg) intravenously initially stimulated, but then inhib-
Diagnosis Increased locomotor activity, box walking, head
ited ceco-colic electrical and mechanical activity for up to 3
jerking, disorientation and/or ataxia
hours in three pain-free ponies [38]. A decrease in gastroin-
testinal motility was detected 1 to 2 hours after intramus-
Treatment The use of sedative agents like acepromazine cular administration of morphine at doses of 0.05 and 0.1
or apha-2 adrenergic agonists can calm and sedate the mg/kg and after intravenous administration at a dose of 0.1
horse, solving the excitement and increased locomotor mg/kg [39]. In another study, morphine administered at
activity. The use of the opioid antagonist naloxone (0.015 0.5 mg/kg twice daily decreased propulsive motility and
mg/kg) entirely prevented locomotor responses to moisture content in the gastrointestinal tract lumen for up
morphine and fentanyl [31]. Naloxone will revert the to 6 hours after each dose [37]. Epidural morphine has also
analgesics effects of any opioid, therefore it should be used been shown to temporarily reduce GI motility but it did not
with caution in painful horses and only in severe cases or cause ileus or colic in a small group of healthy
overdose. unfasted horses [40]. A single intravenous injection of
butorphanol was associated with decreased borborygmi,
Expected outcome The outcome is good as these effects are and decreased defecation; however, the administration of
usually mild and easy to control with the administration of butorphanol as a continuous intravenous infusion over
a sedative. 24 hours was associated with minimal side effects includ-
ing minimal gastrointestinal effects [41].
The literature indicates a multifactorial etiology for peri-
Ileus anesthetic ileus and an equivocal contribution of morphine
Definition Gastrointestinal propulsive motility depends and other opioid analgesics. Therefore, care should be
on a complex interaction between neural, hormonal, taken when extrapolating these data to clinical situations
vascular and neuromuscular pathways. Disruption of this of horses with painful conditions and in which other fac-
intrinsic interaction leads to absence of propulsive aboral tors may also affect GI motility.
movement of food material, also called ileus.
Prevention Continuous intravenous infusions of low doses
may reduce the intensity of gastrointestinal side effects as
Risk Factors
compared with intravenous bolus administration. Avoid
● The use of high doses of either opioids or alpha-2 adren- high doses of opioids and alpha-2-adrenergic agonists and
ergic agonists reduce the dose of opioids and/or alpha-2 adrenergic
● The use of opioids in pain-free horses may predispose to agonists to the minimum effective dose. In painful horses
ileus the effective management of pain is important and the use
● Prolonged starvation (>18 h) of clinical doses of opioids (e.g. 0.1–0.3 mg/kg of morphine)
● Recent changes in management such as exercise, diet is recommended, as the analgesic effect may override
and transport increase the risk in hospitalized horses. theoretical concerns of decreased gastrointestinal motility.
● Stress response to anesthesia, surgery and pain Using pain scales may help to identify the patients that are
● Local inflammation and edema of the intestine in pain and in need of analgesia, allowing a more correct
● Endotoxemia dosage and avoiding overdosing.
References 115
Diagnosis It is out of the scope of this chapter to detail the N-methylnaltrexone, a peripheral opioid antagonist that
diagnosis and treatment of ileus in horses, as it is a does not cross the blood–brain barrier, therefore not revers-
multifactorial disease, but if high doses of opioids and/or ing opioid-induced analgesia. has been studied in
alpha-2 agents have been administered or they have been horses [44]. At doses of 0.75 mg/kg intravenously,
used for prolonged periods of time, they could be a N-methylnaltrexone partially prevented the effects of mor-
contributing factor. phine on the gastrointestinal tract. Alvimopan, a peripher-
ally acting mu-opioid receptor antagonist, is an emerging
Treatment Naloxone, a full opioid antagonist, induces a treatment for human postoperative ileus. It partially pre-
marked propulsive activity in the colonic segment vents the gastrointestinal effects caused by morphine while
producing onset diarrhea, restlessness, abdominal preserving the central analgesic effects [35, 36].
checking, tachycardia and tachypnea in healthy horses not
pre-treated with opioids [42]. In vitro, naloxone has Expected outcome The prognosis of ileus is guarded. The
prokinetic effects at the ileo-eco-colonic junction [43]. outcome will depend on the etiology and the clinical status
Naloxone also reverses the analgesic effects of opioids. of the horse.
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118
14
Complicationsof Loco-RegionalAnesthesia
Eva Rioja Garcia DVM, DVSc, PhD, DACVAA, DECVAA, MRCVS
Optivet Referrals, Havant, Hampshire, UK
Overview ● Tourniquet failure

● Local and systemic effects of tourniquet ischemia
All pain management techniques and drugs have the
potential to produce complications related to the technique
itself or due to the drugs’ side effects; however, the benefits GeneralComplications
related to the pain relief that they provide usually outweigh
VascularPuncture
the risks. When performing loco-regional blocks the anat-
omy (landmarks) of the region as well as the technique Definition When performing a loco-reginal block,
should be well known to avoid puncture and potential significant bleeding due to puncture of a blood vessel or
damage of structures or organs. This chapter will cover inadvertent intravascular injection of the local anesthetic,
some of the most important and relevant complications either in a vein or an artery, can occur.
related to loco-regional blocks. Complications related to
loco-regional blocks performed for lameness examination Risk Factors
are included in Chapter 44: Complications of Diagnostic
● Use of blind techniques
Tests for Lameness.
● Lack of knowledge of anatomy of the region
● Injecting the local anesthetic with no previous
aspiration
L
Significant bleeding may occur in horses with
with Loco-RegionalAnesthesia
●
coagulopathies
● General complications
○ Vascular puncture Pathogenesis When a nerve is targeted to perform a block,
○ Nerve injury there is always an associated vein and artery nearby;
○ Myotoxicity therefore, there is always the potential to puncture a blood
○ Chondrotoxicity vessel and consequently to induce bleeding and hematoma
○ Allergic reactions formation in the area. Similarly, there is the potential to
● Complications related to specific loco-regional blocks inadvertently inject intravenously or intra-arterially. This
○ Epidural Analgesia
can lead to systemic toxicity, which could be even lethal,
– Ataxia/Recumbency depending on the dose of local anesthetic administered
intravascularly.
● Infection inside the spinal canal
In the spinal canal, there are many blood vessels that
● Pruritus
could be punctured when performing an epidural injec-
○ Retrobulbar Blocks
tion, the most prominent being two venous plexuses at the
● Brainstem Anesthesia floor of the canal, that run parallel to the spinal cord on
○ Inferior Alveolar Nerve Block
each side. When performing a proximal paravertebral
● Self-Inflicted Lingual Trauma block with the needle inserted paramedially (parallel to the
○ Intravenous regional anesthesia (IVRA) sagittal plane, separated a few centimeters from the spinal
General Complications 119
canal), there is also risk of arterial or venous puncture, When performing epidural injections, the risk of punc-
especially if the needle is advanced too far as it could reach turing a venous plexus is lower when the needle is in mid-
the abdominal aorta (left side) or caudal vena cava (right line and is not advanced to the floor of the canal, which is
side). where the venous sinuses run, on both sides of the spinal
A recent retrospective study in horses looked at the cord.
complications associated with loco-regional anesthesia When performing paravertebral blocks, the needle
for dental procedures, and found that hematoma occurred should be advanced carefully until it reaches the transverse
in 5 out of 270 blocks performed, giving a 1.8% incidence process of a vertebra and then “walked off” the process and
rate [1]. There is a report of retrobulbar hematoma forma- advanced only one or two more centimeters to avoid
tion in a dog following inadvertent puncture of a blood reaching the abdomen.
vessel during a maxillary block, which led to exophthal- Loco-regional blocks, especially epidural or paravertebral
mos, periorbital swelling, extensive scleral hemorrhage injections, should be avoided in animals with coagulation
and ecchymosis [2]. In humans, bleeding or intravascular defects.
cannulation occurred in 0.67% of cases where an epidural
technique was performed [3]; however, this article did not Diagnosis If blood is observed in the hub of the needle
report the consequences of this complication. while it is being advanced, it is advisable to reposition the
Systemic toxicity related to local anesthetics injected needle until blood flow stops or to abort the procedure and
intravascularly inadvertently usually starts with the repeat it using a new needle in a slightly different location.
development of neurological signs and it is followed by
Inadvertent intravascular injection may just lead to block
signs of cardiovascular toxicity. There are no published
failure if the total dose was low. But it could also lead to
reports of systemic toxicity in horses following regional
systemic signs of toxicity. The first signs are neurological
anesthetic blocks, most likely because the toxic dose is
due to central nervous system toxicity, starting with
normally higher than the dose administered locally. In
rapid eye blinking, ataxia, progressing to sedation,
small animals, seizures occurred in two medetomidine-
muscle twitching, seizures and unconsciousness [9].
sedated dogs following subcutaneous administration of
When the intravascular dose of local anesthetic is high
lidocaine for skin biopsies, although in these animals a
enough to cause cardiovascular toxicity, the signs may
very high dose was used and most likely this caused the
include ventricular premature beats, ventricular
systemic toxicity and not an inadvertent intravascular
tachycardia and/or fibrillation followed by cardiovascular
injection [4]. Severe cardiovascular depression was
collapse and arrest [10].
reported in an anesthetized cat immediately following
The clinical signs of local anesthetic toxicity are different
mandibular nerve block with bupivacaine and seizure-
in conscious and anesthetized animals. Anesthetized
like activity upon recovery, which could have been due to
animals are more resistant to the central nervous system
inadvertent intravascular injection as the dose adminis-
toxicity and no seizures are observed, while
tered was low [5]. In the human literature, there are
cardiovascular depression might occur at lower doses
reports of inadvertent intravascular injection during dif-
than in conscious animals [10].
ferent types of blocks, leading to seizures and/or cardiac
arrest; however, the overall incidence of major complica-
tions is very low [6]. Treatment Normally no specific treatment is necessary for
hemorrhage/hematoma if the horse’s coagulation is
Prevention Knowledge of the anatomy, careful needle normal. If there is a clotting problem or the bleeding is
insertion and avoiding passing the needle repeated times significant, administration of an antifibrinolytic agent
should decrease the risk of puncturing a blood vessel. could be considered such as tranexamic acid or epsilon-
Aspiration before injection should be done to ensure no aminocaproic acid. If the hematoma is big, drainage of the
intravascular injection. Once it has been ascertained that blood may be attempted, as well as application of local cold
the needle is not in a vessel it should not be moved and treatment and local and/or systemic administration of
injection performed. Whenever the needle is repositioned non-steroidal anti-inflammatory agents.
aspiration should be done again before injecting. When systemic toxicity is noticed, the administration of
Ultrasound-guided needle insertion can prevent punc- local anesthetic should be halted. Treatment of systemic
turing undesired structures such as blood vessels [7, 8]. toxicity is supportive as there is no reversal agent. If
The toxic dose of the local anesthetic should be calcu- seizures are observed, an anticonvulsant drug such as a
lated for the individual horse, and the total administered benzodiazepine (i.e. diazepam) can be administered,
dose should be below this toxic dose. although it may be safer to induce general anesthesia with
120 Complications of ocos egional Anesthesia
a barbiturate (i.e. thiopental). Supportive treatment Risk Factors

consists of endotracheal intubation, oxygen administration
● The neurotoxicity of local anesthetic is greater as con-
and controlled respiration [11]. Signs of cardiovascular
centrations increase.
toxicity induced by lidocaine or mepivacaine are usually
● Blind injection techniques
mild and reversible with positive inotropic drugs such as
● Several passages of the needle and movements of the
dobutamine and fluid therapy. Longer acting local
needle
anesthetics such as bupivacaine, levobupivacaine or
● The type of bevel of the needle can also influence the
ropivacaine are more cardiotoxic and the cardiac
degree of damage as well as the orientation that the
arrhythmias that they produce are usually malignant and
needle has with respect to the nerve fibers.
refractory to routine treatment (i.e. ventricular tachycardia
or fibrillation). In these cases, administration of a low dose Pathogenesis Local anesthetic agents have cytotoxic
of epinephrine (for cardiac arrest), amiodarone (for effects and therefore can produce direct neurotoxicity.
ventricular tachycardia) or defibrillation (for ventricular Small fiber neurons such as C and Aδ (responsible for pain
fibrillation) are the recommended treatments. An and temperature transmission) are more sensitive to
intravenous infusion of a 20% lipid emulsion (“lipid chemical damage than the larger fibers Aα and Aβ
rescue”) is recommended to treat refractory arrhythmias (responsible for motor function, proprioception, pressure
induced by highly lipophilic local anesthetics (i.e. and touch) [16]. These neurotoxic effects will manifest
bupivacaine), as it has been shown to be the only effective clinically as persisting sensory and/or motor deficits in the
treatment in different experimental models [12, 13] and in area innervated by the nerve.
human clinical reports [14. 15]. The degree of damage depends where within the nerve
the local anesthetic solution is injected. The nerves are
surrounded externally by a layer of connective tissue, the
Expected outcome The consequences and the prognosis
epineurium. Inside the nerve the neuronal axons are
of hemorrhage/hematoma could be serious depending on
bundled together forming fascicles, and several fascicles
the location and amount of blood lost. It is likely that this
form a nerve. Between the fascicles there is connective
complication occurs commonly in practice but that it
tissue and intrinsic blood vessels. Fascicles are surrounded
does not carry any serious consequence for the animal.
by another layer of connective tissue, the perineurium.
An immediate consequence to this complication could be
Finally, each individual axon is surrounded by another
a less effective or an ineffective block, due to the dilution
layer of connective tissue called the endoneurium. The
and entrapment of the local anesthetic within the blood/
perineurium is a barrier that regulates the entry of
clots.
substances from adjacent tissues and the blood vessel
If significant bleeding occurs within the spinal canal fol-
endothelium regulates the entry from the vascular
lowing an epidural injection, this could lead to spinal cord
compartment, both maintaining the internal milieu of the
compression, which depending at what level it occurs, it
nerve fascicle. When a local anesthetic is deposited inside
could lead to ataxia and/or recumbency of the animal.
the nerve but outside the perineurium, the regulatory
Puncture of the caudal vena cava or the aorta when
function of the perineurial and endothelial blood–nerve
performing a proximal paravertebral block could lead to
barriers is only marginally compromised and little or no
significant intra-abdominal bleeding; however, no reports
nerve damage occurs [17]. However, when the local
of such complication could be found by the author.
anesthetic is injected inside the nerve fascicle
The outcome of local anesthetic systemic toxicity is
(intrafascicular injection) axonal degeneration and blood–
generally good when only mild central nervous system
nerve barrier changes occur, which become progressively
signs are observed (i.e. muscle fasciculations); however, it
worse when the concentration increases [18, 19].
could be fatal if seizures occur as the horse may injure
Mechanical damage due to needle-tip penetration of the
itself. When cardiovascular toxicity occurs, this could lead
nerve can also lead to injury, but this seems not to be the
to irreversible cardiac arrest, particularly when using the
main cause of clinical complications [20]. Nerve damage is
longer acting local anesthetics (i.e. bupivacaine).
more likely to occur when the solution is injected
intrafascicularly due to interruption of the perineural
NerveInjury tissue around the nerve fascicles, causing a breach of the
blood–nerve barrier leading to edema and herniation of
Definition Direct needle puncture of a nerve and/or the endoneural contents [17]. Nonetheless, intrafascicular
injecting the local anesthetic into a nerve may lead to nerve injection of saline solution that caused pressures transiently
damage. exceeding the nerve capillary perfusion pressure did not
induce any changes in the microscopic anatomy or an electrical current to stimulate a motor response associ-
diffusion barriers within the nerve [19], which indicates ated with a specific nerve, in theory would decrease the
that the main source of peripheral nerve injury is injection risk of intraneural injections; however, studies show that
of the local anesthetic into a fascicle. Based on data in dogs, this is not the case and even the absence of motor response
when lidocaine 2% is injected intrafascicularly with a low to nerve stimulation does not exclude intraneural needle
injection pressure ( 11 psi), normal motor function will placement [28].
return in 3 hours [21]. In another study in dogs where Careful technique, gentle needle movements and using
lidocaine 2% was also administered, neurological function short-beveled needles with the bevel parallel to the nerve
returned to baseline 3 hours after perineural injections and could reduce the risk of nerve damage. Also, stopping the
within 24 hours after intraneural injections with injection injection if high pressure is felt may help to decrease the
pressures below 12 psi [22]. risk of nerve injury, as it was shown that intrafascicular
Long-beveled needles (14-degree angle) are more likely injections associated with high pressures ( 25 psi) caused
to cause nerve damage if they impale a nerve than short- persistent motor deficits with destruction of neural
beveled ones (45 degrees) [23]. Also, if the needle pierces a structure and axonal degeneration, while lower pressures
fascicle with the bevel transverse to the nerve fibers, the ( 11 psi) did not cause any permanent motor dysfunction
damage is greater than if the bevel is parallel to them [23]. or histological abnormality [21].
Application of tourniquets at high occlusion pressures may
cause mechanical deformation of the portion of the nerve Diagnosis The clinical manifestations of nerve damage
under the tourniquet leading to damage. The most sensitive caused by local anesthetics are reported in humans to
neurons to this type of insult are the fast conducting, large include spontaneous paresthesias and deficits in pain and
diameter myelinated fibers (Aα and Aβ) [24]. Ischemic temperature perception, and not so frequently loss of
damage of nerves due to long tourniquet application times motor, touch or proprioceptive function [16]. Clinical signs
may also occur, but these changes seem not to be permanent associated with tourniquet-induced neuropathy are mainly
following ischemic periods of less than 6 hours [25]. motor and proprioception loss and diminished touch
Neurological deficits can also occur secondary to an sense [29].
expanding hematoma that causes nerve compression.
Treatment There is no specific treatment for nerve damage,
To the best of the author’s knowledge there are no reports
only supportive. Treatment of the hematoma or the ischemic
of neurotoxicity associated with clinical local/regional
area may help to regain normal nerve function faster.
anesthesia in horses, which indicates that this complication
is probably very rare considering the vast number of local
Expected outcome In humans, symptoms of nerve injury
blocks performed in equine clinical practice. In humans,
following regional blocks resolved in 4–6 weeks in 92–97%
serious nerve injury resulting in permanent nerve damage
of cases and by 1 year in 99% of cases [30].
is rare, with a 1.5/10,000 incidence reported [26]. Most
reported injuries are transient and often subclinical, with a
reported incidence of transient paresthesia as high as Myotoxicity
8–10% in the immediate days after the block [27].
Definition The occurrence of myositis and/or myonecrosis
following the injection of a local anaesthetic solution into a
Prevention The lowest dose and concentration that will be
muscle
effective to produce a block should be used to minimize the
risk of chemical nerve damage.
Risk factors Local anesthetic-induced myotoxicity is
Puncturing a nerve with a needle is associated with a
concentration-dependent, but it is observed at clinically
burning or prickling sensation (paresthesia) as described in
relevant concentrations of all commonly used local
human medicine. Injection of a local anesthetic into a nerve
anesthetics (e.g. bupivacaine 0.5%, mepivacaine 2%,
will cause pain. Therefore, if the horse reacts during the
lidocaine 2%) [31–33].
advancement of the needle or during the injection of the
solution, this could indicate intraneural placement and the ● The greatest risk of clinically relevant myopathy and
injection should be halted. If the patient is anesthetized or myonecrosis is when local anesthetics are administered
heavily sedated these warning signs will be obtunded and intramuscularly and repeatedly (either serially or
therefore there is an increased risk of intraneural injection. continuously) [34].
Ultrasound-guided needle insertion decreases the inci-
dence of paresthesias compared with other techniques in Pathogenesis Experimentally, all local anesthetics can
humans [8]. The use of a nerve stimulator, which delivers cause toxicity to skeletal muscle with the most toxic being
bupivacaine and the least being procaine [34]. Bupivacaine this seems to be non-significant. In the human literature,
causes the most severe changes characterized by calcific normal muscle function is recovered completely or almost
myonecrosis, formation of scar tissue and a marked rate of completely within a few months post-injection, ranging
fiber regeneration, which were observed 7 and 28 days after between 4 days to 1 year [35, 36]. None/partial and
a continuous femoral nerve block in a study in pigs [32]. complete recovery were observed in 61% and 38% of
Injury mechanisms seem to involve early and late patients, respectively [35].
aberrations to cytoplasmic calcium (Ca2+) homeostasis by
the sarcoplasmic reticulum Ca2+ ATPase [35].
Chondrotoxicity
Clinically, myotoxocity may cause muscular pain and
dysfunction, although in most cases these changes seem to
Definition Local anesthetics can cause toxicity to the
be regenerative and clinically imperceptible.
cartilage when injected intra-articularly, which has been
Clinically relevant myotoxicity is very rare and only
demonstrated both in vivo and in vitro in animals and
described in the human literature. In humans, clinical
humans [42–45].
cases of myotoxicity caused by local anesthetics have been
described mostly following continuous peripheral blocks
Risk factorsHigh concentrations of local anesthetics and
and peri- and retrobulbar blocks. [36–38]. A recently
long exposure times (e.g. constant administration pump),
published systematic review of the literature in humans
compared with a single intra-articular injection.
showed that the incidence of myotoxicity in ophthalmic
studies was 0.77% [35]. ● Mepivacaine appears to be the least toxic of the clinically
available local anesthetics and consequently the recom-
Prevention Using low concentrations of local anesthetics, mended drug for intra-articular administration in
especially of bupivacaine (<0.5%), may decrease the risk of practice.
myotoxicity, especially when serial or continuous ● Some studies have shown that low pH, epinephrine
administration is performed. (adrenaline) and some preservatives (sodium
In vitro, co-administration of erythropoietin, dantrolene metabisulfite) worsen the chondrotoxic effects of local
or N-acetylcysteine protects against bupivacaine-induced anesthetic solutions [46].
myotoxicity, but the clinical relevance of these treatments
is not known at present [39–41]. Pathogenesis The chondrotoxicity produced by local
anesthetics is time- and concentration-dependent. In vitro,
Diagnosis Clinically relevant myositits/myonecrosis will when equine chondrocytes are exposed to clinical
cause muscle pain and dysfunction. The symptoms usually concentrations of bupivacaine (0.5%), lidocaine (2%) or
start 1–2 days post-injection and these are maximal at 3–4 mepivacaine (2%), the worse chondrotoxic effects were
days [36]. Human reports of local anesthetic-induced observed with bupivacaine and the least with
myopathy describe the development of pain, swelling and mepivacaine [44]. The chondrotoxic effects of bupivacaine
tenderness of the affected muscle (particularly with activity and lidocaine seem to be mainly due to necrosis [44].
or stretch). However, the most convincing clinical sign for Ropivacaine is also notably less toxic than bupivacaine or
the diagnosis is delayed onset of intense muscle weakness lidocaine [48] and seems to also be less toxic when
in the setting of normal sensory function and well- compared to mepivacaine [48].
maintained deep tendon reflexes [36]. Regeneration occurs Intra-articular administrating of local anesthetics causes
3–4 weeks post-injection [34], and by this time clinical an inflammatory response early after their administration,
recovery is almost complete [36]. as observed in an equine study where a significant increase
in synovial nucleated cell counts peaked 24 hours after
Treatment There is no specific treatment for this, but intra-articular injections of lidocaine or mepivacaine [49].
physical therapy should be instituted as soon as diagnosis This inflammation can also last for a long time, as
is made to preserve remaining muscle function and demonstrated in a study in rabbits where significant
promote recovery. inflammation of the articular cartilage and synovial
membrane was observed up to 10 days after a single
Expected outcome The infrequency of this complication bupivacaine intra-articular injection [50], and in a study in
and the absence of equine reports makes it difficult to give rats where a reduction in chondrocyte density (50%) lasted
a precise estimate of outcome should this complication up to 6 months following a single intra-articular injection
occurs in horses. It is likely that a certain degree of of bupivacaine 0.5% [51]. However, the clinical relevance
subclinical myositis is present after many local blocks but of this inflammatory response following single intra-
articular injections seems to be low as evidenced by the white blood cell count compared with intravenously
lack of equine clinical reports in the literature. administered morphine [63]. Moreover, intra-articular
The clinical effects of intra-articular local anesthetics morphine does not produce any chondrotoxic effects in
may be modified by multiple factors such as: the presence human and equine in vitro chondrocyte viability studies [58,
of intact articular cartilage as opposed to chondrocytes or 64]; therefore, it may also be considered as an alternative
osteochondral tissue used in vitro; the pre-existing effective and safe drug to provide intra-articular analgesia.
(pathological) state of the articular cartilage; dilution of An in vitro study using bovine chondrocytes showed that
the drug by synovial fluid and arthroscopic lavage fluid; exposure to hyaluronan before exposure to bupivacaine
local absorption of the drug into joint structures and blood significantly decreased cell death, suggesting that intra-
vessels; and ongoing joint reparative processes [52]. articular administration of a mixture of local anesthetic
There are no reports of clinical cases of chondrotoxicity and hyaluronan may protect against chondrotoxicity [65].
in equine medicine associated with the use of intra- However, clinical studies are still needed to prove this.
articular local anesthetics. An in vivo study showed that
single lidocaine 2% or bupivacaine 0.5% injection in normal Diagnosis It seems that the chondrotoxic effects of local
equine joints has a limited effect on collagen degradation anesthetics administered as a single intra-articular
markers and suggested that their administration in this injection are subtle and difficult to detect clinically.
manner is safe [53]. In humans, an important number of Chondrolysis is associated with an increase in pain and
clinical cases of chondrolysis have been reported associated progressive loss of joint motion that appear a few months
with the use of intra-articular infusions of local anesthetics after initial surgery, and which progress rapidly (over 4–6
via pain pumps [54, 55]. Only a very few cases of weeks) as described in the human literature [56, 58].
chondrolysis have been reported following a single intra- It is clinically difficult to differentiate the inflammatory
articular injection of bupivacaine (0.25% with process secondary to the reason for performing an intra-
adrenaline) [56]. articular block (e.g. post-arthroscopy pain management)
from that caused by the local anesthetic solution. As stated
Prevention Using mepivacaine at low concentrations as a in previous sections, single administration of local
single intra-articular injection seems not to cause any anesthetics does not seem to cause any clinical problem
clinical problem; however, repeated administration or and the beneficial effects probably outweigh the risks. If
continuous infusion of local anesthetics into joints should joint pain seems to worsen rather than improve following
be avoided. The intact articular surface is not protective intra-articular administration of a local anesthetic,
against local anesthetic chondrotoxicity [43]. chondrotoxicity should be in the list of differentials.
An in vitro study using human chondrocytes showed that Chondrolysis leads to the disappearance of the articular
the addition of magnesium sulphate to four different cartilage very rapidly with loss of joint space as seen in
local anesthetic agents resulted in greater cell viability than radiography, which will later lead to severe osteoarthritis.
when cells were treated with a local anesthetic alone [57].
However, a study using co-cultures of equine cartilage Treatment There is no specific treatment for
explants and synoviocytes found no difference in cell chondrotoxicity and the therapy is aimed at controlling the
viability when they were exposed to a local anesthetic inflammatory response, including non-steroidal anti-
alone or in combination with magnesium sulphate [58]. inflammatory drugs, intra-articular corticosteroids, intra-
Magnesium sulphate administered intra-articularly on its articular hyaluronan and physical therapy. In cases of
own has analgesic properties, it does not cause chondrolysis, arthroscopic debridement and arthroplasty
chondrotoxicity and attenuates the development of are indicated as described in the human literature [56].
experimental osteoarthritis [59, 60]; therefore, it may be
considered as an alternative effective and safe intra- Expected outcome The outcome of extensive chondrolysis
articular drug. in the horse would be catastrophic unless affecting a joint
Intra-articular administration of morphine is an effective that can undergo arthrodesis, such as the proximal intertarsal
analgesic [61] with a longer duration of effect than the long joint or distal intertarsal or tarsometatarsal joints.
acting local anesthetic ropivacaine [62]. Additionally,
intra-articular morphine also possesses anti-inflammatory
AllergicReactions
effects as demonstrated in research horses with acute
synovitis, who showed significantly less joint swelling, DefinitionAllergic or anaphylactic reactions are
lower synovial fluid total protein, lower serum and synovial mediated by immunoglobulin E (IgE) and may occur
fluid serum amyloid A concentrations, and lower blood following administration of any drug. When severe,
termed anaphylaxis, they can lead to shock and death if laryngospasm and pulmonary edema, which if not treated
not recognized and treated promptly. promptly, will lead to the death of the horse. When allergic
reactions develop during general anesthesia, the apparent
Risk Factors severity of clinical signs may be attenuated; however,
anesthesia does not preclude the development of these
● Type of local anaesthetic
reactions [70].
● Previous exposure to the drug
When these reactions occur, especial attention should be
paid to the cardio-respiratory status of the horse and if a
Pathogenesis Type 1 hypersensitivity reactions occur due life-threatening reaction is developing, treatment should
to previous sensitization and formation of IgE antibodies. be instituted immediately. If an allergic reaction occurs
Re-exposure to the drug will cause mast cell and basophil during general anesthesia, even if it is apparently mild, the
degranulation with liberation of histamine, leukotrienes recovery from anesthesia should be closely monitored for
and prostaglandins, leading to an anaphylactic reaction. signs of respiratory obstruction, as laryngospasm could
These reactions normally occur very quickly following occur after extubation [69].
administration of the drug, usually within 10 minutes,
although delayed reactions can also occur and they may Treatment Treatment might not be necessary for mild
progress slowly or rapidly. reactions. If the urticarial reaction is very significant, a
The ester-type local anesthetics (e.g. procaine) cause glucocorticoid ± an antihistamine drug may be
more allergic reactions than the amide-type local anesthet- administered. If the reaction is severe causing
ics (e.g. lidocaine, mepivacaine) due to a metabolite that is bronchoconstriction, laryngospasm, pulmonary edema
produced during ester hydrolysis named p-aminobenzoic and/or cardiovascular collapse, immediate tracheal
acid (PABA). However, some preservatives used in formula- intubation, oxygen supplementation and administration of
tions of amide-type local anesthetics, such as methylpara- epinephrine (adrenaline) are lifesaving. In these instances,
ben or sodium metabisulfite, are metabolized to PABA [66] the administration of fluids and glucocorticoids (e.g.
and therefore they could also cause allergic reactions. methylprednisolone) may also be necessary. In humans, a
There are reports of horses’ deaths due to acute anaphy- systematic review of the literature failed to find any
lactic reactions to some drugs (e.g. trimethoprim sulphadi- evidence supporting or refuting the usefulness of
azine, phenylbutazone, water-soluble benzylpenicillin glucocorticoids for the treatment of anaphylaxis [71].
salts), but to the best of the author’s knowledge, the occur-
Expected outcome When reactions are mild the outcome is
rence of allergic reactions induced by local anesthetics in
generally good even without any treatment [69]. Acute
horses has not been reported.
anaphylactic reactions may lead to the death of the horse if
not treated promptly.
Prevention Skin testing is used in humans with suspected
hypersensitivity to a local anesthetic that require loco-
regional anesthesia, again to determine whether they are
truly allergic and to which drug/s. However, these tests are omplicationsRelatedto Specific
C
rarely positive [67]. Another option is to do an in vitro Loco-RegionalBlocks
leukocyte migration test, but this test has a high rate of
false positives and false negatives [68]. If these tests are not EpiduralAnalgesia
possible, an antihistamine drug (e.g. diphenhydramine,
Ataxia/recumbency
chlorphenamine) could be administered before the suspect
Definition
drug or alternative drugs/therapies may be considered (e.g.
During or shortly after an epidural injection, the horse may
general anesthesia). Cross-reactivity between ester-type
start showing signs of instability of the pelvic limbs and if
local anesthetics occurs in humans, but is not common
severe, this may lead to collapse (recumbency).
between amides or between esters and amides [67].
Risk Factors
Diagnosis The clinical signs of an allergic reaction may be
mild, normally including urticaria with presence of wheals ● Factors that increase the risk of ataxia include:
and/or facial edema, which may be self-limiting and ● High doses and/or volumes of drugs
resolve without any specific treatment [69]. However, an ● Additive effect of epidural drugs when used in combina-
allergic reaction could also be severe and life-threatening tion (e.g. alpha-2 adrenergic agonist + local anesthetic)
with acute bronchoconstriction, hypotension, arrhythmias, ● Additive effect with systemically administered drugs
Complications elated to Specific ocos egional locks 125
● Epidural catheters placed too rostral within the canal When a local anesthetic and an alpha-2 adrenergic ago-
● Pregnancy nist are combined, the dose of the local anesthetic should
● Obesity be reduced. Less lipophilic alpha-2 adrenergic agonist
● Deteriorated clinical condition of the horse (weakness, drugs with less systemic absorption are preferred by the
exhaustion) author (e.g. xylazine instead of detomidine) as they cause
● Excessive speed of injection, irrespective of the drug used less systemic effects and have a longer duration of spinally-
mediated analgesia.
Pathogenesis Sedation and ataxia following epidural
Slow injection (<1 mL/10 seconds) of epidural solutions
administration of different drugs is common in the horse,
while the horse is observed for signs of discomfort and
especially following alpha-2 adrenergic agonist drugs,
ataxia is recommended and the injection should be slowed
due to their systemic absorption and central nervous
or halted if these signs appear.
system effects [72]. Detomidine causes more systemic
effects (sedation, head drop, ataxia) than xylazine when Diagnosis Signs of ataxia related to the administration of
administered epidurally, due to its increased lipophilicity excessive volume/speed of epidural solution appear very
and systemic absorption [73]. There are several studies quickly during or immediately after the injection. Usually
reporting ataxia following epidural administration of signs of discomfort/pain will appear first, with the horse
alpha-2 adrenergic agonists in horses, especially turning its head toward the injection site or moving forward
detomidine [74]. Recumbency has been reported in the stocks [78]. These signs should alert the clinician
following the administration of 50 microg/kg epidural that the injection is too fast or the volume to large. However,
detomidine in a horse [75]. signs of discomfort could be absent in horses previously
Local anesthetic drugs cause non-specific blockade of sedated with an alpha-2 adrenergic agonist. Ataxia related
nerve transmission, therefore causing motor as well as to the spinal effects of alpha-2 adrenergic agonists and
sensory blockade. Ataxia of the hind limbs and potentially local anesthetic drugs appears within 10–25 minutes after
recumbency may occur when high doses of a local the injection.
anesthetic are administered into the sacrococcygeal or
intercoccygeal epidural space due to excessive cranial Treatment If ataxia occurs but the horse is still standing, it
migration (blockade of the caudal lumbar and cranial can be supported with a tail-tie until the hind limbs regain
sacral spinal roots) [76]. the strength. Ataxia caused by an alpha-2 adrenergic
Epidural ketamine can also cause ataxia, although this is agonist agent may be reversed with an alpha-2 adrenergic
usually mild [77]. antagonist such as yohimbine; however, the analgesic
Epidurally-administered opioid drugs (e.g. morphine, effects will also be reversed [74]. If the horse becomes
methadone, etc.) do not produce motor blockade and recumbent, general anesthesia may be necessary to
therefore do not cause ataxia [78]. continue surgery or to avoid injury of the horse and
Some cases of ataxia/recumbency may be related to a personnel if it is very agitated or distressed [81].
local compressive effect from the injected volume of
solution, and not to the spinal effects of the drug, due to Expected outcome Outcome is generally good if the horse
fast administration of a high volume [79]. A total epidural does not undergo any major injury, especially if it becomes
volume of 20 mL administered at a rate of 1 mL every 10 recumbent.
seconds was painful in a study in horses, and the authors
concluded that this was possibly due to compression of Infection inside the spinal canal
sacral and lumbar spinal roots [78]. Definition
Introduction of bacteria into the spinal canal during the
Prevention The most commonly recommended volume of performance of an epidural injection may cause an
epidurally administered drugs in the literature, irrespective infection leading to epidural abscess formation,
of the drug, is 10–15 mL per horse (for an average size osteomyelitis of the vertebrae or diskospondylitis.
horse weighing 500 kg), to avoid excessive cranial migration
and hind limb ataxia. However, higher volumes (20– Risk Factors
30 mLs) of diluted drugs that do not cause motor deficits ● Contamination of the solution that is injected
(i.e. opioids) have been administered without causing ● Lack of aseptic/sterile technique
ataxia [78–80]. ● Advancement of the needle through infected tissue
In pregnant mares or obese horses, the total volume of before entering the spinal canal
epidural solutions should be reduced as the cranial spread ● Immunodeficiency
is increased. ● Indwelling epidural catheters
Pathogenesis Introduction of pathogens inside the spinal difficult in horses due to the large epaxial musculature.
canal during epidural injection may cause spinal abscess There is a case report of a successful dorsal laminectomy
formation, osteomyelitis of the vertebrae or diskospondylitis. performed in a colt with an infection of the spinous process
If the infection erodes through the dura matter this may of the axis [89].
cause septic meningitis. If the osteomyelitis is extensive
this could cause vertebral fracture. Severe infection may Expected outcome In humans, the outcome of spinal
cause sepsis and the death of the patient. infections following epidural injections was excellent with
The author could not find any report of spinal infections early therapy (surgery ± antimicrobials), although there
related to epidural injections in horses. There is one case are few cases of deaths related to this complication [83].
report of an iatrogenic spinal abscess following a
cerebrospinal fluid tap in a horse [82]. Both bacterial and Pruritus
fungal spinal infections have been reported in the human Definition
literature secondary to epidural injections, most commonly Pruritus or itch is a subjective and irritating sensation that
related to steroid injections [83–86]. causes an urge to scratch. It can be more unpleasant than
In a retrospective study looking at the outcome of pain itself [90].
indwelling epidural catheters in an equine hospital, only 3
out of 43 horses developed local inflammation or signs of Risk Factors
increased sensitivity associated with the catheter site, but ● Administration of neuraxial (epidural and intrathecal)
none of these horses developed any other clinical sign and opioids
bacterial culture of the catheter did not yield any ● Higher doses
growth [87]. A similar retrospective study in dogs did not ● Pregnancy
report any spinal infection, only a low incidence of ● Co-administration of epinephrine (adrenaline) with
inflammation and infection at the catheter entry site that epidural opioids (controversial)
resolved after catheter removal without treatment [88].
Pathogenesis The administration of neuraxial (epidural
Prevention Hair clipping, surgical preparation of the skin and intrathecal) opioids has been shown to induce pruritus
and strict sterile technique using sterile needles and sterile in several species, including horses, sheep, dogs, rats and
solutions should minimize the occurrence of this humans. This side effect appears to be dose-dependent.
complication. A sterile adhesive surgical drape should be The exact mechanism/s of opioid-induced pruritus is
placed over the entry site of indwelling epidural catheters. unclear, but it is likely that more than one mechanism is
The epidural injection should not be performed if there is involved, including the mu and kappa opioid receptors,
any sign of infection in the skin or underlying tissues modulation of serotonergic pathways, prostaglandins
where the needle needs to penetrate. release [91] or the activation of 5-HT3 receptors [92]. In
horses, the few reported cases of pruritus were associated
Diagnosis Clinical signs will depend on the localization of with epidural administration of morphine (preservative-
the infection and its extension. The most common free) through an epidural catheter alone [93, 94] or in
symptoms associated with an infection in the spinal canal combination with detomidine [95]; therefore, it could not
reported in humans are pain of the affected vertebral be totally ruled out that pruritus was caused by local
region and malaise. Horses with vertebral abscesses may irritation due to the catheter itself or by detomidine or its
present with pain, heat, swelling and crepitus over the preservative.
affected area, and with signs of bacteremia (i.e. fever, In humans, parturients are the most susceptible to this
anorexia, depression). Neurologic deficits may also be complication, which may be due to the interaction of
present, depending on the degree and level of spinal cord estrogen with opioid receptors [91].
compression. The final diagnosis is reached with imaging Co-administration of epinephrine (adrenaline) may
modalities and cerebrospinal fluid tap and culture. increase the severity or duration of the pruritus as it
decreases the vascular uptake of the opioid from the
Treatment For vertebral abscesses, the treatment consists epidural space, increasing its concentration, although the
of prolonged antimicrobial therapy, ideally based on results evidence is conflicting [91].
of culture and antibiogram of the pathogens involved. In In horses, there are only 3 case reports (4 horses) of
humans, treatment of these infections consists of surgery pruritus associated with epidural administration of
(debridement and/or laminectomy) and antibiotic/ morphine through an epidural catheter [93–95]. The
antifungal treatment. Access to the infected area may be incidence of this complication in horses is unknown but in
a retrospective study on the outcomes of epidural subarachnoid space causes migration to the brain, resulting
catheterization in 43 cases, no horses developed in anesthesia of the brainstem.
pruritus [87]. In humans, the reported incidence of pruritus In humans, the incidence of central nervous system
after neuraxial opioids is between 30% and 100% [91]. complications presumed to be caused by spread of the local
anesthetic to the brainstem was estimated at 0.27% [98]. In
Prevention The lowest effective dose of neuraxial opioid horses, there are no case reports of this complication in the
should be used. In humans, there is no totally effective literature, but in a cadaveric study of ultrasound-guided
preventive treatment, although ondansetron (a 5-HT3 retrobulbar blocks inserting the needle into the orbital
receptor antagonist), propofol and non-steroidal anti- fossa dorsal and caudal to the eye, injection of contrast
inflammatory drugs administered prophylactically media into the optic nerve sheath could be confirmed in 1
decreased the incidence of neuraxial opioid-induced in 40 cases [99]. The authors of this paper acknowledge
pruritus [91]. that ultrasound visualization of the optic nerve in this case
was not possible. In other animal species, brainstem
Diagnosis Pruritus following intercoccygeal epidural anesthesia was suspected following a retrobulbar block in a
administration of morphine in horses typically occurs cat under general anesthesia [100].
around the tail and gluteal areas [93–95]. Reported clinical
signs include self-excoriation due to rubbing of these Prevention Using short-beveled (spinal needle) and
caudal areas with walls, focal alopecia, biting of the flanks shorter needles decreases the chance of puncturing the
and even rolling on the back in apparent attempts to scratch optic nerve sheath. Using the lowest effective volume
the rump area. (recommended 8–10 ml for a standard size horse) reduces
the caudal spread toward the brain in case of puncture.
Treatment In the equine case reports, treatment consisted Of the three techniques described in horses to perform a
of removal of the epidural catheter and continued retrobulbar block: four-point block; modified Peterson;
administration of phenylbutazone (which had been already and injection into the orbital fossa above the dorsal orbital
initiated to treat the painful condition of the horse), and rim and zygomatic arch, the latter has been suggested to
pruritus subsided over the following hours. In humans, decrease the risk of optic nerve penetration. Ultrasound-
treatment of stablished pruritus consists of the use of an guidance during placement of the needle within the
opioid antagonist (naloxone, nalbuphine), propofol or retrobulbar muscle cone may increase not only the
ondansetron, but none of them is totally effective [91]. In effectiveness but also the safety of this block if the optic
cats, pruritus has been successfully treated with nerve is visualized and avoided [99]. Resistance during
dexmedetomidine and ondansetron [96] or naloxone [97]. injection of the local anesthetic may be due to intraneural
injection, in which case it should be immediately stopped
Expected outcome Pruritus is very uncomfortable to the and needle repositioned.
patient and can lead to self-trauma, but outcome is good if
no complications occur in the traumatized skin regions Diagnosis Symptoms first appear within 2 minutes of
(e.g. infection). injection. Signs reported in humans include confusion,
shivering, seizures, paralysis, loss of consciousness, apnea,
hypotension, bradycardia, and nausea/vomiting [101].
RetrobulbarBlocks
Respiratory arrest is the most common sign in humans and
rainstem anesthesia can last up to 30–60 min [98]. Neurological signs tend to
Definition resolve in 1–2 hours post-injection, although in some cases
Brainstem anesthesia results from spread of the local they may last for up to 12 hours [98]. In a cat that had
anesthetic from the retrobulbar space directly to the brain. suspected brainstem anesthesia following retrobulbar block
during general anesthesia, the observed signs included
Risk Factors apnea, tachycardia and hypertension, within 5 min of
● Long-beveled needles injection, and delayed recovery [100]. Upon recovery from
● Long needles anesthesia, the cat presented tremors and nystagmus,
● High volume of local anesthetic lasting 20 minutes, and absent menace response, mydriasis
● Technique and lack of dazzle and pupillary light reflex lasting 3 hours.
Pathogenesis Inadvertent puncture of the dural optic Treatment There is no specific treatment. In the event of
nerve sheath and injection of the local anesthetic into the respiratory arrest of a horse during general anesthesia
following a retrobulbar block, intermittent positive masticatory trauma to desensitized oral tissues [103].
pressure ventilation should be instituted. The horse should Longer withholding times are necessary if a long-acting
not be recovered from anesthesia at least until spontaneous local anesthetic is used (e.g. bupivacaine).
ventilation has been resumed. In recovery, the horse should An intra-oral technique has been described that uses a
be heavily sedated and anticonvulsive treatment readily lower dose of anesthetic solution compared with the extra-
available. Sling recovery may be considered. If brainstem oral approach (5 mL vs. 10–20 mL) and allows a more
anesthesia occurs with the horse standing, this could pose precise placement, which may decrease the chance of
a risk to the personnel as the horse may collapse and/or tongue paralysis and post-procedural self-inflicted
seizure. Symptomatic treatment should be instituted (e.g. trauma [104].
induction of general anesthesia, tracheal intubation, It has been recommended that in cases where lingual
positive pressure ventilation, anticonvulsive treatment). nerve blockade is suspected, the horse should be resedated
and a full mouth speculum maintained in place at the end
Expected outcome In humans, the possibility of death of the procedure to prevent this complication until
because of this complication is rare (0.13%) [98]. The cat of sensation returns to the tongue [102].
the case report with suspected brainstem anesthesia made
a full recovery with no neurological consequences [100]. In Diagnosis Oral examination will reveal lingual lacerations.
horses, it is unknown what the outcome would be as there
are no reports in the literature, but due to the size and Treatment The treatment instituted in the reported cases
temperament of horses it is suspected that the outcome included broad spectrum antibiotics, anti-inflammatories,
would not be good should this complication occur. and antiseptic rinse [1]. The mouth may be washed with
dilute chlorhexidine twice daily for a few days, until the
InferiorAlveolarNerveBlock(Maxillaryblock) wounds heal [102]. If the wounds are extensive it is
recommended to observe the horse during feeding to look
Selfsinflicted lingual trauma
for signs of pain and difficulty eating.
Definition
The horse biting its own tongue following blockade of the
Expected outcome The outcome was good in all the
lingual branch of the mandibular nerve
reported cases, with complete healing of the lingual
wounds by week 6–7 post-trauma.
Risk Factors
● Early feeding post-blockade IntravenousRegionalAnesthesia(IVRA)

● Bilateral blocks
● Extra-oral versus intra-oral technique (theoretical) Tourniquet failure
Definition
Pathogenesis When the inferior alveolar nerve is blocked If a tourniquet is not effective it will fail to maintain the
at the level of the mandibular foramen, the lingual nerve, local anesthetic within the distal limb, leading to block
another branch of the mandibular nerve, may also be failure and potentially systemic local anesthetic toxicity.
blocked. The lingual nerve provides sensory innervation to
Risk Factors
the rostral two-thirds of the tongue. This may result in the
horse biting its tongue inadvertently, especially if the block ● Type of tourniquet (width)
has been performed bilaterally. ● Greater diameter of the limb
There is a published report of three horses with self- ● No previous exsanguination of the limb
inflicted lingual trauma secondary to extra-oral inferior
alveolar nerve block, one of which was a bilateral Pathogenesis An intact tourniquet is necessary to establish
block [102]. In these cases, a total volume of 15 or 20 mL of and maintain IVRA. If failure of the tourniquet occurs, the
mepivacaine per site was used. A recent retrospective study local anesthetic will leak into the systemic circulation. If
of complications related to dental blocks also reports 2 the amount of local anesthetic leaked is high enough, it can
cases of self-inflicted lingual trauma, both secondary to cause systemic signs of toxicity such as seizures, which is
maxillary nerve block, 24 hours following unilateral or the most common complication of faulty tourniquet
bilateral blocks [1]. reported in the human literature [105].
There are no reports of systemic toxicity due to leakage
Prevention It has been recommended to withhold food for of local anesthetic during IVRA in horses. The occurrence
2 hours following the block to prevent aspiration of feed or of systemic toxicity manifesting as seizures due to local
anesthetic leakage during IVRA in humans is very rare, local changes from the anaerobic metabolism and upon
with an incidence of 2.7 per 10,000 cases [105]. release of the tourniquet the pooled blood and metabolites
from the ischemic limb are released into the systemic
Prevention In horses, three types of tourniquets were circulation. The extreme situation would be what is called
compared showing that a wide rubber tourniquet (12.5 cm) in human medicine “rescue cardioplegia,” which consists
and a pneumatic tourniquet (10.5 cm cuff at 420 mmHg) of myocardial stunning (stopping) that can occur
had greater efficacy than a narrow rubber tourniquet (1 immediately following the release of a compressing force,
cm) [106]. Wide tourniquets transmit a greater percentage harness or tourniquet [108].
of the applied pressure to deeper tissues and lower
pressures are therefore needed, which also helps reduce Risk factors
the possibility of soft-tissue/nerve damage [107]. The
diameter of the extremity was a determining factor in the ● Long tourniquet application time
pressure needed to eliminate blood flow with narrow cuffs ● Decreased cardiovascular reserve (e.g. geriatric, cardiac
but not when using an 18-cm cuff [107]. disease, general anesthesia)
Inadequate or no exsanguination before tourniquet ● Pre-existing acid–base imbalances
placement makes it is more likely to exceed the tourniquet ● Quick tourniquet release
inflation pressure during the injection of the solution,
which will result in leakage of the local anesthetic into the Pathogenesis Tourniquet ischemia results in anaerobic
circulation [101]. Exsanguination of the limb before metabolism, decrease in pH and accumulation of
tourniquet placement (e.g. with an Esmarch rubber extracellular lactic acid, CO2, adenosine, potassium and
bandage) is therefore recommended. ionized calcium. When the tourniquet is removed, these
metabolites are released into the systemic circulation
Diagnosis If there is leakage of local anesthetic into the causing systemic mixed metabolic-respiratory acidosis,
circulation the block will be inadequate, which is the most hyperkalemia and hypercalcemia. The longer the
common sign of tourniquet failure in horses. If a high ischemic period the greater the accumulation of these
volume of local anesthetic is leaked, signs of systemic local metabolites and the systemic acid-base imbalances upon
anesthetic toxicity may appear, including rapid eye reperfusion. The clinical consequences of these alterations
blinking, anxiety, ataxia, sedation, muscle tremors and are minimal in healthy patients with normal
collapse [9]. However, this seems unlikely in horses as the cardiovascular status; however, in patients with limited
volume of local anesthetic solution injected for IVRA in cardiovascular reserve capacity or patients with pre-
the distal limb of a standard size horse would be between existing acid–base imbalances, the sudden release of
30 and 60 mL, which would be a 1.2–2.4 mg/kg dose of these metabolites may lead to clinically relevant
lidocaine 2% in a 500-kg horse. This dose is within the cardiovascular effects including arrhythmias, decreased
clinical dose of systemic lidocaine. myocardial contractility, vasodilation with resultant
hypotension, or even cardiovascular collapse.
Treatment If the block is inadequate, the tourniquet When the tourniquet is released quickly, the cold pooled
should be repositioned and the block performed again (this blood under pressure in the congested limb is rapidly
will increase the total administered dose of local anesthetic released into the systemic circulation, leading to a quick
and therefore the risk of systemic toxicity should the transient increase in preload to the right heart [108]. This
tourniquet fails again). An alternative block may be results in sudden atrial stretch, which could potentially
considered. If systemic signs of toxicity are observed the stun the myocardium into asystole or initiate atrial fibrilla-
treatment is detailed in the General complications tion [109]. Limb reperfusion also leads to a sudden reduc-
“Vascular Puncture” section earlier in this chapter. tion of systemic vascular resistance and venous pooling,
also called post-ischemic reactive hyperemia, which results
Expected outcome The outcome of systemic toxicity is in decreased venous return and cardiac output (~18% in
detailed in General complications “Vascular puncture” humans) [110].
earlier in the chapter. Staggered tourniquet release (deflating the tourniquet
for 30 sec and subsequently re-inflating it to 300 mmHg for
ocal and systemic effects of tourniquet ischemia 3 min, and repeating this sequence 3 times), led to lower
Definition serum lactate concentration and CO2 and less hypotension
During tourniquet application, there is no blood flow to the and bradycardia following the release compared to a stand-
limb, resulting in ischemia. During this time, there are ard quick removal of the tourniquet [108].
There are no published reports of fatalities as a conse- into the systemic circulation and will reduce the cardiovas-
quence of IVRA or intravenous regional limb perfusion in cular consequences of limb reperfusion.
horses, which indicates that it is probably a very safe tech-
nique. A mild and transient decrease in blood pressure is Diagnosis The clinical manifestations of tourniquet
usually observed in the experience of the author after the release may include hypotension, brady- or tachy-cardia,
release of a tourniquet in horses under general anesthesia. arrhyhtmias, tachypnea, and in extreme cases
cardiovascular collapse or cardiac arrest. Close monitoring
Prevention The absolute safe limit of tourniquet duration of the cardiovascular system is therefore recommended
has not been established and may depend on location and during and at least 30–40 min following tourniquet release.
vary from animal to animal. The usual clinical
recommendation is to limit the time of tourniquet to 2 Treatment In healthy animals and when the cardiovascular
hours, although in the author’s clinical experience this changes are mild, no treatment is necessary. In cases of
time has sometimes been exceeded with no negative severe hypotension or cardiovascular collapse, supportive
consequences. In experimental rhesus monkeys, the treatment with intravenous fluids, positive inotropic drugs
systemic changes produced as a result of the application of (e.g. dobutamine) and/or vasoconstrictors (e.g.
a tourniquet for periods of up to 3 hours were not marked phenylephrine) may be necessary. Also, a venous blood
and readily reversible, and the local acid–base changes in sample should be obtained to check acid–base balance and
the ischemic limb recovered in less than 40 min post- serum electrolytes, and treat derangements (e.g.
release [111]. However, it should be noted that these were hyperkalemia, hypercalcemia) as necessary.
healthy animals, and shorter tourniquet times are
recommended in debilitated animals. Expected outcome The outcome is good if the cardiovascular
It is recommended to use a staggered tourniquet release, effects are mild, but it could be fatal if cardiovascular
which will both avoid a sudden release of local anesthetic collapse or cardiac arrest occur.
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135
15
Complicationsof Sedativeand AnesthesiaMedications

Rachel C. Hector DVM, MS, DACVAA and Khursheed Mama DVM, DACVAA
Overview cannot always predict an individual animal’s response to

the drug or drug combinations used to facilitate the
This chapter will highlight key concerns and briefly address procedure, and a variety of behaviors may manifest that
management of complications associated with use of could result in injury to the horse or personnel. These
sedative and anesthesia medications and drug-induced include unexpected movements (kicking/striking), panic,
recumbency in horses. ataxia, or even collapse.
Risk Factors
L
Poor patient temperament (e.g. flighty, restless, fractious,
with Sedativeand Anesthesia
●
or aggressive horse)
Medications
● Noxious stimulus from the surgical procedure
● Complications during standing sedation ● Irregular or slippery floor surfaces
● Complications during general anesthesia ● Unexpected environmental sounds or stimuli
– Unanticipated movement ● Inadvertent overdoses of medications by epidural or sys-
– Hypotension temic route
– Cardiac arrhythmias ● Inadvertent intra-arterial (e.g. intra-carotid) drug
– Hypoventilation administration
– Hypoxemia
– Aberrations in body temperature
Pathogenesis Ataxia is a common manifestation of alpha-2
● Complications during anesthetic recovery adrenergic agonists, the most frequently used sedatives in
– Poor recovery quality equine practice. Ataxia is considered to be less profound
with romifidine as compared to detomidine and
● Other complications associated with sedative and anes- xylazine [1]. Anecdotally, phantom limb movements (i.e.
thetic drugs kicking) or aggressive behaviors (such as biting) in even
– Increased urine output normally amenable horses following alpha-2 agonist
– Blood glucose abnormalities administration have also been observed by many who work
– Decreased gastrointestinal motility with horses [2, 3].
Excitement and increased locomotor activity may be
seen when opioids are used in the absence of adequate
omplicationsDuringStanding
C sedation (e.g. without an alpha-2 agonist or aceproma-
Sedation zine), particularly at high doses and in the absence of
pain [4]. The degree to which behavioral opioid side effects
Definition Many surgical procedures can be performed manifest is individually variable and is possibly related to
safely in horses using standing sedation. However, one genetic mu opioid receptor polymorphism [5].
136 Complications of Sedative and Anesthesia edications
A phenomenon termed “epinephrine reversal” may dural space should be limited to less than 10 ml in an
occur with administration of acepromazine alone to an adult normal size horse [9].
already excited horse. Drug-induced alpha-1 adrenergic
blockade unmasks beta-2 adrenergic activation produced
Treatment If a horse becomes recumbent, the area around
by circulating catecholamines, causing significant
the horse should be cleared of equipment and non-essential
decreases in vascular resistance that result in severe
personnel. Depending on the cause of collapse, some
hypotension and collapse [6].
horses may stand immediately. Some may be extremely
Intra-arterial injection of sedative drugs typically causes
agitated while others calmer. Supportive care may be
near-immediate agitation, collapse, and convulsions that
required (e.g. large volume intravenous fluids, padding,
may resolve over the course of several minutes to an hour.
extraction from a particular position, or physical assistance
Death can occur acutely, or long-term neurological side
to stand) while drugs are metabolized or in some cases
effects may dictate euthanasia [7].
reversed. If the horse has sustained serious injury, general
Recumbency can be seen following weakness or paralysis
anesthesia may be required to assess and/or treat the horse
of the hind limbs induced by migration of drugs injected
or complete the procedure.
into the inter-coccygeal (caudal) epidural space to the
lumbar region, where the motor nerves to the pelvic limbs
originate. This is most likely to occur with high volumes of Expected outcome If potential behavioral problems are
local anesthetics, whose mechanism of action includes recognized early and the procedure can be halted or
both sensory and motor blockade, but has been reported different drugs or techniques selected, there may be no
with alpha-2 agonists [8]. long-term consequences to the horse. However, catastrophic
While there is little work documenting the incidence of injury can occur, in some cases necessitating extensive
serious drug-related complications during standing further treatments (e.g. long bone fracture repair) or
procedures, in the authors’ experience “breaks” in horse euthanasia.
behavior happen with some regularity. These can occur at
any time during a procedure and be very sudden in nature,
and can include aberrations such as horses dramatically omplicationsDuringGeneral
C
“exiting” the stocks. Though plenty has been written about Anesthesia
the commonly used sedatives, there is no data to support
the superiority of one drug or combination of drugs over UnanticipatedMovement
another for all possible procedures. Much success relates to
Definition Unexpected movement (e.g. of the limbs or
the experience of the person administering the sedation
head) during anesthesia may be considered a complication,
and the individual characteristics of the horse.
as it may result in injury to the horse or personnel and
damage to surgical and anesthesia equipment.
Prevention Patients for standing procedures should be
carefully selected, as some horses are not amenable to
Risk Factors
standing surgery even when sedated with standard drug
dosages. The surrounding environment should be closely ● Inadequate dosing of anesthetic drugs
monitored and efforts made to reduce ambient noise, ● Lack of experience monitoring or attention to anesthetic
provide footing with traction, and limit distractions. depth
Thoughtful selection of sedative and analgesic drugs ● Ophthalmic procedures
should be based on patient and procedure, including the
use of local anesthetic techniques when possible. Delivery
Pathogenesis Movement occurs primarily as a result of
of sedative drugs via an intravenous catheter is preferred
inadequate depth of anesthesia. However, it is the authors’
rather than “off the needle” to reduce risk of inadvertent
experience that some horses will move without warning,
intra-arterial injection, particularly when multiple doses of
even when maintained at what appears to be an appropriate
sedatives must be given.
plane of anesthesia based on objective and subjective
Using opioids such as butorphanol or morphine as a
monitoring parameters.
part of the sedation protocol in combination with an
alpha-2 agonist does not guarantee prevention but is
thought to reduce the likelihood of sudden movements/ Prevention While it seems obvious that anesthesia depth
phantom kick behaviors. To avoid hind limb paralysis, the influences movement on the surgical table and the answer
volume of local anesthetics injected into the caudal epi- is to keep the horse at a deeper plane of anesthesia, this is
Complications During General Anesthesia 137
confounded by the negative effects of the inhalation respiratory rate can increase during a light plane of
agents on cardiorespiratory function and the potential for anesthesia and before movement occurs.
other complications (even death) with an anesthetic The use of anesthetic agent analyzers may be useful to
overdose. guide inhalation anesthesia dose if available. Anesthetic
The use of adjunctive medications with analgesic or depth assessment can be challenging when injectable
inhaled anesthetic sparing properties may be beneficial [10– anesthetic agents are used in combination with inhalants
13]. Infusions of ketamine, lidocaine, alpha-2 adrenergic or as the sole means of maintaining recumbency as reflexes
agonists (e.g. xylazine, detomidine, romifidine, used to assess depth as described above are better
medetomidine, dexmedetomidine), guaifenesin, maintained [23].
benzodiazepines, and propofol have been used for this Much has been written on the use of adjunctive anes-
purpose. When considering the use of any adjunctive drug, thetic techniques, and the reader is referred to in-depth
the cardiorespiratory effects must be weighed against the reviews of partial or total intravenous anesthesia in
overall health status of the horse. For example, while horses [24]. Documentation regarding movement during
alpha-2 agonists have been shown to provide analgesia, anesthesia however is sparse, but it is reported that
reduce the minimum alveolar concentration (MAC) of horses undergoing ocular surgery are more likely to
inhalant anesthetics, and improve recovery quality in move during the procedure as compared to horses under-
horses, they also cause significant decreases in cardiac going orthopedic procedures. This is perhaps related to
output. Other drugs may have better cardiovascular effects the fact that ocular signs commonly used to monitor
but negatively influence recovery quality. Benefits and anesthetic depth are hidden from the anesthetist in these
risks of individual drugs should be evaluated in context of types of surgeries. Interestingly, the use of a gas analyzer
the individual case. improved the odds that horses would remain motionless,
The literature is inconclusive with regard to the benefit though horses undergoing enucleation still tended to
of systemically administered opioids as an anesthetic move even when end-tidal inhalant concentrations were
adjunct [14]. Mu opioids largely tend to increase MAC for monitored [25].
inhaled anesthetics or do not enhance inhalant anesthetic Some work has been done evaluating bispectral index
sparing properties of other infusions [15–17]. Provision of (BIS) monitoring in anesthetized horses. This type of
regional opioids (e.g. intra-articular or epidural monitoring was developed to attempt to provide an
administration) has been definitively shown to be beneficial objective measure reflecting the level of hyponosis of the
for analgesia [18–20]. patient based on electroencephalogram tracings,
The use of regional anesthesia techniques (e.g. intra- predominantly in human medicine where neuromuscular
testicular block for castration [21], distal limb blocks) can blockade is commonly used and accidental awareness is a
minimize the potential for horse movement while also particular problem. Data in horses is conflicting, but
providing analgesia and a reduced need for systemically studies indicate that depending on the drug, BIS might be
administered anesthetics. somewhat predictive of depth of anesthesia but not always
For procedures in patients where involuntary movement of intraoperative movement [26–28].
is difficult to manage, neuromuscular blocking drugs could
be administered to prevent further movement. The
anesthetist is cautioned to ensure that horses are Treatment Adjustments can be made to anesthetic depth
concurrently administered appropriate doses of anesthetic as described above, keeping in mind that should a horse
and analgesic drugs, as neuromuscular blocking drugs do become light enough to move during a general anesthetic
not have either of these properties. The use of maintained with inhalants, a rapid bolus of an injectable
neuromuscular blockade alone to immobilize a horse anesthetic (e.g. ketamine, thiopental) is required prior to
should be considered inhumane. Additionally, the ability subsequent adjustment of the vaporizer setting. This is
to provide positive pressure ventilation is critical. because changes in the amount of inhalant anesthetic
delivered to the horse are slowed several minutes by the
Monitoring Generally, the responsibility falls to the large reservoir volume of large animal anesthetic circuits.
individual managing the horse’s anesthesia care to
determine depth based on a combination of behavioral and
Hypotension
physiological parameters. With inhalant anesthetics, a
light plane of anesthesia is typically dictated by a brisk Definition Blood pressure values from calm, unsedated
palpebral reflex, lacrimation, spontaneous blinking, and horses range from 120–140, 80–100, and 100–120 mmHg
rapid nystagmus [22]. Heart rate, blood pressure, and for systolic, diastolic, and mean arterial pressure,
respectively [29]. A target mean arterial blood pressure bolus for the treatment of hypotension. The anesthetist
between 70 and 90 mmHg is suggested for anesthetized should be aware that ephedrine is a central nervous system
horses, depending on the horse’s size and corresponding stimulant and its provision may result in a lightened plane
muscle mass, padding, and anticipated duration of of anesthesia. Tachyphylaxis (progressively less drug effect
anesthesia. In foals, blood pressure may be maintained at with subsequent dosing) is also seen, as ephedrine’s
lower values (mean arterial blood pressure between 50 and mechanism of action involves release of stores of
65 mmHg) depending on their age and size, in keeping endogenous catecholamines that eventually become
with values considered normal for them [30, 31]. depleted [37].
In patients with volume depletion, replacement of
Risk Factors volume (e.g. crystalloid or colloid bolus, blood transfusion)
should be attempted. Foals with anesthetic-induced
● Use of inhalant anesthetics, especially in the absence of
hypotension will also often respond positively to a
inotropic support
crystalloid fluid bolus (5–10 ml/kg). It may be challenging
● Patients with systemic disease or compromise (e.g. endo-
to provide the appropriate volume rapidly in an adult
toxemia, hypovolemia)
horse, and fluid pumps can aid in providing large volume
replacement.
Pathogenesis Hypotension is a common, even expected,
Vasoconstrictive drugs such as norepinephrine,
complication with use of inhaled anesthetics in the horse
phenylephrine, or vasopressin may also be used if the cause
as they dose dependently resulting in reduction of
of hypotension is deemed to be related to inappropriate
myocardial contractility. In medically compromised
decreases in systemic vascular resistance (e.g. as seen with
horses, inhaled anesthetics may also induce vasodilation
endotoxemia).
as has been reported in human beings [32]. Data from
The use of concurrently administered medications such
horses in which inhalation anesthetics were administered
as the alpha-2 adrenergic agonist drugs can help improve
in absence of other medications shows blood pressure and
blood pressure due to their effects on vascular smooth
cardiac output reaching about half of normal awake
muscle receptors. Following a single dose of intravenously
values described in the horse at a surgical plane of
administered drug in both the standing and anesthetized
anesthesia [33, 34].
horse, the duration of this vasoconstrictive effect is drug
dependent [38, 39], but when given by a constant rate
Prevention Ability to monitor blood pressure as well as infusion, the effect is sustained with all these drugs [40–
knowledge and availability of the drugs used to support 42]. Whether used as part of an injectable [40] or
blood pressure during anesthesia maintenance are inhalation [43] protocol, heart rate is likely to decrease
important in preventing hypotension and its consequences. with a corresponding decrease in cardiac output; second-
degree heart block, sinus pauses, and occasionally
Monitoring While indirect monitoring (e.g. cuff, Doppler) ventricular escape beats may also be evident following
may be used for short procedures in healthy horses with administration of alpha-2 agonist drugs. This effect is most
anesthesia times of less than 1 hour, direct arterial blood notable after high-dose intravenous administration. The
pressure monitoring is generally recommended for consequence of a significant decrease in cardiac output in
inhalation anesthesia. Arterial catheters are commonly the face of increased vascular resistance (and thus normal
placed percutaneously in the facial, transverse facial, or blood pressure) on organ function has not been fully
dorsal metatarsal arteries. elucidated for the horse.
Treatment The positive inotrope dobutamine is ideal for Expected outcome Hypotension during anesthesia can
treatment of hypotension as it counters the decrease in range from mild and short-lived to prolonged and life-
cardiac contractility caused by the inhalation agents and threatening. Horses that experience sustained hypotension
improves both cardiac output and blood pressure. are at risk for end-organ dysfunction as a result of poor
Dobutamine also increases intramuscular blood flow in perfusion.
both the dependent and non-dependent limbs of Documentation of the deleterious consequences of
anesthetized horses [35]. Dobutamine is used as a constant hypotension are available in humans, where low mean
rate infusion due to its short duration of action. arterial blood pressure (<55 mmHg) for as little as 10–20
Ephedrine also increases blood pressure, cardiac output, minutes during anesthesia is associated with an increased
and muscle blood flow in horses [36]. Due to its relatively risk of acute kidney injury, myocardial damage, and 30-day
longer duration of action, it is given as an intravenous mortality [44]. Although data of this kind is not available
in horses, it is prudent to consider that the same Pathogenesis Bradycardia and bradyarrythmias are
physiological consequences are possible and thus hypoten- commonly seen in horses with the use of alpha-2 adrenergic
sion should be treated. agonists as a result of both central decreases in sympathetic
Specific to horses, an early landmark experimental study tone and a baroreceptor-mediated response to hypertension.
showed that myopathy associated with hypotension (mean These are also common as vagally-mediated physiological
blood pressure of 55–65 mmHg for over 3 hours) during arrhythmias in normal horses and should disappear during
inhalation anesthesia in horses contributes negatively to physical activity [50]. Pathological high-grade second-
recovery from anesthesia and survival [45]. In addition, a degree or third-degree AV block as a result of toxicities,
long duration of hypotension poses a greater risk for the electrolyte derangements, or AV nodal dysfunction occurs
development of myopathy in clinical cases [46]. Since this but is rare in horses [51, 52].
time, the widespread use of the positive inotrope Tachycardia and ventricular tachydysrhythmias, while
dobutamine to maintain mean arterial pressure above 70 not common during equine anesthesia, may occur with
mmHg has significantly reduced the severity of post- concurrent use of sympathomimetics and anticholinergics
anesthetic myopathy cases [47]. or with the combined use of two sympathomimetics in an
Additionally, it has been shown that (direct) blood effort to improve blood pressure. Ventricular arrhythmias
pressure monitoring reduces the risk of cardiac arrest can also be observed in medically compromised horses,
death in horses [58, 49], possibly because hemodynamic especially if anesthetized prior to adequate fluid
problems are detected and corrected earlier in their time resuscitation. As compared to adult horses, foals tend to
course. respond to inotropes with an increase in heart rate, which
in turn results in an increase in cardiac output [30]. This is
thought to result from the inability of the foal to increase
CardiacArrhythmias
contractility due to immature cardiac muscle development.
Definition Resting heart rate for horses ranges from 28–44 Tachycardia can occur as a response to the underlying
beats per minute and some variation in heart rhythm, such disease process, such as sepsis or endotoxemia associated
as second-degree atrioventricular (AV) block, is considered with bowel disease. Tachycardia may also occur in response
normal in athletic animals. Interestingly, it is not clear how to noxious stimulation and is anecdotally observed with
low a heart rate is too low when considering treatment of surgical interventions in well innervated areas, for example
the same in the perianesthetic period, but experienced during surgical neurectomies. Large volume hemorrhage
anesthesiologists will often express concern with rates commonly results in tachycardia as a response to
below 18–20 beats per minute. While it is common to see hypovolemia in other species, but this response may not be
premature atrial contractions in anesthetized horses, they seen in anesthetized horses until volume loss is
seem to be of no particular consequence. Atrial fibrillation, near-fatal [53].
which is occasionally observed during anesthesia, can Atrial fibrillation can be considered “lone” (occurring in
cause cardiovascular compromise depending on the the absence of underlying structural cardiac disease), and
ventricular rate. In general, a rate similar to the normal this is seen not uncommonly in racehorses and draft
heart rate for the horse allows for better cardiac filling and horses. Atrial fibrillation can occur for the first time under
maintenance of cardiac output and blood pressure. anesthesia in a horse with no signs of cardiac disease [54],
or it can develop in horses with cardiac disease and/or
Risk factors for bradycardia/bradyarrythmias Horses with cardiac failure with atrial enlargement.
high fitness levels While structural cardiac disease-causing arrhythmias is
common in humans and small animals, arrhythmias seen
● Use of alpha-2 adrenergic agonists
in horses are more commonly associated with systemic
● Underlying cardiac disease
disease or as a result of drugs used during anesthesia.
Normal horses have supraventricular arrhythmias or AV
Risk factors for tachycardia/tachyarrhythmias Use of
block, whereas horses with colic also have ventricular
anticholinergics
arrhythmias [55]. Endotoxemia associated with colic is
● Use of positive inotropes, especially at high doses or thought to be a primary cause of myocardial injury, which
more than one at a time results in the development of ventricular arrhythmias.
● Surgical procedure of a highly innervated area Cardiac troponin I is used as a biomarker for myocardial
● Hypovolemia, endotoxemia, sepsis, systemic damage in humans, dogs, and horses. Its concentrations
inflammatory response syndrome are elevated in septicemic foals and adult horses with both
● Underlying cardiac disease experimentally-induced endotoxemia and naturally
occurring colic [56]. Horses presenting for colic with high When long acting alpha-2 adrenergic agonists are used
cardiac troponin I concentrations are more likely to have a as anesthetic pre-medication, concurrent administration of
strangulating lesion (thus requiring surgery), have acepromazine results in a higher heart rate than that seen
ventricular arrhythmias, and experience a poorer outcome with the alpha-2 agonist alone [62] because the vasodilatory
than horses in which is cardiac troponin I is normal properties of acepromazine offset the baroreceptor-induced
[57, 58]. bradycardia from the alpha-2 agonist. Additionally,
acepromazine use has been shown to reduce the prevalence
Monitoring A three-lead electrocardiogram (ECG) can be of arrhythmias during the anesthesia period [63].
used during anesthesia for the diagnosis and monitoring of Pathologic arrhythmias in horses (e.g. high-grade
cardiac rhythm disturbances. A commonly used second-degree AV block and third-degree AV block) are
configuration of ECG leads used by cardiologists is to place treated via pacemaker implantation [64]. In these horses,
the negative electrode in the right jugular groove, the elective procedures should not be performed until the
positive electrode on the thorax near the left elbow, and the cardiac rhythm disturbance has been successfully treated.
remaining electrode somewhere away from the heart. This For tachyarrhythmias in anesthetized horses, treatment
ECG is then recorded in lead 1 (base–apex should be focused on the underlying cause (volume
configuration) [51]. However, there are multiple replacement; management of potassium, calcium, and
combinations of lead locations that will project an magnesium levels; correction of underlying bowel disease).
acceptable ECG in the anesthetized horse, and lead Intravenous lidocaine may be used as a non-specific
placement will often be dictated by the position of the treatment of ventricular tachycardia, though horses may
horse and the surgical procedure. convert spontaneously to sinus rhythm.
Heart rate increases associated with the use of
Treatment Anticholinergics in horses are not considered a dobutamine will usually resolve shortly after the infusion
routine tool in treating bradycardia and second-degree is discontinued. For longer acting sympathomimetics (e.g.
heart block in horses. Unlike in dogs where the combined ephedrine), the effect may be sustained for up to an hour.
use of alpha-2 agonists and anticholinergics is well studied When vasoconstrictive drugs (e.g. phenylephrine,
and not recommended due to the increase in heart work, norepinephrine, vasopressin) are used in the management
studies using the same combination of drugs in horses are of hypotension, heart rate typically drops when vascular
limited [59, 60]. Hyoscine-n-butylbromide and atropine resistance increases.
both have relatively short duration and in one study were Atrial fibrillation can be managed in anesthetized horses
shown to reverse detomidine-induced bradycardia and via electrical cardioversion. In many horses with atrial
increase cardiac index as a result of the increase in heart fibrillation, the purpose of anesthesia is to perform the
rate (tachycardia). However, hypertension was noted at the cardioversion procedure. Therefore, knowledge of the
doses studied [60]. This along with tachycardia caused by anesthetic management of this condition is useful, and
the anticholinergics has the potential to increase approaches have been thoroughly reviewed [65–67].
myocardial work. There is also concern for the development
of ileus and signs of colic with the use of anticholinergics,
Expected Outcome Many arrhythmias common to horses
although reported effects on gastrointestinal motility are
are relatively inconsequential (e.g. atrial premature
mixed. In addition, despite mild to moderate bradycardia,
contractions, physiologic bradyarrhythmias) and do not
many horses maintain acceptable hemodynamic
affect outcome in the anesthetic period. Some less-common
parameters during anesthesia when treated with inotropes.
arrhythmias cause significant hemodynamic disturbances
The authors therefore suggest the cautious use of
and could be fatal.
anticholinergics in horses when a low heart rate is cause
for concern (e.g. the horse is concurrently hypotensive),
reversal of medications causing the decrease is not possi-
Hypoventilation
ble, and where other treatment efforts have not been suc-
cessful. When considering anticholinergics, use of Definition Ventilation is the means by which the lungs
sympathomimetic drugs should be discontinued tempo- remove carbon dioxide, a product of metabolism, from the
rarily to avoid potential for serious cardiac dysrhythmias body. Carbon dioxide regulation is also important in the
as reported in halothane anesthetized horses [61]. It is maintenance of normal pH, as an elevation in carbon
also prudent to monitor these horses for signs of gastroin- dioxide of about 20 mmHg from normal will reduce the pH
testinal stasis in the recovery period and intervene if by approximately 0.1 unit. Hypoventilation or increased
necessary. arterial carbon dioxide tension is the most commonly seen
ventilatory aberration in anesthetized horses. For the though it is not necessary to routinely ventilate the horse to
unsedated, calm, air-breathing horse at sea level, arterial values considered normal in other species (i.e. as low as
carbon dioxide values range between 45 and 50 mmHg. 35–45 mmHg). Rather ventilation to arterial carbon dioxide
These values are somewhat higher than those reported for values of 55–60 mmHg will still maintain pH within an
dogs and humans [68]. acceptable range in healthy horses and minimize the
negative influences of ventilation on cardiovascular
Risk Factors function.
Under circumstances of normal carbon dioxide produc-
● Use of respiratory depressant drugs (e.g. inhalant tion, ventilation guidelines enable one to correlate easily
anesthetics) observed parameters and arterial carbon dioxide. Normal
● Abdominal distention (e.g. unfasted horse, pregnant minute ventilation is 100–200 ml/kg/minute in the large
mare, colic with gas-filled bowel) animal patient. This is a product of tidal volume and res-
● Thoracic injury or pleural space disease piratory rate. Normal tidal (per breath) volume ranges
● Laparoscopic procedures with carbon dioxide between 10 and 20 ml/kg and respiratory rate may range
insufflation [69] from 4–8 breaths per minute. Tidal volume may be
● Use of neuromuscular blockade (paralytics) in the estimated by excursions of the rebreathing bag whereas
absence of mechanical ventilation respiratory rate is easily obtained by looking at the
rebreathing bag or the animal’s chest. Recording tidal
Pathogenesis The newer inhalation anesthetics volume and respiratory rate over one minute provides
(isoflurane, sevoflurane, and desflurane) dependently minute ventilation.
influence ventilation such that arterial carbon dioxide It is important to remember that ventilation and certain
values may reach 65–75 mmHg with a corresponding ventilation strategies are often employed in an attempt to
decrease in pH in the unstimulated horse at a surgical prevent or treat hypoxemia. Correction of hypercapnia
plane of anesthesia 70–73]. may not be the direct goal, but arterial carbon dioxide
The absence of fasting, gastrointestinal or abdominal levels will drop as minute ventilation is increased.
distention, and recumbency can further compromise the
horse’s ability to ventilate. At extreme carbon dioxide Expected outcome Moderate hypercapnia in healthy
tensions (> 90 mmHg), increases in intracranial pressures anesthetized horses has been shown to improve
and sedative and anesthetic effects can further compound cardiovascular performance with no reported negative side
respiratory depression [74, 75]. effects [77]. Hypercapnia in an anesthetized patient with
concurrent metabolic acidemia (e.g. a strangulating colic)
Monitoring The anesthetist can sometimes intuit a can cause pH to drop well below the normal range. Whether
hypercapnic horse due to the presence of bright red mucus this degree of acidosis is a primary factor in short- or long-
membranes that occur as a result of carbon dioxide induced term survival in horses is not known because it is difficult
vasodilation, but monitoring of arterial carbon dioxide to separate intraoperative pH from a number of outcome-
tensions via blood gas analysis is the gold standard for modulating variables related to the severity of the horse’s
assessing ventilation in horses. Blood gas analysis also underlying disease.
provides useful information about blood pH. There are good studies describing the cardiovascular
Capnography, while useful, may not always accurately effects of hypercapnia in healthy anesthetized horses [77,
represent arterial carbon dioxide values. Large gradients 78]. Increases in circulating epinephrine and
develop in anesthetized horses between the carbon dioxide norepinephrine associated with hypercapnia underlies
measured at the end of an expired breath and that measured improved cardiovascular performance and the philosophy
in arterial blood. The gradient results from ventilation of of “permissive hypercapnia” in the management of
alveolar dead space and is not necessarily consistent over anesthetized horses. The exact level of hypercapnia that
the course of the anesthesia. The gradient is wider in larger should be targeted for maximum benefit is not clear.
horses and those being mechanically ventilated [76]. Although the terms mild, moderate, and severe have
Therefore, the measurement of a normal end-tidal carbon been used to describe different numerical values of arterial
dioxide does not preclude the presence of arterial carbon dioxide tensions in different studies, horses with
hypercapnia. carbon dioxide values above 60–65 mmHg show increases
in mean arterial pressure, stroke volume, and cardiac
Treatment Mechanical ventilation is commonly used to output with concurrent decreases in systemic vascular
control carbon dioxide tensions in anesthetized horses, resistance. Slightly lower values (55–60 mmHg) may be
associated with an increase in mean arterial pressure as a more reflects some degree of hypoxemia. An arterial
result of increases in vascular resistance but a lower cardiac oxygen tension of less than 60 to 80 mmHg is a value more
output compared to normocapnic or more significantly universally considered hypoxemic and one that is likely to
hypercapnic horses. Therefore, the effects of carbon dioxide result in tissue hypoxia.
may be biphasic and higher values may be beneficial from
the standpoint of improved cardiac output [77, 78]. Risk Factors
However, severe hypercapnia is also associated with
● Low fraction of inspired oxygen
severe acidemia (arterial carbon dioxide of >85 mmHg
● Dorsal recumbency
correlated with a pH near 7.1 in the absence of metabolic
● Abdominal distention (e.g. unfasted horse, pregnant
changes), increases in intracranial pressure, increases in
mare, colic with gas filled bowel)
heart rate, anesthetic effects, and the potential for the
● Pulmonary, pleural space, or cardiac disease
development of arrhythmias [74, 79]. Additionally,
experimental studies evaluating hypercapnia and
Pathogenesis Suboptimal oxygenation (arterial oxygen
cardiovascular function are limited to healthy horses, and
tension below 500 mmHg in a horse on a high fraction of
the potential for further risks or benefits of hypercapnia in
inspired oxygen) is not uncommon during general
systemically compromised horses has yet to be explored.
anesthesia in horses, especially those positioned in dorsal
With respect to retrospective analyses in horses
recumbency, and is often explained by postural influences
undergoing colic surgery, one study of horses having
on ventilation perfusion matching [84]. In healthy standing
surgery for correction of large colon volvulus showed that
horses, ventilation and perfusion are relatively evenly
intraoperative hypercapnia (arterial carbon dioxide >70
matched [85]. When placed under anesthesia in dorsal
mmHg) was a negative predictor of survival to hospital
recumbency, a large portion of the lung is compressed
discharge (though anesthetic survival was unchanged) [80].
under the diaphragm and abdominal contents. Atelectasis
In another study, intraoperative hypocapnia (arterial
of these lung fields leads to the development of physiological
carbon dioxide <40 mmHg) but not hypercapnia was a
right to left shunts, which decrease arterial oxygen tensions.
negative predictor for survival of anesthesia [81]. Whether
Shunt fraction is higher in heavier horses and in dorsal
these values simply reflect severity of underlying disease
compared to lateral recumbency [84].
and management strategies used to correct concurrent
True hypoxemia (arterial oxygen below 60–80 mmHg),
problems (e.g. ventilation for hypoxemia) is not clear.
while sometimes seen in healthy horses anesthetized on
In human medicine, there is increasing use of permissive
high fractions of inspired oxygen, more commonly results
hypercapnia as a ventilation strategy, since it has been
when positioning is compounded by disease processes that
shown to reduce mortality in patients with acute respiratory
create further alveolar collapse (e.g. abdominal distention)
distress syndrome irrespective of tidal volume. Hypercapnic
and low cardiac output states. Hypoxemia is also common
acidosis appears to have a significant anti-inflammatory
in horses anesthetized in the field where supplemental
effect, and benefits and risks of hypercapnia in critically ill
oxygen is not provided or those placed into the recovery
humans are currently being investigated [82]. Data of this
stall after inhalant anesthesia and allowed to breathe room
type is not available in horses.
air [83, 86].
Hypoxemia
Monitoring The arterial oxygen tension, similar to carbon
Definition Normal values for arterial oxygen tension in air dioxide and pH, is measured using a blood gas analyzer.
breathing horses (presuming normal ventilation) at sea- The measurement of oxygen tension from an arterial blood
level (barometric pressure ~760 mmHg) range between 80 sample, though costly, provides useful information about
and 100 mmHg [83]. When horses are maintained with the patient’s oxygenation. Blood samples are easily
fractional inspired oxygen fractions greater than 90%, as is obtained in the horse either by percutaneous puncture of a
common during anesthesia, oxygen values under similar peripheral artery or preplaced arterial catheter.
conditions should approximate 500 mmHg [73]. The Measurement of oxygen saturation using a pulse oxime-
alveolar gas equation may be used as needed to predict ter provides a means of continuously monitoring the
arterial oxygen tensions over a wide range of inspired patient’s oxygenation at a lesser cost. While it may not
oxygen fractions. provide information pertaining to lung function, it can
Hypoxemia is defined in many ways. When considering inform when circumstances will result in compromise to
ideal lung function, an arterial oxygen tension that is lower the animal. Values should range between 98 and 100%
than that predicted by the alveolar gas equation by 20% or during anesthesia, and in this range reflect an arterial
oxygen tension greater than 100 to 120 mmHg. A saturation such that the front end of the horse is tilted upward.
value of approximately 90% corresponds to an arterial However, the degree to which this can be performed
oxygen tension of about 60 mmHg, which as mentioned depends on the nature of the surgical procedure.
previously can contribute to tissue hypoxia. The ease of
application and portability of pulse oximetry makes this a Treatment While many strategies are attempted to counter
useful and user-friendly tool for monitoring oxygenation arterial hypoxemia, no method is consistently successful.
during equine anesthesia. Pulse oximeter probes fall into Hence in the circumstances when hypoxemia does not
two categories, transmittance and reflectance. The former respond to treatment strategies, it is best to minimize
probes are more common and typically attached to the anesthesia time if possible. When this is not possible, the
horse’s tongue. The lip, nasal mucosa, ear, or vulvar/penile anesthetist should try to compensate for the decreased
mucous membranes may be used as alternative sites. oxygen content by increasing cardiac output with use of
The anesthetist may be able to detect hypoxemia via the fluids and inotropes if appropriate.
presence of cyanosis of the mucous membranes, though A high fraction of inspired oxygen (>95%) improves arte-
this is not evident until hypoxemia is severe and even then rial oxygen tensions in anesthetized horses. Although
may not be obvious in the presence of vasoconstrictive using a low fraction of inspired oxygen during anesthesia
drugs or anemia. Hypoxemic horses may demonstrate has the theoretical benefit of reducing pulmonary shunts
hypoxic ventilatory drive and breathe rapidly, deeply, or created by adsorption atelectasis, horses anesthetized using
around the ventilator. In addition, they can be tachycardic low inspired oxygen fractions are at greater risk of
and hypertensive. This is easily misinterpreted as a light hypoxemia and arterial oxygen tensions increase
plane of anesthesia, therefore these signs should be dramatically with oxygen supplementation, even though
considered in light of the entire clinical presentation when shunt fraction does increase [90, 91].
monitoring anesthesia. Application of recruitment maneuvers consists of
creating high peak inspiratory pressures (60–80 mH2O) for
Prevention Pre-oxygenation using a nasal cannula and a prolonged inspiratory hold during several breaths. This in
oxygen flow rate of 15 liters per minute for 3 minutes has combination with the use of positive end expiratory
been shown to improve arterial oxygen tensions pressure (PEEP) can be successful in improving arterial
immediately after anesthetic induction in healthy horses oxygen tensions in horses [92–94]. These techniques,
undergoing elective procedures [87]. It is the authors’ however, have detrimental effects on cardiac output. When
experience that if the horse is well-sedated, tolerance of the cardiac output is significantly decreased, oxygen delivery
nasal insufflation tubing is good and the tubing can be to tissues is reduced and thus the benefits of having higher
maintained in place throughout the induction period. oxygen tensions may be negated.
A demand valve can be used to provide ventilation with Bronchodilators have been used with mixed results to
100% oxygen immediately after induction, particularly in improve oxygenation. Early studies used intravenous
horses at high risk of hypoxemia (e.g. colic with distended clenbuterol, which was successful but had undesirable
abdomen). Use of a demand valve also provides optimal systemic side effects such as sweating and tachycardia [95].
oxygen tensions in recovery from anesthesia as compared Inhaled salbutamol has been used more recently with
to oxygen insufflation alone [83]. success, improving arterial oxygen tensions without
Horses are more likely to become hypoxemic in dorsal causing tachycardia, though sweating was still noted and a
recumbency. When a choice is available, from the small percentage of horses failed to respond to treatment.
standpoint of oxygenation, horses should be placed in In order to deliver the drug, an inhaler and endotracheal
lateral recumbency for surgical procedures as ventilation/ tube adapter are used [96].
perfusion matching is improved compared to dorsal Horses should routinely be provided with high flow
recumbency [88]. oxygen insufflation (15 liters per minute) in the recovery
Initiation of positive pressure ventilation at the beginning stall [97]. Horses entering the recovery stall already
of anesthesia (but not after an extended period of hypoxemic, despite high fractions of inspired oxygen
spontaneous ventilation) will lessen the severity of during anesthesia, may benefit from the use of a demand
decreases in arterial oxygen tensions caused by positioning valve as described earlier.
and subsequent development of physiological right to left
shunts. [88, 89]. Expected Outcome Despite the fact that oxygen is essential
To help decrease the weight of the gastrointestinal for cellular processes and it would seem that hypoxemia
contents on the diaphragm and thus pressure opposing should influence survival, there are few data on the effect
pulmonary expansion, the surgical table can be adjusted of hypoxemia on clinical outcome in horses. Two studies in
horses undergoing colic surgery failed to link intraoperative Pathogenesis Normal body temperature is controlled by
hypoxemia and negative outcome [80, 81]. Regardless, thermoregulatory centers in the brain and reflects the
studies reflect that serum biochemical changes do occur in balance of heat generated from metabolic processes and
experimental horses when arterial oxygen is low over a heat dissipated. Anesthesia affects thermoregulatory
period of several hours [98]. centers in the brain and also influences generation and
Additionally, horses with suboptimal oxygenation on dissipation of heat. Due to a decrease in metabolic rate
high fractions of inspired oxygen during anesthesia have induced by the sleep state of anesthesia, heat generation is
the potential to become severely hypoxemic when moved decreased. However, in general, heat loss is increased by a
to the recovery stall and provided a lower oxygen fraction number of mechanisms related both to anesthesia and
in addition to drugs that depress ventilation (e.g. post- surgery. Cool intravenous fluids and inspired gases, cold
anesthetic sedation). Severe hypoxemia in experimentally tables, surgically clipped and prepped areas, and open body
apneic horses is associated with rapid progression to cavities all contribute to this loss of heat. Therefore, in
cardiovascular collapse [99], and this scenario in a clinical general, most patients regardless of body size tend to lose
case is certainly possible. heat during anesthesia. In addition, horses lose heat when
Horses undergoing colic surgery, in which recruitment placed on the floor of the recovery stall [100].
maneuvers and positive end expiratory pressure were used
to maintain arterial oxygen tensions over 400 mmHg, had Monitoring Temperature monitoring, though valuable and
fewer attempts to stand and shorter recoveries with a very simple to perform, is often ignored in clinical practice.
higher (though statistically insignificant) median recovery Temperature can be measured either intermittently using a
quality score compared to controls that were ventilated thermometer placed in either the rectum or auricular canal
conventionally [94], which would suggest that aggressive or continually using a thermistor probe placed in the
attempts to correct arterial oxygen are of benefit at least to esophagus or rectum.
recovery from anesthesia. However, as stated earlier, the
cardiovascular effects of these ventilation strategies are not
Prevention In human medicine, hypothermia is prevented
benign. In a horse presenting with hemodynamic instabil-
ity, efforts should be made to augment cardiovascular func- largely through the use of pre-warming techniques. This
tion prior to and during attempts to improve arterial oxygen would be practically difficult to implement and has not
tensions. been studied in horses. However, other risk factors for
hypothermia can be mitigated.
Ambient operating room temperatures can be adjusted
Aberrationsin BodyTemperature to the warmest possible, taking into account the comfort of
Definition Larger patients are less likely to lose the same the surgeons. The immediate area around the patient can
degree of body heat under anesthesia as a smaller patient also be kept warm using heat lamps, though careful
due to the smaller surface area to body weight ratio, but it attention should be given to the fact that heat lamps can
is not uncommon for body temperature to decrease cause burns to both the patient and nearby equipment.
substantially, even in the adult horse during general Horses can be placed on thoroughly dried and warmed
anesthesia [100–102]. Although hypothermia is most surgical surfaces such as a water bed or heating pad rather
common, the opposite extreme in body temperature may than a surgical mat alone. Intravenous fluids can be
also occur. Malignant hyperthermia, which is an extreme warmed prior to use via storage in an incubator. Protecting
situation, has only been sporadically reported in the horses the patient from becoming wet from surgical fluids or flush
exposed to inhalation anesthetics [103–105]. will mitigate evaporative heat loss. Active warming devices
(e.g. forced air warmers) can be used whenever possible,
Risk factors for hypothermia General anesthesia depending on the surgical procedure, with particular
attention to covering the extremities.
● Cool intravenous fluids
● Cold operating room and recovery stall surfaces
● Uncovered limbs Treatment Treatment of hypothermia via the use of active
● Open body cavities (e.g. abdominal surgery) warming devices is possible in horses, but is more likely to
● Lack of ability to keep the horse dry be successful in small patients and if initiated at the
● Lack of active warming devices beginning of the surgical procedure. It is especially
important for foals and perhaps practically easier to provide
Risk factors for hyperthermia Genetic predisposition to active warming. Attention should be given not only to the
malignant hyperthermia surgical period but also to the recovery period, where
Complications During Anesthetic Recovery 145
warming should continue if possible. In addition, drying Pathogenesis It is often said that if an animal has a poor
wet patients will help prevent continued evaporative heat induction, the recovery too will be poor. In the authors’
loss in recovery. experience, neither a good nor poor induction has been a
consistent predictor of recovery quality. Poor recovery
Expected Outcome Under extreme conditions, hypothermia quality or catastrophic injury in recovery likely does not
alters blood viscosity and coagulation pathways and will have a single causative factor, and in some cases catastrophic
increase the likelihood of myocardial fibrillation. Smaller injury can occur in the absence of an otherwise poor
decreases in body temperature as likely to be observed in recovery (e.g. a horse stands in one relatively quiet attempt
the horse will affect anesthetic dose requirements (MAC is but suffers a long bone fracture upon standing).
reduced 5–8% per degree centigrade decrease in body Clearly the temperament of the horse may play a
temperature) and rate of clearance of anesthetic drugs [106, role [112] and learning with repeated anesthesia may play
107]. This has clinical relevance in that an individual may a role in improving recovery [113], but other factors, such
unknowingly over-anesthetize a patient and likely prolong as the general well-being of the animal, nature of the
recovery from anesthesia. procedure, use of analgesic and supportive medications,
Much attention is given to inadvertent perioperative drainage of the urinary bladder, placement of a cast or
hypothermia in human medicine as it is associated with heavy bandage, the environment and footing, assistance
increased morbidity (e.g. wound infection, coagulopathy) provided in recovery, etc. may all influence the recovery
and prolonged hospital stay [108]. It is also associated with from anesthesia.
shivering in the recovery period, which not only increases
metabolic oxygen demand but is also reported to be Prevention Risk of catastrophic injury in recovery has
extremely uncomfortable 109. Although not much work resulted in the increasing prevalence, perhaps even routine,
has been done with respect to the complications associated use of providing a sedative or tranquilizer to horses
with hypothermia in horses, hypothermia does occur recovering from inhalation anesthesia. Studies have
routinely in anesthetized horses and is correlated with compared doses of injectable agents, different injectable
both increasing number of attempts and time it takes for a agents [114, 115], transitioning from inhaled to injectable
horse to stand in recovery [102]. agents [116, 117], and more recently reducing inhaled
anesthesia dose during procedures by concurrent use of
injectable agents [23, 118. 119]. While largely favorable
omplicationsDuringAnesthetic
C results support the use of these techniques, poor recoveries
Recovery sometimes with disastrous consequences to the horse and
injury to personnel still occur.
PoorRecoveryQuality Assistance in recovery can take many forms, ranging
from basic assistance on the tail to stabilize the animal and
Definition Poor recovery quality could be defined in a
helping it rise during attempts to stand to recovery using a
number of ways, from simply uncoordinated to involving
pool, air pillow, or sling. While much has been written on
minor or even serious injury. While historically presumed
these techniques [120–124], there are no comprehensive
cardiovascular events during the anesthesia period
studies to support use of any one method when other
contributed to the mortality rate, recent information
factors surrounding anesthesia management and logistical
suggests that injury in the recovery period is the primary
considerations (e.g. experience of personnel with the
reason for peri-anesthetic mortality in adult horses [59,
system) are applied. In the authors’ experience, the most
110, 111].
broadly applied system and one that can be learned fairly
quickly seems to be the use of head and tail ropes to help
Risk Factors
support and assist the horse to standing.
● Length of procedure
● Temperament of the horse Treatment The anesthetist should always be prepared for
● Physiologic status (e.g. systemically compromised colic, the catastrophic injury in recovery. A dose of sedation and
lactating mare) anesthetic induction drugs should be readily available until
● Painful procedure the horse is safely standing, as treatment might include
● Pre-existing long bone fracture re-sedating or anesthetizing the horse to facilitate
● Placement of heavy bandages, splints, or casts diagnostic testing (e.g. radiographs) and intervention to
● Slippery or uneven recovery surfaces manage the condition. Humane euthanasia may be
● Light plane of anesthesia on transport to recovery stall necessary, depending on the situation.
Expected Outcome Many horses can experience poor longer procedures and is especially recommended in
recovery quality, such as stumbling, flipping over, or female horses when procedures involve rectal or vaginal
making multiple attempts to stand without apparent harm manipulation or when constant rate infusions of alpha-2
or only minor injuries. There is obviously potential for long agonists are used.
bone fractures to occur and outcome thus depends on the
nature and location of the fracture as well as the owner’s
BloodGlucoseAbnormalities
willingness to pursue treatment.
Numerous studies have described complication rates Definition Hyperglycemia is an effect of alpha-2 adrenergic
during equine recovery, which are generally considered agonist drugs, which increase blood glucose concentrations
better following injectable medications than after for variable durations following administration [128, 131].
inhalation anesthesia [40, 125, 126]. However, the overall On the other hand, hypoglycemia is also possible, especially
reporting of mortality does not seem to have changed in foals who are fasted or medically compromised.
significantly, despite newer medications and advances in
other aspects of anesthesia management [48]. Risk factors for hyperglycemia Use of alpha-2 adrenergic
The reader is referred to Chapter 16: Complications agonists
During Recovery from General Anesthesia.
Risk factors for hypoglycemia Neonatal or pediatric patients
(especially fasted)
therComplicationsAssociated
O
with Sedativeand AnestheticDrugs Pathogenesis Alpha-2 agonists cause hyperglycemia as a
result of decreased insulin release from pancreatic beta
cells [37].
IncreasedUrineOutput
Definition Not necessarily considered a complication in its Monitoring Blood glucose concentrations are often
own right but one that might influence management of provided by bench top blood gas analyzers. However,
standing sedation and anesthesia is the notable increase in glucose can also be easily measured via the use of a hand-
urine production following administration of alpha-2 held glucometer. Although specific brands of glucometers
agonist medications to horses. are not necessarily designed for use in equines, some
glucometers have been evaluated in studies against bench
Risk factors Use of alpha-2 adrenergic agonists top analyzers and laboratory standards using both equine
whole blood and plasma [132, 133].
Pathogenesis Xylazine and detomidine have both been
shown to increase urine production multi-fold over normal Treatment While no untoward consequences of an alpha-2
in standing horses [127–129]. The mechanism by which agonist related increase in blood glucose have been
alpha-2 agonists increase urine production is primarily documented in horses, the anesthetist should be aware of
related to inhibition of anti-diuretic hormone [37]. General its occurrence. While in other species hyperglycemia may
anesthesia tends to reduce production [130] but it still result in diuresis, to date urine glucose data suggests that
remains above normal values of approximately 0.5 ml/kg/ this is not the routine situation in the horse in this
hour, even in water deprived animals [127]. circumstance of drug induced hyperglycemia.
Blood glucose concentrations should be carefully moni-
Monitoring Urine production can be assessed via the tored in foals during anesthesia, and hypoglycemia should
placement of a urinary catheter and measurement of urine be treated. Depending on the fluid administration rate,
output over the anesthetic period. 1–5% dextrose in a balanced electrolyte solution will help
correct hypoglycemia.
Treatment There is no specific treatment, but diuresis of
this magnitude may contribute to dehydration and should
DecreasedGastrointestinalMotility
be considered when calculating intravenous fluid
administration rates during sedation and anesthesia. In Definition Many drugs used for management of sedation
addition, horses sedated for standing procedures with and anesthesia in the horse negatively influence
alpha-2 adrenergic agonist drugs will often shift body gastrointestinal motility and may lead to post-anesthesia
position or attempt to posture to void. Therefore, colic. The reported incidence of post-anesthetic
catheterization of the urinary bladder can be helpful for gastrointestinal dysfunction in healthy horses undergoing
ther Complications Associated ith Sedative and Anesthetic rugs 147
elective procedures varies based on whether reduced fecal versus shorter anesthetic duration, use of romifidine as a
output, clinical signs of abdominal discomfort, or treatment premedication, being sedated before anesthesia on two or
for abdominal discomfort are used as case definitions but is more occasions, and the use of procaine penicillin [145].
estimated to be between 2.5% and 10.5% [134]. These differing results indicate that understanding risk
factors for post-anesthetic colic is challenging, and further
Risk Factors studies are required with larger numbers of horses to fully
● Use of anticholinergics elucidate causative factors.
● Use of opioids
● Use of alpha-2 adrenergic agonists Prevention No specific strategy has been proven
● Pre-anesthetic fasting unequivocally useful in the prevention of post-anesthesia
● Post-operative pain colic, but suggestions are outlined below.
To date, studies are not conclusive with respect to the
Pathogenesis Opioids have most notably been associated link between the use of opioids and post-anesthetic
with decreased gastrointestinal motility, which is a direct colic [134, 141, 143, 145, 146]. However, gastrointestinal
effect of stimulation of opioid receptors found throughout stasis is a known complication of opioid use and risk of
the gastrointestinal tract (including the myenteric relevant gastrointestinal dysfunction grows when opioids
plexus) [135, 136]. Alpha-2 adrenergic agonist drugs also are used systemically at high doses over long periods of
play a role in decreasing gastrointestinal motility [137, time. Therefore, these drugs should be used judiciously
138]. Similar to opioids, their effect is at alpha-2 receptors and in regional routes (e.g. intra-articular) whenever
at the level of the myenteric plexus [139]. Anticholinergic possible.
drugs reduce gastrointestinal motility like opioids and Similarly, excessive doses of long-acting alpha-2 agonists
alpha-2 agonists by inhibiting contractile neural activity in given over several hours (e.g. for standing sedation) should
all segments of the gastrointestinal tract [37]. Pre-operative be avoided if possible (i.e. long procedures could be staged
fasting, while generally considered beneficial to anesthesia into two shorter procedures separated by a return to
management (to reduce gastrointestinal volume and feeding).
improve both ventilation and oxygenation), may further Anticholinergics, as discussed previously, are recom-
reduce gastrointestinal motility via decreased colonic mended to be used with care and only when low heart rate
myoelectric activity [139]. is detrimental, reversal of agents causing bradycardia is not
Much of the information published about risk factors possible, and other methods used to improve hemodynam-
for post-anesthetic colic in horses is conflicting, which ics have failed. They should be titrated carefully such that
may be a result of the retrospective nature of most studies, the lowest effective dose is used.
the lack of large numbers of horses in each study, and the Use of local anesthetic techniques may be helpful from
variety of anesthetic and management protocols horses the standpoint of prevention of post-operative pain (thus
are subjected to. aiding a quicker return to normal feeding behavior) as well
Combining information from several studies, factors as to reduce the dose of sedative and systemic analgesic
found to be associated with the development of post- drugs required to complete the procedure.
operative gastrointestinal dysfunction include being an There is also no conclusive recommendation as to the
Arabian horse [140] or racing Thoroughbred [141], most appropriate pre-operative fasting or post-operative re-
orthopedic surgery [142], orthopedic surgery lasting longer feeding regimen to prevent post-operative colic, though as
than an hour [143], out-of-hours orthopedic surgery, mentioned earlier fasting does contribute to decreases in
administration of morphine [144], use of sodium gastrointestinal motility.
penicillin [141, 145], use of ceftiofur, inhalant anesthesia
with isoflurane, having a surgical procedure (vs. MRI) [145], Monitoring In many hospitals, it is routine to monitor and
increased arterial lactate, positioning in right lateral record fecal output in addition to both subjective and
recumbency, and post-anesthetic hypothermia [140]. physiological indicators of abdominal discomfort in the
At the same time, these studies also determined that cer- post-anesthetic period. Early signs of discomfort may be
tain factors (some the same as above) were not associated subtle or masked by systemic use of analgesic drugs (e.g.
with or were even protective for the development of post- phenylbutazone) in the peri-operative period. Since the
operative gastrointestinal dysfunction, including the use of consequences of impaired gastrointestinal motility in the
butorphanol [142], the use of no opioid or butorphanol [144], horse are potentially dire, observation of behavior and
administration of morphine [145, 146], the use of any normal fecal production in the recovery period are
specific anesthetic or peri-anesthetic drugs [140]. longer essential.
Treatment In-depth discussion of the treatment of post- Summary

anesthesia gastrointestinal dysfunction is beyond the scope
of this chapter, and management strategies for post- Complications are associated with sedation and general
operative ileus have been reviewed elsewhere [147, 148]. anesthesia in all species. Some of these are further magni-
fied in the horse as a result of their size, unique associated
Expected Outcome Post-anesthetic gastrointestinal physiology, and temperament. However, anticipation and
dysfunction may respond well to medical management or, management of the same can go a long way toward allevi-
depending on the severity, could necessitate exploratory ating significant untoward outcomes.
abdominal surgery or euthanasia.
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154
16
ComplicationsDuringRecoveryfrom GeneralAnesthesia
Alexander Valverde DVM, DVSc, DACVAA
Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
Overview bidity risk are often considered in the first 24–48 hours
related to the anesthetic/surgery event; therefore, anes-
Horses have the highest anesthetic mortality risk among thetic mishaps can occur from the time of anesthetic drug
veterinary patients. A significant proportion of complica- administration to the intra- and postoperative period. In
tions occur during the recovery period. This review sum- horses, all anesthetic periods are considered high-risk and
marizes the pre- and intraoperative factors that predispose in the immediate recovery period, risk of anesthetic mor-
to higher risk, their pathogenesis, prevention, and/or treat- tality is significantly higher than for other species.
ment. These factors include idiosyncratic characteristics of ● Mortality risk in horses is around 1% (1 case in 100) for
the horse (breed, behavior), cardiorespiratory function, ASA 1–2 cases, and significantly higher than in other
muscle blood flow, and logistic aspects such as proper posi- species [1–9]:
tioning on the surgery table, anesthetic time, type of sur-
– 100 times higher than in people (0.01%, 1 in 10,000)
gery, and infrastructure available to facilitate the recovery.
– 9 times higher than in cats (0.11%, 1 in 909)
– 5 times higher than in dogs (0.05%, 1 in 500)
L – Similar to rabbits (0.73%, 1 in 137)
with Recoveryfrom GeneralAnesthesia ● The risk increases in critical cases (ASA >3) to 2–10% (1
in 10 to 1 in 50), in horses undergoing emergency lapa-
● Morbidity and mortality of general anesthesia rotomy [1, 4, 6, 7].
● Risk factors in general
● Complications associated with recovery from general
anesthesia RiskFactorsin General
● General measures for prevention
● Pathogenesis in general A list of risk factors is presented in Box 16.1. These risks are
● Musculoskeletal/nervous system all related to alterations in cardiorespiratory function and
– Myopathy muscle blood flow during anesthesia, which may be influ-
● Additional actions enced by the type of procedure performed, the time to com-
● Central and peripheral neuropathies plete it, positioning and padding of the horse on the surgery
– Central table, and behavior of the horse during the recovery phase.
– Peripheral nerve damage
● Cardiorespiratory depression during anesthesia impacts
– Cardiovascular system
the horse systemically and if these changes are not prop-
● Respiratory system
erly addressed during anesthesia, they can directly affect
the recovery phase because it also impairs muscle
Morbidityand Mortalityof GeneralAnesthesia perfusion.
● Orthopedic surgery to repair fractures is associated with
Equine anesthesia has the highest reported risk of mortal- an increased risk of anesthetic-related death when com-
ity among domestic veterinary species. Mortality and mor- pared to soft tissue surgeries [7. 9].
Pathogenesis in eneral 155
Box16.1 Factorsthatcontributeto increasedrisk omplicationsAssociated

C
of complicationsin recovery. with Recoveryfrom General
Being a horse Anesthesia
Prolonged anesthesia time [8, 11, 13]
Complications can occur at any time during anesthesia and
Too young (<1 year of age) [9] impact the recovery period, directly or indirectly. These
Older (>5 years of age) [9] complications can lead to immediate outcomes that com-
Excitable temperament [11] promise the horse’s life to different degrees and may result
Inexperience of horse with recovery [12] in accidental death or require of humane euthanasia.
Complications can also take place in a more delayed fash-
Higher ASA classification [7]
ion (e.g. gastrointestinal disorders) and contribute to mor-
Fracture repair [7. 9] bidity and eventually anesthetic-related deaths.
Hypotension (<60–70 mmHg) [18, 31] Anesthetic complications mostly affect the following
Lateral versus dorsal for myopathy [20] systems:
Dorsal versus lateral for myelomalacia [20, 25] ● Musculoskeletal system, including fractures (12.5–38%
Dorsal versus lateral for airway obstruction [10] of anesthetic-related deaths) and post-anesthetic myopa-
thy (7–14%) [2, 4. 6–9]
● Central nervous system/spinal cord pathologies, includ-
ing myelomalacia and nerve compression/paralysis
(4–5%) [2, 4. 6–9]
● Airway obstruction is more likely to occur after pro-
● Cardiovascular system, including cardiovascular col-
longed anesthesia times, especially if in dorsal
lapse from hypovolemia, hypotension and reduced car-
recumbency [10].
diac output [7, 9]
● Horses, unlike other species, attempt to stand soon after
● Respiratory system, including hypoxemia, airway
regaining partial consciousness, often with visible mus-
obstruction and pulmonary edema [7, 9].
cle weakness and ataxia still present, which predisposes
● Gastrointestinal system, including abdominal complica-
them to mishaps, even if there is cardio-respiratory sta-
tions, such as colitis or peritonitis in 13% of non-colic
bility. Younger horses (1–5 years of age) in good health
cases [7, 9], and development of post-anesthetic colic
have a lower risk of anesthetic mortality compared to
(2.8–12%) [6, 14, 15]
older horses (5–14 years of age) [9], which could be
related to better musculoskeletal and athletic condition;
however. they can also be more temperamental and less
experienced with general anesthesia and attempt recov- GeneralMeasuresfor Prevention
eries sooner.
Complications seen in the recovery period can be avoided
● Temperament of the horse has been associated with the
or at least minimized with proper handling of the horse’s
quality of recovery, time to extubation, and to standing;
cardiovascular and respiratory function in the intra-opera-
those more excitable horses have lower quality of recov-
tive anesthetic period that guarantees adequate blood flow
ery due to faster times to standing [11]. A learned behav-
to all tissues, especially musculoskeletal. Adequate hospi-
ior and better-quality recoveries were also seen in horses
tal infrastructure or field conditions for surgery and recov-
anesthetized on three occasions within 7 days, including
ery, proper positioning and padding of the horse, reduced
longer times to achieve sternal and standing positions
surgery time, vigilant monitoring, and immediate actions
and fewer attempts to successful standing during the last
to address problems are all equally important.
anesthetic event [12].
● Injectable techniques to maintain general anesthesia
have a lower mortality risk than balanced techniques Pathogenesisin General
(injectable and inhalational) or total inhalational anes-
thesia. However, injectable techniques are often used in There are four major systems that, when altered, are the
healthy animals for procedures of short duration [9]. main causes for equine anesthetic morbidity and death;
● Prolonged anesthesia time is associated with higher these include the musculoskeletal/nervous, cardiovascu-
morbidity/mortality [8–13] and the risk increases when lar, and respiratory systems. Deviation from normal in
surgery time exceeds 1 hour [13]. any of these three systems can occur at any time in the
156 Complications uring ecovery from eneral Anesthesia
peri-anesthetic period (pre-, intra-, and post-anesthesia), Although mean arterial pressure of less than 60 mmHg
and through their intricate relationships affect the others, during anesthesia has been associated with an increased
e.g. hypotension can result in inadequate muscle perfu- risk of post-anesthetic myopathy [18], it is not just the
sion, hypoxemia can affect cardiac and skeletal muscle quantitative blood pressure measurement but its relation
function, and myopathy can result in pain and increased with muscle compression, padding, and positioning that
cardiorespiratory demands. ultimately affect MuPP and MuBF.
In lateral recumbency, the dependent muscles of the
lowermost limb can be more severely affected by intracom-
Musculoskeletal/NervousSystem
partmental pressures that impede blood flow, than the
non-dependent muscle groups of the uppermost limb [19],
The risk of complications that involve the musculoskeletal
although other studies have not shown differences between
system (myopathy) and/or nervous system (neuropathy) in
dependent and non-dependent muscles [22]. Clinically,
the post-anesthetic period is relatively low, 0.8–1.6% [6, 7,
most cases affected by myopathy involve dependent muscle
16]; however, these are the most frequent complications
groups; this is more obvious with local myositis in which
detected in the recovery period [8].
areas in direct contact with the surface of the pad or ground
are compressed between the bony prominences and sur-
Myopathy face, and the skin appears swollen in recovery.
The compounds creatine phosphate (CP) and adenosine
Definition Abnormal muscle function from ischemia is
triphosphate (ATP) decrease and the compound inosine
the result of inadequate perfusion to the muscle, due to
monophosphate increases, in laterally recumbent horses
hypotension and low cardiac output that cannot overcome
anesthetized with inhalant anesthetics, indicating that
the increase in intracompartmental muscle pressure
energy (ATP) in the muscle has been generated through
(MuCP) caused by recumbency and compression of the
hydrolysis of CP and/or deamination of adenosine
muscle, which results in low perfusion pressure. These
monophosphate (AMP), a sign of metabolic stress from
alterations are usually the result of anesthetic drugs and/or
limited oxygen supply and ischemia in hypoperfused mus-
cardiovascular compromise [17].
cle [22]..In addition, lactate in the muscle and plasma
increases from anaerobic metabolism, and the increase is
Risk Factors
greater in the muscle than plasma [22]. These metabolic
● Mean arterial pressure of less than 60 mmHg during alterations are more likely in compromised horses than in
anesthesia [18] healthy ones due to circulating volume derangement in
● Effect of lateral recumbency on the down-side muscle sick horses [21].
groups (dependent muscle) [19] Myopathy causes both pain and inability to properly use
● Lateral recumbency has a higher risk than dorsal muscles as a result, which may result in abnormal motion
recumbency [20] during recovery and lead to fractures from accidental
● Prolonged anesthesia [8, 13] tripping.
● Systemically compromised (e.g. colic) horses [21]
● Horses that suffer from hyperkalemic periodic Prevention The main recommendations to reduce the
paralysis [20] likelihood of morbidities that affect the musculoskeletal
● Horses that suffer from equine polysaccharide storage system is to limit the anesthesia time (ideally <90 minutes),
disease [20] to maintain mean arterial pressures higher than 60 mmHg
● Inadequate positioning/and or padding on the surgery during anesthesia, to avoid hypoxemia which can
table potentially exacerbate the adverse effects of decreased
perfusion if the horse was hemodynamically unstable, and
Pathogenesis Muscle perfusion pressure (MuPP) is the to properly position and pad the horse during recumbency.
difference between mean arterial pressure (MAP) and Additional actions require management of the horse’s
MuCP, so that MuPP = MAP – MuCP. Muscle blood flow behavior in the recovery stall, since despite all precautions
(MuBF) should also be considered and is a reflection of the a horse can exhibit an excitable or violent recovery and
MuPP over the impediment (vascular resistance, VR) to result in these same types of mishaps.
this flow moving through the vessel, so that MuBF = Isoflurane, sevoflurane and desflurane for maintenance of
MuPP/VR. This means that a decrease in MuPP is the anesthesia are better at maintaining MuPP than halothane,
result of an increase in regional VR and/or a decrease in because cardiac output and regional MuBF is better pre-
cardiac output and blood pressure [17]. served [17, 23]. Despite these differences between inhalant
Musculoskeletal/Nervous System 157
anesthetics, there are no reported differences between quality than from inhalational anesthesia because horses
them for the incidence of post-anesthetic myopathy; remain sedated and recumbent under the effects of inject-
instead, duration of operation/anesthesia and body posi- able sedatives, whereas without them, horses after inhal-
tion during surgery played a more preponderant role, such ant anesthesia attempt to stand while still weak, ataxic, and
that surgeries lasting more than 90 minutes and horses less aware. Therefore alpha-2 agonists (xylazine, romifi-
placed in lateral recumbency were at higher risk [7]. Horses dine), acepromazine, mixtures of xylazine and ketamine,
recovering from longer anesthesia time have longer peri- have been recommended at the time of recovery to prolong
ods of ataxia and worse quality of recovery [11], which may recumbency time and prevent the horse from attempting to
be the result of impaired muscle perfusion during anesthe- stand while elimination of the inhalant anesthetic still
sia (Figure 16.1). In the recovery stall, horses are often occurs [10–12]. This results in longer times to stand, with
placed directly on the floor of the stall and all means of fewer failed attempts and less ataxia because of better coor-
cardiovascular support are stopped, which may further dination and strength.
impair muscle perfusion during this period. For this rea- Recommended doses used for this purpose include 0.02
son, body weight should also be considered a risk factor mg/kg of acepromazine, IV; 0.1–0.3 mg/kg of xylazine, IV;
throughout the peri-anesthetic period. 0.01–0.03 mg//kg of romifidine, IV; 0.15 mg/kg of xylazine,
Sedatives administered during recovery can improve the IV, combined with 0.3 mg/kg of ketamine, IV [10, 12, 24].
quality of this phase by preventing undesirable behavior Pain is a main component of mishaps that involve the
such as excitement and uncontrolled efforts to stand. nervous and musculoskeletal systems, both as a direct result
Recoveries from injectable anesthetics usually are of better from them or as a predisposing cause of the mishap (frac-
Figure16.1 Horses exhibiting signs of weakness that may lead to ataxia and accidents during recovery. This includes casting with
the head under the body, dog sitting, and knuckling of the fetlocks. Source: Alexander Valverde.
tures). Adequate analgesia and sedation is required to pro- decision and management is imperative to best handle the
mote better recoveries and to treat horses that suffer from situation. These actions may include re-anesthetizing the
post-anesthetic myopathy, neuropathies, or fractures during horse until a decision is reached to repair or euthanize.
recovery. Opioids (morphine, 0.1 mg/kg, IV or IM), alpha-2 Fluid therapy is recommended to maintain normov-
agonists (xylazine, 0.3 mg/kg, IV), and non-steroidal anti- olemia due to fluid shifts caused by sympathetic stimula-
inflammatory drugs (phenylbutazone, 4 mg/kg, IV, or flun- tion in response to pain and to maintain adequate blood
ixin, 1 mg/kg, IV) should be considered and administered flow to the muscle and help remove metabolites from it,
according to the severity of the condition. Some authors including the elimination of myoglobin and proper filtra-
recommend the use of acepromazine (0.01–0.03 mg/kg, IV) tion through the kidneys. blood work to quantify the degree
due to its tranquillizing properties as well as vasodilatory of muscle damage (creatine kinase), acid–base balance and
effects that can potentially improve muscle blood flow [10]. electrolytes, is recommended during management of this
complication for reference and prognosis for the case.
Diagnosis Recognition of post-anesthetic myopathy is
based on clinical signs that include lameness to inability to
stand, due to the pain associated with the muscle ischemia AdditionalActions
and the inflammation of the affected area. lLboratory exams
can be performed to demonstrate high levels of muscle Providing a safe environment for recovery is important to
enzymes (e.g. creatine kinase, aspartate transaminase) and prevent musculoskeletal accidents (fractures, lacerations)
lactate from hypoperfusion. during this phase. Prolonged anesthesia time results in
higher morbidity/mortality and lower quality of recov-
Treatment Some horses will require of a sling to achieve ery [8, 12, 13]; depending on the type of surgery performed
and/or remain standing (Figure 16.2). In the case of horses there are several options to recover a horse in an effort to
accidentally fracturing during the recovery period, rapid minimize risk: free recoveries under field conditions, free
Figure16.2 Use of a sling to support a horse to stand up and/or to remain standing is feasible. This type of recovery requires proper
attachment of the sling, and sedation until the horse tolerates the hoist and sling device. Source: Alexander Valverde.
Central and Peripheral Neuropathies 159
recoveries in a wall-padded room with the horse directly on

the floor or a pad or an inflatable-deflatable pillow, use of
head-and-tail ropes to assist the horse, use of a sling, use of
a tilt-table, and use of a hydropool or a pool-raft system
(Figures 16.3–16.6). However, not all of these options are
available in clinics and recoveries will be carried out with
the available resources (Table 16.1). Regardless of the
method, any recovery system is only as good as the experi-
ence of the personnel using it; furthermore, there are no
studies comparing the success rate of different methods.
Expected outcome Improvement from post-anesthetic
myopathy should be expected within 24 hours with proper (a)
therapy support; otherwise the prognosis is less favorable.
(a)
(b) (b) (c)
(c)
(d) (e)
Figure16.4 Use of a hydropool recovery system. Source:

Courtesy of Regula Bettschart-Wolfensberger, Zürich,
Switzerland.
Centraland PeripheralNeuropathies
Figure16.3 Modalities of free recovery with the horse directly
Central(SpinalCordMalacia)
on the floor (A) or on a pad (B), and recovery with head and tail
ropes (C). For the latter, the ring system may be adapted to the Definition Spinal cord malacia is a special form of
conditions of the recovery stall for height, ideally at a height
that helps direct the horse to standing. Source: Alexander neuropathy characterized by poliomyelomalacia and
Valverde. necrosis of the grey matter, that most likely results from
Figure16.5 Use of a pool-raft recovery system. Source: Used with permission from Thieme.
hypoperfusion of the spinal cord or from increased Table16.1 Recovery methods reported by 34 equine practices
susceptibility to hypoxic damage from lipoperoxidation [25]. from universities and private hospitals [48].
TypeofRecoveryMethod Comment
Free recovery Used in 41% of clinics

Head- and tail-ropes Used in 50% of clinics
Sling, tilt-table, hydropool or raft Available in 44% of
system clinics
Risk Factors
● Young draft breed horses [25]

● Dorsal recumbency [20, 25]
Pathogenesis This pathology affects predominantly

young draft horses, but is not restricted to these breeds. A
recent review compiled 30 recognized cases, of which 23
Figure16.6 Use of tilt-table recovery system. Source: out of 30 where draft breeds and 22 out of 30 were two-
Alexander Valverde. years-old or younger [25]. In addition, most horses (29 out
Central and Peripheral Neuropathies 161
of 30) were placed in dorsal recumbency. In general, spinal ● Incorrect lateral positioning of non-dependent limb
cord blood flow measured in anesthetized horses that (brachial plexus at risk)
were positioned in lateral recumbency, was lower than for ● Incorrect dorsal positioning and excessive abduction
other species, despite mean arterial pressure of 60–100 (femoral nerve at risk)
mmHg, [26], which may indicate a predisposition of
anesthetized horses for spinal cord hypoperfusion. Pathogenesis Nerve damage can result from compression,
Whether this risk is higher in draft horses is unknown; ischemia, and rotation/pulling forces and is associated
however, affected horses show ischemia of the spinal cord with prolonged anesthesia time and/or inadequate
from hypoperfusion. Another mechanism has involved positioning or padding of the horse. Compression of a
vitamin E deficiency due to observed changes in some nerve by the horse’s own weight or by structures that come
affected horses in the nucleus cuneatus accesorius that in direct and constant contact with the nerve path can
evidence increased spinal cord susceptibility to hypoxic affect its adequate blood supply and of surrounding
damage from lipoperoxidation [25]. muscles and cause ischemia. In addition, incorrect
positioning can result in excessive overstretching or
Prevention Due to the random occurrence of this rotation of nerves and result in neuropathy [27].
pathology and lack of an explicit explanation for it, there is
no way to anticipate a negative outcome. However, Prevention Adequate positioning, well-padded surgical
maintaining adequate blood pressure and cardiac output, tables or surfaces, minimizing surgical time, and
proper blood oxygen content, minimizing anesthesia time, maintaining optimal cardiorespiratory function during
and if possible, avoiding dorsal recumbency, are all anesthesia are all required steps to decrease the likelihood
common sense actions to avoid this pathology. of neuropathies.
Facial nerve integrity is preserved by removing halters,
Diagnosis This condition is clinically characterized by
especially during lateral recumbency, and by avoidance of
poliomyelomalacia of the spinal cord causing paralysis of
leaning on the horse’s head.
the hind limbs and inability to stand, loss of anal tone, and
Brachial plexus and/or radial nerve integrity is achieved
absence of panniculus response along the caudal thoracic
by placing the dependent limb forward and supporting the
area. It is an irreversible process that requires euthanasia
non-dependent limb parallel to the dependent limb, so
of the patient [20. 25].
there is no compression from it. In addition, avoidance of
In post-mortem, histological findings, once the hemor-
abduction and/or endorotation of the non-dependent limb
rhagic infarction of the spinal cord ensues, include polio-
is recommended to avoid brachial plexus damage in this
myelomalacia and necrosis of the grey matter [25].
limb.
Treatment There is no treatment to reverse this condition.

Diagnosis Facial nerve paralysis is first noticeable during
Expected outcome Bad prognosis recovery by any of the following signs, depending on the
location of the insult: inability to blink, drooping upper lip,
PeripheralNerveDamage drooling, drooping ear, and collapsed nostril.
Signs of radial nerve paralysis include difficulty in bear-
Definition Loss of peripheral nerve integrity that results in
ing weight during recovery and inability to completely
motor and sensory deficit. The nerve damage can vary in
extend and stabilize the elbow. Instead, the elbow appears
severity from affecting nerves to limbs and impairing the
partially extended and dropped, while the foot is rested
horse’s ability to stand or ambulate without risk, to more
typically with its dorsal aspect in contact with the ground.
circumscribed effects such as damage of nerves of the face
Signs of bilateral or unilateral femoral nerve paralysis
that affect sensory and motor function of head structures.
include semiflexed stifle, hock and fetlock joints, and the
horse bears weight on only the toes of the hindlimbs. In
Risk Factors
addition, the hindquarters are lower than the
● Inadequate padding forequarters.
● Prolonged anesthesia
● Halters with metal rings (facial nerve at risk) Treatment Adequate bandage support of the limb and
● Excessive pressure from the surgeon leaning on facial counter limb is recommended for limb neuropathies. The use
structures during head surgery of analgesics, as described for myopathies, is recommended
● Incorrect lateral positioning of dependent thoracic limb because in many instances, muscles are also affected from
(brachial plexus at risk) inadequate positioning. In addition, corticosteroids
(dexamethasone, 0.05–0.1 mg/kg, IV; or prednisolone, 1 mg/ Prevention Ideally, every horse should have optimal
kg, IV) have been used in some cases [27]. hemodynamic function before induction of anesthesia.
Mean arterial pressure of at least 60 mmHg should be
Expected outcome Neuropathies can take longer (days) to maintained to avoid compromised muscle perfusion [18].
treat than myopathies, until the nerve inflammation Critical emergency cases often have compromised
subsides. Depending on the affected nerve (limb vs. face), hemodynamic function that cannot be fully corrected
the horse may require extensive support and the use of a before induction because of dehydration and altered
sling to help with the weight distribution and decrease risk autonomic function. Isotonic crystalloid fluids, hypertonic
of subsequent complications such as overload laminitis of saline, or colloids should be administered preoperatively
contralateral limb. and continue in the intraoperative period in quantities that
help normalize intravascular volume and therefore, cardiac
CardiovascularSystem output and blood pressure, so that other systems
(musculoskeletal) are not negatively impacted throughout
Cardiovascular complications account for up to 50% of anesthesia and in the recovery period. In severely
mortality cases associated with general anesthesia [7, 9]. compromised horses at the time of recovery and if the
They can occur in the intra- or postoperative period. conditions allow, fluid administration should be continued
in the recovery stall.
Definition Complications, such as hypotension and During anesthesia, anesthetic plane should be main-
reduced cardiac output, may lead to cardiovascular tained with the lowest and safest inhalational anesthetic
insufficiency and have a direct effect on other systems such concentration, by use of balanced anesthesia with injecta-
as the musculoskeletal/nervous and gastrointestinal ble analgesics/anesthetics, to minimize the cardiodepres-
system, since adequate perfusion to all organs is necessary sive and vasodilatory effects of inhalational anesthetics,
to maintain homeostasis. and anesthesia time should be reduced because low perfu-
sion affects every system and predisposes to the above-
Risk Factors mentioned complications on the musculoskeletal and
● Recumbency and gravitational forces nervous system.
● Cardiovascular depression from anesthetic drugs
● Hypovolemia and unstable cardiovascular function Diagnosis Adequate monitoring of direct blood pressure
● Compromised health status of the horse during anesthesia would immediately detect a low mean
● Prolonged anesthesia arterial blood pressure and proper measures to improve
volume, contractility and blood pressure established.
Pathogenesis Horses are prone to hypotension (mean Monitoring of packed cell volume and total protein is
arterial pressure <60 mmHg) and decreased cardiac output recommended to assess the extent of fluid therapy to
(<35–45 mL/kg/min) during anesthesia due to several achieve a reduction in high viscosity of blood and heart
factors, including recumbency and gravitational forces, workload, and to avoid compromising oxygen carrying
and cardiovascular effects of injectable and inhalational capacity by hemodilution. In addition, electrolytes (Na+,
anesthetics that may include depression of myocardial K+, Cl-, Ca2+), acid–base values and lactate should be
contractility, changes in systemic vascular resistance, and monitored and corrected accordingly.
heart rate [18, 28–30], even at light planes of anesthesia.
Hypovolemia exacerbates the adverse effects under anes- Treatment In horses with cardiovascular insufficiency,
thesia. In mares undergoing Cesarean section that were hypovolemia, hypotension and low cardiac output are
hypotensive during anesthesia, cardiovascular collapse usually all present. Therefore, a logical approach is to
and fractures during the recovery period were the main correct volume, enhance cardiac contractility, and in some
causes that resulted in death and/or euthanasia [31]. instances, correction of vascular resistance, while at the
Isoflurane concentrations of 1.44–2.36% (1.1 to 1.8 times same time the cardiodepressive effects of anesthetic drugs
the minimum alveolar concentration [MAC]) causes a should be minimized by use of the lowest amounts possible.
dose-dependent decrease in mean aortic pressure and skel-
etal muscle blood flow [32], which affects muscle perfu- Isotonic crystalloid fluids
sion. Similar cardiovascular effects are expected from other In severely dehydrated patients, replacement should be
modern inhalational anesthetics, such as sevoflurane and considered at least 100 mL/kg. At least 20 mL/kg should be
desflurane; however, halothane has been shown to lower administered rapidly (20–60 min) before induction of anes-
blood flow to muscles more than isoflurane [33]. thesia. The remaining volume can be completed in the
Respiratory System 163
intraoperative period. This amount of crystalloids will dis- Ephedrine is also effective due to its α-1, β-1, and β-2
tribute into the intravascular interstitial and intracellular effects. Single doses of 0.06–0.2 mg/kg are effective for up
space over time, but primarily help initially with the intra- to 60 minutes, in increasing heart rate, mean arterial pres-
vascular deficit to normalize blood pressure. sure, cardiac output, and MuBF in a dose-dependent
In normovolemic patients that exhibit hypotension dur- fashion [39].
ing anesthesia, rates of 10–20 mL/kg/h are useful but do
not necessarily reestablish mean arterial pressure. Expected outcome Ideally, volemia and adequate cardiac
Anesthetic depth assessment and lightening of the plane is function should be normalized before the recovery period to
often necessary to avoid the dose-dependent effects of improve outcome. However, in many instances, horses are
inhalational anesthetics. The use of inotropes (dobu- still hypovolemic and unstable during recovery and if the
tamine) is often necessary. conditions allow, fluid administration and cardiovascular
support should be continued during this period.
Hypertonic saline Horses that have been unstable during anesthesia would
Hypertonic saline (up to 7.2%) can be combined with the benefit from an assisted recovery due to weakness from
crystalloids, but should not replace the crystalloids, due to hypoperfusion and possible exhaustion as a result of their
its short duration of action (<1 hour) and to properly initial health status. Management includes proper analge-
hydrate the horse with the crystalloids, which maximizes sics to provide comfort and avoid anxiety.
the osmotic effects of the hypertonic solution. The osmotic
effect of 7.2% hypertonic saline in attracting fluids from the
intracellular space and/or retaining them in the intravas-
RespiratorySystem
cular space can increase the plasma volume twice as much
as a similar volume of isotonic crystalloids [34]. Doses of
Respiratory complications account for 4% of mortality
2–4 mL/kg of hypertonic saline are recommended and
cases [7, 9].
advantageous because of the small volume of infusion.
Respiratory complications leading to hypoxia:
Colloids
Definition Hypoxemia, airway obstruction and pulmonary
Pentastarch 10% (4 mL/kg) administered pre-induction has
edema are the most common complications observed in
been shown to be more effective than hypertonic saline
the recovery period. All of them can potentially result in
7.2% (4 mL/kg) in hypovolemic colic horses, in preserving
tissue hypoxia and affect all systems. Tissue hypoxia is
cardiac output and stroke volume during anesthesia [35].
defined as inadequate oxygen supply to support oxygen
demands, which forces to anaerobic metabolism.
Inotropes
Dobutamine through its β-1 agonist effects is very effective at
Risk Factors
increasing mean arterial pressure in horses through an
increase in contractility and cardiac output, despite its effects ● Recumbency and gravitational forces
on lowering vascular resistance. This helps maintain ade- ● Cardiovascular depression from anesthetic drugs
quate MuBF according to MuBF = MuPP/VR, and makes it ● Prolonged anesthesia
the preferred inotrope in horses, because it can increase ● Lung disease
MuBF in dependent and non-dependent muscles [36, 37]. ● Draft horses at higher risk than light horses
Doses of 0.5–4 μg/kg/min to effect are usually effective;
however, in conditions of hypovolemia and/or vasodilatory Pathogenesis Absolute hypoxemia (PaO2 <60 mmHg) and
shock, the effectiveness of dobutamine is less and proper relative hypoxemia (PaO2 < the expected value for the
support with fluids and vasopressors is also recommended. corresponding inspired fraction of oxygen [FiO2]) are
The use of norepinephrine with its mixed α-1 and β-1 ago- common in anesthetized horses due to ventilation and
nist effects (0.05–0.4 μg/kg/min) on its own or the α-1 ago- perfusion unequal distribution that results from
nist phenylephrine (0.25–2 μg/kg/min) with recumbency, right-to-left shunting, and effects of anesthetic
dobutamine [38] is recommended in those cases, to rees- drugs. Dorsal recumbency is correlated with the degree of
tablish vascular tone while the contractility is still sup- hypoxemia during anesthesia, and it may persist during
ported. In the latter cases, caution is advised to not rely on recovery despite positioning the horse in lateral
blood pressure entirely, since cardiac output is often not recumbency.
measured and excessive vasoconstriction can negatively Hypoxemia can also occur readily when the horse is
affect MuBF. transferred from the operating room to the recovery stall
because of interrupting the administration of a high FiO2 does not kink during recovery or is obstructed by blood,
during this time. If the horse has been mechanically venti- airway secretions or any surface of the stall.
lated and has not resumed effective spontaneous breathing Instillation of phenylephrine (10–15 mg diluted with
it can also become hypoxemic. 10–20 mL of saline) into the ventral meatus of the nasal
Airway obstruction can occur in an intubated horse passages, 30–50 minutes before the end of surgery, is effec-
because of kinking or occlusion of the endotracheal tube tive at reducing the thickness of the nasal mucous mem-
during recovery. After extubation, airway obstruction can brane through its vasoconstrictive effect, and reduces the
be the result of edema of the nasal passages, edema of the requirements for upper airway support in the recovery
larynx, dislodgement of the epiglottis and obstruction with period [43], but is ineffective in cases of hemiplegia, where
the soft palate, preexisting laryngeal hemiplegia, blood obstruction originates from the larynx.
clots from airway/sinus surgery, or casting of the horse and
malpositioning of the head under the body or against the Pulmonary edema
wall in the recovery stall. Avoidance of airway obstruction is the first step to prevent
Undiagnosed hemiplegia is frequent and airway obstruc- pulmonary edema. If airway obstruction occurred and was
tion can unexpectedly occur, especially in draft horses, effectively resolved but pulmonary edema ensues, therapy
which have a higher prevalence of hemiplegia than lighter should include all aspects that help prevent further epi-
horses [40] and a higher incidence of complications, sodes of obstruction, including a tracheostomy if neces-
including obstruction, even after corrective surgery [41]. sary, and controlling the consequences of the edema.
Pulmonary edema has been reported to occur as a result
of upper airway obstruction or laryngeal obstruction. A Diagnosis Horses can tolerate a significant degree of
horse with airway obstruction develops high negative hypoxemia; however, it should not be ignored and go
intra-thoracic pressures during inspiration in an attempt to untreated. Horses that exhibit increased respiratory effort
breathe, which also enhances venous return and increases without obstruction are probably hypoxemic. An arterial
hydrostatic pressures in the pulmonary circulation, result- blood gas would determine if hypoxemia is present.
ing in extravasation of fluid from capillaries into the pul- Total airway obstruction is diagnosed by the inability of
monary interstitium and alveoli, causing edema [42]. the horse to breathe and the level of increased anxiety that
ensues immediately. Usually horses will struggle and panic
Prevention during an obstruction episode, which makes treatment
dangerous until the horse basically loses consciousness.
Hypoxemia
Partial airway obstruction is manifested with abnormal
Absolute hypoxemia and relative hypoxemia are worri-
sounds and increased effort to breathe, the horse can also
some because those values are likely to decrease in the
panic and become anxious, which also makes treatment
recovery phase during transport and if the oxygen supple-
dangerous, but there is more time to attempt to correct the
mentation is less than effective. Healthy horses tolerate
situation.
hypoxemia relatively well, especially horses anesthetized
Pulmonary edema is likely if airway obstruction occurs
under field conditions (injectable anesthesia) for short and
and increased respiratory efforts are observed in the horse.
elective procedures, and without supplementation of O2.
The diffusion barrier caused by edema in the interstitium
Conversely, horses with compromised health status and
and alveoli can result in inadequate gas exchange and
anesthetized for prolonged periods may not tolerate hypox-
hypoxemia. An arterial blood gas would determine if
emia and the reduced O2 delivery to tissues, including
hypoxemia is present.
muscles. Therefore, limiting the anesthesia time should be
a priority if possible.
Treatment
Airway obstruction Oxygen supplementation
Horses with diagnosed laryngeal hemiplegia should be Placement of an insufflation catheter into the endotracheal
closely monitored during recovery. Horses tolerate well the tube of the intubated horse or into the nasal passage of an
presence of the endotracheal tubes during recovery and extubated horse and supplementation of 15 L/ min of O2
consciousness. Depending on the preference of the anes- is recommended to prevent or treat for hypoxemia. Ideally,
thetist, the endotracheal tube can be secured in place (oro- O2 should be supplemented until breathing is regular and
tracheally) for recovery, removed, or replaced with a the horse assumes sternal recumbency, which helps nor-
nasotracheal tube and secured in place. Maintenance of a malize ventilation and perfusion distribution. The effec-
patent airway includes vigilance that the endotracheal tube tiveness of O2 supplementation is dependent on the
References 165
insufflation flow and minute volume of the horse, since ous signs of partial airway obstruction, may require of
fast respiratory rates and high tidal volumes can dilute and heavy sedation or anesthesia to perform the tracheostomy.
minimize the insufflation flow. A flow of 15 L/ min and
placement of the insufflation catheter as far as possible Pulmonary edema
into the endotracheal tube (intubated horse) or nasal pas- A patent airway through a tracheostomy, nasotracheal
sages (extubated horse) have been shown to provide the tube, or clear nasal passages is required if airway obstruc-
best results, both in horses recovering from anesthesia and tion is still a risk. Supplementation of O2 as described
in an ex vivo model [44, 45]. above helps improve gas exchange in the presence of a dif-
fusion barrier represented by the alveolar edema.
Salbutamol Supportive drug therapy should include control of lung
Aerosolized salbutamol (albuterol) at 2 μg/kg can be water and transcapillary pressures with diuretics, such as
administered during anesthesia via the endotracheal tube furosemide (0.5–1 mg/kg, IV), use of bronchodilators (sal-
in ventilated and spontaneously breathing horses and has butamol) to improve PaO2, non-steroidal anti-inflamma-
been shown to double the PaO2 within 20 minutes in tory drugs (phenylbutazone, 4 mg/kg, IV, or flunixin, 1 mg/
hypoxemic horses (PaO2 < 70 mmHg), most likely due to kg, IV) or glucocorticoids (dexamethasone, 0.02–0.04 mg/
its β-2 bronchodilatory effects, without changes in heart kg, IV) to control the effects of prostaglandins on broncho-
rate or mean blood pressure [46]; however, a series of 5 constriction and vascular permeability [10–42].
cases was reported in which transient increases in heart
rate and decreases in mean arterial pressure occurred asso- Expected outcome Airway obstruction has the most drastic
ciated with this type of delivery [47]. changes of pulmonary complications because the horse
panics during its inability to breathe. This results in violent
Tracheostomy actions that could lead to trauma (fracture) during the
In extubated horses, obstruction can ensue as a result of disorganized efforts of the horse in the recovery stall and
impaired flow from edema of the airway to physical eventually suffocation. Actions need to be immediate, but
obstruction of the larynx by the soft palate or the nostrils safety of personnel is also a priority.
pressed against the walls or the head under the body. A tra- Hypoxemia and pulmonary edema can be medically
cheostomy kit should be available at all times, and more so treated or at least controlled to improve outcome.
if airway obstruction is a possibility. This kit should include
several sizes of tracheostomy tubes, which can be smaller General Expected Outcomes Complications in the recovery
diameter than the endotracheal tube used, to facilitate its period are the result of multifactorial events. Avoiding risk
placement. This is an emergency situation, if airway factors that make the horse more likely to suffer from
obstruction is present, and should be performed by an complications is imperative. Under anesthesia, short
experienced person capable of introducing the tube quickly recumbency time, proper positioning, adequate
and in a horse that is likely to be violent and non-amenda- hemodynamic function, and pain control are required;
ble to the procedure. Some horses may require a tracheos- whereas during recovery, a calm environment and the best
tomy in advance of recovery. Those horses in which a suitable set-up of free or assisted recovery should be
tracheostomy is required during recovery, because of obvi- tailored to the patient and type of surgery performed.
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168
17
ComplicationsAssociatedwith SurgicalSiteInfections
Denis Verwilghen DVM, MSc, PhD, DES, DECVS1 and J. Scott Weese DVM, DVSc, DACVIM2
1
School of Veterinary Science, University of Sydney, Australia
2
Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
Overview pure aseptic techniques are the key components of SSI

prevention.
Despite (and sometimes because of) advances in surgery,
surgical site infections (SSIs) remain among the most istof ComplicationsAssociated
L
feared and potentially devastating surgical complications with SurgicalSiteInfections
and continue to have a major impact on healthcare costs [1,
2] due to additional treatment, antibiotics, hospital stay ● Definition and classification
and mortality. While a 0% SSI rate goal is likely unachieva- ● Procedural definitions
ble, the toll that infections are taking on the success rates of ● Wound definitions
surgical procedures is still unacceptably high and current ● Infection definitions
SSI rates can undoubtedly be reduced even further. ● SSI epidemiology
Ever since the development of the germ theory, it has ● The basic SSI risk index
become clear that “instead of fighting bacteria in wounds, ● Infection rates and risk factors
it is likely better not to introduce them.” Followed by this ● SSI Prevention
statement made by Pasteur, surgeons like Koch, Lister and ● Understanding the occurrence of SSI
Halstead developed the principles of antisepsis and later ● Overall preventive measures
asepsis (Table 17.1), elements that have likely had the big- ● Time is SSI
gest impact on patient survival and surgical success rates. ● Surgical experience, technique and operating room etiquette
With the waning effectiveness of our antibiotic arsenal ● Hand hygiene
and the fact that no pathogen has yet been reported to ● Optimizing the cleanliness of the surgical procedure
develop any resistance to aseptic technique, the adoption ● Lack of compliance as contributor to SSI
and adherence to simple and cost‐effective methods of ● Preoperative preventive measures
● Postponing elective surgeries in case of remote infection
Table 17.1 Antisepsis versus asepsis or systemic disease
● Antimicrobial prophylaxis
Antisepsis Asepsis ● Perioperative preventive measures
● Post‐op
The process of Working germfree. Further ● Wound protection and hygienic care
destroying germs. introduced after the discovery of the
Introduced by Lister, the germ theory of disease, the method ● SSI surveillance
method of anti‐sepsis of asepsis, focuses on preventing the ● SSI recognition
was meant to fight occurrence of sepsis rather than ● Common pathogens recovered from equine surgical site
infection when already fighting it. Aseptic technique infections
present. includes the use of antiseptics to
destroy germs. ● Sampling of wound and interpretation of results
● Management of SSI
TREATMENT PREVENTION
● Multidrug resistance
efinition and Classification 169
Definitionand Classification ● General anesthesia: the administration of drugs that

enters the general circulation and affects the central
Recognition and surveillance of SSIs are key elements for nervous system to render the patient pain free, amnesic,
treatment and prevention. Proper identification and sur- unconscious and often paralyzed with relaxed muscles.
veillance is best performed by direct visual inspection of ● Anesthetic time: time needed between the induction of the
the wound by a person that understands and applies a anesthetic state of the patient and the end of the procedure.
standardized definition of SSI [3]. In the absence of veteri- ● Preparation time (PT): time needed between the induc-
nary‐specific infection definitions, the closest useable defi- tion of the anesthetic state of the patient and the start of
nitions are those reported in the American Centers for the surgical procedure. This time includes the time for
Disease Control and Prevention (CDC) documents on full preparation of the surgical field and surgical team,
Surgical Site Infection definitions [4] and European CDC including draping.
Surveillance of Surgical Site infections in European ● Recovery time (RT): time needed between the end of the
hospitals – HAISSI protocol [5]. The below definitions procedure and the full recovery of consciousness (end of
have been adapted from these two documents to be useful anesthetic time) of the patient.
in equine veterinary settings, since some of the standard
human criteria are not useable or applicable in veterinary Duration of the surgical procedure [8]
medicine. The interval between the procedure/surgery start time and
the procedure/surgery finish time:
Procedure start time (PST): time when a procedure is
ProceduralDefinitions
●
begun (e.g. incision is made for a surgical procedure).

A surgical procedure is defined as a procedure that takes ● Procedure finish time (PFT): time when all instruments
place during an operation in which at least one incision is and sponge counts are completed and verified as correct,
made through the skin or mucous membrane, or where all postoperative radiological studies to be done in the
there is re‐operation via an incision that was left open during operating room are completed, all dressings and drains
a previous operative procedure. Surgical procedures can be are secured, and the surgeons have completed all proce-
divided into: elective (performed by choice and can be dure‐related activities on the patient.
scheduled as it does not involve a medical emergency that is
life‐threatening to the patient); semi‐elective (medically
WoundDefinitions
indicated to preserve the patient’s life but can be scheduled
and does not need to be performed immediately); urgent ● Surgical Wound: wound or wounds created by the surgi-
(medical stabilization of the patient is warranted prior to the cal intervention that were not present on the patient
intervention and would have to be performed within 24–48 before the procedure.
hours to preserve the patient’s life); and emergency (must be ● Trauma: blunt or penetrating injury that occurs prior to
performed without delay) procedures. the start of the surgical procedure.
ASA status of the patient [6, 7] based on assessment of the ● Wound class: assessment of the degree of contamination
patient’s preoperative medical status is to be recorded in sur- of the surgical wound of the primary principal procedure
veillance. The American Society of Anesthesiologists (ASA) being performed at the time of the operation (see
Classification of patient’s physical status is as follows: Table 17.2).
● Wound contamination definitions: see Table 17.3
● ASA I: normal healthy patient
● Wound closure definitions: see Table 17.4
● ASA II: mild systemic disease: no functional limitation
● ASA III: severe systemic disease: definite functional
limitation InfectionDefinitions
● ASA IV: severe systemic disease that is a constant threat
● SSI Date of Event: the date when the first element used to
to life
meet the criteria of SSI criterion occurs for the first time
● ASA V: a moribund patient unlikely to survive 24 h with
during the surveillance period.
or without an operation
● SSI Appearance Interval: the number of days between
the date of the procedure (defined as day 1) and the SSI
Duration of the anesthetic procedure
date of event.
The interval in minutes and hours between the time of
induction of the patient until full conscious recovery is The original human CDC definitions [4] involve a time-
obtained and patient is standing: frame of 30 to 90 days following an intervention in which a
170 Complications Associated ith Surgical Site Infections
Table 17.2 Wound class definitions
WoundClass Definition
Clean An uninfected operative wound in which no inflammation is encountered and the respiratory,
alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily
closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow non‐
penetrating (blunt) trauma should be included in this category if they meet the criteria.
Clean/Contaminated An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under
controlled conditions and without unusual contamination.
Contaminated Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique or
gross spillage from the gastrointestinal tract, and incisions in which acute, non‐purulent
inflammation is encountered including necrotic tissue without evidence of purulent drainage, are
included in this category. This includes open surgical wounds returning to the operating room.
Examples of major break in sterile technique include but are not limited to non‐sterile equipment or
debris found in the operative field.
Dirty/Infected Old traumatic wounds with retained devitalized tissue and those that involve existing clinical
infection or perforated viscera. This definition suggests that the organisms causing postoperative
infection were present in the operative field before the operation.
Notes:
● Placement of any drain at the time of surgery does not change the classification of the wound.
● Operations performed in high wound classes are not reasons for exclusion of the patient for later meeting criteria for SSI (e.g. animals
that develop SSI following excision of purulent omphalophlebitis will still be eligible for SSI recording).
Table 17.3 Wound contamination definitions developing infection can be classified as an SSI (superficial
infections 30 days/deep and organ infections up to 90 days).
WoundcontaminationDefinitions In the European equivalent [5], a 1‐year timeframe for sur-
geries involving an implant is still used. In equine surgery
Wound The presence of bacteria within a wound these short timeframes of 30 to 90 days may lead to an
contamination without any host reaction
underestimation of infection rates. In a small animal pro-
Wound The presence of bacteria within a wound
spective active surveillance study, in which cases were fol-
colonization which multiply and do not create a host
reaction lowed for 1 year, all infections, including those with
Critical wound Multiplication of bacteria causing a delay in implants, occurred before the 30‐day timespan [9]. This
colonization wound healing, usually associated with an corroborates guidelines based on human epidemiological
exacerbation of pain but still without overt studies where a 30‐day time limit is put forward as suffi-
host reaction cient, even for implants surgeries [10]. However, shorten-
Wound infection The deposition and multiplication of bacteria ing of the monitoring period of 1 year to 90 days for implant
in tissue with an associated host reaction.
surgeries and from 30 to 21 days for other types of surgeries
resulted in 6% to 14% of SSIs being missed according to a
Table 17.4 Wound closure definitions recent large‐scale human epidemiology study [11].
Additionally, when investigating only deep and organ
Primary Defined as closure of the skin level during the space infections, limiting the timeframe to 30 days would
closure: original procedure regardless of the presence of
drains or other devices or objects extruding through lead to under‐reporting of approximately one‐quarter to
the incision. Thus, if any portion of the incision is two‐thirds of infections in coronary bypasses and hip and
closed by any means, a designation of primary knee prostheses [10]. Thus, determining optimal guide-
closure is attributed. lines for equine SSI surveillance is challenging given the
Non‐ Defined as closure that is other than primary and lack of equine‐specific data.
primary includes surgeries where the skin is left completely
In equine hospitals, monitoring can be challenging. The
closure open during the original procedure. The deep tissue
layers may be closed by some means (with skin left concept of active post discharge surveillance systems, as
open), or deep and superficial layers may both be left put in place in human settings and similar to those used in
completely open. Wounds with non‐primary closure a small animal studies, are lacking or very uncommon, in
may or may not be packed.
part because of the significant time that is required for
SSI Epidemiology 171
active surveillance (e.g. active follow up of all patients at SSIEpidemiology

the end of the SSI window). It can also be noted that in
equine surgical settings many wound infections will never Epidemiological studies provide important information
get referred back to the surgical care institution where the concerning groups, factors and procedures that are most
intervention was performed. Further weeks or even months associated with risk of SSI. Understanding risk factors can
can pass before owners decide to present their animal back help identify cases that are the most vulnerable and direct
for non‐healing or even purulent wounds. It is the experi- any potential interventions, something that can signifi-
ence of one of the authors (DV) that infections related to a cantly reduce infections rate in human patients [12]. Such
surgical intervention can sometimes appear and/or only be systems are in their infancy in veterinary medicine and
noticed many months after the procedure and that the tim- large‐scale patient recoding systems similar to the National
ing of first appearance of clinical signs often totally remains Nosocomial Infection Surveillance (NNIS) or HELICS sys-
unknown. Signs like local tenderness, heat or slight swell- tems available in America and Europe, respectively, are
ing may never be noticed by the horse owners before they lacking.
become clinically substantial or wounds become overtly
discharging. Therefore, it is likely, and until better active
discharge monitoring systems are put in place, a strict TheBasicSSIRiskIndex
timeframe should be replaced with “if the infection can be The traditional wound classification system which strati-
linked to the surgery independent of the time of fies each wound into one of four categories based on the
appearance.” expected contamination level of the wound during the pro-
The use of standard and consistent wound infection defi- cedure is widely used but has major limitations [13]. While
nitions is critical for proper identification of SSIs, for com- describing the wound, this system does not take the intrin-
paring rates over time and for consistent overall sic patient risk into account. A composite risk index that
surveillance. Current definitions based on depth of infec- captures the combined influences of the wound, procedure
tion are reported in Tables 17.5 and 17.6. and patient status is required before meaningful compari-
Table 17.5 Wound infection definitions
SuperficialIncisionalInfections
Must meet the following criteria:

− Infection that occurs within 30 days after any operative procedure OR if the infection can be linked to the surgery independent of the
time of appearance.
○ AND
− Involves only the skin and the subcutaneous tissues of the incision
○ AND
− Patient shows signs of at least one of the following
○ Purulent drainage with or without laboratory confirmation from the superficial incision
○ Organisms that are identified following an aseptically obtained specimen from the superficial incision or subcutaneous tissues by
culture or non‐culture based microbiological testing
○ Superficial incision that is deliberately opened and culture‐ or non‐culture‐based testing is not performed
○ AND
− Patient has at least one of the following signs:
● Pain or tenderness
● Localized swelling
● Erythema
● Heat
○ Diagnosis of a superficial incisional SSI by the surgeon or attending physician.
− Comments: The following do not qualify for superficial SSI:
○ Diagnosis of cellulitis by itself (redness, warmth, swelling) does not meet criteria for superficial wound infection.
○ A singular stitch abscess alone confined to the point of suture penetration.
(Continued)
Table 17.5 (Continued)
DeepIncisionalInfections:

− Infection that occurs within 30 to 90 days after any operative procedure OR if the infection can be linked to the surgery independent
of the time of appearance.
○ AND
− Involves only the deep soft tissues of the incision (e.g. fascial and muscular layers)
○ AND
− Patient shows signs of at least one of the following:
○ Purulent drainage from the deep incision
○ A deep incision that spontaneously dehisces or is deliberately opened or aspirated by the surgeon and organisms are identified
following an aseptically obtained specimen from the tissues by culture‐ or non‐culture‐based microbiological testing
■ AND
■ Patient has at least one of the following signs:
● Fever (>38,4°C / >101.12°F)
● Localized pain or tenderness
○ Diagnosis of an abscess or other evidence of infection involving deep incision that is detected on gross anatomical or
histopathological exam or imaging test.
OrganSpaceInfections:

− Infection that occurs within 30 or 90 days after any operative procedure OR if the infection can be linked to the surgery independent
of the time of appearance.
○ AND
− Involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure.
○ AND
− Patient shows signs of at least one of the following
○ Purulent drainage from a drain that is placed into the organ/space
○ Organisms that are identified following an aseptically obtained fluid or tissue from the organ/space by culture or non‐culture based
microbiological testing
○ Diagnosis of an abscess or other evidence of infection involving deep incision that is detected on gross anatomical or
histopathological exam or imaging test.
○ AND
Meet at least one of the criteria for specific organ/space infection listed for specific organs/spaces (see Table 17.2).
Infection present at the time of surgery (PATOS):
PATOS denotes that there is documented evidence of infection at the start or during the surgical procedure. Fresh traumatic wounds
that are contaminated at the time of surgery are not considered PATOS.
Multiple layers are involved in the infection:
The type of SSI reported should reflect the deepest layer involved.
sons between SSI rates can be made, such as the US number of hours. Most standardized operative procedures
National Nosocomial Infection Surveillance (NNIS) system in human medicine have 75th percentile duration values
Basic SSI risk index. This index is used to assign SSI published, though those are not available for equine sur-
development risk to surgical patients and is a significantly gery. However, it is reasonable to assume that in a well‐
better predictor [13]. The index is based on three major cri- organized and routinized equine surgical environment,
teria: procedure duration, degree of wound contamination clean procedures like closed sterile castration, single or
and ASA classification of the patient. The actual SSI risk double joint arthroscopies and laryngoplasties can be per-
index is the sum of the scores as described in Table 17.7. formed within the timeframe of 1 hour.
Duration of procedure is a common recurrent denomina- Such a model is not available for equine surgical practice
tor linked to infection risk development. This criterion is but would warrant development including evaluation of
therefore basically included as the 75th percentile of dura- procedure‐specific factors. For example, although few
tion of the surgery in minutes rounded to the nearest whole well‐defined studies describe the risk factors for abdominal
SSI Epidemiology 173
Table 17.6 Specific organ infection criteria. Source: Based and wound infections following celiotomy [14], one study dem-
adapted from Meakins (1989) [128]. onstrated a 45% absolute infection risk reduction in patients
where the wound was protected with an abdominal band-
BONE-Osteomyelitis
age [15]. Such risk or protective factors and their specific
− Patient has organisms identified from bone by culture or non‐ weight or importance to the development of SSI [16] could
culture based microbiological testing method.
be incorporated into an equine SSI index model.
− Patient has evidence of osteomyelitis on gross anatomic or
histopathological exam.
− Patient has at least two of the following localized signs: fever InfectionRatesand RiskFactors
(>38.4°C), swelling, pain or tenderness, heat, or drainage
− And at least one of the following: Various studies have reported SSI rates in veterinary sur-
○ organisms identified from blood by culture or non‐culture gery, including overall infection and procedure specific
based microbiological testing method in a patient with infections (Table 17.4). An equine meta‐analysis of 6,797
imaging test evidence suggestive of infection (e.g. X‐ray, CT
surgeries revealed a mean infection risk independent of
scan, MRI, scintigraphy, which if equivocal is supported by
clinical correlation (i.e. physician documentation of type of surgery of 7.3%, varying from 0% in clean proce-
antimicrobial treatment for osteomyelitis). dures, but up to more than 60% in procedures categorized
○ imaging test evidence suggestive of infection (e.g. X‐ray, CT as dirty [17]. However, most studies have some limitations,
scan, MRI, radiolabel scan) which if equivocal is supported often due to the lack of correct or clear definitions of SSI,
by clinical correlation (i.e. physician documentation of
the absence of proper prospective surveillance and a small
antimicrobial treatment for osteomyelitis).
sample size. In retrospective studies, large numbers of
Jointorbursainfection
infections, particularly more superficial ones, are never
− Patient has organisms identified from synovial fluid by culture reported because they may be treated by veterinarians
or non‐culture based microbiologic testing method. other than the primary surgeon and/or not be reported in
− Patient has evidence of joint or bursa infection on gross the medical record at the surgical facility [18]. Therefore,
anatomic or histopathologic exam.
retrospective studies likely provide an underestimation of
− Patient has at least two of the following signs with no other
recognized cause: true SSI rates. Proper SSI monitoring and establishment of
○ swelling, pain or tenderness, heat, evidence of effusion, or
reliable SSI rates requires active, patient‐based prospective
limitation of motion. surveillance using standardized definitions [4] (Table 17.8).
− And at least one of the following: In human surgery settings, where surveillance programs
○ elevated joint fluid white blood cell count and neutrophil are more rigorous than in veterinary medicine, the overall
count (per reporting range: see section on synovial sepsis SSI rate is around 5%, which is still considered an underes-
complications)
timation for the above‐mentioned reasons.
○ organisms and white blood cells seen on Gram stain of
synovial fluid Table 17.9 provides an overview of reported infection
− imaging test evidence suggestive of infection (e.g. X‐ray, CT rates for different surgical classifications in equine surgery.
scan, MRI, radiolabel scan) which if equivocal is supported by This data is based on an analytic review of surgical reports
clinical correlation (i.e. physician documentation of published in peer review veterinary journals over the last 5
antimicrobial treatment for synovial infection). years [17].
Table 17.8 Surveillance systems
Table 17.7 Basic SSI risk index calculation factors [5]. PassiveSurveillance ActiveSurveillance
Routine reporting of cases by Routine reporting of cases by

Calculation Score=0,if: Score=1,if: healthcare providers or non‐ trained healthcare providers in
trained medical personnel. No addition to active contact by
Wound class Clean Contaminated special effort is made to infection control team with
Clean‐Contaminated Dirty identify cases. surgeons and nursing team in
order to identify cases.
ASA class ASA‐1 ASA‐3
ASA 2 ASA‐4 Active Prospective Post Discharge Surveillance
ASA‐5
Active surveillance performed on in‐house patients and for a
Duration of operative T >T period defined by the SSI definition timing during which
procedure T monitoring of the development of SSI is recorded, even if
Basic SSI risk index Sum of scores patient has left the care facility.
Table 17.9 Reported SSI rates in Equine Surgery [17].
Typesurgery Numberofsurgeries AbsolutemeanSSI Mean%SSI
Overall 6,228 494 7.93%

According to wound class
Clean 3,203 157 4.90%
Clean‐Contaminated 2,165 225 10.39%
Contaminated 315 36 11.42%
Dirty 545 76 13.94%
According to type of surgery
Soft Tissue 2,568 316 12.21%
Orthopedic 2,620 178 6.78%
According to body system
Cardiovascular 24 4 16.66%
Dental 74 15 20.27%
Endocrine 2 0 0%
Gastro‐Intestinal 1,924 182 9.45%
Integumentary 67 4 5.79%
Lower respiratory 45 7 15.55%
Musculoskeletal 2,654 169 6.36%
Ocular 115 1 0.87%
Reproductive Female 601 33 5.49%
Reproductive Male 523 48 9.17%
Upper respiratory 284 24 8.45%
Urinary 113 6 5.30%
According to planning level
Elective 3,410 157 4.6%
Emergency 2,805 337 12.01%
According to specific procedures
Arthroscopy 1,400 14 1%
Tenoscopy 187 16 8.55%
Closed sterile castration 283 16 5.6%
Fracture repair 298 61 20.46%
C‐section 145 8 5.51%
Laparotomy 1,769 172 9.72%
Laparoscopy 414 23 5.55%
Laryngoplasty 164 1 0.6%
SSIPrevention amount” of bacterial for proper healing with avoidance of

infection will depend on the fine balance between the
Understandingthe Occurrenceof SSI host’s susceptibility and inherent defense mechanism
against pathogens and tissue injury and the virulence of
The occurrence of SSI is the result of a complex interplay the pathogen and the degree of the inflicted surgical injury
between multiple factors related to the patient and its envi- and potential foreign material left behind. This theory is
ronment. Surgical procedures performed in totally sterile supported by the fact that detection of bacterial contamina-
environments are virtually impossible. The “tolerated tion at the site of abdominal incisional closure in horses is
SSI Prevention 175
not predictive of SSI occurrence [19]. Additionally, admin- ple, it would be unthinkable to perform surgeries
istration of perioperative antimicrobials and the inherent comparing SSI rates with and without hand asepsis.
or acquired antimicrobial resistance of the pathogen have Furthermore, the lack of consistent definitions and the use
to be taken into account. of surrogate outcomes instead of endpoint studies have
The bacterial contamination in a surgical wound origi- complicated interpretation of findings. Many recommen-
nates from an endogenous and exogenous source. dations are therefore based on theoretical grounds and
Endogenous sources of contamination originate from the extrapolation. In veterinary medicine, evidence is even
patient’s commensal microbiota at the surgical site or dis- weaker and extrapolation from human medicine is com-
tant body sites (e.g. skin, oropharynx, gastrointestinal mon. Nevertheless, absence of proof can never be proof of
tract – linked to surgical wound class). The exogenous absence [21].
sources of contamination are those originating from the
surgical team, the environment and the materials and
OverallPreventiveMeasures
instruments used. Other risk factors can similarly be
divided into endogenous and exogenous. In humans, it has Time is SSI
been estimated that approximately half of all the identified Procedure‐time is a well identified SSI risk factor in human
SSI risk factors are endogenous (e.g. age, systemic disease, and veterinary studies, not only the length of time of the
history of prior surgery) and many of those are difficult or surgery itself, but the overall procedural time from induc-
impossible to modify in the direct preoperative and periop- tion to recovery is important. Longer surgery times will
erative phase [20]. However, many exogenous (e.g. change lead to longer wound exposure times and longer tissue
of surgeon during surgery, visitors during surgery, hair manipulation with more opportunities for pathogens to
removal methods, etc.) factors can be readily addressed. seed into the wound, and at the same time allow for greater
Surgical asepsis prevents wound contamination from chance of wound desiccation. Additionally, overall proce-
microorganisms that originate from the patient, the operat- dure time presumably contributes to compromise of vari-
ing room personnel, and the environment. The methods ous host defense mechanisms that are difficult to
and practices that prevent contamination during surgery specifically evaluate.
are defined in part by aseptic surgical techniques and are While surgeon experience can be one factor in extending
described in the perioperative prevention sections of this the duration of the surgical procedure, the overall anesthetic
chapter. Proper SSI prevention measures are not an indi- time will be dictated by the entire surgical and anesthetic
vidual action of the surgeon during the procedure, but they team. Procedure planning, availability of appropriate instru-
involve proper preparation of the facilities and the environ- mentation, coordination with diagnostic imaging and myr-
ment, the surgical site, the surgical and anesthesia team, iad other factors can reduce the overall procedural time. In
and the surgical equipment. Basic rules are straightforward human hospitals, unfamiliarity of the surgical, anesthesia
and simple to implement, but unfortunately are not always and nursing teams with their precise roles and poor com-
followed. Every member of a healthcare setting, including munication can result in higher SSI rates [22]. A recent
the surgeon, assistants, cleaning staff and the management small animal study found a 2% increase of SSI rates with
team carry responsibility in the achievement of the overall every increasing minute of procedure time [23]. With an
aseptic procedures and the corresponding success and fail- efficient and well‐prepared team, a target patient prepara-
ures of the surgical procedures. Adhering to all these prac- tion time of 30 minutes is feasible, even for preparation of
tices builds the basis of what is known as surgical and OR multiple surgery sites. In a recent pilot study, students were
team conscience. requested to observe the team of students performing a sur-
The overall aims in the prevention of SSI are to embrace gical and anesthesia procedure and note coordination, team
methods and principles that will reduce the amount of responsibility and efficiency. It was reported that better team
endogenous and exogenous microbiological contamina- leadership, equipment preparation, anticipation of needs
tion, reduce the pathogenicity of the microbes involved, during the procedure and proactivity in surgical assistance
increase the host’s own defense mechanisms, reduce the could have reduced the 90‐minute procedure time by one‐
inflicted tissue trauma and reduce the amount of foreign third (Denis Verwilghen, personal communication).
body material left behind. Although many of the principles
of aseptic technique have found acceptance and evidence Surgical experience, technique and operating room
validation through their historical merits, many would etiquette
have difficulty passing the stringent test of current times. Many surgeons rightly consider that the most critical fac-
High evidence obtained by double blinded controlled rand- tors in prevention of SSI are sound judgment, proper tech-
omized trials is impossible for ethical reasons as, for exam- nique and strict adherence to Halsted’s principles of the
surgeon and surgical team [24]. It is impossible to perform dently contributed to an increase in infections rates.
randomized trials in this subjective area. Maintaining ade- Considering the implementation of checklists into surgical
quate hemostasis whilst preserving blood supply, gentle routine was shown to decrease surgical complications of all
handling of the tissues, removal of devitalized tissue, eradi- sorts significantly [33]; improving theater discipline may
cation of dead space and appropriate management of the also be able to reduce other morbidities than purely SSI.
postoperative incision are all gestures and actions that can
be learned but for which experience will increase perfor- Hand hygiene
mance [25] and ultimately reduce complications. This Hand hygiene has long been recognized as an important
statement is supported by several human studies in which infection control tool [34] and, despite a lack of randomized
the experience of the surgeon, both in general and for a controlled trials, is considered the pillar for prevention of hos-
particular procedure, was associated with lower SSI or pital‐associated infections [20, 35]. Unfortunately, knowledge
wound complication rates [26]. about correct surgical hand preparation is low among both
Studies have also reported a higher incidence of wound human [36] and veterinary surgeons (Verwilghen et al.
dehiscence in abdominal procedures when closure was unpublished data).
performed by a trainee rather than an attending sur- Currently, the wearing of surgical gloves by members of
geon [27, 28]. Similar findings were reported in an equine the operating team is standard procedure to prevent bacte-
study in which closure of the abdominal wound by first‐ rial transfer from hands to the operating wound.
and second‐year residents was a significant risk factor for Considering unnoticed glove punctures are reported to
development of SSI [29]. Considering surgical and anes- occur in up to 60% of used gloves [37] and glove puncture
thesia time is often reported as a crucial risk factor in com- doubles the risk of infection [38], surgical glove wear can
plication development, it is easy to relate inexperience with never be a substitute for proper pre‐surgical hand prepara-
longer surgery. However, in the above‐mentioned veteri- tion [39]. What is considered the current state‐of‐the‐art
nary study, surgery and anesthesia time were not different protocol on pre‐surgical hand asepsis [40, 41] adapted for
among level of experience [29], suggesting that several equine use [42–44] is explained stepwise in Figure 17.1.
other factors, such as technique, sound judgment, and The purpose of correct pre‐surgical hand preparation is
adherence to aseptic principles contribute to a greater to remove and/or kill transient skin organisms and to
extent in unexperienced surgeons. Relating to the authors’ reduce resident bacterial flora for the duration of a surgical
personal experience, increased confidence with procedures procedure. This should be achieved while minimizing
grows with the years and number of procedures performed, damage to the skin that might promote rebound bacterial
reducing stress and improving decision making and con- overgrowth or compromise future hand antisepsis attempts.
centration to the task. Techniques involving aggressive cleaning of the skin with
The establishment of proper operating room etiquette alkaline medicated soaps (e.g. chlorhexidine (CHX)) have
receives limited attention in the veterinary community and shown to have deleterious effects on the local defense
its importance is likely underestimated. Although probably mechanisms of the skin [45]. Techniques involving brushes
a surrogate outcome to assess behavior of the surgical and scrubbing cause small excoriations, consequently
team, noise level in the surgical theater has been signifi- damage the skin and increase the risk of skin colonization
cantly correlated with higher SSI rates in human medi- by pathogenic bacteria species without providing any addi-
cine [30]. Noise leads to a significant decrease in tional effect on instant bacterial reduction [46, 47]. If hands
concentration capacity [30] and to a significant increase in are visibly soiled and surgical scrub is to be carried out,
errors [31] performed during the surgery. Talking about current recommendations are to use a soft sponge for fore-
non‐surgery related topics has shown to not only reduce arms and hands, and a soft brush for the fingertips, if any
concentration to the task but is significantly associated aids are to be used [48]. While scrubbing has been the tra-
with higher sound levels [30]. ditional hand antisepsis method, the issues noted above
One of the most interesting articles on the subject, that have led to increased use of alcohol‐based hand rubs
should remind us that our daily work involves variable (AHR). Randomized controlled trials showing any signifi-
issues that impact outcomes, is the study: Impact of intra‐ cant differences in SSI rates between any of the above‐
operative behavior on surgical site infections, by Beldi mentioned methods are lacking, but the use of AHR is
et al. [32]. This prospective investigation in over 1,000 pro- considered superior for a number of reasons [40]. The anti-
cedures showed clearly that a lapse in discipline by the sur- bacterial efficacy of products containing high concentra-
gical team was an SSI risk factor. Increased movement in tions of alcohol significantly surpasses that of any
the theater, exchange of surgical team members, noise and medicated soap currently available [49]. The initial reduc-
the presence of visitors in the operating room, all indepen- tion of the resident skin flora is so rapid and effective with
SSI Prevention 177
Cle
wwwan
. Hands – Safe Animals
.eu
Clean Hands Save Lives
Hygienic Hand Sanitation Protocol
ww
w.
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te e
.e
rin
a ien
hyg
Your 5 Moments for Hand Hygiene – Equine
1 4 5
Before touching After touching
a patient After touching
the patient
the patient’s
surroundings
2
Before a
clean/aseptic
3
After body fluid
procedure
exposure
When? Clean hands before touching the patient.
1 Before touching patient Why? To protect the patient against harmful germs you carried on your hands.
Examples: Clinical examination, handling patient, restraining patient,…
When? Clean hands immediately before and after an aseptic task.

Before a clean/
2 aseptic procedure
Why? To protect the patient against harmful germs, including patients own, from entering its body.
Examples: Blood sampling, IV catheter manipulation, intra-articular joint treatment,
medication administration, catheter placement, wound care,…
When? Clean your hands immediately after exposure risk to body fluids and after glove removal.
3 After body fluid exposure Why? To protect yourself and the health-care environment from harmful patient germs.
Examples: After contact with any body fluid like urine, blood, nasal discharge, saliva, faeces,…
When? Clean hands after touching a patient and its immediate surroundings, when leaving the patient’s side.
4 After touching a patient Why? To protect yourself and the health-care environment from harmful patient germs.
Examples: After clinical exams, after bandage changes, grooming,…
When? Clean your hands after touching any object or furniture in the patient surroundings when leaving
After touching the patient’s
5 surroundings
even if the patient has not been touched.
Why? To protect yourself and the health-care environment from harmful patient germs.
Examples: When leaving the exam room, stable area or the hospital.
The steps on how to clean your hands
1 2 3 4 5 6 7
› Waterless rubs are your preferred way of sanitising your hands. * Depending on the formulation of the product used
› A 30 – 60 second application of the rub* according to the above technique is necessary. (refer to manufacturer recommendations). Use products
that have passed the prEN1500 norm or similar.
› Use water and soap for 40 – 60 seconds only when hands are visibly soiled.
It’s in your hands! www.veterinaryhandhygiene.eu
Figure 17.1 State-of-the-art presurgical hand asepsis preparation method as now recommended. The poster depicts the four
important steps of hand hygiene. Step one focuses on proper skin condition and nail care. Step 2 is a decontamination step in which
the hands and forearms are washed with a neutral nonmedicated soap. Step 3 is the actual disinfection step, consisting of a rubbing
application of a hydro-alcoholic solution. The application time for this is dependent on the formulation of the solution used. Step 4
emphasizes the importance of skin care and the application of hydrating creams after surgery. Source: The Veterinary Hand Hygiene
project, www.veterinaryhandhygiene.eu. Reproduced with permission.
AHR that bacterial regrowth to baseline values on the a wound debridement or tumor resection, double gloving
gloved hand takes more than 6 hours [50]. from the start with discarding outer pair is a better option
These observations also were confirmed in a veterinary than performing an actual change of gloves that will expose
trial that compared the activity of an AHR solution to CHX the naked hand. Further glove perforation in equine sur-
and PVP soap [51]. In that study, a 1.5‐minute application of gery is high, as was shown with 66% of investigated surger-
an AHR solution was performed, and the 3 h residual effect ies having perforated gloves [61]. Traditionally it has been
on bacterial inhibition AHR was revealed to be significantly put forward that orthopedic surgeries are at increased risk
better than for traditional hand scrubbing with PVP and for glove perforation, though a recent study revealed a
CHX. A recent publication performed in veterinary students higher degree of glove perforations in equine soft tissue
challenged this finding and suggested CHX‐containing procedures [61]. Since the ability to detect glove perfora-
products to be superior to alcohol products [52]. However, tion during surgery is low [61], double gloving and/or the
contrary to standard testing guidelines [53, 54], that study wear of indicator undergloves may help in reducing and or
did not use a neutralizing agent to inhibit the in vitro effects identifying perforations. Increased glove contamination
of CHX residues, leading to potential overestimation of the and perforation has been shown at around 60 minutes of
efficacy of CHX [55–57]. In addition, initial antimicrobial procedure time [61, 63]. Changing outer gloves around this
efficacy is not the only relevant factor, and poorer skin health time and before handling implants is a potential interven-
scores (mostly on dryness) have been identified in veterinar- tion. When changing gloves intraoperatively, closed glov-
ians using CHX versus AHR [58]. This is in line with the ing cannot be performed as this would require pulling back
observations that long‐term use of medicated soaps signifi- the gown sleeve over the hand, which will increase con-
cantly increases the risk of dermatitis [43]. tamination. Then the use of the third‐party gloving method
Additionally, combining antibacterial soap and AHR should be preferred over open gloving.
does not provide any additional benefit, but increases in
the risk of dermatitis, which can ultimately make the skin Lack of compliance as contributor to SSI
more difficult to decontaminate [51]. The prime and most threatening factor for the develop-
Hand‐washing prior to the use of AHR application has ment of SSI is the surgical staff. SSIs are considered the
shown to negatively alter the effectiveness of AHR solu- most preventable of all the healthcare associated infec-
tions, particularly if hands are not completely dried before tions, yet compliance with standard recommendations is
AHR application [59]. Pre‐washing of hands should there- often unsatisfactory [63]. In a survey performed among
fore be minimized as much as possible and only be per- Canadian human surgeons, 63% did not comply with the
formed if hands are visibly soiled [59, 60]. current recommended guidelines on preoperative bathing,
hair removal, antimicrobial prophylaxis and intraoperative
Optimizing the cleanliness of the surgical procedure skin preparation [64]. In comparison, an observational
Surgical planning is key to success of a procedure. Revising study in companion animal clinics revealed inconsistent
the steps of the surgical procedures, dividing the procedure and often poor compliance with well‐established surgical
into parts from more‐dirty to clean is a scientifically unsup- preparation practices [65]. Recommended times for anti-
ported strategy but the most commonsense key in avoid- septic soap during patient surgical site and surgeon hand
ance of SSI. For all procedures, table set‐up should be preparation are at least 2 minutes; however, observations
performed with division of instruments from opening to made in the above‐mentioned study reports this can be as
closing (dirty to clean) of the wound and instrument boxes low as 10 and 7 seconds, respectively [65]. Furthermore,
should be composed as such to have duplication of instru- this study reported that non‐sterile contact with the previ-
ments to allow for this. For classification contaminated ously aseptically prepared surgical site occurred in at least
and dirty procedures, two separate tables with different 36% of cases [65]. Many similar examples are available in
sets of instruments, extra layer of draping and change of human surgery [36] and the example most difficult to
surgical attire once the contaminated part of the procedure understand is probably that of hand hygiene, where
is over should be standard. extremely low compliance is noted.
Various points in the surgical procedure provide oppor- When it comes to pre‐surgical hand preparation, despite
tunities for contamination or mitigation. Proper opening of their own stated beliefs that AHRs are superior to aqueous
instruments and the draping procedures reduce initial con- rubs, 66% of respondents to a survey among ACVS and
tamination. Double gloving for draping with discarding the ECVS specialists reported not following those
outer pair before the start of the surgery can further reduce recommendations [66].
contamination risks. Additionally, when change of gloves More extensive hygienic measures than recommended
will be expected during the procedure, as would happen in do not seem to have a significant impact on SSI; however,
SSI Prevention 179
missing adherence to the established hospital protocols has ponents of the Surgical Care Improvement Project (SCIP)
shown to result in a 3.5 increase in the risk for SSI develop- are: i) basing antimicrobial selection on pathogens expected
ment [32]. In human settings, where the current SSI rate is to be present at the surgical site; ii) ensuring appropriate
around 5%, it is postulated that if full compliance with timing of antimicrobial administration to ensure peak
guidelines and protocols was met, infection rates for clean serum drug concentration at time of first incision; and iii)
surgeries would be below 0.5% [67]. discontinuing administration of prophylactic antimicrobi-
als within 24 hours postoperatively. Similar guidelines are
not available for equine surgery, but there is little reason to
Pre฀OperativePreventiveMeasures
think that these general concepts would be any different.
Postponing elective surgeries in case of remote Objective data pertaining to the need for antimicrobials
infection or systemic disease for specific equine surgical procedures is lacking.
Although randomized trial data are lacking, postponing Antimicrobials are widely used, and almost certainly over-
elective surgeries in patients with remote infections or sys- used, for perioperative prophylaxis, leading to risk of
temic disease is regarded as high evidence by the human adverse effects (e.g. enterocolitis) and antimicrobial resist-
CDC SSI prevention guidelines [68] and is supported by ance selection pressure. However, in the absence of data
numerous retrospective reports in which remote infections indicating a lack of need, some surgeons are reluctant to
were found to be significant risk factors in the development avoid antimicrobials, even in clean procedures where a
of SSI [69–71]. The most common remote site infections lack of need has been demonstrated in other species. The
are the GI tract or the lungs [72]. Urinary infections have potentially devastating consequences of some surgical
also been incriminated [73], although data are less infections (e.g. septic arthritis) cannot be ignored, but nei-
certain [20]. ther can the potential adverse effects, and consideration of
The preoperative systemic inflammatory status of the when antimicrobials are required is important. An often‐
patient has been correlated with increased risk in repeated suggestion is that antimicrobials are indicated for
humans [74, 75], as have a number of factors like obesity, procedures where the infection rate is 5% or higher. This is
smoking, diabetes and nutritional status of the patient and hard to assess given the limited SSI data that are available
intake of certain medication [68]. In horses affected with for specific procedures in equine surgery and the fact that
pituitary pars intermedia dysfunction (PPID), an elevated most SSI surveillance studies involve horses that have
wound infection risk is likely present, as these horses received perioperative prophylaxis.
exhibit delayed wound healing and have a tendency to A study of 444 horses, undergoing elective arthroscopy
develop secondary infections. Delaying surgery until involving a total of 636 joints without perioperative antimi-
appropriate medical treatment for PPID has proven effec- crobials, only identified a septic arthritis incidence of 0.5%
tive could potentially reduce the risk of infection. Wound of joints in 0.7% of horses [76], consistent with a lack of
and skin infections are likely both of greatest occurrence need for routine antimicrobial prophylaxis. More broadly,
and greatest risk in equine patients, and postponing elec- it is reasonable to assume that perioperative antimicrobials
tive surgery in individuals with those conditions is a pru- are justifiable in most clean‐contaminated, contaminated
dent approach. and dirty procedures, but rarely in clean procedures. An
In any other cases affected with concomitant diseases argument can be made for prophylaxis for procedures
that substantially would increase the risk of infection and involving implants and where the consequences of SSI can
cannot be controlled, the benefit of the elective surgical be devastating. However, the latter argument is somewhat
procedure versus complication risks should be assessed. tenuous given the fact that it opens the door for prophy-
Routine hematologic screening of patients can be con- laxis in essentially any orthopaedic procedure in a perfor-
sidered, with postponement of elective procedures if clini- mance horse, something that is likely unwarranted.
cally relevant abnormalities are identified. Furthermore, the administration of antimicrobials can
have devastating results of its own for a singular patient,
Antimicrobial prophylaxis namely antimicrobial‐induced diarrhoea, which can be dif-
Antimicrobials can play a critical role in reducing the risk ficult to control and even lead to mortality.
of infection in certain types of surgery, but are often mark- Selection of a drug that will target the expected patho-
edly overused in equine surgery. Rationale use of periop- gens involves understanding the most likely organisms and
erative antimicrobials is based on maximizing the impact their typical susceptibility patterns. Pathogen patterns can
on infections while minimizing potential negative conse- vary by procedure. For example, staphylococci tend to
quences such as antimicrobial‐associated diarrhoea and dominate in orthopedic SSIs, while Enterobacteriaceae are
development of resistance. In human medicine, key com- more common in SSIs after abdominal surgery.
Timing of perioperative prophylaxis is important, with The author’s current protocol is to administer crystalline
the general principle being that antimicrobials should be penicillin IV at induction. Considering the aim for time
present at therapeutic levels throughout the surgical from induction to first cut to be equal or less than 30 min-
period, from first incision until final closure. For time‐ utes, the first re‐dosing is performed at 50 minutes after
dependent antimicrobials (e.g. penicillin, cephalosporins) start of surgery, then every 80 minutes after (Figure 17.2).
this involves administering the first dose 30–60 minutes Concentration dependent drugs with long half‐lives (e.g.
prior to the first incision. This window may often be missed, aminoglycosides, fluoroquinolones) do not require intra-
particularly with delays between administration and the operative re‐dosing and should be administered approxi-
start of surgery. For example, a study of elective arthros- mately 1 hour prior to first incision. Regular re‐assessment
copy (a procedure where it is questionable whether antimi- of SSI rates, SSI pathogens, and SSI pathogen antimicrobial
crobials are even indicated), the median time from susceptibility is important to determine whether changes
antimicrobial administration to incision was 135 min- in the perioperative antimicrobial approach is needed.
utes [77], while a median of 70 minutes was reported in a A single equine study [79] claims reduction of SSI post
study of colic surgery [78]. Those timeframes would result arthroscopy with intra‐articular administration of ceftiofur
in minimal and likely ineffective drug levels at the time of at end of surgery. However, the statistical relevance of this
surgery because of the short half‐lives of commonly used finding can be debated considering the marginal difference
drugs such as penicillin and cephalosporins. The rapid from 0.7 to 0.5 % of infections (SSI occurring in only 1
decrease in drug levels is also relevant for prolonged proce- case). During arthroscopies, many time‐points contribute
dures, with a decrease to sub‐therapeutic drug levels while to contamination risk. First, the procedure itself, second,
the procedure is still underway. The standard approach is the bandage protection in the immediate postoperative
to re‐dose the antimicrobial every two half‐lives (e.g. every phase, and finally at suture removal 10–14 days after inter-
80 to 100 minutes for penicillin G) from the first dose until vention. End surgery intra‐articular deposition of antimi-
incision closure. Unfortunately, this is often not performed crobials is unlikely to target the latter two time points. And
properly, as was evident in a study of colic surgery that due to the nature of the actual arthroscopic procedure,
reported appropriate intraoperative dosing in only 1.8% of unless major break in asepsis occurs, the actual surgical
situations where it was indicated [78]. contamination risk is extremely low. In general, for clean
Understanding local SSI pathogen and antimicrobial procedures, the application of local antimicrobials should
susceptibility patterns is important for choosing an optimal be discouraged as it cannot be shown to provide any
perioperative antimicrobial. Intravenous crystalline peni- benefit.
cillin is commonly used and is a preferred option when the
prevalence of beta‐lactamase production among common Postoperative antimicrobials
SSI pathogens (predominantly staphylococci) in the area is The use of postoperative antimicrobials is a controversial
low. As a time‐dependent drug with a short half‐life, it subject, as the potential for clinical efficacy needs to be bal-
should be administered within 30 minutes of first incision anced with concerns about selection for antimicrobial
and be re‐dosed intraoperatively every 80 to 90 minutes resistance and adverse effects, and the relative risk of those
until the procedure is completed. The role of the anesthesia is poorly understood based on limited data. In humans, it is
team in complying with this is crucial and the anesthesia uncommonly recommended to extend administration of
chart can be adapted to mention antimicrobial antimicrobials greater than 24 h after surgery [80].
administration. Postoperative continuation of antimicrobials is commonly
IV Redose IV Redose IV Redose IV

80 min 80 min 80 min Penicillin
Penicillin Penicillin Penicillin
T -30 T0 T 50 T 130 T 210
Induction Incision
Figure17.2 Perioperative antimicrobial prophylaxis based on use of crystalline penicillin.

SSI Prevention 181
used in equine surgery but data indicating a need are can be associated bidirectional; one can be the origin of the
totally lacking. The cost‐benefits of postoperative antimi- other. Catheter infections are common in equine post‐sur-
crobial prophylaxis is hard to assess given limited study, gical patients. Microorganisms can colonize the venous
but it is reasonable to assume that antimicrobial regimens catheter and lead to bloodstream infections via three main
used in equine surgery are often excessive and increase the routes. Contamination of the external surface of the cath-
risk of complications while having little impact on SSI pre- eter through bad preparation of the insertion site; internal
vention. It has been suggested that low‐risk equine proce- catheter contamination through the catheter hubs, injec-
dures (e.g. all elective procedures without implants) receive tion ports and line; usually by hands of healthcare workers;
no postoperative antimicrobials, with 24 hours of postop- and contaminated intravenous drugs, infusates and nutri-
erative antimicrobials from moderate risk procedures (e.g. tional preparations [88]. Particular attention should thus
emergency procedures without gross contamination) and be placed on proper technique during both insertion of the
72 hours for high‐risk procedures (e.g. substantial implants catheter and future manipulation. No objective data relat-
such as meshes, gross contamination, procedures with per- ing complications of hand preparation techniques during
sistent compromised tissue) [81]. This recommendation is insertion are available yet the insertion of a catheter can be
consistent with a study of colic surgeries that reported no regarded as a sterile procedure and sterile gloving is there-
benefit of 120 h of antimicrobials compared to 72 h [82], fore a mandatory feature. Furthermore, hand hygiene acts
yet longer durations are commonly used [83]. However, the should be performed before and after each manipulation of
need for any postoperative antimicrobials in clean, clean‐ the catheter (see Figure 17.3 on five moments of hand
contaminated or dirty procedures beyond a 24‐hour win- hygiene in Equine Healthcare) and gloves should be worn.
dow, has been challenged [84]. Gloves may not be necessary in the protection of the patient
It is even so in human medicine, that extension of anti- if proper hand hygiene is performed, yet repeated exposure
microbial administration has shown to increase the risk of of drugs to healthcare workers skin can have deleterious
SSIs, potentially due to the alterations in the normal prolong‐term effect and is best avoided by wearing of
tective microbiota of the skin to a more pathogenic shift. gloves [89]. Hub, site and tubing should be hygienically
cared for and the necessity of the catheter line should be
assessed at least every day and removed as soon as possible.
PerioperativePreventiveMeasures
Most patients undergoing elective procedures do not even
Several techniques and procedures contribute to the reduc- have the need for a catheter after the procedure has been
tion of the endogenous and exogenous microbiota contam- completed, although it is common to see patients remain-
ination of the surgical wound. A non‐exhaustive list of ing with one for the entire duration of their hospitaliza-
items is presented in Table 17.10. This table shows the evi- tion, putting them at an unnecessary risk of infection. If
dence and recommendations for the practices based on the animal needs administration of drugs it should always
human and veterinary data. be determined if they can be administrated by an alterna-
tive route.
Suture removal is likely the last moment at which seed-
Post-op
ing of contaminants in a surgical site can occur. Proper
Wound protection and hygienic care aseptic preparation of the sutured wound and hand hygiene
In non‐diseased and nutritionally uncompromised individu- are therefore mandatory prior to suture removal. This is
als. sutured non‐traumatic surgical wounds are sealed from particularly important when removing sutures following
the outer environment within 24 to 36 hours [85]. Appropriate intra‐synovial surgeries. Small subcutaneous abscesses can
wound protection during at least this period of time is there- form and seed into the synovial cavity. Alternatively, if
fore crucial. For reasons explained elsewhere (see manage- sutures have inadvertently been placed too deep, pulling
ment of SSI) the use of antiseptics on wounds may not be dirty sutures could lead to direct contamination of the syn-
advised. However, certain primary layers, like the ovial cavity.
Dialkylcarbamoyl chloride‐impregnated dressing (SorbactR),
allow reduction of the bacterial bioburden founded on physi- SSI surveillance
cal principles. Based on hydrophobic interaction, bacteria Surveillance of SSI, including appropriate feedback to the
were captured on the surface of the dressing [86] and were surgical team, has long been shown to be an important part
shown in a randomized controlled trial to substantially reduce of strategies to reduce hospital‐associated infections in
SSI in women undergoing Cesarean sections [87]. general and particularly SSI [13, 90] and surveillance has
General hygiene methods are to be implemented in every now become an essential part of SSI prevention [91]. Active
step of postoperative care. SSI and bloodstream infections surveillance programs may have an impact on SSI rate
Table 17.10 Intraoperative measures for SSI prevention [129].
HumanEvidenceandrecommendations VeterinaryEvidence
Preoperative Patient Preparation

Surgical Site Preparation: Hair removal
● Clipping superior to shaving ● No RCT or valuable studies available.

● Timing hair removal, no effect ● Presence of hair does not reduce ability
Hair removal only if it interferes with surgical site of antiseptics to reduce bacterial flora in
sites for arthrocentesis in horses [131]
● Clipping before induction vs. after
induction increases SSI risk [132]
Veterinary Removing of hair can be seen as the first step toward gross decontamination of the surgical site and should be
Recommendations performed in horses.
Removing of hair mostly indicated unless in non‐ to very poor‐haired regions.
Use clippers, not razors for hair removal
Remove hair immediately before surgery/after induction of anesthesia
Start with clean patient/Groom outside the surgery ward

Surgical Site Preparation: Disinfection
− Little evidence for superior method. − No RCT available
− Use of 0.5% or 2% chlorhexidine with methylated considered − Number of studies available [138–147]
superior [20, 133], however latest trial no difference with iodine but conflicting results and no evidence
based alcohol [134]. for superior method.
− Alcohol‐based products probably more efficient and longer − Most studies look at bacterial reduction
lasting than aqueous based solutions [135]. and not SSI endpoint.
− Investigation into new methods that target high bacterial load
into hair follicles,[136].
− Cyanoacrylate microbial sealants: small positive difference in
SSI rates but still weak evidence[137].
No particular recommendations
Recommendations ✓ Prepare surgical site immediately before surgery with aqueous or alcohol‐based biocide.
✓ Chlorhexidine and povidone iodine are suitable, though final preparation with alcohol‐based product is
recommended.

Surgical Site Preparation: Preoperative bathing or showering with skin antiseptics
There is no evidence for benefit of preoperative bathing or showering − No studies in this field available.
with chlorhexidine over other wash products to reduce SSI [148]
Recommendations For maximum efficacy of the product and in order to reduce spreading of large quantities of active ingredient
of biocides (potential for chlorhexidine resistance development[ 149]) in the environment, gross
decontamination with a neutral soap wash of the surgical area is advised before starting the actual aseptic skin
preparation procedure

Surgical Site Preparation: Draping
− Little evidence investigating various drape types − Retrospective study found no difference
− Use of drapes based on theoretical rational of reducing in SSI using disposable versus drapes
contamination of surgical site by surrounding area [153]
− Disposable drapes provide highest cost–benefit ratio [150] and − Cost‐effectiveness of single use probably
are more efficient in reducing SSI than reusable [151] same as in humans
− One randomized trial (low number of patients) showing clear
superiority of single use compared to reusable in reduction SSI [152]
Recommendations ✓ Draping the surgical site is advised

✓ Best practice: use of impervious single use disposable drapes [154]
SSI Prevention 183

Surgical Site Preparation: Incise films
− No effect [155, 156] of incise drapes on reduction of SSI rate, − No trial available
non–iodophore impregnated incise drapes may even increase
the risk of surgical site infections [155, 156] due to higher
bacterial regrowth under the drape [156].
− Application technique is important, lifting of the edges of
adhesive drapes may enhance bacterial contamination [67]
If used, use iodophore impregnated with proper application
technique
Recommendations Do not use routinely, if used, use iodophore impregnated with proper application technique

Surgical Site Preparation: Plastic buster type drapes
− Pure plastic draping is not used in human medicine, no trials Plastic buster type drapes are widely used
available. in veterinary medicine. Although there are
− Certain national policies ban the use of plastic drapes due to no trials available, neither on the difference
known increase in bacterial count under plastic (i.e. Denmark) between SSI rates nor on the bacterial
growth potential underneath buster type
plastic drapes and conventional woven
reusable or disposable drapes, evidence
from human medicine reveals substantial
increase in bacterial regrowth under plastic
drapes. Increased moisture retention near
the skin could facilitate bacterial growth
[156]. Clinical experience reveals that
patients often sweat profusely under these
drapes. Plastic buster drapes are therefore
not recommended
Recommendations ✓ Until further evidence with regards to their safety is available, their use should be abandoned.
Preparation of the Surgical Team
Masks and Caps
● No difference between masked/capped and unmasked/ ● No studies available
uncapped procedures [157]
● Bacterial contamination of the operative field has shown to be
reduced [154]
Recommendations Scrubbed‐in personnel should always wear masks and caps. Considering face masks and head caps contribute
to theater discipline and are therefore beneficial in reducing SSI in other ways, it remains advisable for all
people in the surgical room to wear them.
Gowns
● Strong theoretical rational for reducing bacterial count [62] ● No evidence specific to veterinary
● Reduced SSI with single‐use gowns and impervious material medicine
demonstrated in non‐randomized studies [158]
● Randomized studies, no significant difference [154].
● Bacterial strike‐through found in 26 out of 27 cloth gowns
tested compared to 0 out of 27 of paper gowns. There is a 4‐fold
higher level of baseline bacterial contamination on cloth gown
sleeve than in paper gown sleeves [62].
Recommendations Wear of sterile gowns is recommended for all surgical procedures. As per European standards, the use of
single‐use disposable gowns is recommended [154]. Pure plastic gowns are not recommended for similar
reasons as mentioned above for plastic draping.
(Continued)

Gloves
● Gloving based on theoretical rational of reducing bacterial ● Glove perforation shown to vary from 10
contamination originating from hands. No CRT with and to 26% [163–165]
without wear of surgical gloves. Historical benefit shown. ● Most prevalent in index finger non‐
● High rate of glove puncture depending on procedure. Up to dominant hand [164, 165].
80% of punctures go unnoticed [159, 160]. ● Significantly more punctures in
● Importance of good hand preparation independently of wear orthopedic vs. soft tissue surgery
of surgical gloves, since higher SSI rates demonstrated due to [163–165]
glove punctures [38] ● Most punctures occur in procedures
● Bacterial passage is demonstrated in ~5% of perforations [161] lasting longer than 60 minutes
● Recommended timing for glove change is variable and [163–165].
depending on procedure, range from 60 to 150 minutes [162]
but significantly more punctures have been found 90 minutes
within surgery [160]
● Puncture risk increases by 1.12 per 60 minutes of surgery
Recommendations ● Use of sterile gloves is always needed.
● Good hand preparation independently of use of sterile gloves.
● Change gloves after 60–90 minutes.
Double Gloving
● From low‐powered studies there is no evidence that double ● No studies available.
gloving reduces SSI, however a second pair of gloves significantly
reduces perforations to the innermost gloves [166, 167].
● Perforation indicators result in significantly more detection of
perforations [166].
● Change outer glove before handling implants due to increased
bacterial load on outer glove[62]
● Recommendations ● Use double gloving for draping and discard outer pair for the surgical procedure.
● Use double gloving for implant‐related procedures or procedures with high risk of glove perforation.
● Use double gloving, special orthopedic gloves or indicator gloves for orthopedic procedures or procedures
lasting longer than 60 minutes.
● Change outer gloves before handling implants.
Intraoperative Measures
Debridement
● There is lack of RCT trials comparing the effect of debridement ● No studies available.
and different debridement methods [168].
Recommendations Debridement of contaminated wounds remains a key factor in reducing the bacterial and foreign body load,
both factors known to increase the risk of SSI. The method of debridement should however be chosen based on
situation and surgeon’s preference.
Wound dressing
● At present, following the conclusions of a 2014 Cochrane ● No randomized trial or metanalysis
review, there is no evidence to suggest that covering surgical available.
wounds healing by primary intention with wound dressings ● Some equine studies show the protective
reduces the risk of SSI or that any wound dressing is more effect of belly bands and/or stents
effective than others. Based on small poor‐quality trials [169]. bandage in reducing SSI risk [15, 170].
● Recent randomized controlled studies show the benefit of ● All available studies are small with
Dialkylcarbamoyl chloride‐impregnated dressing with considerable bias.
significant reduction of SSI following C‐sections [87]
Recommendations Although evidence is confusing, covering the surgical site has many advantages to improve healing.
Considering the environment in which our veterinary patients reside, and considering their tendency to lick
and bite their surgical wounds, independently of the scientific evidence, wound protection remains advised.
SSI Recognition 185
Suture choice
● Monofilament sutures are less prone to potentiate infections ● Triclosan impregnated sutures did not
than multifilament sutures due to decreased bio‐adherence and decrease infection in TPLO surgeries
improvement of phagocytic cells to reach bacteria on or within [172]
sutures [67]. ● No beneficial effect of triclosan in equine
● Continuous sutures of the same material are associated with abdominal wall closure [173]
fewer infections than interrupted sutures, possibly due to
reduction of tissue necrosis at suture site and more even
distribution of tension and reduced suture material [67].
● Stapled wound in orthopedic surgery are more at risk of
infection than sutured wounds [171].
● Different studies show decrease in SSI rates with the use of
antimicrobial impregnated sutures [67].
Recommendations − Suture choice is important.
− Antimicrobial impregnated sutures may be of some theoretical benefit, but they have not been tested
sufficiently in well controlled studies. Their widespread use is therefore not recommended at this time.
decrease, merely by reporting without any other formal SSIs), along with effective data entry and retrieval, are
form of intervention [92]. Nevertheless, SSI data collection required for proper SSI surveillance.
allows for calculation of risk specific infection rates and
can be used by the local hospital and entire healthcare sys-
tem to set priorities in infection control programs, review SSIRecognition
of protocols and evaluation of the effectiveness of their
efforts [93]. In one of the first large‐scale reports from US Early intervention on developing SSI will offer the best
hospitals published in 1985 it was estimated that 32% of chance at resolution. Clinical signs of developing infection
hospital‐associated infections could be avoided by the comprise fever that cannot otherwise be explained, increas-
implementation of a program [90], and a specific surgical ing postoperative swelling, pain and heat at palpation, ery-
wound program in the same period showed that SSI rates thema and persistent drainage. In cases of orthopedic
declined from 3.5% to less than 1% after implementation of surgeries, the development of postoperative lameness is a
a surveillance program [94]. good sign of suggestive SSI development. All early signs of
Implementation of such programs firstly requires the use infection should prompt the surgeon to further investigate
of standardized definitions (see above), allowing compari- the wound.
son within and among veterinary healthcare institutions. In this era of emerging bacterial resistance to antimicro-
Putting those strategies into practice is complex, requires bial therapies, efforts to reduce antibiotic overuse should
engineering changes in behavioral and system aspects [95, be made. Tailoring antibiotic needs to the specific patient
96], and often become frustrating for driving forces behind and its disease status rather than blindly following stand-
the program. However, the efforts have been rewarded ard duration protocols is to be advocated. Microbiology
with significant reductions in SSI rates, at least in human results are not always satisfactory with low sensitivity due
medicine [97, 98]. to potential contamination, suboptimal sensitivity (e.g. in
There are various challenges to identification of SSIs. In synovial fluid microbiology) and include diagnostic delays.
humans, 20 to 94% of SSIs are only diagnosed post dis- Further certain samples may be difficult to obtain due to
charge [3, 99, 100] and considering the typically short hos- the invasive nature of the sampling, for example in cases of
pital stays of equine patients, it is reasonable to assume suspected deep organ or space infections. Hence, differen-
that a large percentage of equine SSIs are not identified in tiation between a bacterial infection and an uncomplicated
hospital. Even when cases are identified, many may not be inflammatory reaction that is not in need of antibiotic ther-
reported in the medical journal system [9]. A combination apy can be difficult to make. Accurate and timely diagnosis
of coordinated passive surveillance (proper recording and of SSI is already a challenge but prediction and evaluation
reporting of SSIs identified through clinical case manage- of response to treatment is probably an art. Close monitor-
ment) and active surveillance (active follow up to seek out ing of patients that have a status or have had a procedure
Clean Hands –
Safe Animals
Clean Hands Save Lives
Pre-Surgical Hand Asepsis Protocol
4 Steps: Hygiene, Wash, Disinfect and Care

Surgical personnel should always take care of hand hygiene
Have a proper hand hygiene in and outside the surgical theater.
Hygiene
No artificial nails
Clean Hands Short nails No Nail polish No jewellery No wounds
1 minute handwash with Neutral Soap

This is a cleaning procedure. Before Ist surgery of the day or when hands are visibly soiled.
Hand Washing
Use soap and Gently wash hands and forearms including Pick and brush fingernails, Dry hands and arms
a dry sponge. elbow without brushing. rinse with water. with regular paper.
1.5 minute rub with Hydro-Alcoholic Solution*

This is the hand disinfecting step. Keep solution wet for 1.5 minutes on skin.
Hand Disinfection
Time your 1.5 minute rub! Rub over hands, forearm and elbow. Allow to dry before gloving!
Apply on hands and forearms. Include upper arm in abdominal procedures. Concentrate on areas often missed. Don’t wave hands!
Areas frequently missed

Good Skin Care during disinfecting step!
Take care of your hands when leaving the surgical theater.
Areas frequently missed
during disinfecting step.
Most frequently missed.
Skin Care
Apply cream on back of hands, rub hands back to back then rest of hand.
It’s in your hands!

www.veterinaryhandhygiene.eu
Figure17.3 Prevention of healthcare associated infections and surgical site infections also occurs by performing appropriate
hand hygiene procedures outside of the surgery theater. This poster describes the five moments of hand hygiene for use in
hospital care. Acts of hand hygiene must be performed before patient contact, after patient contact, before an aseptic procedure,
after contact with body fluids, and after contact with the patient’s surroundings. Source: The Veterinary Hand Hygiene project,
www.veterinaryhandhygiene.eu. Reproduced with permission.
SSI Recognition 187
performed for which increased risk factors have been both groups within the first three days after surgery. But
described is beneficial. However, prediction of SSI develop- while serum concentrations in horses with uncomplicated
ment based on known risk factors has only limited predic- recovery returned to preoperative levels thereafter, levels
tive value [101] and should be complemented with remained above 500 ug/ml in horses developing signs of
additional predictive values for individual patients. SSI. More classical parameters linked to infection like fever,
In humans, many different markers have been tested in WBC count and fibrinogen were not different in the two
order to allow predictive or differentiating values for septic groups, thus suggesting that SAA may be a more sensitive
versus non septic complications. Parameters like C‐reac- marker of SSI [111]. Synovial fluid and serum levels of SAA
tive protein and WBC counts seem to lack sufficient speci- are higher in animals with septic synovitis compared to
ficity for this task but pro‐calcitonin (PCT) has shown to be those with non‐septic processes [112]. Serial SAA monitor-
highly valuable in different high evidence trials [102]. PCT ing post arthroscopy would therefore have the potential to
is the prohormone of calcitonin and is produced ubiqui- predict or differentiate between a septic and non‐septic
tously in response to mediators released during bacterial joint flare.
infections. In humans, PCT shows a clinically favorable Recently, a novel flexible pH sensing hydrogel fiber
kinetic profile as it increases within 6 to 12 hours of stimu- wound dressing was developed for monitoring of wound
lation and circulating levels will halve daily when infection healing [113]. The skin pH in humans is slightly acidic
is under control. either by antibiotic therapy or the host and once the skin barrier is breached due to the presence
immune system [103]. Measuring of PCT allowed for dif- of wound fluid it becomes more alkaline. During the heal-
ferentiation of postoperative non‐infectious fever from ing processes, the wound pH shifts back to acidic over
infections occurring after orthopedic surgeries [104]. neutral. When infected, the local environment will either
Further use of PCT in monitoring of therapeutic antimi- become very alkaline or acidic, thus continuous pH moni-
crobial effect in postoperative infections was shown to be toring of the skin could be beneficial in early detection of
beneficial and allowed for reduction of duration of antibi- superficial SSI.
otic treatment without increase in morbidities and mortali- Simple visual serial inspection is the best method for
ties [102]. An equine specific PCT quantification kit has monitoring the occurrence of SSI [101]. With a moderate
been developed recently [105] and provides good differen- positive predictive and high negative predictive value, vis-
tiation between healthy and SIRS horses [106]. In septic ual inspection of the wound, taking parameters of exuda-
foals, a linear correlation between the SIRS score and tion, wound slough (necrosis), odor, and wound edge
serum levels of pro‐calcitonin was identified, including distance into account, the prediction of SSI was able to be
cut‐off values to determine septic from non‐septic individ- made between 1 and 5 days before the actual diagnosis of
uals [107]. However, currently no studies evaluating the SSI was confirmed. However, the above assumes that the
usefulness of PCT as a guide in detection of SSIs or moni- attending veterinarian is familiar with the definitions of
toring of treatment response are available. Better identifi- SSI [3], which is not always the case. It is not uncommon to
cation of the equine‐specific kinetics of the marker in have the owner indicating that their primary attending vet-
healthy and local septic versus non‐septic inflamed wounds erinarian considered dehiscence and draining in surgical
is needed before we will be able to use this marker to its full wounds as normal and would heal properly, as they had
potential. seen it before (Verwilghen D, Personal communication).
The acute phase protein Serum Amyloid A (SAA) that is Interpretation of the normal is still extremely variable.
synthesized by the liver during inflammatory and septic Serial ultrasound monitoring of suspect surgical sites
conditions has the potential to predict development of will complement visual detection of early signs of wound
wound complications [108, 109]. With good accuracy, dogs infection. The benefit in equine ventral midline incisions
developing septic wound complications following pyome- has long been shown [114], but is surely valuable in moni-
tra surgery had significant higher SAA values post‐surgery toring the healing of other surgical wounds since ultra-
than dogs without complications [108]. Little research is sound allows for cheap, easy and early identification of
available in horses on the subject, though in uncompli- wound complications. Ultrasonographic features sugges-
cated post castration recovery of horses, a raise and fall pat- tive of wound infection will generally include subcutane-
tern of SAA classically occurs with a return to preoperative ous swelling and edema, loss of normal tissue architecture
levels within 4 to 7 days after the castration [110]. When around the infected suture line, fistulous tract (for infec-
comparing uncomplicated versus complicated castration with drainage), marked periosteal reaction when the
tions [111], in which the latter developed overt signs of infection involves the bone (not visible on X‐ray for days
wound inflammation and drainage compatible with SSI, but early detection with ultrasound (US), fluid around
serum SAA levels increased to around 500 ug/ml SAA in implants when fracture repair infected, increased Doppler
signal in the surrounding of the wound, and occasional gas tive values in diagnosing infection in humans following
pocketing (either produced by bacteria or because the internal fixation of fractures [115]. The use of so‐called
wound has opened/breached) (David F. Personal “white blood cell scans,” in which white blood cells are
Communication). Confusing ultrasonographic signs can tagged with indium‐111, are extremely sensitive to the
be noted in complicated but not necessarily infected detection of early onset osteomyelitis but also in detection
wounds such as seroma or hematoma. Fluid pocketing of so‐called hidden soft tissue infections.
with low echogenicity usually indicates a low cellularity.
The presence of echogenic fluid either indicates a recent
CommonPathogensRecoveredfrom Equine
bleeding (with or without the “hematocrit sign” division
SurgicalSiteInfections
between the cellular/echogenic part of the collection that
is ventral and the acellular (plasma) or the anechoic part A small number of bacterial species account for the vast
that stays (dorsal) or an established infection. Presence of majority of SSIs. In general, these are bacteria that are
heterogeneous fluid with floating or coagulated/formed commonly found on the skin or mucous membranes of
particles (fibrin tags) usually indicates a resorbing hema- horses or humans, as well as organisms that live in the
toma or an established infection. An aspiration of the fluid horse’s environment. Staphylococcus aureus, E. coli and
for cytology/culture will be necessary to rule out any infec- other Enterobacteriaceae (e.g. Enterobacter) and
tious process. Presence of fluid tracking around the suture Pseudomonas spp. are the most widely reported patho-
line is usually well visible on US, independent of presence gens [116–119], but a range of other bacteria may be
of infection. When performing ultrasonography on surgi- involved. Enterococci are commonly reported in some
cal wounds, aseptic techniques (a sterile glove on the studies [117], but enterococci are not typically highly viru-
probe) and the use of alcohol to increase skin contact is lent and may be present as clinically irrelevant contami-
preferred over the use of gel. Gel has the tendency to be nants or co‐infections. Similarly, coagulase negative
difficult to remove and could itself create a medium for staphylococci are not uncommonly isolated [116, 118], but
bacterial proliferation and contribute to the establishment are typically of limited virulence and may be more likely
of an infection if it was not already present (David F. indicative of contamination rather than causes of disease.
Personal Communication). Multidrug resistant pathogens such as methicillin‐resistant
Early recognition of infections on radiography is difficult S. aureus (MRSA) and extended spectrum beta‐lactamase
as overt bone remodeling (~30% of bone needs to be (ESBL) producing Enterobacteriaceae are increasingly
resorbed before it is visible on X‐ray) needs to occur before implicated in equine SSIs, and emergence of multidrug
radiographic signs appear. Even in late stages of infection, resistant bacteria continue to create challenges.
radiography has low sensitivity since the appearance of the
infection will not be correlated to its severity. In acute
Samplingof Woundand Interpretation
infection, the signs are often limited to non‐specific signs
of Results
like soft tissue swelling or separation of tissue planes. In
internal fixation, radiolucency development around the Culture (qualitative and at least semi‐quantitative) and
implants and periosteal reaction that cannot be explained susceptibility testing is important to guide treatment deci-
by the fracture healing are indicative of infection. Late sions. It is also important to help understand the epidemi-
radiographic signs will include lysis in the cancellous bone ology of SSIs, identify changes (e.g. emergence of
and or the medullary cavity. Serial X‐ray evaluation is often resistance) and to guide empirical therapy (by knowing the
needed to confirm the suspicion of infection radiographi- most common pathogens and their typical susceptibility
cally, though serial monitoring is generally insensitive to patterns). Ideally, specimens should be collected for aero-
evaluate the response to treatment. bic and anaerobic (if indicated) bacterial culture and sus-
The more readily availability of computed tomography ceptibility testing in all SSIs. Culture is probably most
(CT) in equine practice will likely also allow for more early important with severe infections and in horses that are at
and better detection of postoperative infections, mostly increased risk of having a multidrug resistant infection
related to fracture repair and dental and sinus surgeries, (e.g. those that have previously been infected or colonized
since CT allows for a much higher sensitivity in bone with a multidrug resistant bacterium, or that have recently
remodeling than radiography. received antimicrobials).
However, scintigraphy has been shown to be valuable in Yet, while culture data can be critically important clini-
the detection of early orthopedic infections. For instance, cally, they can be misleading if improperly collected or
technetium‐99m‐methylene diphosphonate ((99m)Tc‐ tested. Therefore, care must be taken to avoid inadvertent
MDP) three‐phase bone scintigraphy provided high predic- sampling of commensal organisms, some of which are
anagement of SSI 189
potential SSI pathogens but also common contaminants or the surrounding tissues, systemic administration of antibi-
wound colonizers. This can include measures such as asep- otics is not recommended (Finn Gottrup, Personal
tic preparation of skin when deep sites are being sampled Communication). Local wound care, along with applica-
and taking care to minimize contact with adjacent areas tion of biocides or local antimicrobials, may be adequate.
when sampling focally infected areas or draining tracts. Topical treatments for superficially infected wounds may
Antimicrobial susceptibility results are important for be composed of antibacterial dressings like silver alginates,
drug selection but do not influence interpretation of honey and others. For a comprehensive review on topical
whether an isolated bacterium is clinically relevant. antiseptics and dressings for wound treatment, see
Multidrug resistance does not mean that a bacterium is Jacobsen [120, 121]. Antiseptic agents may provide less
more likely to be involved in disease. Some common and antimicrobial resistance selection pressure, but antiseptic
low virulence commensals (e.g. coagulase negative staphy- resistance and co‐selection for antimicrobial resistance is
lococci) are often resistant. receiving increasing attention [122]. Furthermore, certain
Submission of specimens for cytological examination is antiseptics and concentrations may be cytotoxic to cells
often overlooked but it can be important to help choose essential to the wound healing process, such as fibroblasts,
empirical therapy (e.g. detection of Gram‐positive cocci vs. keratinocytes and leukocytes [123]. Although this cytotox-
Gram‐negative rods), to help interpret culture results (e.g. icity appears to be concentration dependent, as several
multiple potential pathogens grown on culture but only antiseptics in low concentrations are not cytotoxic, their
one dominant cytologically) and for identification of antimicrobial effect remains questionable in low concen-
organisms that may be difficult to isolate (e.g. Actinomyces, trations [124]. The dilution of the product when applied on
Nocardia, Mycobacterium). Cytology is an easy, quick and the wounds together with the presence of wound exudate,
cost‐effective tool that should be considered for all serum and blood seem to significantly decrease the activity
infections. of antiseptics in vivo. As stated by Atiyeh et al. [125],
Sample and processing are also important, particularly a repeated and excessive treatment of wounds with antisep-
need to get samples processed by the laboratory as quickly tics without proper indications may have negative out-
as possible. Delays may result in both false positive (over- comes or promote a microenvironment similar to those
growth of contaminants) or false negative (loss of viability found in chronic wounds. Thorough cleansing of the
of SSI pathogens in a specimen). wound with saline solution and use of more natural anti-
Results must be interpreted in the context of the patient’s microbial agents is advised.
condition and sample type. Culture and susceptibility test- Negative pressure wound therapy has shown the ability
ing is important, but is not the sole determinant of treat- to significantly reduce the bioburden in wounds [126]
ment. Results must be interpreted in the context of the and with adaptations of some technicalities related to the
infection type, the patient’s clinical condition and response application of the system in horses has been shown to be
to an interceding empirical antimicrobial therapy. extremely functional in wound treatment of equids, par-
Contamination should be suspected in samples that yield ticularly SSI cases (Verwilghen Denis, Personal
mixed growth or growth of minimally pathogenic bacteria Communication).
that are common commensals (e.g. coagulase negative Wound exploration in cases of SSI can be beneficial.
staphylococci). Following certain procedures like dental extraction, sinus
explorations or other bone surgeries, bone sequestra may
induce a non‐healing process and keep the infection “alive”
Managementof SSI for long periods of time. Ultrasound or X‐ray may be bene-
ficial in identifying bone sequestra. Additionally, imaging
Dealing with SSI starts with early recognition of the infec- techniques can also identify the occurrence of retained sur-
tion and characterization of the offending pathogen, along gical items. Surgical instruments and most often surgical
with recognition of procedure‐ (e.g. implant) and patient‐ sponges can be left behind. When totally sterile those
(e.g. comorbidities) specific factors that could influence retained surgical sponges may elicit either an exudative or
treatment. Specific details for each type of wound infection an aseptic fibrous type of tissue reaction. If contamination
that can occur related to a specific procedure are explained has been present, an infectious process will occur more
in the relevant chapters. easily. The problem related to retained surgical items is
Antimicrobials may be an important component of treat- even larger than SSI alone as litigation, even if no harm to
ment, but systemic antimicrobials are not necessarily the patient has been done, is generally accompanied with
required for superficial SSIs. In human patients, when the error [127]. This complication also occurs in equine
wound infections remain localized without infiltration into surgery and is likely largely underestimated as no
standardized counting methods are routinely used. Horses gens, such as methicillin‐resistant Staphylococcus
can present with a purulent inguinal abscess up to one year pseudintermedius (MRSP), multidrug resistant
following closed sterile castration after a swab is left in Acinetobacter and multidrug resistant Enterococcus spp.,
place (Verwilghen D, Personal communication). are occasionally involved, along with a wide range of less
Investigation for foreign bodies, in case of non‐resolving common species. Multidrug resistant infections may origi-
SSI and or delayed occurrence of SSI, is mandatory. nate from many sources, including the patient’s own
Focusing on increasing the host’s own defense mecha- microbiota, veterinary personnel, owners and caretakers,
nisms is a strategy rarely utilized or often forgotten in the veterinary hospital environment and the farm environ-
equine medicine with regards to wound infections or SSI. ment. Resistant infections are not restricted to complicated
Surgical procedures themselves induce metabolic, endo- cases or referral facilities, as multidrug resistant pathogens
crine and immunological alterations and therefore have an such as MRSA and ESBL‐producing Enterobacteriaceae
impact on the host’s defense mechanisms [128, 129]. These are endemic in the horse population in many regions.
changes may be exacerbated by poor nutritional status of Therefore, multidrug resistant infections must be consid-
the patient [130]. In addition, starvation delays healing, ered in any horse with an SSI.
increases the risk of infection, reduces the effectiveness of The general approach to management of infections
antimicrobials, and following an exploratory laparotomy caused by multidrug resistant bacteria does not differ from
this could lead to an increased risk of adhesions and wound that of infections caused by susceptible pathogens.
complications, increase of hospitalization duration, and Resistance is not inherently associated with virulence, and
reduced outcome [131]. Ensuring that the animal is pro- isolation of a multidrug resistant bacterium does not mean
vided with sufficient nutrient intake together with nutri- that there is a need for a more aggressive treatment, or
tional monitoring is likely to be beneficial in our battle indeed, any different response compared to an infection
against SSI, and appropriate nutrition should be a part of caused by a susceptible bacterium, as long as an effective
our treatment plan. Additionally, the use of immunostimu- antimicrobial option exists. However, the potential for ini-
lants, such as intravenous immunoglobin administration, tial empirical failure and the limited antimicrobial options
Propionibacterium acnes (EquiStim), CpG DNA, or para- that are present with some multidrug resistant infections
pox virus ovis (Baypamun or Zylexis), can be considered in can have a negative impact on treatment (and presumably
immunocompromised surgical patients to strengthen the outcome). The limited systemic antimicrobial options also
host immune defense system in an attempt to prevent SSI. may increase the importance of adjunctive approaches
However, currently there is no literature on the use of such as local or topical therapy and surgical debridement.
immunostimulants to prevent SSI. In some countries, there are additional challenges because
of bans on the use of some antimicrobials (e.g. carbapen-
ems) in animals, drugs that are rarely needed but are occa-
MultidrugResistance sionally used for some multidrug resistant infections.
Because of the potential for horse–horse and horse–
Multidrug resistance is an increasing problem in patho- human transmission of many multidrug resistant patho-
gens that cause surgical site infections. Methicillin‐resist- gens, infection control measures should be enhanced when
ant Staphylococcus aureus (MRSA), ESBL producing dealing with multidrug resistant infections. Detailed
Enterobacteriaceae (e.g. E. coli, Enterobacter) and multid- description of the infection control response is beyond the
rug resistant Pseudomonas spp. are the most common and scope of this chapter, but approaches such as enhanced
important multidrug resistant pathogens that are encoun- barrier precautions (e.g. gloves, gown, overboots) and iso-
tered in most regions. Other multidrug resistant patho- lation are commonly used.
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196
18
Complicationsof ReconstructiveSurgery
Jacintha M. Wilmink DVM, PhD, DRNVA1 and Debra C. Archer BVMS PhD, CertES(soft tissue), DECVS,
F C Sn, F A2
1
WU A C (Wound anagement and econstruction in orses)n, Wageningenn, he Netherlands
2
Institute of Veterinary Clinical Studies, University of Liverpool, Liverpool, UK
Overview mal or subcutaneous) plexus; the middle (cutaneous)

plexus; and the superficial (subpapillary) plexus [3]. The
Reconstructive surgery can be used to achieve closure of deep plexus has to be taken into account, in particular dur-
certain full thickness wounds, caused either by trauma or ing reconstructive surgery, as this plexus is most easily
by excision of a skin lesion, which cannot be closed directly damaged. It runs in close association with the cutaneous
by suturing alone. The principle is that adjacent skin with musculature (panniculus muscle) which is present in the
sufficient vascularization is mobilized to cover and close body and upper limbs, and it runs just below the dermis at
the original wound. The extent of skin loss combined with the extremities, where there is no cutaneous muscle [3].
the amount of loose skin surrounding the wound dictates Besides the deep plexus, associated direct cutaneous ves-
whether closure is possible or not [1]. Several techniques sels have to be preserved during reconstructive surgery.
are described, usually performed in combination, such as Therefore, undermining of skin should be performed
presuturing, adjustable sutures, implanted elastomers, ten- below the panniculus muscle, when present, and in the
sion sutures, tissue expansion intraoperatively, undermin- loose subcutaneous tissue beneath the dermis at the
ing, relaxing incisions or skin mesh expansion and several extremities [5].
types of plasties. In addition to successful skin mobiliza-
tion and tension relief, debulking of granulation or scar tis-
sue adds to the chances of successful wound closure [2].
L
Sufficient cutaneous blood supply of the mobilized skin
is crucial to successful reconstructive surgery. Two types of
with ReconstructiveSurgery
cutaneous blood supply have been identified in mammals.
● Intraoperative: Failure to close the wound with recon-
Animals with loose skin (or fur-bearing), such as horses,
structive surgery
dogs and cats, have only direct cutaneous arteries, whereas
● Early postoperative: Hemorrhage
humans, apes and swine have musculocutaneous arter-
● Late postoperative: Wound dehiscence
ies [2–4]. The direct cutaneous arteries run parallel to the
skin and supply a greater area of the skin in contrast to the
musculocutaneous arteries that run perpendicular to the
skin and supply a smaller area of skin. As a result, several I ntraoperative:Failureto Close
human pedicle grafting techniques are not applicable for the Woundwith Reconstructive
veterinarians. While detailed descriptions of the vascular Surgery
supply to the skin of humans and dogs are available, there
is unfortunately little information about the patterns to the
skin of horses [2]. In general, the direct cutaneous arteries Definition Reconstructive techniques appear inadequate
ascend to the cutaneous vascular system which can be sub- to mobilize sufficient skin to close the wound during the
divided into three interconnected levels: the deep (subder- surgical procedure.
Intraoperative: Failure to Close the Wound ith econstructive Surgery 197
Risk Factors gery [2], because the gain in stress relaxation is limited in
horses, and edema and inflammation can easily be induced
● Size of the wound
which will decrease the elasticity of the skin (Wilmink,
● Tension: particularly if the wound is perpendicular to
personal observation). Moreover, stretching of skin around
the skin tension lines
a chronic wound with external devices is difficult as a
● Limited skin extensibility-elasticity
result of edema and fibrosis along the wound margins [2].
● Not enough room to undermine tissue/skin (because of
Tissue expanders that are placed subcutaneously adjacent
anatomical structures)
to a defect, can expand the skin; however, the process takes
● Flap is made too small
several weeks, and a fibrous capsule is formed around the
● Unfavorable design of the flap(s)
expander limiting the elasticity of the acquired skin. So far
● Inappropriate estimation of multiple/all factors involved
there is not much experience available for the use of skin
stretching and expansion techniques in horses [2], reveal-
Pathogenesis Whether a wound can be closed by ing that the value of these techniques during equine recon-
reconstructive surgery depends on the size of the wound structive surgery and in prevention or treatment of
and the availability of skin that can be mobilized in the complications might be limited compared to skin mobiliza-
proximity of the wound. The combination of both can tion and tension relieved by other techniques such as
create an impracticable situation for complete closure of undermining, debulking of fibrous tissue or exuberant
the wound, which is often encountered when (traumatic) granulation tissue, presuturing, relaxing incisions or mesh
wounds are located on the limbs of horses. Elasticity and expansion, tensions sutures and plasties.Failure to close
mobility of equine skin is less compared to that of small the wound may or may not have been anticipated, but it
animals, making reconstructive surgery in equine wounds can also be planned deliberately after having considered
a greater challenge. Moreover, reconstructive surgery can the limitations of the reconstructive techniques. Sometimes
often only be performed in a later stage after wounding complete closure cannot be achieved using reconstructive
when demarcation has taken place and infection is under techniques, but partial closure enables the wound area and
control. During this delay where second intention healing final scar to be reduced significantly by using full-thickness
occurs, skin properties will change by the formation of skin. Such partial closure can be combined with skin graft-
fibrous granulation tissue under the skin in the proximity ing techniques in the same procedure.
of the wound, reducing skin extensibility and elasticity.
This process is influenced by the duration of the wound Prevention Failure to close a wound using reconstructive
and its treatment. A longer duration and an inappropriate techniques can be prevented by making a realistic surgical
treatment result in more fibrotic scar tissue because such plan in which all factors influencing closure are assessed:
wounds have been subjected to a persistent inflammatory shape and direction of the wound, tension, availability of
response, which further decreases the extensibility of the skin and possibilities to undermine the skin, quality and
surrounding skin. Skin flaps, when present in older elasticity of skin around the wound, presence of skin flaps,
wounds, usually have developed granulation tissue and the choice of plasties [2]. Tension lines and geometry
underneath that will subsequently contract, decreasing the of the wound should be considered before deciding on the
flap’s size and extensibility. Even after removal of the direction of incisions and the type of plasties.
contracted granulation tissue, the elasticity of the skin is The ideal incision during reconstructive surgery should
less than that of unaffected skin. be made parallel to the tension lines and wounds should be
Knowledge about both tension lines and the properties closed in a direction that will prevent or minimize skin ten-
of various plasties are important. The choice and direction sion [6]. Incisions made parallel to tension lines will gap to
of a plasty will determine the degree of tension relief that a lesser extent and are subject to less tension during sutur-
can be achieved, the possibility to stretch the skin, and the ing than incisions made perpendicular or oblique to these
success of wound closure. Tension lines on the limbs run lines. This means that the axis of removal of a mass (scar
parallel to the limb’s long axis [6], and along these lines tissue, EGT or a tumor) is determined by tension lines, skin
maximal skin extensibility is present [7]. extensibility and position of the lesion. In the case of a cir-
In other species, skin stretching with external stretching cular wound on the lower limb for example, the preferred
devices and expansion techniques with inflatable balloons incisions in theory are vertical, making use of the availabil-
or silicone elastomer are described [8], as well as presutur- ity of the skin at both sides of the incision. However, when
ing and adjustable suture techniques [9, 10], aiming to the circular wound is relatively large compared to the cir-
acquire more skin available to close a defect. These tech- cumference of a limb, there may not be enough skin avail-
niques are not very usual during equine reconstructive sur- able at the sides of the wound without creating too much
198 Complications of econstructive Surgery
tension on the wound and obstructing perfusion in the EarlyPostoperative:Hemorrhage

proximity of the wound and the leg after suturing. In such
cases the tension relief has to be provided from an incision Definition Blood accumulation due to vessel disruption
perpendicular on the tension lines, as proximal and distal during or immediately after reconstructive surgery that
of the wound, there will be more skin available for more can disturb the attachment and healing of flaps to the
tension relief by making longer flaps. underlying tissue. Hemorrhage can be a life-threatening
The shape and direction of the wound or scar that is complication during or following reconstructive surgery of
going to be reconstructed determines from where skin can large body wounds.
be mobilized, so it determines the direction of incisions
and choice of plasty. In general, a plasty will be planned as Risk Factors
such that the wound will be closed over the smallest dis-
tance between wound margins. Many lower limb wounds ● Chronic wounds with fibrotic tissue containing large
have a horizontal shape as a result of the original trauma. blood vessels
During reconstructive surgery of such wounds we are ● Skin reconstructions after large mass removals
forced to use the skin proximal and distal to the wound, to ● Limited options for compression after surgery, which is
cover the wound and limit tension, against the above- often the case when wounds are located on the body
mentioned preferences. Although the skin left and right to
such a wound is less retracted and better available, the dis- Pathogenesis Reconstructive surgery is often used for the
tance to cover the wound would be more, creating more management of chronic wounds or scars. Additionally, it
tension. can be used to close a skin defect that has been created
The availability of skin very much depends on the area of following tumor resection or other surgical procedures,
the body. Pinching the skin to elevate it over the site of pro- e.g. en bloc resection of the penis and prepuce. Trauma to
posed reconstruction can provide a rough estimate of the blood vessels at the surgical site is inevitable but good
skin’s inherent extensibility to cover a wound, as well as knowledge of regional anatomy can avoid damage to
the possibility to undermine tissue [2]. Pinching the skin large vessels close to the site. However, vascularization is
just around a chronic wound will also give some indication altered or increased in wounds healing by second
of the possible degree of extensibility. intention or around tumors, which increases the risk of
Evaluation of all above-mentioned factors will contrib- hemorrhage. Hemorrhage can complicate the procedure
ute to the success of reconstructive surgery. and inhibit postoperative healing of the site. Hemorrhage
can be a specific problem after performing extensive
surgical reconstruction on the body where it can be
Diagnosis and monitoring Failure to close a wound by a
difficult to control because the options for providing
reconstruction is obvious. The wound should be closed as
compression are limited, for example after penile
much as possible.
amputation or reconstructions of large body wounds. In
such cases, hemorrhage may seem under control during
Treatment After incomplete reconstruction of a surgery; however, the increase in blood pressure during
granulating wound or a scar, the remainder of the wound recovery can result in subsequent recurrence of
can be grafted in the same surgical procedure or can be left hemorrhage.
open to heal by second intention. The size of the remaining
defect will determine the choice: small wounds will heal by Prevention Hemorrhage during or following reconstructive
second intention, whereas large wounds can better be surgery on the limbs can be prevented by using a tourniquet
grafted. Following reconstructive surgery, the surgical site during the procedure and by applying pressure over the site
should always be protected. Distal limb wounds are immediately following surgery. However, the pressure that
preferably immobilized by a cast, whereas wounds at other can be applied at the site is often limited because
locations should be bandaged or a stent should be sutured reconstruction usually is followed by immobilization
over the surgical site. straight after the surgery to protect the reconstruction
during anesthetic recovery and the early postoperative
Expected outcome The expected outcome of incomplete period.
reconstruction of a wound principally depends on the Hemorrhage from reconstructions on the body can be
original wound and structures involved, as well as the prevented by using thermocautery and by ligating large
percentage of the wound that is successfully closed by blood vessels. However, this can be tedious and time-con-
reconstruction. suming work and complete hemostasis can be difficult to
Late Postoperative: Wound Dehiscence 199
achieve. Exerting physical pressure at the site as best as Pathogenesis Reconstructive surgery of wounds or scars
possible can help to prevent or control further is different from general surgery, because the surgery
hemorrhage. takes place in fibrous scar tissue that has reduced elasticity
and altered perfusion with many unstructured blood
Diagnosis and monitoring In most cases, hemorrhage is vessels. Tissues that are being mobilized and stretched to
easily identified visually. Bandages must be checked cover a defect have reduced elasticity and are almost
regularly after surgery, especially during the first 24 hours. always sutured under tension, because complete tension
relief is not feasible. In the case of open wounds, the
wound bed is not sterile, whereas after the removal of
Treatment In most cases, hemorrhage will stop within a
malignant tumors when cytotoxic agents or cryosurgery
few hours after surgery. However, when bleeding from a
are used, the healing process can be further altered or
limb wound continues when it is immobilized in a cast, it
delayed. Because of all these factors, healing of the wound
may be necessary to remove the cast and to control the
after reconstructive surgery is inherently delayed and the
hemorrhage first, by placing a firm pressure bandage until
likelihood of wound dehiscence is increased compared to
bleeding stops before applying a new cast. When
general surgery.
hemorrhage from reconstructions on the body continues
Additional factors during the procedure of reconstruc-
and application of pressure over the site has been
tive surgery and aftercare can increase the chance on
insufficient to control it, hemostatic dressings such as
wound dehiscence, such as improper preparation of wound
chitosan gauzes can be applied to areas that are bleeding
and surroundings, hemorrhage, necrosis and insufficient
followed by application of new bandages. The next day the
immobilization.
gauzes should be removed and excess chitosan should be
When the preparation of the wound and surroundings
flushed from the site.
have not been optimized, the risk of bacteria disturbing
healing or the development of an overt wound infection
Expected outcome Normally, hemorrhage after increases.
reconstructive surgery can be stopped with the Hemorrhage during or after surgery increases the risks
aforementioned measures. The success of healing of the of a wound (surgical site) infection developing, because
reconstruction depends on how much healing is disturbed blood acts as a culture medium for bacteria. The reader is
by bleeding and by the attempts to achieve hemostasis. All referred to the former section for information about the
the interventions can lead to partial or total dehiscence of prevention and control of hemorrhage.
the reconstruction (see next complication). In a worst-case Necrosis of skin is usually due to the combination of
scenario, the extent of blood loss may result in hemorrhagic reduced perfusion combined with too much tension
shock and death, but this is uncommon and can generally (Figures 18.1a, b) [11]. This is more likely to occur in longer
be avoided by good surgical planning, close monitoring of skin flaps and in flaps that are narrow [12].
the patient postoperatively, and knowledge of how to Motion of the area where reconstructive surgery has
manage significant hemorrhage if it occurs. been performed is deleterious for healing [13]. Motion has
always a negative effect on wound healing, but this effect is
more detrimental after reconstructive surgery than after
atePostoperative:Wound
L general surgery. This is due to the fact that healing after
Dehiscence reconstruction is delayed due to the reduced quality of tis-
sue involved in the surgical wound (fibrous tissue), the
Definition The breakdown of sutured lines after increased chances of contamination, undermining of adja-
reconstructive surgery, resulting in an open wound with cent tissues and likely damage to the cutaneous vascular
loose flaps and undermined skin system, and the greater tension on the incision after sutur-
ing reconstructions.
Risk Factors
● hemorrhage Prevention Wound dehiscence after reconstructive surgery

● Infection can be prevented by good preparation of the wound or scar
● Use of cytotoxic agents and the surroundings, proper preoperative surgical planning
● Tension considering wound hemostasis, antisepsis, surgical
● Necrosis of skin techniques and the method of closure, and finally by
● Motion at the site immobilization of the reconstructed area.
(a) (b) (c)
Figure18.1 Surgical reconstruction of a chronic non-healing wound on the lateral-plantar aspect of the calcaneus. Total excision of
the wound and scar tissue was performed: (a) before surgery; (b) immediately after suturing. A long skin flap was created based at the
medio-proximal site of the wound, to cover the wound on the lateral-plantar aspect of the calcaneus. After removal of the full limb
cast, the distal end of the flap had sloughed and had disappeared. It was considered that the combination of the length of the flap,
tension on the sutures, and pressure from the cast had resulted in reduced perfusion which caused devitalization of the distal aspect
of the flap. (c) Two months later the wound has contracted significantly and the final result will be a small epithelial scar. Source:
Jacintha M. Wilmink and Debra C. Archer.
The chance of surgical site infection can be minimalized bandages), using a dressing such as foams impregnated
by reducing contamination of the wound, scar tissue and with silver or polyhexamethylbiguanide (PHMB).
the surrounding skin beforehand by undertaking the fol- When the bandage is changed, the wound is cleaned
lowing measures. In the case of a scar without an open with sterile saline and the skin around the wound is dis-
wound that is presented for reconstructive surgery, the sur- infected while the wound is again protected to prevent
gical site can be aseptically prepared similar to routine sur- contact with the disinfectant. Immediately before sur-
gery. In the case of an open wound, a preparation period of gery, prophylactic broad-spectrum antibiotics, such as a
approximately 5–7 days is advised to diminish the bacterial penicillin–gentamicin combination, are administered.
burden in and around the wound. The bacterial burden is The surrounding skin is again prepared as per normal
in general a mixed culture of bacterial species which is preoperative antiseptic procedures and the wound
preferably reduced by use of general topical antimicrobial remains protected. Thereafter the wound should be irri-
measures avoiding the use of systemic antibiotics. If there gated with either sterile saline or a non-toxic disinfectant
is prior history of an overt wound infection at the site, cul- (see below). If possible, total excision of the wound and
ture and sensitivity testing might be valuable. The use of wound margins is performed. The incisions are preferably
systemic antibiotics during the preparation period is dis- made through normal unaltered skin close to the defect,
putable because it provides a high risk on the development and are extended under the wound so that the entire
of antimicrobial resistant bacteria at the site [14]. The prep- wound is excised without touching its surface. If total
aration period starts with clipping or shaving, washing and excision is not possible or when the wound can only be
disinfecting the skin around the wound; meanwhile the partially covered by the reconstruction, the choice of
wound should be protected from contact with hairs, soap wound disinfectants before surgery is very important as
and disinfectants. Then, the wound surface is debrided and many disinfectants are toxic to leucocytes and fibroblasts
an antimicrobial dressing is placed for 3–7 days (1 or 2 and will disturb healing.
Late Postoperative: Wound Dehiscence 201
A correct diluted chlorhexidine solution (0.05%) may be plished by separating the skin and subcutaneous tissue from
used, but antimicrobial solutions based on PHMB or octi- their underlying attachments to fascia (in the extremities).
nidine appear to have even less detrimental effects on tis- On the body, the cutaneous muscle is undermined. Normally,
sue and have a good lasting antimicrobial effect [15, 16]. the planes of tissue are easily identified. However, this can
Despite the use of appropriate types and concentrations of be difficult in the proximity of older wounds or scars on
disinfectants on the wound, the open wound area should which reconstructions are usually performed. The amount
always be considered as contaminated and therefore should of skin that needs to be undermined is roughly the distance
be handled as little as possible. After excision of the wound, equal to the width of the defect itself on either side of the
surgical instruments and gloves should be changed. The wound [6]. During undermining of tissue, tension can be
incisions of the reconstruction are sutured with monofila- assessed by drawing the skin edges together. If tension
ment synthetic suture material, which evokes minimal appears too great, undermining can be extended, or com-
reaction in the tissues and does not act as a foreign body. bined with other skin mobilizing procedures (relaxing inci-
Deeper sutures are omitted, to limit the amount of foreign sions, plasties). Careful judgment is needed to prevent
material in the depth of the suspected contaminated disruption of the cutaneous blood supply.
wound. Proper bandaging and immobilization should pro- Debulking granulation tissue or fibrous tissue in prox-
vide the essential contact between the wound layers. imity to the lesion during reconstruction of chronic
Dependent on the type of wound and surgery, systemic wounds or scars will considerably reduce tension over the
antimicrobials can be continued, but with a proper wound suture lines. Using the normal skin thickness as a guide,
preparation there is usually no need to do this for longer the skin overlying the granulation or scar tissue is dis-
than 24–72 hours after surgery. sected free until a normal subcutaneous tissue plane is
Tension can be reduced by taking into account the ten- encountered. Once the surrounding skin is free, excessive
sion lines, by tension-reducing suturing techniques, and by tissue within the wound is excised in an effort to conform
skin mobilization procedures [2]. Skin stretching and the wound bed to the normal underlying tissues. Care
expansion techniques are not widely used in equine recon- must be taken to maintain the blood supply to the under-
structive surgery [2]. For equine reconstruction, the intra- mined skin and to avoid transecting vital structures [2].
operative placement of towel clamps after mobilization of Relaxing incisions can aid in advancing skin to cover a
skin and before suturing is a more practical application of defect. These incisions are created parallel to the long axis
the combination of tissue expansion and presuturing. of the defect at a distance equal to the width of the wound,
These towel clamps achieve stress relaxation and relieve and the skin between defect and incision is undermined
tension on the reconstruction site, which improves apposi- and advanced to the wound. Another option is to create
tion of skin and facilitates suturing. multiple small incisions parallel to the defect in the
Tension lines should be considered when making a sur- undermined skin adjacent to the defect, so-called mesh
gical plan, as these help to prevent excessive tension on the expansion, but this technique does not provide as much
surgical incision created. However, also the shape of the skin relaxation as one long relaxing incision. Such inci-
wound or scar that is going to be reconstructed determines sions widen when the defect is closed. Plasties, such as
from where skin can be mobilized, so it determines the V-Y plasty, Z-plasty, or H-plasty, will provide additional
direction of incisions and choice of plasty. The reader is relief in tension. Although the relief in tension by plasties
referred to the first section for more information about the in equine reconstructive surgery is not as much as in
prevention of tension related to tension lines. small animals, it will certainly contribute to improved
Tension-reducing suturing techniques, such as horizon- closure of defects [2].
tal or vertical mattress sutures or far-near-near-far sutures, Necrosis of skin flaps can be prevented by a careful prep-
can decrease tension at the wound margin. These tension aration of the flap, taking care to preserve the cutaneous
sutures are placed away from the skin edges. Sections of blood flow, by limiting the length and increasing the width
rubber tubing (supports/stents) can be added under the of flaps, and by taking the measures already discussed to
loops of the tension sutures, which will distribute pressure minimize tension at the site.
and may prevent interruption of blood flow underlying Motion can be limited by immobilization of the surgical
these sutures. After placing tension sutures, the skin edges area. Reconstructions on the limbs are preferably immobi-
are approximated and can be closed with less tension [2]. lized by a rigid cast. Removal of the cast too early is a major
Skin mobilization procedures, such as undermining skin risk for wound dehiscence (Figures 18.2a, b). However,
around a lesion, tissue debulking, relaxing incisions, mesh reconstructions on the body are challenging to immobilize;
expansion and plasties [2], contribute most to the reduction these can only be supported by stents and bandages. It is
of tension on the incision. Undermining skin is accom- important that they should never be left unprotected.
(a) Diagnosis Wound dehiscence after reconstruction is easy

to identify by visual inspection.
Treatment When wound dehiscence after a reconstruction

occurs, skin and skin flaps should never be excised, but
they should be saved to contribute to wound closure at a
later stage. In order to achieve this, the open wound and
wound flaps have to be treated with antimicrobial
dressings to decrease the bacterial load at that site. When
the resultant granulation tissue is healthy, a second
attempt can be made to repeat the reconstruction or to
(b) reduce the wound in size with help of skin flaps and
undermined skin. Granulation tissue that develops at the
dermal side of undermined skin or skin flaps will cause
inversion of the skin or contraction of flaps (Figure 18.3a).
Flaps may seem useless and it appears appealing to many
surgeons to excise these contracted flaps. However, it is
vital to preserve this viable skin and skin flaps should
never be excised as this tissue is very useful for subsequent
repair. Such contracted diminished flaps can be stretched
again after excision of all contracted granulation tissue,
and can additionally be enlarged by meshing. In this way,
seemingly minor flaps can be used to cover relatively
large defects (Figure 18.3b).
Figure18.2 a and b: A non-healing wound on the dorsal Expected outcome Even after dehiscence of a skin
aspect of the fetlock closed using a halve H-plasty. Cast reconstruction, the site can heal properly at a later stage.
immobilization was limited to the first 6 postoperative days However, the costs and time to achieve wound healing are
because of a cast complication. Subsequent bandaging resulted
increased, and in some cases, financial constraints may
in motion of the surgical area and dehiscence of the
reconstruction. Source: Jacintha M. Wilmink and Debra C. Archer. result in treatment being stopped.
(a) (b)
Figure18.3 a and b: The flap of the failed reconstruction in Figure 18.2 contracted progressively. The flap was maintained until the
wound was ready for a second surgery. During that surgery, the contracted underlying granulation tissue was excised. Stretching and
mesh expansion of the flap enabled the wound to be covered entirely.
References 203
References
1 Bailey, J.V. (2006). Principles of reconstructive surgery. In: 9 Liang, M.D., Briggs, P., Heckler, F.R. et al. (1988).
Equine Surgery, 3e (ed. J.A. Auer and J.A. Stick), 254. St. Presuturing – a new technique for closing large skin
Louis: Elsevier Saunders. defects: clinical and experimental studies. Plast. Reconstr.
2 Stashak, T.S. and Schumacher, J. (2016). Principles and Surg. 81: 694.
techniques for reconstructive surgery. In: Equine Wound 10 Scardino, M., Swaim, S.F., and Henderson, R.A. (1996).
Management, 3e (ed C.L. Theoret and J. Schumacher), Enhancing wound closure on the limbs. Compend.
200–201. Iowa: Wiley Blackwell. Contin. Educ. Pract. Vet. 18: 919.
3 Pavletic, M.M. (2010). The skin. In: Atlas of Small Animal 11 Bristol, D.G. (1992). The effect of tension on perfusion of
Reconstructive Surgery, 3e (ed. M.M. Pavletic), 3–15. Iowa: axial and random pattern flaps in foals. Vet. Surg. 21:
Wiley Blackwell. 223–227.
4 Mayhew, P. (2015). Tension-relieving techniques and local 12 Hinchcliff, K.W., Macdonald, D.R., and Lindsay, W.A.
skin flaps. In: Manual of Canine and Feline Wound (1992). Pedicle skin flaps in ponies: viable length is
Management and Reconstruction, 2e (ed. J. Williams and related to flap width. Equine Vet. J. 24: 26–29.
A. J. Moores), 69. United Kingdom: British Small Animal 13 Pavletic, M.M. (2010). Wound dehiscence. In: Atlas of
Veterinary Association. Small Animal Reconstructive Surgery, 3e (ed. M.M.
5 Pavletic, M.M. (2010). Tension relieving techniques. In: Pavletic), 153. Iowa: Wiley Blackwell.
Atlas of Small Animal Reconstructive Surgery, 3e (ed. 14 Nolff, M.C., Reese, S., Fehr, M. et al. (2016). Assessment
M.M. Pavletic), 254. Iowa: Wiley Blackwell of wound bio-burden and prevalence of multi-drug
6 Swaim, S.R. and Henderson, R.A. (1990). Management of resistant bacteria during open wound management. J.
skin tension. In: Small Animal Wound Management, 1e Small Anim. Pract. 57: 255.
(ed. S. Swaim and R. Henderson), 87. Philadelphia: Lea & 15 Müller, G. and Kramer, A. (2008). Biocompatibility index
Febiger of antiseptic agents by parallel assessment of
7 Cartee, R.E. and Cowles, W.R. (1978). Surgical implications antimicrobial activity and cellular cytotoxicity. J.
of extensibility of the skin of the equine carpus. Am. J. Vet. Antimicr. Chemother. 61: 1281–1287.
Res. 39: 387. 16 Müller, G., Langer, J., Siebert, J. et al. (2014). Residual
8 Pavletic, M.M. (2000). Use of an external skin-stretching antimicrobial effect of chlorhexidine digluconate and
device of wound closure in dogs and cats. J. Am. Vet. Assoc. octenidine dihydrochloride on reconstructed human
217: 350. epidermis. Skin Pharmacol. Physiol. 27: 1–8.
204
19
Complicationsof ExcessiveGranulationTissue
Jacintha M. Wilmink DVM, PhD, DRNVA1 and Debra C. Archer BVMS, PhD,
CertES(soft tissue), DECVS, FRCVS, FHEA2
1
WOUMAREC (Wound Management and Reconstruction in Horses), Wageningen, The Netherlands
2
Overview Granulation tissue that is any higher than the surrounding

wound margins, is excessive, with the exception of young,
Excessive or exuberant granulation tissue (EGT) is not a early, edematous granulation tissue that bulges just above
direct surgical complication but a complication of wounds the wound margins during bandage changes and does not
healing by second intention. Wounds have to heal by sec- require special treatment (Figure 19.1b). EGT may be
ond intention when they cannot be closed, because of a tis- localized to one site in a wound, and a tissue deficit may
sue deficit, tissue trauma, or an elevated risk of infection, exist at a different site in the same wound. This means that
or when they dehisce after closure. Second intention heal- treatment sometimes is focused only on the areas of the
ing is seen more often in traumatic wounds than in surgical wound where EGT has developed.
wounds. However, after certain surgical procedures, for
example tumor resection, a resultant tissue deficit or devel- Risk Factors
opment of incisional dehiscence may require the site to be ● breed
left to heal by second intention. EGT may also develop fol- ● location of the wound
lowing skin grafting. ● chronic inflammation
Besides EGT being a complication, the surgical treat-
ment of EGT can lead to complications. Pathogenesis Formation of granulation tissue is an
essential component of wound healing. The tissue provides
several cell types with important functions during healing,
L such as endothelial cells, leukocytes, and fibroblasts, and it
with ExcessiveGranularTissue is the base for wound contraction and epithelialization.
The fibroblast, the major type of cell in granulation tissue
● EGT formation and in EGT, changes its phenotype during healing and
● Excessive hemorrhage after EGT excision thereby its function. This process depends on many factors
● Damage to important structures during EGT excision in the wound environment. Initially, fibroblasts have a
migratory phenotype, allowing them to move from the
surrounding tissues into the wound bed. Once at its
EGTFormation destination, the fibroblast phenotype changes into a
proliferative and synthetic form. The number of fibroblasts
increases and ECM is produced. Thereafter, fibroblasts can
Definition EGT is defined as an excess of granulation differentiate into myofibroblasts, the phenotype that exerts
tissue in a wound, i.e. more granulation tissue than contraction. Finally, fibroblasts and myofibroblasts
required for wound healing. EGT feels firm, becomes disappear from the wound by apoptosis, and the cellularity
granular in nature, protrudes over the wound margins and, of the repair tissue diminishes. The development of EGT in
if not treated, it will delay wound healing (Figure 19.1a) [1]. a wound coincides with a disordered succession of
EGT Formation 205
(a) (b)
Figure19.1 (a) A wound on the dorsal aspect of the tarsus showing the typical features of EGT: firm tissue, protrusion over the
wound margins, irregular surface and purulent exudate, that requires excision. (b) A wound on the plantar aspect of the metatarsus
with young early edematous granulation tissue that does not require special treatment.
fibroblast phenotypes [1]. Specificially, the proliferative resolved by the initial, weak inflammatory response.
and synthetic phenotypes predominate in EGT, while Additionally, a delay in contraction means that the surface
differentiation into functional myofibroblasts is delayed. area of an open wound remains larger, thus perpetuating
The course of the inflammatory response in a wound, with the inflammatory response because leukocytes disappear
the ensuing release of several cytokines and growth factors, only after epithelium covers the surface of the wound. The
plays an important role in the phenotype expression and substantial presence of leukocytes in exposed granulation
function of the fibroblast and thus the development of EGT tissue may explain up-regulated synthesis of cytokines in
in limb wounds of horses. the absence of epithelium [5] and may lower oxygen ten-
Following trauma, the acute inflammatory response in sion in the wound as a result of the high oxygen consump-
limb wounds of horses is weaker during the first 3 weeks tion by these cells. Persistence of mediators, such as TGF-β,
than that of limb wounds of ponies, and the concentration platelet-derived growth factor (PDGF), and fibroblast
of TGF-β in limb wounds of horses is lower during the first growth factor (FGF) induces fibrosis, whereas prostaglan-
10 days than that in limb wounds of ponies [2–4]. TGF-β1 din (PG)E1, PGE2, and interferon (IFN)γ inhibit contrac-
not only stimulates production of ECM but also favors the tion, while yet others, such as tumor necrosis factor
differentiation of fibroblasts into myofibroblasts, thereby (TNF)α, interleukin (IL)-1, and IL-6 do both [6, 7].
encouraging wound contraction. An inferior initial con- The aforementioned development of chronic inflamma-
centration of TGF-β may delay this differentiation, result- tion in limb wounds of horses substantiates several studies
ing in the presence of fewer myofibroblasts in favor of the documenting a fibrogenic-rich, local cytokine profile in
rapidly proliferating and synthesizing fibroblast pheno- limb wounds [3–10]. One of these cytokines, TGF-β1, stim-
types. A reduced number of myofibroblasts means that ulates migration and proliferation of fibroblasts and their
contraction is delayed and is inefficient, whereas prolifera- production of ECM proteins, such as fibronectin and col-
tion of fibroblasts and synthesis of ECM continues [1]. lagen [11], while inhibiting the degradation of ECM [12,
The weak acute inflammatory response seen in wounds 13]. It is thus noteworthy that the expression of TGF-β1
of horses was shown to be followed by a persistent or persists in limb wounds throughout the proliferative phase
chronic inflammatory response [2], due in part to the con- of repair, whereas it quickly returns to baseline values in
tinued presence of contaminants and non-viable tissue not body wounds after the initial inflammatory phase of
206 Complications of xcessive ranulation issue
healing [3, 9]. This persistent production of TGF-β1 in limb musculature covers most structures of the trunk so that
wounds may partially be the work of the fibroblasts within perfusion of a wound in this location is not usually sub-
the wound that also express more TGF-β receptors [14, 15]; stantially disturbed. Second, the lumens of microvessels in
the signaling components are thus in place to stimulate cel- granulation tissue of limb wounds are occluded signifi-
lular proliferation and encourage accumulation of compo- cantly more than those of microvessels found in body
nents of ECM. wounds [24] due to hypertrophy of the lining endothelial
Although it is relevant to know that horses form EGT cells [25], which causes hypoxia in the granulation tissue
more frequently than ponies, and wounds on the limbs are of limb wounds. Third, the abundant presence of leuko-
more prone to the development of EGT than wounds on cytes in exposed granulation tissue and high oxygen con-
the body [16], both breed and the location of the wound are sumption by these cells, further lowers the oxygen tension
factors that cannot be controlled in traumatic injuries. during the chronic inflammatory response in the granula-
Chronic inflammation is therefore the key risk factor tion tissue of limb wounds.
stimulating the overproduction of granulation tissue that In summary, the combination of an inefficient, weak,
can be controlled. Chronic inflammation is frequently a acute inflammatory response and the ensuing chronic
result of local wound infection or colonization of bacteria inflammation in limb wounds of horses delays the differ-
at the wound surface, but it may also be just the inherent entiation of fibroblasts into myofibroblasts, reducing
chronic inflammatory response without a specific cause wound contraction and favoring proliferation of fibroblasts
that is usually present in granulating wounds in horses as and synthesis of proteins. Reduced oxygen tension further
stated before. A generalized wound infection will often not contributes to this. This results in a rapid increase in tissue
result in formation of EGT, but will delay its formation and volume, by cellular proliferation, rather than a decrease in
create an indolent wound. However, a local infection tissue volume, by contraction. The chronic inflammation
related to the presence of bony sequestra, necrotic seg- inherent to second intention healing in limb wounds of
ments of tendons, ligaments or other tissue, and/or foreign horses, while often unrecognized clinically because of the
bodies trigger the chronic inflammatory response. mild accompanying signs, is no doubt an important trigger
Similarly, wound contamination with dirt or bacteria for formation of EGT. The interaction between inflamma-
strongly attracts leukocytes, leading to chronic inflammation, subsequent formation of EGT and lack of contraction
tion. Another reason for chronic inflammation is motion: establishes a vicious cycle, because these physiological
movement in the wound tears the granulation tissue and phenomena stimulate one another [1].
creates grooves and clefts. This incites further inflamma-
tion and cell proliferation in an attempt to repair these Prevention The formation of EGT can to a large extent be
defects. Repeated damage will therefore promote EGT for- prevented by modulating the inflammatory response.
mation. Iatrogenic causes can be occlusive bandages or Acute inflammation should be stimulated in wounds
casts [17–19] and aggressive substances or methods applied healing by second intention that still need more granulation
to a wound that will further enhance fibroblast prolifera- tissue. This can be done by using dressings and products
tion and inhibit wound contraction. In the case that no spe- that promote inflammation, such as alginates, chitosan,
cific causal factor can be identified during a thorough and honey products [26]. The granulation tissue that is
examination of a wound with EGT, it may well be that the formed under these circumstances is more likely to show
inherent chronic inflammatory response that commonly early wound contraction and is less prone to EGT formation
occurs in distal limb wounds of horses is the key trigger for (personal experience).
the formation of EGT [1]. The likelihood of EGT formation can be reduced by
Low oxygen tension is another factor that additionally excluding causal factors, particularly those that are infec-
stimulates proliferation of fibroblasts and production of tion and inflammation related. The history of the initial
ECM [20, 21], and thus contributes to the development of wound may already indicate possible causes: involvement
EGT. Low oxygen tension in limb wounds is due to various of the periosteum or exposure of cortical bone may result
causes. First, limbs have a relative lack of tissue covering in development of a sequestrum; partial or complete rup-
the underlying bone and important soft tissue structures ture of tendons or ligaments can result in necrosis of these
and, subsequently, there is a limited vascular bed and rela- tissues; the chance of hidden foreign bodies such as wood
tively poor collateral circulation. Impairment of circula- being present, etc. Careful and thorough examination of
tion from trauma results in lower oxygen tension in the the wound is very important to rule out any cause that can
healing wound, as addressed earlier, with the ensuing trigger chronic inflammation and thus the formation of
effects on proliferation of fibroblasts and synthesis of EGT. Clefts that form in granulation tissue should be
ECM [22–23]. Conversely, thick and well-vascularized probed using flexible and rigid sterile probes to identify
EGT Formation 207
draining tracts to such causes. Complimentary diagnostic ited by moderate pressure exerted by a bandage. Frequently,
modalities, such as radiographic or ultrasonographic the edematous swelling disappears when wound contrac-
examination, may be required. tion begins. Strictly speaking, this edematous granulation
Movement may contribute to EGT formation where tissue is technically not EGT [29].
wounds are located near or over a joint. Although move- The tissue is classified as EGT when the protruding tis-
ment is usually not the sole cause, immobilization can help sue feels firm and takes on a granular appearance. Firm
to prevent development of, or recurrence, of EGT. Irritating tissue protruding over the margin of the wound should be
and caustic substances should not be applied to the wound treated. In most cases, treatment of EGT is straightforward,
surface, as these cause cell death and provoke chronic and excision appears to be the best choice of treatment.
inflammation. The skin around the wound is clipped or shaved and asepti-
The bacterial load on the wound and the skin around cally prepared. The wound is cleaned using sterile isotonic
the wound should be minimized by mechanical cleaning. saline solution and swabs, and is debrided using sterile
The skin around the wound should be clipped and cleaned, instruments. When a thick layer of granulation tissue is
and the wound should be cleaned gently with saline. Only going to be excised, the wound can be cleaned with a mild
in the case of a clear bacterial problem in the wound, very disinfectant. Granulation tissue should be excised as soon
mild disinfectants can be used for a short period to clean as it starts to protrude above the wound margin [2].
the wound. The wound should be bandaged to prevent Excision can be performed with the horse standing. It is
additional contamination and trauma, and to protect not necessary to desensitize the granulation tissue because
exposed bone and tendons from desiccation and contami- it is not innervated. The excess granulation tissue is excised
nation. The dressings covering the wound should be semi- as close to the adjacent skin level as possible while taking
occlusive and absorb the exudate well, because occlusive care to preserve the migrating epithelium at the wound’s
dressings promote EGT formation [27], with the exception periphery.
of silicone dressings [28]. Most foam dressings are semi- Excision should commence at the distal-most aspect of
occlusive and absorb exudate well, thus removing toxic the wound and progress proximally so that hemorrhage
products from the wound surface. Exudate collected on does not obscure the surgical field. In most cases it is not
the wound surface will provide a microclimate conducive necessary to use a tourniquet to limit hemorrhage. After
to cellular proliferation. Special attention should be given excision, a sterile pressure bandage is applied to stop hem-
to the padding and fixating layer: padding saturated with orrhage. When this has stopped, treatment can be contin-
exudate is occlusive and it will promote EGT formation as ued by placing a foam dressing on the wound surface. In
well and the fixating layer in itself should also not be the case of obvious unhealthy and older granulation tissue,
occlusive. in which bacterial colonization is likely, excision can be fol-
EGT formation in limb wounds can additionally be pre- lowed by a short period of topical antimicrobial therapy
vented by placement of skin grafts: these grafts reduce the (such as a foam with Silver or PHMB) to further reduce
wound area and promote healing, thus indirectly prevent- surface contamination. The goal of excision is to remove
ing EGT. excess and nonviable tissue, as well as gross contaminants,
which consequently also eliminates a large number of leu-
kocytes present in the superficial layer of the granulation
Diagnosis and monitoring The diagnosis and monitoring of
tissue. Excision therefore diminishes the stimulus for
EGT is simple and can be done visually: any protrusion of
chronic inflammation and immediately reduces the num-
firm granulation tissue more than 3 mm above the level of
bers of leukocytes present.
the surrounding skin is excessive and should be treated. At
The treatment of large masses of chronic EGT is slightly
every bandage change, the wound should be monitored for
different (see also next section). The chronic tissue is usu-
development of, or recurrence of, EGT.
ally very fibrous, nourished by large blood vessels and, in
some cases, may be partially innervated. It is advisable to
Treatment The treatment of EGT depends, to a certain debulk such wounds with the horse anesthetized, because
extent, on the age of the wound and the nature of the of the horse can react violently when the EGT is excised in
granulation tissue, as well as the treatment performed so far. standing position, possibly because of the partial re-inner-
Early edematous granulation tissue bulging just above vation or by traction of the weight of the lump hanging
the margin of the wound generally does not require special during excision. Additionally, general anesthesia allows for
treatment. Protrusion of this young tissue is evident when better control of hemorrhage and its possible systemic con-
the bandage is removed, and increases when the wound is sequences. After excision, a pressure bandage is applied to
left uncovered for a short time. Swelling can usually be lim- control hemorrhage. In a later stage, when a new bed of
granulation has begun to form, skin grafting would be the controlled and is maintained on the wound until contrac-
best option to promote healing. tion and epithelialization are underway, after which it can
Topical application of a corticosteroid to stop the forma- be replaced by a foam dressing. The use of the silicone
tion of EGT is useful [30] but remains controversial. dressing is easy but it has some disadvantages: its initial
Corticosteroids counter inflammation and can control the costs are high, although it is reusable after washing it under
chronic inflammatory response present in limb wounds of tap water. Additionally, the silicone dressing does not
horses. Moreover, some corticosteroids may selectively absorb exudate, which make frequent bandage changes
attenuate the release of fibrogenic TGF-β1 and β2 from necessary, as collection of exudate on the wound surface
monocytes and macrophages, counteracting proliferation can have a negative effect on healing. The first option is the
of fibroblasts and formation of ECM [31]. This rationalizes author’s personal preference because of the quick results
the use of a corticosteroid in the treatment of newly-formed seen (personal experience).
EGT. However, corticosteroids have also been shown to Although uncommon, some horses mount a very strong
exert a negative influence on angiogenesis, contraction, and and chronic inflammatory response in the wound, often
epithelialization, thereby delaying wound healing [32, 33], accompanied by periosteal new bone formation when the
demonstrating the risk of frequent use of topical corticos- wound initially had exposed bone. In such a case, resorting
teroids. A corticosteroid, therefore, if used, should only be to repeated applications of a longer-acting corticosteroid,
used cautiously as a single application at the place where it such as triamcinolone, may be appropriate to break the
is required at the first signs of excessive fibroplasia but not vicious cycle of “inflammation-proliferation.” If exuberant-
standardly or repeatedly. In this way the wound can benefit appearing granulation tissue recurs despite the aforemen-
from the reduction of the chronic inflammatory response tioned approach, the clinician should suspect tumor
and the negative influence on healing is prevented. transformation of the wound, and a tissue sample (ideally
Corticosteroids are also useful when EGT occurs follow- including margins of the wound) should be obtained and
ing skin grafting (see Chapter 21: Complications of Skin submitted for histological examination.
Grafting). Caustic agents or cryogenic surgery should not be used
When EGT reoccurs, possible causes should be ruled out to treat EGT because these induce necrosis, stimulate
again, and when no underlying inciting cause can be chronic inflammation, damage the new epithelial border,
found, the most probable cause for the formation of EGT is and ultimately inhibit healing by promoting proliferation
the inherent chronic inflammatory response characteristic of the granulation tissue.
of limb wounds of horses. This is seen more often when
owners change the bandages. In these cases, the bandaging
protocol should be critically assessed, including the used Expected outcome Treatment of EGT is usually successful
materials for bandaging to exclude any potential for occlu- when treatment is initiated at the first signs of EGT
sion. Also, the way in which wound excision is done by the development and when the causal factors have been
veterinarian should be assessed step by step. Special care is eliminated. Correct wound management is essential, which
needed to reduce both inflammation and bacterial contam- means that the wound is bandaged to protect the site from
ination of the wound surface. After excision and when contamination and to limit swelling of the limb. The success
hemorrhage has stopped, there are two options for further of the healing of the wound and the return to function of the
treatment. The first option is to use an antimicrobial foam horse however, is dependent on the structures that were
for a few days, followed by one topical application of corti- initially damaged, the size of the original wound and the
costeroid. At every bandage change, the skin around the quality of treatment. The final outcome of large limb wounds
wound is disinfected, the wound is irrigated with sterile can be sub-optimal or unacceptable when the scar is of
saline, and sterile dressings are used. In this way bacterial inferior quality or if the limb is persistently swollen. Some
contamination of the surface is minimized, whereas the scars are fragile and easily damaged, others are thick,
chronic inflammation is reduced. Usually a dramatic proliferative and motion limiting, and sometimes these scars
improvement is seen, because this approach halts the can cause pain. Persistent swelling of the limb can also limit
aforementioned vicious cycle, allowing healing to ensue. motion.
Sometimes a second application of corticosteroid is Where treatment of the wound has been insufficient
required, but further applications should not be necessary. and excision of EGT has been delayed, a chronic mass of
Treatment can be continued with normal foams when pro- EGT can develop, often simultaneously with fibrous
liferation has stopped and the wound contracts. swelling of the limb. In those cases, the chronic EGT can
A second option is the use of silicone sheet dressings [28]. be eliminated and the wound treated, but swelling of the
The dressing should be applied after hemorrhage has been limb is often irreversible.
amage to Important Structures uring xcision of 209
The worst-case scenario is time-consuming and expen- Treatment A pressure bandage is commonly used to stop
sive treatment resulting in a healed wound but where the hemorrhage. In cases where pressure bandages cannot be
horse cannot return to its previous/intended use because used and manual pressure is not sufficient, hemostatic
the quality of scar is insufficient and/or the limb is persis- dressings, such as chitosan gauzes can be used [34, 35].
tently swollen. Celox is a product available for veterinary use (www.
celoxmedical.com). It contains chitosan from shellfish and
Excessive Hemorrhage After EGT Excision it stops major arterial bleeding within 3 minutes. Excess
Celox can be flushed from the wound at a later stage with
Definition Excision of EGT will always cause hemorrhage,
saline solution. Thermo-cauterization can be used to stop
because granulation tissue consists of many blood vessels
bleeding from a single large vessel; however, it should not
and capillaries. Excessive hemorrhage is defined as blood
be used for the entire wound surface because a layer of
loss that is abundant, difficult to stop and that may result in
necrosis is induced, which will evoke chronic inflammation
systemic compromise (hemorrhagic shock).
and a trigger new formation of EGT.
Risk Factors
Expected outcome Preparation prior to embarking on
● chronic masses of EGT excision of large masses of chronic EGT is key, having steps
● EGT on sites other than the limbs in place to control hemorrhage and manage the horse that
has lost large quantities of blood, e.g. blood transfusion
Pathogenesis Chronic masses of EGT are vascularized by equipment.
large blood vessels and the tissue is also very fibrous in In the worst-case scenario, severe hemorrhage could
nature. Excision is therefore more difficult and more time- result in hemorrhagic shock and death. This will generally
consuming than average because of the size of the masses only occur when hemorrhage was not diagnosed in time or
that can develop and the fact that the tissue is hard to when treatment was insufficient.
excise. This means that hemorrhage during the procedure
can be significant and can have systemic consequences for
the patient. amageto ImportantStructures
D
Hemorrhage after EGT excision from sites of the body
DuringExcisionof EGT
other than the limbs is often more difficult to stop because
the options for exerting pressure by bandages are limited.
DefinitionDuring excision of EGT, other structures might
be damaged when close to the wound surface.
Prevention Excessive hemorrhage can be prevented by
taking measures beforehand. The treatment of chronic
Risk Factors
masses of EGT is easier and safer to perform under general
anesthesia. A tourniquet can be applied proximal to the ● Proximity of relevant anatomical structures
mass of EGT to limit hemorrhage. Excision will be faster to ● Defects in synovial structures that healed by the forma-
perform compared to performing this in the standing tion of granulation tissue
patient, limiting hemorrhage and a pressure bandage can
be applied more quickly to control hemorrhage. Finally, Pathogenesis Traumatic wounds can involve many
intravenous fluids can be administrated easily when important structures. Most of these structures such as
necessary, to compensate for blood loss. bone, tendons and ligaments, are deeper within the wound
In all other locations where tourniquets or pressure and will be covered by a clear layer of granulation tissue
bandages cannot be used, or where manual pressure is during second intention healing. When EGT develops and
expected not to be sufficient, other methods should be has to be excised, such structures are usually not at risk and
available to stop hemorrhage (hemostatic dressings, ther- they are more easily recognized during excision. In
mocautery; see Treatment below). contrast, synovial structures that have been damaged and
have healed by second intention by the formation of
Diagnose and monitoring Excessive hemorrhage is easy to granulation tissue, are at risk of being re-opened when the
diagnose and monitor and can be done visually. To monitor overlying EGT has to be excised. This risk is even greater
hemorrhage after excision of EGT, the patient should be when the EGT is young, soft and has not yet contracted.
checked regularly, and the amount of blood that has
accumulated in a bandage or has been lost from a wound Prevention Re-opening of synovial structures can be
should be assessed. prevented by avoiding excision. It is important to prevent
EGT developing in the first place by treating the wound flushed as necessary and the wound should be managed
appropriately in the first instance (as already discussed). If using sterile antimicrobial dressings and bandages until
EGT does occur, further development should be inhibited healthy granulation tissue has closed the synovial structure.
at the first signs of development by using topical steroids or The use of a cast or splint should be considered on high
a silicone gel dressing on the wound. Only after contraction motion areas, which is usually the case when joints are
has occurred and the granulation tissue has become firmer involved.
should excision be performed and this must be done very
cautiously and only when necessary. Palpation of the Expected outcome The expected outcome depends on
granulation bed gives an indication of its thickness, and which synovial structure is involved, the size of the defect,
sometimes ultrasound guidance can be helpful during and how soon the defect in the synovial structure heals by
excision. newly-formed granulation tissue. A defect originating
during excision of EGT and diagnosed immediately, can
Diagnosis The diagnosis of opening a synovial structure have a good prognosis. However, success rates can be
during excision is usually easy and can be done visually. In variable depending on the structure involved. The prognosis
case of doubt or for monitoring its closure, synoviocentesis of extensor tendon sheaths is usually good, whereas the
of the structure can be performed remotely from the prognosis of flexor tendon sheaths or joints can vary. When
wound. By injecting sterile saline, penetration of the such structures develop an infection, the success will
synovial structure can be confirmed and closure can be decrease significantly. The worst-case scenario is the
monitored during healing. development of an infection that cannot be successfully
treated and that results in euthanasia of the horse.
Treatment When a synovial structure is damaged during
excision of granulation tissue, the structure should be
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212
20
Complicationsof SkinNeoplasia
Debra C. Archer BVMS PhD, CertES(soft tissue), DECVS, FRCVS, FHEA1 and
Jacintha M. Wilmink DVM, PhD, DRNVA2
1
2
Overview ● Late postoperative

● Recurrence of neoplasia
The skin (integument) is a common site for equine neopla- ● Metastatic spread
sia, with the most frequent lesions being sarcoids (46–51% ● Delayed healing
of equine skin submissions), squamous cell carcinoma ● Poor cosmetic or functional result
(18–19%) and melanoma (5–10%) [1–3]. Surgical removal
alone or in conjunction with other adjunctive therapies
should be undertaken when lesions are small, making
Intraoperative/technical
them easier to remove with potentially fewer complica- IncompleteSurgicalExcision
tions [4]. Histopathological assessment of resected tissues
to determine tumor type, stage and grade assists with treat- Definition This is defined as gross or histological evidence
ment planning and prediction of likely complications such of neoplastic cells at the site of surgical margins, which
as local recurrence and metastatic spread. Readers are may or may not be intentional [9].
referred to other texts for details of specific clinical features
of different types of skin neoplasia, in-depth management Risk Factors
options and prognosis [4–8]. Complications related to ● Visibly ill-defined margins between normal and abnor-
surgical management of neoplastic disorders of the pre- mal tissue
puce and penile integument are covered in Chapter 40: ● Extensive tumors
Complications of Penile and Preputial Surgery. ● Tumors in anatomic sites limiting wide margins of
excision
L Pathogenesis If the nature and extent of the skin neoplasm
with SkinNeoplasia (e.g. benign vs. evidence of malignancy) has not been
accurately determined preoperatively, increased risk of
● Intra-operative/technical incomplete excision may result. Some skin neoplasms may
● Incomplete surgical excision have a well-defined capsule, whereas others may be more
● Recurrence of neoplasia adherent to underlying tissue planes and may have less
● Hemorrhage visibly defined margins between normal and abnormal
● Damage to adjacent structures tissue, increasing the likelihood of incomplete excision.
● Failure to close the skin defect Incomplete excision of a neoplastic skin mass may be more
● Early postoperative likely to occur in the case of extensive tumors and those in
● Incisional dehiscence and delayed healting anatomic sites that limit wide margins of excision being
● Surgical site infection (see Chapter 17: Complications taken. The body of most tumors is usually quiescent and
Associated with Surgical Site Infections) hypoxic, whereas the leading edge of the tumor is the most
Intraoperative/technical 213
invasive and well vascularized. Incomplete (subtotal) creation of fresh wound margins in normal tissue of 2–3
resection may therefore selectively leave the most cm may be indicated [9]. In human and small animal
aggressive components of the tumor behind [10]. oncology, this may be followed up with chemotherapy
within 7–10 days following surgery or with radiation
Prevention In general, the first surgery has the best chance therapy around 1–3 weeks postoperatively [9]. In equine
of complete removal and should be well planned in order oncology, adjunctive treatments may include topical
to obtain suitable surgical margins [9]. Incomplete chemotherapy, cryotherapy and radiation therapy [4, 6].
resection is rarely indicated except for diagnostic purposes
because tumor regrowth will normally reoccur within a Expected outcome Tumor regrowth at the site is most likely
short period of time, usually in response to enhanced to occur without further treatment. Equine mast cell
vascularization of the tumor bed compared to normal tumors can be variable in their biological behavior and
tissue. spontaneous remission of these neoplastic masses has been
Good preoperative planning is important to try to ensure reported following incomplete surgical excision [5].
that appropriate surgical margins are obtained. This should
include confirmation of the diagnosis, stage and grade of Recurrenceof Neoplasia
the tumor by fine needle aspirate or biopsy prior to under-
taking surgery. For small masses that are easily accessible, Definition This is defined as regrowth of neoplasia at the
an excisional biopsy (with curative intent) may be planned. surgical site or in the skin at distant sites (i.e. without
In other cases, it may be more appropriate to obtain a spread to organs other than skin, as is the case in
biopsy for diagnostic purposes (rather than curative intent) metastasis).
and ideally this should include the interface between neo-
plastic tissue and normal appearing skin [7]. In the latter Risk Factors
situation, it is important that a biopsy is taken in such a ● Neoplasia type
way that the biopsy site can be removed if subsequent sur- ● Size
gical management is undertaken to avoid recurrence of ● Rate of growth
neoplasia at the site [10]. Radiography, ultrasonography, ● Mobility within the proximate tissues
computed tomography (CT) and sometimes magnetic reso- ● Tumor borders
nance imaging (MRI) may be utilized to determine the
extent of a solid tumor and optimize the surgical Pathogenesis Recurrence is due to incomplete surgical
approach [10] and in equine oncology is dependent on the excision (see previous section) or seeding of tumor cells
anatomic area (Figure 20.1). For tumors with a high prob- into the tissues during surgery [12]. Sarcoids are an
ability of local recurrence, the depth of dissection should example of equine skin neoplasms that do not metastasize
include at least one tissue plane away from the tumor, to other locations in the body but may reoccur in the skin
including any underlying fascia [9]. In equine oncology, at adjacent or remote sites, e.g. sarcoids [4]. Mast cell
there is limited evidence for optimal surgical margins for tumors are reported to reoccur infrequently at the surgical
specific types of equine skin neoplasms. Where surgical site [13], but can reoccur at another site [5]. The type of
excision of mucocutaneous squamous cell carcinomas neoplasia and the location in which neoplastic masses have
(MC-SCC) is being undertaken, a surgical margin of 0.5– developed can be of prognostic importance. The biological
1.0 cm is recommended [7]. Surgical margins of 16 mm behavior of tumors can also differ between species [14].
have been recommended for excision of sarcoids [11]. Positive prognostic factors for tumors include slow rate of
growth, mobility within the proximate tissues, a first
Diagnosis Resected tissues should always be appropriately attempt at surgery, discrete tumor borders, small tumor
fixed and submitted for histopathological examination by a size and a low-grade nature. Surgery may be less effective
certified veterinary pathologist. Areas of special interest for the same tumor type and grade if the mass is ill-defined,
should be marked (e.g. sutures, India ink) to enable the recurrent or has a recent history of rapid growth [10].
pathologist to assess the margins [9]. Success rates for sarcoids following electrosurgical or laser
excision are around 83–87% [15, 16], and recurrence is
Monitoring This will be based on ongoing visual more likely in horses previously treated for sarcoids and
assessment of healing of the site (see next section). sarcoids located on the head [15]. Surgical excision of
discrete melanomas may be expected to be successful [17],
Treatment Where incomplete excision has been confirmed whereas anaplastic melanomas may be very aggressive and
following surgery, excision of the previous wound bed and expected to reoccur [18].
214 Complications of Skin Neoplasia
(a)
(b) (c)
Figure20.1 Mast cell tumor in the metacarpal region of a horse (a). MRI and radiographic examination of the limb (b) and (c)
revealed a soft tissue mass with a well-defined lateral border but poorly defined medial borders. The abnormal signal intensity on
MRI was continuous with the connective tissue of the mid part of the suspensory ligament and periligamentar tissues of the proximal
part of the suspensory branches extending to the medial side of the suspensory ligament in its mid portion. The lateral part of the
DFTS was poorly defined also, but there was no evidence of infiltration of bone. Complete surgical excision was considered to be
impossible to achieve due to extensive infiltration of the normal soft tissue structures in this region and so the mare underwent
surgical debulking of the mass as a palliative measure. This was successful for around 18 months until MCT developed at other sites.
Prevention Key principles of oncological surgery such as or forceps avoiding direct handling of the neoplastic mass.
obtaining sufficient surgical margins of excision must be If the tumor bed is incised during the procedure, surgical
adhered to in order to mimimize the chance of tumor instruments and gloves should be changed and consideration
recurrence [9]. To reduce the risk of seeding of tumor cells given to more radical incision of the wound bed in order to
into tissues at the surgical site, benign lesions should be achieve complete excision of all tumor tissue. Lavage of the
excised before removal of malignant ones. To prevent site with sterile saline can help to mechanically remove any
contamination between instruments, separate instrument exfoliated neoplastic cells [9]. One of the proposed
sets should also be used between each mass. Large, tumor- advantages of using laser (and other electrosurgical devices)
associated blood vessels should also be ligated early on in to surgically excise masses such as sarcoids is the
the surgical procedure. Only normal tissue along the tumor vaporization of neoplastic cells and reduced chance of
side of resection should be manipulated using stay sutures seeding neoplastic cells at the surgical site [15, 19].
Diagnosis Regrowth may be suspected based on visual Risk Factors

changes in the skin at the surgical site or development of
● Tumor type and grade
similar masses at other sites. Diagnosis of tumor regrowth
should be confirmed by biopsy/FNA. Pathogenesis Different equine skin neoplasms have specific
Monitoring Regular visual assessment of the site is biological behaviors that will determine the likelihood of
important. It can be difficult to monitor sites healing by metastatic spread occurring (see specific texts for further
second intention as differentiation between exuberant details). Sarcoids are confined to the integument and
granulation tissue, hypertrophic scarring or sarcoid although so-called “malignant” forms can track down
recurrence can be difficult (Figure 20.2). Areas of suspicious lymphatic vessels and invade local tissues, disseminated
regrowth should be biopsied but histopathological metastases have not been reported [4]. Metastatic spread
differentiation between sarcoid regrowth and formation of from epithelial tumors is usually via local lymph nodes [10].
granulation tissue can be difficult. Metastatic spread to distant organs is reported to occur in
around 19% of horses with mucocutaneous forms of
Treatment Where regrowth occurs at the surgical site, squamous cell carcinoma (MC-SCC) [7], whereas metastatic
adjunctive therapy will depend on the type of tumor and spread rarely occurs in equine mast cell tumors [21, 22].
location of recurrence [4]. These may include intra-tumoral There is no evidence that surgical removal of melanomas
cisplatin [20] or piroxicam [7]. causes them to become more aggressive in nature [17] and
early removal of melanomas, in addition to making them
Expected outcome Equine oncology is still in its relative
easier to remove, may reduce the likelihood of metastatic
infancy compared to human and small animal oncology
spread occurring over time [23].
and development of immunohistochemical methods to
more accurately predict tumor behavior in horses are areas Prevention Following patient work-up, histopathological
of ongoing research [15]. Further clinical studies are examination of biopsied tissue should provide information
required to provide better evidence-based information about the tumor type and degree of malignancy. Where the
about outcome based on different classifications for specific degree of malignancy is considered to be high, assessment
equine tumors (types, stage and grade) and outcomes and biopsy of any enlarged regional lymph nodes
following use of surgical and adjunctive therapies. should be considered for complete tumor staging [10].
Lymphadenopathy may occur due to metastatic spread or
MetastaticSpread
may be a reactive tissue response to tumor factors, infection
Definition Metastasis is defined as the development of or inflammation, especially where skin tumors are ulcerated
secondary malignant growths at a distance from a primary or inflamed [24]. Firm, irregular lymph nodes that are
site of cancer. sometimes fixed to surrounding tissues may also be
suspicious of metastatic spread [10]. Lymph node biopsy
and removal is a standard part of management of neoplasia
in people and is increasingly being performed in veterinary
oncology, including utilization of sentinel lymph node
evaluation [25]. Prophylactic removal of normal draining
lymph nodes or chains of lymph nodes should not be
performed. Other contraindications for lymph node removal
include lymph nodes that are fixed to normal surrounding
tissues or where erosion has occurred through the capsule or
if the lymph node is in a critical area [10]. Limited work has
been done in this area in equine oncology, although
ultrasonographic assessment of lymph nodes has been used
to stage lymphoma in horses [26].
Diagnosis Diagnostic tools that are used in human and

small animal medicine to detect metastatic spread may be
limited in horses due to patient size (e.g. CT evaluation of
Figure20.2 Areas of irregular tissue at the site of previous
the thorax for metastases to the lungs) or economic factors.
laser removal of a sarcoid. Biopsy of this tissue was suspicious
for sarcoid regrowth and so adjunctive topical chemotherapy Metastatic spread may be suspected based on clinical
was successfully undertaken. examination, including identification of enlarged regional
lymph nodes, history of recent weight loss or evidence of ● Blood clotting abnormalities
poor bodily condition or the results of further diagnostic ● Low platelet counts
tests, e.g. radiographic identification of suspected thoracic ● Hepatic disease
metastases [4].
Pathogenesis Neovascularization that exists in tumors
Monitoring This will be dependent on tumor type and may increase the risk of intra- or postoperative
likelihood of metastasis occurring. In high-risk horses, hemorrhage [9]. Equine skin tumors such as melanomas
repeat veterinary assessment on a frequent basis may be may be extensive and frequently have a good vascular
indicated. supply [9]. Increased risk of hemorrhage in horses is more
likely to be due to increased perfusion of the area due to
Treatment There are limited reports of treatment for tumor growth and surgical margins that may include large
metastatic spread in equine oncology. Chemotherapy is arteries and veins. Similar to human and small animal
infrequently undertaken but piroxicam administration was patients, blood clotting abnormalities, low platelet counts
reported to result in successful remission of SCC that had and liver failure increase the risk of hemorrhage during
developed on a horse’s lip [27]. surgery.
Expected outcome Metastatic spread to other organs Prevention Any concurrent patient disease should be
generally carries a poor prognosis. In equine oncology identified prior to surgery and where excessive hemorrhage
there is limited evidence-based information about the rates is anticipated, collection of blood for transfusion may
of metastatic spread of equine skin tumors, options for occasionally be indicated. Meticulous hemostasis and
treatment and prognosis. Further research in this area is ligation of large blood vessels in the surgical field is
required. important to avoid excessive hemorrhage and formation of
a hematoma/seroma postoperatively. Where a mass is
Hemorrhage anticipated to be well vascularized or is large and requires
extensive tissue dissection, electrocautery or bipolar vessel
Definition Excessive bleeding at the time of surgery, sealing devices enable hemorrhage to be controlled more
postoperative haemorrhage from the surgical site or quickly and efficiently. Laser and electrosurgical devices
development of a haematoma/seroma (Figure 20.3) also result in less hemorrhage at the site of surgical excision
compared to conventional scalpel blade excision.
Risk Factors Appropriate closure of the incision should be performed to
● Proximity of large blood vessels avoid formation of dead space, particularly where large
● Neovascularization skin masses have been removed. Placement of surgical
drains may be indicated, particularly where blood or serum
may accumulate in a tissue defect. Packing of the site with
appropriate materials or application of pressure dressings,
e.g. bandage/stent bandage can also help to control any
hemorrhage that may occur postoperatively.
Diagnosis Visual evidence of hemorrhage from the

surgical site. Subcutaneous swelling may be indicative of
seroma or hematoma formation and ultrasonographic
assessment can assist diagnosis.
Monitoring This will be based on assessment of the rate

and amount of blood lost and the horses systemic
parameters including heart rate, PCV, TP and systemic
lactate.
Figure20.3 Horse that developed severe hemorrhage Treatment Excessive hemorrhage following removal of
following standing surgical excision of a skin mass in the
inguinal region. A large hematoma subsequently developed in skin tumors is relatively uncommon and will depend on
the inguinal and upper limb area. the individual case. Rarely, repeat surgery may be required
to ligate a large blood vessel that is the source of include use of imaging modalities such as ultrasonography,
hemorrhage. Where the skin defect cannot be closed, radiography, CT or MRI, depending on the location of the
hemorrhage from exposed vessels may be controlled by mass, availability of equipment and economics. Care must
temporary application of hemostats or placement of a be taken when using laser to resect skin masses located
pressure bandage over the site. Hematomas and seromas close to structures such as the auricular cartilage, to avoid
may progressively resolve but where infection is suspected thermal necrosis of underlying cartilage (Figure 20.4).
(e.g. development of fever, marked pain at the site),
drainage is required. Diagnosis Confirmation of penetration into or damage to
a key anatomic structure during surgery or identification
Expected outcome Good, providing hemorrhage can be of damage during the postoperative period
controlled
Monitoring and treatment
This will depend on the structure
that has been damaged or is suspected to be at risk of
Damageto AdjacentStructures
delayed onset injury.
Definition Undesired damage to adjacent anatomic
structures as a consequence of removal of a skin neoplasm. Expected outcome This will be dependent on the structure
This may occur during surgery or may be a delayed tissue that has been damaged, how quickly the damage is
response, e.g. thermal damage to tissues following use of diagnosed and how it has been managed.
laser.
Failure to Close the Skin Defect
Risk Factors
Definition Inability to suture the defect closed, preventing
● Location of neoplasm
primary healing of the surgical incision from occurring
● Extensive neoplastic spread
● Poor surgical technique
Risk Factors
● Inappropriate use of surgical lasers
● Large skin tumors
Pathogenesis Where neoplastic cells have invaded into ● Tumors requiring wide margins of surgical excision
deeper tissues, complete excision of the mass will therefore ● Skin masses in areas where tissue cannot be freely
require deeper tissues to be removed, increasing the mobilized
inherent risk of damage to key adjacent structures,
depending on the location of the mass. The risk will be
increased where neoplastic skin masses are overlying key
anatomic structures such as joints, tendons, tendon sheaths
and nerves. Carbon dioxide and diode lasers emit light that
is converted into heat and is absorbed into adjacent tissues
that can result in a zone of thermal necrosis. This will be
dependent on the laser used, total dose used and properties
of adjacent tissues [28].
Prevention Early removal of neoplastic masses prior to

deeper extension into local tissues is important to avoid
damage to adjacent structures during complete surgical
excision. If masses are extensive, the risk of damage to
important adjacent structures may prevent complete
surgical excision and other means of treatment either with
surgery (debulking) or without, e.g. radiation therapy may
be planned instead. Visual, ophthalmic (masses in the Figure20.4 Horse presented for ear reconstruction following
periorbital region) and palpable examination of the mass is laser removal of a sarcoid on the inner aspect of the pinna 4
weeks previously that had resulted in thermal necrosis of the
an important part of preoperative planning. Further
underlying cartilage and an obvious defect in the ear. The
information that will assist surgical planning and amount of laser energy that had been delivered to the tissues
determine the likelihood of this complication occurring was not provided.
Pathogenesis Equine skin is relatively inelastic and limits Risk Factors

mobilization of adjacent skin for closure and primary
● Surgical site infection
intention healing. Where neoplasia has recurred and
● Excessive tension
follow-up surgery is being performed, patients will
● Excessive motion
frequently have less normal tissue for closure. In addition,
● Incomplete surgical excision of tumor
seeding of neoplastic cells into previously non-involved
● Thermal necrosis following laser excision
tissue planes may have occurred requiring a wider resection
● Immunosuppression
than may have been required for the initial tumor, resulting
● Effects of adjuvant therapies
in creation of a larger defect [10].
Pathogenesis General causes of wound dehiscence after

Prevention Aggressive resection that requires open wound
primary closure, such as surgical site infection, excessive
management and secondary intention healing is preferred
tension and motion and any factor affecting second
compared to less aggressive wound closure, potentially
intention healing can delay healing following tumor
leaving neoplastic cells in situ [9]. Neoplastic masses
resection (see also Chapter 18: Complications of
should be removed at an early stage while they are small
Reconstructive Surgery). Residual neoplastic tissue may
and the resultant skin defect can be closed by primary
disrupt normal tissue healing as may tumor-related
closure or by reconstructive surgery to allow primary
cytokines and bioactive substances, cancer cachexia and
healing of the skin. Previously untreated tumors have
other paraneoplastic syndromes [9]. Immunosuppression
normal adjacent anatomy facilitating closure, depending
(if present), tumor-related factors and reduced immunity
on the size of the defect. The surgeon should have a good
by adjuvant therapies can delay healing in all species and
working knowledge of alternative methods for
may make the site more susceptible to infection [9]. Latent
reconstruction of the site [29] and use of skin grafting
thermal necrosis of tissue following laser excision of
techniques [30], either at the time of surgery [31] or as a
masses may contribute to incisional dehiscence
planned second surgical procedure.
postoperatively [19].
Diagnosis Inability to close the tissue defect at surgery

Prevention General methods to prevent complications
following primary and second intention healing are
Monitoring The site should be managed appropriately for discussed in Chapter 18: Complications of Reconstructive
second intention healing or following placement of a skin Surgery and Chapter 19: Complications of Excessive
graft. Granulation Tissue. To minimize the risk of incisional
dehiscence related to neoplastic cells remaining in situ,
Treatment It is important to have a good knowledge of good surgical planning and appropriate tissue margins
open wound management techniques together with should be taken. Where lasers are used to remove skin
options for skin grafting and reconstructive techniques tumors, these should be used carefully. ensuring that the
that may be used to assist healing of the site. power applied and total energy delivered to the tissues is
appropriate [32].
Expected outcome Healing by second intention can be

Diagnosis Visual evidence of dehiscence at the site of a
slow and may be complicated by formation of excessive
previously sutured skin incision, sanguinous or purulent
granulation tissue (Chapter 19: Complications of Excessive
discharge from the surgical site, evidence of abnormal
Granulation Tissue), and may have a poor cosmetic and/or
proliferative tissue at the site or slower than normal healing
functional outcome.
by secondary intention
Monitoring Biopsy of any abnormal tissue at the site

EarlyPostoperative should be undertaken. Ongoing monitoring will involve
complete systemic examination and frequent
IncisionalDehiscenceand DelayedHealing re-examination of the surgical site.
Definition Failure of the surgical site to heal by primary
intention (following closure of the incision) or healing by Treatment This will depend on the underlying reason for
secondary intention that is slower than expected delayed tissue healing.
Early Postoperative 219
Outcome This is dependent on whether the underlying Pathogenesis Removal of a skin neoplasm can damage
reason for delayed wound healing is due to residual key supporting structures (see section titled “Damage to
neoplastic tissue at the site or systemic effects of neoplasia Adjacent Structures”) or create skin defects. Resection at
(poor prognosis), or if this is due to normal complications sites where function of tissues such as the eyelids
that may occur during healing of equine wounds. (Figure 20.5), lips or nostrils is compromised by formation
of scar tissue or loss of underlying tissue support. Lasers
generates thermal energy that can damage tissue and cause
PoorCosmeticorFunctionalResult scars or result in leukotrichia [33].
Definition Obvious visual deformity of tissues at the
Prevention A thorough understanding of the regional
surgical site or reduced mobility of tissue that compromises
anatomy and physiology is essential, together with
normal functioning of the site, e.g. normal movement of
knowledge of the technique for surgical resection and
eyelids
reconstructive techniques.
Risk Factors
Diagnosis Visual assessment of the site
● Neoplastic masses that require extensive tissue
resection MonitoringRepeat assessment of the site for evidence of
● Anatomic location of masses development of further deformity or development of
(a) (b)
(c)
Figure20.5 (a–c) Removal of a melanoma on the lower eyelid. Use of a sliding H plasty enabled the site to be reconstructed in order
to miminize any functional deformity of the eyelid and to maximize the cosmetic outcome.
secondary effects, e.g. corneal ulceration secondary to depending on the location of the deformity (see surgical
exposure keratitis where eyelid function has been texts for further details).
compromised
Expected outcome Cosmesis does not normally have any
Treatment Initial surgical planning should include effect on the outcome other than reduced client satisfaction
consideration of ways in which the cosmetic outcome can depending on the horse’s use and owner expectations.
be maximized and normal function of the tissues preserved. Functional compromise can limit athletic use, e.g.
Owners should be aware of the potential risks of poor compromise to normal mobility of the nares and reduced
cosmesis and/or compromised function at the site prior to nasal airflow at high speeds or may result in secondary
surgery. Further surgical reconstruction can be undertaken problems such as chronic exposure keratitis and recurrent
corneal ulcers where eyelid function is compromised.
References
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16 Hapeslagh, M., Vlaminck, L.E.M., and Martens, A.M.
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222
21
Complicationsof SkinGrafting
Debra C. Archer BVMS PhD, CertES(soft tissue), DECVS, FRCVS, FHEA1 and
Jacintha M. Wilmink DVM, PhD, DRNVA2
1
2
Overview Intraoperative/technical
Skin grafting is used to promote healing of full-thickness Hemorrhage

skin defects in horses that cannot be closed by conven-
Definition Hemorrhage will occur when granulation
tional suturing or reconstructive techniques, and where
tissue is excised prior to grafting and when pockets are
second intention healing is anticipated to be slow or to
created for the insertion of pinch and punch grafts. If skin
result in an unsatisfactory cosmetic or functional out-
grafting is being performed immediately following removal
come [1]. Skin grafts can also be utilized directly after
of a skin tumor, hemorrhage will be encountered as per
removal of a skin tumor [2] when the defect cannot be
routine surgery.
closed. A successful skin graft is therefore often a more
cost-effective approach that results in quicker return of a
Risk Factors
horse to its normal activity and a better cosmetic and func-
tional outcome. Readers are referred to surgical texts for ● Excision or incisions of the granulation bed
further details of how to perform each of these skin graft- ● Surgical excision of masses directly followed by grafting
ing techniques [1].
Pathogenesis Granulation tissue contains a large number
of capillaries and so any incision into this tissue will result
L in hemorrhage. However, this can usually be controlled
with SkinGrafting easily with application of pressure. Significant hemorrhage
from larger blood vessels may be encountered where large
● Intraoperative/technical masses of EGT are removed (see Chapter 19: Complications
– Hemorrhage (see also Chapter 7: Complications of Excessive Granulation Tissue).
Associated with Hemorrhage)
– Insufficient donor skin Prevention If excision of large quantities of EGT is
● Early postoperative required, this should be done several days in advance;
– Graft failure techniques to prevent and control hemorrhage are
– Graft displacement/removal covered in Chapter 7: Complications Associated with
– Pain or dehiscence at donor site Hemorrhage. Excision of granulation tissue during
– Formation of excessive granulation tissue (EGT) (see surgical placement of skin grafts should be limited and
also Chapter 19: Complications of Excessive only be superficial. Where grafting is being performed
Granulation Tissue) immediately following removal of a skin tumor,
● Late postoperative hemostasis must be achieved prior to a graft being placed.
– Self-mutilation (biting or rubbing) This may involve ligation of vessels or use of electrocautery
– Poor cosmetic/functional outcome devices. Where electrocautery is used, it should not be
Insufficient Donor Skin 223
applied to the entire graft bed to avoid creation of a layer and less contraction occurring in STSG due to the lower
of necrosis that may inhibit graft take. volume of elastin-containing dermis [5]. In horses, the
degree of contraction can approach close to 50% (authors’
Diagnosis monitoring Hemorrhage will be obvious at the observations). The availability of sufficient donor skin to
time of grafting being performed. Monitoring is covered cover the site to be grafted is an important consideration
below. when planning the type of grafting to be performed.
Wounds up to 300 cm2 can be grafted successfully with full-
Treatment Excision of superficial layers of the granulation thickness skin grafts (FTSG) and up to 600 cm2 with split-
bed immediately prior to grafting should be performed thickness skin grafts (STSG) with mesh expansion [6].
first. Application of a pressure bandage over the site whilst FTSG therefore are generally used for smaller defects,
grafts are being harvested is usually sufficient to control although meshing can enable some expansion. For very
hemorrhage. The bandage can be removed when the grafts large wounds, the Meek micrograft technique is the best
are ready to be placed. Alternatively, when preparing choice [7].
recipient sites for punch and pinch grafts, cotton-tipped
applicators can be applied into each defect. Meshing can Prevention Preoperative planning is important in
help to prevent a hematoma or seroma forming under a determining if sufficient donor skin will be available. The
sheet graft as it allows free drainage of blood or serum and size of the region to be grafted will determine whether a
enables sheet grafts to be placed on an actively bleeding sheet graft can be placed and what thickness of graft can be
surface [3]. At the time of grafting, hemostasis of the used. The size of the area that can be grafted with an FTSG
recipient bed is required as accumulation of excessive will be limited by the ability to suture the donor site [2] and
exudate or blood under the graft will hinder normal graft preoperative planning should take into account that an
adherence and revascularization and may result in failure FTSG has to be cut larger than the recipient bed, because
of the graft(s) to take [4]. Pressure following application of graft shrinkage will occur after it is harvested [8]. FTSG
a dressing and bandage together with immobilization of can be meshed using a Padgett skin graft mesher with a 1:3
the limb will help to reduce any ongoing or recurrence of expansion ratio or staggered fenestrations can be created
hemorrhage. with a scalpel blade to provide some expansion of the
graft [2]. Where a larger skin graft is required than an FTSG
Expected outcome Hemorrhage that is not controlled may can provide, an STSG will enable a larger area to be covered.
physically displace pinch and punch grafts, resulting in However, dependent on the type of dermatome, STSG can
failure of some or all grafts to take. Failure of sheet grafts only be harvested at locations where the skin is more
may also occur if a hematoma or seroma physically tightly attached and with a firm base (lateral thorax,
separates the graft from the recipient bed as capillaries hindquarters, ventral abdomen), and not on locations that
from the recipient site are unable to reach the graft within are easy to suture (pectoral area). Harvesting an STSG will
the first few days. However, a moderate degree of leave a scar at the donor site, and hair follicles included in
hemorrhage may be tolerated by meshed sheet or modified the graft will result in reduced hair growth at the donor site
Meek micrografts and fibrin also helps the graft to adhere and must be taken into account. Additionally, the partial
to the graft bed [1]. thickness wound at the donor site is very painful for several
weeks after grafting. STSG can be meshed with ratios of 1:3
to 1:9, but ideally these grafts should not be expanded
InsufficientDonorSkin beyond 1:3 due to reduced cosmesis at the site beyond this
ratio [9]. Modified Meek micrografts should be considered
Definition Not enough donor skin available to cover the where large skin defects are to be grafted [7]. This technique
site to be grafted also provides ratios of 1:3 to 1:9 but has the advantage that
donor skin can be harvested in smaller parts from different
Risk factors Large skin defects that require grafting locations because there is no need for one big sheet of skin.
When using the electric Humeca dermatome, STSG can be
Pathogenesis Equine skin is relatively inelastic and harvested from the ventral abdomen. The required width
passive recoil of elastin fibres in the dermis causes primary for the Meek micrografts is 4.2 cm, and when excising the
contraction of a skin graft to occur immediately after it is part of the dermis that is left behind from the donor site,
harvested. The degree of contraction ranges in human skin the wound can be primarily closed without problems and
from 9% to 22%, dependent on the thickness of the graft, can heal by primary intention without leaving a scar at the
with FTSG exhibiting the greatest degree of contraction donor site and preventing pain [1]. Punch and pinch grafts
224 Complications of Skin rafting
are usually reserved for management of small-moderate recipient site and vessels in the graft dermis. This is
size skin defects where the cosmetic appearance of the followed by a process of vascular proliferation, particularly
healed site is not important. Because these techniques are from the recipient bed, resulting in full circulation being
very labor-intensive and very tedious and the cosmetic and restored to the graft within 4–7 days of grafting [5]. This is
functional outcome will be poor, they are not useful for the followed by epidermal proliferation and hyperplasia
treatment of large wounds. between days 7–8 post grafting, restoration of the lymphatic
circulation in the first 7 days and re-innervation of the graft
Diagnosis/Monitoring Lack of coverage of the defect will and full return of sensory function 2–4 weeks following
be evident at the time of grafting. grafting, although in people it can take many months for
full sensation to return [5]. Grafts will not “take” over
Treatment Where the size of the wound exceeds what can avascular tissues such as exposed bone, cartilage, tendon or
be covered with FTSG or STSG, consideration should be nerve, without periosteum, perichondrium, peritenon or
given to other forms of grafting, e.g. modified Meek perineurium respectively, nor when placed over fat [10],
technique [7]. Grafting of large wounds with pinch/punch because there is insufficient vascular supply to the graft [5].
grafts is not practical and the cosmetic and functional
outcome will be poor. Prevention Multiple factors need to be considered to
minimize the chance of graft failure occurring. These
Expected outcome This will be dependent primarily on the include selection of the appropriate type of graft (for details
size and location of the defect to be grafted, the skin about selection of grafts, see [1]), appropriate preparation
grafting technique used, and whether the skin graft(s) are of the recipient site and thus correct timing of grafting,
accepted. correct preparation of the graft and careful management of
the patient following grafting (complications relating to
physical disruption are covered in the section titled “Graft
EarlyPostoperative Displacement/Removal”).
Infection is a major cause of graft failure because bacte-
GraftFailure ria have a negative impact on graft take. Chronic equine
wounds often contain pathogens such as Pseudomonas
Definition Failure of grafts to establish and maintain a
spp., Staphylococcus spp. and Enterococcus spp. [11], and
successful vascular supply at the recipient site
therefore minimizing the bacterial load at the recipient site
prior to grafting is essential. Systemic antimicrobials have
Risk Factors
been shown to have no effect in reducing the quantity of
● Infection bacteria in granulating wounds in people [12, 13], but topi-
● Inflammation cal antimicrobial agents have been demonstrated to reduce
● Physical displacement – hemorrhage/mechanical shear the bacterial load at the recipient site prior to skin graft-
forces (see “Graft Displacement/Removal”) ing [13]. During the period of recipient site preparation,
therefore, systemic antimicrobials are not indicated and
Pathogenesis A complex series of events that are unique topical antimicrobial products and dressings such as foams
to free skin graft transplantation take place following containing silver or polyhexamethylene biguanide (PHMB)
placement of skin grafts and understanding of these should be utilized to reduce the bacterial load at the recipi-
processes is key in avoiding graft failure. Free skin grafts ent site. [1, 7].
are completely separated from their original vascular bed Chronic inflammation, inherently present in equine
and graft survival is dependent on development of a new wounds healing by second intention [14, 15], is also a
blood supply from the vascular bed in which they have major cause of graft failure [1].
been placed. In the first 24 hours following grafting, a To reduce the bacterial load and chronic inflammatory
fibrin “glue” attaches the graft to the recipient bed and the response, meticulous preparation of the recipient site well
graft becomes oedematous due to uptake of wound exudate. before grafting is undertaken is essential, and timing of
This initial phase is termed “plasmatic inhibition” and grafting is important. Hair around the recipient site should
keeps the graft moist, provides it with a supply of nutrients be clipped with a wide margin and the skin should be asep-
and maintains patency of the graft vessels until tically prepared, whilst protecting the wound surface.
revascularization takes place. Inosculation is the process of Excision of the superficial layers of the granulation bed
revascularization that occurs 48–72 hours following allows removal of unhealthy/necrotic tissue or biofilm, will
grafting, whereby anastomoses form between vessels at the reduce the number of bacteria at the surface and will
remove the leucocytes predominantly present in the super- Monitoring Careful visual inspection will reveal grafts that
ficial layers of the granulation bed [7]. The use of topical have not taken within 7–10 days. Loose grafts and any
antimicrobial products or dressings will further reduce the exudate must be removed by irrigation with saline. Eschars
number of bacteria and the inflammatory response. New will usually not form with moist wound management.
granulation tissue subsequently forms, which is well vascu- When necrotic grafted tissue is present after sheet grafting,
larized, in contrast to mature granulation tissue that is more this should be removed gently to avoid bacterial growth
fibrous and less vascular [8]. Grafting therefore should usu- underneath and to prevent disruption of the accepted part.
ally be performed within 10 days of excision. Any excessive The site should be monitored for infection and formation
granulation tissue that develops during the preparation of excessive granulation tissue.
period should be debrided again. Additional reduction of
the inflammatory response can be achieved by a single Treatment Once graft necrosis occurs and where sheet
application of topical corticosteroids 1–2 days before graft- grafts have been placed, the entire graft is likely to fail.
ing [1]. Whilst some shallow grooves and clefts in the gran- Where island grafts have been placed the percentage taken
ulation bed have little impact on survival of island grafts, may be sufficient to speed epithelialization at the site
including Meek micrografts [7], sheet grafts require a high- sufficiently. Bacterial colonization or infection must be
quality granulation bed free from defects and exudation [6]. treated with antimicrobial wound dressings. Any excessive
At the time of grafting, granulation tissue must be healthy granulation tissue in the grafted wound should be treated
and well vascularized, the surface should be regular in with topical corticosteroids.
appearance without visible tissue necrosis or clefts, the
number of bacteria at the surface should be reduced, and Expected outcome Most dependent on the size of the
chronic inflammation should be limited. original wound, the skin grafting technique utilized and
Correct preparation of the graft following harvesting is the take of the grafts. If a sheet graft fails, the whole grafting
vital. Removal of subcutaneous tissue is important because procedure will need to be repeated for optimal healing to
adipose tissue is poorly vascularized and is not a good tis- occur. In the case of island grafts, the proportion of grafts
sue medium for new vessel ingrowth [5], and normal sub- that have failed to “take” will determine whether additional
cutaneous tissue makes the graft thicker and delays grafts need to be placed. Acceptance of Meek micrografts is
in-growth of vessels to the dermis. The grafts must then be usually high, even when the wound bed is not perfect [7].
secured in place.
Methods to reduce the chance of physical disruption of GraftDisplacement/Removal
grafts are covered in the section on Graft Displacement and
Definition Physical disruption of skin grafts from the
Removal.
recipient bed
Diagnosis Visual inspection during bandage changes,
Risk Factors
showing loose grafts. Normally, graft attachment by
revascularization will occur approximately 7 days after ● Fluid accumulation (hemorrhage/seroma)
grafting, and will be apparent at the time of the first ● Failure to secure the graft (sheet grafts)
bandage change at around 9–10 days following grafting. ● Excessive movement
Any graft that is not attached after that period is usually ● Adherence of the primary dressings to the grafts
lost. Initially, island grafts will shrink and change color and ● Self-mutilation
sheet grafts often become oedematous and pale. Sometimes
the epidermal layer of the graft(s) sloughs and this tissue Pathogenesis Hemorrhage after placement of pinch or
may be seen on the dressings when removed. Necrotic punch grafts can displace the grafts from the prepared
spots may appear along the top of the granulation pockets holes in the granulation bed. Inadequately secured sheet
where pinch or punch grafts have been placed [8], but the grafts or modified Meek micrografts can also be physically
remaining pale dermis of the accepted graft will still be disrupted. Insufficient pressure applied by bandages or
attached to the granulation bed [1]. Island grafts can bandages that slip will fail to physically secure grafts in
become covered by EGT, obscuring the grafts. In both place and limb movement will disrupt the attachment of
situations grafting may be mistakenly considered to have grafts to the wound, especially over regions of high motion
failed and trimming granulation tissue at this stage can such as joints. Bandage changes can also disrupt the fragile
result in viable grafts inadvertently being removed and attachment of grafts, particularly when the bandage has
must therefore be avoided (see Section: “Formation of adhered to the grafted wound. Some horses may also rub or
Excessive Granulation Tissue After Grafting”). bite the bandages.
Prevention Grafts must be appropriately secured to the

recipient bed, either by suturing or using staples (sheet
grafts, Meek grafts) and/or by pressure (punch, pinch, or
Meek grafts). Other methods such as fibrin glue have
been tried but have been shown to have no effect on graft
survival [16]. Tunnel grafts can be useful in highly mobile
sites as they are secured within the surrounding tissues [6,
8]. Where pinch grafts are used, each graft must be
carefully tucked into the pockets within the granulation
tissue and compressed by application of a bandage. To
ensure a snug fit of punch grafts, the biopsy punch used
to create a pocket for the graft in the recipient bed should
be 2 mm narrower than the size used to obtain the graft,
because the graft will contract and reduce in size following
harvesting (primary contraction). Sheet grafts must be
sutured to the site under slight tension to prevent
occlusion of dermal vessels that occurs if the graft is
allowed to fully contract [8]. The dermal vessels should be
open to enable the important formation of anastomoses
between these vessels and those in the recipient bed
which is vital for graft acceptance (inosculation, see
Section: Graft Failure). Meshing provides more three-
dimensional mobility, enabling a sheet graft to conform
better to an irregularly contoured surface or a concave
area without “tenting” of the graft [3, 9].
Graft(s) should be covered by a sterile antimicrobial
foam that absorbs exudate. The primary dressing can be
secured with staples/adhesive tape to reduce the shear
forces, whereas stent bandages can be used in areas that
are difficult to bandage. A bandage should be placed with Figure21.1 Initially successful Meek grafting but subsequent
enough pressure to stop hemorrhage, but must not be graft failure occurred following placement of a bandage that
was too tight and compromised the regional circulation. Most of
placed too tightly as this can compromise vascularization the micrografts at the plantar aspect did not survive this
and cause graft failure (Figure 21.1). Bandages, even insult [1].
when bulky, do not completely immobilize the underly-
ing site and grafts applied over highly mobile areas require
additional immobilization by using a splint, cast, bandage Monitoring No monitoring: leave the grafted site alone for
cast or sleeve cast [7]. The carpus or tarsus can easily be the first 9–10 days to enable grafts to take without risk of
immobilized by application of a bandage followed by a physical disruption.
splint or sleeve cast. It is often thought that casts after
grafting are disadvantageous because the grafts cannot be
Treatment If the graft is only displaced but is still in contact
assessed on a frequent basis. However, bandage changes
with the wound bed, acceptance may occur in the new
before grafts have “taken” risk physical disruption and
position (Figure 21.2). Once the graft has been separated
displacement of grafts. Because casts are left on for longer,
from the recipient bed, the time to re-establishment of
this risk is minimized. Casts are usually left on for 9–10
vascularization will be prolonged and the graft(s) will
days allowing enough time for grafts to “take” but before
usually fail.
EGT forms in the non-grafted parts of the wound (e.g.
between islands grafts or through gaps in meshed sheet
grafts). Bandages should be left on for the same time Expected outcome This is dependent on how much of the
period [1–7]. graft remains in direct contact with the recipient site.
Partial detachment of sheet grafts can result in total graft
Diagnosis Visual evidence of physical displacement of loss, but island grafts are independent of each other and
graft(s) can survive more easily [7].
(a) (b)
Figure21.2 (a) Meek graft recipient site 9 days after grafting. Note the displacement of the grafts, probably caused by hemorrhage
from the recipient site during the surgical procedure. (b) Image of the same location 2 months later. The grafts that remained on the
granulation bed have taken, stretched, and epithelialization has occurred.
PainorDehiscenceatthe DonorSite Where the donor site is sutured, wound dehiscence may
occur due to excessive tension, motion, or a surgical site
Definition Hypersensitivity of the donor site due to
infection (see Chapter 17: Complications Associated with
exposure of nerve ends after harvesting STSG or break
Surgical Site Infections). Tension on the sutured donor site
down of the donor site after suturing respectively
depends on the location on the body and the direction of
the long axis of the donor site; tension will be more when
Risk Factors
the donor site is located over the hindquarters or ventral
● Donor sites of STSG abdomen, particularly where the long axis of the donor site
● Large skin defects or sites of high movement (increased would be perpendicular to tension lines. Tension is less at
tension) the pectoral area, and the donor site for this reason can be
sutured more easily.
Pathogenesis The donor site after harvesting of STSG
often causes more postoperative discomfort compared to Prevention These are inherent complications following
the grafted area in people [5] and this is also evident in harvesting of large FTSG or STSG (after removing the
horses [1]. This pain sensation is due to exposure of remaining dermis), followed by suturing. Skin grafts are
multiple nerve endings in the dermis, and can be usually harvested from sites that are less conspicuous to
problematic when the donor site has to heal by second reduce visible evidence of scarring, lack of hairs or growth
intention. The pain is hard to control with systemic of white hairs. Where larger quantities of skin need to be
analgesia, and touching or cleaning the site may not be harvested, the ability to perform closure of the defect whilst
tolerated by the patient for several weeks. minimizing tension on the site should be considered to
reduce the risk of dehiscence, such as undermining the Risk factors Recurrent EGT prior to grafting (JMW,
skin around the site. Full thickness skin grafts are usually personal observation)
taken from the pectoral region as the site can usually be
closed by primary intention healing and scarring may be Pathogenesis The development of EGT after grafting is
less obvious if the graft spans the midline of the pectoral usually caused by both an active chronic inflammatory
region [17]. STSG are harvested under general anaesthesia, response and a relatively high bacterial load. High levels of
usually from the ventrolateral abdomen or thorax. To pro-fibrotic cytokines promote EGT formation and inhibit
prevent the exposure of nerve endings after harvesting split contraction (see Chapter 19: Complications of Excessive
thickness grafts, the remainder of the dermis can be Granulation Tissue). Some horses form EGT more readily
excised, creating a full thickness skin defect that is much than others, and these wounds are more at risk following
less painful. These skin defects can then be closed with grafting. EGT formation through the latticework of a
skin sutures, and most of them heal by primary intention meshed graft occurs more often when maximal expansion
without noticeable discomfort [1]. This approach is has been undertaken [17].
practical and avoids the need to manage a painful donor
site over a long period of several weeks.
Prevention This is based on suitable preparation of the
Diagnosis Dependent on the thickness of an STSG, the recipient site prior to grafting, and the use of appropriate
donor site usually epithelializes between weeks 1 and 5 if antimicrobial foams following grafting. By performing the
left to heal by second intention. Dehiscence of the donor first bandage change approximately 9 days after grafting,
site of an FTSG is visually obvious. formation of EGT is usually limited, whereas graft take has
already occurred. Leaving the first bandage on for a longer
Monitoring Donor sites of an STSG will heal as an open time will increase the risk of EGT formation.
wound comparable to an abrasion. Dehiscence of an FTSG
can be managed as per normal healing by second intention.
Diagnosis Visual evidence of granulation tissue at the site.
Treatment The donor site of an STSG left to heal by second Where skin grafting has been used after tumor removal
intention should be bandaged to achieve moist wound and EGT recurs several times, a biopsy should be taken to
healing, which reduces pain and protects the site from rule out tumor recurrence.
irritation by environmental factors. This can be challenging
dependent on the location, but with modern adhesive tapes Monitoring Ongoing visual assessment of reduction in
almost every wound can be bandaged. As most partial EGT
thickness grafts are harvested from the abdominal region,
abdominal bandages can be easily applied. If the horse is
Treatment EGT that develops after grafting can be treated
still showing signs of discomfort, systemic analgesics
by topical application of corticosteroids on the locations
should be administered.
where granulation tissue protrudes above the grafts, which
Expected outcome Pain at the donor site of an STSG left to does not necessarily include the entire wound.
heal by second intention will usually reduce over time, Triamcinolone is more effective in reducing EGT than
although this can take several weeks. Application of hydrocortisone or dexamethasone (JW personal
dressing that provides moisture to the donor site, will communication). Usually a single application is sufficient
provide a quick but partial pain relief. When the deep to reduce EGT to the normal level of the grafts, but when
dermis is excised and the donor site is sutured, the degree necessary it can be repeated. If corticosteroids are used too
of pain is no greater than routine surgery and disappears often, they will suppress epithelialization. However, the
within a few days [1]. Dehiscence of sutured donor sites presence of EGT is more deleterious for the grafts than
sometimes occurs but these usually heal uneventfully with using corticosteroids and therefore EGT should always be
limited scarring [6, 18]. treated. Excision of EGT is inadvisable because of the risk
to damage the grafts [1].
Formationof ExcessiveGranulationTissue
Expected outcome One or two applications of topical
AfterGrafting
corticosteroids will control EGT and are usually sufficient
Definition Excessive granulation tissue (EGT) formed to enable epithelialization from the graft margins to occur.
after grafting either between island grafts or through the Corticosteroids should not be applied too frequently to
latticework of a meshed graft avoid inhibition of epithelialization.
Late Postoperative 229
LatePostoperative Initially bandages should only be left off for a short period
of time and under supervision whilst providing some form
Self-Mutilation(BitingorRubbing) of distraction to the horse (e.g. food). If the horse is not
interested in the wound, and the limb does not swell, the
Definition Trauma to the grafting site caused by the horse bandages can be left off for longer. If the horse starts to rub
physically disrupting the site by biting or rubbing at the area or lick/bite the site, bandages should be left on and
Risk factors Unknown measures should be taken to prevent the horse from being
able to reach the wound, e.g. application of a neck cradle.
Pathogenesis Self-mutilation is probably due to altered Sometimes this has to continue for several weeks before
sensation when the graft becomes re-innervated. People apparent irritation decreases. In the meantime, the scar
who have undergone skin grafting may encounter pain or tissue should be managed with topical application of fatty/
itching [19], and it would be highly plausible that this may rehydrating substances, e.g. cod-liver oil, because the lack
also occur in horses. Personal observation (JW) suggests of sebaceous glands results in scaling and crusting of the
that this is most likely to occur in horses in the first 5–6 scar, which can increase itching.
weeks following grafting, particularly following initial
removal of bandaging and dressing materials that have Diagnose/monitoring Observation of the horse
provided physical protection.
Treatment If the horse has damaged the grafted wound, the
Prevention Staged removal of bandages should be wound needs to be managed in the same way as a wound
undertaken once successful grafting has been achieved. healing by second intention (Figure 21.3). In a worst-case
(a) (b)
Figure21.3 (a) Appearance of a wound dorsal to the fetlock that had been grafted 6 weeks before with a Meek graft. The horse
knocked with the leg against the fence when she was alone, which was not recognized. (b) One week later, the graft appeared
completely destroyed.
scenario, where self-mutilation results in damage to the Pathogenesis Skin grafting is usually undertaken to speed
entire graft, skin grafting may need to be repeated. up healing and to improve the cosmetic and functional
outcome of wounds that would otherwise have to heal by
Expected outcome The time for healing of the site will second intention. However, even after a successful graft,
depend on the amount of damage by self-mutilation. If the the healed wound will still be visibly different from the
horse has chewed off the entire graft and granulation bed, normal surrounding skin, as placement of skin from one
it will become a frustrating and expensive situation. part of the body to another will result in variation in
Euthanasia may be the end result if the owner does not presence of hairs, hair colour and length. The more skin
wish to continue treatment. grafts that are placed and the greater the thickness of these,
the better the cosmetic and functional result is likely to be.
PoorCosmetic/FunctionalOutcome The reason why hair at the recipient site may grow to a
Definition An unsightly scar or limited range of motion longer length than the donor site is unknown but is
after grafting probably related to differences in temperature of the tissues
between the recipient and donor site [7].
Risk Factors Island skin grafts can result in thin skin coverage and a
● Large skin defects cobblestone appearance to the skin [8] with sparse and
● Location of skin defect irregular hair growth (Figure 21.4) [1]. Pinch grafts are of
● Skin grafting technique used greater thickness at their center compared to the periphery
(a) (b)
Figure21.4 (a) An example of a poor cosmetic outcome in a grafted wound over the dorsal aspect of the tarsus: variable hair growth
and different lengths of hair and a scaly irregular and thin epithelium are evident. The wound had undergone pinch grafting several
years previously. (b) An example of a good cosmetic outcome in another grafted wound of similar size at the same location: regular
growth of longer hairs can be seen, whereas the narrow rims of newly-formed epithelium in between the islands are not visible. This
wound had received a Meek graft several years before.
Late Postoperative 231
which will result in more variable hair regrowth compared donor site less obvious (Figure 21.5) [17]. Where possible,
to punch grafts that are uniform and full thickness [10]. closure of the donor sites with sutures will reduce
The end result of pinch and punch grafts may not be cos- scarring. However, even after successful grafting, the
metically acceptable in a show horse and alternative meth- healed wound will still be visibly different from normal
ods of grafting (e.g. sheet grafts) or skin reconstruction skin, if only because longer hairs grow at the site. Owners
may need to be considered. Modified Meek micrografts can must be informed about the likely cosmetic outcome of a
provide an excellent cosmetic result, because numerous certain grafting technique to prevent disappointment
identical islands can be placed in a uniform way and due to afterwards.
these islands comprising virtually full thickness skin,
adnexa are retained [7]. Diagnosis/monitoring Based on visual inspection of the site
The thickness of sheet grafts will determine the likely
cosmetic outcome at the site. Split thickness grafts <0.5 Treatment and expected outcome Unfortunately, once these
mm in thickness have limited strength and durability, and complications develop, there is little that can be done
the lack of hair follicles and exocrine glands result in sparse without performing new surgery. Drying and scaling of the
hair growth and scaling. Grafts of 0.63–0.75 mm have bet- graft site can be reduced by application of fatty and/or
ter durability and hair coverage [8], although this is varia-
ble depending on the skin thickness and depth of adnexa,
which varies with location and between individuals. FTSG
provide the best cosmetic and functional result as the skin
has all the properties of surrounding skin, provides maxi-
mum hair growth and can withstand pressure and fric-
tion [8]. If grafts are meshed, they should be applied with
limited expansion if good pilation is required, as meshing
results in small epithelial scars that are spread uniformly
through the healed wound [2].
Contractures are seldom seen after grafting equine
wounds and placement of grafts increases the flexibility of
tissues at the site compared to the epithelial scar that would
form without grafting. Skin grafting is not the first choice
for management of wounds on the neck and trunk, as these
usually heal mainly by wound contraction. Grafting of
these wounds is only considered in special cases, i.e. very
large wounds, and it is advisable to wait until contraction
has reduced the size of the wound before performing graft-
ing to minimize the size of the final scar. In areas where
contraction could result in compromise to function (e.g.
skin defects of the ear and upper eyelid), skin grafts should
be placed at an early stage [10] and full thickness grafts are
preferred.
Prevention The type of graft and the location of the

donor site determine the likely cosmetic and functional
outcome both at the donor and recipient site. Cosmesis
can be optimized by choosing a donor site that is similar
to the skin surrounding the recipient site (thickness and
hair color) and it is important to match the direction of
hair growth when placing grafts [10, 17]. Cosmesis and
functional outcome of the recipient site is best after full Figure21.5 The selection of the donor site is important to
thickness or thick partial thickness sheet graft or Meek provide a good cosmetic outcome. Appearance of lateral thorax
from where a split-thickness skin graft (STSG) had been taken.
graft. Skin grafts are usually taken from less conspicuous The thicker the STSG and the more hair follicles are harvested,
locations including the neck, pectoral region, ventral the less remain at the donor site causing an unsightly, bare and
abdomen, and ventral thorax, to make any scarring of the thin epithelial scar.
hydrating products, e.g. cod-liver oil, or hydrating cream can be excised and replaced by a better-quality skin graft.
and longer hairs at the recipient site can be trimmed. If the As grafting is then performed in a fresh wound, graft
cosmetic or functional outcome is unsatisfactory, the scar acceptance is usually very good.
References
1 Schumacher, J. and Wilmink, J.M. (2017). Free skin 11 Westgate, S.J., Percival, S.L., Knottenbelt, D.C. et al.
grafting. In: Equine Wound Management (ed. C. Theoret (2011). Microbiology of equine wounds and evidence of
and J. Schumacher), 509–542. John Wiley & Sons Inc. bacterial biofilms. Vet. Microbiol. 150: 152–159.
2 Toth, F., Schumacher, J., Castro, F., et al. (2010). Full- 12 Robsonn, M.C., Edstrom, L.E., and Krizek, T.J. (1974).
thickness skin grafting to cover equine wounds caused by The efficacy of systemic antibiotics in the treatment of
laceration or tumor resection. Vet. Surg. 39: 708–714. granulating wounds. J. Surg. Res. 16: 299–306.
3 Davison P.M., Batchelor, A.G., and Lewis-Smith, P.A.
13 Lipsky, B.A. and Hoey, C. (2009). Topical antimicrobial
(1986) The properties and uses of non-expanded
therapy for treating chronic wounds. Clin. Infect. Dis. 49:
machine-meshed skin grafts. Br. J. Plast. Surg. 39 (4):
1541.
462–468.
4 Andreassi, A., Bilenchi, R., Biagioli, M. et al. (2005). 14 Wilmink, J.M., Stolk, P.W.T., van Weeren, P.R. et al.
Classification and pathophysiology of skin grafts. Clin. (1999). Differences in second-intention wound healing
Dermatol. 23 (4): 332–337. between horses and ponies: macroscopical aspects.
5 Johnson, T.M., Ratner, D., and Nelson, B.R. (1992). Soft Equine Vet. J. 31: 53–60.
tissue reconstruction with skin grafting. J. Am. Acad. 15 Wilmink, J.M., van Weeren, P.R., Stolk, P.W.T. et al.
Dermatol. 27: 151–165. (1999). Differences in second-intention wound healing
6 French, D.A. and Fretz, P.B. (1990). Treatment of equine between horses and ponies: histological aspects. Equine
leg wounds using skin grafts: thirty-five cases, 1975–1988. Vet. J. 31: 61–67
Can. Vet. J. 31: 761–765.
16 Schumacher, J., Ford, T.S., Brumbaugh, G.W. et al. (1996)
7 Wilmink, J.M., Van Dem Boom, R., van Weeren, P.R. et al.
Viability of split thickness skin grafts attached with fibrin
(2006). The modified Meek technique as a novel method
glue. Can. J. Vet. Res. 60: 158–160.
for skin grafting in horses: evaluation of acceptance,
wound contraction and closure in chronic wound. Equine 17 Schumacher, J. (2012). Skin grafting. In: Equine Surgery,
Vet. J. 38: 324–329. 4e (ed. J.A. Auer and J.A. Stick), 285–305. Elsevier, Ltd.
8 Hanson, R.R. (2009). Complications of equine wound 18 Holder, T.E., Schumacher, J., Donnell, R.L. et al. (2008).
management and dermatologic surgery. Vet. Clin. N. Am. Effects of hyperbaric oxygen on full-thickness meshed
Equine Pract. 24: 663–696. sheet skin grafts applied to fresh and granulating wounds
9 Hanselka, D.V. (1974). Use of autogenous meshgrafts in in horses. Am. J. Vet. Res. 69: 144–147.
equine wound management. J. Am. Vet. Med. Assoc. 164: 19 Mauck, M.C., Smith, J., Liu, A.Y. et al. (2017). chronic
35–41. pain and itch are common, morbid sequelae among
10 Bristol, D.G. (2005). Skin grafts and skin flaps in the individuals who receive tissue autograft after major
horse. Vet. Clin. N. Am. Equine Pract. 21: 125–144. thermal burn injury. Clin. J. Pain. 33: 627–634.
233
22
Complicationsof Oraland SalivaryGlandSurgery

Padraic Martin Dixon MVB PhD, FRCVS, DEVDC (Equine) and Richard J.M. Reardon BVetMed (hons), MVM,
Ph n, F An, Cert S(orth)n, C Sn, C(equine)n, C S
Division of Veterinary Clinical Studies, The Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, Scotland
Overview ● Complications associated with 1st premolar “wolf tooth”

(Triadan 05) extraction
Most equine oral surgical procedures are dentistry-related – Fracture of wolf teeth during extraction
and almost all have the potential to cause serious short- or – Laceration of the greater palatine artery
long-term complications. Numerous oral procedures ● Complications associated with cheek teeth dentistry
involve risk of damage to the buccal branches of the facial – Complications of widening of cheek teeth diastemata
nerve. One consequence of permanent damage to the dor- ○ Pulpar thermal damage or pulp exposure
sal branch of this nerve is the inability to flare the nostril – Complications of reducing overgrowths (odonto-
which can severely diminish athletic performance and plasty) of cheek teeth
facial nerve damage should be avoided at all costs. ○ Pulpar exposure or thermal injury during cheek
teeth reductions
○ Fracture and pulpar exposure of the mandibular
L Triadan 11 cheek teeth
with Oraland SalivaryGlandSurgery – Complications of cheek tooth repulsion
○ Trauma to the infraorbital nerve
● Complications associated with local nerve blocks ○ Damage to adjacent structures
– Infra-orbital and mental nerve blocks ○ Delayed healing of alveolus
– Violent reaction/nerve trauma during needle ○ Orosinus (oromaxillary) fistula
placement ○ Oronasal fistula
– Inferior alveolar and maxillary nerve block ○ Persistent postoperative sinusitis following cheek
○ Inferior alveolar nerve block: Tongue trauma tooth extraction

○ Mamillary nerve block: periorbital hematoma and – Complications of oral extraction
infection ○ Damage to adjacent structures
● Complications associated with incisor dentistry ○ Fracture of teeth during extraction
– Complications of orthodontic treatment of overjet and ○ Non-healing alveoli
overbite ○ Damage to the soft palate during oral extractions
○ Trauma to the buccal branches of the facial nerve ○ Laceration of the greater palatine artery
○ Damage to the greater palatine artery – Complications of removal of the lateral alveolar plate
○ Postoperative pain and nursing problems (lateral buccotomy technique)
○ Damage to orthodontic prostheses ○ Iatrogenic damage to the buccal nerve branch/es
○ Incisor and gingival damage ○ Iatrogenic damage to the parotid duct
– Complications of incisor extraction – Complications associated with salivary gland surgery

○ Infection ○ Complications of parotid salivary gland ablation
234 Complications of ral and Salivary land Surgery
omplicationsAssociatedwith Local
C direct nerve stimulation at needle placement. In some
NerveBlocks cases, persistent nerve damage may result in signs of facial/
nasal irritation, which often can be managed with
Local anesthetic techniques are used commonly for dental acetylpromazine and systemic anti-inflammatory therapy
procedures. Appropriate aseptic technique should be used and normally resolves within a few days.
to minimize the risk of cellulitis or abscess formation,
which are reported sequelae. Expected outcome The usual outcome is a complete
resolution of signs.
Infra-Orbitaland MentalNerveBlocks
In addition to the complications listed below, injection at I nferiorAlveolarand Maxillary
these sites is frequently performed under pressure, so care NerveBlocks
should be taken not to eject local anesthetic forcefully from
the needle hub that will startle the horse should it become These two nerve blocks involve deep injection adjacent to
disconnected. Use of a Luer lock syringe can help reduce large blood vessels and important nerves, which can poten-
the likelihood of this. tially result in significant complications.
Inferior alveolar nerve block: tongue trauma

ViolentReaction/NerveTraumaDuringNeedle
Placement Definition
Self inflicted damage to the tongue by the teeth
Definition Needle insertion to facilitate administration of
anesthetic into the infra-orbital and mental foraminae can Risk Factors
result in violent reactions, even in deeply sedated horses.
Additionally, particularly for techniques inserting long ● Poor evaluation of the site of mandibular canal and plac-
needles into the foraminae, trauma to the nerve is possible. ing needle tip too dorsally
● Injection of an excessive volume of local anesthetic that
Risk Factors diffuses dorsal to mandibular canal and anesthetizes the
lingual nerve
● Poorly sedated horse
● Thick overlying skin and muscles that make identifica-
tion of nerve foramina difficult Pathogenesis Anesthesia of the inferior alveolar nerve as
● Inaccurate needle positioning it enters the mandibular canal anesthetizes all the
ipsilateral mandibular teeth. A standard technique is to
Pathogenesis Needle directly contacts branches of the pass a 130–150-mm long needle up the medial aspect of the
nerve within canal or after they have exited foramen. mandible, prior to deposition of 10 to 20 ml of local
anesthetic beneath the pterygoideus muscle at the
Prevention Administering subcutaneous local anesthetic estimated site of the mandibular canal. Dorsal diffusion of
over the foramina prior to insertion of the needle within local anesthetic may also anesthetize the lingual nerve,
the canal may reduce adverse reactions from the horse [1]. which can result in severe self-inflicted trauma to the
Recent anatomical and functional review of the infra- tongue (Figure 22.1), especially if the horse is allowed to
orbital canal indicates that directing the needle along the eat while the nerve block is still effective [2].
ventral floor of the canal may minimize iatrogenic needle-
induced nerve trauma [1]. The use of a Tuohy needle may Prevention Accurate assessment of the site of local
also minimize nerve damage [1]. anesthetic administration, e.g. by pre-measuring the depth
of needle placement, may be helpful and marking a spot on
Diagnosis Diagnosis is obvious, i.e. violent sudden head the side of the face to aim at. Try not to place the local
movement, possibly accompanied by snorting or even the anesthetic too dorsally. Do not use excessive volumes of
horse jumping forward during needle placement. Most local anesthetic (i.e. >20 ml). Prevent horses from eating
acute reactions spontaneously cease in a few seconds. until the nerve block has worn off (2–4 hours: local
anesthetic dependent). A recently described technique [3]
Treatment In most cases, nerve irritation is transient and for intra-oral administration of this nerve block may reduce
horses settle quickly with minimal intervention following the likelihood of this problem.
Complications Associated ith Incisor entistry 235
Risk factors for retrobulbar infections Poor aseptic

preparation of site
● Poor injection technique
● Failure to administer broad-spectrum antibiotics prior to
extraction of infected teeth
Diagnosis Periorbital swelling develops within 24 hours of

maxillary nerve block administration.
Prevention Ultrasonography can be used to guide needle

placement away from large blood vessels. Injection into the
extra-periorbital fat body has been shown to minimize the
risk of complications [7]. Use of an appropriate needle
length (a 2-inch [5-cm] long needle is normally sufficient
for the lateral approach to the fat pad).
Treatment Cold packing and compression acutely.

Figure22.1 Laceration on the left side of the tongue following Administer non-steroidal anti-inflammatories (NSAIDs).
an inferior alveolar nerve block.
The management of the more severe complications such as
bacterial infections, should be performed on a case-by-case
basis.
Diagnosis Inappetence or slow eating following inferior
alveolar nerve block or recognition of tongue lacerations
Expected outcome Fortunately, most complications are
(Figure 22.1)
only temporary due to hemorrhage, with periorbital
swellings usually resolving within about a week
Treatment Once trauma is recognized, remove all food for
(Figure 22.2).
a few hours. Superficial tongue lacerations heal quickly
and usually require minimal interventions, other than
systemic anti-inflammatories (such as phenylbutazone).
C
Significant lacerations, i.e. more than approximately one-
third diameter, may require suturing.
with IncisorDentistry
Complicationsof OrthodonticTreatment
Expected outcome
of Overjetand Overbite
Maxillary nerve block: periorbital hematoma and
Orthodontic treatment of overjet and overbite can be ben-
infection
eficial to many foals [9], but these treatments can have
Anesthesia of the maxillary nerve at the level of entry to
immediate and long-term complications [9–12],
the maxillary foramen, ventral to the globe, anesthetizes all
the ipsilateral upper dental arcade, paranasal sinuses and
Trauma to the buccal branches of the facial nerve
maxillary soft tissues. Numerous reported complications of
Definition
injection in this region include: puncture of adjacent ves-
Neural dysfunction caused by damage to the buccal
sels and retrobulbar hematoma, ataxia, collapse, blindness,
branches along their course in the cheeks
central nervous system toxicity, cellulitis, respiratory
depression, neurological deficits, convulsions and cardiac
Risk factors Failure to recognize position of buccal nerves
arrest; infection may also rarely occur [4–8].
preoperatively and during surgery
Definition Hemorrhage and blood accumulation around
Pathogenesis Because of the limited opening of the equine
the globe that may develop into an infection.
jaws, especially in the smaller foal mouth, a stab incision is
made in the skin and cheeks, opposite the upper 07–08
Risk factors for periorbital hemorrhage Non-familiarity with
interproximal spaces, for intra-oral tension band wire
local anatomy
placement. During this procedure, the buccal branches of
● Insertion of needle too deep into periorbital fat pad the facial nerve can be traumatized.
Figure22.2 Transverse CT image at level of caudal aspect of mandibular Triadan 11 teeth and external appearance of a horse that
underwent a right-sided (left of image) maxillary nerve block 3 days previously and developed a right-sided periocular and facial
swelling (solid arrows), as a result of periocular hematoma (dotted arrow). This case was managed with cold packing acutely and
systemic non-steroidal anti-inflammatories and made a full recovery.
Diagnosis On recovery from the general anesthesia, Damage to the greater palatine artery
evidence of buccal nerve damage is usually obvious by the Definition
presence of ipsilateral lip or nasal paresis/paralysis. Iatrogenic disruption of the greater palatine artery during
insertion of a Steinman pin leading to marked hemorrhage
Prevention The skin on the cheeks should be shaved to into the oral cavity
help identify the buccal nerves. The circa 1-cm long skin
and cheek incisions should be made parallel with the Risk factorsInserting drill or Steinmann pin at too dorsal
facial crest and as dorsal as possible. After incising the an angle between the 07/08 interdental space
skin, examine the subcutaneous tissues for buccal nerve
branches and gently move them away before inserting Pathogenesis When a Steinmann pin or drill is inserted
wire through the cheeks. When the second end of the through the cheeks and then through the 07/08
wire is being inserted through this buccal incision, it is interproximal spaces, if the pin is excessively angulated
important that soft tissue, including possibly a buccal dorsally and depending on the individual anatomy of the
nerve branch, is not trapped in the wire loop. Intra-oral foal, it may puncture the greater palatine artery, causing an
placement of wires across the interproximal space is immediate and often marked hemorrhage.
possible without making a cheek incision in adult horses
by using a high-speed dental drill. This technique can be Diagnosis Profuse bleeding from the site is seen on the
used in foals to prevent buccal nerve damage, but intra- hard palate.
oral wire placement may not be as stable as those fitted
transbuccally. Prevention The pin should be directed just slightly dorsally
to exit close to the gingival margin at the lateral edge of the
Treatment Nonsteroidal anti-inflammatory drug (NSAID) hard palate. The use of an oral approach to the interproximal
therapy (combined with anti-gastric ulcer therapy, such as space (as discussed above) would also eliminate this
omeprazole to counteract the potentially adverse effects of complication.
NSAIDs on the gastro-intestinal tract), may speed up
resolution of the neuropraxia. Treatment Apply local pressure with, for example, surgical
swabs until the hemorrhage stops. The greater palatine
Expected outcome Neural dysfunction is usually temporary artery is not an end artery and single ligation is not effective.
as it is due to bruising (i.e. neuropraxia) rather than
severance of the buccal nerves and most foals will have Expected outcome The artery is usually lacerated rather
resumption of normal neural function within a few than being transected and most will remain patent.
weeks [9, 11, 12]. Swelling at the site is normally transient.
Complications Associated ith Incisor entistry 237
Postoperative pain and nursing problems problem in advance. Prostheses wear out over time during
Definition normal mastication and additionally can be damaged by
Foal being unable to nurse normally after oral treatment foals rubbing them against fixed objects, possibly because
of oral discomfort.
Risk Factors
Diagnosis Prosthesis damage should be detected on
● Foals of primiparous mares routine (at least once daily) oral examination of foal. The
● Older mares with small teats foal suddenly stops nursing or eating due to acute oral
● Large acrylic biteplates on foals discomfort, e.g. a broken wire cutting oral soft tissues.
Pathogenesis Some foals have trouble nursing immediately Prevention Ensure that prostheses are tight and well
following surgery, especially if an acrylic biteplate is fitted applied, without excessive bone cement, or protruding
along with the wire brace and with primiparous mares that wires that will result in oral irritation. Also check the foal’s
have small udders and teats. environment for structures they could catch or rub the
prostheses on.
Diagnosis Inappetence or poor suckling following
prosthesis placement or mare preventing foal nursing or
Treatment Broken wires and acrylic prostheses should be
kicking out when foal is nursing due to udder pain
replaced immediately, under general anesthesia, to avoid
damage from the wire ends and to prevent the rest of the
Prevention Try to minimize the size of implant and ensure prosthesis from becoming loose.
the implant is smooth – excessive acrylic and/or sharp
protruding wires or acrylic are more likely to result in
Expected outcome Good if damaged prostheses are
trauma to the foal’s mouth or mare’s udder. Ensure post-
replaced timely
bracing pain relief is adequate for the foal. If foal is old
enough, wean it prior to surgery [9].
Incisor and gingival damage
Treatment Foals should be treated with NSAIDs and anti- Definition

gastric ulcer medication. Feed should be supplemented Swelling or ulceration of gingiva and/or physical damage
and nursing carefully monitored to ensure sufficient to or displacement of the incisors caused by implants
calorific intake, particular in the early postoperative period,
as most foals learn to adapt within a few days. Milk mare Risk Factors
and feed foal with this milk from a bottle. Should feeding/ ● Inherent to the technique
suckling problems persist for more than a couple of days ● Inadequate technique
(unusual), the implant should be assessed and revised if
necessary. Pathogenesis Tension band wires always cause some
degree of gingival damage, which is often hidden beneath
Expected outcome Most nursing problems are transient, the acrylic biteplate (Figure 22.3). Less commonly, the
i.e. foals learn to adapt to the implant within a few days. (deciduous) incisors, especially the 01s, can become
displaced, loosened or even lost due to prosthesis tension
Damage to orthodontic prostheses band pressure.
Definition
Failure or wear of implanted prosthesis leading to loosen- Diagnosis Gingival or incisor trauma will be obvious once
ing of fixation the prosthesis is removed.
Risk Factors Prevention Do not apply the prosthetic wires too dorsally
● Prostheses not firmly attached over the incisors and smooth off acrylic at this site before it
● Prosthesis hurting foal hardens or with a small S file after it sets.
Pathogenesis Orthodontic wires commonly break Treatment Ulcers usually heal without specific treatment
unilaterally or bilaterally, causing the biteplate to loosen or after removal of implants. Displaced teeth may require
fall off [9] and owners must be made aware of this common rasping.
Figure22.3 Gingival ulceration following removal of the first

prosthesis for treatment of severe overjet in a foal.
Expected outcome Usually good in most cases, unless

severe deformation has been caused.
Complicationsof IncisorExtraction
Infection
Definition Figure22.4 Gingival hyperplasia and wound dehiscence with
Bacterial colonization and proliferation causing purulent food pocketing 10 weeks after surgical extraction of multiple
mandibular incisors because of severe EOTRH.
discharge accumulation at the extraction site
Risk Factors
● Poor surgical training and technique alveolus – to reduce extraction trauma) with primary
● Attempting simple extraction where a surgical extraction closure of mucoperiosteal defects can help minimize feed
is required impaction (Figure 22.5). An alveolectomy, i.e. resection of
● Intercurrent Cushing’s disease the occlusal aspect (alveolar crest) and protruding aspects
of the reserve crown alveolar margins (jugae), ideally
Pathogenesis Because of their gingival and mucoperiosteal with a high-speed dental drill, can improve the ability to
attachments, extractions of incisor teeth invariably leave suture the mucoperiosteal and gingival margins tension-
oral defects that are difficult to close. Because of their free and fully close the extraction site following incisor
position these defects are prone to food contamination and extraction, which in turn reduces the likelihood of
infection (Figure 22.4). To compound the issue, incisor infection.
extractions are commonly required in cases with equine
odontoclastic tooth resorption and hypercementosis
Treatment Systemic antibiotics and anti-inflammatories
(EOTRH), where gingival regression and periodontal
and twice daily lavage with 0.1% detergent-free
infection are also commonly present. Most wounds will
chlorhexidine is frequently achievable by the owner.
eventually heal by secondary intention.
Diagnosis Delayed healing of extraction site, malodorous Expected outcome Most gingival/alveolar wounds will
breath or excessive protuberant granulation tissue at heal in 4–6 weeks, even with minimal treatment. Oral
extraction site wounds in older horses that fail to heal, or appear to
develop exuberant granulation tissue at a single site, should
PreventionPerforming a surgical extraction (using a be biopsied to rule out the presence of tumors such as
mucogingival flap and removal of some of overlying squamous cell carcinoma.
Complications Associated ith st Premolar Wolf oothh” (riadan 0) xtraction 239
Figure22.5 Surgical extraction of a developmentally displaced 201.
omplicationsAssociatedwith 1st
C dental elevators or bone gouges that are of appropriate size
Premolar“WolfTooth”(Triadan05) and sharp, and possibly with the use of a small mallet.
Extraction Radiography, particularly oblique projections with low
exposures, should be performed postoperatively to confirm
complete removal of fragments.
Fractureof WolfTeethDuringExtraction
Definition Incomplete extraction of the tooth leading to Expected outcome Good after removal of the remaining
complications fragment
Risk Factors
Lacerationof the GreaterPalatineArtery
Definition Iatrogenic disruption of the palatine artery
● Poor instrumentation
leading to marked oral hemorrhage
● Inadequate analgesia and sedation
Pathogenesis If the dental elevator slips in a medial

Pathogenesis If wolf teeth fracture below the alveolar
(palatal) direction during wolf tooth extraction, the greater
level during extraction, the roots of these non-diseased
palatine artery can be lacerated [12].
teeth are often left in situ and the alveoli usually heal over
fully. However, if wolf teeth are fractured above the alveolar
Risk Factor
level, sharp protrusions of these teeth may cause marked
gingival inflammation and pain when contacted by tack. ● Inadequate sedation/analgesia
Some horses with fractured teeth may develop infection or ● Poor technique
sequestration at these sites. ● Inadequate instrumentation
Diagnosis The development of or an increase in biting Diagnosis Immediate and profuse hemorrhage will occur
problems after wolf tooth extraction should lead to an oral from the ipsilateral side of the hard palate.
examination where there will be inflamed, painful mucosa
over the wolf tooth partial extraction site. Prevention Appropriate sedation and local anesthetic,
with use of appropriate and sharp instrumentation. Take
Prevention Appropriate restraint (sedation) and local special care in the angulation of elevators, especially on
anesthesia to help prevent sudden head movements during palatal side of wolf teeth.
extraction that might fracture the tooth. Careful fatiguing
of the periodontal attachments prior to applying extraction Treatment Initially, pressure should be applied to the
forceps. Appropriate and sharp extraction equipment bleeding site digitally, and then 4–6 surgical swabs can be
makes dental fracture less likely. packed over the damaged vessel and taped around the
upper jaw for an hour or so. Once pressure has been placed
Treatment If a wolf tooth fracture occurs, other than at the on the artery, such sedated horses are best maintained with
root tip, the dental remnants should be extracted under their head elevated on a sling or headstand to reduce
sedation and local analgesia, using specialist, long, offset hemorrhage. Systemic anti-inflammatories should then be
administered for 3–5 days. (See above section on Laceration No more than 2–3 mm of interproximal dental tissue
of Greater Palatine Artery in Foals.) should be removed from a tooth on either side of the
diastema, especially from the more rostrally (mesially)
Expected outcome Some post-laceration inflammation and
positioned tooth. Many caudal mandibular interproximal
swelling of the hard palate is inevitable but rarely causes
(interdental) spaces are at oblique angles to the cheek teeth
long-term sequelae.
row or are curved and great care must be taken to follow
the actual interproximal space when widening such
diastemata. The safest technique involves the constant use
omplicationsAssociatedwith Cheek
C of an oral endoscope or intra-oral mirror during widening
TeethDentistry to prevent inadvertently exposing a pulp cavity [13, 15]. Do
not use wide burrs (i.e. >5mm diameter) and use sharp
Complicationsof Wideningof CheekTeeth burrs that will remove the desired dental tissue without
Diastemata causing excessive pulpar thermal insult.
Pulpar thermal damage or pulp exposure
Treatment If pulpar exposure occurs, there is a possibility
Definition
of pulpar infection leading to apical infection and tooth
Iatrogenic damage to or exposure of the pulpar tissue dur-
loss and so immediate endodontic treatment is the best
ing diastemata widening
option and has excellent success. In the absence of referral
facilities for endodontic treatment, placing calcium
Risk Factors
hydroxide paste directly over the exposed pulp with a bent
● Poor anatomical knowledge hypodermic needle and then filling the entire widened
● Poor surgical technique interproximal area with a 2-part Polymethylmethylacrylate
● Individual anatomical variation in pulpar anatomy or (PMMA) material such as bone cement or hoof acrylic
diastema orientation can be performed. In any case, the horse should receive
● Inadequate sedation broad-spectrum antibiotics (i.e. penicillin and an
● Prolonged odontoplasty (widening) without water cool- aminoglycoside) and NSAID therapy, because pulpar
ing of site inflammation with resultant ischaemia is the main cause
of pulpar death.
Pathogenesis Widening of cheek teeth diastemata with
high-speed burrs (interdental odontoplasty) is used to Expected outcome Teeth with exposed pulps treated by
prevent food impaction and thus treat the associated immediate endodontic therapy have an excellent prognosis
painful periodontal disease in more severe cases. This for survival. Unrecognized pulp exposure and/or thermal
technique risks injuring the pulps of the adjacent cheek damage to pulps result in high likelihood of pulp necrosis
teeth by either direct pulpar exposure or less obviously by and tooth death (see below).
thermal injury [13–15].
Complicationsof ReducingOvergrowths
Diagnosis Hemorrhage is observed between or on occlusal
(Odontoplasty)of CheekTeeth
surface of adjacent teeth following diastema odontoplasty.
An exposed pulp may be direct observed with an oral Pulpar exposure or thermal injury during cheek teeth
endoscope or dental mirror. If pulpar exposure leads to reductions
apical infection, this may lead to the development of a
Definition
mandibular swelling and/or sinus tract some weeks or
Iatrogenic damage to or exposure of the pulpar tissue dur-
months later or may lead to occlusal exposure of other pulp
ing odontoplasty
horns some months to years later.
Risk Factors
Prevention Use a water-cooled instrument if possible. If
performing diastemata widening using a non-water-cooled ● Poor anatomical knowledge
instrument, the burr should be kept in contact with the ● Inadequate training/poor surgical technique
teeth for a maximum of 5 seconds, after which water
should be sprayed on the site to prevent thermal pulpar Pathogenesis As little as 3 mm of sub-occlusal secondary
damage, the burr cooled in water. The site should then be dentine overlies the pulp chambers of some normal adult
carefully examined with a dental mirror or an endoscope. cheek teeth, even if they are overgrown. Consequently,
Complications Associated ith Cheek eeth entistry 241
there is a significant risk of causing pulpar exposure or Prevention When performing odontoplasty using a non-
thermal damage to such pulps when cheek teeth water-cooled motorized instrument, the float should be
overgrowths are reduced (rasped, floated, perform kept in contact with the teeth for a maximum of 5 seconds,
odontoplasty), especially when using mechanized after which water should be sprayed on the site to prevent
instruments without water cooling, and if burrs are kept thermal pulpar damage, the instrument cooled in water
in contact with the teeth for more than 10 seconds [16]. A and the site should then be carefully examined with a
thermally injured pulp will develop necrosis of the pulp dental mirror or an endoscope. Tall dental overgrowths
horn tip and thus cannot lay down any further secondary should be reduced in incremental stages, e.g. 3 mm at say,
dentine beneath the occlusal surface, which may 3-monthly intervals. Many tall overgrowths do not need to
eventually result in pulpar exposure and even pulpitis be fully reduced [17, 18]. The non-validated procedure of
and death of the tooth. rounding-off the rostral aspects of the 06s (i.e. creating
Pulpar exposure may not be recognized until signs of api- so-called “bit seats") should not be performed aggressively,
cal infection (e.g. mandibular or maxillary swelling) if at all, because the additional rostral (6th) pulp horn in
develop, or the tooth develops discoloration or fracture, these teeth may only have a few mm of sub-occlusal
possibly even some years after this odontoplasty damage secondary dentine overlying it. The unproven procedure of
has been caused. Some horses show severe oral discomfort “bit seating” risks causing pulpar exposure or overheating
with reduced appetite and quidding after aggressive dental of the 06s, with death of the tooth as described above
floating, that may be due to pulpar exposure or to exposure (Figure 22.7).
of deeper sensitive subocclusal dentine. Direct pulpar
exposure – usually manifested by exposure of a pink Treatment For dental sensitivity without pulpar exposure,
occlusal surface (blood tinged dentine) or even bleeding rubbing calcium hydroxide paste deeply into the occlusal
from the exposed pulp (Figure 22.6), may or may not be surface to seal dentinal tubules along with NSAID
immediately recognized unless the teeth are carefully
examined following treatment
Diagnosis Recognition of pulpar exposure by oral

endoscopic or dental mirror examination immediately
following floating. The development of anorexia or slow
mastication immediately following dental floating or the
development of mandibular or maxillary swellings or
unilateral nasal discharge weeks to months following
dental treatment.
Figure22.6 Inadvertent exposure of the 5th pulp horn (dotted

ellipse) of tooth 307 during widening of a diastema between Figure22.7 Open 6th pulp horn in tooth 106, 3 years following
307 and 308. “bit seating.” Courtesy of Tom Johnson.
treatment for 1–2 weeks is usually successful. Cases with Treatment For cases with pulpar exposure, endodontic
pulpar exposure should have endodontic treatment. If treatment should be performed. If this treatment is
endodontic treatment is unavailable, compression of unavailable, compress calcium hydroxide paste as deep as
calcium hydroxide paste as deep as possible into the possible into the exposed pulps and administer broad-
exposed pulps and application of a layer of composite spectrum antibiotics (that include a penicillin), as a mixed
restorative material over this along with systemic NSAID infection including anaerobes will be present. NSAID
and antibiotic therapy is advised. therapy and close monitoring with placement of temporary
tracheostomy should be carried out if necessary. For cases
with pulpar necrosis and periapical infection, tooth
Expected outcome Most cases of oral sensitivity are
extraction (exodontia) is recommended, although orthograde
transient and resolve within a few weeks. Teeth with
endodontic therapy could be considered as an alternative.
exposed pulps treated by immediate endodontic therapy
have a good prognosis for survival. Unrecognized pulp
Expected outcome Teeth with exposed pulps treated by
exposure and/or thermal damage to pulps result in a high
immediate endodontic therapy have a good prognosis for
likelihood of pulp necrosis and tooth death, with clinical
survival. Unrecognized pulp exposure and/or thermal
signs developing months to years later.
damage to pulps result in high likelihood of pulp necrosis
and tooth death. Signs would be expected to resolve fully
Fracture and pulpar exposure of the mandibular
following tooth extraction. Approximately 80% success is
riadan cheek teeth
reported [20] for orthograde endodontic treatment,
Definition although access at this caudal mandibular site would be
Incomplete removal of Triadan 11 leading to pulpar expo- challenging.
sure and infection
Risk Factors Complicationsof CheekToothRepulsion
● Poor anatomical knowledge Repulsion under general anesthesia was formerly the
● Inadequate training/poor surgical technique standard method of cheek teeth extraction. In addition to
the risks and costs of general anesthesia, the high level of
postoperative complications associated with this proce-
Pathogenesis Pulpar exposure of Triadan 11 leads to
dure [21] have led to the older technique of oral extraction
pulpar infection that can extend to deeper tissues and may
being revived. Complications are common following cheek
lead to life-threatening infection of the mandibular and
tooth repulsion because this technique causes much trau-
retropharyngeal areas [19].
matic damage to the alveoli and the supporting mandibu-
lar or maxillary bones, whilst disrupting the periodontal
Diagnosis Sudden development of a painful caudal ligaments by percussive forces. Up to 70% of horses under-
mandibular or pharyngeal area swelling and or dysphagia, going cheek tooth repulsion, especially of maxillary cheek
a day or so following dental treatment of a mandibular 11 teeth, may require further surgical and nonsurgical
tooth, possibly in a febrile and dull horse treatments [21–24].
Trauma to the infraorbital nerve

Prevention Suspected “overgrowths” of the 311 and 411
should be carefully evaluated to ensure that they are in fact Definition
true overgrowths and not teeth of normal height lying in a Iatrogenic damage to the infraorbital nerve
dorsally curved caudal mandible (termed “curve of
Spee”) [17, 18] or supernumerary teeth. If true overgrowths Risk factors Use of a wide dental punch for repulsion
of the lower 11s are in fact present, they should, as noted always carries this risk.
above, be reduced in stages, e.g. 3 mm at a time, a few times
a year, preferably by using a mechanized float with water Pathogenesis When repulsing a caudal maxillary cheek
cooling. Manual dental shears (“molar cutters”) or tooth through a trephine opening, the punch can damage
percussion guillotines can fracture these teeth or remove the infraorbital canal and nerve that overlies the apices of
excessive tooth, causing pulpar exposure; these redundant these teeth. This is of particular concern in young horses
instruments should not be used any more, now that our where the canal lies in direct contact with the medial
understanding of dental anatomy has improved. aspect of the dorsal alveoli of these teeth. Repulsion of the
upper 06s and 07s (occasionally of the 08s) that lie in the Prevention Accurate positioning of the punch using
maxillary bone rostral to the maxillary sinuses also risks radiographic guidance and taking care not to allow the
damaging the infraorbital nerve after it has exited the punch to move during repulsion. Maximize oral extraction
infraorbital foramen. techniques to loosen the tooth prior to repulsion to
minimize the repulsion force required and use minimal
Diagnosis Clinical signs of infraorbital damage include diameter punch (a Steinmann pin, if possible). Use
violent headshaking and general distress, nasal rubbing off alternative technique such as minimally invasive
inanimate objects with self-trauma of the ipsilateral nostril. transbuccal extraction or intra-oral sectioning and removal
of teeth with damaged clinical crowns.
Prevention Avoid repulsion – alternative techniques for
extraction of teeth with fractured crowns, such as the Treatment In cases of suspected damage to adjacent teeth,
minimally invasive transbuccal technique, allows broad-spectrum antibiotic therapy should be administered
extraction of most teeth without need for repulsion. If and the teeth carefully re-examined and radiographed
repulsion, e.g. with a Steinman pin is to be used on a tooth some months later for evidence of apical infection that may
with no crown, use accurate imaging (CT and radiography) necessitate extraction or endodontic restoration. Where
to guide punch placement. damage to surrounding bones has occurred, antibiotic
therapy should be administered for 7 to 10 days and loose
Treatment Treat with systemic anti-inflammatories. bone should be removed to prevent sequestration. Non-
Acetylpromazine, which also has anxiolytic activity, may healing alveoli should be investigated for the presence of
also be helpful. intra-alveolar or adjacent bone sequestrae or localized
osteomyelitis that should be curetted and further antibiotic
Expected outcome Fortunately, many horses with therapy administered, respectively. The use of computed
infraorbital nerve damage show good resolution of clinical tomography provides optimal assessment of these complex
signs within 2 weeks after nerve injury. three-dimensional structures that are further anatomically
altered with such trauma and infection.
Damage to adjacent structures
Definition Expected outcome Following extraction of sequestered

Iatrogenic damage to adjacent teeth and supporting bone bone, most cases heal uneventfully. In some instances,
persistent supporting bone infection results in production
Risk Factors of additional sequestrae, which may necessitate multiple
treatments to resolve. In many cases, damage to adjacent
● Poor surgical technique dental reserve crown or apex does not remove tooth vitality;
● Inadequate use of radiography during repulsion however, if collateral damage devitalizes adjacent teeth,
● Poor radiographic techniques during repulsion with these will require extraction or endodontic therapy.
angulation of images Traumatic bone damage is usually well tolerated and even
extensive iatrogenic fractures usually heal very well.
Pathogenesis Because of the varying rostro-caudal
angulation of the cheek teeth reserve crowns in relation to Delayed healing of alveolus
their clinical crowns and occlusal surfaces, the optimal site
Definition
of dental repulsion often does not overlie the clinical
Persistence of infected dental fragments following cheek
crown [12, 21, 25]. Inaccurate positioning or movement of
tooth repulsion (much more common than following oral
the punch in the rostro-caudal plane can result in damage
extraction) will prevent alveolar healing.
to adjacent teeth, or in the medio-lateral plane, can
penetrate or fracture the supporting maxillary or
Risk Factors
mandibular bones.
● Repulsion vs. oral extraction
Diagnosis By direct observation of repulsion pin at wrong ● Mandibular vs. maxillary cheek teeth extractions
site, e.g. protruding at side of hard palate; and/or detection ● Young horses (with long reserve crowns)
by intra-surgical radiography. The later development of ● Poor surgical technique
apical infection in an adjacent tooth or of swelling/
infection of adjacent bones may indicate such repulsion Pathogenesis Skin wounds associated with cheek tooth
damage. repulsion are highly contaminated and so often discharge
for a week or so following this surgery. The presence of presence of more apically situated alveolar bone or dental
longer-term purulent or malodorous discharge from fragments. Intra-alveolar dental fragments are usually
repulsion wounds indicates delayed or non-healing of an radiographically identifiable (Figure 22.8), but larger, thin,
infected alveolus and/or of the supporting bones. The alveolar sequestrae can be difficult to detect radiographically
presence of food in exudate from repulsion wounds (and even sometimes with CT) in the actively remodeling,
indicates loss or loosening of alveolar packing. Such cases irregular alveolus, but may be detected by digital and visual
should have the alveolar packing examined per os. examination.
If PMMA alveolar packing becomes loose and is dis- Loose intra-alveolar sequestrae, which include most
placed into surrounding tissues, this also can result in oral bony sequestrae, may be removed per os digitally or by
soft tissue trauma and often, acute onset oral pain. Loose high-pressure lavage (Figure 22.9). If sequestrae are
alveolar packing should be removed and the alveolus attached, use of adjustable, right-angled equine dental
examined digitally and visually with a dental mirror or oral picks and curettes with interchangeable heads up to 10 cm
endoscope. A week or so following extraction, a normally- in length are indicated [26]. If firmly attached dental frag-
healing alveolus will be covered by smooth red granulation ments cannot be removed with dental picks, the minimally
tissue, while the presence of exposed calcified tissue (white invasive transbuccal technique can be used. Alternatively,
to pale brown in color) indicates the presence of seques- a Steinman pin may be used under radiographic guidance
tered alveolar bone or dental fragments. to repulse the fragments into the oral cavity with the
Diagnosis Non-healing of alveolus detected at oral

examination after extraction as evidenced by palpable
sharp tissue present in alveolus, within a week following
extraction and/or malodor off breath and alveolus or
swelling and purulent tracts on the supporting bones
Prevention Repulsion using the minimal necessary force

in the correct direction is likely to cause less damage to the
surrounding alveolus. Consequently, oral loosening of
teeth prior to repulsion is recommended (if a clinical crown
is present). Post-extraction radiographs should be obtained
to check for possible remaining dental fragments after
repulsions. The repulsed tooth (especially its apex) should
be examined following extraction to ensure it is all present.
The alveolus should be digitally examined post extraction
for loose fragments – the alveolus will have some normal Figure22.8 Small apical (caudal root) fragment (arrow)
sharp ridges – that should not be mistaken for dental or radiographically evident following oral extraction of tooth 407.
bone fragments. Additionally, a visual post-extraction
examination of alveolus should be performed (oral
endoscope or dental mirror) to look for pale (dental)
structures. Select appropriate alveolar packing material for
extraction site. PMMA is often used to seal the occlusal
aspect of the alveolus following repulsion of caudal
maxillary cheek teeth because of its excellent retention and
the consequence of loss of alveolar packing at this site, i.e.
oromaxillary fistula formation is very significant. Wax, soft
plastic impression material or antibiotic impregnated
gauze can be used for alveolar packing following cheek
teeth repulsion at other sites.
Treatment Systemic NSAIDs and antibiotics are indicated

as these patients frequently have significant inflammation
and infection at the extraction site. Radiography of the Figure22.9 Thick alveolar sequestrae removed 4 weeks
affected alveolus should also be performed to assess for the following oral extraction of tooth 308.
diameter of pin proportionate to the stability of the frag- Diagnosis The development of a (usually malodorous)
ments. Care must be taken not to damage the infra-orbital unilateral nasal discharge following extraction of a caudal
canal with the Steinmann pin. Rounded, dense, pearl-like maxillary cheek tooth or the occurrence of food in nasal
areas of reactive cementum in the alveolus usually do not discharge after treatment of dental sinusitis by repulsion
cause postoperative problems and need not be removed.
Prevention Use appropriate alveolar packing to protect the
Expected Following extraction of dental
outcome alveolar tract during healing, as discussed above. Monitor
fragments and/or sequestered bone, most cases heal the extraction site and keep packing in the alveolus until
uneventfully. However, in some instances, persistent the tract has healed (for 4–6 weeks following repulsions).
infection results in production of additional sequestrae,
which may need multiple treatments to resolve. Treatment The affected sinuses should be lavaged of food
and exudate by direct lavage through the repulsion site and
rosinus (oromaxillary) fistula the sinuses should then be carefully examined
sinoscopically to ensure that all food material and exudate
Definition
have been removed (Figure 22.11). The affected alveolus
Iatrogenic formation of communication between oral and
should be examined digitally and visually as well as being
sinus cavities
imaged radiographically or by CT if possible, to confirm
the absence of dental or bony remnants that may have
Risk Factors
delayed/prevented alveolar healing. The adjacent teeth
● Repulsion vs. oral extraction should be evaluated to determine whether the alveolar
● Use of a wide punch plate between them and the extracted tooth has been
● Multiple sites of repulsion with much alveolar damage removed by disease or surgery, which limits the ability of
● Inadequate alveolar packing, such as PMMA granulation tissue to fill that area of the alveolus. If this is
the case, the adjacent tooth may occasionally need to be
Pathogenesis If loss of alveolar packing occurs following extracted to resolve the oro-maxillary fistula.
caudal maxillary cheek tooth (Triadan 08-11) repulsion, an If the oro-maxillary fistula is chronic, the alveolus should
orosinus fistula (Figure 22.10) can develop and the be curetted to remove any contiguous oral and sinus epi-
purulent, unilateral nasal discharge may contain food [12, thelium in the fistula. The occlusal aspect of the alveolus
22]. A fistula develops when epithelium later lines the wall should then be sealed with PMMA attached to the adja-
of the tract between the oral cavity and sinus lumen. cent, dried (etched with 40% phosphoric acid gel – if
Figure22.10 (a) Oral aspect of an oro-maxillary fistula following repulsion of 109. (b) Appearance of oro-sinus fistula (arrow) from
the oral aspect of the alveolus, following curettage to remove epithelium from the fistula.
Figure22.11 Sinoscopic removal of feed material from the rostral maxillary sinus (left), subsequent to which it is possible to
visualize a PMMA plug (arrow) in the 109 alveolus through a fistula (right). This PMMA plug is protruding too apically in alveolus, and
should be removed in about 6 weeks’ time to allow assessment of alveolar healing. It can be then replaced with a shorter alveolar
plug.
possible) interproximal dental surfaces. Care should be Diagnosis The presence of food-containing nasal
taken not to insert the PMMA more than 2 cm into the discharge following repulsion of a rostral maxillary cheek
alveolus to allow alveolar healing. Excessive insertion of tooth suggests the presence of an oro-nasal fistula as does
PMMA can occur when retrograde pressure is not applied the presence of malodor off breath following repulsion of a
(or not possible) to the apical aspect of the PMMA when rostral maxillary cheek tooth.
packing the alveolus. An alternative technique to facilitate
healing of fistula include levator nasolabialis [22, 27] or Prevention Use appropriate alveolar packing to protect the
levato labii superioris transposition [28]. tract during healing and monitor the extraction site and
keep the alveolus packed until the tract has healed.
Expected outcome Most fistula heal, although time to
healing is related to fistula size. Therefore, healing can take Treatment The non-healing alveolus should be investigated
many months and sometimes require multiple and treated as described above and the nasal cavity
debridements or more advanced techniques. endoscopically examined (Figure 22.12). Additionally, the
two nasal conchal bulla should be endoscopically examined
ronasal fistula for the presence of calcified granulomas and lavaged of any
trapped food or inspissated exudate they may contain [29].
Definition For problematic oronasal fistulas that do not respond to
Iatrogenic formation of communication between oral and conventional treatment, a sliding mucoperiosteal flap
sinus cavities procedure [30], or alveolar bone flap [31] can be used (see
below).
Risk Factors Identical to risk factor for oro-sinus fistula
(see above) Expected outcome Most fistulas heal well with the above
conservative treatment, although time to healing is related
Pathogenesis If premature loss of alveolar packing occurs to fistula size. Therefore, healing can take many months
following repulsion of Triadan 06-08 cheek teeth, an and sometimes require multiple debridements or more
oronasal fistula can similarly develop. advanced techniques.
● Dental fragments left in apical aspect of alveolus

● Failure to perform endoscopic and/or imaging of middle
meatus to detect concurrent nasal conchal bulla disease
Pathogenesis Following cheek tooth extraction to treat

dental sinusitis, persistent sinusitis in the absence of residual
alveolar dental or bone sequestrae, or of oro-maxillary
fistulation, usually indicates the presence of inspissated pus
or dead dental or bone material within the sinuses, especially
within the two rostral compartments, i.e. ventral conchal or
rostral maxillary sinuses, or within the nasal conchal
bullae [29]. Alternatively, the sinusitis may have been fully
treated but the nasal conchal bullae have become infected.
Diagnosis Persistence of a unilateral malodorous nasal

discharge following treatment of dental sinusitis and nasal
endoscopy may allow identification of the source of
persistent discharge.
Figure22.12 Endoscopy of the right nasal cavity of a horse Prevention Thorough evaluation of cases at the time of
with an oro-nasal fistula resulting in the presence of feed extraction to ensure all dead loose fragments are removed
material within the nasal passage.
from the alveolus (as described earlier). Ensuring that all
inspissated material and conchal bone fragments are
Complications associated with the sliding mucoperi- removed from the sinuses and nasal passages, including by
osteal flap procedure, which in some cases necessitates a performing endoscopy of middle meatus to examine the
full-thickness incision of the ipsilateral lips from the com- nasal conchal bullae and for the presence of conchal bone
missure to level with the oronasal fistula to allow surgical and inspissated pus in the middle meatus and for the
access, include damage to the dorsal buccal branch of the presence of sino-nasal fistulae.
facial nerve (the nerve should be identified and marked
prior to making the incision), and damage to the greater Treatment Treatment is reliant on identification and
palatine artery. It is recommended that either the greater removal of the causal agent, i.e. inspissated material /bone
palatine artery is ligated both rostral and caudal to the site sequestra/dead tooth. Radiography including dorsoventral
of the mucoperiosteal flap, or if possible, it should be iden- projections (or preferably computed tomography) to detect
tified, dissected free and left intact beneath the flap. empyema of the ventral conchal sinus and lateral-oblique
A technique using an alveolar bone flap to seal a chronic views to examine for the presence of intra-alveolar
oronasal fistula following 106 extraction has been sequestrae. Sinoscopic examination using a frontal sinus
described [32]. This approach, which is over the maxilla at the approach with fenestration of the maxillary septal bulla [33,
level of the alveolus, requires special attention to minimize 34] to allow examination of the two rostral sinus
the likelihood of damaging the infraorbital nerve, the parotid compartments. Endoscopy of the middle nasal meatus to
salivary duct and the mandibular labial artery. Additionally, remove inspissated pus and conchal sequestrae. Following
care should to be taken not to penetrate the buccal mucosa, removal of inspissated exudate, the sinuses can be lavaged
which would allow oral contamination of the incision. with an indwelling catheter [34].
Persistent postoperative sinusitis follo ing cheek Expected outcome Removal of all causative material
tooth extraction (inspissated pus/necrotic bone/dental fragments)
usually results in rapid resolution and no recurrence of
Definition
clinical signs.
Persistent postoperative infection of the sinus cavity
Risk Factor Complicationsof OralExtraction

● Inspissated pus left in sinuses Because oral extraction of cheek teeth can be performed in
● Conchal bone fragments left in sinuses the standing horse, the risks and expense of general
anesthesia are removed. As oral extraction does not require

surgery of the supporting bones, postoperative complica-
tions are relatively uncommon and some complications are
easy to treat [35–37].
Damage to adjacent structures
Definition
Iatrogenic damage to adjacent teeth and supporting bone
Risk Factors Poor surgical technique
Pathogenesis The forceful use of dental separators,

especially of wide-blade separators too early during the
extraction process, can fracture or loosen adjacent cheek
teeth. It can also fracture the longer roots present on older Figure22.13 Compression of tooth 206 into its alveolus by a
cheek teeth (especially mandibular) that are being fulcrum during extraction of 208.
extracted. In rare instances, use of a fulcrum can result in
compression of a more rostral normal tooth into its maxillary 06s or 07s is likely to damage irreversibly the
alveolus. blood supply to these teeth, predisposing to apical infection.
Extraction of the compressed tooth is recommended,
Diagnosis Immediately observe looseness of or iatrogenic although endodontic therapy can also be performed. The
fractures of adjacent teeth severity of fractures to adjacent teeth dictate the likely
outcome. Minor (uncomplicated) chip fractures of the
Prevention If a 07 is being extracted, separators should not clinical crown are very likely to be inconsequential, while
be used between it and the 06, because this will loosen the complicated crown fractures (affecting the pulp horns) can
healthy 06 more than the diseased 07. Separators should result in tooth death requiring extraction if not managed
also be used with great care when extracting caudal appropriately.
mandibular cheek teeth in horses with oblique or curved
Fracture of teeth during extraction
interproximal spaces or in horses with a marked curve of
Spee. In the latter cases, the right-angled blades of the Definition
separators will not fit into the non-vertical interdental Incomplete removal of the tooth
spaces of such cheek teeth, but might instead fracture these
Risk Factors
teeth [36, 37]. When caudal mandibular cheek teeth have
been fully loosened during an oral extraction, a fulcrum ● Pre-existing dental fractures
must be used cautiously, in case the vertically directed ● Marked caries of tooth to be extracted (e.g. upper 09 with
force fractures their caudally-angled reserve crowns. coalescing infundibular caries)
Application of the fulcrum fully on the maxillary 06s ● Poor surgical a technique
should be performed with care, as compression of this ● Poorly sedation and/or analgesia
tooth into the alveolus is possible (Figure 22.13).
Pathogenesis This sequel most commonly occurs when
Treatment Treatment depends on the type and severity of
the tooth being extracted has become mechanically weak
damage to adjacent teeth. For example, most 06s and 11s due to pre-existing disease (commonly advanced
iatrogenically loosened by separators will re-develop infundibular caries or idiopathic fractures). This sequel is
normal attachments. If adjacent teeth are fractured during unavoidable in some cases, even with prolonged, gentle
extraction, they should be assessed for pulpar involvement oral extraction.
and open pulp horns should be endodontically treated. Diagnosis All or some of the clinical crown fractures off
during extraction.
Expected outcome In most cases, where slight movement
(displacement) of an adjacent tooth has occurred, these Prevention Avoid forceful use of dental separators (and
will re-develop normal attachments through remodeling of indeed almost any dental equipment), as well as attempting
the periodontal ligament. Upward compression of the to elevate the tooth before it is fully loose.
Treatment and expected outcome Extraction of the sequestration are non-healing of the alveolus (and
remaining fragments can frequently be performed associated tract if present) and bony swellings and
successfully using specialized equine dental picks per os. occasionally oral discomfort if the alveolus is painful or if
In some cases (frequently of larger more stable tooth some sharp bone protrudes into the mouth. Some horses
fragments), the minimally invasive transbuccal technique will develop a swollen mandible or a mandibular tract.
may be required. In cases with peri-apical infections (e.g.
dental sinusitis or draining tracts), removal of all infected Prevention Cause minimize surgical trauma to the
dental material is essential to allow healing. alveolus during tooth extraction; use appropriate alveolar
packing post extraction. Perform repeated post-extraction
Non-healing alveoli monitoring, especially following difficult mandibular
Definition extractions.
Failure of the treated alveolus to fill in with healthy tissue
in a timely manner Treatment Identify possible sequestrae. While most are
easy to diagnose by palpation or visualization, small deep
Risk Factors sequestrae can sometimes be hard to identify
● Mandibular vs. maxillary cheek teeth radiographically. Remove detected sequestrae digitally or
● Younger teeth with long reserve crowns with specialized right-angled curettes. If sequestrae lie
● Excessive force during extraction deep within the alveolus with some remaining attachments,
● Lavaging blood clots from post-extraction alveoli they can be difficult to remove.
● Lavaging post-extraction alveoli with use of
disinfectants Expected outcome Following removal of all sequestrae,
healing occurs uneventfully. Occasionally, with osteomyelitis
Pathogenesis Following oral extraction of apically infected of supporting bones, further sequestrae form subsequent to
cheek teeth that do not have an external sinus tract, the initial sequestrae removal, and require additional treatments
alveoli are often packed with one or two surgical swabs or and antibiotic therapy.
soft dental impression material to prevent food impaction.
This packing should be removed 7–10 days later if still Damage to the soft palate during oral extractions
present and by this time, most alveoli will have healed Definition
significantly, with soft granulation tissue filling in the Iatrogenic damage to the soft palate
alveolus. When normal healing is impaired, this is
inevitably due to sequestration of some alveolar cortical Risk Factors
bone [37]. Larger alveolar (and possibly supporting bone)
sequestrae are more common following mandibular cheek ● Poor surgical technique
teeth oral extraction; sometimes, in cases where significant ● Inadequate sedation and/or analgesia predisposing to
alveolar trauma occurred during extraction (frequently excessive tongue movement
when multiple attempts have been made at extraction)
and/or where significant alveolar/peri-alveolar Pathogenesis Oral extraction of caudal maxillary cheek
inflammation and infection exists, particularly chronically. teeth and especially of a caudal supernumerary maxillary
It is worth advising owners of the potential for this sequela, cheek tooth (Triadan 12) risks damaging the soft palate.
particularly in cases with the above predisposing factors.
Post-extraction oral examinations should be performed a Diagnosis Dysphagia or food containing nasal discharge
number of times at weekly intervals. following a maxillary Triadan 10 or 11 extraction
(differentiate from an oro-maxillary fistula). Soft palate
Diagnosis After removing the alveolar packing 7–10 days damage may be visible during oral examination and/or
postoperatively, most alveoli will have healed significantly, endoscopy of the nasopharynx.
and palpation will reveal that the alveolus is fully lined by
soft granulation tissue and that no sharp areas are present. Prevention Great care should be taken when placing the
If the alveolus has not healed, digital palpation will often extraction forceps on the palatal aspect of these caudal
reveal the presence of roughened areas that are inevitably cheek teeth, as a fold of the soft palate can quickly displace
due to sequestration of some alveolar cortical bone [37]. into the forceps with the inevitable, induced soft palate
The most common clinical signs associated with alveolar movements.
Treatment If the soft palate is deeply lacerated more than oral extraction impossible or in cases with impacted
2 cm medially from its lateral margin, there is risk of teeth [42]. The use of specialized, long intra-oral burrs to
oropharyngeal fistula development, which can be surgically section and remove the reserve crowns of these teeth is an
corrected per os in two layers with much difficulty, usually alternative safer technique.
requiring general anesthesia.
Iatrogenic damage of the buccal nerve
Expected outcome If the fistula is repairable, the prognosis Definition
for return to normal is good; however, such surgical repairs Iatrogenic damage to the buccal nerve branch/es
can be very challenging and carry a considerable risk of
dehiscence. Risk factors The use of this potentially dangerous
technique
Laceration of the greater palatine artery
Pathogenesis The buccal nerve is physically damaged
Definition Iatrogenic disruption of the palatine artery during the surgical approach. Short- and long-term damage
leading to marked oral hemorrhage to the dorsal buccal nerve causes ipsilateral nostril and
possibly lip paresis as previously discussed.
Risk Factors
● Poor surgical technique Prevention Identify the buccal branches of the facial nerve
● Individual anatomical variation in artery position as previously described. If branches of the buccal nerve
cross the surgical field, they should be identified and
Pathogenesis When extracting maxillary cheek teeth, surgically isolated to prevent accidental damage.
especially when using sharp picks and/or a “claw type”
dental extractor, care must be taken to avoid damaging the Treatment and expected outcomeIf neuropraxia is
greater palatine artery. suspected, then systemic NSAID administration and time
Inadequate sedation/analgesia causes excessive head (as previously discussed) are usually successful.
movement that may increase risk of damage of the palatine
artery. Iatrogenic damage to the parotid duct
Definition
Diagnosis A sudden onset of heavy hemorrhage from the Iatrogenic damage to the parotid duct
lateral aspect of the hard palate during extraction (also see
above) Pathogenesis The parotid duct is physically damaged
during the surgical approach. Parotid duct damage causes
Prevention Adequate sedation and local anesthesia can leakage of saliva from the surgical site, with this salivary
best allow careful placement of forceps on palatal side of flow increasing when the horse eats [43–46]. Most
the diseased tooth. lacerations of the parotid duct (or its branches) are not
identified until after surgery when the horse begins to eat.
Treatment and expected outcome Treatment of this sequela
is as described earlier. Risk Factors
● Failure to catheterize the parotid duct before performing

surgery along course of parotid duct
Complicationsof Removalof the Lateral
● Swellings of angle of mandible that obscure route of
AlveolarPlate(LateralBuccotomyTechnique)
parotid duct
Removal of the buccal alveolar bone to allow cheek teeth
extraction has mainly been used for extraction of the three Diagnosis Wetness of face below buccotomy wound or
rostral maxillary and the mandibular cheek teeth (via buc- spurting of saliva from buccotomy site during eating.
cotomy or through the masseter muscle) [38–41]. Because Damage to the parotid duct can be confirmed by
of the significant risk of causing damage to adjacent struc- catheterizing the duct from its oral papilla.
tures, this technique should be reserved for dental extrac-
tions where no reasonable alternative is available, such as Prevention Risk of damage to the parotid duct can be
cases with large calcified apical depositions where the apex eliminated or minimized by catheterizing the duct per os
of tooth is significantly wider than the alveolus, making via the parotid papilla (usually opposite the maxillary 08)
Complications Associated ith Salivary land Surgery 251
prior to any surgical procedure that risks damaging it. This

allows accurate identification of duct during surgery.
Treatment If parotid duct damage is identified at the time

of injury, the duct can be carefully repaired with fine
absorbable sutures. However, most duct damage is a
laceration of the duct wall versus a complete transection.
Consequently, most lacerations spontaneously heal within
1 to 3 weeks and further investigations and surgical
treatment can be deferred to beyond 3 weeks. Some more
chronic fistulas may need suture repair with or without the
use of an indwelling catheter that acts like a stent [12, 43].
Alternatively, or following failure to repair the duct,
chemical ablation of the parotid gland can be performed,
but such chemical ablation of the parotid gland carries its
own significant complications (see below). Surgical
removal of salivary glands is also possible [47, 48].
Expected outcome Most damaged parotid ducts heal

without intervention.
C
with SalivaryGlandSurgery
Figure22.14 Chronic salivary leakage (solid arrow and rostral
Primary disorders of the equine salivary glands requiring to it) following surgical debridement of a left mandibular
surgery are relatively uncommon, but surgery of the abscess (dotted arrows).
parotid glands may be required for drainage of strangles-
related retro-pharyngeal abscesses or removal of intra- lature and nerves. Formalin (10%) is the current recom-
parotid melanomas. Surgical access to these salivary glands mended chemical [50, 51] and results in the least necrosis
requires careful consideration of surrounding structures. and inflammation (compared to 2% chlorhexidine and 3%
Of the three major pairs of salivary glands (sublingual, silver nitrate) [50, 51] and much less inflammation than
mandibular and parotid), the parotid glands and ducts are the previously recommended Lugol’s iodine. Reported
most frequently involved in surgical procedures and dam- transient complications following chemical ablation
age to their ducts can result in fistula formation with include: facial swelling, facial nerve neuropraxia, dyspnoea
chronic saliva leakage (Figure 22.14). and anorexia (likely the result of localized inflammation
and occurs more commonly with chlorhexidine and silver
nitrate than formalin) [50, 51]. Water-soluble contrast
Complicationsof ParotidSalivaryGland
material can also stop glandular secretions [44, 50], and
Ablation
therefore ducts should be drained and thoroughly lavaged
Parotid salivary gland ablation can be performed by duct after contrast sialography.
ligation or by chemical injection. Duct ablation results in
gland atrophy caused by back pressure within the duct, but Risk Factors
this technique may be ineffective in cases with chronic ● Use of Lugol’s iodine, silver nitrate or chlorhexidine
duct dilation, as the back pressure may be insufficient to solutions to cause chemical ablation
stop the secretory activity [49]. Other potential complica- ● Poor surgical technique with duct ligation technique
tions include duct rupture or inadvertent duct penetration
during suture placement. Clinical signs The presence of excessive and persistent
Injection of chemicals to involute the parotid salivary swelling of the parotid gland following chemical ablation
gland should be performed via the parotid duct, because possibly with parotid gland necrosis or discharge. The
transcutaneous injection will be less effective and may presence of continues salivary leakage following inadequate
damage surrounding tissues that contain important vascu- parotid duct ligation.
Prevention Careful suture placement around the parotid Treatment NSAIDS and broad-spectrum antibiotics
duct, avoiding penetration of its lumen. For ablation, use should be administered and perform surgical drainage of
Formalin solution instead of other chemicals and use discharging or necrotic areas following chemical ablation.
water-soluble contrast for sialography. Re-ligation of poorly ligated parotid glands.
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254
23
Complicationsof EsophagealSurgery
Louise L. Southwood BVSc, PhD, DACVS, DACVECC
Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
Overview metabolic disturbances, mucosal dehiscence and ulcera-

tion, periesophageal infection, esophageal fistula forma-
Equine esophageal surgery is infrequently performed tion, stricture, aspiration pneumonia and pleuropneumonia,
because of the relatively uncommon occurrence of esopha- laryngeal hemiplegia and Horner’s syndrome, and lamini-
geal problems needing surgical management and poten- tis [1, 2]. Feeding tube placement through a cervical
tially because of the high incidence of complications [1, 2]. esophagostomy for enteral nutrition is another esophageal
In one study, complications occurred in 52% of horses surgical procedure which has its own additional inherent
undergoing esophageal surgery with a median of three complications including reflux of ingesta around the feed-
complications per horse [1]. Short-term survival in the lat- ing tube (particularly if tube is in the stomach), obstruction
ter study was 67% and long-term survival only 41% [1]. The of the tube with feed, dislodgement of the feeding tube
most common problems requiring surgical treatment are (particularly with a short tube with the distal end of the
esophageal stricture [3–5], pulsion diverticulum [6, 7], tube in the lower esophagus), and esophagitis and mucosal
esophageal cysts [8], foreign material retrieval [9], esopha- erosion at the distal end of the tube when it is positioned in
geal perforation secondary to external cervical trauma [10] the esophagus [11].
or injury during nasogastric intubation, and dysphagia [1]. Generally, the complications associated with esophageal
Horses with esophageal perforation are more likely to have surgery are a consequence of the characteristic anatomy
complications compared to other horses [1]. Surgical pro- and physiology of the esophagus [12–14]. Movement dur-
cedures that have been performed include esophagomyot- ing deglutition and with head and neck extension com-
omy, esophagotomy, esophagostomy for feeding tube bined with the relative intolerance of the esophagus to
placement, and esophageal resection and anastomosis. longitudinal tension lead to mucosal dehiscence and the
associated sequela of infection, fistula formation, and stric-
ture. The esophagus lacks a fibrous protein serosal layer
L which is important in leakage-prevention and healing [12].
The arterial supply to the cervical esophagus originates
with EsophagealSurgery from the carotid arteries and the thoracic and abdominal
esophagus from the bronchoesophageal and gastric arter-
● Water, electrolyte and metabolic disturbances
ies [15]. The blood supply is arcuate but segmental with
● Periesophageal infection
minimal collateral circulation and is easily disrupted [12,
● Esophageal fistula formation
15]. Rapid regeneration of the esophageal squamous epi-
● Stricture
thelium can lead to mucosal/submucosal suture line
● Aspiration pneumonia and pleuropneumonia
necrosis [16].
● Laryngeal hemiplegia and Horner’s syndrome
However, there are reports of esophageal surgery being
● Laminitis
performed successfully without complications and it is
Complications occur as a consequence of the primary worth briefly noting some of these reports which may give
disease process as well as the inherent nature of the esoph- us insight into method prevent complications. A 3–5-cm
ageal surgery and include water, electrolyte, acid–base and esophagotomy was successfully performed experimen-
Watern, lectrolyten, Acid– ase and etaeolic istureances 255
tally [16] and for retrieval of a nasogastric tube frag- mal esophagostomy. Ponies fed hay immediately after
ment [9]; the mucosa/submucosa was apposed using 3-0 esophagostomy had more complications compared to
polypropylene in a simple continuous pattern with intralu- ponies fed a slurry [20].
minal knot placement followed by muscularis layer apposi-
tion using 2-0 polyglactin 910 in a simple interrupted
pattern [9, 16]. No complications occurred potentially ater,Electrolyte,Acid–Base
W
because the esophageal tissue was heathy (one group of
and MetabolicDisturbances
horses were normal ponies [16]), the longitudinal
esophagotomy was short with minimal disruption to the
Definition Dehydration or hypohydration is defined loss
adventitia and blood supply, and a drain was placed at the
of total body water. Plasma electrolyte disturbances most
surgical site. Of note is that ponies undergoing sutured
often observed with esophageal disease include
repair of their esophagotomy had better and quicker heal-
hyponatremia (Na <132 mEq/L), hypochloremia (Cl <94
ing and fewer complications than ponies with the
mEq/L), (mild) hypokalemia (K <2.7 mEq/L), and
esophagotomy allowed to heal by second intention [16].
metabolic acidosis (pH <7.35, base excess (BE) < –3
An esophagostomy was placed proximal to the esophagos-
mEq/L, and HCO3- or total CO2 (TCO2 <24 mEq/L)
tomy for feeding via an indwelling tube [16].
followed by metabolic alkalosis (pH >7.45, BE >1 Eq/L,
Successful surgical repair of a pulsion diverticula has
and HCO3- or TCO2 >31 mEq/L). Metabolic disturbances
been reported using a technique whereby the mucosa is
most often observed include hypertriglyceridemia (plasma
not penetrated, and the protruding mucosa is inverted
triglyceride concentration >50 mg/dL or 0.565 mmol/L),
with the defect in the tunica muscularis closed using a
hyperlactatemia (plasma lactate concentration >2
V-Y plasty [6, 15]. These horses typically have a better
mmol/L), and alterations in glucose metabolism (normal
prognosis compared to horses with other esophageal
blood glucose concentration 70–110 mg/dL or 3.89–6.11
problems [1].
mmol/L). See also Chapter 28, Postoperative Complications
Resection and anastomosis of short <5-cm esophageal
after Colic Surgery.
segments for treatment of stricture have been reported [3,
17–19]. In one report, a 2-cm segment of esophagus was
Risk Factors
resected, and the esophageal ends were apposed with 4–5
pre-placed full-thickness vertical mattress sutures using ● Loss of saliva through the mouth/nares associated with
0 polyglactin 910 [3]. Parenteral nutrition was provided for an esophageal obstruction, or through an esophagos-
6 days followed by enteral nutrition administered through tomy or esophageal fistula can lead to dehydration and
an indwelling nasogastric tube for 3 days then a slurry until electrolyte and acid–base disturbances.
day 12 at which time grazing was allowed [3]. Resection of ● Metabolic disturbances are associated with prolonged
3–5 cm of cervical esophagus and anastomosis was suc- periods of inappetence, anorexia, or dysphagia associ-
cessfully performed in foals <5 months [17]. Anastomosis ated with esophageal disease.
was accomplished by ventroflexing the foal’s neck, placing ● Pony, miniature horse or draft breeds, donkeys, pregnant
stay sutures, apposing the mucosa/submucosa and deep mares and overweight animals are particularly at risk for
muscular layers in an inverting interrupted pattern using complications associated with fat metabolism and can
2-0 absorbable suture material, followed by the tunica develop hyperlipemia and fatty infiltration of the liver
muscularis and adventitia using 4-0 silk in an interrupted and renal tubules.
pattern [17]. Importantly, a drain was placed at the surgical ● Systemic illness associated with severe local cellulitis or
site and a nasogastric tube was left in place for feeaRYLA- aspiration pneumonia can lead to dysregulation of glu-
BJFding [17]. The only complication was a small fistula cose metabolism primarily insulin resistance and
that rapidly healed spontaneously [17]. hyperglycemia.
Based on these reports, esophageal surgery can be suc- ● Neonates are at risk of hypoglycemia.
cessfully performed with careful preoperative planning. ● Hyerglycemia and glucosuria (and associated fluid loss)
Complications may be prevented by avoiding entering the can be observed with parenteral nutrition.
esophageal lumen (if possible) or performing the surgery
in healthy esophageal tissue, a gentle surgical technique to Pathogenesis Large volumes of water and electrolytes are
avoid vascular disruption, careful suture placement, pro- lost in saliva leading to dehydration, hyponatremia,
viding adequate surgical site drainage, and the use of post- hypochloremia, and hypokalemia [21]. Horses produce
operative parenteral nutrition or enteral nutrition via an about 40–90 mL/minute of saliva. Initially a metabolic
indwelling nasogastric tube or tube placed through a proxi- acidosis is observed associated with the loss of bicarbonate
256 Complications of sophageal Surgery
in saliva and possibly dehydration leading to lactic acidosis. Complications of the Postoperative Colic Patient) or enteral
Metabolic alkalosis is associated with renal compensation. nutrition via an indwelling nasogastric tube or feeding
Pathogenesis of metabolic disturbances are described in tube placed through an esophagostomy. Animals with
Chapter 28: Complications of the Postoperative Colic chronic malnutrition should be monitored for hypoka-
Patient. lemia, hypomagnesemia, and hypophosphatemia, espe-
cially during the initial 4–7 days associated with re-feeding
Prevention Prevention is achieved by identifying and syndrome.
correcting the underlying esophageal problem causing
the large volumes of saliva loss, providing intravenous Expected outcome Electrolyte disorders are common [2,
fluid and electrolyte therapy, and adequate nutritional 11, 16] and can be severe in some animals occasionally
support. resulting in death [11]. In most instances, however,
correction of the underlying disease and supportive care
Diagnosis Dehydration is diagnosed based on history and results in resolution of water, electrolyte, and metabolic
physical examination (tachycardia, tacky mucous disturbances.
membranes, prolonged capillary and jugular refill times,
extremity temperature and demeanor), increases in packed
cell volume and total plasma protein, hyperlactatemia, and
MucosalDehiscenceand Ulceration
high plasma creatinine concentration. The percentage
dehydration can be estimated with 5% being the minimal
Definition Disruption of the mucosal/submucosal repair
detectable dehydration, 6–8% mild–moderate dehydration,
leading to exposed deeper tissues and necessitating second
10% severe dehydration, and 12% dehydration associated
intention healing with granulation tissue formation and
with imminent death [22, 23]. Electrolyte disturbances are
fibrosis (scar tissue). Ulceration refers to a defect in the
readily diagnosed with a plasma chemistry profile either
esophageal mucosa/submucosa.
using a bench top or point-of-care (e.g. iSTAT) analyzer.
Blood lactate, glucose and triglyceride concentrations can
be measured using point-of-care or bench top analyzers Risk Factors
and should be monitored closely during resuscitation ● Repair of injured or infected esophageal tissue, e.g. asso-
(lactate) and in animals at risk of hyper-/hypoglycemia and ciated with ingesta or foreign body obstruction [10].
hypertriglyceridemia. ● Failure to debride injured or unhealthy tissue prior to
apposition [10].
Treatment Intravenous fluid and electrolyte therapy ● Horses undergoing hydropulsion under general anesthe-
(replacement and maintenance) should be administered. sia prior to esophagotomy had a higher incidence of
Placement of a lateral thoracic catheter should be dehiscence, likely reflecting the severity of the associated
considered because of the risk of jugular vein septic mucosal injury [1].
thrombophlebitis in horses with a periesophageal infection ● Inadequate esophageal rest period following surgery; per
and ulceration associated with an indwelling feeding os feeding of a moistened pelleted diet to ponies after
tube [15]. Water loss can be calculated by multiplying the esophageal mucosal resection resulted in mucosal
percentage dehydration by the body weight (e.g. 5% dehiscence [24].
dehydration × 500 kg = 25 L water deficit). Fluid ● Feeding hay immediately postoperatively was associated
replacement can be administered as 20 mL/kg boluses of with mucosal dehiscence [20].
commercially available polyionic isotonic fluids with ● Indwelling feeding tube for prolonged periods can lead
reassessment of hydration in between boluses. In horses to esophageal ulceration [11].
with chronic (>48 hours) hyponatremia, sodium correction
should be at <10 to 12 mEq/L/day or <0.5 mEq/L/hour to
avoid osmotic demyelination syndrome [22]. Maintenance Pathogenesis When an esophagotomy is performed at the
fluid therapy site of injured or infected esophageal tissue or when the
(–4 mL/kg/h) using polyionic isotonic crystalloids sup- mucosa/submucosal edge of a perforation is not adequately
plemented with potassium (20 mEq/L) should be adjusted debrided, dehiscence is likely to occur. Excessive tension at
based on monitoring of hydration and electrolytes. Water the surgical site associated with early feeding by mouth of
and electrolytes can also be provided enterally once particularly bulky feed can also result in mucosal
the animal is stable. Nutritional support should be pro- dehiscence. In an experimental study, 50% of ponies
vided either by parenteral nutrition (see Chapter 28, developed dehiscence following esophagotomy [20].
Periesophageal Infection 257
Prevention While prevention can be challenging, when Risk Factors

possible, an esophagotomy should be performed at a
● Surgical procedures during which the esophageal lumen
location along the esophagus where healthy mucosa is
is entered
observed (e.g. proximal or even distal to the site of an
● Mucosal dehiscence and anastomosis leakage
obstruction). In an experimental study, postoperative
● Preoperative esophageal perforation
feeding had the greatest impact on dehiscence (compared
● Esophagostomy with feeding tube placement
to esophagotomy technique) with ponies fed hay having a
● Misplacement of a feeding tube through an esophagos-
higher incidence of dehiscence after esophatotomy
tomy following tube dislodgement.
compared to ponies fed a soft diet for 9 days [20]. On the
other hand, per os feeding of even a moistened pelleted Pathophysiology The esophageal lumen is not sterile,
diet resulted in mucosal dehiscence following esophageal neither is the feed and water ingested, and any mucosal
mucosal resection in ponies [24]. Therefore, avoiding per breach can lead to contamination and infection of the
os feeding for at least 10–14 days postoperatively is esophageal tissues. Preoperative contamination associated
recommended. Nutrition can be provided parenterally with esophageal perforation can be particularly challenging.
during the immediate postoperative period in the form of Gastric reflux around a feeding tube placed through an
2.5–5% dextrose, dextrose and amino acids, or dextrose, esophagostomy with the tip on the stomach can lead to
amino acids, and lipids (see Chapter 28, Postoperative contamination of the peri-esophagostomy tissues [11].
Complications after Colic Surgery). Enteral nutrition can Infection can dissect between the tissue planes in the neck,
be given through an indwelling nasogastric tube or via a making drainage challenging and leading to mediastinal
tube placed through a proximal esophagostomy. infection.
Commercially available products, e.g. Purina Well-Gel, can
provide adequate nutrition for several days. Prevention Avoiding esophageal lumen penetration, when
possible, can prevent infection of the periesophageal
Diagnosis Diagnosis can be made based on clinical signs
tissues. When surgically treating a pulsion diverticulum,
including local heat, pain, swelling, and drainage of saliva
inverting the mucosa and repairing the tunica muscularis
through the skin incision or surgically placed drain. Repair
rather than mucosal resection avoids entering the
can be monitored endoscopically with dehiscence diagnosed
esophageal lumen [2, 6]. Similarly, use a staple device (e.g.
when there is observation of the mucosal edges being no
TA-90, US Surgical Corp, Norwalk, Connecticut) to excise
longer apposed [4, 20]. Contrast radiography may be useful
the excessive mucosa associated with an intrathoracic
for identifying small areas of mucosal dehiscence [15].
pulsion diverticulum was also successful [7]. Esophageal
Treatment There are not many reports on treatment cysts can be marsupialized to the skin to avoid entering the
following mucosal dehiscence per se. Peri-incisional lumen; the cyst lining can be lavaged with cauterizing
infection should be managed with ventral drainage, lavage, solutions such as 7% iodine [8]. Drain placement adjacent
and hot and cold packing. Per os feeding should be avoided; to the esophagus for 48 hours allows for removal of blood
however, drinking may provide a means of lavage of the and serum from the surgical site and may help prevent
infected tissues. infection [15].
Expected outcome Reports on expected outcome are variable
Diagnosis Diagnosis is made based on clinical signs of
and likely dependent on the primary disease, surgical
fever and heat, pain, swelling, and draining at the surgical
procedure performed, and extent of dehiscence. Dehiscence
site. Transcutaneous ultrasonographic evaluation may be
may lead to fistula formation with second intention
useful to assess the tissue planes affected and determine if
healing [20]. On the other hand, periesophageal infection
there are specific areas for drainage.
and stricture formation have been reported as sequela of
mucosal dehiscence [4, 24]. Severe or dissecting infections
Treatment Periesophageal infection can be managed with
can lead to systemic inflammatory response and laminitis.
ventral drainage, hot/cold packing, daily cleaning and
lavage, and debridement. Broad-spectrum parenteral
PeriesophagealInfection antimicrobial drugs should be administered. While
bacterial culture and sensitivity testing is ideal, it may
Definition Infection of the tissues adjacent to the reveal a mixed bacterial population representative of the
esophageal surgical site. Periesophageal infection is esophageal microbiome. Analgesia with non-steroidal
common, affecting approximately half of the horses anti-inflammatory drugs is important. Provision of
undergoing esophageal surgery [1, 2]. nutrition via a route other than per os is recommended.
Expected outcome Jugular thrombosis can occur if Expected outcome In one study, spontaneous healing of
infection is severe and extensive, particularly if the jugular the fistula occurred in all long-term survivors and fistula
vein is catheterized [11]. Mediastinitis secondary to formation did not affect long-term survival [2]. Formation
dissecting infection has been described in horses with of a traction diverticulum often occurs as a consequence
esophagostomy and feeding tube placement, particularly if and this may in fact be beneficial for preventing stricture
the feeding tube becomes dislodged and it is incorrectly recurrence. One pony with a feeding tube placed through a
replaced into the periesophageal tissues [11]. Horses with a cervical esophagostomy developed a permanent fistula [11].
surgical site infection had a significantly higher odds (11
times) of euthanasia compared to horses that did not
develop an infection [1]. Stricture is also likely to occur Stricture
following periesophageal infection. Horses with severe
infection and signs of SIRS may develop laminitis and Definition Esophageal stricture is defined as a narrowing
regional inflammation and swelling may lead to laryngeal of the esophagus leading to problems with deglutition and
hemiplegia or Horner’s syndrome. typically associated with fibrosis and scar tissue formation.
Fibrosis/scarring can involve the tunica muscularis and
tunica adventitia (type 1), manifest as webs (cicatrix) or
EsophagealFistulaFormation fibrous rings in the mucosa and submucosa (type II), or a
full-thickness circumferential lesion (type III) [15].
Definition A fistula is an abnormal or surgically created
opening between the esophagus and the skin. Risk Factors
Risk Factors ● Trauma (surgical or other) to the esophagus

● Circumferential mucosal/submucosal ulceration (e.g.
● Esophageal feeding tube placement feed or foreign body impaction)
● Surgical procedures during which the esophageal lumen ● Any procedure involving entering the esophageal lumen
is entered ● Mucosal dehiscence following esophageal surgery
● Primary disease esophageal perforation (e.g. secondary ● Mucosal resection and anastomosis
to feed impaction or nasogastric tube trauma) ● Primary lesions being esophageal stricture
● Mucosal dehiscence
Pathogenesis Mucosal/submucosal dehiscence or
Pathophysiology Persistent drainage from the esophageal
ulceration leads to healing by second intention and scar
lumen and through the skin either via the surgical incision
tissue formation. Periesophageal trauma or infection can
or a created drainage site can lead to fibrous tissue deposition
lead to fibrosis of the adventitia and tunica muscularis.
(walling off) along the tract and fistula formation. Fistula
formation is an intended sequela following feeding tube
placement through an esophagostomy. Diagnosis Stricture can be tentatively diagnosed based on
clinical signs of recurrent obstruction (choke), inappetence,
Prevention See Section on Mucosal Dehiscence above. bruxism, sialorrhea or ptyalism, nasal discharge, coughing,
and weight loss. Esophagoscopy and contrast radiography
Diagnosis Diagnosis can be made based on clinical signs are used to make a definitive diagnosis (Figures 23.1
of leakage of saliva through the skin incision. Endoscopic and 23.2). Ultrasonography may be able to better elucidate
evaluation of the esophagus is useful for evaluating the more specific esophageal layers involved; however,
esophageal defect; however, contrast radiography may be accuracy of this method has not been reported. Thoracic
better for identification of very small fistula that are not ultrasonographic or radiographic examination should be
clinically apparent with leakage of contrast material into performed to determine if aspiration pneumonia is a
the tissues [15]. complication.
Treatment In most cases, fistulas are not treated and Treatment Treatment of esophageal stricture is
allowed to heal by second intention. Care should be taken challenging. Successful medical management with dietary
to monitor hydration status and plasma electrolyte modification has been described [25, 26] as typically
concentration and correct any abnormalities. The skin unsuccessful [2, 4]. Fibrosis of the tunica muscularis and
should be kept clean and petroleum jelly applied to the adventitia can be managed by myotomy/myoplasty and
skin below the drainage site to prevent scald. scar tissue excision [2, 27, 28]. Improvements in this
Stricture 259
technique include separation of the mucosa from the

muscularis circumferentially with or without closure of
the myotomy. Successful intrathoracic esophagomyotomy
has also been described [27]. Second intention healing of
the myotomy may result in stricture formation [29].
Esophagopexy (suturing the tunica muscularis to the
sternocephalicus muscle and dorsal fascia) may create a
traction diverticulum and prevent re-stricture allowing
earlier return to a normal diet [29].
Management of full-thickness or mucosal/submucosal
scaring is more challenging. Partial or complete resection
of the affected tissue and end-to-end anastomosis has been
reportedly successful [3, 17–19]; however, periesophageal
infection and dehiscence often occurs [2]. Esophageal
patch grafting has been described [17]; however, in one
study this was unsuccessful because of leakage, infection,
and fistula formation [4].
Ventral esophagostomy with feeding tube placement at
the stricture site (i.e. indwelling esophageal tube for 14
days used for extra oral feeding) can lead to formation of an
Figure23.1 Endoscopic appearance of esophageal stricture. esophageal fistula and ultimately a traction diverticu-
The discolored area in the image represents damaged lum [4]. Traction diverticula have a wide base at the esoph-
esophageal wall. Source: Courtesy of Dr. Eric Parente, New ageal lumen and tapering toward skin and typically do not
Bolton Center, University of Pennsylvania.
cause clinical problems [4]. Esophagostomy also allows an
approach through which longitudinal incisions in mucosal/
submucosal cicatrix can be made (e.g. at 5-mm intervals)
(a) (b)
Figure23.2 Esophageal stricture (arrows) diagnosed with contrast radiography: (a) static contrast latero-lateral thoracic radiograph;
and (b) still image from a cine loop acquired during a fluoroscopic study of an adult horse. The white barium appears black on
fluoroscopy. Of note is that fluoroscopy is a better representation of the stricture, its dimensions, and the cranial esophageal dilation
compared to plain radiographs. Source: Courtesy of Dr. Kathryn Wulster, New Bolton Center, University of Pennsylvania.
similar to that accomplished with bougienage [4]. Pathogenesis When the deglutition is interrupted, either
Longitudinal incisions of the mucosa reportedly heal with- because of a functional or mechanical esophageal
out stricture, with mucosal regeneration in the longitudi- obstruction, saliva, water, and feed re-enter the pharynx
nal mucosal defects [20]. Fistulation can be used to stabilize and may overwhelm the protective mechanism of the
the esophagus prior to surgical repair, create a barrier larynx which prevents the feed bolus from entering the
between the esophageal lumen and subcutaneous tissues, trachea during swallowing. Interestingly, in one study,
and allow for drainage. An esophagostomy typically heals there was no significant difference in the contamination of
within 30 days. the trachea between horses that subsequently developed
Balloon dilation [30–33] and bougienage [34] have been aspiration pneumonia and those that did not [36], whereas
reported. A balloon dilator up to 25–50% greater than the in another study moderate to severe tracheal contamination
stricture diameter is recommended [30]. One to 6 balloon increased the risk of developing aspiration pneumonia [37].
dilations 1 to 18 days apart may be required with up to 4 The duration of esophageal obstruction prior to admission
dilations being performed at a single time point, depending was significantly longer in horses that developed aspiration
on the degree of mucosal damage [30]. Intralesional corti- pneumonia (median 18, range 2–48 h) than in those horses
costeroids (triamcinolone or methylprednisolone) injected that did not (median 4, range 0.5–48 h) [36]. Aspiration of
transendoscopically into the submucosa may be used to feed and microbes into the airways causes inflammation
reduce re-stricture [30, 35]. Mucosal scar fenestration with and infection. Contamination leads to increase in blood
dilation can be successful [2]. flow, neutrophil migration, and an increase in inflammatory
mediates. The severity of infection depends on the type and
Expected outcome Strictures associated with the tunica number of bacteria and the effectiveness of prophylactic
muscularis or adventitia have a good prognosis with surgical antimicrobials. Cranioventral lung lobes are most often
repair [2, 4]; however, complications are more often observed affected.
following surgical management of mucosa/submucosal
lesions with infection, dehiscence, fistula formation, and Prevention Prophylactic broad-spectrum parenteral
re-stricture, often necessitating euthanasia [2]. Long-term antimicrobial drugs are important to prevent infection in
survival for medical treatment of a primary esophageal horses with esophageal dysfunction/obstruction that are at
stricture was 22% (n = 9) and surgical treatment 44% (n = high-risk of aspirating feed. Perioperatively, horses should
9) [2]. Horses typically developed recurrent obstruction and be maintained on parenteral nutrition or have a feeding
aspiration pneumonia associated with medical management tube placed either through an esophagostomy or through
which primarily involves diet modification (i.e. feeding of a the nares to prevent aspiration of feed. Early resolution of
slurry) [2]. Horses with a stricture of more than 14 days esophageal dysfunction or obstruction and/or the use of
duration had a better prognosis with medical management, parenteral nutrition or administration of enteral nutrition
likely because of esophageal remodeling which can occur up via an indwelling tube may decrease the risk of aspiration
to 60 days [26]. Successful conservative management has pneumonia.
also been reported in foals less than 4 weeks old developing
a cervical esophageal stricture associated with esophageal Diagnosis Aspiration pneumonia should be anticipated in
obstruction [25]. any horse with esophageal dysfunction or obstruction. A
tentative diagnosis can be made based on clinical signs,
including mild to moderate fever and tachypnea, coughing,
spirationPneumonia
A and nasal discharge which may be malodorous. Horses
may also be dull, inappetent, and tachycardic, depending
and Pleuropneumonia
on the disease severity. Signs initially may be subtle and
easily attributed to other complications such as local
Definition Aspiration pneumonia is defined as an infection
infection. A rebreathing examination should be performed
of the lungs (pneumonia) and pleural space
on any horse with a fever or tachypnea. While thoracic
(pleuropneumonia) secondary to saliva, water, and feed
auscultation, even with the use of a rebreathing bag, is not
entering the airways because of pharyngeal/laryngeal or
a particularly sensitive method for identifying lung
esophageal dysfunction or mechanical obstruction.
pathology, observing the horse’s response to the rebreathing
examination and the time for the horse to completely
Risk Factors
recover can provide valuable information. Horses with
● Pharyngeal/laryngeal or esophageal dysfunction lung pathology often cough or become distressed when
● Esophageal obstruction either partial or complete taking deep breaths and take more than 3–4 breaths for
aryngeal emiplegia and ornerrs Syndrome 261
breathing to return to normal. Thoracic ultrasonographic Expected outcome Aspiration pneumonia can be a life-
examination is useful for identifying areas of lung threatening complication for horses with esophageal
pathology, including irregularity of the pleural surface, pathology [2, 25, 30]. Survival was significantly lower in
consolidation, abscessation, and accumulation of pleural horses that developed aspiration pneumonia compared to
fluid (Figure 23.3). Pneumonia can also be diagnosed using those that did not in one study [2] but not in another
thoracic radiographic examination. In horses with septic study [1]. Persistent respiratory disease requiring exercise
pleuropneumonia, bacterial culture and sensitivity of modification was also reported in one study [2]; however,
transtracheal wash fluid was more sensitive than pleural the specific details of the respiratory disease were not
fluid for identifying the causative agent [38]. Transtracheal reported.
wash may be useful; however, because of excessive
contamination it may not be as useful as other causes of aryngealHemiplegiaand Horner’s
L
pneumonia. A sample of both transtracheal wash and
Syndrome
pleural fluid, if present, should be collected for culture and
sensitivity testing.
Definition Laryngeal hemiplegia is a disorder whereby
there is no movement of the arytenoid cartilage and vocal
Treatment Broad-spectrum parenteral antimicrobial
fold [41] (Figure 23.4). Horner’s syndrome refers to the
drugs, ideally based on bacterial culture and sensitivity
clinical signs associated with cranial sympathetic
testing, are recommended. Excessive fluid should be
denervation [42].
drained from the pleural space. Thoracotomy increased the
odds of survival of horses with pleuropneumonia [38, 39].
Risk Factors
The use of recombinant tissue plasminogen activator may
be useful in horses with fibrinous pleuropneumonia [40], ● Known trauma to the cervical region
which is associated with a higher admission respiratory ● Periesophageal inflammation and infection
rate and pleural fluid height, necrotizing pneumonia, and a ● Trauma to the recurrent laryngeal nerve during surgery
poorer survival [41]. Anti-inflammatory drugs (e.g. non- ● Excessive or prolonged head and neck extension during
steroidal anti-inflammatory drugs) and other analgesia surgery
should be used. ● Esophagostomy with feeding tube placement
(a) (b)
Figure23.3 Transcutaneous ultrasonographic image through the 9th left intercostal space (ventral to the left of the image): (a) and
latero-lateral radiographic image of the thorax; and (b) of a horse with aspiration pneumonia. Note the consolidated area of ventral
aspect of the lung (a) and the radiopaque ventral aspect of the thorax (b). Source: Courtesy of Drs. Joanne Slack and Kathryn Wulster,
New Bolton Center, University of Pennsylvania.
Treatment Bilateral laryngeal paralysis can be observed

either because of the primary disease, as a complication of
surgery or because of excessive head and neck extension
during surgery, and an emergency tracheostomy is
necessary in these cases. Consider preemptively placing a
temporary tracheostomy if periesophageal trauma occurs
during surgery.
Expected outcome Laryngeal hemiplegia may be transient

or may persist necessitating prosthetic laryngoplasy (or
partial arytenoidectomy) in athletic horses [2, 4, 8].
Laminitis
Definition Inflammation of the sensitive lamina within

the hoof that may be secondary to mechanical, enzymatic,
or metabolic-related breakdown of laminae.
Figure23.4 Transnasal endoscopic appearance of the larynx of

a horse with left-sided laryngeal hemiplegia. Source: Courtesy of Risk Factors
Dr. Eric Parente, New Bolton Center, University of Pennsylvania.
● Previous history of laminitis
● Underlying equine metabolic syndrome or pituitary pars
intermedia dysfunction (typically in older horses)
Pathogenesis Laryngeal hemiplegia occurs as a
consequence of recurrent laryngeal neuropathy, which can ● Systemic illness including SIRS
occur secondarily to inflammation and swelling in the ● Severe aspiration pneumonia or cellulitis associated with
cervical region or trauma during surgical approaches to the the surgical site
esophagus. Laryngeal hemiplegia was observed in 13% of ● High concentrate feed
horse examined after esophageal surgery in one study [2]. ● Corticosteroids
Horner’s syndrome occurs secondary to injury to or
inflammation associated with the vagosympathetic trunk.
Pathogenesis The exact mechanism by which the lamina
Concomitant laryngeal hemiplegia can be seen [42] as both
is destroyed has not yet been determined. However, any
nerves lie in the carotid sheath adjacent to the esophagus.
disease process that causes systemic inflammation, causes
inflammation in the digital lamina and alterations in
Prevention Avoiding injury to the recurrent laryngeal
digital perfusion [43, 44].
nerve and vagosympathetic trunk during esophageal
surgery and preventing mucosal dehiscence and peri-
incisional infection. Care should be taken with placement Prevention Management of the primary disease is a key
and management of esophagostomy feeding tubes to component of laminitis prevention, including appropriate
prevent leakage of feed into the periesophageal tissues. surgical debridement and drainage of infection sites,
antimicrobials, and anti-inflammatory drugs. Application
Diagnosis Laryngeal hemiplegia is diagnosed with upper of ice to the distal limb and hooves appears to be effective
respiratory tract endoscopy. Horses may make a noise in preventing the inflammatory response [42–45].
(roaring) when they return to exercise. Horner’s syndrome
is diagnosed based on the history of esophageal surgery or Diagnosis A tentative diagnosis is made based on an
cervical inflammation/infection and clinical signs increase in the digital pulses and hoof temperature. The
associated with the syndrome. The most prominent signs horse may have some discomfort when walked in the stall.
associated with Horner’s syndrome are ptosis, local Laminitis is usually bilateral with the forelimbs affected
sweating and increased cutaneous temperature in the more frequently; however, all four feet may be involved.
denervated area. Mild enophthalmos, miosis and increased Radiographs should be taken to evaluate the degree of
lacrimation may also be observed [41]. distal phalangeal rotation or sinking.
References 263
Treatment Horses with laminitis should be confined to a lidocaine, and ketamine). Impression material placed in
well-bedded stall. Use of thick mats or sand can be the sole may provide some support.
beneficial. Reduce caloric intact/avoid high-concentrate
feed. Analgesia should be provided with NSAIDs and Expected outcome The expected outcome is dependent on
additional analgesia provided as necessary (e.g. gabapentin, the severity and grade of laminitis (see Chapter 28:
constant rate infusion of butorphanol or morphine, Complications of the Postoperative Colic Patient).
References
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indications, complications, and long-term outcome of in the dog: a literature review and case report. J. Am.
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1257–1262. 15 Fubini, S.L. (2019). Esophagus. In: Equine Surgery, 5e
2 Craig, D.R., Shivy, D.R., Pankowski, R.L. et al. (1989). (ed. J.A. Auer, J.A. Stick, J.M. Kümmerle, and T. Prange),
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the horse. Equine Vet. J. 14 (2): 163–164. 1506–1513.
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5 Hoffer, R.E., Barber, S.M., Kallfelz, F.A. et al. (1977). 18 Derksen, F.J. and Stick, J.A. (1983). Resection and
Esophageal patch grafting as a treatment for esophageal anastomosis of esophageal stricture in a foal. Equine
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7 Ford, T.S., Schumacher, J., Chaffin, M.K. et al. (1991). techniques and form of feed. Am. J. Vet. Res. 44:
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9 Baird, A.N. and True, C.K. (1989). Fragments of Fluid Therapy in Small Animal Practice, 2e (ed. S.P.
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12 Markowitz, J., Archibald, J., and Downie, H.G. (1964). Conservative treatment of oesophageal stricture in five
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41 Tomlinson, J.E., Byrne, E., Pusterla, N. et al. (2015). The
30 Lillich, J.D., Frees, K.E., Warrington, K. et al. (2001).
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31 Prutton, J.S.W., Marks, S.L., and Aleman, M. (2015).
42 Archer, R.M., Lindsay, W.A., and Duncan, I.D. (1991).
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33 Reichelt, U., Hamann, J., and Lischer, C. (2012). Balloon
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34 Tillotson, K., Traub-Dargatz, J.L., and Twedt, D. (2003). effect of hypothermia on influx of leukocytes in the
Balloon dilation of an oesophageal stricture in a one- digital lamellae of horses with oligofructose-induced
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35 Fretz, P.B. (1972). Repair of esophageal stricture in a 45 Dern, K., van Eps, A., Wittum, T. et al. (2018). Effect of
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265
24
Complicationsof StomachSurgery
Overview successfully managing chronic gastric impaction in ponies

or small horses via a gastrotomy on the caudal or visceral
Gastric surgery is uncommon in horses because of the rela- aspect of the greater curvature after incising the omen-
tively poor surgical accessibility and high risk for contami- tum [4] or placement of a tube or suction through a stab
nation and septic peritonitis [1]. However, there are several incision in the middle of a pre-placed purse string
reports of successful outcomes following gastrotomy for suture [5]. There were no complications reported with
treatment of gastric impaction and removal of bezoars and these procedures, except one pony [5] developed an inci-
foreign bodies; repair of partial gastric perforation; and sional suture abscess likely unrelated directly to the proce-
bypass procedures for gastric outflow obstructions. dure. The authors [5] noted that previous reports had
Complications can occur as a result of the surgical proce- suggested difficulty with hydrating and evacuating gastric
dure but are also common because of the primary disease contents, hence the reason for the gastrotomy, which was
process, which is often chronic at the time the decision is found to be effective.
made for surgical intervention. Complications associated More recently, successful removal of a trichophytobezoar
with gastric surgery are often similar to those associated via a greater curvature gastrotomy in an 8-week-old foal [6]
with abdominal surgery (i.e. postoperative ileus, adhe- and a 15-cm gastrotomy for removal of a persimmon phyto-
sions, surgical site infection, thrombophlebitis) and are bezoar [7] in a 2-year-old Quarter Horse have been reported.
covered in detail in Chapter 31: Complications of Equine In the former case [6], a surgical site infection did develop.
Laparoscopy. This chapter will focus on complications Similarly, removal of a nasogastric tube fragment via a gas-
more specific to gastric disease and surgery. trotomy was also successfully reported without complica-
Gastric impaction is most often treated medically with tion [8]. Removal of a phytobezoar from the caudal thoracic
gastric lavage via nasogastric tube. If the diagnosis is made portion of the esophagus near the cardia via a gastrotomy
during exploratory celiotomy, the impaction may be rehy- was also successfully reported without complication [9].
drated by injecting 1–3 L water or saline into the impacted Extending the ventral midline incision into the cranial
ingesta via a needle placed through the stomach wall with abdomen, using saline-soaked laparotomy sponges to iso-
the fluid delivered through extension set [2]. No complica- late the stomach, and placing stay sutures at the ends of the
tions except a large colon impaction in one horse were proposed gastrotomy site help to reduce contamination [6].
reported with this procedure in one report [2]. The large The gastrotomy can be closed using a full-thickness simple
colon impaction may have been a consequence of seques- continuous pattern then a Cushing pattern in the seromus-
tration of fluid in the oral gastrointestinal tract, consist- cular layer or using a two-layer Cushing pattern with 2-0
ency of digesta associated with gastric impaction, or an polyglactin 910 [4, 6]. Antiulcer medication including
underlying generalized motility disturbance. Gastric sucralfate should be administered perioperatively.
impaction can also be surgically managed by lavage of gas- Successful repair of partial-thickness [10] and full-thick-
tric contents via a nasogastric tube while lubricated/ ness [11] gastric rupture with no peritoneal contamination
hydrated contents are massaged via a ventral midline celi- has also been reported. In the latter instance, the serosal sur-
otomy [3]. It is critical that the nasogastric tube is passed face was mostly intact [11]. Complications of colonic dis-
prior to induction of general anesthesia. Reports exist of placement and body wall dehiscence were reported [10] and
266 Complications of Stomach Surgery
were unlikely related to the surgical procedure itself, except Pathogenesis Postoperative septic peritonitis typically
that the celiotomy incision was extended to the xiphoid car- occurs when there is gross contamination of the peritoneal
tilage which can lead to complications with body wall heal- cavity that is not contained/removed during surgery or
ing [10]. Treatment of peritonitis with broad spectrum occurs from intestinal leakage postoperatively. The
parenteral antimicrobials, use of gastroprotectants, frequent immune system is overwhelmed leading to diffuse septic
gastric decompression, and slow refeeding with small peritonitis, SIRS, and shock, or the site of contamination
amounts frequently is recommended [10, 11]. Facilitation of is contained through formation of adhesions and
gastric emptying with a motility modifying drug such as abscessation potentially leading to failure to thrive and
metoclompramide may also be indicated [10]. recurrent colic.
An approach through the thorax via the diaphragm has
been used to gain access to the stomach for surgical man-
Prevention Adequate surgical exposure and draping can
agement of a gastric stricture in the region of the cardia;
help prevent excessive gross contamination during surgery.
however, the pony died from severe pleuropneumonia [12]
Exposure is optimized by creating a sufficiently long and
and this approach is not recommended.
cranial celiotomy, either at or just caudal to the xiphoid,
Gastric outflow obstruction due to duodenitis-proximal
exteriorizing the large colon from the abdomen, use of
jejunitis and pyloric and duodenal stenosis has been treated
Balfour or other retractors, use of ample moist laparotomy
with gastroduodenostomy or gastrojejunostomy with or
sponges and/or drapes, stabilization of the stomach with
without jejunojejunostomy [13–18]. Complications can
either stay sutures or Allis tissue forceps, and occlusion of
result from the primary disease and the surgical
the jejunal lumen using either digital pressure or Penrose
procedure(s) [13–17]. Complications include septic perito-
drains when performing gastrojejunostomy-
nitis, failure to thrive with or without recurrent or chronic
jejunojejunostomy. Suction and moist sponges should be
colic, aspiration pneumonia, melena, gastric ulceration
readily available to help control contamination and the
and perforation. Other reported complications include sal-
area conservatively lavaged during and copiously lavaged
monellosis and diarrhea, superficial surgical site infection,
at the completion of the procedure [15]. Exposure is
ileus, Parascaris equorum, joint sepsis, cecal and colonic
typically enhanced when animals have been held off feed
torsion [13–18].
for several days and the gastrointestinal tract is empty [14].
Use of a stapling device can decrease contamination [19];
L however, its use has been associated with stenosis (see
with StomachSurgery Sections on Failure to Thrive and Recurrent Colic, and
Gastric Ulceration and Perforation below).
● Septic peritonitis
● Failure to thrive and recurrent or chronic colic Diagnosis Diagnosis of septic peritonitis is based on
● Aspiration pneumonia clinical findings of persistent and often high fever, dull
● Melena demeanor and inappetence, tachycardia and tachypnea,
● Gastric ulceration and perforation colic, diarrhea, and leukopenia or leukocytosis. Clinical
signs can vary depending on whether the septic peritonitis
SepticPeritonitis is acute and diffuse (e.g. associated with gastric perforation
and septic shock) or more chronic and localized (e.g.
Definition Septic peritonitis can be defined as identification associated with intraperitoneal contamination during
of abnormal peritoneal fluid (total nucleated cell count surgery or a small site of leakage leading to adhesion or
>100 × 109/l with cytological evidence of free or abscess formation and recurrent colic, inappetence, failure
phagocytosed bacteria) in combination with clinical signs to thrive).
consistent with a severe infection including dull demeanor, Transabdominal ultrasonographic evaluation can be use-
inappetence/anorexia, pyrexia, SIRS, shock, and pain/ ful for identifying an increase in volume of peritoneal fluid
colic. See also Chapter 28: Postoperative Colic Patient. which may have an increase in echogenicity and fibrin.
Thick bowel is often identified ultrasonographically in
Risk Factors
patients with septic peritonitis. Abdominocentesis can be
● Intraoperative contamination guided based on ultrasonographic findings. Peritoneal
● Inadequate surgical exposure fluid nucleated cell count and total protein concentration
● Gastric ulceration should be within normal limits 7–10 days after surgery [20]
● Leakage at surgical site and persistently high nucleated cell count is diagnostic of
Failure to hrive and ecurrent or Chronic Colic 267
peritonitis. Identification of intracellular bacteria, large primarily with duodenal stricture (secondary to duodenal
numbers of mixed bacteria, or plant material is diagnostic ulceration) around the common hepatic duct [13, 16] or
for septic peritonitis and likely intestinal perforation or reflux of duodenal contents into the bile duct. Biliary
leakage. Diagnosis can also be made during repeat hyperplasia and fibrosis as well as duodenal villi atrophy
laparotomy. can occur [13, 16]. Suppurative pancreatitis has also been
reported [17]. Of note is that these complications are
Treatment Treatment consists of broad-spectrum associated with the primary disease process of gastric
parenteral antimicrobials ideally based on bacterial culture outflow obstruction secondary to gastroduodenal
and sensitivity testing, and abdominal lavage which may ulceration and should be identified prior to surgery.
be performed via a drain placed through the ventral Afferent or efferent loop obstruction post gastrojejunos-
abdomen. Repeat celiotomy is often indicated to determine tomy can occur due to internal herniation included jejunal
the source of septic peritonitis, provide thorough abdominal volvulus, intussusception, displacement, kinking, peridu-
lavage, and surgical correction if possible. odenal abscessation [13], adhesion formation, or stricture
of the efferent loop. Stricture at the gastrojejunostomy
Expected outcome The outcome of horses with septic
associated with use of a stapling device [19, 22, 23] can
peritonitis post gastric surgery is grave, particularly if it is
result in gastric rupture [19]. In addition to recurrent and/
associated with gastrointestinal perforation or anastomosis
or chronic colic, afferent or efferent obstruction can also
leakage. Long-term complications association with
contribute to loop syndrome and maldigestion/
adhesions, abscessation, and stenosis are likely to occur.
malabsorption.
Most horses (and foals) are euthanized following diagnosis
Loop syndrome can occur following gastrojejunostomy,
of septic peritonitis.
whereby digestion and subsequently absorption may be
affected if feed is not exposed to pancreatic and hepatic
ailureto Thriveand Recurrentor
F secretions as a result of the bypass [14]. Overgrowth of bac-
teria in a blind loop can result in chronic weight loss [13].
ChronicColic Gastrojejunostomy can also result in dumping syndrome
which occurs when feedback inhibition of the duodenum
Definition “Failure to thrive” is a term generally applied to
on gastric emptying does not occur and hyperosmolar con-
foals whereby they do not attain expected growth rate or
tents (especially carbohydrates) empty into the jejunum
size for their age. It is often associated with a dull hair coat,
resulting in fluid shifts from the circulation into the intesti-
small and thin stature and dull demeanor. The equivalent
nal lumen [24, 25]. Alkaline reflux gastritis has been
for adult horses would be weight loss or failure to gain
reported in humans following resection or bypass of the
weight with or without inappetence. Recurrent colic has
pylorus, whereby bile-rich intestinal fluids reflux back into
been defined as at least 3 colic episodes within 1 year [21]
the stomach (see Section on Gastric Ulceration and
with at least 48 hours eating and defecating normally and
Perforation below). Abdominal pain and weight loss can
free of colic signs [22]. Chronic colic refers to persistent
occur secondary to these complications as well as the prob-
signs of colic for at least 3 days with no or only brief
lems with decreased intestinal transit and inadequate mix-
resolution of signs between observed colic episodes.
ing of ingesta with pancreatic enzymes and bile [26]. While
Recurrent and/or chronic colic can be a complication of
these complications are most often reported in foals, horses
gastric disease and surgery.
may also have problems with weight gain and maintenance
Risk Factors
following gastrojejunostomy [14]. See Section on Gastric
● Septic peritonitis with adhesion or abscess formation Ulceration and Perforation below.
● Portal hepatitis/cholangiohepatitis and liver Adult horses with gastric impaction may have underly-
abscessation ing pathology causing the impaction. In one study, post-
● Afferent or efferent loop obstruction post mortem examination of six horses with gastric impaction
gastrojejunostomy revealed gross muscular thickening of the stomach wall,
● Afferent or efferent loop maldigestion/malabsorption focal fibrosis of the stomach wall in four horses, and focal
syndrome post gastrojejunostomy myositis in one horse [27].
● Persistent gastric ulceration
● Primary gastric dysfunction Prevention Some of the complications leading to failure to
thrive and colic are inherent to the underlying disease
Pathogenesis See Section on Septic Peritonitis above. process. A conservative re-feeding program following
Cholangiohepatitis and liver abscessation are associated gastric surgery is recommended [14]. Parenteral nutrition
should be considered. Frequent, small feedings are (pleuropneumonia) secondary to saliva, water, or feed
advised [14]. Foals can have a gradual re-introduction to entering the airways because of pharyngeal/laryngeal or
nursing, and grazing is an ideal method of feed esophageal dysfunction or mechanical obstruction.
re-introduction for horses when grass is available.
Commercial products such Well Gel or pelleted feeds may Risk factors Pyloric or gastric outflow obstruction
be beneficial. High-grain diets should be avoided [14].
Anti-ulcer medication should be administered for a
Pathogenesis Pyloric or gastric outflow obstruction causes
prolonged period (see Section on Gastric Ulceration and
reflux of gastric contents into the oro- and nasopharynx
Perforation below).
which is then aspirated into the lungs. Aspiration
Loop syndrome may be prevented with a jejunojejunos-
pneumonia is often diagnosed preoperatively in foals with
tomy [14, 17] but the necessity of jejunojejunostomy could
gastric outflow obstruction due to pyloric or duodenal
be debated [17]. The mesentery associated with the jejuno-
obstruction; however, this can also occur postoperatively
jejunostomy should be sutured to itself and the adjacent
with gastrojejunostomy stenosis or efferent loop
jejunum to prevent bowel herniation through the ring cre-
obstruction. Any horse or foal with spontaneous reflux or
ated by the jejunojejunostomy [17]. Correct anatomical ori-
requiring frequent nasogastric intubation for gastric
entation of the jejunum along the greater curvature of the
decompression is at risk for aspiration pneumonia.
stomach for gastrojejunostomy is critical to prevent volvu-
lus and kinking. The jejunum should be oriented with the
oral aspect on the left side and aboral aspect on the right Prevention Early diagnosis and management of gastric
side [17]. outflow obstruction and frequent gastric decompression
via nasogastric intubation may prevent or minimized
Diagnosis Hepatic and biliary complications can be aspiration pneumonia.
diagnosed based on high liver enzyme activity and
ultrasonographic evaluation of the liver. Diagnosis of other
Diagnosis Diagnosis is based on clinical signs (coughing,
complications can be based on transabdominal
nasal discharge, tachypnea, fever) and thoracic and
ultrasonographic evaluation, during repeat laparotomy or
tracheal auscultation. Rebreathing examination is
necropsy. Occasionally foals fail to thrive or have recurrent
recommended. Transthoracic ultrasonography and
colic with or without gastric reflux and the mechanical or
radiography can be used to confirm the diagnosis. Feed
functional reason is not identified.
material may be observed in the trachea endoscopically.
Treatment See Section on Gastric Ulceration and Transtracheal wash can be performed; however, this may
Perforation below. Adhesiolysis via laparotomy or not be as reliable as it is with other types of pneumonia.
laparoscopy may be performed. Reversal or revision of
gastrojejunostomy may also be attempted. In human Treatment Broad-spectrum parenteral antimicrobials are
patients, laparoscopic procedures have been described to the mainstay of treatment. While antimicrobial selection
manage loop syndrome and obstruction [28, 29]. should ideally be based on bacterial culture and sensitivity
testing, this may be challenging because the transtracheal
Expected outcome The prognosis for foals and adult horses
wash sample may only be representative of tracheal
developing problems with failure to thrive or weight loss
contamination from aspiration.
and recurrent and/or chronic colic following gastric
surgery is grave. Attempts to reverse or revise
gastrojejunostomy have been reported; however, the foals Expected outcome With early diagnosis and appropriate
did not survive (see Section on Gastric Ulceration and antimicrobial therapy, the outcome can be favorable,
Perforation below). Foals/horses are often euthanized, and depending on the development of other postoperative
the definitive diagnosis made at necropsy. complications.
spirationPneumonia(see
A Melena
Chapter 23:Complicationsof
EsophagealSurgery) Definition Melena is the passage of dark tarry stools
containing partially digested blood and is usually associated
Definition Aspiration pneumonia is defined as an infection with bleeding from the esophagus, stomach, duodenum, or
of the lungs (pneumonia) and pleural space oral part of the jejunum.
astric Ulceration and Perforation 269
Risk Factors ● Use of non-absorbable sutures for gastric

procedures [30–32]
● Gastrotomy or gastrostomy
● Gastric rupture (partial)
● Gastric ulceration
Pathogenesis Gastric ulceration is often part of the
primary disease process in foals undergoing
Pathogenesis Intraluminal bleeding occurs during
gastrojejunostomy-jejunojejunostomy. Post
gastrotomy or gastrotomy from the large gastric vessels.
gastrojejunostomy, ulceration may be associated with
Bleeding may also be observed associated with gastric
reflux bile-rich alkaline duodenal contents into the
rupture [11]. Most cases of gastric rupture, however, are
stomach. Non-absorbable suture material can cause
associated with acute onset of severe signs of shock leading
chronic inflammation leading to ulceration associated with
to death or euthanasia and melena is unlikely to be
the resection/anastomosis site. Pathogenesis in human
observed. Bleeding ulcers are uncommon in horses and
patients with marginal ulceration following gastric bypass
foals.
surgery is ischemia due to mesenteric vascular disease with
cigarette smoking, type II diabetes, and hypertension being
Prevention Gastrotomy should be performed on the identified risk factors [33, 34].
visceral aspect of the stomach in a hypovascular area [4].
Prevention Gastric ulceration can be managed and

Diagnosis Diagnosis is made based on the clinical finding
prevented with sucralfate and H2-receptor antagonists or
of dark, tarry feces. A decrease in the packed cell volume
proton pump inhibitors. Performing a jejunojejunostomy
and total plasma protein and an increase in blood lactate
in conjunction with a gastrojejunostomy may prevent
concentration along with clinical signs of hemorrhage
reflux of bile-rich alkaline duodenal contents into the
(dull demeanor, tachycardia, tachypnea) may be observed
stomach. Use of absorbable suture material is
if the hemorrhage is severe.
recommended. Avoiding concentrate feed may also prevent
ulceration following gastric surgery.
Treatment Treatment is usually conservative [11].
Administration of ɛ-aminocaprioc acid (EACA) may be
indicated to stabilize clot formations (EACA binds to Diagnosis Diagnosis of gastric ulceration is made based
lysine-binding sites within the plasminogen/plasmin on gastroscopy findings. However, in the context of
molecule, interfering with the ability of plasmin to lyse complications following gastric surgery, the diagnosis is
fibrin clots). Rarely is blood transfusion necessary; often made at necropsy following perforation.
however, it should be considered if the horse is showing
clinical signs associated with hemorrhage with a decreasing
Treatment Treatment of gastric ulceration involves anti-
packed cell volume and total plasma protein.
ulcer medication including sucralfate, proton pump
inhibitors (omeprazole, pantoprazole), and possibly H2-
Expected outcome Most horses do well with conservative receptor antagonists (ranitidine).
management. Fatal hemorrhage is rare. Reversal of the gastrojejunostomy in two foals at 4 and 12
months postoperatively was performed in an attempt to
manage persistent gastric ulceration. Gastrojejunostomy
GastricUlcerationand Perforation reversal led to gastric perforation and septic peritonitis
within 24 hours post reversal [16]. The authors concluded
Definition Gastric ulceration refers to the loss of areas of that reversal can be dangerous because of perforation of
gastric mucosa (and submucosa) which may be a primary gastric ulcers [16].
disease (equine gastric ulcer syndrome, which not Laparoscopic repair of marginal ulcers following gas-
discussed in this chapter) or a complication of gastric tric bypass surgery has been described in human
surgery. patients [35].
Risk Factors
Expected outcome The outcome can be favorable with
● Gastrojejunostomy long-term treatment with anti-ulcer medication.
● Gastrotomy Perforation, however, is typically fatal.
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8 DiFranco, B., Schumacher, J., and Morris, D. (1992). 750–751
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272
25
Complicationsof SplenicSurgery
Eileen Sullivan Hackett DVM, PhD, DACVS, DACVECC
Overview protected location covered in large part by the caudal ribs

and diaphragmatic reflection. Sources of splenic trauma
Although splenic surgery is relatively uncommon in the related to blunt abdominal trauma can include falling, as
horse, surgical complications related to the spleen are not during patient movement or anesthetic recovery, vehicle
rare. The most common complications related to splenic collision, or kick injuries from another horse.
surgery in the horse are inadvertent trauma, hemorrhage, Direct surgical trauma can also result in laceration or
and adhesions. Recognition of complications and timely puncture of splenic tissues. Laparoscopic cannula or tele-
institution of appropriate treatments should improve out- scope insertion for routine laparoscopic procedures per-
comes related to splenic complications. formed from the left paralumbar fossa in the standing,
sedated horse can result in accidental splenic trauma
(Figure 25.1). During laparoscopic procedures, inadvertent
istof Complicationsof Splenic
L visceral injury is more likely in the absence of abdominal
Surgery insufflation. Veress needle insertion in preparation for lap-
aroscopy can also result in inadvertent penetration [1].
● Splenic trauma Some degree of surgical trauma is often difficult to avoid
● Splenic adhesions
● Hemorrhage
● Gastrosplenic ligament trauma
● Pneumothorax
SplenicTrauma
Definition Splenic trauma can be defined as abrasion,

fracture, or penetration of the splenic capsule and/or
underlying parenchyma. The sources of splenic trauma are
varied, as it can result from blunt or penetrating injuries.
Risk Factors
● Blunt abdominal trauma

● Direct surgical trauma
● Ingestion and subsequent migration of ingested metallic
Figure25.1 Laparoscopic image with an arrow indicating
foreign bodies location of splenic trauma from instrument insertion resulting
in capsular puncture and minor hemorrhage. The spleen (S) and
Pathogenesis Splenic trauma occurs in horses and results nephrosplenic ligament (NSL) are indicated. Source: Eileen
in a wide spectrum of consequences, despite its relatively Hackett.
Splenic Trauma 273
during suturing or tacking of the splenic capsule for splenic the telescopic light source. Withdrawal and repositioning
repair or closure of the nephrosplenic space. Inadvertent of the cannula is necessary to gain appropriate visibility
injury to the spleen can occur during surgical correction of within the peritoneal cavity. Signs of splenic rupture are
nephrosplenic colonic entrapment. Nephrosplenic colonic typically recognized as colic or other consequences of
entrapment occurs when the large colon displaces in the hypotension, and are primarily due to massive blood loss
left dorsal abdomen and becomes incarcerated in the and uncontrolled hemorrhage into the abdomen.
nephrosplenic ligament. Surgical correction of nephros- Penetration by ingested foreign bodies is often visible with
plenic colonic entrapment can be associated with splenic radiographic or ultrasound imaging, depending on location
trauma or abrasion. Similarly, injury can occur during and material. A diagnosis of a penetrating foreign body is
splenic adhesiolysis. Splenic penetration is more likely in supported by signs of colic, fever, abdominal effusion, and
cases where the spleen is enlarged or displaced in a more blood analysis characteristics suggestive of severe
caudal position. Enlargement or caudal displacement inflammation.
could be confirmed preoperatively through routine perfor-
mance of rectal or transcutaneous ultrasound examination Prevention Preoperative ultrasound of the site of cannula
and identification of the location of the caudal splenic bor- placement can assist in avoiding splenic penetration and
der. Because the greater curvature of the stomach and optimizing the cannula insertion site [4]. Cannulas inserted
spleen are connected by the gastrosplenic ligament, caudal into the 17th intercostal space in the standing horse should
displacement of the spleen can occur with gastric disten- be positioned immediately dorsal to the dorsal splenic
tion (Figure 25.2). In these cases, appropriate diagnostics extremity (Figure 25.3). Use of a mini-laparotomy, or
and treatment for gastric distention should be imple- Hasson’s technique, to insert laparoscopic cannulas has
mented. Subcapsular hematoma and subsequent postop- been described to improve instrument insertion safety [1].
erative splenic rupture have been reported following Alternatively, a hand-assisted method could limit risk of
laparoscopic procedures in people and attributed to stretch- splenic trauma during cannula insertion. Reports of hand-
ing of pre-existing peritoneal-splenic adhesions during assisted methods have been described for correction of
pneumoperitoneum [2]. nephrosplenic colonic entrapment and closure of the
Splenic trauma has been associated with ingestion of nephrosplenic space in a single procedure, though the
metallic foreign bodies, such as wire and needles. This can extent of laparoscopic abdominal exploration is reduced
occur subsequent to jaw wiring, if the implants cycle and because of the absence of insufflation [4, 5].
break during feed ingestion. Caution should be exercised
when horses are exposed to these elements.
Diagnosis Upon insertion of a laparoscopic telescope into

a portal that has penetrated the spleen, the operator will
observe only a dark cavity that is poorly illuminated with
Figure25.3 Ultrasonographic image of the left dorsolateral

abdomen of a horse within the 17th intercostal space. An arrow
Figure25.2 Laparoscopic image from a horse undergoing indicates the ideal location for cannula insertion immediately
standing exploratory surgery. An arrow indicates gastric dorsal to the spleen (S) to avoid splenic puncture. The kidney (K)
distention. The spleen (S) is also visible. Source: Eileen Hacklett. is also visible. Source: Eileen Hackett.
274 Complications of Splenic Surgery
Treatment Depending on severity, splenic trauma can Risk Factors

result in life-threatening hemorrhage or simply result in
● Splenectomy
poor visibility or delayed surgical intervention [6]. In cases
● Correction of nephrosplenic colonic entrapment
with massive blood loss, medical treatment can be
successful, and might consist of analgesia, abdominal ● Nephrosplenic space closure
compression bandages, and whole blood transfusion. ● Exploratory celiotomy
Whole blood transfusion is often necessary in conjunction ● Peritonitis
with surgical treatment, although autotransfusion could be
attempted with blood recovered from the abdomen. Pathogenesis The spleen is connected to the dorsal body
Surgical access is typically either ventral midline open wall ventral and lateral to the left kidney by the
celiotomy or a lateral approach with rib resection. In cases nephrosplenic ligament, which contains the splenic artery
of severe splenic trauma, splenectomy may be indicated. and vein, lymphatic vessels, and sympathetic and
Laparoscopic splenectomy could be considered in cases parasympathetic innervation. Visceral adhesions to the
that are hemodynamically stable [7]. Otherwise, capsular nephrosplenic ligament transection site have been observed
repair can be attempted with open or laparoscopic following splenectomy. Splenectomy has traditionally been
splenorrhaphy [8]. In less severe cases, in which a performed as an open procedure under general anesthesia
subcapsular splenic hematoma forms and hemorrhage is in right lateral recumbency. Laparoscopic techniques have
controlled, the extent of splenic trauma and splenic gained popularity because of the minimally invasive nature
hematoma can be observed using abdominal laparoscopy of the approach, which decreases operative time, surgical
with the horse under general anesthesia or in the standing trauma, and convalescence. Standing hand-assisted
position [9, 10]. Up to 90% of the parietal surface of the laparoscopic splenectomy has been reported in horses
spleen can be examined using these techniques [9]. Splenic without splenic pathology [6]. Hand-assisted approaches
penetration upon insertion of laparoscopic instruments combine the benefits of open and laparoscopic techniques,
typically does not result in serious hemorrhage, though namely by allowing the addition of tactile sensation.
bleeding can obscure abdominal structures. Bleeding will However, postoperative complications observed with this
be visible on the cannula obturator or aspirated from a approach include formation of adhesions between the site
Veress needle that has penetrated the spleen [1]. In cases of of nephrosplenic ligament resection and the large colon,
minor bleeding, no specific treatment is necessary. It is small colon, and small colon mesentery [6]. Partial or
always prudent to monitor horses with splenic trauma complete splenectomy is indicated in horses with severe
carefully for 12 to 24 hours in order to ensure early detection splenic trauma, abscessation, or infarction [6]. Localized
of clinical signs associated with serious hemorrhage. inflammation and peritonitis are often associated with
these disease conditions, beyond that associated with the
Outcome Small splenic lacerations often do not result in surgical procedure, compounding the risk of postoperative
profuse bleeding and are not associated with significant adhesion formation.
morbidity and mortality [11]. In cases with serious Splenic adhesions to the body wall are observed in horses
hemorrhage, outcome is determined by response to that undergo repetitive nephrosplenic colonic entrap-
medical and/or surgical therapy. ment [12]. Adhesions can be multifocal and can vary in
Penetration of abdominal viscera has a guarded progno- location along the parietal splenic surface (Figure 25.4).
sis, especially when accompanied by splenic abscessation. Nephrosplenic space closure is performed to prevent
Early diagnosis and surgical intervention are necessary to incarceration of the displaced colon [12]. Closure of the
salvage horses with perforating abdominal metallic foreign nephrosplenic space has been reported utilizing multiple
bodies [3]. surgical methods and approaches. Nephrosplenic space
closure is completed with simple continuous or Ford inter-
locking suture patterns or polypropylene mesh [4, 5, 13].
SplenicAdhesions Either intracorporeal or extracorporeal knots can be uti-
lized to complete the suture line, depending on the sur-
Definition Splenic adhesions, composed of blood vessels geon’s preference. More recently, endoscopic suturing
and fibroblasts, are fibrous bands of scar tissue that form devices have been described in this application, although
due to inflammation, injury, or infection, and can occur as significant complications arose with this approach, includ-
a complication of surgical procedures. Splenic adhesions ing longer surgical duration, needle breakage, and tearing
can form within the nephrosplenic space and between the of the perirenal fascia, nephrosplenic ligament, and dorsal
spleen and body wall or adjacent viscera. splenic capsule [14]. Use of the endoscopic suturing device
emorrhage 275
Alternatively, a combination of blunt and sharp dissection

is necessary to free the spleen from the body wall.
Inadvertent laceration of the spleen is likely during
adhesiolysis and these areas should undergo capsular over-
sewn using an appositional suture pattern [15]. Adhesions
of the parietal surface of the spleen to the peritoneum on
midline, traditionally observed during ventral midline
celiotomy, might be difficult to detect and resect from a
standing flank approach. Regardless of the surgical
approach utilized during adhesiolysis, careful blunt
dissection is at times required to free the splenic adhesions
in areas that are palpable but not visible.
Figure25.4 Laparoscopic image from a horse undergoing Splenectomy can be considered when severe adhesions
standing exploratory surgery. An arrow indicates the site of an between the spleen and other viscera prevent surgical cor-
omental adhesion on the parietal surface of the spleen. The rection of other lesions, such as diaphragmatic hernia or
spleen (S) is also visible. Source: Eileen Hackett.
nephrosplenic colonic entrapment.
with a 9-mm straight needle was considered to be under- Outcome Recurrence of splenic adhesions and repeat colic
sized for the application and did not offer distinct advan- episodes have been documented following previous
tages over conventional laparoscopic suturing [14]. A exploratory celiotomy for nephrosplenic colonic
polypropylene mesh nephrosplenic space closure tech- entrapment in which splenic adhesiolysis was
nique has been described as an alternative to sutured clo- conducted [15]. Nephrosplenic colonic entrapment can
sure [13]. When utilized, polypropylene mesh is secured to occur in the presence of splenic capsular adhesions to the
the nephrosplenic space with a laparoscopic tacking body wall, which suggests that the pathway of colonic
device [13]. Adhesions between small colon mesentery and movement is varied and complex in some cases.
the surgical mesh within the nephrosplenic space have
been reported with this technique [13]. This could be sec-
ondary to abrasion of adjacent viscera by exposed mesh,
Hemorrhage
still visible during follow-up laparoscopic exam in research
horses 4 weeks following implantation [13].
Definition Bleeding from the spleen can range from minor
to life-threatening, depending on degree of injury and
Diagnosis Splenic adhesions are typically identified
proximity to the splenic vasculature.
intraoperatively during open or laparoscopic procedures.
Splenic adhesions may be suspected in some cases, such as
Risk Factors
in horses in which nephrosplenic colonic entrapment does
not resolve with medical therapy alone. ● Use of electrosurgical instruments for vessel sealing and
dividing
Prevention Adhesion prevention is complex. Minimizing ● Pharmacologic agents
surgical time, trauma, and contamination are important ● Splenic trauma
considerations. Manual traction on the spleen is necessary
to surgically correct nephrosplenic colonic entrapment. Pathogenesis The size of the splenic artery and vein in
Because of the risk of splenic trauma and subsequent horses precludes exclusive use of electrosurgical devices
adhesion formation, care should be taken to minimize for secure hemostasis. Use of a vessel sealer and divider as
injury to the spleen during correction. the sole source of hemostasis in horses has resulted in
failure and hemorrhage obscuring surgical visibility [6].
Treatment In cases with fibrous splenic adhesions to the The spleen is capable of dramatic expansion during
body wall and concurrent nephrosplenic entrapment, engorgement and contraction because of smooth muscle
correction of the colonic orientation through medical contractile elements in the splenic capsule and vasculature.
means or with rolling therapy is unlikely [15]. Careful For this reason, the spleen is highly responsive to adrener-
surgical removal of the colon from the nephrosplenic space gic agonists such as etilefrine (α and β activity) and phenyle-
followed by colectomy could be required to prevent phrine (α1 activity). Phenylephrine solutions can be used to
subsequent colic associated with re-entrapment. facilitate splenectomy and other surgical procedures as they
produce splenic contraction. Use of these agents to facilitate progression or worsening of signs. Severe hemorrhage,
splenic or visceral manipulation intraoperatively will result such as that associated with splenic rupture, is a medical
in hypertension. Administration of phenylephrine solu- emergency. As with splenic trauma, medical treatment can
tions has been associated with life-threatening hemorrhage be successful, and might consist of analgesia, abdominal
when used in older horses, especially in those 15 years of compression bandages, and whole blood transfusion.
age and older [16]. Anitfibrinolytics, such as aminocaproic or tranexamic acid,
Splenic trauma is likely to result in hemorrhage if the can be administered to reduce blood loss secondary to
splenic capsule is penetrated or fractured. Degree of hem- trauma or surgery. Splenectomy or surgery to repair the
orrhage is related to the severity of trauma and proximity source of splenic hemorrhage may be indicated to address
to splenic vessels. Surgical methods that result in capsular the source of the hemorrhage, but is risky in cases that are
penetration, such as nephrosplenic space closure not hemodynamically stable.
(Figure 25.5), or capsular repair are likely to result in
hemorrhage. Outcome Prognosis is excellent with minor hemorrhage
and guarded in cases with severe hemorrhage.
Diagnosis Ultrasonographic examination is useful to
identify splenic hematoma or hemoperitoneum. In horses
with serious abdominal hemorrhage, signs of abdominal
pain and hypotension will be evident. Horses with acute GastrosplenicLigamentTrauma
hemorrhage will often have a low normal packed cell
volume despite massive blood loss [17]. Abdominal Definition The spleen is connected to the stomach by a
hemorrhage can be confirmed with abdominal paracentesis. portion of the greater omentum distinguished as the
gastrosplenic ligament. Trauma to this ligament can result
Prevention Multiple ligatures or vascular clips of sufficient in hemorrhage and predispose to adhesion formation or
size should be utilized to occlude the splenic artery and visceral entrapment.
vein, and electrosurgical devices can then facilitate
transection if available. Complete occlusion and hemostasis Risk Factors
should result from the vascular ligation technique and this
● Increased abdominal pressure
should be confirmed prior to continuing in order to
● Exploratory celiotomy
maximize visibility and minimize postoperative
● Correction of jejunal or colonic gastrosplenic ligament
hemorrhage complications.
entrapment
Treatment Minor splenic hemorrhage often requires no
specific treatment beyond continued monitoring for Pathogenesis Soft tissue rents, such as those in mesenteric
attachments, have been associated with conditions that
contribute to increased abdominal pressure, such as
breeding, pregnancy, dystocia, strenuous exercise, crib-
biting, ascites, and severe gastrointestinal distention with
or without rolling [18].
Manipulation of abdominal viscera can result in trauma
to the gastrosplenic ligament. This can occur during man-
ual repositioning of the spleen during correction of
nephrosplenic colonic entrapment or during palpation
within the left cranial abdomen.
Even careful removal of herniated intestines from the
gastrosplenic ligament results in tearing and hemorrhage
in this location, as enlargement of the rent is necessary to
correct the entrapment [19].
Diagnosis Horses with acute gastrosplenic ligament

Figure25.5 Laparoscopic image from a horse undergoing trauma will likely present with colic pain and
standing nephrosplenic space closure. Minor hemorrhage is
hemoabdomen. Gastrointestinal entrapment can result in
evident along the suture line, predominantly due to splenic
capsular puncture. The spleen (S) and nephrosplenic ligament signs consistent with visceral ischemia, as well as
(NSL) are visible. Source: Eileen Hackett. gastrointestinal dilation nasogastric reflux. Transcutaneous
Pneumothorax 277
ultrasonography can be utilized to evaluate for presence Pathogenesis Complications of laparoscopic nephrosplenic
and characteristics of free abdominal fluid and space closure, and other procedures utilizing a 17th
gastrointestinal dilation. Exploratory celiotomy or intercostal space laparoscopic portal, include inadvertent
laparoscopy is required for antemortem confirmation of penetration of the thoracic cavity and creation of
gastrosplenic ligament trauma. pneumothorax [5]. This can also occur during open splenic
procedures performed in right lateral recumbency and
Prevention Despite some risk of re-entrapment, closure of utilizing rib resection. Pneumothorax has been documented
defects in the gastrosplenic ligament immediately following in patients undergoing laparoscopic procedures that have
correction of the entrapment have not been attempted concurrent congenital diaphragmatic defects [22]. Surgeons
because of the friable nature of the repair tissue [20]. should be vigilant regarding inadvertent diaphragmatic
Recurrence of gastrosplenic intestinal entrapment trauma that rarely occurs during laparoscopic procedures
following surgical correction has been documented [19]. but can result in serious complications [23].
Staged repair or excision of the ventral ligament could be
considered to mitigate risk [18]. Resection of the Diagnosis Prompt recognition of pneumothorax is
gastrosplenic ligament is difficult utilizing a laparoscopic important, especially prior to signs of respiratory difficulty.
approach in the standing horse, because the view of the Ultrasonographic or radiographic examination can confirm
ventral portion is obscured by the spleen [6]. pneumothorax. Insertion of the telescope into a
laparoscopic cannula that has been inadvertently inserted
Treatment Treatment of gastrosplenic ligament trauma into the thorax instead of the abdomen provides visual
consists of reduction of herniated contents, repair of the confirmation of thoracic penetration and pneumothorax,
traumatize portion, or excision of the ligament distal to any with concurrent lung collapse. Lack of normal lung sounds
rents. during chest auscultation and evidence of reduced tidal
volume, or increasing intrathoracic pressure, and rising
Outcome Intestinal entrapment within the gastro-splenic end tidal carbon dioxide, are associated with pneumothorax.
ligament is associated with abdominal discomfort and Of all measured physiologic variables, tidal volume is the
medial deviation of the spleen. Large colon and small most useful as it will display distinct alteration before other
intestinal segments can become entrapped in this location. hemodynamic or respiratory variables are affected.
Passage of intestines through rents within the ligament are Uniquely, thoracocentesis allows confirmation of
typically in a caudal to cranial direction [20]. Enterotomy pneumothorax and is also therapeutic.
and evaluation of intestinal contents can facilitate
correction [20]. Rupture of the gastrosplenic ligament has Prevention Preoperative ultrasound of the site of cannula
been associated with gastric torsion because of subsequent placement has been advocated to assist in avoiding
increased gastric mobility [11]. inadvertent thoracic cavity penetration [4]. The caudal and
ventral extent of the lung field varies from horse to horse
and ultrasound examination immediately prior to surgery
can specifically identify the lung field, increasing the
Pneumothorax
margin of safety for cannula insertion. Inadvertent
penetration is more difficult in open procedures, where
Definition Pneumothorax is defined as the presence of gas
incisional location is less flexible.
or air in the thoracic cavity between the lungs and chest
wall, which results in variable collapse of the lungs
Treatment When the thoracic cavity has been penetrated
depending on severity. Horses often have fenestrations in
upon cannula insertion, redirection of the laparoscopic
the caudal and ventral mediastinum, therefore bilateral
cannula and correction of pneumothorax by aspiration of
pneumothorax can result from a unilateral source [21].
air are then required. Aspiration of air can be performed by
applying vacuum suction to the insufflation portal of the
Risk Factors
cannula and observing lung re-expansion laparoscopically
● Inadvertent thoracic cannula insertion during abdomi- prior to redirection. However, repeat aspiration of both
nal laparoscopy sides of the chest might be required, as maintenance of
● Inadvertent diaphragmatic trauma during open negative pressure is difficult until portal closure has been
laparotomy completed. Awake horses should be supported with
● Congenital diaphragmatic defects in horses undergoing intranasal oxygen, and those under general anesthesia
laparoscopy/laparotomy should receive 100% inspired oxygen.
Outcome Timely recognition and correction of cavity can be associated with significant postoperative
uncomplicated pneumothorax allows correction and control morbidity, including thoracic abscessation and delayed
of the event. Pneumothorax identified intraoperatively can healing [24].
be successfully treated [23]. Inadvertent entry of the thoracic
References
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279
26
Complicationsof AbdominalApproaches
Shauna P. Lawless MVB and Eileen Sullivan Hackett DVM, PhD, DACVS, DACVECC
Overview IncisionalEdema
Abdominal surgery is common in the horse and surgical Definition Peri-incisional edema refers to an accumulation
complications related to abdominal approaches are well of transudate in the interstitial space surrounding a surgical
documented. The most prevalent complications related to incision.
abdominal approaches in horses are incisional swelling,
drainage and infection, which can predispose horses to Risk Factors
develop dehiscence or herniation. Recognition of complica-
● Incision location
tions and timely institution of appropriate treatments should
● Suture material
improve outcomes related to abdominal approach
● Post-surgical trauma
complications.
Pathogenesis Incisional edema is common in horses
following laparotomy. Incisional edema occurs in the
L majority of horses following ventral midline celiotomy [1].
with AbdominalApproaches It also occurs secondary to surgical trauma and is
exacerbated when the surgical site is in a dependent
● Incisional edema location. When minor, some consider incisional edema a
● Incisional drainage normal physiological consequence of laparotomy, versus a
● Incisional infection true incisional complication [2]. Incisional edema should
– Surgical factors not be overlooked if severe, as it can lower tissue
oxygenation and healing, and can appear concurrently
– Illness severity of the patient
with more serious incisional complications including
– Wound protection
infection, dehiscence, and herniation.
○ Repeat laprotomy In open procedures, a smaller incision could result in
● Dehiscence less inflammation, disruption of lymphatic channels, and
– Surgical factors mechanical stress on the incision location. Absence of
– Patient factors incisional edema 24–36 hours postoperatively has been
associated with a shorter mean incision length in horses
● Hernia
(27 cm vs. 31.5 cm) [3]. Horses with repeat celiotomy
– Wound healing
incisions created in a right paramedian location develop
– Mechanical stress more incisional edema than those through ventral median
– Patient factors incisions [4].
– Surgical factors Individual horses have variable responses to suture
– Conservative treatment material. Unlike observations in other species, where it has
– Surgical repair been reported that subcutaneous sutures increase early
280 Complications of Aedominal Approaches
incisional swelling, the prevalence and severity of inci- presence of edema can itself decrease tissue perfusion,
sional edema is not affected by the presence of subcutane- which inhibits local defense mechanisms and increases the
ous sutures in horses [5, 6]. A trend has been identified risk of infection [10]. Peri-incisional edema can affect local
toward increased incisional edema with the use of anti- oxygen tension, resulting in delayed wound healing and
bacterial coated suture material in this application [3]. suppression of local immune function, which can further
Violent or prolonged anesthetic recovery increases the impact surgical recovery.
likelihood of incisional edema in horses with ventral
midline abdominal incisions [2, 7].
IncisionalDrainage
Diagnosis Incisional edema is typically identified on
clinical examination (Figure 26.1), including palpation of Definition The definition of incisional drainage varies
the area surrounding the incision. Edema will often be significantly between studies. In some cases, incisional
present symmetrically around the incision, and will be soft, drainage is defined as serous or serosanguinous discharge
cool, and non-painful on palpation. In cases of severe peri- from the incision associated with local edema, but without
incisional edema, ultrasonographic examination can be heat or pain [11]. In other cases, drainage is defined as
used to confirm the presence of edema, and rule out wound discharge of serum or purulent material
incisional infection or herniation. (Figure 26.1). Drainage can be indicative of incisional
infection or a precursor to more serious incisional
Prevention Careful tissue handling and minimizing complications, such as acute dehiscence or incisional
incision length should decrease the risk and severity of herniation, which are both frequently associated with
postoperative incisional edema. Elimination of unnecessary drainage [3].
dissection beneath subcutaneous tissues or adjacent to the
linea alba, during the surgical approach or closure, will Risk Factors
also limit surgical trauma and lymphatic disruption.
● Lesion type
● Surgical duration
Treatment The application of an abdominal support
● Illness severity
bandage is recommended in horses with moderate to
severe peri-incisional edema. Use of a hernia belt (CMTM
Pathogenesis The incidence of incisional drainage
Hernia Heal Belt) has been shown to provide superior sub-
following equine celiotomy ranges from 24–27%. [1, 12]
bandage compression compared to the use of an elastic
Drainage of any kind, whether serosanguinous or purulent,
tape bandage or nylon binder [8]. Hand walking for 10–15
is indicative of abnormal wound healing [12]. Drainage
minutes twice daily might also help to decrease the
during hospitalization is often transient. In 50% of horses
formation of incisional edema during stall rest in the
with incisional drainage, it resolves prior to hospital
postoperative period.
discharge [7]. However, absence of drainage prior to
hospital discharge does not indicate normal incisional
Expected outcome A majority of cases with completely
healing, as by 14 days post-discharge, the number of cases
healed skin incisions will still have significant edema
associated with the incision for 30 days postoperatively [7].
Although the presence of incisional edema in itself is not
associated with any serious complications, other than a
mild increase in discomfort in the area surrounding the
incision, its presence increases the risk of developing
incisional complications [9].
The presence of incisional edema is associated with a
higher risk of developing wound suppuration. Horses with
excessive incisional edema are reported as having a nearly
3.5 times greater risk of developing incisional infection
than those without incisional edema [6]. It is unclear
whether the presence of incisional edema is the cause or a
signal of developing further complications. Incisional Figure26.1 Marked incisional edema surrounding an equine
edema might form secondary to the inflammatory stimulus ventral midline celiotomy incision. Incisional drainage is
of infection within the sutured incision. However, the apparent.
Incisional Drainage 281
with incisional drainage will often double [7]. The highest should be cleaned several times daily with sterile 0.9%
risk period for development of incisional drainage from saline solution and antiseptics should be avoided as this
equine abdominal incisions is within 2 weeks of can further delay wound healing [16–18]. Flushing of the
surgery [13]. wound should be performed with caution as it can promote
Risk of incisional drainage from abdominal celiotomy spread of infection along the incision line. Topical
incisions in horses has been associated with the primary antimicrobials, such as triple antibiotic ointment or
lesion identified and corrected. Some investigators describe amikacin, can also be applied [19–21]. The application of
cases of large colon obstruction or strangulating small an abdominal bandage or hernia belt is recommended in
intestinal lesions as having a greater likelihood of inci- cases that develop incisional drainage, to prevent acute
sional drainage [7]. dehiscence or incisional hernia formation (Figure 26.2). A
Increased duration of general anesthesia is associated hernia belt should be used in cases with incisional drainage
with an approximate increase in the rate of incisional to reduce the risk of hernia formation, given the superior
drainage by 14-fold [7]. performance reported compared with alternative
Factors commonly associated with severity of critical abdominal bandages [8].
illness have also been linked to development of incisional
drainage. For example, horses with a heart rate >60 bpm at Expected outcome Drainage has been shown to be
presentation are at greater risk. Pyrexia has also been significantly associated with the development of more
associated with an increased likelihood of incisional serious incisional complications, such as infection,
drainage, with pyrexic patients 16 times more likely to have dehiscence or herniation. [14, 22, 23]. In one study, 46% of
incisional drainage than normothermic horses [7]. horses with incisional drainage developed wound-healing
Other risk factors associated with incisional drainage complications [9]. The odds of incisional herniation are 63
postoperatively include degree of pain on presentation and times greater in horses with incisional drainage [11].
duration of colic prior to admittance [7]. Drainage at day 14 or day 30 postoperatively has been
significantly associated with hernia formation, but
Diagnosis Incisional drainage is diagnosed by careful drainage during hospitalization or at discharge is not,
monitoring and visual inspection of the abdominal incision suggesting that transient drainage postoperatively does not
at least twice daily postoperatively. Any persistent always result in deleterious consequences [7].
serosanguinous discharge for greater than 24–48 hours
postoperatively indicates abnormal wound healing, and Incisional Infection
could indicate incisional infection. A sample of the
Definition Incisional infection is the most common
draining fluid should be collected aseptically and submitted
complication following open ventral midline celiotomy.
for bacterial culture and sensitivity.
The definition of incisional infection varies between
Prevention Decreasing the duration of anesthesia may be
helpful in reducing incidence of wound drainage [7].
Surgical techniques to reduce the risk of incisional drainage
include the use of a subcutaneous suture layer, avoiding
the use of chromic gut and braided non-absorbable suture
for closure, avoiding the use of a near-far–far-near pattern,
minimizing trauma to the incision, and isolating the bowel
carefully prior to performing an enterotomy or resection [7,
14, 15]. Systemic antibiotics may delay the onset of
drainage. The use of an abdominal bandage in the
postoperative period resulted in a 12.5-fold reduction in the
risk of incisional drainage at 14 days postoperatively [7].
Treatment Incisional drainage should be treated promptly

to reduce the likelihood of development of further
incisional complications, such as infection, dehiscence or
herniation. Staples or sutures adjacent to the site of Figure26.2 A hernia belt has been applied to a horse healing
drainage should be removed, and the skin left open in this from incisional infection and dehiscence following ventral
region to facilitate drainage from the incision. The incision midline celiotomy.
studies. Some authors define incisional infection as the of dead space, degree of trauma, and length of procedure
presence of purulent discharge associated with swelling, contribute to risk of incisional infection, therefore
heat and pain around the incision [11, 13, 15]. Others adherence to surgical principles is paramount in
define it as purulent, persistent serosanguinous, or minimizing risk. The host immune response is capable of
hemorrhagic drainage [1, 6, 7, 24, 25]. Still other authors suppressing <105 CFU/gm or ml when not impaired.
define it as the presence of any type of incisional drainage, However, tissue trauma associated with surgery can impair
irrespective of culture results or character of drainage [2, response and delay healing [15, 36, 37]. Various factors
12, 26–28]. associated with closure technique have been associated
with an increased risk of incisional infection. Excessive
Risk factors Numerous risk factors have been identified trauma to the incisional edges has been shown to increase
for equine abdominal celiotomy related to the three the risk of surgical site infection in several studies [13, 30].
components associated with wound infection, which Surgeon experience can determine the likelihood of
include bacterial inoculum, bacterial nutrition, and incisional infection [2]. Closure by a first- and second-year
impaired host immune response [12]. surgical resident increases the risk of surgical site infection
compared to closure by a third-year or boarded surgeon,
Surgical factors
which suggests that the risk of incisional infection is
● Location and characteristics of the celiotomy incision associated with skill of closure. It is known that overly
● Suture materials, suture patterns used large bites or excessive tightening can lead to ischemia and
● Method of closure, degree of peri-incisional tissue necrosis of the linea alba, resulting in infection and
trauma and amount of dead space dehiscence [38]. Conversely, uneven or incomplete closure
● Surgical technique, surgeon experience allows peritoneal fluid to pass through the linea alba and
● Lesion location (part of the gut involved) and type of accumulate in the subcutaneous tissues, producing
lesion (confounding evidence) conditions that promote incisional infection. Dissection of
● Degree of intraoperative tissue trauma and contamination the linea alba prior to closure should be avoided [11]. A
● Length of procedure (>2 hours) near-far–far-near pattern has been associated with
increased rate of infection compared to an interrupted
Illness severity of the patient suture pattern [15]. It is unclear what role subcutaneous
suturing plays relative to infection rate [6]. A modified
● Length of procedure (>2 hours)
subcuticular pattern has been considered to improve
● Preoperative left shift and/or pyrexia
infection rates by decreasing bacterial wound penetration
● Early postoperative colic and/or pyrexia
via suture material [24]. In people undergoing abdominal
● Prolonged fasting (unclear)
surgery, skin staples increase the risk of surgical site
● Intraoperative hypoxemia
infection compared to intradermal suture [39, 40]. This has
also been observed in horses, with a nearly 4-fold higher
Woundprotection
risk of developing a surgical site infection when skin
● Length of procedure (>2 hours) staples were used compared to a continuous dermal suture
● Immediate postoperative contamination of wound pattern [2] Apposition of skin edges and sealing of the
● Prolonged use of occlusive bandaging wound is likely less effective with staples compared to
continuous skin sutures, allowing for early postoperative
contamination. Regarding type of suture material, an
RepeatLaparotomy
increased rate of incisional infection has been reported
Pathogenesis Reported incidence ranges from 7% to 37%, with the use of polyglactin 910 in horses [13]. Use of
which is likely underestimated due to failure of follow up antimicrobial-coated suture material does not decrease
beyond hospitalization [1, 2, 6, 11, 13, 24, 25, 27–32]. It has likelihood of incisional complications in the equine
been reported that a proportion (13–100%) of surgical site abdomen [3].
infections can develop after hospital discharge [26, 28]. Regarding incision length, increasing length has been
The infection rates for abdominal celiotomy in horses are shown to increase the risk of incisional infection, especially
higher than the reported rate of surgical site infections in in horses with incisions >27 cm [31]. Similarly, other
other species: 13.3% in humans, 5.5% in small animals, and studies have reported that shorter incisions were associated
12.8% in cattle [33–35]. with less incisional complications [3]. Prolonged duration
Among surgical factors, the location of the celiotomy of general anesthesia is associated with an increased risk of
incision, suture material used, method of closure, amount incisional complications, especially in horses that undergo
procedures longer than 2 hours [41]. Performing surgery rolling and recumbency in the early postoperative period,
with an eye to duration is critical, as well as awareness of increased tension on the incision line from abdominal
increased risk with longer and more complex procedures. distension, or the impact of prolonged fasting on healing
Differences have been observed between open and and immunity is unclear [25, 31, 43]. Hypoxemia during
minimally invasive surgical techniques in horses, with celiotomy performed under general anesthesia increases
laparoscopic techniques having a lower incidence of the risk of surgical site infection. Low oxygen tension
incisional infection compared to open techniques [42]. decreases the bactericidal effect of neutrophils, which
People undergoing laparoscopic cholecystectomy have a decreases chemo-attractants and increases the risk of
lower rate of incisional infection (1.1%) compared to those infection [38].
undergoing open cholecystectomy (4%), with similar Wound protection has also been identified as an
results reported for urinary and pulmonary laparoscopic important factor. Environmental contamination of the
surgeries. The least invasive procedure should be selected surgical site during and following recovery plays a
to correct abdominal disorders in horses. significant role in development of surgical site infection in
Regarding lesion type, there have been conflicting reports horses following abdominal surgery. High surgical room
on whether lesion location influences likelihood of surgical contamination and isolation of bacteria from the incision
site infection postoperatively. Several studies suggest that immediately after recovery from anesthesia have been
large intestinal and cecal lesions increase the risk of identified as risk factors for surgical site infection [26].
incisional infection [13, 30]. In contrast, others report that Identification of the bacterial etiology during routine
lesion location or type is not associated with likelihood of hospital surveillance can aid in design of wound protection
incisional drainage [24]. Reports on the significance of strategies. Isolation of Streptococcus, Staphylococcus and E.
intraoperative contamination vary between authors. Clean- coli organisms supports superficial contamination of the
contaminated surgeries have been associated with an wound from commensal or environmental
increased risk of surgical site infections, which suggests contaminants [12].
that intestinal bacterial contaminants play a role in Protection of the abdominal incision during recovery
development of incisional infection [13, 32]. Abdominal from general anesthesia and in the early postoperative
surgeries with intraperitoneal contamination have an period is recommended, but occlusive dressings can
increased incidence of surgical site infection compared to negatively impact the wound environment if not removed
those without intraperitoneal contamination [11]. expeditiously. This has been evaluated in multiple studies
Incisional infections also occur more frequently in horses investigating the impact of sutured stent bandages
undergoing procedures accompanied by heavy overlying the abdominal wound on risk of surgical site
contamination, such as enterotomy in locations other than infection. If used, sutured stent bandages should be
the pelvic flexure, multiple enterotomies, and large colon removed approximately 12 hours after surgery, and should
resection, when compared to those undergoing lightly not be used concurrently with an adhesive drape, to
contaminated procedures, including simple exploratory mitigate risk of infection [2, 11].
laparotomy, resection/anastomosis, pelvic flexure Repeat laparotomy has been shown to increase the risk
enterotomy, or surgical enema [25, 31]. Other studies of surgical site infection, with a prevalence of incision
indicate that contamination at surgery does not seem to be infection ranging from 44–87.5% reported for horses that
a critical factor in development of incisional infection [27]. have undergone more than one open laparotomy [11, 15,
Illness severity of the patient plays a crucial role. There is 28]. Despite the documented increase in risk with repeat
evidence to suggest that surgical site infection is more laparotomy, it is unclear what role the interval between
likely in horses undergoing celiotomy attendant with surgeries or incision locations play in mitigating or
severe illness, which explains in part the concurrent increasing risk.
observation of surgical site infection and other postoperative
complications. There is a positive association between Diagnosis Incisional infections generally develop in the
incisional drainage or infection and fever and preoperative first 3–7 days following surgery, but onset can be delayed
left shift with fever, with approximately one-third of febrile by up to 14 days, especially if postoperative antibiotics are
horses in one study developing incisional drainage [12]. used [26, 44]. Horses developing incisional infection often
Postoperative peritonitis and jugular thrombophlebitis initially become pyrexic prior to local signs of incisional
have been correlated with an increased risk of surgical site infection being noted. Severe incisional edema and
infection. Several studies have shown a significant excessive tenderness of the incision can precede incisional
association between postoperative colic and an increased infection, and could be an early warning sign in some
risk of incisional infection and whether this is due to cases. Purulent drainage is indicative of infection.
Prevention The risk of incisional infection can be

decreased by targeting patient preparation, surgical
technique, and post-surgery wound protection and care.
Proper aseptic preparation of the patient and preparation
of the surgery site has been shown to reduce incisional
infection, as well as the following measures: minimizing
surgery time, strict adherence to aseptic technique,
minimizing trauma to the surgical wound, careful tissue
handling, avoiding excessive or reactive suture material,
and avoiding overly large suture bites that cause ischemia
of the abdominal wall by creating excessive tension 1 [45].
To this end, an optimal bite size of 15 mm should be Figure26.3 Appropriate closure of the linea alba following
utilized when closing the equine linea alba ventral midline celiotomy incision in a horse.
(Figure 26.3) [38]. Perioperative systemic antibiotic
therapy should be utilized in horses undergoing
exploratory celiotomy, but prolonged postoperative use is
likely not indicated [46]. Lavage of the incision in the
linea alba prior to closure of the subcutaneous tissues and
skin decreases rate of incisional infections, with a rate of
incisional infections of 20% in horses that did not have
lavage performed, compared to 13% in those that did have
lavage performed [2]. Incisional lavage removes blood
clots and gross contamination, which can reduce bacterial
load at the incision. Topical application of antibiotics to
the linea alba incision prior to closure of the subcutaneous
tissues and skin has been associated with a decrease in
the rate of incisional infection [2, 11].
Figure26.4 An incise drape has been applied to cover an
An incise drape applied to the surgical wound during equine ventral midline celiotomy incision prior to anesthetic
anesthetic recovery will also prevent incisional contami- recovery to prevent incisional contamination.
nation and subsequent infection (Figure 26.4) [11, 12, 15,
26]. The application of an abdominal bandage to protect
the incision immediately after recovery from anesthesia Treatment A sample of incisional drainage should be
has been recommended to help prevent incisional infec- collected aseptically and submitted for bacterial culture
tion, with a 45% absolute risk reduction of incisional and sensitivity testing, to allow for identification of
complications reported in one study [7]. Use of a sutured infection etiology and appropriate selection of
stent bandage in recovery, followed by stent removal 5 antimicrobials for treatment. Staples or sutures adjacent
days postoperatively and abdominal bandage placement to the site of drainage should be removed, and the skin
also resulted in a significant decrease in likelihood of sur- left open in this region to facilitate drainage from the
gical site infection, with a 10-fold increase in the odds of incision. In some cases, removal of subcutaneous sutures
developing an incisional infection in patients in which a might also be necessary. The incision should be cleaned
stent bandage was not used [27]. Sutured stent bandages several times daily with sterile 0.9% saline solution, and
have been shown to be preferential when compared to topical antimicrobials can be used. Horses that are
stent bandages secured with an incise drape in one report, afebrile after drainage has been established, and without
with a decreased rate of incisional infection noted when a excessive local tissue reaction or systemic signs of illness,
sutured stent bandage was used [2]. It is theorized that might not require systemic antibiotics. However, in horses
sutures decrease tension on the primary incision line and that are febrile, or with severe local tissue reaction,
apply direct pressure to the incision. Technique selection systemic antibiotic treatment should be considered.
can aid in prevention of postoperative incisional infec- Flushing the wound should be avoided to prevent spread
tion. Laparoscopic techniques are associated with a lower to deeper tissue planes. The application of an abdominal
incidence of incisional infection, faster healing of inci- bandage or hernia belt is recommended in cases with
sions, quicker return to use, and less postoperative pain incisional infection to prevent acute dehiscence or
compared to open techniques [42]. incisional hernia formation.
Expected outcome Incisional infection is significantly Factors leading to incisional breakdown related to the
associated with an increased risk of more serious wound patient include abdominal distension, tissue weakness,
complications, such as acute dehiscence and incisional postoperative pain resulting in rolling postoperatively,
herniation. Incisional infection results in increased length violent recovery from general anesthesia, incisional
of hospitalization, increased likelihood of incisional hernia infection, and severe systemic disease postoperatively. In
formation, and delayed return to use [7, 11, 12, 23, 47]. people, factors associated with surgical wound dehiscence
Purulent incisional drainage in the early postoperative include increased age, concurrent illness, emergency sur-
period has been associated with an increased likelihood of gery, postoperative coughing, and wound infection [49].
dehiscence and hernia formation [7]. Incisional infection
is likely to result in a longer period of recuperation, Diagnosis Partial dehiscence is detected by examination
including a lengthier period of stall rest prior to return to and palpation of the suture line and discovery of leakage of
use, and the use of abdominal bandages for 2–3 months fluid from the incision, retraction of the wound edges, or
postoperatively. loss of wound continuity. Full thickness dehiscence is
detected by leakage of amber peritoneal fluid from the
Dehiscence incision, palpation of evident gaps in the sutured abdominal
wall, and prolapse of peritoneal contents. Abdominal
Definition Dehiscence is defined as separation of the
bandaging or hernia belt application will contain prolapse
layers of a surgical wound, and can be either partial or full but will not prevent evisceration. Frequent monitoring of
thickness. Full thickness dehiscence in horses following the abdominal wound is necessary in cases in which
exploratory celiotomy can result in evisceration [29]. dehiscence is suspected.
Risk factors Prevention Care in incision design, protection, and closure

Surgical factors Incisional trauma are necessary to prevent dehiscence. Appropriate suture
composition, size, and placement are imperative. USP No.
● Incision size
7 polydioxanone or USP No. 6 polyglactin 910 have been
● Incision location
recommended for closure of the linea alba in adult
● Surgeon experience
horses [50]. Special care should be taken in closing the
cranial linea alba, since this region has been shown to have
Patient factor Abdominal distension
reduced tensile strength compared to the caudal linea alba.
● Inherent tissue weakness The surgeon should ensure there is no mesentery, bowel or
● Early postoperative colic omentum entrapped within the suture line. Minimizing
● Violent recovery from general anesthesia transrectal abdominal palpation post-celiotomy may be
● Incisional infection protective, as palpation per rectum results in an increase in
● Severe systemic disease postoperatively abdominal pressure [45]. Optimizing the quality of
anesthetic recovery is critical. The use of a belly bandage in
Pathogenesis Incisional dehiscence results from structural recovery has been advocated during recovery.
failure of the abdominal wall and can be related to healing
deficits. Disruption of the incision usually occurs early in Treatment An abdominal bandage should be applied prior
the postoperative period and can be preceded by to surgery to protect the incision and any protruding
serosanguinous incisional drainage. viscera. In the case of eventration, early detection is crucial
Factors leading to incisional breakdown related to surgi- to minimize bowel trauma, contamination, and ischemia.
cal technique include incisional trauma from inappropri- The patient should be anesthetized, positioned in dorsal
ate tissue handling, sutures placed too close to the edge of recumbency, and all sutures removed. The incision should
the incision, weakening/breakage of the suture, slippage/ then be aseptically prepared. In the case of evisceration,
untying of knots, and migration of omentum, bowel, or exposed bowel should be thoroughly lavaged with isotonic
mesentery between sutures of the linea alba. The linea alba fluids to remove superficial contamination. The incision
is thinner in the cranial abdomen and subjected to higher should be lavaged and superficially debrided to remove
expansile stress in this location [48]. Risk of dehiscence is necrotic, infected, or heavily contaminated tissues, and a
observed with longer incisions, especially when located in sample should be collected and submitted for culture and
the cranial abdomen. In people, an increased risk of sensitivity analysis.
abdominal dehiscence is seen with decreased surgeon Abdominal lavage should be performed prior to closure,
experience. and placement of an abdominal drain to facilitate continued
postoperative abdominal lavage and drainage should be In cases with partial dehiscence, an abdominal bandage
considered. One strategy for closure of the abdominal and hernia belt should be applied until incisional healing
wound following dehiscence is application of full thickness has occurred. With proper support during healing, surgical
interrupted monofilament stainless steel wire mattress closure might not be required in horses with partial
sutures [51]. Rubber or plastic stents can be used to abdominal wall dehiscence.
distribute tension and prevent the wire cutting through the
skin and underlying tissue prematurely (Figure 26.5). Expected outcome Partial dehiscence results in delayed
These sutures are preplaced, and the wound closed by healing and increased risk of full thickness dehiscence or
sequential tightening of these sutures. Daily wound care herniation. Dehiscence is a life-threatening complication.
and staged suture removal can be instituted during healing. If full thickness dehiscence is not promptly addressed with
Necrosis will be evident at each suture site, which will immediate surgery, subsequent trauma, contamination,
result in loosening prompting removal (Figure 26.6). An and ischemia of the intestines might result in death of the
abdominal bandage should be applied until incisional animal.
healing.
Hernia
Definition Incisional hernias are defects in the body wall

of horses following exploratory celiotomy.
Risk factors
Wound healing
Incisional edema, drainage, and infection
Mechanical stress
● Location of incision (cranial ventral abdomen)

● Violent recovery from anesthesia
● Early postoperative exercise
Figure26.5 Ventral midline celiotomy incisional dehiscence ● Trans-rectal abdominal palpation in the early postopera-
treated with full thickness interrupted monofilament stainless tive period
steel wire vertical mattress sutures. Plastic stents have been
used to distribute tension and prevent the wire cutting through
the skin and underlying tissue prematurely. Patient factors
● Age
● Body weight
● Tachycardia upon admission
● Postoperative leucopenia
● Postoperative pain
Surgical factors
● Suture material
● Procedure duration
● Repeat laparotomy
Pathogenesis Incisional hernias result from inadequate

healing of the surgical incision. Incisional hernias develop
in between 5% and 20% of horses following ventral midline
Figure26.6 Ventral midline celiotomy incisional dehiscence
celiotomy [9, 11, 24, 47]. Most incisional hernias develop
treated with full thickness interrupted monofilament stainless
steel wire vertical mattress sutures 14 days previously. Necrosis after hospital discharge and are usually identified between
is evident at each suture site. 2 and 12 weeks after surgery [23, 29]. Hernias can form as
Hernia 287
a single large defect (Figure 26.7), but approximately 20% tion forces [48]. Risk factors associated with incisional her-
of horses develop multiple smaller hernias along the nia formation include violent recovery from anesthesia [12].
incision (Figure 26.8) [45]. Early uncontrolled postoperative exercise contributes to
Risk factors associated with incisional hernia formation hernia formation, especially prior to 4 weeks post-sur-
include incisional edema, drainage, and infection, with the gery [48]. Based on studies evaluating healing of the equine
majority of equine hernias resulting from poor wound heal- linea alba, horses should not return to controlled exercise
ing [14]. Severe peri-incisional edema increases tension on prior to 60 days postoperatively to avoid incisional hernia
sutures and contributes to ischemia of the incisional formation [48]. Trans-rectal abdominal palpation results in
edges [23]. Incisional infection contributes to weakening of increased intra-abdominal pressure and should be avoided
the tissues and suture material because of bacterial activity in the early postoperative period [45].
and inflammation at the laparotomy site [14, 23]. Older horses and those with higher body weight are at
Incisions in the cranial ventral abdomen are at greater great risk of incisional hernia formation [1]. Tachycardia
risk of hernia formation due to mechanical stresses. The upon admission and postoperative leucopenia associated
cranial portion of the ventral midline incision is more sus- with septicemia increases the likelihood of incisional com-
ceptible to dehiscence, as the linea alba in this location plications [1, 22, 52]. Horses with more postoperative pain
supports a relatively greater visceral load due to the shape are at greater risk of hernia formation [1].
of the abdomen, and therefore undergoes greater distrac- Closure of the linea alba with chromic gut suture is a fac-
tor associated with hernia formation [1]. Increased proce-
dure duration increases the likelihood of incisional hernia
formation [7]. Repeat laparotomy is also a significant risk
factor for incisional hernia development [23].
Diagnosis Incisional herniation can be identified by

examination and palpation of the incision and detection of
pliant areas, weakening, or defects in the body wall.
Established ventral hernias are usually grossly visible.
Ultrasonographic examination of the healing incision can
confirm defects in the body wall and evaluate contents of
the hernia sac.
Prevention Appropriate and meticulous surgical

technique, including minimizing trauma and proper body
wall closure, should be applied to reduce the risk of
incisional hernia formation [38]. Use of a commercial
Figure26.7 A Friesen horse that has developed a large hernia
hernia belt following ventral midline celiotomy reduces
associated with previous ventral midline celiotomy. This horse
underwent three celiotomy procedures and developed incisional the incidence of incisional hernia development in horses
infection. The hernia is visible along the ventral abdomen. that develop incisional complications and in horses
considered to be at increased risk for hernia development [3].
Treatment
Conservative treatment
Small hernias and those detected early can be managed
conservatively with an abdominal support bandage. A her-
nia belt (CMTM Hernia Heal Belt) is useful to provide sup-
port to the abdominal wall during healing. A prolonged
duration of abdominal bandaging or hernia belt use, for
between 3 and 8 months, might be necessary [45].
Figure26.8 A horse that has developed multiple small hernias Surgical repair
associated with previous ventral midline celiotomy. This horse
underwent two celiotomy procedures. The hernias are visible Surgical repair should be applied when a hernia fails to
along the ventral abdomen. heal with conservative management or enlarges after
turnout or activity, especially in athletic horses.

Hernioplasty, either by suturing or mesh implants, pro-
vides the best cosmetic outcome and prognosis for return
to use for riding or breeding [14]. Surgical repair should
not be attempted until there is complete resolution of
incisional infection and fibrous tissue maturation of the
hernia ring. For this reason, hernia repair should be
delayed for at least 3 months after hernia develop-
ment [45]. Horses should be fasted for 12–24 hours prior
to surgery. Small hernias can be repaired by primary
suture closure, while repair of larger hernias can be
approached using a double-crossing continuous suture
pattern by two surgeons [45]. Hernioplasty utilizing syn-
thetic mesh and fascial overlay can be applied to large
Figure26.9 Mesh hernioplasty of a single large hernia that
hernias not amenable to primary repair (Figure 26.9), but developed following a previous ventral midline celiotomy.
surgical mesh infection can result in serious complica-
tions [45]. Following hernioplasty, an abdominal bandage result in severe colic and death without treatment [14].
or hernia belt should be used for at least 30 days in con- Surgical repair improves overall prognosis for return to
junction with restricted activity. use. However, short-term complications related to the
repair can delay healing or impact results. Major
Expected outcome Horses with small incisional hernias complications of surgical repair include tearing of the
can return to athletic use without adverse effects. Larger muscle and fibrous tissue incorporated in repair during
hernias typically require repair, regardless of the intended recovery and incisional drainage and wound complications
use [14]. Visceral adhesions adjacent to the hernia can following [52].
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291
27
Complicationsof the IntraoperativeColicPatient

Anje G. Bauck DVM, DACVS-LA and David E. Freeman MVB PhD, DACVS
College of Veterinary Medicine, University of Florida, Gainesville, Florida
Overview RupturedViscus
Intraoperative complications were recorded in 2.7% of

horses that recovered from anesthesia for colic surgery in Definition Catastrophic intra-abdominal contamination
one study [1], although the actual prevalence could be from full-thickness perforation of a segment of the
higher, depending on definitions, and milder forms might gastrointestinal tract.
not be detected in retrospective studies. Intraoperative
complications differ from postoperative complications Risk Factors
because they are usually immediately apparent or at least
● Large colon impaction
suspected during surgery and can confront the surgeon
● Distention of part of the gastrointestinal tract, especially
with a crisis that warrants immediate action. Those that
colon or cecum
escape detection or cannot be fully resolved are likely to
● Traumatic surgical technique
cause postoperative complications and death.
● Compromised, friable visceral wall
● Failure to partly decompress severely distended or
impacted segments by appropriate methods before exte-
L riorizing them
with the IntraoperativeColicPatient ● Presence of the natural vacuum effect that tends to retain
the impacted segment in the dorsal abdomen
● Ruptured viscus
● Excessive intra-abdominal contamination Pathogenesis Opening the abdomen loses the intra-
● Partial thickness tears abdominal pressure that can oppose the bursting pressure
● Hemorrhage from small intestinal mesentery in a distended viscus. Consequently, transmural pressure
● Rupture of the portal vein in the colon wall increases dramatically in the impacted
● Hemorrhage from large colon mesentery segment.
● Miscellaneous intra-abdominal hemorrhage Although iatrogenic rupture accounts for only 1.7% of
● Intraoperative injury to small intestinal mesentery deaths in horses after all types of colic surgery [1], it has
● Miscellaneous iatrogenic vascular injuries been reported in 21% of horses undergoing surgery for
● Intestinal ischemia at the anastomosis large colon impaction [2]. Attempts to exteriorize part of
● Anesthesia-related complications an impacted large colon or cecum can rupture these
● Intestinal rotation segments because the necessary force to elevate them out
● Failure to identify the lesion of the abdominal cavity can increase tension in the
● Failure to correct the lesion abdominal wall. The most likely site of iatrogenic rupture
● Instrument failure is the right dorsal colon, which has a considerable capacity
● Failure to remove an intra-abdominal surgical item for impacted material and is therefore under tremendous
● Enteropexy tension as it is elevated from the dorsal abdomen. It is also
292 Complications of the Intraoperative Colic Patient
the most fixed segment of the large intestine through its be removed [3]. At the end of the procedure, the abdominal
attachments to other viscera and the dorsal abdomen. cavity can be lavaged with an additional 20 L of normal
saline with 103 units of heparin/L [3]. A 30-French Foley
Prevention Prevention of large colon rupture can be catheter should be inserted 3 cm to the right of midline at
accomplished by extending the abdominal incision the most cranial aspect of the celiotomy for daily abdominal
sufficiently to reduce tension on the colon or cecum as it is lavage [3]. Long-term intravenous antibiotic treatment is
exteriorized. Needle decompression to remove gas can indicated. However, antibiotics in the lavage fluid are
reduce the overall tension in the wall of the impacted probably unnecessary and have been implicated in
viscus. The impacted segment can be partly exteriorized to adhesion formation [5]. If the tear is almost circumferential
be decompressed through an enterotomy and then the or otherwise beyond repair, or its blood supply is
remainder can be more safely exteriorized. jeopardized, resection of the affected colon segment should
Patience is required to exteriorize the colon in incre- be considered [6]. This option might not be available if the
ments, and the flattened palms or forearms should be used cecum is affected.
instead of fingers to elevate the deeper segments. The
abdominal contents can be floated in a sterile physiological Expected Outcome Repair of an intra-abdominal tear has
solution to separate the colon away from the abdominal been described in a horse that incurred a partly
wall. This also breaks the vacuum effect in the dorsal abdo- circumferential colon rupture deep in the abdomen during
men, which combines with the weight of the colon to correction of a right dorsal displacement of the colon [3].
increase the amount of tension required to exteriorize it. The horse recovered, but it developed peritonitis and
weight loss initially, an incisional infection and hernia, and
Diagnosis Intra-abdominal contamination can become recurrent bouts of colic, presumably from adhesions [3].
readily apparent intraoperatively. Rupture of the viscus Results with this case might not be widely accepted as
may be accompanied by a sudden decrease in tension in satisfactory. In those cases, in which the tear occurs outside
the wall of the affected organ. the abdominal cavity so that contamination can be
The smell of intestinal contents emanating from the contained and the tear prevented from propagating,
abdomen can become immediately apparent. The surgeon removal of contamination and effective closure of the tear
might detect intestinal contents on other viscera or on his/ should produce a favorable outcome.
her hands and arms
Treatment Rupture of the colon or any viscus deep in the xcessiveIntra-Abdominal

E
abdomen is grounds for immediate humane euthanasia. If Contamination
the ruptured segment of intestine can be exteriorized
before intra-abdominal contamination develops, it should Definition Abdominal contamination with intestinal
be carefully packed off from remaining abdominal contents greater than expected for colic surgery that is not
contents. The abdominal incision can be extended as associated with a ruptured viscus
needed to relieve intra-abdominal tension on the ruptured
Risk Factors
segment. An assistant should grasp the edges of the tear
with saline-soaked sponges and keep them in close contact ● Presence of any lesions that may require opening an
so that the tear does not propagate under any remaining intestinal segment in a poorly accessible location
tension. The affected segment should be evacuated quickly ● Poor surgical technique
through an enterotomy distant to the site of rupture, such ● Inadequate use of protective barriers, drapes and suction
as the pelvic flexure for the colon or the apex for the cecum.
The rupture site should be cleaned with saline-soaked Pathogenesis Any procedure that involves opening an
sponges and the contamination contained to prevent intestinal segment that is poorly accessible and deep within
involvement of other visceral surfaces and the abdominal the abdomen, such as colotomy for removal of sand [1] or
incision. The contaminated portion should also be lavaged enteroliths [6] can result in excessive abdominal
with saline and heavily contaminated omentum contamination. Gastrotomy or gastroenterostomy in an
amputated [3]. The abdominal cavity is then thoroughly adult horse can be associated with excessive contamination,
lavaged and contents removed through suction until the especially if the stomach is not enlarged sufficiently to
suctioned fluid is clear [3]. A liquid proportioner could bring it to the abdominal incision edges.
deliver a large volume of isotonic saline solution instead of Other examples are correction of a cecocolic intussuscep-
water [4] if severe intra-abdominal contamination needs to tion through a right ventral colotomy, large colon resection
Partial Thickness Tears 293
far distally on the right dorsal colon, or enterotomy or A small incision should be made initially and as much
enterectomy in the most proximal and distal parts of the free fluid and gas as possible should be removed from the
small colon. lumen by suction. The incision can be extended in
increments, taking great care to suction draining fluid and
Prevention Prevention of heavy contamination is to clean the edges with saline-soaked laparotomy sponges
preferable and usually more time-efficient and more (18 in. by 18 in. or larger). Smaller sponges require frequent
effective than managing it as it develops during surgery. application, quickly become saturated, and can be difficult
The segment to be opened should be isolated from the to count in a timely manner.
remainder of the abdominal cavity by suturing one or more
plastic drapes around the proposed incision site Diagnosis Excessive abdominal contamination is readily
(Figure 27.1). Saline soaked laparotomy drapes can be observed intraoperatively. If contamination is not
included above or below the plastic drapes to augment the adequately addressed at surgery, clinical signs of peritonitis
barrier effect, and many should be available to clean (fever, abdominal pain, inappetence), with supporting
contaminated edges. Sodium carboxymethylcellulose can hematological and peritoneal fluid cytological findings
be applied to the isolated serosal surface before it is opened may be observed postoperatively.
and subsequently to prevent adherence of lumen contents
to it.
Treatment Excessive abdominal contamination can
Organization is critical and every member of the surgical
require intra-abdominal lavage with warm saline or other
team needs to be assigned a role that facilitates the
physiological solution (10–20 L) and postoperative lavage
procedure and protects exposed serosal surfaces. This
through an indwelling intra-abdominal catheter inserted at
includes traction to improve exposure and cleaning up
the end of surgery (see above). Intravenous antimicrobial
contamination as it develops. Additional assistant sur-
drugs might need to be administered for longer than
geons might need to scrub in to provide additional help.
typically planned, depending on the postoperative clinical
course and even culture of peritoneal fluid samples. Large
colon resection can be used to remove heavily contaminated
colon [6] and the cecal apex can be removed if a typhlotomy
site has become severely contaminated or traumatized. In
the author’s experience, postoperative lavage, or other
specific measures to treat postoperative peritonitis, are
rarely indicated after most procedures associated with
contamination, largely because of the efficacy of methods
used to contain leakage at surgery.
Expected outcome With appropriate preventative

measures as described, heavy contamination can often be
avoided. If excessive abdominal contamination does
occur, a prompt intraoperative response to control the
spread of contamination, along with cleaning with saline-
soaked sponges and appropriate high- volume lavage, can
often result in good outcomes with minimal risk of
postoperative peritonitis. Failure to adequately contain
the contamination at the time of surgery can lead to
postoperative peritonitis, which can be expensive and
difficult to treat.
PartialThicknessTears
Figure 27.1 Portion of stomach wall sutured to a plastic drape Definition Tears through the seromuscular layer of any
to prevent abdominal contamination during gastrotomy.
Carboxymethylcellulose and laparotomy sponges can be added segment of stomach or intestine, in which the mucosa and
to further contain spillage. submucosa are still intact
Risk Factors Risk Factors
● Presence of impaction ● Small intestinal resection and anastomosis places horses

● Traumatic surgical technique at greater risk of intra-abdominal hemorrhage than sur-
● Compromised, friable bowel gery for simple replacement or enterotomy, according to
one study [7]
Prevention Similar to above measures to prevent a full ● Mesenteric lipoma
thickness tear or rupture (see above) ● Mesenteric rent
Pathogenesis Partial-thickness tears can develop in the
same manner as full-thickness tears, but are not Pathogenesis Failure to adequately occlude a mesenteric
immediately life-threatening. They can propagate in size or vessel during small intestinal resection and anastomosis
convert to a full-thickness tear if they are missed or ignored can cause immediate bleeding or form an expanding
during continued attempts to exteriorize the colon. hematoma in the mesentery (Figure 27.2). Some bleeding
vessels escape detection during surgery, but hemorrhage
Diagnosis Careful visual inspection following
can become profuse when the horse becomes more
exteriorization of the bowel should be performed to identify
normotensive after anesthesia. Blind intra-abdominal
partial tears in the seromuscular layer. If the tear is in an
transection of a lipoma stalk could also cause inadvertent
inaccessible location, gentle palpation of the manipulated
transection of a mesenteric vessel, but the source of
bowel may reveal the defect.
bleeding is usually accessible when the intestine and the
Monitoring Postoperatively, the horse should be monitored affected mesentery are exteriorized.
closely for clinical and clinicopathological changes to Mesenteric hematomas can present as primary diseases
indicate that partial-thickness tears progressed to full- and have been associated with necrosis of the contiguous
thickness tears. segment of small intestine and rupture with fatal
hemorrhage during recovery [8]. Hematomas that develop
Treatment As with full-thickness tears, if the colon is in the mesentery following intraoperative mesenteric
distended and places tension on the torn edges, the colon injury could cause similar problems if not treated by
must be decompressed through an enterotomy to prevent ligation or resection. However, access might not be possible,
propagation of the tear in length or in thickness. Tears that in which case the horse can be recovered with the
are accessible should be repaired with a single layer hematoma (Figure 27.2). Mesenteric hemorrhage can also
Lembert pattern. While the colon is undergoing be caused during reduction of small intestine entrapped in
decompression, a surgical assistant should observe the tear a mesenteric rent [9].
during the process and carefully grasp the adjacent colon
with a saline-soaked sponge to keep the edges close
together and prevent propagation.
Expected outcome If the defect is accessible and

appropriately repaired, partial thickness tears have little
effect on outcome. If partial thickness tears develop in
segments that are inaccessible, horses can recover with
such defects without developing complications. Recurrence
of distention with gas, liquid or solid contents after surgery
could convert the tear to a full-thickness defect, although
this is rare.
emorrhagefrom SmallIntestinal
H
Mesentery
Definition Hemorrhage from tearing or inadequate Figure 27.2 Mesenteric hematoma associated with a
strangulating lipoma. A similar injury can be inflicted by trauma
ligation of one of the small intestinal mesenteric vessels.
to the mesentery during surgery. The affected vessel was
This was one of the most common intraoperative inaccessible for ligation and removal of the hematoma in this
complications reported in one study [1]. case and had to be left in place.
emorrhage from Small Intestinal esentery 295
Prevention Appropriate methods for mesenteric resection part of the mesentery is difficult, and can require the help
play a critical role in preventing hemorrhage from of many assistants and long handled instruments. The
mesenteric vessels during small intestinal resection and affected segment of small intestine is drawn up and spread
anastomosis. During this procedure, mesentery is resected to tense the mesentery, and laparotomy sponges are placed
as needed to free up a long segment of small intestine for deep in the abdomen to prevent adjacent viscera and
decompression through an enterotomy in the strangulated pooled blood from obstructing the view. Instruments that
segment [10]. As the mesentery is resected, the major can be used to ligate deep tears are long handled needle
vascular branches are ligated and divided close to and drivers, a long Deschamps’ needle, laparoscopic needle
dorsal to their bifurcation into the arcade branches to the holders, and the EndostitchTM. Although vascular clips can
small intestine [10]. No attempt is made to remove all the be used to close mesentery [12], tension on the mesenteric
strangulated mesentery as this can be difficult and adverse edges pushes the closed ends of the clips apart and loosens
effects are rare even if partly retained. During this process, them.
the cut edge of the mesentery should be gathered in a If the surgeon is concerned about the volume of blood
continuous pattern to retain the incised mesenteric edges lost during hemorrhage or the difficulty in controlling
outside the abdomen so the transected major mesenteric hemorrhage, the anesthetist should be advised so that the
arteries and veins are in full view. Double or triple ligation horse’s status can be closely monitored and volume support
is not recommended because these steps can be time- can be provided (see monitoring above). In many cases the
consuming and unnecessary. The authors prefer to use the bleeder is not accessible for ligation, and treatment of
Ligate Divide Stapler (LDSTM) or the LigasureTM, because blood loss is the only option in the hope that the hemorrhage
these simultaneously occlude the vessel at each side of the ceases and the horse can recover from anesthesia. The goal
line of transection. If there is a concern about the security of treatment should be to maintain a mean arterial pressure
of any of these sealing methods, a ligature can be applied of at least 60 mmHg through volume replacement and
also. If a short segment is involved, ligation is adequate and inotropic treatments to support vital organs [11].
inexpensive. The gathered mesenteric stump should be Despite causing hemodilution, crystalloid fluid infusion
checked during and after the mesentery is gathered for any IV can increase delivery of oxygen to the tissues by
bleeding mesenteric vessels and this can be repeated at maintaining or enhancing stroke volume and cardiac
least once before the abdomen is closed. output and decreasing vascular resistance through
decreased viscosity [11]. Hypertonic saline can temporarily
Diagnosis Hemorrhage from exteriorized mesentery is restore mean arterial blood pressure, cardiac output, acid–
often readily apparent intraoperatively. In cases where base equilibrium, and mean circulatory filling pressure by
hemorrhage arises from mesentery deep in the abdomen, producing an osmotic fluid shift into the vascular
retrieval of blood on the surgeon’s hand after insertion into compartment [11]. It can also enhance myocardial
the dorsal abdomen, combined with a drop in blood contractility [11]. Hypertonic saline can provide rapid
pressure and rise in heart rate, can indicate significant cardiovascular support while waiting for blood from a
hemorrhage. donor [11]. The main purpose of a blood transfusion is to
provide red blood cells and improve oxygen delivery, but
Monitoring Intraoperative anesthetic monitoring continued treatment with IV crystalloid solutions might be
including heart rate, blood pressure, oxygen saturation required to support extracellular fluid volume.
(SpO2), PCV/TP, blood lactate and arterial blood gas. The Any ventilation/perfusion imbalance that develops will
purpose of this is to detect severity of blood loss and to require supplemental oxygen to maximize hemoglobin
guide treatment selection to support the patient’s saturation and improve tissue oxygenation [11]. Anesthetic
cardiovascular status and extracellular fluid volume. depth should be carefully monitored because the decreased
When suction is used to remove blood from the abdo- vascular volume and cardiac output can reduce inhalant
men, the volume should be recorded in the suction bottles removal and thereby increase the alveolar anesthetic
to provide an approximate measure of blood removed [11], concentration [11]. Balanced anesthetic techniques with
recognizing the effect of dilution with any lavage fluid that agents that are unlikely to depress cardiovascular function
might have been infused. are used to diminish hypotensive effects from the
inhalant [11]. Doses of any drug should be reduced because
Treatment If the injured mesenteric vessel is involved in its volume of distribution can decrease in the hypovolemic
the primary lesion and can be exteriorized after correction, horse, thereby increasing the drug concentration to
it can be ligated or removed during resection of the diseased dangerous levels [11]. Once bleeding is controlled, any
intestine. However, ligation of a torn vessel in the dorsal blood free in the abdomen should be removed by suction
and lavage to minimize the risk of postoperative peritonitis include: i) massaging fluid from the entrapped segment
or abdominal adhesions. However, these risks might be into the empty and collapsed distal segment; ii) drawing
offset by the benefits of autotransfusion. empty intestine distal to the incarceration through the EF
(left to right), so fluid from the strangulated intestine can
Expected outcome If the source of hemorrhage is identified be distributed into that empty loop [15]; iii) by transection
and controlled before loss of significant blood volume and over-sew of the proximal jejunum to replace one
(>20% blood volume), prognosis is generally good. strangulated segment of intestine with normal mesentery;
Significant hemorrhage from vessels which cannot be and iv) to empty the proximal segment through an
identified at surgery is often fatal. In some cases, enterotomy, so a short empty segment can be drawn into
hemorrhage will either be delayed or not be identified until the EF to replace a strangulated segment. With the last two
the horse recovers from anesthesia. Please refer to methods, the abnormal intestine can be resected to include
Chapter 7: Complications Associated with Hemorrhage, the enterotomy site or over-sewn ends as part of the
for discussion of postoperative hemoabdomen. resection and anastomosis.
Although enlargement of the EF has been proposed [18],
this is not currently recommended without specific
guidelines.
Ruptureof the PortalVein
Diagnosis The first indication of hemorrhage is the
DefinitionHemorrhage as a result of acute rupture of the
presence of dark venous blood on the surgeon’s hand and
portal vein during correction of epiploic foramen
arm when withdrawn from the abdomen after the EFE has
entrapment (EFE).
been released. Typically, signs of blood loss become
immediately apparent to the anesthetist, usually as a
Risk Factors
precipitous drop in blood pressure and increased heart
● EFE of the small intestine usually or large colon (rarely) rate. After that, venous blood will be noted to accumulate
● Excessive traction on the intestine during correction of in the dorsal abdomen.
EFE
Monitoring See Section on Hemorrhage from Small
Pathogenesis The portal vein is vulnerable to tearing Intestinal Mesentery above.
where it forms the cranioventral edge of the epiploic
foramen (EF) [13–15]. Rupture of the portal vein can arise Treatment Because of the location, repair of the vein is
during extraction of entrapped intestine from the EF impossible from a ventral midline approach and permanent
during correction of EFE. In some horses, a large volume occlusion of the vein is probably incompatible with life.
of blood might be evident in the abdomen at the start of
surgery, which has led to the suggestion that pressure from Expected outcome Survival from this type of hemorrhage
the entrapped intestine could cause so [16, 17]. is unlikely [13–15].
Prevention An EFE is reduced by carefully drawing the

incarcerated segment from right to left, in the opposite
emorrhagefrom LargeColon
H
direction to that responsible for the lesion. The surgeon
grasps a proximal or distal loop at the point of entry into
Mesentery
the vestibule of the omental bursa and draws it away from
Definition Hemorrhage from tearing or inadequate
the EF, while pushing the strangulated segment or its
ligation of one of the large colon mesenteric vessels
contents in the same direction from the right side of the
abdomen. The line of traction should be in a horizontal
Risk Factors
plane because vertical upward traction can drag thick-
walled intestine across the portal vein. Although this ● Large colon resection and anastomosis
method works in most cases, other methods will be ● Large quantity of mesenteric fat around the colonic
required in more difficult entrapments [10]. vessels
The surgeon can either reduce the volume of fluid in the ● Use of inadequate methods for vessel occlusion
strangulated segment or replace one of the strangulated
loops in the EF with a smaller structure (mesentery or Pathogenesis Failure to adequately ligate a mesenteric
normal intestine). Methods to accomplish these goals vessel during large colon resection could manifest as
emorrhage from arge Colon esentery 297
obvious intraoperative bleeding or as an expanding

hematoma in the colonic mesentery, especially if a major
colonic artery is involved. However, large colon resections
are usually done with the colon exteriorized under some
tension, which could partly obstruct the mesenteric arteries
and reduce perfusion pressure so that bleeders are not
evident at surgery. Major vessels in the mesentery of the
large colon can appear to be completely occluded at the
end of surgery, but can bleed profusely after the horse
recovers from anesthesia and becomes more normotensive.
Prevention Ligation of individual vessels within the

mesenteric attachment is usually unrewarding and risky.
An alternative is to apply the TA90TM stapler (Figure 27.3)
twice to the full thickness of the mesentery on the side to
be retained, and this could be combined with ligation. All Figure 27.4 After large colon resection, as the anastomosis is
allowed to return to the abdominal cavity, the colonic stump
veins and arteries that project beyond the transected
should be carefully checked to ensure that it does not bleed
mesentery should be individually clamped and ligated once the tension has been removed from it.
securely. The vessels on the side of transection to be
discarded can be occluded with a Carmalt or similar
clamp. Diagnosis Hemorrhage from colonic vessels may be
To ensure that satisfactory hemostasis has been achieved, apparent intraoperatively. If not apparent at the time of
tension should be released on the colon and mesentery surgery, this complication may present as a postoperative
when surgery is completed to eliminate stretching in ves- hemoabdomen.
sels that would interrupt blood flow to the ligated segment
(Figure 27.4). Any bleeders observed at that time should be Monitoring See Section on Hemorrhage from Small
carefully ligated. When the colon stumps are returned to Intestinal Mesentery above.
the abdomen, the anastomosis and colonic mesentery are
carefully inspected again to ensure that there is no hemor- Treatment Unless the colonic mesenteric bleeder is
rhage from the mesenteric vessels when they are no longer obvious, all the mesentery, fat and enclosed vessels
under tension (Figure 27.4). proximal to it should be occluded as a group in a single
ligature. A sliding half hitch is recommended to ensure
complete compression of the fat and mesocolon around the
enclosed vessels, and size 2 polyglycolic acid suture is
preferred. If the individual bleeder can be identified
projecting beyond the mesenteric fat, it can be grasped
with a hemostat and ligated. Great care must be taken
when adding additional ligatures to the large colon
mesentery, because blind insertion of ligatures on needles
can puncture large veins or arteries, which can form a
rapidly expanding hematoma. This can force the surgeon
to attempt ligation at a site further from the transected
colon, which could eventually jeopardize blood supply to
that segment and the anastomosis. This is especially true if
the colon resection is performed close to the abdominal
incision.
Expected outcome If source of hemorrhage is identified

Figure 27.3 Method of occluding colonic mesenteric vessels and controlled prior to loss of significant blood volume
with the TA-90TM instrument, which has been fired and staples
can be seen between the jaws that do not include the
(>20% blood volume), prognosis is generally good. In some
mesentery. The pin on the right has also been fired and fully cases, hemorrhage will either not occur or not be identified
engaged in the lower jaw of the instrument. until the horse recovers from anesthesia. Please refer to
Chapter 7: Complications Associated with Hemorrhage, hemorrhage will likely continue from other sources unless
for discussion of postoperative hemoabdomen. the underlying condition is successfully treated. Whole
blood transfusions may be necessary in cases of severe, but
non-fatal, hemorrhage.
iscellaneousIntra-Abdominal
M
Expected outcome The prognosis for intra-abdominal
Hemorrhage
hemorrhage depends on the source of the hemorrhage and
the success of the surgeon in identifying and ligating
Definition Nonspecific but severe intra-abdominal
damaged vessels. If damaged vessels are identified quickly
hemorrhage identified intraoperatively but not related to a
before significant blood loss has incurred, this complication
specific surgical procedure
will likely have no impact on the expected outcome. More
severe hemorrhage will result in difficulties maintaining
Risk Factors
blood pressure during and after anesthesia, but this may be
● Iatrogenic trauma during surgery overcome with blood transfusions and other supportive
● Preexisting coagulopathy care. In cases of consumptive coagulopathies, the prognosis
● Preexisting injury to abdominal vessels is generally poor.
● Ischemic injury that increases friability of vessel walls
Pathogenesis Hemorrhage during abdominal surgery can

I ntraoperativeInjuryto Small
also arise from intraoperative trauma that tears splenic
IntestinalMesentery
vessels, vessels in the mesenteric root [19], or rupture a
hematoma in the jejunal mesentery [8]. Continued
Definition Tears of the mesentery incurred at the time of
bleeding from a preexisting source, such as a ruptured
surgery
uterine artery, is another form of hemorrhage that could
continue into the operative period and defy attempts at
Risk Factors
ligation. Uncontrollable intraoperative hemorrhage and
oozing could be caused by severe disseminated intravascular ● Small intestinal lesion requiring manipulation
coagulation (consumptive coagulopathy) [20]. ● Foals
Prevention Use atraumatic surgical technique and Pathogenesis Manipulation of loops of small intestine
carefully inspect vessels following ligation. Appropriate carries a high risk of mesenteric tear, usually with tearing
coagulation testing to identify patients judged to be at high of mesenteric vessels. This injury is more likely in foals
risk of coagulopathy or preemptive treatment of these than in adults because they have small, fine vessels with
at-risk horses. little protection in very delicate mesentery.
Diagnosis Retrieval of blood clots or copious volumes of Prevention The most likely cause of mesenteric vascular
blood on the surgeon’s hand and arm after deep insertion injury is hooking a finger or thumb into a branch close to
into the dorsal abdomen, combined with a drop in blood the mesenteric attachment of the intestinal segment as it is
pressure and rise in heart rate, are strong indicators of life- being handled. When segments of small intestine are being
threatening intraoperative hemorrhage. manipulated under tension, the surgeon should fold the
tips of fingers into the palm of the hand and use the back
Treatment Treatment of intra-abdominal hemorrhage of the fingers and thumb to grasp the intestinal wall. This
depends on the source of the hemorrhage. If injury to a prevents the fingers from coming into contact with the
specific mesenteric vessel can be identified as the source, mesentery close to the attachment to the intestinal wall,
the surgeon can take steps to cross-clamp and ligate as where tearing is likely.
necessary. However, if the source of hemorrhage is from a
damaged vessel deep within the abdomen that is Diagnosis Injury to the mesentery can be observed
inaccessible, it may not be possible to identify and ligate intraoperatively.
the vessel. If the hemorrhage is minor and the horse is not
suffering from a coagulopathy, hemorrhage may resolve Treatment Hemorrhage from this injury is usually minor
without treatment, although postoperative hemoabdomen and easy to control, but needs to be addressed promptly if
is likely. In cases of consumptive coagulopathies, it spreads through the mesenteric sheets, and any
iscellaneous Iatrogenic ascular Injuries 299
associated mesenteric defect needs to be repaired also. If anastomosis; ligation of the wrong vessel during resection
only the mesentery is torn close to the mesenteric vessels, of small intestinal mesentery; or accidental interruption of
all attempts should be made to find a mesenteric edge that blood supply to the intestinal wall following resection of a
can be sutured without risk of occluding or puncturing a mural or mesenteric lesion that shares its vasculature.
vessel. If this is impossible, the intact mesentery to the
side of the vessels can be sutured so that it covers the Prevention After an anastomosis is completed, the
defect. If the defect is small, it can be closed transverse to remaining 25- to 35-cm gap is closed from the mesenteric
its longitudinal orientation. Regardless of method, size edge of the intestine to the gathered mesenteric stump. As
3–0 absorbable suture material in a simple continuous the resection is performed, this gap is created by resecting
pattern is used. mesentery so that at least 10 cm of intact mesentery extends
To control mesenteric hemorrhage or to prevent expan- beyond the major mesenteric vessels to the anastomosis.
sion of a hematoma in the mesentery, a ligature might need This allows enough distance from the mesenteric vessels to
to be applied on both sides of the bleeder, including artery close the mesenteric gap without including or puncturing a
and vein. In most cases, a vein is involved but separation of major artery or vein (Figure 27.5).
artery and vein proximal and distal to the site of injury is The authors recommend resection of a mesodiverticular
difficult in blood-stained mesentery. Provided only a short band, whether it is an incidental finding or the cause of
segment of an arcade artery is lost, sufficient arterial inflow strangulation. This is generally a safe procedure but, in
will remain to preserve intestinal viability. If a major mes- some horses, an arterial branch carried through a
enteric artery is injured, which is rare, it can be ligated at mesodiverticular band might be the only blood supply to
each side of the bleeding point. Remaining major mesen- the antimesenteric surface of the associated small intestine.
teric arteries and veins can provide adequate vascular sup- In that case, the band is not resected. A test occlusion of the
port to the associated intestinal segment. Nonetheless, that mesodiverticular vessel can be considered with a hemostat
intestinal segment should be rechecked later in the surgery (non-serrated surface of jaw).
to ensure that ischemia has not developed. If a mass or tumor is resected close to the mesenteric
attachment to an intestinal segment, shared blood supply
Expected outcome If damage to the mesentery is repaired to the associated segment of intestinal wall could be lost.
without compromising blood supply to the bowel, there Such a complication might not be immediately apparent,
should be no long-term consequences of this injury. Failure but if it is, a resection and anastomosis is required if there
to control hemorrhage during surgery could lead to is doubt about integrity of blood flow. Use of fluorescein or
postoperative hemoperitoneum and life-threatening blood other measures of vascular integrity might be useful in
loss. Any defect left unrepaired in the mesentery could lead such cases to detect blood flow [21].
to small intestinal incarceration.
iscellaneousIatrogenicVascular
M
Injuries
Definition Iatrogenic injury to intestinal or mesenteric

vasculature that could cause intraoperative hemorrhage or
jeopardize intestinal viability.
Risk Factors
● Small intestinal resection and anastomosis.

● Removal of a discrete mass or diverticulum from the
intestinal wall and then closing the defect in the
remaining intestinal segment.
● Mesodiverticular bands and Meckel’s diverticulum.
Figure 27.5 Method of leaving an edge of mesentery (white
arrow) that is sufficiently distant from the nearest mesenteric
Pathogenesis Different causes include: trauma to or vessels to prevent inadvertent injury to them during mesenteric
occlusion of a major mesenteric vessel during closure of closure. The black line indicates the proposed line of jejunal
the small intestinal mesentery after resection and transection for the anastomosis.
Diagnosis Iatrogenic injury to a major vessel during exisiting coagulopathy. A surgical error that can lead to
surgery could cause obvious bleeding, and the injured intestinal ischemia at a small intestinal anastomosis is
vessel can be identified. If blood flow to a small intestinal transection of the jejunum at right angles or greater to the
segment is interrupted through removal of an attached mesenteric attachment [22, 23].
mass or Meckel’s diverticulum, discoloration of that Another error is transection of the jejunal vascular
segment should become apparent. However, this response arcade at a point too distant (>10 cm) from the point of
can be delayed and missed at surgery. branching from the major mesenteric vessel (Figure 27.6).
Because that arcade is the only source of blood flow to the
Treatment If mesenteric vessels are punctured during anastomosis and because blood flow through it could
mesenteric closure, and if hemorrhage cannot be controlled decline as the distance from the major branch increases,
by pressure, then the anastomosis should be revised to the intestine at the anastomosis is at risk of inadequate
include intact mesentery and with at least 10 cm of perfusion. Another potential error is transection of the
mesentery between the cut edge and the major mesenteric jejunum at >10 mm from the last jejunal vessel [22, 23].
vessels. If a major mesenteric vein and artery are ligated in Another cause of accidental vascular occlusion is kinking
error during small intestinal resection, this can be corrected of the mesenteric vessels during mesenteric closure after
by cutting as much of the knot as possible and then teasing jejunocecostomy [24].
the remainder apart gently with tips of mosquito forceps.
The obvious indentation in the tissues at the point of Prevention Appropriate location and angulation of
ligation and lack of palpable pulses does not signify transection, appropriate placement of ligatures, and
permanent loss of blood flow. An alternative is to include identification of tissues at risk and repeating anastomosis
the involved segment in a planned resection and if needed
anastomosis, if this action does not require loss of too
much intestine or too much prolongation of surgery time. Diagnosis During an anastomosis, brisk arterial bleeding
If the surgeon becomes concerned about the risk of should be noticed from the transected submucosal vessels
continued postoperative bleeding from an injured vessel throughout the procedure until the anastomotic suture line
then that vessel needs to be ligated. If any intraoperative compresses the vessels. Absence or abrupt cessation of such
procedure injures a mesenteric blood vessel sufficiently to bleeding could indicate a loss of mucosal blood supply.
risk local ischemia, then that vessel and associated intestine Intestinal ischemia may result in purple–blue coloration
might need to be resected. of the mucosa or serosa of the anastamosis. This may be
noted during completion of the anastomosis or immedi-
Expected outcome If intestinal ischemia goes undetected ately after.
at surgery, it can cause severe postoperative colic that
requires a repeat celiotomy or euthanasia. Hemorrhage
that is not addressed at the time of surgery could result in
postoperative hemoabdomen.
I ntestinalIschemiaat
the Anastomosis
Definition Ischemia of either mucosa and/or serosa of the

intestinal segements of the anastomosis that may or may
not become apparent at the time of surgery
Risk Factors
● Resection and anastomosis

● Pre-existing coagulopathy Figure 27.6 Selection of a site for mesenteric transection for
an anastomosis (block arrow). Note that this is approximately 10
cm from the branching of the major mesenteric artery (small
Pathogenesis A small intestinal anastomosis can be prone
arrow). This ensures sufficient vascular perfusion to the
to ischemia because blood flow to one edge might be anastomosis, which could be jeopardized if a site further from
jeopardized by inadvertant vascular occlusion or an the point of branching were selected.
Intestinal otation 301
Treatment If ischemia does become apparent during sudden release of endotoxin from the ischemic intestine.
surgery, it should be addressed by revision of the However, flunixin meglumine is usually administered
anastomosis. before surgery, and so an intraoperative dose risks
overdosing, and both these drugs could cause renal injury
Expected outcome If anastomotic ischemia goes undetected in a dehydrated horse.
at surgery, it can cause severe postoperative colic that
requires a repeat celiotomy or euthanasia. Diagnosis and monitoring Intraoperative anesthetic
monitoring including heart rate, blood pressure, oxygen
saturation (SpO2), PCV/TP, blood lactate and arterial
blood gas
Anesthesia-RelatedComplications
Treatment The following treatments should be
Whereas intestinal decompression or extraction of dis-
administered when indicated:
tended colon from the abdomen can increase arterial oxy-
gen tension (PaO2) during anesthesia of horses with colic, ● Pretreatment with flunixin meglumine, polymixin B or
closure of the ventral midline incision can have the oppo- heparin
site effect [25]. These findings underscore the important ● Inotropes (dobutamine, calcium. etc.)
role of intestinal decompression in anesthetic manage- ● Correct volume deficits (balanced electrolyte solutions)
ment of the colic patient.
● Hypertonic saline, colloids
Definition Complications as a result of, or exacerbated by, ● Decrease gas inhalant (can supplement with constant
general anesthesia during colic surgery and noted during rate infusions [CRIs] of lidocaine, alpha-2 agonist, keta-
the anesthetic period mine etc.)
Risk Factors Expected outcome Although other factors could be

implicated in reperfusion injury in such cases, the actual
● Endotoxemia and/or hypovolemia effect of released strangulation on cardiovascular changes
● Strangulated lesions can be inconsistent, often transient, and usually manageable.
● Severe gas distention
Pathogenesis In one study, 1.3% of intraoperative deaths

IntestinalRotation
(not euthanasia) were attributed to endotoxemic and
hypovolemic shock [1]. The risk of endotoxemic shock is
Definition Rotation of the small intestine 360 degrees
greatest when strangulation of a segment of small or large
around its long axis when performing an anastomosis
intestine (more common) is corrected, presumably because
the restored blood flow can convey endotoxin from the
Risk Factors
ischemic tissue [20]. Consequently, the horse can suffer an
acute and marked decrease in blood pressure [12]. This ● Resection of a long segment of small intestine
response has been experimentally induced in pony large ● Performing a jejunocecostomy more so than jejunojeju-
colon by detorsion and was attributed to vascular injury or nostomy, but possible with both
endotoxin production [26]. ● Inexperienced surgeon
Despite the proposed role of endotoxin in response to
reperfusion after correcting a strangulation, this has not Pathogenesis A surgeon error can result in accidental
been supported in a study that measured endotoxin release rotation of the small intestine 180 to 360 degrees around its
under these conditions [27]. long axis. Rotation is more likely to happen with
jejunocecostomy than jejunojejunostomy, because the
Prevention Pretreatment with heparin before release of latter has two mesenteric edges to oppose and the surgeon
the strangulation can prevent the sudden hypotension and can use these as a guide for correct orientation. Also closure
increased vascular resistance and thromboxane of the mesentery by gathering its cut edges during resection
concentration associated with this procedure, and it can reduce the risk by maintaining the mesenteric and
significantly increased colonic blood flow during 40 intestinal orientation throughout the resection and
minutes of reperfusion [26]. Flunixin meglumine or anastomosis. For a jejunocecostomy, there is no opposing
polymixin B could also be used to block the effects from a mesenteric edge on the distal end to which the proximal
jejunal mesentery can be attached. However, the ileum and cause persistent colic. If identified at the time of surgery,
ileal mesentery can be used for that purpose, although they surgical correction of a rotated jejunojejunostomy will
are not always as accessible and are usually separated from prolong the anesthesia time, and potentially exacerbate
the jejunal mesentery by the anastomosis. small intestinal inflammation due to additional handling
of the small intestine. In repeating the anastomosis of a
Prevention The first step in preventing this error is to jejunocecostomy, there is also the risk of surgical site
correct the strangulation, decompress the small intestine, contamination from the open cecal anastomosis. However,
and then to arrange the small intestine in its normal with meticulous surgical technique, rotation can be
orientation from proximal to distal, tracing along it identified and corrected with no lasting impact on outcome.
manually to ensure that there are no rotations at any point.
As the mesentery is resected, it should be continuously
gathered to keep its edges in full view on the abdomen, so
the risk of accidental rotation becomes almost impossible. Failureto Identifythe Lesion
Mesenteric transection close to the arcade branches should
provide sufficient mesentery for this purpose, whereas the Definition Failure to identify the lesion is evident to the
unnecessary attempt to remove all abnormal, hemorrhagic surgeon as an inability to find an intestinal obstruction or
mesentery will have the opposite effect. In the latter displacement that is consistent with the preoperative
situation, the incised mesenteric edge can be lost from clinical findings and laboratory data, despite a thorough
sight into the abdomen, and then prevention of rotation and systematic abdominal exploration.
becomes more difficult.
Risk Factors
Diagnosis A rotation will likely be noticed after the
● Presence of specific surgical lesions (see “Pathogenesis”
anastomosis is complete and the mesentery is closed. The
below)
mesentery will be seen to wrap around the intestine in
– Non-strangulating lesion
these cases and this wrap will persist as the entire jejunum
– Dorsal diaphragmatic hernia
is traced proximally.
– Strangulating lipoma to the small colon
Treatment Intestinal rotation can only be treated by – Multiple (>1) strangulating lesions
revision of the anastomosis. For jejunojejunostomy, the – Impaction of cupola of cecum
anastomosis is resected and new margins are defined, and – Rupture of the base of the cecum
the small intestine is traced proximally and distally to – Enterolith
relevant landmarks and then arranged so that the – Pheochromocytoma
mesentery can be traced directly to the proposed site of ● Incomplete or non-systematic abdominal examination
anastomosis without rotation. An end-to-end ● Inexperienced surgeon
jejunojejunostomy is then completed. If a jejunocecostomy
needs to be revised, the suture line can be undone or the Pathogenesis Failure to find a lesion can lead to treatment
cecum can be incised as close as possible to around the of another “lesion” that is either coincidental, secondary or
anastomosis. This step will leave an opening in the cecum imagined. In rare cases, the horse can have a lesion that
somewhat larger than needed for the revised anastomosis, cannot be explained by preoperative findings, and a
but the excess opening can be closed after the anastomosis thorough search for another lesion should be conducted in
is completed. The mesenteric sutures (not the gathering such cases (e.g. a non-strangulating displacement when a
suture) should be cut close to the knot and simply pulled strangulating lesion is expected based on preoperative
through the tissue to free up the mesenteric edge. The data).
mesentery should then be organized by tracing the jejunum Strangulation of small intestine in a small diaphragmatic
proximally to the duodenocolic fold and then tracing it defect can be missed if this is high in the dorsal abdomen
distally again so that the rotation is eliminated. A hand- in an area in which the surgeon is unfamiliar and has
sewn end-to-side or side-to-side anastomosis is then used limited access. A diaphragmatic defect can be missed if the
for jejunocecostomy. This approach is preferred to closing intestine incarcerated in it falls out and lies free in the
the original cecal stoma and placing the new anastomosis abdomen when the horse is anesthetized and placed in
further distally or laterally on the cecum. dorsal recumbency. Such a finding could be incorrectly
attributed to release of a strangulation from the EF or
Expected outcome If not corrected, the rotated mesentery similar site and if the diaphragm were not examined to
will compress the intestine when the horse stands and locate the defect responsible.
Failure to Correct the esion 303
Strangulation of the small colon by a lipoma can be ● Pheochromocytoma: if this tumor is suspected as a cause
missed [28], because this does not present with the same of hemoabdomen in a horse with colic, the adrenal
acute clinical features as the same lesion in the small intes- glands should be palpated at the cranial pole of the kid-
tine. It tends to mimic a large colon disease, either displace- neys for any obvious enlargement, irregular shape, nod-
ment or intraluminal obstruction, with slow development ules or associated blood clot [32]. Although no surgical
of clinical signs and a marked colonic distention. A second treatment of this disease currently exists in the horse,
strangulating lesion in the small intestine can be missed if diagnosis would lead to either immediate euthanasia or
the surgeon focuses on treating the first lesion and fails to a possible surgical treatment (removal of tumor through
examine the remainder of the intestinal tract. a standing procedure).
Impaction of the cupola of the cecum can be missed,
largely because this is not always palpated per rectum Diagnosis Failure to identify a lesion that is consistent
preoperatively and clinical signs can be vague and highly with the preoperative clinical findings and laboratory data
variable [29]. Also, the cupola is in the dorsal abdomen could indicate a missed lesion. However, failure to find a
where it can be difficult to locate. An atypical cecal rupture specific cause for the horse’s preoperative clinical signs is
causes peritonitis that is readily diagnosed preoperatively an uncommon but recognized result of an exploratory
and intraoperatively, but without direct contamination of celiotomy. In such cases, the horse can respond favorably
the peritoneal cavity with intestinal contents. In these to surgery, presumably because a displacement of some
cases, the rupture could be in the cecal base within the kind corrected spontaneously when the horse was
mesenteric attachments of the cecum to the dorsal body anesthetized and rolled into dorsal recumbency. Persistence
wall, and is therefore not evident at surgery [30, 31]. With of the clinical signs after surgery indicates that a lesion was
this disease, an odor of intestinal contents emanates from probably missed and another surgery might be necessary.
the abdomen on opening it. However, examination of the Treatment Treatment will vary depending on specific
abdominal cavity will not reveal the location of the tear lesion, but accurate diagnosis is crucial in determining
because of its inaccessible location. appropriate treatment. The absence of a lesion should
Enteroliths and foreign bodies can be missed, especially prompt the surgeon to repeat exploration with specific
those buried in a large impaction with colon contents. A considerations to the areas discussed above.
pheochromocytoma is a rare endocrine tumor of the
adrenal gland that causes colic and hemoperitoneum in Expected outcome Outcome will vary depending on the
older horses [32]. It can be missed at surgery. specific lesion. When a lesion is missed, the preoperative
clinical signs usually persist.
In cases such as a diaphragmatic defect, there may be no
Prevention Diaphragmatic hernia: manual palpation of
immediate effect on outcome if strangulation does not
the diaphragmatic surface should be included in all surgical
recur in the initial postoperative period. However, failure
explorations, especially in cases in which the cause of a
to identify and repair the defect would allow recurrence in
strangulation is not clear.
the future. Similarly, failure to identify and remove all
● Strangulation of the small colon: entire length of the enteroliths could lead to obstruction immediately after sur-
small colon should be examined by the surgeon (either gery or later.
by visual assessment or manual palpation of the most If a lesion such as a small colon strangulation is not iden-
proximal and distal segments). tified, the horse will continue to deteriorate following
● Enteroliths or foreign bodies: emptying of the colon by recovery from anesthesia, prompting a repeat surgical
enterotomy is critical so that all contents can be revealed exploration.
in the empty lumen. Although an enterolith with a flat
surface or pyramidal shape would suggest that another
enterolith must be present to produce such an
Failureto Correctthe Lesion
appearance, an enterolith of any shape should prompt a
Definition Some lesions cannot be corrected at surgery
thorough search of the large and small colons for others.
and lead to intraoperative euthanasia.
● Impaction of the cupola: an attempt should be made at
the time of surgery to specifically examine the cecal base.
Risk Factors
● Atypical cecal rupture: the cecal base and retroperitoneal
space along the dorsal abdomen should be carefully ● Presence of specific surgical lesions (see “Pathogenesis”
palpated for any evidence of emphysema in these sites, a below)
hallmark for this lesion [30]. ● Inexperienced surgeon
Pathogenesis Examples of lesions that may be difficult or ● A mesenteric avulsion with small colon necrosis can be
impossible to correct at surgery include inaccessible caused by a peripartum accident and can leave a segment
abscesses, diffuse adhesions, widespread neoplasia, of necrotic distal small colon that might not be accessible
ruptured viscus, inaccessible strangulated intestine, or for resection and anastomosis.
inaccessible intraluminal foreign bodies. ● Strangulation in a mesenteric rent, especially if a large
segment of intestine is involved, can be difficult and even
● A right dorsal colon displacement with medial flexion
impossible to reduce in rare cases [9]. Multiple rents can
can also be difficult to completely correct [33].
also complicate reduction [19].
● A diaphragmatic hernia that is too large in a dorsal to
● Rents in duodenojejunal mesentery that extend to the
ventral direction to allow the contents to be returned to
dorsal abdomen can be impossible to repair completely
the abdominal cavity can defy all attempts at correction
through a ventral midline approach (Figure 27.8).
(Figure 27.7).
Affected horses must then recover with the defect to
have it repaired as a standing procedure [12].
Prevention See treatment below.
Diagnosis Thorough surgical exploration of the abdomen

and attempted treatment methods can identify those
lesions that are irreparable (see below).
Treatment Some lesions are untreatable and warrant

intraoperative euthanasia. However, if the surgeon is
unsure, every attempt at correcting the lesion should be
made before electing euthanasia. Some specific
manipulations which can be attempted are listed below:
Figure 27.7 Diaphragmatic hernia in a horse with much of the ● Large diaphragmatic hernia: the cranial end of the horse
large colon in the thoracic cavity. Lesions such as this are very
difficult to correct at surgery and the size of the defect can be a might have to be elevated by tilting the table and allow-
challenge to closure. ing intestinal contents to return through gravity to the
(a) (b)
Figure 27.8 (a) Rent in the duodenojejunal mesentery that strangulated small intestine in a prepartum mare. All of this tear could
not be exteriorized at surgery. (b) Same defect in another broodmare at necropsy demonstrating that the mesenteric defect can extend
all the way to the dorsal part of the abdomen where it would be beyond reach for closure during surgery.
Instrument Failure 305
abdominal cavity. The size of the defect can be sufficient InstrumentFailure

in some cases to complicate reasonable attempts at
repair. Definition Complete or partial failure of an instrument to
accomplish intended task at surgery.
● Mesenteric avulsion with small colon necrosis: these
lesions can be treated by resection and anastomosis if Risk Factors
accessible [34], but not if too distal in the small colon
and therefore beyond access (Figure 27.9). ● Poor surgical technique
● Improper use of instruments
● Right dorsal colon displacement with medial flexion: in ● Defective or damaged instruments
such cases, a point can be reached when the cecum can ● Improperly assembled instruments
be fully exteriorized and the cecocolic fold fully exposed. ● Poor understanding of instrument role and use
However, if the colon lies so that the cecocolic fold can
be traced from cranial to caudal, rather than the normal Pathogenesis An example of a devastating instrument
caudal to cranial position from the cecum, correction is failure is a slipped hemostat from a major vascular bundle,
incomplete. Then, the colon will have to be subjected to allowing the vessels to retract out of view and causing
one more rotation until the displacement has been com- profuse intra-abdominal hemorrhage.
pletely corrected. Usually, the direction of this corrective Although Doyen forceps are commonly used for the
rotation is clockwise around the dorsal attachment of the Parker Kerr technique of blind ending the jejunum or
colon as viewed from the ventral abdomen. ileum, they are unsuitable for this purpose because of a
tendency to slip off the intestinal wall. This is most likely
● Rents in duodenojejunal mesentery: a planned later repair with the ileum, which is too thick-walled under normal
by laparoscopy can be effective in such cases [12]. conditions and more so when diseased. This malfunction
allows the ileum to retract into the abdomen and cause
intra-abdominal contamination.
Expected Outcome Intraoperative euthanasia is warranted
The ILA and GIA stapling instruments can be applied
if the surgeon has exhausted all attempts to correct the
blindly in the abdomen, as for amputation of a strangu-
lesion. If the surgeon is less experienced, a more senior
lated ileum that is beyond access for other procedures.
surgeon should be consulted.
These instruments have a low failure rate unless the forks
have been connected inappropriately, and blind intra-
abdominal application increases this risk. Blind applica-
tion of the TA 90 instrument deep in the abdomen could
increase the risk of misaligning this instrument so it does
not fire the staples properly.
Prevention Good surgical technique, proper application of

instruments and well-maintained instruments are critical
in preventing instrument failures. However, specific
preventative methods to common instrument failures
encountered during colic surgery are listed below:
● Slipped hemostat: this can be prevented by placing more
than one instrument on such vascular bundles or using
heavy instruments, such as Rochester Pean forceps or
Carmalts.
● Doyen failure during a Parker–Kerr procedure: if Doyens
are the only clamps available, the transected edges of the
Figure 27.9 Avulsion of the mesocolon from the most distal ileum projecting above the jaws should be grasped at
part of the small colon as a postpartum accident in a each end with curved hemostatic forceps to retain them
broodmare. Note that the devitalized segment of small colon in place. Carmalt forceps are preferred to Doyens because
has been exteriorized as much as possible, but with a long
they can grasp the ileal wall more securely, although
segment within the abdomen. Because the distal segment
extends to the rectum, it could be beyond reach for resection incising the ileum too close to the instrument edges can
and anastomosis in this case. cause these instruments to lose their grip.
● Failure of a stapling instrument: the TA 90TM ideally ● Failure to label instruments to make sure the appropri-
should not be fired unless the retaining pin is fully ately labeled pack has the full count before and during
engaged with the hole on the anvil side to ensure that the surgery, and to count instruments correctly at the end of
staples meet the anvil correctly (Figure 27.3). Failure to surgery
do this can cause the staples to malfunction. There are ● Foals are especially at risk because the working space on
occasions when the TA 90TM must be applied many times the ventral abdomen can get “crowded” and the
across a broad segment of intestine, as in closure of the omentum can rapidly engulf small sponges
colon during large colon resection. The surgeon has no
option under these conditions but to use the instrument Pathogenesis Failure to remove an intra-abdominal
without engaging the retaining pin. Misalignment of the surgical item only becomes an intraoperative complication
linear stapling instruments (GIA or ILA) deep in the if the surgeon becomes aware of this accident before the
abdomen can be prevented by ensuring that the abdomen is closed. Failure to recognize this error during
instrument is correctly assembled before using the firing surgery, like most surgical errors, can lead to postoperative
mechanism. complications. The most likely piece of surgical equipment
to be left in the abdomen is a gauze sponge, which causes
gossybipoma (Latin: gossypium, meaning cotton), a fatal
Diagnosis Instrument failure is usually readily apparent
disease in horses.
intraoperatively, through profuse hemorrhage, loss of
tissue from the instrument’s grasp, or failure of the
instrument to function as expected. Prevention The contents of all surgical packs should be
recorded beforehand and an instrument count should be
completed periodically throughout the procedure, and
Treatment Specific instrument failures can often be
certainly as the procedure reaches its conclusion.
corrected, although prevention is preferable. Attempts
Instruments and sponges should not be placed on the
should be made to locate tissue lost from an instrument’s
ventral abdomen during surgery but should be placed on
grasp and to then reapply the instrument correctly. Any
the table when they are no longer required. Sponges of 4 in.
consequence of the failure, such as contamination or
× 4 in. dimensions are not recommended for abdominal
bleeding, should be treated appropriately.
surgery in horses, and large laparotomy sponges (18 in. ×
18 in. or larger) are preferable. The large size makes them
Expected outcome If instrument failures are quickly and easier to locate and allows effective use in small and
appropriately addressed at the time of surgery, there is manageable numbers. The used sponges are then placed
often little impact on expected outcome. However, failure on a drape on the floor behind the horse and are counted
to do so or severe consequences of the instrument failure, frequently during the surgery to ensure that all are
such as hemorrhage or contamination, could be fatal accounted for before the abdomen is closed. Anesthesia
postoperatively. personnel should record the number of sponges opened
throughout surgery and the operating room nurse should
match the count of used sponges against the anesthesia
ailureto Removean Intra-
F record. A surgical checklist should be standard in all
AbdominalSurgicalItem hospitals to prevent such avoidable and serious
complications. In those procedures in which laparotomy
Definition Failure to remove an intra-abdominal surgical sponges are placed deep in the abdomen, the blue tag
item should be secured to the large abdominal drape to keep
them within easy access and to prevent them migrating
Risk Factors into the abdomen.
● Surgical procedure in which numerous instruments,
many different instrument packs, lap sponges etc. are Diagnosis Careful examination of the surgical field and
required on the operating field (i.e. resection, deep intra- counting of instruments and surgical sponges before
abdominal procedures) closure should help identify any missing items.
● Poor surgical technique Postoperative radiographs to detect metallic instruments or
● Failure to count sponges the radiopaque strip in sponges that might have been left in
● Use of small sponges (4 by 4s) instead of large laparot- the abdomen, although useful in small animals and human
omy sponges patients, are unproductive in the horse.
Enteropexy 307
Treatment If an intra-abdominal item is not identified and

removed at the time of surgery, it becomes a postoperative
complication. Treatment during the postoperative period
may require a repeat celiotomy to remove the item and
aggressive treatment of any complications from this
accident.
Expected outcome Failure to remove an intra-abdominal

sponge can cause postoperative gossybipoma, a fatal form
of peritonitis in horses. Small intestine could become
incarcerated in the rings or between handles of hemostats
and similar instruments left in the abdomen.
Enteropexy
Definition Inadvertent fixation of a segment of the

intestines to the abdominal wall during closure
Risk Factors
● Presence of gas- or fluid-filled viscus at the time of Figure 27.10 Method of using the thumb forceps as a backstop
closure and to elevate the edge of the linea alba during abdominal
closure. Note the surgeon is also using the forefinger to retain
● Failure to palpate and clear the deep surface of the intestine in the abdomen.
abdominal wall during closure
Treatment If this error is made, sutures can be pulled out
Pathogenesis Enteropexy is a rare complication that is
until the affected segment of intestine is freed. It is rarely
caused by inadvertent inclusion of a segment of intestine,
necessary to close the puncture sites in the small intestine.
usually the jejunum, in the suture line used to close the
Any segment of suture thought to have penetrated into the
linea alba [35]. It can arise if the intestine is partly distended
intestinal lumen should be cut off and a new strand used in
at the time of closure and gas-filled loops protrude through
its place.
the incision edges.
Expected outcome Failure to prevent this intraoperative
Prevention Accidental inclusion of intestine should be
complication can lead to postoperative intestinal
detected intraoperatively by digitally sweeping the deep
obstruction or leakage [35].
surface of the abdominal wall along the suture line
periodically during closure. Enteropexy can be avoided by
using a visceral retainer to keep intestinal segments in the
abdomen and below the incision edges. The back of thumb
forceps can be used to provide a backstop to the needle so
that structures under the incision are protected
(Figure 27.10). This is especially crucial at the end of the
suture line when the edges are too close to see structures
beneath them. Loops of small intestine can also be digitally
excluded from the surgical field by using the fingers to
elevate the linea alba at the same time (Figure 27.11).
Decompression of distended intestine through an
enterotomy or gas removal as part of the surgical procedure
should prevent insinuation of distended loops between the
edges during closure.
Diagnosis Digitally sweeping the deep surface of the

Figure 27.11 Method of using the back of the hand to retain
abdominal wall every 2 to 4 bites can identify an inadvertent any loops of intestine within the abdomen as the linea alba is
enteropexy. being closed.
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the epiploic foramen in fifteen horses. Can. Vet. J. 29: endotoxin in cases of equine colic. Vet. Rec. 123: 269–271.
378–382. 28 Mair, T.S. and Smith, L.J. (2005). Survival and
14 Livesey, M.A., Little, C.B., and Boyd, C. (1991). Fatal complication rates in 300 horses undergoing surgical
hemorrhage associated with incarceration of small treatment of colic. Part 4: Early (acute) relaparotomy.
intestine by the epiploic foramen in three horses. Can. Equine Vet. J. 37: 315–318.
Vet. J. 32: 434–436. 29 Sherlock, C.E. and Eggleston, R.B. (2013). Clinical signs,
15 Vachon, A.M. and Fischer, A.T. (1995). Small-intestinal treatment, and prognosis for horses with impaction of the
herniation through the epiploic foramen: 53 cases cranial aspect of the base of the cecum: 7 cases (2000–
(1987–1993). Equine Vet. J. 27: 373–380. 2010). J. Am. Vet. Med. Assoc. 243: 1596–1601.
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30 Klohnen, A., Wilson, D.G., and Cooley, A.J. (1996). Cecal 33 Huskamp, B. and Kopf, N. (1983). Right dorsal
perforation and communication with the retroperitoneal displacement of the large colon in the horse. Equine
space after cecal impaction in a Thoroughbred gelding. Pract. 5: 20–29.
Can. Vet. J. 37: 685–687. 34 Livesy, M.A. and Keller, S.D. (1986). Segmental ischemic
31 Gray, S.N., Dechant, J.E., Yamout, S. et al. (2014). Atypical necrosis following mesocolic rupture in postparturient
presentation of caecal perforation in two horses. Equine mares. Comp. Cont. Educ. Pract. Vet. 8763–768.
Vet. Educ. 26: 422–425. 35 Freeman, D.E., Richardson, D.W., Tulleners, E.P. et al.
32 Yovich, J.V., Horney, F.D., and Hardee, G.E. (1984). (1992). Loop colostomy for management of rectal tears
Pheochromocytoma in the horse and measurement of and small-colon injuries in horses: 10 cases (1976–1989).
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310
28
Complicationsof the PostoperativeColicPatient

Overview resection and anastomosis or a prolonged surgery, tend to

have a higher complication and mortality rate than horses
Morbidity and mortality associated with colic surgery is with simple colonic obstructions [5, 11, 13–15]. Length of
higher than other surgical procedures [1]. Complications bowel resected [16] and duration of colic [15] may also
are reported to occur in 30–70% or more of horses impact complications and survival. Epiploic foramen
undergoing colic surgery, depending on how a complication entrapment of the small intestine has also been identified
is defined [2–5]. Multiple complications can and often as a risk factor for non-survival [5]; however, other studies
occur in one patient [4, 5]. Complications occurring during have not supported this finding and in fact reported a
the immediate postoperative period include pain/colic, higher survival for horses with epiploic foramen
pyrexia, incisional drainage or surgical site infection (SSI), entrapment [17].
reflux associated with ileus or complications with a small Postoperative complications can also delay or even
intestinal anastomosis, enterocolitis or diarrhea, jugular decrease return to use following colic surgery [18], with
vein catheter-associated complications, systemic complications such as body wall hernia formation,
inflammatory response syndrome (SIRS), and shock [2–6]. diarrhea, and laminitis leading to lower odds of return to
Complications often prolong hospitalization and increase use compared to horses without complications [18]. In
the expense associated with treatment [7, 8]. Recurrent another study, development of complications did not affect
colic is the most common complication following hospital return to use of racehorses; however, the data may have
discharge [9, 10] and can affect 30–35% [6, 9] of horses. been underpowered [19].
Repeated colic episodes are often caused by postoperative Horses should be monitored closely during hospitaliza-
intraperitoneal adhesion formation [9] or recurrence of the tion following colic surgery and then during the early period
initial cause of colic. Surgical site infection and abdominal following hospital discharge to identify long-term complica-
wall hernia formation can also develop following hospital tions. An example of a postoperative monitoring sheet is
discharge [9, 10]. shown in Figure 28.1. With the introduction of electronic
There is no doubt that the development of complications medical records, graphical representation of clinical data
leads to an increase in mortality [3, 22, 12], with the most can be used to identify trends to help with patient care.
common reasons for death or euthanasia during the post- Trends over time are often more useful than a variable at a
operative period being pain/colic and reflux or ileus [11, single point in time. A postoperative colic patient’s clinical
12]. Age, breed, heavier body weight, and admission sever- variables should be trending toward normal values within 12
ity of pain, tachycardia, and high blood lactate and glucose to 48 hours of surgery, depending on the lesion identified at
concentrations, as well as high admission packed cell vol- the initial surgery; observations outside of normal reference
ume (PCV), admission hypoproteinemia, and hypotension values should prompt further investigation. Similarly, it is
during general anesthesia, have been associated with post- important to consider all of the information available in
operative complications and non-survival [1, 5, 12–14]. light of the horse’s specific clinical signs. Remembering that
Horses with small intestinal and cecal disease, as well as “common things occur commonly,” it is critical that the
those with strangulating obstructions and undergoing a interpretation of findings makes sense.
Overview 311
(a)
(b)
Figure 28.1 Monitoring (a) and treatment (b) used in the management of postoperative colic cases at New Bolton Center, University
of Pennsylvania. Source: Courtesy of New Bolton Center.
312 Complications of the Postoperative Colic Patient
L observation of the horse and both numerical and
with PostoperativeColicPatient comprehensive pain scores (Tables 28.1 and 28.2) [20, 22].
The pain score developed by Pritchett et al. [21]
● Pain/colic (Table 28.1) has been used to evaluate clinical cases, as
● Pyrexia well as postoperative pain in experimental and clinical
● Incisional complications research. Pain during the postoperative period can also be
● Postoperative reflux and postoperative ileus associated with laminitis, body wall pain, or other
● Diarrhea complications.
● Intravenous catheter-associated complications
● Hemoperitoneum Risk Factors
● Enterotomy and enterectomy complications ● Leaving ischemic intestine in the abdomen. [2, 11]
● Septic peritonitis ● Small intestinal obstruction, strangulating obstruction,
● Postoperative intraperitoneal adhesions and resection [2, 11]
● Metabolic complications ● Reported to occur in 30% to 50% of horses following
● Endotoxemis/SIRS and shock small intestinal resection depending on the type of
● Laminitis anastomosis with variable findings between
studies [23, 25]:
Pain/colic – Horses undergoing jejunocecostomy had a higher
prevalence of postoperative colic (39%) compared to
Definition Pain is the physiological and behavioral horses requiring a jejunojejunostomy (28%) [23].
response to tissue injury, primarily intraperitoneal – No difference in postoperative colic during hospitaliza-
inflammation, ischemia, and distention of a hollow viscus tion between horses undergoing jejunojejunostomy
or tension on ligaments. Postoperative pain or colic is (33%), jejunoileostomy (43%), and jejunocecostomy
defined by the clinical signs of lying down for excessive (42%) [24].
periods, inappetence or anorexia, restlessness, flank- – Horses undergoing jejunocecostomy did have a higher
watching, repeated stretching as if to urinate, kicking at incidence of colic and mortality following hospital dis-
the abdomen, pawing at the ground, and rolling [2]. charge compared to horses undergoing jejunojejunos-
Subtle signs of pain, however, can be noted with careful tomy or jejunoileostomy (see below) [24].
Table 28.1 Numeric rating scale that can be used to evaluate the postoperative colic patient [21, 22].
Behavior 1 2 3 4
Gross pain None – Occasional Continuous

behavior
Head position Above withers – At withers Below withers
Ear position Forward with frequent – Slightly back with little –
movement movement
Location in stall At door observing Standing in middle and Standing in middle and Standing in middle and
environment facing stall door facing sides of stall facing back of stall
Spontaneous Moves freely Occasional steps – No movement
locomotion
Response to open Moves to door Looks at door – No response
door
Response to Moves to observer with Looks at observer with ears Moves away from observer Does not move/ ears back
approach ears forward forward
Lifting feet Freely lifts feet when Lifts feet after mild – Extremely unwilling to lift
asked encouragement feet
Response to grain Moves to door/ Looks at door – No response
reaches for grain
Pain/colic 313
Table 28.2 Composite pain score that can be used to evaluate postoperative colic patients. [20, 22].
Behavior Criteria Score
Appearance BAR, lowered head and ears, no reluctance to move 0

(reluctance to move, BAR, occasional head movements, no reluctance to move 1
restlessness, agitation) Restless, pricked up ears, abnormal facial expressions 2
(teeth grinding, yawning, sedated/grimace face), dilated
pupils
Excited, continuous body movements, abnormal facial 3
expression
Sweating No obvious signs of sweat 0

Damp to the touch 1
Wet to the touch, beads of sweat apparent over animal 2
Excessive sweating, beads of sweat running off animal 3
Kicking at abdomen Quietly standing, no kicking 0

Occasional kicking at abdomen (1–2 ×/5 min) 1
Frequent kicking at abdomen (3–4×/5 min) 2
Excessive kicking at abdomen (>5 ×/5 m in) 3
Pawing on the floor Quietly standing, no pawing 0

(pointing, hanging limbs) Occasional pawing (1–2 ×/5 min) 1
Frequent pawing (3–4 ×/5 min) 2
Excessive pawing (>5 × /5 min) 3
Posture Stands quietly, normal walk 0

(weight distribution, comfort) Occasional weight shift, slight muscle tremors 1
Non-weight bearing, abnormal weight distribution 2
Stretching out, prostration, muscle tremors 3
Head movement No evidence of discomfort, head straight ahead 0

Intermittent head movements laterally/vertically, frequent 1
flank staring (1–2 ×/5 min), lip curling (1–2 ×/5 min)
Intermittent and rapid head movements 2
laterally/vertically, frequent flank staring (3–4 ×/5 min),
lip curling (3–4 ×/5 min)
Continuous head movements, excessive flank staring 3
(>5 ×/5 min), lip curling (>5 ×/5 min)
Appetite Eats feed readily or feed is being withheld 0

Hesitates to eat 1
Shows little interest in eating, eats very little or takes feed 2
in mouth but does not chew or swallow
No interest in eating 3
Response to observer
Interactive behavior Pays attention to people 0

Exaggerated response to auditory stimulus (observer calling to horse) 1
Excessive-to-aggressive response to auditory stimulus (biting, turning
hindquarters toward the observer to kick) 2
Stupor, prostration, no response to auditory stimulus
3
– No difference in postoperative pain or the requirement Pathogenesis The etiology for pain during the postoperative
for repeat celiotomy between horses undergoing jeju- period is most often associated with ongoing gastrointestinal
nojejunostomy (48%) and jejunoileostomy (50%) [25]. or peritoneal disease or complications with an anastomosis.
● Jejunocecostomy technique may also influence postop- Often the specific cause remains undiagnosed. Ileus,
erative pain/colic; however, findings between studies are intestinal obstruction, adhesions, and ongoing ischemia are
inconsistent [26, 27]: among the more common causes of postoperative pain [2].
– Horses undergoing hand-sewn side-to-side jejunoce- When considering horses undergoing jejunojejunostomy,
costomy had a lower occurrence of postoperative colic jejunoileostomy or jejunocecostomy, reasons for colic
(9%) compared to horses undergoing a stapled side-to- diagnosed at repeat celiotomy or necropsy were obstruction
side jejunocecostomy (60%); the possible reasons given at the anastomosis including kinking at a jejunocecostomy,
pertained to the more appropriately-sized stoma with ileus, and adhesions [24, 27]. Intestinal ischemia (jejunum
a hand-sewn technique and potential leakage from a or ileal stump), small intestinal volvulus (particularly post-
staple line that was not over-sewn [26]. jejunocecostomy), septic peritonitis, anastomosis leakage,
– No significant difference in postoperative colic hemoperitoneum associated with ligature failure, colitis,
between horses undergoing stapled or hand-sewn colon entrapped in the jejunal mesentery, and pyloric
side-to-side (51%) vs. hand-sewn end-to-side (32%) outflow obstruction, were other causes [24, 27]. Causes of
jejunocecostomy [27]. pain or colic following colonic resection may also include
● Lower total plasma protein and higher packed cell vol- leakage or abscessation at the resection or anastomosis site,
ume in horses undergoing jejunocecostomy were associ- hemorrhage particularly at the site of mesenteric vessel
ated with postoperative colic implicating critical illness ligation, or ongoing ischemia especially following correction
and severity of intestinal injury playing a role in postop- of a large colon volvulus [28, 29]. For horses undergoing
erative colic [27]. surgical correction for a cecal impaction, re-impaction is the
● Surgeon experience was associated with survival (and most important cause of pain or colic during the postoperative
likely by association postoperative pain/colic), with mid- period [30]. Similarly, for horses undergoing surgical
career surgeons (ACVS Diplomates for ~8–12 years) treatment for descending colon impaction [31, 32], or
having the best outcome [27]. descending colon resection and anastomosis [33],
● Approximately 30% of horses undergoing colon resection re-impaction is an important cause of postoperative colic.
have signs of colic during the postoperative period [28, 29]. Less common complications leading to postoperative colic
● Most horses that experience colic following hospital dis- include intussusception associated with jejunal end-to-end
charge have only sporadic colic episodes [9]. Some functional anastomosis [34] and ileocecocolic
horses, however, have problems with recurrent colic or intussusception following jejunocecostomy [35].
severe colic necessitating celiotomy or euthanasia [9]:
– Horses with small intestinal obstructions, undergoing Prevention Early surgical intervention and meticulous
resection, developing postoperative ileus, or with signs aseptic and atraumatic surgical technique are imperative
of colic during the immediate postoperative period, for prevention of complications that may lead to
were at risk for long-term problems with recurrent postoperative pain and colic. Perioperative analgesia
colic [8, 9]. should be provided typically with the use of a non-steroidal
– Horses with abnormal peritoneal fluid at admission anti-inflammatory drug (NSAID). Flunixin meglumine
had a higher incidence of postoperative colic follow- (e.g. 1.1 mg/kg IV q12 hours for 2–3 days and then 0.5 mg/
ing hospital discharge [9]. kg IV q12 hours for 12–36 hours or as needed) tends to be
– Adhesions (see section on Postoperative Intraperitoneal the mainstay of NSAID treatment; however, use of
Adhesions) and recurrence of the primary problem cyclooxygenase-2 selective or cyclooxygenase-I sparing
are the most common reasons for colic following hos- NSAIDs, such as meloxicam (0.6 mg/kg IV q24 hours) or
pital discharge. firocoxib (0.27 mg/kg IV loading dose followed by 0.09 mg/
– Horses undergoing jejunocecostomy had a higher kg IV q24 hours) should be considered, because these drugs
occurrence of colic following hospital discharge (50%) may have a less detrimental effect on intestinal healing [36,
compared to horses undergoing jejunojejunostomy 37]. While there was no difference in postoperative
(24%) and jejunoileostomy (19%) [24]. Of horses complications, horses administered meloxicam did have a
undergoing small intestinal resection and anastomo- higher frequency of showing gross signs of pain compared
sis, all horses that were euthanized for colic within to horses administered flunixin meglumine [38].
12 months following hospital discharge had either a Meloxicam, however, was associated with a higher
jejunocecostomy or repeat celiotomy [24]. neutrophil count during the postoperative period, possibly
Pain/colic 315
associated with less systemic inflammatory response head movements, and interactive behavior were the most
(SIRS) or endotoxemia [38]. Meloxicam is not currently important elements of the total pain score [22]. Subtle
licensed for use in horses in the United States. Firocoxib signs that may be associated with pain should resolve
provided analgesia after small intestinal surgery that was within 6–24 hours of surgery and are often managed with
not significantly different to that provided by flunixin NSAIDs. Early hand-walking and re-feeding of small
meglumine; however, horses treated with firocoxib had a amounts of fresh grass subjectively tend to improve the
significantly lower concentration of sCD14, a marker of demeanor of horses following colic surgery.
endotoxemia, suggesting better intestinal barrier function Differential diagnoses for horses with mild signs of colic
with firocoxib [39]. Of note is that injectable firocoxib during the immediate postoperative period include
cannot be administered using routine heparinized saline accumulation of gastroduodenal contents (postoperative
flush because it precipitates in aqueous solutions. reflux) due to postoperative ileus or obstruction at an
Intravenous administration directly into the jugular vein, anastomosis, colonic impaction, surgical site pain, or
after filling of the catheter and extension tubing with impending enterocolitis. Moderate to severe and persistent
blood, or using a dimethysulfoxided-based flush solution, abdominal pain can be associated with (ongoing) intestinal
is required. ischemia or non-viable intestine, intestinal strangulation
A butorphanol constant rate infusion (CRI, 13 ¯g/kg/ (e.g. segmental jejunal volvulus), or recurrence of the
hour for 24 hours) improved behavior scores, decreased primary lesion. Recurrent pain is often associated with
weight loss, and lowered plasma cortisol concentrations adhesion formation causing a partial obstruction,
compared to isotonic saline (control) [40]. Horses in the particularly in horses after small intestinal surgery. Gastric
butorphanol CRI group, however, did have a longer time to ulcers are an uncommon cause of pain in the postoperative
first defecation postoperatively [40]. Despite the benefits colic patient but should be considered in horses that show
demonstrated in this study, the routine use of butorphanol signs after eating or after administration of water and
for pain management in horses following colic surgery has electrolytes via nasogastric tube.
not gained widespread acceptance. Reasons may include Horses showing any overt signs of colic warrant further
that most horses subjectively recover without the need for investigation. A physical examination including abdominal
additional analgesia beyond an NSAID, cost and labor palpation per rectum and minimum database point-of-care
associated with CRI of medication using an infusion pump, blood work (packed cell volume [PCV], total plasma
and concerns with decreased intestinal motility associated protein [TPP], blood lactate and blood [BG] concentrations)
with butorphanol use. However, its use could be considered should be completed. Physical examination and blood
in horses at risk for postoperative pain. work should be within normal limits or trending toward
It should be noted that if a horse is experiencing moderate being within normal limits 24 to 48 hours postoperatively.
to severe pain postoperatively, particularly pain Tachycardia at 48 hours was associated with non-survival
unresponsive to an NSAID or a single dose of an alpha-2 following surgical correction of a large colon volvulus [41]
agonist, it is likely that there is a problem such as technical and tachycardia and tachypnea can be an indication of
error or ongoing pathology and repeat celiotomy should be pain and/or shock warranting further diagnostic
considered. evaluation. The cardiovascular system can be assessed by
evaluating mucous membrane color, moistness, and
Diagnosis Most horses likely experience some degree of capillary refill time, extremity temperature, pulse quality,
pain during the immediate postoperative period. Signs of and jugular refill. Evidence of SIRS/endotoxemia,
pain can vary from barely perceptible during the early hemorrhage, or hypovolemia can be identified leading to
postoperative period to overt signs of moderate to severe further diagnostic evaluation or resuscitation therapy (see
colic. Stance, head, and ear position and response to being Sections on Hemoperitoneum and Endotoxemia/SIRS).
approached as well as heart and respiratory rates can be Pyrexia is common during the early postoperative period
used to detect subtle signs of pain (Tables 28.1 and 28.2). (see Section on Pyrexia) [7] but persistent pyrexia and pain
Use of a composite or numerical pain score to evaluate may be an indication for repeat celiotomy in horses with
horses after colic surgery may help direct therapy and lead postoperative reflux [42]. Digital pulses should always be
to earlier recognition of complications. While the composite monitored and the horse walked around the stall, because
pain score had lower inter-observer variability, both laminitis is an infrequent but important cause of
composite and numeric scores were significantly higher for postoperative pain (see Section on Laminitis) [3, 18, 19,
horses developing complications and non-survival and do 43]. Palpation per rectum postoperatively should be within
not appear to be affected by breed, lesion location or the normal limits and can be useful for identifying the
type of lesion [22]. Pawing at the floor, overall appearance, presence, amount, and consistency of feces in the rectum,
distended small or large intestine, and pelvic flexure, cecal, analyzer [49] 48 hours after surgery. Horses with SIRS had
or small colon impaction. A high PCV is often associated a higher SAA following colic surgery (IQR 2,000–3,000
with endotoxemia/SIRS. Hypoproteinemia is typically mg/L) [49]; however, it is a non-specific marker of
caused by intestinal losses associated with severe mucosal inflammation and was not useful for differentiating
injury. An increasing PCV with a decreasing TPP is a well- different causes of inflammation, because horses with
recognized ominous sign and is most often observed with postoperative colic and diarrhea had similar SAA (1 500–
non-viable intestine, bowel leakage, or impending colitis. 2,500 mg/L) [4]. Therefore, these laboratory tests may be
BG and lactate concentration should also be within normal useful for identifying the degree of SIRS or endotoxemia
limits within 24–48 hours postoperatively [44–46]. but are not likely to be specifically helpful in determining
Endotoxemia, non-viable intestine, poor perfusion, the cause of postoperative pain.
intestinal obstruction, or ileus should be considered in Transabdominal ultrasonographic examination may be
horses with persistent hyperglycemia or hyperlactatemia useful for identify an excessive volume of peritoneal fluid
postoperatively. These physical examination and minimum associated with septic peritonitis secondary to anastomosis
database blood work findings are non-specific; however, leakage or ischemic bowel (Figures 28.2 and 28.3a) or
they can be used to assess whether the postoperative pain is fluid-filled cecum or colon that may be associated with
associated with mild ileus or a more serious cause of impending enterocolitis (Figure 28.3b). Dilated small
postoperative colic such as non-viable intestine or intestine is a non-specific finding and may be associated
anastomosis complications requiring repeat celiotomy or with a mechanical obstruction, ischemic small intestine, or
euthanasia.
Nasogastric intubation should be performed on any
horse showing signs of colic, inappetence, or having
tachycardia at any time during the postoperative period,
because ileus leading to gastric distention is a common
cause of postoperative pain. Gastric rupture can occur with
little to no pre-emptive signs and is unfortunately fatal.
Alternatively, performing a brief transabdominal
ultrasonographic evaluation of the gastric and duodenal
region can be performed and is considered a reasonable
approach to assessing gastric distention and outflow [47,
48]. The duodenum can be evaluated ventral of the right
kidney in the intercostal spaces 15 to 17 [48] with a 3.5
MHz curved array transducer; dilated duodenum
(permanent filling), even with some degree of contraction,
warrants passage of a nasogastric tube [47]. The size of the
stomach can be assessed by determining the number of Figure 28.2 Postoperative transabdominal ultrasonographic
intercostal spaces through which the stomach is visible [48]. image of an 18-year-old Hanovarian gelding that had
The use of ultrasonographic evaluation in this manner is undergone jejunojejunostomy following resection of non-viable
bowel associated with a strangulating pedunculated lipoma.
clearly dependent on the billing structure of the hospital Ultrasonographic evaluation 8 days postoperatively was
and is likely prohibitively expensive in some hospitals. unremarkable. Because the pyrexia (up to 104.5oF) persisted and
Additional laboratory data may be useful. Leukocyte or was unresponsive to the antimicrobial therapy, ultrasonographic
neutrophil count is often low in horses with non-viable evaluation was repeated on day 10 postoperatively and an
increased volume of echogenic-free peritoneal fluid was
intestine or colitis. It is important to recognize that even identified (arrows, right 8th intercostal space; ventral to the left)
horses with an uncomplicated recovery can be leukopenic/ with thickening of the right ventral colon. Abdominocentesis
neutropenic for a few days postoperatively [4, 49]; however, was performed and the peritoneal fluid was turbid orange with
horses with postoperative colic and diarrhea did have a intracellular bacteria identified on cytological examination.
Repeat laparotomy revealed septic peritonitis secondary to
lower neutrophil count compared to horses without anastomosis leakage at the mesenteric border with associated
complications (neutrophil count <2,000 cells/uL for horses adhesions. The affected jejunal segment was resected and a
with diarrhea) [4]. Serum amyloid A (SAA) increases in jejunojejunostomy and abdominal lavage performed. Bacterial
horses following colic surgery, with uncomplicated cases culture and sensitivity testing were positive for Escherichia coli,
Streptococcus equi, and Pseudomonas aeruginosa; he was treated
having SAA approximate interquartile range [IQR] 500– with trimethoprim sulfamethoxazole. The horse was doing well
1,500 mg/L in one study using a point-of-care analyzer [4] without any further complications at least 3 year after surgery.
and 1,500–2,500 mg/L in another study using a bench top Source: Courtesy of New Bolton Center.
Pain/colic 317
(a) (b) (c)
Figure 28.3 Postoperative transabdominal ultrasonographic image of a 30-year-old pony gelding 24 hours after surgery for a
strangulating pedunculated lipoma. The serosal surface of the bowel regained color following transection of the lipoma pedicle and
approximately 75% of the small intestine from the proximal jejunum to the ileum was of questionable viability. No resection was
performed. Postoperatively, the pony was tachycardic, tachypneic and pyrexic and showed mild signs of pain. (a) Image of left side
10th intercostal space (ventral to the left) demonstrating markedly increased volume of relatively anechoic peritoneal fluid (arrows)
and (b) left side 14th intercostal space (ventral to the left) showed there was a large volume of liquid digest in the colon, also
suggesting impending diarrhea (arrow head). The pony had a segment of non-viable jejunum (c) that was resected and a
jejunojejunostomy was performed. The bowel at the anastomosis site was inflamed but viable. Although the pony developed a focal
adhesion at the anastomosis site, he did well for at least 2 years after surgery and then developed colic signs associated with
adhesion formation and was euthanized. Source: Courtesy of New Bolton Center.
ileus, making it challenging to determine the need for sur- useful as a diagnostic as well as a therapeutic procedure.
gical management (Figure 28.4). Transabdominal ultra- Relaparotomy is indicated in any postoperative colic
sonographic examination can be useful for identifying patient showing persistent signs of pain. Repeat laparot-
adhesions to the ventral body wall (Figure 28.5) or even omy is reportedly performed in up to 10% of horses under-
other regions (Figure 28.6). It is important to interpret going colic surgery, with the majority being performed
ultrasonographic results in conjunction with other clinical within the first 5 days of the initial surgery [51, 53]. A high
findings. Transabdominal ultrasonographic examination proportion of horses undergoing repeat celiotomy had a
should be repeated if clinical signs do not resolve; however, small intestinal lesion identified during the initial surgery
the cost-benefit of repeated examinations should be con- and had undergone a resection and anastomosis. Reasons
sidered in light of the costs of repeat celiotomy. for repeat laparotomy include colic, reflux, hemoperito-
Peritoneal fluid analysis is not particularly useful in the neum, peritonitis, and body wall complications [51–53].
early postoperative period because cell count and protein While the authors of one study reported that horses with
tend to be high after abdominal surgery in normal animals. ileus diagnosed at relaparotomy had a greater volume of
Peritoneal fluid leukocyte counts can be up to 200,000 reflux following the initial surgery compared to horses
cells/uL on day 4 and up to 80,000 on day 6 and total pro- with anastomosis complications [53], another study focus-
tein concentration up to 5.3 g/dL on day 4 and 6.8 g/dL on ing on horses with postoperative reflux following small
day 6, postoperatively [50]. However, identification of intestinal surgery did not find an association between the
intracellular bacteria (Figure 28.7) is consistent with septic volume of reflux and the reason for the reflux [42]. In the
peritonitis warranting repeat celiotomy or euthanasia if the latter study, higher postoperative peak rectal temperature
clinical signs are also consistent with septic peritonitis. A and timing of postoperative colic were associated with a
high cell count and protein beyond 10–14 days should also mechanical obstruction or non-viable bowel [42]. The most
be considered abnormal. Normal peritoneal fluid volume, common lesions identified on repeat laparotomy include
cell count, and protein in the postoperative period can ileus/small intestinal distention, adhesions, non-viable
likely be used to rule-out septic peritonitis or intestinal intestine, anastomosis obstruction, anastomosis leakage,
ischemia. septic peritonitis, hemoperitoneum, and recurrence of a
It can be challenging to determine the reason for postop- displacement [42, 51–53]. Of note is that many horses
erative pain or overt signs of colic. Relaparotomy can be undergoing relaparotomy for body wall complications also
(a) (b)
Figure 28.4 (a) Postoperative transabdominal ultrasonographic image from the left inguinal region in a 19-year-old Trakehner
gelding on day 3 after resection of 2 meters of non-viable jejunum/ileum associated with a strangulating pedunculated lipoma and
jejunoileostomy. The horse had become severely painful immediately after surgery and had subsequently produced large volumes of
reflux (3–4 L/hour). Ultrasonographic evaluation revealed multiple dilated loop of small intestine with no increase in wall thickness
or peritoneal fluid. The findings were reported to be consistent with ileus. The horse deteriorated and once again became painful;
repeat celiotomy revealed an extensive non-viable segment of small intestine (b) and he was euthanized. Source: Courtesy of New
Bolton Center.
(a) (b)
Figure 28.5 Postoperative transabdominal ultrasonographic evaluation of a 6-month-old Thoroughbred filly that had undergoing
correction of an ileocecal intussusception. During preoperative abdominocentesis, the jejunum was penetrated with a needle and a
small area of jejunum was found to be leaking at surgery. The site of leakage was positioned away from the incision, over the side of
the horse’s abdomen, and the intestine was decompressed through the leakage site (a, arrow). The site of leakage was closed and the
abdomen thoroughly lavaged. The filly developed a fever and mild episode of colic postoperatively. (b) Ultrasound revealed a segment
of jejunum potentially adhered to the body wall at the site of the infected incision (arrow). Unfortunately, laparoscopy and adhesiolysis
was not performed at this time and the foal was readmitted one month later with severe signs of colic and was euthanized. At
necropsy, a jejunal volvulus associated with the adhered segment of jejunum was diagnosed. Source: Courtesy of New Bolton Center.
Pain/colic 319
gery; however, the expense can obviously be prohibitive for

some owners. However, the expense associated with ongo-
ing medical therapy and multiple diagnostic tests should
be weighed against the benefits of obtaining a definitive
diagnosis and potentially treatment with relaparotomy.
Treatment Management of postoperative pain includes

flunixin meglumine, firocoxib or meloxicam (non-US
countries). The vast majority of horses do well with this
analgesic regimen and additional analgesia is not necessary.
Butorphanol CRI may also be used to provide analgesia [40];
however, it has not gained widespread acceptance possibly
because of the decrease in gastrointestinal transit time
associated with its use, particularly with prolonged use
(>72 hours) [40, 54]. Intravenous lidocaine (1.3 mg/kg IV
Figure 28.6 Transabdominal ultrasonographic image (obtained bolus given over 15 minutes followed by 0.05 mg/kg/min
at the right inguinal area) of the pony from Figure 28.3, 11 days
after the first surgery. The pony had recurrent episodes of colic
CRI) may have some analgesic properties; however, the
and reflux associated with re-feeding following his second amount of analgesia provided is controversial and the
surgery. Palpation per rectum was suggestive of a segment of results of one study suggested that it has limited visceral
thickened jejunum adhered in the right inguinal area. analgesic properties in an experimental duodenal and cecal
Ultrasonographic examination of the right inguinal area was
consistent with this finding. The diagnosis of a focal adhesion at
distention model [55]. Ketamine (0.4–0.8 mg/kg/hour) is
the anastomosis site was confirmed with laparoscopy and an anti-inflammatory drug that also provides analgesia and
adhesiolysis was performed. The pony did well for at least 2 has been used as an analgesic for horses with colic [56].
years after surgery and then developed colic signs associated Ketamine is reported to inhibit lipopolysaccharide (LPS)-
with adhesion formation and was euthanized. Source: Courtesy
of New Bolton Center.
induced tumor necrosis factor (TNF)-¯ and interleukin
(IL)-6 in vitro [57]. Doses of up to 1.5 mg/kg/hour for 6
had other lesions identified on abdominal exploration [53]. hours were not associated with any side effects [58].
Relaparotomy or laparoscopy are important in the diagno- Isolated episodes of pain can be managed with doses of
sis of horses with persistent signs of pain after colic sur- xylazine (0.3–0.5 mg/kg IV), butorphanol (0.02–0.1 mg/kg
IV), or detomidine (0.01–0.04 mg/kg IV) [59]. Detomidine
had the most profound sedative and analgesic effects
followed by xylazine; butorphonol had little to no effect on
colic signs when used alone [59]. Of note is that flunixin
meglumine provided less analgesia than detomidine [59].
Xylazine, detomidine, and butorphanol all decrease
intestinal motility [60]. While there are several acceptable
analgesic regimens for postoperative colic patients, it is
important to consider that the majority of horses do not
require analgesia beyond NSAIDs for the early postoperative
period and the need for additional analgesia should raise
concern regarding complications associated with the initial
surgery and prompt closer monitoring or additional
diagnostic tests. Horses that are severely or persistently
painful and unresponsive to analgesia require repeat
celiotomy or euthanasia.
Figure 28.7 Cytology of peritoneal fluid from a horse with Expected outcome Unfortunately, colic pain during the
septic peritonitis secondary to intestinal leakage/perforation. postoperative period is associated with both an increased
Note the mixed bacteria throughout the slide (double arrows) risk of recurrence of colic and death, either during hospital
and the intracellular bacteria (arrow). There were only scant
or following hospital discharge [8]. The odds that a horse
nucleated cells on the slide because most cells are destroyed
(asterisks) when intestinal perforation/leakage occurs. Source: having postoperative colic during hospitalization would
Courtesy of New Bolton Center. have colic following hospital discharge was 11.6 (95%
confidence interval [CI] 3.6–37.4) compared to horses there are individual risk factors for each of the causes of
without postoperative colic [8]. Horses with small pyrexia.
strangulating intestinal lesions and undergoing resection ● Surgery associated with the descending colon may be
are reported to have more problems with colic [9]. associated with a higher occurrence of postoperative
Postoperative colic was the most serious complication pyrexia compared to surgery for other types of
following surgical correction of small intestinal volvulus lesions [10, 33].
and was significantly associated with non-survival [2]. The ● A higher proportion of horses undergoing enterolith
hazards ratio for non-survival for horses experiencing removal from the descending colon were pyrexic after
postoperative colic during hospitalization was 7.6 (95% CI surgery, compared to horses undergoing enterolith
2.8–19.2) compared to horses not experiencing removal from the ascending colon [10].
postoperative colic [8]. Horses experiencing problems with ● Eighty percent of horses developed pyrexia following
colic following hospitalization have a higher risk of being resection and anastomosis of the small colon; pyrexia
euthanized or dying compared to horses with no colic was not associated with a lower survival [33].
(2.58, 95% CI 1.10–5.92) [9]. Relaparotomy is generally
associated with a low short-term survival (<50%), Pathogenesis Figure 28.8 provides an overview of the
particularly for horses diagnosed with septic peritonitis, pathophysiology of pyrexia. Pyrexia involves an elaborate
adhesions, or with signs of shock [51–53]. While there is interaction between the immune and central nervous
ample evidence that relaparotomy is associated with a systems, ultimately leading to an increase in the
lower survival compared to single laparotomy [51–53], it is thermoregulatory set-point of the hypothalamus [62].
important to consider that it is not the relaparotomy per se Pyrogens such as LPS, peptidoglycans, and
but the underlying reason for the relaparotomy that is
responsible for the lower survival. Further evidence is need
to determine postoperative clinical variables associated Exogenous pyrogens
e.g. lipopolysaccharide
with the need for relaparotomy (i.e. differentiating ileus
from non-viable bowel or anastomosis complications) and +
the optimal time after the first surgery to perform
Monocytes, macrophages, endothelial cells, other
relaparotomy. Cost-benefit analysis on early relaparotomy immune cells produced pro-pyretic cytokines
versus continued medical management warrants e.g. interleukins, interferon, tumor necrosis factor-α
investigation and is likely different for each hospital.
+
Inducible COX-2
Pyrexia
+
Definition Pyrexia may be defined as a rectal temperature
>38.3°C and the intensity of pyrexia can be categorized as Prostaglandin-E2
slight (38.3–38.8°C), mild (38.9–39.4°C), moderate (39.5–
+
39.9°C) and severe (>40°C) [7]. Pyrexia is observed
Anterior hypothalamus
commonly following colic surgery with 60–85% of horses
being pyrexic during the early postoperative period [4, 7, +
33, 61]. Hyperthermia due to non-inflammatory or non-
infectious causes is likely uncommon in the postoperative Thermoregulatory
set-point
colic patient.
+ +
Risk Factors
● Pyrexia may be associated with systemic inflammation Heat conservation Heat production
e.g. vasoconstriction e.g. muscle fasciculations
(SIRS, see Section on Endotoxemia/SIRS) or sepsis (SIRS
plus infection).
● Risk factors for different infections (SSI, diarrhea, throm-
bophlebitis, septic peritonitis, pneumonia) are discussed PYREXIA
with each complication.
● Horses with a higher postoperative critical illness score Figure 28.8 Schematic outlining the pathophysiology
had a higher risk of postoperative infection [7]; however, associated with pyrexia. Source: Courtesy of New Bolton Center.
Pain/colic 321
muramyldipeptides induce pyrogenic cytokines such as than 3 hours after the incision was made (5.8 times rela-
IL-1β, IL-6, interferon (INF)-α, and TNF-α. These pyrogenic tive risk of SSI) [65]. Preoperative antimicrobials should
cytokines are released into the hypothalamic circulation and be administered so that the peak concentrations occur
stimulate inducible COX-2 and subsequently local during surgery; plasma and tissue drug levels should
prostaglandins of the E series, which re-set the hypothalamic exceed minimum inhibitory concentration (MIC) for the
set-point [62]. Anti-pyrogenic cytokines such as IL-10 and organism(s) likely to be encountered for the duration of
glucocorticoids limit the magnitude and duration of surgery [66]. Findings from a study of human general sur-
pyrexia [62]. gery patients suggested that the rate of SSI decreased by
Pyrexia can be associated with SIRS or can be the result up to 11.3% as antimicrobial administration moved closer
of an infection or sepsis. SIRS is defined by having two or to incision time, with the optimal time being 4 minutes
more of the following clinical features: tachycardia (>50 prior to incision [67]. The current recommendation is for
beats/min); hyperthermia (>38.6°C [101.5°F]), or hypo- administration of the preoperative dose to start within 60
thermia (37.2°C [<99.0°F]); leukocytosis (>10.0 × 109/L minutes of, and to be completed before, the incision is
[10.0 × 103 cells/uL]), or leukopenia (<5.0 × 109/L [<5 × made (exception with vancomycin and fluoroquinolones
103 cells/uL]); tachypnea (>30 breaths/min) [49]. SIRS can in human patients) [68].
occur in any horse after colic surgery; however, it tends to Redosing during surgery is recommended if the proce-
occur more frequently in horses that have had a strangulat- dure extends beyond 2 half-lives of the antimicrobial drug
ing obstruction or with complications such as postopera- used or if there is excessive blood loss during surgery [68].
tive colic, reflux/ileus or diarrhea, all of which may be While there has been no clear demonstration of a decreased
associated with intestinal and peritoneal inflammation. SSI when antimicrobials were administered closer to the
Sepsis is defined as SIRS associated with an infection. It is time of incision for colic surgery [7, 69], it is still recom-
important to note that not all infections are associated with mended to administer antimicrobials within 60 minutes of
SIRS. surgery and to re-dose when appropriate during prolonged
Infection is common after colic surgery, with 42% horses procedures. The reasons for the lack of association between
diagnosed with an infection in one study; 30% had a single timing of antimicrobial drug administration and SSI after
infection site and 12% multiple sites of infection [7]. colic surgery may be because of the often relatively short
Incisional infection, salmonellosis and clostridiosis, pneu- duration of surgery [66], the fact that some horses under-
monia, catheter-site infection, and septic peritonitis should going colic surgery may not require antimicrobial drugs
be considered as the potential sources of infection. (i.e. clean procedures), and that there are other variables
that are more critical in the development of SSI post-colic
Prevention Pyrexia is typically prevented with the use of surgery (see Section on Incisional Complications).
perioperative NSAIDs (see Section on Pain/Colic); however, Potassium penicillin can cause hypotension when admin-
horses often have some degree of pyrexia despite NSAID istered during general anesthesia, which can be particu-
treatment. In most instances, pyrexia is mild and transient larly problematic for horses undergoing colic surgery
but can be an indication that an infection is present. See (Bernd Driessen, DVM, University of Pennsylvania, per-
Sections on Incisional Complications, Catheter-Associated sonal communication); therefore, it is recommended to
Complications, Diarrhea, and Septic Peritonitis, for administer potassium penicillin prior to induction of gen-
prevention of infection. eral anesthesia.
Prophylactic antimicrobial drugs are administered dur- There is no evidence in human or veterinary medicine
ing the immediate perioperative period to horses under- that extended prophylaxis beyond the immediate
going colic surgery to prevent primarily SSI. Typically, postoperative period (>24 hours) decreases infection [68,
first-line broad-spectrum parenteral antimicrobial drugs 70–76]. It is important to recognize when deciding on a
such as potassium penicillin (22,000 U/kg IV every prophylactic antimicrobial regimen that contamination is
6 hours) and gentamicin (6.6 or 8.8 mg/kg IV every 24 not infection and that contamination does not require a
hours) are used [63]. Timing of preoperative antimicrobi- prolonged prophylaxis [71]. There was no association
als is critical to prevent infection. It has been recognized between duration of antimicrobial drug use and SSI with
for over 50 years that antimicrobials must be adminis- patients receiving antimicrobials for 13–24 hours having
tered prior to surgery [64]. Human patients undergoing an SSI of 13%, 25–48 hours 18%, 49–72 hours 19%, and
clean or clean-contaminated elective surgical procedures longer than 72 hours 27% [69]. Of note is that horses
administered antimicrobials 0 to 2 hours preoperatively administered antimicrobials for <12 hours had an infection
had a lower SSI of 0.6% compared to 2–24 hours before rate of 30%; however, the numbers of horses in that
surgery of 3.8% (6.7 times relative risk of SSI) or more category were low, thus making a clear interpretation
difficult [69]. It is, therefore, not unreasonable to provide

prophylactic antimicrobial drugs for up to 24 hours after
surgery (e.g. up to three doses of potassium penicillin and
one dose of gentamicin postoperatively) until further
information becomes available regarding shorter duration
prophylaxis.
Diagnosis It is critical to recognize that pyrexia does not

always indicate that the patient has an infection,
particularly a bacterial infection requiring antimicrobial
drug therapy. Horses with a mild transient fever during the
early postoperative period may not have an infection and
may have non-septic intestinal or peritoneal inflammation
associated with the primary lesion or surgery. Pyrexia
occurs in up to 40% of human patients following a major
surgical procedure with only 16% of pyretic human patients Figure 28.9 Excessive per-incisional edema can be an
indication of a surgical site infection as a source of
following abdominal surgery actually having a bacterial
postoperative pyrexia, particularly if there is also heat and pain
infection [77, 78]. Infection-associated pyrexia occurred on associated with the surgical site. Source: Courtesy of New Bolton
average 2.7 days after surgery, whereas pyrexia not Center.
associated with infection occurred 1.6 days after
surgery [68]. Similarly, 85% of horses were pyrexic after indication of infection and may be useful for identifying a
colic surgery, with 50% having only a slight increase in site for drainage [79] (Figure 28.10).
rectal temperature and 29% mild, 18% moderate and only Enterocolitis or salmonellosis should be suspected in
8% severe pyrexia [7]. Only 42% of horses in the latter study horses with fever and persistent leukopenia/neutropenia
had an infection [7]. (see Section on Diarrhea). Salmonellosis can be diagnosis
Horses with a rectal temperature >102.5oF (>39oC), based on identification of Salmonella enterica in the feces
pyrexia persisting for longer than 48 hours, and initial or reflux using either culture or polymerase chain reaction
pyrexia observed beyond the initial 48 hours after surgery, (PCR) [80–82]. Clostridiosis can be diagnosed based on
should raise suspicion that an infection may be present [7]. identification of clostridial toxins [83–85]; however, molec-
The main differential diagnoses for horses with pyrexia ular techniques may be more reliable [86].
postoperatively include incisional SSI, colitis, salmonellosis, Pneumonia should be suspected in any horse with
intravenous (IV) catheter-associated complications, viral pyrexia associated with any nasal discharge or cough.
infection, pneumonia, and less commonly septic peritonitis Tachypnea, even mild, should also raise concern regarding
associated with anastomosis leakage or necrotic intestine. a respiratory tract infection. A rebreathing examination
Hematology and measurement of acute phase proteins is should be performed on any horse with unexplained
not always useful because of the inflammatory response pyrexia. Abnormalities on thoracic auscultation during the
associated with the primary disease and surgical rebreathing examination, coughing or distress during the
manipulation of the bowel (see discussion under Section examination, and a prolonged recovery (i.e. more that 1–3
Pain/Colic); however, severe or persistent leukopenia is deep breaths) following removal of the rebreathing bag
most likely associated with colitis or non-viable should prompt further diagnostic tests. Transthoracic
intestine [4]. ultrasonographic examination (Figure 28.11) and less often
Localization of the source of pyrexia can be challenging. thoracic radiographs can be used to further evaluate the
Incisional or superficial SSI is the most common infection lung fields. It is important to keep in mind that the trans-
following colic surgery (see Section on Incisional thoracic ultrasonographic appearance of the lung of horses
Complications). Incisional infection can be diagnosed following general anesthesia for colic surgery, particularly
based on drainage of even a small amount of serous or older horses, has not been determined and care should be
purulent fluid from the incision beyond the initial 48 hours taken with interpretation of findings. Transtracheal wash
after surgery. Excessive peri-incisional edema (Figure 28.9), (Figure 28.12) is indicated to obtain a sample for cytology
heat, and pain on palpation (with gloved hands) should and bacterial culture and sensitivity testing [87, 88].
also raise suspicion of an incisional infection being the If the source of pyrexia is not identified, removing the
source of fever. Identification of fluid pockets using intravenous catheter should be considered. The catheter
ultrasonographic evaluation of the incision can also be an should be removed aseptically and sterile scissors used to
Pain/colic 323
(a) (b)
Figure 28.10 Ultrasonographic image of a ventral midline surgical site 10 days after surgery showing fluid and fibrin accumulation
adjacent to the body wall (asterisks). The suture is a small hyperechoic area (arrow, b). The horse had a superficial surgical site
infection that was draining. Source: Courtesy of New Bolton Center.
(a) (b)
Figure 28.11 Trans-thoracic ultrasonographic appearance of a horse with pneumonia as a source of pyrexia: (a) Irregular appearance
of the pleural surface; and (b) lung consolidation. While this horse had not actually had colic surgery, he was being treated for
proximal enteritis with large volumes of reflux for 5 days. He became pyrexic on day 2 and his lung sounds were abnormal on
auscultation. Bacterial culture and sensitivity of a transtracheal wash sample (Figure 28.12) grew a multidrug resistant Klebsiella
pneumoniae and Streptococcus dysgalactiae subspecies equisimili. He was successfully treated with a prolonged course of intravenous
amikacin. Peak and trough concentrations of amikacin were measured to confirm the appropriate dose rate and dose interval. Source:
Courtesy of New Bolton Center.
(a) (b)
(c) (d)
Figure 28.12 Transtracheal wash kits are available and human central venous catheters may also be used. Transtracheal wash [87,
88] is performed with the horse sedated with xylazine and butorphanol. An area on the ventral midline of the upper third of the
horse’s neck is clipped and aseptically prepared. The tracheal rings should be easily palpated. After infiltration of a small volume of
2% lidocaine, a stab incision is created on midline at a level between the tracheal rings using a #15 blade. (a) The trachea is stabilized
with one hand and with the other a 10- to 14-gage needle or trochar is inserted between the tracheal rings toward the bifurcation
with the bevel pointed in a ventral direction. (b) The catheter is fed through the needled ensuring that it passes easily into the
tracheal toward the bifurcation. (c) Approximately 20 mL of sterile saline is injected through the catheter using a 60-mL syringe
followed by rapid aspiration. (d) The process is repeated until an adequate sample is obtained. A portion of the sample is placed in a
culture vial for bacterial culture and sensitivity testing and an EDTA tube for cytology. The tubing is removed first, followed by the
needle. Source: Courtesy of New Bolton Center.
cut the tip for bacterial culture and sensitivity testing (see Treatment Empirical administration of antimicrobials in
Section on Thrombophlebitis and Catheter-Associated horses with pyrexia during the early postoperative period is
Complications). Septic peritonitis is an uncommon com- not recommended. If pyrexia persists beyond 36–48 hours,
plication following colic surgery and is often associated every attempt should be made to localize the source of
with another primary problem such as non-viable bowel, infection that might be causing the pyrexia. Ideally,
severe enterocolitis, complications with the anastomosis, selection of antimicrobial drugs should be based on
and occasionally a severe incisional infection (see Setion bacterial culture and sensitivity testing, particularly if the
on Septic Peritonitis). horse is not systemically ill. Occasionally the source of
Incisional Complications 325
pyrexia cannot be localized, the fever is high and persistent reported from numerous retrospective studies have var-
beyond several days, and the horse is systemically ill; ied and are often contradictory. These contradictory find-
empirical use of antimicrobials is indicated in these horses ings might result from the definition of SSI used, whether
and selection of a broad-spectrum first-line antimicrobial or not long-term follow up was obtained, surgeon experi-
is recommended. ence, type of horses and lesions treated, and differences
in variables included in the analysis and how the varia-
Expected outcome While one study did show an association bles were defined or categorized.
between fever and high fever and non-survival (95% of ● Surgical procedure (enterotomy/enterectomy):
horses with no fever survived to hospital discharge
compared with only 83% of horses with a fever and 57% of ● While it seems logical that SSI would be greater follow-
horses with a high fever) [3], the underlying disease ing a clean/contaminated procedure, most studies report
causing pyrexia or fever is likely the reason for the negative no association between enterotomy/enterectomy and
effect on survival. The expected outcome is dependent on SSI [61, 89, 91–93, 98–100].
the inciting cause of pyrexia, early diagnosis and treatment ● High operating room environmental colony forming
of the infection, and the response to treatment. units (CFU) and high post-recovery skin bacterial CFU
were associated with SSI [99].
● Performing an enterotomy/enterectomy procedure with
the potential for contamination immediately adjacent to
Incisional Complications
the incision was associated with a higher SSI rate
compared to pelvic flexure enterotomy, small intestinal
Definition The most common incisional complication is a
resection, and no enterotomy/enterectomy [69].
superficial surgical site infection (SSI). SSI has been defined
● Small intestinal resection was associated with SSI in
differently in different studies. Definitions have included:
another study [90] with differences potentially associated
i) the presence of purulent discharge associated with
with the specific techniques used for the various
swelling, heat and pain around the skin incision (with
procedures.
wound drainage defined as the presence of serous or
serosanguinous discharge from the wound associated with ● SSI has also been associated with large colon lesions
local edema but without heat or pain) [2]; ii) persistent potentially associated with trauma to the body wall asso-
drainage for >36 h of serous, purulent or serosanguinous ciated with large colon manipulation [98].
fluid from the incision that occurs after the initial 48-h ● Horses with an incision <27 cm, which remained within
postoperative period and is treated either locally or the fenestration of the drape and possibly within the
systemically [7]; and iii) either persistent serosanguinous thicker portion of the linea alba, had fewer SSI [69]. Of
drainage starting >24 hours after surgery or purulent note, attempting to remove a distended and heavy colon
drainage (suppuration), with or without positive bacterial through a small incision is not recommended because of
culture [89, 90]. Some surgeons prefer to use the term the risk of viscus perforation.
“incisional drainage” or “incisional complication” rather ● Longer duration of surgery [91, 95] and hypoxemia [95]
than infection, unless there is growth on bacterial during general anesthesia have been associated with
culture [61, 90]. higher SSI rates.
Body wall herniation is most often a sequela of SSI or ● Horses with intraperitoneal contamination, septic peri-
wound drainage and is defined as where part of an organ tonitis and those with thrombophlebitis also had a higher
protrudes through the body wall. One to several distinct SSI [2].
fibrous hernia ring(s) are palpated, varying in size from as ● Method of body wall closure and wound protection has
small as 1 cm up to the length of the incision. Horses may been associated with SSI:
also have a weakening of the body wall and abnormal ven-
● Wound closure performed by an inexperienced surgeon
tral contour without a defined hernia ring. Rarely acute
was shown to increase the risk of SSI [89].
dehiscence, defined as separation of the body wall incision
● Not closing the peritoneum increased the odds of inci-
edges, and evisceration can occur.
sional complication compared to closing the peritoneum
(odds ratio 7.68, 95% confidence interval 2.71–
Risk Factors
21.81) [101]. These findings are in contrast to early stud-
● SSI is typically reported in 15–25% of horses following ies that suggested that suturing the peritoneum increased
colic surgery [2, 7, 61, 69, 89–93]; however, reports vary adhesion formation [102] leading to many surgeons not
from as low as 3% [94] to over 40% [95–97]. Risk factors intentionally incorporating the peritoneum in the linea
alba closure. The peritoneum may provide physiological ● Increase in body weight was associated with a higher SSI
support for body wall healing and isolate the linea alba rate [90].
and subcutaneous tissue from the potentially contami- ● Horses had a higher incidence of SSI in the summer and
nated peritoneal cavity. winter months compared with spring and autumn [90].
● Dissection between the linea alba and skin prior to body
Body wall hernia formation occurs in up to 3–16% [9, 91,
wall closure [2] and near-far–far-near (v. simple
101, 106, 107] of horses after colic surgery. Risk factors for
interrupted) suture pattern [100] have been associated
body wall hernia formation previously reported
with a higher occurrence of SSI.
are [106–108]:
● In one study, SSI did not differ when 2-layer (body wall
and skin suture) vs. 3-layer closure was performed [93], ● SSI (incisional drainage or infection)
but in another a 3-layer closure was protective [90]. ● Repeat celiotomy; 32% horses undergoing repeat celiot-
● Use of antibacterial (triclosan)-coated suture material omy developed hernia formation [108]
did not decrease SSI [103] ● Excessive edema
● Use of a modified subcuticular suture pattern decreased ● Postoperative colic
SSI [92] ● Leukopenia
● Subcutaneous closure with polyglycolic acid increased ● Castrated males
SSI [95]. ● Use of chronic gut [107]
● Lavage of the linea alba prior to skin closure was protec-
Acute body wall dehiscence with evisceration is
tive against SSI, whereas skin stapling (vs. skin suture)
uncommon and potentially fatal. Failure can occur at the
was associated with a higher SSI [89].
body wall, along the suture line or at the knot with knot
● Use of a stent bandages (vs. iodine-impregnated adhesive
slippage or suture breakage at the knot. Potential risk
drape) increased SSI in one study [2], but a stent
factors include [111–114]:
bandaged decreased it in another [94]. Once again, the
contradictory findings may be associated with study ● Absorbable sutures weakening at a time when wound
design, case selection, type of stent bandage, and timing strength is mainly dependent on suture strength (5 to 8
of removal postoperatively. days in human beings)
● Placement of a sterile towel (8%) or a polyhexamethylene ● Inappropriate suture size
biguanide–impregnated protective dressing (0%) secured ● Suture breakage caused by increased abdominal pres-
with sutures over the incision site was associated with sure or violent recovery (shear forces concentrating at
significantly lower incisional infection following colic the knot, with breakage usually occurring at the knot).
surgery, compared with horses that had sterile gauze The necessity of slinging during the early postoperative
placed over the wound secured with an iodine-impreg- period, nursing foal
nated adhesive drape (36%) [1–4]. ● Knot slippage or untying (especially with polyester
● The use of an abdominal bandage during the postopera- sutures)
tive period decreased SSI [105]. ● Technical error with failure to take appropriate bites
through the body wall or improperly placed sutures
● A strong association between postoperative colic and
cutting through tissue
increased rate of SSI has been reported in multiple
● Extension of the incision to the xiphoid cartilage can
studies [69, 90, 91]. The association with postoperative
result in difficulty with closure, failure of the body wall
colic is likely related to a combination of surgical site
to heal, peritoneal-cutaneous fistula and acute
trauma, contamination, and potentially the initial cause
evisceration (Figure 28.13)
of colic and procedure performed.
● Body wall failure secondary to repeat celiotomy, septic
● Similarly, repeat laparotomy has been associated with
peritonitis, intestinal leakage
SSI in multiple studies [2, 69, 100] and is an accepted risk
factor for SSI.
● Younger horses were associated with fewer SSI com- Pathogenesis While several risk factors have been
pared to older horses in some studies [95, 101], but not in identified, the exact etiology and pathogenesis for SSI is not
other studies [60]. completely clear and is somewhat debated. Tissue injury,
● Ponies/miniature horses, draft breeds, Standardbreds [95, bacterial contamination, antimicrobial drug resistance,
69], Arabians, and crossbreeds were reported to have a and an overwhelmed or impaired host immune response
lower risk of SSI compared to Warmbloods, American are key features to the underlying pathophysiology of
breeds, and Thoroughbreds [60]. infection. Tissue injury is inherent to surgery; however,
during general anesthesia recovery and during the postop-

erative procedure is likely important [99]. High post-recov-
ery skin bacterial CFU [99] and dislodgement of protective
dressing during the recovery period [104] were associated
with SSI. The relationship between postoperative colic and
SSI is one of the most repeatable findings [69, 90, 91] and
interesting, particularly in light of the finding that body
wall closure incorporating the peritoneum prevented
SSI [101]. While it is somewhat logical that postoperative
colic leads to increase surgical site trauma and contamina-
tion, it is also possible that these horses had more severe or
ongoing intestinal pathology or low-grade septic peritonitis
and that SSI is an extension of peritoneal cavity pathology.
Interestingly, the author has had some horses develop
what appeared to be an SSI; however, there was no heat,
pain, swelling, or actual drainage. The horses had the skin
apposed using 2-0 monofilament suture material in a
simple continuous pattern and it appeared that the problem
was local skin necrosis and sloughing, possibly associated
with avascular skin necrosis from the skin sutures
(Figure 28.14).
Hernia formation occurs because of tissue damage from
trauma or infection and failure of the body wall to heal.
Typically, the skin remains intact. The aforementioned
pathophysiology for SSI is likely the same for hernia forma-
tion, seeing as SSI is the most important risk factor for her-
Figure 28.13 A 10-year-old Thoroughbred broodmare had a nia formation.
Cesarean section for a large malformed fetus. The mare
Several studies have addressed optimal methods of body
developed postoperative hemorrhage requiring a transfusion
and subsequent immune-mediated thrombocytopenia. The body wall closure to prevent dehiscence. Ideally suture material
wall incision inadvertently extended to the xiphoid cartilage. should be as strong as the tissue being sutured [115].
The mare developed an MRSA surgical site infection. Two However, there is a sparcity of sutures stronger than the
months after surgery, she eviscerated omentum and bowel and
was euthanized. Source: Courtesy of New Bolton Center.
longer surgery duration [91, 95], longer incision extending

into cranial aspect of the body wall (thinner and narrower
linea alba) [69], inexperienced surgeon [89], the need to
manipulate the colon to correct a large colon lesion [98],
postoperative colic [69, 90, 91], and repeat laparotomy [2,
69, 100] have all been associated with SSI and contribute to
tissue trauma. While studies have failed to show an
association between intraoperative culture and subsequent
SSI [109, 110], heavy contamination of the surgical site
either because of the procedures performed [69, 90], high
operating room environmental CFUs [99], septic peritonitis
and intraperitoneal contamination [2], increased SSI,
whereas lavage of the linea prior to skin closure was
protective against SSI [89].
Discrepancies between studies may be because of limita- Figure 28.14 Photograph shows a horse that developed what
appeared to be an SSI; however, there was no heat, pain,
tions with bacterial culture techniques including sample
swelling or significant drainage and the skin just appeared to
collection and processing methods, and variability in anti- undergo avascular necrosis, possibly because of the skin sutures
microbial drug sensitivity and resistance. Contamination being too tight. Source: Courtesy of New Bolton Center.
equine linea alba, with most linea alba-suture constructs 44% and linea alba thickness 34% of the variability in
studied failing at the suture knot [116–121]. Insufficient breaking strength, with the thicker caudal linea alba hav-
suture size can lead to the suture tearing through the body ing a higher breaking strength compared to the thinner
wall or breaking [120]. Typically, USP 2 or 3 polyglactin 910 cranial linea alba. It is recommended, however, to some-
(0.5 mm and 0.6 mm diameter, respectively) is used in celi- what vary the suture bite distance between about 12 and
otomy wall closure. Larger diameter and braided sutures 15 mm from the cut edge, so that the body wall does not
have greater tensile strength [121, 122]. USP 7 braided tear adjacent to the incision. Sutures should be placed 10
polydiaxanone (1 mm diameter) had a higher bursting to 15 mm apart, with 15 mm resulting in a slightly faster
pressure compared to USP 2 polyglactin 910 [120]. USP 2 closure and less suture material in the wound [127]. Knot
polyglactin failed at the knot, whereas the body wall failed security is also important, with recent studies showing
when the linea alba was sutured with USP 7 braided poly- better mechanical properties (bursting strength increased
diaxanone [120], suggesting that the latter is in fact suffi- 25%) and smaller knot volume with a self-locking (for-
ciently strong for linea alba closure. In the latter study, in warder start with an Aberdeen end knot) compared to a
body walls closed with USP 7 polydiaxanone, increasing surgeon’s (start and end) knot [128, 129].
age was negatively correlated with bursting strength (r =
–0.99) [120]. Incisional complications in a subsequent ret- Prevention While not all identified risk factors, such as
rospective clinical study of horses undergoing linea alba signalment [69, 90, 95, 120, 123, 124], lesion [2, 98] and
closure using USP 7 braided polydiaxanone were similar to required surgical procedure [69, 90, 98] can be avoided,
other studies [2, 7, 61, 69, 89–93], with 25% of horses devel- there are several potential measures that can be undertaken
oping drainage, 12% infection, 5% partial dehiscence, and to prevent incisional complications. Early surgical
3% hernia formation [91]. Using an ex vivo model, ventral intervention for horses with strangulating lesions,
midline compared to right ventral paramedian celiotomies meticulous atraumatic and aseptic surgical technique, and
had a higher bursting strength when closed using USP 7 intraoperative efficiency to decrease surgery time are
braided polydiaxanone [123]. Once again, age and also the essential. Protection of the body wall incision and
Quarter Horse breed were associated with lower body wall peritoneal cavity with several layers of laparotomy sponges
bursting strength [123]. However, there was no difference or drapes during contaminated procedures, lavage of the
in complications when a ventral midline and right parame- linea alba [89], and protection of the surgical site during
dian incisions were compared in clinical cases [124]. recovery from general anesthesia using a stent bandage [94,
In horses having had a ventral midline celiotomy (origi- 104] that is less likely to become dislodged and a
nal surgical approach) then undergoing repeat celiotomy, postoperative abdominal bandage [105], may help prevent
similarly, there was no difference in healing or tensile SSI. Keeping the incision length short and in the caudal
strength between repeat ventral midline celiotomy and linea alba may decrease infection [69]; however, this should
right ventral paramedian celiotomy, suggesting that either not be at the expense of having an incision long enough to
approach is satisfactory for repeat celiotomy [125]. Based traumatically exteriorize a distended and friable colon.
on these studies, larger size braided synthetic absorbable Incorporation of the peritoneum in the body wall closure
suture material should be selected depending on commer- could potentially prevent infection. Appropriately timed,
cial availability. A ventral midline was stronger than a right broad-spectrum, parenteral prophylactic antimicrobial
ventral paramedian incision when closed using USP 7 drugs can prevent infection (see Section on Pyrexia).
polydiaxanone, because the body wall rather than the Rest for at least 8 weeks is important to prevent inci-
suture material failed; however, when using smaller diam- sional complications. Compared to control unoperated
eter suture material there is no difference between the two linea alba (tensile strength 484.9 ± 58.3 N), operated linea
approaches because the suture material (not the body wall) alba had a lower tensile strength at 2 weeks (87.7 ± 61.4 N)
fails most commonly at the knot. and 4 weeks (305.8 ± 61.7 N) after surgery [128]. At 8 and
A simple continuous suture pattern used to close the 16 weeks, however, the tensile strength was not different to
linea alba had a higher bursting strength than an inverted the control linea alba (465.4 ± 56.5 and 477.8 ± 57.2 N,
cruciate interrupted pattern [126], with the former pattern respectively) [130]. Therefore, after an uncomplicated
being quicker and leaving less suture material in the recovery, exercise can begin at 8 weeks.
wound and currently being the recommended technique
for body wall closure. The optimal bite size from the cut Diagnosis SSI typically occurs 2 to 21 days (75th percentile
edge of the linea alba is 15 mm, based on a lack of increase 12 days [69]) after surgery and is usually diagnosed based
in breaking strength with larger bites (using size 5 stain- on serous or purulent drainage of fluid from one or more
less steel) [121]. In the latter study, bite size accounted for localized areas along the incision (Figure 28.15). Of note is
(a) (b)
Figure 28.15 Drainage of purulent material from the incision. Source: Courtesy of New Bolton Center.
that horses are often discharged from the hospital prior to ria such as Escherichia coli, Enterococcus, and enterobac-
10–12 days and the owner or caregiver may be the one to teriaceae. Importantly, these organisms tend to be
first observe drainage. inherently resistant to antimicrobial drugs, making
Horses may [91, 101] or may not [7] be febrile and the empirical selection of antimicrobials not recommended.
fever can be low grade or high, likely depending on the In one study, the most common bacterial isolates were
infecting organism(s), extent of the infection, and the Escherichia coli (59.5%), Enterococcus spp. (42.4%), and
horse’s individual response to the infection. Persistent Staphylococcus spp. (25.4%). Penicillin resistant isolates
pyrexia (>102ºF or >39ºC) observed beyond the initial accounted for 92% of isolates and 18% of isolates were
perioperative period (>48 hours after surgery) is more gentamicin resistant [90].
likely associated with an infection than a low-grade Diagnosis of a body wall hernia is made on physical
transient fever immediately after surgery [7] and should examination weeks to months after surgery, often by the
prompt a more thorough evaluation (see Section on owner or caregiver (Figure 28.18). Small hernias often are
Pyrexia). Pyrexia often resolves in uncomplicated SSI once unnoticed and may only be diagnosed if a repeat celiotomy
adequate drainage is established. Occasionally horses can becomes necessary.
become moderately systemically sick (dull, inappetent,
tachycardic, and tachypneic) with an SSI; however,
observation of these signs should promptly rule out other
complications
Transient drainage of serosanguineous within the initial
24–48 hours postoperatively is not usually indicative of
infection and is often associated with leakage of peritoneal
fluid through the body wall incision. Small volumes of ser-
osanguineous fluid may be inconsequential; however, large
volumes or persistence of drainage warrants further evalu-
ation of the body wall. Defects along or adjacent to the
body wall incision can usually be identified with careful
palpation. Ultrasonographic evaluation can provide details
of the extent (length and width) and location (along or
adjacent to the body wall incision) and can be used to mon- Figure 28.16 Ultrasonographic image of a body wall defect in
itor defect progression (Figures 28.16 and 28.17). a 30-year-old pony gelding (see Figure 28.3) that developed
Aseptically obtaining a sample of fluid from the wound peritoneal fluid drainage within 24 hours of repeat celiotomy. A
for bacterial culture and sensitivity testing is important body wall defect was noted (asterisks). The body wall defect was
conservatively treated with stall confinement and an abdominal
for monitoring hospital nosocomial infections and for support bandage and healed appropriately without hernia
appropriate antimicrobial drug selection, if necessary. formation. The pony was being ridden within a year of surgery.
The most common infecting organisms are enteric bacte- Source: Courtesy of New Bolton Center.
Figure 28.18 Diagnosis of a body wall hernia is typically made

by the owner several weeks after surgery. The photograph is of a
3-year-old Warmblood filly that had initial abdominal surgery
for a small intestinal strangulating obstruction with
jejunocecostomy. She required repeat celiotomy for a large cecal
abscess (Figure 28.27, Streptococcus equi subspecies
zooepidemicus and an anaerobe were isolated from the abscess)
and multifocal adhesion formation. Adhesiolysis was performed
and the abdominal abscess was treated with penicillin and
Figure 28.17 Ultrasonographic image of the abdominal ventral metronidazole. She developed salmonellosis and mild incisional
midline of a 13-year-old post-partum mare that had necrotic drainage and a hernia (Figure 28.22). Source: Courtesy of New
jejunum and septic peritonitis post foaling. The mare underwent Bolton Center.
bowel resection and a jejunojejunostomy and developed severe
body wall drainage and partial dehiscence (arrow indicate
suture; asterisks indicate body wall defect). An abdominal drain An abdominal bandage may be beneficial to keep the site
was placed; the mare developed partial dehiscence of her clean. Change abdominal up to 1–3 times a day, depending
incision. She was successfully treated medically with a hernia on the volume of drainage from the SSI or peritoneal cavity.
belt, abdominal drainage, antimicrobials and stall confinement.
Failure to keep the site clean and dry may result in damage
Source: Courtesy of New Bolton Center.
to the skin of the ventral abdomen, which can become
severe. Use of an abdominal hernia belt (Figure 28.19) may
Treatment Management of SSI primarily involves be useful for preventing hernia formation and could poten-
establishing drainage and keeping the site of drainage tially decrease the duration and volume of drainage by pro-
clean and dry using sterile saline. Establish drainage by viding some stability of the surgical site for healing. The
removing staples or skin sutures at one or more sites abdominal hernia belt had higher sub-bandage pressures
identified on physical (moist or soft area, active drainage) (mean 39 mmHg, 95% confidence interval 37–41 mm Hg)
or ultrasonographic (fluid accumulation) examination. when compared to an elastic bandage (25, 24–28 mmHg) or
Use sterile Kelly hemostats to open carefully only the skin a nylon abdominal binder (5, 4–8 mmHg) [132], suggesting
for drainage. When the skin is apposed using a continuous that it might provide superior body wall support. Horses
absorbable suture pattern, drainage may be established were also more likely to lie down wearing the hernia belt
without cutting the suture material if necessary, during the than the nylon binder and the hernia belt was less likely to
first 7–10 days of healing. The skin should be healed after slip in a caudal direction than the elastic bandage [131].
7–10 days and the suture can be cut without the entire skin Take care, however, that the hernia belt (or any abdominal
incision dehiscing. Dehiscence of the skin often occurs as a bandage) is correctly placed and padded along the horse’s
consequence of SSI. Healing occurs by second intention back, particularly the withers. Inadequate padding can
and is generally of little consequence. Occasionally skin lead to severe pressure necrosis (Figure 28.20).
and subcutaneous tissue dehiscence occurs with exposure Body wall dehiscence can be life threatening. While
of the body wall sutures. While this is obviously concerning, small body wall defects may be managed conservatively
with body wall support (abdominal bandage or hernia belt) (Figures 28.16 and 28.17) with confinement and abdomi-
and confinement, the wound eventually heals. Hernia nal support, address large defects surgically by placing the
formation is likely to occur. horse under general anesthesia and repairing the body
(a) (b)
Figure 28.19 Abdominal hernia belt (CM Equine Products). Note that the hernia belt is not well padded (a) over the withers (see
Figure 28.21). It is generally not recommended to have a horse wearing a hernia belt in a large paddock ((b) Horse from Figure 28.19).
Source: Courtesy of New Bolton Center.
wall. Repair may be completed by re-suturing the linea

alba in instances where the suture broke. If the body wall is
infected or damaged, debridement and placement of sup-
port wires may be required. Wiring of the body wall is per-
formed with 18-gauge wire in an interrupted vertical
mattress pattern with or without suture apposition of the
body wall, subcutaneous tissue [132].
While antimicrobials are generally not needed for resolu-
tion of the infection, occasionally horses will become sys-
temically ill (high fevers, inappetence, or dull demeanor)
as a consequence of an SSI, and AMD may be indicated in
these cases. Antimicrobials may also be indicated in severe
infections, particularly if associated with septic peritonitis.
AMD selection should ideally be based on bacterial culture
and sensitivity testing. Antimicrobial-impregnated sponges
or beads may be used in some horses and lavage with Tris-
EDTA may be of benefit (David Levine, DVM, personal
communication).
Core abdominal rehabilitation exercises (carrot exer-
cises), for 4 weeks beginning 4 weeks after surgery if there
are no incisional complications or 4 weeks following reso-
lution of any incisional complications, are safe and may
help with faster convalescence and improved
performance [133].
Body wall hernias can be repaired primarily or using a
prosthetic mesh. Primary hernia closure resulted in a good
Figure 28.20 Pressure necrosis of the withers associated with cosmetic outcome in 84% of horses, which was not differ-
an improperly placed and padded hernia belt. The horse was
kept in a paddock. Confinement is recommended when use of a ent to that when additional support of the repair was pro-
hernia belt is deemed necessary. Source: Courtesy of New Bolton vided with mesh placement [134]. Horses in which a mesh
Center. was used had a longer duration of surgery and hospitaliza-
tion, and were more likely to develop postoperative compli-

cations while having a longer duration of convalescence
prior to return to use [134]. Prosthetic mesh repair of
abdominal wall hernias [135–137], including a laparo-
scopic approach [138], have been described. Endoscopic
component separation of the body wall is via a laparoscopic
approach, whereby components of the body wall (abdomi-
nal fascial tunics) distant from the hernia are strategically
incised to allow body wall advancement on one or both
sides of the defect toward its center and re-establishment
of the linea alba [139]. The procedure was evaluated in
cadavers and resulted in only modest body wall advance-
ment [139]. A high complication rate was reported in one
study following retroperitoneal placement of a woven plas-
tic mesh secured to the hernia ring using #2 polyester fiber
with body wall closure over the mesh [140]. Complications
included abdominal discomfort (with 30% of horses ulti-
mately being euthanized for recurrent colic), seroma and
hematoma formation in all horses, skin necrosis, incisional
drainage in 62%, and internal abdominal oblique tearing in
23% of horses (weighing over 590 kg) [140]. Hernia repair
is unnecessary in the majority of horses and should only be
considered if cosmetic appearance of the ventral body wall
is necessary.
Figure 28.21 Hernia formation should not affect athletic
activity (horse from Figure 28.19). Source: Courtesy of Janelle
Expected outcome SSI can be expected in up to 10–25% of Gunther.
horses after abdominal surgery. Drainage from the incision
is likely to occur until the sutures are absorbed (56–70 days,
i.e. up to –3 months after surgery). The duration of drainage Ileus (postoperative ileus, POI) is currently defined as a
is unlikely to be decreased by AMD use and bacterial temporary arrest of intestinal peristalsis [143] or “a syn-
causing SSI may be resistant to commonly-used drome of functional inhibition of propulsive bowel motil-
antimicrobials. SSI requires prolonged treatment (wound ity” [144]. Despite this definition, in postoperative colic
management, confinement, with or without abdominal patients, ileus is most often a clinical diagnosis. While
bandaging) and has an increased likelihood of herniation [9, there is consensus that the definition of POI involves the
61, 98] and delayed return to athletic activity [18]. Hernia presence of reflux following nasogastric intubation [145,
formation should not affect athletic activity [141] 145], various definitions have been used. Several clinical
(Figure 28.21) and hernias are usually repaired if cosmesis studies have used a classical definition of POI as >20 L of
is important. reflux following nasogastric tube passage during a 24-hour
period after surgery or >8 L at any single sampling time
after surgery [147–150]. Merritt and Blikslager [151], on
the other hand, developed a more comprehensive defini-
ostoperativeReflux
P tion encompassing other clinical findings: gastric reflux of
and PostoperativeIleus 4 L upon any given intubation, or >2 L/h on repeated
intubation of gastric contents of pH >4.0; persistent tachy-
Definition Postoperative reflux (POR) describes the net cardia (>40 beats/min); mild to severe signs of abdominal
volume of fluid obtained when a siphon is created following discomfort; rectal and/or ultrasonographic evidence of
nasogastric intubation and is typically a complication multiple loops of fluid distended small bowel.
following surgery for small intestinal disease. While the
volume of reflux considered clinically relevant is up for Risk factors
debate, a volume greater than 2 L is generally considered The overall occurrence rate of POI in horses following colic
abnormal. Postoperative reflux may be caused by a surgery is about 15–20% [147, 148, 152] and following colic
functional or mechanical obstruction [142]. surgery for a small intestinal lesion 10–60% [24, 149, 150,
Postoperative eflux and Postoperative Ileus 333
153, 154], depending on the type of lesion and surgical pro- While duration of anesthesia and surgery may reflect the
cedure, and definition of POI or POR. complexity of surgery, longer surgery duration is also
likely to increase bowel injury (see below).
● Small intestinal lesion, particularly horses with a stran-
gulating obstruction and undergoing resection and anas- ● Increasinbl tg length of resected intestine was associated
tomosis [2, 147–149, 150, 152–154]: with increasing risk of postoperative ileus [149].
– In one study, horses with a strangulating peduncu- ● Age:
lated lipoma had a high risk of POI compared to other – Roussel et al.[148] reported that horses >10 years had
small intestinal lesions [155]. a higher risk of postoperative ileus (57%) compared to
– POI was higher in horses undergoing jejunoileostomy horses <10 years (44%); however, age was not included
(33%) and jejunocecostomy (20%) compared with jeju- in the final multivariable analysis, most likely because
nojejunostomy (0%) in one study [153], but POR (>2 L older horses are more likely to have a strangulating
at any time point) was not significantly different small intestinal lesion compared to younger horses
between types of anastomoses in another study [24]. predisposing them to postoperative ileus.
– Length of small intestinal resection was associated – Holcombe et al. [149] reported an increase in the odds
with POI in one study (no POI 1.8 ± 2.7 m vs. POI 2.3 ratio for postoperative ileus of 1.1 for each 1-year
± 2.8 m) [149] increase in age. The overall rate of postoperative ileus
● Leaving ischemic bowel in the abdomen [2]. was 38% in horses of 11 to 20 years and 38% in horses
● Admission critical illness associated with a high packed >20 years with a lower proportion of younger horses
cell volume [147–149, 152, 54, 155] and heart rate [150, (<10 years) developing postoperative ileus (16%) [149].
152], and metabolic dysregulation (hyperglycemia) [152, These results may suggest that there is no difference in
154]: the occurrence of postoperative ileus between mature
– Horses undergoing small intestinal colic surgery with and geriatric horses; however, young horses are less
an admission PCV >50% were 4.67 times more likely likely to develop postoperative ileus.
to develop postoperative reflux compared to horses – Other studies have not reported a significant associa-
with a PCV <50% [150]. tion between increasing age and postoperative
– Horses with POI were significantly more likely to have ileus [147, 150, 152–155].
a PCV 45% compared to horses without POI (POI – In a retrospective study comparing complication rates
46% vs. no POI 15%; odds ratio 5, 95% confidence inter- in geriatric and mature non-geriatric horses with colic,
val 3–9) [148]. the overall incidence of postoperative reflux (defined as
– The risk for developing postoperative ileus increased >2 L reflux at any time) was higher in geriatric (>16
with increasing heart rate [150]. These findings illus- years and >20 years) compared to mature horses (35%,
trate the importance of early referral and surgical 27%, and 21%, respectively) [3]; however, geriatric
management of horses with strangulating small intes- horses were at least twice as likely as mature horses to
tinal lesions. have a small intestinal strangulating lesion [156]. When
● Reflux at admission [150, 154]: only horses with small intestinal lesions were consid-
– The presence of >8 L at admission was associated with ered, there was no difference in the incidence of POI in
POI (OR 3, 1.1–8) in one study [150]. geriatric (>16 years, 35%) compared to mature (38%)
– Horses with reflux at admission had 5 times higher horses [3]. Based on these data, geriatric horses do not
risk of POR (OR 4.61, 1.3–16) and a 10 times higher have a higher incidence of POI compared to mature
risk of high-volume POR (OR 10, 2-46) in another horses, once the lesion-type is considered; however,
study [154]. young horses may have a lower incidence [149].
– Reflux at admission may reflect the duration of ● Horses undergoing pelvic flexure enterotomy may have a
obstruction, intestinal injury, and the lesion type. lower occurrence of postoperative ileus [147, 148].
● Duration of general anesthesia and surgery [147, 148]: ● Intravenous lidocaine may decrease POI (see below) [147,
– Duration of anesthesia >3 hours was associated with 150].
POI (OR 3, 1.4–7) with duration of anesthesia for ● Ileus can also affect the large intestine. Specific examples of
horses with POI being 3.25 (1–8.5) vs. no POI 2.25 large intestinal ileus are in horses with a large (ascending)
(1–5) hours [147]. colon volvulus that become distended, painful, and have a
– Surgery duration >2 hours was associated with a 3 lack of intestinal borborygmi and fecal production postop-
times increased risk of developing POI (OR 2.9, eratively or horses with cecal or small (descending) colon
2–5) [148]. impactions that re-impact during the postoperative period.
Pathogenesis Propulsion of ingesta along the distended intestine (decreased blood flow and oxygen
gastrointestinal tract is dependent on contraction of enteric delivery) [159]. With decompression, blood flow returned
smooth muscle in response to generation of an action to above baseline values, and there was an increase in
potential (spiking activity). Table 28.3 shows the contractile microvascular permeability, edema formation, neutrophil
activity of the stomach and small intestine in the fasted infiltration, and serosal damage after as little as 2 hours of
state. Each phase of activity moves along the intestinal distention [158–160]. Edema, hemorrhage, and neutro-
tract [157]. Enteric smooth muscle generates slow waves philic inflammation have been observed in the proximal
(spontaneous oscillations of the membrane potential), (and distal [161]) jejunal resection margins of clinical
which are inadequate to generate an action potential. Input cases [161, 162], particularly in the serosa, smooth muscle,
from the enteric (intrinsic) and autonomic (extrinsic), fascial planes, and myenteric and submucosal plexus [162].
namely sympathetic (adrenergic) and parasympathetic In experimental horses undergoing 1 or 2 hours of jejunal
(cholinergic, vagus), nervous systems is required for ischemia, neutrophilic inflammation increased 2 hours
sufficient depolarization to reach the threshold potential post ischemia and then increased further by 18 h post
and generate an action potential [157]. The enteric nervous ischemia. Neutrophilic inflammation was observed in all
system consists of ganglia in the myenteric (Auerbach’s) intestinal layers, particularly the serosa, fascial planes, cir-
and submucosal (Meissner’s) plexus and uses neuropeptides cular and longitudinal muscle layers, and myenteric
and nitric oxide as neurotransmitters. Sympathetic plexus [162]. Neutrophilic inflammation was mirrored by
hyperactivity results in splanchnic vasoconstriction and an increase in calprotectin-positive cells, indicating leuco-
decreased propulsive motility; therefore, α-adrenergic cyte activation [162]. Evidence of cellular stress at the oral
agonists impair motility and α-adrenergic antagonists border of the anastomosis was observed in horses with
enhance intestinal motility. small intestinal strangulating obstruction [163].
Parasympathetic hypoactivity causes a reduction in An increase in ubiquitin (indicating proteasome degra-
motility and decrease in intestinal secretion. dation via ubiquitin chain formation) in the nucleus of
Cholinomimetics should, therefore, promote intestinal mucosal enterocytes, heat shock protein (HSP70, indicat-
motility [157]. Importantly, complete severance of the ing protein restoration) in smooth muscle cell nucleus, and
autonomic nervous system has little effect on intestinal c-jun (indicating an early proinflammatory response) in
motility [157]. This emphasizes the importance of the the enteric neurons suggest that both degenerative and
enteric nervous system and smooth muscle cells on repair pathways are activated in the non-resected intestine,
maintenance of propulsive intestinal motility and the although these findings were not associated with the devel-
impact that damage to these cells has in the role of postop- opment of POI or outcome [163]. Similarly, proteinase-
erative ileus. activator receptor 2 (PAR2), which is activated by trypsin
The cause of postoperative ileus is likely multifocal, vari- and mast cell tryptase and induces inflammation (includ-
able between patients, and has not necessarily been well ing vasodilation and increased vascular permeability), tis-
defined in the horse. Intestinal ischemia and reperfusion sue damage, cytokine production and bacterial
injury, prolonged intestinal distention, intestinal inflam- translocation, mRNA and protein expression was increased
mation, postoperative pain, drugs administered, endotoxin the marginally injured intestine (adjacent to strangulat-
emia and shock can cause and imbalance between the ing lesion) than healthy tracts and strangulated intes-
sympathetic and parasympathetic nervous input to the tine [164]. Intestinal manipulation alone (abrasion model)
intestine, impairment of enteric nervous system function, has been shown to increase neutrophilic inflammation and
and injury to the enteric smooth muscle cells leading to may contribute to POI [165]. Routine intestinal manipula-
accumulation of ingesta, liquid, and gas within the stom- tion as would be performed during decompression, how-
ach and small intestine and signs of POI. An early transient ever, did not cause more neutrophilic inflammation than
neurogenic phase and a later inflammatory phase have that observed at a remote site in an ischemia-reperfusion
been described for POI [143]. Neuronal motility inhibition model, providing evidence of a more generalized intestinal
is thought to be self-limiting, with function returning when inflammation. Information from both clinical and experi-
nociceptor and mechanoreceptor stimulation ceases. The mental studies strongly indicate that there is damage to the
subsequent inflammatory response, however, results in a normal-appearing intestine adjacent to a strangulating
longer period of hypomotility [143]. obstruction and an inflammatory response involving the
Several studies have demonstrated injury to and inflam- smooth muscle and enteric nervous system possibly con-
mation of the segment of bowel proximal (oral) to the site tributing to POI, albeit a lack of association between these
of resection [158–163]. Experimentally, small intestinal histological findings and the clinical manifestation of
intraluminal distention leads to low-flow ischemia of the POR [166].
Exposure of small intestine to ambient temperatures intervention, the oral section of bowel adjacent to the
below body temperature (37oC), such as that occurring anastomosis should be healthy. Resection of all affected
during exploratory celiotomy, may impair motility [167]. bowel is critical to prevent POR and the bowel forming the
Enteric smooth muscle slow wave frequency was anastomosis should have normal motility, serosal color,
temperature sensitive and approximately linearly related to diameter, and wall thickness (if feasible). Reported
temperature in an ex vivo model [167]. Initial slow wave guidelines suggest removing 30–50 cm of adjacent healthy
frequency was restored with return to body temperature intestine at each end of the injured segment [173]; however,
and the recovery time was related to hypothermia removal of >50 cm of bowel proximal (oral) to the injured
duration [167]. segment may be necessary in some cases to ensure that the
Systemic disease, including endotoxemia, shock, and anastomosis is being performed in a bowel as healthy as
electrolyte disturbances, may also impair motility. possible. Performing an anastomosis in an injured bowel is
Endotoxin may decrease motility via a prostaglandin-E2 likely to result in POR. Similarly, leaving a non-viable
mechanism [168, 169]. Horses that developed POI had bowel in the abdomen usually leads to POR and adhesion
significantly lower serum concentrations of ionized formation (see Section on Postoperative Intraperitoneal
magnesium after surgery. Similarly, the odds for developing Adhesions).
ileus during hospitalization were 11.94 times higher for Excessive manipulation of the bowel should be avoided.
horses with admission plasma calcium concentration Complete decompression of the jejunum, however, is
(<1.27 mmol/L, very low) in comparison with considered imperative to prevent POI/POR by several
normocalcaemic horses (1.46–1.61 mmol/L) [170]. surgeons and is likely important in light of the effect of
Endotoxemia, a high packed cell volume, and alkalosis distention on jejunum. Routine manipulation of jejunum
(hypochloremic metabolic alkalosis often observed with similar to that during decompression did not cause an
small intestinal obstruction) were associated with inflammatory response in excess of that from remote
hypocalcemia, making it difficult to determine cause-effect non-manipulated sites [166]. Use of sodium carboxym-
for POI [170]. ethylcellulose may decrease trauma to the bowel during
Surgical technique may have an impact on POR. In one manipulation, particularly decompression and decompres-
study, a higher proportion of horses undergoing a stapled sion should be effective and efficient. The bowel should be
side-to-side jejunocecostomy had POR (40%) compared to lavaged with warm (37ºC) fluids only and returned to and
a hand-sewn side-to-side jejunocecostomy (9%) [26], yet in kept in the peritoneal cavity when possible to avoid the
another study there was no significant difference between negative effects of hypothermia on motility. Using an appo-
end-to-side and stapled or hand-sewn side-to-side sitional pattern, particularly for jejunoileostomy, tended to
jejunocecostomy [27]. In the former study it was proposed decrease POR compared to an inverting pattern [24].
that there may be a small volume bowel leakage and Technical skill is critical in small intestinal surgery, with
inflammation associated with not over-sewing a staple one study showing that number of years board certified by
line [26]. Case numbers in both studies were small [6, 27]. the American College of Veterinary Surgeons was associ-
While there was no significant difference between horses ated with short-term outcome; the probability of survival
undergoing jejunojejunostomy or jejunoileostomy using a was highest for those board certified for 10–15 years and
single-layer Lembert or a double-layer simple continuous decline thereafter [27].
and Cushing pattern [171], horses undergoing a double- Refeeding after gastrointestinal surgery is a poorly stud-
layer appositional pattern (simple continuous) tended to ied yet critical component of patient care, particularly
have fewer postoperative complications and a better short- when pertaining to POR. Early refeeding of small amounts
term survival, particularly for horses undergoing of feed (e.g. grazing or small volumes of a complete pelleted
jejunoileostomy [24]. The latter finding may be because feed) is important for mucosal health and motility. Feed
there is no (or very little) cuff when an appositional pattern can be gradually increased thereafter, depending on the
is used avoiding obstruction at the anastomosis site. procedure performed, appearance of bowel at surgery,
length of bowel resected, and the clinical appearance of the
Prevention Early identification of horses with a horse. Feeding a large amount of coarse hay to a horse with
strangulating obstruction, such that surgery is performed SIRS, intestinal inflammation, impaired motility, and an
prior to bowel injury, is ideal albeit not always possible. anastomosis (particularly one with cuff formation) is likely
Horses with intestinal strangulation not requiring a to result in POR. Horses with cecal and small (descending)
resection had fewer complications compared to horses colon disease tend to be predisposed to re-impaction and
undergoing resection and anastomosis [172]. Furthermore, gradual refeeding is recommended. While horses with
even if resection is deemed necessary, with early surgical large colon lesions can typically be refed more rapidly,
Table 28.3 Phases of intestinal motility in the small for differentiating between POI, non-viable bowel, and a
intestine [157]. simple obstruction (Figure 28.4). Although the number of
horses with POR was too small for statistical analysis,
PhaseActivity Function horses undergoing exploratory celiotomy for a small
intestinal lesion, postoperatively had thicker small
1 No spike potentials No contractions
intestinal walls, increased loop diameter, slower motility,
2 Intermittent spiking activity Propulsion of
and hypoechoic contents, particularly in horses that had
ingesta
undergone small intestinal resection and anastomosis,
3 Regular spiking activity (migrating Propulsion of
motor complex) ingesta when viewed ultrasonographically from the caudoventral
abdomen [174]. Ultrasonographic findings of horses that
4 Rapidly diminishing spiking activity –
had a large colon lesion were similar to those of horses
undergoing an elective surgical procedure under general
occasionally a horse will develop an impaction or signs of anesthesia [175]. The effects of general anesthesia and
colic, possibly because of dysmotility or even POI. non-abdominal surgery are usually mild and transient [175].
These findings support the notion that even horses without
Diagnosis Horses with POR usually have transient signs complications following small intestinal surgery may have
of colic (mild to moderate), inappetence, dull demeanor, abnormal ultrasonographic findings and clearly further
tachycardia, and hemoconcentration. A nasogastric tube studies are needed to determine the diagnostic value of
should be passed in any horse showing these signs during transabdominal ultrasonography for predicting POR and
the postoperative period. Depending on the anastomosis diagnosing horses with POR. Peritoneal fluid analysis may
site or the underlying pathophysiology, horses may not not be particularly useful during the early postoperative
have POR for up to 12–24 hours. Time of recovery from period, except if intracellular bacteria are identified.
anesthesia to development of POI was a median of 13 A definitive diagnosis is made during repeat laparotomy
hours (0.5–120 hours) and duration of POI was a median of (or necropsy). The decision to proceed with repeat
days (1–7 days) [152]. Occasionally, POR may be observed laparotomy in a horse with POR can be challenging.
with refeeding. Depending on the hospital billing structure, repeat
Differential diagnoses for horses with POR include POI, laparotomy can be expensive and more expensive than
obstruction at an anastomosis, kinging or volvulus at the medical management of POI. That being said, prolonged
anastomosis (primarily jejunocecostomy), intussusception, medical management substantially impacts expense of
volvulus at a site other than at the anastomosis, hemorrhage treatment and could be considered inhumane in horses
and hematoma formation at the anastomosis site, intestinal with POR requiring surgical correction. There have been
ischemia and necrosis, intestinal leakage, septic peritonitis, very few studies investigating clinical variables associated
and adhesions. The timing of the onset of reflux and with POR caused by POI versus a problem requiring repeat
clinical signs will alter the differential diagnosis. For laparotomy. Horses with POR after small intestinal surgery
example, a horse with mild transient colic signs resolving and pyrexia and persistent or recurrent colic, or a long time
with nasogastric intubation and gastric decompression, between surgery and onset of colic signs, are more likely to
inappetence, and transient POR, is likely to have POI, have a surgical reason for POR and repeat laparotomy
whereas a horse with moderate to severe and persistent should be considered [176].
colic signs, fever, and persistent or marked tachycardia Total or peak reflux volume or reflux duration were not
may have problems with ongoing intestinal ischemia useful for differentiating a mechanical from a functional
(Figure 28.4) or septic peritonitis. Horses where colic signs obstruction [176]. Of note, the majority of horses (73%) in
and POR are recurrent and associated with attempts at the latter study had either a medical reason for POR or
refeeding may be associated with adhesions (Figure 28.6) responded to medical management. Similarly, the most
or other cause of partial obstruction. common finding during repeat laparotomy was POI (35%),
Diagnosis is primarily based on response to treatment. and 30% of horses had (small or large intestinal)
Trans-abdominal ultrasonographic evaluation may be use- anastomosis complications [53]. Horses with POI (vs.
ful in that if there is an excessive amount of peritoneal anastomosis complications), had a higher POR volume on
fluid, it may be consistent with septic peritonitis associated the second day after the first celiotomy (38.5 L [0–113.5 L]
with ischemic bowel or anastomosis leakage. Adhesion vs. 0 L [0–71 L]) and on the day of the second celiotomy (15
formation, particularly to the ventral body wall, may also L [0 –45 L] vs. 0 L [0–32 L]) and more horses with POI
be identified on ultrasonographic examination. required additional analgesia on the first day after the first
Ultrasonographic examination, however, may not be useful celiotomy (55%) compared to horses with (small or large
intestinal) anastomosis complications (25%) [53]. Because volume and total plasma protein concentration. Partial
of the breadth of the study inclusion criteria [53], these parenteral nutrition should be considered in horses with
results are difficult to interpret for horses with POR. persistent POR (>48–72 hours); however, repeat
However, diagnostic (at least) repeat laparotomy should be laparotomy to obtain a definitive diagnosis should probably
considered for horses with POR and persistent, recurrent be considered before substantially increasing the daily
or severe colic signs, colic signs occurring beyond the expense associated with treatment.
initial perioperative period, high fever, and reflux not at Motility modifying drugs are often used prophylactically
least beginning to resolve in 48–72 hours. to prevent POI or therapeutically for presumed POI
(Table 28.4). The effects of administrating multiple proki-
Treatment Treatment primarily consists of withholding netic drugs simultaneously (e.g. intravenous lidocaine and
feed, intravenous fluids and electrolytes, frequent gastric erythromycin) are unknown and information on their use
decompression, NSAIDs, and motility modifying drugs. in foals is scant.
Analgesia may be necessary; however, analgesia Surveys of specialists regarding promotility drug use for
requirements beyond perioperative NSAID administration treatment of POI indicated that a continuous rate infusion
should prompt consideration that there may be a problem (CRI) of lidocaine HCl was most commonly used [145, 146,
necessitating repeat laparotomy. Gastric decompression 177] followed by erythromycin lactobionate, metoclopra-
should be performed every 2 to 4 hours depending on the mide HCl, and cisapride citrate [177]. Its use, however, is
rate of nasogastric reflux. The goal should be to obtain <5 not without controversy [178–180]. Intravenous lidocaine
L at any one time. The nasogastric tube can be left in place was initially incorporated into the treatment regimen for
for several hours at a time in an attempt to decrease trauma perioperative colic patients as a visceral analgesic and
to the nasopharynx and allow for frequent gastric motility stimulant based on findings in human patients.
decompression without being labor intensive. However, soon after its use, lidocaine CRI was found to
Administration of sucralfate per os (i.e. not via the actually increase the transit time of feces in normal
nasogastric tube, 20 mg/kg q 6–8 h) may help alleviate horses [181] and while it was reportedly a good somatic
some of the discomfort associated with frequent analgesic, it did not provide visceral analgesia [55].
decompression. Intravenous fluids should be administered Important findings with regards to the potential beneficial
at a rate sufficient to replace losses (i.e. calculate the role of lidocaine CRI for treating postoperative colic cases
volume of reflux and divide it by the number of hours over include attenuation of ischemia-reperfusion injury in an in
which the reflux was obtained), as well as to meet vivo 2-hour jejunal ischemia model through an anti-
maintenance fluid requirements. Adequacy of fluid therapy inflammatory mechanism and by ameliorating the
should be monitored based on physical examination inhibitory effects of flunixin meglumine on mucosal
findings, urine output, measuring blood lactate barrier restoration [182, 183], improvement in smooth
concentration, and monitoring trends in packed cell muscle contractility and basic cell function following
Table 28.4 Prokinetic drugs used in horses with postoperative ileus.
DoseRate/
ProkineticDrug MechanismofAction RouteofAdministration AdverseEffects
Erythromycin Motilin receptor 1 to 2 mg/kg diluted in 1 L saline given IV over Abdominal pain
lactobionate agonist 60 minutes every 6 hours. Diarrhea
Tachyphylaxis
Metoclopramide Dopamine 1) 0.04 mg/kg/h IV CRI* Extrapyramidal signs
HCl D2 antagonist 2) 0.25 mg/kg diluted in 500 mL saline given IV
over 30 to 60 minutes every 6 hours.
Neostigmine Cholinesterase 0.0044 mg/kg SQ every 0.5 to 1 hour. Dose rate Abdominal pain
methylsulfate inhibitor can be increased incrementally to a maximum
dose rate of 0.02 mg/kg.
Acepromazine Alpha-adrenergic 0.01 mg/kg IM every 4 hours. Sedation
maleate antagonist
CRI, constant rate infusion

*
recommended
ischemia-reperfusion injury [184], and a decrease in POI in mixed 5-hydroxytryptamine (serotonin, 5-HT)3 receptor
clinical studies [147, 150, 185]. antagonist/5-HT4 receptor agonist. Metoclopramide HCl
Lidocaine CRI was associated with decreased POI (odds stimulates intrinsic cholinergic nerves via activation of
ratio 0.25, 95% confidence interval 0.11–0.56) and improved 5-HT4 receptors leading to enhanced acetylcholine release
survival short-term survival (3.33, 1.02–11.1) of horses in nerve endings and improved gastrointestinal motility. It
after colic surgery [150]. A higher proportion of lidocaine- is also reported to have adrenergic blocking activity, which
treated horses (65%) stopped refluxing within 30 hours of may also improve gastrointestinal motility. Metoclopramide
initiating treatment, whereas only 27% of the saline-treated is a substituted benzamide, with cisapride and mosapride
horses stopped refluxing within 30 hours [185]. Compared having a similar structure. Metoclopramide HCl has been
with placebo, lidocaine CRI treatment resulted in a shorter shown to improve intestinal motility both in vitro [191] and
hospitalization time for survivors and no difference in in vivo [192]. Metoclopramide HCl administered as a
short-term survival or complication rates [185]. constant rate infusion decreased the incidence and severity
Postoperative colic patients treated with a lidocaine CRI of POI following small intestinal resection and
had better jejunal motility based on ultrasonographic anastomosis [192]. Metoclopramide ameliorated the
examination compared to untreated horses [186]. inhibitory effect of endotoxin on gastric emptying in
Therefore, potential clinical benefits with the use of a normal horses [193]. Metoclopramide as well as cisapride
lidocaine CRI have been demonstrated in multiple studies and mosapride improved jejunal motility in normal
and with any beneficial effect possibly though minimizing horses [194]. Other studies have not demonstrated an effect
ischemia-reperfusion injury and inflammation. On the of metoclopramide on jejunal motility [195] Specific 5-HT4
other hand, other studies have not shown similar benefit. agonists, such as prucalopride, have been investigated. [196,
In a 1-hour ischemia model, lidocaine did not decrease 197]. Prucalopride reportedly increased motility based on
neutrophilic inflammation at 4 hours post ischemia, transabdominal ultrasonographic examination in a non-
whereas it did decrease intestinal cyclooxygenase-2 blinded, non-controlled small clinical study [197].
expression. [166]. In one study, widespread 5-HT4 receptor immunoreactiv-
The latter study is supported by an in vitro study demon- ity was observed in all intestinal smooth muscle layers;
strating that lidocaine did not inhibit neutrophil adhesion 5-HT4 receptors, however, were absent from the myenteric
and migration [187]. In a large retrospective study, a lido- plexus and interstitial cells of Cajal [198]. Yet in another
caine CRI had no impact on the presence, volume, or dura- study, 5-HT4 receptors immunoreactivity was localized to
tion of POR or survival [180]. A meta-analysis showed that large percentages of myenteric and submucosal neu-
there was no benefit of prophylactic lidocaine CRI on POR; rons [199]. However, by using an ex vivo model, there were
it was, however, associated with a higher survival rate [178]. reportedly no functional 5-HT4 receptors on myenteric cho-
These disparate results may be because of variation in case linergic neurons nor longitudinal or circular muscular
selection, lesions severity and other treatment regimens, 5-HT4 receptors in equine jejunum, and prucalopride was
experimental model used, and the fact that the exact mech- ineffective at stimulating motility, indicating that these spe-
anism of its effect on motility and possibly analgesia (if cific 5-HT4 agonists may not be effective in horses [196].
any) have not been determined. The dose rate is 1.3 mg/kg Prucalopride at this point has not gained widespread clinical
bolus given over 15 minutes followed by 0.05 mg/kg/min- acceptance and is available as an oral preparation limiting its
ute CRI to achieve a serum concentration of –2 ug/mL. A use in horses with POR. Importantly, metoclopramide HCl,
lower dose rate should be considered for horses under gen- which is more commonly used, can cross the blood–brain
eral anesthesia [188, 189]. Use of a fluid pump and a one- barrier and also suppress the central D2 receptor, which can
way valve injection port attached to the intravenous cause extrapyramidal side effects, such as tremor, agitation,
catheter is strongly recommended to prevent complica- excitement, and aggression. Metoclopramide HCl is recom-
tions. One important disadvantage is the cost. A rare commended as a continuous rate infusion beginning at half the
plication is collapse and seizure with toxic levels; however, therapeutic dose rate (Table 28.4). Horses should be moni-
horses recover rapidly when the lidocaine CRI is stopped. tored closely for signs of adverse effects and the infusion rate
Occasionally horses can become dull or ataxic, in which increased to the target rate if extrapyramidal signs are not
instance the dose rate is lowered or the infusion stopped. observed. If adverse effects are observed, the infusion rated
The range of serum lidocaine concentration associated should be decreased or the infusion stopped. Currently,
with clinical signs of toxicity is 1.85–4.53 ug/ml [190]. cisapride citrate is not routinely used in horses as a promotil-
Metoclopramide HCl is a dopamine D2 receptor ity drug, because it is only available as an oral preparation
antagonist that antagonizes the inhibitory effect of that has negligible absorption per rectum. Cisapride can
dopamine on gastrointestinal smooth muscle. It is also a cause arrhythmias in human patients.
Diarrhea 339
Erythromycin lactobionate is a motilin receptor agonist laparotomy should also be discussed with the owner for
that initiates the migrating motor complex and promotes any horse refluxing for beyond 48-72 hours that has not
antegrade peristalsis (Table 28.4). Dose rates exceeding 10 started to respond to medical treatment or when POR was
mg/kg can disrupt propulsive motility [157]. Erythromycin not an anticipated postoperative complication.
decreased contractile amplitude of the equine pyloric
antrum circular smooth muscle and increased contractile Expected outcome The survival of horses with POR is
amplitude of the longitudinal smooth muscle in vitro [191], significantly lower than horses that do not develop POR.
which may explain its role in accelerating the rate of gastric Anecdotally, these horses tend to be at risk of developing
emptying in horses in vivo. Erythromycin increases motility intraperitoneal adhesion formation and may have more
in healthy horses [200, 201]. Repeated dosing of problems with recurrent colic, which may be because of
erythromycin decreases the motilin receptor density, the injured and inflamed amotile bowel being predisposed
leading to development of tolerance (tachyphylaxis). to adhesions or because the risk factors and pathophysiology
Jejunal distention and inflammation led to a significant are similar for the two complications (see Section on
decrease in the number of motilin receptors, whereas Postoperative Intraperitoneal Adhesions). Following small
jejunal ischemia-reperfusion injury resulted in a less intestinal resection in horses, 47% experienced POI, which
significant decrease in receptors [202]. These findings are increased the risk of death 29.7-fold [203]. POI increased
important with regard to the pathophysiology of POI, as the risk of non-survival in horses with epiploic foramen
well as the use of erythromycin in the management of this entrapment [204]. In another study, 4 out of 31 (13%)
complication. An important consideration prior to treating horses with POI died and of 148 horses, only 10 (7%) died
with erythromycin is the ethical impact of administering with 4 out of 10 (40%) deaths in the short-term postoperative
an antimicrobial drug for a non-antimicrobial use. period attributed to POI [152]. Geriatric horses with POR
Neostigmine methylsulfate is a cholinesterase inhibitor compared to mature non-geriatric horses did not have a
that prolongs acetylcholine activity at the synaptic junction higher risk of death, with the overall odds ratio for death in
by delaying its metabolism (Table 28.4) [157]. Complications horses with POR being 5 (95% CI 2-12) [3]. While horses
of abdominal pain can occur. Acepromazine maleate is an undergoing repeat laparotomy, in general, have a lower
α-adrenergic antagonist that may attenuate the sympathetic survival rate (primarily because of the underlying disease
hyperactivity and increase in catecholamine concentration or complication), horses undergoing repeat laparotomy for
following laparotomy (Table 28.4) [157]. High POR had an 80% survival in one study [205] and
catecholamine concentrations may increase synthesis of identification of distended small intestine (POI) during
intestinal norepinephrine, which is an inhibitory repeat laparotomy increased the likelihood of survival in
neurotransmitter released by enteric ganglia postsynaptic another study [52].
neurons. Norepinephrine inhibits release of acetylcholine
(an excitatory neurotransmitter) from cholinergic neurons.
Acepromazine maleate has no analgesic properties and
Diarrhea
even at low doses can cause quite profound sedation.
Hypotension can occur following administration; therefore,
Definition Diarrhea can be defined as the passage of non-
it should not be used in horses with signs of shock.
formed feces [33] or more specifically as more than 2
Bethanechol Cl is not commonly used for prevention or
episodes of loose feces in any 24-hour period [206].
treatment of postoperative ileus, because of data showing
that it does little to restore coordinated intestinal motility
Risk Factors
and side effects including abdominal pain, diarrhea, saliva-
In one study, 53% of horses undergoing colic surgery devel-
tion, and gastric secretion [157].
oped diarrhea and yet in another study only 3.2% devel-
When to perform a repeat laparotomy to treat POR is
oped diarrhea/colitis [2]. The difference possibly associated
controversial and can be a challenging medical and
with the types of lesions seen and definition of diarrhea
financial decision (see Diagnosis above). It is important to
used.
consider, however, the cost of ongoing medical treatment
in horses with a cause of POR necessitating surgery ● Large intestinal lesions [10, 207]:
whereby medical management is futile. Likely any horse – Horses undergoing surgery for a large intestinal lesion
with colic (beyond transient mild to moderate colic were 2.5 times as likely to develop severe diarrhea
responding to gastric decompression) and POR, particularly compared to horses with other lesions [207].
if associated with a high fever, has a more serious cause of ● Large colon resection (transient, self-limiting
POR, and repeat laparotomy should be considered. Repeat diarrhea) [28]
● Small colon lesions [208] and small colon resection [33] moderate mucosal injury, dysmotility, and dysbiosis.
● Diarrhea of 1 to 11 days duration occurred in 19 (46%) Moderate to severe mucosal injury associated with a large
horses after surgical correction of a sand impaction [209] colon volvulus, and enteropathy or impaction, or large
● Diarrhea was the most common complication in minia- colon resection may lead to a more prolonged duration of
ture horses following colic surgery, affecting 38% of diarrhea.
horses in one study [210] and 20% in another study [211]. Salmonellosis is probably the most recognized disease
The predominant lesion of horses in the study was a associated with diarrhea post-colic surgery. The potential
fecalith in the small (most common) or large colon [210, for Salmonella species to cause nosocomial infections
211]. leading to outbreaks and hospital closure has led to it being
● Horses with salmonellosis are at a higher risk of having one of the most studied pathogens [221–224]. While
diarrhea. Risk factors for salmonellosis are variable numbers vary considerably, in one study 20% of horses had
between hospitals [211–220] and have included: positive fecal cultures for Salmonella spp., with 74%
reportedly asymptomatic carriers [214]. Of the 26% of
– Diarrhea at the time of hospital admission [217] or
postoperative colic patients developing diarrhea, only 12%
within 6 hours of hospital admission combined with
had a positive fecal culture for Salmonella spp. [214].
hospitalization exceeding 8 days (OR 20.3, 95% CI
Salmonella spp. vary in pathogenicity and almost all strains
5-94) [211].
have some degree of pathogenicity [225]. Salmonella spp.
– Horses with diarrhea were more likely to shed
are ingested and cause disease through epithelial cell inva-
Salmonella spp. (OR, 1.88; 95% CI, 1.02–3.45) [219].
sion stimulating pro-inflammatory cytokine release and
Importantly in this study, most isolates were not mul-
subsequently diarrhea and mucosal injury or necrosis.
tidrug resistant (MDR) and antimicrobial use did not
Salmonella induces its own phagocytosis in a non-
increase the odds of shedding a MDR strain.
phagocytic host cell (intestinal epithelium) through type
– Travel time to veterinary teaching hospital longer than
III secretion systems (Salmonella pathogenicity islands
1 hour (OR 3.5, 95% CI 1.2–11) [212]
[SPIs] genes), which are multi-channel proteins allowing
– Change in diet while hospitalized [217].
Salmonella to inject its effectors across the epithelial cell
– Nasogastric intubation [218] membrane activating host signal transduction pathways
– Warmbloods and Arabians had increased odds for causing reconstruction of the epithelial cell actin
shedding Salmonella in one study [213] but no breed cytoskeleton and outward extension of the epithelial cell
predisposition has been identified in the majority of membrane which engulfs the bacteria. Pathogenic
other studies. Salmonella strains are capable of persisting in the vacuole
– Peak seasonality of the disease was from June through created by the epithelial cell membrane and resist lysosome
September in one study [220]. fusion and enzyme degradation using the type III secretion
– Horses requiring surgery [213, 215, 216] (OR, 2.5; 95% system, whereby effectors proteins are injected into the
CI, 1.1–5.8 [213] or as high as OR, 8.2; 95% CI, vacuole causing remodeling and blocking lysosomal
1.1–60.2 [216]) fusion [225]. The subsequent inflammatory response and
– Horses with more severe gastrointestinal disease (OR, mucosal injury lead to diarrhea and clinical signs associated
2.6; 95% CI, 1.1–6.2) [213]. with salmonellosis. Salmonella can enter the systemic
– Large colon impaction (feed or sand) [214] circulation through the intestinal epithelium and can
– Repeat laparotomy [214] persist in macrophages allowing them to be carried in the
– Horses treated with antimicrobial drugs prior to hospi- reticuloendothelial system [225].
talization [2156]. Similarly, horses treated with paren- Clostridium difficile and C. perfringens have not been
teral antimicrobials while hospitalized had 6.4 times studied as intensely as Salmonella spp. in postoperative
greater risk and horses with parenteral and enteral colic patients [226. 227]. Horses with colic were more likely
40.4-times greater risk of developing to shed C. difficile (cumulative prevalence with 3 samples
salmonellosis [218]. was 19%) and C. perfringens (cumulative prevalence 16%)
– Foals compared to adults with gastrointestinal disease compared to healthy horses (C. difficile 0% and C. perfrin-
(OR, 3.27; 95% CI, 1.68–6.38) [215]. gens <5%); however, single day prevalence of C. difficile
and C. perfringens was <10%, suggesting that multiple sam-
Pathogenesis Diarrhea is the result of an imbalance ples are needed. C. difficile shedding increased from day 1
between intestinal secretion and absorption of fluid. to day 3 or 10, whereas C. perfringens shedding decreased
Transient, self-limiting diarrhea is not uncommon after during hospitalization. C. difficile shedding has been
colic surgery and most likely associated with mild to reported in 0–25% of healthy horses [228, 229] and does not
Diarrhea 341
produce disease unless there is dysbiosis allowing C. diffi- Biosecurity and surveillance are critical for preventing
cile to sporulate, proliferate, and produce disease-causing diarrhea caused by nosocomial infection and disease
toxins [226]. Similarly, C. perfringens can be identified in outbreaks associated with infectious organisms such as
the feces of 0–8% of healthy adult horses and up to 35% of Salmonella spp. [234]. Handwashing or sanitization, use of
broodmares [230, 231]; however, while disease has been personal protective equipment (often as simple as gloves
identified in foals, the role of entertoxigenic C. perfringens and shoe covers), and hospitalizing postoperative colic
strains in adult horse diarrhea is unclear [226]. Clostridia patients separate from the main hospital population are
produce several toxins. C. difficile toxin A (enterotoxin) minimum biosecurity procedures that can be instituted.
induces inflammation and hypersecretory diarrhea Horses with diarrhea, particularly those with diarrhea
through an intestinal epithelium-sensory neuron-inflam- associated with fever, leukopenia and inappetence (see
matory cell interaction. Toxin A causes an increase in fluid below), should be isolated. Patient and environmental
secretion, mucosal injury and neutrophil infiltration. monitoring using polymerase chain reaction (PCR) for
Substance-P from intestinal sensory nerves causes infiltra- Salmonella spp. (screening) can be used to identify early
tion of macrophages and mast cells and upregulation of Salmonella shedding and environmental contamination.
endothelial adhesion molecule expression. Subsequent Cost-benefit analysis needs to be considered when
neutrophil migration into the mucosa causes mucosal designing a biosecurity and surveillance program. In the
injury and necrosis [232]. C. perfringens produce alpha and instance of an outbreak or even suspected outbreak,
beta toxins [232]. Alpha toxin (phospholipase C) interferes consultation with an epidemiologist with expertise and
with glucose uptake and energy production and activates experience with a salmonella outbreak is recommend to
enterocyte signaling pathways, the aracadonic cascade, help guide cleaning and hospital management
and increases small intestinal mucosal secretion [232]. procedures [234].
Beta toxin causes enterocyte necrosis, ulceration, severe
intestinal inflammation, and hemorrhage [232]. C. perfrin- Diagnosis Diagnosis of diarrhea is readily apparent based
gens enterotoxin (CPE) causes cellular necrosis through its on identification of liquid feces on the stall floor, walls, or
insertion into cell membranes. creating pores leading to horse’s perineum and hind limbs. Clinical signs associated
cellular membrane permeability to water and macromole- with diarrhea caused by an infectious cause of diarrhea can
cules. Loss of the epithelial layer of the intestinal mucosa vary from none to shock and death within 12–24
causes inflammation, intestinal edema, hemorrhage, and hours [229].
SIRS [232]. CPE also alters tight junction integrity leading Occasionally, horses with impending diarrhea may have
to increase in intestinal permeability [232]. fever, dull demeanor, inappetence, and mild abdominal
pain. Transabdominal ultrasonographic evaluation may be
Prevention Diarrhea may be difficult to prevent in several performed to identify a large volume of liquid digesta in
postoperative colic patients, because of the inherent nature the large intestine. Care should be taken with interpretation
of the underlying disease. Di-tri-octahedral (DTO) smectite of this ultrasonographic finding, if an enterotomy was
(Platinum Biosponge®, 0.5 kg/500 kg body weight in 4 L performed during surgery, enteral fluids were recently
water administered via a nasogastric tube every 24 hours administered via nasogastric intubation, or if feed has been
for 3 days beginning 4 hours after surgery) reduced the withheld for a prolonged period of time.
occurrence of postoperative diarrhea in horses with large In most instances, the cause of diarrhea is not identi-
colon disease compared to placebo (4 L water administered fied. However, a fecal sample should be obtained for
via a nastogastric tube every 24 hours for 3 days), with the Salmonella PCR and culture if PCR is positive and prob-
prevalence being 11% in the treated and 41% in the placebo ably Clostridium toxins. In one study, the final multivari-
group [233]. While a stable and healthy gastrointestinal able model for predicting salmonella shedding included
microbiome is critical for preventing infection with surgical treatment for colic (OR, 1.60; 95% CI, 0.70–3.62),
pathogenic microorganisms such as Salmonella spp. and fever >103°F (OR, 2.70; 95% CI, 0.92–7.87), abnormal leu-
Clostridium spp., probiotics did not have an effect on kocyte count (leukocytosis or leukopenia; OR, 1.38; 95%
Salmonella spp. shedding in one study [212, 214]. Timely CI, 0.61–3.09), and clinical signs of inappetence and leth-
recognition and treatment of horses with colic and prompt argy (OR, 16.69; 95% CI, 4.08–68.24) [214]. In another
surgical intervention when necessary, discriminant study, salmonella shedding was associated with diarrhea
antimicrobial drug use, and early re-feeding of at least developing during hospitalization when hospitalized for
small amounts frequently (trophic feeding) postoperatively, >8 days (OR, 20.3; 95% CI, 5.1–94.4), laminitis developing
may help reestablish mucosal function, motility, and during hospitalization (OR, 12.0; 95% CI 2.5–58), abnor-
restore the microbiome. mal results of nasogastric intubation (OR, 4.9, 95% CI
1.6–16), and leukopenia being evident within 6 hours of I ntravenousCatheter-Associated

hospitalization (OR, 4.6, 1.3–17) [212]. Salmonella testing Complications
and isolation of horses showing these clinical signs is
recommended. Definition Intravenous catheter-associated complications
include peri- or paraphlebitis, thrombophlebitis, septic
Treatment Treatment is generally supportive with fluid thrombophlebitis, air embolism, and catheter
therapy and antidiarrheal medication (e.g. DTO-smectite fragmentation. Peri- or paraphlebitis is defined as
and bismuth subsalicylate). Colloidal support may be inflammation of the vein and surrounding tissue (cellulitis)
necessary in horses with severe protein losing enteropathy and may or may not be septic [239]. Thrombophlebitis is
with the plasma albumin acutely decreasing to below 2 g/ defined as intraluminal venous thrombosis secondary to
dL (typically corresponding to a total plasma protein <4 g/ mural inflammation of the vessel wall [239–241] and may
dL). In a small study, horses with colitis administered (septic thrombophlebitis) or may not (thrombophlebitis)
plasma had a significantly higher survival rate (80%) be associated with infection. Vein thrombosis is defined as
compared to horses administered hetastarch (47%) [235]. a thrombus without mural inflammation and is usually a
Plasma administration is expensive and while it provides long-term sequela of thrombophlebitis [239]. Subclinical
benefits beyond oncotic pressure it may not be the ideal catheter-related disease (ultrasonographic identification
colloid to improve oncotic pressure. Metronidazole may be thrombus formation and/or a more than 50% increase in
considered in horses with diarrhea associated with C. the thickness of the wall of the vein compared with a
difficile. More recently, fecal microbial transfaunation has previous or control vein measurement) [242]. In the equine
been used in the management of diarrhea, salmonellosis, patients, the jugular vein is affected most often because it is
and clostridiosis and investigation into the effectiveness the usual site of catheter placement. Air embolism occurs
and optimal methodology is ongoing [236]. Horses with when air enters via an inadvertently left open jugular
diarrhea, particularly if associated with SIRS, are at risk of venous line into the venous circulation because of the
developing laminitis and digital cryotherapy is negative pressure relative to atmospheric pressure [239].
recommended. Catheter fragmentation occurs with catheters made from
polytetrafluoroethylene (PTFE) break or when a wire used
Expected Outcome Survival rate of horses with colitis (75%) for silastic catheter insertion is lost into the venous
was not significantly different from horses without colitis circulation [239]. A catheter fragment usually passes
in one study (83%) [2]. Horses with diarrhea after colic through the heart and into the lung where it remains
surgery had lower odds of returning to use 6 months after without consequence. In small horses and foals, the
surgery compared to horses without diarrhea [237]. catheter may become lodged in the heart warranting
Mortality is variable with salmonellosis, with some strains retrieval. Other complications such as perivascular leakage,
having infection rates of up to 44% during an outbreak [219, exsanguination, and inadvertent arterial catheterization
220]. Similarly, clostridiosis can have a high mortality are less-common complications. Occasionally horses can
rate [229, 238]. Death or euthanasia is typically a develop a septic arteritis and cellulitis as a result of arterial
consequence of shock secondary to severe intestinal injury catheterization for blood pressure and blood gas monitoring
and mucosal necrosis or septicemia, laminitis, or financial during general anesthesia.
constraints imposed by the owner or caregiver. In one
study, while postoperative colic patients with salmonellosis Risk Factors
had a lower short-term survival (77%) compared to horses
● The prevalence of thrombophlebitis has been reported as
without salmonellosis (9%), those that survived to hospital
approximately 8–10% [2, 3] and the prevalence of sub-
discharge in fact had a higher long-term survival and
clinical catheter-related disease was 31% [242]. In one
similar incidence of recurrent colic compared to horses
study, 15% of neonatal foals administered parenteral
that did not have salmonellosis [8]. Both groups of horses
nutrition developed thrombophlebitis or local sep-
returned to their intended use [8]. Length of hospital stay
sis [243]. In another study, approximately 60% of horses
and treatment costs were higher in horses with
had mild pathological changes (swelling, hematoma for-
salmonellosis [8]. In general, Salmonella shedding was not
mation based on physical examination [244].
associated with decreased average survival times or impacts
to health of stablemates, perhaps due to owner implemented ● Generally, postoperative colic patients with signs of
biosecurity precautions. Regardless, recently hospitalized colic after surgery have a higher occurrence of throm-
horses should be segregated after discharge and hygiene bophlebitis, as do horses with SIRS and signs of
practices employed [219]. shock [2].
Intravenous Catheter-Associated Complications 343
● Rectal temperature >101.5F (>38.5ºC) at the time of if the thrombus becomes infected through contamination
catheterization increased the odds of subclinical from the catheter insertions site or bacteremia.
catheter-related disease (OR, 4.4; 95% CI, Iatrogenic air embolism occurs when air enters the
1.1–22.7) [242]. venous circulation through an inadvertently left open
● NSAID administration via the catheter decreased the jugular vein catheter or line. The negative pressure in the
odds of subclinical catheter-related disease (OR, 0.36; venous circulation relative to atmospheric pressure causes
95% CI, 0.13–0.96) [242]. the air to enter the circulation. Small amounts of air are
● Endotoxemia or SIRS (OR, 18.5; 95% CI, 1.4–251) [245] inconsequential; however, large air emboli move through
● Salmonellosis (OR, 67; 95% CI, 2.3–1,992) [245] the right side of the heart into the pulmonary circulation
● Large intestinal disease (OR, 3.6 95% CI, 1.04–13) [245]: causing cardiac and respiratory signs. Reduced cardiac
– Horses with an impaction at least anecdotally have a output occurs. Hypoxemia, hypotension, increased
higher risk of catheter associated complications poten- vascular permeability and acute inflammation cause
tially associated with them being recumbent and roll- pulmonary edema [239]. Microemboli diffuse through the
ing during impaction resolution. alveolar membrane and are exhaled. When the amount of
● Hypoproteinemia (OR, 4.7; 95% CI, 1.2–19) [245] air exceeds the pulmonary filtering capacity, air enters the
● Antiulcer and antidiarrheal treatment (OR, 31.1; 95%; systemic arterial circulation, including the coronary and
CI, 5.9–163) [245] cerebral circulation, and can be associated with severe
● Admitted to the internal medicine service (OR, 15.9; 95% clinical signs including sudden death [239].
CI, 2.9–87) [245]
● Administration of non-sterile (locally produced) intrave- Prevention The use of aseptic and atraumatic technique
nous fluids (OR, 7.8; 95% CI, 1.6–38) [241] during catheter insertion and catheter use applies.
● Fever (OR, 6.9; 95% CI, 1.4–34.7) [241] Intravenous catheters should never be left in place beyond
● Diarrhea (OR, 5.1; 95% CI, 1.1–24) [241] the period of time absolutely necessary for treatment. Oral
● Anesthesia (OR, 0.12; 95% CI, 0.02–0.62) [241] medication should be considered whenever possible and
appropriate (e.g. oral rather than intravenous flunixin
● Duration of intravenous catheter dwell time [244, 246].
meglumine). Use of direct venipuncture can also be
In one study, the risk of venous complications increased
considered for drugs such as firocoxib. PTFE catheters and
when polytetrafluoroethylene (PTFE) catheters
the associated fluid administration and extension sets
remained in the veins for more than 24 hours [244].
should be replaced every 72 hours or more frequently if
● Catheter material with the least vascular as associated
contamination is a problem. Injection caps should be
with silastic, followed by polyurethane (PU). PTFE
changed daily. The mane should be braided and kept away
caused marked reaction [247]. In another study, patho-
from the catheter insertion site, particularly if it is dirty.
logical problems were identified in a higher number of
Use of PU catheters or silastic catheters inserted using an
horses with PTFE (7%) compared to PU (3%)
over-the-wire (Seldinger) technique is recommended any
catheters [244].
time prolonged catheterization is anticipated or in any
● Neonatal foals [248]
patient at risk. While a few studies failed to demonstrate a
● Administration of parenteral nutrition or irritating
difference between PTFE and PU catheters [241, 246],
medication [239]
results of other studies suggest that by using catheters
made of materials (especially silastic) that are less stiff or
Pathophysiology Pathophysiology of thrombophlebitis is rigid, the duration of catheterization can be increased to 14
ultimately an imbalance between coagulation and days or longer with minimal complications [247]. Use of a
fibrinolysis (see Section on Coagulopathy). SIRS and shock double-lumen catheter is recommended for administration
lead to a hypercoagulability, impaired fibrinolysis and of parenteral nutrition to avoid disconnecting the fluid line
anticoagulant pathways (coagulopathy) [239, 240]. from the patient and risking contamination. Horses at risk
Virchow’s triad describes the three factors leading to for coagulopathy may be prophylactically treated with low-
thrombus formation: trauma, decreased blood flow, and molecular weight heparin (enoxaparin) or clopidogrel in
altered coagulation. Catheter insertion causes endothelial an attempt to prevent thrombophlebitis; however, their
trauma and inflammation. Local endothelial trauma benefit is yet to be demonstrated. If there is even slight
combined with the lower head carriage of critically ill swelling at the catheter site, the catheter should be removed
horses causing some degree of venous stasis and without delay and the vein monitored for 48–72 hours.
coagulopathy associated with SIRS, endotoxemia, and Application of topical 1% diclofenac sodium to the affected
shock, predisposes to thrombophlebitis [239]. Sepsis occurs site may decrease inflammation.
Iatrogenic complications such as air embolism, catheter can develop head and neck circulatory impairment and
fragmentation, perivascular leakage, exsanguination, and pain. While in most instances the diagnosis is based on
inadvertent arterial catheterization are generally prevented physical examination, ultrasonographic evaluation may
by meticulous catheterization procedure, attention to provide additional information, such as the extent and
detail during catheter maintenance, careful monitoring, consistency of the thrombus (Figure 28.23). In one study,
and removal of any catheter that is associated with swelling, the ultrasonographic appearance of the thrombus was
damaged or not properly placed in the vein. In one study, classified as non-cavitating if it had uniform low to medium
most cases of catheter-associated air embolism resulted amplitude echoes, or as cavitating if it was heterogenous
from extension set disconnection occurring within with anechoic to hypoechoic areas representing fluid or
approximately 24 hours after catheter placement and less necrotic tissue within the thrombus, and/or hyperechoic
commonly extension set damage [249]. areas suggestive of gas [250]. Identification of a cavitating
lesion was associated with signs of pain on palpation of the
Diagnosis Diagnosis of thrombophlebitis is typically made affected vein, heat over the vein, and swelling of the vein
based on clinical signs of jugular vein thickening, absence consistent with a septic thrombophlebitis [250].
or only partial jugular fill, and the jugular vein being rope- Ultrasonography was useful for identifying a site for
like on palpation. Horses with septic thrombophlebitis had aspiration of a sample for bacteriological culturing and
additional signs of heat, pain, and swelling and may even sensitivity testing [250], which is important for
be reluctant to move their neck and may become inappetent. antimicrobial drug selection and monitoring of hospital
Horses may be febrile and catheter-associated infection can acquired infections.
be a source of fever of undetermined origin. Drainage may Clinical signs associated with catheter-associated venous
be observed at the catheter insertion site (Figure 28.22). air embolism include tachycardia, tachypnea, recumbency,
Horses with severe or bilateral jugular vein thrombophlebitis muscle fasciculations and agitation, with abnormal behav-
(a) (b)
Figure 28.22 Horse with bilateral septic jugular vein thrombophlebitis; (a) left and (b) right side. The horse had Potomac horse fever
that was unresponsive to therapy and was ultimately euthanized because of severe laminitis. Note the generalized head and neck
swelling likely associated with a combination of venous occlusion and cellulitis; the thrombus formation extends from her thoracic
inlet to her head. There is dilation of the small vessels of her face (a). Abscessation occurred at the catheter insertion site (b). Source:
Courtesy of New Bolton Center.
Intravenous Catheter-Associated Complications 345
(a) (b)
(c)
Figure 28.23 Ultrasonographic appearance of the horse from Figure 28.23. Note the thrombus formation and perivascular cellulitis
and abscessation (a). Note the mixed echogenicity and cavitation (asterisks) consistent with septic thrombophlebitis (b) transverse and
(c) longitudinal views. Source: Courtesy of New Bolton Center.
ior including kicking and flank biting, pathological vein) is also recommended in any horse with an unexplained
arrhythmias, more severe neurologic signs (blindness and fever. Aseptic catheter removal allows submission of the
seizures), or sudden death [249]. Diagnosis is based on his- catheter tip for bacterial culture and sensitivity testing,
tory of finding the jugular vein catheter or line compro- which might be useful if sepsis becomes a more serious
mised and clinical signs. complication. Application of topical 1% diclofenac sodium
The location of catheter fragments can usually be iden- (Surpass®) and cold packing the affected site may be
tified based on physical examination, radiography or beneficial. Hot packing may be detrimental. Occasionally
ultrasonography. horses can be painful, reluctant to move their neck and
have difficulty eating; non-steroidal anti-inflammatory
Treatment The catheter should be removed immediately. drugs or other analgesia may be indicated if this occurs.
Catheter removal (with or without replacement in another Antimicrobials are not indicated in horses with a localized
cellulitis or mild thrombophlebitis. Horses with severe, Hemoperitoneum

painful cellulitis or septic thrombophlebitis may benefit
from antimicrobial drugs ideally based on bacterial culture Definition Hemoperitoneum or hemoabdomen is defined
and sensitivity testing. An uncommon sequela is septic as an abnormal accumulation of blood in the peritoneal
endocarditis, which should be considered if the fever cavity [259]. Of note is that hemorrhage can also occur
persists or a heart murmur develops. intraluminally at the site of anastomosis or resection [260]
Thrombolytic therapy may be utilized in severe cases (see Section on Anastomosis Complications).
and involves pharmacological dissolution of the throm-
bus by intravenous administration of plasminogen activa- Risk Factors
tors that activate the intrinsic fibrinolytic system Hemoperitoneum is uncommon following colic surgery,
components. Streptokinase and tissue plasminogen acti- affecting <1% of horses [259] and being the reason for re-
vator are two potential thrombolytic agents that may be laparotomy in only 6% of horses [51]. The main risk factors
considered [240]. identified were:
Surgical management of septic jugular thrombophlebitis
has been described whereby jugular vein thrombectomy ● Intestinal resection (small intestinal, large or small colon
was performed with the horse under standing sedation and resection) [259]
local anesthesia [251]. The thrombus was removed through ● Thoroughbred horses were also over-represented in one
multiple incisions in the vein, with the incisions left open study [259]
to drain and heal by second intention. One horse required ● Omentectomy (anecdotal)
linguofacial vein ligation to control postsurgical hemor-
rhage [251]. Reconstruction of the jugular vein in horses Pathogenesis The reason for postoperative hemoperitoneum
with post-thrombophlebitis stenosis using a saphenous is often undetermined. At postmortem, the source of
vein graft from the contralateral limb has been described hemorrhage was identified in 5 out of 11 horses in one study
and was successful in two horses with one horse thrombos- with identification of a mesenteric or splenic
ing the graft [252]. hematoma [259]. Postoperative hemoperitoneum most often
Treatment of horses with venous air emboli is support- occurs because of hemorrhage from vessels that were ligated
ive. Various approaches have been described for successful and transected during a resection (Figure 28.24). Horses
catheter fragment removal [253–256]. may have a coagulopathy; however, once hemorrhage has
occurred, it can be difficult to determine if the coagulopathy
is the cause or an effect of the hemoperitoneum, because
Expected outcome Athletic performance of horses used for loss of protein and clotting factors associated with
non-racing events was not affected by thrombophlebitis [257]. hemorrhage can lead to a secondary coagulopathy.
Thrombophlebitis in racing Standardbreds was associated Hemorrhage can also occur from the body wall or from a site
with a decreased chance of return to racing; however, of abdominal drain placement.
performance was not diminished in those that resumed
racing. No significant difference in performance was Prevention The reason for postoperative hemoperitoneum
detected regardless of the primary disease, whether a horse is often surgical error. Large mesenteric vessels should be
had unilateral or bilateral thrombophlebitis, or the treatment double ligated using a distal transfixing ligature and
administered [257]. Importantly, thrombophlebitis can proximal encircling ligature. Ligation can be performed
cause secondary bacteremia, septicemia, pulmonary with stapling equipment or a vessel sealing device; however,
embolism, endocarditis and infarctive pleuropneumonia it is recommended to at least place a ligature if one of these
[239, 258]. devices is to be used. While omentectomy has been
Mortality associated with iatrogenic catheter-associated recommended for adhesion prevention, this procedure
air embolism was 19% and include two cases of sudden should only be performed when necessary, because
death and other horses euthanized because of persistent improper ligation can result in hemorrhage from the
neurological deficits. Mortality was more common in mesenteric remnant and hemoperitoneum.
horses with observed blindness, sweating or recumbency;
however, blindness resolved in the majority of affected Diagnosis Hemoperitoneum should be suspected in any
horses [249]. horse postoperatively that shows signs of dull demeanor
A favorable outcome has been reported following and mild colic, with pale mucous membranes and
surgical or percutaneous retrieval of catheter unexplained moderate to marked tachycardia. Horses
fragments [253–256]. should have the PCV and TPP monitored closely
Hemoperitoneum 347
Figure 28.25 Ultrasonographic appearance of a

hemoperitoneum. Note the large volume of echogenic swirling
peritoneal fluid. The bowel often appears to be floating in the
large volume of fluid. Source: Courtesy of New Bolton Center.
transfusion is recommended in most horses because it

provides erythrocytes, clotting factors, albumin and other
proteins. Blood transfusion is indicated in any horse with a
PCV <18% with ongoing hemorrhage, tachycardia, high
lactate concentration, and dull demeanor. Antifibrinolytic
Figure 28.24 Mesenteric hemorrhage identified at repeat drugs (e-aminocaproic acid and tranexamic acid, yunnan
celiotomy in a 19-year-old Thoroughbred mare. The horse had a baiyao) are recommended. Broad spectrum parenteral
strangulating pedunculated lipoma, resection, and
jejunojejunostomy. She developed a postoperative
antimicrobial drugs (e.g. penicillin and gentamicin) are
hemoperitoneum. Medical management was initiated; however, recommended to prevent the development of septic
the horse began to show recurrent colic signs and repeat peritonitis. The horse should be kept quiet and confined to
celiotomy was pursued 14 days after the initial celiotomy. The a stall. A low dose of acepromazine can be administered.
horse was euthanized because of the extensive mesenteric
hemorrhage and adhesions formation. Source: Courtesy of New
Relaparotomy is indicated in horses with signs of colic.
Bolton Center. Major (donor red cells and recipient serum) and minor
(donor serum and recipient red cells) cross-matches for
postoperatively; a progressive and marked decrease in PCV agglutination and lysis should be performed, if practical. If
and TPP particularly with an increase in blood lactate hemorrhage is severe and life-threatening, blood can be
concentration should prompt further diagnostic tests. In given without a cross-match, preferably from a
one study, horses with postoperative hemoperitoneum, Standardbred or Quarter Horse gelding (lower incidence of
had an average heart rate of 86 beats/minute, blood lactate Aa and Qa antigens) or gelding from the same breed. While
concentration of 5.6 mmol/L, and PCV of 16% [259]. transfusion without a cross match is considered safe in
Drainage of blood from the surgical site may also be horses that have not previously received a blood or plasma
observed [259]. Horses usually begin to show signs within transfusion, complications associated with transfusion
the first 24 hours after surgery [259]. reaction are more likely if the horse is not cross-matched.
Diagnosis of postoperative hemoperitoneum is made Horses have over 30 serologically relevant red blood cell
using transabdominal ultrasonographic evaluation of the antigens resulting in over 400,000 blood types and, there-
abdomen. A tentative diagnosis is made based on finding a fore, there is no universal donor or perfect cross-match.
large volume of swirling hyperechoic (cellular) peritoneal However, the most immunogenic antigens are Qa and Aa,
fluid (Figure 28.25). Blood is obtained via abdominocente- so hospital-owned donors ideally lack these antigens and
sis to confirm the diagnosis. Relaparotomy (and possibly antibodies against them. Even with cross-matching, 80% of
laparoscopy) may be used to determine the source of transfused red cells may be lost within days. Thus, in
hemorrhage. horses, transfusion of whole blood provides support while
erythropoiesis is stimulated. Recently, the mean lifespan of
Treatment Treatment consists of supportive care including transfused allogeneic red blood cells was 39 days based on
intravenous polyionic isotonic crystalloid fluids. Blood calculation of a linear regression survival curve and mean
post-transfusion red blood cell half-life was 20 days. This (1 out of 6) [51]; however, in another study, the survival
contrasts with humans where transfused cells have the was much higher at 65% (15 out of 23), with admission
same life span as autologous red cells (~120 days). A first blood lactate concentration being the clinical variable
transfusion usually does not incite a transfusion reaction; associated with survival [259]. The main reasons for non-
however, a cross-match is highly recommended prior to survival are hemorrhagic shock, septic peritonitis,
subsequent transfusions and in multiparous mares (if time adhesions and intestinal stricture.
permits).
Allogeneic transfusion of whole blood is used to improve
oxygen delivery to the tissues. Whole blood also exerts nterotomyand Enterectomy
E
oncotic pressure and, therefore, will expand the intravascu- Complications
lar volume. In cases of acute and severe hemorrhage, 15%
of the patient’s blood volume of whole blood can be given Definition Enterotomy/enterectomy complications
(i.e. 6–8 L/500 kg horse). Another method to determine the include any complications associated with an intestinal
volume of whole blood to administer is to estimate the vol- incision or the resection and anastomosis procedure.
ume of blood loss and initially replace 50% of the loss. It is Complications are not uncommon and can include
unnecessary to transfuse the entire volume lost, as move- obstruction associated with stenosis, stricture, kinking
ment of fluid from the interstitial space will expand the (volvulus), impaction, or hematoma formation; leakage or
intravascular volume. A donor can also donate approxi- dehiscence; ongoing ischemia; and intraluminal or peri-
mately 15% of its blood volume, averaging 6–8 L, without anastomosis hemorrhage.
adverse effects, although heart rate and respiratory rate
should be monitored carefully. Consider replacing some of
Risk Factors
the intravascular volume of the donor with intravenous
crystalloid or enteral fluids. ● Hemorrhage associated with an intestinal incision
Blood should be collected using strict aseptic techniques occurred in approximately 1–2% of procedures [260].
into bags pre-filled with 100 mL of anticoagulant per 1 L of Potential risk factors include:
blood. Collection into glass bottles results in loss of the plate- ● Horses undergoing a large intestinal procedure, particu-
lets, which rapidly adhere to the glass. Acid-citrate dextrose larly pelvic flexure enterotomy. [260]
(ACD) is an acceptable anticoagulant if the blood is to be ● Stapled anastomosis [261–263] with the closed diameter
used immediately. However, if longer-term storage is antici- of the staples 2.0 mm allows passage of vessels through
pated, citrate-phosphate-dextrose with adenine (CPD-A) the stapling device without being occluded. Provision of
will preserve 2,3-diphosphoglycerate concentration and blood supply to the anastomosis is critical and small or
adenosine triphosphate (ATP) levels resulting in longer sur- excessive staples may impair healing [263].
vival of red cells. Whole blood should be administered slowly ● Use of an inverting suture pattern [264–266]
for the first 30 minutes through a filter administration set ● Enterotomy adjacent to tenial band or not along anti-
while observing for hypersensitivity or anaphylaxis. Blood mesenteric border [264]
can be given at a rate of 10–20 ml/kg/hour using a blood ● Horses with a coagulopathy
administration set. No calcium containing fluids, such as ● Intraluminal hemorrhage has also been observed follow-
Lactated Ringer’s solution, should be concurrently adminis- ing intestinal biopsy using an 8-mm biopsy punch in a
tered. Horses should be monitored for signs of transfusion horse with severe eosinophilic enteritis
reaction or anaphylaxis (tachycardia, tachypnoea, increase
Other anastomosis complications:
in rectal temperature or urticaria). If signs of transfusion
reaction or anaphylaxis develop, stop the transfusion. If ana- ● Horses undergoing jejunoileostomy or jejunocecostomy
phylaxis is severe, epinephrine (2–10 mL/450 kg horse of appear to be at an increased risk of complications com-
1:1,000) should be administered. Mild to moderate transfu- pared to other procedures [24, 267].
sion reactions (e.g. urticaria) can be managed with a dose of ● Performing an anastomosis in injured or inflamed bowel
diphenhydramine (2–4 mg/kg per os or 0.5–1 mg/kg IV or ● Inexperienced surgeon [27]
IM). Heart rate, arterial blood pressure, and lactate concen- ● See also Sections on Pain/Colic, Postoperative Reflux
tration should be monitored to assess tissue perfusion fol- and Adhesion Formation.
lowing transfusion.
Pathogenesis The pathogensis is typically associated with
Expected outcome The survival for horses undergoing intraoperative decision making and surgical technique and
relaparotomy for hemoperitoneum in one study was 17% well as technical error. Intraluminal hemorrhage often
nterotomy and nterectomy Complications 349
occurs from a small mucosal/submucosal vessel that was jejunum adjacent to the anastomosis may be sutured
not ligated during the enterotomy closure or anastomosis (tacked) to the cecum toward the cecal apex to avoid
procedure (i.e. not incorporated into the suture or staple kinking adjacent to the anastomosis site. The mesenteric
line). Perianastomosis hematoma formation can occur at defect should be closed such that it does not cause the
the time of mesenteric closure when one of the small jejunum to kink at the anastomosis site. A pelvic flexure
vessels along the intestinal mesenteric border is perforated enterotomy with emptying intestinal contents oral to
with the needle. Hemorrhage may not be obvious during anastomosis is recommended to prevent obstruction at a
surgery, with bleeding re-starting upon recovery from small colon anastomosis site. Consider water and
general anesthesia. electrolyte administration via a nasogastric tube post
One of the main causes of anastomosis obstruction is small colon anastomosis to maintain soft feces. A
cuff formation at the anastomosis site during conservative re-feeding regimen involving small amounts
jejunojejunostomy, jejunoileostomy, and small colon of feed such as fresh grass (grazing), leafy hay, or pellets is
anastomosis. It can be particularly problematic for recommended.
jejunoileostomy because of the very thick ileal muscular Care should be taken with mesenteric closure and the
layer. The jejunocecostomy procedure requires meticulous site of intestinal resection selected such that there is
attention to detail, with one study showing surgeon sufficient mesentery between the cut edge and vessels to
experience being the most important variables associated avoid trauma to the vasculature. Prevention of intraluminal
with short-term survival [27]. Kinking at the anastomosis hemorrhage can be challenging, and bleeding (intra- or
site is more specifically associated with jejunocecostomy extraluminal) is not always recognized at the time of
and may be attributed to mesenteric length and mesenteric surgery, possibly due to the positioning of the bowel and
closure technique and positioning of the jejunum adjacent tension on the vessels or intraoperative hypotension [260].
to the anastomosis. A stapled jejunocecostomy can develop Large vessels should be double ligated. Scrupulous use of
a stenotic anastomosis long-term. Performing an electrocautery can be used to prevent bleeding from small
anastomosis in inflamed or injured intestine likely mucosal or submucosal vessels. An enterotomy should be
contributes to anastomosis complications. Obstruction at performed through a tenial band or at least on the
small colon anastomoses can occur because of the antimesenteric border of the intestine. A full-thickness
consistency of intestinal contents. While early refeeding of simple continues pattern over-sewn with an inverting
small amounts of feed such as fresh grass or a pelleted feed pattern is recommended at least for large intestinal
is recommended, feeding large amounts of feed during the enterotomy procedures.
period when intestinal inflammation is at its peak (i.e.
initial 24 hours postoperatively) can cause an obstruction Diagnosis Horses developing anastomosis complications
at small intestinal and small colon anastomosis sites. usually have signs of colic which may be mild, intermittent,
Anastomosis leakage typically occurs at the mesenteric and associated with re-feeding (e.g. partial obstruction), or
border of the intestine and likely occurs because of failure acute and severe (e.g. ongoing intestinal ischemia) (see
to obtain appropriate suture bites through the submucosa, Section on Pain/Colic). Postoperative reflux and distended
tearing of suture through injured and inflamed intestine, small intestine on palpation per rectum or transabdominal
ongoing intestinal necrosis, or poor knot tying. ultrasonography is typically observed in horses with
anastomosis complications involving the small intestine
Prevention The site for intestinal resection should be (see Section on Postoperative Reflux). Ultrasonographic
carefully selected such that the anastomosis is performed evaluation, however, is not typically useful for determining
in healthy, non-inflamed, motile intestine of normal wall the actual cause of the colic and intestinal distention.
thickness, whenever possible. Performing the anastomosis Complications associated with persistent signs require
in healthy intestine may require resecting considerably repeat laparotomy for a definitive diagnosis and treatment.
more than that which is obviously non-viable. Avoid Horses with an obstruction at a small colon anastomosis
excessive tissue inversion during jejunojejunostomy, have absent fecal output, no feces on rectal examination,
jejunoileostomy, and small colon anastomosis. An and may develop mild colic and abdominal distention.
appositional pattern (simple continuous in mucosa/ Intestinal leakage is associated with fever which is typically
submucosa and simple continuous in seromuscular layer, a high fever, dull demeanor, and septic peritonitis (see
interrupted at 180 degrees) should be considered, Section on Pyrexia and Septic Peritonitis).
particularly for jejunoileostomy [24]. Jejunocecostomy Horses with intraluminal hemorrhage often have
should be performed such that the anastomosis is directly melena observed within 72 hours of surgery and lasting
on the antimesenteric border of the jejunum and the for 12 to 96 hours [260]. A rapid and marked decrease in
PCV (down to 12–22%), tachycardia, dull demeanor, pale

mucous membranes, and muscle fasciculations are typi-
cal clinical signs [260]. Horses may show mild signs of
colic associated with the presence of intraluminal blood
or clot formation causing an intestinal obstruction. A ten-
tative diagnosis is made based on clinical signs and iden-
tification of melena. Transabdominal ultrasonographic
examination may be useful to rule out hemoperitoneum
(see Section on Hemoperitoneum) and intraluminal hem-
orrhage may be observed. Definitive diagnosis can be
made during relaparotomy.
Treatment While medical treatment of some anastomosis

complications may be successful (e.g. simple obstruction at
a small colon anastomosis), repeat laparotomy is often
required for diagnosis and treatment. Anecdotally, horses
developing anastomosis complications in hospital have
problems with recurrent colic necessitating re-admission
or euthanasia. Repeat laparotomy is indicated in any horse
with recurrent, persistent or severe colic signs, postoperative
septic peritonitis, or persistent reflux, particularly if
associated with a high fever. Once the diagnosis is made
during surgery, the decision for anastomosis revision is
made. En bloc resection of a jejunojejunostomy site
including adjacent affected tissue is feasible and
recommended. The healthy adjacent bowel is anastomosed.
Complications associated with a jejunoileostomy require Figure 28.26 Horse that had undergone a previous
jejunoileostomy that developed complications. During repeat
performing a jejunocecostomy; however, if the bowel and
laparotomy, the jejunoileostomy (arrow heads) was bypassed via
adjacent tissue at the jejunoileostomy site is reasonably a side-to-side jejunocecostomy (arrows). Complete or incomplete
healthy, this can be a bypass procedure rather than a bypass can be performed. Source: Courtesy of New Bolton Center.
resection and anastomosis, i.e. bypass of the obstructed
anastomosis (Figure 28.26). Similarly, if a jejunocecostomy Hemoperitoneum). Relaparotomy may be indicated for
has become obstructed, the obstructed anastomosis can be some horses, particularly if there are signs of intestinal
bypassed by performing a second jejunocecostomy using obstruction associated with clot formation. Identification
the immediately orad jejunal segment. If there is of a vessel to ligate is challenging; however, vessel ligation
abscessation, necrosis, leakage, hematoma formation or may be possible in some horses [260].
adhesions, an en bloc resection and jejunocecostomy is
required. If kinking (or volvulus) of the oral jejunal Expected Outcome In one study, 9% of horses surgically
segment appears to be the problem, consider suturing treated for small intestinal strangulation required repeat
(tacking) the jejunum to the cecum for approximately 20 laparotomy, with only a few of these horses requiring
cm toward the cecal apex. revision of the original anastomosis [166]. In another
Obstruction at a small colon anastomosis site may be study, 6% of horses underwent repeat laparotomy following
managed medically with enteral fluids, particularly if the initial surgery for colic [52]. Information on long-term
identified early and these horses should be monitored survival and complications following anastomosis revision
carefully during the early postoperative and refeeding is scant. Anecdotally and based on the small case numbers
period. Often these anastomoses are performed adjacent to available in the literature, horses can do very well. However,
the caudal extent of the body wall incision and anastomo- humane and financial aspects must be considered. Horses
sis revision is not possible. with extensive pathology should be euthanized. Survival of
Treatment of intraluminal hemorrhage involves intrave- horses with intraluminal hemorrhage was good (5 out of 7)
nous fluid therapy. Blood transfusion and the use of in one study, with the reasons for death being hemorrhagic
antithrombolytic drugs are strongly recommended if hem- shock and enterocolitis, possibly associated with
orrhage is moderate to severe (see Section on intraluminal blood [260].
Septic peritonitis 351
Septic peritonitis
Definition Postoperative septic peritonitis can be defined
as identification of abnormal peritoneal fluid with a total
nucleated cell count >100 × 109/l with cytological evidence
of free or phagocytosed bacteria (Figure 28.7) in
combination with clinical signs consistent with a severe
infection including dull demeanor, inappetence/anorexia,
pyrexia, SIRS, shock, and pain/colic [5]. Peritonitis can be
diffuse or localized and abscessation can develop.
Risk Factors
Septic peritonitis is uncommon following colic surgery
(<5%) [2, 4, 7, 10] and was the reason for re-laparotomy in
4 out of 27 horses in one study [51] and 10 out of 96 horses
in another study [52]. When it occurs it is often associated
with either:
● Severe intraoperative contamination
● Enterotomy or anastomosis leakage
● Intestinal ischemia
● Severe salmonellosis or colitis
● Severe superficial SSI, or
● Hemorrhage during surgery or postoperatively
Figure 28.27 Ultrasonographic appearance of the intramural
Pathogenesis While all postoperative colic patients have cecal abscess in the horse in Figure 28.19. The abscess could be
some degree of peritoneal inflammation (peritonitis) after palpated per rectum. The abscess was treated with long-term
intravenous and then oral antimicrobial drugs and was partially
abdominal surgery, septic peritonitis is an uncommon and drained laparoscopically following by instillation of procaine
serious complication. Septic peritonitis is associated with a penicillin directly into the abscess. Source: Courtesy of New
bacterial infection (other organisms may be involved and Bolton Center.
remain unrecognized). Most bacterial contamination that
occurs during surgery is managed through thorough Prevention Septic peritonitis can be prevented with the
peritoneal lavage, systemic antimicrobial drugs, and most use of meticulous aseptic and atraumatic surgical
importantly the host immune response. Rarely technique, good hemostasis, removing all non-viable
contamination with a particularly virulent or resistant bowel, and anticipating gross contamination of the
organism may lead to septic peritonitis. When there is a peritoneal cavity. If peritoneal contamination is anticipated,
large amount of hemorrhage with hematoma formation use of several layers of drapes or moistened laparotomy
either intra- or postoperatively, the blood can act as a sponges to isolate the affected bowel from the peritoneal
medium for bacterial growth. However, in most instances, cavity is warranted. Quickly closing any open bowel with a
the pathogenesis involves leakage from an anastomosis or simple continuous pattern can prevent further dispersion
enterotomy site (which may or may not be identified if it is of intestinal contents. Using stay-sutures to elevate an
a very small site of leakage) or intestinal necrosis. Leakage enterotomy site can help keep intestinal contents within
from a small, pin-point anastomosis or enterotomy site that the bowel lumen. Lavage of the peritoneal cavity both
remains unrecognized may lead to abscess and/or adhesion intraoperatively and postoperatively may be useful (see
formation. Intramural hemorrhage can also predispose below). Use of intraperitoneal antimicrobial drugs did not
horses to abscess formation (Figure 28.27). Septic decrease the rate of postoperative septic peritonitis [2] and
peritonitis is often associated with a superficial SSI may in fact increase intraperitoneal adhesion
(incisional infection); in these cases, it can be difficult to formation [268].
determine if the septic peritonitis led to drainage through
the body wall incision and secondary SSI or if the SSI was DiagnosisDiagnosis of postoperative septic peritonitis
so extensive that it extended into the peritoneal cavity. can be challenging because most horses have a high
peritoneal fluid nucleated cell count following exploratory affected bowel; however, care should be taken to ensure
celiotomy for up to a week [50]. Septic peritonitis should that a full-thickness defect is not created when performing
be suspected based on clinical signs of unexplained high such a procedure. Often repeat celiotomy is indicated to
fever, dull demeanor, inappetence/anorexia in identify the cause of septic peritonitis and with the goal of
combination with knowledge of findings during treatment. Surgical treatment may involve resection of
exploratory celiotomy and any intraoperative non-viable bowel, revision of an anastomosis, debridement
complications. Horses with septic peritonitis often lose of a severe incisional infection with possible wiring of the
weight rapidly. Other causes of postoperative fever should body wall, and copious abdominal lavage.
be excluded including incisional infection, enterocolitis
including salmonellosis, pneumonia, or catheter- Outcome None of the horses undergoing relaparotomy for
associated complications (see Section on Pyrexia). septic peritonitis survived to hospital discharge in one
Transabdominal ultrasonographic examination may be study and septic peritonitis was a positive indicator of
useful for identifying a markedly increased volume of death (hazards ratio for non-survival 4.41 (1.43–13.6) [52].
peritoneal fluid, which should increase suspicion of One issue with retrospective studies is that death typically
septic peritonitis or another intraperitoneal complication refers to euthanasia and is often dependent on owner
(Figure 28.28). Identification of fibrin strands financial constraints and requests and clinician experience.
ultrasonographically is consistent with septic peritonitis. If it is deemed financially feasible and humane, treatment
Ultrasonographic findings may be unremarkable and if of septic peritonitis with or without repeat laparotomy can
septic peritonitis is still suspected, ultrasonography be successful. Recurrent colic associated with adhesion
should be repeated in 1–2 days. Other complications such formation can be a long-term complication.
as incisional infection and colitis may be suspected based
on transabdominal ultrasonographic examination.
Abdominocentesis and peritoneal fluid analysis should ostoperativeIntraperitoneal
P
be performed on any horses suspected of having septic
Adhesions
peritonitis. Horses with a normal volume of peritoneal
fluid on ultrasonographic examination and a nucleated
Definition An adhesion is defined as an abnormal union
cell count <10,000/uL, do not have septic peritonitis.
of membranous surfaces because of injury or inflammation.
Cytology should be performed on horses with a high cell
Adhesions can be fibrinous (Figure 28.28a) or fibrous and
count to identify intracellular bacteria (Figure 28.7). A
are classified as omental (Figure 28.28b), fibrous band,
sample of peritoneal fluid should be submitted for
bowel-to-bowel and mesenteric-to-bowel (Figure 28.28c),
bacterial culture and sensitivity testing.
bowel-to-body wall, and multiple (Figures 28.28d, e) [271].
Treatment Systemic broad-spectrum parenteral

Risk Factors
antimicrobial drugs such as penicillin and gentamicin
Adhesions are estimated to occur in 14–30% of horses
should be initiated empirically. Antimicrobial choice,
undergoing small intestinal surgery and 5% of horses
however, should ultimately be based on results of bacterial
undergoing colic surgery [272–276]. Identified risk factors
culture and sensitivity testing. Determining the optimal
for adhesion formation include:
duration of antimicrobial drug treatment is challenging
and should be based on clinical signs, peritoneal fluid ● Small intestinal lesions [272, 274, 275, 277]
nucleated cell count, fibrinogen or serum amyloid A ● Small colon lesions
concentration, and in the case of an abdominal abscess, ● Resection and anastomosis [275]
ultrasonographic monitoring of abscess size. Antimicrobial ● Foals [278]
treatment probably does not need to be continued to the ● Miniature horses (possibly because of the higher occur-
point of complete ultrasonographic resolution of an rence of small colon lesions) [279]
abscess. Abdominal lavage can be performed ● Intestinal injury (ischemia and reperfusion injury from
postoperatively using a drain placed during surgery or prolonged intestinal distention (see Section on
postoperatively [269, 270]. Drain placement can be Postoperative Reflux) or surgical manipulation.
performed under ultrasonographic guidance. Abscesses ● Excessive intraoperative contamination and septic peri-
that are close to the body wall can be drained percutaneously; tonitis or abscess formation (see Section on Septic
however, larger abscesses may require repeat celiotomy or Peritonitis)
laparoscopy to drain and infuse antimicrobial drugs. ● Intra- or postoperative hemorrhage
Intramural abscesses may be drained into the lumen of the ● Superficial SSI
Postoperative Intraperitoneal Adhesions 353
(a) (b)
(c) (d)
(e)
Figure 28.28 (a) Bowel-to-bowel fibrinous adhesions: with fibrinous adhesions the bowel can be readily separated and note the
intestinal inflammation; (b) omental adhesion to the large colon which is often not associated with clinical signs; (c) bowel-to-bowel
and mesentery-to-bowel adhesions (arrows); (d) multiple bowel-to-bowel and mesentery-to-bowel adhesions in a horse that had a
strangulating obstruction; the serosa regained its color during surgery but the horse developed persistent postoperative reflux and
colic and repeat celiotomy was not financially feasible; (e) multiple bowel-to-bowel adhesions associated with a postoperative
mesenteric hematoma (arrows). Source: Courtesy of New Bolton Center.
● Postoperative reflux associated with prolonged small cera and can be a source of peritonitis and hemorrhage.
intestinal distention and intestinal inflammation [271] Omentectomy is recommended in foals and horses when it
● Repeat laparotomy leading to additional serosal becomes traumatized and inflamed during the surgical
trauma [276] procedure. Omentectomy is performed by exteriorizing as
● Severe systemic disease (SIRS/endotoxemia) [271] much omentum as possible, dividing it into several smaller
pieces, and ligating it using 0 synthetic absorbable suture
material.
Pathogenesis Injury to the intestinal serosal surface from Sodium carboxymethylcellulose (SCMC) is a lubricating
prolonged intestinal distention or surgical trauma, and/or agent that has been used for several years to prevent post-
serosa and peritoneal inflammation associated with foreign operative adhesions in horses. Historically, 1–2 L of SCMC
material (e.g. suture material, intestinal contents) or was instilled into the abdomen at the completion of sur-
bacterial contamination leads to serofibrinous exudate and gery. More recently, however, SCMC is being used for han-
fibrin deposition [271]. The fibrin matrix creates bowel-to- dling the bowel and is placed directly on the bowel at the
bowel, mesentery-to-bowel, or bowel-to-body wall completion of surgery. Experimental studies have shown
fibrinous adhesions within 1–2 hours of injury [271] and some benefit of SCMC use for adhesion prevention [280,
may even be observed during surgery particularly in foals. 281] and a retrospective study also showed some bene-
Normally, the peritoneal fibrinolytic system leads to lysis of fit [282]. In the latter study, however, cases were not ran-
fibrin and fibrinous adhesion to fibrin degradation products domly assigned to treatment groups, making results
(FDP) within 48–72 hours (prior to fibrous maturation). difficult to interpret; however, anecdotally, SCMC applied
The fibrinolytic system primarily involves plasminogen, to the bowel during manipulation and at the completion of
which is converted to plasmin by tissue plasminogen surgery does appear to be effective in adhesion prevention.
activator (and to a lesser extent urokinase plasminogen Postoperative intraabdominal lavage is effective for
activator). Fibrinolysis is regulated by plasminogen preventing adhesion formation [283]. The procedure
activator inhibitors type 1 and 2, which are stimulated by involves placement of a fenestrated drain (e.g. thoracic or
trauma, infection, and SIRS/endotoxemia, and bind to and orthopedic drain) through the body wall at the completion
inactivate tissue (and urokinase) plasminogen activator. of surgery. The abdomen is filled with 10 L polyionic
Alpha-2 antiplasmin and alpha-2 antitrypsin also inhibit isotonic fluid. The drain is secured to the skin using a
plasmin activity. Decreased plasminogen activator activity purse-string and Chinese finger-trap suture pattern. A one-
can result from decreased concentration of plasminogen way valve is placed over the end of the drain. The fluid
activators or increased concentration of plasminogen placed into the abdomen at the end of surgery is drained
activator inhibitors [271]. Regardless of the mechanism, following recovery from general anesthesia. The abdomen
when fibrinolysis does not occur, fibroblasts and endothelial is lavaged with 10 L polyionic isotonic fluids every 8 hours,
cells migrate into the fibrin matrix creating granulation beginning for 48–72 hours postoperatively. The drain acts
tissue which is subsequently covered by fibroblasts and as both the ingress and egress portal. It is important to keep
mesothelial cells originating from the primordial the drain clean and remove it as soon as it is no longer
mesenchymal cells [271]. being used for lavage. Complications can arise with drain
placement including hemorrhage, occlusion of the holes,
Prevention The most important approach to preventing and uncommonly ascending infection. Postoperative
adhesion formation is early referral and surgical treatment, lavage procedure is labor intensive and is usually reserved
particularly for horses with small intestinal strangulating for patients at high-risk for adhesion formation (e.g. horses
lesions. Atraumatic and aseptic surgical technique, with previous adhesions or septic peritonitis).
meticulous hemostasis, and short surgical time are critical Flunixin meglumine with antimicrobial drugs and
for adhesion prevention. Prevention of postoperative ileus, dimethylsulfoxide (DMSO) were found to be effective in
obstruction at the anastomosis site, infection (incisional adhesion prevention in a foal ischemia model [284].
and peritonitis), and the need for repeat laparotomy are
also important for minimizing adhesion formation. Diagnosis Clinical signs associated with adhesion
Omentectomy is used by some surgeons to prevent adhe- formation a caused by partial obstruction, mesenteric
sion formation between the omentum and parts of the gas- tension, volvulus or incarceration. While some adhesions
trointestinal tract. Omentectomy was reportedly beneficial may remain subclinical, anecdotally horses eventually
in one study [277]; however, the study was limited by the show clinical signs of recurrent colic or have an acute colic
retrospective approach and lack of randomization. The tis- episode. Most signs occur in within 60 days after
sue at the omentectomy site can adhere to abdominal vis- surgery [274]; however, signs may not occur for several
Metabolic Complications 355
years. Colic is the most consistent clinical sign associated Risk Factors
with postoperative intraperitoneal adhesion and can vary
● Gastrointestinal disease and abdominal surgery can have
from mild and intermittent associated with a partial
a substantial impact on metabolic function as a conse-
intestinal obstruction to severe associated strangulation of
quence of SIRS, gastrointestinal dysfunction, and with-
a segment of bowel in the adhesion or volvulus. Classically,
holding feed or inappetence. It is important to recognize
horses begin to show signs of colic with or without reflux
that most healthy adult horses are able to maintain an
when being fed a maintenance diet. Signs typically resolve
acceptable metabolic state postoperatively with basic
when feed is withheld, gastric decompression is performed
support, namely, maintenance IV polyionic isotonic flu-
and flunixin meglumine administered, only to recur when
ids with the addition of potassium chloride during the
the horse is refed. Adhesions in the caudal abdomen and
immediate postoperative period and anti-inflammatory
pelvis may be identified on palpation per rectum with
analgesic drugs. Beginning refeeding early during the
distended, thickened bowel that cannot be manipulated.
postoperative period, even if it is brief periods of grazing
Ultrasonography is useful for confirming adhesions
several times throughout the day or small handfuls of
suspected based on palpation per rectum and identifying
hay or a pelleted feed, can help maintain metabolic func-
adhesions to the ventral body wall, particularly the incision
tion. Patients at risk and requiring close monitoring of
if there is an SSI. Laparoscopy is useful if the general area
metabolic variables include:
of adhesion formation has been identified, i.e. ventral body
wall, caudal abdomen, or small colon. Adhesions are often ● Horses that are refluxing large volumes for prolonged
diagnosed during repeat laparotomy periods of time (>3 days)
● Horses that are critically ill (SIRS, endotoxemia) or
Treatment Adhesions can be managed in some horses inappetent
with diet change, including using a pelleted feed or fresh ● Pregnant or lactating mares
grass and flunixin meglumine as needed. Adhesiolysis may ● Obese animals
be necessary in horses with recurrent, persistent or severe ● Ponies, miniature horses, donkeys
pain. Adhesiolysis can be performed via a laparotomy or ● Draft breeds
laparoscopic approach. Some surgeons advocate ● Neonates
performing a laparoscopic exploration and adhesiolysis of ● Patients managed on parenteral nutrition
fibrinous adhesions if necessary, with the horse under Pathogenesis Blood glucose concentration: Blood glucose
general anesthesia in dorsal recumbency within 7 days of concentration is typically maintained within a range of
colic surgery in horses and foals predisposed to adhesion ~80–120 mg/dL (4.4–7.2 mmol/L). Stress, sepsis, systemic
formation. En bloc resection and anastomosis is indicated inflammatory response syndrome (SIRS)/endotoxemia and
if adhesions are extensive. pain can all lead to failure to maintain blood glucose within
Expected outcome While adhesion formation is generally an acceptable range. A decrease in insulin production and
associated with a less favorable outcome, a more recent an increase in insulin resistance can lead to hyperglycemia
study suggested that the mortality in horses with or without in adult horses. Cortisol and epinephrine can cause an
adhesions was similar, and did not influence long-term increase in conversion of stored glycogen to glucose and
survival [276]. However, approximately half of the horses lipopolysaccharide, tumor necrosis factor-alpha, and
had large intestinal lesions and adhesion formation. In interleukin-1 and -6 increase insulin resistance. While
another study, adhesion formation was associated with hyperglycemia is typically transient, persistent
mortality in horses undergoing repeat laparotomy (HR hyperglycemia can lead to osmotic diuresis (renal threshold
1.77, 95% CI 1.03–3.04) [52]. The outcome most likely ~150 mg/dL [~8.3 mmol/L]), with dehydration as well as
depends on the underlying cause of the adhesion formation, impair immune and endothelial function. Neonates are
extensiveness and location of adhesions, financial ability different to adults. Adults typically have the stores and
of owner, and willingness of the surgeon and owner to mechanisms in place to maintain their blood glucose
pursue treatment. concentration, whereas neonates cannot maintain blood
glucose as readily. Perioperative neonates (<14 days old)
require up to 8 mg/kg/min glucose in intravenous fluids if
Metabolic Complications milk is not tolerated. Neonates with colic often have
co-morbidities which can also contribute to problems with
Definition Alterations in several metabolic, variables maintaining BG and they should be monitored closely
including blood glucose, triglycerides, and lactate during the postoperative period. Admission hyperglycemia
concentrations, can occur perioperatively. is common in horses with colic, with it typically returning
to normal during the immediate postoperative period [285– Diagnosis Diagnosis is readily made by measuring blood
287]. A high BG at admission also has a strong association glucose, triglycerides, and lactate concentrations using
with strangulating obstruction [286, 288]; however, its either a bench top or point-of-care analyzer (POC). Trends
association with postoperative complications has not been over time are much more useful than a measurement at a
evaluated. single point in time. Blood glucose should be monitored in
neonates, pregnant mares, critically ill animals, and horses
● Plasma or serum triglyceride concentration: Plasma tri-
on parenteral nutrition. BG can be measured relatively
glycerides should be <50 mg/dL (<0.57 mmol/L).
inexpensively on a point of care (POC) glucometer. Urine
Hyperlipemia refers to a triglyceride concentration >500
should also be monitored for glucosuria (urine dipstick)
mg/dL (>5.65 mmol/L), is often grossly visible in the
when horses or foals are receiving parenteral nutrition. If a
plasma and typically occurs in ponies, miniature horses
horse or foal is receiving parenteral nutrition and is
and donkeys. Hyperlipemia may lead to fatty infiltration
persistently hyperglycemic, insulin should be administered
of the liver and is associated with a poor prognosis.
either as a SQ bolus or an IV constant rate infusion rather
Hyperlipidemia refers to an increase in blood triglycer-
than decreasing the amount of dextrose administered.
ide concentration 50–500 mg/dL (0.57–5.65 mmol/L).
Triglycerides should be monitored closely in animals at
Plasma triglyceride concentration is typically within nor-
risk for complications associated with hypertriglyceri-
mal limits in horses presenting for colic [286]. Most post-
demia (ponies, miniature horses, donkeys, and particularly
operative colic patients develop a mild to moderate
miniature Sicilian donkeys). Hypertriglyceridemia is
transient hypertriglyceridemia (150–300 mg/dL [1.69–
extremely common in these animals. If hyperlipemia is
3.39 mmol/L]) during the initial 24–36-hour postopera-
diagnosed, hepatic and renal function should be
tive period [287]. The hypertriglyceridemia usually
monitored.
resolves with introduction of feed. When a susceptible
Blood lactate should be monitored in any critical postop-
animal is in a negative energy balance, decrease in insu-
erative colic patient (i.e. postoperative intestinal strangula-
lin and increase in hormone sensitive lipase cause fat
tion) until it is <1 mmol/L.
mobilization and decreased esterification leading to an
increase in free fatty acids. The free fatty acids are re-
Treatment Hyperglycemia is uncommon during the
esterified to produce very low-density lipoproteins and
postoperative period, unless there is severe underlying
triglycerides (hypertriglyceridemia), which are filtered
disease associated with a poor prognosis or the patient is
through the liver causing fatty infiltration or remain in
receiving parenteral nutrition. Hyperglycemia associated
the circulation (hyperlipemia, hyperlipidemia).
with parenteral nutrition administration can be managed
● Blood lactate concentration: Lactate is the end product of
with insulin therapy. Insulin therapy is given in preference
anaerobic metabolism of glucose and can be a reflection
to lowering the rate of glucose administration, because
of poor tissue perfusion, poor oxygen delivery, and shock.
these patients require the calories provided by the glucose.
Shock is defined as a decrease in oxygen supply to the
While mild to moderate hypertriglyceridemia in healthy
cell leading to a decrease in ATP production which
horses may be monitored, hypertriglyceridemia in ani-
ultimately results in cell death. Normal plasma lactate
mals at risk of hyperlipemia should be treated promptly.
concentration is <1.7 mmol/L in adult horses. Horses on
Most horses respond to administration of fluids contain-
IV fluids should have a lactate concentration <1 mmol/L.
ing dextrose. While somewhat anecdotal, beginning by
Ponies and miniature horses may have a higher blood
adding 1.25% or 2.5% dextrose and monitoring triglycer-
lactate concentration compared to horses and care must
ides and BG will likely lead to a decrease in blood triglyc-
be taken with interpretation of values in these
eride concentration (except in miniature Sicilian
equids [290].
donkeys). Administration of insulin may be necessary
and should effectively decrease plasma triglyceride
Prevention Metabolic disturbances are best prevented by concentration [289].
early treatment of the underlying disease, appropriate fluid Persistent hyperlactatemia (>1 mmol/L) during the post-
therapy including colloidal support, and provision of operative period suggests that fluid therapy is inadequate
appropriate enteral nutrition. If provision of enteral (e.g. postoperative reflux or diarrhea) in which case the
nutrition is not possible, metabolic support can be provided fluid rate should be adjusted potentially with the addition
in the form of supplementing IV fluids with dextrose of colloidal support or that there is underlying intestinal
(1.25%, 2.5%, 5%, or more) or parenteral nutrition. Lipids pathology (e.g. postoperative large colon volvulus with a
should not be used in animals with or at risk for non-viable colon) warranting further diagnostic
hypertriglyceridemia. procedures.
ndotoxemiaySI S and shock 357
Expected outcome Admission hyperglycemia is common Table 28.5 Nomenclature for systemic conditions affecting
in horses with colic [285–287] and BG concentration is postoperative colic patients
associated inversely with survival [285, 286]. Hypo- and
hyperglycemia representing a failure to regulate BG during Nomenclature
(Acronym) Definition/ClinicalSigns
the postoperative period is uncommon in adult horses, but
is also associated with a less favorable outcome [286, 287]. Endotoxemia Endotoxin (lipopolysaccharide from
Hyperlipemia, particularly associated with hepatic and Gram-negative bacteria cell wall) circulating
renal failure, carries a guarded prognosis and prevention in the blood. Endotoxin can stimulate a
critical. systemic inflammatory response (SIRS).
Plasma lactate concentration was generally higher in Systemic Systemic inflammatory response to severe
inflammatory clinical disease with 2 or more of the
non-survivors compared to survivors admitted on an
response following: (1) fever or hypothermia; (2)
emergency basis; however, importantly there was syndrome tachycardia; (3) tachypnea or hypocapnia;
considerable overlap between survivors and non- (SIRS) and (4) leukopenia, leukocytosis, or a high
survivors [291]. Plasma lactate concentration also number of circulating band (immature)
neutrophils.
decreased rapidly over time in survivors and non-survivors,
but tended to remain higher in non-survivors [291]. Plasma Multiple organ Functional abnormality of more than 1 vital
dysfunction organ system including lungs, kidneys,
lactate concentration and the change in concentration over syndrome cardiovascular, central and peripheral
time was best for predicting survival of horses with severe (MODS) nervous systems, coagulation,
disease, such as colitis or large colon volvulus [291]. Plasma gastrointestinal tract, liver, adrenal glands,
lactate concentration was measured in horses admitted to a and skeletal muscle.
tertiary referral hospital with a large colon volvulus [292]. Sepsis SIRS plus infection.
Mean (± SD) admission plasma lactate concentration was Severe sepsis Sepsis plus MODS, hypoperfusion, or
significantly lower in surviving horses (2.98 ± 2.53 hypotension.
mmol/L) than non-survivors (9.48 ± 5.22 mmol/L). No Septic shock Sepsis induced hypotension despite adequate
horse with a plasma lactate concentration >10.6 mmol/L fluid resuscitation plus perfusion
abnormalities (lactic acidosis, oliguria,
survived. Mean plasma lactate 24 hours after surgery was altered mentation).
0.96 ± 0.60 mmol/L (range, 0.3–2.6 mmol/L) for survivors
Hyperdynamic Tachycardia, tachypnea, hyperemic mucous
compared with non-survivors (3.24 ± 3.08 mmol/L; range, shock membranes, rapid capillary refill time,
1.1–6.9 mmol/L) [292]. decreased borborygmi compared to normal,
muscle fasciculations, and dullness.
Hyperdynamic shock is characterized by a
high cardiac output and low peripheral
Endotoxemia/SIRSand shock vascular resistance.
Hypodynamic Tachycardia, tachypnea (rapid, shallow
Definition Definitions are provided in Table 28.5. shock respiration), prolonged capillary and jugular
refill times, dry and purple to pale mucous
Risk Factors membranes, weak peripheral pulses, cool
extremities, and hypothermia. Hypodynamic
● Diarrhea/colitis/salmonellosis shock is characterized by low cardiac output,
● Proximal enteritis high peripheral vascular resistance, and
● Non-viable intestine (e.g. large colon volvulus) systemic hypotension. MODS often follows
– Strangulating lesions [2] signs of hypodynamic shock.
● Severe (gram negative) infection Disseminated Abnormality in 3 out of 5 of the following
– Postoperative infection intravascular categories: hypofibrinogenemia,
coagulopathy thrombocytopenia, prolonged clotting time
– Neonates with comorbidities [293] (DIC) tests (partial thromboplastin time (PTT),
prothrombin time (PT), activated clotting
Pathophysiology Endotoxin or LPS, present in the normal time (ACT)), decreased antithrombin III
equine gastrointestinal tract, enters the circulation via the (ATIII) activity compared to normal, high
fibrin (fibrinogen) degradation products
intestinal mucosa or from an infection site. In the healthy (FDP).
animal, absorption is such that when it enters the portal
circulation where it is either neutralized by anti-LPS
antibodies or binds to LPS-binding proteins (LPS-BP) and inflammation cause disruption of mucosal epithelial cell
cleared by the hepatic mononuclear phagocytic tight junctions and this combined with hypomotility and
system [294]. Intestinal ischemia reperfusion injury and disruption of the healthy microbiota increase LPS
absorption which can overwhelm the hepatic system and testinal tract and intestinal wall (edema formation).
result in circulating LPS [294]. LPS-BP stimulates protein Distributive shock creates a “relative hypovolemia” associ-
proinflammatory cytokine and enzyme production of ated with vasodilation and is typically associated with
mononuclear phagocytes through the toll-like receptor/ endotoxemia [296]. Phases of shock are compensated,
CD14 and nuclear factor (NF)- κB transcription factor early decompensated, and late decompensated leading to
pathway [295]. Mononuclear phagocyte activation leads to death. Compensatory mechanisms involve stimulation of
production of protein mediators including interleukin-1, the sympathetic nervous system, activation of the rennin-
-6, -8, -12, tumor necrosis factor, complement system, angiotensin-aldosterone system, release of anti-diuretic
coagulation system, interferon-γ, elastase/cathepsin B, hormone (vasopressin), and adrenocorticotropic hor-
kinin/kallikreins; lipid mediators including platelet mone [296]. These mechanisms serve to improve blood
activation factor, thromboxane A2, prostaglandins, and supply to the vital organs through increasing heart rate and
leukotrienes; reduced oxygen species; and anti- cardiac contractility and causing vasoconstriction and
inflammatory mediators [295]. It is important to recognize water retention to increase the venous return to the heart
that cell wall components of Gram-positive bacteria and and direct blood flow to the vital organs [296].
trauma can also cause SIRS; however, horses are exquisitely
sensitive to endotoxin. Activation of the immune system Prevention Early diagnosis and appropriate treatment of
can lead to mild signs such as fever or more severe signs horses with colic, particularly horses with a strangulating
associated with SIRS, DIC, and shock [295]. obstruction, and early recognition of postoperative
Shock is defined as inadequate tissue perfusion and is complications, especially complications necessitating
characterized by poor tissue oxygenation causing inade- repeat laparotomy, is critical for prevention.
quate cellular ATP production and ultimately cell dysfunc-
tion and death. It results from as an imbalance between Diagnosis SIRS is diagnosed based on the defining clinical
tissue oxygen delivery (DO2) and oxygen consumption features (Table 28.5) and is common during the
(VO2). In general, the limiting factor is DO2 in colic postoperative period. particularly in horses that have had
patients [296]. DO2 is the product of cardiac output (Q) and correction of a strangulating lesion. Shock, on the other
arterial oxygen content (CaO2). Cardiac output (Q) is the hand, is diagnosed based on clinical signs of dark pink/
product of heart rate (HR) and stroke volume (SV). CaO2 is purple or pale (hemorrhage) mucous membranes,
primarily based on the hemoglobin concentration ([Hb]) prolonged capillary and poor jugular refill, poor pulse
and arterial hemoglobin oxygen saturation (SaO2). In quality, moderate to marked tachycardia, and
summary: inappropriately cool extremities. Hypotension (mean
arterial blood pressure <60 mmHg) and oliguria/azotemia
Shock DO2 VO2 reflective of the disease process and compensatory
DO2 Q CaO2 mechanisms are observed. Horses have a high blood lactate
Q HR SSV concentration indicative of insufficient tissue oxygenation
and anaerobic metabolism (see Section on Metabolic
SV is primarily affected by preload (blood volume and Disturbances). Horses with non-viable bowel leading to
blood volume distribution), afterload (systemic vascular signs of shock have the hallmark clinical feature of a
resistance), and cardiac contractility in postoperative colic gradually increasing PCV with a concurrently decreasing
patients. total plasma protein (TPP, protein losing enteropathy).
While physical examination, observation of urine output,
CaO2 Hb SaO2 1.34 PaO2 0.0031 and measurement of PCV, TPP, and blood lactate
VO2 Q Hb 13.4 SaO2 – SvO2 concentration are key in diagnosing and monitoring SIRS
and shock, measurement of mean arterial blood pressure,
In adult colic patients, pulmonary function is generally central venous pressure, central venous oxygen tension,
normal and SaO2 adequate [295]. Except in postoperative and colloid oncotic pressure may be useful in some critical
patients with moderate to severe hemorrhage, the hemo- cases when there is clearly no surgical reason for SIRS/
globin concentration should also be within normal lim- shock. Coagulopathy can be assessed by a coagulation
its [296]. Therefore, the CaO2 is unlikely to contribute to profile (Table 28.5) and viscoelastic testing [298–300];
shock in colic patients, except in complicated cases [296]. however, care should be taken with interpretation of these
Hypovolemic and distributive shock are classically tests [298–300], particularly because alterations in
observed in colic patients [296]. Hypovolemia is caused by coagulation and fibrinolysis occur in horses undergoing
inadequate water intake and loss of water into the gastroin- colic surgery without complications. [301].
Laminitis 359
While SIRS and shock are diagnosed based on the clini- Expected Outcome Horses with transient signs of SIRS
cal signs, diagnosis of the reason should be pursued. In during the postoperative period can do well with
some horses, the reason is apparent, based on the primary appropriate supportive care. Outcome is often dependent
diagnosis, e.g. large colon volvulus. Transabdominal on the underlying disease. However, horses showing signs
ultrasonography may be helpful to monitor peritoneal fluid of shock during the postoperative period are unlikely to
volume, bowel wall thickness and motility, and intestinal have a favorable outcome [2, 11]. In one study investigating
contents. Repeat celiotomy is indicated if there are any survival following repeat laparotomy, non-survival was
concerns with non-viable intestine. associated with increased packed cell volume at 24 h
following initial laparotomy (hazard ratio 1.06, 95% CI
Treatment Resuscitation and maintenance of 1.04–1.10) [52]. In another study, investigating
cardiovascular function during the postoperative period is postoperative large colon volvulus patients, increased heart
dependent on administration of crystalloid and colloid rate at 48 h postoperatively (HR 1.04, 95% CI 1.02–1.06)
fluid therapy using a goal directed approach. Supportive and colic during postoperative hospitalization period (HR
care is the mainstay of treatment of SIRS and shock. 2.63, 95% CI 1.00–6.95) were associated with reduced
Intravenous fluid therapy with polyionic isotonic postoperative survival [41].
crystalloids should be administered at an appropriate rate.
The rate can be determined based on monitoring clinical
signs of perfusion, blood lactate concentration, and Laminitis
urination. Urine output can be monitored subjectively in
adult horses; however, if urine output appears to be Definition Inflammation of the sensitive lamina within
inappropriately high, despite ongoing concerns with shock, the hoof that may be secondary to mechanical, enzymatic,
glucosuria should be ruled out and in severe cases of SIRS, or metabolic-related breakdown of laminae (see also
polyuria can occur because of an inappropriate response to Section on Esophagus).
antidiuretic hormone. Horses may require an initial 10
mL/kg bolus of a polyionic isotonic fluid (e.g. Plasmalyte®, Risk Factors
Normasol®, or lactated Ringer’s solution) with reassessment
of the cardiovascular system after the bolus. The bolus can ● Laminitis is an uncommon complication following colic
be repeated. Alternatively, 7.2–7.5% sodium chloride surgery affecting <1% of horses [2]. Risk factors include:
(hypertonic saline, 4 mL/kg) can be used for resuscitation. ● Systemic inflammation/endotoxemia; while pneumonia,
A typical and relatively safe maintenance fluid rate is 2 diarrhea, abdominal surgery, and vascular abnormalities
mL/kg/h and ongoing losses through diarrhea or reflux as well as hyper- and hypofibrinogenemia, hypoproteine-
need to be replaced. A reasonable initial fluid rate for a mia, and high PCV were all risk factors, only endotox-
postoperative colic patient showing signs of shock is 3–5 emia was significantly associated with laminitis in a
mL/kg/hour with adjustments made based on monitoring. multivariable model [311].
Potassium chloride (KCl) should be added to the ● Proximal enteritis [312, 313]: with one early study report-
intravenous fluids of horses not eating and other ing that 28% of horses with proximal enteritis developed
electrolytes should be measured and corrected. Colloidal laminitis [313]:
support is often indicated, particularly if TPP <4 g/dL or ● Horses with proximal enteritis weighing >550 kg and
albumin <2 g/dL. Hydroxyethyl starch or plasma can be with hemorrhagic reflux were at a high risk for develop-
used to provide colloidal support in postoperative colic ing laminitis [312].
patients [296]. ● Colitis with one study reporting prevalence of laminitis
Endotoxin can be managed using NSAIDs, polymixin B, as 11.5% [313].
hyperimmune J5 plasma, and potentially pentoxifyl- ● Previous episode of laminitis (anecdotal)
line [294, 303]. Novel therapies targeting components of
the inflammation cascade are under investigation [294, Pathophysiology The exact mechanism by which the
303]. Digital cryotherapy should be applied [307, 308]. Low lamina is destroyed has not yet been determined. However,
molecular weight heparin [302] and clopidogrel [304–306] any disease process that causes systemic inflammation,
may be useful for managing horses suspected of laminitis, causes inflammation in the digital lamina and alterations
albeit results are inconsistent with these drugs. Once again, in digital perfusion [315, 316].
management of the underlying disease process causing
SIRS/shock is critical, particularly if there is non-viable Prevention Prevention of laminitis is challenging. Early
intestine necessitating repeat laparotomy or euthanasia. identification of patients at risk is critical. Digital
cryotherapy has been shown to decrease laminitis [307,

308]. Signs of endotoxemia/SIRS and shock should be
managed (see Section on SIRS and Shock). In one study of
horses with proximal enteritis, the proportion of horses
received heparin that developed laminitis (0.0%; 0/12) was
less than that among horses that did not receive heparin
(30%; 31/104) [312]. Postoperative colic patients should be
monitored closely for an increase in their digital pulses,
hoof temperature, and any indication of lameness and if
any of these signs are observed, digital cryotherapy should
be applied and the horse should be confined to a stall deep
bedding with or without additional digital support in the
form of stall mats.
Diagnosis Diagnosis of acute laminitis is based on physical

examination with the horse showing signs of hoof pain
(Obel grade, Table 28.6), increased intensity of digital
pulses, and increased hoof wall temperature [317–319].
Horses should be observed from outside the stall for Figure 28.29 Severe laminitis with rotation of the distal
abnormal stance (e.g. placing all of their weight on the phalanx through the sole. Note the gas between the hoof wall
hind limbs and off their forelimbs) and weight shifting, and the digital lamina. The horse had Obel grade IV signs of
laminitis. See also Figures 28.22 and 28.23. Source: Courtesy of
which can be an indication of hoof pain. Horses should be New Bolton Center.
walked around the stall to monitor for lameness. In horses
with apparent clinical signs, the coronary band should be
palpated for evidence of softening associated with complete cause vasoconstriction thereby decreasing delivery of
disruption of the attachment between the third phalanx “laminitis trigger factors,” and provide analgesia [308].
and hoof wall. Radiographs can be performed to assess the Care should be taken when applying digital cryotherapy,
degree of rotation, thickness of the sole, distance between because complications have been reported including severe
the dorsal hoof wall and third phalanx, accumulation of cellulitis and skin necrosis [320].
gas or air, and any indication of abscess formation Analgesia includes non-steroidal anti-inflammatory
(Figure 28.29). drugs and various combinations of constant rate infusions
including lidocaine, butorphanol, morphine, and keta-
Treatment Treatment involves digital cryotherapy, mine. Some clinicians advocate the use of gabapentin.
analgesia, and sole support. Digital cryotherapy is thought Sole support can be provided with the purpose being to
to decrease the lamina requirements for glucose and reduce the strain on the suspensory apparatus of the distal
oxygen, have an anti-inflammatory effect (decreasing phalanx, provide sole/frog support, break-over relief, and
inflammatory cytokines, leukocyte adhesion, oxygen possibly improve perfusion and comfort. Sole support can
radicals from neutrophils, proteinases and collagenase), be in the form of glue-on shoes [322], padded boot, indus-
trial polystyrene foam insulated pads [323], or impression
Table 28.6 Obel grade for laminitis [317].
material (2-part silicone-based putty (Mr. Patrick Reilly,
Farrier Service, New Bolton Center: personal
Grade
communication).
I Horse alternately and incessantly lifts the feet; lameness Expected outcome Prognosis is dependent on the degree of
is not evident at the walk but a short, stilted gait is noted pain and initial response to treatment, extent of lamina
at the trot. separation (rotation and sinking of the distal phalanx
II Horse exhibits a stilted gait at the walk but moves relative to hoof), and the willingness of the owner to
willingly; a foot may be lifted off the ground without
continue to pursue treatment. While persistent reflux is the
difficulty.
most common reason for euthanasia of horses with
III Horse moves reluctantly and resists attempts to have a
foot lifted.
proximal enteritis, laminitis was the second-most common
reason [313]. Horses that developed laminitis after colic
IV Horse refuses to move, doing so only if forced.
surgery had a significantly higher odds ratio of not
References 361
returning to use following colic surgery [18]. In one study (OR = 1.76); vascular pathology (OR = 2.12); distal
investigating variables associated with non-survival of displacement of the third phalanx (OR = 2.68); pneumonia
horses with acute laminitis, the factors significantly (OR = 2.87); and lameness of Obel grade II (OR = 2.99),
associated with an increased risk for death in the final grade III (OR = 9.63), or grade IV (OR = 20.48). The use of
multivariable model were Thoroughbred (OR = 1.57); glue-on shoes significantly reduced the risk for death (OR
racehorse (OR = 1.76); treatment with flunixin meglumine = 0.36) [322].
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309 Welch, R.D., Watkins, J.P., Taylor, T.S. et al. (1992). laminitis. Vet. Immunol. Immunopathol. 178: 22–28.
Disseminated intravascular coagulation associated with 317 Menzies-Gow, N.J., Stevens, K.B., Sepulveda, M.F. et al.
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29–35. grading system for equine laminitis. Vet. Rec. doi:
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310 Cesarini, C., Monreal, L., Armengou, L. et al. (2010).
318 Dyson, S.J. (2003). Diagnosis of laminitis. In: Diagnosis
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311 Snook Parsons, C., Orsini, J.A., Krafty, R. et al. (2007).
319 Stokes, A.M., Eades, S.C., and Moore, R.M. (2004).
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314 Underwood, C., Southwood, L.L., McKeown, L.P. et al. laminitis at a tertiary care hospital. Can. Vet. J. 51:
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374
29
Complicationsof Surgeryof the Rectumand Anus

Michael A. Spirito DVM
Davidson Surgery Center, Hagyard Equine Institute, Lexington, Kentucky
Overview large – up to 10 or 15 cm fistulas are not uncommon. It is

important not to rush into surgery but instead to let them
The rectum is the terminal part of the large intestine: it heal, because in most instances these large fistulas will
extends from the pelvic inlet to the anus with an shrink down to less than 2 cm given time and appropriate
approximate length of 30 cm. The first part or peritoneal therapeutic treatment. The repair of a 2 cm defect is
part of the rectum is similar to the small colon and is obviously going to be much more rewarding than a 10 cm
suspended by a continuation of the mesocolon called the fistula.
mesorectum. The second part or retroperitoneal part forms It has been my experience to see rectal lacerations that
a flask-shaped dilation termed the rectal ampulla, which is are the result of increased pressure in the rectum due to
attached to the surrounding structures by connective tissue either intense straining or pressure from the foal, which
and muscular bands [1]. can be responsible for bursting the rectum.
The anus is the terminal part of the alimentary canal. Last, the third-degree perineal laceration is less common
The muscular arrangement of the anus contains the in our practice but still frequently encountered. With
sphincter ani internus and the sphincter ani externus. The proper planning these can be dealt with very successfully.
spincter ani internus is the terminal thickening of the
circular smooth muscle layer within the gut wall. This is
surrounded by the spincter ani externus, which is a broad istof ComplicationsAssociated
L
ring of striated muscle [1]. Immediately ventral to the with Surgeryof the Rectumand Anus
rectum and anus lies the perineal body, which is a
pyramidal fibromuscular mass located in the midline of ● Intraoperative/technical complications:
the perineum between the urogenital and terminal part of – Failure of epidural block
the alimentary systems. The perineum structure contains ● Early postoperative complications
striated muscle, smooth muscle and collagenous and – Surgical site impaction
elastic fibers. Anatomically, the perineal body lies just ● Intraoperative complications:
beneath the skin and functions as a point of attachment for – Inadequate surgical closure of the perineum
the muscle fibers from the pelvic floor and perineum itself – Hind limb weakness, paresis or paralysis
(www.teachmeanatomy.info). – Dehiscence
The most common surgery that is performed in the rectal
region is for perineal lacerations. These injuries are most
often sustained in foaling. I ntraoperative/Technical
The laceration that is most often encountered is a rectal- Complications
vaginal fistula. This is in general the result of a hoof being
introduced into the rectum during foaling, which is quickly Failureof EpiduralBlock
replaced into the birth canal prior to becoming a third-
degree perineal laceration. When the fistula is first Definition An epidural can be considered ineffective if
encountered, usually the day after foaling, it can be quite sensation remains in the perineal region 30 minutes after
administration of a caudal epidural at the sacrococcygeal EarlyPostoperativeComplications

space or between the first two coccygeal vertebrae.
SurgicalSiteImpaction
Risk Factors
Definition Surgical site impaction is an important
● Previous caudal vertebral injury complication that may lead to partial or even total failure
● High body condition score of the surgical site.
● Clinician inexperience
● Inappropriate dosage of block Risk Factors
● Dry feces prior to surgery

Pathogenesis The anesthetic solution needs to be injected
● Dehydration
into the epidural space for it to be effective. In patients with
● Pain and inflammation
a high body condition score, it can be difficult to identify
● Anal stricture
the location of the vertebrae and correct injection site.
Previous injury to this area may hinder penetration through
the intervertebral space. Under-dosing and individual Pathogenesis Impaction can occur due to the feces being
variation in response to the block may explain partial too dry, coupled with the swelling that occurs in the
anesthesia or selective side or anesthesia. immediate postoperative period. When the anal sphincter
has been operated on it has a tendency to cause the horse to
Prevention An 18-g 1.5-inch spinal needle is inserted into be reluctant to evacuate.
the intervertebral space after correct location by lifting of
the tail. The needle is usually inserted perpendicular to the Prevention These can be easily avoided by perioperative
skin but this may vary at the sacrococcygeal or diet changes and pain management. The mare often
intercoccygeal spaces in some patients. The individual benefits from bran mash 12–24 hours prior to surgery and
should be sedated prior to attempting to enter the epidural the administration of mineral oil, or a similar stool softener,
space and use of a nose or neck twitch restraint can be prior to the surgical procedure and then once daily for 3 to
used. Some clinicians use small amounts of local anesthesia 5 days postoperatively. Bran mash, or other low residue
subcutaneously at the site of injection to facilitate the feed, should be continued in the postoperative period. Care
placement of the spinal needle. The hub of the needle can should be taken not to administer the oil too far in advance
be filled with the anesthetic solution or saline and the of the surgical procedure, as the passing of mineral oil
needle advanced until the block is aspirated, at which point during the repair would be less than ideal. Performing the
the epidural space will be entered. An appropriate dose of procedure in conjunction with the appearance of the new
local anesthesia should be used. spring grass will also help to maintain a soft stool that will
easily pass by the surgical site. Pain and surgical site
Diagnosis This is determined about 15 min post injection. inflammation should be managed by administration of 1.1
Effective anesthesia will cause the patient to show signs of mg/kg of flunixin meglumine once daily for 3 to 5 days
flaccid rectum and loss of sensation in the perineum. If this postoperatively.
has not occurred 15 min after injection, then it should be
considered a failure. Diagnosis The complication is suspected by monitoring
fecal output of the mare and definitely diagnosed through
Treatment Repeat block is recommended. If the repeat rectal palpation. Other signs include pain or straining
block also fails, regional anesthesia can be performed. during defecation and notable swelling in the peri-anal
Local anesthetic solution (2% lidocaine or 2% mepivacaine) region of the perineum.
is injected along the dorsal lateral aspects of the rectum (at
10 and 2 o’clock) using 18-g, 5-inch needles. This technique Treatment The rectum should be manually evacuated, and
provides desensitization of the nerves that innervate the the suture line palpated rectally and vaginally to access the
rectum and perineum via local infiltration along the integrity of the repair. A more aggressive stool softening
regional nerves as they course caudally. regiment should be commenced and the mare evaluated
through rectal palpation every 6–12 hours until she is
Expected outcome Most failed epidurals are remedied by a passing feces freely. The horse should be given aggressive
second attempt. It is rare to find that it does not work on fluid therapy. This would include IV fluid therapy, 25 liters
the second attempt. to begin with, and naso-gastric tubing with 4 liters of water,
376 Complications of Surgery of the ectum and Anus
some Epsom salts, and 2 liters of mineral oil repeated after tissue in order to create two viable tissue planes to oppose
12 hours. An abundance of caution, patience and to create a functional seal between the rectum and the
lubrication should be used during rectal examination to vagina. For this closure to be successful, there must not be
reduce the risk of iatrogenic suture breakdown. In some too much tension on the suture.
cases, it may be helpful to leave the rectal sphincter closure
for a second stage to decrease the possibility of impaction, Treatment If there does not appear to be adequate tissue to
and ease the passing of feces. close the defect, dissection should be extended lateral and
cranial in a much more extensive manner than initially
Expected outcome This is generally a manageable planned. The dissection may be extended lateral into tissue
complication if the repair is robust, diagnosis is early and forming the wall of the vagina/vestibulum and this tissue
treatment aggressive. Occasionally this will cause the may be advanced axially and be used to create the dorsal
repair to fail if it is chronic and severe, although this is a vaginal shelf.
very infrequent occurrence.
Expected outcome Generally, this is a surmountable

problem if the surgery is planned out prior to initiating the
IntraoperativeComplications dissection. The tissue available will be variable in each case
and it is important to assess the tissue available prior to the
InadequateSurgicalClosureof the Perineum dissection. There are often flaps of tissue that can be
Definition Failure to achieve adequate tissue to affect a employed in the repair that are viable sources of tissue to
viable closure of the rectal vaginal space be used in the closure and these need to be critically
evaluated and employed artfully.
Risk Factors
● Severe third-degree perineal laceration that extends HindLimbWeakness,ParesisorParalysis

more than 10 cm
● Post-foaling sloughing of the affected tissues Definition The patient displays hind end instability with
● Significant scar formation in the remaining tissue inability to stand following epidural.
Risk Factors
Pathogenesis Insufficient dissection into the tissue planes
provide small-sized tissue flaps with limited elasticity or ● Low body condition score
pliability. This will increase the risk of suture failure. The ● Wet or slick floor under the individual
presence of scar tissue in the area decreases tissue elasticity ● Advanced age
and requires deep tissue dissection with the formation of ● Arthritic joints
large flaps that will increase the pliability of the tissue and ● Overdosed epidural anesthesia
decrease the load long the suture line.
In cases with extensive chronic lacerations, the abnor- Pathogenesis This will occur in any individual at any time
mal anatomy and presence of scar tissue will make identi- during the procedure but is usually after a period of time as
fication and dissection of tissue planes difficult. the individual fatigues. As time passes in the stocks, the
horses will tend to cross their legs and depend on one leg to
Prevention It is important to attempt to visualize the support them. This can cause the other leg to find its way to
normal anatomy and attempt to create and follow normal an unsuitable position and with the presence of urine on
tissue planes in the dissection prior to closure of the defect, the floor cause the horse to lose control of the hind end and
whether it is a fistula or a complete tear. In the case of a collapse in the stocks.
fistula or grade 3, tear it is important to dissect further In some cases, this may be related to the use of an exces-
craniad to the cranial margin of the tear and establish two sive dose of local anesthesia.
recognizable rectal and vaginal/vestibular tissue planes. If
the procedure is started at the cranial margin of the tear Prevention It is important to monitor the dosage of the
and the dissection is continued craniad to include several anesthetic closely. Much more than 12 cc of 2% mepivacaine
centimeters of the normal tissue, then the rest of the should be considered risky with regards to instability of the
dissection will be easier. In grade 3 tears, it is very important hind end. Always be aware of the potentially catastrophic
to assess the available scar tissue and follow the normal results of over-dosage. Keep the area under the hind legs as
Reference 377
dry as possible and provide flooring that is appropriate for the tissue planes, this may be due to using suture that is
the situation. Keep a watchful eye on the level of sedation inappropriately sized or to the tissue being too friable at the
and the position of the hind legs. onset of the surgery
Prevention The surgery should not be initiated until the

Treatment Try and get the individual up again; this can
acute inflammatory phase in the affected tissues is over
usually involve may people pulling on ropes placed under
and tissue has regained strength. In most cases, this is four
the horse in an attempt to get the horse back on its feet. If
to six weeks post foaling. Performing this procedure sooner
this is unsuccessful the horse should be anesthetized and
will increase risk of failure as tissues will be too friable and
placed in a recovery room where it can be placed in a sling
contaminated. Monofilament suture materiel is preferable
to facilitate standing. The horse can be maintained on
to braided suture, and 0 size suture is usually adequate.
inhalation anesthesia while supportive therapy, fluids, etc.
Monofilament 4/0 suture can also be used in a continuous
are administered. This period of time also allows for the
pattern in the mucosae of the rectum to initially help in
epidural anesthesia to become further metabolized.
creating a viable seal on the rectal side. This is performed
on the completion of the surgery as a last step.
Expected outcome These measures are generally successful For large fistulae and third-degree rectovaginal tears, it is
in getting the horse safely standing. recommended to suture the tissue planes independently
and leave a dead space in between the rectal and vaginal
Dehiscence closures. The vaginal plane should be sutured in two layers.
If there a lack of available tissue, the rectal plane can be
Definition Failure and pullout of the sutures in the created sutured in one plane. The advantage of leaving an open
perineal shelf dead space is that it will rapidly fill in with granulation tis-
sue, which will usually occur within a week. Daily lavage
Risk Factors of the dead space will limit the bacterial load and will cre-
● Tension on the suture planes ate a more robust repair with the additional thickness pro-
● Postoperative impaction vided by the granulation tissue.
● Inadequate seal between the rectal and vaginal spaces Treatment If dehiscence occurs, repeat surgery is required
after 3–4 weeks.
Pathogenesis Dehiscence is usually the result of a poor
seal at the rectal tissue plane. If there is no separation Expected outcome The repeat surgery is usually no easier
between the rectal and the vaginal vaults, then there will be than the first, but in most cases, there has been some
subsequent sepsis of the tissues and consequently poor healing of the initial surgical site that will make the second
healing. If the tension is such that the sutures pull through attempt less involved.
Reference
1 Didio, L.J.A. (1953). Splanchnology: Digestive system of

the horse. In: The Anatomy of the Domestic Animals, 4e
(ed S. Sisson and J.D. Grossman), 387–444. Philadelphia:
W.B. Saunders.
378
30
Complicationsof AbdominalSurgery:IncisionalHernia
John P. Caron MVSc, DVM, DACVS
Department of Large Animal Clinical Sciences, Michigan State University, East Lansing, Michigan
Overview HerniaRepairMethods
Incisional hernia follows midline celiotomy in horses with The principal options for surgical treatment of incisional
a reported frequency of 8–16% [1–3]. A number of hernias in horses include:
predisposing factors have been identified, the most
1) Open primary suture closure or herniorrhaphy (with or
important of which are postoperative incisional drainage
without subcutaneous or onlay
or infection [3, 4]. Indeed, in a prospective study of midline
mesh reinforcement)
celiotomy incisional complications, horses with
2) Open mesh hernioplasty (with or without subsequent
postoperative incisional drainage were 62.5 times more
closure of the hernia ring)
likely to develop an incisional hernia than those without
3) Laparoscopic mesh hernioplasty
drainage [4]. Additional factors implicated in the
occurrence of incisional hernia include: excessive exercise Herniorrhaphy and hernioplasty techniques have some
postoperatively, weight exceeding 300 kg, previous undesired outcomes in common. For example, failure of
celiotomy, postoperative leukopenia, and abdominal the repair (recurrence) is a potential complication shared
pain [1, 2, 5]. Surgical repair of incisional hernias is largely by all techniques. It is generally accepted that recurrence
for cosmetic reasons – affected horses are used for various occurs more frequently following open suture
athletic pursuits and mares with incisional hernias have approximation than after hernioplasty procedures,
successfully carried and borne foals [5, 6]. ostensibly due to excessive tension on appositional sutures
leading to mechanical failure. To manage tension inherent
to primary herniorrhaphy, some clinicians reinforce the
L primary body wall closure with a subcutaneous
with HerniaRepair polypropylene mesh secured to the external rectus
sheath [7, 8]. This onlay mesh technique is often successful;
● Hernia repair methods however, the superficial location of the prosthesis carries
the risk of mesh contamination and infection.
Millions of celiotomies are conducted in people each
– Inadvertent enterotomy year and incisional hernia is a surprisingly frequent event.
● Postoperative complications Frequent hernia recurrence, attributed to excessive ten-
– Seroma sion, spurred the development of mesh hernioplasty tech-
– Surgical site infection niques. A tension-free repair, using a synthetic or
biological prosthesis to bridge the abdominal wall defect,
– Mesh infection
greatly reduces hernia recurrence compared to open
– Suture sinus/fistula
suture approximation [9, 10]. Similar surgical objectives
– Hernia recurrence led to the adoption of open mesh hernioplasty for use in
– Adhesion/abrasion-related complications horses and cattle [11, 12]. Open mesh hernioplasty is
– Abdominal muscle rupture more time-consuming and entails greater technical
demands than a primary closure (with or without onlay ● Trocar-related injuries to bowel distant to the hernia
mesh-reinforcement) but virtually eliminates tension on site – an inherent risk of any laparoscopic procedure.
the repair (and the presence of synthetic foreign material ● Laparoscopic (or open) adhesiolysis of bowel at a pro-
in a relatively precarious subcutaneous location). Despite posed site of patch placement. This risk is elevated with
apparent advantages over suture approximation, open the use of energy sources for sectioning adhesions due to
mesh hernioplasty in horses (and people) is associated the possibility of thermal injury causing delayed bowel
with important complications including wound or mesh wall necrosis [15–17].
infection, suture fistulae, and recurrence [5]. These com-
plications are linked to the extensive dissection to achieve Prevention Inadvertent injury to adherent bowel segments
the surgical exposure required for mesh placement. near the body wall defect is a risk for open and laparoscopic
Importantly, the mesh hernioplasty does not completely approaches to hernia repair. The presence of regional
eliminate recurrence in treated horses. In one report, bowel-body wall adhesions can usually be established by
complete or partial recurrence occurred at a rate of preoperative ultrasonographic examination and these
approximately 30% for both primary herniorrhaphy and findings can be used to tailor the surgical approach.
open mesh hernioplasty [13]. Speculation that a less inva- Careful introduction of the laparoscopic trocar/cannula
sive method of mesh hernioplasty would reduce the fre- assemblies using a modified Hasson (open) technique for
quency of some or all of the aforementioned complications abdominal access is preferred by most surgeons conducting
inspired laparoscopic mesh hernioplasty. The develop- the procedure in people, as this minimizes the risk of
ment of increasingly biocompatible mesh materials, such inadvertent bowel injury [15]. Introduction of subsequent
as expanded polytetrafluoroethylene, permitted intraperi- trocar/cannula assemblies with direct visual monitoring
toneal positioning and fixation of a hernia patch through safeguards against this problem.
a number of modest laparoscopic access portals. Avoiding accidental trauma to viscera during adhesiolysis
Promising early results in people encouraged veterinary depends on careful operative technique. The risk of delayed
practitioners to adapt the technique to horses [14]. bowel injury during adhesiolysis is substantially reduced
by minimizing or even avoiding the use of electrocautery
or other energy sources for this purpose [15–17].
Diagnosis Acute, full-thickness injury is readily observed
InadvertentEnterotomy intraoperatively. Thermal injuries, leading to delayed
perforation, are typically only detected by indirect clinical
Definition Full-thickness perforation of a segment of
signs of peritonitis (fever, abdominal pain, inappetence),
bowel: i) in the vicinity of the hernia (bowel-abdominal
with supporting hematological and peritoneal fluid
wall adhesion) during the initial surgical approach; ii) to a
cytological findings.
viscus underlying the area where a trocar/cannula
assembly is introduced laparoscopically (access injury); or
Treatment Full-thickness intestinal injury with spillage
iii) during attempts to free adherent intestinal segments
generally constitutes a contraindication to placement of a
(adhesiolysis).
synthetic patch. For primary herniorrhaphy, closure of the
defect can still be attempted. Intestinal injury during a
Risk Factors
laparoscopic hernioplasty usually requires conversion to
● Bowel-body wall adhesions an open procedure for intestinal repair and abdominal
● Distended intestine lavage. With a body wall defect of sufficient width to
● Open approach preclude primary repair, mesh hernioplasty should be
● Instrument-related (use of trochar and/or energy delayed until peritoneal inflammation subsides. In
sources) humans, this is typically at least one week after the initial
injury [18]. Despite the fact that adhesions to the celiotomy
Pathogenesis Undiagnosed intestinal adhesions in the site are a relatively rare occurrence in horses, the possibility
area of the hernia. Unlike humans with incisional hernias, of intraoperative visceral injury is an important element of
in the author’s experience bowel-body wall adhesions are a client education.
relatively rare feature of the condition in horses. Accidental
injury to adherent viscera is most likely during an open Expected outcome When recognized at the time of
approach – adhesions are typically situated close to the occurrence and managed appropriately, bowel perforation
hernia defect. is not necessarily associated with serious, untoward
380 Complications of Aedominal Surgery: Incisional ernia
consequences in humans [19, 20]. The more insidious Diagnosis The presence of a seroma is evident on clinical
delayed necrosis of the bowel is typically of more examination as a non-painful, fluid-filled sac (Figure 30.2).
significance with the development of local or diffuse The diagnosis is confirmed by ultrasonographic
peritonitis. Peritonitis stimulates adhesion formation and examination, revealing a homogeneous accumulation of
often results in mesh contamination, depending on its anechoic fluid with an underlying, intact repair.
location. Clearly, peritonitis can be life-threatening in and
of itself. Extensive adhesions can cause colic symptoms Treatment Treatment of seroma is unnecessary in most
and physical or secondary intestinal obstruction and circumstances. Barring contamination, gradual and
greatly complicate subsequent intra-abdominal procedures. uneventful resolution occurs with time. Particularly in the
presence of a repair utilizing mesh, the temptation to drain
a serum accumulation should be resisted. Seroma
PostoperativeComplications recurrence after drainage is the rule and percutaneous
aspiration invites contamination with subsequent surgical
Seroma site infection and/or mesh infection.
Definition A subcutaneous accumulation of

serosanguineous fluid at the site of a herniorrhaphy or
hernioplasty [21]
Risk factors Given that the development of a seroma is

consistently observed following hernia repair, its
classification as a complication and identification of its
associated risks are debatable [17, 22].
Prevention Seromata (plural of seroma) are

characteristically unavoidable given the nature of incisional
hernia surgery, but the volume of a seroma can be
minimized and its resolution hastened with the early
postoperative placement of an abdominal support
wrap [14].
For laparoscopic mesh hernioplasty, one or more sutures Figure30.2 The appearance of a seroma occupying the
original hernia sac 24 hours following laparoscopic incisional
placed through the hernia sac and fixed to the implanted hernioplasty (arrows). Seroma is a consistent development
mesh is effective in attenuating the volume of a seroma, following open or laparoscopic mesh hernioplasty. Source: John
leading to more rapid resolution (Figure 30.1). P. Caron.
(a) (b)
Figure30.1 Laparoscopic incisional mesh hernioplasty: (a) Preoperative appearance of hernia sac. (b) Twenty-four-hour postoperative
appearance. Suture(s) placed in the fibrous hernia sac and secured to the prosthesis reduces its volume and speeds resolution.
(Compare to Figure 30.2, where an attenuating suture was not placed.) Source: John P. Caron.
Postoperative Complications 381
SurgicalSiteInfection(SSI) (explantation) is usually required (See Section on Mesh

Infection below).
Definition An infection within 30 days at the site of a
herniorrhaphy or hernioplasty in the absence of an
Expected outcome As for SSIs at other locations, a spectrum
implant, or infection identified as long as one year after the
of severity exists. Some are easily managed and have little
procedure when a synthetic prosthesis is placed.
impact; deep SSI resulting in peritonitis has the potential to
be life-threatening. Localized peritonitis can lead to
Risk Factors adhesions, the impact of which can range from no
● Undetected, persistent infection in the region of the pre- symptoms to functional or physical obstruction requiring
ceding celiotomy corrective surgery. An ever-present risk with any SSI is
● Extensive scarring from multiple abdominal procedures mesh infection by local extension (see Section on Mesh
● Breaks in surgical technique during surgery Infection below).
● Systemic illness, immunosuppression or a distant focus
of infection Evidence Surgical site infections can be local or
generalized (cellulitis). SSIs are a relatively common
Pathogenesis Surgical site infections require the presence occurrence after incisional hernia repair in people and
of exogenous or endogenous bacteria in numbers sufficient considerable effort has been made to identify contributing
to overwhelm natural host defense mechanisms. More factors and establish means for their prevention [23].
detail on the general pathogenetic mechanisms of SSIs can Fortunately, horses do not share a number of the risk
be found elsewhere in this text. factors that contribute to SSI in people (e.g. nicotine use,
diabetes, morbid obesity).
Prevention Thoughtful case selection, careful preoperative The anatomical location of the prosthesis after open her-
patient evaluation and optimal timing of surgery. Hernia nia repair influences SSI occurrence. In recent meta-analy-
repairs should await the resolution of any open wounds, ses of hernia repair in people, onlay (subcutaneous)
draining tracts or signs of infection. placement had a statistically higher risk for SSI than repairs
with more deeply placed prostheses [24, 25].
● Accepted practices for skin disinfection, draping and While not uniformly reducing the frequency of other
surgeon preparation should be routine. complications such as recurrence, it is established that SSI
● Strict adherence to Halsted’s principles is paramount, is significantly less likely after laparoscopic hernioplasty
particularly when employing prosthetic materials. than with open techniques [10, 26, 27]. A lower incidence
● Appropriate use of perioperative antimicrobials is of SSI is attributed to smaller incisions, less soft tissue
advised, particularly when mesh implantation is planned trauma, and less surgeon contact with incisions among
(See Section on Mesh Infection below). other incremental advantages.
Interestingly, in humans, the role of prophylactic
Diagnosis Diagnosis is based on local and systemic signs antimicrobials in inguinal and abdominal hernia repair
of infection. Clinical diagnosis, in the acute phase, can be remains controversial. Despite long-standing advocacy for
complicated by the local pain, edema and seroma typical of their use [28, 29], their efficacy was challenged when used
the immediate postoperative period following any in conventional single-dose preoperative protocols [30].
herniorrhaphy or hernioplasty. That said, postoperative Recently, others showed a beneficial effect of extended
drainage or fever beyond 24–36 hours are a cause for antibiotic prophylaxis in ventral hernia patients undergo-
concern. Persistence of signs of local inflammation beyond ing incisional hernia repair by a variety of methods [31,
7–10 days is suggestive, suppurative drainage is strongly 32]. Given the presence of a permanent synthetic implant,
indicative and positive culture of representative samples is the potentially catastrophic effects of mesh infection, and
confirmatory. the less controlled environment occupied by equine
patients, the use of prophylactic antibiotics in equine her-
Treatment Treatment is guided by general principles for nia repair seems warranted.
SSI management. Antimicrobial administration, ideally
based on culture and sensitivity, supplemented by local
wound care and drainage comprise the mainstay of therapy.
MeshInfection
More aggressive therapy is warranted for SSI involving Definition Bacterial infection involving an implanted
deeper tissues, including surgical debridement. When an prosthetic mesh. While not recognized intraoperatively, its
SSI ultimately involves the prosthesis, its removal development is most likely related to intraoperative events.
Risk Factors provides a physical barrier to abdominal contamination,

albeit fragile. Similarly, preserving the fibrous hernia sac,
● Intraoperative contamination of the mesh prosthesis
followed by its use as a supplementary tissue layer over
● Extension from incisional or suture track infection
the prosthesis, provides additional protection in the
● Contamination following unrecognized bowel injury
event a superficial SSI is encountered [11].
● Distant body site infection
● Transfascial or incisional sutures represent a potential
source of indirect mesh contamination. It is
Pathogenesis Like other synthetic surgical implants,
recommended that monofilament absorbable material
biofilms develop on non-degradable mesh materials both in
such as polydioxanone (or equivalent) be employed for
vitro and in vivo [33, 34]. Bacteria in biofilms exhibit a
transfascial mesh fixation. Collective experience
number of characteristics that make them distinctly
indicates that mesh implantation is sufficiently advanced
resistant to antimicrobial treatment, even when the same
at the time of loss of substantial suture strength that
organisms in a free-floating, planktonic form are susceptible.
non-absorbable sutures are not required.
● Postoperative abdominal support incorporating a sterile
Prevention Mesh infection that mandates explantation is
primary layer is recommended to reduce the likelihood
an expensive and disappointing problem that leaves the
of postoperative contamination via the approach and/or
patient with the original abdominal wall defect and
transfascial retention suture incision(s). Accordingly,
requires waiting for surgical site inflammation to resolve
dressings should be changed using aseptic technique
prior to another attempt at repair. A number of specific
during the early convalescent period.
considerations for hernia repair employing a synthetic
prosthesis supplement the general recommendations
Diagnosis Signs are referrable to temporal aspects and the
outlined under Section on Surgical Site Infections above:
anatomical location(s) of infection. Early mesh infection is
● Avoiding subcutaneous mesh placement. Although sat- typified by fever, swelling, pain and drainage from the
isfactory results have been reported for onlay mesh rein- primary incision (open repair) or one or more of the
forced herniorrhaphy in horses [7], others have incisions used for laparoscopic hernioplasty. Late mesh
experienced a 30% mesh infection rate using a similar infection is characterized by the formation of draining
technique [8]. Moreover, comparable results with tracts or, less commonly, the development of an abdominal
primary herniorrhaphy without onlay mesh wall abscess. Involvement of the “visceral” aspect of the
reinforcement [8], indicates that placement of an onlay mesh can cause signs of local or generalized peritonitis.
prosthesis might represent an unnecessary risk. Infection restricted to the “parietal” aspect of the prosthesis
● Due to the untoward consequences that can result from results in typical local symptoms, i.e. draining tract(s)
implant infection, administration of prophylactic (Figure 30.3). As the commonly used prosthetic materials
antimicrobials is indicated for mesh-reinforced primary are non-absorbable, clinical signs of infection are typically
hernioplasty and open and laparoscopic mesh protracted. Ultrasound examination of the surgical site
hernioplasty (See Relevant Literature under Section on may help identify extension and characteristics of the
Surgical Site Infection. infection.
● To minimize the likelihood of mesh contamination dur-
ing surgery, it is common practice for the surgeon to don
fresh surgical gloves prior to handling the prosthesis.
Other preventative measures could include the use of a
dedicated surgical table for mesh preparation (e.g. labe-
ling the prosthesis and preplacing sutures). Every effort
should be made to avoid contact of the patch with the
patient’s skin. Use of an antimicrobial-containing pros-
thesis or soaking a patch in antibiotics prior to placement
may incrementally reduce the risk of mesh infection.
● It seems that intra-abdominal consequences of mesh
infection following open mesh hernioplasty might be
minimized by preserving the peritoneal lining during
placement, the so-called retroperitoneal – subfascial
Figure30.3 Clinical appearance of chronic mesh infection.
(sublay) placement, although to the author’s knowledge Three of several draining tracts referable to mesh infection of 7
there are no comparative studies available. Doing so years duration are visible (arrows). Source: John P. Caron.
Treatment Infections associated with external drainage Evidence Recent research has investigated the possibility
and no involvement of the peritoneal cavity can be left of reducing mesh infection by altering the composition of
untreated; however, resolution is unlikely. prostheses (bioresourceable and biological mesh) or by
Conservative management of mesh infection is usually measures to provide local antibiosis (antibiotic
unrewarding. In selected human patients, combinations impregnated mesh or pre-implantation antimicrobial
of systemic and local antimicrobial administration and soaking).
local wound care are effective in resolving infection with Studies of antimicrobial impregnated prostheses or anti-
preservation of the prosthesis [35, 36]. In others, supple- biotic treatment of conventional materials have demon-
menting these measures with removal of exposed, unin- strated some ability to inhibit bacterial growth and impede
corporated mesh yields favorable outcomes [37]. More mesh infection both in vitro and in vivo [40]. Clinical
often, infected prostheses are refractory to these measures results, to date, have not completely confirmed these puta-
and mesh removal or explantation is necessary for tive benefits [41].
resolution. A number of biological meshes of human, porcine or
Mesh composition influences the likelihood that explan- bovine origin have been used for incisional hernia repair
tation will be required. Salvaging some or all of a macropo- in humans. It has been claimed that biological materials
rous mesh (e.g. polypropylene) by the above measures is have similar strength, superior integration and greater
generally more likely than when the implanted material is resistance to bacterial colonization than do synthetics.
microporous (e.g. expanded polytetrafluoroethylene). Proponents suggest that the latter property is of consider-
Overall, in the absence of systemic signs indicative of intra- able advantage and that biologics can be used under con-
abdominal involvement, attempts to treat the problem taminated conditions where a synthetic product would be
without mesh explantation are justified. If the response is contraindicated. However, a study of experimental con-
favorable, the repair is preserved. Explantation can be contamination of synthetic and biological meshes implanted
ducted later if less aggressive measures are proven in rats did not support these claims [42]. Nonetheless,
fruitless. reports of biological mesh explantation are rare [43].
As indicated, complete resolution of mesh infection with Disadvantages of biological mesh hernioplasty are a
medical and limited surgical treatment is unusual. higher rate of hernia recurrence compared to synthetics,
Transient improvement in signs is possible; however, comparable wound complications, a greater propensity to
drainage eventually recurs. Importantly, depending on the form visceral adhesions, and an up to ten-fold greater cost
location and composition of the prosthesis, explantation than synthetics [44, 45].
can be difficult [38]. Moreover, removal of the prosthesis Non-biological bioresorbable mesh is another approach
does not always result in complete resolution of signs, to reducing mesh-related complications. Theoretically, an
which can persist due to chronically infected body wall absorbable prosthesis represents less risk of late mesh
tissues [39]. These observations further underscore the infection; however original materials were associated with
importance of preventative efforts. high recurrence rates in human patients, likely due to pre-
mature loss of strength [46]. More recently developed
Expected outcome Benign neglect, in the absence of other products promise more favorable absorption characteristics.
serious developments, is likely to result in protracted, Encouraging results with the prophylactic use of an onlay
unremitting drainage from the involved portion(s) of the bioresorbable mesh for high-risk human abdominal
implant. procedures was recently reported [47].
Although rare, an established infection of a subfascially
or intra-peritoneally-placed patch can result in life-
threatening peritonitis or lead to the development of intra- SutureSinus/Fistula
abdominal adhesions or bowel erosion and enteric fistula. Definition A suture sinus is a communication between a
Barring the development of acute, diffuse peritonitis, fascial or mesh fixation suture (usually at the knot) and the
mesh infection usually manifests itself as one or more skin. These are typically related to bacterial colonization of
areas of chronic suppurative drainage. This development non-absorbable sutures used in the repair.
might not negatively influence the serviceability of an
affected horse and is tolerated by some clients. Resolution
Risk Factors
of infection causing more dramatic clinical signs or
resulting in unacceptable cosmesis generally necessitates ● Risk factors parallel those that contribute to surgical
explantation. The obvious result is “iatrogenic recurrence” wound infections in general:
of herniation. ● Contamination of suture(s) during placement
● Suboptimal wound closure allowing wound contamina- ● Infection

tion and subsequent bacterial colonization of sutures ● Patient-related factors
● Use of non-absorbable sutures (though sinuses can occur
after the use of absorbable materials) Pathogenesis Premature attempts at repair. It is widely
held that a minimum of 2–3 months after the original
Pathogenesis A result of the recognized microbiological celiotomy be provided to allow maturation of the hernia
mechanisms associated with bacterial colonization of ring prior to any surgical intervention. This preparatory
foreign materials period may be prolonged in the case of persistent infection
or drainage.
Prevention Although involvement of absorbable suture ● Inadequate evaluation of the hernia defect. Small defects
materials is possible, experience indicates that the interspersed with areas of marginally adequate fibrous
development of suture sinuses is minimized with the use tissue can co-exist with a clinically evident hernia – a so-
of absorbable materials. Original reports of open and called “missed hernia.” In this instance, “recurrence”
laparoscopic equine mesh hernioplasty cited the use of can occur in a region of the original celiotomy adjacent
non-absorbable suture materials for mesh fixation; to a previously diagnosed and treated hernia [48].
however, subsequent personal experience has demonstrated ● Inadequate size, number, composition or placement of
that modern monofilament absorbable materials retain sutures for primary repaired defects.
sufficient strength to be used for laparoscopic fixation of
● Attempts at primary repair of hernias of considerable
intraperitoneal mesh prostheses in horses. Strict attention
width (excess tension on the repair).
to asepsis is required during the placement of mesh
● Inadequate size of prosthetic mesh. Insufficient overlap
retaining sutures, regardless of the specific surgical
of the prosthesis is a common cause of mechanical dis-
technique employed.
ruption of a laparoscopic hernioplasty using the onlay
technique [18].
Diagnosis Affected horses have well-defined fistula(e), in
● Sub-optimal fixation of the prosthesis – too few or inad-
the vicinity of an incision, that develop some time after
equately sized transfascial sutures.
surgery. In many instances, exploration of the fistula
● Infection, of either the soft tissues or mesh, impairs incor-
reveals the presence of some portion of the offending
poration of the patch and increases the risk of failure.
suture. Ultrasonography may also be useful to investigate
Obviously, mesh explantation results in a failed repair.
the extension of these fistulas. Prompt resolution of signs
● Defective extracellular matrix synthesis. While yet to be
with suture removal supports the diagnosis. Differential
documented in horses, it is speculated that abnormalities
diagnosis includes the more serious complication of mesh
in collagen metabolism might be contributory to ineffec-
infection.
tive abdominal wall healing in people [49]. Suboptimal
connective tissue healing might explain the formation of
Treatment Removal of the offending suture is likely to
the original hernia and could contribute to recurrence
result in resolution of drainage and healing of the sinus,
following surgical repair.
barring microbial colonization of the mesh.
Prevention Appropriate timing of the procedure. Attempts
Expected outcome In the absence of remaining foci of at surgical repair should wait for a minimum of 3 months
infection, suture sinuses resolve with the removal of the to allow resolution inflammation/infection and allow
affected suture(s). complete maturation of scar tissue in the body wall at the
hernia site [50]. Optimal collagen type and amount
provides for the most secure herniorrhaphy or hernioplasty,
HerniaRecurrence
thus minimizing the likelihood of mechanical failure.
Definition Partial or complete failure of a previous
● Case selection. Although defects of up to 15 cm in width
incisional hernia repair with viscera breaching a defect in
have been successfully repaired primarily [8], hernias
the abdominal wall
having these dimensions undergo mechanical failure
with some frequency when treated in this manner. In the
Risk Factors
author’s opinion, serious consideration should be given
● Inadequate timing of repair to mesh hernioplasty for defects >8 cm in width.
● Incomplete repair of small less obvious hernia defects ● Adequate mesh overlap. When conducting mesh hernio-
● Sub-optimal technique plasty, the size of the prosthesis should allow for consid-
erable overlap with the adjacent body wall. Doing so ● Adequate mesh fixation. For open and laparoscopic
distributes forces over a large area of mesh and provides mesh hernioplasty, adequate numbers of suitably placed
for more secure fixation. For open hernioplasty, the ben- transfascial sutures provide for optimal mesh stability
efits of this additional soft tissue dissection probably out- and retention. Fixation of a prosthesis with mesh fixa-
weigh the incrementally increased risk of infection. tion devices or “tacks” is only provisional. Adequate
Generous overlap of the body wall with the hernia patch numbers of full-thickness transfascial sutures must be
is associated with fewer recurrences after laparoscopic placed to avoid mesh displacement and recurrence.
mesh hernioplasty in people [51]. Accordingly, the Spacing should be approximately 2 cm when transfascial
author uses a prosthesis overlap of at least 5 cm of sutures are used exclusively. Spacing can be increased to
healthy abdominal wall margin circumferentially as this 4 cm when fixation is supplemented with adequate num-
is recommended in horses (Figure 30.4). Additional bers of well-placed mesh fixation devices (Figure 30.4).
overlap should be considered for larger defects.
Diagnosis Hernia recurrence is usually evident visually,
particularly when the horse’s underline previously had a
more normal appearance (Figure 30.5). The ultrasonographic
presence of bowel in a hernia sac without an intervening
body wall or mesh echo confirms the diagnosis. Recurrent
incisional hernia must be differentiated from two other
possible reasons for an abnormal ventral abdominal contour.
Seroma is a consistent finding following mesh hernioplasty
that few consider a complication (see Section on Seroma
above). Diagnosis of seroma is easily accomplished
ultrasonographically, where a uniformly anechoic (fluid-
filled) sac overlies an intact hernioplasty. Recurrence should
also be distinguished from a “bulge” where the sagging
contour of an attenuated body wall might resemble a true
Figure30.4 Laparoscopic image of a composite mesh hernia. A bulge is typified ultrasonographically by a thin but
prosthesis in position, illustrating two key technical intact abdominal wall/mesh prosthesis echo.
considerations to reduce the risk for recurrence. (1) Prosthesis
placed to provide generous overlap (≥5 cm circumferentially) of
Treatment Regardless of the surgical technique chosen to
the body wall surrounding the defect (solid black line shows
approximate position of the hernia ring). (2) Placement of manage an incisional hernia, recurrence is unlikely to be
closely-spaced transfascial sutures and mesh fixation devices successfully treated by conservative means, such as
for secure fixation (arrows). These principles also apply to open protracted abdominal support bandaging. Following an
mesh hernioplasty. Source: John P. Caron.
(a) (b)
Figure30.5 Open mesh incisional hernioplasty. Preoperative (a) and 90 days postoperative (b) appearance. (a) Original defect measured
approximately 50 × 25 cm. (b) Partial recurrence is evident at the caudal aspect of the repair (closed arrows). The weight of abdominal
viscera caused a bulge where the prosthesis spanned the sizeable cranial body wall defect (open arrows). Source: John P. Caron.
adequate period of time for wound healing and maturation, of defects modest width (1–3 cm) is rare in horses [47].
one or another mesh hernioplasty technique should be Moreover, sizeable hernias in horses can be successfully
considered when an initial primary herniorrhaphy is managed with primary herniorrhaphy, without onlay mesh
unsuccessful. Perhaps the most appealing option in the reinforcement [8]. This may be, at least in part, a result of
case of a partially or completely failed open mesh the lack of other metabolic factors that delay healing and
hernioplasty is a follow-up laparoscopic procedure – the contribute to hernia recurrence in people. Clients should
presence of a prosthesis is not a contraindication for the be informed that the risk of recurrence increases in
intraabdominal placement of another mesh (Figure 30.6). proportion to defect width and that a follow-up mesh
hernioplasty might be required in the event of a failed
Expected outcome Failure of a herniorrhaphy or primary herniorrhaphy.
hernioplasty is rarely a life-threatening complication. In people, the risk of recurrence with mesh hernioplasty
Nonetheless, recurrence represents considerable time, appears to vary with prosthesis location. Sublay (subfas-
expense and effort with a disappointing result. It should be cial) hernioplasty is associated with fewer recurrences than
noted that failures can be complete or partial. A substantial onlay (subcutaneous) placement [23, 24]. The direct appli-
reduction in the size of the body wall defect might be an cability of these data to horses is unknown; however, given
acceptable result; however, complete recurrence usually the reported risk of mesh infection that accompanies the
warrants another attempt at repair. The possibility of a technique [8], onlay techniques appear a less appealing
partial or complete failure of a hernia repair, regardless of option.
repair technique, is another important aspect of client
education.
Adhesion/Abrasion-RelatedComplications
Evidence In people, recurrence after conventional
Definition Bowel-mesh adhesions or abrasive injury to
herniorrhaphy is common. Long-term follow up of primary
serosal surface of hollow viscera accompanying the
hernia repairs revealed a cumulative recurrence rate of
presence of an intraperitoneally-placed prosthesis can
63% [52]. It has been shown that defect width is an
result in a number of uncommon but severe complications,
important factor in recurrence following herniorrhaphy in
including intestinal perforation and peritonitis, functional
human patients. Abdominal wall defects smaller than 4 cm
or physical bowel obstruction and enterocutaneous fistula.
have a recurrence rate of 25% compared to 41% for larger
hernias [53]. As a result, mesh hernioplasty is typically
Risk Factors
conducted in people with defects exceeding 3–5 cm [17].
Like people, hernia recurrence after primary herniorrhaphy ● Intraperitoneal placement of macroporous synthetic
prostheses (e.g. polypropylene)
● Additional procedures (e.g. bowel resection) performed
with concomitant hernioplasty.
● Perioperative intra-abdominal contamination
● Surgical trauma to peritoneal surfaces
Pathogenesis The presence of a prosthesis induces an

inflammatory response that is integral to mesh
incorporation. Imbalances of pro-inflammatory mediators
participating in the wound healing contribute to the
formation of adhesions [54]. Small intestinal adhesions
can cause functional obstruction, or displacement about
the axis of an adhesion can lead to physical obstruction
with associated signs. Full-thickness defects in a bowel
segment, a result of abrasion or secondary to adhesion, can
result in local or diffuse peritonitis or an enterocutaneous
Figure30.6 Laparoscopic appearance of failed open mesh fistula.
hernioplasty conducted 18 months previously (“Defect”). Parietal
peritoneum covers the prosthesis but isolated segments of mesh
Prevention Avoid macroporous, synthetic prostheses in an
retention sutures remain visible (arrows). Failed previous
hernioplasty is not a contraindication for subsequent intra-peritoneal location. In some instances, particularly in
laparoscopic repair.Source: John P. Caron. large hernias repaired with open mesh hernioplasty, the
peritoneal lining of the hernia sac cannot be completely intra-peritoneally-situated polypropylene mesh is a
preserved. Consequently, at least some portion of the reliable model for creating intraabdominal adhesions [57].
prosthesis will be in contact with abdominal contents. For Apparently, not all species behave similarly; while
laparoscopic mesh hernioplasty in horses, use of a adhesions have been observed in horses with
composite patch with a microporous visceral layer is intraperitoneally--+placed macroporous synthetic
recommended to materially reduce the likelihood of bowel- materials [12, 58], this is not a uniform development [12,
mesh adhesions [14]. 58]. If necessitated by economic or surgical imperatives,
traditional synthetic materials can be used
Diagnosis Signs typical of an intestinal accident intraperitoneally; however, client education regarding the
accompany adhesion-induced bowel obstruction. Full- short- and long-term risks is warranted.
thickness erosion with leakage into the abdominal cavity Laparoscopic mesh hernioplasty is an increasingly popu-
produces signs of local or diffuse peritonitis. A draining lar method for incisional hernia treatment in people and
tract from which gastrointestinal content exudes is generally entails intraperitoneal placement of the patch.
diagnostic for enterocutaneous fistula. In people, This trend has stimulated investigations of a wide variety
enterocutaneous fistulae have been observed long after the of composite mesh materials and coated conventional
original hernioplasty [55, 56], and similar events are materials. [59, 60]. Unfortunately, compared to conven-
possible in horses. Fistulograms are used to characterize tionally-used products, composite prostheses are substan-
the involved bowel segment when an enterocutaneous tially more expensive.
fistula occurs in a person. Ultrasonographic evaluation,
abdominocentesis at site remote from mesh/infection,
AbdominalMuscleRupture
diagnostic laparoscopy or exploratory celiotomy provide
supplementary diagnostic information in horses. Definition Presumed mechanical disruption of abdominal
muscle(s) with extensive hemorrhage into the abdominal
Treatment Treatment for complications secondary to tunics
bowel–mesh injury or adhesion varies with the specific
entity. Signs referable to an intestinal accident indicate Risk factors This complication appears to be unique to open
exploratory celiotomy. A paramedian approach should be mesh hernioplasty with subfascial placement of a prosthesis
strongly considered to avoid areas involved in adhesions followed by suture apposition of the hernia ring [5].
and, if possible, to maintain and intact hernia repair.
Peritonitis from erosive bowel injury also necessitates Pathogenesis The hypothesized pathogenesis involves
celiotomy for adhesiolysis and closure or resection of the transfascial suture placement at or near the myo-fascial
involved portion of the gastrointestinal tract, accompanied junction of the internal abdominal oblique muscle, a
by accepted methods to manage peritonitis. A similar putative area of abdominal wall weakness [5]. An
approach is indicated for management of an alternative explanation, to account for the substantial
enterocutaneous fistula. Partial or complete mesh explan- intramural hemorrhage that occurs in affected horses, is
tation due to contamination is likely to be required for transfascial suture-induced damage to branches of the
these types of complications if they occur in direct contact superficial or deep epigastric vasculature in the area.
with the prosthesis.
Prevention Avoid apposition of the hernia ring tissues
Expected outcome Any of the consequences of untoward over a subfascial prosthesis. Because the specific etiology
bowel-mesh interactions can have serious or life- of this complication remains obscure, specific
threatening consequences. Acute diffuse peritonitis and recommendations for its prevention are elusive. The
extensive (inoperable) adhesions normally require authors of the original report recommend avoiding the
euthanasia of affected horses. Successful treatment in the apposition of the body wall over a sublay prosthesis [5].
short term may be compromised by recurrent, restrictive Parenthetically, the contribution of a prosthesis to the
adhesions in the long term. Clearly, complications resulting mechanical strength of the repair is uncertain when
in concomitant prosthesis infection typically require subsequent herniorrhaphy is conducted; the resultant loss
explantation of the prosthesis. in tension on the mesh substantially attenuating its role in
visceral (or herniorrhaphy) support.
Evidence Intraperitoneal placement of a number of the
originally-employed synthetic materials has been Diagnosis Colic-like symptoms accompanied by acute
associated with important complications. Indeed, in rats, swelling at the margin of the hernioplasty is a consistent
feature. Confirmation of hemorrhage into the abdominal Expected outcome Depending on the severity of
wall is confirmed ultrasonographically. hemorrhage, reported morbidity varies from a transient
need for supportive care to euthanasia as a result of
Treatment Blood loss can be sufficient to require fluid additional systemic complications [5]. Affected horses can
resuscitation or blood transfusion and supportive care. develop a hematoma of sufficient volume that the overlying
Hemorrhage control is affected by abdominal compression integument can be compromised with resultant areas of
using elastic bandages. No other specific treatment skin loss.
recommendations exist.
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391
31
Complicationsof EquineLaparoscopy
Donna L. Shettko DVM, MSM, DACVS1 and Dean A. Hendrickson DVM, MS, DACVS2
1
Western University of Health Sciences, Pomona, California
2
Overview cific injuries include 0.6 per 1,000 intestinal injuries, 0.3
per 1,000 urological injuries and 0.1 per 1,000 vascular
Laparoscopic surgery has gained notoriety and popularity injuries [4]. Seventy-six percent of all injuries involve
over the past couple of decades. A few of the benefits of lapa- bowel and retroperitoneal vascular injuries, with
roscopic surgery include reduced postoperative pain, faster approximately 50% of the small and large bowel injuries
onset of postoperative activity and improved wound healing unrecognized for at least 24 hours [5]. It is very important
resulting in less wound infections [1]. In veterinary medi- for any intra-abdominal complication be recognized
cine and especially in equine surgery, laparoscopic surgery quickly and expeditiously in order that the patients achieve
has become common and often preferred over open proce- the full benefits of laparoscopic surgery [3].
dures. It has become accepted as the standard procedure for Complications need to be recognized in the most
many commonly performed surgeries such as ovariectomy, expedient manner possible [6]. One should be thinking
cryptorchidectomy and nephrosplenic ablation. A few of the and anticipating that complications can begin with
differences unique to laparoscopic surgery is that surgery is sedation, anesthesia and positioning, as well as with the
performed on a three-dimensional patient on a two-dimen- specific surgical procedures [6]. Increased morbidity and
sional monitor, there is the fulcrum effect of the body wall mortality result when surgeons do not recognize injuries
on the instrument’s movement, placing trocars through a early and/or do not respond quickly [4].
small skin incision without being able to visualize the It is important to learn how to deal with surgical
abdominal structures in their path, limited mobility within complications associated with laparoscopy, including
the peritoneal space, and lack of training [2]. when to anticipate and avoid them. But more importantly
Complications can occur with open or laparoscopic sur- it is imperative to learn how to recognize any of the
gery. Although many clinicians, surgeons and clients tend complications that can occur and if they do happen how to
to think of laparoscopic surgery as minor surgery, it is deal with them.
major surgery with the potential for major complications The possibilities of complications begin prior to the
such as visceral injury and bleeding [2]. The complications initiation of the surgical procedure. The complications
which occur may be more subtle than with open addressed will be patient positioning, sedation and
procedures [3]. But complications do exist and it is anesthesia, access, insufflation, thermal injuries,
important to be aware and reminded of those complications. hemostatic techniques, and lastly, complications related to
In a meta-analysis of 27 randomized controlled trials specific commonly performed procedures.
comparing laparoscopy and laparotomy for benign
gynecological procedures, the risk of minor complications
after gynecologic surgery is 40% lower with laparoscopy istof ComplicationsAssociated
L
than with laparotomy, although the risk of major with EquineLaparoscopy
complications is similar [4]. In one study there were 256
complications reported after 70,607 laparoscopic ● Standing positioning
procedures, with the overall rate of major complication to ● Position: dorsal recumbancy
be 1.4 per 1,000 procedures [4]. The reported rates per spe- ● Epidural sedation
392 Complications of quine aparoscopy
● Aesthetic blockade Treatment In preparation and planning for laparoscopic

● Access surgery, the surgeon must assess the horse’s temperament.
● Insufflation Recognizing the anatomical structures to be worked on
● Thermal injuries based on the surgical procedure. For example, if the dorsal
● Ligation abdominal structures are the focus of the procedure, then
● Ligating loops standing surgery should be considered [6].
● Surgical laser
● Vessel sealing Expected outcome One should remember that
● Ultrasonic cutting and coagulating devices complications can occur with any patient position chosen
● Cryptorchid castration for the surgical procedure.
● Ovariectomy
● Nephrosplenic space ablation
● Urinary surgery Position:DorsalRecumbency
● Thorascopy
Definition If ventral structures are the anatomic structures
to be targeted during the surgical procedure, then the
StandingPositioning dorsal recumbency position is required [2]. By placing the
horse in lateral recumbency with the desired side up, the
Definition Once the decision has been made to perform targeted anatomical structures can be reached. When
laparoscopic surgery, the decision for either standing with performing laparoscopic surgery, in dorsal recumbency the
sedation or general anesthesia for dorsal recumbency is horse may be placed in the Trendelenburg position to aid in
considered. The position depends on the procedure to be visualization of the anatomy and surgical manipulation in
performed as well as the patient’s ability to tolerate the caudal abdomen [2]. The horse may be positioned in
standing. reverse Trendelenburg to assist in visualization of the
cranial anatomy [2].
Risk Factors
Risk Factors
● Horse’s temperament does not tolerate standing [2]
● The anatomical structures to be worked on cannot be ● Underlying disease condition
done standing [2] ● Trendelenburg position at a 30-degree angle. The poten-
● Not holding the horse off feed [2] tial complications increase with the amount of the
● Lack of support staff or personnel to monitor the horse tilt [8]:
during key times during the surgical procedure [2] – This angle is steep in order to displace the abdominal
viscera cranially to aide in visualization of the
Prevention Obtaining a thorough history from the owner ovaries [2]
should include information regarding how well the horse – Movement of the diaphragm can be severely limited
tolerates tying, standing in stocks, and injections [6]. by the weight of the abdominal viscera [2]
To avoid potential difficulties with access and visualiza- – Reduced functional reserve capacity [8]:
tion of the abdominal cavity when performing standing ○ Increasing atelectasis [8]
laparoscopic surgery, the horse should be held off feed for ○ Awareness of potential ventilation-perfusion
12–24 hours prior to the procedure [7]. This is to decrease mismatch [8]
the volume of the intestinal contents and to improve ○ Raised intracranial pressure [8]
visualization [7]. ○ Raised intraocular pressure [8]
○ Regurgitation [8]
Diagnosis It is important to anticipate, prepare and ● Falling or sliding off the table
recognize the complication. There are key times to be ● Physiological changes which can occur with abdominal
especially astute and be prepared to the possibility of insufflation with CO2
complications [2]. A likely time for the horse to be anxious ● Not holding the horse off feed long enough
and not stand and possible jump out of the stocks is during ● Lack of adequate monitoring
epidural placement, portal placement, and grasping of the ● Positive pressure ventilation not available
testis or ovary prior to local anesthesia. ● Lack of required equipment
Anesthetic Blockade 393
Prevention Knowledge of physiological changes associated Treatment The surgeon should take into consideration
with surgical positioning and the physiological changes that the horse will become sedated with the epidural and
which occur with laparoscopic surgery can help predict continued monitoring of the horse is required [6].
potential problems. In preparation for surgery the horse Adjustments to the systemic sedation should be done to
should be held off feed for 24 hours [7]. It is important to avoid the horse becoming unstable and falling [6]. If the
take into consideration that the time held off feed is often horse exhibits symptoms of heavy sedation, wait for the
for a longer period of time with dorsal recumbent horse to recover or for the sedation to lighten prior to
positioning [9]. Laparoscopy under general anesthesia placing the surgical instruments [6].
should not be performed without adequate monitoring and
positive pressure ventilation. Expected outcome Injury to the horse, people or a break in
the sterile field can occur with the possibility of not
Diagnosis Any complication should be identified with completing the surgical procedure.
appropriate physiological monitoring.
Treatment For ventilation of the horse in Trendelenburg, AnestheticBlockade

positive pressure ventilation is needed [2]. To prevent the
horse from sliding or falling fall off the table, make sure to Definition In addition to the epidural, local anesthetic is
adequately secure the horse to the table [2]. required to anesthetize the skin and the target organs. The
most commonly-used local anesthetic is lidocaine.
Expected outcome A poor outcome can be averted with
appropriate monitoring, early recognition and correction Risk Factors
of the identified complication.
● Inadequate anesthesia
● Overdose of the anesthetic agent leading to toxicity
EpiduralSedation ● Incorrect placement of local anesthesia
● Incising non anesthetized skin
Definition Sedation and local anesthesia are used for
standing laparoscopic surgery, negating the need for Prevention Allow adequate time for the anesthetic to work
general anesthesia. Both Detomidine and Xylazine have as well as using the correct dose. To avoid incising the skin
been effectively used for epidurals. that is not adequately anesthetized, make sure to incise
into a visible lidocaine bleb and test the bleb to determine
Risk Factors if the anesthetic has taken affect [2].
● Over-sedation [6] Diagnosis With patient monitoring, the risk of inadequate

● Inadequate plane of anesthesia for surgery [6] anesthetic blockade is less likely to occur. Diagnosing
● Difficulty standing, loss of balance and coordination [6] lidocaine toxicity requires knowing the signs of symptoms
of toxicity. Lidocaine toxicity produces a concentration
Prevention To prevent problems with the epidural dependent spectrum of effects to the central nervous system
sedation, the correct drug and the correct dosage should be and cardiovascular systems [10]. A few of the signs of
calculated. One recommendation for the epidural is to use toxicity are movement, agitation, or abrupt movements [10].
either detomidine as an epidural (40 ug/kg brought to a A few of the central nervous system symptoms of lidocaine
total of 12–15 mL in the first or second coccygeal space) or toxicity to be aware of include eyelid blinking/nystagmus,
given intravenously to effect (20 mg detomidine in 1 L of muscle twitching, ataxia, recumbency, seizures and
polyionic fluids) [6]. Detomidine has been administered at coma [10]. The cardiovascular effects include hypotension/
a dose for epidural detomidine of 60 ug/kg [6]. At this dose, bradycardia, and cardiovascular collapse [10].
horses have become very sedate and unstable to stand and
may fall [6]. Having adequately trained staffing monitoring Treatment Without adequate anesthesia the horse will
the horse will identify if the horse is having difficulty react and be difficult to handle. For inadequate anesthetic
tolerating the procedure or anesthesia. blockage of the portal sites, infuse the sites with additional
local anesthetic. To avoid lidocaine toxicity, the
Diagnosis Monitoring the patient will identify the recommendation is to not exceed 200 ml per 500 kg
anesthetic plane and the status of the horse. horse [2, 10]. Horses may react to the manipulation of
ovary or the testes. In order to prevent the horse from exerted when entering through the abdominal wall [12].
moving, local anesthetic can be injected into the ovarian Make sure that the cannula has a small diameter, the
pedicle and the mesorchium [2]. Also, for additional surface is smooth with a sharp point and the cutting edge
anesthesia blockade for cryptorchidectomy or ovariectoomy, will decrease the excessive force required when penetrating
infuse 2% lidocaine in the mesovarium and mesorchium into the abdominal cavity [12]. In equine laparoscopic
prior to ligation and transection will preempt any surgery, the sharp trocar is not being used due to the reports
movement [2]. Due to the testes increasing in size after of bowel puncture [2].
injection with lidocaine, more time will be needed for the In standing surgery, small-diameter chest tube, mare
anesthetic to take effect and injecting into the ovary is not urinary catheter and blunt obturators are used [2].
as effective [2]. Many insufflation cannulas have been used in equine
laparoscopic surgery. The 15 cm or 20 cm are two of the
Expected outcome If signs of toxicity are identified they commonly used cannula lengths. (2) The length of the
will resolve with the discontinuation of the lidocaine [10]. cannula makes a difference, since the longer the cannula
If the horse is moving and reacting to the manipulation of the more difficult it is for the inexperienced surgeon to
the ovary or testes, more time may be needed for the use [2].
anesthetic to work [2]. Additional anesthesia may be Disposable trocars have features intended to minimize
needed if an inadequate dose has been used [2]. these injuries. One feature is a plastic sleeve that snaps
over the cutting tip after the abdominal wall has been
penetrated [13]. Another feature of the disposable trocar to
Access avoid visceral injury is that the trocar and scope are inserted
as one for visualization as the trocar is passed through the
Definition The first step in performing a laparoscopic abdominal wall [13].
procedure is to obtain access to the abdominal cavity [11]. There are techniques to test that you have successfully
Fifty-percent of the complications which occur in entered the abdominal cavity. A few of these techniques
laparoscopic surgery occur prior to the beginning of the include the hissing sound test, aspiration test (involves
surgery; when accessing the peritoneal cavity [4]. In attaching a syringe filled with saline and attempting to
people the complications associated to the initial aspirate any material), and attaching the needle to an
abdominal access occur in less than 1% of the patients [5]. insufflator that measures the pressure at the tip (the pres-
Procedure-based surveys of laparoscopic entry access sure will be 5 mm Hg if appropriately placed) [4].
injuries show a low incidence varying from 5 per 10,000 to Prevention of vascular injury includes the surgeon’s skill,
3 per 1,000 [12]. Trocar or Veress needle used for instrument sharpness, the angle of the trocar when insert-
insufflation caused the most bowel injuries 41.8% ing into the abdominal cavity, degree of abdominal wall
(114/273) [12]. elevation and volume of pneumoperitoneum [14]. In a
retrospective study by Desmaizieres [15], complications
Risk Factors associated with different cannula insertion techniques in
standing horses were reported [15]. Forty horses had lap-
● Injury to major blood vessels [5]:
aroscopic surgery for diagnostic or surgical proce-
● The inferior epigastric vessels are the vessels often
dures [15]. Twelve out of the 40 horse had problems with
injured [5]
insufflation or cannula insertion; 6 had peritoneal detach-
● Visceral injuries commonly to the bowel [5]
ment, 4 had splenic puncture and 2 had descending colon
● Abdominal wall hematomas [5, 12]
puncture [15]. Eleven of the 12 complications occurred in
● Penetration of the abdominal wall [5]
groups in which the pneumoperitoneum was induced
● Separation of the peritoneum from the abdominal
prior to cannula insertion with a Veress needle or a 12-g
wall [5]
catheter and in the group with the cannula inserted prior
● Wound infection [5]
to the pneumoperitoneum [15].
● Fascial dehiscence [5]
● Herniation [5]
Diagnosis If the abdominal anatomy is not identified
when initially entering the abdominal cavity, you should
Prevention Access to the abdomen requires knowledge of consider that you have entered the retroperitoneal space.
anatomy of the abdominal wall and underlying organs [11]. Scanning the abdominal wall and anatomy after entry to
To avoid problems with introduction of the trocar, the the abdominal cavity will aid in identifying the source of
surgeon can avoid the organs by controlling the axil force any hemorrhage.
Insufflation 395
Treatment The treatment depends on the complication ● Insufficient abdominal insufflation

encountered. Experience in performing laparoscopic ● Insufflating the extra peritoneal space:
surgery will decrease the incidence of complications – CO2 can pass through the pericardial and pleural
during access to the abdomen. Abdominal wall hematomas spaces through anatomical, congenital or acquired
are monitored. The horse may be uncomfortable from the defects [14]
hematoma which may require pain relief.
● Associated pneumoperitoneum physiologic changes:
Expected outcome Trocar injury is one of the most serious – Decrease in compliance and increase in airway
and preventable complications. This is the aspect of the pressure [14]
surgery that, no matter how carefully performed, injury to – Alterations in ventilation/perfusion ratios may lead to
the abdominal structures can occur. No entry techniques or an increase in mismatching leading to hypoxemia and
device is absolutely safe. Safe access to the abdomen is a hypercarbia [14]
very challenging part of performing laparoscopic surgery.
Bowel and retroperitoneal vascular injuries comprised 76%
of all injuries incurred in the process of establishing a Prevention It is recommended not to exceed 15 mmHg of
primary port [12]. It has been reported the organs and the intra-abdominal pressure [2]. For a consistent
structures injured when establishing the primary access pneumoperitoneum, an electronic carbon dioxide insufflator
port are, in descending order of frequency: small bowel, is used [2]. The volume of gas needed is dependent on the
iliac artery, colon, iliac or other vein, and mesenteric type and depth of anesthesia [2].
vessel [12]. Secondary port placement injury occurs, even
after placing a primary visualization port [12]. Diagnosis When extra peritoneal insufflation occurs, the
A retrospective trial was conducted to assess which fac- visual field will be obscured. The sooner the problem is
tors were predictive of a complication with the placement identified the opportunity to correct and proceed with the
of trocars [5]. At three months follow up, the rate of com- procedure is possible. Cardiopulmonary monitoring will
plication was 5% related to the access of the abdominal cav- allow rapid identification of any physiological changes that
ity, with the most frequent complications being abdominal occur.
wall hematoma [5].
Treatment To alleviate the effects of extra-peritoneal CO2,

Insufflation use positive end expiratory pressure, increase minute
ventilation, and increase pressure to decrease abdominal
Definition Abdominal distention is used to create enough pressure gradient [14]. Eventually postoperative, the
space to perform the minimally invasive surgery. trapped CO2 will diffuse out [14].
Insufflation with carbon dioxide allows for visualization of
the abdominal contents, facilitation of instrument and
Expected outcome High pressure (15 mmHg)
organ manipulations required to perform each specific
pneumoperitoneum in standing sedated mature horses can
procedure. (2)
be performed safely without any short-term or cumulative
adverse effects on hemodynamic or cardiopulmonary
Risk Factors
function [16]. In a study by Latimer, a pneumoperitoneum
● Pneumomediastinum [14] of CO2 at 15 mmHg did not produce significant effect the
● Pneumopericardium [14] cardiopulmonary effects as well as blood gas, hematology
● Pneumothorax [14] and chemistry values in six healthy mature horses
● Subcutaneous emphysema [14] undergoing standing laparoscopic surgery [16]. In standing
● Exceeding intra-abdominal pressure: laparoscopic surgery, a mild peritoneal inflammatory
– When pressures exceed 20 mmHg for prolonged peri- response is often found following abdominal insufflation
ods of time, both cardiovascular and respiratory effects with CO2 [2, 16]. There was significant increase in the
can occur such as a decrease in blood supply to the peritoneal fluid total nucleated cell count 24 hours
serosa of the gastrointestinal tract [4] following left flank exploratory laparoscopy compared to
– Reduction in venous return by compressing the infe- baseline values for left flank exploratory laparoscopy or
rior vena cava causes a rise in systemic vascular sham procedure at 24 hours. There were no differences in
resistance [14] peritoneal fluid protein concentrations within or between
– Fall in cardiac output [14] groups at any time [16].
ThermalInjuries defect in the ground plate or an alternative pathway

exists [17]. Awareness of adequate preoperative preparation
Definition Electro-surgery is widely used in laparoscopic of being held off feed can help to increase the intra-
surgery. The majority of laparoscopic complications occur peritoneal free space and reduce potential bowel injury [17].
when entering the abdominal cavity, 41.8% followed by the When using monopolar electro surgery, both cut or
delivery of energy to the surgical site, 25.6 % (70/273) and coagulation can be used for cutting or hemostasis, which
during specific high-risk procedures [17, 18]. can cause greater charring and tissue damage. It is wise to
use bipolar when possible [17].
Risk Factors Electrosurgical technique plays a role in preventing
tissue damage. Using multiple shorter activation times
● Electro-thermal complications: allows the normal tissue to cool. Correct technique is to
– Stray current from defective insulation [19, 17] activate the electrode only when the tissue is in the
– Capacitive coupling or direct coupling [19, 17] surgeon’s field of vision [17].
– Capacitive coupling happens when the electric cur- The tissue injuries secondary to capacitive coupling or
rent is transferred from the active electrode through direct coupling may be minimized by activating the active
intact insulation into adjacent conductive tissue with- electrode only when it is in contact the target tissues [19].
out direct contact [20]. The most common example of The injuries will also be reduced by limiting the amount of
a capacitive coupling is the placement of an active time that the coagulation setting (with its high-voltage
electrode, surrounded by its insulation, down a metal peaks) is used and by using metal cannulas that allow stray
or a plastic trocar [18]. Extensive burns and operating current to be dispersed through the patient’s abdominal
room fires can occur from these current leaks, with wall and not through the internal tissues [17].
temperatures measured to be as high as 700°C [21]. Injuries that are a result of breaks in the insulation are
With a high enough concentration of current, injury to preventable [19]. To avoid problems with thermal injuries,
adjacent organs is possible [21]. secondary to insulation damage quality assurance
– Direct coupling occurs when the active electrode is measures can be instituted. Instruments should be
accidentally activated or is in close proximity to inspected prior to packing for sterilization [19]. Both
another metal instrument [20]. preoperative and postoperative evaluation to assess for
– Insulation failure from high voltage currents and the insulation defects should be carried out [19]. These steps
frequent re-sterilization of instruments, which will can reduce the occurrence of thermal burns.
weaken or breaks the insulation [21]. If the insulation
does not adequately insulate the instrument, the faulty Diagnosis Capacitance coupling and direct coupling can
insulation can conduct electricity causing damage to cause injury to the bowel or blood vessels [17, 19]. It is
tissue [19]. Instruments used in laparoscopy are insu- reported that 50% of the reported bowel injuries that do
lated to make sure the current is directed to the instru- occur are a result of thermal energy [18]. A thermal cautery
ment tip and the current does not escape along the injury to the bowel can cause delayed perforation of the
shaft [19]. No matter what the insulation material is viscus due to the slow transmural tissue necrosis and
made of, all of it is degradable [21]. impaired local healing [13].
● Misidentification of anatomic structures [17] Bowel injuries occur from both contact and conductive
● Mechanical trauma [17, 20]. energy in proximity to the field of dissection. Contact burn
injuries may be recognized at the time of surgery and
treated but conductive burns may not be recognized at
Prevention It is important to understand how electro- all [13].
surgery works, characteristics of the equipment used,
desired tissue effects and the type of injuries that can Treatment The patient often will not present with any
occur [20]. It is also important to understand the principles clinical manifestations of a thermal injuries until several
of using electric currents, techniques to achieve the desired days postoperative [19]. By this time the complications can
tissue effects and the ability to avoid complications [20]. be severe [19]. Therefore, it is important to perform a good
Measures to prevent thermal injuries begin in both the surgical repair for even minor thermal injury to the
preoperative and the intra-operative period. It is important bowel [13].
to have an understanding of electrosurgical physics. For
example, if the output cannot accomplish the desired Expected outcome Since visualization is limited with
effect, the surgeon should suspect that there may be a laparoscopic surgery, the surgeon is not able to observe
Ligating Loops 397
outside of the field of vision to identify areas of tissue 10-mm port to compress the identified area of bleeding.
damage [2]. During a laparoscopic procedure, Soaking the sponge with dilute (1:10,000 or 1:100,000)
approximately 10% of an instrument is visible on the video epinephrine has also been described for controlling
monitor at one time, translating in that 90% of the electrode bleeding during laparoscopic cholecystectomy [23]. Fibrin
is outside the visual field [19]. It is estimated that 67% of glue has also been used to provide hemostasis [24].
thermal injuries are not recognized at the time of the Moderate bleeding will need be addressed and treated,
surgical procedure [19]. However, since the depth of while serious bleeding or hemorrhage needs to be acted
penetration of thermal energy extends beyond what is upon urgently. Converting the procedure to an open
visualized by the surgeon, unrecognized injuries can procedure may be the definitive treatment required for
present later after progression of the damage to the serious bleeding [23].
tissue [21].
Expected outcome The surgeon’s skill and related factors
are reported as the most important factors in ligature
Ligation failure in laparoscopic cholecystectomies [22]. Surgeons
who had operated on less than 100 cases have been reported
Definition Failure of ligatures in laparoscopic surgery is to have a higher rate of bleeding complications [22].
always a source for potential complications. Tying ligatures
is difficult with the spatial challenges unique to laparoscopic
surgery. LigatingLoops
Risk Factors Definition One of the devices available for hemostasis

during laparoscopic surgery is ligating loops. Using ligating
● Bleeding complications account for up to one-third of
loops for hemostasis is the least expensive technique [26].
major laparoscopic complications in laparoscopic chole-
cystectomies, with hemorrhage reported as the second-
Risk Factors
most common cause of death in those patients after
anesthesia-related complications [22]. ● Technically difficult
● Obscured visualization occurs when the lumen of the ● Difficult in getting the ligature around the desired struc-
port becomes wet or bloody. Irrigation should be used ture and achieving hemostasis [2]
judiciously to minimize soiling of the tip of the ● Ligature slippage [27]:
laparoscope [23]. – The loop is not tight enough for the knot to lock when
placing the loop [27]
– Having too much tissue in the loop [27)
Prevention Training is very important in mastering and
– Cutting the tissue too close to the loop during transec-
maintaining proficiency in laparoscopic knot tying.
tion [27]
Laparoscopic knot tying is considered more complex as it
– Pacing the loop on a wedge-shaped piece of
involves the use of two long instruments with a distant
tissue [27]
fulcrum, it is performed with the two-dimensional image
● Fixed diameter of the loop [2]
and the visual cues from the operative field are absent [25].
● Small size of the available suture [2]
● Short knot pusher that was attached to the ligating
Diagnosis The laparoscope can distort the amount of
loop [2]
bleeding that has occurred. Bleeding needs to be assessed,
● Slipping of the ligating loop [2]
especially given this altered perception [23].
Treatment Once the site of the bleeding can be inspected, Prevention It is important to relax the tissue when finally
the bleeding is managed with hemostatic modalities such tightening the loop to minimize tension on the loop for
as compression, clip, suture or cautery [23]. Even mild secure knot locking. Monofilament suture material has
bleeding should be monitored and assessed before increased knot security over braided material but the loop
completing the surgical procedure [23]. tends to keep its shape during placement [2]. Several self-
Most small to mid-sized vessels will spasm causing the tied knots have been developed to allow the surgeon to
bleeding to slow with simple compression [23]. Mild-to- make their own ligating loops. Two studies on the use of
moderate bleeding can often be controlled with compressive larger sutures for horses confirmed the ability of self-tie
maneuvers [23]. A gauze sponge can be passed through a ligating loops to provide equal or better knot security when
compared to commercially available ligating loops [30, 31]. Diagnosis Observing the incisional line for any bleeding is
In some cases, especially when using the 4-S Modified required.
Roeder knot with Size 1 Maxon, the knot security
approaches that of a four-throw square knot [2, 30, 31]. Treatment Assessing then managing the bleeding.
Diagnosis Bleeding should be immediately identified. Expected outcome In one study, involving 10 horses
undergoing laparoscopic ovariectomy, the endoscopic
Treatment Management of any bleeding encountered stapling device was found to work very well [18]. In the
must be addressed. Rodgerson reported ligature slippage in study, the stapling device required less surgical time
a laparoscopic ovariectomy procedure [27]. In order to stop than ligating loops, and required minimal ovarian
the hemorrhage, the mesovarium was transected to aid in manipulation without reported intra- or postoperative
visualization of the hemorrhaging vessels [27]. Cautery complications [18].
was then used for coagulation of the mesovarium [27].
Expected outcome Ligating loops have been consistently

shown to be adequate for ligation and hemostasis in equine
SurgicalLaser
laparoscopy, especially in the areas of ovariectomy and
Definition Two of most common lasers used in equine
cryptorchidectomy [2]. The first reports on using ligating
laparoscopic surgery are the diode and CO2 laser, with the
loops in horses for castration was in 1996, where normally
diode most commonly used [32]. Lasers use light energy at
descended testes were pulled back into the abdomen and
wavelengths specific to the target tissue to cut and
were ligated [28]. In a study by Boure et al. [29] a
coagulate [5]. The energy for cutting and coagulation is
commercially available ligating loop was used to ligate and
generated by the photons of light energy delivered to the
provide hemostasis during an ovariectomy in mares [29].
tissue by direct or indirect irradiation [32]. When laser
The ovarian pedicle was not dissected until after placement
energy is applied to the tissue, it is reflected, absorbed,
of two ligatures and then the pedicle was transected
scattered and transmitted, based on the moisture content
between the ligatures [29]. Bleeding complications were
of the tissue and wavelength of the laser [32].
not reported in these cases [29].
Risk Factors
StaplingDevices
● Significant tissue vaporization [32]
● Smoke spreading liquefied tissue during instrument
Definition Surgical stapling devices used in laparoscopic
manipulation [32]
surgery are safe and easy to use for both hemostasis and
● Visualization of the surgical field will be obscured with
transecting the abdominal organs [2]. One factor to take
the smoke [32]
into consideration is that the staplers are more expensive
● Electrical shock may occur when the capacitor retains an
than the ligating loops [2].
energy charge after the laser is unplugged [32]
● Abdominal insufflation be will reduced [32]
Risk Factors
● Using too long or too a short staple will lead to bleeding

after the stapler is fired: Prevention The use of lasers requires training to avoid any
– A short staple fired through thick tissue that is not problems. Fire precautions should be adhered to. Keeping
compressed to the final staple height will not interlock a fire extinguish available, keeping the tissue cool with
properly, or will rip through the tissue [5]. saline and keeping the laser in the standby mode when not
– Too long a staple will not adequately compress the tis- using during the procedure [32]. Do not use lasers for
sue and bleeding will occur through the staple line [5]. hemostasis on vessels of 3 mm or greater in diameter [2].
Prevention One point to remember and plan for is that Diagnosis Loss of visibility is easily recognized.
larger diameter cannulas are needed when using surgical
staples [2]. It is important to remember to choose the Treatment Suctioning is required to remove the smoke
correct staple height, which requires taking into that has obscured the visual field. Loss of insufflation will
consideration the stapler, the stapler cartridge and the occur with suctioning, which will require
tissue [5]. re-insufflation [32].
Cryptorchid Castration 399
Expected outcome The disadvantages associated with the blade [2]. The heat produced is less than 150°C reaching to
laparoscopic laser used for ovariectomies include cost of a depth of 0.5–2.0 mm and the tissue damage in the
specialized equipment, need for advanced training in laser surrounding tissue of 0.2–3 mm [2].
and laparoscopic surgery, and increased operative
time [33]. Risk Factors
● Hemorrhage due to size of pedicle [2]

● Hemorrhage due to incorrect energy settings [2]
VesselSealing
Definition LigaSure from Valley Lab (LigaSure, Valley Prevention When using these instruments for hemostasis,
Lab/Covidien, Boulder, CO) is a commonly-used device to it is important to remember that the ovarian pedicles of the
seal vessels using radio frequency energy in the bipolar horse can be larger than 3 mm, with the maximum vessel
mode [2]. The device is able to coagulate and cut at the size of 3 mm for effective hemostasis with the ultrasonic
same time. The vessel diameter that the radiofrequency devices [2]. The pressure that is applied with the energy
can seal is up to 7 mm in diameter and tolerates three times setting will dictate the speed of cutting and the effectiveness
the normal blood pressure [2]. of coagulation device [2].
Risk Factors Diagnosis Observing for hemorrhage and checking that

the settings are correct
● Hemorrhage [2]
● Poor visualization [2]
● The abdominal total protein will be elevated reportedly Treatment Management of the hemorrhage. In a report
at 24 hours, but return to the same level as the ligating using ultrasonic cutting and coagulating devices in horses,
loop by 72 hours [2] hemostasis was achieved with the use of vascular clips [6].
In one study of 10 mares that had ovariectomies, 40% of the
ovarian pedicles required additional hemostasis with
Prevention Training is important in avoiding any ligating loops [6].
complications.
Expected outcome Use of the ultrasonic surgery offers
Diagnosis Observation of the bleeding
surgeons some important benefits. Ultrasonic cutting and
coagulation devices can reduce the need for ligatures,
Treatment Management of any hemorrhage or bleeding
fewer instrument exchanges simplify procedure steps, and
electricity is not transmitted through or to the patient,
Expected outcome Using the LigaSure provides improved
greater precision near vital structures and minimal smoke
vessel sealing, while at the same time there is minimal
for improved visibility in the surgical field [35]. Ultrasonic
thermal spread to the surrounding tissue [34]. In a study, it
cutting and coagulation cause minimal lateral thermal
was found that the operating time was significantly shorter
tissue damage, and minimal charring and desiccation of
in the LigaSure group compared with the control group (P
tissue [35].
< 0.04) [34]. It was also noted that there was no statistically
significant difference between the two groups in operative
blood loss (P = 0.433), but perioperative hemorrhagic
complications were less frequent in the LigaSure group (0% CryptorchidCastration
vs. 6.8%, P = 0.057) [34].
Definition Cryptorchidectomy is a commonly performed
laparoscopic procedure, due to the ease of the surgery and
the recovery.
ltrasonicCuttingand Coagulating
U
Devices Risk Factors
Definition The device cycles at 55,500 Hz causing friction ● Hemorrhage

and heat, which denatures the protein in the vessel wall ● Ligature failure [6]
resulting in coagulation [2]. The amount of energy which ● Failure of cauterization of the mesorchium [6]
is generated is determined by the power level and type of ● Dropping of the testes [6]
Prevention Methods to prevent hemorrhage from the ovary through the body wall [6]. To aid in retrieval of
occurring include releasing tension on the testicular stump the ovary, the abdominal wall incision can be enlarged
prior to completely tightening the ligature. Intervention for and manual exploration can be done to find and remove
hemorrhage control includes applying another ligature, the ovary [6].
using a ligating loop, vascular clip or electrocautery [6].
Diagnosis Possible causes for the failure of the ligature
Diagnosis Diagnosis of bleeding or dropping of the testicle used in ovariectomies include failure to secure the ligature
is confirmed with observation. appropriately, placement of the ligature too close to the
ovary, or transection of the ovarian pedicle too close to the
Treatment Occasionally the testis is dropped into the suture ligature resulting in the ligature slipping [6, 27].
abdomen after transection and before removal from the
abdominal cavity. It is not the best surgical technique to Treatment To aid in visualization of the ovaries, horses
leave the testis in the abdomen to undergo aseptic positioned in dorsal recumbency need to be positioned in
necrosis [6]. To retrieve a dropped testis, the portal can be Trendelenburg at a 30-degree angle [2]. This angle is steep
enlarged and the abdomen can be manually explored in in order to displace the abdominal viscera cranially to aide
order to remove the testes [6]. in visualization of the ovaries [2].
In order to avoid intraoperative hemorrhage at the
Expected outcome Recognition and treatment of the ovarian pedicle, adequate hemostasis is required. To
complications will ensure a positive outcome. begin with the ovarian pedicle, ligature needs to be placed
proximally which can be accomplished by transecting a
portion of the proper ligament or passing the suture
Ovariectomy through the mesovarium [27]. Once hemorrhage has
occurred, techniques to ameliorate hemorrhage should be
Definition Surgical removal of the ovary can be implemented, such as placing additional ligating loops,
accomplished laparoscopically. applying vascular clips or using electrocautery [6, 36].
Additional techniques to prevent hemorrhage of the ovar-
Risk Factors ian pedicle include reducing the amount of tissue of the
ovarian stump and placing two ligating loops around the
● Inadequate observation of the genital tract [27]
larger ovarian vessels [6].
● Hemorrhage from the abdominal wall associated with
placement of the portals [27]
Expected outcome It is important to know how to correct
● Difficulty in exteriorizing the ovary through the
the problem before a devastating outcome.
abdominal wall [27]
● Hemorrhage of the transected ovarian stump may occur
due to the abundant vascular supply [2, 6]
● Ligature slippage [6, 27] NephrosplenicSpaceAblation
● Dropping the transected ovary into the abdomen [6]
Definition To perform a nephrosplenic space, ablation
sutures or mesh are placed in the nephrosplenic space to
Prevention Hemorrhage of the transected ovarian stump
induce fibrosis [37]. Ablating the nephrosplenic space
may occur with more frequency due to the abundant
prevented recurrence of LDDLC, and significantly
vascular supply [2, 6]. In order to avoid intra-operative
lowered the overall incidence of colic and ventral
hemorrhage at the ovarian pedicle, adequate hemostasis is
celiotomy [37].
required.
When attempting to remove the ovary from the abdomi-
Risk Factors
nal cavity, the transected ovary can be dropped into the
abdomen. Due to the density and larger size, the ovary ● Bleeding at the site of the ablation [6]
seems to be dropped more often compared to the intra- ● Bowel perforation [6]
testis [6]. Leaving the transected ovary in the abdomen is ● Tearing of the perirenal fascia, nephrosplenic ligament,
not supported by the literature. Therefore finding and and dorsal splenic capsule ([37]
removing a dropped ovary is recommended [6]. To avoid ● Breakage of the needle, longer surgery times, instrument
this complication, using instrumentation that has ade- failures and delivered inadequate suture occurred with
quate grasping such as an oschner assists in removal of the automated suturing devices [38]
Thorascopy 401
Prevention The custom-designed cannula provides good horses [41]. This technique provides the opportunity to
access to the operative site [37]. Complications have not visualize and access the bladder, which allows urolith
been reported with polyglyconae suture material for removal [41].
nephrosplenic space closure [37].
Diagnosis Survey of the operative site and surrounding Thorascopy

tissue to identify any complications
Definition Thorascopy is occasionally performed for
Treatment To aid in performing this procedure, technical evaluation of pulmonary pathology; procure biopsies,
adaptations are done which include use of different visualization of the lung and to treat abscesses secondary
cannula site locations and use of development of a custom to pleuropneumonia. An incomplete mediastinum is
cannula [37]. responsible for many of the complications that may occur
when performing a thorascopy [6].
Expected outcome Few complications have been reported Risk Factors
with the laparoscopic nephrosplenic ablation procedure [6].
The amount of bleeding from the site does not pose a ● Intraoperative and postoperative hemorrhage due to
problem and aids in the adhesion formation of the spleen damage to intercostal vessels [39]
to the abdominal wall [6]. ● Hematoma [39]
● Lung perforation [39]
● Diaphragmatic injury [39]
UrinarySurgery
Prevention It is important to plan ahead and have suction
Definition Urinary surgery is often performed in horses available [6]. When inserting the trocar, glide the trocar off
for urolith removal. the cranial edge of the caudal-most rib to avoid the
nerves [39]. It is recommended to create the pneumothorax
Risk Factors slowly to determine the ability of the horse to cope with the
respiratory changes.
● Contamination of the peritoneal cavity [2, 6]
In order to decrease the occurrence of complications
● Formation of urolith following unintentional penetra-
when performing laparoscopic surgery, it is prudent to
tion into the bladder lumen [39]
maintain the best visual field, be careful with the use of
● Injury to the pudendal or superficial epigastric blood
electrosurgical instruments, check that the bowel has not
vessels [40]
been injured prior to exiting the abdomen and finally
● Difficulty in removal of large urolith [41]
inspect the cannulation sites [3]. Most abdominal compli-
cation of laparoscopic surgery can be managed effectively.
Prevention Pre-surgical lavage of the bladder using a Early recognition of potentially serious complications of
urinary catheter, preoperative antibiotic and adherence to laparoscopic surgery provides the foundation for diagnosis
aseptic technique will aid in the prevention for any and management [3]. The knowledge of the pitfalls of lapa-
complications [6]. It is wise to avoid the use of roscopic surgery and the challenges allows the surgeon the
nonabsorbable sutures [6]. tools to prevent complications.
Diagnosis Observation of peritoneal contamination of Diagnosis Monitoring the horse for any signs of respiratory
bleeding will be noted at the time of surgery. It is important changes should be done during the procedure, in
to be aware of the suture material that is used during anticipation of any problems.
surgery. Treatment Intercostal nerve block may aid in the insertion
of the portals [6]. To aid in the placement of the portals,
Treatment The parainguinal laparocystotomy is an blunt dissection versus sharp dissection through the thorax
approach that is an option in order to avoid injury to the musculature and subcutaneous tissue is better tolerated by
pudendal or superficial epigastric blood vessels [40]. the horse [6].
Expected outcome Using minimally invasive Expected outcome Both sides of the thorax will fill with air,
transparalumbar fossa laparoscopic approach has been used necessitating the need for suction. Hematomas may be self-
successfully for cystotomy and urolith extraction in standing limiting or result in a hemothorax [39].
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404
32
Complicationsof EndoscopicLaserSurgery
Jan F. Hawkins DVM, DACVS
Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, Indiana
Overview surgical program requires additional personnel trained in

the use of surgical lasers. This includes surgeons, house
Equine endoscopic laser surgery is an effective method of officers, technicians, and anesthesia personnel (when gen-
managing multiple disorders of the equine upper eral anesthesia is performed). A fundamental understand-
respiratory tract [1–4]. The use of endoscopic techniques in ing of how lasers work and their effect on tissues is
combination with flexible laser fibers has changed the way paramount to the successful outcome of the surgical proce-
multiple abnormalities of the upper respiratory tract are dure. This understanding is gained from concentrated
treated. Procedures which previously required general didactic studying of laser physics and practical application
anesthesia and traditional surgical techniques have been via residency training or advanced continuing education.
replaced with standing endoscopic laser surgery. The inherent risks of laser usage to personnel, expensive
Endoscopic laser surgery requires specialized training and equipment, and the patient must be evaluated before initi-
expertise. The most important factor in obtaining a ating any laser surgical procedure. Laser safety for the per-
successful outcome is surgeon experience with endoscopic sonnel and the patient should always be a consideration.
and surgical laser equipment. A thorough and complete Misapplication of laser energy to the wrong structure can
understanding of how lasers work and what their affects result in postoperative complications. The development of
are on the target tissue are an absolute necessity. The risk postoperative complications secondary to laser surgical
for iatrogenic damage to adjacent normal tissues associated procedures results in delayed return to performance and
with the primary surgery site is high. The primary reason increased financial cost to the owner.
being that the use of the laser fiber inserted through the
biopsy channel of the endoscope removes the tactile istof ComplicationsAssociated
L
response most surgeons are comfortable with. Unlike
with EndoscopicLaserSurgery
traditional surgical techniques the procedure has to be
performed with the aid of a video monitor, similar to
● Laser surgery methods
arthroscopy. To be efficient with surgical lasers, surgeons
● Interoperative complications
must practice often in an area where the population density
– Hemorrhage
of horses is large enough to support a laser surgical
– Introgenic tissue damage
caseload. Typically, this requires being in proximity to a
– Smoke (laser plume) accumulation and toxicity
large population of race horses, although laser surgery of
– Airway fire
the upper airway is common in sport horses.
– Granulation tissue formation
Another important factor when considered the use of
surgical lasers is the requirement for specialized
instrumentation. At a minimum this requires a diode laser LaserSurgeryMethods
capable of generating a minimum of 25 watts and ideally
up to 100 watts, videoendoscopy, filtered suction device, Before attempting a laser surgical procedure, the surgeon
specialized laser eyewear, bronchoesophageal grasping must have received advanced training, either through a
forceps, and laser-safe surgical instrumentation. A laser surgical residency training program or advanced continu-
Laser Surgery Methods 405
ing education. No surgeon should attempt to use a laser The flexible fiber of the diode/Nd:YAG laser is the laser
“out of the box” without appropriate training. Similarly, a of choice for the equine endoscopic surgeon. This fiber can
complete understanding of laser physics and laser interac- be used in contact and noncontact fashion. For the majority
tions with tissue should be mastered prior to using the of laser surgical procedures, which require tissue incision
laser. (cutting), the diode laser is set to 15–25 watts, continuous
The decision for endoscopic correction depends on wave. For surgical procedures requiring photoablation, a
surgeon experience, accurate diagnosis of the presenting high wattage setting should be used (25–50 watts). Once
complaint, determination of whether the procedure can be the laser has been deployed, the laser safety officer should
completed endoscopically, is the essential equipment monitor the number of joules expended during the
available, and whether the procedure can be completed procedure. In general, the higher the number of joules
with the patient standing or under general anesthesia? used for the procedure, the greater the risk for delayed
Decision making is based on historical and physical thermal necrosis. For example, 1,200–1,400 joules should
examination findings. Initial examination of the patient is be expended to correct an uncomplicated epiglottic
centered on standing endoscopic examination of the entrapment. At the opposite extreme, when the goal is
patient. A thorough endoscopic examination should photoablation and latent thermal necrosis, 10,000 joules is
include videoendoscopic examination of the entire upper not unusual.
respiratory tract. The majority of cases can be diagnosed A surgeon planning an endoscopic laser surgical
with standing or dynamic endoscopic examination. No procedure must be well versed in endoscopic equipment
plan for endoscopic laser surgery should be developed until and how to use it. All endoscopic equipment should be
an accurate diagnosis has been made. inspected prior to initiation of the surgical procedure. This
It is essential for standing surgical procedures that the should include an assessment of suction capabilities and
patient be adequately restrained by experienced personnel. an open biopsy channel for lavage. A 1-meter long
Patients moving excessively or are uncooperative are not endoscope is acceptable for the majority of laser surgical
candidates for standing laser procedures. Excessive patient procedures.
movement increases the risk of iatrogenic damage to The laser surgical unit should be tested to ensure it is
adjacent normal tissue(s). A minimum of four people is operational, can be turned on and set to the appropriate
required to complete an endoscopic laser surgical settings for the procedure. Laser fibers for the procedure
procedure: surgeon, surgeon assistant, laser safety officer, should be inspected and functional. It is not unusual for
and a person dedicated to horse restraint. commercially available fibers to have fiber use limits
Once a diagnosis has been made, a treatment plan is (preprogrammed number of uses). Appropriate surgical
discussed with the owner. The primary determining fac- instrumentation should be available so it can be used if
tor in whether a laser procedure can be performed endo- needed to complete the procedure. Appropriate
scopically, is access to the appropriate surgical site. The bronchoesophageal grasping forceps for transnasal use
laser fiber can only reach where the endoscope can visu- must be available. Endoscopic sprayers for topical
alize the lesion. To successfully complete an endoscopic application of local anesthetics greatly facilitates patient
laser procedure, visualization must be available long comfort and cooperation. For standing procedures, IV
enough to complete the procedure. Inadequate visuali- sedation should be available prior to the initiation of the
zation can prolong the surgical procedure and contrib- procedure.
ute to iatrogenic laser damage to adjacent normal Restraint is critical for standing endoscopic procedures.
structures. Visualization can be obscured by hemor- Inadequate horse restraint greatly complicates successful
rhage, smoke, and breathing by the horse during the completion of the procedure. Inadequate restraint leads to
procedure. excessive patient movement. Horses that are appropriately
Airway management should always be considered prior sedated can sway enough that head movement can make
to and during the surgical procedure. Horse airways are laser incision challenging. Inappropriate horse motion can
reactive and prone to edema formation. Excessive mucosal lead to contact of the laser fiber onto normal tissue.
swelling can contribute to upper respiratory tract Finally, how instructions are followed by owners and
obstruction. In severely affected horses, a temporary trainers is a primary determining factor on whether a
tracheostomy or nasotracheal intubation may be necessary successful outcome is achieved. Owners may not administer
to provide an open airway. This can be especially anti-inflammatory and antimicrobial therapy as
problematic in draft horses. Draft horses with laryngeal recommended, contributing to prolonged healing of the
hemiplegia treated with laser ventriculocordectomy are surgical site. Likewise, inadequate withdrawal from
prone to laryngeal edema. exercise contributes to upper airway inflammation and
406 Complications of ndoscopic aser Surgery
edema. Upper airway turbulence secondary to forced may not be enough application of laser energy to result in
inhalation of air keeps healing mucosa inflamed and direct hemostasis of the blood vessel. Delivery of laser
edematous. This contributes to prolonged healing and energy to the vessel without thrombosis results in
most of the time a delay in return to full exercise. hemorrhage. Subarachnoid hemorrhage has been reported
following laser photovaporization of ethmoid
hematoma [7].
IntraoperativeComplications Hemorrhage obscures the field of view of the endoscope
when bleeding covers the lens of the endoscope.
Hemorrhage Hemorrhage adjacent or involving the target tissue
prevents visualization of the target area for the laser.
Definition Excessive hemorrhage from lasered target
tissue resulting in impaired visualization (Figure 32.1).
Hemorrhage can be severe enough to result in Prevention In some situations, hemorrhage cannot be
discontinuation or inability to complete the endoscopic prevented. For example, there is always a blood vessel
procedure. associated with the ventral aspect of the laryngeal ventricle
and it always bleeds to some degree. If possible, this vessel
Risk Factors should be avoided until the final stages of the procedure
when the ventral aspects of the vocal cord and ventricle are
● Anatomical location
incised [5, 6]. For nasal or ethmoidal masses, again
● Improper laser settings
hemorrhage cannot be prevented but only managed; all of
● Iatrogenic damage to adjacent vessels
these masses will hemorrhage to some degree; it is just a
matter of severity.
Pathogenesis The most common sites for hemorrhage
Impaired visualization does not always stop or slow the
associated with endoscopic laser procedures is the laryngeal
procedure. However, when it does develop, a few options
ventricle and masses involving the nasal passage and
are available to manage the hemorrhage and complete the
ethmoid turbinates [5, 6]. Hemorrhage results when there
procedure. The only situations where hemorrhage can be
is direct contact with the laser fiber and the blood supply to
avoided is when the vessel can be directly visualized. In
the targeted tissue. Depending on the laser setting, there
those limited situations every effort should be made to
avoid contacting the laser fiber with the vessel. For
example, blood vessels are sometimes visible when per-
forming laser palatoplasty.
Diagnosis The diagnosis is readily accomplished with

endoscopic evaluation at the time of surgery. Hemorrhage
associated with laser surgical procedures rarely creates
problems with completing the procedure. It is rare for
hemorrhage to persist or develop following the endoscopic
laser procedure and require specific therapy.
Treatment For most cases hemorrhage is treated with

time, lavage with water through the biopsy channel of the
endoscope, or pressure with gauze either inserted through
the nares or controlled with bronchoesophageal grasping
forceps. In rare cases lasered nasal masses may require
temporary gauze packing placed into the nasal passage and
secured with suture closure of the nares on the affected
side.
Expected outcome The expected outcome is successful

Figure32.1 Intraoperative videoendoscopic image of the
completion of the procedure and uneventful wound
ventral aspect of the rima glottis of a horse showing excessive
hemorrhage associated with standing diode laser healing. Rare cases may require discontinuation of the
ventriculocordectomy. Source: Jan F. Hawkins. surgical procedure and completion at a later time.
IatrogenicTissueDamage procedures. Patient movement at an inopportune time

could result in laser fiber contact with a normal
Definition Iatrogenic tissue damage is the direct result of
structure.
application of laser energy to the wrong anatomical
Laser energy can be delivered to the tissue in a noncon-
structure adjacent to the intended target (Figure 32.2) or
tact or contact manner [1]. The Nd:YAG or diode laser can
secondary to excessive delivery of laser energy.
be used in both contact and noncontact fashion. With non-
contact laser delivery, nothing touches the tissue except the
Risk Factors
laser light, imparting a purely optical interaction. Diode or
● Impaired visualization Nd:YAG laser fibers can be used with screw-on type sap-
● Patient movement phire tips to deliver intense heat for contact laser incision.
● Disease to be treated Likewise, the tips of quartz or sculpted fibers produce var-
● Type of laser surgical technique used (e.g. contact vs. ied interactions, depending upon the wavelength of laser
non-contract) light used. The development of latent thermal necrosis is
● Technical error through delivery of excessive laser increased when these lasers are used at high wattages (50–
energy to the targeted or adjacent normal tissue 100 W) and prolonged laser-contact-tissue-time. Scattered
laser energy can damage subsurface tissues, such as nerves
Pathogenesis Iatrogenic tissue damage occurs at the or vessels, or coagulate darkly pigmented skin. When
direct hand of the endoscopic surgeon. The main reasons deeper tissues are at risk, lower wattages and contact tech-
are the surgeon’s inability to recognize the association niques should be considered. The laser beam should be
between the target tissue and tissue adjacent to the directed tangentially across the surface or a contact tech-
intended target and/or the delivery of excessive laser nique should be used, and the integrity of the laser fiber tip
energy to a correct structure leading to thermal injury to should be ensured. In general, lower power densities can
neighboring tissues. be achieved with contact laser fibers. This lessens thermal
Endoscopic procedures are frequently performed with injury to adjacent tissues and decreased latent thermal
two-dimensional imaging on a video screen. Therefore, necrosis.
it is difficult to appreciate the three-dimensional aspects,
particularly depth when performing endoscopic laser Prevention Every effort should be made to clearly identify
the target tissue and determine the relationship of the
target tissue to surrounding anatomical structures. Laser
energy should be delivered with care, preferably via contact
laser fiber to minimize iatrogenic tissue damage and latent
thermal necrosis.
Observation of the procedure on a video screen aids visu-
alization, particularly through magnification. Hemorrhage
should be minimized where possible (see Section on
Hemorrhage). Where possible, surgical instruments,
inserted through the nasal passage or surgical approach,
should be used to protect or retract the target tissue away
from normal adjacent anatomical structures. For example,
an epiglottic hook can be used to protect the epiglottic car-
tilage during laser correction of epiglottic entrapment
(Figure 32.3). If laser penetration of the target tissue is
anticipated. then the laser fiber should be oriented to only
contact tissue that has been previously incised with the
fiber.
Diagnosis Recognition of iatrogenic tissue damage is

apparent in most instances at the time of surgery under
Figure32.2 Postoperative videoendoscopic image of the direct endoscopic guidance. However, in some instances,
ventral aspect of the rima glottis of a horse showing iatrogenic
iatrogenic tissue damage is only apparent in 2–3 days
diode laser damage to the right laryngeal vocal cord following
noncontact laser ablation of the left vocal cord and laryngeal following the initial laser procedure secondary to latent
ventricle. Source: Jan F. Hawkins. thermal necrosis (Figure 32.2).
Figure32.3 An epiglottic hook is being used elevate the Figure32.4 Postoperative videoendoscopic image of the
aryepiglottic fold prior to diode laser correction of epiglottic ventral aspect of the rima glottis of a horse showing iatrogenic
entrapment. Source: Jan F. Hawkins. ventral laryngeal webbing following bilateral laser
ventriculocordectomy. Iatrogenic damage to the tissue
separating both vocal folds contributed to the ventral webbing.
Treatment Treatment includes anti-inflammatory and Source: Jan F. Hawkins.
antimicrobial drug administration. Exercise restrictions
should be recommended while the tissue is healing. At no
● Inhalation of smoke into the lower respiratory tract by
point following iatrogenic damage should the patient be
the patient
exercised if abnormal function is present. Rare cases
● Inhalation of smoke by surgical personnel
require additional surgery to resect webbing or fibrosis
following laser surgical procedures (Figure 32.4).
Pathogenesis As a side effect of laser contact with the target
tissue, smoke is generated secondary to destruction of tissue
Expected outcome Most cases of iatrogenic tissue damage
and release of heat and debris [8]. The amount of smoke
will resolve without permanent complications. However,
generated is directly related to the power density delivered to
this is dependent on what structure has been damaged. For
the target tissue. In general, the higher the power density,
example, iatrogenic damage to nerves with the guttural
the greater the amount of smoke generated during the
pouch can result in permanent disability. In selected cases,
surgical procedure. Because the majority of endoscopic laser
iatrogenic tissue damage results in impaired function of
procedures are performed within the confines of the
normal structures and can require additional surgical
respiratory tract, smoke production can interfere with
procedures.
visualization during the procedure. Smoke can be removed
from the surgical site via: endoscopic suction devices,
Smoke(LaserPlume)Accumulationand Toxicity respiration by the patient to exhale the smoke, and diffusion
of smoke within the confines of the respiratory tract. For the
Definition Smoke (laser plume) is generated secondary to
laser surgical procedure to continue, smoke has to be
laser energy application to the targeted tissue. In general,
evacuated from the surgical site. Smoke generation is
the higher the power density the greater the amount of
decreased with contact laser surgery compared to noncontact
smoke generated from the laser surgical procedure.
procedures. In general, higher laser wattages and increased
power density associated with noncontact laser procedures
Risk Factors
results in increased smoke production.
● High power density Along with decreased visualization, generated smoke
● Closed cavity (nasal passage, nasopharynx, larynx) (laser plume) can be toxic to the patient and the surgical
personnel [8]. Laser plume can include infectious particles Expected outcome Intraoperative smoke accumulation
(viruses and bacteria), mutagens, and chemicals. Every preventing direct endoscopic visualization can be evacuated
effort should be to evacuate smoke via suction and personal with suction of dedicated smoke evaluation. Complications
protective equipment should be used to minimize secondary to inhaled laser plume or smoke has not been
inhalation by the patient and the surgical team. Despite the observed by the author for either patients or surgical
stated risks of laser plume, the author has not observed any personnel.
negative side effects by either patients or surgical staff
following any laser surgical procedure.
AirwayFire
Prevention The production of smoke during a laser
Definition Airway fires can develop secondary to ignition
surgical procedure is not preventable. Therefore, smoke
of ventilated oxygen when performing laser surgery of the
accumulation during the surgical procedure has to be
upper respiratory tract [9–22].
evacuated either by suction, exhalation by the patient, or
dissipation within the airway. Ideally, smoke generated
Risk Factors
during the laser surgical procedure should be evacuated via
suction. For endoscopic procedures, suction tubing is ● Laser surgical procedures of the head and upper respira-
attached to a suction port on the endoscope. Most tory tract
endoscopic units have a dedicated suction unit. For laser ● Oxygen-rich environments
surgical procedures, a filtered suction unit is used to
evacuate the smoke from the respiratory tract or body Pathogenesis Laser surgical procedures of the equine
cavity. These filters frequently will clog with laser plume upper respiratory tract in the presence of oxygen-rich
debris and require frequent changes. In fact, if the filters environments have the potential for initiating an airway
clog, the suction unit will no longer evacuate the smoke. fire. The risk of an airway fire is virtually eliminated when
Similar to endoscopic suction devices, dedicated laser the patient breathes room air. Any laser surgical procedure
plume smoke evacuation devices are available. These in the presence of oxygen can lead to an airway fire because
dedicated smoke evacuation devices can be held up to the of its extreme combustibility. Oxygen concentrations as
nostrils to remove exhaled smoke from the nares. low as 40–50% can lead to an airway fire with even the
Surgical personnel should minimize their exposure to lowest of laser wattages [9–11].
inhaled laser plume. Protection of surgical personnel from
inhaled laser plume can be accomplished with suction as Prevention The risk of airway fires is dramatically
detailed above and through the use of personal protective lowered when horses are not ventilated with any
equipment. It is recommended that personnel exposed to concentration of oxygen during laser surgical procedures
laser plume wear surgical masks to filter laser plume. Both involving the head or upper respiratory tract. The author
surgical masks and N95 respirators have both been shown routinely places endotracheal tubes to maintain a patent
to removed aerosolized debris found in laser smoke or airway during the laser surgical procedure but under no
plume [8]. However, to be effective, the masks/respirator circumstances is the horse ventilated during the
must be properly worn. A properly worn mask or respirator procedure. The majority of laser surgical procedures
must completely cover or seal the mouth and nose to be involving the upper respiratory tract can be performed
effective. with injectable anesthesia. The author prefers a
combination of guaifenesin, xylazine, and ketamine
Diagnosis Smoke or laser plume detection is easily made (Triple drip) for all laser surgical procedures involving the
under direct endoscopic and visual examination. upper respiratory tract. If hypoxemia during anesthesia
Deleterious side effects of laser plume inhalation by either develops while oxygen insufflation is not being
the patient or the surgical personnel is difficult to evaluate, administered, the laser surgical procedure can be
although viral infection in humans is possible [8]. The discontinued and ventilation re-instituted. Once
author has not observed respiratory issues, bacterial or stabilized the oxygen can be disconnected and the horse
viral infections in postoperative patients or personnel allowed to exhale and dissipate the oxygen within the
following laser surgical procedures. lungs, trachea, and nasal passages. Procedures being
conducted within the oral cavity can sometimes be
Treatment No treatment is generally necessary for conducted with shielding of the endotracheal tube with
inhalation of laser plume or smoke in the author’s saline soaked towels to minimize air ignition. Despite the
experience. theoretical prevention of airway fires with protection of
the endotracheal tube, the author would still recommend Risk Factors
that oxygen not be delivered if there is any risk of oxygen
● Iatrogenic laser damage
ignition during the laser surgical procedure.
● High laser power density
● Inappropriate return to exercise
Diagnosis Creation of a flame during a laser surgical
● Poor treatment compliance
procedure would be readily apparent through simple visual
● Excessive postoperative inflammation or infection
observation.
Pathogenesis The equine upper respiratory tract is reactive

Treatment The majority of airway fires in human patients
to insult. This results in edema, inflammation, and
are fatal and are untreatable. There have been no published
superficial infection. An excessive tissue response (e.g.
reports of airway fires in horses secondary to laser surgical
edema, inflammation, or iatrogenic tissue damage)
procedures of the upper respiratory tract.
contributes to the development of excessive granulation
tissue formation [1]. The development of excessive
Expected outcome If an airway fire occurs, death is the
granulation tissue formation results in impaired
most likely outcome.
postoperative healing and abnormal function. The presence
of excessive granulation tissue contributes to the
GranulationTissueFormation development of excessive wound fibrosis, impaired
function, and in some instances, strictures of the laser
Definition Excessive granulation tissue can form at any
surgical site leading to recurrence of the condition being
site following laser surgical procedures of the upper
treated with the laser.
airway [12–20]. The most common location is the
subepiglottic tissue following correction of epiglottic
entrapment (Figure 32.5). Less common sites include the Prevention Preoperative treatment with anti-
arytenoid, laryngeal ventricle, guttural pouch and trachea. inflammatories is recommended to minimize postoperative
edema and swelling. Frequently, a combination of systemic
and topical anti-inflammatories is required to minimize
this complication. Selected anti-microbial administration
can be useful in some horses to minimize the risk for
postoperative surgical site infection.
The surgeon should make every effort to minimize the
number of joules used to complete any laser surgical proce-
dure. The delivery of excessive joules results in increased
iatrogenic tissue damage, latent thermal necrosis and
increased risk for granulation tissue formation. Every effort
should be made to avoid damage to underlying normal tis-
sues such as the epiglottic tip cartilage during surgical cor-
rection of epiglottic entrapment (Figure 32.6).
Owner compliance is important. Owners that re-institute
training prior to complete healing post laser surgery are at
risk for prolonged healing related to continual inflammation
at the surgical site. Poor compliance with administration or
anti-inflammatory or antimicrobial therapy can contribute
to ongoing inflammation at the surgical site and contribute
to excessive granulation tissue formation.
Diagnosis The diagnosis of excessive granulation tissue

Figure32.5 Granulation tissue mass associated with formation can be confirmed with endoscopy. In most
aryepiglottic fold following standing laser correction of situations, endoscopy via the nasal passage is satisfactory
epiglottic entrapment. The epiglottis is being elevated with to confirm the diagnosis. In some cases of persistent dorsal
bronchoesophageal grasping forceps placed in the nasal
passage contralateral to the endoscope. This mass required
displacement of the soft palate following endoscopic
surgical debridement via ventral laryngotomy. Source: Jan F. correction of epiglottic entrapment, affected horses may
Hawkins. require endoscopy via the oral cavity.
original surgery site. This has been reported following fen-

estration of the median septum of the guttural pouch for
treatment of guttural pouch tympanites [21].
Expected outcome The outcome for excessive granulation
tissue post-endoscopic laser surgery is variable, depending
on the location and potential for surgical excision. Focal
granulation tissue masses associated with the laryngeal
ventricle, arytenoid, guttural pouch, or epiglottis may be
amenable to excision. Small, focal masses can be grasped
with bronchoesophageal forceps positioned transnasally and
excised with a contact diode laser fiber (Figure 32.7). Masses
of this type can be excised with a good prognosis. Diffuse
areas of granulation tissue combined with excessive fibrosis
have a more guarded prognosis because of the problems with
abnormal function. This is particularly problematic when
associated with the epiglottis. Subepiglottic inflammation
associated with some cases following correction of epiglottic
entrapment correction results in secondary intermittent or
persistent dorsal displacement of the soft palate (DDSP) [14–
26, 22]. Excessive granulation tissue formation following
Figure32.6 Postoperative videoendoscopic image of the laser correction of epiglottic entrapment can contribute to
epiglottis showing subepiglottic granulation tissue formation intermittent or persistent dorsal displacement of the soft
and necrotic epiglottic tip cartilage associated with standing palate [14–16, 22]. Intermittent or persistent DDSP can be
diode laser correction of epiglottic entrapment. This is
frequently associated with iatrogenic laser damage to the performance limiting, even following surgical resection of
epiglottic tip during surgical correction. Source: Jan F. Hawkins. excessive granulation tissue.
Treatment Once present, granulation tissue may require

prolonged treatment with anti-inflammatory and
antimicrobial medication, prolonged time away from
exercise, and in some instances additional surgery to resect
granulation tissue and excessive fibrosis associated with
the procedure [12–20]. First and foremost, conservative
management is preferred over surgical resection of
granulation tissue. Horses should be initially treated with
complete removal from exercise and administered anti-
inflammatory and antimicrobial medication. Treatment is
monitored with repeated endoscopic examinations.
Small, focal granulation tissue masses can sometimes be
debrided with bronchoesophageal grasping forceps
inserted via the nasal passages or with a Ferris Smith ron-
geur inserted via a laryngotomy incision. Horses which do
not respond to conservative management may require sur-
gical debridement with the horse under general anesthe-
sia. For example, some cases of severe granulation tissue
formation or fibrosis secondary to laser correction of epi-
glottic entrapment, can be surgical debrided via laryngot-
omy. The downside of aggressive surgical debridement,
particularly involving the epiglottis, is impaired epiglottic Figure32.7 Videoendoscopic image of the corniculate processes
of the laryngeal arytenoid cartilages. Bronchoesophageal
function which contributes to persistent DDSP. Horses suf-
grasping forceps are being used to grasp granulation tissue at the
fering from stricture following creation laser surgical pro- axial aspect of the corniculate process of the left arytenoid
cedures may require additional surgery and revision of the cartilage before diode laser excision. Source: Jan F. Hawkins.
Evidence The majority of evidence related to endoscopic randomized clinical trials for types of treatment.
laser surgery complications is based on case reports and Fortunately, the overall complication rate for endoscopic
case series, limited research, and expert clinical opinion laser surgery is relatively low compared to many other
and experience; the primary reason being the lack of equine surgical procedures [1–4].
References
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Equine Surgery, 5e (ed J.A. Auer and J.A. Stick), 238–255. laser for treatment of chronic empyema in two horses. J.
St. Louis, MO: Elsevier. Am. Vet. Med. Assoc. 218 (3): 405–407.
2 Palmer, S.E. (2003). The use of lasers for treatment of 13 Hay, W.P. and Tulleners, E. (1993). Excision of
upper respiratory tract disorders. Vet. Clin. N. Am. Equine intralaryngeal granulation tissue in 25 horses using a
Pract. 19: 245–263. neodymium: YAG laser (1986 to 1991). Vet. Surg. 22 (2):
3 Blikslager, A.T. and Tate, L.P. (2000). History, 129–134.
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(2): 251–269. hypoplasia in racehorses with epiglottic entrapment
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Surgery (ed B.C. McGorum, P.M. Dixon, N.E. Robinson, 621–626.
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Elsevier. neodymium:yttrium aluminum garnet laser correction of
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6 Hawkins, J.F. and Andrews-Jones, L. (2001).
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413
33
ComplicationsFollowingSurgeryof the EquineNasalPassagesand Paranasal

Sinuses
Lynn Pezzanite DVM, MS1 and Jeremiah T. Easley DVM2
1
Department of Clinical Sciences and Translational Medicine Institute, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO
2
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO
Overview iv) if caudal to the septum of the RMS, then in CMS; v) if

rostral to the septum of RMS then in RMS or VCS; vi) if
rostral to septum of RMS and abaxial to infraorbital canal
PertinentAnatomyfor Surgery
then in RMS; and vii) if rostral to septum of RMS and axial
of the ParanasalSinusesand NasalPassages
to infraorbital canal then in the VCS (Figure 33.1). Lastly, if
The equine paranasal sinuses are complicated anatomi- you are dorsal to the VCS and rostral to the DCS then you
cally. An accurate and thorough understanding of the have located the dorsal conchal bullae (DCB) and if you are
anatomy is required prior to surgical intervention to mini- directly rostral to the VCS then you have located the ventral
mize intraoperative and posteroperative complications conchal bullae (Figure 33.1). During surgical planning,
and result in positive outcomes for the horse and client. there are a few key steps in identifying the location of these
Diagnosis and treatment of diseases of the sinuses can be landmarks, which are as follows: i) nasolacrimal
challenging due to the large size of the paranasal sinuses duct – extends from the medial canthus of the eye to the
and difficulty of access to this region. The paranasal nasoincisive notch; and ii) infraorbital foramen – located
sinuses consist of seven pairs of sinus compartments: the by placing middle finger on facial crest and thumb on
frontal sinus, dorsal conchal sinus (DCS), ventral conchal nasoincisive notch, followed by the placement of the
sinus (VCS), caudal maxillary sinus (CMS), rostral maxil- pointer finger into the infraorbital foramen when placed
lary sinus (RMS), ethmoidal sinus and sphenopalatime on the maxillary bone (Figure 33.2). By identifying and
sinus. Communication occurs between the CFS, CMS, avoiding both the nasolacrimal duct and infraorbital canal/
ethmoidal and splenopalatine, while a separate commu- foramen, a safe surgical approach can be made to the
nication occurs between the VCS and RMS [1, 2]. paranasal sinuses. Identification of these important
Structures within the paranasal sinus compartments such anatomical structures can also be highly valuable to
as the infraorbital canal, frontomaxillary aperture, naso- advanced diagnostic imaging interpretation and surgical
maxillary aperture and septum of the RMS, play a vital planning.
role in understanding surgical anatomy of the paranasal While anatomical understanding of the paranasal
sinuses and if able to be identified, serve as landmarks for sinuses is vital to surgical success and minimization of
paranasal sinus surgery. When identified, these four complications, it is important to realize that sinus disease
structures will guide the surgeon throughout surgical can significantly distort or even eliminate important
exploration. structures, making anatomical understanding and surgery
To simplify the complexity of the equine paranasal challenging. Severe, chronic sinus disease has resulted in
sinuses, the authors like to follow a few simple rules during distortion or elimination of the infraorbital canal,
surgical exploration: i) if dorsal to the frontomaxillary frontomaxillary aperture and the septum of the RMS.
aperture, then in the DCS or frontal sinus compartments; Locally aggressive disease will either erode or push these
ii) if ventral to the frontomaxillary aperture and abaxial to structures away from their original and correct position. In
infraorbital canal, then in the CMS; iii) if ventral to fron- addition, surgical access to the nasal septum is limited due
tomaxillary aperture and axial to the infraorbital canal, to its location within the nasal passage surrounded by the
then approaching the sphenopalatine sinus compartment; nasal bones dorsally, hard palate ventrally, and the nasal
414 Complications Follo ing Surgery of the quine Nasal Passages and Paranasal Sinuses
(a) (b)
(c) (d)
Figure33.1 Anatomy of the sinuses. (a) Close-up image of the sinus compartments via a frontonasal sinus flap. Green arrows =
frontomaxillary aperture; red arrow = nasomaxillary aperture (drainage of sinuses into the nasal cavity); white star = infraorbital canal
as it extends through the CMS and RMS/VCS; Eth = ethmoidal sinus; CMS = caudal maxillary sinus; DCS = dorsal conchal sinus; VCS =
ventral conchal sinus; RMS = rostral maxillary sinus, white line = septum of maxillary sinuses (dorsal aspect of septum) has been
removed to provide access to VCS and RMS. (b) Close-up sinoscopic image via a CFS trephination looking down into the sinus
compartments. Green arrows = frontomaxillary aperture; white arrows = intact septum of maxillary sinuses; white star = infraorbital
canal as it extends through the CMS; Eth = ethmoidal sinus; CMS = caudal maxillary sinus; CFS = conchofrontal sinus (combination of
frontal and dorsal conchal sinus compartment). (c) Close-up sinoscopic image via a CFS trephination looking down into the sinus
compartments after the septum of the maxillary sinuses has been broken down in order to provide access to the VCS and RMS; white
star = infraorbital canal as extends across the VCS and RMS (note the separation of the VCS from the RMS by the infraorbital canal);
DCS = dorsal conchal sinus; CMS = caudal maxillary sinus; VCS = ventral conchal sinus; RMS = rostral maxillary sinus. (d) Close-up
sinoscopic image via an RMS trephination. Note the small size of the sinus compartments via this approach. The RMS approach
provides direct access to the RMS, but the infraorbital canal limits access to the VCS. Green arrow = direction of endoscope over top of
the infraorbital canal to access the VCS, which is not easily performed; VCS = ventral conchal sinus; RMS = rostral maxillary sinus.
conchae laterally [3]. However, when the surgeon has a distorted or at least the surgeon can identify the original
thorough understanding of paranasal sinus and nasal pas- location and thus understand the accurate anatomy at that
sage anatomy, these structures can be identified even when location.
Complications Associated ith Surgery of the quine Nasal Passages and Paranasal Sinuses 415
cause [6–8]. Dental-related sinus disease is the most com-

mon cause of secondary sinusitis, and typically arises from
bacteria spreading from one or more infected dental apices
of the caudal four maxillary cheek teeth (08, 09, 10, and 11)
through the alveolar bone [5]. Infection of the apex of the
fourth premolar may also result in secondary sinusitis in
horses older than 5 years of age [4]. Unilateral nasal dis-
charge is the most common clinical sign in dental-related
sinus disease [5]. Bilateral nasal discharge is uncommon
with unilateral sinusitis, as the nasal septum prevents
access of drainage to the contralateral nasal passage.
Bilateral nasal discharge is more commonly associated
with diseases of the guttural pouches, lungs and
pharynx [5].
Diagnostic techniques for the evaluation of the sinus
compartments and apices of maxillary cheek teeth include
a detailed physical examination including percussion,
nasal endoscopy, sinoscopy, radiography, scintigraphy,
computed tomography, magnetic resonance imaging, and
bacterial culture and histological examination in some
cases [5]. Thorough understanding of sinus and dental
anatomy, in conjunction with additional diagnostic and
advanced imaging techniques, is paramount to accurate
diagnosis, successful treatment and positive outcome in
cases of sinus-related disease in the equine patient. Many
complications associated with sinus surgery can be avoided
Figure33.2 Photograph of the dorsal aspect of the head of a or minimized by thorough understanding of anatomy and
horse after frontonasal sinus flap. Note the dense mucopurulent
discharge at the rostrolateral corner of the flap indicating good pre-surgical planning [9]. Sinus-related disease is
presence of infection. Source: Courtesy of Valerie Moorman. rarely considered an emergency and therefore appropriate
and thorough preoperative planning, including a complete
The paranasal sinus compartments are intimately understanding of the disease process and potential
involved with the maxillary cheek teeth. Tooth roots of the complications of surgical intervention, is recommended.
caudal fourth cheek teeth (4th premolar, 1st, 2nd, and 3rd With improved diagnostic imaging and earlier intervention,
molars or 108-11 and 208-211) fill the majority of the RMS a more precise surgical plan may be developed that
and CMS in horses younger than 5 years of age. In the minimizes risk of complications. Seeking additional advice
mature horse, the 4th premolar (108, 208) and 1st molar from surgery and radiology specialists is recommended in
(109-209) alveoli lie within the RMS and the 2nd and 3rd many cases.
molar (110, 210, 111, 211) alveoli lie within the CMS.
However, location of the 4th premolar (108, 208) can vary,
dependent on the age of the horse [4]. Surgical
complications as a result of damage to the alveoli of cheek
C
teeth can be avoided when the surgeon has a clear with Surgeryof the EquineNasal
understanding of dental anatomy and its relationship to Passagesand ParanasalSinuses
the paranasal sinuses [4].
– Pertinent anatomy for surgery of the paranasal sinuses
and nasal passages
ClinicalDiagnosisof SinusDisease
– Clinical diagnosis of sinus disease
Sinusitis can be a primary disease process or secondary to
● Intraoperative/technical complications
dental disease, mycotic infections, oromaxillary fistula,
sinus cysts, sinus neoplasia, progressive ethmoid – Hemorrhage
hematoma, or trauma [5]. Primary sinusitis is a bacterial – Trauma
infection that develops without apparent predisposing – Incomplete septal resection
● Early postoperative complications return from the nasal cavity and sinuses in the standing
– Incisional infection position results in less pooling of blood in the venous
– Suture periostitis sinuses and therefore less hemorrhage.
– Sinus packing complications
Prevention One of the most effective ways to limit
hemorrhage in equine sinus and nasal surgery is to perform
– Incomplete resolution
the surgery in the standing position. Standing sinusotomy
– Disease recurrence
of the horse was first reported by Schumacher et al. in
– Airway narrowing due to adhesions or granulation tis-
2000 [10]. Since that time, standing sinusotomies are more
sue formation
of the norm than the exception. While the ultimate decision
– Etiopathogenesis
to perform a sinusotomy in the standing position should be
– Facial deformities
based on patient safety and surgeon preference, the authors
– Respiratory noise
feel that the limited hemorrhage improves the ability to
perform surgery accurately, which can result in decreased
complications and improved outcomes. Aside from the
I ntraoperative/Technical obvious risks and increased costs of general anesthesia,
Complications standing surgery is associated with less bleeding and lower
intravenous fluid delivery requirements compared with
Hemorrhage general anesthesia [5]. In surgery for the removal of the
nasal septum, severe intraoperative hemorrhage can be
Definition Bleeding during sinus surgery in a fast and
minimized by fast surgical time and nasal tamponade, and
uncontrolled manner. See also Chapter 7: Complications
may be influenced by selection of surgical technique [11].
Associated with Hemorrhage.
Several surgical procedures have been described for
nasal septum resection in horses [3, 22, 26]. Using the
Risk Factors
3-wire method, speed following commencement of cutting
● Performing surgery in recumbent position under general is important to minimize intraoperative bleeding, as
anesthesia versus standing substantial hemorrhage occurs once the trephination is
● Extended length of surgical procedure made and the nasal mucosa is disrupted to place the dorsal
● Disease entity and caudal wires [11]. It is recommended that creation of
● Involvement of specific anatomical sites (ethmoid the trephine hole should be delayed until needed for
turbinates and central nasal regions) placement of the caudal and dorsal wires [11]. When using
the 2-wire laryngotomy technique, no significant
Pathogenesis Unfortunately, hemorrhage is an inevitable hemorrhage occurs until the nasal septum is cut with
result of paranasal sinus surgery due to the extensive wires, and therefore the amount of time elapsed between
vasculature of the sinus mucosa. Often, sinus disease this step of the surgery and complete packing of the nasal
involves vascular soft tissue masses with an abundant passage is short [3]. In addition, the dorsal approach for
blood supply. The amount of hemorrhage in sinus surgery removal of the nasal septum allows for direct observation
is variable and often depends on the disease entity. of the nasal septum and thus access to control hemorrhage
There are specific sites within the sinus and nasal cavity by clamp application to the exposed septal ends and
that tend to bleed more excessively than other regions deliberate placement of packing. [15]. It was proposed that
during surgery, including the ethmoid turbinate regions this immediate control of hemorrhage decreases the
(both nasal and sinus portions) as well as the central nasal potential requirement of blood or blood product
regions, including the conchal bone close to the ethmoid administration and may reduce the potential for transient
turbinates as well as the nasal septum tissue. Involvement upper airway obstruction secondary to blood clot
or surgical invasion of these highly vascularized anatomical postoperatively reported by Doyle and Freeman [11–15]. In
structures will increase the amount of bleeding. conclusion, although technique selection for the removal
Blood loss from hemorrhage is far greater in the of nasal septum surgery may be dictated by a number of
anesthestized patient compared to the standing patient. In considerations, certain techniques may be implemented to
the standing position, the horse’s head is at a higher level reduce intraoperative hemorrhage.
than the heart, thus limiting the blood pressure within the The anatomical structures with abundant vasculature
head, decreasing the amount of edematous sinus mucosa (ethmoid turbinate regions and central nasal regions, see
and thus decreasing hemorrhage [9]. Improved venous above) will inevitably result in excess hemorrhage when
Trauma 417
damaged. Often, neither region can be avoided when adrenergic agonist to saline lavage solution. This results in
performing a frontonasal sinusotomy, which is why a vasoconstriction of the vessels of the sinus mucosa. Cold
frontonasal sinusotomy tends to bleed in excess compared saline lavage solution can also help cause vasoconstriction
to a maxillary sinustomy approach. Although more but some surgeons have reported irritability of the patient.
invasive, from the authors’ experience, the frontonasal Following the procedure, packing the sinus compart-
sinusotomy provides much greater access to the sinus ments in accordion fashion with gauze and leaving in place
compartments and they consider the benefits of the for 24 hours following surgery can significantly aid in con-
frontonasal sinusotomy to outweigh the risks of trolling hemorrhage. The packing can pass from the sinuses
hemorrhage. In conclusion, an accurate understanding of into the nasal cavity and out of the corresponding nostril
sinus anatomy, an exhaustive diagnostic work-up of the for removal at a later time. Excessive bleeding upon
sinus disease, a detailed surgical plan, and determination removal can occur, but is typically self-limiting. Packing of
and patience by the surgeon, will aid in preventing the paranasal sinus compartments should be avoided if
hemorrhage and other complications in sinus surgery. possible. Avoidance of gauze packing will help to limit fur-
ther postoperative complications that will be discussed
Diagnosis In most situations of sinus surgery, hemorrhage later in this text.
will be diffuse in nature. Excessive blood loss can occur If hemorrhage cannot be controlled and the horse is
and is considered a serious complication of sinus surgery. showing systemic signs of excessive blood loss, the most
Bleeding will occur from the entirety of the mucosal lining. appropriately next step is to end the surgery, pack the sinus
This can be directly visualized and pooling occurs within compartments and initiate a blood transfusion. Excessive
the ventral sinus compartments such as the RMS, VCS, or blood loss is considered an emergency situation and blood
CMS. Excessive blood may also run directly out of the nose. transfusion is required in a timely fashion. Thus, it is
Locating specific bleeding arterial vessels can be important to plan ahead and perform a cross-match prior
challenging due to blood pooling and limited visualization. to surgery. The benefits of performing a cross-match and
Total blood loss during surgery is difficult to accurately having a blood donor horse available far outweighs the risk
account for, making the decision for a blood transfusion a of losing a horse due to the inability to perform a life-saving
challenge. Blood can be quantified by collection and blood transfusion, even if the horse ends up not needing
weighing for a calculation of volume. This method is the transfusion.
inaccurate due to the addition of saline solution utilized
intraoperatively. Thus, the most accurate and effective way Expected outcome The head has a significant blood supply,
to monitor excessive blood loss is via vital parameters such especially in specific regions of the sinuses and nasal cavity,
as pale mucous membranes, prolonged capillary refill time, making hemorrhage an expectation of any surgery involving
tachycardia, and hypotension as well as serial monitoring the head. Fortunately, intraoperative hemorrhage, especially
of packed cell volume and total protein concentration. in the standing position, rarely results in clinical signs of
excessive blood loss. On the other hand, significant
Treatment Hemorrhage will occur in all scenarios of sinus hemorrhage can have a negative impact on recovery from
surgery and planning ahead for excessive blood loss is of general anesthesia associated with hypoxemia and low blood
vital importance. As mentioned previously, hemorrhage pressure, so the risk is two-fold in the fact that hemorrhage
during sinus surgery is often diffuse, especially in regions is more excessive under general anesthesia [17]. In the
of the highly vascular ethmoid turbinates. If excessive majority of sinusotomy procedures, the impact of
bleeding occurs during sinus surgery, it can limit hemorrhage on the horse is often less of an issue compared
visualization making completion of surgery more difficult, to its impact on the surgeon. Hemorrhage will negatively
thus increasing the risk of intraoperative or postoperative impact surgical visualization that can result in increased
complications. If specific bleeding arterial vasculature can surgical time and error. Hemorrhage should be controlled as
be localized, ligation should be performed. This can be effectively as possible intraoperatively, while still achieving
done with either suture or cautery (bipolar or monopolar). the surgical goals.
A LigasureTM vessel sealing can also be utilized for ligation
of large vessels up to 7 mm in diameter or even along the
edges of bleeding mucosa. If vessel ligation is not possible, Trauma
temporarily packing the sinus compartments with gauze or
laparotomy sponges can help to slow the bleeding to some Definition Iatrogenic damage to tissues surrounding the
degree. Some surgeons have found phenylephrine to be sinus surgical site, including the sinusotomy bone flap,
helpful in limiting hemorrhage by adding the alpha-1- infraorbital and trigeminal nerves, and nasolacrimal duct.
Risk Factors care be taken intraoperatively to prevent trauma to the

bone flap rather than discarding the flap or attempting to
● Inadequate preoperative planning
treat trauma postoperatively.
● Inadequate knowledge of anatomy
Contact should be maintained between the sinusotomy
● Distorted architecture caused by the disease
bone flap, periosteum, and overlying soft tissues throughout
● Inadequate intraoperative visualization of anatomic
the surgical procedure, to reduce the risk of loss of vascular
structures due to hemorrhage.
supply to the bone flap. Care should be taken to avoid
iatrogenic damage to the infraorbital nerve intraoperatively.
Pathogenesis Unrecognized trauma to the sinusotomy
Normal anatomical architecture may not be present in the
bone flap during surgery can result in loss of vascular
case of invasive masses, such as paranasal sinus cysts or
supply and subsequent necrosis of part or the entire bone
neoplasia, and therefore it is advised to proceed cautiously
flap. Large masses, such as paranasal sinus cysts or
with debridement until location of important structures is
neoplasia, may also result in significant facial, nasal and
verified. Appropriate presurgical planning and knowledge
paranasal anatomical deformation, or infraorbital nerve
of anatomy may help to minimize trauma to the lacrimal
trauma. Distorted anatomy or accumulation of blood may
duct upon sinus entry.
hinder anatomical recognition and pose anatomical
When axial fracture of the bone flap results following
structures at risk of iatrogenic intra-operative trauma (i.e.
three-sided ostectomy in nasal septum removal, instability
trauma to the infraorbital nerve during surgical
of the closure results due to inherent weakness of the nasal
debridement). Trauma to the lacrimal duct upon initial
bones axially over the firm attachment to the underlying
incision during bone flap sinusotomy may also occur.
nasal septum. Removal of a rectangular flap of nasal bones
Additionally, septic meningitis and head-shaking have
is recommended until the septum is resected followed by
been reported following sinus surgery [18, 19].
reattachment of the flap to the parent bone along its
In the dorsal approach for nasal septum resection, it has
perimeter. This technique has not been associated with any
been recognized that there is an inherent weakness in the
observed complications [15].
nasal bones axially over the firm attachment of the under-
In nasal septum resection, original techniques described
lying nasal septum [15]. Ostectomizing the nasal bone on
using an osteotome or a wide guarded chisel to create the
only three sides can result in midline fracture after attempt-
ventral and dorsal cuts through the septum, in addition to
ing to hinge the nasal bone flap laterally. Instability and
a vertical cut through the caudal portion of the septum [16].
reduced cosmesis and security of the closure result if axial
However, section of the septum in the vertical plane at this
fracture of the flap occurs. Of pertinence to any approach
level resulted in the remaining septal stump being in close
for nasal septal resection, the degree of trauma inflicted
proximity to the ventral conchae, where subsequent
during resection may be the most important contributing
granulation, swelling or fibrosis could impinge on the
factor in development of excessive granulation tissue for-
conchae or result in adhesions and further airway
mation postoperatively.
narrowing [16]. Tulleners and Raker [15] described a
technique to reduce trauma in order to minimize excessive
Diagnosis Necrosis and sequestrum of the bone flap granulation tissue formation surrounding the septal stump,
postoperatively may be recognized as incisional drainage consisting of making a caudal cut at a 60-degree angle with
and failure of union between the bone flap and adjacent an osteotome so that the caudal edge was in a wider part of
periosteum. Trauma to the infraorbital nerve as a result the nasal passage, so that a larger portion of the diseased
of surgical manipulation or local invasion by a large mass septum could be removed [16].
can result in neuritis, in unilateral hyperalgesia and Additional techniques have been described using
rarely in self-mutilation of the muzzle postoperatively obstetrical wire to create the ventral and dorsal cuts in the
[7, 20]. nasal septum, using three wires, or using a dorsal approach
in order to eliminate trauma to the adjacent conchae
Prevention Some clinicians have advocated for discarding caused by the osteotome [11, 16]. Use of obstetrical wires
the bone of the sinosotomy flap, although in most cases may allow for removal of the caudal extent of the septum
acceptable cosmetic outcome may be obtained while in a less traumatic manner than could be accomplished by
maintaining the bone flap. In fact, in one retrospective osteotomes [11]. Because the cuts are made with preplaced
study in which a modified frontonasal sinus flap was wires that closely follow septal attachments at all times or
employed and bone flap was discarded, only 58% of horses are guided and protected by a catheter, there is reduced risk
were considered to have a good cosmetic appearance of inadvertent injury to adjacent structures such as the
postoperatively [21]. Therefore, it is recommended that nasal conchae [3, 11]. It is important to note that when
Trauma 419
using the three-wire technique, that the dorsal and ventral resulted in resolution or improvement of epiphora and
cuts are discontinued at the rostral cut so that they do not good functional and cosmetic outcomes [25,26].
continue into and weaken the rostral remnant of the
septum [11]. The dorsal approach, while more invasive Expected outcome Prognosis following debridement of the
initially, should be less traumatic to the remaining tissues infected or necrotic tissue at the osteotomy site is good.
of the nasal passages than chisel or obstetrical wire Development of sinocutaneous fistulas is rare; however,
techniques [11, 15, 16]. the osteotomy site may heal with a cosmetic deformation.
Degree of trauma inflicted during septal resection and Hyperalgesia and self-mutilation secondary to iatrogenic
ability to control subsequent hemorrhage may be the most damage or compression following mass expansion of the
important factor (more so than selection of specific surgical infraorbital nerve are expected to improve with reduced
technique) in the prevention of excess granulation tissue inflammation surrounding the nerve postoperatively as
formation postoperatively. well as systemic medications (e.g. nonsteroidal anti-
inflammatories, gabapentin). Percutaneous electrical
Treatment If necrosis of the bone flap occurs following stimulation may result in short- to medium-term
sinusotomy procedure, effective treatment is difficult. amelioration of signs in trigeminal neuritis [23].
Debridement of necrotic bone including subsequent Administration of magnesium intravenously may dampen
removal of the bone flap in conjunction with supportive signs of neuropathic pain and decrease head-shaking
therapy such as appropriate antimicrobials may be behavior [24].
necessary if this occurs.
Sensory nerve conduction and somatosensory evoked
potentials of the trigeminal nerve in horses with idiopathic IncompleteSeptalResection(Crossing
headshaking were evaluated [22]. This study confirmed of Wires)
involvement of the trigeminal nerve hyperexcitability in
Definition Portion of abnormal nasal septum left within
the pathophysiology of disease, supporting a functional
the nasal cavity during septal resection
rather than structural alteration in the sensory pathway of
the trigeminal complex that can be seasonal [22].
Risk Factors
Neuromodulation with percutaneous electrical stimulation
was described as a safe, well-tolerated, repeatable treatment ● Use of three-wire technique [11]
for the management of trigeminal-mediated headshaking, ● Inappropriate placement of wires within nasal cavity
with encouraging efficacy for amelioration of clinical signs
in the short- to medium-term time frame [23]. It was Pathogenesis The three-wire trephination technique of
further described that the low-threshold firing of the septal resection has the potential complication of crossing
trigeminal nerve in trigeminal-mediated headshaking, of the dorsal and caudal wires, which would impede clean
resulted in apparent facial pain [24]. This study transection of the septum and could lead to undesired cuts
demonstrated that administration of magnesium into the septum [11]. If the wires are crossed within the
intravenously had neuroprotective effects on nerve firing nasal passage, some abnormal septum may be left
that dampened signs of neuropathic pain, significantly un-resected.
decreasing head-shaking behavior in horses with
trigeminal-mediated headshaking [24]. Resolution of Risk factors Surgical error
inflammation within the sinus cavity may help to resolve
or alleviate hyperalgesia and self-mutilation resulting from Diagnosis Detection of the technical error during surgery
neuritis, as a result of compression from an invasive mass. is difficult due to intraoperative hemorrhage. The surgeon
Self-mutilation is more commonly a postoperative may perform radiographs or endoscopy following
complication associated with surgical trauma to the nerve placement of wires prior to cutting to ensure location of
or increased inflammation surrounding the nerve wires if desired. Postoperatively, the horse may show
postoperatively. Treatment with medication such as incomplete resolution of clinical signs and upper airway
gabapentin may help to alleviate clinical signs [17]. endoscopy postoperatively will reveal presence of
Transection of or damage to the nasolacrimal duct result- unresected abnormal septum.
ing in obstruction may be treated with catheterization or
canaliculosinosotomy to divert lacrimal secretions into the Prevention In placement of the wires using the three-
caudal maxillary sinus [25, 26]. Canuliculosinosotomy wire-technique described by Doyle and Freeman (2005),
may be performed in the standing sedated horse, and it is critical that the wires are not crossed within the nasal
cavity and that each wire must be directed toward the side nature of sinus surgery, a low percentage of incisional
it is cutting as much as possible to force each cut along the drainage is not surprising or concerning [17].
line of attachment (i.e. dorsal and ventral
attachments) [11]. It is also important to note that the Diagnosis Incisional infection is apparent postoperatively
dorsal and ventral cuts are arrested at the rostral cut so as mucopurulent incisional drainage following sinus flap
that they do not continue into and weaken the rostral osteotomy. Diagnostic imaging (i.e. radiographs,
remnant of the septum. [11]. ultrasound) may also be useful in diagnosis of incisional
Crossing of wires is not possible with the laryngotomy or infection.
dorsal approach techniques [3, 15]. These techniques may
be used as an alternative to enhance the ease and safety of Prevention Careful inspection of the osteotomy site prior
the technique and improve speed of execution in to closure of the periosteum and skin intraoperatively to
comparison with the three-wire trephination technique [3. identify and remove any devascularized regions of bone
11]. The laryngotomy approach was safe and expedient can minimize the possibility of sequestrum development
with minimal complications, except for transient as an inciting cause for postoperative infection. Adherence
granulation tissue formation near the rostral stump [3]. to aseptic techniques should be achieved when possible to
The laryngotomy approach is also associated with increased decrease the risk of infection.
invasiveness (i.e. laryngotomy incision) in comparison to
the other techniques. The dorsal approach was associated Treatment When incisional drainage is identified, local
with good to excellent cosmetic outcome and return to aseptic preparation and systemic antimicrobials dictated
previous level of work without perceived limitations by aerobic and anaerobic bacterial culture and sensitivity
associated with respiratory function and minimal results are indicated and typically sufficient for treatment.
complications [15]. If incisional drainage is prolonged or unresponsive to
treatment, the incision site may be further assessed using
Treatment If failure to remove the targeted amount of ultrasonography. A small percentage of cases may require
septum occurs, removal of additional septum in subsequent further local standing debridement to resolve focal septic
surgeries is difficult [15]. Precautions should be taken osteitis [17].
toward prevention of incomplete removal rather than
revision. Expected outcome Resolution of incisional drainage is
anticipated in most cases with appropriate antimicrobial
Expected outcome Removal of additional septum is treatment based upon bacterial culture and sensitivity and
difficult if complete excision is not achieved during the local antiseptic preparation. A second surgical procedure
first procedure. involving reopening of the incision to debride
de-vascularized bone may be necessary in cases of
sequestration, but still carries a good prognosis for complete
EarlyPostoperativeComplications resolution of signs.
IncisionalInfection
SuturePeriostitis
Definition Colonization and multiplication of
Definition Development of firm swelling at the operated
microorganisms (bacterial, fungal) at the previously
site following sinus flap osteotomy or dorsal approach for
operated site
nasal septum resection
Risk Factors
Risk factors None currently described
● Lack of adherence to aseptic technique Suture periostitis is a rare postoperative development of
● Unidentified devascularized bone resulting in seques- a firm swelling on the operated site following sinus flap
trum formation postoperatively osteotomy or dorsal approach for the removal of the nasal
● Performing surgery in standing position versus under septum. It has been occasionally reported to occur on the
general anesthesia contralateral side not directly associated with the surgical
incision [20]. It is theorized that the bone flap has
Pathogenesis Postoperative incisional drainage occurs in destabilized the suture lines of the head resulting in
approximately 10% of all sinusotomies, and a sequestrum inflammation along the suture lines (Dixon, personal
can often be the inciting factor [20]. Due to the non-aseptic communication). Suture periostitis is thought to be an
exuberant periosteal reaction at the junction of the facial Risk factors Creation of a large sinonasal fistula
bone plates, and is more commonly associated with frontal
bone approaches [17, 20]. Pathogenesis Packing the sinus and nasal passage
to reduce hemorrhage postoperatively following
Diagnosis Suture periostitis is apparent as a swelling on establishment of a fistula between the sinus and nasal
the affected side (Figure 33.3). Suture periostitis may be passage is commonly performed. If the fistula to the nasal
mildly painful to palpation during the acute phase, and passages is large, it is possible for the packing to enter the
may result in lacrimation on the affected side due to nasal passage and be pushed caudally and ventrally onto
obstruction of the lacrimal ducts. the soft palate where it may be swallowed into the
Prevention No preventative measures have been identified. esophagus [17].
However, as our understanding of this complication
progresses, surgeons may learn of measures to be taken for Diagnosis Movement of the sinus packing should be
prevention in the future. suspected and investigated in horses that are observed to
swallow more than normal postoperatively. In these horses,
Treatment Swelling from suture periostitis typically endoscopic examination may be performed in order to
resolves without treatment over the course of several determine whether horses are swallowing the packing or if
months [17]. Antibiotic therapy may be indicated if there is there is unrecognized hemorrhage caudal to the packing
bacterial infection present secondary to inflammation. that is stimulating swallowing.
Expected outcome Suture periostitis may result in poor
Prevention Loosening or swallowing of packing may be
cosmetic outcome following sinosotomy, but clinical signs
prevented by utilizing a sterile stockinette as a sleeve for
typically resolve without treatment.
the packing when it is placed [27]. The packing is placed
within the stockinette prior to placement in the sinus,
SinusPackingComplications
preventing independent loops from being dislodged
Definition Movement of sinus packing caudally and postoperatively.
ventrally from the sinus through a sinonasal fistula into the Sinus packing should be avoided if significant bleeding is
soft palate where it may be swallowed not present following sinus surgery.
(a) (b)
Figure33.3 (a) Photograph of the left side of the head of a horse at approximately 3 months following sinus frontonasal flap
osteotomy. Note the swelling on the dorsal margin of the face consistent with suture periostitis. (b) Laterolateral radiographic image
of the dorsal aspect of the head of the same horse in (a), showing suture periostitis of the frontonasal suture and characterized by
widening, sclerosis and new bone formation at the suture. Source: Courtesy of Jack Easley.
Treatment If packing is recognized to be partially within Paranasal sinus cysts are associated with relatively high
the esophagus, the entire packing may be removed nasally, postoperative success rates for complete resolution in 82%
or the packing may be grasped endoscopically and removed to 93% of cases following sinus bone flap procedure [7, 20].
from the unpacked nostril and sutured in place to the Complete removal of the cyst lining is recommended, but
nostril for complete removal at a later time [17]. may not be necessary for resolution of clinical signs in
some cases [20]. However, in cases where the cyst lining
Expected outcome Good outcome if horses with packing was not completely removed, horses were more likely to
are closely monitoring and the packing is promptly have prolonged or persistent nasal discharge
removed after identification for the complication. In horses postoperatively, which may be attributed to a persistent
which have developed this complication and packing is not secretory lining present or resultant structural changes in
removed quickly, esophageal choke may ensue. the nasal cavity resulting in persistent inflammation [20].
Progressive ethmoid hematomas are relatively common
in the equine population, with highly variable reported
rates of incomplete resolution and recurrence, which may
LatePostoperativeComplications be attributed to the multiple different reported methods of
treatment and follow-up evaluation [28–30]. The true
IncompleteResolutionof PrimaryDiseaseor recurrence rate is likely higher than that reported when
Recurrence horses are re-evaluated endoscopically and radiographically
Definition Perseverance or return of disease signs at one to two years following initial treatment [17].
In nasal septal resection, use of preplaced wires should
Risk Factors allow for more precise and cleaner cuts, as the wires will
follow septal attachments closely, particularly deep in the
● Dependent upon nature of primary disease process nasal cavity [11]. This may help to eliminate the risk of
● Surgical technique error incomplete removal of lesions or failure to remove the
● Inadequate knowledge of anatomy desired amount of septum.
● Inadequate preoperative planning
Diagnosis Recognition of incomplete resolution of
Pathogenesis Incomplete resolution or recurrence of the primary disease process or recurrence is recognized as
primary problem may result in chronic infection and continued or recurring clinical signs (e.g. nasal discharge,
sequestration, and is considered the most common epistaxis), or abnormalities noted on diagnostic imaging
complication in the treatment of sinus disease. Incomplete such as endoscopy, radiography, computed tomography or
resolution may be partially attributed to the nature of the magnetic resonance.
primary disease process, as well as a combination of Fenestration of the concha into the nasal cavity may
inadequate exposure or preoperative planning resulting in result in chronic low-grade serous nasal discharge in some
inadequate surgical debridement. horses. It may be difficult to distinguish incomplete
Likelihood of incomplete resolution or recurrence of resolution from recurrence in some cases; however,
disease is dictated in large part by the nature of the pri- recognition of the problem and treatment options are the
mary disease process. Accurate prognosticating of the same for both situations.
owner is therefore determined by appropriate diagnosis
of the disease at initial presentation based on diagnostic Prevention A thorough diagnostic work-up of sinus cases
imaging, appropriate surgical intervention, and postop- is recommended. Use of advanced volumetric imaging
erative histopathology and microbiology. For example, techniques provides invaluable information for surgical
treatment of primary sinusitis carries one of the highest planning and accurate prognosticating for the owner.
success rates (84%), and if diagnosed at early stages may When dealing with long-standing primary sinusitis,
be effectively treated with antimicrobials with or without surgical sinusotomy and antimicrobial therapy is necessary
lavage [8]. If diagnosed at later stages, primary sinusitis is to remove inspissated pus and debride the sinus lining. A
more appropriately addressed with surgical sinusotomy sinonasal fistula may be used to provide long-term drainage
in order to remove inspissated pus and debride the sinus and direct access to the sinus postoperatively [8, 17]. Recent
lining. studies have shown that recurrence can often be a result of
Treatment of sinus neoplasia is associated with the high- disease within the ventral and dorsal conchal bullae [31]. It
est rate of incomplete resolution or recurrence for all sinus- is important to evaluate the nasal conchal bullae in
related diseases, reported to be up to 88% of cases. challenging cases where disease has recurred.
Biopsy and histopathology of sinus neoplasia is indicated complications associated with previous septal resection
for any presumed tumor. This may be performed prior to techniques, as it can result in airway obstruction [3, 11, 14,
sinusotomy for more accurate prognosis postoperatively 16, 33–35]. This complication has been attributed to
for recurrence and recovery. making a vertical (rather than oblique) cut through the
Preoperative identification of sinus involvement of cases caudal nasal septum, resulting in an exposed granulating
with progressive ethmoid hematomas will allow for plan- edge in a narrow part of the nasal passage [16]. Original
ning on surgical treatment of the sinus cavity, which will techniques for nasal septum resection described use of an
allow a more comprehensive treatment of the mass. Surgical osteotome to section the septum in the vertical plane,
treatments include laser ablation or mechanical debride- which resulted in the remaining septal stump in close
ment. Intra-lesional injection with formalin provides an proximity to the ventral conchae, where subsequent
inexpensive, minimally invasive, and sometimes effective granulation, swelling, or fibrosis could impinge on or
alternative to surgery. A large frontonasal sinusotomy in the produce adhesions to the conchae and cause further airway
standing sedated horse often results in improved visualiza- narrowing [16]. Excessive granulation tissue on the caudal
tion of the hematoma often resulting in complete debride- cut edge was reported several months following surgery in
ment and improved outcomes. There has been one report of 4 out of 8 horses that underwent resection by chisel [16].
brain damage from extension of formalin into the cranial Abnormal thickening caudally and ventrally was reported
vault necessitating euthanasia [32]. in an additional 3 out of 8 horses in the same report.
In nasal septal resection, use of preplaced wires should
allow for more precise and cleaner cuts as the wires will Diagnosis Excessive granulation tissue and adhesion
follow septal attachments closely, particularly deep in the formation can result in reduced airflow through the nasal
nasal cavity [11]. This may help to eliminate the risk of passages, limited performance and in more severe cases,
incomplete removal of lesions or failure to remove the airway obstruction.
desired amount of septum. Excessive granulation tissue or airway passage narrow-
ing resulting from adhesions may be diagnosed via endos-
Treatment If incomplete resolution of the primary disease copy of the nasal passages several months following
process occurs, a second sinusotomy surgery can be surgery. Increased respiratory noise and limited perfor-
performed through the original site, but is associated with mance may be noted by owners prior to endoscopic evalu-
increased risk of incisional complications. Advanced ation. Nasal discharge may be present due to airway
multi-planar imaging is recommended in a situation of inflammation.
incomplete resolution or chronic disease. If failure to
remove the desired amount of septum occurs, removal of Prevention Technique modification where the caudal cut
additional septum is difficult. in septal resection was angled at 60 degrees rostrocaudally
minimized the likelihood of postoperative airway
Expected outcome Repeat sinusotomy surgery is associated obstruction as the granulating caudal edge was located in
with increased risk of incisional complications and lower the wider portion of the nasal passage [16]. In addition, use
cosmetic results. If resection the condition is complete, of obstetrical wire for the dorsal, caudal, and ventral septal
prognosis is good. If resection is incomplete recurrence is incisions may allow for removal of the caudal extent of the
likely. In cases of neoplasia, prognosis will be determined septum in a less traumatic manner than could be
by the nature of the mass. accomplished by osteotomes. The wire method for cutting
the caudal edge can produce a smooth cut that may be
AirwayNarrowingDue to Adhesions, angled as desired by manipulating the wire caudally with
GranulationTissueFormationorFacialBone the catheter through which it is threaded [11].
collapse
Treatment Attempts to break down adhesions or debride
Definition Reduced diameter of nasal passages following
granulation tissue may be made transendoscopically or
nasal septum resection or collapse of facial bones following
through a dorsal sinus flap approach. However, incomplete
sinusotomy if sinus flap is performed too far distally
excision of the septal stump initially often still results in
Risk factors Inadequate surgical technique reduced airway diameter and limited performance
postoperatively.
Etiopathogenesis
Formation of excessive granulation tissue on the caudal Expected outcome Excessive granulation tissue and
aspect of the septal stump is one of the most important adhesion formation has been observed to result in
postoperative airway obstruction. The most likely reason cosmetic correction of a depression fracture of the nasal
that horses are unable to perform athletically following bones or the removal of a nasal mass is also being consid-
nasal septum resection procedure are related to excess ered [35]. The dorsal flap approach allows reconstruction
granulation tissue formation that decreases nasal meatal of the normal contour of the bridge of the nose in horses
cross-sectional area and/or the ability to remove all with depression fractures and diseased septa. In one study,
diseased septal tissue [15]. Prognosis following owners were reportedly happy with the cosmetic outcome
transendoscopic debridement of granulation tissue and and 3 out of 4 horses had improved facial contour
disease septal tissue is presumably good pending complete postoperatively [35].
removal of undesired tissue. Multiple procedures may be
necessary to achieve desired results. Treatment Efforts should be made to prevent or reduce
facial abnormalities as treatment following development is
difficult.
FacialAbnormalities
Definition Cosmetic deformities of facial contour Expected outcome Facial deformities may result in reduced
following septal resection or collapse of the facial bones cosmesis postoperatively or can be performance limiting
following sinusotomy if sinus flap is performed too far with reduced airflow such as in nostril collapse occurring
distally. in young foals.
Risk factors Septal resection performed in horses less than

RespiratoryNoise
one year of age
Definition Increased sound related to respiratory tract
Pathogenesis Facial abnormalities including rostral
flattening of the bridge of the nose, extreme convexity of Risk factors None currently described
the nose and upper airway obstruction due to loss of nostril
support have been reported following nasal septum Pathogenesis Extensive nasal septum resection has been
resection [11, 12, 14–16]. Collapse of the rostral nasal bones reported to result in production of mild respiratory noise in
has been reported most frequently in young horses less all horses when working postoperatively without affecting
than one year of age, suggesting that the cartilaginous performance negatively [11, 16]. The mild respiratory noise
nasal septum is important for support of the developing was attributed to altered airflow dynamics and turbulence
nasal bones in foals [11, 16]. in the enlarged nasal cavity.
Diagnosis Facial abnormalities are visually apparent Diagnosis Increased respiratory noise, both inspiratory
postoperatively upon physical examination. and expiratory, is apparent during exercise, which has been
attributed to altered airflow dynamics and turbulence in
Prevention Septoplasty technique has been described the enlarged nasal cavity.
that preserves nasal support afforded by the septum. This
procedure may be better suited to lesions in the most Prevention Prevention of respiratory noise postoperatively
rostral part of the septum and may be of most benefit to may not be possible in cases of extensive nasal septum
foals as they are dependent on septal support to prevent resection, as noise results from altered airflow dynamics
facial deformity and nostril collapse. [16, 36]. However, and turbulence in the enlarged nasal cavity. Development
nasal septal resection is generally not recommended in of new surgical techniques in the future may result in
horses less than one year of age, and if these horses do reduced postoperatively noise through minimizing
require surgery, a sufficient amount of rostral septum resection of tissue and disruption of the normal nasal
must be left behind to support the nostrils and decrease anatomy.
nasal collapse postoperatively [11]. The technique
described by Yarbrough et al. may be utilized in foals with Treatment No treatment for continued respiratory noise
rostral lesions in order to decrease airway obstruction postoperatively is recommended as all horses returned
while allowing for normal development of the facial successfully to use, although none were intended to
contour [36]. participate in strenuous activity [11].
In addition, nasal septum resection through a dorsal
approach may be particularly well suited for horses where Expected outcome Performance following nasal septum
removal of the nasal septum in conjunction with either resection was not affected despite respiratory noise in one
References 425
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did not participate in strenuous athletic activity [11]. appropriately set as guarded for high-level activities such
Although horses have successfully raced following nasal as achieving full racing potential [11, 16].
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427
34
Complicationsin PharynxSurgery
Norm G. Ducharme DVM, MSc, DACVS1 and Fabrice Rossignol DVM, DECVS2
1
Cornell University Hospital for Animals (CUHA), College of Veterinary Medicine Cornell, University, Ithaca, New York
2
Equine Clinic Grosbois, Boissy Saint Leger, France
Overview istof ComplicationsAssociated

L
with PharyngealSurgery
Pharynx surgery in adults, mainly includes procedures
used to treat palatal instability and dorsal displacement of ● Laryngeal Tie Forward
the soft palate (DDSP). – Intraoperative complications
DDSP is a multifactorial disease with many predisposing ○ Intraoperative bleeding
factors such as neurological abnormalities (motor and/or ○ Cartilage/bone breakage or laceration
sensory), anatomic deficits, and acquired structural deficits. – Early postoperative complications
DDSP can be reproduced by desensitization of the pharyn- ○ Seroma
geal branch of the vagus [1], resection of the thyroideus ○ Incisional infection
muscle [2], and desensitization of the hypoglossal nerve [3]. – Late postoperative complications
Replacement of the thyroideus muscle function with sutures ○ Vocal cord collapse
has led to the introduction of laryngeal tie-forward surgery ○ Unilateral breakage of the suture
(LTF) [4]. Staphylectomy is an older technique that is still used ○ Fracture stylohyoid bone postoperatively
or advised by some surgeons in an attempt to stiffen the caudal ○ Failed Laryngeal Tie Forward
border of the soft palate. It may be also performed in associa- ● Staphylectomy

tion with LTF to treat permanent displacement of the soft pal- – Dysphagia/laryngeal incompetence
ate. Staphylectomy is also sometimes combined with ● Sternothyroideus myotenectomy
sternothyroideus myotenectomy (Llewellyn procedure [5]) as – Intraoperative complications
a first-line surgical procedure for horses with DDSP. ○ Bleeding
Laser cautery of the soft palate or palatoplasty is sometimes – Postoperative complications

used alternatively to staphylectomy to create a fibrosis and ○ Recurrence of DDSP
then a stiffening of the soft palate. As for staphylectomy, scien- ● Laser palatoplasty
tific studies have failed to prove the usefulness of laser palato- – Postoperative complications
plasty. However, these techniques are still used in the racing ○ Dysphagia and coughing
industry. ○ Perforation of the soft palate
Oral palatoplaty using red iron via an oral approach is

still used and popular in the United Kingdom, but without
any scientific support.
Surgical success depends on proper case selection-based LaryngealTieForward
preoperative evaluation and possible treatments and/or man-
agement by modifying/eliminating these recognized factors. ● Laryngeal Tie Forward (LTF) consists of surgical eleva-
In this chapter, possible intraoperative and postoperative tion and advancement of the larynx [6].
complications of LTF and a few other alternative proce- ● Prognosis is better if the postoperative position of the lar-
dures will be described. ynx, in relation to the basihyoid, is more dorsal [6].
428 Complications in Pharynx Surgery
● This procedure, despite the marked modification in rela-

tive position of the thyroid cartilage and hyoid bone,
leads to fewer complications than the laryngoplasty.
Intraoperativebleeding
Definition
Blood accumulation in the surgical field obscuring surgical
visualization and recognition of anatomical structures as a
result of iatrogenic vessel disruption
Risk factors Branches of the cranial thyroid and caudal

laryngeal artery/vein run dorsal to the sternothyroid (ST)
tendon and muscle and along the lateral and dorsal part of
the caudal border of the thyroid cartilage (horizontal V Figure34.1 Intraoperative view on a horse under general
shape). anesthesia and dorsal recumbency. An approach between the
paired sternohyoideus (SH) muscles has been made and the
● Branch of the lingual artery/vein located just abaxial and right side of the larynx is viewed. Rostral is to the left of the
dorsal to the basihyoid bone and lingual process. image. Right caudal border of the thyroid cartilage (THC) and a
● Branch of the lingual artery located close, lateral and branch of the cranial thyroid artery (white arrow). The tendon of
the right sternothyroid muscle (ST) is elevated using a Kelly
slightly dorsal to the lingual process, within the myohy-
forceps. TH: Thyrohyoid muscle.
oideus muscle.
● Excessive use of scissors instead of blunt and finger dis-
Branch of the lingual artery at the hyoid:
section increases the risk of vascular damage.
● Place a temporary tagged sponge until the sutures are
Pathogenesis Bleeding occurs when one or more of these tied. Once the sutures are tied, there is usually enough
vessels are inadvertently punctured or lacerated during pressure of the rostral aspect of the thyroid cartilage on
surgical dissection. Bleeding can be difficult to control, the bleeding vessels dorsal to the basihyoid bone and the
especially when the lacerated vessel is located dorsal to the bleeding stops.
basihyoid bone and may lead to loss of visualization and ● If bleeding does not fully resolve after tying the sutures,
postoperative seroma. apply an absorbable gelatin sponge (Gelfoam® Pfizer) in
the small space between the ventral aspect of thyroid
Prevention Branch of cranial thyroid artery or caudal cartilage and the dorsal aspect of the basihyoid bone.
laryngeal artery/vein at the thyroid wing:
Branch of the lingual artery at the hyoid:
● Lift the ST muscle and tendon by placing a curved Crile
● Do not dissect the mylohyoideus muscles adjacent to the
hemostat immediately caudal to the cricoid cartilage,
lingual process.
before placing the suture in the wing of the thyroid carti-
● Place the wire passer immediately adjacent to the junc-
lage (Figure 34.1)
tion of the lingual process and basihyoid bone. Progress
● Ligatures can be useful at the caudal (muscular) portion
close to the rostral aspect of the bone, advance the tip of
when removing a 2–3 cm section
the suture/wire passer toward the midline, and exit
Branch of the lingual artery/vein or their branches: immediately dorsal to the basihyoid bone also on its mid-
line. Use a finger to apply counter pressure on the thyro-
● Remain very close to the lingual process and basihyoid
hyoid membrane (Figure 34.2).
on the midline when passing the sutures using the pas-
● Gently retrieve the passer and sutures using a passer of
ser. Use a proper passer with a small radius of curvature
appropriate radius that allows close contact with the
to keep close to the basihyoid bone.
bone (e.g. 4-cm radius Synthes passer).
Treatment Branch of the thyroid or caudal laryngeal artery
Expected outcome The prognosis is favorable if the
at the thyroid wing:
hemorrhage is properly managed. In some cases, bleeding
● Clamp the small vessel and apply ligature. Cauterization can be difficult to control and can lead to postoperative
may denervate the cricothyroid muscle. hematoma and seroma. In the worst-case scenario, rarely,
Laryngeal Tie Forward 429
Cartilage/BoneBreakageorLaceration
Definition Loss of integrity or tearing of the thyroid cartilage
wings or fracture of the basihyoid bone in association with
placement of sutures
Risk factors
● Failure of caudal part of the thyroid wings:

– Young horses (2-year-old Thoroughbreds)
– Repeat LTF
– Use of a too agressive (like cutting/reverse cutting) or
too large a needle
– Single pass through thyroid cartilage
● Basihyoid: original technique involving drilling a hole
through the basihyoid bone.
Figure34.2 Intraoperative view during an LTF procedure.
Rostral is to the left of the image. The wire passer is passed
immediately adjacent to and to the left of the junction of the
Pathogenesis Passing the suture too close to the caudal
lingual process (LP) and basihyoid bone (BH), from ventral to border of the thyroid cartilage wing (<0.8 cm) may lead to
dorsal of the BH and exits immediately dorsal and on the suture pull out.
midline of the BH (white arrow). A finger is used to apply counter Hyper extension of the head during recovery, or in the
pressure on the thyrohyoid membrane to facilitate the
procedure.
early postoperative period, can also increase the stress on
the sutures and cartilage or bone. The consequence is pros-
thesis loosening and failed LTF
the seroma may become infected. In this situation, the
surgical wound should be partially opened and lavaged
Prevention
thoroughly. Antibiotherapy should be prolonged and
ideally based on results of culture and susceptibility results ● Thyroid:
of samples. Removal of implant sutures is often necessary, – Use a 4-bite technique through the thyroid cartilage
but this should be delayed when possible for two months in wing 3–4 mm apart (this can be used in horses of any
order to get a degree of fibrosis and laryngeal stability. age without complications).
Intraoperative hemorrhage and associated loss of visu- – Use metallic buttons [9], especially in patients at risk,
alization may lead to consequences that may affect the out- such as 2-year-old horses (buttons can be used in all
come of the case. These consequences may vary, depending horses, irrespective of age without complications).
of the vessel involved: ● Basihyoid: pass the sutures around the basihyoid using
an adequate size wire passer and avoid technique involv-
● Puncture of branch of cranial thyroid artery/vein or cau-
ing drilling through the basihyoid.
dal laryngeal artery/vein:
– Sub-optimal implantation through caudal aspect of
Diagnosis If occurring intraoperatively, it is clearly evident.
thyroid wings cartilage: tearing of the thyroid cartilage
In cases where this complication occurs in the postoperative
by the sutures.
period, suture pull out is usually associated with recurrence
– Damage to the cricothyroid muscle or its innervation
of clinical signs (see Section on Failed Laryngeal Tie Forward
by the external branch of the cranial laryngeal nerve:
below).
risk of vocal cord collapse [7, 8].
● Puncture of lingual artery/vein or its branches tend to
Treatment
cause profuse bleeding and difficulties to complete the
procedure: ● Thyroid: if laceration of the caudal aspect of the wing:
– Compression or damage to hypoglossal nerve: further – Repeat the procedure using 3–4 passages and taking
risk of epiglottic retroversion larger bites so that sutures are placed in a more cranial
– Medial deviation of vocal cords due to swelling of the position in the thyroid cartilage.
ventricle and compression. This complication is usu- – Consider metallic suture buttons [9].
ally short-termed, unless infection develops at the site. ● Hyoid: if fracture of the basihyoid bone:
– Permanent DDSP due to inflammation in severe – If laceration after drilling technique: repeat the proce-
cases. dure passing around the basihyoid bone.
– If complete bone fracture on one side (rare condition): Risk factors Seroma
consider aborting the procedure and use another strat-
● Puncture of the laryngeal ventricle
egy than a tie forward.
Pathogenesis Bacterial colonization of the seroma leads to
Expected outcome For the complications listed above, the
bacterial proliferation and infection. The laryngeal ventricle
prognosis is fair to good, except in the case of hyoid broken
can be punctured when sutures are passed through the
on one side.
thyroid cartilage if the needle is advanced too dorsally and
rostrally. In these cases, contamination with bacteria located
EarlyPostoperativeComplications inside the ventricle leads to surgical site infection.
Infection at the surgical site causes increased morbidity
Seroma and expense and may require suture removal and, in some
cases, lead to failed LTF.
Definition Accumulation of serosanguineous fluid in the
surgical area under the skin
Prevention Avoid placing the sutures too dorsally and/or
rostrally through the thyroid wings and do not perform a
Risk factors Bleeding
ventriculo-cordectomy by laryngotomy after a TF. If
● Dead space ventriculocordectomy is required, perform this technique
carefully, using the laser 24 hours before performing the
Pathogenesis Occurrence of bleeding intraoperatively or use LTF. In cases of postoperative bleeding from the ventricle
of inadequate or unsuccessful hemostasis techniques in after ventriculocordectomy, prolong administration of
surgery increase the risk of blood accumulation in the surgical antimicrobials.
site that can lead to formation of seroma postoperatively.
The reported incidence of seroma formation after LTF is Diagnosis Swelling at the surgical site is usually evident. This
1.1% [4], although this seems to be more frequent in other swelling tends to be warm, indurated and painful, and affected
reports and also based on the authors’ personal experience patients tend to show pyrexia. Ultrasound examination of the
and personal communications. area reveals accumulation of hypochogenic fluid in the
subcutaneous space. Upper airway endoscopy may reveal
Prevention The risk of bleeding can be reduced by using inflammation of the pharynx and larynx. In cases of abscess
the technique described earlier. When closing the formation, this may cause swelling to a degree that can
sternohyoideus muscles, it is recommended to incorporate partially obstruct the pharynx or compress the ventral aspect
the fascia of the ventral aspect of the larynx to decrease of the larynx (i.e vocal cords are displaced toward the midline
dead space. This should be at the thyroid cartilage but the because of swelling).
crico-thyroid membrane should be spared. Use of a stent
bandage for two to three days may also be advised. Treatment In cases with early signs of incisional infection,
sutures should be removed to allow drainage, a sample
Diagnosis Swelling at the surgical site is usually evident. should be obtained for bacterial culture and susceptibility
This swelling tends to be soft and non-painful, and affected tests, and the horse be placed on antimicrobials.
patients do not show fever. Ultrasound examination of the In cases of chronic drainage without formation of
area reveals accumulation of hypochogenic fluid in the abscess, it is recommended that suture removal is delayed
subcutaneous space. Upper airway endoscopy does not for 60 days to allow peri-laryngeal fibrosis to prevent cau-
reveal obvious abnormalities. dal retraction of the larynx after prosthesis removal.
In cases of infection involving TF sutures and formation
Treatment Most of the cases can be treated conservatively. of an abscess, the prosthesis should be removed to prevent
Puncture, fluid sampling and drain should only be used if compression of the larynx. This can be performed on the
no response to conservative management is observed. horse standing:
Expected outcome Favorable, although in some cases infection ● Perform a skin incision at the basihyoid and dissect care-
may develop. fully through subcutaneous tissue. Identify and grasp the
suture knot, transect and remove sutures.
Although more challenging, a similar approach can be
Incisionalinfection
●
successfully used with metallic suture buttons or in the

Definition Bacterial colonization and proliferation at the presence of a 4-loop technique, as infection usually sof-
surgery site, leading to inflammation and drainage. tens the cartilage.
ate Postoperative Complications 431
Expected outcome Favorable, although the final degree of Risk factors Inadequate suture material or suture handling
abduction achieved after resolution of the infection may
● Technical errors
not be optimal and in some cases revised surgery may be
● Grazing in the early postoperative period
required.
● Use of the first described TF technique for side laryngeal
deviation
LatePostoperativeComplications
Pathogenesis This may occur as a result of the suture
VocalCordCollapse being placed becoming damaged by inadequate handling
(i.e suture crushed by instrument) or failure of the knot,
Definition Medial deviation of vocal folds causing partial but these are rare. Although most common, it is a result of
obstruction of the laryngeal lumen suture pull out from the thyroid cartilage wing.
In cases where the original TF technique has been used,
Risk factors May be a preoperative co-existing condition whereby sutures are tied ipsilaterally (left ventral suture is
● Excessive dissection toward the cricothyroid muscle knotted with the left dorsal suture and the right ventral
● Technical error involving the cricoid thyroid suture is knotted with the right dorsal suture), unilateral
● Incisional infection (as mentioned above) suture failure will lead to laryngeal and epiglottis deviation
toward the failed side.
Pathogensis Wide dissection in the area of the cricothyroid In cases where the more recent TF technique has been
muscle may cause interference with the function of the used, whereby sutures are tied contralaterally (left ventral
cricothyroid muscle or its innervation, either by iatrogenic suture is knotted with the right ventral suture and the left
damage during dissection, or fibrosis after surgery. dorsal suture is knotted with the left ventral suture), unilat-
This can also occur if sutures have been passed through eral suture failure will lead to bilateral loss of laryngeal
the cricoid cartilage instead of the thyroid cartilage. The advancement without lateral deviation.
risk of this surgical error may be increased after previous The consequence will be a failed LTP and possible
tenectomy of sternothyroid muscle, because of the lack of dysphagia.
sternothyroid tendon which is generally used as an ana-
tomical landmark. Diagnosis This is usually observed by recurrence of clinical
signs, including noise and/or dysphagia. Upper airway
Diagnosis Affected horses usually develop respiratory endoscopy will reveal epiglottis deviation toward the broken
noise and decreased performance and diagnosis is achieved side after the original TF procedure, and loss of advancement
by exercising endoscopy. in cases after the second procedure. Radiographic
examination will reveal lack of advancement after the recent
Prevention Perform preoperative exercising endoscopy to procedure but not in cases after the original TF procedure.
detect presence of co-existent conditions. If any condition,
such as vocal cord collapse is detected, this should be Prevention Avoid grazing and feeding from the ground in
treated. the early postoperative period (3–4 weeks).
Lift the ST tendon before transection to prevent inadvert- To avoid the side deviation of larynx and epiglottis, con-
ent damage to the cricothyroid muscles or their innerva- nect left ventral to right ventral suture and left dorsal to right
tion by the external branch of the cranial laryngeal nerve. dorsal to form an equal suture traction from left and right
sides on the basihyoid bone. Alternatively, connect both left
Treatment Perform laser VC when the complication is to both right using a single knot when using metallic suture
diagnosed, which is usually after recovery and when the buttons [9].
horse is back in full training.
Treatment Repeat Tie Forward
Expected outcome Favorable after VC
Expected outcome Fair to good if the problem is diagnosed
UnilateralBreakageof the Suture and the LTF can be repeated.
Definition Loss of suture tension and laryngeal advancement,
FractureStylohyoidBonePostoperatively
which can cause side deviation of the larynx and epiglottis
(after using original TF technique) or total loss of laryngeal Definition Fracture of the stylohyoid bone that normally
advancement (after using later TF technique). affects the “mid-body”
Halter being caught and horse

Risk factors (potential) Pathogenesis Failed LTF has a reported incidence of 6% [5],
pulled upward or backward although it may be more frequent in the authors’ opinion. It
tends to occur within the first weeks after surgery but some
● Assisted recovery from anesthesia with head rope
occurs later when the horse resumes training.
● Violent head movements in extension during training
Technical errors include iatrogenic damage to the intrin-
sic musculature of the soft palate (palatinus m.) when pala-
Pathogenesis This is a rare complication with an incidence tal thermoplasty is performed in association with TF. If due
of ~3/1,000. The cause was unknown but two of the three to suture failure, associated clinical signs have usually
affected horses had their head halter caught on a structure acute onset (from one day to the next). Young horses are at
(hook for bucket), causing marked head traction after higher risk of failure secondary to partial or total breakage
surgery. Otherwise unknown pathophysiology. of the cartilage.
In some cases, recurrence of clinical signs may be due to
Prevention Do not assist recovery of these horses with a previously undetected or neglected co-existing condition
head ropes causing head extension and traction. When or predisposing factor during preoperative exercising
moving the horse from surgery to recovery stall, support its endoscopy:
head to prevent excessive traction on hyoid apparatus.
Avoid leaving the horse with halter on if there are items ● Co-existing disease:
where the halter can get caught. – Ary-epiglottic fold (AEF) collapse
– Intermittent epiglottic entrapment
Diagnosis At the time of fracture, horses become acutely – Evolution of laryngeal hemiplegia (LH)
dysphagic and show difficulty in swallowing. Although ● Neurological deficit:
fractures may occur in the early postoperative period, the – Decreased tone of palatinus/palatopharyngeal muscle
authors have seen one horse presented with recurrence of (pharyngeal branch of the vagus nerve) due to pharyn-
DDSP 3 years post-surgery (personal observation). gitis and/or guttural pouch inflammation.
On upper airway endoscopy, there is a lateral swelling on – This is more frequent in 2-year-olds, especially when
the wall of the nasopharynx at the level of the fractured LTF has been performed before medical management
stylohyoid bone (near tip of epiglottic cartilage). In the of UA inflammation.
acute phase, the submucosal tissue appears bruised at the – Some horses may have intrinsic lower athletic quality
level of the swelling. Radiography or computed tomogra- that was not detected due to the disease.
phy confirm the diagnosis.
Prevention Preoperative diagnosis should be exhaustive to
Treatment With rest and administration of NSAIDs, and detect all associated abnormalities that should be adequately
the hematoma usually resolves in ~30 days. Full healing of managed at the same time as the LTF. Follow guidelines of
the fracture requires ~3 months proper surgical technique.
There must be good communication with the trainer
Expected outcome In the majority of cases, clinical signs regarding recovery time, especially for 2-year-old horses.
(dysphagia) resolves but DDSP can persist, especially if the Three to four months of rehabilitation with musculation
larynx has moved caudally and ventrally. may be necessary. Feed at shoulder height and do not turn
out a 2-year-old immediately after surgery. If turn out is
required, consider delaying surgery prior to returning to
FailedLaryngealTieForward training.
Definition Recurrence of the clinical signs due to failure of We routinely advise postoperative management tech-
surgery and subsequent caudoventral migration of larynx niques and include them in the surgical report of all cases
(crossing nose band, tack, racing strategies, etc.) and check
Risk factors Technical errors (weak grasp into the thyroid this is clearly understood by the trainer and the referral vet.
cartilage, weak knot, etc.) Advise postoperative exercising endoscopy if any doubt
regarding possible recurrence.
● Suture weakness (small diameter under No. 5 Fiberwire)
● Cartilage or bone failure Diagnosis History and clinical examination reveal recurrence
● Young horses of clinical signs, most commonly with acute onset. Resting
● Grazing in early postoperative period endoscopy should be performed to assess for pharyngitis,
● Assisted recovery with head rope guttural pouch inflammation, or ulcers on the caudal soft
Staphylectomy 433
palate, that may explain recurrence of clinical signs. This – Decrease level of exercise for two to three months and
should be followed by exercising endoscopy. give more time, especially in 2-year-old horses.
Assessment of possible failure of the suture prosthesis
If prosthesis relaxation/failure with caudal/ventral dis-
and ventral/caudal displacement of the larynx can be per-
placement is apparent during radiographic exam and endos-
formed with other imaging modalities. On a laterolateral
copy, and DDSP at exercising endoscopy:
radiograph with head in extension, assess the position of
the rostral calcified part of the thyroid in relation to the ● Perform exercising endoscopy with Cornell™ collar, if
thyro-hyoid bone (Figure 34.3). If metallic suture buttons available. If this resolves the DDSP, consider a repeat
were used, these are no longer in the correct postoperative laryngeal tie-forward procedure
position. Resting ultrasonography reveals that the sutures ● Repeat Tie Forward:
are no longer tight during head extension. – Similar approach
– Intubation may be more difficult
Treatment If the prosthesis is stable on imaging examination – Leave previous sutures in place
but the horse is displaying DDSP at exercising endoscopy: – Consider metallic suture buttons at the thyroid cartilage
– Larynx should be freely dissected from the surround-
● Treat associated lesions by AEF resection, if not or sub- ing fibrous tissue, mainly lateral to thyroid wing and
optimally performed previously. between basihyoid and rostral part of the thyroid.
● Manage predisposing factors:
Expected outcome If the LTF was originally successful, the
– Pharyngitis
prognosis is good, otherwise the success rate is around 50–60%
– Improve musculation, body condition, improve tongue
musculature (use double hay net or small hay net)
– Vary the consistency of the food, dry vs. wet; place a Staphylectomy
salted stone in the feeder.
– Improve/modify tack such as crossing nose band, ● Staphylectomy consists in partial resection of the most
slight overcheck for trotters, and use a bit to prevent caudal part of the soft palate. It was originally described
them from pulling. as a treatment for an excessively long soft palate. This
(a) (b)
Figure34.3 Radiographic assessment of the stability of the sutures after a tie forward using metallic suture buttons. Lateromedial
view with head in extension (rostral is to the left). (a) Normal appearance: the rostral mineralized part of the thyroid cartilage (black
arrow) is positioned rostral to the thyrohyoid bone (TH) and dorsal to the basihyoid bone. The white arrow indicates correct and stable
position of the metallic button implants at the caudal part of the thyroid cartilage. The radiopaque artifacts at the bottom of the
image are metallic skin staples. (b) Failure of the construct. The rostral mineralized part of the thyroid cartilage (black arrow) is more
ventral and caudal in relation to the thyrohyoid bone, as compared with (a). The metallic button implants are indicated with white
arrows; these are no longer in the same position and one has migrated cranially far from its initial position. There is a metallic
implant in a more caudal and dorsal location (*) that was placed at the caudal aspect of the cricoid during a previous tie back
procedure. The radiopaque artifacts at the bottom of the image are metallic skin staples.
condition does not exist, except perhaps in neonatal Pathogenesis/risk factors Resecting more than 0.75 to 1 cm
foals, so staphylectomy should also be discontinued as a of the soft palate may disturb the seal between the
routine treatment of DDSP. oropharynx and nasopharynx (Figure 34.4) and may lead
● However, it is still used or advised by some surgeons in an to pharyngeal incompetence, with passage of water, saliva
attempt to stiffen the caudal border of the soft palate in order and/or food into the nasopharynx and/or trachea. This can
to prevent displacement or facilitate replacement [10]. be devastating as it can predispose to chronic lower airway
● Usually performed in association with desmotomy/ infection (i.e. bronchopneumonia) and persistent DDSP.
myotomy of the sternothyroid tendon and muscle (ST).
● Efficient for treatment of permanent DDSP in associa- Prevention When performing the surgery, do not remove
tion with LTF, depending on predisposing causes [11]. more than a 1-cm length of caudal edge and do not remove
● Indicated for resection of a granuloma/cyst/ulcer on the the lateral margin.
caudal free edge of the soft palate. Use Allis or sponge forceps as landmarks when perform-
● Can be used via laryngotomy or by using laser through ing via laryngotomy. If using the laser on the standing
endoscope. horse, mark the intended line of resection by making sev-
eral dots with the laser before grasping the caudal border of
the soft palate to prevent inadvertent excessive resection.
Dysphagia/PharyngealIncompetence
Treatment Assess for mechanical cause (seal disturbance
DefinitionInability to separate oropharynx from due to removal of an excessive resection of the soft palate)
nasopharynx during deglutition or persistent DDSP versus neurological cause. Laryngeal Tie Forward will
minimize the gap between the oropharynx and nasopharynx
Risk factors Excessive resection at the level of the caudal edge of the soft palate. However,
(a) (b)
Figure34.4 (a) Endoscopic view of the pharynx of a horse that underwent a staphylectomy. Excessive amount of the soft palate was
removed, leaving too much communication between the oro- and naso-pharynx. The apex of the epiglottis is obscured by the caudal
aspect of the soft palate that is displaced dorsally. This horse was dysphagic. (b) Endoscopic view of the pharynx of the same horse as
in (a) after a laryngeal tie forward has been performed. Note the adequate position of the epiglottis dorsal to the soft palate.
aser Palatoplasty 435
it may be challenging when Laryngeal Tie Forward has Risk factors Technical: removal of small muscle portion
already been performed (treatment of permanent DDSP).
Pathogenesis This is the most common complication of
Expected outcome Fair to good after a successful Tie Forward STM and may be related to development of fibrotic adhesions
between the muscle stump and the larynx or local fibrosis
anchoring the larynx in a more caudal position.
SternothyroideusPartialMyectomy
Prevention Remove a large muscular section (2–3 cm) of
● Used since the late 1900s, often in association with
the sternothyroideus.
staphylectomy for surgical management of DDSP.
● In some areas, it is still the first-line surgical procedure
Diagnosis Based on clinical signs and endoscopy, which
for horses with DDSP, mainly because it requires a mini-
will be similar to those in recurrence after LTF (see above)
mum of surgical equipment, does not require referral to
a surgical facility, and is less expensive than an LTF.
Treatment Repeat myotenectomy and remove a larger
● Sternothyroideus partial myectomy (STM) is also always
portion of muscle and/or perform a Tie Forward.
performed in association with LTF.
● Complications of STM are usually rare and minor (i.e.
Expected outcome Fair to good
bleeding and infection) if the proper structure is reached.
IntraoperativeComplications LaserPalatoplasty
Bleeding
Definition ● Laser cautery of the soft palate or palatoplasty is used via
Hemorrhage because of disruption of a vessel a nasal approach and is one of many surgical procedures
which have been described to manage DDSP.
Risk factors Excessive dissection in a dorsal direction. ● It is supposed to stiffen the soft palate through laser-
induced fibrosis, and then improve palatal stability.
● Resection of large muscle portion. ● The hypothesis for laser cautery of the soft palate was
borrowed from human medicine, where people with per-
Pathogenesis Branches of the cranial thyroid and caudal sistent issues with snoring were thought to have exces-
laryngeal artery/vein run dorsal to the sternothyroid (ST) sive flaccidity of the soft palate.
tendon and muscle and along the lateral part of the caudal ● Recent research [13] has not supported any benefit of
border of the thyroid cartilage (horizontal V shape). this technique regarding appreciable “stiffening” of the
soft palate. However, the procedure is still popular.
Prevention Management and prevention measures are the ● Laser cautery of the soft palate is also performed using red
same as when used in LTF procedure (see above). Lift the ST iron via an oral approach, mainly in the United Kingdom.
muscle and tendon by placing a curved Crile hemostat Complications related to this procedure will not be
immediately caudal to the cricoid cartilage (Figure 34.1). described here.
Placement of ligatures at the caudal (muscular) portion when
removing a 2–3 cm section can minimize risk of bleeding from
PostoperativeComplications
the muscular stump. Use of electrocautery is another option.
Dysphagiaand coughing
Diagnosis Similar to bleeding associated with LTF These are the most common complications.
Treatment Similar to bleeding associated with LTF Definition Transient clinical signs of dysphagia and coughing
Expected outcome Similar to bleeding associated with LTF Pathogenesis Unknown but most likely secondary to
transient inflammation and pain in the nasopharynx
Prevention Use appropriate laser settings and technique.
Recurrenceof DDSP For diode laser, use a 600-μm bare laser fiber, at 15 Watts in
Definition continuous wave mode and activate the laser for 1–2 second
Recurrence of clinical signs associated with DDSP at 2 mm intervals.
Start the procedure at the midline of the soft palate, 2–3

mm from the caudal free edge. Extend approximately 1.5
cm rostrally, around most of the rim of the palate. Repeat
the procedure until a total of 2,400 joules have been
delivered.
Diagnosis Based on clinical signs and endoscopy, which

may reveal inflammation in the nasopharynx.
Treatment Anti-inflammatory medications for 7 days
Expected outcome This complication seems to be transient

and will respond well to anti-inflammatory treatment, with
majority of horses recovering without complications or
sequelae.
Perforationof the softpalate

Rare condition but sometimes encountered, especially
when laser is used too aggressively (Figure 34.5).
Definition Full thickness perforation of the soft palate creating Figure34.5 Endoscopic view of the nasopharynx of a horse 1
a communication between nasoharynx and oropharynx month after laser palatoplasty. Note the presence of full thickness
perforation of the caudal margin of the soft palate (white arrows)
and permanent dorsal displacement of the soft palate.
Risk factors Technical: delivery of excessive laser energy
Prevention Appropriate laser setting and technique (see Diagnosis Clinical signs and endoscopic findings indicative
above) of presence of saliva and/or food in the nasopharynx or
nasal cavity and evidence of a full thickness defect in the soft
Pathogenesis This complication may become apparent palate.
during surgery but in other cases, communication between
oro- and naso-pharynx may not be obvious until a later Treatment Treat only if associated clinical signs. Treatments
stage, as the communication may be related to delayed to consider include tie forward with or without conversion
tissue damage caused by the laser. Some horses seem to of the perforated part to staphylectomy.
tolerate this complication, although others will show
pharyngeal incompetence with saliva and/or food entering Expected outcome Fair, unless iatrogenic laceration is too
the nasopharynx. large.
References
1 Holcombe, S.J., Derksen, F.J., Stick, J.A. et al. (1998). soft palate in horses: A prospective study 2001–2004.
Effect of bilateral blockade of the pharyngeal branch of Equine Vet. J. 37: 418–423.
the vagus nerve on soft palate function in horses. Am. J. 5 Llewellyn, H.R. and Petrowitz, A.B. (1997).
Vet, Res. 59: 504–508. Sternothyroideus myotomy for the treatment of dorsal
2 Ducharme, N.G., Hackett, R.P., Woodie, J.B. et al. (2003). displacement of the soft palate. Proc. Ann. Conv. Am.
Investigations into the role of the thyrohyoid muscles in Assoc. Equine Pract. 43: 239–243.
the pathogenesis of dorsal displacement of the soft palate 6 Cheetham, J., Pigott, J.H., Thorson, L.M. et al. Racing
in horses. Equine Vet. J. 35: 258–263. performance following the laryngeal tie-forward
3 Cheetham, J., Pigott, J.H., Hermanon, J.W. et al. (2009). procedure: a case-controlled study. Equine Vet. J. 40:
Role of the hypoglossal nerve in equine nasopharyngeal 501–507.
stability. J. Appl. Physiol. 107: 471–477. 7 Dart, A.J. (2006). Vocal fold collapse after laryngeal
4 Woodie, J.B., Ducharme, N.G., Kanter, P. et al. (2005). tie-forward correction of dorsal displacement of the soft
Surgical advancement of the larynx (laryngeal tie- palate in a horse. Vet. Surg. 35: 584–585.
forward) as a treatment for dorsal displacement of the
References 437
8 Holcombe, S.J., Rodriguez, K., Lane, J. et al. (2006). displacement of the soft palate: an observational study.
Cricothyroid muscle function and vocal fold stability in Vet. Surg. 45: 816–823.
exercising horses. Vet. Surg. 35: 495. 11 Ortved, K.F., Cheetham, J., Mitchell, L.M. et al. (2010).
9 Rossignol, F., Ouachée, E., and Boening, K.J. (2012). A Successful treatments of persistent dorsal displacement
modified laryngeal tie-forward procedure using metallic of the soft palate and evaluation of laryngohyoid position
implants for treatment of dorsal displacement of the soft in 15 racehorses. Equine Vet. J. 42: 23.
palate in horses. Vet. Surg. 41: 685–688. 12 Alkabes, K.C., Hawkins, J.F., Miller, M.A. et al. (2010).
10 Carmalt, J.L., Johanssen, B., and Waldner, C. (2016). Evaluation of the effects of transendoscopic diode laser
Comparisons between staphylectomy and tie-forward palatoplasty on clinical, histologic, magnetic resonance
procedures in combination with a sternothyroideus imaging, and biomechanical findings in horses. Am. J.
myotenectomy for the treatment of intermittent dorsal Vet. Res. 71: 575–582.
438
35
Complicationsin LarynxSurgery
Fabrice Rossignol DVM, DECVS1 and Norm G. Ducharme DVM, MSc, DACVS2
1
Equine Clinic Grosbois, Boissy Saint Leger, France
2
Cornell University Hospital for Animals (CUHA), College of Veterinary Medicine, Cornell University, Ithaca, New York
Overview – Immediate postoperative complication

○ Dyspnea
This chapter covers the complications associated with laryn- – Late postoperative complications
○ Dysphagia and coughing
geal surgery. As these complications can be life-threatening,
○ Intralaryngeal granulation tissue
it is important to understand what can go wrong and try to
○ Residual noise
prevent it from happening.
● Epiglottic entrapment
– Preoperative complications
L ○ Iatrogenic damage to the soft palate, esophagus,
with LarynxSurgery epiglottis or pharynx

○ Iatrogenic burn at the tip of the epiglottis when
● Prosthetic laryngoplasty using the laser

– Intraoperative complications – Short-term complications
○ General anesthesia ○ Edema/epiglottitis/sub-epiglottic granuloma
○ Hemorrhage – Long-term complications

○ Needle breakage ○ Re-entrapment
○ Perforation of the laryngeal/nasopharyngeal/esoph- ○ Dorsal displacement of the soft palate (DDSP)
ageal mucosa
– Early postoperative complications
○ Seroma formation ProstheticLaryngoplasty
○ Wound infection
○ Sudden major loss of abduction Recurrent laryngeal neuropathy (RNL) is the most fre-
○ Acute dysphagia and coughing quent cause of unilateral (generally left) laryngeal collapse
– Late postoperative complications at exercise [1]. Prosthetic laryngoplasty (PL) is the tech-
○ Gradual loss of abduction nique most commonly used to treat RNL [2]. This tech-
○ Chronic coughing and dysphagia nique was developed in 1970 and uses a synthetic prosthesis
● Laser ventriculo-cordectomy to “tie back” the affected arytenoid cartilage in a perma-
– Preoperative complication nent state of partial abduction to increase rima glottides
○ Bleeding and prevent dynamic collapse [2].
– Immediate postoperative complication Despite significant surgical successes, the undesirable
○ Swelling/edema prevalence of surgical failure and the high frequency of
– Late postoperative complications postoperative complications [3], outcome is considered
○ Webbing moderate, at best, particularly in horses used for high
● Partial arytenoidectomy intensity exercise covering more than 1,200 m [4–12]. The
– Intraoperative complications prognosis in sport horses is usually better [2, 13]. The ideal
Prosthetic Laryngoplasty 439
prosthetic laryngoplasty should not overly disturb the nor- General recommendations to minimize complications when
mal physiology of swallowing and should restore airway performing a laryngoplasty under general anesthesia Anything
capacity to near normal values. Laryngoplasty is usually that can be done to expedite the procedure will provide
combined with unilateral or bilateral ventriculo-cordec- benefits in decreasing perioperative complications in
tomy (VC) to reduce noise. Order of the surgical proce- horses at increased risk [29]. Time-saving measures include
dures is important, since performing VC before PL has but are not limited to:
been shown to facilitate arytenoid abduction during PL.
● Having a checklist of all the steps required and all mem-
The most common complication is progressive loss of PL
bers of the team be familiar and have authority to inter-
abduction, which can lead to surgical failure and the recur-
vene when a step is missed [30].
rence of clinical signs. Some adaptations and variations of
● Clipping instead of shaving the surgical site done on the
the technique have been described, mainly to improve
day of surgery prior to anesthetic induction.
long-term stability of the arytenoid abduction. These
● Performing the ventriculo-cordectomy on the standing
include using two prostheses to increase the diameter of
horse, using a laser, preferably just before PL, and having
the rima glottis [14], suture reinforcement at the muscular
the surgical table, gown, gloves, and equipment laid out
process (MP) or at the cricoid cartilage, involving the use of
before induction.
washers, metallic suture buttons, corkscrew securing
● Entrusting anesthesia management to skilled personnel
devices [14–17], application of different types of sutures
with appropriate monitoring equipment at their disposal.
such as various large-diameter polymers or elastic suture
● Using adequate and possibly extra padding on surgical
material [18–20], and improved suture placement within
tables.
the cartilage [17, 18, 21–24]. Stabilizing the cricoarytenoid
● Laryngoplasty can be successfully performed on the
joint by mechanical debridement [25], laser ablation [26]
standing horse and avoids the risks associated with gen-
or injection of PMMA [27] into the joint, have also been
eral anesthesia and recovery [13]. This technique yields
reported to improve stability and reduce loss of abduction
comparable results to laryngoplasty on the anesthetized
over time.
horse and should be recommended when PL is required
Tracheal penetration of feed material/water/saliva is the
in patients at risk for general anesthesia, provided the
second major complication, which is likely the cause of post-
surgeon is experienced with using this technique under
operative dorsal displacement of the soft palate seen in many
general anesthesia. An additional advantage is that it
horses. Therefore, a patient-tailored laryngoplasty consists
allows accurate intraoperative adjustment of the degree
of finding the most suitable balance between appropriate
of arytenoid abduction.
airway patency and risk of tracheal aspiration in each indi-
vidual case. Other complications are not common but can
Hemorrhage
have devastating effects.
Definition Blood accumulation in the surgical field obscuring
surgical visualization and recognition of anatomical structures
IntraoperativeComplications as a result of iatrogenic vessel disruption
General anesthesia
Risk factors Large breeds
General concepts on pathogenesis and risk factors in horses
undergoing PL under general anesthesia For complications ● Repeated surgery
related to general anesthesia, see Chapter 15: Complications ● Linguofacial vein or its branches:
of Sedative and Anesthesia Medications and Chapter 16: – Local infiltration of local anesthetic along the inci-
Complications during Recovery from General Anesthesia. sion, especially during standing surgery
However, complications associated with general ● Cranial thyroid artery/vein and caudal laryngeal artery/
anaesthesia in patients undergoing PL are to be highlighted, vein or branches:
as larger horse breeds are most commonly affected by RLN – Excessive dissection around caudal aspect of the
and these heavier horses seem to have more intra- and cricoid
postoperative anesthetic-related complications than lighter – Grasping of the cricoid cartilage
horses. Kraus et al. [28] reported that anesthetic recovery – Grade 3 vs. chronic grade 4 RLN
was prolonged in 4% of draft horses, with 7% suffering from ● Caudal laryngeal artery/vein branches:
myopathy or neuropathy following PL with ventriculectomy – Separation of cricopharyngeus and thyropharyngeus
(VE) or ventriculo-cordectomy (VCE). Dixon et al. [2] muscles
reported anesthesia-related mortality in 1% of LP cases in a – Desmotomy of CAD muscle
mixed breed population. – Debridement of cricoarytenoid joint
440 Complications in arynx Surgery
Pathogenesis The linguofacial vein or one of its branches

may be damaged, especially when extending the incision
caudally or while exiting the needle from the muscular
process. The branches forming the linguofacial veins run
near the internal surface of its fascia, close to the second
cervical nerve and need to be dissected [31]. The risk is
greater in large breeds and draft horses. The linguofacial
vein can also be punctured or incised when performing a
standing tie back, as infiltration of local anesthetic along
the incision hinders visualization of the vein.
The cranial thyroid artery or vein or its branches, or the
caudal laryngeal artery or vein may be inadvertently punc-
tured when dissecting the caudal aspect of the cricoid, when
grasping the cricoid cartilage with a clamp, or when insert-
ing a needle through the cartilage. The risk is increased in
large breeds and repeat laryngoplasty, and when significant Figure35.1 Latex arterial injection anatomical dissection
CAD muscle persists, as in grade 3 RLN. The course of the showing the left lateral larynx. Note the recurrent laryngeal
caudal laryngeal artery/vein can vary, but is typically on the nerve/artery/vein bundle (RLN bundle), the caudal laryngeal
artery (CLa) and cranial thyroid artery (CTa), and the safer site
lateral aspect of the recurrent laryngeal nerve and follows (green arrow) of anchorage of the cricoid cartilage with a clamp
the caudal contour of the cricoid cartilage. to avoid or minimize bleeding. Blue arrow illustrates suggested
As the caudal laryngeal artery/vein approaches the cau- most ventral extend of dissection of the crico-pharyngeus
dolateral aspect of the cricoid cartilage, it branches into the muscle. CrP: Cricopharyngeus muscle; ThP: Thyropharyngeus
muscle; CC: common carotid artery. Source: Courtesy of Dr. John
dorsal cricoarytenoid (CAD) and the cricopharyngeal mus- Pigott, Cornell Ruffian Equine Specialist, Cornell University.
cle at its ventral and caudal third. These branches may be
punctured during separation of the cricopharyngeus and
thyropharyngeus muscles to expose the muscular process, to a more ventral position to allow suture placement dor-
or during desmotomy of the CAD muscle at its insertion on sally to minimize the risk of puncture. When placing a
the MP, while debriding the cricoarytenoid joint. clamp on the cricoid cartilage to retract the larynx, bluntly
Occasionally, horses that have no significant, or a fully remove the peri-laryngeal fascia and place the clamp on
controlled intraoperative hemorrhage, will develop gross the immediate lateral aspect of the recurrent laryngeal
swelling of the LP site postoperatively, presumably due to nerve, artery and vein bundle. The reason for this is to
extensive head and neck stretching during anesthetic avoid the caudal laryngeal artery/vein that join the caudal
recovery, resulting in hemorrhage. border of the cricoid cartilage a little more ventrally (green
arrow – Figure 35.1).
Prevention Thorough knowledge of the anatomy of the The sutures can also be passed through the caudal cricoid
laryngeal vessels is essential, as well as careful surgical cartilage using a passer device (Scorpion Multifire, Humpback®
technique. Ref AR-13995, or FastPass® Ref AR-13997, Arthrex) (Figure
To prevent laceration of the linguofacial vein when enlarging 35.2). The passer device was originally developed for intra-
the incision, the authors generally use a smaller retractor or a articular suturing in human arthroscopic surgery. The needle
finger to laterally displace the fascia-muscle junction while was reinforced in 2013 to be more suitable for equine cricoid
extending the incision caudally with curved mayo or metzen- cartilage. The Scorpion Multifire device allows precise, non-
baum scissors, with the tips oriented ventrally. The first cervical traumatic passage of the sutures through the caudal border of
nerve can usually be seen or felt with a finger within the thin the cricoid cartilage and prevents inadvertent penetration of
fascia covering the cricopharyngeus muscle, at the level of the the laryngeal mucosa, and any vessel trauma. We use a loop
caudal part of the cricoid cartilage. If a needle is used to pass the suture (Fiberlink® Arthrex) as leader to pass any type or size of
suture through the MP from medial to lateral, the lingofacial laryngoplasty suture through the cricoid cartilage.
vein can be punctured during the exit from the MP. The assis- The cricopharyngeal branch of the caudal laryngeal
tant needs to be aware of this and should position the retractor artery/vein is usually clearly visible in the ventral caudal
just above the MP in a stable rostral position to guard the vein third of the cricopharyngeus muscle, after separation by
from the needle as it exits from the MP. minimal blunt dissection (lateral approach), or when using
The caudal laryngeal artery should be palpated along the a caudal approach (modified approach caudal to the cri-
caudal border of the cricoid cartilage and bluntly dissected copharyngeus muscle [25]). Therefore, when dissecting
(a) (b)
Figure35.2 (a) Tie back being performed on a horse under standing sedation. Rostral is to the left of the image. The caudal
laryngeal artery (CLa) is palpated and displaced to a more ventral position before placing the clamp at the caudal border of the
cricoid cartilage (Cr) on the immediate lateral aspect of the recurrent laryngeal nerve, artery and vein bundle. CLa: caudal laryngeal
artery; Cr: caudal border of the cricoid cartilage, white arrow: sagittal notch. (b) Use of a passer device (Scorpion Multifire, Humpback®
Ref AR-13995, or FastPass® Ref AR-13997, Arthrex) to prevent vessel puncture when passing the sutures at the cricoid cartilage. Cr:
cricoid cartilage; CrP: cricopharyngeus muscle: white arrow: Fiberlink suture (Arthrex) exiting from the Scorpion Multifire (Arthrex).
Source: Fabrice Rossignol and Norm G. Ducharme.
between the thyropharyngeus and cricopharyngeus mus- until the laceration is clearly apparent. Place one or two
cles, start the dissection dorsal to the divergence of the curved mosquito forceps at the base of the laceration and
thyro- and cricopharyngeus muscles and continue in a dor- close it using 3-0 or 4-0 absorbable monofilament such as
sal direction (blue arrow – Figure 35.1) polydioxanone in a simple continuous pattern.
Clamping the CAD muscle before tenotomy also mini- Visualization and detection of the bleeding vessel is difficult
mizes hemorrhage. By performing PL in the standing horse, at the caudal aspect of the cricoid cartilage when branches of
hemorrhage is reduced and does not impede visualization, the cranial thyroid artery or vein are punctured, mainly
perhaps because of the horse’s head being raised [13]. because these vessels are embedded in connective tissue
medial to the caudal edge of the cricoid cartilage. In this situ-
Diagnosis Swelling at the surgical site is commonly noticed. ation, temporary packing with sponges may often slow the
This swelling tends to be soft and not painful, although in bleeding and allow placement of the prosthetic suture through
cases with large haematoma, the site may become harder. the muscular process. Hemorrhage usually stops or is signifi-
Perilaryngeal swelling caused by a hematoma will develop cantly reduced when the suture is tightened and tied.
within hours of anesthetic recovery, unlike perilaryngeal When a perilaryngeal swelling caused by a hematoma is
swellings caused by a seroma or infection, which usually detected during the immediate postoperative period, it is
take several days to develop [31]. advisable to delay draining until 24–48 h postoperatively, to
reduce the likelihood of hemorrhage recurrence. If swelling
Treatment When the bleeding vessel can be located, it results in respiratory noise/distress, the rostral aspect of the
should be clamped and ligated, or coagulated using bipolar LP wound should be opened and the hematoma gently
electrocautery to avoid damage to the innervation of the removed with a blunt curette, followed by lavage of the wound
thyrohyoid or cricothyroid muscles. Identification of the with sterile saline and antimicrobials [2, 32]. Continued sys-
exact location of bleeding, especially bleeding at the temic administration of antimicrobials is recommended until
cricopharyngeus muscle or after tenotomy of the CAD, can the wound is sealed to decrease risk of ascending infection.
be facilitated using a Frazier suction tip with a control vent.
Laceration of the linguofacial vein results in profuse Expected outcome In most cases, hemorrhage can be
bleeding. One efficient strategy in this rare but stressful stopped by pressure or after placement and tightening of
situation is to immediately stop the bleeding by placing the the sutures. If a hematoma is drained, the wound usually
little finger over the puncture site. Then lift the vein with heals without complications unless infection develops at
the finger and bluntly dissect it from the perivenous tissue, the surgical site.
Intraoperative surgical hemorrhage hinders surgery by We usually recommend a No. 3 Mayo ½-inch taper point
reducing visualization, and can predispose to sub-optimal needle to pass through the cricoid cartilage. Many different
placement of the prothesis and incisional complications needles have been used: swaged-on, reverse-cutting needle
such as hematoma, seroma and increased risk of infection. on the Ti-Cron, or No. 3 Martin uterine reverse-cutting nee-
dle for MP, and a No. 3 to 6 Mayo catgut needle can also be
Needle breakage used. One of the authors always uses a 13-gauge Jamshidi to
Definition Needle failure with loss of needle integrity, with tunnel the MP. A hypodermic needle can also be used.
possible loss of needle piece within tissues
Treatment The broken needle piece should be retrieved;
Risk factors Limited experience however, excessive dissection should be avoided, as this
can predispose to hemorrhage, postoperative swelling and
● Thin needle, blunt or reused needles dysphagia. Provided the needle fragment does not penetrate
● Mature or draft horses the laryngeal lumen, and stays within the confines of the
● Technical error cartilage, the needle may be left in situ.
Pathogenesis Needle bending or breakage may occur

Perforation of the laryngeal/nasopharyngeal/
during laryngoplasty procedures [1], depending on the size
esophageal mucosa
and type of needle used and on the surgeon’s experience.
Definition Penetration of the airway or digestive tract lumen
Small needles or use of blunt or reused needles may require
with the prosthesis leading to contamination of the suture
higher torque and more stress being placed on the needle,
prosthesis
which may increase risk of needle breakage. Grasping the
needle too far back toward the shoulder of the needle will
Pathogenesis/risk factors Intraoperative contamination of
increase risk of needle bending and breakage because of
the sutures/incision can result from:
increased force and torque on the needle.
Mature animals may have a high degree of mineraliza- ● Perforation of the crico-arytenoid articulation during
tion within thryroid and/or cricoid cartilages, which may curettage
also increase risk of needle failure. ● Penetration of the laryngeal lumen when passing the
Passing the needle through the caudal cricoid cartilage is sutures around the cricoid cartilage
the most likely cause of excessive pressure on the needle, ● Penetration of the esophagus while exiting the sutures
and broken needles can be difficult to locate and remove from the cricoid cartilage [33]
from this region. ● Penetration of the esophageal mucosa [34] when passing
Needle breakage can also occur at the MP [32], especially sutures around the muscular process (Figure 35.3).
when the surgeon wants to get a strong bite by including ● Less frequently, the suture can penetrate the nasopharyn-
the arcuate crest (spine), as is recommended to improve geal mucosa (just rostral to the arytenoid muscular pro-
construct stability. As surgical incisions become increas- cess): Dixon et al [2] described the case of a fistula extending
ingly smaller, the temptation is to place the needle in such from an infected LP incision into the nasopharynx.
a way that excessive force needs to be applied to pass the
needle through the cartilage. Pathogenesis Penetration of the dorsocaudal aspect of the
laryngeal lumen can occur during suture placement
Prevention Make an adequately long incision, based on through the cricoid cartilage and may later cause LP wound
surgical experience, and make sure that the assistants provide infection, with sequelae, including fistulization toward the
good retraction. This will ensure optimal access for suture lumen, chronic incisional wound drainage and coughing.
placement and help to prevent this complication. In such cases, fistulization and chronic inflammation of
While placing the prosthesis, the surgeon should focus the cartilage and surrounding soft tissue invariably leads to
on the cricoid cartilage, MP and the needle only, and assign prosthesis relaxation and failure.
responsibility for checking the TV monitor (for lumen The authors also consider that passage of the suture
assessment) to the assistant. toward the adventitia of the esophageal vestibulum in the
Employ single-use needles, and grasp the needle at midlevel rostral part of the MP may also play a role in postoperative
and not too far caudally. chronic coughing, esophageal incompetence and esopha-
Do not change the direction of the needle once the cricoid geal reflux, by disturbing the anatomy of the rostral part of
cartilage or muscular process has been penetrated. Instead, the esophagus when the sutures are tightened, and subse-
gradually push the needle through the cartilage along its curve. quently compromising the physiology of swallowing [34].
(a) (b)
(c)
Figure35.3 Left side (a) rostral to the left of the image and dorso-rostral view (b) of the larynx showing the entry of the esophagus
(vestibulum esophagi) covering the rostral part of the arytenoid cartilage (c) An instrument has been inserted into the lumen of the
vestibulum esophagi. VOe: Vestibulum esophagi; Oe: esophagus; MP: muscular process; CAD: Cricoarytenoideus dorsalis m.; TH: thyroid
wing. Source: Fabrice Rossignol and Norm G. Ducharme
Prevention Adequate knowledge of anatomy is key in However, the authors suggest that the responsibility for
preventing this complication. Use of intraoperative observing the luminal side of airway during suture passage
endoscopic assessment is useful to prevent inadvertent or curettage of the crico-arytenoid joint, be trusted to an
intraluminal passage of the suture, particularly laryngeal assistant.
and nasopharyngeal penetration, or at least to identify and It is recommended that before passing sutures through
encourage immediate management of the complication. the cricoid cartilage, the surrounding fascia is bluntly
Endotracheal intubation with a slightly smaller (18–20 mm) removed by using a sponge. To follow, the most caudal and
tube allows ample tracheal access to evaluate inadvertently ventral sides of the dorsal aspect of the cricoid cartilage
placed sutures. The cuff of the endotracheal tube should not should be well exposed before placing a retracting forceps
be located within the larynx, but caudal to it. However, on the cricoid cartilage (Figure 35.4). Then, and before
intraoperative endoscopy cannot be used accurately to assess placing the suture, a gloved finger can be placed under-
esophageal penetration. neath the dorsocaudal aspect of the cricoid to prevent
While endoscopic monitoring should be part of the rou- mucosal penetration by the clamp used to retract the cri-
tine surgical procedure, the authors advocate that the pri- coid. The lateral edge of the esophagus is then dissected
mary surgeon performing suture placement should not be away from the cricoid cartilage, prior to suture placement,
checking the lumen while performing “risky steps.” to prevent penetration of the esophagus during exit. Either
(a) (b)
Figure35.4 (a) Tie back being performed on a horse under standing sedation. Rostral is to the left of the image. The connective
tissue under the most ventral and caudal part of the cricoid cartilage has been bluntly dissected using a mosquito or a small Kelly
forceps under endoscopic guidance forceps before placing the sutures. The C1 nerve (C1) and branches of the cranial thyroid artery
(black arrows) are spared. (b) Intralaryngeal endoscopic control of this dissection. Entrance to the trachea is visible and black arrow
indicates tips of the mosquito placed ventral to the caudodorsal border of the cricoid cartilage. Source: Fabrice Rossignol and Norm G.
Ducharme.
an index finger or Glover forceps can be used to retract the

soft tissues caudal to the cricoid cartilage in a ventral direc-
tion before advancing the tip of the needle under the cau-
dal cricoid. A small curved mosquito can also be carefully
used under endoscopic guidance, to free the most caudal
and ventral aspect of the cricoid cartilage, in order to facili-
tate suture placement and stability, especially when using
the passer device (Scorpion Multifire, Arthrex). The tip of
the mosquito should be directed dorsally in contact with
the cricoid cartilage.
In the early stages of the procedure, when the muscular
process is being exposed, it is recommended to identify and
retract forward the esophageal vestibulum to avoid its pen-
etration. The thyroid can be pulled with a small retractor or
a hook to place the esophageal adventitia under tension Figure35.5 Tie back being performed on a horse under
and make them easier to lift with small curved Kelly for- standing sedation. Rostral is to the left of the image. Clinical
ceps (Figure 35.5). The risk of perforating the esophagus case: The esophageal adventitia (white arrow) is raised and
retracted rostrally from the muscular process (black arrow) using
and/or its adventitia is increased if rostral sutures are a small Kelly forceps. Source: Fabrice Rossignol and Norm G.
passed through the arcuate crest (rostral spine), especially Ducharme.
at the medial aspect, instead of/compared with passing the
sutures through the tip of the MP. Once the suture is placed Needle placement through the cricoid cartilage and
through the muscular process, the thyroid should be curettage of the CA joint should always be done under
retracted to view the rostral-medial part of the arcuate crest endoscopic guidance, because VC can cause hemorrhage
and to assess for possible oesophageal involvement. In the that interferes with visualization of those areas. At least 30
event of the suture passing through the caudal part of the min should be allowed between the performance of the VC
adventitia, this still can be detached by moving the suture and the laryngoplasty procedure to allow sufficient time
backward and forward through the MP, while pushing the for the blood to drain out of the extra-thoracic trachea and
adventitia rostrally. larynx.
Diagnosis Intraoperative diagnosis can be easily performed via suitably place the sutures, cannot be closed surgically and
endoscopic assessment or manual manipulation, as indicated some degree of LP wound seroma formation always occurs
above. If the complication is diagnosed in the postoperative postoperatively [2]. The incidence of seroma decreases with
period, it is usually suspected based on signs of infection and/or the surgeon’s increased experience, and is lower if a correct
dysphagia and repeat endoscopic assessment. In some cases, surgical technique, respectful of the tissues and anatomy, is
horses may develop fistulas. used. However, it is unclear why some cases develop
extensive seroma following uneventful surgery. This may be
Treatment If the needle has penetrated the larynx, it should due to inadvertent iatrogenic damage to the local lymphatic
be backed out, the incision should be lavaged copiously with drainage system during LP surgery.
sterile saline and antimicrobials, and the prosthesis Clinical LP wound seromas were reported in 7% of cases
placement should be re-started with a new needle. Prolonged by Hawkins et al. [7]. The incidence of seroma is increased,
antimicrobial administration is advised. and seems inevitable, in repeat surgery.
Unfortunately, penetration of the esophageal lumen, at
the cricoid cartilage level or rostral to the MP, is difficult to Prevention Use a proper surgical technique, including blunt
assess. Penetration should be suspected in cases of chronic dissection of the anatomical structures, especially during the
infection and fistulization with or without dysphagia: surgical approach to the cartilage. Use of a stent bandage over
the incision may also help to compress the surgical wound
● In such situations, remove the sutures and allows 4 weeks and prevent seroma. The authors usually leave it in place for
before performing a revision procedure. Alternatively, one 48 to 72 hours postoperatively. Some surgeons use a full
can consider performing a partial arytenoidectomy at the pressure bandage in the early postoperative period [35].
time of suture removal. Other surgeons recommend placement of Penrose drains
● Passage of the sutures through the advantitia of the esoph- in LP wounds for all horses undergoing LP revision sur-
ageal vestibulum rostral to the MP should be suspected gery, because of the propensity of such horses for seroma
with excessive coughing or odd swallowing behavior formation [2].
when another cause, such as hyperabduction, is not a pri-
mary concern. Diagnosis Seroma formation can easily be assessed by
● In our experience, such horses respond well to repeat lar- checking whether or not the vertical ramus of the mandible is
yngoplasty with rostral dissection of the esophageal well-defined. Occasionally, a large seroma may also compress
advantitia, with or without removal of the sutures. the esophagus, causing dysphagia that may respond to seroma
drainage [2]. Seroma may be confused with an incisional
Expected outcome Infection after lumen penetration usually infection by the attending veterinarian, leading to unnecessary
requires suture removal and leads to failure of the laryngoplasty. and prolonged antibiotics therapy or, even worse, a surgical
Even if sutures may be replaced later, this is always a risky and drainage procedure which may contaminate the laryngoplasty
challenging procedure, and partial arytenoidectomy may be sutures. If a seroma does not respond to conservative therapy,
necessary early postoperative infection should be suspected.
Treatment If the seroma occurs during the immediate

EarlyPostoperativeComplications postoperative period, the authors usually delay discharging the
horse from hospital until the seroma has been stabilized. We
Seroma formation
extend the postoperative anti-inflammatory and antimicrobial
Definition Accumulation of sero-sanguineous fluid at the
administration.
surgical site in between tissue planes or structures
If a wound infection rather than seroma formation is
suspected, ultrasound examination is recommended.
Risk factors Dead space creation inherent to the surgical
Relatively anechoic fluid would support the diagnosis of
procedure
seroma, while the presence of echogenic areas consistent
● Excessive dissection with fibrin clots would support the diagnosis of infection.
● Limited surgeon’s experience Additionally, or alternatively, aseptic aspiration of the area
● Potential iatrogenic damage to the local lymphatic drainage (usually approached ventral to the linguofacial vein) and
● Repeat surgery cytological/bacteriological examination of the fluid sample
can be performed.
Pathogenesis Due to the many surrounding vital structures, In cases of large seromas, the fluid can be drained by asep-
the extensive dead space in an LP wound, produced to tic needle aspiration, and 200–300 ml of fluid is commonly
removed. If the seroma re-develops quickly after needle

drainage, or if spontaneous fluid leakage occurs from the
wound, the rostral aspect of the incision can be opened, a
sterile canula (such as used for abdominocentesis) inserted,
and the seroma can be drained twice a day until resolution.
If there is concern of an early stage of infection, the seroma
cavity can be lavaged with 500 ml of saline and diluted anti-
biotic (e.g. penicillin 10 × 106/ liter UI or ceftiofur 1g/ liter).
If seroma formation occurs after the horse has been dis-
charged from the hospital, close communication with the
referral veterinarian is important to select the best strategy
for treatment, either at the stable or after re-hospitaliza-
tion, to prevent any further complications.
Expected outcome In most cases, seromas resolve without

further major complications, including those cases that
Figure35.6 Endoscopic view of the lumen of the larynx and
require opening of the rostal aspect of the incision for
trachea showing passage of the suture through the laryngeal
drainage of large seromas. The worst-case scenario is mucosa into the laryngeal lumen. Source: Fabrice Rossignol and
surgical site infection, which is discussed in the next section. Norm G. Ducharme.
Wound infection the alimentary or respiratory system must be performed, by

Risk factors Those related to penetration into digestive or applying the methods described earlier. When a ventriculo-
airway lumen (above) cordectomy is necessary, use the laser technique or if performed
conventionally, partial or complete closure of the laryngotomy
● Those associated with seroma
wound will decrease the risk of LP surgical site infection. We
● Infection of a laryngotomy wound, if performed for con-
have encountered some cases of sterile dehiscence solely of
current VE or VCE.
the skin incision, which might be related to the administration
● Potentially, use of two suture prosthesis
of excessive doses of corticosteroid after laser VC. This
complication seemed to stop when corticosteoirds were
Pathogenesis The incidence of surgical wound infection varies
administered at lower doses (20 mg dexamethasone per day for
from 4 to 17% [2, 7]. Wound infection can be a complication of
2 to 3 days maximum).
a large seroma (or a large seroma can be the first sign of
infection). Infection of a laryngotomy wound if performed for
concurrent treatment by VE or VCE, will significantly increase Diagnosis Diagnosis is easily made clinically: swelling of
the risk of LP incisional complications [2]. Deep wound the laryngoplasty area that is usually painful, fever, and
infection, with dehiscence or fistulization, is less common and sometimes with purulent drainage from the surgical
has been recorded in 3% of cases in numerous studies [2, 7, 10]. wound. When not opened, sample for cytological analysis
As described earlier, wound infection can be a result of to confirm the diagnosis.
prosthesis penetration through the laryngeal mucosa
(Figurt 35.6), nasopharyngeal mucosa, or through the ves- Treatment Most laryngoplasty infections, when detected
tibulum esophagi at the rostral part of the MP. early in the postoperative period, can be effectively treated
Recent studies have demonstrated an interest in using by drainage, lavage and appropriate antimicrobials based
two sutures, and engaging the arcuate crest (rostral spine) on culture and sensitivity patterns of obtained aspirate or
of the arytenoide cartilage to improve strength and stability draining samples, and without suture removal [2, 7]. In the
of the laryngoplasty construct. This should reduce the risk case of persistent draining that does not respond to such
of prosthesis loosening but may increase the risk of perfo- treatment, possible lumen penetration of the suture should
rating the esophageal lumen, located at the level of the be assessed endoscopically. In the case of penetration, the
arcuate crest, if this structure has not been carefully dis- prostheses need to be removed immediately after its
sected and retracted before placing the sutures [34]. detection to prevent chronic inflammation of the area. As
early removal of the suture often results in failure of the
Prevention Proper management of any large seroma is critical. arytenoid abduction, a partial arytenoidectomy can be
Careful surgical technique to prevent suture penetration into performed during prosthesis removal. This can usually be
completed through the laryngoplasty incision, by luxating too laterally, they will elevate the arytenoid but provide
the cricoarytenoid joint using a small periosteal elevator poor abduction and adduction of the vocal process.
and curved mayo scissors and removing the sutures with Passing the suture more caudally at the MP, close to the
the arytenoid including the MP. tip, provides easier abduction but weaker anchorage. Indeed,
In cases of infection without suture penetration, some sur- passing the suture ventrally and rostrally ensures strong
geons prefer delaying suture removal until a degree of peri- resistance to pull-out but less than optimal abduction.
laryngeal and joint fibrosis has occurred that will provide Surgeons should find the best balance between these two
some stability and prevent further arytenoid collapse [35]. positions. A double loop may also be used to ensure both
However, in our experience, infection almost always results abduction and stability at the MP and to provide a good bal-
in relaxation due to edema and cartilage weakening, and ance. However, it should not be associated with reinforce-
intense fibrosis can lead to the risk of other complications ment at the cricoid cartilage, such as a similar double loop or
such as dysphagia. Therefore, we usually remove the pros- a metallic suture button, to prevent sliding of the suture. In
thesis at the time of diagnosis of infection. this situation, only the lateral thread would be placed under
tension.
Expected outcome As for mucosal penetration, if the Another cause of early loss of abduction occurs when the
sutures are infected and need to be removed, infection will strands of the dorsal and lateral sutures cross each other
lead to loss of abduction, and often recurrence of clinical under the cricopharyngeus muscle.
signs. Partial arytenoidectomy may be necessary. Prosthesis breakage is a less common cause of loss of
If infection is superficial and can be managed by drain- LP abduction and occurred in 1.5% of cases in a study
age and medical treatment, prognosis is fair to good. using stainless steel prostheses [2]. One of the authors
encountered a failure at the knot when using a No 5
Fiberwire.
Sudden major loss of abduction
Definition Acute recurrence of collapse of affected arytenoid
Prevention Careful surgical technique is most important.
cartilage after performing an LP
Whatever the technique used, the following strategy should
be adopted and used as a checklist:
Risk factors
● Technical errors: ● Cricoid cartilage:

– Excessive force to produce abduction also increases – Carefully assess caudal cricoid shape and thickness,
the risk of cartilage tearing or breakage and variation in the anatomy of the drosocaudal notch.
– Incorrect placement of the sutures – Use 2 sutures as the prosthesis.
● Weak cartilage (rare) – Exit the sutures 1 to 1.5 cm from the caudal border
when using the standard technique, 0.8 to 1 cm maxi-
Pathogenesis Marked or complete acute loss of LP abduction mum when using metallic buttons.
occurs in 3 to 15% of cases, usually in the first 7 days following – Engage the notch with both sutures (if deep enough)
surgery [7, 10]. Dixon et al. [2] reported that in a study of or at least with the most medial (dorsal) suture.
200 patients, 5% required repeat surgery within 2 weeks of LP, – Exit the medial suture very close (0.5 cm) to the mid-
due to excessive loss of abduction caused by suture migration line. The lateral suture should exit 1 cm lateral to the
in the thinner cricoid cartilage. However, other authors have medial suture.
found that LP failures can occur both from pull-out at the – If the notch is very deep, take care when passing the
cricoid or at the muscular process [36] and Dean et al. [37] more medial/dorsal suture, as it may exit close to the
observed increased failure rate at the MP in an in vitro study. rostral-lateral border of the notch and fail.
Applying excessive force to produce abduction also – Avoid aggressive needles (similar to MP – see below).
increases the risk of cartilage tearing or breakage. In our – Check suture stability by pulling both strands caudally
experience, acute failure of the laryngoplasty construct is to assess the strength of the caudal border of the cri-
most likely related to inappropriate placement of the coid, then apply cyclic tension on the suture, with a
sutures. The anatomy of the caudal aspect of the cricoid sawing motion, to “bed” the suture in the notch.
cartilage can vary considerably in depth, size, position of – If the notch is absent or small, consider an alternative
the sagittal notch, and in thickness and strength of the car- such as double loop.
tilage. As a result, sutures may cut through the cricoid car- – Consider using metallic implants or washers, as they
tilage or slip laterally in the case of a weak cartilage, and/or do not rely on the most caudal aspect of the cricoid
when there is a small or no notch. If the sutures are placed (which is highly variable) as a point of anchorage.
● Muscular process (MP): ● A fresh pair of sterile gloves and surgical kit are used
– Minimize trauma to the MP by using the least aggres- after the wound is open.
sive needle (size and cutting effect) to adequately place ● Previous sutures are examined and the failure located.
the sutures. ● The two sutures are replaced, using strategies (double
– Do not use large cutting needles [19]. loop or metallic buttons) to reinforce cartilage anchorage
– Use an N6 Tapperpoint (Mayo catgut) needle, of the sutures.
Tappercut (V 37 Ethibond) needle, 14G intradermic or ● We use two sutures of No 2 Fibertape® or No 5 Fiberwire®
13 G Jamshidi needle + crochet style hook). (Arthrex) reinforced by metallic suture buttons (Arthrex
– Do not place the first suture (lateral) too ventrally into or Imex) at the cricoid cartilage (Figure 35.7a) and some-
the MP, otherwise you will be unable to abduct the times at the MP.
arytenoid cartilage (Figure 35.7c). ● When these buttons are used at the cricoid, the sutures
– Engage the arcuate crest with one suture. We use the should exit no more than 0.8 mm rostral to the caudal
dorsal suture to engage the crest (Figure 35.7c). edge. The lateral suture coming from the cricoid cartilage
– Check that you can easily abduct the arytenoid by is passed more dorsally and caudally through the MP than
placing a hemostat on the tendon of the CAD. This is the medial/dorsal suture. A location at 1 cm rostral and 1
useful, especially in the standing horse. cm ventral to the insertion of the CAD is aimed to provide
– Apply tension to the dorsal strand of the suture before optimal abduction.
tying. Check this before knotting. ● The dorsal suture coming from the cricoid cartilage is
– If excessive force must be applied to abduct the aryte- passed through the MP 1 cm rostral to the previous lateral
noid cartilage, the sutures are not well placed. Consider suture and as ventrally as possible through the arcuate
replacing them, or at least the one placed closest to the crest, to provide optimal stability (Figures 35.7a and b).
tip of the MP (lateral/ventral suture). ● If the MP is lacerated or broken by the previous failed
– Use 5 flat knots. suture, both sutures can be placed more rostrally in the MP
– Consider opening the crycoarytenoid joint and mechan- and the surgeon can use his finger to displace the MP cau-
ical debridement (before placing the suture through the dally while tightening the sutures to improve abduction.
MP) [25] or inject PMMA (after placing the sutures) ● When using metallic suture buttons at the MP, make
using a minimally invasive technique, without opening sure the exit point of the suture on the muscular process
the joint [28]. is dorsal.
● The surgical field is copiously lavaged with saline, pos-
sibly containing antimicrobials, and closed in 3 layers.
Diagnosis Sudden loss of abduction in the acute postoperative
Close the skin using sutures, not staples, because the
period is usually observed during early postoperative repeat
skin might be slightly fibrotic due to previous surgery.
endoscopy. If it occurs later, the horse will show recurrence of
● Some surgeons insert a Penrose drain to prevent seroma
clinical signs consistent with recurrent laryngeal neuropathy
in repeat laryngoplasty.
and this will be confirmed with upper airway endoscopic
● Continue administration of antimicrobials for a minimum
examination.
of 5 days, as well as keeping the horse hospitalized.
Treatment Acute prosthesis failure is uncommon but Expected outcome In our experience, repeat laryngoplasty
requires immediate surgical revision. Timing a repeat usually has a very good prognosis, and most of the cases
laryngoplasty in the first 10 days after surgery must be with failed abduction can be successfully treated, especially
considered with caution. Undergoing two general anesthesias in the first months after the first surgery.
in close proximity can increase the risk of intestinal disorders,
including fecal impaction. The risk of postoperative seroma Acute dysphagia and coughing
and infection is also increased after repeat laryngoplasty. Definition Horse displays clinical signs of dysphagia and/
However, the authors prefer to re-operate in the standing or coughing in the early (<7 days) postoperative period.
horse immediately after the detection of prosthesis failure,
and the following technique is observed: Risk factors Inherent to the concept of the technique
● After aseptic preparation of the surgical site, the skin ● Dixon grade 1 (Figure 35.8) arytenoid abduction
and fascia sutures are removed with a different surgical ● Laryngeal incompetence associated with right arytenoid
kit and each layer of the wound successively lavaged cartilage dysfunctionality (more common in the late
with sterile saline. [months/years] postoperative period)
(a) (b)
(c)
Figure35.7 Dorsal (a and b) and lateral (c) views of an anatomic specimen with amyotrophy of the CAD. Use of an Arthrex
laryngoplasty kit with placement of two sutures of N2 Fibertape® reinforced by metallic suture buttons at the cricoid cartilage. (c) The
dorsal suture (blue) is passed through the rostral spine (acuate crest) to improve stability, and the lateral suture (white) is passed
through the dorsal aspect of the MP to improve abduction. TH: thyroid wing, MP: muscular process; Cr: caudal border of the cricoid
cartilage. Source: Fabrice Rossignol and Norm G. Ducharme.
● Presence of large seroma compressing the esophagus of laryngoplasty due to the concept of the technique. Speirs
● Modification of the anatomy of esophageal entry if the et al. [38] reported coughing during eating for a few weeks
sutures are passed through the vestibulum esophagi at the MP postoperatively in 40% of horses; Dixon et al. [2] observed
● Bilateral VC coughing at some stage postoperatively in 43% of cases,
whilst Hawkins et al. [7] reported coughing in 22% of cases
Pathogenesis Some degree of postoperative aspiration of during postoperative hospitalization. Coughing during the
food and/or saliva, and coughing, are inevitable consequences immediate postoperative period is usually associated with a
high level (Dixon grade 1) (Figure 35.8) of arytenoid Treatment During the immediate postoperative period,
abduction and food and saliva aspiration into the trachea is feed the horse from the ground and those showing clinical
usually the most common cause of this problem [2, 5]. The signs of couching or dysphagia should be administered
authors of this chapter think that laryngeal incompetence antimicrobial combination such penicillin and
occurs when the right arytenoid cartilage fails to cross the metronidazole. Most horses will show some spontaneous
midline. This might also explain why horses with less relaxation of the prosthesis within the first 7 days, with
excessive postoperative abduction (Dixon grade 2) can react improvement of coughing. However, if clinical signs persist
differently in terms of aspiration. with major dysphagia and if water and food come from the
Less common, coughing can also be due to a large ser- nose during eating, prosthesis relaxation is required. If
oma compressing the esophagus. possible, perform the procedure with the horse standing to
Even with a moderate postoperative abduction (Dixon grade better assess the abduction and respect the same
3), bilateral VC also leads to an increased risk of dysphagia by precautions regarding asepsia and wound care as for acute
decreasing the seal and ability of the rima glottis to close at its prosthesis loosening. Remove the most tightened or both
ventral part during swallowing. This was observed by the initial sutures and replace with 1 or 2 new sutures using
authors in bilateral or even in some unilateral VC, when exces- the passage through the cartilages, then tighten under
sive tissue has been removed at the most ventral part. endoscopic guidance. If clinical signs of dysphagia/
coughing are mild, it may be advisable to wait 4–5 weeks
Prevention Avoid excessive abduction (Dixon grade 1) and before suture relaxation.
tighten sutures under endoscopic guidance. The degree of
abduction can be more accurately assessed by performing Expected outcome Most horses will show some spontaneous
the procedure in the standing horse [13]. The optimal relaxation of the prosthesis within the first 7 days, with
degree of abduction aimed during the surgical procedure is improvement of coughing. However, if clinical signs persist
a Dixon grade 2. Sport horses can also be positioned in and are associated with over-abduction, laryngeal incompetence
grade 2, but a Dixon grade 3 is adequate in those horses. can lead to chronic bronchitis, and less frequently to pneumonia,
inability to perform, and sometimes chondritis due to irritation
Diagnosis Saliva and food particles can be observed in the by saliva and food material. Davenport et al. [9] reported that
nasal passage and trachea. If the arytenoid is not over- post-LP performance was limited by a chronic cough in 6% of
abducted, performing an endoscopic swallowing test, and/ racehorses, while Strand et al. [8] reported that the racing
or an endoscopy while the horse is eating may be useful to careers of 10% of cases were limited due to chronic aspiration
assess the cause of the dysphagia (food/saliva passage at and coughing.
the dorsal aspect VS ventral aspect of the rima glottides). Based on the authors’ experience, horses that undergo
suture relaxation after over-abduction have an excellent
prognosis. When the surgery is delayed, despite obvious
signs of dysphagia, prognosis is more guarded. Saliva may
irritate the arytenoid at the corniculate process and may
lead to ulceration and chondritis.
Gradual loss of abduction
Definition Recurrence or collapse of affected arytenoid
cartilage commonly within the first 6 weeks after performing
an LP
Risk factors Suboptimal placement of the prosthesis

● Weakened cartilage for disease
● Excessive tension on the prosthetic suture
● Same risk factors as those in acute failure (see above)
Figure35.8 Resting endoscopic view of the larynx of a horse

Pathogenesis Late postoperative loss of abduction is one the
48 hours after VC and tieback. Hyperabduction of the left
arytenoid cartilage (Dixon grade 1) following laryngoplasty. most common complications after prosthetic laryngoplasty.
Source: Fabrice Rossignol and Norm G. Ducharme. In three studies, between 76% and almost all of the horses lost
at least one grade of abduction in the 6 weeks after surgery [2, Diagnosis Affected horses usually show recurrence of
11]. The same surgical technique with 2 implants of 6 metric clinical signs and these will depend on the athletic use of the
stainless-steel wires was used in all three studies. horse. These clinical signs will include exercise intolerance
Abduction loss rarely occurs after 6 weeks. It is often dif- in athletes required to exercise at maximal level (racehorses)
ficult to determine the exact reason for this failure. and the recurrence of some degree of noise due to DUAO.
Suggested factors include acute mechanical cartilage fail-
ure, cyclic cartilage failure resulting in gradual prosthesis Treatment It is important that the owner’s actual complaint is
loosening, improper prosthesis placement resulting in bio- obtained and the horse is thoroughly examined clinically (type
mechanical disadvantage, and any disease state rendering of noise, exercise performance, possible lower respiratory
the cartilage weaker than normal. Each mm lost is associ- infections, coughing, etc.). Perform an endoscopy at rest,
ated with a loss of 0.6-degree abduction and 24 mm2 in including a tracheal examination. Then perform an exercising
cross-sectional area of the rima glottis [40]. It would there- endoscopy, if possible, at the same speed as during a race or
fore appear that small variations in suture tension can competition.
result in considerable variation in postoperative abduction If moderate abduction is present (Dixon grade 3) without
and possible outcome. Excessive tension on the prosthetic arytenoid collapse but with DUAO (right VCC, left rem-
suture may increase the risk of failure and loss of abduc- nant VCC, MDAF), perform a laser resection of these struc-
tion. Except in rare cases of crico-arytenoid joint fibrosis or tures and repeat endoscopic examination during exercise
ankylosis, especially in the case of repeat laryngoplasty, two to three months later. Bilateral VC decreases the risk of
excessive tension on the prosthetic laryngoplasty is related DUAO but increases the risk of coughing.
to incorrect placement of the sutures. In racehorses, if the degree of arytenoid cartilage abduc-
Chronic and progressive prosthesis failure usually has the tion is more severely decreased to a Dixon grade 4 or 5 and/
same causes and risk factors as those responsible for acute or if the horse shows marked arytenoid collapse during
failure and described earlier. Dixon et al. [2] suggested that exercising endoscopy, consider performing a repeat laryn-
contraction of the caudal pharyngeal sphincter muscles dur- goplasty (LP) or partial arytenoidectomy (PA). In sport
ing swallowing causes marked medioventral pressure on the horses with Dixon grade 4 (and sometimes 5), always per-
abducted arytenoid and that this repetitive pressure would form an exercising endoscopy before repeat surgery, as
be a major contributor to LP abduction loss. Witte et al. [12] some such horses can maintain enough stability for a sub-
have since demonstrated that the force exerted on the LP maximal level of exercise. Repeat laryngoplasty is usually
prosthesis during swallowing is significantly greater than the authors’ first choice (before PA) both in race and sport
that exerted during coughing and suggested that even nor- horses, except in the case of previous infection.
mal swallowing causes LP abduction loss. It is important to discuss the expectations after surgery
The caudal edge of the cricoid cartilage is the most with the owner, including possible conversion to PA and its
important portion and the least predictable component of consequences and risks. If indicated, first perform the laser
the equine laryngoplasty procedure [24]. This area of the VC and/or aryepiglottic fold (AEF) resection. Resect any
cartilage is often composed of soft, very thin cartilage that ventral scar or webbing as it may prevent further arytenoid
tapers to a fine edge. It is readily deformed and is variably abduction.
notched. Progressive lateral sliding of the suture along The repeat LP procedure is similar to the one used for
the caudal border of the cricoid cartilage can likely acute loss of abduction described earlier, with addition of
be attributed to the variable shape of this part of the the following steps:
cartilage.
Irrespective of the cause, it should be accepted that some ● Dissection may be difficult. Pay special attention during
postoperative loss of LP abduction is inevitable in most early dissection at the linguofacial vein and carotid
horses, but that some strategies seem to be efficient in lim- artery.
iting the risk and/or reducing the degree of relaxation. ● Find a plan of dissection close to the crico-pharyngeus
muscle. You need to see the fibers of this muscle before
Prevention Follow the same strategy as for prevention of progressing more dorsally.
acute loss of abduction, using the checklist proposed ● Focus on dissection of the caudal aspect of cricoid carti-
earlier. Repeat laryngoplasty is a difficult procedure but lage and MP. Correct identification of the thyroid wing is
gives reasonably good results if properly managed. We essential to allow adequate dissection and exposure of
usually perform this procedure with the horse standing as the MP.
dissection, exposure, and assessment of arytenoid ● Previous prosthetic sutures can be removed or left in
abduction is easier. place after cutting them at the MP.
● Open the cricoiarytenoid (CA) joint and remove all adhe-

sions including those between the thyroid wing and MP
(break down adhesions on ventral medial to the thyroid
wing).
● Place 2 new sutures as prosthesis.
– Consider metallic implants at the cricoid (Figure 35.7)
and possibly at the MP, especially if the latter has been
weakened by previous sutures.
– Consider curettage and/or bone cements in the CA
joint.
– Check the quality of abduction by caudal traction on
the CAD tendon, using a mosquito or Kelly forceps. If
you feel that tightening the sutures will not abduct the
arytenoid and maintain abduction, consider PA.
– Consider the same precautions regarding risk/man-
agement of seroma as for repeat LP in the acute stage.
– Consider hospitalizing the horse for 7 days and repeat
endoscopic assessment to assess maintenance of
abduction. Consider PA if loosening of abduction.
Expected outcome Progressive relaxation of the prothesis

results in a reduced diameter of the rima glottis, and then to a
decrease in tidal and minute volume, and increased respiratory
pressure. A reduced rima glottis has also been associated with
a higher incidence of dynamic upper airway obstructions Figure35.9 Dynamic endoscopic view of the larynx of a horse
with dynamic upper airway obstruction (DUAO), including medial
(DUAO) following surgery, such as right or bilateral medial deviation of aryepiglottic folds (MDAF) and reduction of the
deviation of the aryepiglottic folds (MDAF) (Figure 35.9), arytenoid abduction grade observed at exercising endoscopy
right vocal cord collapse (VCC) or remnant left VCC, and following laryngoplasty surgery. Source: Fabrice Rossignol, Norm
dorsal displacement of the soft palate (DDSP) [39, 41–43]. G. Ducharme.
The clinical impact of gradual loss of abduction will depend
on the athletic discipline of the horse. A submaximal degree
LP abduction
of abduction of the arytenoid cartilage (Dixon grade 2), restor-
ing about 80% of the maximum diameter of the rima glot-
● Technical errors in surgery
tis [44], seems optimal to consistently improve upper airway
● Factors that increase risk of adhesions at the surgery site
capacity in horses exercised at maximum levels. However, the
(excesive dissection, seroma, infection)
clinical performance of national hunt horses with grade 3
● Bilateral or unilateral VC
arytenoid abduction following LP, compared with those with
grade 2 abduction, was not reduced. In sport horses, stability
is more important than abduction and such horses can toler- Pathogenesis Long-term coughing is often related to food
ate a Dixon grade of abduction of up to 4 with good tolerance and/or saliva aspiration. This is usually associated with a
of exercise [45]. Complete loss of abduction (Dixon grade 5) is high level (grade 1) of arytenoid abduction [2, 7], although
usually correlated with dynamic collapse during exercise [41]. severe dysphagia and coughing may be observed in some
The postoperative resting grade should be determined with horses with lower degrees of LP abduction. Possible causes
caution, as one-third of horses are expected to lose at least one include:
grade between rest and exercise [43].
● Excessive retraction of the cricopharyngeus and thy-
Chronic coughing and dysphagia ropharyngeus muscles during surgery, affecting esopha-
Definition Horse displays signs of coughing and/or geal sphincter function [46].
dysphagia several weeks/months after LP. ● Adhesions due to sutures involving the esophagus dorsal
to the larynx [47].
Risk factors High level of arytenoid abduction (Dixon ● Adhesions due to sutures between esophageal entry (vesti-
grade 1), although it may also occur with lower degrees of bulum esophagi) and MP. Caudal displacement of the MP
during PL may disturb the anatomy of esophageal entry which would give useful information for revision surgery
(Figure 35.3) and then compromise swallowing [34]. (compromise of the esophageal anatomy).
● This may also cause esophageal reflux, sometimes visible Assess the positioning of the tip of the epiglottis and possible
during exercising endoscopy [29, 43, 48], and induce irri- deviation to the left. Assess relative cranio-caudal positioning of
tation/coughing. the left versus right corniculate cartilages in a transverse plane.
● Bilateral VC or unilateral VC with aggressive tissue The crico-tracheal space should be palpated and compared
removal, especially at the most ventral part of the rima between the operated and the non-operated sides; this will
glottis, may allow passage of saliva/food when associated allow identification of lateral deviation of the larynx associated
with PL. with scarring, which may be related to the dysphagia.
● Adhesions may also prevent or interfere with laryngeal An endoscopic swallowing test may be conducted to
elevation during swallowing. determine the cause of the dysphagia: failure of laryngeal
● Deviation of the larynx to the left due to unilateral cau- elevation, esophageal reflux, defect in rima glottidis seal at
dal displacement of the left arytenoid cartilage by sutures the level of vocal cord (most common), and defect in rima
and adhesions. In this situation, the epiglottis only has glottidis seal at the level of arytenoid cartilage. The esopha-
contact with the right corniculate process during swal- geal entry may be examined using equine laryngeal for-
lowing and this leaves a gap on the left side for passage of ceps, by elevating the palate-pharyngeal arch just above
food within the tracheal lumen. In this situation, the epi- the left arytenoid cartilage. Exercising endoscopy at lower
glottis can rotate and penetrate the laryngeal lumen on speed may also be contemplated to detect if esophageal
the left size. This complication can be observed with a reflux occurs.
retrograde swallowing test, using the endoscope intro- A retrograde swallowing test can be performed to observe
duced through a tracheotomy. the closure of the rima glottidis by the epiglottis, and to locate
● Adhesions of esophagus near the MP or cricoid may the defect allowing the passage of food into the tracheal
results in esophageal stricture and be associated with lumen. This test is useful as relative movements of the vocal
esophageal reflux. cords and epiglottis can be more accurately observed than
during standard endoscopy (Figure 35.10).
Prevention Avoid hyper-abduction during LP by the use Finally, ultrasonographic examination of the larynx in
intraoperative endoscopic evaluation. When performing these horses should be completed to assess for presence of
LP under general anesthesia, use a small endotracheal tube arytenoid chondritis.
(20 mm in diameter) and consider temporary extubation to
1) If over-abduction is detected (Dixon grade 1):
improve observation of the arytenoid cartilage abduction.
Laryngoplasty performed in the standing horse provides ● Consider waiting 120 days after previous surgery for pos-
the most accurate assessment of intraoperative arytenoid sible spontaneous relaxation. This may be useful to get
abduction. some degree of peri-articular fibrosis and sufficient aryt-
Use a proper technique, including careful dissection of enoid stability after prothesis removal.
the dorsal aspect of the cricoid cartilage and MP. Avoid ● Continue the usual management, such as feeding from
passing the rostral suture through the esophageal adventi- the ground and washing the mouth prior to exercising
tia, especially at the spinal level. When performing ventric- the horse.
ulo-cordectomy, avoid aggressive cord resection of the ● If symptoms and hyper-abduction persist after 120 days,
ventral part of the folds, especially when using the laser. perform a repeat laryngoplasty to relax the arytenoid
Avoid bilateral VC in sport horses as, in the authors’ experi- abduction.
ence, it increases the risk of dysphagia. ● Adopt the same approach and precautions as those used
in repeat laryngoplasty for prosthesis relaxation in the
acute stage.
Diagnosis Horse displays clinical signs, including coughing
● In some cases, removal of the prosthesis may be suffi-
and of dysphagia.
cient because of the degree of fibrosis. However, most
authors recommend removal and replacement of the
Treatment A complete resting endoscopic examination sutures to resolve coughing/dysphagia complications.
including examination of the trachea and guttural pouches ● Use the thyroid wing as a landmark to assess and expose
should be performed to rule out other conditions that may the MP.
lead to chronic coughing and/or dysphagia, such as primary ● Hawkins [7] prefers to remove the sutures without any
lower respiratory inflammation, guttural pouch diseases or special dissection at the MP, rather than performing the
arytenoid chondritis. Assess degree of perilaryngeal reflux, dissection necessary to uncover the suture knot.
(a)
(b) (c)
Figure35.10 Retrograde swallowing test. (a) The endoscope is introduced through a small tracheotomy and advanced craniad to
visualize the larynx from a caudial view. Food is provided to the horse. (b) Normal horse: during swallowing, the two vocal processes
(VP) are in close contact (black arrow) and the epiglottis is not visible. (c) Dysphagic horse after laryngoplasty and left ventriculo-
cordectomy. The larynx is deviated to the left with the left arytenoid cartilage in a more caudal position. During swallowing, the vocal
processes are not in contact (black arrow). The epiglottis (Ep) is rotated and penetrates into the laryngeal lumen on the left side,
allowing passage of the food into the trachea (white arrows). This horse underwent a repeat laryngoplasty and the arytenoid was
replaced in a more rostral position. The horse recovered completely. Source: Fabrice Rossignol and Norm G. Ducharme.
Laser Ventriculo-Cordectomy 455
● In most cases, we usually cut the sutures at the MP and between the muscular process and the thyroid. Free the
remove the knot. We only remove the sutures if they do muscular process and reposition the left arytenoid more
not require too much caudal dissection. We then free the rostral at the same plan relative to the right side.
MP from the esophageal adventitia to which it some- ● Most horses respond well to repeat LP with the pre-
times adheres and pull the esophagus caudally while described steps.
tying the sutures. ● Consider performing a laryngeal tie forward, when
● The CA joint, as well any adhesions involving the thyroid coughing and dysphagia persist in spite of the previously
wing, may be minimally-invasively freed from adhesions described management [49].
by using a swab, under endoscopic guidance.
● We prefer performing the surgery in the standing horse Expected outcome Dysphagia may lead to inflammation of
so as to better assess the arytenoid position after cutting the lower respiratory tract, which can in turn contribute to a
the suture. gradual decline in racing performance after LP [7].
Davenport et al. [9] reported that post-LP performance was
2) If hyper-abduction is not present and if no other signs
limited by a chronic cough in 6% of racehorses, while Strand
can explain the dysphagia:
et al. [8] reported that the racing careers of 10% of cases were
● When the endoscopic exam shows a unilateral or bilat- limited by chronic aspiration and coughing. In sport horses,
eral VC with very few tissues remaining ventrally, con- chronic coughing after LH is associated with a major
sider injecting both remnants with silicon, high-density depreciation, especially in dressage and event horses. In rare
hyaluronic acid, or polymethylmetacrylate (PMMA) and cases, bronchopneumonia may be the long-term result.
wait 2–3 weeks (Figure 35.11).
● If there is no response to this treatment, perform a repeat
laryngoplasty, check any esophageal adhesions, and free LaserVentriculo-Cordectomy
the muscular process from the adventitia of the diverticu•
lum esophagi. Ventriculo-cordectomy (VC) is commonly performed in
● If the larynx is deviated to the left, perform a repeat lar- association with PL to reduce or normalize abnormal air-
yngoplasty. Break the adhesions lateral to the larynx, and way sounds. Sometimes it is used to treat exercise intoler-
ance and abnormal airway sounds in horses working at low
velocity (such as draft horses, some leisure horses, low-
level sport horses etc.).
It is the treatment of choice for bilateral vocal cord col-
lapse without arytenoid collapse diagnosed during exercis-
ing endoscopy or in grade 3 LH with partial collapse of the
arytenoid during exercise. We also use it to treat 3/yearly
grade 4 with arytenoid collapse at exercise, associated with
a first and second cervical nerve graft.
Ventriculo-cordectomy can be performed via laryngot-
omy under general anesthesia or in the standing horse, or
more commonly by using trans-endosocopic laser, usually
in the standing horse. Some complications may occur
when using laser for this purpose.
PreoperativeComplication
Bleeding
Definition Intraoperative hemorrhage that hinders
visualization and progress of the surgical procedure
Figure35.11 Endoscopic view of the larynx of a horse that was
coughing and dysphagic with excessive retraction of the left vocal Risk factors No coagulation of vocal cord vessel
cord, leaving a gap between the left and right ventral aspect of
the rima glottidis during adduction and swallowing. The image ● Diode laser
shows the left vocal cord remnant after being injected with
polymethylmetacrylate (PMMA) (yellow arrows). Source: Fabrice Pathogenesis Some significant blood vessels are located
Rossignol and Norm G. Ducharme. at the rostral–abaxial edge of the vocal cord, usually at the
junction between the dorsal and middle third. These ● Then the scope is passed through the left nasal passage
vessels arise from the caudo-lateral aspect of the fold and and the broncho-esophageal forceps through the right
commonly transected routing the procedure when the nasal passage. The left vocal cord is grasped immedi-
vertical and aventral cut are performed. Although the ately dorsal to the rostral incision. Pull the vocal fold
diode laser has multiple advantages to perform this axially to form a triangle (apex in the forceps). Vertically
surgery, it has a suboptimal effect on coagulation of incise the base of this vocal cord triangle, starting 3–4
vessels. mm distal to the vocal process of the arytenoid cartilage
Bleeding obscures vision due to blood projection toward (Figure 35.12c). Continue the vertical incision in a ven-
the lens of the endoscope and blood clots covering the tis- tral direction until the ventral incision is reached and
sue. Light is absorbed by the red color of blood, which excise the vocal cord. Before starting the vertical inci-
also decreases endoscopic visualization. As a conse- sion, the multiple vessels that run in a lateral to medial
quence, the procedure may become more difficult to com- direction can be coagulated using the technique
plete and thus increase the surgical time and the amount described previously.
of laser thermal energy. Repeated unsuccessful cuts ● Do not over-proceed laterally at the mid-third of the ver-
increase the energy dispensed, leading to postoperative tical incision, but progress toward the caudal part of the
edema and/or iatrogenic damage to the adjacent anatomi- initial ventral incision.
cal structures. Blood accumulation in the trachea may ● Perform a full thickness transverse cut through the voca-
also be a risk if another laryngoplasty is performed just lis muscle at the end of the procedure (Figure 35.12d).
after the first, especially in the standing horse. Blood
accumulation into the tracheal lumen may be a factor of Diagnosis Obvious during intraoperative endoscopic
stress for the horse who can cough or can move during visualization
standing laryngoplasty.
Treatment When bleeding occurs during laser ventriculo-
cordectomy, the following steps can be followed. Use the
Prevention Use of a head support to raise the head of the
equine laryngeal forceps and part of the grasped vocal
horse can be helpful. Topical application of 10 cc of a 0.15%
cord to apply pressure over the bleeding area by pressing
solution of phenylephrine on the vocal cord/saccula after
the medial part of the fold against the lateral part. This
applying lidocaine via the biopsy channel of the video-
will decrease bleeding, which may help to locate the
endoscope, may help to decrease the amount of intraoperative
vessel. Once the vessel is identified, activate the
bleeding.
coagulation mode of the laser (if present). Place the fiber
The authors now attempt to coagulate the ventricular
beam just at the base of the vessel (not directly on the
vessels prior to starting the cuts by applying the laser fiber
bleeding vessel end), and activate in a short 2–3 mm
just laterally to the expected cut line at the dorsal third of
vertical line until the bleeding stops. Visualization of the
the fold from within the ventricle, at about 3 to 4 mm
bleeding may be improved by increased traction on the
depth. We then activate the laser for 2 seconds, and repeat
fold. Apply pressure on a regular basis using the forceps
the procedure 3 to 4 times, about 2 mm more ventral in a
and part of the fold.
dotted line (Figure 35.12a).
If the previous actions are not successful or the bleeding
Careful and adequate preparation (cutting and stripping)
continues, it is sometimes more useful and less risky to
of the tip of the laser fiber with appropriate scissors and
stop the procedure and to raise the horse’s head until coag-
trimming device should be carried out. Use of a laser in
ulation occurs spontaneously. The area can then be flushed
coagulation mode is helpful to coagulate the vessel.
with saline, and the blood clot left to drain by putting the
Following a standardized step-by-step procedure is man-
head down. The procedure can then be started again.
datory to decrease risk of bleeding. For example, if the left
vocal cord is going to be removed:
Expected outcome In most cases, the bleeding can be
● Pass the scope through the right nasal passage. Begin the controlled with the previous steps and the procedure can be
incision at the caudal, medial and ventral aspect of the completed. In cases where the procedure cannot be continued
vocal fold and extend it to the rostral aspect of the vocal safely, it is recommended to stop the procedure at that time
cord (Figure 35.12b). It is safer when starting with this and continue after a few hours or the following day. In these
procedure to not over-extend the incision to the lateral cases, however, the degree of swelling in the surgical site will
surface of the vocal cord at this time, because one vessel be increased and the risk of bleeding will remain. Topical
is located at the junction of the rostral and abaxial edges application of phenylephrine and careful attention to previous
of the vocal cord. prevention steps are highly recommended.
Laser Ventriculo-Cordectomy 457
(a) (b)
(c) (d)
Figure35.12 Laser ventriculo-cordectomy. (a) Fiber is placed inside the left ventricle just lateral to the expected cut line at the
dorsal third of the fold, about 3 to 4 mm deep, and activated to preventive coagulation of the vessel. (b) The fiber is at the ventral
aspect of the cord, leaving 3 to 4 mm of tissue at the most ventral part. The incision was started at the caudal and ventral aspect of
the vocal fold and extended to the rostral aspect of the vocal cord. (c) The vocal fold is pulled axially and this forms a triangle of vocal
fold (apex in the forceps). The base of this vocal cord triangle is incised vertically from dorsal to ventral just axial to the dotted line
(Figure 35.11a) until the ventral incision is reached. (d) An approximately 2 to 3 mm long horizontal cut is performed through the
vocalis muscle. Source: Fabrice Rossignol and Norm G. Ducharme.
ImmediatePostoperativeComplication and corticosteroids (preferably intravenously), and their

administration should be extended as necessary based on
Swelling/edema
clinical and endoscopic progression as necessary. A
Definition Excessive inflammation of the tissues at the
tracheostomy may be required in cases with respiratory
surgical site
distress, which do not respond to medical treatment and in
Risk factors Technical surgical errors continuous dyspnea.
● Administration of excessive energy Expected outcome Most of the affected horses will show
adequate clinical progression and decreased inflammation
Pathogenesis Mild to moderate inflammation at the surgical within the first 2 days in response to the systemic
site is common after venriculo-cordectomy, especially if administration of anti-inflammatory drugs. Later, excessive
performed with laser. In most cases, this degree of inflammation can lead to the development of polyps or
inflammation resolves with routine treatment (systemic adhesions between the two vocal cord remnants, also called
corticosteroids, non-steroidals and/or topical nasal spray). webbing. The risk seems to be increased when VC is not
However, excessive swelling and associated edema may associated with laryngoplasty in advanced RLN (i.e. grade 3.3
occur as a result of iatrogenic damage after laser ventriculo- to 4), due to the lack of immediate postoperative abduction,
cordectomy. Iatrogenic damage is an important inherent and in bilateral VC (as compared to unilateral VC).
risk of laser surgery. This risk is increased if excessive energy
is dispatched. The energy dispensed (in Joules) is calculated
from the laser power (in Watts) × time of activation on the LatePostoperativeComplications
tissue (in seconds). Use of excessive power or more Webbing
commonly an increased surgical time if an improper Definition Webbing, or laryngeal cicatrix, is an iatrogenic
technique is used, with repeated unsuccessful attempts, lesion characterized by the presence of a mucosa-covered
bleeding or carbonization, will lead to excessive release of fibrous band of tissue, stretching across the laryngeal
energy into the tissues. A diode laser is typically applied at lumen uniting both vocal cords, extending from their
18 to 20 W and a total of 3,500 Joules is usually required for ventral aspect in a dorsal direction for a variable distance.
unilateral VC, and 5,500 Joules for bilateral VC. It is associated with a stenosis of the ventral rima glottis
Prevention Adequate surgical technique should be Pathogenesis/risk factors Bilateral VC performed at the
employed, administering as little energy as possible. Special same time
care needs to be applied after nerve graft or when bilateral
VC is performed without LP, as lack of abduction will ● VC without concurrent LP
increase risk of complications such as webbing. Unilateral ● Laser VC
VC is preferred in sport horses unless preoperative
exercising endoscopy indicate that bilateral VC is required Pathogenesis/risk factors This lesion is usually iatrogenic
(i.e. bilateral medial vocal fold collapse). Lasering near to and occurs after endo-laryngeal mucosal injuries, when
or on the false vocal cord (ventricularis fold) should be granulation tissue from denuded areas on opposite sides of
avoided, as this is associated with more postoperative the larynx join together and mature into a fibrous fold,
swelling. Administration of preoperative and immediate which later becomes covered with mucosa. Webbing
postoperative NSAIDs and corticosteroids (topical, typically develops after simultaneous bilateral VC. It also
intravenous and/or per os) and endoscopic monitoring are seems more frequent when VC is performed without
recommended. concomitant laryngoplasty. The risk seems higher when
the laser is used compared to conventional cut-down
Diagnosis Cases with excessive swelling and edema technique via laryngotomy.
typically show major and dramatic acute dyspnea during the This lesion produces abnormal inspiratory sound and
immediate postoperative period, and if severe enough may limits arytenoid abduction.
result in death of the affected horse. Endoscopic examination
reveals excessive inflammation and edema of the surgical Prevention Use of a proper technique in order to minimize
site, causing different degrees of airway obstruction. formation of postoperative edema. When performing
bilateral cordectomy, perform the right cordotomy at a
Treatment Horses should be administered anti-inflammatory different level to the left caudo-ventral incision, and prefer
drugs, including non-steroid anti-inflammatories (NSAIDs) a simple horizontal cut at the dorsal third on the right side,
Partial Arytenoidectomy 459
instead of a full removal of the cord, as for the left side. Do ynx) also improves visualization of the corniculate process
not remove too much tissue ventrally at the left side (leave where dissection of the mucosa is strategic. A temporary
a minimum of the ventral 3 mm of cord intact) and always midline incision of the cricoid cartilage can help improve
start with a horizontal incision at the ventral aspect of the visualization and does not seem to have a negative effect if
cord to serve as a step. the fibrous perichondrion is closed at the end of the
It is sometimes recommended to use a two-step proce- procedure.
dure, i.e. perform right VC 2–3 weeks after left VC in selected Hemorrhage can be minimized by applying 0.15% solu-
cases; however, the authors do not consider this necessary if tion of phenylephrine before incising the mucosa or a
the procedure is performed as described earlier. sponge with 3 cc of 1:1,000 epinephrine after incision of
the mucosa and blunt dissection of the muscle off the lat-
Diagnosis Affected horses typically show abnormal eral side of the arytenoid.
inspiratory sound and limited arytenoid abduction as a
consequence of the cicatrix or webbing.
ImmediatePostoperativeComplication
Treatment Sagittal incision using laser is rarely efficient, Dyspnea
and may be used only when a small band is located at the Definition Horse displaying difficult and noisy breathing
mid vocal cord. When the cicatrix band is wider and located
at the ventral aspect of the vocal cords, a flap technique Risk factors Surgical technique
involving laryngotomy should be used: a right-based
● Presence of tissue inflammation at the time of perform-
mucosal flap including the fibrous tissue is dissected. The
ing the surgery.
fibrous tissue is re-sected and the remaining mucosal flap
is sutured to the right margin of the cricothyroid
Pathogenesis Dyspnea may occur as a result of the presence
membrane [50].
of acute edema of the laryngeal lary-epiglottic area, which
may be the result of excessive surgical manipulation of
Expected outcome The prognosis is fair to good if the
dissection of tissue. The risk of dyspnea is increased when
webbing is properly managed. A repeat laryngoplasty may
surgery is performed during acute inflammation, as in the
be necessary, as webbing is often associated with prosthesis
case of chondritis, or if chondritis is present on the opposite
loosening.
side.
Prevention Treat acute inflammation and swelling

PartialArytenoidectomy associated with chondritis prior to surgery, especially in
the case of “kissing” lesions on the opposite side or bilateral
Partial arytenoidectomy (PA) is used to treat arytenoid chondritis. A sharp incision is preferred over laser surgery
chondritis and failed laryngoplasty when repeat laryngo- to treat kissing lesions such as granuloma.
plasty will not improve abduction, or if the sutures are Examine the larynx endoscopically and ensure airway
infected. It is usually associated with ipsilateral VC if this patency by plugging the tracheostomy tube together with
has not been performed previously. PA has been performed the laryngotomy wound and listening for respiratory stri-
with [51] or without mucosal closure [52]. A modified dor before deciding to remove the tracheostomy tube.
technique has been described [53] using the aryepiglottic
folds as a flap to cover the mucosal defect. The differences Diagnosis The affected horse displays typical signs of
between PL and PA are modest at submaximal exercise and dyspnea with difficulty breathing and respiratory noise in
airway mechanisms are returned to near normal. most cases.
Treatment Administer non-steroidal anti-inflammatories

and corticosteroids preferably intravenously and prolong
Intraoperative complications are uncommon. The most the use of antimicrobials. Maintain the tracheostomy tube
likely complication is poor visualization (due to limited light until the glottis lumen is restored (usually 24–48 h).
and hemorrhage) impeding surgical precision. Lighting can
be enhanced by a headlamp and with additional light from a Expected outcome If diagnosed promptly and managed
video-endoscope placed inside the oropharynx. Using the appropriately, horses usually recover without consequences.
video-endoscope placed in the oropharynx (avoid nasophar- Undiagnosed or mismanaged cases may result in asphyxia.
LatePostoperativeComplications Prevention Whatever the technique, it is critical to preserve

enough corniculate mucosa (Figure 35.13b).
Dysphagia and coughing
Definition Horse displays clinical signs of dysphagia and/ ● Performing the procedure under endoscopic guidance
or coughing in the postoperative period. can be helpful.
● Some external landmarks can also be useful to locate the
Risk factors incision line, such as the junction between the puncti-
form and smooth/striatus muscosa.
● Surgical technique factors: ● Use a standard or modified technique when suturing
– Excessive tissue removal at the dorsal part of the rima and do not pull the corniculate mucosa too caudally as to
glottis cause a deviation of the epiglottis.
– Iatrogenic transection of selected structures
Diagnosis The horse displays typical clinical signs including
Pathogenesis This complication is usually related to a coughing and poor performance, as a result of chronic
modification of the larynx anatomy due to the incomplete pulmonary inflammation. Less frequently, some horses may
seal provided during adduction of the contralateral develop broncho-pneumonia with its associated clinical
corniculate process when swallowing. The most relevant signs of coughing and pyrexia.
risk factor seems to be the lack of tissue in the rostral part
Treatment Conservative management includes feeding
of the repair, at the entry to the esophagus, just ventral to
the horse on the ground or providing pasture grazing.
the palatopharyngeal arch (Figure 35.13a). Removal of too
Specific treatment consists of attempting to improve the
much tissue in the dorsal part of the rima glottis causes the
seal at the rostral part of the arytenoid defect, by submu-
food bolus to passively drop into the trachea instead of
cosa augmentation by using silicon [52] or PMMA, hyalu-
moving toward the esophagus.
ronic acid, or hydrogel such as Arthramid®.
Other described factors are transection of the inter-aryt-
A tie-forward can be proposed if initial management is
enoid ligament [54] and traumatic transection of the dorsal
unsuccessful.
cartilage at the junction with the MP [51].
The horse displays typical clinical signs including cough- Expected outcome Some horses respond to conservative
ing and poor performance, as a result of chronic pulmo- treatment, but frequently this is not enough. Submucosal
nary inflammation. Less frequently, some horses may augmentation may produce improvement as tie forward.
develop bronchopneumonia with its associated clinical However, prognosis remains guarded and in some cases this
signs of coughing and pyrexia. complication can cause a permanent performance limitation.
(a) (b)
Figure35.13 Partial arytenoidectomy (PA). (a) Dysphagia after excessive tissue removal at the upper rostral part of the arytenoid
(white arrow). (b) Modified PA: enough tissue has been preserved at the rostral part. The aryepiglottic fold has been pulled back and
sutured to cover the arytenoid mucosal defect (white arrows). Source: Fabrice Rossignol and Norm G. Ducharme.
Epiglottic Entrapment 461
Intra-laryngeal granulation tissue Prevention Closure of the mucosal flap seems to improve
Definition membrane stability. One modified technique [53] uses the
Proliferative fibroblastic tissue at surgical site causing air- aryepiglottic fold as a flap to cover the arytenoid defect.
way obstruction. This may provide better stability of the aryepiglottic
membrane and should be considered as an alternative
Risk factorsSurgical technique: excessive dissection or technique. However, too much caudal tension on the fold
incomplete mucosal coverage of the surgical site will increase the risk of dysphagia if it significantly deviates
the epiglottic cartilage.
● Excessive bleeding
● Unidentified causes
Diagnosis The horse shows respiratory noise. This needs
Pathogenesis Intralaryngeal granulation tissue is usually to be investigated by exercising endoscopy.
identified 1 month after surgery and was described in 17%
of horses treated with mucosal closure [51]. It usually Treatment Depending on the endoscopic findings, resection
develops at the dorsal aspect of the rostral part of the of the right and/or left aryepiglottic fold using laser may be
incision. This mass can reduce the diameter of the rima required. The authors have sometimes applied laser “spot
glottis, and may be associated with noise and poor thermoplasty” to the rostral part of the palatopharyngeal arch
performance. to decrease vibration of this structure, with positive results.
Prevention The surgeon must be meticulous when Expected outcome In cases with required limited tissue
suturing, especially at the dorsal part when preserving a resection, the prognosis after treatment is favorable. In
mucosal flap for primary closure. Minimize hematoma cases with moderate to severe stability of the soft tissues,
perioperatively by leaving the ventral edge of the flap open the prognosis is guarded.
to drain and by applying finger pressure to the flap at the
end of the procedure.
EpiglotticEntrapment
Diagnosis Clinical signs of partial upper airway obstruction
Entrapment of the epiglottis in a fold of subepiglottic tissue
such as respiratory noise may occur. Upper airway endoscopy
is a common abnormal finding in racehorses. Diagnosis of
reveals presence of granulated tissue.
persistent epiglottic entrapment (EE) is readily confirmed
by resting endoscopic examination. Intermittent entrap-
Treatment Resection with laser or scissor excision at 1
ment can be diagnosed using exercising endoscopy. Most
month postoperatively
entrapments are uncomplicated but some chronic cases
can become excessively thickened, ulcerated, and with an
Expected outcome Favorable after resection provided that apparently fibrotic entrapping membrane. These cases are
there is no other associated complication such as dysphagia. often associated with epiglottic hypoplasia.
Uncomplicated cases of EE cause significantly less air-
Residual noise way obstruction than laryngeal hemiplegia [55]; however,
Definition Persistent respiratory noise by the operated in some cases EE may cause DDSP and therefore greater
horse airway obstruction. Excessively thickened and inflamed EE
induces significant obstruction of the rima glottis and sub-
Risk factors Inherent to surgical procedure epiglottic inflammation can be associated with permanent
DDSP [56]. Correction of EE is indicated in horses to
● Incomplete tissue resection
reduce respiratory noise and improve racing success, and
● Suboptimal muscosal closure
to prevent progressive worsening of the condition.
Several techniques exist:
Pathogenesis Some degree of residual noise seems
inevitable after PA and is due to vibration of the remaining ● Trans-nasal endoscopically guided contact Nd:YAG [57]
tissues and membranes such as the palatopharyngeal arch or diode laser [47] axial division
and the left or right aryepiglottic fold; however, this is not ● Trans-nasal [58, 59] or transoral axial division using a
always associated with poor performance. In cases where curved bistoury under endoscopic guidance and general
some tissue remains redundant after surgery, this tissue anesthesia [60] or in the standing horse [61]
can be the source of respiratory noise. ● Trans-endoscopic electro-surgical axial division [62]
● These tissue-sparing techniques consist of a sagittal sec- Iatrogenic burn at the tip of the epiglottis when using
tion with or without excision of small triangles of mucosa the laser
at the rostral border of the cut Definition Laser energy applied to the surface of the
● A more radical surgical excision of the entrapped sub- epiglottis
epiglottic tissue has been described, initially through a
laryngotomy [63]. It is now still but rarely considered for Risk factors Surgical error
the removal of chronic entrapment of thickened and
● Inadequate instrumentation
ulcerative tissue [64]
Pathogeneis Energy applied to the epiglottis causes burning
and thermal damage to mucosa, submucosa and, in some
PreoperativeComplications
cases, the epiglottis cartilage. This energy can be applied
Iatrogenic damage to the soft palate, esophagus, directly onto the epiglottis tip or through a metal instrument
epiglottis or pharynx that is not covered by a protectant layer such as silicone.
Definition Structural damage to any of these structures
with subsequent functional consequences Prevention Use a blunt silicon-covered hook to protect the
epiglottis [66] (Figure 35.14) or lift it with forceps to separate
Risk factors Standing surgery the entrapment tissue from the tip of the epiglottis beneath.
Extreme care should be applied when applying the laser at
● Use of a hook knife, especially if not guarded
the tip of the epiglottis, where the fold is attached.
When performing further sections of the entrapped tis-
Pathogenesis These complication may occur when a hook
sue near to the tip of the epiglottis, preferably use endo-
knife and trans-nasal approach are used, especially in the
scopic scissors instead of laser, and forceps to apply rostral
standing patient. The control of the hook knife is lost and
traction while cutting.
causes laceration of one or more of the structures listed
above. The consequences can be devasting as the Diagnosis In some cases, the lesion can be obvious at the time
functionality of the involved structure/s is compromised. of surgery. In other cases, thermal tissue damage may only
become apparent at a later stage during endoscopic examination.
Prevention A transoral approach under general anesthesia In more severe cases, horses may display noise or coughing.
is preferred if a conventional hook knife is used. When a
trans-nasal approach is adopted, a guarded hook knife [65] Treatment Medical treatment using NSAIDs, corticostreroids,
should be used. Continuous endoscopic guidance is advised and antibiotics, with regular endoscopic controls. Do not feed
to decrease risk of iatrogenic damage. with irritating aliments, such as rough hay.
Expected outcome Guarded, as may lead to access formation,

Diagnosis In most cases, the iatrogenic damage is
cartilage defects, and DDSP.
recognized when it occurs during the surgical procedure.
In some other cases, it may only be diagnosed at a later Short-TermComplications
stage during an upper airway endoscopy.
Edema/epiglottitis/sub-epiglottic granuloma
Treatment If a soft palate laceration occurs, this should be Definition Swelling, inflammation of the subepiglottic
repaired immediately via an oral approach, pharyngotomy tissues, lateral or ventral to the epiglottic cartilage
or laryngotomy, using a technique similar to the one used
for cleft palate management. Risk factors Excessive energy dispatched using laser surgery
If the hook gets caught in the esophagus or guttural pouch, ● Improper technique
anesthetize the horse while controlling the head. Esophageal
relaxation usually allows release of the esophagus under Pathogenesis Major postoperative inflammation and edema
endoscopic control, sometimes with manipulation with an can occur after using Diode or Yag lasers, when a high energy
equine laryngeal forceps. Guttural pouch hook penetration level is dispatched and/or when the laser is activated close to
is more safely released under general anesthesia the epiglottis tissue. This is usually more common in
complicated and chronic cases, as more energy is needed to
Expected outcome Consequences of these complications perform sagittal section and resection of the margins, and an
are serious and prognosis is at best guarded and in severe already inflamed epiglottis is more prone to further
cases unfavorable. inflammation. Use of electrosurgery increases the risk [62].
Epiglottic Entrapment 463
Excessive edema can result in permanent DDSP, an Expected outcome Most of the inflammation of the
ulcerated epiglottitis and chronic infection, and increases epiglottis after laser surgery heals well, despite very intense
the risk of re-entrapment. and impressive immediate postoperative inflammation.
Prevention When using the laser, choose an appropriate

technique which releases as little energy as possible. Laser Long-TermComplications
entrapment surgery should be performed with less than Re-entrapment
1,000 J. If more energy is needed, consider the use of Definition Recurrence of inflammation and tissue
endoscopic scissors. covering the rostral part of the epiglottis
The following checklist describes our technique using a
Diode laser with minimal energy dispatched: Risk factors Excessive inflammation
● Use a blunt U hook to protect the epiglottis and place the ● Insufficient tissue removal of the triangles at the mar-
entrapped fold under traction. gins of the cut, when excessive mucosa can be observed
● Use low power (6–8 W). after the sagittal cut
● Make a sagittal partial thickness stab incision or dotted
line at the tip of the entrapment prior to manipulation to Pathogenesis Recurrence rate is 5 to 15% using the hook
identify midline (Figure 35.14a). or laser, but more frequent with electrosurgery.
● Then place the blunt U hook between the entrapped tis- Recurrence seems to be increased in cases of compli-
sue and the epiglottis. Apply gentle traction on the U cated entrapment with chronic inflammation and ulcera-
hook and make a transverse cut at the tip of the hook, tion and if some sub-epiglottic tissue remains after the
until the latter can be protruded through the incision initial sagittal division [57, 58, 64].
(Figure 35.14b).
Prevention Use a minimally invasive technique, as
● Make a sagittal cut from rostral to caudal (rostral tissue is
described earlier. Remove extra tissue according to
thinner) using the laser (Figure 35.14c).
appearance after swallowing. Consider surgical excision
● Make additional cuts at the corners of the sectioned por-
via laryngotomy in complicated cases, although this
tion, if necessary, using endoscopic scissors:
increases the risk of DDSP.
– abaxial insertions of the fold to the tip of the epiglottis
– triangles at the margins of the cut (Figure 35.14d), if they are
Diagnosis Clearly visible at endoscopy
not positioned under the epiglottis after swallowing twice
● This method, involving laser sagittal cutting and possibly Treatment Repeat surgery, with some excision of the
partial excision of the triangle wedges using scissors, can remaining tissue (lateral triangles as described earlier), and
be used to free the epiglottis with very low energy release. prolonged postoperative anti-inflammatory treatment.
● Use postoperative broad-spectrum antibiotics and IV
NSAIDS or steroids postoperatively. Expected outcome Usually favorable when good strategy.
● Electrosurgery should not be used. Excessive tissue removal may increase the risk of DDSP.
● If entrapment is associated with epiglottis infection, it is
safer to treat the latter medically and wait for the edema Dorsal displacement of the soft palate (DDSP)
and inflammation to resolve before considering surgery. Definition Intermittent or permanent dorsal displacement
of the soft palate
Diagnosis Marked inflammation and edema of the peri- Risk factors Inflammation, fibrosis at the ventral aspect of
epiglottic tissue is often associated with permanent DDSP the epiglottis
(Figure 35.15). In this situation, application of lidocaine
via the canal of the endoscope allows restoration of the ● Excessive tissue removal
normal dorsal position of the epiglottis in relation to the
soft palate and epiglottic assessment. Pathogenesis Permanent DDSP is usually a consequence
of inflammation and pain. Intermittent DDSP can occur
Treatment Administer corticosteroids (local and IV), NSAIDs when too much sub-epiglottic tissue has been removed,
and antimicrobials. Provide a less aggressive feed (i.e. remove excessive sub-epiglottic scarring has occurred, and
dry hay, offer mash, etc.). especially if epiglottic hypoplasia is present.
(a) (b)
(c) (d)
Figure35.14 Laser transection of epiglottic entrapment. A low power (6 to 8 watts) is used. (a) A dotted line is performed along the midline of
the entrapment using the laser prior to manipulation to identify midline. (b) Note the use of a blunt silicon covered hook to protect the epiglottis
during laser sagittal incision in the treatment of epiglottic entrapment. A transverse cut is performed at the tip of the hook, until the tip can be
protruded through the incision (black arrow). (c) A sagittal cut is then performed from rostral to caudal (rostral tissue is thinner) using the laser. (d)
Removal of remaining small abaxial triangles of mucosa using endoscopic scissors. Source: Fabrice Rossignol and Norm G. Ducharme.
References 465
Prevention Prefer tissue sparing techniques with axial

division. Consider performing laryngeal tie-forward associated
at the same time of epiglottic entrapment release when the
epiglottis is very hypo-plasic.
Diagnosis Resting and exercising endoscopy
Treatment When permanent DDSP is observed, use

lidocaine and instrument manipulation for the assessment
of the status of the epiglottis, and to see if entrapment is
present. As it is a consequence of sub-epiglottic
inflammation, first apply medical treatment. Then consider
a laryngeal tie-forward procedure, possibly associated with
staphylectomy after long-term non-response to medical
treatment. Perform laryngeal tie-forward when
postoperative intermittent DDSP occurs.
Figure35.15 Permanent displacement of the soft palate
associated with inflammation and edema of the periepiglottic
tissue following surgical treatment of epiglottic entrapment Expected outcome Usually fair to good after proper
using laser. Source: Fabrice Rossignol and Norm G. Ducharme. management
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468
36
Complicationsof Surgeryfor Diseasesof the GutturalPouch

Anje G. Bauck DVM, DACVS-LA and David E. Freeman MVB PhD, DACVS
University of Florida College of Veterinary Medicine, Gainesville, Florida
Overview – Complications with transarterial embolization

techniques
Complications of guttural pouch surgery can be life-threat- ○ Intracarotid reactions
ening, because the unique anatomy of the guttural pouches ○ Complications with approach
brings them into intimate contact with vulnerable and crit- ○ Air or clot embolization
ical components of the nervous, respiratory, and cardiovas- ● Complications of surgery for temporohyoid osteoar-
cular systems. There is little forgiveness for surgical error, thropathy (middle ear disease)
which demands that the surgeon focus on ways to antici-
– Hemorrhage
pate and prevent them. The following are complications
– Peripheral nerve injury – hypoglossal nerve
that can be expected after the most common surgical treat-
– Regrowth of the stylohyoid bone
ments for guttural pouch diseases.
– Iatrogenic fractures
L
with Surgeryfor Diseases omplicationsof Surgeryfor Guttural
C
of the GutturalPouch PouchEmpyema
● Complications of surgery for guttural pouch empyema Surgical approaches to the guttural pouches are hyoverte-
– Failure to resolve brotomy, Viborg’s triangle, and Whitehouse (modified and
– Peripheral nerve injury original). These all enter the guttural pouch at almost the
– Parotid gland/duct trauma same location, medial to the stylohyoid bone and along the
● Complications of surgery for guttural pouch tympany floor or caudal aspect of the medial compartment
– Peripheral nerve injury (Figure 36.1). The hyovertebrotomy is a more caudal and
– Failure to resolve dorsal approach than the others and so it exposes the
● Complications of surgery for guttural pouch mycosis nerves where they are more closely grouped along with the
– Failure of ligation procedures internal carotid artery (ICA). This grouping allows these
– Complications with balloon-tipped catheters structures to be more easily palpated and avoided. However,
○ Complications upon approach – iatrogenic damage ventral drainage through this approach is difficult to
to nearby structures achieve and nerve damage is still possible. Also, dissection
○ Errors in identification of affected artery is close to the parotid gland and this needs to be deflected
○ Aberrant branches to prevent injury. With the Viborg’s triangle approach, care
○ Arterial penetration must be taken to avoid the parotid duct superficially. This
○ Incisional infection and the Whitehouse approaches converge on the floor of
○ Catheter dislodgement the guttural pouch between the stylohyoid bone and the
○ Balloon-related complications ventral straight muscles, where the glossopharyngeal
○ Blindness nerve, the pharyngeal branch of the vagus nerve and the
○ Failure of surgery to prevent hemorrhage hypoglossal nerve are located (Figure 36.1).
Complications of Surgery for uttural Pouch mpyema 469
IX, X, XI, XII Failureto Resolve

D
3
Definition Continued presence of inspissated purulent
2 4
material or chondroids in the guttural pouch following
5
initial treatment period
1 6
Risk Factors
IX
D A, B, C XII
● Inadequate surgical drainage or poor surgical planning
● Use of hyovertebrotomy or Viborg’s triangle approaches
C ● Chronic, severe empyema
A B
DEF
Pathogenesis In severe and/or chronic cases of guttural

Figure36.1 Transverse section of the interior of the left pouch empyema, conservative approaches to treatment
guttural pouch to demonstrate that three standard approaches:
may be ineffective. This may include attempts to flush the
Whitehouse, regular (A) and modified (B), and Viborg’s triangle
(C), approach from different sites but eventually must enter a guttural pouches through an endoscopic channel with the
confined part of the floor of the medial compartment (blue line) assistance of a basket snare, or the use of an indwelling
between the stylohyoid bone (6) and the ventral straight Foley catheter in lieu of surgical drainage. Although these
muscles (2). The internal carotid artery and sympathetic trunk (4)
methods may be effective in mild to moderate cases,
and cranial nerves IX to XII and their branches are located in
that confined area. The hyovertebrotomy (D) is a more dorsal failure to provide adequate surgical drainage in severe
approach and enters where all of these structures are more cases will often result in treatment failure. The more
closely grouped (green line) and therefore more easily dorsally-located approaches to the guttural pouch, such
recognized. However, no approach eliminates the risk of nerve
as the hyovertobrotomy or Viborg’s triangle approach,
damage. 1 = median septum; 3 = cartilaginous part of the
eustachian tube; 5 = external carotid artery and maxillary artery. provide less drainage than the more ventrally-located
Source: Reproduced from Freeman, D.E. (2008) Complications of approaches, such as the Whitehouse or modified
surgery for diseases of the guttural pouch. Vet. Clin. N. Am. Equine Whitehouse approaches.
Pract. 24 (3): 485–497, with permission from Elsevier.
Prevention Use of the Whitehouse approaches are

Deep dissection should aim toward a fixed structure, such preferred over the hyovertebrotomy or Viborg’s triangle, as
as the stylohyoid bone, or blind dissection will simply under- these approaches provide a large opening that is more
mine the mucosal lining ahead of it without making pro- ventrally-located and with more complete drainage. After
gress. Dissection through all deep layers to the guttural adequate surgical drainage, the incision should be left open
pouch should be with blunt instruments or digitally, and not to heal via second intention. The open incision can be used
through incision with scissors or scalpel. Identification of for repeat daily lavage.
the lining is difficult, especially in the absence of distention,
but can be facilitated by a lighted endoscope inserted into Diagnosis and Monitoring The guttural pouch should be
the medial compartment. However, mucosal inflammation flushed with balanced electrolyte solution for several days
obscures normal anatomy so nerves cannot be identified. following surgery. The color and consistency of the lavage
Although an incision in the guttural pouch mucosa has fluid collected after flushing can indicate if there is
been described by using Allis tissue forceps to elevate the continued build-up of purulent material within the
lining and then cutting this tented segment with scissors, pouch. Endoscopic exams should be used as needed to
this is not recommended because it carries a high risk of monitor progression of treatment. If the horse was
incising nerves in the mucosa. Also, retractors should be confirmed positive for Streptococcus equi equi
applied with care to avoid nerve damage, if used at all. (“Strangles”), appropriate microbiological testing should
Instead the lining should be punctured with the closed tips be performed on the collected guttural pouch lavage fluid
of scissors or a forceps (Carmalt or Kelly hemostat), forced to confirm negative carrier status (i.e. PCR or culture).
directly and deliberately through the mucosa medial to the Appropriate biosecurity protocols should be observed in
stylohyoid bone. Successful penetration is evident as any suspect case of S. equi equi as directed by the hospital’s
purulent material escapes during this procedure. The biosecurity office, until which time results of appropriate
instrument is not withdrawn, because this risks losing the diagnostic tests are available. All diagnostics and
opening. Instead the same instrument is used to enlarge treatments should be performed in an appropriate
the opening, and further enlargement is accomplished by isolation facility in any suspect or confirmed cases of S.
spreading the edges digitally. equi equi.
470 Complications of Surgery for iseases of the uttural Pouch
Treatment Response to medical treatment of empyema is Prevention Knowledge of the location of the nerves within
usually satisfactory, but if it fails, or if the purulent material the pouch is an important factor in preventing peripheral
becomes inspissated or forms chondroids, surgical drainage nerve injury during guttural pouch surgery. With careful
of the guttural pouch becomes necessary [1]. Surgical surgical technique and use of described approaches, the
drainage can be more effective and even less costly than a risk of nerve injury can be minimized. Please see
variety of nonsurgical methods that can be time- “Overview” above for descriptions of appropriate surgical
consuming, traumatic, unsafe and ineffective [2–4]. Failure technique. In chronic cases, entry into the guttural pouch
of medical treatments and surgical drainage to resolve can be more difficult due to thickening of the guttural
chronic forms of empyema can be resolved by creating a pouch wall. Although it is tempting to use sharp dissection
permanent fistula by laser from the guttural pouch into the rather than blunt dissection in these cases, this should be
pharynx [5]. Combined with postoperative daily lavage of avoided; appropriate use of blunt dissection is key to
the guttural pouch with an indwelling Foley catheter, this preventing iatrogenic nerve injury.
procedure can lead to resolution of chronic empyema and/
or chondroids [5]. The fistula provides a route for drainage Diagnosis and monitoring Peripheral nerve injury will
separate from the pharyngeal orifice, which is so inflamed usually become apparent when the horse is fed after
and distorted from chronic disease that it is no longer surgery. Damage to the glossopharyngeal nerve and
functional [5]. pharyngeal branch of the vagus nerve will typically
manifest as dysphagia. Clinical signs may include coughing,
Expected outcome Response to treatment is usually sneezing or return of feed material, water, mucus, and
satisfactory if adequate drainage is provided. saliva from mouth and nostrils. In chronic cases, signs of
aspiration pneumonia may develop. Endoscopic
examination should reveal evidence of cranial nerve
PeripheralNerveInjury damage responsible for dysphagia, such as dorsal
displacement of the soft palate, collapse of the roof of the
Definition [6] pharynx, and food material in the nasal passages, larynx
● Damage to one or more of the multiple nerves located in and pharynx. Damage to the recurrent laryngeal nerve
close proximity to the guttural pouch. Depending on the should be evident as laryngeal hemiplegia on the affected
degree of neuronal damage this can be classified as: side. Endoscopic examination and test feeding should be
performed and repeated daily to monitor improvement.
● Neuropraxia (Sunderland 1st-degree injury): loss of
nerve function without loss of axonal continuity; Treatment There is no satisfactory treatment of
Wallerian degeneration of the axon does not occur. neurotmesis induced by traumatic injury or nerve
● Axonotmesis (Sunderland 2nd-degree injury): disruption transection during guttural pouch surgery, although time
of the axon of the nerve; Wallerian degeneration of the can be allowed for the horse to adapt to loss of normal
axon does occur. swallowing mechanisms. If neuropraxia or axonotmesis is
● Neurotmesis (Sunderland 3rd-, 4th- and 5th-degree induced by inflammation or trauma from nearby dissection,
injury): disruption of the axon as well as the connective then allowing time and treatment with non-steroidal anti-
tissue sheath; Wallerian degeneration of the axon does inflammatory drugs (NSAIDs) and corticosteroids might
occur. allow full recovery. Enteral and parenteral feeding methods
can be used to provide nutritional support, but can be
Risk Factors costly, need to be used for weeks or months, demand
considerable commitment by all concerned, and require an
● Traumatic surgical technique acceptance of failure, despite the effort required.
● Poor surgical planning
Expected outcome In cases of neuropraxia, the horse could
Pathogenesis Risks of guttural pouch surgery include regain function within 3 to 8 days [6]. In cases of
permanent dysphagia and other neurological signs from axonotmesis and neurotmesis, nerve function will only be
surgically inflicted nerve damage. These complications regained through regeneration and reinnervation.
usually arise from damage to the glossopharyngeal nerve Therefore, the long-term prognosis is likely dependent on
and pharyngeal branch of the vagus nerve, which are close degree of nerve damage. Long-term complications
to sites of guttural pouch entry by most surgical methods associated with aspiration pneumonia may be the limiting
(Figure 36.1). factor in these cases and prognosis is often poor.
Complications of Surgery for uttural Pouch ympany 471
ParotidGland/DuctTrauma and a chalky deposit can develop over time along the
intermandibular space from calcium deposited from the
Definition Postoperative salivary drainage through a
parotid saliva.
wound as a result of accidental trauma to the parotid gland
or one of its ducts Treatment Conservative treatment is usually sufficient to
allow damage to these structures to heal by second
Risk Factors intention. Failure to heal by second intention might require
● Traumatic surgical technique repair with a stent and end-to-end anastomosis of the
● Poor surgical planning severed ends. An alternative to primary repair is duct
● Using a surgical approach that is close to the parotid duct ligation or chemical ablation if drainage fails to resolve
(Viborg’s Triangle or Modified Whitehouse approach) after approximately 3 weeks [7]. Formalin (10%) or water-
soluble iodinated contrast material are two agents currently
Pathogenesis Risks of guttural pouch surgery include recommended for chemical ablation [8, 9]. Complications
trauma to the parotid gland or duct. The duct runs of this procedure include facial swelling, facial nerve
superficially close to the floor of the guttural pouch and paralysis anorexia or dyspnea, so conservative treatment
may be damaged during the more ventral approaches should be attempted first [7].
(Figure 36.2).
Expected outcome Salivary drainage as a result of damage
to the parotid gland or duct usually resolves slowly over
Prevention Knowledge of the location of the parotid gland
weeks after surgery.
and duct is an important factor in preventing trauma to
these structures during guttural pouch surgery
(Figure 36.2). With careful surgical technique and use of omplicationsof Surgeryfor Guttural
C
described approaches, the risk of parotid injury can be PouchTympany
minimized. Please see “Overview” above for descriptions
of appropriate surgical technique. Guttural pouch tympany can be treated by temporary alle-
viation through needle decompression or an indwelling
Diagnosis and monitoring Damage to the parotid duct can trans-nasal catheter. A more definitive approach is to
be readily diagnosed by observing the incision site while surgically open the guttural pouch (see approaches above)
the horse is eating. Saliva will be noted draining from the and establish an egress route for trapped air through a
incision almost immediately as the horse begins masticating fenestration in the median septum or though enlargement
of the pharyngeal orifice [1]. Open and laser approaches
have been described for these procedures [10–12]. The pre-
ferred open approach for tympany is through Viborg’s tri-
angle or through a modified Whitehouse approach
(Figure 36.1). The tympanitic pouch is easier to enter than
the normal or inflamed pouch because the distended lining
is usually in a subcutaneous position, and the nerves are
Parotid
Salivary more obvious than normal or have been displaced from the
1
Gland line of dissection. However, chronic inflammation can
prevent nerve identification, even if the interior is well
illuminated with the endoscope. A delay to surgery could
2
predispose to empyema and bronchopneumonia [13]. The
3 prognosis for full recovery after surgery for tympany is
good [1, 12], although nerve damage secondary to surgery
DEF
4 can cause dysphagia, aspiration pneumonia, and death.
Parotid Parotid
Salivary Salivary
Duct (a) Duct (b) PeripheralNerveInjury
Figure36.2 Parotid salivary duct (a) is part of duct exposed on Neurological deficits secondary to surgery can be handled
lateral aspect of the head. Parotid salivary duct (b) is part of duct
as described above for empyema. Please refer to Section
exposed on medial aspect of the mandible.
1 – Hyovertebrotomy; 2 – Viborg’s; 3 – Whitehouse; 4 – Modified above on Complications of Surgery for Guttural Pouch
Whitehouse Empyema.
Failure to Resolve catheter at least once during the treatment period [16].
Most commonly, this treatment can fail when owners
Definition Continued presence or recurrence of the
become frustrated about the need for repeated replacement
guttural pouch tympany following initial treatment period
after catheter dislodgement [16, 17[.
Risk Factors
Diagnosis and monitoring Failure to resolve or recurrence
● Bilateral disease of guttural pouch tympany will be readily apparent by the
● Failure to diagnose bilateral disease pathognomomic clinical sign of unilateral or bilateral,
● Inadequate size or completeness of fenestration non-painful, elastic swelling of the parotid region.
● Conservative treatment methods
Treatment The selection of a procedure to correct a failed
Pathogenesis Failure to correct the tympany at the first surgery could depend on the cause of the failure. The
surgery was reported in 30% of 50 foals that had standing fenestration procedure can fail if the fenestration seals, or
laser surgery with sedation in one study, with 14% requiring if the mucosal lining was removed only from the near side
the second surgery during initial hospitalization and 16% of the septum and was left intact on the far side, relative to
requiring the second surgery during a second the surgical approach [1, 11, 14]. Such cases should respond
hospitalization [12]. Six of 7 foals that needed a second to repeat of the fenestration procedure, taking care to
surgery had been treated initially by combined fenestration ensure that the resulting opening in the median septum is
of the median septum and resection of parts of the plica patent and allows passage of an endoscope or instrument
salpingopharyngeal [12]. Repeating the first surgery was from one pouch to the other. Fenestration of the median
successful in most of the foals that needed a second septum should be at least 2 cm2 in size [1], Additional steps
surgery [12]. such as placement of an indwelling Foley catheter through
Accurate distinction between unilateral and bilateral the fenestration can be considered, but is usually
involvement is one possible cause of surgical failure. Based unnecessary and difficult to maintain.
on most reports [12–15], recurrence or complications can The fenestration procedure can also fail if the disease is
be expected in horses in which the initial surgery involves bilateral. In such cases, if the median septum was effectively
enlarging the pharyngeal ostium on the affected side. fenestrated, a small segment (1.5 × 2.5 cm) of the medial
lamina of the eustachian tube and associated mucosal fold
Prevention Although a salpingopharyngeal fistula can of the plica salpingopharyngea can be removed at the
provide a satisfactory treatment, its effects on upper airway second surgery. However, resection of the mucosal fold of
dynamics in racehorses is unknown or not established. the plica salpingopharyngea can fail to relieve tympany if it
Therefore, fenestration of the median septum should be induces sufficient swelling and inflammation along the
the first surgery attempted in foals that lack strong clinical mucosal incision to close the pharyngeal orifice [15].
evidence of bilateral involvement. It is recommended that Bilateral partial resection of the caudal extent of the plica
the size of the fenestration is at least 2 cm2 to minimize the salpingopharyngea and fenestration of the median septum
risk of the defect sealing [1]. Although this approach will can be performed with laparoscopic instruments to reduce
fail if the condition is bilateral, and the owner needs to the risk of nerve damage [13]. Alternatively, transendoscopic
recognize this, it can be justified by its simplicity and by electrocautery or laser methods can be used to create a
recognizing that even more aggressive approaches can also fenestration in the median septum or to make a fistula into
fail [12–14]. An alternative to surgery should also be the guttural pouch through the pharyngeal recess or in the
considered, and favorable success rates with indwelling wall of the pharynx, caudal to the guttural pouch
trans-nasal Foley catheters in the pharyngeal orifice for 4 opening [10]. The salpingopharyngeal fistula created in
to 6 weeks have been reported [16, 17]. Although this way can seal if the Foley catheter used to keep it patent
maintaining the catheter in place for 4 to 6 weeks, in order initially does not stay in place for the period required for
to induce the necessary necrosis in the pharyngeal orifice the fistula to mature (~4–6 weeks) [16], if the fistula is
can be a challenge, this method can provide an inexpensive, created within the defective part of the pharyngeal ostium,
safe and permanent solution in such cases [16, 17]. The or if it is occluded by inflammation [10, 11, 13].
catheter is usually secured in place by suturing the end to
the external nares or taping to the headcollar, although Expected outcome Repeat septum fenestration is often
these steps are not always sufficient to prevent the foal successful, so long as the condition is unilateral and repeat
from prematurely removing the Foley catheter. In a recent fenestration successfully removes an adequate section of
retrospective, 4 out of 8 foals required replacement of the the septum. In cases in which a salpingopharyngeal fistula
Complications of Surgery for uttural Pouch ycosis 473
is required, its effects on upper airway dynamics in technique and a thorough understanding of the vascular
racehorses have not been established. Bilateral cases can anatomy of the major vessels and location of the lesion
respond favorably to partial resection of the plica may help reduce the likelihood of treatment failure. An
salpingopharyngeus [18]. understanding of not just the typical anatomy but also the
most common branching patterns described is necessary
for proper decision making at the time of surgery [22, 232].
omplicationsof Surgeryfor Guttural
C Intraoperative angiography can be critical to identifying
any anatomical variations which may require adjusted
PouchMycosis
placement of ligatures.
Approximately 50% of horses with hemorrhage from gut-
Diagnosis and monitoring Complete failure of the ligation
tural pouch mycosis die from this complication [19], which
procedure is usually accompanied by severe epistaxis, as in
has led to development of highly effective procedures for
the original condition, usually within a short period after
vascular occlusion of the affected arteries [1]. The arteries
surgery, as during anesthetic recovery.
most commonly affected are the ICA, the maxillary artery
(MA), and its parent branch, the external carotid artery
Treatment Ligation of the ICA reduces flow to 19% of
(ECA). The occlusion procedures must be performed as
control values [24], but does not drop blood pressure distal
emergencies after the first bout of hemorrhage to prevent
to a ligature, so that the ligature may not immediately
subsequent bouts that could render the horse a poor
prevent fatal hemorrhage [25]. Ligation distal to the site of
candidate for anesthesia and surgery. Therefore, delays in
arterial erosion is difficult and likely to damage the
diagnosis or treatment can have fatal consequences. Also,
sympathetic nerve trunk [26]. Ligation of the ipsilateral
the affected artery must be correctly identified and
common carotid artery (CCA) in a horse bleeding from the
distinguished from aberrant branches to allow effective
ICA would increase flow in the affected artery and would
occlusion. Various methods have evolved over the years to
be contraindicated; however, the same procedure might be
allow complete and safe occlusion of the affected artery,
of benefit in horses bleeding from the ECA and its
and each of these has its own set of complications.
branches [24]. Therefore, if the source of hemorrhage is
unknown, ligation of the ICA directly would seem
Failureof LigationProcedures preferable to ligation of the CCA [24]. Although ligation of
the major palatine artery (MPA) could prevent retrograde
Definition The single ligation procedure is the simplest
flow to the ECA, a combination of this procedure with
procedure for occluding the carotid branch affected by
occlusion of the ECA and ICA can cause ischemic optic
guttural pouch mycosis and complications are few except
neuropathy and permanent blindness [27]. Occlusion of
for one, and that is failure to consistently prevent
the CCA on the side of the lesion combined with antifungal
hemorrhage [20].
treatments failed to prevent hemorrhage in 21% of horses,
which would not be regarded as a satisfactory outcome
Risk Factors
compared with other vascular occlusion methods [28]. All
● Use of a ligation procedure with a single ligature on the horses with treatment failures had lesions affecting the
cardiac side of the lesion ICA [28].
● Severe hemorrhage (may limit preoperative planning)
● Inexperienced surgeon Expected outcome If the ligation procedure fails in the
● Failure to identify the affected artery postoperative period and is accompanied by severe
epistaxis, emergency surgical intervention is warranted to
Pathogenesis A single ligature close to the origin of the prevent fatal hemorrhage.
ICA can prevent fatal hemorrhage in most cases, possibly
because of gradual thrombosis of the stagnant column of
Complicationswith Balloon-TippedCatheters
blood distal to the ligature [21]. However, before that
happens, fatal or severe hemorrhage can arise from The advantage of the nondetachable balloon-tipped
retrograde flow through the cerebral arterial circle (circle catheter over single ligation is immediate intravascular
of Willis). occlusion of normograde and retrograde flow to the
vascular defect on the affected artery [1]. Without
PreventionAdequate surgical planning, intraoperative interruption of retrograde flow, both the ICA, the ECA and
imaging (i.e. fluoroscopic angiography), meticulous branches are at risk of fatal persistent postoperative
hemorrhage. Complications with this procedure can arise Errors in identification of affected artery
in different ways as follows. Definition
Failure to correctly identify the affected artery at preopera-
Complications upon approach – Iatrogenic damage to tive endoscopic exam or failure to occlude the involved
nearby structures artery at surgery
Definition
Damage to the parotid gland or parotid duct upon surgical Risk Factors
approach or failure to locate the affected artery ● Large, diffuse lesion
● Active bleeding
Risk Factors ● Aberrant vasculature patterns
● Traumatic surgical technique ● Inexperienced surgeon
● Poor surgical planning ● Anatomical variation or arterial branching
● Poor anatomical knowledge ● Absence of imaging guidance for surgery
Pathogenesis Surgical treatment of guttural pouch

Pathogenesis The approach to the ICA involves dissection
mycosis requires occlusion of retrograde and normograde
through fascia attaching the wing of the atlas to the parotid
flow through the affected artery (ICA, ECA and MA).
salivary gland, where it is possible to damage lobes of the
Accurate endoscopic identification of the affected artery is
parotid gland and cause transient parotid leaking [29]. To
not always possible, unless the lesion is discrete and
occlude the MPA and prevent retrograde flow to the ECA
situated on one artery only. If the lesion is extensive and
and its branches, a difficult dissection is required from the
overlies both the ICA and ECA and branches of the latter,
edge of the interalveolar space. This can cause hemorrhage
then both these vessels are occluded. Aberrant vascular
from the plexus of vessels in the palatine mucosa and
patterns may also complicate the correct identification of
complicate identification of the artery. Also, this artery is
the affected vessel. Distinction between the OA and ICA
quite small, and spasm induced by handling tends to
can be difficult in some horses, especially those with a
reduce its size further.
thick neck and those in which both arteries arise as a single
trunk and bifurcate at a variable distance from the
Prevention Damage to the parotid gland can be avoided by CCA [22].
using a more ventral approach below the wing of the atlas
that would expose the CCA immediately caudal to the Prevention Contrast angiographic studies ideally should
point of origin of the ICA. Dissection rostrally from this precede balloon catheterization to identify the affected
point should readily expose the ICA and occipital artery artery (arterial wall defects, outpouching of the wall), and
(OA). aberrant branches. However, unlike the detachable
embolization methods (see below), the presence of the
Diagnosis and monitoring Damage to the parotid gland or balloon shaft in the artery of interest makes post-insertion
duct may not be noted until the postoperative period. Saliva angiography almost impossible (see Pathogenesis below).
will be seen leaking from the incision or accumulation of If both the OA and ICA arise in the normal fashion, the
saliva may be evident under the skin. recommended method for identification is to dissect them
free and then elevate each one gently with umbilical tape
Treatment Hemorrhage can be controlled by pressure, or a Penrose drain. The ICA should then be evident deep to
clamping with hemostats, and electrocautery. the OA and along a more rostral course.
See Treatment section for “Parotid Gland/Duct Trauma”
above for treatment of parotid gland or duct iatrogenic Diagnosis and monitoring The patient may suffer additional
trauma. episodes of epistaxis postoperatively if there is a failure to
correctly identify the affected lesion.
Expected outcome Iatrogenic hemorrhage is usually
transient and should be addressed at the time of surgery. If Treatment If there is a concern that the affected artery was
properly addressed at surgery, there is little effect on incorrectly identified, it is recommended that endoscopic
expected outcome. Salivary drainage as a result of damage exam of the guttural pouch be repeated during surgery to
to the parotid gland or duct usually resolves slowly over confirm. As noted above, angiographic studies may help
weeks after surgery. confirm which artery is affected.
Expected outcome If there is a failure to correctly identify Prevention If angiography is not available, as much ICA as
the affected lesion, episodes of catastrophic postoperative possible should be exposed by careful dissection toward the
epistaxis may occur postoperatively. roof of the guttural pouch (~6 cm), in the hope that any
aberrant branch can be found and ligated [31]. If familiar
Aberrant branches with the standard branching pattern and aware of the
Definition described aberrant branching patterns, the surgeon can
Aberrant branches are a pattern of vasculature within the usually prevent complications associated with ligation of
guttural pouch that is different from the standard branching an aberrant vasculature.
pattern described. Although aberrant branches are rare [22]
they can cause catastrophic failure when any occlusion Diagnosis and monitoring The strongest intraoperative
device, such as a balloon catheter, is inserted blindly indication that a catheter is in an aberrant branch of the
[39. 31]. ICA, especially if penetration through a defect in the artery
is ruled out by endoscopy, is lack of resistance to passing it
Risk factors No specific risk factors have been identified beyond the 13-cm mark [30, 31]. Catheterization of the
that predispose to aberrant vasculature, but placement of affected artery can be monitored endoscopically to ensure
occlusion devices blindly increase the risk of catastrophic that the catheter is in the correct vessel, although this can
complications associated with these aberrant branches. be difficult if landmarks are obscured by blood or the
lesion. The catheter tip should be visible as it passes up the
Pathogenesis The major limitation with the artery, and the balloon can be inflated at intervals to
nondetachable balloon-tipped catheter is that it is usually demonstrate its position. Fluoroscopy is the method of
inserted blindly (without fluoroscopic guidance) into an choice to define aberrant branches and to confirm occlusion
artery or arteries identified as the most likely sources of of affected branches, but is not always readily available in
hemorrhage based on endoscopic examination [29, 32, many hospitals. Contrast studies cannot be used in an
33]. The presence of aberrant branches of the ICA [22] arterial branch that is occupied by a balloon catheter.
are not identified by this method in the absence of However, a single postoperative radiograph can be used to
preoperative angiography and this method does not allow confirm accurate placement (Figure 36.4). Any occlusion
negotiation away from such branches, even if they are device in the ICA should be readily identified as a
identified beforehand. Also post-insertion angiography is radiopaque structure superimposed on the air density of
impossible because the catheter shaft limits access to the the guttural pouch, partway between the ventral aspect of
arteries of interest. Angiography through the CCA might the atlas or the jugular process(es) caudally and the vertical
be of value if the catheter is placed in the wrong vessel, ramus of the mandible cranially (Figure 36.5). Absence of
provided that the misplaced catheter shaft does not the occlusion device in this site probably indicates a
obstruct flow to the site of bleeding. different location, most likely the occipital artery
Four groups of variations in ICA anatomy have been (Figure 36.4).
identified in 17% of 100 pouches in healthy horses and the
most common is origin of the ICA and OA as a common Treatment Depending on the precise location and pattern
trunk (5%) [22]. Others are an aberrant branch of the of the aberrant vasculature, modifications to the location
extracranial ICA that connects with the basilar artery of the intravascular occlusion may be necessary. For
(Figure 36.3), an aberrant branch of the ICA that ramifies example, in the case described above (duplication of the
into the surrounding tissues, and an aberrant branch of ICA that connects with the caudal cerebellar artery:
the ICA that gives rise to several smaller branches, includ- Figure 36.3), the surgeon has little choice but to occlude
ing connections with the ipsilateral OA [22]. Others this branch in such cases, but must not occlude it too close
include an abnormal ICA course that connects this artery to its junction with the caudal cerebellar artery
with the caudal cerebellar artery at its origin from the (Figure 36.3), to prevent temporary or permanent
basilar artery and where occlusion can cause fatal neuro- neurological signs [23].
logical complications (Figure 36.3). In this variation, the
ICA does not connect with the arterial circle on that side Expected outcome Occlusion of aberrant branches can
(Figure 36.3). A branching or duplication of the ICA that cause neurological complications [30] or allow retrograde
connects with the caudal cerebellar artery can be identi- flow to the eroded segment and fatal hemorrhage [31].
fied by angiography in some horses and might even be the Ligation of an accessible aberrant branch should prevent
branch affected and therefore the source of hemor- the catheter from entering it, but such direct access can be
rhage [23] (Figure 36.3). poor.
(a) Rostral Cerebral (b)

Artery
Site of exit
from Venous
Sinuses
First bend of Hypophysis Caudal
Sigmoid Flexure Communicating Artery
B B
Roof of
Guttural
Pouch
Caudal
Intercarotid
Lesion Artery C
Basilar Artery Styloid Process

of Petrous Part
of Temporal Bone
Caudal
A Cerebellar Artery A
Normal
Left Internal
Carotid Artery DEF DEF
(c) (d)
B
A
A
DEF
DEF
Figure36.3 (a) Dorsal view of the normal anatomy of the terminal portions of the internal carotid arteries and the arterial circle at
the base of the brain and roof of the guttural pouch. Rostral is to the top of the image. Proximal (A) and distal (B) occlusion devices
(nitinol plugs in this example) are positioned ideally in the left internal carotid artery relative to the lesion. (b) Anatomy of an aberrant
branch to the basilar artery. All nitinol plugs are positioned ideally to arrest flow to the lesion on the internal carotid artery. If plug C
were omitted, retrograde flow from the basilar artery to the internal carotid artery (red arrow) would be unimpeded. If plug B were
omitted in the erroneous belief that C was in the internal carotid artery, retrograde flow from the arterial circle would persist [27].
Placing plug A at the green arrow would be effective in this case and eliminate the need for plug C, but this placement would be
ineffective if the infection were on the aberrant branch. (c) Anatomy of an internal carotid artery connecting with the caudal cerebellar
artery at its junction with the basilar artery, and without any direct connections with the arterial circle. Proximal (A) and distal (B)
occlusion devices (nitinol plugs) are positioned ideally relative to the lesion on the internal carotid artery. However, if B were inserted
to the red arrow, it would occlude the caudal cerebellar artery and cause neurological signs [26]. (d). Anatomy of an internal carotid
artery bifurcation or duplication, with one branch following the usual course and the other connecting with the caudal cerebellar
artery [28]. All plugs are appropriately placed for this lesion. Plug C must not be placed too far distally or it will occlude the caudal
cerebellar artery [28]. Plug A could be placed distal to the bifurcation at the green arrow and be effective in this example, but would
be ineffective if the branch to the caudal cerebellar artery were eroded proximal to plug C.
Figure36.4 Laterolateral radiograph taken the day after

insertion of a nondetachable balloon catheter into the occipital
artery instead of the intended vessel, the internal carotid artery Figure36.5 Landmarks used to locate the internal carotid
(rostral is to the right). The long black arrow indicates the point artery in the guttural pouch and the appropriate site for the
at which the radiopaque catheter shaft starts to be most proximal occlusion device (nitinol plug in this case). This is
superimposed on the atlas, beneath the skin staples. Redundant an intraoperative laterolateral fluoroscopic image of the
catheter is evident in the ventral aspect of the surgery site. The guttural pouch area of a horse undergoing transarterial coil
catheter cannot be seen superimposed on the guttural pouch embolization. Rostral is to the right. The guttural pouch outline
cavity, between the ventral tubercle of the atlas (white arrow) should be defined caudally by the ventral aspect of the atlas
and the vertical ramus of the mandible (short black arrow), (left white arrow) and cranially by the vertical ramus of the
which means that it is not in the internal carotid artery. The mandible (right white arrow). The black arrow indicates the
short white arrow indicates the dorsal edge of one stylohyoid jugular process and the most proximal occlusion device should
bone. not be advanced beyond this level.
Arterial penetration with endoscopic monitoring during surgery may help

Definition minimize the risk of this complication. The use of a
Penetration of the affected artery during passage of the 6-French venous thrombectomy catheter (Fogarty-Edwards
balloon-tipped catheter [32] Laboratories) is recommended to prevent this complication,
because it has a soft flexible tip that facilitates difficult
Risk Factors negotiation through the bend on the roof of the guttural
pouch and then through the first bend in the sigmoid of the
● Compromised integrity of the vessel wall from advanced ICA.
lesions.
● Traumatic surgical technique. Diagnosis and monitoring Resistance to passage will be lost
● Use of a rigid tip of the 6-French arterial embolectomy if arterial penetration occurs, and a long segment of
catheter. catheter can be advanced with ease. Endoscopy of the
pouch should help confirm diagnosis of this complication.
Pathogenesis Any device inserted through a catheter
could penetrate the defect in the eroded segment of artery, Treatment If a balloon catheter penetrates the arterial
but this is more likely with the nondetachable balloon defect during insertion (Figure 36.6), it can be withdrawn
catheter. As the catheter is being inserted in the ICA, it can and re-advanced as needed, while rotating the catheter to
penetrate the defect in the artery and enter the guttural take advantage of any curvature in its shaft that would
pouch (Figure 36.6). direct it away from the arterial defect. If this fails, the
balloon is inflated with saline, the catheter withdrawn so
Prevention Unfortunately, susceptibility of the vessels to as to snug the inflated balloon against the outer edge of the
penetration is an inherent risk of this procedure and a hole in the artery, and another catheter is passed alongside
complication that should be discussed with owners prior to the first (Figure 36.6). With the hole blocked in this way,
surgery. However, careful surgical technique combined the second catheter should easily advance beyond this
although it only develops in a minority of cases [29]. With

a catheter in the ICA, the shaft spans the mycotic plaque
and bacteria can track from this to the incision. Infection is
most likely if the distal arterial pressure displaces the
balloon into the infected segment of artery. With a catheter
B
B
in the MPA, the arteriotomy is performed through the oral
mucosa, which could be a source of contamination.
A Burying of catheters is also not a possibility at this location.
A
Prevention Displacement of the balloon-tipped catheter

can be prevented by using a rigid catheter and by inflating
the balloon to its maximum diameter.
DEF If the MPA is used for access, nondetachable balloon
catheters should be removed after approximately 7 days.
Figure36.6 Accidental penetration of the defect in the
internal carotid artery by the red balloon catheter (A). This is
corrected by withdrawing this catheter until the balloon impacts Diagnosis and monitoring Purulent exudate at the surgical
against the hole, thereby plugging it so a second catheter (B) site will be the most common clinical sign associated with
can be inserted beside it into the correct location. Then the an incisional infection. If severe, patient may also develop
balloon of catheter (A) is deflated and that catheter is
withdrawn. Rostral is to the left. pyrexia and changes in the hemogram consistent with an
infection.
level. The first catheter can then be removed and the
second one advanced fully (Figure 36.6). If a second Treatment Once signs develop (swelling, drainage, fever),
catheter is not available, and attempts at redirection fail, the catheter must be removed by a cutdown procedure,
the catheter can be left with the balloon inflated and which is facilitated if the catheter were inserted in a
snugged securely against the edges of the arterial defect so subcutaneous pocket that would favor access to it. Failure
as to occlude and collapse the artery at this level. Another to do this could complicate access, which could lead to
approach, but more invasive and less desirable, is to open breakage of the catheter during removal or to failure to
the guttural pouch through a hyovertebrotomy (Figure 36.1) locate the catheter [29]. Balloon inflation with contrast
and digitally block the hole in the artery as the catheter is material instead of saline will prevent catheter removal
passed to and beyond it. Regardless of the method of because it can become too dehydrated to remove and allow
correction, any catheter placed after arterial penetration balloon collapse. Parenteral antibiotics may be necessary in
should be regarded as contaminated and should be severe cases that continue to show signs of infection, even
removed at approximately 7 days. This would be facilitated after removal of catheter.
by burying the redundant ends of the catheter in a
subcutaneous location under the original incision. Expected outcome Most infections are self-limiting upon
removal of the catheter. However, delays in removing an
Expected outcome Fortunately, this mishap is rare, and infected catheter can lead to fatal meningitis [1]. One horse
when it occurs, it rarely triggers bleeding [29] was presented with a draining tract at the site of catheter
placement 4 years after it had undergone balloon
Incisional infection catheterization for guttural pouch mycosis [1]. The
embolization catheter was removed with some difficulty,
Definition
but the horse developed a fever and severe seizures, and
Infection of the surgical site where the balloon-tipped cath-
was euthanized 2 days after catheter removal [1]. Necropsy
eters exit the incision
findings demonstrated a septic meningitis [1]. This case
demonstrates the importance of catheter removal as soon
Risk Factors
as signs of infection become evident or as a planned
● Displacement of the balloon into the infected segment of prophylactic procedure.
the artery
● Access through the MPA Catheter dislodgement
Definition
Pathogenesis The most common complication of using Postoperative migration of the catheter within the lumen
the nondetachable balloon catheter is incisional infection, of the artery
Risk Factors Pathogenesis Balloon deflation can occur after inflation

with air instead of saline, because air will diffuse out of the
● Long catheter ends that are not adequately buried
balloon over time. The balloon could also be damaged
● Balloon deflation (see below)
during insertion by handling it with the edge of a metal
Pathogenesis Blood pressure in the segment of ICA distal instrument.
to the inflated balloon can force the balloon backward into
the infected segment of artery. Such displacement can Prevention Before the catheter is inserted, it should be
cause the balloon to penetrate through the hole in the filled and aspirated repeatedly with saline while the
artery into the guttural pouch, which could lead to an catheter tip is held below the syringe plunger. This will
incisional infection (see above). Hemorrhage is possible purge it of air and prime it with saline, as well as test
but rare after such displacement. Catheters in the MPA and balloon integrity. Despite the temptation to fill the balloon
transverse facial artery cannot be buried, and are with a radiopaque compound so that it can be demonstrated
sufficiently exposed to get hooked on fixed objects and radiographically in the artery, this is not recommended.
become prematurely extracted. Contrast materials tend to become inspissated within the
balloon, so that subsequent balloon deflation and catheter
Prevention Adequately burying the catheter ends (when removal can be difficult or impossible.
possible) may help reduce the risk of premature
dislodgment. Otherwise, attempts to keep the head Diagnosis and monitoring Balloon deflation may lead to
bandaged or the catheter ends otherwise protected are catheter migration or dislodgement (see above).
recommended.
Treatment If there is no migration of the catheter
Diagnosis If a catheter in the MPA becomes completely
associated with damage to the balloon, this complication
dislodged, this will be immediately apparent upon
may go undiagnosed and may not require specific
examination of the patient’s surgical site. As noted above,
intervention. For treatment, please refer to the Section on
catheter dislodgement is only rarely associated with acute
Catheter Dislodgement above.
hemorrhage. If the catheter migrates without complete
dislodgement, this may be associated with an incisional Expected outcome Premature deflation of the balloon may
infection (as noted above). result in treatment failure if balloon-tipped catheter is not
replaced. However, if adequate time has passed since the
Monitoring Patient should be carefully observed for
time of placement, deflation of the balloon may have no
evidence of hemorrhage following dislodgement or
effect on outcome.
displacement of the catheter.
Treatment Depending on the length of time the balloon- Blindness

tipped catheter was in place prior to dislodgement, this Definition
complication may or may not require an additional surgery Acute, postoperative, ipsilateral blindness
to occlude the artery. This is rarely required, especially if
the catheter remained in the desired location for at least 3 Risk Factors
to 4 days.
● Severe hemorrhage
Expected outcome If hemorrhage does not occur when the ● Concurrent ligation of the ECA and ICA [34]
catheter is dislodged, the expected outcome is unchanged
(providing that balloon-tipped catheter is replaced if Pathogenesis Horses can develop ipsilateral blindness if the
deemed necessary). occlusion procedure interrupts blood flow to the eye. Severe
hemorrhage alone can cause bilateral blindness. Blindness
Balloon-related complications has not been reported after balloon-catheter occlusion of the
Definition ICA only, but has been reported after ligation of the ECA
Damage to the balloon component of the balloon-tipped and ICA [34]. Balloon catheter occlusion through the MA
catheter does not cause blindness, even when combined with
occlusion of the ICA [33], but combined ligation of the ECA
Risk Factors
and MPA can cause blindness when combined with ICA
● Excessive air insufflation of the balloon occlusion [27]. Blindness when the ECA is occluded by
● Handling of the balloon with a metal instrument during ligation and not the balloon catheter can be attributed to the
insertion “steal phenomenon” [35] (Figure 36.7).
occlusion [35]. This diversion “steals” blood from the oph-

b thalmic artery in this case and causes blindness. The risk
9 9’ for the steal phenomenon to arise if the MA is not occluded
at (b) in Figure 36.7B is unknown, and could be low if flow
L Eye R Eye L Eye R Eye L Eye R Eye
A
from the opposite MA is sufficient to support flow to the
8 8’ opposite eye. However, such flow from the opposite MA
7 7’
6 6’ b would also allow retrograde flow through the lesion and
4 A
a a continued risk of hemorrhage.
5 3 3’ 5’
B B
Prevention Concurrent ligation of the ICA and ECA
should be avoided if possible. Use of a balloon-catheter is
preferred because the catheter shaft fills the MPA lumen so
1 2 1’
blood flow diversion to it is reduced. Detachable
DEF
Normal “Steal” Occlusion with embolization methods prevent the steal phenomenon by
phenomenon coils or plugs selectively occluding the affected vessels so that regional
blood flow is minimally disturbed.
Figure36.7 Role of the “steal phenomenon” to cause blindness
after some, but not all occlusion procedures, demonstrated on
the left side (prime after numbers indicates the right side): 1 = Diagnosis Evidence of unilateral, ipsilateral blindness will
left common carotid artery; 2 = basilar artery; 3 = internal often become apparent shortly after the patient recovers
carotid artery; 4 = circle of Willis; 5 = external carotid artery; 6 =
maxillary artery; 7 = internal ophthalmic artery (from circle of from anesthesia. The horse may become reluctant to move
Willis); 8 = external ophthalmic artery (from the maxillary through narrow spaces such as stall doors and stocks. A
artery); 9 = major palatine artery. The external ophthalmic artery complete ophthalmic and cranial nerve exam should
(8) is the major blood supply to the horse’s eye and it confirm the diagnosis.
anastomoses inconsistently with the internal ophthalmic artery
(7). The major palatine artery joins with the same artery from
the other side to form a substantial arterial loop in the upper Monitoring Cranial nerve exams such as the menace
jaw. The “steal” phenomenon develops when the external carotid response and pupillary-light response should be repeated
is ligated at “a” and the major palatine artery is ligated at “b” to
reduce or eliminate blood flow through the intervening segment
daily to monitor for resolution of blindness.
(a) and prevent bleeding through the maxillary artery. The
internal carotid artery is occluded at the same time if there is Expected outcome Owners should be warned of the low
doubt about the source of hemorrhage. In combination, these risk of unilateral blindness following any ligation technique
ligations decrease blood pressure in A (goal of the surgery),
which would favor such diversion of blood flow from the
for occlusion of the ECA and its branches that pass within
external ophthalmic artery in the direction of the arrow. Blood the guttural pouch. Although blindness may be permanent,
flowing into the external ophthalmic artery from critical a case recently treated by the authors experienced
collateral sources, such as the internal ophthalmic artery, would resolution of the blindness approximately two weeks
also drain into A through the external ophthalmic artery (arrow).
This flow of blood along the arrow demonstrates how segment
following only ICA occlusion.
A “steals” blood from the eye, so the eye loses compensatory
collateral flow when its normal blood supply is occluded. The Failure of surgery to prevent hemorrhage
role of the internal carotid artery occlusion is unknown in this Definition
explanation, except that it could reduce blood flow through the
internal ophthalmic artery, thereby jeopardizing blood flow to
Failure of balloon-tipped catheterization to prevent
the eye even more. Blindness is considerably less likely after hemorrhage
balloon catheter occlusion of segment A, presumably because
the catheter shaft physically reduces the intravascular volume in Risk Factors
A and hence its capacity to “steal” blood from the eye. If the
affected arterial segments are selectively occluded by ● Placement of the catheter in an incorrect artery
embolization with coils or plugs, blood flow to the eye should
● Blind placement techniques
be preserved, presumably because retrograde flow through the
major palatine artery is intact. (Reproduced from Freeman D.E. ● Aberrant vasculature
(2008). Complications of surgery for diseases of the guttural ● Extensive disease
pouch. Vet. Clin. N. Am. Equine Pract. 24 (3): 485–497, with
permission from Elsevier.)
Pathogenesis The balloon-tipped catheter techniques
The conditions for the steal phenomenon are met when should prevent hemorrhage in all horses in which they
a major artery is occluded, and blood is diverted by back- are used, provided that the balloon is placed in the desired
flow from collateral channels into the segment distal to the location in the diseased artery. Without fluoroscopic
guidance, and with reliance on blind placement instead, ure to occlude the affected vessel can be reduced with this
fatal hemorrhage can arise from failure to occlude the methodology. However, the equipment necessary is not
affected segment of ICA because the catheter was available at all hospitals, nor is the expertise. Also keeping
misdirected into an aberrant branch [31] or into the OA the appropriate inventory of catheters, coils or plugs con-
(Figure 36.4). Failure to prevent hemorrhage with any stantly available for a small number of cases is costly, espe-
method can be caused by inadvertent occlusion of an cially because these materials have limited shelf lives that
aberrant branch [31] or of the wrong artery such as the can expire within the timeframe that spans the typical rates
ICA when MA is involved, OA when ICA is involved of admission for this disease. Under these conditions, non-
(Figure 36.4), or linguofacial trunk instead of the detachable balloon catheters are suitable and offer such
ECA [36]. advantages as simplicity of use, availability from nearby
human hospitals, and a high success rate.
Prevention Fluoroscopic guidance may minimize the risk The most recent generation of methods to occlude the
of incorrect placement, although it does not prevent it affected vessels in horses with hemorrhage from guttural
entirely. pouch mycosis includes detachable embolization devices,
such as self-sealing latex balloons [43, 44], transarterial
Diagnosis and monitoring Failure of the balloon-tipped coil embolization (TACE) [39, 40], and nitinol plugs [1,
catheterization techniques may result in fatal hemorrhage 41]. The last two seem to be the most popular and both
during the postoperative period. However, many horses are delivered under fluoroscopic guidance, and can
will continue to have mild epistaxis after surgery, but this is occlude aberrant vessels [1, 39–41]. These embolization
caused by continuous drainage of pooled blood from the procedures are considerably less invasive than the origi-
guttural pouch, and this does not indicate failure of the nal balloon catheter method and require shorter anesthe-
catheterization technique. sia and shorter hospitalization times. Both coils and
nitinol plugs can be delivered through a catheter inserted
Treatment If the patient is stable enough to undergo a into the CCA, which is exposed through a cutdown proce-
second surgical procedure, treatment involves repeating dure [1, 39–41], or even through ultrasound guided cath-
the surgery to catheterize the correct vessel and to remove eterization [36, 42].
the catheter from the “wrong” artery. The TACE procedure can be done standing to reduce cost
or to spare a poor candidate for general anesthesia from
Expected outcome Hemorrhage as a result of failure of the anesthetic risks [45]. Most complications with the standing
procedure can range in severity from mild epistaxis to TACE procedure can be avoided if the surgeon is
sudden and fatal hemorrhage. Although vascular occlusion experienced with the technique and knowledgable of the
procedures have been credited with hastened resolution of anatomy [36]. If there is any concern about suitability of
the mycotic lesion [37], this is questionable based on the the patient for this procedure, it should be conducted under
author’s experience [38]. general anesthesia [36].
Intracarotid reactions
Complicationswith TransarterialEmbolization
Definition
Techniques
A small number of horses can react adversely to intraca-
Selection of the method with the greatest likelihood of suc- rotid manipulation of the angiographic catheter, especially
cess and the lowest risk of complications is the most criti- when TACE is done standing. This can result in sudden
cal first step in achieving a successful vascular occlusion in collapse (if procedure is performed standing) or adverse
horses with guttural pouch mycosis. The ability to selec- responses under anesthesia.
tively occlude affected arteries with a minimally invasive
approach makes detachable embolization methods (coils Risk Factors Intra-arterial injection of contrast material
or plugs) most likely to meet these requirements [1, 39–42].
Fluoroscopic angiography is required for anatomical iden- Pathogenesis Injection of contrast material (meglumine
tification and location of the target vessels, to exclude vas- ioxithalamate) seems to increase the risk of intracarotid
cular anomalies and vascular connections between the reactions, especially if delivered rapidly [36]. Such
ICA and OA, to confirm correct positioning of the emboli- responses could be attributed to a transitory reduction in
zation device, and to detect any sites of leakage, partial cerebral blood flow or ischemia induced by arterial
occlusion, or aneurysm formation in the arterial defect [36, spasm [36]. Similar transient ischemic attacks have been
39]. Problems with incisional infection, blindness, and fail- recorded in human patients [36].
Prevention There are no specific preventative measures insertion is avoidable, and can be corrected by withdrawing
for these reactions but they can be minimized or completely the catheter slightly and repositioning it into the CCA
avoided by using general anesthesia and slow injection under fluoroscopic guidance [39]. Hematoma formation in
methods of the desired bolus size. the carotid sheath after catheter removal is rare and can be
avoided by closing the carotid arteriotomy with 5-0 silk or
Diagnosis and monitoring
Standard anesthetic monitoring similar material or by pressure bandaging if an ultrasound-
procedures and tools should be utilized following an guided approach is used [36].
intracarotid reaction.
Diagnosis and monitoring Misdirection of the arterial
Treatment The procedure should be continued under
catheter can be diagnosed via fluoroscopy. Hematoma
general anesthesia if the horse gives any suggestion of an
formation of the carotid sheath will be clinically apparent
adverse response during a standing procedure [36]. Also, if
in the immediate postoperative period as progressive
the standing procedure identifies complicated anatomic
incisional swelling. Physical and ultrasound examination
variations or arterial spasm or partial arterial occlusion,
of the swelling are useful tools to monitor the resolution of
the procedure might need to be completed under general
this condition.
anesthesia to provide the surgeon with the necessary
control for critical intraoperative steps [36].
Treatment There are no specific treatments for exposure
Expected outcome Recovery from this accident is typically of the surgeon’s hands to radiation, other than appropriate
complete. preventative measures as discussed above. Similarly,
misdirection of the angiographic catheter is a complication
Complications with approach which should be prevented or corrected during the
Definition procedure. A hematoma of the carotid sheath should be
Examples of complications encountered with the approach treated with pressure bandages and ice packs in the
for transarterial embolization procedures include: immediate postoperative period. Topical anti-
● Exposure of the surgeon’s hands to radiation during inflammatories such as 1% diclofenac sodium cream
fluoroscopy (Surpass®) may also be beneficial.
● Misdirection of the angiography catheter into the cranial
thyroid artery Expected outcome Radiation exposure to the surgeon will
● Hematoma formation in the carotid sheath be cumulative over years and there may be no negative
consequences in the immediate postoperative period.
Risk Factors However, good veterinary practice dictates that surgeons
should make every attempt to limit the amount of radiation
● Poor surgical planning and inadequate knowledge of the
exposure to them and their staff. In regards to misdirection
relevant anatomy
of the angiographic catheter, the expected outcome would
● Surgeon inexperience with transarterial embolization
only be negatively affected if the misdirection were not
procedures
immediately corrected at the time of surgery. If not
corrected, the embolization device would not be deployed
Pathogenesis Radiation of the surgeon’s hands occurs if
in the correct location and treatment failure could be
the arteriotomy is performed in a cranial location on the
expected.
neck, in an area that would be directly exposed to the
fluoroscopic beam. Misdirection of the angiography
Air or clot embolization
catheter into the cranial thyroid artery may be a result of
Definition
surgeon inexperience or lack of fluoroscopic guidance.
Accidental injection of air or dislodgement of a clot into
Finally, hematoma formation can occur if primary closure
the arterial system during an embolization procedure
of the artery is not completed satisfactorily.
Risk Factors
Prevention Exposure of the surgeon’s hands to radiation
during fluoroscopy is avoided by using the CCA for catheter ● Improper injection technique
insertion [39] distant to the area of interest for fluoroscopy. ● Traumatic surgical technique
An ultrasound probe can also be used to guide TACE and
reduce radiation exposure [46]. Misdirection of the Pathogenesis Air can be introduced into the arterial
angiography catheter into the cranial thyroid artery during system if there is a bubble of air remaining in the syringe
Complications of Surgery for emporohyoid steoarthropathy ( iddle ar isease) 483
used for injection. Air emboli will naturally begin to form tip might extend into and induce thrombosis at an
around the catheter immediately after introduction. undesirable site (such as in the arterial circle) or penetrate
through the defect in the artery [36, 39]. Too small a coil
Prevention Injection of air into the carotid arterial system might become dislodged from the desired site and plug a
must be avoided by carefully expelling air from all syringes, critical artery downstream. As with any intraarterial
and by performing injections with the plunger of the method of occlusion, arterial spasm or partial occlusion
syringe upward. To avoid embolization of thrombi that from fibrosis or thrombosis at the arterial wall defect could
may have formed within the catheter, heparinized saline is prevent passage of the catheter and this should be evident
flushed and aspirated before injection of contrast agent [1, with contrast fluoroscopy [29, 37].
39]. Trauma to the vessel should also be avoided to prevent
vasoconstriction, thrombosis, and difficulty in vascular Prevention A coil 20% larger than the arterial diameter is
filling [1, 39]. The distal (cerebral) side of the lesion in the placed first [36], and additional smaller imbricating
ICA is embolized first, to protect the cerebral circulation embolization coils follow until complete occlusion is
from any intraoperative errors such as air or clot obtained [39]. For the distal ICA coil, diameters of 5 to 8
embolization [1, 39]. mm are usually necessary, although 3 mm may be required
in smaller horses or ponies [36, 39]. In cases of fibrosis or
Diagnosis and monitoring During the procedure, standard thrombosis at the arterial wall, if the catheter cannot be
anesthetic monitoring procedures and tools should be used advanced rostral (cephalic) to the lesion, one occlusion
to monitor for any evidence of air or clot embolization. device should be placed as far distally in the artery as
Postoperatively, the patient may begin to show neurological possible, just adjacent to the lesion, and another is then
deficits, the type and severity of which will depend on the placed in the usual proximal (cardiac) site [36].
degree to which cerebral circulation was compromised.
Diagnosis and monitoring Fluoroscopic guidance during
Treatment General treatment recommendations for the procedure will assist the surgeon in judging if the coil
cerebral hypoxic events, such as an air emboli, in the horse is the appropriate size and is placed at the correct location
would include anticonvulsant therapy (if necessary), during the procedure.
intravenous DMSO (1 g/kg, 10% solution given with
lactated Ringer’s solution), corticosteroids, NSAIDs Treatment Misplacement of the coil may result in
(flunixin meglumine, 1.1 mg/kg), intravenous fluids, and treatment failure, which can have fatal or irreversible
nasal or tracheal oxygen. If a cerebral hypoxic event consequences. It may not be possible to correct these
develops secondary to thromboemboli, anticoagulant failures, even if a second surgical procedure is performed.
therapy (heparin, aspirin, etc.) may also be warranted.
Expected outcome Complications with coil placement can
Expected outcome Air or clot embolization can result in a allow fatal postoperative hemorrhage or cause neurological
range of negative outcomes. The extent and location of abnormalities.
cerebral incident will determine the effect on expected
outcome. These complications can range from mild,
recoverable neurological deficits to death. omplicationsof Surgery
C
for TemporohyoidOsteoarthropathy
Misplacement of embolization coils
(MiddleEarDisease)
Definition
Incorrect placement of the coil during an embolization
Unilateral partial ostectomy of the stylohyoid bone or uni-
procedure
lateral ceratohyoidectomy have been used as a prophylactic
measure in horses with temporohyoid osteoarthropathy
Risk Factors
(middle ear disease). With both procedures, removing a
● Incorrect coil size portion of the hyoid apparatus decreases the forces on the
● Poor understanding of the relevant anatomy ankylosed temporohyoid joint and thereby prevents
● Arterial fibrosis/thrombosis repeated fractures in and adjacent to that joint [47]. In a
● Limited experience with this surgical technique recent retrospective, ceratohyoidectomy was identified as
the more commonly performed surgical procedure with a
Pathogenesis Coil size is critical because if too large, a coil greater return to function compared to the partial stylohy-
will not expand fully and engage within the artery, and the oidectomy procedure [48]. Potential bridging callus of the
stylohyoid bone has also been reported [49], which is why artery completely or partly. The safest method for dissecting
the authors currently recommend a ceratohyoidectomy for the ceratohyoid bone off its attachments, both deep and
treatment of temporohyoid osteoarthropathy. superficial, is by shaving them off the bone with a narrow
osteotome or periosteal elevator. The edge of the instrument
should be kept against the surface of the ceratohyoid bone
Hemorrhage
in the process so that is does not engage the nerves or the
Definition Hemorrhage from the lingual artery artery.
encountered at surgery
Diagnosis and monitoring Transection of the artery or vein
Risk Factors will be obvious at the time of surgery. Appropriate
anesthetic monitoring should be used to monitor the
horse’s response to hemorrhage.
● Poor surgical planning
● Poor anatomical knowledge
Treatment If the lingual artery is transected, ligation of
the proximal transected end is required and ligation of the
Pathogenesis One of the most common complications of
distal end is recommended also. Packing alone can achieve
ceratohyoidectomy is severe intraoperative hemorrhage
some partial relief but is usually inadequate. Because the
from transection of the lingual artery, a branch of the
lingual artery is not readily located deep in a pool of blood,
linguofacial artery (Figure 36.8), or transection of the
the linguofacial artery can be exposed deep to an incision
linguofacial vein. Transection of the lingual artery may also
ventral and medial to the linguofacial vein, and can be
occur upon approach for a partial stylohyoidectomy [1, 47].
ligated at that level instead. This will slow the hemorrhage
considerably, but incisional packing is also required.
Prevention This complication can be prevented by careful
Another alternative is to locate the facial artery close to the
deep dissection to expose the artery and adjacent nerves so
edge of the skin incision and trace it deep from that site to
they can be avoided or gently elevated out of the surgical
its division from the lingual branch (Figure 36.8). By
field. The linguofacial vein runs along the medial aspect of
tracing rostrally from that site, the lingual artery can be
the mandible at the level of the basiohyoid bone; therefore,
located (Figure 36.8).
the incision should be made at least 1 cm medial to the
edge of this vein. Also, blind sharp transection of the
Expected outcome Hemorrhage can prolong surgery time,
ceratohyoid articulation with the stylohyoid bone should
as it takes time to locate and ligate the damaged vessels. It
be avoided because this could easily transect the lingual
is unlikely that this complication will have a negative effect
on outcome, unless the source of the hemorrhage is not
Skin identified and addressed at the time of surgery or severe,
Skin incision life-threatening hemorrhage occurs.
Facial a. d
e c
Hypoglossal n.
External carotid a. PeripheralNerveInjury – HypoglossalNerve
Lingual a.
Linguofacial trunk b Definition Transient or permanent damage to the
hypoglossal nerve incurred during ceratohyoidectomy or
a
partial stylohyoidectomy.
Risk Factors
External carotid a.
● Traumatic surgical technique and/or poor surgical
planning
Figure36.8 Anatomy of the left lateral aspect of the ● Sharp dissection in the deeper layers without adequate
stylohyoid apparatus, with ventral uppermost. Rostral is to the
right. a = Stylohyoid bone (irregular shading is diseased exposure and nerve protection.
portion); b = epihyoid bone; c = ceratohyoid bone; d = lingual
process; e = thyrohyoid bone. The blue shading indicates bones Pathogenesis Damage to the hypoglossal nerve may occur
to be removed at surgery. Note the close relationship between during dissection of the muscles over the ceratohyoid bone.
the lingual artery and hypoglossal nerve with the ceratohyoid
bone close to the deep dissection required to detach the Use of sharp dissection (vs. blunt dissection), increases the
ceratohyoid bone from the stylohyoid bone. risk of this complication. Hypoglossal nerve paresis has
Complications of Surgery for emporohyoid steoarthropathy ( iddle ar isease) 485
also been described following ceratohyoidectomy, which Prevention Because of this complication, a
appeared at necropsy to have resulted from fibrosis in the ceratohyoidectomy has been proposed to be a safer, easier
surgical incision, and not from direct injury to the and more permanent surgical alternative.
nerve [38]. It has also been described as a complication
with partial stylohyoidectomy [47], although this procedure Diagnosis and monitoring Recurrence of clinical signs may
is being performed less commonly [48]. When performed be the first indicator that the stylohyoid bone has regrown.
as a bilateral procedure, partial stylohyoidectomy may If there is suspicion of this complication, endoscopy of the
cause permanent problems with prehension [47]. Clinical guttural pouch or radiographs can confirm the diagnosis.
signs of unilateral hypoglossal nerve injury might not be Advanced imaging such as computed tomography may
evident, despite obvious atrophy of the ipsilateral lingual also be useful for surgical planning.
muscles [38].
Treatment Stylohyoid ostectomy can be repeated, although

Prevention As with prevention of hemorrhage during a it is recommended that a ceratohyoidectomy be performed
ceratohyoidectomy or partial stylohyoidectomy procedure instead to prevent reestablishing the stylohyoid apparatus.
(see above), risk of damage to the hypoglossal nerve is
minimized by careful, blunt dissection and elevation of the
Expected outcome Regrowth of the stylohyoid bone will
nerves and vessels away from the surgical field.
likely result in recurrence of clinical signs.
Diagnosis and monitoring Injury to the hypoglossal nerve

can become apparent after surgery as protrusion of the IatrogenicFractures
tongue on that side between the incisors and interdental Definition A potential complication of ceratohyoidectomy
space. Examination of the cranial nerves should be or partial stylohyoidectomy is iatrogenic fracture of bones
performed and repeated daily to monitor progress. Close of the skull during the surgery.
inspection of the tongue following surgery may eventually
reveal muscle atrophy [38]. Risk Factors

Treatment Please refer to “Peripheral Nerve Injury” in the
● Advanced disease resulting in a rigid ankyloses of the
Section on Complications of Surgery for Guttural Pouch
temporohyoid joint
Empyema, earlier in the chapter.
Pathogenesis During a ceratohyoidectomy or partial

Expected outcome Please refer to “Peripheral Nerve
stylohyoidectomy surgery, the forces generated by
Injury” in the Section on Complications of Surgery for
intraoperative manipulation of the hyoid bones can be
Guttural Pouch Empyema, earlier in the chapter.
transmitted through the ankylosed temporohyoid joint and
fracture it and the petrous part of the temporal bone.
Regrowthof the StylohyoidBone
Definition Regrowth of the stylohyoid bone within the Prevention Careful surgical technique to remove the
guttural pouch following a partial stylohyoidectomy ceratohyoid bone with minimal torque on the hyoid
apparatus will minimize the risk of iatrogenic fracture. In
horses with severe neurological deficits, a standing
Risk Factors
approach has been described for ceratohyoidectomy to
● Performing a partial ostectomy of the stylohyoid bone avoid risks associated with recovery from general
(vs. a ceratohyoidectomy). anesthesia in horses with severe vestibular nerve damage
● Removing a small piece of the stylohyoid bone so the gap and associated neurological deficits [50]. A standing
is small enough to allow repair. approach to a partial stylohyoidectomy has not been
described.
Pathogenesis The two ends of the bone can form a bony
union, producing a complete stylohyoid bone. Regrowth of Diagnosis and monitoring If the petrous temporal bone
the stylohyoid bone can occur in as little as 6 months fractures at surgery, clinical signs (i.e. neurological
following surgical resection, resulting in recurrence of deficits) may worsen after surgery, rather than gradually
clinical signs [49]. improve.
Treatment Systemic anti-inflammatories such as Expected outcome With a limited number of reported cases,
corticosteroids and NSAIDs may mitigate the clinical signs, it is difficult to gauge what the specific effect of iatrogenic
but there are no specific treatments for fracture of the fracture will be in horses with temporohyoid osteoarthropathy,
petrous temporal bones. but it is likely that it will prolong the recovery.
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488
37
Complicationsof EquineTrachealSurgery
John Peroni DVM, MS, DACVS
Department of Large Animal Medicine, Veterinary Medical Center, University of Georgia, Athens, Georgia
● Inappropriate knowledge of the anatomy of the ventral

The most common reason horses require tracheal surgery region of the neck
is because of upper airway obstruction. Acute obstructions ● Poor restraint
can be encountered on an emergency basis when a life-
threatening airflow impediment causing respiratory Inadequate local anesthesia
distress necessitates a tracheostomy. Alternatively,
untreatable and chronic upper airway pathology may Pathogenesis Most tracheal surgeries are performed in
require a tracheostomy as a means to achieve permanent standing, awake horses restrained by chemical and physical
airflow diversion through the trachea. Regardless, the means. During the approach to the trachea the incision is
complications of tracheal surgeries are relatively few and typically centered on midline at the junction of the upper
can be greatly minimized by using appropriate technique and middle thirds of the neck. Minor bleeding from the
and being aware of the anatomy of the trachea and musculature, particularly in horses with thick muscular
surrounding tissues. necks, is to be expected. An incision performed off-midline
or any local anatomical abnormalities such as swelling and
a poorly restrained horse may allow for accidental injury to
L the neuro-vascular anatomy located on either side of the
with EquineTrachealSurgery trachea. Carotid and jugular vein injury is uncommon, but
awareness of this anatomy is important.
● Intraoperative and technical complications
– Hemorrhage Prevention If the incision is made on midline at the
– Hematoma and seroma junction of the upper and middle thirds of the neck and
aimed at splitting the paired sternothyrohyoid muscles, the
– Infection
risks of injuring the jugular veins or carotid arteries is
– Subcutaneous emphysema extremely minimal. Infiltration of local anesthesia in an
inverted U shape above the surgery site will provide
adequate local analgesia prior to incising the skin. It is also
I ntraoperativeand Technical important to appropriately restrain the horse in stocks and
Complications sedate using the neuroleptanalgesic combination of choice.
Familiarity with sedation protocols that ensure pro-
longed neuroleptoanalgesia is very important. Adequate
Hemorrhage
delivery of local anesthesia to the site of surgery is a vital
Definition Hemorrhage is defined as escape of blood from component of a smooth approach to the trachea. Preference
a vessel and may occur intraoperatively during tracheal is given to an inverted U-shaped block pattern encompass-
approach. ing the surgical site over a line block. The latter may
Intraoperative and echnical Complications 489
obscure and prevent appropriate palpation of the tracheal Risk Factors

rings along the midline of the neck, compromising an ade-
● Inherent to surgery of the trachea, as by definition, is a
quate surgical approach.
clean contaminated surgical procedure, because the res-
Diagnosis Local bleeding from muscle is easy to detect piratory tract is inherently contaminated by a resident
and can be averted using appropriate surgical technique bacterial population
and providing hemostasis as needed with hemostatic ● Tracheostomy performed with urgency as a life-saving
forceps. Electrocautery can be used, although it may not be procedure
practical in the standing awake horse. Accidental injury to ● Inadequate knowledge of regional anatomy
the major vasculature of the neck will be self-evident,
presenting with a substantial amount of blood invading the Pathogenesis Despite this unavoidable risk factor,
surgical site. infections of the tracheostomy site are rare.
Performing surgery hurriedly in an emergency situation,
Treatment Once carotid or jugular injury has been
such as when the tracheostomy is required as a life-saving
recognized, the goal is to apply immediate pressure to the
procedure, may decrease the site being prepared
area and temporarily obstruct venous or arterial flow. This
appropriately and possibly a less accurate surgical approach
can be done manually or by wrapping the neck with
will increase the risk of infection.
adhesive bandage roll material and gauze packing. It may
A hurried tracheal approach performed on an emergency
be possible to suture the wall of a partially damaged blood
basis may result in a skin incision that is too long relative to
vessel using appropriately-sized absorbable suture material
the tracheal incision, leading to the formation of a
in a simple continuous pattern. Placing vascular clamps
subcutaneous pocket ventral to the tracheostomy site. Over
proximal and distal to the injury will facilitate visualization
time, this pocket will collect exudate draining from the
and closure. Longitudinal arteriotomies have been shown
incision and secretions being expelled via the muco-ciliary
to be associated with a greater degree of stenosis than
apparatus resulting in a localized infection.
transverse arteriotomies, although the effect of this in the
Even less likely is the accidental penetration of the
horse has not been evaluated [1].
esophagus which lies dorsolateral to the trachea. Following
Expected outcomes Exsanguination or severe blood loss appropriate surgical technique and a basic understanding
are possible with common carotid artery trauma but are of the local anatomy makes accidental esophageal
not expected during tracheal surgery, assuming the injury penetration very unlikely.
is addressed promptly and appropriately. More importantly,
hematomas and swelling at the surgery site may affect local Prevention An appropriately performed skin incision will
nerve function since the common carotid, vago-sympathetic result in an optimal transition between the subcutaneous
nerve bundle, and the recurrent laryngeal nerve are tissue and the tracheostomy incision, minimizing dead
contained in a common neurovascular sheath lying on the space formation and the possibility of local infection.
dorsolateral aspects of the trachea. Recurrent laryngeal
neuropathy following tracheal surgery has not been
reported; however, it is possible that local swelling and Diagnosis Localized swelling below the incision may be
inflammation may affect this nerve that is important for the most obvious clinical sign, with pain on palpation and
laryngeal function. exudate pooling from the ventral aspect of the incision.
Hematomaand Seroma Treatment Exploring the surgical site and cleaning with
an appropriate antiseptic will allow the clinician to inspect
The reader is referred to the Hematoma and Seroma sec-
the depth of the pocket formed. This should then be
tion in Chapter 56: Complications of Muscle Surgery, as
addressed by placing a through-and-through Penrose drain
information provided there is applicable to hematoma and
which should exit at the lowest portion of the incision to
seroma associated with tracheal surgery.
allow for adequate drainage. This, with or without broad-
spectrum antibiotics, should allow for rapid resolution of
Infection the local infection.
Definition Infection is defined as bacteria (most

commonly) establishing colony forming units within or in Expected outcomes A good outcome is expected if this
proximity to the tracheal surgical site. issue is addressed promptly.
490 Complications of quine racheal Surgery
SubcutaneousEmphysema Prevention An appropriately performed skin incision will

result in an optimal transition between the subcutaneous
Definition Subcutaneous emphysema occurs when gas or
tissue and the tracheostomy incision, minimizing the
air becomes trapped in the subcutaneous tissue layer.
opportunity for air trapping and the resulting emphysema.
Risk factors Inherent risk to surgery of the trachea

Diagnosis Subcutaneous emphysema can be easily
palpated during a physical exam of the surgical site. There
Pathogenesis Subcutaneous emphysema is an inherent
is a characteristic feel of small air pockets under the skin
risk of tracheal surgery because of the close proximity
that cannot be mistaken for any other clinical entities.
between the air expelled from the tracheal stoma and the
surrounding subcutaneous tissue. Air flowing out of the
Treatment No specific treatment is required, although
tracheal stoma becomes trapped in the subcutaneous tissue
revision of the surgical site may prevent recurrence of the
and progressively expands to the surrounding area. This
problem.
may be more likely to occur when a tracheostomy tube is
too tightly placed within a small skin incision, resulting in
Expected outcomes A good outcome is expected if this
air being trapped and therefore captured by the
issue is addressed promptly.
subcutaneous tissue.
Reference
1 Dickson, C.S. and Magovern, J.A. (1991). Transverse

versus longitudinal arteriotomy: An experimental study
in dogs. J. Vas. Surg. 14 (2): 181–183.
491
38
Complicationsof EquineThoracicSurgery
John Peroni DVM, MS, DACVS
Department of Large Animal Medicine, Veterinary Medical Center, University of Georgia, Athens, Georgia
Overview monary effects in horses. Although large-scale studies in

horses are not available, it is generally thought that thora-
Thoracic surgery is not common in the equine patient; coscopy poses minimal risks to the patient; however, the
however, thoracic trauma may require surgical intervention technical challenges associated with this surgery mean
to address rib fractures or advanced pleuropneumonia may that surgeons’ experience plays a major role in lessening
require a rib resection to favor drainage of contaminants complications. In the hands of experienced human sur-
from the chest cavity. The purpose of this chapter is to geons, thoracoscopy has been shown to be safe with a mor-
describe, recognize and manage complications of equine tality of 0.35% (95% confidence interval (CI) 0.19–0.54%)
thoracic surgery, with a particular emphasis on trauma, rib and likely to be less if diagnostic procedures alone are
fractures and thoracoscopy. performed [2].
Rib fractures in horses are a relatively rare cause of
lameness and reduced performance and are often a result
of trauma occurring during competitive endeavors. As a istof ComplicationsAssociated
L
recent report would attest, most cases of equine rib with EquineThoracicSurgery
fractures are managed conservatively with only few
requiring surgical intervention. In fact, out of 50 horses ● Intraoperative and technical complications
with rib fractures, five underwent surgical intervention – Hemorrhage
with two partial resections under general anesthesia and – Lung and diaphragmatic injury
two using standing sedation. One of the horses had a ● Early postoperative complications
locking compression plate applied under general – Pneumothorax
anesthesia [1]. – Hemothorax
Thoracoscopy is an endoscopic-assisted surgical ● Late postoperative complications
technique used to evaluate the thoracic cavity. Compared – Infection
to open procedures, thoracoscopy is considered minimally
invasive, is better tolerated by the patient and is associated
with fewer complications, faster healing of the surgical site
I ntraoperativeand Technical
and minimal postoperative pain. Over the last decade,
equine surgeons have improved their mastery of rigid
Complications
endoscopy in thoracic disease, therefore thoracoscopy is
Hemorrhage
now used more regularly, to which the publication of more
extensive case series and descriptions of novel techniques See also Chapter 7: Complications Associated with
can attest. Furthermore, with rigid thoracic endoscopy Hemorrhage.
becoming increasingly more applicable in equine clinical
practice, clinicians have described in detail the endoscopic Definition Hemorrhage is defined as escape of blood from
anatomy of the equine chest and have established its safety a vessel and occurs intraoperatively during instrument
as determined by assessing hemodynamic and cardiopul- placement and/or during manipulation of intrathoracic
492 Complications of quine horacic Surgery
anatomy. Hemorrhage may go undetected until after the Expected outcomes For a few days postoperatively, it may
surgical procedure is completed. be important to monitor common hematological
parameters such as packed cell volume and total solid
Risk Factors concentrations, in addition to performing twice daily
physical exams aimed at detecting changes in heart and
● Inappropriate knowledge of the thoracic anatomy
respiratory rates, mucous membranes color and capillary
● Inexperience with placement and manipulation of surgi-
refill time. Most clinical cases exhibiting blood loss will do
cal instruments
so temporarily and are therefore self-limiting and rarely
● Abnormal intrathoracic anatomy such as adhesions or
require intensive treatment such as blood replacement
pleuritis, which may increase the propensity for bleeding
therapy.
upon entering the chest
Pathogenesis During the approach to the chest cavity, Lungand DiaphragmaticInjury

intraoperative and postoperative hemorrhage associated
with inadvertent damage to the intercostal vasculature is Definition The lung and the diaphragm are not likely to be
possible. It is also possible that manipulation of the thoracic injured when performing a rib resection or during
structures may also lead to bleeding. The lung is a highly debridement and removal of rib fractures. In contrast, they
vascular tissue and especially when inflamed or covered are the most likely structures to be inadvertently injured at
with pleural adhesions it has a propensity to bleed the time of insertion of the first endoscopic portal into the
profusely. chest. Subsequent manipulation of the lung or mediastinal
anatomy may also lead to injury.
Prevention Either during the repair of rib fractures, or the
removal of a rib for drainage purposes, the surgeon may Risk Factors
inadvertently damage the intercostal blood vessels. This ● Inappropriate knowledge of the thoracic anatomy
can be prevented by careful dissection and knowledge of ● Inexperience with instrument placement and
the vascular anatomy. In thoracoscopy, upon insertion of manipulation
trocar/cannula units within the selected intercostal space, ● Abnormal intrathoracic anatomy such as adhesions or
the surgeon should glide the instrument off the cranial pleuritis, which may increase the propensity for bleeding
edge of the caudal-most rib, thus preventing a laceration of upon entering the chest
the intercostal vasculature located along each rib’s caudal
edge. Pathogenesis When evaluating horses with chest injuries,
veterinarians may be challenged with the diagnosis and
Diagnosis Continued low-grade bleeding during surgery management of a pneumothorax. Additionally, open chest
may cause impaired visualization of intrathoracic injuries present challenges relating to pleural
structures. This is particularly obvious in thoracoscopy contamination and infection, presence of foreign material
because of constant dripping of blood onto the lens of the and rib fractures. Traumatic pneumothorax, in particular,
endoscope and is usually a result of oozing from the is usually secondary to a penetrating chest injury; however,
intercostal muscle or from the intercostal artery. non-penetrating blunt trauma may also cause
pneumothorax by compressing and rupturing alveolar
Treatment Hematomas originating from inadvertent clusters causing air to leak from the lower respiratory tract
laceration of the intercostal vasculature are usually self- into the pleural space. It is our experience that horses with
limiting, although may be a cause of protracted hemothorax. acute chest trauma are those most susceptible to severe
Accidental injury to the intercostal vasculature is difficult complications and should therefore be carefully selected
to address once it has occurred, therefore this specific and managed as surgical candidates. Pneumothorax
complication is best prevented by knowledge of the indicates the presence of “free” air or gas within the pleural
pertinent vasculature anatomy of the rib cage. Once this space. In most instances, air will be confined to the pleural
complication has been recognized it may be possible to space; however, free air may be contained within the
apply sutures to the damage vasculature; however, the adventitial tissue planes (interstitial pulmonary
intercostal artery is difficult to retrieve through the small emphysema) or in the mediastinum (pneumomediastinum).
endoscopic portals, making primary closure of the vessels Blunt or sharp trauma to the chest wall and iatrogenic
difficult. Management of hemothorax is described in a procedures (placement of chest tubes, drains or thoracic
later section below. procedures) are leading causes of pneumothorax in horses.
Most thoracic injuries are unilateral and may involve the or removing fragments of ribs following trauma.
axillary region or the lateral chest wall and associated ribs. Occasionally rib fragments may be lodged in the lung tissue
Although possible, injuries to the pectoral region rarely and further injury can be caused during removal. For this
involve intra-thoracic structures because of the powerful reason, it is paramount that the pleural space be optimally
musculature covering this area, the narrow thoracic viewed by using endoscopic techniques with either a rigid
opening between the first ribs and the parabolic shape of or a flexible endoscope. This will prevent a number of
the anterior thorax. At the time of injury, horses exhibit operative difficulties.
clinical signs resulting from the combination of traumatic Injury to the lung and diaphragm upon trocar insertion
shock and the onset of pneumothorax. Restlessness and is possible but is uncommon if a pneumothorax is correctly
apprehension, tachycardia, tachypnea, dyspnea and established prior to entering the chest cavity. Lung damage
cyanotic mucous membranes are common physical is more likely to occur when surgery is performed in horses
findings. The severity of the signs associated with with chronic pleuropneumonia due to the possibility of
pneumothorax depends on the speed at which the lung mature adhesions connecting the lung surface and the
collapses following injury, the presence of bilateral parietal pleura of the chest wall. In this instance, scar tissue
pneumothorax and whether the injury is open or closed. may only allow partial lung collapse, even though a
In thoracoscopy, the endoscope used is a 58-cm long, pneumothorax is adequately induced. As a result of these
10-mm diameter rigid telescope (30-degree Hopkins concerns, it may be important to examine the thorax with
telescope), which is guided through the chest wall via ultrasound preoperatively in order to determine the
disposable or non-disposable trocar/cannula units. These presence and extent of restrictive adhesions. Furthermore,
may be of variable length and configuration; however, an the use of a blunt tip trocar may be more prudent in horses
11-mm diameter, 15-cm long cannula with a sharp trocar is with chronic disease; alternatively, an ultrasound guided
generally used. When standing and awake horses are approach may be used to ensure that the lung surface is not
prepared for thoracoscopy, it is paramount to achieve an immediately beneath the selected point of entry into the
appropriate state of physical and chemical restraint so that chest.
abrupt movements are avoided as much as possible. Horses Inadvertent lacerations of the diaphragm are uncommon
are generally contained in stocks and sedated using a during equine thoracoscopy and are avoided by having
continuous IV drip infusion of detomidine. The 13th appropriate knowledge of the topographic anatomy of the
intercostal space is commonly used as the access point to diaphragm as it relates to the chest wall. The diaphragm is
the chest serving as the site for endoscopic portal placement. a musculotendinous structure that separates the thoracic
Analgesia is provided by placing 5 ml of 2% carbocaine in and abdominal cavities. Its curved insertion on the thoracic
the skin and deep subcutaneous tissues in the proximal wall extends from the 8th and 9th costal cartilages, across
portion of the intercostal space just ventral to the line of costochondral junctions of the 9th–15th ribs to the middle
the epaxial musculature primarily formed by the of the 18th rib to end at the vertebral end of the last rib. In
longissimus dorsi mm. A stab incision is made through skin its central portion, the dome of the diaphragm projects
and a pneumothorax induced by inserting a teat cannula cranially up to the 7th–8th intercostal space. Knowing
into the thoracic cavity through the incision and intercostal these critical anatomical landmarks will avoid
musculature. This critical step allows the lung to collapse diaphragmatic injury and is the reason why the 13th or
forming a space between the parietal pleura and the lung. 14th intercostal spaces are commonly selected as the entry
With each breath the horse takes, air can be readily heard points into the chest.
rushing into the chest through the teat cannula as
atmospheric and pleural pressures equilibrate. The teat Diagnosis As a matter of routine surgical technique, the
cannula is removed and a trocar/cannula system can be surface of the lung should be examined upon entering the
placed with slow rotational movements taking care not to chest cavity in order to ensure that no pleural injury has
abruptly penetrate the chest wall and damage the lung. The occurred. Should an injury be recognized, subsequent steps
cannula is replaced by the endoscope and surgery can would be dependent upon the extent of the damage.
begin. The likelihood of lung injury during placement of
additional cannulas is small because, unlike the first portal, Monitoring Fortunately, most parenchymal lacerations
the endoscope can be used to view the entry into the chest heal very quickly without intervention; however, any
cavity. damage to sizeable bronchioles may result in the
development of a pneumothorax postoperatively. Most
Prevention Inadvertent lung perforation or diaphragmatic critically, lacerations to the lung parenchyma may result in
injury should be preventable when repairing rib fractures formation of a flap of tissue that would allow air to escape
into the chest cavity during inhalation and not be absorbed air can be detected postoperatively via thoracic radiographs
during exhalation, thus leading to the formation of a in most cases. However, avoiding a large pneumothorax is
so-called tension pneumothorax which can be life- important and can be done by paying attention to retrieving
threatening. Details of pneumothorax subsequent to as much air as possible from the chest via suction at the
thoracoscopy are presented in the next section. end of the procedure.
Treatment Surgical techniques aimed at closure of lung Diagnosis The rate of onset and the severity of the clinical
parenchyma have been developed in people and have been signs associated with pneumothorax depend on the degree
denominated “lung-sparing techniques,” and include at which the lung collapses following surgery, the presence
suture pneumonorrhaphy, stapled and clamp pulmonary of a bilateral pneumothorax and whether the lung injury
tractotomy with selective vessel ligation, and non- has occurred leading to pressure accumulation on the chest
anatomical resection. In horses, these procedures may be cavity (tension pneumothorax). Common clinical signs
difficult to accomplish due to lack of appropriate that should alert the clinician to this complication include
instrumentation and the sheer size of the anatomy, restlessness and apprehension, tachycardia, tachypnea,
therefore every attempt should be made to prevent any dyspnea and cyanotic mucous membranes. Postoperative
accidental trauma to the lung surface. pneumothorax can be diagnosed with thoracic
ultrasonography and/or radiography. On ultrasound, an
air-filled space can be detected with a curvilinear probe
EarlyPostoperativeComplications separating the lung surface from the upper portion of the
chest.
Pneumothorax
Monitoring Ultrasound is a sensitive and straightforward
Definition A condition in which air is present in the
diagnostic to use in case postoperative monitoring is
pleural cavity resulting in lung collapse. Pneumothorax
required. Fortunately, in the majority of cases, iatrogenic
may occur spontaneously, as a result of lung disease or
pneumothorax resolves spontaneously and without the
injury or puncture of the chest wall.
need for any specific intervention, although the clinician
should expect the process of spontaneous elimination of
Risk Factors
air from the pleural space to take time.
● Rib fractures
● The presence of a pneumothorax before surgery Treatment Approximately 1.25% of the volume of one
● Lung biopsy hemithorax is reabsorbed in 24 hours, which means that a
● Poor technique during access to the chest cavity resulting 20% pneumothorax would take about 16 days to be
in lung laceration spontaneously eliminated [5, 6]. The rate of absorption of
● Failure to restore negative pleural pressure following air can be accelerated with the intra-tracheal or intra-nasal
surgery administration of 100% supplemental O2. This is based on
the principal that gases diffuse through biological
Pathogenesis A review of the literature describing the use membranes at a rate depending on pressure gradients. In
of thoracoscopy in horses without thoracic infection or the case of a pneumothorax, the Fick principle dictates that
trauma, reveals that the most common complication is the the rate at which air will diffuse from the pleural space into
occurrence of a residual postoperative pneumothorax seen the pulmonary capillaries depends on the partial pressure
on postoperative chest radiographs [3, 4]. The frequency of differences of each gas, the blood flow per surface are
this complication is high in horses undergoing lung biopsy available for gas exchange, and the solubility of each gas in
and may occur bilaterally. The dorsal mediastinum in the tissues. If a pneumothorax occurs, the pressure of the
horses affords complete separation of the two hemi- air in the thoracic cavity is 760 mm Hg minus the –5 mm
thoraces but the cranial mediastinum can be often Hg of intrapleural pressure (~755 mm Hg). In the capillary
incomplete resulting in a communication between the two blood, the sum of the partial pressures of gases is about 706
sides of the chest. As a result, most postoperative mm Hg (PH2O = 47, PCO2 = 46, PN2 = 573, and PO2 = 40
pneumothoraces are bilateral. mm Hg). The gradient for gas exchange between capillary
bed and pleural space is therefore 49 mm Hg (pneumothorax
PreventionIn most horses with pleuritis and pneumonia = 755 mm Hg – capillary blood = 706 mm Hg), favoring the
undergoing thoracoscopy, prevention of a residual slow reabsorption of the trapped air. When 100% O2 is
pneumothorax is not possible. A small amount of residual administered, the partial pressures in the capillary blood
arly Postoperative Complications 495
favors the formation of a greater pressure gradient resolve without intervention. Air exchange may be
decreasing the partial pressure of N2 to close to zero, while compromised in horses with significant lung disease,
the partial pressures of oxygen, carbon dioxide and water therefore a postoperative pneumothorax may further
remain basically unchanged. Because of the fall in PN2, the exacerbate pulmonary function. In these cases, the outcome
net gradient increases to about 500 mmHg, which is almost can still be favorable as long as treatment measures are
10 times greater than that achieved while breathing room implemented, such as accurate chest evacuation and
air. This has been shown clinically [6–8]. supplemental oxygen administration.
Evacuation of a pneumothorax can be achieved by sev-
eral invasive methods. Simple aspiration has minimal mor-
Hemothorax
bidity and is reserved for small animals but has been
successfully used in adult horses presented with the first Definition Hemothorax is a collection of blood between
occurrence of pneumothorax. Should a postoperative the lung and the chest wall.
pneumothorax necessitate evacuation, simple aspiration
with a blunt teat cannula attached via silastic tubing to a Risk Factors
suction device is very effective. This can be accomplished
● Rib fractures
by placing the cannula through a stab incision within
● Chest trauma
surgically prepared 13th or 14th intercostal spaces just
● Poor surgical technique and knowledge of the pertinent
below the epaxial muscles. Tube thoracostomy may be
anatomy.
necessary when a pneumothorax is associated with
cardiopulmonary alterations and is therefore of a more
clinically relevant magnitude. The pneumothorax may be Pathogenesis In addition to inadvertent damage to the
initially aspirated using a mechanical suction unit followed intercostal vasculature (discussed earlier), postoperative
by the intra-thoracic insertion of a large-bore chest tube hemothorax can result from blood loss encountered during
located in the proximal third of a caudal intercostal space any number of surgical procedures including rib resection,
(Figure 38.1). The chest tube is coupled with a Heimlich simple wound exploratory, thoracoscopic pulmonary
valve consisting of a collapsible rubber tube connected to wedge biopsy, mass biopsy, diaphragm laceration repair
the chest tube. Upon inhalation, a negative pressure and others. Similar to abdominal procedures, in most
collapses the rubber tubing and upon exhalation, the tube clinical cases, the surgeon should expect a degree of
opens and allows the air trapped in the thorax to escape. hemorrhagic fluid collection within the chest following
any thoracic surgery including thoracoscopy. This is
Expected outcome With the exception of tension typically not preventable and likely self-limiting without
pneumothorax, which can be life threatening, most horses any long-term effects on the individual patient.
with postoperative pneumothorax will spontaneously Occasionally, however, excessive bleeding in the chest
cavity may occur and is most often the result of bleeding
from adhesions formed during the development of
pleuropneumonia, which were not sufficiently coagulated
during surgery or inadvertently damaged.
Prevention As with all minimally invasive surgery, access

to the site of hemorrhage is challenging. Should bleeding
occur intraoperatively during thoracoscopy, the conversion
to an open procedure to allow direct access to the problem
is not likely to be successful. In all cases, it is paramount to
be familiar with the anatomy and the surgical technique so
that hemorrhage is prevented. It is also critical to have a
well thought-out back-up plan to deal with possible
bleeding using endoscopic equipment, such as endoscopic
cauterizing or vessel sealing devices.
Diagnosis It is important for the clinician to recognize the

Figure38.1 Left hemithorax thoracic tube placed within the
13th intercostal space to aid in pneumothorax evacuation. typical signs associated with blood loss. These include
Source: John Peroni. restlessness and apprehension, tachycardia, tachypnea,
dyspnea and cyanotic mucous membranes. Blood loss LatePostoperativeComplications

within the chest cavity is particularly dangerous because
large volumes of fluid may lead to decreased lung expansion Infection
with progressive decreased venous return to the heart and
signs of acute cardiopulmonary failure. Definition The inoculation and subsequent multiplication
of microorganisms within the chest cavity
Monitoring Should horses experience any of the above

Risk Factors
listed progressive signs in the postoperative period, the
clinician should perform a detailed ultrasound exam in ● Pleuritis and pleural abscess
order to determine the volume of blood collected in the ● Open chest wounds as a result of rib fracture
chest. ● Poor understanding of appropriate surgical techniques
Treatment Blood spilled into the chest cavity has a Pathogenesis Rib fractures that result in an open chest
tendency to lose clotting ability because platelets in injury will inevitably lead to a degree of contamination
contact with pleural mesothelial cells become rapidly that may eventually result in a localized abscess or pleuritis.
inactive [9, 10]. Free thoracic blood should be regarded as Rib resections often performed as a means to remove
a valuable source of red cells, protein and other cellular fractured bony fragments or to evacuate pleural abscess are
components. typically not associated with worsening infections.
Much of the knowledge available regarding cavitary Infections after thoracoscopy are fortunately rare and
blood collection comes from data obtained by studying even in horses with pleuropneumonia there does not seem
hemoperitoneum (abdominal hemorrhage). It is likely to be a worsening of the condition following exploratory
that knowledge gained from managing patients with thoracoscopy. One notable exception would be when sur-
abdominal hemorrhage is applicable to those with tho- gery is utilized to guide the drainage of intra-pleural
racic hemorrhage. Based on this, we can speculate that abscesses. In these situations, the goal is to decompress the
red blood cells free in the chest following acute hemor- abscess either to the outside or via aspiration of infection.
rhage will be actively returned to the circulation for sev- In either case, thoracoscopy can appropriately guide the
eral days [11]. Furthermore, red blood cells that have placement of a thoracotomy incision or provide appropri-
organized into a hematoma, do not undergo lysis and ate visualizations for intra-thoracic decompression of pul-
maintain a normal biconcave conformation for 4 to 8 days monary abscesses. In either of these procedures,
in the dog [11–13]. This supports the notion that up to appropriate intraoperative technique is paramount to avoid
two-thirds of extravasated red cells found free in the accidental spillage of infectious material within the pleural
abdomen or the chest can be recycled back to the circula- cavity, which would then lead to worsening of the condi-
tion. This clinical and experimental evidence would sug- tion by distributing infectious organisms to the chest.
gest that drainage of the chest cavity following hemorrhage
may not be indicated, because intrapleural blood may Prevention The above-mentioned complications are best
serve as a reservoir of blood components which, over handled by employing appropriate surgical technique and
time, may return to the circulation. Unfortunately, unlike preventing their occurrence by ensuring that optimal
in abdominal hemorrhage, the progressive collection of visualization of the pertinent structures is achieved and by
fluid in the chest will have a major impact on the horse’s coupling surgical approaches with the concurrent use of
cardio-pulmonary function, therefore the clinician will transthoracic ultrasound so that precise abscess evacuation
have to evaluate on a case-by-case basis the need to is achieved.
decompress the pleural cavity by removing variable
amounts of blood that may be causing respiratory and
Diagnosis Clinical signs that may aid in the early diagnosis
cardiac complications.
of pleural abscess or infection also include fever, depression,
lethargy, and inappetence. Furthermore, pleural pain
Expected outcome Most horses will experience a degree of (pleurodynia) evident as guarding and flinching on
bleeding in the chest cavity after thoracoscopy and it is percussion of the chest, shallow respiration and
usually self-limiting and of minimal concern. It would be, endotoxemia may also be evident. Auscultation will
however, prudent to monitor the chest with ultrasound for typically reveal a lack of breath sounds in the ventral lung
a few days to ensure that only an expected small volume of fields and abnormal lung sounds (often crackles) in dorsal
blood is present in the pleural space. lung fields. Cardiac sounds may be muffled or absent.
References 497
Spillage of infectious material during surgery may not be evaluate pulmonary parenchymal lesions, mediastinal
apparent, therefore the clinician should examine the chest structures, and the presence/severity of
with ultrasound regularly in the postoperative period for pneumothorax [15].
several days to ensure that the reminder of the chest cavity
is clear. Ultrasonographic evidence of a large area of pul- Treatment Should accidental contamination of the chest
monary consolidation, in conjunction with serosanguine- cavity occur, establishing appropriate ventral drainage and
ous suppurative pleural effusion, is consistent with initiating a broad spectrum or targeted antibiotic regimen
pulmonary infarction and necrotizing pneumonia. guided by culture and sensitivity is paramount. Performing
Adhesions of the visceral to parietal pleura can be visual- a targeted rib resection to favor drainage of the chest cavity
ized using thoracic ultrasonography. Ultrasonography will minimize the severity of the problem.
should be performed before thoracocentesis to determine
the best site for maximal drainage and to avoid cardiac or Expected outcome Most horses will tolerate thoracic
diaphragmatic puncture. Pleural fluid should be drained contamination as long as it is appropriately dealt with.
relatively slowly to avoid hypotension. The hemithorax Ultimately, the prognosis for these conditions depends
that appears to contain the most fluid is drained first. largely on the severity of lung disease and other critical
Thoracic radiography is indicated after pleurocentesis to patient related factors
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2 Rahman, N.M., Ali, N.J., Brown, G. et al. (2010). Local (5): 397–398.
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3 Lugo, J., Stick, J.A., Peroni, J. et al. (2002). Safety and Thorac. Cardiovas. Surg. 58 (3): 113–111.
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498
39
Complicationsof TesticularSurgery
James Schumacher DVM, MS, DACVS, MRCVS1 and Thomas O’Brien MVB, DACVS-LA2
1
Department of Large Animal Clinical Sciences, College of Veterinary Medicine University of Tennessee, Knoxville, Tennessee
2
Fethard Equine Hospital, Kilknockin, County Tipperary, Ireland
Overview – Complications of cryptorchidectomy associated with

choice of approach
Complications of testicular surgery comprise the most – Complications associated with laparoscopic
common complications associated with equine surgery. cryptorchidectomy
While castration is generally considered an entry level
skill, the procedure leads to many issues that will be
discussed in this chapter. omplicationsAssociated
C
with Castrationof EntireStallions
L Castration of entire stallions (i.e. stallions with both testes
with TesticularSurgery in the scrotum) is one of the most common elective
procedures performed by equine practitioners, and even
● Complications associated with castration of entire though the public perceives castration as a routine
stallions procedure, complications occur with frequency and are the
– Preoperative and operative considerations most common cause of malpractice claims against equine
– Hemorrhage practitioners in North America [1, 2]. Complications can
– Visceral prolapse or evisceration occur immediately, or within days, months, or even years
– Scrotal infection and excessive edema after castration. One retrospective study found that 10% of
– Pyrexia horses developed a complication after routine castration [3],
– Septic funiculitis and another found the incidence of complications to be
– Tetanus 22% [4]. Although most complications associated with
– Septic peritonitis castration are not serious and resolve with or without
– Penile damage treatment, some complications, such as severe hemorrhage
– Hydrocele or evisceration, can be life-threatening. Some, such as
– Signs of colic formation of a hydrocele or retention of masculine
– Retention of masculine behavior behavior, cause no distress to the horse but can cause
– Complications associated with hemicastration serious distress to the owner.
– Miscellaneous complications of castration
– Complications associated with improper care after Preoperativeand OperativeConsiderations
castration
The surgeon’s first steps to avoid complications associated
● Complications associated with cryptorchidectomy with castration should be to examine the horse’s medical
– Failure to locate an abdominal testis history for any condition, such as congenital inguinal her-
– Evisceration after a conventional inguinal approach niation, that might predispose the horse to a complication,
for cryptorchidectomy and to examine the horse. Physical examination should
Complications Associated ith Castration of ntire Stallions 499
include palpation of the scrotum and inguinal regions, cutaneous incision, when performed using aseptic
especially those of young horses, for inguinal herniation technique, diminishes the likelihood of infection and
and for the presence of both testes. Detection of inguinal decreases edema and signs of pain [7–10]. Primary closure
herniation or cryptorchidism may affect the choice of sur- is particularly useful when the horse cannot be exercised
gical approach, anesthesia, and the facilities at which the after castration. Multiple-layer closure of the scrotal
horse is castrated. incision is unnecessary, and only the scrotal skin need be
During physical examination, the surgeon can also deter- sutured [10]. The cutaneous incision is best closed with an
mine if the horse can be castrated safely while standing. absorbable suture using a simple-continuous intradermal
Stallions that react with hostility to genital palpation are suture pattern, so that removing the cutaneous sutures is
best castrated while anesthetized. Castration is also diffi- unnecessary.
cult to perform with the horse standing, if the horse has In a study by Mason et al., only 6% of castrated horses
poorly developed testes or if the horse is small. Castrating a that had the scrotal incision sutured suffered complications,
horse while the horse is standing minimizes the risk of whereas 22% of horses whose scrotal incision was left open
death associated with general anesthesia and traumatic to heal by second intention experienced a complication,
injury during recovery, but in one study, the incidence of the most common being infection [4]. Suturing the scrotum
complications associated with castration did not differ extends the time of surgery, requires aseptic technique and
between horses castrated while standing and those cas- general anesthesia, necessitates meticulous hemostasis to
trated while anesthetized [3]. avoid formation of a scrotal hematoma (Figure 39.1), and
The technique by which a horse is castrated (i.e. the increases the cost of the procedure. In a study by Mason
open, closed, or half-closed technique) may influence the et al., castration performed with primary closure of the
likelihood of the horse developing a postoperative scrotum, with the horse anesthetized, cost about 3 times
complication. Using the open technique of castration, the that of castration performed with the horse standing with
entire parietal tunic of each testis and spermatic cord are the scrotal incision left unsutured [4].
retained by the horse, whereas with the closed technique Castration with primary closure of the wound performed
of castration, the portion of the parietal tunic surrounding using an inguinal approach, with the horse anesthetized,
the testis and the portion of the spermatic cord distal to the has also been shown to result in fewer complications [11].
site of transection are removed. With the half-closed In one study of 238 horses castrated using the inguinal
technique, the parietal tunic distal to the site of transection approach, only 5 horses (2.1%) developed a complication
is removed, but the testis and distal portion of the ductus which, in each case, was hemorrhage into the scrotum.
deferens and spermatic vessels are prolapsed through an This complication was resolved by evacuating the scrotal
incision created in the parietal tunic at the distal portion of blood through a scrotal incision created with the horse
the cord before the cord is transected. standing.
Two different studies found that equids castrated using
the half-closed technique had a higher incidence of
complications than did equids castrated using the closed
technique [3, 5]. Theories contributing to an increased
incidence of complications when using the half-closed
technique included increased tissue handling, increased
contamination, and longer duration of surgery. However,
the differences in technique between the closed and half-
closed techniques of castrations and the time required to
complete the castration are slight, and the higher incidence
of complications found in horses undergoing the half-
closed technique of castration might be because horses
undergoing this technique tend to be older than those
undergoing the closed technique of castration [3. 6].
For practical and economic reasons, the scrotal wound is
usually left unsutured to heal by second intention, but
some complications associated with castration, such as
Figure39.1 This horse developed a hematoma in the sutured
excessive edema, scrotal infection, and septic funiculitis
scrotum after castration. The clotted blood must be evacuated
(i.e. infection of the spermatic cord), can be avoided by to resolve the scrotal enlargement. Source: Courtesy of Dr.
suturing the cutaneous incision. Primary closure of the Michael Schramme, Ecole Nationale Veterinaire de Lyon.
500 Complications of esticular Surgery
Hemorrhage>
Definition Bleeding at the surgical site that occurs
intraoperatively or in the early postoperative period
Risk Factors
● Donkeys
● Poorly performing emasculator
Pathogenesis The most common serious complication of

castration is excessive hemorrhage, and the source of
hemorrhage is nearly always the testicular artery [12].
Donkeys seem have a higher incidence of excessive
hemorrhage after castration, perhaps because their
testicular arteries may be larger than those of a horse [13].
A survey of equine practitioners, performed to determine
the type and frequency of postoperative complications of
castration, found the incidence of excessive postoperative
hemorrhage among horses undergoing castration while
standing or in lateral recumbency to be 2.44% [5].
Excessive hemorrhage can result from poor surgical
technique or from a poorly functioning emasculator. An
uncommon cause of excessive hemorrhage is reversing
the emasculator inadvertently (i.e. placing the cutting
portion of the emasculator proximal to the crushing por-
tion). This results in severe hemorrhage, because the cord Figure39.2 Intraoperative image of a horse anesthetized and
in dorsal recumbency undergoing castration following half-
is transected proximal to the site at which it was crushed. closed technique. Crushing and transecting the parietal tunic
The horse may also hemorrhage excessively if scrotal skin and cremaster muscle separately from the spermatic vessels and
is included unintentionally in the emasculator’s jaws, ductus deferens may be prudent when castrating a mature
causing the testicular vessels to be crushed inadequately. stallion with large testes when using a closed (or half-closed)
technique (i.e. a technique in which the parietal tunic of each
The emasculator should transect the cord at an angle per- testis is excised). Arrowhead points to the parietal tunic to which
pendicular to the cord, because transecting the cord at the cremaster muscle is attached (but hidden from view). Source:
any angle other than at a right angle increases the cross- Jim Schumacher and Tom O’Brien.
sectional area of the transected end of the testicular
artery. spermatic cord before the cord can be adequately crushed
by the emasculator. The blade of the emasculator should
Prevention Use of a properly functioning emasculator is not be so sharp that the cord is completely severed when
crucial. Crushing and transecting the parietal tunic and the jaws of the emasculator are closed [15]. The blade
cremaster muscle separately from the spermatic vessels should be dull enough that the crushed cord must be torn
and ductus deferens may be prudent when castrating a from the emasculator, but with only slight effort. An
mature stallion with large testes using a closed technique emasculator can be dulled with a round file or by using it
(i.e. a technique in which the parietal tunic of each testis is to cut rope.
excised (Figure 39.2)). The spermatic cord should not be Emasculators commonly used by practitioners are the
under tension as it is crushed and transected, and the improved Whites, the Reimer, and the Serra emascula-
emasculator should be directed toward the horse’s tors [5]. The improved Whites and the Serra emasculators
abdomen before the cord is released, so that the testicular crush and cut the cord at the same time, whereas two arms
artery does not recoil. Applying the emasculator to the cord on the Reimer emasculator are compressed to crush the
for 2 to 3 minutes, rather than releasing it quickly, may be cord, and a separate arm to which a blade is fixed is com-
helpful in reducing the likelihood of severe hemorrhage [14]. pressed to sever the cord distal to the crushed segment.
One of the most common causes of excessive hemor- Because the cord is severed with a separate handle, the
rhage is using an emasculator so sharp that it severs the cord cannot be cut before it is satisfactorily crushed. Both
jaws of the Serra and Reimer emasculators are curved, so

that the cord is crushed evenly. The grooves on the crush-
ing blades of the Serra emasculator are oriented parallel to
the cord, rather than perpendicular, as are the grooves of
the Reimer and improved Whites emasculators, decreasing
the chance of accidentally transecting the cord with the
crushing portion of the jaws [12]. A survey of practitioners,
performed to determine the type and frequency of postop-
erative complications of castration, found a significantly
higher incidence of hemorrhage associated with the use of
the Reimer emasculator than with the Serra emascula-
tor [5]. The Sands emasculator resembles the Reimer emas-
culator but has no third handle with a blade to transect the
cord (Figure 39.3). The cord must instead be severed distal Figure39.4 Close-up view of the Henderson Equine Castrating
to the crushed segment with a scissors or scalpel blade. Instrument (Stone Manufacturing and Supply Company, Kansas
One of the authors (JS) crushes the cord at two sites, using City, MO). This pliers-like instrument is clamped across the cord,
just proximal to the testis. Source: Jim Schumacher and Tom
two Sand’s emasculators, and transects the cord distal to
O’Brien.
the most distal emasculator. Using two Sands emasculators
speeds surgery and improves hemostasis.
An instrument effective in eliminating hemorrhage after The spermatic cord or only the testicular vessels and duc-
castration is the Henderson Equine Castrating Instrument tus deferens contained within it can be ligated to prevent
(Stone Manufacturing and Supply Company, Kansas City, excessive hemorrhage, but using a ligature may increase
MO) (Figure 39.4). This pliers-like instrument is clamped the likelihood of infection at the surgical site, because the
across the entire cord, just proximal to the testis, and presence of foreign material reduces resistance to infection
attached to a battery-powered variable speed drill. The tes- of tissue contaminated with bacteria [5]. Non-absorbable
tis is initially rotated slowly, then the speed of the rotations suture should not be used to ligate the cord if the scrotum
is gradually increased. The cord separates eventually at is left unsutured, and monofilament suture should be pre-
about 8 to 10 cm proximal to the instrument. The large ferred over multifilament suture, because it is less likely to
number of twists in the cord seals the severed vessels. harbor bacteria. Ligation, with or without the use of an
Castration using this instrument is usually performed with emasculator, may be more effective than applying an emas-
the horse while anesthetized, but horses can also be cas- culator alone in preventing hemorrhage. However, one
trated with this instrument while standing, eliminating study found that applying a monofilament, absorbable lig-
complications associated with general anesthesia ature to the spermatic cord, proximal to the emasculator,
(Figure 39.5) [16]. neither decreased the incidence of severe postoperative
hemorrhage nor increased the incidence of postoperative
infection [17]. Another study found that applying a multi-
filament absorbable ligature to the spermatic cords, in
addition to applying an emasculator, was not associated
with development of a complication [3]. However, a survey
of practitioners, performed to determine the type and
frequency of postoperative complications of castration,
found that although respondents perceived that applying a
ligature to the spermatic cords did not eliminate the
likelihood of excessive hemorrhage, it did increase the like-
lihood of infection [5].
Diagnosis and monitoring Dripping of blood from the

scrotal wound for several minutes after castration is
expected and should cause no concern, whereas unabated
streaming of blood for 15 to 30 minutes should be
Figure39.3 Sands emasculator. This emasculator is similar to a
Reimer emasculator but has no cutting component. Source: Jim considered excessive and a cause for alarm. Uncommonly,
Schumacher and Tom O’Brien. the horse may hemorrhage into the abdomen, rather than
Figure39.5 The Henderson Equine Castrating Instrument (Stone Manufacturing and Supply Company, Kansas City, MO) is clamped
across the spermatic cord and attached to a battery-powered variable speed drill. The testis is rotated until the cord separates
proximal to the clamp. The large number of twists in the cord seals the severed vessels. Source: Courtesy of Christoph Koch, University
of Berne.
through the scrotal wound, making excessive bleeding incremental boluses of the intravenously administered
difficult to identify [11, 18]. Hemorrhage into the abdomen anesthetic agent will be required [3].
can be diagnosed by observing swirling, hyperechoic If the horse must be anesthetized to grasp the end of
abdominal fluid during ultrasonographic evaluation of the the hemorrhaging cord and has suffered severe loss of
abdomen.
Treatment To resolve severe hemorrhage after castration,

the spermatic cord should be ligated or, preferably,
re-crushed with the emasculator or a heavy crushing
forceps, such as a Rochester–Carmalt forceps. A long,
right-angled forceps, such a right-angled Stille kidney
pedicle clamp or a Mixter forceps, may be easier to apply
than a straight or curved forceps if the horse is standing
(Figure 39.6). The end of the cord can be grasped and
re-crushed with the horse sedated, provided the cord is
desensitized with local anesthetic solution before
castration. The severed end of the spermatic cord may be
difficult to locate, if the cord was crushed and cut as far
proximally as was possible, and for this reason, an
emasculator should not be applied as proximally as possible
when castrating a horse.
If the horse was castrated while anesthetized, it must be
re-anesthetized to safely grasp the severed end of the
cord, unless the cord was desensitized with local anes-
thetic solution prior to castration. Instilling local anes-
thetic solution into the testis or cord when the horse is
castrated while anesthetized, ensures that the cord is
desensitized when the horse recovers from general anes-
thesia, thereby providing some temporary postoperative
analgesia. Administering local anesthetic solution into
Figure39.6 A Stille kidney clamp has been attached to the end
the testes prior to castrating a horse anesthetized with an
of the severed spermatic cord after castration to stop
intravenously administered anesthetic agent has the addi- hemorrhage from the testicular artery. Source: Jim Schumacher
tional benefit of decreasing the likelihood that additional and Tom O’Brien.
blood, it should be treated for hypovolemic shock by VisceralProlapseorEvisceration

administering a balanced crystalloid solution, such as
Definition Escape of abdominal viscera through the
lactated Ringer’s solution, to restore vascular volume.
vaginal ring. If the prolapsed viscera protrude from the
Signs associated with substantial loss of blood include
scrotal wound to become exposed to environmental
tachycardia, tachypnea, pale mucous membranes, cold
contaminates, the condition is termed eventration or
extremities, a weak pulse, and general weakness. The
evisceration [24]. Abdominal viscera involved include
magnitude of the blood loss during the first 6 to 24 hours
omentum and/or intestine.
is difficult to determine by monitoring the horse’s hema-
tocrit and total serumal solids, because fluid in the
Risk Factors
extravascular fluid spaces distributes slowly into the vas-
culature and because splenic contraction induced by ● Preoperative inguinal hernia
hypovolemia moves stored red blood cells into the vascu- ● Breed (Standardbred and draught horses; andecdotally,
lature [14]. The hematocrit and total serumal solids are American Saddlebreds and Tennessee walking horses)
usually normal initially when hemorrhage is severe. A ● Young animals (<6 months of age)
decrease in total serumal solids is often not evident for ● Increased intra-abdominal pressure
6 hours, and a decrease in hematocrit may not be evident
for 12 to 24 hours [19]. Pathogenesis This is the most serious of all complications
If the end of the cord within the inguinal canal is inac- of castration. A survey of practitioners, performed to
cessible, the inguinal canal can be packed with sterile determine the type and frequency of postoperative
rolled gauze for 24 to 48 hours to compress the bleeding complications after 23,000 castrations, found the incidence
vessel [3, 14, 20]. The intra-abdominal portion of the tes- of visceral prolapse to be 0.2% [5]. Another study found the
ticular artery can also be sealed laparoscopically using incidence of visceral prolapse after castration of 371 horses
electrocoagulation, a suture, or a vascular clip, with the to be 2.96% [25], and a recent study evaluating the
horse standing or anesthetized [18, 21]. The surgical proce- complications after castration found that only 1 of 324
dure to laparoscopically seal the testicular vasculature is (0.3%) horses suffered visceral prolapse [3].
similar to the procedure used to remove an intra-abdomi- A horse that develops visceral prolapse after castration
nal testis. The spermatic vessels are identified proximal to may do so because the horse has an inguinal hernia that
the vaginal ring and are sealed, with or without retracting has gone undetected [23]. The risk of visceral prolapse is
the vessels into the abdomen. greatest if the horse is a Standardbred or draught horse,
Ten to 30 mL of 10% formalin in 1 L of isotonic saline because these horses have a high incidence of inguinal her-
solution has been administered with apparent success niation [5, 26]. One study reported that 43 out of 568 (7.6%)
by one of the authors (JS), without apparent side effects, draught colts prolapsed omentum or intestine acutely or
to slow excessive hemorrhage associated with castra- within the first week after routine castration [26]. Based on
tion. In one study, 8 to 16 mL of a 4 to 12% solution of anecdotal evidence, American Saddlebreds and Tennessee
formaldehyde administered intravenously to horses of walking horses may also have a higher incidence of con-
average size decreased time of coagulation by 67% for 24 genital inguinal herniation than do other breeds. The like-
hours [22]. However, another study found that intrave- lihood of visceral prolapse diminishes substantially if the
nous administration of formalin to healthy horses at horse is more than 6 months old, because most congenital
doses that did not induce adverse reactions had no inguinal hernias resolve by the time the horse reaches this
detectable effect on measured hemostatic variables [23]. age [27].
A drug often administered to resolve hemorrhage is ami- Other factors besides congenital inguinal herniation that
nocaproic acid, which acts to decrease fibrinolysis. This may precipitate visceral prolapse include increased intra-
drug is administered intravenously at a dose of 20–100 abdominal pressure, caused by resistance of the horse to
mg/kg [3]. restraint while being castrated, or that occurs when the
horse rises from recumbency after being castrated [24].
Expected outcome A horse with severe hemorrhage from Increased intra-abdominal pressure may force a section of
one or both spermatic cords should be expected to recover intestine or omentum through the vaginal ring, especially
completely, provided that hemorrhage from the spermatic if the inguinal canal is open, as occurs when a hind limb is
cord can be stopped or substantially slowed. Unsterile flexed during recovery from anesthesia. Rearing or
techniques to occlude a hemorrhaging spermatic cord mounting may also increase the likelihood of visceral
could result in scrotal infection or septic funiculitis (see the prolapse, because when the horse is in either of these
Section on Septic Funiculitis below). positions, the vaginal rings reside at the most dependent
portion of the abdominal cavity. A horse that eviscerates intestine that has entered the inguinal canal encourages
after castration often does so as it arises after recovering more intestine to protrude, and strangulation of intestine
from general anesthesia, and if not then, usually within by the constricting vaginal ring soon causes the horse to
4 hours after castration [25, 28]. One horse was reported to display severe signs of colic. If the scrotal skin is left
have eviscerated 7 days after castration [29] and another at unsutured, the prolapsed intestine can usually be seen
12 days [30]. protruding from the castration site. If the skin is sutured,
swelling of the scrotum may be apparent. Ultrasonographic
Prevention Horses that have a higher than normal risk for examination of the scrotal sac and palpation of the vaginal
visceral prolapse (i.e. horses less than 6 months old or rings, performed per rectum, aids diagnosis of prolapse of
horses that are members of a breed predisposed to inguinal intestine.
herniation) should be castrated while anesthetized, and
castration should be performed using a closed technique Treatment Treating a horse that has eviscerated is
(i.e. that technique of orchiectomy in which a portion of obviously a dire emergency (Figure 39.7). The horse should
the parietal tunic is removed) after ligating each spermatic be anesthetized as soon as possible, but if the horse cannot
cord proximal to the site of transection. Prolapse of viscera be anesthetized immediately, measures must be taken to
or omentum into the spermatic cord proximal to the prevent damage to the prolapsed viscera. Progression of
ligature has not been reported, although this could still evisceration can be halted by retaining exposed viscera in
occur. The cremaster muscle, which is not considered part the inguinal region with a moist sheet or towel, or by
of the spermatic cord, should not be included in the pushing viscera back into the scrotum, after which the
ligature, because doing so could cause the ligature to loosen scrotal incision is closed temporarily with sutures or towel
when this muscle contracts. The cremaster muscle can be clamps [24].
excluded from the ligation by crushing it, along with the The intestine should be returned the abdomen as soon as
spermatic cord, at the site of ligation with a crushing possible to avoid ischemic damage, but only after it has
instrument, such as the Sands emasculator, which has no been cleaned. Pushing intestine back into the abdomen
cutting blade. The closed technique of castration alone, through the vaginal ring is more difficult than is pulling
without applying a ligature proximal to the site of
transection, is ineffective in reducing the likelihood of
evisceration [24, 26].
An instrument that seems as though it might be effective
in preventing visceral prolapse after castration is the
Henderson Equine Castrating Instrument (Stone
Manufacturing and Supply Company, Kansas City, MO; see
Section on Hemorrhage above for a description). Because
the parietal tunic is sealed by using this device, visceral
prolapse seems less likely to occur than when the sper-
matic cord is crushed and transected with an emasculator,
but in one unpublished study, one of 158 horses castrated
while standing with the Henderson Equine Castrating
Instrument developed an omental prolapse two days after
castration [16]. In another study, one of 180 horses cas-
trated using the Henderson Equine Castrating Instrument,
while anesthetized, suffered bilateral visceral prolapse
after rising from anesthesia [31]. A measure other than
using the Henderson Equine Castrating Instrument should
be used to prevent visceral prolapse, if the horse is consid-
ered to be at risk of suffering visceral prolapse after Figure39.7 This horse suffered eventration 4 hours after being
castration. castrated while standing. The referring veterinarian was unable
to halt progression of eventration, because of the temperament
Diagnosis and monitoring Horses that have suffered of the horse. A large portion of small intestine had escaped the
abdominal cavity by the time the horse had arrived at a referral
prolapse of the omentum through the vaginal ring do not surgical facility. The horse survived, despite having about
typically show abnormal clinical signs. However, when two-thirds of its small intestine resected. Source: Courtesy
intestine has prolapsed through the ring, peristalsis of Patrick Pollock, University of Edinburgh.
intestine back into the abdomen through a celiotomy cre- contamination at the surgical site, inability to inspect and
ated on the ventral midline. The vaginal ring may need to lavage the abdominal contents, greater difficulty in
be enlarged to enable return of intestine into the abdomen. performing intestinal resection and anastomosis, and
The vaginal ring can be enlarged by stretching it with a fin- difficulty in determining the viability of intestine after
ger or, if necessary, by cutting it with a blunt-pointed bis- returning intestine to the abdomen. The percentage of
toury. The horse should receive antimicrobial therapy horses in that study surviving long term was 44%.
before and after surgery, and the horse’s peritoneal fluid Other factors that may influence the likelihood of sur-
should be examined after surgery if the horse exhibits signs vival after visceral prolapse include the length of the pro-
of septic peritonitis. lapsed intestine and the necessity for performing resection
Protrusion of greater omentum through the scrotal inci- and anastomosis. Another study reported a relatively high
sion occurs with more frequency than does protrusion of incidence of survival after visceral prolapse (72.2%), even
intestine and need not be treated as a dire emergency though intestine was replaced through the scrotal incision
(Figure 39.8). The horse’s vaginal rings should be exam- (i.e. an inguinal approach), rather than through a ventral
ined per rectum to ensure that only omentum, and not midline celiotomy and even though surgery to correct vis-
intestine, has traversed the vaginal ring. Protruding omen- ceral prolapse was performed in the field [26].
tum is transected, using an emasculator, as aseptically and The prognosis of survival of a horse that develops protru-
as proximally as possible, with the horse standing or anes- sion of omentum through the scrotal incision is good, and
thetized. Forcing the horse to stand in a stall for 48 hours complications minimal, if the horse is treated properly.
after amputating exposed omentum may be helpful in pre-
venting the omentum from again protruding from the
inguinal canal. If additional security against prolapse of ScrotalInfectionand ExcessiveEdema
omentum is desired or if omentum continues to exit the Definition Clinically identifiable preputial and scrotal
scrotal incision, the horse can be treated, while anesthe- swelling, most commonly observed during the early
tized, by suturing the superficial inguinal ring, after the postoperative period
protruding omentum has been amputated and its ligated or
crushed stump returned to the inguinal canal or Risk Factors
abdomen.
● Surgical technique
Expected outcome In a study examining prognostic ● Contamination
indicators for survival of 18 horses that had suffered visceral ● Patient’s systemic condition and health
prolapse after castration, the risk of the horse dying was 5
times greater if intestine was resected and replaced through Pathogenesis Clinically identifiable preputial and scrotal
an inguinal approach alone, rather than through a ventral edema develops after nearly every castration, unless the
midline celiotomy [29]. Explanation for the high risk of scrotal wound is sutured, is generally greatest around the
mortality with the inguinal approach included greater fourth day [12], and is usually completely resolved by two
weeks [14]. For a large number of horses, postoperative
edema becomes excessive. A survey of practitioners,
performed to determine the type and frequency of
postoperative complications of castration, found excessive
scrotal and preputial edema to be the most common
complication of castration [5]. Whether excessive edema
associated with castration is due solely to surgical trauma
and perhaps poor drainage, or results from scrotal infection
at the open wound, is difficult to ascertain. In one study, of
a large number of horses undergoing conventional
castration (i.e. the scrotal wound was left unsutured),
excessive edema was the most common complication (25
out of 121 horses, 21%), and was thought to be caused by
scrotal infection [4].
Figure39.8 Prolapse of the greater omentum from the
abdomen and inguinal canal after castration. Source: Courtesy of Prevention Excessive edema can be avoided by promoting
Patrick Pollock, University of Edinburgh. drainage from the open scrotal wound. Excising a large
portion of the scrotum to promote drainage and exercising cord (see Section on Septic Funiculitis below). Ascension
the horse vigorously for at least a week prevent the scrotal of infection into the peritoneal cavity is rare,
wound from sealing and trapping fluid containing bacteria
and inflammatory products within the scrotal cavity. To
Pyrexia
remove a large portion from the bottom of the scrotum, the
scrotal raphe is grasped between the thumb and forefinger Definition Body temperature >38.5ºC in the early
and, while applying traction to the scrotum, a portion of postoperative period
the tented tissue is excised with a scalpel. Some practitioners
prefer to remove the testes through two parallel incisions, Risk factors Surgical trauma
one on each side of the scrotal raphe. The incisions should
be long enough to provide adequate drainage; removing
Pathogenesis In a study examining complications
the portion of scrotum between the incisions enhances
associated with castration of 238 horses performed per
drainage.
primam using an inguinal approach, it was found that 51
Pain associated with excessive postoperative edema and
horses (20.2%) developed a rectal temperature greater
infection decreases the horse’s inclination to exercise, thus
38.4oC for 1 to 2 days [11]. No treatment was required,
decreasing the ability of the wound to drain, thereby com-
and the pyrexia resolved spontaneously. The cause of
pounding the edema. Other complications that can occur
pyrexia was attributed to a normal postoperative response
secondary to excessive edema include phimosis or
to trauma. Schumacher et al., in a study examining the
paraphimosis.
effect of castration of horses on peritoneal fluid, observed
that 11 of 24 (46%) horses developed pyrexia after
Diagnosis and monitoring Swelling at the scrotal site and castration, but the authors of this study attributed fever
prepuce is obvious. The site may be warm and painful to to the presence of blood within the peritoneal cavity. In
the touch, and affected horses may be pyretic, obtunded that study, the concentration of red blood cells and
and have a decreased appetite. Many horses show no nucleated cells in the peritoneal fluid correlated
clinical signs associated with the edema. significantly with body temperature [47]. In a study
examining complications associated with castration of
Treatment Excessive edema can be resolved by forcing the cryptorchid horses, 43% of 324 horses developed a fever,
horse to exercise vigorously, after opening the sealed scrotal which was not related to the approach or associated with
wound by massaging the scrotum or by inserting a gloved lack of administration of antimicrobial therapy before
finger into the scrotal cavity. Administering a nonsteroidal surgery [11, 32].
anti-inflammatory drug, such as phenylbutazone (2.2 to
4.4 mg/kg, IV) or flunixin meglumine (1.1 mg/kg, IV), to a Diagnosis and monitoring Increased body temperature is
horse suffering from excessive edema after castration may recognized during routine clinical examination. Monitoring
be helpful in resolving excessive edema by increasing the of the elevated body temperature is advised and to ascertain
horse’s inclination to exercise. Unless the horse displays whether the increased body temperature persists.
clinical signs of infection associated with edema, such as
pyrexia and inappetence, antimicrobial therapy is probably
Treatment Studies have shown no treatment was required,
unnecessary.
and fever resolved spontaneously [11]. If pyrexia persists,
High-pressure lavage of the scrotal wound using a gar-
investigation of possible causes and appropriate treatment
den hose may promote drainage by keeping the scrotal
are indicated.
wound open, but a survey of practitioners, performed to
determine the type and frequency of postoperative compli-
cations of castration, found that horses that receive high- Expected outcome Horses displaying transient pyrexia
pressure lavage of the scrotum after castration may be show complete recovery, unless pyrexia is associated with
more prone to developing scrotal infection [5]. other complications.
Expected outcome The outcome of horses suffering from

SepticFuniculitis
excessive scrotal or preputial edema after castration is
favorable. However, infection of the scrotal wound may be Definition Infection of the spermatic cord as a consequence
accompanied by or lead to infection of the spermatic cord, of castration that may become obvious in the late
a condition referred to as septic funiculitis or scirrhous postoperative period
Risk Factors closed technique, whereby a large portion of the parietal

tunic was removed, because the infected portion of the
● Surgical technique (open castration)
cord is likely to extend quite far proximally, making
● Contaminated surgery
exposure of its proximal extent difficult. The infected
● Intra- or postoperative bleeding
segment of cord is removed by severing the cord proximal
to the enlarged, infected segment, using an emasculator
Pathogenesis Septic funiculitis occurs from extension of
or écraseur (Figure 39.9), and the wound is left unsutured
scrotal infection or from a contaminated emasculator or
to heal by second intention.
ligature. The open method of castration, in which the
parietal tunic and cremaster muscle are not removed, may
predispose the horse to septic funiculitis [33]. The common Expected outcome Healing proceeds rapidly, if the infected
name for a cord chronically infected with pyogenic portion of the spermatic cord can be excised; for the vast
bacteria is “scirrhous cord” [34, 35]. The lesion usually majority of affected horses, the proximal aspect of the
soon becomes evident because the scrotal wound fails to infected portion of the spermatic cord can be accessed and
heal, but it may not become apparent for years after transected, even when castration was performed using a
castration [12, 36]. closed technique.
Prevention Septic funiculitis can be avoided by using

Tetanus
sterile technique when performing a castration. If ligating
the spermatic cord or spermatic vessels is deemed necessary Definition Horses become infected with Clostridium tetani
to prevent excessive hemorrhage, the ligature should be at the scrotal wound and develop paralysis of the voluntary
absorbable and monofilament. muscles and assume a characteristic protrusion of the third
eyelid and a “saw-horse” stance [39].
Diagnosis Horses with acute septic funiculitis experience
preputial and scrotal edema, pain, and pyrexia, and are Risk Factors
sometimes lame on the ipsilateral pelvic limb [37]. The
infected cord eventually enlarges with hard fibrous tissue, ● Failed preoperative immunization
and abscesses, which may discharge periodically through ● Perioperative contamination of the surgical site
sinus tracts. The infected cord rarely may become so large
that it interferes mechanically with movement of the pelvic Pathogenesis The surgical site becomes contaminated
limb. Uncommonly, infection may ascend the cord so far with Clostridium tetani.
proximally that a hard mass can be palpated per rectum
adjacent to the vaginal ring [38].
Treatment Whether septic funiculitis can be resolved

with antimicrobial therapy and establishment of scrotal
drainage alone has not been established. To ensure
resolution of infection, the infected portion of the cord
should be excised, especially if infection has been caused
by a contaminated suture. To excise the infected portion
of cord, the horse is anesthetized and positioned in dorsal
recumbency, an incision is made over the superficial
inguinal ring on the affected side, and the infected portion
of cord is isolated from normal tissue. The infected
portion of cord is dissected from surrounding tissue
without great difficulty, provided that surgery is
Figure39.9 Excised infected spermatic cords of a horse that
performed within a few weeks after castration. Removing developed bilateral septic funiculitis (scirrhous cord) after
a chronically infected portion of the cord, however, is castration performed using an open technique (i.e. a technique
difficult because of fibrous adhesions to the parietal tunic of castration in which the parietal tunic of each testis is retained
within the horse). Infection is contained within the parietal tunic
and the development of a large vascular supply to the
of each spermatic cord, and the parietal tunic of each cord is
infected cord. Excising the infected portion of the cord attached to the scrotal scar. Source: Jim Schumacher and Tom
can also be difficult if the horse was castrated using the O’Brien.
Prevention This complication of castration can be avoided Prevention Performing castration using aseptic technique
by ensuring that the horse is immunized against Clostridium should decrease the already low likelihood of a horse
tetani. The American Association of Equine Practitioners developing septic peritonitis as a post-castration
recommends administering a booster vaccination of complication.
tetanus toxoid if a horse receives a wound more than
6 months after the last booster [40], but a recent study Diagnosis and monitoring Affected horses typically are
showed that horses immunized with 3 doses of tetanus pyrexic, inappetent, and obtund. Peritonitis should not be
vaccine after they are more than 5 months old are likely to considered septic on the basis of the nucleated cell count in
have serumal antibody titers sufficient to protect against C. the peritoneal fluid alone, because a count greater than
tetani for more than 3 years [41]. Horses not previously 10,000/μL indicates only that the peritoneum is
immunized with tetanus toxoid should be administered inflamed [47]. Peritonitis should be considered septic only
tetanus antitoxin and tetanus toxoid [40, 42], keeping in when peritoneal inflammation is accompanied by bacterial
mind that a rare but often fatal complication associated infection. The presence of degenerated neutrophils or
with administration of tetanus antitoxin is Theiler’s intracellular bacteria in the peritoneal fluid, coupled with
disease [43]. signs of septic peritonitis, such as pyrexia, tachycardia,
diarrhea, weight loss, signs of colic, and reluctance to
Treatment Horses infected with C. tetani can be treated move, indicates that peritonitis is accompanied by bacterial
with high doses of penicillin, tetanus antitoxin, a infection of the abdominal cavity [49, 50].
nonsteroidal anti-inflammatory and analgesic drug, and
supportive therapy [44, 45]. Necrotic scrotal tissue should Treatment Horses with septic peritonitis should be
be excised, and scrotal drainage established. administered antimicrobial and nonsteroidal anti-
inflammatory and analgesic drugs and supportive therapy,
and the peritoneal cavity should be lavaged to remove
Expected outcome Over 70% of horses affected with tetanus
bacteria and inflammatory exudate. Septic peritonitis
succumb to the disease [46].
occurs only rarely after castration [47], even though the
vaginal and peritoneal cavities communicate, perhaps
SepticPeritonitis because the funicular portion of the vaginal process is
collapsed as it courses obliquely through the inguinal
Definition Infection of the peritoneal cavity by ascending canal [51] and because mesothelial cells lining the vaginal
bacteria from the surgical site process are phagocytic [52].
Risk Factors
Expected outcome The outcome of horses affected with
● Surgical trauma septic peritonitis varies according to the type of bacteria
● Contamination during surgery causing septic peritonitis, time elapsed between
development of the condition and initiation of treatment,
and the type of treatment provided to the horse. Affected
Pathogenesis Horses often develop subclinical, non-septic
horses have a guarded prognosis for survival.
peritonitis after castration, because the vaginal and
peritoneal cavities communicate [47]. A nucleated cell
count greater than 10,000/μL in peritoneal fluid indicates PenileDamage
that the peritoneum is inflamed, and in a study by
Definition Inadvertent damage to the penile body during
Schumacher et al., a nucleated cell count greater than
surgery or drug-induced penile prolapse
10,000/μL was found in the peritoneal fluid of 15 out of
24 horses (63%) for at least 5 days after routine,
Risk Factors
uncomplicated castration [47]. A nucleated cell count
greater than 100,000/μL was common. Non-septic ● Inadequate anatomical knowledge
peritonitis of these horses was characterized clinically only ● Preoperative administration of a phenothiazine-deriva-
by transient pyrexia (see Section on Pyrexia above). tive tranquilizer
Horses may develop non-septic peritonitis after castra-
tion, because blood in contact with the peritoneum causes Pathogenesis The surgeon may inadvertently isolate the
inflammation [48], and most horses suffer some degree of shaft of the penis from surrounding fascia while trying to
intra-abdominal hemorrhage after castration [47]. find and isolate an inguinally retained testis, because the
compliance and texture of the penis and that of a testis are Expected outcome The outcome of horses suffering from
somewhat similar, and in doing so, may damage the penis penile damage incurred during castration depends on the
sufficiently to result in paraphimosis. Paraphimosis, if extent of damage and lapse of time between damage and
prolonged, can result in permanent penile paralysis [15], treatment. The outcome is generally favorable for survival,
presumably from damage to the pudendal nerves (JS, but if damage is extensive, the cosmetic appearance of the
observation). A portion of the shaft of the penis, if mistaken horse may be affected.
for a testis, may even be amputated (Figure 39.10). This
complication is most likely to occur when the surgeon is
Hydrocele
searching for an inguinal testis.
Sharp dissection that damages the urethra results in Definition A hydrocele, or vaginocele, is an accumulation
extravasation of urine into surrounding fascia, which in of fluid within the parietal tunic, or vaginal sac, that may
turn, results in severe necrosis of that fascia [53, 54]. appear months or years after castration [12].
Administering a phenothiazine-derivative tranquilizer as a
pre-anesthetic agent can result in priapism or penile paraly- Risk factors Open technique of castration
sis, but the incidence of this complication after administra-
tion of acepromazine is low [55, 56]. Complications of Pathogenesis The condition is rare and idiopathic, but
castration involving the penis can be avoided if the surgeon open castration (i.e. the technique of castration in which
is familiar with urogenital anatomy and techniques of the parietal tunic that surrounds the testis is not removed)
castration. predisposes the horse to the condition. With this condition,
the vaginal cavity, an outpouching of the peritoneal cavity,
Treatment The penis of a horse that develops fills with peritoneal fluid.
paraphimosis after castration should be supported with a
sling to prevent damage to the penis and internal lamina Diagnosis This accumulation of fluid within the scrotum
of the prepuce and to decrease preputial edema. may mimic a testis or an inguinal hernia (Figure 39.11).
Immediate surgical apposition of lacerated penile tissue Palpation and ultrasonographic examination of the
is required if the penis has been incised. Penile amputation scrotum indicate presence of fluid within the vaginal
caudal to the fornix of the prepuce and creation of a cavity. Fluid contained within the hydrocele can be reduced
urethral stoma at the perineum may be required, if the temporarily into the abdomen, and aspiration of this cyst-
penile damage at the site of castration cannot be
adequately repaired.
Figure39.10 Intraoperative image of a pony anesthetized and

in dorsal recumbency. This pony’s penis was inadvertently
transected by a lay person, who was castrating using both a
scrotal and an inguinal approach to the testes. The pony was
treated by removing the distal segment of the transected penis
and by creating permanent urethral stoma caudal to the scrotal Figure39.11 An accumulation of fluid within the scrotum
wound. A urinary catheter has been placed into the urethra caused by formation of a hydrocele may give the horse the
through the newly created urethral stoma. Source: Jim appearance of having a scrotal testis or a scrotal hernia. Source:
Schumacher and Tom O’Brien. Jim Schumacher and Tom O’Brien.
like structure, although not usually necessary for diagnosis, Retentionof MasculineBehavior
produces a clear amber fluid.
Definition Continued male behavior after castration
Treatment The horse need not be treated for this condition
Risk Factors
if the hydrocele does not inconvenience the horse or is not
aesthetically displeasing to the owner. To remove the ● Incomplete castration
hydrocele, the horse is anesthetized, positioned in dorsal or ● Innate psychic behavior
lateral recumbency, and prepared for aseptic surgery. Skin ● Season of the year
is incised directly over the fluid-filled parietal tunic, and
the tunic is bluntly freed from the scrotal fascia after Pathogenesis Libido is normally lost gradually after
transecting the scrotal ligament, which attaches the tunic castration, even though the serumal concentration of
to the scrotum (Figure 39.12). The tunic is transected, testosterone and estrogen decline rapidly to basal
using scissors or an emasculator, as proximally as possible. concentrations within 6 hours [57]. In one study, mean
The scrotal incision is sutured or left open to heal by scores of libido declined slowly after castration until they
secondary intention. stabilized by day 56 [57]. Castration does not always
completely eliminate masculine behavior, even after
Expected outcome This complication has purely cosmetic several months. Some geldings may display masculine
consequences. Very rarely, the hydrocele may enlarge to behavior, especially in the spring and summer, such as
the extent that it interferes with locomotion. genital investigation and mounting, and may even develop
an erection [58]. A gelding that still exhibits libido and a
temperament characteristic of a stallion is sometimes
Signsof Colic
referred to as a “false rig.”
In a study of 238 stallions castrated using an inguinal One cause attributed to persistence of masculine behav-
approach with primary closure of the inguinal incisions, ior after castration is extra-gonadal production of andro-
8.8% of horses showed transient signs of colic after recover- gens, and one purported source of these extra-gonadal
ing from general anesthesia, interpreted as resulting from androgens is the epididymis. A horse that exhibits mascu-
postoperative pain (i.e. false colic) [11]. Horses more than line behavior after castration, allegedly because the sur-
10 years old tended to be more likely than horses less than geon failed to remove a portion of the epididymis, is
5 years old to show signs of colic. A horse displaying signs sometimes referred to as being “proud cut” [58]. However,
of colic after castration should be examined closely to the epididymis is closely attached to the normal, descended
determine if signs of colic are caused by pain associated testis, making the surgeon unlikely to leave the epididymis
with castration or are caused by intestinal pain. behind during castration. Even if the surgeon were to leave
a portion of the epididymis behind, that portion of the
epididymis would neither produce nor release androgens.
The cause of masculine behavior should not be attributed
to failure to remove all epididymal tissue, and therefore
there is no such thing as a proud-cut horse [58].
Persistence of masculine behavior after castration has
also been attributed to production of testosterone by the
adrenal cortex in response to an increase in the
concentration of interstitial cell-stimulating hormone in
the plasma, which increases in response to the decrease in
serumal concentration of testosterone that occurs after
castration [59]. The serumal concentration of testosterone
or dihydrotestosterone of false rigs, however, is no greater
than that of geldings that do not exhibit masculine behav-
ior [58], and therefore, persistence of masculine behavior
Figure39.12 Intraoperative image of a horse anesthetized and after castration should not be attributed to the production
in dorsal recumbency undergoing removal of a hydrocele. The of testosterone by the adrenal cortex.
fluid-filled parietal tunic is separated from attaching fascia and
excised. This figure shows an incision in the hydrocele exposing
Masculine behavior displaying a false rig should be
the yellow fluid contained within. Source: Jim Schumacher and attributed to innate behavior associated with normal social
Tom O’Brien. interaction among horses, rather than to extra-gonadal
production of androgens [58, 60].Twenty to 30% of geld- supply within the spermatic cord include the incision-liga-
ings exhibit masculine behavior toward mares and aggres- tion technique, the section-ligation-release technique, and
sion toward other horses, and about 5% exhibit aggression the pinhole technique, each of which is performed with the
toward people; this prevalence of masculine behavior of equid anesthetized [65, 66]. The serumal concentration of
horses castrated before puberty is similar to that of horses testosterone normally falls to that of a gelding within 7
castrated after puberty [60]. Owners should be advised of days after the spermatic vessels are ligated, but the atro-
these statistics, so that if the horse continues to display phied testis, though small and non-functional, can be pal-
some form of objectionable masculine behavior, miscon- pated for several months or more [64]. The epididymis
ception about the surgeon’s ability to perform castration remains viable, but because it provides no contribution to
properly can be avoided. masculine behavior, the equid behaves as a gelding.
Persistence of masculine behavior persists after castration Revascularization of testicular tissue, and hence reten-
when the surgeon mistakenly fails to remove one of the tion of masculine behavior, has been reported to occur
testes [61]. This mistake occurs when a portion of the occasionally after in situ techniques of interrupting blood
epididymis of an abdominally-retained testis has descended supply within the spermatic cord or within the abdomen of
through the vaginal ring into an everted vaginal process so inguinal cryptorchid stallions and entire stallions, and has
that the epididymis lies within the inguinal canal. The sur- been attributed to collateral blood supply to the testis from
geon mistakenly identifies the tail of the epididymis as a the cremasteric or external pudendal arteries [65–67]. In
hypoplastic inguinal testis and, confident that it is a testis, one study, intra-abdominal laparoscopic transection of the
removes it. The horse unsurprisingly continues to exhibit spermatic cords of 241 cryptorchid and normal stallions,
masculine behavior, while the owner and surgeon are performed without removing the testes, resulted in com-
convinced that both testes have been removed. This mistake plete necrosis of all abdominally retained testes but incom-
can be avoided if the surgeon incises the vaginal process plete necrosis of 5.6% of inguinally retained testes and 3.4%
(i.e. the parietal tunic) and examines the contents contained of normally descended testes [68].
within before amputating the process (Figure 39.13). Although the pinhole technique has been used effec-
Some in situ methods of castration, by which the testes tively to castrate calves [69], it fails to induce complete
are rendered non-functional by ligating their blood supply, necrosis in the testes of donkeys, and therefore this
may occasionally result in retention of masculine behavior. method of castration may result in retention of masculine
In situ techniques of castration include ligation/transection behavior [65]. The section-ligation-release and the inci-
of the spermatic vessels within the abdomen (i.e. sion-ligation techniques, on the other hand, result in
laparoscopic castration) [62–64] or within the spermatic complete necrosis of the testes, but the client should be
cord [65, 66]. In situ techniques of interrupting blood informed that a testis, though small and non-functional,
can still be palpated within the scrotum. Ligating the
spermatic cord close to the testis (i.e. within the inguinal
canal) rather than ligating it intra-abdominally, appar-
ently disrupts the collateral blood supply from the cre-
masteric and external pudendal artery, preventing failure
of castration [69].
Prevention Removal of both testes. The surgeon should

not mistake the epididymis lying within an everted vaginal
process for a hypoplastic testis. Innate, non-hormonally-
controlled masculine behavior cannot be prevented.
Diagnosis and monitoring The clinician, when presented

with a horse thought to be a gelding but displaying
masculine behavior, must first determine whether the
Figure39.13 Intraoperative image of a horse anesthetized and
in dorsal recumbency undergoing removal of retained testis cause of unexpected masculine behavior is innate or from
through an inguinal approach. The testis of this horse resided incomplete castration. This determination is made by
within the abdomen, and this everted vaginal process contained finding a testis by palpation per rectum or during
only the epididymis. By opening the vaginal process to inspect
ultrasonographic examination of the abdomen, performed
its contents, incomplete cryptorchid castration can be avoided. A
small portion of the epididymis can be seen protruding through per rectum or percutaneously, or by conducting hormonal
the incision. Source: Jim Schumacher and Tom O’Brien. assays.
Palpating an abdominal testis per rectum confirms that behavior after castration is hormonally induced [58. 59,
the horse has been incompletely castrated, but an abdomi- 73–77]. Based on results of different studies, the basal seru-
nal testis is difficult to palpate, because it is small and flac- mal concentration of testosterone of geldings should be
cid, and because it typically has a wide range of movement, less than 40 pg/mL, and that of horses with testicular tissue
allowed by an elongated proper ligament of the testis. The should be greater than 100 pg/mL and is often 1,000 to
vaginal ring cannot be palpated per rectum if the horse has 2,000 pg/mL [59, 74, 77]. The serumal concentration of tes-
complete abdominal testicular retention (i.e. the testis and tosterone in horses with testicular tissue is lowest during
epididymis are both contained within the abdomen), so the winter and may be low in horses younger than 3 years
being able to palpate the vaginal ring is evidence that the old. The wide variation in basal serumal concentrations of
testis or at least its epididymis, has descended through the testosterone of geldings and stallions may cause the
ring. Failure to palpate an abdominal testis per rectum concentrations of testosterone to overlap, leading to error
should not be considered conclusive evidence that one in interpretation [59, 74–77]. One study found a 14% error
does not exist, and similarly, palpation of a vaginal ring per using basal serumal concentrations of testosterone to
rectum should not be considered good evidence that a tes- differentiate geldings from horses with testicular
tis has descended through it, because the ring can be pal- tissue [77], whereas in another study, error in predicting
pated per rectum even if only the epididymis has descended the presence of testicular tissue based on the basal concen-
into the inguinal canal. tration of testosterone was only 5% [73].
Finding the ductus deferens on the caudomedial aspect of The concentration of serumal testosterone rises in
the ring during palpation per rectum is also not irrefutable response to administration of human chorionic
evidence that the testis has descended, because the ductus gonadotropin (hCG), the pituitary analog of luteinizing
deferens can be palpated at this location only if the hormone (LH), which is similar or identical to interstitial
epididymis has descended through the vaginal ring [70]. In cell-stimulating hormone, if the horse has testicular tissue,
one study, the presence of an undescended testis was thereby increasing the accuracy of predicting whether a
determined, with reasonable accuracy, to be abdominally horse has testicular tissue. In one study, accuracy increased
retained if the ductus deferens could not be palpated from 86%, when only the basal serumal concentration of
entering the ipsilateral vaginal ring [32]. Accuracy of testosterone was used to predict the presence of testicular
predicting the location of the retained testis by palpation tissue, to 94.6%, when the hCG stimulation test was per-
per rectum dropped from 90 to 67% if palpation was formed. [58, 74, 77].
performed after an unsuccessful attempt at To perform the hCG stimulation test, serum is collected
cryptorchidectomy, presumably because of scarring in the before and at any time between 30 minutes and 2 to 3 days
inguinal region or because the ductus deferens had after intravenously administering 6,000 to 12,000 units of
retracted into the abdomen. hCG [58, 74, 76]. The horse is predicted to have testicular
An abdominal testis can often be identified ultrasono- tissue if its serumal concentration of testosterone increases
graphically with a 5-MHz linear-array transducer inserted and exceeds 100 pg/mL in response to administration of
rectally [71]. The abdomen is examined in a to-and-fro pat- hCG. The horse is predicted to be a gelding if the serumal
tern while advancing the transducer cranially from the concentration of testosterone is less than 40 pg/mL and
region of the vaginal rings. However, transrectal ultrasono- fails to increase. Response to administration of hCG is
graphic examination is ineffective in locating an inguinally poorest during the winter and in horses younger than 18
located testis. An abdominal testis can also be imaged months old [74].
transabdominally by applying a 3.5-MHz sector scanner or The presence of testicular tissue in horses more than 3
a linear-array transducer longitudinally to the inguinal years old correlates highly with serumal concentrations of
region and advancing it cranially in a to-and-fro pattern conjugated estrogen (i.e. estrone sulfate) [74, 77]. The
between the midline and the flank [72]. Testicular paren- serumal concentration of estrone sulfate is about 96%
chyma is identified as a spherical homogenous structure accurate in predicting the presence of testicular tissue in
surrounded by a more echogenic tunica albuginea [71, 72]. horses of unknown castration status, provided that horses
The testis can be discriminated from other abdominal younger than 3 years are excluded. A serumal concentration
structures, such as an empty loop of small intestine, the of estrone sulfate greater than 400 pg/mL indicates that the
density of which is sometimes identical to that of a cryp- horse is a stallion, whereas a concentration of less than 50
torchid testis, by its central vein or by the presence of an pg/mL indicates that the horse is a gelding [58]. A
epididymis lying adjacent to it [72]. laboratory’s standard values for concentrations of
The concentration of androgens and estrogens in the testosterone and estrone sulfate in geldings and horses
plasma or serum can be used to determine if masculine with testicular tissue may vary from those cited above, so
knowing the laboratory’s standards is important when

assessing the results of a hormonal assay.
Determining serumal concentrations of anti-Müllerian
hormone, produced by the Sertoli cells of the testis, may
also be useful for diagnosing equine cryptorchidism,
because the serumal concentration of this hormone is
high in cryptorchid horses but at or below the limit of
detection in geldings [78, 79]. The biological half-life of
anti-Müllerian hormone is only 1½ days, making testing
for the serumal concentration of this hormone useful if
the success of a recently performed castration is in
doubt [79, 80].
Treatment Shortening the spermatic cords was reported to

abolish masculine behavior in three-quarters of 18 false
rigs, but the author of that report offered no satisfactory
explanation for the apparent success of this procedure [81].
The procedure seems unlikely to lessen masculine behavior
because the spermatic cords contain no Leydig cells and
are, therefore, incapable of producing androgens.
Masculine behavior of false rigs should be considered
innate, rather than hormonally induced, and this innate
behavior is best eliminated or reduced by eliminating or
in dorsal recumbency undergoing removal of retained testis
limiting the false rig’s social interactions with other through an inguinal approach. Note that this right abdominal
horses [58]. testis, exteriorized through a parainguinal approach, is larger
In horses with retained testis, the abdominal testis must than most abdominal testes and that the epididymis is missing.
The horse’s left scrotal testis had been removed months earlier,
be located and removed to abolish hormonally-induced
and at the same time, only the inguinally-located epididymis of
masculine behavior after incomplete castration. The the right abdominal testis had been removed. That is, this horse
retained abdominal testis can be removed through the had undergone an incomplete cryptorchid castration. Source: Jim
vaginal ring, using an inguinal approach, or through a Schumacher and Tom O’Brien.
parainguinal approach. Removing a testis through the
vaginal ring may be difficult if the contralateral descended cocele, and torsion of the spermatic cord. Hemicastration
testis has been removed at a previous surgery, because can be performed per primam, or the scrotal wound can be
removing the descended testis causes the abdominal testis left unsutured to heal by second intention. A study per-
to undergo compensatory hypertrophy (Figure 39.14). formed to determine the effects of leaving the scrotal
wound unsutured on fertility found no difference between
Expected outcome Removing the abdominal testis from a the two techniques on the quality of semen at 30 and 60
horse that has undergone incomplete castration eliminates days after hemicastration, suggesting that the function of
persistent masculine behavior. However, 20 to 30% of the remaining testis is not dramatically influenced by
geldings exhibit masculine behavior toward mares [59]. whether or not the scrotal wound is sutured or left open to
The only recourse for ameliorating persistent, non- heal by second intention [82].
hormonally-caused masculine behavior displayed by a Removing the descended testis of a cryptorchid stallion
horse after bilateral orchiectomy is to isolate the horse or has been advocated to promote descent of the cryptorchid
perhaps to impose stricter discipline. testis [83]. Hemicastration may bring about descent of an
inguinal testis, because the testis undergoes compensatory
hypertrophy in response to increased secretion of intersti-
ComplicationsAssociatedwith Hemicastration
tial cell-stimulating hormone from the hypophysis [84].
Hemicastration is sometimes performed for legitimate rea- However, an abdominal testis is unable to descend through
sons, such as to preserve fertility when one testis or sper- the vaginal ring soon after birth [85], making removal of its
matic cord is diseased, causing temperature-induced descended counterpart ineffectual in bringing about its
dysfunction of spermatogenesis of the other testis. descent. An inguinally retained testis is located easily dur-
Examples of such diseases include neoplasia, orchitis, vari- ing inguinal exploration and should always be removed
along with the descended testis. A descended testis should omplicationsAssociated

C
never be removed without first removing the non- with Cryptorchidectomy
descended testis, because, if the non-descended testis can-
not be located, doing so allows a dishonest owner to Failureto Locatean AbdominalTestis
fraudulently represent the horse as a gelding. The remain-
ing, non-descended abdominal testis enlarges by compen- Definition The surgeon fails to locate a retained testis
satory hypertrophy, making its removal through an during a conventional inguinal approach for
inguinal or parainguinal approach more difficult [86]. cryptorchidectomy.
Failure of the surgeon to record which testis was removed
further compounds the difficulty of cryptorchidectomy Risk Factors
performed after hemicastration. ● Inadequate knowledge of relevant anatomy
● Anatomical abnormality (testicular agenesis, testicular
degeneration, persistence of the cranial suspensory
MiscellaneousComplicationsof Castration ligament)
Incarceration of intestine through a rent in the mesoductus
deferens, resulting in signs of colic, was reported to occur Prevention The surgeon must have detailed knowledge of
in two horses years after castration [87]. The rent in relevant anatomy and surgical approaches to
mesoductus deferens was speculated to have occurred at crytorchidectomy and must be able to modify the surgical
the time of castration. Another unusual complication of approach when encountering difficulty in locating the
castration occurred when a gelding’s penis became retained testis.
entrapped in a rent in the suspensory ligament of the pre-
Pathogenesis and treatment The non-invasive inguinal
puce resulting in phimosis. The ligament was apparently
approach is an approach commonly used to remove an
lacerated when the horse was castrated [88].
abdominal testis, and the biggest challenge when using
this approach is locating the vaginal process. When located,
the vaginal process is incised to expose the epididymis
ComplicationsAssociatedwith ImproperCare
contained within. The testis is exteriorized through the
afterCastration
vaginal ring by placing traction on the proper ligament of
Some complications of castration can be avoided if the the testis, which connects the tail of the epididymis to the
horse is cared for properly. Confining the horse to a small testis. This approach is described as being non-invasive,
clean area for 24 hours after castration avoids delayed hem- because no more than the tip of a finger is inserted into the
orrhage from the severed testicular artery and may decrease abdomen.
the risk of visceral prolapse by allowing formation of a The vaginal process, if naturally everted into the inguinal
fibrin seal at the vaginal ring [28]. After this period of con- canal, is easily located and incised (Figure 39.13). An
finement, the horse should be exercised to the degree nec- inverted vaginal process must be everted into the inguinal
essary to prevent excessive preputial and scrotal edema. canal, but doing so is often difficult. One method of
However, if the scrotum was sutured, postoperative everting an inverted vaginal process [89], is to place tension
swelling is slight, even if the horse is not exercised, provided on the inguinal extension of the gubernaculum testis,
the procedure was performed using sterile technique and which connects the scrotum to the vaginal process, but
hemorrhage from the spermatic vessels into the scrotum locating this extension is sometimes difficult. This ligament
has been prevented. The owner should be advised that can be found at the junction of the cranial and middle third
placing a horse into a field does not ensure that the horse of the superficial inguinal ring, on the medial or lateral
receives adequate exercise. Protecting the wound against crus of the ring. The ligament is best located by grasping
flies is usually unnecessary, provided that the horse’s tail- loose tissue at this site, between the thumb and forefinger,
hairs are long enough to reach the scrotal wound. A survey and placing traction on this tissue. Using the contralateral
of practitioners, conducted to determine the types and thumb and forefinger, fascia is stripped from the tissue,
frequency of complications associated with castration, and in doing so, the inguinal extension of the gubernaculum
found that horses that receive perioperative antimicrobial testis contained within this tissue becomes apparent
treatment may be less likely to develop infection at the (Figure 39.15) and, at the same time, the vaginal process
open scrotal wound, whereas horses that receive everts into the inguinal canal, where it appears as a white
hydrotherapy to keep the scrotal wound clean, open, and structure containing the small cremaster muscle on its lat-
draining are more apt to develop infection [5]. eral aspect (Figures 39.13 and 39.15).
Complications Associated ith Cryptorchidectomy 515
to a non-invasive parainguinal approach [90]. This

approach can be characterized as non-invasive, because
only one or two fingers are inserted into the abdomen. For
this approach, a 4- to 5-cm incision is made in the aponeu-
rosis of the external abdominal oblique muscle, about 2 cm
medial and parallel to the superficial inguinal ring and
centered over the cranial end of the ring. The internal
abdominal oblique muscle beneath the aponeurosis is
parted in the direction of its fibers using blunt dissection,
and the abdominal cavity is entered by tearing the perito-
neum with a finger. Perforating the peritoneum with an
instrument risks damage to a viscus, such as the bladder.
The epididymis can be palpated adjacent to the vaginal
ring, which is located caudolateral to the site of entry into
the abdomen [90]. The epididymis is grasped between the
index and middle fingers and exteriorized, and the body of
the epididymis is followed to the tail of the epididymis.
Traction on the proper ligament of testis, which connects
the tail of the epididymis to the testis (Figures 39.16
and 39.17), pulls the testis through the incision. Some sur-
geons prefer the parainguinal approach over the inguinal
approach, because with the parainguinal approach, the
vaginal ring is not disturbed, thereby eliminating the
necessity of apposing the right and left cruses of the super-
ficial inguinal ring with sutures if risk of visceral prolapse
through the disturbed vaginal ring is possible. The superfi-
cial inguinal ring is more difficult to close with sutures
in dorsal recumbency undergoing removal of an abdominally
retained testis through an inguinal approach. The everted than is the aponeurosis of the external abdominal oblique
vaginal process is indicated with the thick arrow. The cremaster muscle.
muscle is attached to the lateral aspect of the vaginal process If locating the epididymis using the non-invasive parain-
and cannot be seen in this picture. The sponge forceps is
guinal approach proves difficult, the incision can be
clamped on the inguinal extension of the gubernaculum testis
(thin arrow). An incision in the everted vaginal process exposes enlarged to accommodate a hand. The testis can usually be
the epididymis. Source: Courtesy of Patrick Pollock, University of
Edinburgh.
If the inguinal extension of the gubernaculum testis

cannot be located, the inverted vaginal process can be
everted using a sponge forceps [70]. Using this technique,
a finger is inserted through the vaginal ring into the
inverted vaginal process, and a sponge forceps is inserted
into the process next to the finger. The apex of the vaginal
process is grasped in the jaws of the forceps, and by apply-
ing traction to the forceps, the inverted vaginal process
everts. The vaginal ring is usually located beneath the
third finger when four fingers are inserted into the ingui-
nal canal.
The surgeon may encounter difficulty in locating an
abdominal testis using the inguinal approach described Figure39.16 The ligament of the tail of the epididymis (LTE)
above if a previous attempt at castration has disturbed ana- connects the vaginal process (VP) to the tail of the epididymis
(TE). The proper ligament of the testis (PLT) connects the tail of
tomical structures used to locate an abdominal testis, such
the epididymis to the testis, and by placing traction on this
as the inguinal extension of the gubernaculum testis or the ligament, the testis can be pulled through the vaginal ring into
vaginal process. In this case, the approach can be converted the inguinal canal. Source: Jim Schumacher and Tom O’Brien.
be the cause of abdominal cryptorchidism, the surgical

approach should be laparoscopically through the ipsilat-
eral flank with the horse standing, because this approach
allows the dorsocaudal aspect of the abdominal cavity to be
explored. The surgeon should bear in mind that laparos-
copy performed with the horse standing does not always
allow the retained testis to be identified, and celiotomy per-
formed on the ventral midline or in the paralumbar fossa
may be required to find and remove the testis.
Expected outcome Thorough examination using those

diagnostic techniques necessary to determine if the horse
has a cryptorchid testis leads to confirmation of the absence
or presence of a testis. Locating and removing a cryptorchid
testis eliminates hormonally controlled masculine
Figure39.17 The proper ligament of the testis of an behavior.
abdominal testis is sometimes quite long (thick arrow), whereas
that of an inguinal or scrotal testis is short (thin arrow). Source:
Jim Schumacher and Tom O’Brien. EviscerationAftera ConventionalInguinal
Approachfor Cryptorchidectomy
located in the inguinal region, but if the testis remains elu- Definition Escape of abdominal viscera through the
sive, the ductus deferens can be found in the genital fold of vaginal ring (see the Section on Complications Associated
the bladder and traced cranially to the epididymis and tes- with Castration of Entire Stallions in this chapter).
tis, a maneuver that seems as though it would be easy but
is actually quite difficult. The surgeon may encounter dif- Risk Factors
ficulty in locating an abdominal testis if the horse suffers
from unilateral testicular agenesis or from degeneration of ● Similar to those resulting in evisceration after normal
an abdominal testis caused by torsion of the spermatic castration
cord, in utero or after birth [91–95]. Testicular atresia or ● Excessive enlargement of the vaginal ring
degeneration is discovered by tracing the ductus deferens
to the epididymis which, if the testis has degenerated, is Pathogenesis The vaginal ring must often be enlarged to
attached to a miniscule testis or, if the horse suffers from extract an abdominal testis when performing
testicular atresia, to no testis. cryptorchidectomy using an inguinal approach. Intestine
Persistence of the cranial suspensory ligament should be may prolapse through an enlarged vaginal ring, unless
considered whenever a cryptorchid testis cannot be found measures are taken during surgery to prevent this.
in its usual locations [96]. Disappearance of the ductus def-
erens dorsal to the intestinal viscera suggests that the cra- Prevention The size of the vaginal ring should be
nial suspensory ligament of the testis has persisted during ascertained after an abdominal testis has been removed
embryogenesis, causing the retained testis to be located at using the inguinal approach. The horse can be recovered
the caudal pole of the kidney [96]. During much of gesta- from anesthesia and allowed unrestricted activity if the
tion, the testis is suspended cranially from the kidney by vaginal ring accommodates no more than the tips of the
the cranial suspensory ligament and dorsally to the body index and middle fingers [89]. However, measures must be
wall by the mesorchium [85, 97]. The cranial suspensory taken to prevent evisceration if the ring has been dilated
ligament forms by gestational day 55 and regresses at about beyond this size, and one measure is to pack the inguinal
5 months of gestation, facilitating normal descent of the canal with sterile rolled gauze to prevent escape of intestine
testis. A testis retained abdominally because of persistence through the vaginal ring. The gauze is maintained in the
of the cranial suspensory ligament is difficult to access canal for one or two days by closing the scrotal incision
through a conventional inguinal or parainguinal approach with sutures. The horse’s inguinal region should be
to the abdomen with the horse in dorsal recumbency, and examined by palpation per rectum after the horse recovers
the dorsally located testis is also difficult to view laparo- from anesthesia to ensure that the gauze has not entered
scopically when the horse is in dorsal recumbency [96]. If the abdomen through the enlarged vaginal ring. Gauze
persistence of a cranial suspensory ligament is suspected to extending through the vaginal ring prevents the ring from
Complications Associated ith Cryptorchidectomy 517
contracting, and intestine soon adheres to the gauze. The inguinal ring or left unsutured to heal by second inten-
vaginal ring should also be examined by palpation per tion. A hernia or kidney needle is ideal for suturing the
rectum before the packing is removed to ensure that ring because the needle is stout, making it difficult to
intestine has not become adhered to it. break, and because its point is blunt, preventing it from
A much more reliable method of preventing eviscera- damaging the surgeon’s fingers.
tion is to appose the medial and lateral cruses of the
superficial inguinal ring with suture. Closing access of Treatment See Section on evisceration following normal
intestine to the inguinal canal by suturing the vaginal or castration in this chapter.
deep inguinal ring may seem a more logical way to pre-
vent evisceration, but the vaginal and deep inguinal rings Expected outcome See Section on evisceration following
are inaccessible for suturing. The superficial inguinal ring normal castration in this chapter.
is most easily sutured by using heavy suture on a hernia
or kidney needle. The ends of the suture are tied together,
Complicationsof Cryptorchidectomy
after passing the suture through the eye of the needle,
Associatedwith Choiceof Approach
thereby doubling the suture. After passing the needle and
suture through the cranial aspect of the medial and lat- Whereas the inguinal approach allows removal of either an
eral cruses of the superficial inguinal ring, the needle is abdominal or an inguinal testis, only an abdominal testis
passed between the two strands to secure the suture to the can be removed using the parainguinal, paramedian, or
ring (Figure 39.18a). A doubled strand of suture is inserted flank approach for cryptorchidectomy, because retracting
in a similar fashion at the caudal aspect of the ring an inguinal testis into the abdomen is often difficult or
(Figure 39.18b). Each doubled strand is advanced toward impossible. The abdomen should be confirmed to be the
the center of ring, using a simple-continuous suture pat- location of a cryptorchid testis before using these
tern, where the doubled strands are tied together approaches for cryptorchidectomy.
(Figure 39.18c). Incarceration of intestine by the vaginal Considerations when deciding whether to perform cryp-
ring has not been reported, even though viscera can enter torchidectomy with the horse standing, using a flank
the inguinal canal through the vaginal ring. Inguinal fas- approach, are the horse’s demeanor and size. The horse
cia and skin can be sutured after closing the superficial must be willing to stand quietly for surgery and must not
(a) (b) (c)
Figure39.18 (a) An inguinal approach has been made to the inguinal canal on this cadaver. The superficial inguinal ring of the
cadaver is being sutured with heavy suture on a kidney needle. The ends of the suture have been tied together, and after passing the
needle and suture through the cranial aspect of the medial and lateral cruses of the superficial inguinal ring, the needle is passed
between the two strands to secure the suture to the ring. The cranial portion of the ring is sutured with the doubled strand using a
simple-continuous suture pattern. (b) A doubled strand of suture is inserted in a similar fashion at the caudal aspect of the ring and is
advanced toward the center of ring, using a simple-continuous suture pattern. (c) The doubled strands are tied together. Source: Jim
Schumacher and Tom O’Brien.
be so small that creating an incision large enough to insert at the ventral aspect of the abdomen, with the horse anes-
a hand into the abdomen is difficult. thetized and in dorsal recumbency, are the caudal epigas-
tric and caudal superficial epigastric artery and vein. The
vessel most at risk of inadvertent puncture, when surgery
ComplicationsAssociatedwith Laparoscopic
is performed at the flank, usually with the horse standing,
Cryptorchidectomy
is the circumflex iliac artery [100, 101]. Puncture of one
A risk of any laparoscopic surgery is inadvertent penetra- of these vessels leads to hemoperitoneum or subcutane-
tion of an internal structure, such as the kidney, spleen, or ous hemorrhage, which increases the surgical time and
a vessel, by a trocar, because at least one trocar-cannula may complicate healing. There are no anatomical descrip-
assembly must be inserted blindly. Another risk is retrop- tions of the location, variation, and branching of these
eritoneal insufflation when trying to induce pneumoperi- vessels relative to palpable landmarks. The caudal epigas-
toneum. In one study, 12 out of 40 horses undergoing tric artery normally courses along the lateral border of the
laparoscopy while standing had complications related to rectus abdominis muscle, so to avoid damaging this artery,
insufflation or insertion of a cannula [98]. Problems the stab incision should not penetrate deeper than the
encountered included detachment of the peritoneum external sheath of the rectus abdominis muscle, and the
caused by insufflation of the retroperitoneal space, punc- lateral aspect of the rectus abdominis muscle should be
ture of the spleen, and puncture of the descending colon avoided.
The likelihood of creating complication while inserting a Improper use of electrosurgical coagulation during a
cannula can be minimized by using an optical trocar laparoscopic procedure may also result in perforation of a
(Visiport, Covidien Surgical, Norwalk, CN), which allows viscus [102]. The risk of inadvertent thermal injury is far
the surgeon to observe the layers of the body wall as the greater when using a monopolar electrosurgical unit to
trocar is inserted through them [98]. The trocars are typi- coagulate the spermatic vasculature than when using a
cally <15 m long, and may not be long enough to penetrate bipolar unit [103]. When using a monopolar unit, the
the body wall of a large or obese horse [6]. An Endo TIP grounding plate must be properly attached to the horse to
(endoscopic threaded imaging port, Karl Storz, El Segundo, avoid cutaneous burns.
CA, USA) is a laparoscopic cannula designed to decrease In a recent study, laparoscopic techniques of cryp-
the risk of accidental trauma to abdominal viscera [6, 99]. torchidectomy were associated with a longer surgical
It consists of a l0-cm diameter, hollow, stainless-steel can- time, a longer time of hospitalization, and greater
nula, with a thread around its outer surface that ends dis- expense than were non-invasive techniques of conven-
tally in a blunt tip. It is inserted into the abdomen, using a tional cryptorchidectomy [32]. Similarly, another recent
rotating motion, without the use of a trocar. Its placement study found that horses that underwent laparoscopic
into the abdomen can be observed by inserting a laparo- cryptorchidectomy while anesthetized had significantly
scope into the cannula as the cannula is rotated through longer times of surgery and anesthesia and experienced
the body wall. The likelihood of puncturing a viscus can significantly more postoperative complications than did
also be minimized by withholding feed from the horse for horses that underwent conventional cryptorchidec-
at least 24 hours to decrease the volume of ingesta within tomy [104]. However, this study found that performing
the intestine. Hemorrhage caused by puncturing the spleen cryptorchidectomy laparoscopically was advantageous if
usually ceases within minutes [100]. a previous attempt at conventional cryptorchidectomy
Vessels most at risk of inadvertent puncture while cre- was unsuccessful or if the side of testicular retention was
ating portals for instruments when surgery is performed not known.
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46 Ribeiro, M., de Nardi, G., Megid, J. et al. (2018). Tetanus 64 Wilson, D.G., Hendrickson, D.A., Cooley, A. et al. (1996).
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51 Shively, M.J. (1984). Veterinary Anatomy. College Station, cauterization and transection of the its blood supply. J.
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522
40
Complicationsof Penileand PreputialSurgery

1
2
Overview omplicationsAssociated
C
with PartialPhallectomy
Complications associated with penile surgery are primarily
those associated with partial phallectomy and include Partial phallectomy is most commonly performed because
hemorrhage, dehiscence, and urinary obstruction at the of penile or preputial neoplasia, when neoplasia is so exten-
newly-created urethral stoma. The most common reason sive that more conservative treatment, such as cryosurgery,
for performing partial phallectomy is to resolve penile or hyperthermia, local excision, or segmental posthetomy, is
preputial carcinoma, so other complications include impractical. It is also performed when penile paralysis is per-
recurrence of carcinoma and metastasis. manent and accompanied by irreparable penile damage.
Using Franks [1], Williams’ [2], or Scott’s [3] technique of
partial phallectomy, a portion of the penis distal to the cul de
sac of the preputial cavity is amputated. Another technique
L of partial phallectomy is en bloc resection of the penis and
with Penileand PreputialSurgery internal and external lamina of the prepuce, with or without
penile retroversion [4, 5]. Common to all techniques of par-
● Complications associated with partial phallectomy tial phallectomy is the necessity to create a new urethral
– Hemorrhage stoma and to achieve hemostasis by ligating the large
– Dehiscence branches of the external pudendal vessels and dorsal artery
– Urinary obstruction of the penis and compressing corporeal tissue. Complications
associated with partial phallectomy include persistent or
– Recurrence of neoplasia
severe hemorrhage at the site of amputation, obstruction of
● Complications associated with segmental posthetomy urination, cystitis, urine-induced dermatitis of the pelvic
– Dissimilar size of circumferential incisions limbs, and return of carcinoma. A complication associated
– Dehiscence of the sutured internal lamina with en bloc resection is dehiscence of the cutaneous inci-
● Complications associated with the Bolz technique of sion created to remove the external lamina of the prepuce.
phallopexy
– Invasion of preputial cavity or urethra with a suture Hemorrhage
– Necrosis of skin beneath the bolsters Definition Bleeding from the penile stump after partial
● Complications associated with corporeal anastomosis to phallectomy
resolve priapism
– Failure of the shunt to prevent the stallion from Risk Factors
becoming impotent ● Improper surgical technique
● Other possible complications associated with corporeal ● Performing partial phallectomy on a stallion or recently
anastomosis castrated horse
Complications Associated ith Partial Phallectomy 523
● Housing a horse near mares in estrus before the penile of anemia and decreased circulatory volume ensue, if
stump has healed hemorrhage fails to resolve. These signs include a high
pulse, rapid respiration, a decrease in the hematocrit, and
Pathogenesis Minor hemorrhage from the penile stump increased concentration of lactate in the blood.
after partial phallectomy, regardless of the technique used,
should be expected for at least several days after partial Treatment Horses that have persistent hemorrhage at the
phallectomy. In one study, hemorrhage at the end of stoma after partial phallectomy can be treated by
urination was observed in 29 out of 35 horses (83%) after spongiotomy or urethrotomy at the level of the ischium [8].
partial phallectomy, and for some horses, hemorrhage To perform spongiotomy or urethrotomy, the horse is
persisted for up to 5 weeks [6]. Hemorrhage at the stoma restrained in stocks and sedated. The perineum is
after partial phallectomy usually emanates from the corpus desensitized by administering epidural or local anesthesia,
spongiosum penis (CSP) at the urethral stoma (authors’ and the tail is bandaged and secured dorsally to the stocks.
observation). The CSP completely surrounds the urethra, Even if the horse has been administered epidural anesthesia,
and consequently, to create the urethral stoma, this instilling local anesthesia subcutaneously at the proposed
corporeal body is incised. The most likely explanation for site of incision is prudent, because epidural anesthesia is not
hemorrhage at the stoma at the end of urination (i.e. always completely effective in desensitizing the skin of the
terminal hematuria) is that the intraluminal urethral perineum (authors’ observation).
pressure decreases suddenly at the end of urination while, The perineal area is prepared for aseptic surgery, and the
at the same time, the pressure in the CSP increases slightly, bladder catheterized through the urethral stoma with a stal-
because the bulbospongiosus muscle contracts to expel the lion catheter (circa 16 Fr). A 4-cm, vertical skin incision,
last vestiges of urine [7]. Minor and brief hemorrhage may centered over the ischium, is created on the perineal raphe.
be accompanied by minor dehiscence, which is usually The incision is continued through the retractor penis and
inconsequential, but major or persistent hemorrhage may bulbospongiosus muscles using a scalpel. The tunica albug-
result in major dehiscence at the stoma, which in turn, may inea surrounding the CSP is incised (i.e. spongiotomy) to
lead to stricture at the stoma. expose corporeal tissue (Figure 40.1). The incision can be
extended into the urethral lumen, but doing so is not neces-
Prevention Regardless of the technique of partial sary for the success of surgery in resolving hemorrhage. The
phallectomy, the urethral stoma is created by suturing the spongiotomy or urethrotomy is left unsutured. Success of
urethral mucosa of the stoma to penile or preputial spongiotomy or urethrotomy in eliminating hemorrhage at
epithelium. Sutures should incorporate the surrounding the urethral stoma is attributed to decreased pressure in the
CSP and its tunic and should compress the CSP tightly. CSP and diversion of blood flow from the urethral stoma to
Major hemorrhage from the CSP can be avoided by first the spongiotomy or urethrotomy, thus permitting the stoma
suturing the urethral mucosa to the tunica albuginea to heal. Although the horse bleeds from the perineal inci-
surrounding the CSP and then suturing the mucosa and sion, often for days, and especially at the end of urination,
tunic to the penile or preputial epithelium. A simple- hemorrhage at the urethral stoma resolves, allowing the
continuous suture pattern is probably more effective than a stoma to heal. The spongiotomy or urethrotomy is nearly
simple-interrupted suture pattern in providing completely healed by 2 weeks.
compression. Failure to adequately ligate the large vessels lying dor-
Stallions should be castrated at least 3 weeks before sally and laterally on the shaft of the penis may result in
undergoing partial phallectomy to decrease the likelihood hemorrhage, soon after partial phallectomy, that forms a
of erection, which is accompanied by increased pressure in hematoma in the loose fascia surrounding the stoma,
the cavernosal tissue, which may result in hemorrhage and resulting in enlargement of the penile stump (Figure 40.2).
dehiscence. Applying a stallion ring may help avoid The hematoma resulting from this hemorrhage can be
increased pressure in the cavernosal tissue of a recently expressed after 1 or 2 days, by which time hemorrhage has
castrated horse by preventing erection. Recently castrated resolved, through a small stab incision in the preputial
horses that have undergone partially phallectomy should integument overlying the clot. If swelling caused by
not be housed near a mare until the surgical site has healed. hemorrhage becomes severe, resulting in paraphimosis,
the horse should be anesthetized, and the bleeding vessels
Diagnosis and monitoringBleeding is obvious and is most identified and ligated.
commonly observed at the end of urination. The horse
should be observed closely to determine the amount Expected outcome Some dehiscence at the stoma should be
hemorrhage and progression of hemostasis. Clinical signs expected if the horse bleeds from the stoma at the end of
524 Complications of Penile and Preputial Surgery
Figure40.2 A complication of partial phallectomy is

hemorrhage from a corporeal body or from one or more of the
large vessels on the dorsal and lateral aspects of the penis. This
horse developed a large subcutaneous hematoma immediately
after recovering from anesthesia after undergoing partial
phallectomy. Swelling rapidly resolved when a large blood clot
was evacuated from the subcutaneous space through a small
incision the day after surgery. Source: Courtesy of Dr. Michael
Schramme, Ecole Nationale Veterinaire de Lyon.
Pathogenesis Some authors have observed that the suture

line at the stump of the penis is prone to dehisce when the
Figure40.1 Perineal urethrotomy or a spongiotomy can be penis is amputated proximal to the preputial ring and have
performed to resolve chronic hemorrhage emanating at the
urethral stoma from the corpus spongiosum penis (CSP) after
attributed this propensity of dehiscence to excessive
partial phallectomy. This figure shows the tunic surrounding the tension placed on the suture line when the penis is
corpus spongiosum penis being incised to expose corporeal retracted into the prepuce [9]. These authors recommend
tissue. The urethra and the CSP surrounding it are stabilized partial phallectomy by en bloc resection, when the penis
with Babcock forceps. This incision decreases pressure in the
CSP, thereby eliminating hemorrhage at the stoma. Source: Jim
must be amputated proximal to the preputial ring. We
Schumacher and Tom O’Brien. have not observed a high incidence of dehiscence when
performing partial phallectomy proximal to the preputial
ring and have frequently successfully performed partial
urination. If hemorrhage remains minor, complete healing phallectomy between the preputial ring and the preputial
of the stoma without stricture should be expected. If orifice. Dehiscence, in our experience, is usually the result
hemorrhage is severe or persistent, spongiotomy or of hemorrhage, which is usually due to failure to
urethrostomy may be necessary to avoid severe anemia or adequately compress the corporeal tissue, especially that
circulatory collapse. Severe hemorrhage may result in of the CSP.
extensive dehiscence at the stoma.
Diagnosis Obvious suture pull-out at the surgical site
which, in most cases, is associated with hemorrhage at the
Dehiscence site.
Definition Failure of sutures at the stump resulting in
healing by second intention Prevention Some surgeons recommend performing partial
phallectomy by en bloc resection of the penis and prepuce,
when lesions on the internal lamina of the prepuce
Risk Factors
necessitating partial phallectomy extend proximal to the
● Hemorrhage at the stoma or at the site of amputation (if preputial ring [9]. We believe en bloc resection to be usually
the site of amputation is distal to the stoma) unnecessary, unless lesions involve the external lamina of
● Amputation proximal to preputial ring (disputed) the prepuce or are thought to have invaded corporeal
Complications Associated ith Partial Phallectomy 525
tissue. Dehiscence can usually be prevented by adequately bladder resulting from edema obstructing the urethra at
compressing the corporeal tissue and ligating the the site of amputation [10]. In another report, one horse
vasculature dorsal and lateral to the tunica albuginea. required a urethrotomy after it developed acute urinary
obstruction, likely because of urethral edema, 9 days after
Treatment Because dehiscence is a consequence of partial phallectomy [6].
hemorrhage, please refer to methods of resolving The most common cause of urinary obstruction after
hemorrhage in the Section on Hemorrhage earlier in this partial phallectomy is formation of a cicatrix at the urethral
chapter. stoma, resulting from dehiscence of the sutured mucosa
and integument at the stoma (Figures 40.3a and b), and the
Expected outcome Slight dehiscence at the stoma is likely most common cause of dehiscence is probably hemorrhage
to be inconsequential, but major dehiscence may result in from failure to sufficiently compress the CSP, which
stricture at the stoma which, in turn, may result in dysuria. encircles the urethra.
Diagnosis Urinary obstruction is diagnosed by closely

UrinaryObstruction observing the urethral stoma for swelling or formation of a
urethral cicatrix and by observing the ability of the horse to
Definition Blockage of urinary flow at the site of partial
urinate without impediment.
phallectomy, as a consequence of inflammation, edema, or
stricture Treatment If urination is obstructed because of swelling at
the stoma, the urethra should be catheterized until swelling
Risk Factors has subsided. The stoma must be revised, or a permanent
● Surgical trauma perineal urethrostomy performed, if obstruction is the
● Excessive tension on the sutured stump result of a cicatrix at the stoma.
Hemorrhage at site of partial phallectomy, usually as a
Expected outcome Applying proper treatment, as described
●
result of insufficient compression of the CSP

above, results in a successful outcome.
Pathogenesis Severe urethral edema in the immediate

Recurrenceof Neoplasia
postoperative period after partial phallectomy can cause
urinary obstruction [6. 10]. In one report, 2 out of 38 horses Definition Appearance of neoplastic tissue at the site of
undergoing partial phallectomy died within 17 days after amputation or metastases to region lymph nodes or
undergoing partial phallectomy, because of rupture of the internal organs
(a) (b)
Figure40.3 Stenosis of the urethral stoma after partial phallectomy performed in a gelding as treatment for urine-induced
dermatitis of the hind limbs caused by hypospadias. Stenosis developed when the sutured stoma dehisced because of infection. A
metal probe is being inserted through the small-sized urethral opening (a). The gelding urinating in image (b) Source: Jim Schumacher
and Tom O’Brien.
Risk Factors with retroversion of the penile stump, had an incidence of

recurrence of only 12.5%. In that study, horses with poorly
● Failure to completely resect neoplastic tissue
differentiated squamous cell carcinomas tended to have a
● Poorly differentiated squamous cell carcinoma
higher incidence of regional metastases and a less
● Involvement of the superficial inguinal lymph nodes
successful outcome after treatment than did horses with a
● Involvement of corporeal tissue
highly differentiated carcinoma.
Howarth et al. reported that only 12% of horses affected
Pathogenesis The most common indication for partial
with penile or preputial carcinoma had metastatic spread
phallectomy is carcinoma of the glans penis or the internal
to the inguinal lymph nodes [10]. van den Top et al.
or external lamina of the prepuce, and a complication of
reported the incidence of recurrence for horses with con-
partial phallectomy performed for this reason is recurrence
firmed metastasis to the inguinal lymph nodes to be 25%,
of carcinoma at the site of amputation or metastases to
regardless of the technique of partial phallectomy [9].
regional lymph nodes or internal organs (Figure 40.4).
Howarth et al. and Mair et al. found that male horses with
Howarth et al., reviewing the outcome horses with
genital carcinoma had a poor prognosis for survival after
suspected squamous cell carcinoma of the penis or prepuce,
partial phallectomy, if the carcinoma had metastasized to
found that surgical treatment was successful (i.e. long-term
the inguinal lymph nodes [6, 10]. Mair et al. found palpa-
survival without recurrence of neoplasia) in only 64.5% (20
tion of the superficial inguinal lymph nodes to be often dif-
out of 31) of horses when the follow-up period was not less
ficult, especially palpation of those of obese ponies, and
than 18 months [10]. Mair et al. on the other hand, in a
often gross enlargement could be appreciated only if it was
similar retrospective study of horse with penile or preputial
severe [6]. In that study, the inguinal lymph nodes of some
carcinoma, found that only 19.3% (6 out of 31) of horses
horses with penile or preputial carcinoma were enlarged as
had recurrence of carcinoma within 6 years after
a result of hyperplasia secondary to balanoposthitis, rather
surgery [6]. van den Top et al., examining the effect of
than from metastatic neoplasia.
various surgical treatments of horses for penile or preputial
The owner of a horse that has had invasion of corporeal
squamous cell carcinoma found, when the follow-up
tissue by a carcinoma should be warned that internal
period was not less than 18 months, that 25.6% of horses
metastases are likely. In one study, three out of four horses
had recurrence of neoplasia after undergoing partial
that had metastases of genital carcinoma to the abdomen
phallectomy distal to the preputial ring [9]. However,
had gross or histological evidence that the neoplasm had
horses treated by resection of the entire prepuce (i.e. the
invaded corporeal tissue [6]. Invasion of corporeal tissue by
internal and external lamina) and that portion of the penis
a carcinoma is a negative prognostic factor for survival in
contained within the preputial cavity (i.e. en bloc resection),
men with penile or preputial carcinoma [11] and is also
likely to be so in horses, because neoplastic invasion into a
corporeal tissue is likely to result in hematogenous spread
of carcinoma.
Prevention Recurrence of neoplasia can be avoided by

removing tissues invaded by the neoplasm, which
necessitates identifying the tissues involved (e.g. corporeal
tissue, regional nodes). Horses at high risk of having
metastases to regional lymph nodes or internal organs can
be treated with a systemically administered chemotherapeutic
agent, such as doxorubicin or piroxicam [12, 13], but little
information regarding the efficacy of systemically
administered chemotherapy to treat horses for neoplasia is
available.
Figure40.4 Reappearance of a carcinoma after partial Diagnosis Regrowth of neoplastic masses at the surgical
phallectomy performed to resolve carcinoma of the internal site is obvious, but neoplastic invasion of regional lymph
lamina of the prepuce. The horse is anesthetized and in dorsal
nodes may not be evident until these nodes have enlarged
recumbency. The towel claps have been applied to the dorsal
aspect of the penile stump where the mass recurred. Source: Jim substantially. Invasion of internal organs is usually not
Schumacher and Tom O’Brien. evident until dysfunction of the invaded organ is evident.
Complications Associated ith Segmental Posthetomy 527
Treatment Horses with recurrence of neoplasia can be Risk Factors

treated with chemotherapy (see above) and/or undergo a
● Inaccurate apposition of the distal circumferential inci-
second more extensive resection.
sion to the proximal circumferential incision, a problem
more likely to occur when posthetomy is extensive
Expected outcomeA horse’s prognosis for survival is poor
● Infection or neoplasia at the site of posthetomy
if the neoplasm has invaded corporeal tissue or has
metastasized. Pathogenesis Presence of inflammation or bacterial
contamination in the segment of lamina being removed
(e.g. bacterial contamination associated with neoplasia)
C increases the risk of infection and, therefore, the risk of
with SegmentalPosthetomy dehiscence.
Prevention Minimize trauma and contamination during

Segmental posthetomy entails resecting a circumferential
surgery. Administer broad-spectrum antimicrobial therapy
segment of the internal preputial lamina and is sometimes
before performing posthetomy.
performed to remove preputial neoplasms, granulomas, or
scars so extensive that simple excision of the lesions is Diagnosis The circumferential wound resulting from
impossible. A paralyzed penis can be maintained perma- dehiscence is obvious when examining the surgical site.
nently within the preputial cavity by removing nearly all of
the internal lamina of the prepuce (i.e. the Adam’s proce- Treatment Allow the wound to heal by second intention
dure) [14]. Other terms for the procedure include posthio- (Figure 40.5). Spanning the dehisced wound with 4 or
plasty, circumcision, and reefing [15].
DissimilarSizeof CircumferentialIncisions
Definition A difficulty sometimes encountered when
suturing a large, proximal circumferential incision to a
much smaller, distal circumferential incision [14]
Risk factors Extensive posthetomy
Pathogenesis Because the circumference of the internal

lamina of the prepuce is greater proximally than distally,
the circumference of the proximal incision is larger than
the circumference of the distal incision.
Diagnosis The incongruence between the circumference

of the distal incision and that of the proximal incisions
becomes obvious when trying to appose the distal incision
to the proximal incision.
Prevention and treatment The circumference of the

proximal incision can be reduced by removing a triangle,
about 3 cm wide and 4 cm long, from the internal lamina
proximal to the posthetomy, on each side of the penis [14].
The base of each triangle is the circumferential incision.
Suturing the sides of each triangle decreases the
circumference of the proximal incision.
Figure40.5 Dehiscence of the sutured internal lamina of the
prepuce of a donkey after segmental posthetomy, performed to
Dehiscenceof the SuturedInternalLamina resolve paraphimosis. The proximal and distal margins of the
dehisced wound are held together with sutures to prevent
Definition Failure of the sutured internal lamina to heal expansion of the wound. Source: Courtesy of Michael Schramme,
by primary intention Ecole Nationale Veterinaire de Lyon.
more equally-spaced sutures may prevent the wound from Invasionof PreputialCavityorUrethra
expanding, thus speeding healing. with a Suture
Definition The preputial cavity or urethra is entered with a
Expected outcome The wound develops granulation tissue
suture, exposing the surgical site to bacterial contamination
and heals eventually by second intention.
or to contamination with urine.
omplicationsAssociatedwiththe
C Risk Factors
BolzTechniqueof Phallopexy
● Inadequate anatomical knowledge
● Failure to catheterize the urethra
The Bolz procedure is performed to avoid partial phallec-
● Surgical error
tomy as a treatment for penile paralysis and entails retract-
ing the paralyzed penis into the preputial cavity where it is
permanently anchored with sutures [16]. To perform this Pathogenesis One or both sutures placed through the
procedure, the penis is freed from surrounding fascia annular ring inadvertently enter the preputial cavity or the
through an incision at the scrotal scar so that it can be urethra.
retracted into the incision. Retracting the penis creates a
sigmoid flexure in the penis (Figure 40.6), and the penis is
Prevention To avoid entering the preputial cavity with a
anchored in this position, as described by Bolz, by placing
suture, an assistant should palpate the fornix of the
a heavy, non-absorbable percutaneous suture through the
preputial cavity, while the sutures are placed through the
annular ring of the reflection of the internal preputial lam-
annular ring of the reflection of the internal preputial
ina onto the tunica albuginea of the penis on each side of
lamina onto the penis, to ensure that a suture does not
the penis [16]. The sutures, when tightened, retract the
penetrate the preputial epithelium. The urethra should be
penis into the preputial cavity. The sutures are tied over
catheterized, so that it can be easily identified during
bolsters, such as rolls of gauze or large buttons, to prevent
placement of the sutures, to ensure that a suture does not
the suture from cutting through the skin. The position of
penetrate the urethra.
the penis within the preputial cavity can be adjusted by
tightening or loosening the sutures after the horse recovers
from anesthesia. The percutaneous sutures are removed Diagnosis Infection and associated inflammation develop
when sufficient time has elapsed for adhesions to form that at the surgical site when a suture has entered the preputial
are sufficient in strength to maintain the penis in its cavity. When the urethra has been invaded by a suture,
retracted position. urine draining at the suture site may become obvious, and
the horse may show signs of dysuria.
Treatment The misplaced suture(s) must be removed or

replaced. The scrotal incision should be left open to
promote drainage of exudate or urine. If urethral damage
caused by a suture is severe, a stent should be maintained
in the urethral lumen until the urethral wound has healed,
to decrease the likelihood of development of an obstructing
cicatrix. The horse may require a urethrotomy if urination
is difficult.
Expected outcome The horse may develop a

urethrocutaneous fistula or a urethral stricture, if a suture
has penetrated the urethra. Stenting the urethra may avoid
formation of a structuring cicatrix. Infection at the surgical
in dorsal recumbency undergoing the Bolz procedure. The penis site caused by inadvertently inserting a suture into the
is retracted through an incision created on the perineal raphe preputial cavity is likely to resolve if the sutures are
caudal to the scrotal scar or scrotum to create a sigmoid flexure removed and the surgical site left unsutured to heal by
in the penis. The penis is anchored in this position by placing second intention. The clinician or owner is left caring for a
sutures through the annular ring of the reflection of the internal
preputial lamina onto the tunica albuginea of the penis. Source: horse with a prolapsed penis until the sutures can be
Jim Schumacher and Tom O’Brien. replaced.
Complications of Corporeal Anastomosis to esolve Priapism 529
Necrosisof SkinBeneaththe Bolsters and tissue adjacent to the ring should be expected to form
when sutures that invoke a fibrous response are used.
Definition Pressure ischemia and sloughing of the skin
beneath the bolsters. This complication seems to be
inevitable, when the sutures are placed percutaneously omplicationsof Corporeal
C
and tied over bolsters.
Anastomosisto ResolvePriapism
Risk factors Placing the sutures percutaneously
Priapism, or persistent erection without sexual excitement,
Pathogenesis Using percutaneously placed sutures allows is an uncommon problem that occurs when the erect penis
the penis to be repositioned within the preputial cavity, if fails to detumesce [17]. The affected horse becomes impo-
necessary, after the horse recovers from anesthesia, but tent if the condition is not soon resolved, because the erec-
necrosis of skin beneath the rolls of gauze or buttons is tile tissue of the CCP becomes fibrotic and because the
inevitable. In addition, fibrosis may be insufficient at pudendal nerves suffer damage [18].
2 weeks to retain the penis within the preputial cavity, by Horses have been treated for priapism by massaging the
which time cutaneous necrosis is usually well underway. penis, slinging the penis against the body wall, and applying
an emollient dressing to the prepuce [19], but these treat-
Prevention Adhesions between the annular ring and ments, although helpful in preventing damage to the penile
tissue adjacent to the ring sufficient to retain the penis and preputial integument, are unsuccessful in resolving the
within the preputial cavity are more likely to form when condition. Normal venous drainage must be re-established
sutures that invoke an intense fibrous response, such as to bring about detumescence. To establish venous drainage,
polyester sutures, are used. Sutures that invoke little affected horses and men have been treated by intravenous
inflammatory response, such as polypropylene or nylon, administration of drugs with anticholinergic action [20] or
should not be used. by administering an alpha-adrenergic drug, such as phe-
To avoid necrosis of skin beneath bolsters, the penis can nylephrine, into the CCP in the early stages of priapism [21].
also be anchored within the preputial cavity using heavy Horses and men with protracted priapism experience only
absorbable sutures affixed to subcutaneous tissue adjacent temporary detumescence after this treatment (authors’
to the scrotal incision. Although modifying the technique of observation) [22].
phallopexy described by Bolz [16] in this manner prevents A horse that fails to respond permanently within a few
necrosis of skin, re-positioning the penis within the prepu- hours to these treatments can be treated by irrigating its CCP
tial cavity is impossible after the horse recovers from anes- with heparinized, isotonic saline solution to remove stag-
thesia. The glans penis may protrude through the preputial nant, sickled erythrocytes [23]. If irrigation of the CCP fails to
orifice if the penis is inadequately retracted, affecting the resolve priapism, a shunt should be created, by anastomosing
cosmetic appearance of the horse. If the penis is retracted the CCP to CSP. This shunt is created in the horse’s perineal
excessively, the horse may develop urine-induced contact region, with the horse anesthetized and in dorsal recum-
dermatitis from urinating into the preputial cavity. bency. The CSP provides an exit for blood trapped within the
CCP, because in contrast to the CCP, the CSP does not act as
Diagnosis Skin beneath the bolsters should be examined a closed system during erection (Figure 40.7) [17, 24].
periodically. Necrosis of skin is obvious.
Failureof the Shuntto Preventthe Stallion

Treatment The sutures should be removed, provided
from BecomingImpotent
enough time has elapsed (i.e. at least 2 weeks) that
adhesions between the annular ring and tissue adjacent to Definition Impotency is the failure to achieve or maintain
the annular ring are strong enough to prevent the penis sufficient pressure in the CCP required for intromission.
from prolapsing from the preputial cavity. If insufficient
time has elapsed for formation of strong adhesions, the Risk factors Postponing corporeal anastomosis for so long
sutures and bolsters should be left in situ, despite that the horse’s cavernosal tissue becomes fibrotic and the
progression of necrosis. Cutaneous wounds created by the pudendal nerves damaged
pressure of the bolsters heal by second intention.
Pathogenesis Impotence after creating the shunt can be
Expected outcome The penis is expected to remain within the result of damage to the cavernous tissue caused by
the preputial cavity, if strong fibrous adhesions have priapism or from failure of the shunt to eventually close to
formed between the annular ring and tissue adjacent to the the extent that the pressure in the CCP required for
annular ring. Strong adhesions between the annular ring intromission cannot be achieved or sustained [24]. Failure
damage becomes irreversible after the onset of priapism

has not been determined for horses.
Expected outcome Horses appear to suffer no discomfort

after the surgery, and swelling is minimal. The shunt may
close as the CCP resumes normal outflow of blood, but
whether the shunt must close to avoid impotence is not
known. In one report, a stallion that had received two
corporeal shunts as a treatment for priapism, regained
normal erectile and ejaculatory function within a year after
priapism had resolved [25]. In a prospective study, all of 5
normal stallions that received a shunt between the CSP and
the CCP were able to maintain normal erectile and
ejaculatory function, even though the shunt of 3 of the
stallions failed to close [26]. The authors of that study
concluded that the inability of a stallion to develop a normal
erection after a shunt has been created, as a treatment for
priapism, is probably the result of damage to erectile tissue
caused by priapism, rather than from failure to achieve or
maintain sufficient corporeal pressure because of the shunt.
The erectile function of men whose cavernosal tissue has
been damaged by protracted priapism has been improved by
instilling a vasoactive drug, such as papaverine, phenoxyben-
zamine, or phentolamine, into the CCP [7, 27]. Administering
a vasoactive drug into the CCP may also be useful for improv-
Figure40.7 This diagram shows the transverse section of the ing the erectile function of horses suffering from impotence
penile shaft. A shunt can be created between the corpus caused by damage to the CCP. If a stallion’s penile sensitivity
cavernosum penis and the corpus spongiosum penis to provide
has been reduced because the pudendal nerves have been
an exit for stagnant blood trapped within the corpus
cavernosum penis as a treatment for priapism. CCP = corpus damaged by priapism, imipramine, an antidepressive drug,
cavernosum penis; CSP = corpus spongiosum penis; BS = can be administered to the stallion before breeding to lower
bulbospongiosus muscle; RP = retractor penis muscle; TA = the stallion’s ejaculatory threshold [28].
tunica albuginea. Source: Jim Schumacher and Tom O’Brien.
of detumescence is accompanied by stasis of blood within OtherPossibleComplicationsAssociated

the CCP. Stagnation of blood increases the partial pressure with CorporealAnastomosis
of CO2, and this increase causes erythrocytes to sickle and
Complications of the cavernosal shunt in men include ure-
damages the endothelium of the cavernosal tissue; the
throcavernous or urethrocutaneous fistula, penile gan-
sickled erythrocytes occlude venous outflow from the CCP.
grene, infection, and pain during erection [24]. These
Endothelial damage and occlusion eventually result in
complications have not been reported after creation of a
trabecular fibrosis, decreasing the size of the sinusoidal
cavernosal shunt in horses, perhaps because so few horses
spaces in the CCP and the capability of the CCP to become
have been reported to have received a shunt. To avoid for-
rigid during erection. Protracted erection also damages the
mation of a urethrocavernous or urethrocutaneous fistula,
pudendal nerves, causing penile paralysis, perhaps from
the diameter of the stallion catheter inserted into the ure-
causing the nerves to become stretched or to be compressed
thra at the time of surgery to help identify the urethra and
against the pelvis [18]. Loss of erectile function and
surrounding CSP, should not be so large that it severely
sensitivity results in impotence.
compresses the CSP, which encircles the urethra.
Compressing the CSP by using a large-diameter stallion
Diagnosis The affected horse continues to display inability
catheter makes the corporeal tissue of the CSP difficult to
to achieve erection.
discern, thereby increasing the likelihood of incising the
urethra while creating the anastomosis. Using suction dur-
Prevention and treatment The cavernosal shunt should be ing surgery helps to maintain visibility at the surgical site
created before the cavernous tissue or the pudendal nerves after the CSP is incised, so that the incision is not inadvert-
become irreversibly damaged, but the time at which ently extended into the urethral lumen.
References 531
References
1 Frank, E.R. (1964). Veterinary Surgery. 7th edition. 14 Guillaume, A. (1919). Simplified surgical treatment of
Minneapolis: Burgess Publ. Co. paralysis of the penis in the horse. Vet. J. 26: 37–40.
2 Williams, W.L. (1943). The diseases of the genital organs 15 Peyton, LC: (1980). The reefing operation in large animals
of domestic animals. In: The Diseases of the Genital (a pictorial essay). Vet. Med. Small Anim. Clin. 75:
Organs of Domestic Animals. Worcester, MA: Ethel 112–117.
Williams Plimpton. 16 Bolz, W. (1970). The prophylaxis and therapy of prolapse
3 Scott, E.A. (1976). A technique for amputation of the and paralysis of the penis occurring in the horse after the
equine penis. J. Am. Vet. Med. Assoc. 168: 1047–1051. administration of neuroleptics. Vet. Med. Rev. Leverkusen.
4 Doles, J., Williams, J.W., and Yarbrough, T.B. (2001). 4: 255–263.
Penile amputation and sheath ablation in the horse. Vet. 17 Pohl, J., Pott, B., and Kleinhans, G. (1986). Priapism: a
Surg. 30: 327–331. three-phase concept of management according to
5 Markel, M.D., Wheat, J.D., and Jones, K. (1988). Genital aetiology and prognosis. Br. J. Urol. 58: 113–118.
neoplasms treated by en bloc resection and penile 18 Blanchard, T.L., Schumacher, J., Edwards, J.F. et al.
retroversion in horses: 10 cases (1977–1986). J. Am. Vet. (1991). Priapism in a stallion with generalized malignant
Med. Assoc. 192: 396–400. melanoma. J. Am. Vet. Med. Assoc. 198: 1043–1044.
6 Mair, T.S., Walmsley, J.P., and Phillips, T.J. (2000). 19 Pearson, H. and Weaver, B.M.Q. (1978). Priapism after
Surgical treatment of 45 horses affected by squamous cell sedation, neuroleptanalgesia and anaesthesia in the
carcinoma of the penis and prepuce. Equine Vet. J. 32: horse. Equine Vet. J. 10: 85–90.
406–410. 20 Wilson, D.V., Nickels, F.A., and Williams, M.A. (1991).
7 Taintor, J., Schumacher, J., and Schumacher, J. (2004). Pharmacological Treatment of Priapism in 2 Horses. J.
Comparison of pressures in the corpus spongiosum penis Am. Vet. Med. Assoc. 199: 1183–1184.
during urination between geldings and stallions. Equine 21 Muruve, N. and Hosking, D.H. (1996). Intracorporeal
Vet. J. 36: 362–364. phenylephrine in the treatment of priapism. J. Urol. 155:
8 Mählmann, K. and Koch, C. (2014). Perineal incision into 141–143.
the corpus spongiosum penis to resolve persistent post 22 Varner, D.D. (2004). Theriogenologist. Department of
urination hemorrhage after partial phallectomy. Equine Large Animal Surgery and Medicine, Texas A&M
Vet. Educ. 26: 532–535. University. Personal communication.
9 van den Top, J.G.V., de Heer, N., Klein, W.R. et al. (2008). 23 Schumacher, J. and Hardin, D.K. (1987). Surgical
Penile and preputial squamous cell carcinoma in the treatment of priapism in a stallion. Vet. Surg. 16: 193–196.
horse: A retrospective study of treatment of 77 affected 24 Cosgrove, M.D. and LaRocque, M.A. (1974). Shunt
horses. Equine Vet. J. 40: 533–537. surgery for priapism; review of results. Urol. 4: 1–4.
10 Howarth, S., Lucke, V.M., and Pearson, H. (1991). 25 Boller, M., Fürst, A., and Ringer, S. et al. (2005). Complete
Squamous cell carcinoma of the equine external recovery from long standing priapism in a stallion after
genitalia: A review and assessment of penile amputation propionylpromazine/xylazine sedation. Equine. Vet. Educ.
and urethrostomy as a surgical treatment. Equine Vet. J. 17: 305–311.
23: 53–58. 26 Schumacher, J., Varner, D.D., Crabill, M.R. et al. (1999).
11 Soria, J.C., Theodore, C., and Gerbaulet, A. (1998). The effect of a surgically created shunt between the
Carcinome epidermoide de la verge. Bull. Cancer. 85: corpus cavernosum penis and corpus spongiosum penis
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12 Moore, A.S., Beam, S.L., Rassnick, K.M. et al. (2003). 1999;28:21–24.
Long-term control of mucocutaneous squamous cell 27 Virag, R. (1982). Intracavernous injection of papaverine
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532
41
Complicationsof Ovarianand UterineSurgery

1
2
Overview ● Complications associated with Cesarean section

– Uterine hemorrhage
Uterine surgery is not commonly peformed in the horse. – Uterine adhesions
Consequently, complications are not commonly found. As – Retained fetal membranes, metritis, laminitis
ovariectomy becomes more popular in the sport horse, – Septic peritonitis
complications associated with ovariectomy will become – Signs of abdominal pain
more common. – Complications with the abdominal incision
– Anesthetic complications
– Decreased fertility
istof Complicationsof Ovarian
L – Death of the mare or foal
and UterineSurgery
● Complication associated with ovariectomy omplicationsAssociated

C
– Complications associated with poor selection of with Ovariectomy
approach
– Difficulty exteriorizing the ovary Ovariectomy of the mare is performed to create a teaser
– Severe hemorrhage mare for collecting semen or a recipient mare for embryo
– Evisceration transfer, to rectify undesirable behavior, to sterilize a mare
– Septic peritonitis so that it can be registered with its breed association, to
– Metastasis of ovarian neoplasia eliminate signs of colic associated with ovulation, or to
– Signs of colic remove a tumorous ovary [1–3]. The most common reason
– Intra-abdominal adhesions for unilateral ovariectomy is to remove a tumorous ovary,
– Incisional complications and the most common tumor of the ovary in mares is, by
– Damage to a viscus or cervix far, the granulosa-cell tumor [4]. Postoperative morbidity
– Complications associated with general anesthesia and mortality associated with ovariectomy, at least for
– Failure to eliminate undesirable behavior ovariectomy performed to remove a granulosa-cell tumor,
– Complications associated laparoscopic ovariectomy is greater than that seen with other elective abdominal
● Complications associated with total and partial procedures [4].
ovariohysterectomy
– Poor surgical access
ComplicationsAssociatedwith PoorSelection
– Septic peritonitis
of Approach
– Hemorrhage
– Infection at the uterine stump Surgical approaches for bilateral or unilateral ovariectomy
– Signs of colic include the vaginal, flank, ventral midline, paramedian,
– Infertility after partial hysterectomy and diagonal paramedian celiotomies. The vaginal celiotomy
Complications Associated ith variectomy 533
is often referred to as a colpotomy. Ovariectomy can be Risk Factors

performed using laparoscopic techniques, including hand-
● The surgical approach is too small to accommodate the
assisted laparoscopic techniques, and can be performed
dimensions of the ovary
with the mare anesthetized, using any of these approaches,
● Short ovarian pedicle (nulliparous mares; small, non-
or with the mare standing, through a vaginal or flank celi-
tumorous ovary)
otomy. Ligating and transecting the ovarian pedicle are
easier when laparoscopic ovariectomy is performed with
the mare standing, rather than recumbent, because the Pathogenesis This complication may be related to the
ovary is oriented normally and is easier to manipulate [5]. ovary being too large to be accommodated by the surgical
The mare must be placed in the Trendelenburg position incision or to allow access for safe transection of the
when laparoscopic ovariectomy is performed, with the ovarian pedicle. Ovaries with short pedicles are also
mare anesthetized, but this positioning increases the risk difficult to exteriorize. Exteriorizing an ovary may be easy
for cardiovascular anesthetic complications. if the mare is multiparous and if the ovary is tumorous,
The temperament of the mare is an important factor because pregnancy stretches the suspensory ligament of
when deciding whether to remove an ovary with the mare the ovary, as does a heavy, tumorous ovary. The ovarian
standing or anesthetized. Ovariectomy of a fractious or ill- ligament of a small, light-weight tumorous ovary or a non-
tempered mare is best performed with the mare tumorous ovary of a nulliparous mare is likely to be short,
anesthetized to protect the safety of the patient and the making the ovary difficult to exteriorize.
surgeon. The necessity for cosmesis or rapid return to
function are other factors to consider when choosing the Prevention The surgeon should accurately assess the size
surgical approach. The scar resulting from a flank approach of the ovary before surgery, because the size of the ovary is
may be conspicuous, even when the ovary is removed using an important consideration when selecting the surgical
laparoscopic technique, especially if the wound fails to approach. For example, the maximum diameter of an ovary
heal by first intention. Ovariectomy through a vaginal that can be removed through a colpotomy is about 10
approach avoids a cutaneous scar and provides the most cm [2, 6, 8], and because of this, vaginal ovariectomy is
rapid return to function of all the approaches. The scar left usually reserved for spaying mares. Exteriorizing an ovary
by a paramedian, oblique paramedian, or ventral midline larger than 15 cm in diameter through a flank incision is
approach is inconspicuous, but the time between surgery often difficult, especially if using a grid or modified grid
and the mare’s return to function is much longer than approach, because the body wall in the flank is thick and
when ovariectomy is performed using a vaginal approach. muscular. The difficulty is compounded if the paralumbar
The vaginal approach also allows access to both ovaries fossa is small. A tumorous ovary larger than 15 cm in
through a single incision and, therefore, is most often used diameter may also be too large to exteriorize through an
for spaying mares. The colpotomy is generally left oblique paramedian celiotomy [9]. The length of the
unsutured, making vaginal ovariectomy a rapid procedure. ovarian pedicle is an important consideration in
Ovariectomy performed with the mare standing, through a determining approach. The distractive force placed on a
flank or vaginal celiotomy, is less expensive than other short ovarian pedicle may cause pain and a vagosympathetic
methods of ovariectomy, because it avoids the expense of response, resulting in decreased arterial pressure which, in
general anesthesia. Vaginal ovariectomy, however, requires turn, may result in postoperative complications (see
the use of a specialized instrument, the écraseur. Section on Complications Associated with General
The approach selected is based on the reasons for perform- Anesthesia below) [4].
ing ovariectomy, size of the ovary, facilities and equipment A flank or oblique paramedian approach may be indi-
available, financial constraints imposed by the owner, tem- cated if the ovarian pedicle is short, provided the ovary is
perament of the mare, and experience and expertise of the not so large that extraction through the celiotomy is diffi-
surgeon. Each approach can be accompanied by complica- cult, because when using either of these approaches, the
tions, some of which are inherent to the approach, such as, ovary is close to the celiotomy [3, 10]. Exteriorizing an
for example, accidental transection of the circumflex iliac ovary through an oblique paramedian celiotomy may be
artery, when an ovary is removed through a flank celiotomy. easier than exteriorizing an ovary thorough a flank
celiotomy, because the body wall in the area of the oblique
paramedian incision is thinner and more flexible than the
DifficultyExteriorizingthe Ovary
body wall in the flank [10]. The pedicle of an ovary that is
Definition Difficult exteriorization of the ovary and its too large to be extracted through a flank approach can be
vascular pedicle for excision ligated and transected using laparoscopic technique,
534 Complications of varian and Uterine Surgery
performed in the flank with the mare standing, and the ovarian pedicle relies on crushing the pedicles with an
ovary subsequently removed through a ventral midline écraseur (Figure 41.1), rather than on ligatures, and
approach with the mare anesthetized [5]. because excessive hemorrhage, if it does occur, is difficult
Withholding feed, but not water, for 24 hours or more to recognize at the time of surgery [3]. Fatal hemorrhage
before surgery, regardless of the approach, may aid during colpotomy can also occur if the vaginal branch of
exteriorization of the ovary [4]. Compressing the body wall the uterine artery is lacerated when the surgeon perforates
around a partially exteriorized ovary, after paralyzing the the fornix of the vagina to enter the abdomen.
mare by using a neuromuscular blocking agent, such as
cisatacurium, may expose the pedicle sufficiently to allow Prevention When removing a tumorous ovary, with a
ligatures to be placed around the pedicle. For ovaries that highly vascular pedicle, using non-laparoscopic technique,
cannot be exteriorized, an écraseur, emasculator, or an the ovarian pedicle should be divided into two or three, or
intestinal stapling device may be used to achieve hemostasis more sections, and each section double-ligated with
(see Section on Severe Hemorrhage below). transfixing sutures [2], provided the ovary and its pedicle
can be exteriorized. The ovarian pedicle can be ligated by
Diagnosis Obvious during surgery using an autosuture device when the pedicle cannot be
exteriorized [11]. Staples are inserted in two staggered rows
Treatment Extracting a granulosa-cell tumor with one or using the TA 90 (thoraco-abdominal 90 mm), and the
more large cysts through the celiotomy can sometimes be ovarian pedicle is transected between the ovary and the
eased by aspirating fluid from the cysts to decrease the size staples (Figure 41.2). The stapler is applied two or three
of the tumor [2, 10]. Traction applied to stay sutures placed times. Doran et al. recommended using the GIA 50, but
in the capsule of the ovary may also aid passage of the only if the diameter of the ovarian tumor is less than 15 cm,
ovary through the celiotomy. because of the device’s shorter staple line and shorter
staple leg [11]. Using a stapling device on the ovarian
Expected outcome A good outcome should be expected, if pedicle may still allow minor bleeding from cut vessels
the surgeon has selected the best approach, based on within the pedicle [12]. Using an autosuture device
detailed knowledge of the various approaches for shortens surgical time.
ovariectomy, and has correctly assessed the size of the Even though a tumorous ovary 10 cm or less in diameter
ovary to be removed and the length of the ovary’s pedicle. can be removed through a colpotomy, the increased likeli-
hood of bleeding because of increased blood supply to a
tumorous ovary, even when the tumorous ovary is small,
SevereHemorrhage may make the vaginal approach a risky choice. Some
Definition Severe hemorrhage from the ovarian artery and authors recommend that when spaying a mare using the
its branches is a serious and possibly fatal complication of vaginal approach, the mare should be in diestrus or anes-
ovariectomy. trus, because ovarian vascularity is minimized at these
times [2, 3]. Hooper et al. observed that 4 out of 5 mares
Risk Factors
● Conventional (non-laparoscopic) surgical approach

● Faulty surgical equipment
Pathogenesis Hemorrhage is a consequence of inadequate

hemostasis of the transected ovarian pedicle. This
complication is much less likely when ovariectomy is
performed laparoscopically, because laparoscopy allows
optimal viewing of the ovary and its pedicle, it allows the
pedicle to be ligated and transected with little tension, and
it allows inspection of the transected pedicle(s) to ensure
hemostasis is adequate.
Severe and often fatal hemorrhage is more likely to occur
Figure41.1 An écraseur is used to cut and crush the ovarian
when using the vaginal approach for ovariectomy than pedicle when performing an ovariectomy through a colpotomy.
when using other approaches, because hemostasis at the Source: Jim Schumacher and Tom O’Brien.
serumal total protein should be determined at 6 to 12 hours

after surgery and compared to that determined before
surgery to ensure that hemorrhage from the severed
ovarian pedicle(s) is not severe. Clinical signs associated
with blood loss include tachycardia tachypnea, cold
extremities, a weak thready pulse, pale mucous membranes,
weakness or ataxia, and poor jugular distension [14]. A
large quantity of blood in the abdomen should be obvious
during ultrasonographic examination of the mare’s
abdomen.
Treatment The mare’s hematocrit should be assessed

before ovariectomy and at appropriate intervals after
surgery. A mare showing signs of severe blood loss after
ovariectomy should be treated for hypovolemic shock by
Figure41.2 Intraoperative image of a mare undergoing
ovariectomy while anesthetized and in dorsal recumbency using
administering a balanced crystalloid solution to restore
a diagonal paramedian approach. This ovary, enlarged because circulatory volume (please refer to Chapter 7: Complications
of the presence of a granulosa-cell tumor, was removed with the Associated with Hemorrhage). Laparoscopic identification
aid of a TA-90 automatic stapling device. This instrument places and occlusion of the hemorrhaging pedicle may be
two over-lapping rows of staples across the pedicle of the ovary.
Source: Jim Schumacher and Tom O’Brien. indicated.
Expected outcome If hemorrhage can be stopped, and

that hemorrhaged after ovariectomy, performed using an
appropriate treatment instituted, the affected mare should
écraseur, in conjunction with hysterectomy of a normal
be expected to recover. Hemorrhage may be so severe,
uterus, were in estrus at the time of surgery [13].
however, that the mare may die from hemorrhagic shock.
To avoid hemorrhage at the pedicle when performing
ovariectomy using an écraseur, the surgeon must ensure
that the ovarian pedicle is not stretched as the chain of the
Evisceration
écraseur crushes and cuts the pedicle, because stretching
the pedicle may cause the pedicle to recoil, resulting in Definition Escape of viscera from a body cavity – usually
severe hemorrhage from the ovarian artery. The palm of a abdominal viscera from the abdominal cavity
hand should be positioned beneath each severed pedicle to
feel for hemorrhage emanating from the ovarian artery. If Risk Factors
the amount of hemorrhage is alarming, long forceps, such
● Colpotomy
as a Knowles cervical forceps, can be inserted vaginally
● A “muscle-cutting” flank incision, rather than a “mus-
through the colpotomy, and applied to the pedicle for sev-
cle-splitting” flank incision
eral hours to induce hemostasis.
Laceration of the vaginal branch of the uterine artery can
Pathogenesis Evisceration after ovariectomy performed
be avoided by perforating the fornix of the vagina at the
using the vaginal approach is possible, because the
proper location, which is at the 10:30 or 1:30 o’clock posi-
celiotomy typically is left unsutured.
tion, about 4 cm lateral to the base of the vaginal portion of
the cervix. An incision at this site is cranial to the vaginal
branch of the uterine artery, which is located close to the Prevention To decrease the likelihood of evisceration
9:00 or 3:00 o’clock position. This artery can usually be pal- through the colpotomy, some surgeons have recommended
pated easily when the vagina is distended with air [2]. leaving the mare tied for 4 to 5 days after surgery to prevent
Infusing the vagina before surgery with 1 L of a balanced the mare from becoming recumbent [3]. However, Colbern
electrolyte solution helps to distend the vagina. and Reagan reported that none of 51 mares eviscerated had
ovariectomy performed using a vaginal approach, even
Diagnosis and monitoring Hemorrhage after ovariectomy, though the mares were left untied [8]. The likelihood of
regardless of the approach, may go undetected at the time evisceration can also be eliminated by suturing the
of surgery, so the mare should be confined to a stall for the colpotomy, but intra-vaginal manipulations required to
first 24 hours after surgery. The mare’s hematocrit and suture the incision may result in vaginitis, which can lead
to straining. The colpotomy contracts rapidly, and after 3 peritonitis, because the colpotomy, which is usually left
days, usually only one finger can be introduced into the unsutured, provides a route for vaginal bacteria to enter the
colpotomy (authors’ observation). abdominal cavity. Risk of infection of the peritoneal cavity
Dehiscence of the skin, and occasionally the external is low with other approaches.
abdominal oblique muscle, is common after ovariectomy
performed through a flank celiotomy and is no cause for Prevention The perineum, vulva, and vestibule and
alarm, unless the peritoneal cavity was entered at surgery vagina must be adequately prepared for surgery, when
using a muscle-cutting incision, rather than a muscle- performing ovariectomy by colpotomy. Even though
splitting (i.e. grid) incision. A muscle-cutting incision vaginal ovariectomy can be performed without
increases the risk of dehiscence, herniation, and administering epidural anesthesia [8], epidural anesthesia
evisceration [15]. administered before surgery minimizes the risk of
contamination, because it decreases the risk of the mare
Diagnosis Evisceration is obvious when intestine defecating during surgery. Performing a Caslick’s
protrudes from the celiotomy. Evisceration after colpotomy vulvoplasty after vaginal ovariectomy prevents bacterial
is obvious when intestine protrudes from the vulva but contamination of the vagina and peritoneal cavity by
may not be obvious when eviscerated intestine is confined preventing pneumovagina. To avoid inducing septic
within the vagina. A mare that has eviscerated is likely to peritonitis, the vaginal approach for ovariectomy should
show signs of colic. not be used if the mare pools urine or has a vaginal or
uterine infection [3, 8]. Ovariectomy through a colpotomy
Treatment Treating a mare that has eviscerated is should be performed in an aseptic manner, and by
obviously a dire emergency. Intestine should be returned to adhering to Halsted’s surgical principles.
the abdomen as soon as possible to avoid ischemic damage,
but only after it has been cleaned. Intestine can be cleaned Diagnosis and monitoring A mare may develop non-septic
and returned to the abdomen with the mare standing if the peritonitis after ovariectomy if the procedure is
intestine has escaped through a colpotomy or flank accompanied by excessive hemorrhage, because blood in
celiotomy. A colpotomy can be sutured, but with difficulty. contact with the peritoneum causes inflammation [16].
Cross-tying the mare to prevent the mare from becoming Colbern and Reagan found that fluid removed from the
recumbent may be indicated. The mare should receive abdomen of 10 mares at 3 and 7 days after vaginal
broad-spectrum antimicrobial therapy, and the peritoneal ovariectomy showed signs of moderate to severe peritoneal
fluid should be examined periodically. The mare should be inflammation, but no bacteria were seen [8]. Hooper et al.
treated for septic peritonitis if cytological examination of reported a mare that developed clinical signs of peritonitis
the peritoneal fluid indicates that the abdominal cavity is one week after ovariectomy through a colpotomy, but did
infected or if the mare exhibits signs of septic peritonitis not specify if they considered the peritonitis to be septic or
(see Section on Septic Peritonitis below). non-septic [1]. No bacteria were detected in peritoneal
fluid by histological examination or by culture, but signs of
Expected outcome The horse’s prognosis for survival is peritonitis dissipated after the mare was treated with an
guarded. Factors that may influence the likelihood of antimicrobial drug. Peritonitis of this mare may have been
survival after evisceration include the length of the non-septic, and administration of an antimicrobial drug
intestine that has escaped the abdominal cavity and the may have had no effect on the mare’s outcome.
necessity for performing resection and anastomosis. The peritoneal cavity should be considered infected only
when peritonitis is accompanied by bacterial infection [7].
The presence of degenerated neutrophils or intracellular
SepticPeritonitis
bacteria in the peritoneal fluid indicates that peritonitis is
Definition Bacterial infection of the abdominal cavity accompanied by bacterial infection, especially if the horse
displays signs of septic peritonitis, which may include
Risk factors Colpotomy, especially if the mare has poor pyrexia, tachycardia, diarrhea, weight loss, signs of colic,
perineal conformation and reluctance to move [18, 19].
Pathogenesis Ovariectomy is a clean procedure when Treatment Horses with septic peritonitis should be
performed by using any approach except the vaginal administered antimicrobial and nonsteroidal anti-
approach, which should be considered a clean contaminated inflammatory and analgesic drugs and supportive therapy,
approach. Pneumovagina increases the risk of septic and the peritoneal cavity should be lavaged periodically.
Expected outcome The outcome of horses affected with Prevention To reduce the formation of adhesions between
septic peritonitis varies according to the type of bacteria the pedicle and viscera, Meagher et al. described apposing
causing septic peritonitis, time elapsed between the serosal surfaces of the transected ovarian pedicle, using
development of the condition and initiation of treatment, an inverting suture pattern, so that no cut edges of the
and the type of treatment provided to the horse. Affected pedicle were exposed [4]. This, of course, is not possible if
horses have a guarded prognosis for survival. ovariectomy is performed through a colpotomy.
Diagnosis Usually incidental and not associated with

Metastasisof OvarianNeoplasia clinical signs
Granulosa-cell tumors metastasize rarely, so removing a Treatment Usually not required, but adhesiolysis can be
granulosa-cell tumor is usually curative [4]. Meagher et al. performed laparoscopically, if adhesion is associated with
reported that only 1 out of 78 mares that had undergone clinical signs.
removal of a granulosa-cell tumor experienced metastasis
of the tumor [4]. Extensive abdominal metastases Expected outcome Mares that develop adhesions after
necessitated euthanasia of that mare. Some of the other far ovariectomy, yet display no clinical signs associated with
less encountered types of ovarian neoplasms, such as ade- the adhesions, are likely to remain free of clinical signs.
nocarcinoma, may be more likely to metastasize [20]. The consequences of clinically relevant adhesions depend
on the extent of the adhesion and the portion of the viscera
involved.
Signsof Colic
Hooper et al. reported that 2 out of 23 mares displayed
IncisionalComplications
signs of mild to moderate colic for several days every 2 to 3
months after being ovariectomized, but the cause of signs Damage to the circumflex iliac artery, a complication of the
of colic was not discovered, and the relationship between flank approach to the abdomen, leads to hemoperitoneum
signs of colic and ovariectomy was not determined [1]. or subcutaneous hemorrhage, which in addition to
increasing the surgical time, may complicate healing. The
location, variation, and branching of this artery relative to
Intra-AbdominalAdhesions palpable landmarks have not been described. A higher
Definition Fibrous attachments between abdominal incidence of incisional complications, such as formation of
viscera or between the site of celiotomy and abdominal a hematoma or abscess and dehiscence of the skin and
viscera sometimes the external abdominal oblique muscle, are
observed when the ovary is removed through a flank
Risk Factors celiotomy [3]. A horse with incisional dehiscence is treated
by daily cleansing of the wound and systemically
● Colpotomy
administered antimicrobial therapy. Colbern and Reagan
● Polyamide cable ties
observed that 2 out of 51 mares that had undergone vaginal
● Leaving the cut surface of ovarian pedicle exposed
ovariectomy developed an abscess or a hematoma at the
colpotomy and that 3 mares had delayed healing of the
Pathogenesis A colpotomy is usually left unsutured to
colpotomy; delayed healing, however, was not accompanied
heal by second intention, because suturing the colpotomy
by adverse clinical signs [8].
is difficult. A complication, besides evisceration, that can
occur when the vaginal incision into the peritoneal cavity
is left unsutured is adhesions between viscera and the Damageto a Viscusorthe Cervix
colpotomy. Colbern and Reagan reported that 7 out of 51 Definition Iatrogenic damage to a viscus or the cervix
mares undergoing bilateral ovariectomy through a
colpotomy developed adhesions of viscera to the colpotomy, Risk factors Colpotomy
but these adhesions were apparently clinically
insignificant [8]. Cokelaere et al. reported that 2 out of 8 Pathogenesis A viscus or other abdominal structure is far
mares developed a clinically insignificant adhesion more likely to be damaged when ovariectomy is performed
between the small colon and one of the pedicles after through a colpotomy than when it is performed using any
undergoing bilateral ovariectomy using polyamide cable other approach. Damage can occur as the colpotomy is created
ties to ligate the pedicle [21]. or when the ovarian pedicle is transected with the écraseur.
A surgeon inexperienced in vaginal ovariectomy might or septic peritonitis. If the cervix of a mare that is spayed
include a segment of intestine within the loop of the chain through a colpotomy is damaged, cervical incompetence is
of the écraseur, either by mistaking a fecal ball for an ovary likely to be of little clinical significance, unless the mare is
or by not recognizing that a segment of small intestine has to be used as an embryo-transfer recipient.
become entrapped within the loop of chain encircling the
pedicle. Removing an ovary encased in the mesocolon risks Treatment Thorough clinical and ultrasonographic
severing a colonic vessel with the écraseur and creates a examinations are required to determine the organs involved.
defect in the mesocolon through which a viscus can Some mares may require emergency surgery, through a
become entrapped. flank or ventral midline celiotomy or by laparoscopy.
Prevention The likelihood of damaging a viscus, such as Expected outcome The outcome depends on the viscus
the large colon, bladder, or rectum, as the colpotomy is damaged and the degree to which the viscus was damaged.
created, can be reduced by withholding feed for 36 to 48 A mare that has incurred contamination of the abdomen
hours before surgery, by emptying the rectum and with intestinal contents has a poor to guarded prognosis for
bladder [2] and, after creating and dilating a stab incision survival, even when treatment is initiated immediately
in the vaginal mucosa and submucosa, by perforating the after ovariectomy.
peritoneum with nothing other than a finger. Damage to
the cervix, resulting in incompetence of the cervical seal,
can be avoided by incising the vaginal fornix at least 4 cm Neuropraxia,LocalizedorGeneralized
from the base of the vaginal portion of the cervix [8]. MyositisAssociatedwith GeneralAnesthesia
Accidentally mistaking a fecal ball for an ovary, resulting Definition Temporary loss of motor and sensory function
in amputation of the segment of small colon surrounding or inflammation of the musculature caused by ischemia
the fecal ball, can be avoided by fasting the mare and by resulting from compression of peripheral nerves or
administering 4 L of mineral oil 12 to 24 hours in advance dependent muscles during anesthesia
of surgery. Fasting the mare eliminates or reduces feces in
the small colon, and the mineral oil prevents feces from
Risk factors Mares undergoing ovariectomy to remove a
forming into balls that could be mistaken for an ovary.
granulosa-cell tumor while in dorsal recumbency
When removing the ovary on the side contralateral to the
colpotomy, the surgeon should be certain that her or his
hand and the écraseur have passed beneath the small colon Pathogenesis General anesthesia is uncommonly
to grasp the ovary, so that the ovary is not grasped through accompanied with post-surgical paresis caused by
the mesocolon [8]. neuropraxia or localized or generalized myositis. Meagher
Incomplete desensitization of the ovarian pedicle causes et al. found that post-surgical paresis caused by neuropraxia
pain to the mare when the pedicle is transected by the or localized or generalized myositis occurred more
écraseur, which may cause the mare to lunge, kick, or lie frequently among mares undergoing ovariectomy to
down, resulting in tearing of the ovarian vasculature, in remove a granulosa-cell tumor than among horses of
addition to causing a break in asepsis. Sudden and severe similar age, breed, and condition undergoing elective
movement of the mare can be prevented by sedating the surgery for comparable lengths of time [4]. They theorized
mare adequately, by tightly restraining the mare in an that this complication may have been due to inadequate
equine stock, by adequately desensitizing the ovarian peripheral circulation caused by a marked reduction in
pedicle, and by having an experienced person in control of arterial blood pressure when the ovarian pedicle was
the horse’s head. The pedicle can be adequately desensitized tensed. They theorized that excessive tension on the
by applying gauze soaked in 2% lidocaine HCl or 2% ovarian pedicle decreased arterial blood pressure and that
mepivacaine HCl to the pedicle for at least 3 minutes before the decrease in arterial pressure may have been the result
the pedicle is transected with the écraseur. The gauze of a deepened plane of anesthesia required to prevent
should be secured to a long suture so that it can be retrieved, movement caused by pain or because of a more direct
if the gauze is accidently dropped within the abdomen. effect.
Diagnosis Iatrogenic damage to a viscus may be obvious Prevention Desensitizing the ovarian pedicle by injecting
during surgery, but occasionally it becomes obvious only 2% lidocaine HCL or 2% mepivacaine HCl into the pedicle
postoperatively. The affected mare may show signs may minimize hypotension associated with traction on the
associated with colic, endotoxemia, internal hemorrhage, ovary.
Diagnosis and monitoring Obvious signs of paresis or Bilateral ovariectomy eliminates the production and
myositis during and/or after recovery from general release of estrogen, because this hormone is primarily
anesthesia. Monitoring of serum muscle enzymes, hydration, produced in the theca and granulosa cells of ovarian
and renal function is important. follicles [25]. Continued signs of estrus after bilateral
ovariectomy may be caused by the production of estrogens
Treatment and expected outcome As indicated (see by the adrenal cortex, and in support of this theory,
Chapter 16, Complications during Recovery from General administering a corticosteroid, dexamethasone, which
Anesthesia) would suppress adrenal production of steroid hormones, to
ovariectomized mares has been shown in several studies to
Failureof BilateralOvariectomyto Eliminate suppress behavioral signs of estrus [22, 26]. However,
UndesirableBehavior another study found that administering ACTH to stimulate
the adrenal glands of ovariectomized mares failed to
Definition Persistent undesirable behavior displayed by
produce detectable amounts of estradiol, indicating that
the mare after bilateral ovariectomy [1, 22, 23]
the adrenal cortex is not an important source of
estradiol [27]. Authors of that study theorized that
Risk Factors
continuation of signs of estrus displayed by some mares
● Specific behavioral issues before ovariectomy (e.g. fre- after they have been ovariectomized is most likely due to
quent urination, sexual behavior during estrus) absence of the corpora lutea, the major source of
● Failure of pre-surgical hormonal therapy to improve the progesterone, which inhibits behavioral signs of estrus.
mare’s behavior
Prevention Failure of bilateral ovariectomy to eliminate
Pathogenesis Kamm and Hendrickson reported that of 23 undesirable behavior can be ameliorated by properly
mares that underwent bilateral ovariectomy to modify selecting candidates for bilateral ovariectomy. The best
undesirable behavior, 19 (83%) experienced amelioration candidates for bilateral ovariectomy are mares that have
of this behavior [23]. These investigators found that general responded favorably to hormonal therapy before surgery
behavioral problems, such as aggression and disagreeable and mares with general behavioral problems, such as
demeanor, were more likely to be corrected by bilateral aggression and disagreeable demeanor. Undesirable sexual
ovariectomy than were more specific behavioral issues, behavior is likely to persist after bilateral ovariectomy.
such as frequent urination, and that success of ovariectomy
in ameliorating undesirable behavior was especially likely Treatment Persistent signs of estrus after bilateral
if hormonal therapy had been successful in improving the ovariectomy can sometimes be resolved by administering
mare’s behavior [23]. Hooper et al. reported that of 17 progesterone. There is no treatment for mares that continue
mares ovariectomized to modify objectionable behavior, to display other forms of undesirable behavior after
14 (82%) no longer exhibited behavior considered by the bilateral ovariectomy.
owners to be objectionable [1]. The undesirable behavior of
all 17 mares occurred primarily when the mares were in Expected outcome Horses that display undesirable
estrus, and behavioral problems sought by the owners to be behavior after bilateral ovariectomy should be expected to
eliminated were aggressive behavior toward the owner or continue that undesirable behavior.
other horses, inconsistency in performance, signs of colic,
or strong signs of estrus.
ComplicationsAssociatedLaparoscopic
Ovariectomy is unlikely to correct, and may even com-
Ovariectomy
pound undesirable behavior, if the undesirable behavior is
sexual behavior observed during estrus, because ovariec- Complications associated with laparoscopic ovariectomy
tomy commonly results in continued display of sexual are generally caused by procedural error and can be avoided
receptiveness with loss of normal cyclic activity [24]. Not by carefully planning the procedure and by properly
surprisingly, two mares in the study by Hooper et al. ova- preparing the horse. Complications inherent to laparoscopic
riectomized to eliminate signs of estrus continued to dis- surgery include injury to the spleen, kidney, intestine, or a
play signs of estrus [1]. Hooper et al. reported that only 8 large vessel, such as the circumflex iliac artery, during
out of 23 mares (35%) continued to show signs of estrus insertion of a trocar (see Chapter 31: Complications of
after vaginal ovariectomy [1], but Hedberg et al. reported Equine Laparoscopy).
that all of 5 mares continued to display signs of sexual When both ovaries are to be removed with the horse
receptiveness after bilateral ovariectomy [24]. standing, the left ovary should be removed first so that
intra-abdominal pressure equilibrates with atmospheric incision may provide better exposure [32]. Santchi et al.
pressure before the trocar/cannula assembly is inserted reported that displacing the abdominal viscera cranially by
through the right flank. Equilibration with atmospheric tilting the surgical table, so that the hindquarters are
pressure causes the cecum to fall away from the right side elevated above the head, improves access to the caudal
of the body wall, so that injury to the cecum is avoided aspect of the uterus and to the cervix [29]. Exteriorizing the
when the trocar/cannula assemblies are placed through large colon may sometimes also be helpful. An assistant,
the right flank for removal of the right ovary. Inserting a with a hand placed in the vagina, can help identify the
24- to 30-Fr chest drain with a blunt trocar into the cervix and push the cervix into the surgical field.
abdomen to allow equilibration of pressures before Rötting et al. described placing a TA-90 instrument with
inserting the trocar/cannula assembly is safer than a previously fired cartridge on the uterine body as far
inserting a trocar/cannula assembly alone. Fasting the caudally as possible and using this instrument to retract
horse for at least 24 hours before surgery decreases the the cervix cranially [28]. Jaws of the TA-90 provide a secure
likelihood of inflicting injury to intestine, in addition to grasp of the uterus, and are suitably angled so that they can
improving visibility of the ovaries. be applied deep to the incision in the body wall. Rötting
et al. also described placing cruciate stay sutures for
traction, using deep bites on each side of the uterus or cer-
omplicationsAssociatedwith Total
C vix, caudal to the proposed site of transection [28].
Most mares undergoing ovariohysterectomy are
and PartialOvariohysterectomy
pluriparous and suffer from pyometra, and consequently
the ovarian suspensory ligaments have been elongated by
The most common indication for total ovariohysterectomy
multiple pregnancies and by the weight of the intra-uterine
is pyometra that cannot be resolved [28, 29]. Other
fluid, improving exposure of the ovaries and their pedicle.
indications for partial or total ovariohysterectomy of the
The long suspensory ligaments allow better exposure and
mare include uterine neoplasia, uterine rupture during
easier ligation of the vessels within the pedicles. The
foaling accompanied by extensive uterine damage,
pedicle of an ovary can be ligated by using an autosuture
intramural hematoma, mucometra caused by cervical
device when the pedicle cannot be exteriorized (see Section
aplasia, and chronic uterine torsion [28, 30, 31]. Removing
on Complications of Ovariectomy above) [11]. Alternatively,
the uterus alone is curative, but the ovaries are also usually
the ovaries can be removed laparoscopically before
removed to eliminate estrous cycles. Even though
removing the uterus, with the mare standing or recumbent;
postoperative complications of total ovariohysterectomy
the uterus can then be removed with the mare anesthetized,
are common, the outcome is generally favorable.
through a celiotomy on the ventral midline.
PoorSurgicalAccess
SepticPeritonitis
Definition Difficult surgical access to complete the
procedure Definition Bacterial infection of the abdominal cavity
Risk factors Large, overweight mares Risk factors Pyometra
Pathogenesis As much of the uterus as possible should be Pathogenesis Septic peritonitis is the most serious surgical
removed, especially if the uterus is being removed because complication of ovariohysterectomy and is the most
of pyometra, but exposing the desired site of amputation is common cause of morbidity and mortality associated with
often difficult [28, 39]. Amputation through or caudal to the procedure [29]. The likelihood of septic peritonitis is
the cervix may be possible, if the mare is thin [28]. Access much higher if ovariohysterectomy is performed to resolve
to the cervix is more restricted if the mare has considerable pyometra [28, 29].
body fat, necessitating that transection be performed
cranial to the cervix. Prevention The risk of septic peritonitis can be minimized
by removing infected uterine fluid before surgery, by
Prevention and treatment A ventral midline approach that minimizing intraoperative contamination of the peritoneal
divides the udder provides the best exposure for total cavity with uterine fluid, and by securely closing the
ovariohysterectomy [30], but when removing a portion of uterine, cervical, or vaginal stump [29]. Uterine contents
one horn and the ipsilateral ovary, a ventral paramedian can be siphoned from the uterus before surgery by using a
Complications Associated ith otal and Partial variohysterectomy 541
nasogastric tube, after which the uterus should be lavaged An automatic stapling device (e.g. the TA 90) can be used
with a dilute antiseptic solution [28, 29]. to occlude the uterus close to the site of transection, pro-
A TA-90 instrument, with a previously fired and sterile vided that the uterus at the site of occlusion is not thick-
cartridge, placed on the uterine body as far caudally as ened [29]. The staples cannot be used when site of occlusion
possible, can be used not only to retract the uterus to better is the cervix, because the length of the staple arm is too
expose the cervix, but can also be used to occlude the short to appose the thick cervical tissues.
lumen of the uterus. Rötting et al. described placing 2 Before transecting the uterus, one or more laparotomy
right-angled, Best colon clamps, with 7.5-cm-long jaws, sponges should be packed beneath the uterine body to col-
approximately 5 cm cranial to the proposed line of lect exudate that might spill from the lumen of the uterus
transection to prevent leakage [28], and Santchi et al. when the uterus is transected. The stump should be closed
described using 2 Glassman gastroenterotomy clamps to do in at least 2 inverting layers, and the first layer should be
the same [29]. The right-angled jaws on the Best and started and the knot tied before the uterus is incised [28].
Glassman clamps allow the clamps to be placed deep Rötting et al. described performing transection and closure
within the abdomen [28]. One or two electrical cable ties in short increments, so that some attachment of uterus to
can be tightened around the body of the uterus proximal to the stump is preserved during most of the closure to help
the site of amputation to help diminish contamination of maintain traction on the stump [28]. The abdomen should
the surgical site when the uterus is transected (Figure 41.3). be lavaged with isotonic saline solution before the celiot-
These ties are removed after the site of transection is omy is closed.
sutured.
Slone described placing a series of mattress sutures Diagnosis See Septic Peritonitis in previous sections.
across the body of the uterine stump, to avoid spilling
Treatment See Septic Peritonitis in previous sections.
uterine contents [30], but others have avoided their use,
observing that these sutures, because they penetrate the
Expected outcome See Septic Peritonitis in previous
lumen of the uterus, could be a source of peritoneal
sections.
contamination and that they may have a detrimental effect
on blood supply to the stump [29]. Extensive necrosis of
the uterine stump, formation of an abscess at the uterine Hemorrhage
stump, and septic peritonitis leading to death, have been
Definition Uncontrolled bleeding at the surgical site
reported in mares after the uterine stump has been sutured
associated with inadequate hemostasis
using a series of mattress sutures [29, 33].
Risk Factors
● Estrus
● Large, overweight mares
● Using an écraseur, rather than staples or ligatures, to
achieve hemostasis at the ovarian pedicle
Pathogenesis Achieving intraoperative hemostasis is often

difficult, because of poor access to major vessels of the
uterus and ovaries. Pyometra or chronic enlargement of
the uterus of mares with chronic uterine torsion, however,
stretches uterine attachments and improves access to
vessels [34]. Ovariohysterectomy may best be performed
when the mare is in anestrus or diestrus, if hemostasis at
the ovarian pedicle depends on the effectiveness of an
Figure41.3 Intraoperative image of a mare undergoing écraseur, rather than on ligatures or staples [13]. Hooper
hysterectomy using a caudal ventral midline approach to resolve et al. observed that 4 out of 5 mares that hemorrhaged after
chronic pyometra. The mare is anesthetized and in dorsal ovariohysterectomy were in estrus at the time of surgery
recumbency. Two electrical cable ties have been placed proximal and noted that blood supply to the uterus and ovaries of
to the site of amputation of the body of the uterus to diminish
contamination of the surgical site after uterus is amputated. domestic animals is increased when animals are in
Source: Jim Schumacher and Tom O’Brien. estrus [13].
Prevention All major vessels (i.e. the cranial, middle, and stump through the vagina and cervix. Cervical wedge
caudal uterine arteries and the uterine branch of the resection may be required if cervical adhesions interfere
urogenital artery, along with their associated veins) should with lavage and drainage of the stump (see Chapter 42:
be individually double ligated [29]. Hooper et al. theorized Complications of Urinary Surgery).
that transfixing the vaginal artery and vein to the body of
the uterus may result in continual bleeding by reducing the Expected outcome Treating the horse with the appropriate
amount pressure placed on the vessels by the ligatures [13]. antimicrobial drug and lavaging the stump is likely to bring
about resolution of infection. Removing the infected
Diagnosis Hemorrhage may become apparent during stump, if possible, also resolves infection.
surgery, but in some cases, hemorrhage begins
postoperatively. Mares should, therefore, be monitored
Signsof Colic
closely after ovariohysterectomy for signs of internal
hemorrhage (see Section on Hemorrhage above). Santchi et al. noted that 4 out of 6 mares showed signs of
abdominal pain that began within a few hours after
Treatment Transfusion with fresh blood can be used to ovariohysterectomy and lasted for 24 to 36 hours. They
provide clotting factors and ameliorate hypovolemia, when theorized that this pain was the result of the substantial
the mare hemorrhages intra-abdominally after surgery [29]. amount of traction applied to the ovarian pedicles and
Repeat celiotomy may be required to ligate bleeding vessels, broad ligaments to exteriorize the ovaries [29].
if hemorrhage cannot otherwise be resolved.
InfertilityAfterPartialHysterectomy
Expected outcome A horse with severe hemorrhage from
the uterine lumen should be expected to recover completely, Although partial ovariohysterectomy can restore fertility
provided that hemorrhage can be stopped. However, to mares with a lesion in one uterine horn [32], the maxi-
hemorrhage may be so severe that the mare may die from mum amount of a uterine horn that can be removed and
hemorrhagic shock. still allow for maintenance of pregnancy is unknown.
Santchi and Slone, and Wahlen and Astedt, reported that
despite removing about one-third or one-half of a uterine
Infectionatthe UterineStump
horn, 3 mares were each able to deliver one or more live
Definition Bacterial infection at the uterine stump foals [32, 35].
Risk factor Pyometra

C
Pathogenesis Bacterial infection of the uterine stump with CesareanSection
occurs if the stump becomes contaminated with infected
uterine fluid during hysterectomy. Cesarean section of the mare is usually an emergency pro-
cedure performed to resolve dystocia. It is indicated when
Prevention Amputating the uterus caudal to the cervix, in a live foal cannot be delivered rapidly by using assisted or
addition to removing infected tissue, removes cervical controlled vaginal delivery (i.e. delivery performed with
adhesions that may prevent exudate in an infected stump the mare anesthetized and its hindquarters elevated) or
from draining into the vagina. Rötting et al., however, when assisted or controlled vaginal delivery, including
reported that leaving a portion of the uterus of 4 mares delivery using fetotomy, unduly risks the life of the mare or
undergoing ovariohysterectomy to resolve pyometra the mare’s ability to reproduce [30, 36–39]. Cesarean sec-
caused no clinically apparent problem, even when drainage tion may also be performed as a salvage procedure to save a
through a partially sealed cervix was poor [28]. term or near-term foal of a mare to be euthanized for
humane reasons, such as for severe laminitis, colic, or neu-
Diagnosis Clinical signs associated with infection of the rological disease [38, 39]. Cesarean section is also per-
uterine stump may include discharge of purulent exudate formed as an elective procedure if the mare has an
from the vulva, pyrexia, dullness, decreased appetite, and abnormality of the caudal aspect of the reproductive tract
loss of condition. making vaginal delivery impossible, such as a narrowed
birth canal, caused by fracture of the pelvis, or cervical
Treatment Excision of the infected uterine stump or adhesions [36, 38, 40, 41]. Mares have also been subjected
antimicrobial therapy coupled with lavage of the uterine to elective Cesarean section for the purpose of research [42].
Complications Associated ith Cesarean Section 543
Complications associated with Cesarean section,

especially when performed to relieve dystocia, are many,
and some life-threatening. A complication may be the
result of the procedure itself or a result of trauma inflicted
on the reproductive tract because of the dystocia and
manipulations used to resolve it. Complications associated
with Cesarean section include severe uterine hemorrhage,
uterine adhesions, retained fetal membranes, septic
peritonitis, infection or dehiscence of the celiotomy,
infertility, death of the foal, and, not infrequently, death of
the mare.
UterineHemorrhage
Definition Severe, uncontrolled bleeding from the uterine
wall Figure41.4 Intraoperative image of a mare undergoing
Cesarean section. The margin of this hysterotomy has been
compressed with a hemostatic suture which, when pulled tightly,
Risk factors Not incorporating a hemostatic suture at the compresses the hemorrhaging vascular plexus lying between
the myometrium and endometrium. The hysterotomy is closed in
margin of the hysterotomy
1 or 2 layers, after the plexus has been compressed with this
full-thickness, simple-continuous or interlocking suture. Source:
Pathogenesis A major cause of mortality of mares that Courtesy of James Blake Everett, Virginia Polytechnic Institute
and State University.
have undergone Cesarean section is hemorrhage into the
uterus from the vast vascular plexus incised during
hysterotomy [37, 39, 43, 44]. hemostatic suture, because it follows the same lines of ten-
sion as the hemostatic suture. They recommended that the
Prevention To diminish the severity of hemorrhage from Lembert suture pattern include a full-thickness bite of at
the hysterotomy, many surgeons advocate placing a least 2 cm of the uterine wall.
hemostatic suture around the margin of the hysterotomy to Freeman et al. observed that the Lembert suture pattern
compress the vascular plexus (Figure 41.4) [37, 39, 44]. encircles the margin of the incision and compresses
This suture is a full-thickness, simple-continuous or apposing sides of the hysterotomy against each other, in
continuous-interlocking suture that, when pulled tightly, addition to compressing the mural vessels [43]. They
compresses the hemorrhaging plexus against the overlying observed that the Cushing or Connell suture pattern, on
serosa and myometrium and the underlying the other hand, apposes the sides of the hysterotomy in
endometrium [37, 39]. After the plexus has been such a manner that alternating segments of the uterus are
compressed with this suture, the hysterotomy is closed in 1 not compressed across the incision, making this pattern
or 2 layers. inadequate to occlude the mural vessels.
Cox thought the hemostatic stitch to be unnecessary if Placing the hemostatic suture adds time to the surgery,
oxytocin is administered during surgery, to stimulate rapid and although this time might be short, it could increase the
uterine involution after closing the hysterotomy, and after likelihood of the mare developing an anesthesia-related
surgery [45]. Freeman et al., based on results of a retro- complication, particularly if the mare is a draught mare,
spective study of 48 mares that had undergone Cesarean because draught horses are prone to developing post-
section, concluded, contrary to what has been stated by anesthetic myopathy [43]. Placing the hemostatic suture
others [37, 39], that the hemostatic suture is not mandatory before closing the hysterotomy of a draught mare is more
to control hemorrhage from the hysterotomy [43]. They time-consuming, because a large hysterotomy is required
concluded that closing the hysterotomy with a full-thick- to deliver a draught foal.
ness, continuous Lembert suture pattern, using heavy Severe postoperative hemorrhage might best be avoided
suture, was just as effective as the hemostatic suture in pre- by compressing the margin of the hysterotomy with a
venting anemia and mortality [43] and that by omitting the hemostatic suture, if time permits [37, 39, 44], and then
hemostatic suture, Cesarean section could be completed closing the hysterotomy with a continuous Lembert suture,
more rapidly. They surmised that the full-thickness, con- as described by Freeman et al. [43] and by administering
tinuous Lembert suture achieved the same effect as the oxytocin during and after surgery [45].
Diagnosis Hemorrhage from the hysterotomy site into the Slone recommended filling the abdominal cavity with
uterine cavity may be associated with discharge of a large heparinized isotonic saline solution to prevent formation
quantity of blood from the vulva. Signs associated with of fibrin and, thus, adhesions [30], and Vanderplasse
hemorrhagic shock include elevated heart and respiratory recommended palpating the uterus per rectum early after
rates, pale mucous membranes, a weak thready pulse, surgery (i.e. at days 3 and 6) to break down fibrinous adhe-
weakness or ataxia, and poor jugular distension. sions between the uterus and other structures, before the
adhesions become fibrous and impossible to disrupt [46].
Treatment Fluids therapy and/or blood, should be
administered in the event of severe hemorrhage at the Diagnosis Affected mares may display signs associated
hysterotomy. Administration of oxytocin to induce uterine with colic, or the mare may become infertile, because of
contraction may slow hemorrhage, as may administration poor uterine clearance after breeding. Examination of the
of other agents, such as 10% formalin diluted in 1 L of uterus by palpation per rectum and by ultrasonographic
isotonic saline solution. A drug often administered to examination may help identify presence of adhesions.
resolve hemorrhage is aminocaproic acid, which acts to Laparoscopic examination of the uterus may be helpful in
decrease fibrinolysis. Repeat celiotomy and re-suturing of identifying the extent of adhesions to the uterus.
the hysterotomy may be indicated, provided the mare can
be anesthetized safely. Treatment Manipulating the uterus periodically, per
rectum, after surgery, disrupts fibrinous adhesions,
preventing them from maturing into fibrous adhesions.
UterineAdhesions Fibrous adhesions can be resolved by only sharp
Definition Fibrous attachments between the hysterotomy transection, which can often be accomplished
and an abdominal viscus laparoscopically.
Risk Factors Expected outcome The consequences of adhesions at the

site of hysterotomy depend on the extent of the adhesion
● Inflammation of the uterus
and the portion of the viscera involved. Adhesions may
● Exposed sutures at the hysterotomy
prevent the normal expulsion of fluid from the uterus,
resulting in infertility. Some uterine adhesions may be
Pathogenesis Inflammation at the hysterotomy increases
inconsequential.
risk of adhesions, and this risk may be increased when the
uterine wall at the hysterotomy is torn, such as when a
large foal is extracted to a hysterotomy insufficient in RetainedFetalMembranes,Metritis,Laminitis
length to accommodate the foal. Exposure of suture at the
Definition Uterine retention of fetal membranes for longer
hysterotomy may also increase risk of formation of
than 3 hours
adhesions.
Risk Factors
Prevention The hysterotomy is usually closed in two
layers, with heavy absorbable suture material, using a ● Elective Cesarean section performed when a mare is not
continuous Lembert pattern for one layer and a Cushing in the second stage of labor
suture pattern for the other [39, 43]. Vandeplassche et al. ● Trauma to the uterus resulting from dystocia
and Embertson described closing the hysterotomy using ● Inadvertently incorporating the fetal membranes into
first a Cushing suture pattern and then over-sewing this the suture when closing the hysterotomy
layer using a continuous Lembert suture pattern [37,
39]. Freeman et al., on the other hand, recommended Pathogenesis Half or more of mares that have undergone
closing the hysterotomy using first the Lembert suture Cesarean section experience retention of the fetal
pattern and then over-sewing this layer using the membranes, making this the most common complication
Cushing suture pattern. They reasoned that the Lembert of the procedure [37, 38, 41, 47]. A mare undergoing
suture pattern provided better hemostasis than the Cesarean section because of maternal disease, such as
Cushing pattern and that, because the Cushing suture colic, or as an elective procedure, is more likely to
pattern leaves less suture exposed to which adhesions experience retention of fetal membranes than is a mare
can form, the second layer is best closed using the undergoing Cesarean section because of dystocia [36, 38,
Cushing suture pattern [43]. 41]. This is because a mare undergoing an elective Cesarean
section is not in labor or is in the first stage of labor, when become heavily contaminated during pre-surgical attempts
uterine smooth muscle is inadequately primed with at vaginal delivery [39]. Care should be taken to avoid over-
oxytocin and prostaglandin, and therefore unable to distending the uterus, which could risk leakage of
involute [38]. A mare suffering from dystocia is in the contaminated uterine contents into the abdomen through
second stage of labor, a stage when the fetal membranes the sutured hysterotomy. The mare should be continued on
are more likely to separate from the endometrium. Trauma oxytocin until membranes have passed. Fetal membranes
to the uterus caused by dystocia and attempts to relieve hanging below the hocks should be tied in a knot, so that
dystocia, however, may disturb uterine contractions, thus they reside above the hocks, to prevent the mare from
delaying uterine involution and preventing loosening of kicking at them, risking injury to foal, and to provide slight
the chorioallantois from the endometrium. Accidently traction to membranes by increasing their weight. The risk
incorporating the fetal membranes in the suture when of the horse developing metritis/laminitis might also be
closing the hysterotomy also results in retention of the fetal lessened by administering broad-spectrum antimicrobial
membranes [42]. therapy [41]. The mare should be observed closely for signs
Retention of fetal membranes puts the mare at risk of associated with endotoxemia, such as fever, increased pulse
developing endometritis, which in turn, predisposes the and respiratory rate, and darkening of the mucous
mare to developing toxic metritis-laminitis syndrome, but membrane, and for signs of laminitis, such as shifting of
even though retention of fetal membranes after Cesarean weight and increased digital pulses.
section is common, severe metritis and laminitis occur
infrequently [36, 38, 41, 42]. Freeman et al. observed that Expected outcome Even though retention of fetal
the fetal membranes can be retained for days without risk membranes after Cesarean section is common, metritis
of laminitis [41]. Draught mares, however, might be more and laminitis occur infrequently. Laminitis associated with
prone to developing laminitis when the fetal membranes retention of fetal membranes is often severe, resulting in
are retained [48]. severe and permanent disability or death by euthanasia.
Prevention The fetal membranes should be removed

SepticPeritonitis
during surgery, if they separate easily from the
endometrium; if they cannot be separated easily, they Peritonitis as a complication of Cesarean section is reported
should be removed from the margin of the hysterotomy rarely. Vandeplasse et al. reported that 2 out of 63 mares
for 5 to 10 cm to prevent them from being accidentally died of septic peritonitis after Cesarean section, but the
incorporated in the suture when the hysterotomy is cause of septic peritonitis was not specified [37].
closed [30, 36, 39, 43]. Embertson recommended To prevent septic peritonitis, drapes and moistened
administering 40 iu oxytocin in 1 L isotonic saline solution towels or laparotomy sponges should be used to isolate the
intravenously, if the fetal membranes cannot be removed exteriorized gravid uterine horn from the rest of the sterile
during surgery or are not expelled during recovery [39]. field to prevent contamination of the sterile field from
He recommended administering oxytocin over a period of uterine contents [30, 39]. The abdominal cavity should be
1 hour, beginning 2 to 3 hours after surgery, and lavaged thoroughly with isotonic saline solution before the
administering it every 4 to 6 hours until the fetal celiotomy is closed, and this solution, along with blood and
membranes have passed. debris, should be suctioned from the abdominal cavity [30].
Horses with septic peritonitis should be administered
Diagnosis Retention of fetal membranes is recognized by antimicrobial and nonsteroidal anti-inflammatory and
the presence of amnion or the chorioallantois protruding analgesic drugs and supportive therapy, and the peritoneal
from the vulva more than 3 hours after Cesarean section. cavity should be lavaged (see above).
The expelled chorioallantois should be examined carefully
to ensure no portion of it has been retained with the uterus.
Signsof AbdominalPain
Treatment Using the above protocol, the fetal membranes Signs of colic after Cesarean section should be expected
are usually expelled within 6 to 12 hours after the surgery, and should be attributed to pain caused by uterine
but retention beyond this time is not uncommon. The involution, unless clinical examination indicates
uterus should be lavaged daily until the fetal membranes otherwise [40]. Juzwiak et al. reported that 13 out of 17
have passed, beginning 24 hours after surgery, especially if mares (76%) that had undergone Cesarean section showed
Cesarean section was performed to resolve dystocia signs of abdominal pain, usually the day of surgery, attrib-
because, in this case, the reproductive tract is likely to have utable to uterine involution [40].
Complicationswith the AbdominalIncision breed. Proper positioning, adequate padding, good

ventilation, maintenance of adequate blood pressure,
Many of the incisional problems, such as infection and
keeping the mare as light as possible until the foal is
eventration associated with Cesarean section, have been
delivered, and completing the surgery as rapidly as possible,
described as occurring in mares belonging to a draught
are important factors in avoiding post-anesthetic myopathy
breed and when an approach other than a ventral midline
and other complications associated with anesthesia. Please
approach was used [41, 49]. The most frequently-used
refer to Chapter 14: Complications of Loco-Regional
approach is the ventral midline celiotomy because it
Anesthesia; Chapter 15: Complications of Sedative and
provides easy entry into the abdominal cavity and easy
Anesthesia Medications; and Chapter 16: Complications
access to the uterus, and because equine surgeons are
during Recovery from General Anesthesia for anesthesia-
familiar with this approach [39, 42]. Other approaches
related complications of surgery.
include the modified left low-flank (paracostal or
Marcenac), and the paramedian approaches [30, 49]. The
modified low-flank approach (more popular in Europe, at
DecreasedFertility
least in the past, than in the USA) allows surgery to be
performed with the mare in lateral recumbency, but closing Definition Decreased fertility after Cesarean section, in
a low-flank celiotomy is more difficult than closing a comparison to fertility of mares that have not undergone
ventral midline celiotomy, and incisional complications Cesarean section
seem to be high [37]. Some mares are docile enough to
permit surgery to be performed through a high flank Risk Factors
celiotomy with the mare standing, but this is a dangerous
● Dystocia
approach, because the mare cannot be relied on to remain
● Dystocia longer than 90 minutes
quiet during the procedure and because extracting a large
● A failed attempt at vaginal delivery
foal from the small space between the ribs and the
hindquarters may be difficult [37]. For further details, refer
Pathogenesis Retrospective studies examining the fertility
to Chapter 17: Complications Associated with Surgical Site
of mares that have undergone Cesarean section indicate
Infections.
that foaling rates after Cesarean section are diminished
substantially. Vandeplassche et al. reported a foaling rate of
37% in 35 mares after Cesarean section [37], and Juzwiak
AnestheticComplications
et al. reported a foaling rate of 36% in 16 mares after
There is little information to suggest that one anesthetic Cesarean section [40]. Abernathy-Young et al. reported an
protocol is preferable to another, because all anesthetic overall foaling rate for the 3 years after Cesarean section to
drugs cross the placental barrier. Regardless of the be 52%, when duration of dystocia was greater than 90
anesthetic protocol, anesthesia should be induced rapidly, minutes and 68% when duration of dystocia was less than
and the mare maintained in a light surgical plane until the 90 minutes [38]. Byron et al. reported a respectable foaling
foal is delivered, provided that the foal is alive [30]. Delivery rate of 72% after emergency Cesarean section, but this rate
of the foal within 20 minutes of inducing anesthesia is was substantially lower than the foaling rate of 84% for
expected to produce a minimally depressed foal [36]. The these same mares before cesarean section [50].
method of anesthesia should be that which is safest for the
mare, if the fetus is dead [39]. Prevention (i.e. reducing the impact of Cesarean
The likelihood of the foal surviving birth by Cesarean section on fertility)
section and the mare recovering from anesthesia is The foaling rate after Cesarean section performed to
improved when the mare’s blood pressure and partial relieve dystocia is significantly lower for mares bred in
pressure of oxygen are maintained adequately. Some the same year that Cesarean section was performed than
clinicians have recommended positioning the mare in for mares bred in later years, indicating that waiting until
dorsolateral recumbency to decrease compression of the the year after Cesarean section to breed the mare may be
gravid uterus on the caudal vena cava, because compression wise [36, 38, 40]. Abernathy-Young et al. reported that the
of this vein may reduce venous return to the heart, which prognosis for a mare delivering a live foal in years subse-
in turn, may decrease cardiac output, thereby compromising quent to Cesarean section was good if the time from rup-
uterine blood flow [36]. This positioning, however, fails to ture of the chorioallantois to delivery of the foal was less
distribute pressure evenly and could lead to post-anesthetic than 90 minutes and if the mare was less than 16 years
myopathy, especially if the mare is a member of a draught old [38].
Treatment The reader is referred to relevant literature dystocia. The mortality rate of foals is high when dystocia
describing treatment of infertile or subfertile mares. has been protracted by the time Caesarian section is per-
formed, because protracted second-stage labor predisposes
Expected outcome Though Cesarean section appears to be to premature separation of the chorioallantois, resulting in
detrimental to fertility of the mare, fertility after Cesarean fetal asphyxia and death [37]. Byron et al. reported that for
section performed to resolve dystocia compares favorably foals that survived, the median time from rupture of the
with fertility after assisted or controlled vaginal delivery chorioallantois to delivery was 60 minutes [50].
performed to resolve dystocia [37], and the foaling rate Foals of mares that have undergone elective Cesarean
after elective Cesarean section seems to approach that of section are more likely to survive than are foals of mares
mares that have not experienced dystocia [36, 38, 40–42, that have undergone Cesarean section to relieve dystocia
44, 50]. The reduced fertility after Cesarean section is, or that are delivered by Cesarean section during explora-
therefore, more likely a result of trauma to the reproductive tory surgery performed because of a gastrointestinal cri-
tract caused by dystocia and attempts at vaginal delivery sis [36, 38, 41, 42]. Watkins et al. reported that only 1 out
than a result of the surgical procedure itself. of 8 foals delivered by elective Cesarean section failed to
survive to discharge [36], and Freeman et al. reported that
only 1 out of 10 foals delivered by elective Cesarean failed
Deathof the MareorFoal to survive [41]. Abernathy-Young et al. reported that all 4
foals born to mares that had an elective Cesarean section
Definition Death of mare and/or foal
survived [38], and Juzwiak et al. reported that the foals
born to 2 mares by elective Cesarean section
Risk Factors
survived [40].
● Dystocia Foals delivered by Cesarean section are at risk for devel-
● Dystocia longer than 90 minutes oping neonatal maladjustment syndrome [51]. Foals that
● Concurrent intestinal crisis do not experience normal parturition may have an
increased serumal concentration of sedative neurosteroids
Pathogenesis Various retrospective studies of mares that that cross the blood–brain barrier to induce a state of pro-
have undergone Cesarean section report that 81 to 89% of found sedation, mimicking the intrauterine state of the
mares have survived [37, 38, 40, 41, 50]. Causes of death in foal. Thoracic pressure experienced by the foal as it trav-
these studies varied and included postoperative intra- erses the birth canal during the second stage of labor is a
uterine hemorrhage, septic peritonitis, eventration, signal to the foal to cease producing these neurohormones.
fracture of a long bone during recovery from anesthesia, Circulating neurosteroids in the maladjusted foal can be
post-anesthetic myopathy, and concurrent alimentary reduced by recreating the compression exerted on the foal
disease [37, 38, 41]. Abernathy-Young et al. observed that by the cervix and vagina during parturition. Applying 20
prolonged dystocia (i.e. 90 minutes) was associated with minutes of constant pressure to the thorax of 12 foals with
the highest number of maternal deaths [38]. Watkins et al. neonatal maladjustment syndrome, using a rope, resulted
and Freeman et al. reported 100% maternal survival after 8 in marked clinical improvement shortly after procedure
elective Cesarean sections performed on 5 mares [36–41]. was completed [52].
The survival of mares after Cesarean section is more
often related to trauma to the reproductive tract associated Prevention Dystocia should be dealt with as expeditiously
with dystocia necessitating Cesarean section and damage as possible to provide the best outcome for the mare and
to the reproductive tracts during attempts at vaginal deliv- foal. If the live foal cannot be delivered by assisted vaginal
ery prior to Cesarean section than to the surgical procedure delivery within 15 minutes, the mare should be anesthetized
itself. The mare is more likely to survive when emergency and an attempt made at controlled vaginal delivery [39].
Cesarean section is performed soon after the onset of the The foal should be removed by Cesarean section if an
second stage of labor and when severe postoperative hem- attempt at controlled vaginal delivery is unsuccessful
orrhage into the uterus is prevented by close attention to within 15 minutes. A practiced team should be able to
hemostasis when suturing the hysterotomy. deliver a foal by Cesarean section within 20 minutes after
Most studies examining the results of Cesarean section the decision is made to abandon controlled vaginal delivery
in mares report that only 30 to 35% of foals survive [37, 38, and move to delivery by Cesarean section.
40, 50]. Survival of the foal is especially low when Cesarean Fetal maturity must be carefully gauged when Cesarean
section is performed to resolve dystocia and depends on section is performed electively [36], and criteria estab-
many factors, the most important of which is duration of lished for determining fetal maturity before inducing
parturition in the mare can be used to predict proper timing allowed to foal normally, because the risk of abortion after
of elective Cesarean section. These indicators of fetal matu- colic surgery appears small, except for those mares that are
rity are: i) gestational length greater than 320 days; ii) sof- severely endotoxemic or that become hypoxic during sur-
tening of the cervix; and iii) most importantly, substantial gery [29, 38, 39]. Abernathy et al. and Freeman et al. found
mammary development [36]. that although foals delivered by Cesarean section at the
Cesarean section can be performed on mares undergoing time of colic surgery were close to or at term, survival of
colic surgery, if the mare is carrying a term or near-term the foals was poor, demonstrating that an estimate of term
foal, but doing so risks survival of the foal, especially if the is a poor predictor of survival [38, 41]. There is no evidence
mare displays none of the indicators that the fetus is that removing the foal improves the mare’s chances of sur-
mature. Usually the foal is best left in place and the mare vival after colic surgery [41].
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550
42
Complicationsof Vulvar,Vestibular,Vaginal,and CervicalSurgery

1
2
Overview ● Complications associated with repair of a cervical

laceration
Common surgeries of the tubular portion of the reproduc- – Failure to recognize a concurrent abnormality
tive tract of mares include surgery to resolve vesicovaginal – Poor surgical access to the cervical laceration
reflux, repair of a cervical laceration, and surgery to repair – Failure to achieve a good seal after repairing the
a second- or third-degree perineal injury. These surgeries cervix
are performed to correct a conformational abnormality or a – Intra-luminal and peri-cervical adhesions
defect of the genitalia that causes the endometrium to – Septic peritonitis
become contaminated. These surgeries are usually per-
– Endometritis
formed only when results of a breeding soundness exami-
– Re-injury
nation indicate surgery is likely to restore fertility. The
– Failure to conceive or to produce a live foal
most common complication associated with these surger-
– Complications associated with cervical cerclage
ies is failure of surgery to resolve contamination.
● Cervical wedge resection for treatment for pyometra
– Septic peritonitis
L ● Complications associated with surgery to repair a third-
with Vulvar,Vestibular,Vaginal, degree perineal injury
and CervicalSurgery – Failure to recognize a concurrent genital abnormality
– Dehiscence of repair of third-degree perineal
● Complications associated with surgery to resolve vesico-
lacerations
vaginal reflux
– Failure of surgery to restore fertility or to resolve vesi- – Preoperative considerations to avoid dehiscence of
covaginal reflux repair of a rectovestibular laceration
– Complications associated with the Pouret procedure ○ Operative considerations to avoid dehiscence of
– Complications associated with the Monin technique repair of a rectovestibular laceration
of urethroplasty
○ Operative considerations to avoid dehiscence of
– Complications associated with the Brown technique
repair of a rectovestibular fistula
of urerthroplasty
– Complications associated with the Sires and Kaneps ○ Rectal or vesical tenesmus as a cause of dehiscence
technique of urethroplasty or disruption of repair of a rectovestibular lacera-
– Complications associated ith the McKinnon and tion or fistula
Beldon technique of urethroplasty ○ Postoperative care to avoid dehiscence or disruption
– Complications common to all techniques of of repair of a rectovestibular laceration or fistula
urethroplasty ○ or fistula
Complications Associated ith Surgery to esolve esicovaginal eflux 551
C
with Surgeryto Resolve
VesicovaginalReflux
Vesicovaginal reflux, also known as urovagina or urine

pooling, is the accumulation of urine on the floor of the
vaginal fornix (Figure 42.1). The condition is associated
with infertility of mares, because it results in vaginitis,
cervicitis, and endometritis [1–3]. Vesicovaginal reflux is
most likely to occur when the external urethral orifice is
positioned dorsal to the vaginal fornix and is especially
likely to occur when the urethral orifice becomes positioned
cranial to the ischium. Its severity is directly proportional
to the slope of the vaginal floor [4, 5].
Vesicovaginal reflux occurs most commonly in thin,
aged mares that have poor muscular tone of the vagina and
elongated uterine and ovarian ligaments resulting from
multiple pregnancies, and in mares suffering from
dysfunction of the constrictor vulvae and constrictor
vestibule muscles caused by injury during parturition [1–3,
5]. Pneumovagina resulting from defective conformation
of the labia also predisposes to the condition [2]. The Figure42.2 The Pouret procedure to resolve vesicovaginal
tubular portion of the reproductive tract is best examined reflux. Separating the muscular and ligamentous attachments
for evidence of vesicovaginal reflux when the mare is in between the rectum and the vestibule and caudal aspect of the
estrus, because many mares, when in diestrus, do not have vagina causes the vulva to move to a more normal position,
ventral to the ischium, thus diminishing the likelihood of
vesicovaginal reflux, because the tone of the reproductive vesicovaginal reflux and pneumovagina. Source: Courtesy of
tract is increased during this stage of the reproductive Ellie Cypher, University of Tennessee.
cycle [3].
Surgical techniques to correct vesicovaginal reflux are refluxing into the vaginal fornix [1, 3–5]. Surgical
designed to either restore the normal anatomical approaches to extend the site of exit of urine caudally
relationships between the vestibule, vagina, and the include caudal advancement of the urethral (transverse)
external urethral orifice (the Pouret procedure; fold (the Monin procedure) [4] and creation a mucosal con-
Figure 42.2) [6] or to extend the site of exit of urine caudally duit, or tunnel, from the urethral orifice to near the labia [1,
within the vestibule to minimize the likelihood of urine 3, 5]. Techniques of creating a mucosal conduit, or urethral
extension, include those described by Brown et al.
(Figures 42.3a–e), Shires and Kaneps (Figures 42.4a–c),
and McKinnon and Beldon (Figures 42.5a–c) [3, 5].
Failureof Surgeryto RestoreFertilityor

to ResolveVesicovaginalReflux
Definition Vesicovaginal reflux may persist despite a
surgical attempt to resolve it, or the mare may remain
infertile despite surgical resolution of vesicovaginal reflux.
Risk Factors
● Improper selection or execution of the surgical tech-

Figure42.1 Vaginoscopic examination of a standing mare
nique used to resolve vesicovaginal reflux
showing urine in the fornix of the vagina (i.e. vesicovaginal
reflux of urine) resulting from poor perineal conformation. ● Severe endometrial fibrosis caused by chronic vesicov-
Source: Courtesy of Dickson Varner, Texas A&M University. aginal reflux
552 Complications of ulvarn, estieularn, aginaln, and Cervical Surgery
(a) (b) (c)
(d) (e)
Figure42.3 (a–e) The Brown procedure to resolve vesicovaginal reflux. The urethral fold is divided into dorsal and ventral layers,
and the right and left sides of this incision are continued caudolaterally toward the labia. The right and left ventral edges of the
mucosal incision are sutured together, right and left submucosal tissues are apposed, and the right and left dorsal edges of the
mucosal incision are sutured together. The mucosal extension should be wider caudally than cranially to prevent build-up of pressure
during urination, which can lead to dehiscence. Source: Courtesy of Ellie Cypher, University of Tennessee.
Pathogenesis Techniques used to resolve vesicovaginal unlikely to restore the mare’s fertility, if the mare has
reflux have a high incidence of failure, often even when no severe, extensive periglandular endometrial fibrosis
surgical error is discerned. Urine within the uterus [7, 8].
provokes inflammation, and when vesicovaginal reflux Mares experiencing vesicovaginal reflux because of
persist after a surgical attempt to resolve it, the resultant severely abnormal perineal conformation should be
endometritis may lead to periglandular fibrosis. treated by urethroplasty, rather than by, or at least in
addition to, receiving a technique to improve perineal
Prevention The mare should receive a thorough conformation.
examination of its reproductive tract before undergoing
surgery to correct vesicovaginal reflux to identify other Diagnosis Failure of surgery to resolve vesicovaginal
abnormalities that could affect the mare’s prognosis for reflux is identified by observing urine within the vagina
return to normal reproductive function. The endometrium and/or uterus during ultrasonographic examination of
should be examined histologically, if the mare has been these structures or during visual inspection of the vagina.
barren for longer than one season, because surgery is The mare may dribble urine pooled within the vagina.
(a) (b) (c)
Figures42.4 The Shires and Kaneps procedure to resolve vesicovaginal reflux. (a) Loose vestibular mucosa is pulled over a large
catheter inserted into the bladder using interrupted horizontal-mattress sutures. (b) Mucosa dorsal to the sutures is trimmed. (c) The
right and left outer-most mucosal edges are sutured together using a simple-continuous pattern. Source: Courtesy of Ellie Cypher,
University of Tennessee.
(a) (b) (c)
Figure42.5 The McKinnon and Beldon procedure to resolve vesicovaginal reflux. (a) A U-shaped, mucosal flap is created in the
vestibule that extends laterally from the floor of the vagina, 2 to 4 cm cranial to the caudal border of the urethral fold. (b) The incision
is carried caudally along the walls of the vestibule to the labia, and dissection is continued ventrally to create right and left vestibular
flaps. (c) The right and left flaps are joined on the midline with a continuous inverting suture pattern to create a large, mucosa-lined
extension that encompasses the external urethral orifice. The final configuration of the sutured flaps is in the shape of a Y. Source:
Courtesy of Ellie Cypher, University of Tennessee.
Treatment Because pneumovagina from defective vulvar Most mares with non-transitory vesicovaginal reflux are
conformation predisposes to vesicovaginal reflux, a best treated by creating a mucosal conduit, or “urethral
vulvoplasty (i.e. the Caslick’s procedure) or vestibuloplasty extension,” on the floor of the vestibule that extends from
to prevent pneumovagina may be indicated to resolve the external urethral orifice to near the labia, a technique
vesicovaginal reflux, provided that the mare’s perineal known as urethroplasty.
conformation is not severely abnormal. If the mare has
severely abnormal perineal conformation contributing to
the vesicovaginal reflux, however, vulvoplasty or Expected outcome The mare’s prognosis for fertility is
vestibuloplasty is likely to exacerbate the condition, rather good, if an effective surgical technique is selected to resolve
than resolve it, because either of these procedures may to resolve vesicovaginal reflux, if the surgery is performed
result in back-splash of urine into the vagina. without complication, and if the endometrium has not
been irreparably damaged. Many mares continue to examination of those structures or during visual inspection
experience vesicovaginal reflux after urethroplasty, because of the vagina. The mare may dribble urine pooled within
a portion of the urethroplasty dehisces. the vagina.
Treatment The mare should receive urethroplasty if the

ComplicationsAssociatedwith the Pouret
Pouret procedure fails to resolve vesicovaginal reflux. If
Procedure
during dissection, the rectum is inadvertently perforated,
The anatomical relationships between the vestibule and the perforation should be sutured. The perforation should
the urethral opening of mares with poor perineal confor- be sutured in a transverse plane because the musculature
mation (i.e. those mares with a cranially-positioned anus of the rectum is primarily circular, and sutures placed
and most or all of the labia positioned dorsal to the brim of perpendicular to the muscle fibers are less likely to tear
the pelvis) can be improved, thus diminishing the likeli- through tissue than are sutures placed parallel to the
hood of vesicovaginal reflux (and pneumovagina), by using direction of the muscle fibers.
a procedure described by Pouret [6]. Using this procedure,
the muscular and ligamentous attachments between the Expected outcome The Pouret procedure may be more
rectum and the vestibule and caudal aspect of the vagina effective in resolving pneumovagina than in resolving
are separated, in a horizontal plane, for 8 to 12 cm vesicovaginal reflux [8]. Resolution of vesicovaginal reflux
(Figure 42.2). This dissection causes the vulva to move to a should not be expected after the Pouret procedure, if the
more normal position, ventral to the ischium. mare’s perineal conformation is severely abnormal.
Definition Persistence of pneumovagina and/or

ComplicationsAssociatedwith the Monin
vesicovaginal reflux after performing the Pouret procedure
Techniqueof Urethroplasty
Risk Factors Definition The Monin technique of urethroplasty is a
technique in which the site of exit of urine is surgically
● Inaccurate dissection between the rectum and the
positioned more caudally within the vestibule by
vestibule
permanently retracting the urethral fold, which covers the
● Severely abnormal perineal conformation
external urethral orifice [4]. Using this technique, the right
● Contraction of the wound, causing the vulva to be pulled
and left aspects of the margin of the urethral fold are
back dorsally and cranially to the ischium [6, 8].
trimmed with scissors and, after retracting the fold
caudally, sutured to corresponding incisions created on the
Pathogenesis Although abnormal perineal conformation floor of the vestibule. A complication of the Monin
may be improved with the Pouret procedure, the anus still technique of urethroplasty is persistence of vesicovaginal
remains cranially displaced, and the external urethral reflux resulting from dehiscence of the urethral extension.
orifice may still remain dorsal to the vaginal fornix and
cranial to the ischium. Risk Factors
● Suturing the retracted urethral fold under excessive

Prevention Although the Pouret procedure restores the
tension
normal anatomical position of the vulva and vestibule,
● Stretching the urethral fold so tightly that the fold fails to
without reducing the size of the vestibule, it is generally
lie on the vaginal floor, exposing it to damage during
unsuccessful in resolving vesicovaginal reflux of mares
copulation [2]
that have severely abnormal perineal conformation [2, 3,
8]. Placing a hand in the vestibule during dissection
increases the accuracy of dissection and prevents dissection Pathogenesis Complications associated with the Monin
from extending into the rectum. Attaching a weight to the technique are related to improper surgical technique, such
vulva after the open wound created by the dissection begins as placing too much tension on the retracted urethral fold, or
to develop granulation tissue may prevent the vulva from performing the procedure on mares whose vaginal slope is
being pulled dorsally and cranially as the wound contracts. too steep for the procedure to be effective. The incidence of
partial or complete dehiscence of the sutured incisions
Diagnosis Failure of the Pouret procedure to resolve associated with this procedure has not been reported but is
vesicovaginal reflux is identified by observing urine within probably high [2]. The procedure may fail to resolve
the vagina and/or uterus during ultrasonographic vesicovaginal reflux, even when the sutured incisions heal
by first intention. The Monin technique of urethroplasty ● Failure to create a mucosal tunnel sufficient in cross-
may be ineffective for mares that have a vaginal slope greater sectional area to avoid excessively high intraluminal
than 30 degrees [2–4]. The procedure may be effective only pressure generated during urination
for mares with mild perineal conformational faults that
experience mild, transient vesicovaginal reflux, such as that Pathogenesis Brown et al. reported an 11% incidence of
occurring during estrus or soon after foaling [2, 3]. partial dehiscence using this technique [1]. Failure to begin
dissection high enough on the vestibular wall results in a
Prevention The incidence of dehiscence can be decreased urethral extension insufficient in cross-sectional area for
by suturing the urethral fold to each side of the vestibule in the sutured incision to withstand the high hydrostatic
two everting layers, rather than in one, simple-continuous pressure generated within the extension during urination.
layer, as described by Monin [2, 4]. The fold should not be Failure to make the urethral extension wider caudally than
stretched so tightly that it fails to lie on the floor of the cranially leads to increased hydrostatic pressure in the
vagina. Mares with high vaginal slopes (i.e. >30 degrees) urethra during urination, which can lead to dehiscence.
may benefit from other techniques of urethroplasty, such as
the Brown technique of urethroplasty [1] or the McKinnon Prevention The right and left sides of the mucosal incision
and Beldon technique of urethroplasty (see below) [3]. in the vestibule should be directed slightly dorsally to make
the extension wider caudally than cranially.
Diagnosis Failure of the Monin procedure to resolve
vesicovaginal reflux is identified by observing urine within Diagnosis Failure of the Brown technique of urethroplasty
the vagina and/or uterus during ultrasonographic to resolve vesicovaginal reflux is identified by observing
examination of those structures or during visual inspection urine within the vagina and/or uterus during
of the vagina. The mare may dribble urine pooled within ultrasonographic examination of these structures or during
the vagina. visual inspection of the vagina. The mare may dribble
urine pooled within the vagina.
Treatment Mares that continue to suffer from vesicovaginal
reflux after having undergone the Monin procedure should Treatment A fistula in the urethral extension can be
receive one of the other types of urethroplasty, such as the repaired most easily by converting the fistula into an
Brown technique of urethroplasty [1] or the McKinnon incision that extends from the opening of the extension to
and Beldon technique of urethroplasty (see below) [3]. slightly cranial to the fistula. The margin of the incision is
sharply divided into dorsal and ventral flaps, and the right
Expected outcome Urethroplasty performed subsequent to flaps are sutured to the left flaps in three layers. If the cross-
a failed Monin procedure may be more difficult [2]. sectional area of the extension was insufficient because of
failure to begin dissection high enough on the vestibular
wall, risk of re-failure is high, and an alternative technique
ComplicationsAssociatedwith the Brown should be used, such as the McKinnon and Beldon
Techniqueof Urethroplasty technique of urethroplasty [3] (see below) after opening
the extension created using the Brown technique.
Definition Using the technique of urethroplasty described
by Brown et al. (the urethral fold is divided into dorsal and
Expected outcome Urethroplasty performed after Brown
ventral layers, and the right and left sides of this incision
et al. using this technique decreases the cross-sectional
are continued caudolaterally to within about 3 cm cranial
area of the vestibule, but the decrease in cross-sectional
to the margin of the labia (Figures 42.3a–e) [1]. The right
area is unlikely to be of consequence during copulation or
and left ventral edges of the mucosal incision are apposed,
foaling. Repair of a fistula in the extension is expected to
right and left submucosal tissues are apposed, and the right
have a good outcome, provided that the cross-sectional
and left dorsal edges of the mucosal incision are apposed.
area of the extension was sufficient.
A complication of the Brown technique of urethroplasty is
persistence of vesicovaginal reflux resulting from
dehiscence of the urethral extension [1]. ComplicationsAssociatedwith the Shires
and KanepsTechniqueof Urethroplasty
Risk Factors
Definition The technique of urethral extension described
● Failure to make the urethral extension wider caudally by Shires and Kaneps [5] is the simplest technique of
than cranially urethroplasty and is somewhat similar to the technique
described by Brown et al. [1]. Using this technique, a large sectional area of the urethral extension is small [2]. Repair
Foley catheter (circa 30 Fr.) is inserted into the urinary of a fistula in the extension is expected to have a good
bladder, and loose vestibular mucosa on each side of the outcome, provided that the cross-sectional area of the
catheter is pulled over the catheter using interrupted extension was sufficient.
horizontal-mattress sutures to create a ridge dorsal to the
sutures (Figures 42.4a–c). Mucosa dorsal to the sutures is
ComplicationsAssociatedwith the McKinnon
trimmed from this ridge, leaving four edges of mucosa
and BeldonTechniqueof Urethroplasty
exposed. The right and left outer-most mucosal edges are
sutured together using a simple-continuous pattern. The Definition Using the technique of creating a urethral
mattress sutures are removed when the sutured mucosal extension described by McKinnon and Beldon, a
incision has healed. No hemorrhage is encountered during U-shaped, mucosal flap is created in the vestibule that
most of the procedure, and this technique can be performed extends laterally from the floor of the vagina, 2 to 4 cm
more quickly than other techniques of urethroplasty. A cranial to the caudal border of the urethral fold, and then
complication of the Shires and Kaneps technique of caudally along the walls of the vestibule to the labia
urethroplasty is persistence of vesicovaginal reflux (Figures 5 a–c) [3, 8]. Dissection of the right and left
resulting from dehiscence of the urethral extension [5]. vestibular flaps is continued ventrally until the cut edges
of the flaps can be reflected without tension past the
Risk Factors midline. The surgeon should be aware that, when
extending the incision along the walls of the vestibule,
● Failure to create an extension sufficiently spacious to the vestibular bulb, an area of cavernous tissue on the
prevent disastrously high intraluminal pressure right and left walls of the vestibule [9], is incised, sharply
● Taunt vestibular mucosa. increasing hemorrhage. This sudden increase in
hemorrhage subsides rapidly. The right and left vestibular
Pathogenesis Shires and Kaneps reported the incidence of flaps are joined on the midline with a continuous inverting
formation of a fistula within the extension using this suture pattern to create a large, mucosa-lined extension
technique to be 14% [5]. The cross-sectional area of the that encompasses the external urethral orifice. The final
urethral extension provided by this technique of configuration of the sutured flaps is in the shape of a Y,
urethroplasty is small, compared to the other techniques of with the tail of the Y pointing caudally. A fistula, if one
urethroplasty, leading to hydrostatic pressure in the urethra forms, is usually located at the junction of the short arms
so high that a portion of the suture line dehisces. of the Y-shaped suture line [3].
Prado et al. modified the technique of urethroplasty
Prevention The Foley catheter over which the mucosa is described by McKinnon and Beldon by transversely
sutured should be large (circa 30 Fr.). The Shires and splitting the urethral fold at its edge and retracting the
Kaneps technique of urethroplasty should not be used if dorsal half caudally for 4- to 5-cm to cover the submucosa
the vestibular mucosa is taunt. of the dorsal aspect of the cranial portion of the urethral
extension to help prevent a defect from forming in the
Diagnosis Failure of the Shires and Kaneps technique of cranial portion of the extension [3, 10]. The right and left
urethroplasty to resolve vesicovaginal reflux is identified margins and the central long axis of the retracted dorsal
by observing urine within the vagina and/or uterus during shelf are sutured to the exposed submucosa of the
ultrasonographic examination of these structures or during extension. A complication of the. technique of McKinnon
visual inspection of the vagina. The mare may dribble and Beldon technique of urethroplasty is persistence of
urine pooled within the vagina. vesicovaginal reflux resulting from dehiscence of the
urethral extension [3].
Treatment A fistula in the urethral extension can be
repaired most easily by converting the fistula into an
Risk Factors
incision that extends from the opening of the extension to
slightly cranial to the fistula. The margin of the incision is ● Failure to create adequately thick vestibular flaps
sharply divided into dorsal and ventral flaps, and the right ● Failure to begin dissection of the vestibular flaps suffi-
flaps are sutured to the left flaps in three layers. ciently high on the vestibular wall to create an exten-
sion sufficiently spacious for the sutured incision to
Expected outcome This technique sometimes results in withstand the hydrostatic forces generated during
urinary obstruction leading to cystitis, because the cross- urination
Pathogenesis Failure to begin dissection high enough on ultrasonographic examination of these structures or during
the vestibular wall results in a urethral extension visual inspection of the vagina. The mare may dribble
insufficient in cross-sectional area for the suture line to urine pooled within the vagina.
withstand the high hydrostatic pressure generated within McKinnon and Beldon reported that the fistula of 8 of
the extension during urination. Failure to make the the 10 mares (26.6%) was grossly visible and palpable, but
urethral extension wider caudally than cranially leads to the fistula of 2 mares could be detected only by inserting a
increased hydrostatic pressure within the urethra during dye, under pressure, into the lumen of the extension [3]
urination, which can lead to dehiscence. (Figure 42.6). The defect in the extension of these 10 mares
Creating the extension by using the technique described was, without exception, located in the caudal half of the
by McKinnon and Beldon provides a more spacious extension, and caudal to the caudal edge of the retracted
extension than that created by using the technique dorsal shelf of the urethral fold, where it was considered to
described by Brown et al. or that described by Shires and be less likely to contribute to vesicovaginal reflux and to be
Kaneps and is less likely to decrease the cross-sectional more accessible for repair.
area of the vestibule [1, 3, 5]. Because the extension is more The study by Prado et al. showed that digital palpation
spacious, less stress is placed on the suture line during alone is often insufficient to detect a fistula [10]. A minute
urination, and the likelihood of urinary obstruction is fistula may be detected only by infusing a dye, under
less [2, 3]. pressure, into the extension.
Submucosa exposed by using this technique of
urethroplasty becomes covered with epithelium within Treatment A fistula in the urethral extension can be
three to six weeks [3]. Performing vestibuloplasty to resolve repaired most easily by converting the fistula into an
pneumovagina, which often accompanies vesicovaginal incision that extends from the opening of the extension to
reflux, may need to be postponed until the vestibule has slightly cranial to the fistula. The margin of the incision is
epithelialized, because this technique of urethroplasty sharply divided into dorsal and ventral flaps, and the right
leaves the ventral half to two-thirds of the vestibular flaps are sutured to the left flaps in three layers.
submucosa exposed. Some mares pool urine within the urethral extension and
McKinnon and Beldon (1988) reported the incidence of void this urine during exercise, resulting in urine-induced
partial dehiscence of repair using their technique of dermatitis of the perineum [8]. Pooling of urine within the
urethroplasty to be 15% [3]. Prado et al. reported that 10 out urethral extension can be resolved by creating an incision
f 30 mares (33%) that received a modification of the in the urethral extension that extends 2 to 4 cm cranial to
technique of urethroplasty (i.e. covering the cranial portion the labia.
of the extension with the dorsal half of the transversely
split urethral fold) developed a fistula in the extension [10].
None of the mares in that study suffered from vesicovaginal
reflux before surgery [10].
Prevention The mucosal flaps created on each side of the

vestibule should appose each other broadly and without
tension to prevent leakage of urine through the incision
line, which may lead to formation of a fistula [3]. The
vestibular flaps must be thick, so that their circulation is
adequate, and the dissection must be carried out high
enough on the vestibular wall to allow a 2- to 4-cm diameter
urethral extension, because a narrower extension may lead
to retention of urine and may predispose the mare to
cystitis and even nephritis [2]. To create an extension with
sufficient room, the incision in the vestibule should be
made approximately one-half to two-thirds of the distance
between the vestibular floor and roof [3, 8]. Figure42.6 Urethral extension with a fistula. The blue-stained
balloon of a Foley catheter is seen partially protruding through
the hole. Some fistulae are so small that they are difficult to see,
Diagnosis Failure of the McKinnon and Beldon technique
but an unapparent fistula becomes apparent when a dye such as
of urethroplasty to resolve vesicovaginal reflux is identified new methylene blue is inserted, as in this case, under pressure
by observing urine within the vagina and/or uterus during into the extension. Source: Jim Schumacher and Tom O’Brien.
Expected outcome Repair of a fistula in the extension is ble of providing a seal to prevent ascending movement of
expected to have a good outcome, especially because the microorganisms and debris into the uterus [15–17]. The
cross-sectional area of an extension created using the result of cervical incompetency is failure to conceive or
McKinnon and Beldon technique of urethroplasty is eventual loss of the conceptus early or late in gestation.
usually more than sufficient to avoid an excessively high Opinions vary about the length of laceration that causes
intraluminal pressure during urination. Prado et al. the cervix to be incapable of maintaining a seal. LeBlanc
speculated that even a minute fistula may contribute to and Embertson recommended repairing those lacerations
failure of the extension to prevent vesicovaginal reflux, but that extend more than one-third of the length of the portio
whether a defect so small that it cannot be detected grossly vaginalis (i.e. that part of the cervix extending cranially
can result in perpetuation of vesicovaginal reflux is not from the external os to the junction of the cervix and
known [10]. vagina) [16, 18], whereas Brown et al. advocated repairing
lacerations that extend more than 50% of the length of the
portio vaginalis [15]. O’Leary, and Pollock and Russell,
ComplicationsCommonto AllTechniques advised repairing only those lacerations that extend the
of Urethroplasty entire length of the portio vaginalis (Figure 42.7) [19, 20].
In general, factors that contribute to formation of a fistula Regardless of its length, a cervical laceration that interferes
in the urethral extension, regardless of the technique used, with the competency of the cervix must be repaired to
are the difficulty in apposing the cranial aspects of the restore fertility.
mucosal flaps, hydrostatic pressure created during urina-
tion, fibrosis from chronic vaginitis or injury suffered dur-
Failureto Recognizea ConcurrentAbnormality
ing parturition, and a jet-effect dorsal to the urethral
opening during urination [11, 12]. Another factor that Definition The surgeon fails to identify a cervical laceration
could contribute to dehiscence of the urethral extension is and/or determine if the damaged cervix is capable of
using a suture that may prematurely lose tensile strength if providing a seal sufficient to prevent bacterial contamination
placed in an alkaline environment. Using polyglactin 910 of the uterus. The surgeon fails to recognize other
or polyglylcolic acid, therefore, is best avoided in surgeries abnormalities present that may negatively affect fertility of
where this suture contacts the normally alkaline urine of the mare.
horses [12, 13].
To our knowledge, no studies have been performed to Risk Factors
determine the effect of leaving an indwelling catheter in
● Visual inspection alone of the cervix
the bladder after surgery on the incidence of fistula
● Examining the cervix when the mare is in estrus
formation in the urethral extension. Leaving a urinary
● Examining the cervix soon after foaling
catheter within the bladder is likely to result in bacterial
cystitis, even in the face of antimicrobial administration. In
one study, two mares undergoing surgery to create a
urethral extension developed clinical signs of cystitis, and
E. coli was cultured from their urine when an indwelling
urinary catheter was installed for surgery and retained for
the first 4 to 7 days after surgery [1]. A Heimlich thoracic
drain valve inserted into the exposed end of the urinary
catheter prevents aspiration of foreign material into the
catheter and may diminish the severity of cystitis [14].
C
with Repairof a CervicalLaceration
The cervix, the third line of defense against contamination

of the endometrium, must function properly for pregnancy Figure42.7 Vaginoscopic examination of a standing mare
showing a cervical laceration that extends to close to 100% of
to be maintained, and therefore a cervical laceration must the vaginal portion of the cervix (i.e. portio vaginalis). Source:
be repaired when it is so extensive that the cervix is incapa- Courtesy of Dickson Varner, Texas A&M University.
Complications Associated ith epair of a Cervical aceration 559
● Failure to perform an adequate physical examination, Repair of a cervical laceration should be delayed for at
especially failure to examine mare for a concurrent cause least 30 days after injury to allow time for the damaged
of infertility tissues to heal and contract [20, 23, 24]. The lacerated
cervix can be repaired at any time during the estrous cycle,
Pathogenesis Visual inspection alone is insufficient to and timing of repair depends on the preference of the sur-
fully evaluate a cervix for the presence of a laceration, geon. The cervix is soft and more easily retracted when the
because by using visual inspection alone, a laceration mare is in estrus, but distinguishing the layers of the cervix
can be overlooked, especially if the mare is in estrus, during repair performed during estrus is difficult [16]. The
when edematous endometrial folds may obstruct the cervix is most easily repaired with the mare in diestrus or
defect. anestrus, when the endometrial folds are small and the cer-
vix is firm, making the layers of the cervix more easily
Prevention A cervical laceration is best detected and identifiable [16]. Mares can be administered altrenogest
cervical competency best judged by palpating the cervix daily for 2 weeks before surgery to improve cervical
when the mare is in diestrus, a time when edema is tone [19]. A cervix with two lacerations is usually repaired
minimal and the cervix is normally tightly sealed. During in stages, with one laceration repaired a month after the
diestrus, a competent cervix must be dilated to allow a first has been repaired [16, 20]. However, O’Leary et al.
finger to be passed through it into the lumen of the reported good results when repairing cervices with two lac-
uterus [21]. Cervical incompetence should be suspected if erations during one surgery [25].
the tone of the cervical musculature provides little or no
resistance to introduction of an index finger into the lumen Diagnosis Failure to detect a cervical laceration is
of the cervix [22]. Cervical competency is difficult to recognized when the cervix is examined closely to
determine when the mare is in anestrus, because at this determine why the mare has failed to conceive, has aborted
time, the cervix does not usually close [21]. The cervix of a conceptus, or is showing signs of bacterial or fungal
some anestrous mares may be closed, but with endometritis. Signs of infectious endometritis include
manipulation, it is easily opened [21]. The cervix of an abnormal vulvar discharge, pooling of fluid within the
anestrous mare can be examined satisfactorily for uterus, and repeated uterine culture of pathogenic bacteria
competency if 300 mg of progesterone in oil is administered or fungi, despite repeated appropriate treatment for
intramuscularly daily for 3 to 4 days before the cervix is bacterial or fungal endometritis.
examined [21].
Findings while palpating a cervix soon after foaling Expected outcome A cervix can be accurately accessed for
can be difficult to interpret, because relaxation of the cer- the presence of a laceration and the effectiveness of its seal,
vix and swelling obscure all but the most extensive lac- if the cervix is examined by palpation, when the mare is in
eration [19, 21]. This examination may be warranted, diestrus and when at least 3 weeks have passed since
however, if parturition was difficult, because laceration foaling.
of the cervix is sometimes associated with dystocia.
Results of examination are more accurate if the cervix is
examined about 3 weeks or more after foaling, when PoorSurgicalAccessto the CervicalLaceration
edema has subsided and the cervical musculature is
Definition Poor visibility of and surgical access to the
contracted.
cervix and its laceration jeopardizes surgical repair
To identify and evaluate a cervical laceration, the wall of
the cervix should be palpated between the operator’s
Risk Factors
thumb and index finger, with the thumb or finger inserted
into the lumen of the cervix. This method of palpation ena- ● A laceration located on the ventral aspect of the cervix
bles luminal and peri-cervical adhesions to be detected. ● The presence of remnants of the hymen
Occasionally, cervical incompetence caused by a defect ● A speculum, the blades of which fail to extend cranial to
only in the muscular layer of the cervical wall is pal- vesicovaginal border
pated [23]. The entire reproductive tract should be assessed ● Inability to retract the lacerated portion of the cervix into
before repairing a cervix to determine the mare’s prognosis the vestibule
for fertility. This assessment may include bacterial and fun-
gal culture and histological examination of the endome- Pathogenesis and diagnosis Cervical lacerations are most
trium, especially if the laceration is long-standing or if the commonly repaired with the mare standing and sedated,
mare is showing signs of endometritis. after administering epidural anesthesia, which desensitizes
the perineum and prevents the mare from defecating of how the laceration is sutured, the muscular layer must
during surgery [15, 16, 20, 24]. A cervical laceration on the be adequately apposed, because healing of this layer is nec-
ventral aspect of the cervix is more difficult to visually essary to restore competency to the cervix.
discern and to repair than is a laceration on the dorsal
aspect of the cervix. Inability to retract the lacerated portion Intra-Luminaland Peri-CervicalAdhesions
of the cervix into the vestibule increases the difficult of
accessing the laceration for repair. The view of the cervix Definition A serious complication of repair of a cervical
may be obstructed by dorsal remnants of the hymen or by laceration is development of intraluminal and peri-cervical
constriction of the vesicovaginal sphincter, if the blades of adhesions that may prevent normal drainage of endometrial
the speculum are so short that they fail to protrude past the secretions, and/or adequate cervix seal.
vestibule into the vagina.
Risk factorsPoor apposition of the luminal mucosa and/or
the mucosa of the vaginal surface
Prevention and treatment O’Leary et al. reported that
lacerations located in the ventral third of the cervix could Pathogenesis Failure to closely appose the luminal mucosa
be more easily accessed and more quickly repaired with the increases the likelihood of formation of intraluminal
mare anesthetized and in Trendelenburg position (i.e. with adhesions, and failure to closely appose the mucosa on the
the hindquarters elevated 30–45 degrees) than with the vaginal surface of the cervix increases the likelihood of
mare standing [25]. To achieve this positioning, they formation of peri-cervical adhesions.
recommended elevating the pelvis of the mare 3 to 4 feet
above a mat, by using a hoist, leaving the mare’s head and Prevention Suturing the mucosa on the vaginal surface of
withers on the mat. These authors reported that hoisting the cervix using an inverting suture pattern may reduce the
the pelvic limbs to achieve Trendelenburg positioning likelihood of adhesions forming between the sutured
caused much less collapse of the vaginal wall than did laceration and the vaginal wall [22]. If suturing the luminal
tilting the mare on a surgical table. mucosa proves to be difficult, apposition of this layer can
Dorsal remnants of the hymen may need to be excised or be facilitated by using an endoscopic, automated suturing
sutured to the dorsum of the vestibule, when the surgery is device (Endo Stitch Automatic Endoscopic Suturing
performed with the mare standing, if these remnants Device; Auto Suture Company, Division of Covidien
obstruct the view of the cervix [15]. The blades of the Surgical, Norwalk, CT).
speculum should be at least 20 cm long, so that they extend The lumen of the cervix should be palpated periodically
cranially past the vesicovaginal junction. The cervix is to ensure that it remains patent as the luminal mucosa is
retracted with stay sutures placed through the external sutured. Endometrial folds that may interfere with repair
cervical os, one on each side of the laceration [16, 19]. should be excised, because inadvertently incorporating a
These sutures should be placed a sufficient distance from fold into the suture line may result in complete dehiscence
the edge of the laceration that they do not interfere with of the repair or formation of a fistula [19]. Incorporating an
excising scar tissue from the margin of the laceration or endometrial fold into the suture line is most likely to occur
with suturing the laceration. A stay suture inserted into the when the laceration is closed in one layer or when the
external cervical os at the site opposite to the the laceration repair is performed when the mare is in estrus [24]. When
may be helpful in exposing the lumen of the cervix. using a two-layer or three-layer closure, care must be taken
to avoid accidently transecting the suture placed in the
Expected outcome Even when surgical access to the luminal mucosa when a cutting needle is used to penetrate
cervical laceration is optimized by using a proper speculum the tough muscular layer [22].
and by placing the mare in the position that best exposes O’Leary et al. (2013) described inserting a digit into the
the laceration, access to the cervical often remains difficult. lumen of the cervix every other day between 7 and 21 days
after surgery to prevent intraluminal adhesions [25]. Some
surgeons, on the other hand, have advised against inserting
Failureto Achievea GoodSealAfterRepairing
a finger into the lumen of the cervix during the first 2
the Cervix
weeks after surgery to minimize the likelihood of dehis-
The tissues sutured, after scar tissue has been excised from cence [15, 17, 29, 30].
the margin of the laceration, are the luminal mucosa, the
musculature, and the mucosa of the vaginal surface of the Diagnosis Intra-luminal and peri-cervical fibrinous or
cervix. These tissues are apposed in a single layer [20, 25], fibrous adhesions are easily diagnosed by palpating the
two layers [19, 25], or three layers [15–17, 24], but regardless repaired cervix.
Complications Associated ith epair of a Cervical aceration 561
Treatment and expected outcome Pollock and Russell) Endometritis

believed that adhesions can be easily disrupted when the
Definition Inflammation, septic or non-septic, of the
cervix is evaluated 3 or 4 weeks after repair [20]. They also
endometrium
believed that adhesions disrupted at this time could be
prevented from reforming by applying an ointment
Risk factors A cervical laceration that is long-standing
containing a corticosteroid daily for several days to the
cervical mucosa [20].
Pathogenesis Mares with a long-standing cervical
Intraluminal adhesions, even thin, strand-like adhe-
laceration commonly suffer from chronic bacterial or
sions, may prevent the cervix from opening properly, inhib-
fungal endometritis, and this infection may become
iting complete drainage of endometrial secretions, which
exacerbated after repair, because blood entering the uterus
may lead to pyometra (Figure 42.8); peri-cervical adhe-
provides a medium for growth of microorganisms. Air
sions may prevent the cervix from closing sufficiently to
entering the uterus during surgery irritates the
maintain a seal [21].
endometrium [18].
SepticPeritonitis Prevention The uterus should be lavaged with a solution

containing an antimicrobial agent to evacuate blood after
A complication of trimming the margin of a laceration that
repair [16].
extends the entire length of the portio vaginalis or into the
uterine part of the cervix, is penetration of the peritoneal
Diagnosis Mares affected with chronic bacterial
cavity at the cranial extent of the laceration [16]. This
endometritis may have discharge of purulent exudate from
defect into the abdomen closes, however, as the laceration
the vulva and shortening of the estrous cycle. The presence
is sutured. Even though the communication is eliminated
of echo-dense fluid in the uterus, seen during
as the cervix is reconstructed, contamination of the surgi-
ultrasonographical examination of the uterus, is an
cal site can result in septic peritonitis (authors’ experience).
indication that the mare suffers from endometritis. The
The incidence of clinically important peritonitis associated
presence of bacterial endometritis can be confirmed by
with this complication does not appear to be reported.
cytological and histological examination of the
endometrium. See other texts for a detailed description of
how to determine if a mare suffers from bacterial or fungal
endometritis.
Treatment Inflammatory exudate within the uterine

lumen should be evacuated, and an antimicrobial agent
shown to be effective against bacteria or fungi cultured
from the infected endometrium should be infused into the
uterus. See other texts for a detailed description of how to
treat mares for bacterial or fungal endometritis.
Expected outcome LeBlanc believed that mares with a

cervical lesion less than 90 days old at the time of repair
can be bred as soon as 3 weeks but recommended that
mares with a cervical laceration more than 1 year old
receive at least 60 days of sexual rest after repair to ensure
that endometritis has resolved [18].
Re-injury
Definition Reoccurrence of laceration
Figure42.8 This mare developed pyometra when luminal
Risk Factors
adhesions developed in the cervix after its cervical laceration
was repaired. The cervical adhesion was penetrated with a ● Breeding the mare before the repair has healed
finger to allow escape of purulent exudate within the uterus.
Source: Jim Schumacher and Tom O’Brien. ● Subsequent foalings
Pathogenesis Susceptibility to re-injury is probably due to 11 mares (55%) that had repair of a single laceration
the decreased elasticity of scar tissue at the site of repair. produced a live foal [25].
The repaired cervix is prone to re-injury during copulation Brown et al. reported that 5 out of 8 mares (62.5%) bred
until healing is complete (usually by 4 weeks) [20]. Mares after repair of a lacerated cervix conceived, but the number
that have had a cervical laceration repaired are at risk for of these 5 mares that produced a live foal was not reported,
re-injuring the cervix at subsequent foalings, usually at the because none had foaled by the time the report was
same site of the previous laceration [16, 17, 24]. published [15]. Miller et al. reported that 75% of mares
conceived after repair of a cervical laceration and that the
Prevention To avoid re-injury to the cervix at foaling, mean number of foals produced by each mare after surgery
LeBlanc recommended delivering subsequent foals by was 1 (range 0–5) [17]. In a study by O’Leary et al., 9 out of
Cesarean section [18]. 14 mares conceived, and 8 of the 9 had a live foal [25].
These rates of conception (64%) and foaling (57%) were
Diagnosis A cervical laceration is best detected, and significantly lower than the rates of conception (89%) and
cervical competency best judged, by palpating the cervix foaling (78%) reported for a large group of Thoroughbred
per vagina when the mare is in diestrus. A mare that has mares managed similarly [25, 26].
foaled after a lacerated cervix has been repaired should
have its cervix evaluated at 3 weeks or later after foaling, ComplicationsAssociatedwith Cervical
when edema has subsided and the cervical musculature is Cerclage
contracted.
Cervical cerclage can be used to restore competency to a
Treatment A cervical laceration incurred at a subsequent cervix deemed to be too severely damaged to be repaired [20,
foaling should be repaired to preserve fertility, provided 24]. Using this technique, heavy non-absorbable suture is
that the severity of the laceration is such that it prevents placed circumferentially through the cranial aspect of the
the cervix from sealing during diestrus or pregnancy. portio vaginalis, usually within 48 hours after breeding.
The suture should not enter the lumen of the cervix,
Expected outcome Miller et al., examining the results of 53 because doing so may lead to persistent uterine infection.
Thoroughbred mares that had undergone repair of one or The sutures are tightened to obliterate the lumen of the
more cervical lacerations, reported that 26% of the mares cervix and tied. These sutures must be removed before the
incurred a cervical laceration at subsequent parturitions [17]. mare foals to avoid catastrophic damage to the reproductive
However, in a study by O’Leary et al., none of 6 mares tract. The effectiveness of this technique in preventing
suffered a laceration during subsequent foalings [25]. ascending infection into the uterus has not been reported.
Failureto Conceiveorto Producea LiveFoal ervicalWedgeResection

C
The length of the laceration may affect fertility after repair. for Treatmentfor Pyometra
O’Leary et al. reported that 3 out of 4 mares with a
laceration >90% of the length of the cervix failed to Pyometra is usually caused by intraluminal cervical adhe-
conceive, whereas only 3 out of 10 mares with lacerations sions resulting from cervical trauma, such as that caused
that extended <80% of the cervical length failed to by parturition or from administering intrauterine therapy,
conceive [25]. Six out of ten mares with a laceration that performing artificial insemination, or flushing embryos.
extended <80% of the length of the cervix produced a live Cervical adhesions are also a common complication of
foal, whereas no mares that had a laceration >90% of the repair of a cervical laceration. Mares are treated for pyome-
length of the cervix produced a live foal. tra by disrupting cervical adhesions, lavaging the uterus,
Mares with multiple cervical lacerations may be less administering intra-uterine and systemic antimicrobial
likely to conceive and subsequently produce a live foal after therapy, and encouraging expulsion of uterine contents by
the cervix is repaired than are mares that have undergone administering an ecbolic drug, such as oxytocin.
repair of a single laceration. Brown et al. reported that only Ovariohysterectomy was once the only option for treat-
1 out of 3 mares (33%) conceived after repair of 2 cervical ment when pyometra becomes recurrent. A more econom-
lacerations, whereas 4 out of 5 mares (80%) that had a ical and less difficult treatment of mares for recurring
single laceration repaired conceived [15]. However, pyometra is cervical wedge resection, described by Arnold
O’Leary et al. reported that 2 out of 3 mares (66%) that had et al. [27]. Cervical wedge resection is associated with
repair of 2 lacerations produced a live foal and that 6 out of fewer complications than is treatment by ovariohysterec-
Complications Associated ith Surgery to epair a hirds egree Perineal Injury 563
tomy, and because the ovaries and uterus are preserved, Diagnosis Clinical signs associated with septic peritonitis
this treatment may allow the mare to produce foals by include pyrexia, tachycardia, diarrhea, weight loss, signs of
assisted reproductive techniques, such as embryo transfer. colic, and reluctance to move. Identifying degenerated
neutrophils or intracellular bacteria during cytological
SepticPeritonitis examination of peritoneal fluid, obtained by centesis of the
abdominal cavity, confirms the diagnosis.
Definition Peritonitis is inflammation of the peritoneal
cavity and is considered septic when peritoneal
Treatment The opening into the peritoneal cavity should
inflammation is accompanied by bacterial infection.
be closed with sutures. The mare should be administered
Risk Factors antimicrobial and nonsteroidal anti-inflammatory and
analgesic drugs and supportive therapy, and the peritoneal
● Failure to remove the septic contents of the uterus before cavity should be lavaged to remove bacteria and
performing a cervical wedge resection inflammatory exudate (see other texts for treatment of
● Extending the incisions in the cervix cranially past the horses for septic peritonitis).
internal os
Pathogenesis A complication of cervical wedge resection Expected outcome The outcome of horses affected with
is inadvertent penetration of the peritoneal cavity during septic peritonitis varies according to the type of bacteria
excision of a triangle from the dorsum of the cervix, causing septic peritonitis, time elapsed between
resulting in spillage of septic fluid from the uterine lumen development of the condition and initiation of treatment,
into the peritoneal cavity. and the type of treatment provided to the horse. Affected
horses have a guarded prognosis for survival.
Prevention To decrease the likelihood of contaminating
the peritoneal cavity with exudate, uterine contents should
be removed by lavage before performing cervical wedge
C
resection. Penetration of the peritoneal cavity can be with Surgeryto Repaira Third-
avoided by excising only that portion of the dorsal aspect of DegreePerinealInjury
the cervix that extends to the internal os (Figure 42.9).
A perineal laceration occurs at parturition, when the annu-
lar fold of the hymen at the vestibulovaginal junction
obstructs passage of the foal’s foot or nose. A first-degree
perineal laceration is characterized by tearing of the
mucosa of the vestibule and skin at the dorsal commissure
of the vulva, whereas a second-degree perineal laceration
extends through the musculature of the constrictor vulvae
and constrictor vestibule muscles, preventing these muscles
from constricting the vestibule [28, 29]. A first-degree
perineal laceration often goes unnoticed, without
consequence, and a second-degree perineal laceration may
also go unnoticed, but only until the mare develops poor
perineal conformation as a result of the laceration.
A mare that has suffered a first-degree perineal laceration
requires only a Caslick’s vulvoplasty, whereas a mare with a
second-degree perineal laceration requires more extensive
surgery, because the laceration, if not repaired, causes the
perineum to sink cranially and ventrally, subjecting the
Figure42.9 Endoscopic picture of a healed cervix after a mare to pneumovagina and vesicovaginal reflux [28, 29]. A
wedge resection to resolve pyometra. The suture seen dorsal to
the cervix closed a communication between the vagina and the mare with a second-degree perineal laceration is repaired
peritoneal cavity inadvertently created during the surgery. The by vestibuloplasty, the aim of which is to reduce the diam-
mare did not develop signs of septic peritonitis, despite this eter of the abnormally large vestibule and to appose the torn
complication. This complication can be avoided by excising only musculature [29]. The technique is similar to that used to
that portion of the dorsal aspect of the cervix that extends to
the internal os. Source: Courtesy of Carolyn Arnold and Dickson treat mares with pneumovagina caused by faulty perineal
Varner, Texas A&M University. conformation, but is somewhat more extensive.
A third-degree perineal laceration creates a common rec- The mare’s endometrium is usually healthy at the time
tal and vestibular vault, but if the foot or nose entering the of injury, because the injury nearly always happens dur-
rectum is withdrawn back into the birth canal before the ing the mare’s first foaling [28, 29]. Even when the vagina
foal is delivered, much of the perineal body is spared, leav- is constantly contaminated with feces, the uterus is
ing a fistula between the rectum and vestibule. Third- unlikely to be permanently damaged, provided that repair
degree perineal injuries are nearly always rectovestibular, is not neglected beyond several reproductive seasons. The
rather than rectovaginal, even though the condition is endometrium should be examined histologically, if the
often referred to as a rectovaginal laceration or fistula. A mare has gone through several reproductive seasons,
third-degree perineal injury results in contamination of the because chronicity of the laceration may have a perma-
vestibule and vagina with feces, and contamination extends nent deleterious effect on the endometrium, making sur-
into the uterus during estrus, when the cervix opens. gery ineffective in returning the mare to reproductive
soundness.
Failureto Recognizea ConcurrentGenital
Diagnosis Concurrent genital abnormalities are
Abnormality
recognized during inspection of the uterus and cervix
Definition A complication of surgery to correct a third- before the third-degree perineal laceration is repaired.
degree perineal injury is failure to recognize a concurrent
genital abnormality that may render the mare infertile. Treatment A genital abnormality severe enough to affected
fertility, discovered during examination of the reproductive
Risk Factors tract of a mare that has sustained a third-degree perineal
injury, should be brought to the attention of the mare’s
● Failure to palpate the uterus per rectum
owner.
● Failure to inspect the cervix by palpation per vagina
Expected outcome The mare’s outcome depends on the
Pathogenesis The cervix can be lacerated during the same concurrent abnormality discovered. Repairing both a
parturition in which a mare incurs a third-degree perineal cervical laceration and third-degree perineal laceration
laceration, and the mare may be rendered infertile, if the may return the mare to reproductive soundness, but the
laceration is so extensive that a cervical seal cannot be owner must decide if treating the mare for more than one
maintained during diestrus or pregnancy. Trauma to the reproductive abnormality is feasible financially. Repair of
cervix may also result in cervical adhesions that prevent the third-degree perineal laceration is unlikely to restore a
normal discharge of fluid from the uterus, which in turn, mare’s fertility, if the mare has severe, widespread,
may result in pyometra. Trauma to the uterus during periglandular endometrial fibrosis.
parturition may result in uterine adhesions that contribute
to infertility or to obstruction of the alimentary tract,
Dehiscenceof Repairof Third-DegreePerineal
leading to signs of colic.
Lacerations
Prevention The mare’s reproductive tract should be The most common complication of repair of third-degree
examined by palpation per vagina and per rectum to perineal lacerations, regardless of the method of repair, is
determine if the mare has also sustained a cervical dehiscence. In three retrospective studies of mares that had
laceration, has uterine adhesions or pyometra, or is undergone surgery to repair a third-degree perineal injury,
pregnant. If, uncommonly, the vestibulovaginal seal 12 out of 47 mares (26%) [28], 3 out of 17 mares (18%) [31],
remains functional, the vagina and uterus may remain free and 1 out of 10 mares (10%) [32] had dehiscence of the
of contamination, preserving the mare’s ability to conceive repair. Factors leading to dehiscence and other complica-
and maintain pregnancy [28, 30]. In a study examining the tions are discussed below.
health of the endometrium of 8 mares with a third-degree
perineal laceration, endometrial biopsy specimens were Preoperative considerations to avoid dehiscence of
classified as category I for 2 mares, indicating that the repair of a rectovestieular laceration
uterus remained uncontaminated after the injury [30]. Definition
Surgery to repair the injury of a pregnant mare is unlikely A mare that has sustained a third-degree perineal lacera-
to affect the pregnancy, but obtaining a biopsy of the tion should be properly managed, immediately after the
endometrium before or after surgery is likely to cause the laceration was incurred and before surgery to repair the
mare to abort the fetus. laceration, so that complications can be avoided.
Risk Factors (flaxseed) oil or mineral oil, for several days to ease
defecation. Excising devitalized tissue speeds
● Repairing a third-degree perineal injury immediately
epithelialization of the wound and, therefore, decreases
after wounding
the interval between wounding and surgical repair of the
● Repairing a third-degree perineal injury before the
injury.
wound has healed (i.e. re-epithelialized)
Although others have recommended waiting for at least
● Repairing a third-degree perineal injury without taking
6 weeks before attempting repair [28], we believe that
measures to decrease the bulk and consistency of the
delaying repair for more than 4 weeks is unnecessary,
mare’s feces
because by this time, swelling has resolved, the size of the
wound has decreased, and the wounded tissue has covered
Pathogenesis An attempt to repair a third-degree
with epithelium. Delaying repair of a third-degree perineal
laceration or fistula immediately after injury is usually met
injury until the mare’s foal is weaned, however, avoids
with failure, because the damaged tissue quickly becomes
exposing the foal to pathogens in the hospital.
edematous, inflamed, and contaminated with feces, and
A major factor affecting the outcome of the surgery to
because contraction of the perineal musculature quickly
repair a third-degree perineal injury is the consistency and
widens and lengthens the wound (Figure 42.10) [28, 32,
bulk of the mare’s feces. The feces must remain soft to min-
33]. Creating rectal and vestibular flaps, or shelves, is
imize stress on the healing tissues during defecation, but
difficult when the wound is filled with granulation tissue.
fluid feces can leak into and through sutured tissue, result-
Feces dry in consistency increase tension on the sutures,
ing in partial or complete dehiscence [28]. Allowing the
increasing the of dehiscence.
mare to graze lush pasture keeps the feces soft, but if lush
pasture is not available, 2 to 4 L of mineral oil can be
Diagnosis Dehiscence of repair may be visually evident, if
administered by nasogastric intubation the day before
dehiscence involves the perineal body. Dehiscence of the
surgery, so that the feces are soft and unformed at surgery.
rectovestibular flaps can be palpated per rectum or per
Administering raw linseed oil, once or twice daily, is
vestibule, but palpation should be postponed until at least 8
another effective method of softening the feces. Only the
days after repair.
“raw” form of linseed oil should be administered, because
“boiled” linseed oil is toxic when administered orally [35].
Prevention and treatment A mare with an acute, third-
In one study, horses that received mineral oil (10 mL/kg)
degree perineal injury should receive tetanus prophylaxis,
twice, 12 hours apart, had formed feces by 24 hours after
broad-spectrum antimicrobial therapy until the wound
the first administration, but horses that received linseed oil
begins to fill with granulation tissue, a nonsteroidal anti-
(2.5 mL/kg) did not develop formed feces for 96 to 108
inflammatory drug for at least several days to relieve
hours. However, horses that received linseed oil had signs
discomfort, and a stool softener, such as raw linseed
of depression and were anorexic [35].
A mare that has no access to a lush pasture should
receive a diet of alfalfa pellets, beginning several days
before surgery, to decrease the bulk of the stool. The diet of
pellets should be fed in amounts sufficient to allow the
mare to maintain its weight. Although others have
recommended withholding feed for 24 to 36 hours before
surgery [28, 34], we have found withholding feed to be
unnecessary. A mare undergoing perineal surgery should
be administered a broad-spectrum antimicrobial drug
within several hours before surgery, because the surgery
site is contaminated with bacteria. The horse should also
be administered a non-steroidal anti-inflammatory drug
before surgery to diminish inflammation and discomfort
induced by surgery.
Figure42.10 Repair of an acute rectovestibular laceration is
seldom successful, because the tear rapidly lengthens, becomes Expected outcome Ensuring that the wound has healed
contaminated, inflamed, and filled with necrotic tissue, as has
sufficiently and that the stool is soft and decreased in bulk
this acute laceration. Repair should be delayed until the
rectovestibular vault has re-epithelialized. Source: Jim before undertaking repair of a third-degree laceration
Schumacher, Tom O’Brien. decreases the likelihood of dehiscence of the repair.
Operative considerations to avoid dehiscence of repair rectovestibular tissue, regardless of whether or not both
of a rectovestieular laceration stages of reconstruction are to be performed during a single
operation, the rectal and the vaginal submucosa should be
Definition
separated for at least 5 cm cranial to the cranial border of
The risk of dehiscence of the repaired rectovestibular lac-
the defect to create a cul de sac between the rectum and
eration can be reduced by minimizing contamination of
vagina (Figure 42.11). By separating the rectum and vagina,
the surgical site and by implementing techniques in the
the rectum can be distracted caudally, thereby decreasing
repair that minimize tension on the sutures.
the length of the rectal portion of the defect. The further
cranially the rectum and vagina are separated, the further
Risk Factors
caudally the rectum can be distracted.
● Contamination of the surgical site with feces Dissection at the cul de sac is continued caudolaterally
● Performing the repair in one stage, rather than two stages along the right and left walls of the rectovestibular vault, at
● Insufficient dissection of the rectal and vestibular flaps the border of the rectal and vestibular mucosa, to the
● Leakage of rectal contents into the sutured tissue ventral-most aspect of each side of the torn anus. This
● Tension at the cranial aspect of the repair incision along each wall of the rectovestibular vault is
● Excessive pressure in the rectum during defecation deepened until thick right and left flaps, or shelves, can be
apposed on midline without tension to form the dorsal
Pathogenesis and prevention A rectovestibular laceration aspect of the vestibule. The caudal portion of the flaps is
or fistula can be repaired with the mare anesthetized and dissected ventrally from the anus to the point at which the
in dorsal recumbency, but most surgeons perform the dorsal commissure of the vulva is to be created. The
surgery with the mare sedated, after desensitizing the surgeon should be aware that, when creating flaps along
perineum by using epidural anesthesia [28, 31, 32]. The the walls of the vestibule, the right and left vestibular
procedure can be performed by infiltrating the surgical site bulbs, which are composed of cavernous tissue, are incised,
with local anesthetic solution, but epidural anesthesia not sharply increasing hemorrhage [9]. This sudden increase
only desensitizes the surgical site, it also prevents the mare in hemorrhage is no cause for alarm, because the
from moving feces into the surgical site during surgery. A hemorrhage diminishes within minutes.
tampon, made from stockinet filled with cotton, can be If anoperineal reconstruction is to be postponed, rec-
placed into the rectum, cranial to the defect, to prevent tovestibular reconstruction is completed by apposing the
feces from leaking into the surgical site during repair [33, vestibular flaps with a continuous-horizontal mattress
34], but the presence of a rectal tampon causes some mares suture pattern using heavy monofilament, absorbable or
to strain, especially if the mare has not received epidural non-absorbable suture. Repair can be reinforced with
anesthesia. Inserting a rectal tampon is unnecessary heavy absorbable sutures placed in a Lembert suture pat-
because epidural anesthesia eliminates movement of feces
into the rectum.
The two stages of reconstructing a third-degree perineal
laceration, rectovestibular reconstruction and anoperineal
reconstruction, can be performed during the same
operation, or anoperineal reconstruction can be completed
3 weeks or more after rectovestibular reconstruction. Less
stress is placed on the rectovestibular repair when the mare
defecates, if anoperineal reconstruction is postponed until
the reconstructed rectovestibular tissue has healed [28].
The authors, however, prefer to perform both stages of
repair during the same surgical period, even though
performing both stages at the same surgery increases the
likelihood of dehiscence of the rectovestibular repair,
because postponing the anoperineal stage of reconstruction Figure42.11 To reconstruct the rectovestibular tissue,
increases the expense of repair and prolongs time between submucosa between the rectum and the vagina should be
wounding and return to breeding. separated for at least 5 cm cranial to the cranial border of the
defect to create a cul de sac between the rectum and vagina. By
The usual cause of dehiscence is tension on sutures,
separating the rectum and vagina, the rectum can be distracted
which is usually caused by dissection insufficient to allow quite far caudally, thereby decreasing the length of the rectal
tension-free apposition of tissue. To reconstruct the portion of the defect. Source: Jim Schumacher and Tom O’Brien.
tern, so that the suture passes through the vestibular sub- suturing contaminated wounds, such as rectovestibular
mucosa on both sides of the vault. Suturing should begin in wounds, because the interstices of multifilament strands
the cul de sac created cranial to the laceration, between the protect bacteria from the body’s defenses [32].
rectum and vagina, so that a ridge is created in the vaginal
mucosa and submucosa cranial to the laceration. Beginning Diagnosis Dehiscence of repair may be visually evident if
suturing in the cul de sac relieves tension on the sutured dehiscence involves the perineal body. Dehiscence of the
vestibular flaps at the cranial aspect of the laceration, rectovestibular flaps can be palpated per rectum or per
decreasing the likelihood of dehiscence at this portion of vestibule, but palpation should be postponed until at least 8
the laceration. The anus and perineum are reconstructed 3 days after repair.
or 4 weeks later, after the rectovestibular reconstruction
has healed, or surgery is continued with the anoperineal Treatment At least 4 weeks should elapse after dehiscence
phase of reconstruction. of a repaired third-degree perineal injury before another
If the anus and perineal body are reconstructed during repair is attempted.
the same operation that the rectal and vestibular flaps are
reconstructed, the right and left aspects of the longitudinal Expected outcome First-intention healing of a repaired
incision in the rectovestibular vault are deepened dorsolat- rectovestibular laceration is expected, if the surgeon pays
erally to create flaps used to form the ventral aspect of the close attention to techniques during surgery that relieve
rectum. The edge of the right rectal flap is sutured to the tension on the sutured tissue.
edge of the left rectal flap, cranially to caudally. Tension on
the sutured rectal flaps at the cranial aspect of the lacera- Operative considerations to avoid dehiscence of repair
tion is relieved by beginning suturing at the cranial aspect of a rectovestieular fistula
of the cul de sac. This decreases the likelihood of dehis- Definition
cence at the cranial aspect of the laceration. The risk of dehiscence of a repaired rectovestibular fistula
Regardless of which suture pattern is used to appose the can be reduced by minimizing contamination of the
rectal and vestibular flaps, the edges of the rectal flaps surgical site and by implementing techniques in the repair
should be inverted into the lumen of the rectum, and the that minimize tension on the sutures.
edges of the vestibular flaps should be inverted into the
lumen of the vestibule. Sutures should not penetrate the Risk Factors
rectal mucosa [32, 36]. The likelihood of rectal contents ● A fistula greater than three fingers in diameter
leaking between the sutured rectal shelves, resulting in ● Failure to place sutures perpendicular to the lines of
dehiscence, can be diminished by closely spacing the stress
sutures used to appose the rectal flaps. The perineal tissue
between the newly created rectum and vestibule is Pathogenesis and prevention Some surgeons recommend
reconstructed with rows of sutures, and the right and left converting all rectovestibular fistulas into a laceration for
sides of the torn anus sphincter are apposed. By apposing repair [28, 32], but we believe that a rectovestibular fistula
the torn anus loosely, pressure within the rectum during should be converted into a laceration only if it is
defecation is minimized, thereby decreasing the likelihood exceptionally large (i.e. greater than three fingers in
of the rectum becoming impacted with feces while the diameter) or is within the caudal-most portion of the
reconstructed tissue heals. Others have described perineal body (Figure 42.12). A fistula three fingers or less
transecting the anal sphincter dorsally to reduce pressure in diameter can be repaired using a technique described
within the rectum during defecation [36, 37]. To ensure a by Forssell that spares complete disruption of the intact
good labial seal, the mare should receive a Caslick’s perineal body [29]. Using this technique, the skin of the
vulvoplasty perineum is incised in a frontal plane, midway between
Absorbable and non-absorbable sutures have been used the ventral aspect of the anus and the dorsal commissure
with success to repair third-degree perineal lacerations, but of the vulva. This incision is similar to that created when
absorbable suture is more commonly used, because of the performing the Pouret procedure to prevent urine pooling
difficulty in removing non-absorbable sutures after healing or pneumovagina (see Section on Complications of
is complete [28]. Good outcomes, however, were observed Surgery Performed to Relieve Vesicovaginal Reflux above).
in a study examining the effects of using monofilament The incision is extended cranially through the perineal
polypropylene and nylon sutures, buried in the tissues, to body to 3 to 4 cm beyond the fistula, separating the
repair third-degree perineal lacerations [32]. Monofilament rectovestibular defect into a dorsal rectal hole and a ventral
sutures are superior to multifilament sutures when vestibular hole.
Diagnosis Dehiscence of repair can be palpated per rectum

or per vestibule, but palpation should be postponed until at
least 8 days after repair.
Treatment At least 4 weeks should elapse after repaired a

rectovestibular fistula has dehisced before repair is again
attempted.
Expected outcome First-intention healing a repair of the

third-degree perineal fistula is expected, if the surgeon
pays close attention to techniques during surgery that
relieve tension on the sutured tissue.
Rectal or vesical tenesmus as a cause of dehiscence or

disruption of repair of a rectovestieular laceration or
fistula
Definition
Straining to defecate (rectal tenesmus) or urinate (vesical
tenesmus) is a complication that may lead to dehiscence of
the repaired third-degree perineal laceration.
Figure42.12 Rectovestibular fistulae. A fistula of this size is Risk Factors

best converted into a laceration. A small fistula can be repaired
by splitting the perineal body horizontally, past the fistula, to ● Fecal impaction of the rectum and small colon
separate the fistula into a rectal and a vestibular hole; the rectal ● Bacterial cystitis
and vestibular holes are sutured separately. Source: Courtesy of
Reid Hanson, Auburn University.
Pathogenesis Rectal tenesmus may occur after surgery,
whereas vesical tenesmus may occur before or after surgery.
The rectal hole is closed using a pattern that inverts the Feces in the rectum and small colon remain bulky and
rectal mucosa into the lumen of the rectum, and the ves- firm, if measures to reduce their quantity and soften
tibular hole is closed using a pattern that inverts the ves- their consistency, such as modifying the diet and admin-
tibular mucosa into the vestibule. The rectal hole is closed istering a laxative, are not instituted before surgery. The
in a transverse plane because the musculature of the rec- mare may experience discomfort trying to void firm,
tum is primarily circular, and sutures placed perpendicu- bulky feces, leading to impaction of the rectum and
lar to the muscle fibers are less likely to tear through small colon.
tissue than are sutures placed parallel to the direction of One of us (JS) has observed two mares with a third-
the muscle fibers. The vestibular hole is closed in a sagit- degree perineal laceration that everted their urinary blad-
tal plane because the musculature of the vestibule is pri- der because of severe, chronic straining, apparently the
marily longitudinal [29]. Closing the rectal and vestibular result of severe cystitis (Figure 42.13). One of these mares
holes at right angles to each other reduces the likelihood eviscerated through a rent in the everted bladder before
of rectal contents leaking into the vestibule, perpetuating the laceration could be repaired, and consequently was
the fistula. The sutures can be placed uniformly by pre- euthanized, but chronic straining by the other mare
placing them in bisecting fashion. Care must be taken to resolved quickly after the bladder was replaced, the third-
place all sutures into submucosa to avoid tearing tissue degree laceration repaired, and antimicrobial therapy
when sutures are tightened. The dead space between the instituted. Two mares with a third-degree perineal lacera-
rectum and vestibule is left unsutured to heal by second tion were reported by others to experience eversion of the
intention or closed using absorbable suture placed in a urinary bladder – one mare before repair of the laceration
simple-interrupted or simple-continuous suture pattern. and the other mare after repair of the laceration [37]. The
The incised skin of the perineal body is closed with inter- mare that everted its urinary bladder after repair was the-
rupted, non-absorbable, monofilament sutures, which are orized to have done so because of straining, which was
removed at 10 to 14 days. caused by rectal impaction.
References 569
Expected outcome Rectal tenesmus resolves when the

impacted feces have been removed from the rectum. Vesical
tenesmus may resolve after the perineal injury has been
repaired, when the bladder is no longer continuously
contaminated. Instituting antimicrobial therapy speeds
resolution of vesical tenesmus caused by bacterial cystitis.
Postoperative care to avoid dehiscence or disruption

of repair of a rectovestieular laceration or fistula
Evaluation of the repair of a third-degree perineal lacera-
tion should be postponed until the 9th or 10th postopera-
tive day to avoid disrupting the repair. Defects in the repair
after this time are best detected by palpating tissue between
Figure42.13 Prolapse of the bladder of a mare caused by fingers inserted into the rectum and fingers inserted into
cystitis resulting from fecal contamination of the vestibule, the vestibule. Defects less than 1 finger in diameter, discov-
which in turn, resulted from a rectovestibular laceration. Source: ered at this time, often heal completely by contraction
Courtesy of Reid Hanson, Auburn University.
(authors’ observation).
Mares appear to be capable of rapidly resolving chronic
Prevention To avoid fecal impaction, the mare’s feces
inflammation after repair of a third-degree perineal injury.
should be softened and decreased in bulk before surgery.
In one study, all 6 mares that had an endometrium classi-
The mare’s feces should be kept soft and scanty for at least
fied category 2 or 3 before repair of a third-degree perineal
8 days by feeding a pelleted feed and by administering a
laceration had an endometrium classified as category 1
stool softener. A stool softener often need not be
within 8 to 15 days after repair [30]. Results of this study
administered nor the mare fed pellets, if the mare can graze
indicated that mares with third-degree rectovestibular
a lush pasture. The mare should receive an analgesic drug
injuries are candidates for breeding by artificial insemina-
to diminish discomfort during defecation.
tion by 2 weeks after repair of the injury. After 2 weeks of
convalescence, sufficient healing should have occurred to
Diagnosis Straining to defecate after surgery or to urinate
permit safe examination of the reproductive tract per rec•
before or after surgery is obvious.
tum and passage of an insemination pipette through the
cervix.
Treatment Feces impacted within the rectum should be
Natural breeding should not be allowed for several
removed manually but only after administering epidural
months after repair of a third-degree perineal laceration,
anesthesia or scopolamine butylbromide (Buscopan®) to
but postponing breeding for only one month or less is prob-
relax the rectum. Mares that strain excessively after surgery,
ably adequate for mares with a rectovestibular fistula that
whether from rectal impaction or from bacterial cystitis,
has been repaired using the technique described by
should be treated by periodic administration of epidural
Forssell. The likelihood of recurrence of a third-degree per-
anesthesia and sedation until straining has ceased. The mare
ineal laceration at subsequent foalings is low, based on our
should receive antimicrobial therapy, if straining is caused
observations and that others [28, 31], whereas other
by bacterial cystitis. The authors of a report describing 2
authors have reported recurrence to be a substantial
mares displaying tenesmus before or after surgery to repair a
problem [32].
third-degree perineal laceration found that temporary
tracheostomy decreased the intensity of straining [37].
References
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571
43
Complicationsof UrinarySurgery
Sara K.T. Steward DVM1 and Luis M. Rubio-Martinez DVM, DVSc, PhD, DACVS, DECVS, DACVSMR, MRCVS2
1
Veterinary Teaching Hospital, Department of Clinical Sciences, Colorado State University, Fort Collins, CO
2

L
with UrinarySurgery
Urinary surgery in the horse is often performed on an elec-
tive basis, following clinical presentation for inappropriate ● Intraoperative
or undesirable urination. Often these cases involve removal – Hemorrhage
of uroliths from the bladder that in some cases can be per- – Pneumothorax
formed standing with minimal risk of complications. Other – Acute kidney injury
procedures involving bladder, ureters or kidneys are more – Difficulties exteriorizing the bladder when removing
invasive and require transabdominal approach. These bladder calculi
more invasive surgeries involve greater risk of complica- ● Postoperative
tions including hemorrhage, stricture or extravasation of – Uroabdomen/extravasation of urine
urine. Neonates presenting with uroabdomen secondary to – Incontinence
bladder tear are critical patients with significant systemic – Infection
compromise that require medical preoperative stabiliza- – Urine scalding
tion to prevent serious intraoperative accidents (e.g. severe – Stricture/fistula
ventricular arrythmias) [1]. Postoperative complications in – Complications related to suture choice and
these foals include those related with abdominal surgery placement
and dehiscence of the bladder closure sites, but also com- – Complications related to suture choice and
plications related to the systemic compromise of the often- placement
weak neonatal patients, especially in patients not medically
managed in the preoperative period. These complications
include severe electrolyte derangements, myositis and Intraoperative
death [2]. Appropriate preoperative medical management
and systemic stabilization of neonates with uroperitoneum Hemorrhage
are crucial for a successful outcome of these patients (for
Definition Rapid loss of blood from: i) an inadvertently
further information on the preoperative assessment and
ruptured vessel; ii) highly vascularized or inflamed tissue,
medial stabilization of these patients the reader is referred
i.e. bladder wall; or iii) from an incomplete or failed ligation
to: Schott II H.C. Bladder: Disorders requiring surgery:
Uroperitoneum. In: Equine Surgery 5e (ed J.A. Auer, J.A.
Risk Factors
Stick, J.M. Kummerle, and T. Prange), 1130–1133.
Philadelphia: Elsevier Saunders). This chapter discusses in ● Highly vascularized structures (kidney)
greater detail some of the most frequently reported surgical ● Presence of accessory and aberrant vasculature
complications of urinary surgery. While many case series ● Inflammation
of urinary procedures are reported, there is little reported ● Neoplasia
detail of complications and prognoses in the literature. ● Ligation performed under tension
572 Complications of Urinary Surgery
Pathogenesis Uncontrollable hemorrhage is the often postoperative hemorrhage will depend on the amount and
immediate and the most severe complication in equine rapidity of the blood loss. Rapid blood loss will present
urinary surgery, especially during nephrectomies [3]. with clinical signs of blood loss (increased heart rate, poor
Difficult access to structures in the horse, such as the pulse quality, pale mucous membrane and prolonged refill
kidneys or ureters, can lead to inadvertent tearing of capillary time). Serum lactate will increase due to the
vasculature during initial attempts to gain exposure. The decreased tissue perfusion for volume loss. Substantial
source of hemorrhage tends to involve or be in close changes in peripheral blood packed cell volume and total
proximity to major vessels, which makes identification, protein may take some time (up to 24 h) [8]. External
isolation and adequate ligation of the source difficult [4]. swelling and bleeding from the incision site may be
Inflammatory changes to the urinary tract, such as with observed after nephrectomies via traditional flank
urolithiasis, neoplasia, or infection can increase approach; however, this may not be obvious in cases with
vascularization and dilation of the existing vasculature of internal hemorrhage. Ultrasonographic examination of the
the urinary tract, thus leading to increased cumulative abdomen allows assessment of quantity and quality of
blood loss, despite adequate ligation of larger vessels [4–6]. abdominal fluid, with fresh hemorrhage typically appearing
Aberrant vascularization in the presence of chronic as echogenic fluid with a swirling effect. Abdominocentesis
inflammation or neoplastic growth can lead to inadvertent will also help diagnose presence of blood in the abdominal
vessel transection because of abnormal or distorted cavity.
anatomy. The urinary system is plastic in nature and
therefore lends itself to stretching, which is used to improve Treatment Treatment will depend on the severity and rate
surgical access and visualization. Placement of a ligation of blood loss. The reader is referred to Chapter 7:
under tension may occur and this increases the risk of Complications Associated with Hemorrhage, for more
ligature failure. Following release of tension, suture information. Careful monitoring may be sufficient if blood
ligation may become loose or vasculature that was loss is minimal and slows down within a reasonable time
previously not noted to exhibit hemorrhage under tension frame. The use of hemostatic agents, such as aminocaproic
may bleed when tension is released. This may occur both or tranexamic acid, has been described anecdotally in cases
intraoperatively or in the immediate postoperative period. where a hematoma has formed following hemorrhage [9].
Repeat celiotomy or laparoscopy may be required in order
Prevention Accurate identification and ligation of main, to appropriately isolate and ligate the origin of blood loss.
accessory and aberrant vasculature are essential for Depending on the severity, blood transfusion may also be
prevention of acute intraoperative hemorrhage [7]. The indicated [8].
use of adequate laparoscopic equipment, or instrumentation
such as Finnochetto or Balfour retractors when performing Expected outcome In the face of minor or brief hemorrhage,
nephrectomy via conventional approach are key to allow the outcome is expected to be good. However, in several
good visualization and dissection, especially in the adult reported cases during nephrectomy, severe hemorrhage
horse. Hand-assisted laparoscopic techniques offer tactile may prove to be swiftly fatal [4].
sensation and hand retraction which facilitate dissection
compared to full laparoscopic procedures [3]. The renal
Pneumothorax
artery should be ligated before the vein to avoid venous and
renal congestion and engorgement, which would make Definition Accumulation of extrapulmonary air within
vessel ligation more difficult. Revision of the surgical site the pleural space, that causes partial or total collapse of the
prior to abdominal closure allows identification and lung and impairs ventilatory function of the affected lung
rectification of any ligature that may have become loose or
have slipped. Risk Factors Nephrectomy via transthoracic approach or
flank approach using rib resection
Diagnosis Intraoperative hemorrhage typically becomes
obvious at the time of vessel transection, but in some cases Pathogenesis Air entering the pleural cavity is inherent to
where the vessel defect is small, hemorrhage may only the transthoracic approach for nephrectomy. Pneumothorax
become apparent later during the procedure when can also develop during the flank approach via rib resection
accumulation of blood in the surgical field or abdominal as the crura of the diaphragm may be disrupted during the
cavity is noted. Bleeding may also be diagnosed when procedure. Entering air into the pleural cavity will cause a
previously ligated vasculature is examined prior to closure degree of lung collapse and impair distension and
of the abdomen. Diagnostic findings associated with ventilatory capacity of the uppermost lung.
Intraoperative 573
Prevention Mechanical ventilation should be available the trapped air can be removed via thoracocentesis with a
when a nephrectomy is performed under general anesthesia large-gauge needle or teat cannula, and gentle aspiration
via transthoracic or flank approach and rib resection. Good using a three-way stopcock and a 60 mL syringe or a suction
anatomical knowledge, correct identification of anatomical device [11, 14]. Although not always necessary, expansion
structures and careful dissection are important to reduce of the lung and resolution of the pneumothorax can be
the likelihood of disruption of the crura of the diaphragm. assessed with radiography or ultrasonography [11].
Revision of the surgical site before closure to assess the
integrity of the diaphragm will allow closure of the Expected outcome In cases where adequate seal of the
disruption if this has occurred. pleural space is achieved intraoperatively, the residual
pneumothorax resolves within a few days without
Diagnosis Entering the pleural cavity during surgery is complications. In cases with more severe pneumothorax or
easily recognized because of noise caused by air entering those where damage to the lung also occurred during
and exiting the pleural space during respiration. Decreased surgery (lung laceration during rib resection or re-expansion
ventilatory capacity of the lungs may also be recognized by lung edema [15]), and more delicate patients such as those
the anesthetist. with concurrent blood loss or infection, recovery may be
Clinical signs of pneumothorax in the postoperative prolonged or outcome worsened by other negative
period will depend on the severity of the pneumothorax. individual factors.
Even though horses have incomplete mediastinum,
pneumothorax may only affect one hemithorax as the
mediastinal fenestrations may become occluded. AcuteKidneyInjury
Residual pneumothorax will be present in the majority
Definition A sudden insult to the renal system resulting in
of cases after transthoracic approach or when the
either temporary or permanent damage to kidney function,
diaphragm has been disrupted. If pneumothorax is mild, it
including post-renal obstruction, pre-renal azotemia, or
may not result in clinical signs and spontaneously resolved
direct renal injury as a result of infection or
within a few days. In more severe cases, clinical signs
pharmaceuticals [3]
associated with pneumothorax postoperatively may
include restlessness, cyanosis, tachypnea, dyspnea, and
Risk Factors
accentuated respiratory excursions on the opposite side but
not on the affected side, with affected horses developing ● Urolithiasis, both obstructive and non-obstructive
the characteristic shallow, rapid breathing pattern [10]. ● Dehydration
Percussion (hyperresonance), ultrasonography and ● Non-steroidal anti-inflammatory drugs
standing radiography of the caudodorsal aspect of the ● Aminoglycosides
thorax are useful to identify presence of gas within the ● Dehydration
pleural cavity and lung retraction [11]. ● General anesthesia
● Shock
Treatment If disruption of the diaphragm is noted
intraoperatively, the horse should be managed with Pathogenesis Urolithiasis has the ability to compromise
mechanical ventilation and the defect should be sutured to kidney function both directly and indirectly. In cases of
the adjacent costal musculature to seal the pleural cavity renal urolithiasis, the infrastructure of the kidney can be
while achieving and maintaining lung expansion to directly traumatized by the stones and cases of renal
decrease pneumothorax [12]. In cases with postoperative capsular rupture have been reported [16]. Additionally, any
pneumothorax requiring treatment, adequate ventilation, obstructive disease of the lower urinary tract, be it from
oxygenation and systemic perfusion must be assured. uroliths, stricture, or otherwise, has the ability to damage
Supplemental oxygen therapy (nasal insufflation of oxygen renal function in both the acute and chronic phases due to
at 5–15 L/min in adult horses) [13] should be initiated if increased luminal pressure, decreased glomerular filtration
hypoxemia is present (PaO2 < 80mm Hg). Some patients rate (GFR), and altered renal blood flow [17].
may require fluid replacement to assure adequate systemic In systemically compromised patients (e.g. shock),
perfusion, especially if the horse lost a significant volume hypoperfusion is an important risk factor for kidney dys-
of blood during surgery [8]. function, which can be exacerbated by the therapeutic
In most cases, the residual pneumothorax after surgery use of potentially nephrotoxic drugs. Non-steroidal anti-
will by mild and resolve without specific treatment. In inflammatory drugs (NSAIDs), as well as aminoglyco-
cases with a larger volume of air within the pleural cavity, sides, are the most commonly reported contributors to
pharmaceutically-induced acute kidney injury. NSAIDs developing anuric acute renal failure generally carry a
have been well documented to cause papillary necrosis in poor prognosis; those developing polyuric acute renal
the face of dehydration [18], whereas aminoglycosides failure are associated with guarded to good prognosis with
appear to have a greater negative effect on renal adequate therapy. In a human study, 21% of patients with
tubules [19, 20]. post-obstructive acute renal injury developed chronic
General anesthesia can also contribute to renal ischemia renal failure as a result [24]. The inciting cause, chronicity,
because of systemic hypotension and/or renal and time to management all play roles in the long-term
vasoconstriction, which will therefore compromise blood outcome of these patients.
flow to the kidneys decreasing GFR. Anesthetic agents
have effects on cardiovascular and neuroendocrine systems
that are directly implicated in renal blood (for further DifficultiesExteriorizingthe Bladderwhen
information on this matter please refer to Lumb and Jones RemovingBladderCalculi
(2015). Section 9. Urogenital system. In: Veterinary
Definition Difficult access to and exposure of the bladder
Anesthesia and Analgesia, 5e (ed K.A. Grimm, L.A. Lamont,
to the surgical skin incision
W.J. Tranquilli, et al. This is unusually associated with
urinary surgery of the systemically stable adult horse, but
Pathogenesis The bladder is a muscular structure that
should be a consideration in ill patients and neonates.
tends to contract, especially when inflamed or infected.
Although the bladder can distend substantially over time,
Prevention Hydration status and serum biochemistry
it shows limited rapid elasticity and stretch capacity.
values, including creatinine, urea, and electrolytes, should
always be evaluated prior to administration of NSAIDs or
Risk Factors
aminoglycosides in any patient where obstruction or renal
compromise is suspected [21]. Appropriate fluid therapy ● Large patient
and diuresis prior to administration of these ● Overweight obese patient
pharmaceuticals are essential, in order to avoid added ● Chronic infection of the bladder
insult to the kidneys. In some cases, diuresis is impossible
due to the obstructive nature of the disease, and therefore Diagnosis Difficulties encountered when trying to
surgical intervention to resolve the obstruction must be exteriorize the bladder to the incision site are obvious
performed prior to or in conjunction with diuresis. Efforts during surgery.
should be made to maintain adequate systemic blood
pressure under general anesthesia, in order to reduce the Prevention Use of complete laparoscopic techniques with
risk of additional compromise of the kidneys [21]. the patient standing or under general anesthesia avoids the
need for stretching the bladder to the surgical incision site;
Diagnosis Diagnosis is typically through serum chemistry however, these procedures are more difficult and require
values indicative of azotemia (creatinine > 130 technical dexterity.
μmol/L) [21]. In severe cases, development of oliguria or Preoperative planning and selection of the surgical tech-
anuria can be a result of acute kidney injury. nique according to the surgeon’s preferences, expertise and
Ultrasonography of the kidneys can also be useful to assess equipment available are crucial. The following techniques
the architecture of the kidney in these cases [22]. have been described to facilitate the approach, surgical
technique and completion of cystotomy procedures under
Treatment The mainstay of therapy for these cases is to general anesthesia through laparotomy in adult horses.
eliminate the underlying cause of the initial insult (i.e. Fasting the patient for 24–36 hours reduces the volume of
obstructive urolith), as well as to provide adequate fluid ingesta in the gastrointestinal tract [25]. Catheterizing the
therapy support and diuresis. Twice times maintenance bladder and clamping the urinary catheter while the horse
fluid therapy (8 ml/kg/hr) [23] until creatinine is halved is is being prepared for surgery and during the approach to
currently recommended in acute kidney injury with the abdomen facilitates dilation and exteriorization of the
significant azotemia present [23]. bladder [26].
A further technique is hydrodistension and local anes-
Expected outcome In the absence of structural changes to thesia into the bladder. For this technique the bladder is
the kidney, acute kidney injury has the potential to be first drained via a urinary catheter after induction into gen-
transient and without lasting impact to the patient. [21]. eral anesthesia, followed by instillation of 100 mL of 2%
After the obstruction is corrected, those patients lidocatine hydrochloride into the bladder through the same
Postoperative 575
urinary catheter. Ten minutes later a circumferential loop Inadvertent passage of suture material into the lumen of
of elastic gauze is placed around the glans penis to prevent the urinary tract may increase rate of suture biodegradation
leakage and sterile Hartmann’s solution is injected into the and potential dehiscence of closure of cystotomy/
bladder first under pressure and then by gravity for a total urethrotomy [33]. Inadvertent transection of the urinary
of 1.4–2.5 litres. The surgical approach is then performed tract, most often the urethra in males, during surgery
and the bladder drained just before being exteriorised, involving the urogenital system has also been reported,
which is much easier as the bladder is enlarged and which can lead to inadvertent extravasation of urine at the
flaccid [26]. site of transection [34].
During laparoscopically-assisted cystotomy, the
laparoscopic instrumentation is used to grasp the bladder Prevention Complete removal of uroliths, as well as
and exteriorize it to the ventral abdominal wall. The use of preoperative diagnostics to evaluate proximal urinary tract,
Trendelenburgh position can also facilitate visualization i.e. renal ultrasonographic examination, for prevention of
and exteriorization of the bladder [27, 28]. immediate recurrence of obstructive urolithiasis [29, 35, 36].
Additionally, appropriate management of inflammation and
Treatment Good knowledge of different surgical pain to reduce straining in the immediate postoperative
techniques described, availability of adequate and period has been shown to improve rates of healing and
alternative instrumentation and being prepared to change decrease complications [31].
plans and use an alternative approach allow the surgeon to Good anatomical knowledge and careful surgical tech-
adapt and solve this complication. nique. Adequate isolation of urinary tract structures with
appropriate surgical visibility and hemostasis to prevent
Expected outcome In most cases, surgeon’s patience and erroneous incision or erroneous suture placement involv-
adaptability to make necessary adjustments during the ing the urinary lumen; catheterization of the urethra is
surgical procedure conduct to a successful outcome. often useful to provide a prominently palpable representa-
tion of the urethra.
Postoperative Diagnosis As with hemoperitoneum, confirmed diagnosis

of uroabdomen requires abdominocentesis and fluid
Uroabdomen/Extravasationof urine analysis; uroabdomen is conclusively diagnosed when
abdominal fluid creatinine concentration to peripheral
Definition Accumulation of urine within the peritoneal
blood creatinine concentration ratio is >2:1 [37]. An
cavity or peri-urethral tissues subsequent to: i) inadvertent
apparent decrease in urine production may also be an
transection of the urinary tract; ii) failure of repair of
indication of a compromise to the patency or integrity of
urinary tract rent; or iii) obstruction of urinary tract leading
the urinary tract in the immediate postoperative period.
to rupture of the tract proximal to or at the level of the
Severe and focal swelling of the tissues of the perineum or
obstruction
inguinum may be indicative of urine pooling in the
subcutaneous tissues and should be investigated
Risk Factors
ultrasonographically for disruption of the urethra, if
● Obstructive urolithiasis suspected. Endoscopy of the urinary tract may identify the
● Inadequate ligation of ureters following nephrectomy/ location of the disruption.
ectopic ureters
● Inflammation Treatment In cases of bladder compromise, a urinary
● Poor visibility/isolation of urinary tract during surgery catheter can be placed for immediate relief of urine
contamination into the abdomen. The abdomen is tolerant
Pathogenesis Recurrent or incomplete removal of uroliths of urine contamination in the absence of infection, and
can lead to obstruction and subsequent rupture of the successful conservative management of bladder
urinary tract either proximal to the obstruction or via compromise has been reported [38, 39]; alternatively, the
pressure necrosis at the site of the urolith [29–31]. Even in rent can be repaired surgically [5, 39, 40].
cases of surgical intervention, profound inflammation of The effects of catheterization on ureteral and urethral
the urinary tract can lead to both leakage at suture sites or defect healing are both debated and not well described; how-
complete dehiscence. In the case of the bladder, this is a ever, catheterization has loosely been associated with an
relatively rare occurrence; however, dehiscence of increase in ureteral stricture formation and therefore surgi-
urethrotomy sites have been reported [29, 32]. cal correction of ureteral dehiscence is recommended [41].
However, use of an indwelling polyethylene tubing stent Prevention In most cases, incontinence is a sequela of the
was used to successfully treat ureterorrhexis in mares after disease process for which horses require surgical
an attempted surgical repair failed [42]. intervention [44, 49–51]. Appropriate communication with
the owner of the potential permanent outcome of
Expected outcome Uroperitoneum in the absence of incontinence despite surgical intervention is essential in
neoplasia or infection has minimal long-term cases that are at risk. Reconstructive cases, or cases
complications. In theory, a chemical peritonitis leading to requiring urethrotomy, rarely result in urinary
adhesion formation seems logical; however, there are no incontinence. Overall, iatrogenic incontinence in the horse
reports of this occurrence to date. Urine pooling in has not been reported; however, permanent incontinence
subcutaneous tissue, on the other hand, is associated with due to congenital, traumatic, or bladder wall dysfunction
severe soft tissue irritation and sloughing [43]. This too is has been reported.
self-limiting given appropriate drainage and management Although not really preventative, preoperative identifi-
of urethral damage. Stricture of the urethra is the most cation of detrusor and/or urethral sphincter disfunction
common complication of urethral compromise and is should be sought before embarking in surgical treatment
discussed further in the Section involving Stricture/Fistula of ectopic ureters. This can be easily assessed by infusing
below. saline into the bladder and observing whether inconti-
nence develops with the infused fluid being voided
spontaneously [3].
Incontinence
Diagnosis The primary clinical sign of incontinence is
Definition Lack of normal micturition due to damage to: i)
constant or intermittent urine dribbling, or frequent
pelvic innervation of the detrusor muscle (L1-L4) or the
inappropriate urination. It is important to differentiate
urethral sphincter (S1–S3); ii) detrusor muscle atony; or iii)
between detrusor muscle dysfunction and urethral
physical dysfunction of the urethral sphincter
sphincter dysfunction in cases of incontinence. Abdominal
ultrasound is useful to determine bladder size. In cases of
Risk Factors
detrusor muscle dysfunction, the bladder fills until the
● Cystolithiasis intraluminal pressure is greater than that of the urethral
● Neoplasia sphincter, thus causing spill over and urinary
● Dystocia incontinence [52]. Therefore, an enlarged urinary bladder
● Congenital defect (in association with ectopic ureter) is a diagnostic finding in such cases. Cystoscopy of the
urinary bladder may also be helpful, as sebulous urolithiasis
Pathogenesis One possible cause of incontinence may be is often a secondary finding in cases of incomplete bladder
secondary to prolonged distension of the bladder wall, emptying [50, 53]. This is rarely a finding that is a
leading to myopathy of the detrusor muscle, as in cases of complication of urinary surgery, but instead may be a
obstructive urolithiasis [25]. This may be a transient finding during initial evaluation of urinary incontinence
myopathy or, in more chronic cases, may result in lasting that must be taken into consideration for long-term
inability to empty the bladder. Another incidence of prognosis. In cases of urinary incontinence with adequate
incontinence has been reported subsequent to adhesion bladder function, congenital or traumatic origin may be
formation intra-abdominally leading to inability to fully implicated.
contract bladder lumen [44]. In cases of ectopic ureters
distal to the internal urinary sphincter, incomplete ablation Treatment In cases of compromised bladder function,
of ureters would of course lead to continued treatment of the underlying problem along with adequate
incontinence [6]. Although seemingly a logical cause of time for return of bladder function are the only therapies
incontinence, there are few reports of long-term available. Anti-inflammatories and broad-spectrum
complications from incision of the urethral sphincters [45]. antibiotics may aid in the recovery of the bladder wall;
Persistent urinary incontinence is the most significant however, in long-term cases of dysfunction, permanent
postoperative problem in dogs undergoing surgical bladder atony may be a result of long-term compromise of
treatment of ectopic ureters, and is associated with the detrusor musculature [51].
congenital disfunction of the detrusor muscle and urethral
sphincter [46]. Abnormal urethral sphincter was present in Expected outcome Recovery following bladder atony is
two foals with ectopic ureters [46, 47], and one other foal variable. Some horses have been reported as being managed
was also cryptorchid [48]. with repeat catheterization of the bladder every several
Postoperative 577
weeks in order to fully empty sabulous urolithiasis [50, 51]. and achieve adequate emptying and therefore reduce
However, in some cases, bladder rupture or urethral bacterial load. Limiting the use of urinary catheters
stricture led to euthanasia [50, 51]. postoperatively reduces both inflammation and risk of
biofilm formation [56].
As with all surgical procedures, adherence to Halsted’s
Infection
surgical principles and assuring a clean environment for
Definition Establishment of bacterial colonization and postoperative recovery are important factors to reduce
proliferation at the surgical site and surrounding or morbidity.
associated structures
Diagnosis Although the procedure cannot be considered
Risk Factors sterile, collection of urine via sterile urethral
● Intraoperative contamination catheterization is the easiest and most effective method
● Pre-existing contamination or communication to non- to obtain an adequate sample for culture and sensitivity
sterile environment in cases of bladder infection [25]. In cases of surgical
● Pre-existing inflammation site infection at the lower urinary tract, a sterile sample
● Pre-existing infection persistent following surgical may be obtained from the site via culturette or biopsy
intervention sample. In cases of suspected pyelonephritis, a urine
– Urolithiasis culture may be an effective option for diagnosis, and
– Cystitis urine can be selectively obtained from each ureter via
– Pyelonephritis transendoscopic catheterization [3]. In cases of negative
culture, direct aspirate of the surgical site may be
● Systemic involvement of the patient
considered.
Pathogenesis Surgical procedures of the urinary tract Treatment A large majority of urinary infections are
are, in general, at risk of infection due to the direct attributed to ascending pathogens from the environment,
communication with the environment and close proximity which are often sensitive to broad-spectrum antibiotics [58].
to fecal material, especially in females [54]. The urinary However, with the rise of resistant pathogens, a culture
system prevents ascending infection by frequent voiding and sensitivity are indicated for every case in which
of urine from the bladder and therefore rapid turnover of infection is suspected prior to surgical intervention. Lower
the contents in the system [25]. When this turnover is urinary tract infections are typically quick to respond to
inhibited, opportunistic bacteria are more likely to take antibiotic therapy; however, in cases of bladder atony,
hold within the lower urinary tract, most often causing recurrent infection is often seen due to incomplete
cystitis. Some disease factors leading to cystitis and expulsion of urine from the lumen [50].
potential infection include urolithiasis, dehydration Often in cases of unilateral pyelonephritis, nephrectomy
(concentration of urine), detrusor muscle dysfunction or is the most reasonable curative therapy as upper urinary
bladder atony. If not addressed, a bladder infection may tract infection is less likely to respond to systemic
also lead to infection of the upper urinary tract causing a antibiotics, even in the long term [4]. This, of course,
pyelonephritis. should only be pursued once the health of the contralateral
In the context of surgical intervention, one of the biggest kidney has been assessed.
risk factors for infection include indwelling urinary
catheters [55, 56]. The proximity of the surgical site to the Expected outcome Most cases of urinary tract infection
anus may also be a source of gross contamination. resolve following treatment of the underlying cause of
Additionally, indwelling bladder catheters in horses are infection (e.g. congenital defect, perineal conformation)
more prone to irritation and inflammation than other and broad-spectrum antibiotics. In cases where the
species due to the increased calcium content of horse urine underlying cause is not able to be resolved (e.g. persistent
and crystal formation along the catheters [57]. bladder atony), recurrent infection is likely once
antibiotics are discontinued. Resistant pathogens are of
Prevention Ascending urinary tract infection is possible, concern in these cases, as chronic and repetitive antibiotic
even in the non-diseased urinary system and therefore use will inevitably select for the most robust
broad-spectrum antimicrobials are recommended for most pathogens [59]. The overall prognosis in these cases is
urinary surgery. Judicious use of anti-inflammatories is therefore poor and should be dictated by the patient’s
important to regain functionality of the inflamed bladder quality of life.
UrineScalding Risk Factors
Definition Inappropriate voiding of urine leading to ● Use of stents

pathological development of chemical burns of the skin, ● Repeat catheterization
most often on the perineum or skin adjacent to surgical site ● Urethrotomy
● Incomplete or inappropriate mucosal reconstruction
Risk Factors ● Obstructive urolithiasis
● Dystocia
● Perineal urethrotomy Pathogenesis Conservation of luminal diameter is of
● Urethral extension critical importance in the urinary tract. Both in the urethra
● Cystotomy and the ureters, disruption of the mucosal lining is a critical
● Bladder atony risk factor for stricture formation. Even with appropriate
reconstruction of the lumen, inflammation or infection
Pathogenesis Any prolonged contact of urine with non-
can lead to disruption and subsequent fibrosis leading to
mucosal tissue will lead to scalding.
stricture. It has been reported that stents can promote
Prevention When performing reconstructive surgery such stricture formation in anastomosed ureters [6]. Repeat
as urethral extension, perineal urethrostomy or penile catheterization has also been implicated in stricture
retroversion, the surgical location must be carefully formation for this reason, as has urethrotomy and
selected to avoid or minimize the effect of urine scalding. obstructive urolithiasis [51, 63].
Adequate surgical technique, handling of mucosal tissue,
and apposition of mucosal and cutaneous margins when Prevention Early intervention in the cases of obstructive
reconstructing the urinary outlet are the most effective and urolithiasis is critical for prevention of stricture formation.
long-term solution to urine scalding [25]. The location, Meticulous handling of the mucosa when closing
conformation and orientation of the mucosal outlet of the urethrotomy sites, as well as limiting tissue handling, help
urinary tract must be planned accordingly so that when to decrease incidence of stricture formation. Use of
urine is voided, there is no residual draining or dribbling of magnifying loupes or an operating microscope, adequate
urine on cutaneous tissue. [27]. In cases when this is not lighting, and effective suction and suction tip facilitate the
achievable, topical barriers such as Vaseline may be applied surgical repair of ureteral defects. Judicious use of anti-
and cleaned daily in order to prevent scalding. inflammatory drugs may also reduce the risk, although this
has not been specifically shown to be true.
Diagnosis No advanced diagnostics are typically required
Reduction in the duration of catheterization or stenting
to diagnosis urine scald. The lesions most closely resemble
is also recommended to decrease the risk of stenosis. When
burns and occur in locations where urine comes into
performing anastomosis, stents should be removed within
contact with skin.
5–7 days after surgery [64, 65] and use of non-absorbable
Treatment Prevention is the best treatment for urine suture material should be avoided [66]. However, use of an
scalding. The scald lesions themselves are self- limiting indwelling polyethylene tubing stent (outside dimeter, 1.90
once the skin is no longer subjected to contact with urine; mm) was successfully used to treat ureterorrhexis in a mare
however, they may be treated topically with silver after failure of the surgical repair [42]. In this mare, the
sulfadiazine ointment. indwelling tubing stent was maintained in place for 21 days
with a successful outcome.
Expected outcome An excellent outcome is expected for
cases with transient exposure to urine scalding [34, 60, 61].
Diagnosis Urethral stricture is most commonly associated
However, in cases which surgical intervention is impossible
with dysuria in males and can be definitively identified via
or unsuccessful, daily care can become taxing on owners
urethroscopy. Ureteral stricture may present with or
and the resulting scald lesions can be very limiting on the
without signs of colic, hematuria, or in some cases renal
quality of life for the patient [49].
insufficiency. Ureteral stricture may be suspected when
abnormal dilation of the renal pelvis is observed via
Stricture/Fistula
transabdominal ultrasonography. Further diagnostics via
Definition Fibrotic stenosis of the outflow tract of the cystoscopy and direct identification of the ureteral openings
urinary system subsequent to infection, inflammation, at the trigone of the bladder would confirm suspicions of
reconstruction, or congenital defect ureteral stricture.
References 579
Treatment Repeat urethrotomy at the stricture site may be exposed to alkaline urine, which is common in herbi-
indicated in cases of dysuria and obstruction. Often, a vores [33]. This may potentially lead to suture failure and
subischial urethrostomy can be performed to aid in the dehiscence. On the other hand, use of nonabsorbable
healing of the proximal urethra [67]. This is typically left to sutures or staples will be a permanent irritation, may pro-
heal by second intention. In cases of ureteral stricture, long inflammation and risk of stricture formation. In addi-
limited success has been reported in treatment and more tion, exposure of the non-absorbable suture or implants to
frequently unilateral nephrectomy is performed [68]. the lumen can serve as nidus for formation of urinary cal-
culi [33, 62, 69].
Expected outcome The outcome is variable dependent on
the location of stricture in the urinary tract. Most horses Prevention Use Halsted principles when handling urinary
with normal renal function recover well from unilateral system tissues to minimize handling, irritation and
nephrectomy [6]. Successful outcomes following urethral subsequent inflammation. Use absorbable suture material
stricture have been reported, as have euthanasia due to of adequate thickness and pattern, delicate handling
chronic obstruction and intensive management due to instrumentation, adequate suction with fine suction tips,
fibrosis and urine scalding [69]. adequate lighting, and even use of magnifying loupes or
operating microscope for repair of ureteral defects.
ComplicationsRelatedto SutureChoice The bladder is one of the weakest tissues in the body [70],
and Placement but has a high regenerative capacity and regains nearly
100% if the normal strength within 14–21 days [71].
Definition A number of suture-related complications Therefore, use of nonabsorbable suture material is not
include dehiscence, formation of concretions and infection. indicated [66] and in fact contraindicated [62]. Technical
recommendations for urinary surgery state that no suture
Risk Factors
material of any type should be placed in such a fashion that
● Suture choice (non-absorbable suture material) penetrates the urinary epithelium and is exposed to
● Intraluminal suture exposure urine [65, 70].
● Inadequate suture size or pattern
● Inadequate instrumentation Diagnosis Suture dehiscence may manifest as
● Limited visualization and exteriorization of the extravasation of urine or uroperitoneum. Formation of
structure urine calculi may lead to dysuria, infection and/or
obstruction. For further diagnostic techniques and findings
Pathogenesis The accessibility and manipulation of in these conditions, refer to sections above.
anatomical structures such as ureters are very limited. In
addition, the size of the ureter is small, especially in foals. Treatment Treatment for these complications has been
As a consequence, placing an appropriate suture pattern is covered in previous sections in this chapter.
difficult.
Synthetic absorbable sutures are typically absorbed by Expected outcome This will depend on the complication
hydrolysis, and this may be accelerated if the suture is encountered.
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583
44
Complicationsof DiagnosticTestsfor Lameness

Ellen R. Singer BA, DVM, DVSc, DACVS, DECVS, FRCVS
E Singer Equine Orthopaedics and Surgery Ltd., Neston, Cheshire, UK
Overview – Post-injection swelling, lameness and infection

– Motor nerve paresis
○ Fore limb
One of the main challenges in lameness diagnosis in horses
○ Hindlimb
is anatomical localization of the source of pain responsible
for the lameness or poor performance. In the absence of – Poor compliance by the horse
palpable abnormalities, the main tool utilized to localize – Failure to block the lameness
lameness to a specific anatomical area is diagnostic ● Potential influence of diagnostic anesthesia on diagnos-
anesthesia, either peri-neural or intra-synovial. Once the tic images
lameness has been localized – either by abnormal findings – Radiography
on clinical examination or diagnostic anesthesia – then – Ultrasonography
diagnostic imaging techniques can be used to reach a – Gamma scintigraphy
definitive diagnosis. Diagnostic anesthetic techniques and – Magnetic Resonance Imaging
diagnostic imaging techniques are performed every day in ● Potential complications of diagnostic imaging
equine practice and are generally perceived to have techniques
minimal associated risk. However, there are a number of
potential complications that can occur, some preventable,
and others less so. As with all procedures, an awareness of omplicationsEncountered
C
the potential complications allows prevention of those with DiagnosticAnesthesia
complications, in most cases. Awareness of any potential
complications also enables clear explanations of the reason InaccurateNeedlePlacement
for, and the consequences of the complications, should
Definition Placement of the needle in the wrong location
they occur.
to deposit local anesthetic over the desired peripheral nerve
or within the desired synovial structure
L
Risk Factors
with DiagnosticTestsfor Lameness
● Poor anatomic knowledge
● Complications encountered with diagnostic anesthesia: ● Failure to review technical details
– Inaccurate needle placement
– Unpredictable desensitization Pathogenesis Lack of attention to detail and/or poor
– Complications of perineural local anesthesia anatomical knowledge of the equine musculoskeletal
– Complications of intra-synovial anesthesia system and the landmarks for perineural and intra-synovial
○ Volume injection, will result in inaccurate needle placement, and
○ Diffusion therefore possible misinterpretation of the results of the
○ Leakage block.
584 Complications of iagnostic ests for ameness
The accuracy of needle placement is important; how- for access to these structures is very specific as the synovial
ever, in light of the potential concomitant problem of diffu- cavity must be entered directly.
sion of the local anesthetic, there is considerable overlap of
evidence for these two common complications. The Prevention An essential prerequisite for performing and
importance of accurate placement of needles for a palmar interpreting the results of peri-neural or intra-synovial
digital nerve block (PDNB) over the neurovascular bundle diagnostic anesthesia is knowledge of equine
axial to the collateral cartilages has been demonstrated in musculoskeletal anatomy. Precise anatomical placement
two studies [1, 2]. Using an induced model of proximal and use of appropriately low volumes of local anesthetic
interphalangeal (PIP) joint inflammation with E. coli should minimize the problem of diffusion for perineural
endotoxin, Schumacher et al. demonstrated that anesthesia, facilitating appropriate interpretation of the
desensitization of the PIP joint was only likely to occur nerve block. For intra-synovial anesthetic techniques, the
following placement of diagnostic anesthetic solution at ability to aspirate synovial fluid from the intended structure
least 2 cm proximal to the proximal margin of the collateral prior to injection is the most appropriate guarantee that the
cartilages of the digit [1]. synovial cavity has been successfully located. In addition,
Proximal diffusion of local anesthetic was more likely to the injection of local anesthetic solution into the cavity
occur using an injection site 2 cm proximal to the collateral should require limited pressure on the syringe, similar to
cartilages compared to injection more distally, axial to the an intravenous injection.
collateral cartilages [2]. Therefore, a difference in needle In some structures, such as the navicular bursa, inclu-
placement of 1 cm or more proximal to the margin of the sion of a small amount of contrast with the solution and a
collateral cartilages for a PDNB could lead to erroneous post-injection radiograph (Figure 44.1) are recommended
interpretation of the results, i.e. that the lameness was local- to evaluate accurate completion of the procedure [3]. A
ized to the distal digit, rather than including the possibility small in-house or in-vehicle library [4–6], as well as
of lameness associated with the PIP joint or further proxi- knowledge of a suitable website, can provide an instant
mal. Accurate needle placement becomes more important resource should there be a need to review anatomy, anes-
for intra-synovial aaesthesia, as the anatomical landmarks thetic volumes or specific techniques. A quick reference
(a) (b)
Figure44.1 (a) Lateromedial radiographic view of the left front foot of a horse after an attempt to inject into the navicular bursa. A
spinal needle has been advanced from the heel bulbs toward the navicular bursa. Contrast material that has been injected is not
present within the navicular bursa. Contrast material has been deposited into the tissues palmar to the deep digital flexor tendon and
navicular bursa and is also visible within the lymphatic vessels traveling proximal. In this case, the needle had not been advanced
dorsal enough to penetrate into the navicular bursa. (b) Lateromedial radiographic view of the digit of a horse after contrast material
has been injected into the navicular bursa. Note the presence of radiopaque material within the proximal recess of the navicular bursa
and also coursing distal between the palmar aspect of the navicular bone and the dorsal aspect of the deep digital flexor tendon.
Source: Image courtesy of Dr. Luis M. Rubio-Martínez, Sussex Equine Hospital.
Complications ncountered ith iagnostic Anesthesia 585
guide [5] is especially useful for diagnostic nerve blocks UnpredictableDesensitization

that are not performed on a regular basis.
Definition Lack of desensitization in the expected areas or
desensitization in unexpected areas
Diagnosis Once a nerve block has been performed, the
needle(s) have been removed and the local anesthetic has Risk Factors
taken effect, determination of incorrect needle placement
is difficult. For perineural local anesthetic techniques, ● Use of higher or lower volumes of local anesthetic than
the areas of skin desensitization that have occurred can are commonly recommended
help determine the anatomical areas affected by the local ● Poor anatomical knowledge of the operator (see above)
anesthetic. For example, pressure on the heel bulbs, ● Choice of local anesthetic solution (i.e. lidocaine)
pastern and palmar/plantar portion of the coronary band
should not be resented by the horse after a PDNB has Pathogenesis and prevention Unpredictable desensitization
been accurately placed with effective blocking of sensory is one of the frustrating features of local anesthetic use in
nerve transmission. If pressure is not resented on the the diagnosis of lameness, with the degree of
dorsal pastern or fetlock region, then proximal diffusion desensitization usually more but sometimes less than
of the local anesthetic may have occurred. Persistence of expected. This complication can be related to the accuracy
sensation may indicate poor placement of needles or of needle placement (see above), but unpredictable
failure of the local anesthetic to work. For intra-synovial desensitization is also possible when accurate technique
anesthesia, visible subcutaneous or peri-synovial with the appropriate volume of local anesthetic is
swelling around the site of injection likely indicates poor employed. The volume of local anesthetic used at any
placement or leakage of the local anesthetic solution individual site is determined from the available literature;
from the joint. however, diffusion of local anesthetic is somewhat
Knowledge of anatomical structures adjacent to the unpredictable and can vary between horses, regardless of
location of needle placement for all diagnostic anes- volume or location, although greater volumes tend to
thetic techniques will aid interpretation of the response diffuse further. The diffusion can be associated with
to nerve blocks [7–10] and facilitates explanation of anesthetic tracking between tissue planes and along the
unexpected alterations in gait associated with diagnostic neurovascular bundle, or may be associated with the time
anesthetic techniques, such as radial nerve paresis fol- between placement of the block and assessment of the
lowing intra-synovial anesthesia of the cubital joint (see block’s efficacy (2). Greater diffusion of local anesthetic
below). was noted at 20 compared to 10 minutes in some studies;
however, in general, maximum diffusion appears to occur
by about 5–10 minutes (11, 12).
Treatment If inaccurate needle placement results in There is growing evidence that lidocaine hydrochloride
desensitization of more than the desired structures, then (either with or without epinephrine) is less reliable than
the only treatment is to allow time for the associated mepivacaine hydrochloride for diagnostic anesthesia.
nerve(s) to repolarize and for sensation to return before Mepivicaine hydrochloride appears to have a more
repeating the block. The timing of repolarization will predictable onset and completeness of action compared to
depend on the pharmacokinetics of the various local lidocaine [13, 14]. In the clinical situation, the onset of
anesthetic drugs: lidocaine hydrochloride (1–2 h), action of mepivacaine is usually within 5 minutes [15],
mepivacaine hydrochloride (2–4 h), and bupivacaine with a more controlled study based on ground reaction
hydrochloride (4–8 h) (6). If the inaccurate placement force measurement confirming that onset of action was
results in unintended injection of a synovial structure predictable by 15 minutes, with good analgesia at 1 hour
without adequate aseptic preparation of the area, then a and waning effects at 2 hours [16].
decision can be made regarding the need for administration There are numerous publications that report the
of either systemic or local antimicrobials. diffusion of local anesthetics beyond the expected area
with perineural and intrasynovial anesthesia, as well as
Expected outcome Inaccurate needle placement can result describing the potential overlap of areas desensitized by
in an erroneous diagnosis because of misinterpretation of specific nerve blocks. Awareness of the potential for
results leading to either a false positive or a false negative misinterpretation of diagnostic anesthesic techniques is
conclusion, either of which will delay a correct diagnosis. essential during lameness evaluations. Some particular
In cases of inadvertent synovial invasion without adequate areas of potential confusion are presented below, with
asepsis, synovial sepsis may develop (see below). evidence to highlight the potential issues that may be
encountered. Each individual nerve block has not been greater [2]. For perineural anesthetic techniques, distal
discussed; however, the message is to be aware of the diffusion is rarely a problem, since diagnostic anesthesia is
potential problems and to be proactive and discriminating usually performed by starting with the distalmost peri-
when performing these techniques. articular nerve block and then proceeding proximally.
A summary of potential complications is presented for However, proximal diffusion can lead to the unintended
perineural anesthesia (Table 44.1) and intra-synovial desensitization of nearby structures, for instance,
anasthesia (Table 44.2). desensitization of the metacarpophalangeal joint following
local anesthesia of the palmar digital nerves at the level of
the collateral cartilages or the proximal sesamoid bones [1,
Complicationsof PerineuralLocalAnesthesia
11, 17, 18]. Recently, there have been concerns and
The local spread of the diagnostic anesthetic solutions anecdotal reports of lameness associated with sagittal
beyond the intended area is common for most peri-neural groove bone oedema and fractures of P1 sagittal groove
anesthetic techniques. As the volume of local anesthetic resolving with a palmar digital or abaxial sesamoid nerve
used increases, the distance of diffusion is potentially block [17, 19, 20].
Table44.1 Complications of perineural anesthetic techniques. The complications listed exclude those that are present for every
block, including infection and non-compliance of the horse.
Block Complication
Palmar/plantar nerves at the level of the collateral cartilages Proximal diffusion

(palmar digital nerve block) Needle touching the nerve – violent reaction from horse
Injection into the digital flexor tendon sheath
Palmar/plantar nerves at the level of the base of the proximal Proximal diffusion
sesamoid bones (abaxial sesamoid nerve blocks) Needle touching the nerve – violent reaction from horse
Injection into the palmar/plantar pouch of the metacarpo/
tarsophalangeal joint
Low 4-point/6-point Proximal diffusion
Hematoma formation
Injection into the digital flexor tendon sheath
High 4 point Damage to the suspensory ligament
Injection in to the carpometacarpal or tarsometatarsal joint
Injection in to the carpal or tarsal sheath
Subcarpal ● Injection into the palmar pouch of the middle carpal joint
● Wheat block ● Injection into the carpal sheath
● Castro ● Damage to the suspensory ligament body, injection of the
● Infusion of suspensory ligament origin carpometacarpal joint or carpal sheath
Median and ulnar Median block – hematoma of the cephalic or accessory cephalic
vein; hitting the nerve with needle insertion
Ulnar block – bent needle if using caudal approach
Subtarsal ● Diffusion of local anesthetic proximal and distal, injection of
● Deep branch of lateral plantar nerve tarsometatarsal joint, injection of the tarsal sheath
● Lateral and medial plantar metatarsal nerves ● Damage to the suspensory ligament body, injection of the
tarsometatarsal or tarsal sheath
Tibial and peroneal Poor desensitization
Dragging of the toe due to blocking the motor function to the dorsal
extensor muscles
Sacroiliac joint/region Sciatic nerve paresis
Distress of the horse
Recumbency?
Table44.2 Complications of intra-synovial/thecal anesthetic techniques. The complications listed exclude those that are present
for every block, including infection and non-compliance of the horse.
Synovialstructure Complication
Joints
Navicular (podotrochlear) bursa Damage to the DDFT during needle placement

Damage to the fibrocartilage of the navicular bone during needle placement
Diffusion to the distal interphalangeal joint
Distal interphalangeal joint Diffusion to the navicular (podotrochlear) bursa

Desensitization of the palmar digital nerves
Proximal interphalangeal joint Palmar approach – leakage of local anesthetic to the palmar/plantar digital
nerve, injection of the DFTS
Metacarpo/tarsophalangeal joint Damage to the articular cartilage
Middle carpal joint Damage to the articular cartilage

Diffusion to the area of the origin of the suspensory ligament
Radiocarpal joint Damage to the articular cartilage
Cubital (radiohumeral) joint Radial nerve paresis

Bent needle (caudal proximal approach)
Scapulohumeral joint Suprascapular nerve paresis

Bent needle
Tarsometatarsal joint Difficult to inject even a small volume
Distal intertarsal (centrodistal) joint Difficulty locating small injection site

Difficulty injecting
Tarsocrural joint Hematoma of the saphenous vein
Stifle joint ● Bent needle, damage to meniscus, failure to obtain fluid

● Medial femorotibial ● Bent needle, damage to meniscus, failure to obtain fluid
● Lateral femorotibial ● Bent needle, damage to articular cartilage
● Femoropatellar
Coxofemoral joint Difficult injection (use ultrasound guidance)
Sacroiliac joint Sciatic nerve paresis

Distress of the horse
Digital flexor tendon sheath ● Leakage from injection site desensitizing palmar/plantar nerves
● Damage to the superficial or deep digital flexor tendons, particularly with the
approach axial to the proximal sesamoid bones
● Poor diffusion between proximal and distal pouches if palmar/plantar annular
ligament is thickened
● Inability to aspirate or obtain fluid – proximal approach
Carpal sheath ● Damage to the deep or superficial digital flexor tendons (proximal or distal
approach)
● Hematoma (distal approach)
Tarsal sheath Damage to the deep digital flexor tendon
Bicipital bursa Damage to the tendon or muscle of the biceps brachii
Calcaneal bursa Damage to the superficial digital flexor tendon

Damage to the gastrocnemius tendon insertion
A series of papers document the proximal diffusion of the perineural anesthetic entering the CMC joint was with
local anesthetic following diagnostic anesthesia of the pal- separate injection of the medial and lateral palmar metacar-
mar nerves at the level of the proximal sesamoid bones [11], pal nerves, axial to the relevant small metacarpal bone [22].
the palmar and palmar metacarpal nerves at the distal one- Inadvertent placement of local anesthetic into adjacent
third of the metacarpal region [21], and following the vari- synovial structures is also possible when performing diag-
ous techniques to anesthetize the proximal palmar nostic anesthetic techniques elsewhere in the lower limb.
metacarpal region [22). The distance that local anesthetic Injection of local anesthetic to block the palmar and palmar
diffuses proximally following perineural anesthesia may metacarpal nerves at the level of the button of the splint
vary between sites; however, diffusion of 20–30 mm occurs. bones resulted in 66% injection of the DFTS (palmar nerves)
The nerve blocks to the palmar metacarpal region, which and 33% injection of the metacarpophalangeal joints [23].
block the palmar and palmar metacarpal nerves, do not Based on the results of this study, the recommendation is to
show proximal diffusion of the local anesthetic to the same inject the palmar nerves slightly more proximal than the
extent as the more distal perineural blocks [22]. There is button of the splint bones, to reduce the risk of inadvertent
reasonable evidence that injection of the palmar/plantar injection of the DFTS.
and palmar/plantar metacarpal/tarsal nerves at the level of The above examples demonstrate the need to perform
the button of the splint bone is unlikely to result in desen- distal limb perineural anesthetic techniques carefully, with
sitization of the proximal suspensory ligament, provided the smallest possible volume of local anesthetic to limit the
that the volume of local anesthetic is limited to 2–2.5 potential complication of proximal diffusion of the local
ml [21, 23]. anesthetic and, therefore, misinterpretation of the results.
In the plantar metatarsal region, the local anesthetic Testing for loss of skin sensation as an indicator of local
placed to block off the deep branch of the lateral plantar anesthetic effect is useful to help interpret the area that has
nerve (DBrLPN) can have quite proximal and distal been desensitized by the block; however, loss of skin
diffusion, which has been documented with in vitro sensation is not always synonymous with loss of sensation
anatomical studies using new methylene blue [10, 24] and of the deeper tissues.
in vivo contrast material [12, 20]. Hinnigan et al. tested
nociceptive thresholds pre- and post-anesthesia of the
Complicationsof Intra-SynovialAnesthesia
DBrLPN and found that 20% of horses subjected to the
DBrLPN block lost sensation to the lateral heel bulb and For intra-synovial anesthesia, even if synovial fluid was
coronary band, likely the result of inadvertent noted in the needle hub, the operator should check that
desensitization of the lateral plantar nerve [10]. This effusion of the synovial structure occurs following injection
finding is not surprising, based on the close anatomic to further confirm that successful injection of the structure
proximity of the two nerves. This study emphasizes the has been achieved. The presence of synovial effusion may
importance of performing a low 4- or 6-point nerve block not be helpful in some joints due to their size or the volume
to rule out a distal limb lameness when interpreting the injected relative to the total joint volume. In these structures
results of a DBrLPN block. In addition, all of the studies (e.g. navicular bursa, proximal interphalangeal joint,
documenting the diffusion of dye or contrast material in centrodistal joint) a small amount of contrast material can
this region found that inadvertent injection of either the be mixed with the local anesthetic and a radiograph used to
tarsometatarsal joint or the tarsal sheath occurs in a confirm correct placement of the local anesthetic.
percentage of horses [10, 12, 20, 24]. This finding further In general, intra-synovial anesthesia is considered more
reinforced the need for careful interpretation of gait specific than perineural anesthesia; however, there are
alterations post nerve blocks and the potential necessity to situations in which the synovial pouch overlies other
block adjacent synovial structures individually structures (i.e. peripheral nerves), the local anesthetic
(tarsometatarsal and centrodistal joints, tarsal sheath) to leaks out of the synovial structure to affect adjacent
increase the degree of certainty regarding the location of peripheral nerves, or diffuses between different adjacent
the lameness. synovial structures. One of the early papers to alert
Perineural anesthesia of the origin of the suspensory liga- veterinary surgeons to this possibility demonstrated that
ment region appears to be particularly prone to inadvertent an intra-articular nerve block of the tarsometatarsal joint
desensitization of the lower joints of the carpus or tarsus. In resulted in local anesthetic solution in the region of the
both the fore- and the hind limb, efforts to desensitize the proximal suspensory ligament [25]. In addition, there is
origin of the suspensory ligament commonly results in local potential diffusion of local anesthetic solution between
anesthetic solution entering the carpometacarpal and tarso- adjacent synovial structures, with and without confirmed
metatarsal joints [22, 25]. The highest incidence (50%) of anatomical communications [26, 27].
Volume anesthetic solution appears most likely between the TMT

The volume of local anesthetic solution injected can and the CD joints [27]. The degree of diffusion that occurs
influence the likelihood that local anesthetic solution will in small tarsal joints with osteoarthritis present is unknown.
have an effect in regions beyond that intended. A study of Anecdotally, a proportion of horses with small tarsal joint
different volumes of mepivacaine hydrochloride for osteoarthritis of the CD joint do not have resolution of
diagnostic anesthesia of the distal interphalangeal (DIP) lameness, unless this joint is injected directly. Diffusion of
joint demonstrated that the higher volume (10 ml) of mepivacaine has been demonstrated between the three
anesthetic led to desensitization of the palmar angles of the joint pouches of the stifle (femoropatellar, medial
sole, compared to the smaller volume (6 ml), which only femorotibial, lateral femorotibial) with clinically relevant
desensitized the dorsal margin of the sole. The authors concentrations only occurring in less than 40% [27];
suggest that greater distension of the DIP joint capsule therefore, injection of each stifle joint pouch separately is
allowed the local anesthetic to affect the branches of the usually advocated unless the aim is to target a specific joint
palmar digital nerves adjacent to the palmar aspect of the pouch.
DIP joint with the higher but not the lower volume of
anesthetic solution [28]. A study using radiopaque contrast Leakage
material to study the percentage of horses (~31%) with Following intra-synovial injection, leakage of local
communication between the tarsometatarsal and distal anesthetic solution can occur retrograde along the needle
intertarsal joints identified leakage of contrast into the tract, and into the surrounding tissue. A recent cadaver
tarsal sheath and the peri-tarsal tissues when high study using new methylene blue dye demonstrated in vitro
pressures of injection were used [29]. This study supports leakage following injection of the digital flexor tendon
the use of minimal volumes of local anesthetic for intra- sheath via the out-pouching between the palmar/plantar
synovial anesthesia, since excessive distension of the joint annular ligament and the proximal digital annular
can result in desensitization of adjacent structures, thereby ligament [9]. Due to anatomical proximity, leakage of local
decreasing the specific nature of any block. anesthetic from this site occurs onto the palmar/plantar
nerves at the level of the abaxial sesamoid bones. Therefore,
Diffusion there is potential for desensitization of the peri-thecal
Even when using the recommended amounts of local structures distal to the site of blocking rather than only the
anesthetic for a particular joint, diffusion between adjacent DFTS. Although leakage from the site may not be
synovial pouches or adjacent synovial structures can occur. preventable, two strategies can be employed to prevent
There is good evidence for diffusion of local anesthetic misinterpretation of a positive response to a DFTS block
between the distal interphalangeal joint and the navicular when using an approach between the PAL and the PDAL:
bursa in both directions, indicating that diagnostic check for heel bulb sensation following the block to
anesthesia of either structure is not specific [26, 30]. There determine if diffusion to the palmar/plantar digital nerve
is some evidence that the degree of diffusion between the has occurred [8, 9]; or use one of the other approaches to
DIP joint and the navicular bursa may be time-dependent, the DFTS, either proximal, axial or distal [5, 8]. However,
with a suggestion that within 10 minutes of injection of the the successful performance of these alternative approaches
DIP joint, diffusion to the navicular bursa may have can vary with individual horses or veterinary surgeons.
occurred [30]. Diffusion from the navicular bursa to the The specific example above has been documented;
DIP joint is thought to be less common than the however, other intra-synovial blocks of the distal limb
opposite [26]; however, there is no easy method to could also present with this complication, so assessment of
determine if this has occurred in a clinical situation. The presence or absence of skin sensation in the region of the
best clinical advice is to endeavor to test the results of intra- block would be prudent to be as certain as possible that
synovial diagnostic anesthesia within 5–10 minutes of only the injected synovial structure has been
injection for the distal limb joints. Injection of contrast desensitized [28]. In general, testing the skin sensation
material with subsequent radiography could be helpful; distal to an intra-articular block site could indicate whether
however, this adds another task which might delay perineural anesthesia had occurred, despite injecting
assessment of the lameness within the recommended time directly into a joint. Although less likely to affect a specific
frame. nerve, injection of large volumes of local anesthetic
For the tarsometatarsal, centrodistal and tarsocrural solution into the TMT (>4 ml) or CD (>1 ml) likely result
joints, diffusion between the joints has been demonstrated in peri-articular leakage of local anesthetic with the
to occur at a low concentration in the majority of injections; possibility to desensitize surrounding articular and soft
however, diffusion of clinically relevant levels of the local tissue structures [25, 29].
Good anatomical and technical knowledge of each Pathogenesis Hematoma formation is the result of
nerve block is essential; however, to some degree the laceration of a blood vessel in the region of the nerve block,
amount of diffusion to unexpected areas is unpredictable. either due to the placement of the needle or movement of
Therefore, it is important for the veterinary surgeon to be the horse during the procedure. Nerve blocks performed
aware of the likelihood of diffusion and to become accus- adjacent to vascular structures, in particular palmar/
tomed to checking for the degree of superficial desensiti- plantar nerves in the distal third of the metacarpal/tarsal
zation of the limb prior to interpretation of the result of a region (low 4/6-point blocks) carry a higher risk of
diagnostic nerve block. hematoma, since the neurovascular structures are in close
proximity within a relatively small anatomical area. There
Diagnosis Recognizing unpredicted desensitization is some risk with the palmar/plantar digital blocks
requires diligently assessing the areas of skin desensitization performed at the level of the collateral cartilages or the
following blocks and prior to repeat assessment of lameness. base of the proximal sesamoid bones, since the vascular
A good knowledge of the expected areas of loss of skin structures are subcutaneous and immediately adjacent to
sensation is essential. Ideally, with intra-synovial anesthesia the nerves; however, this is an uncommon occurrence.
there should not be any loss of skin sensation. Unfortunately, Distal limb swelling may result from a reaction to the
skin sensation can be difficult to assess in some horses due anesthetic substance or tissue damage due to needle
to excessive responsiveness (anticipation of being touched) insertion. Differentiation of hematoma from a reaction to
or thickened skin (poor response to poking). the procedure or medication may be difficult. Rarely, a
subcutaneous infection can develop following a perineural
Treatment Fortunately, if there is a query about excessive nerve block. The occurrence is so rare that a specific cause
diffusion of local anesthetic or evidence that the block was cannot be given, but a sensible suggestion is carrying of
placed inaccurately, then the simple approach is to allow dirt or debris into the skin and subcutaneous tissue when
the anesthetic to wear off and to repeat the nerve block on blocking, possibly the result of poor preparation of the site
another occasion. This repetition of the procedure can or a high bacterial load on the horse’s skin. Infection of
confirm or refute the previous results. subcutaneous tissue often requires 2–3 days to become
evident and can be difficult to distinguish from mild
Expected outcome The complication of excessive diffusion reaction to the local anesthetic agent in the first instance.
should not have any significant untoward effects, besides a An increase in lameness can become apparent following
need to repeat the block and reassess the response, which a lameness evaluation. Most commonly, an increase in
would be an issue of time for the veterinary surgeon and lameness the following day is the result of the horse using
money for the client. The most significant poor outcome an injured area more than normal following successful
would be a misdiagnosis and inappropriate treatment of desensitization of the area of pain. Increased lameness,
the horse; however, in most cases this can be mitigated joint effusion or worsening of joint effusion following
against with careful checking of skin sensation following intra-synovial anesthesia is uncommon; however, this
diagnostic anesthesia. occurrence warrants careful assessment. Occasionally,
synovial effusion is palpably increased the day following
injection, which could be a direct response to the local
Post-InjectionSwelling,Lameness anesthetic or alternatively the result of the horse moving
and Infection more on a diseased joint, tendon sheath or bursa.
Immediate severe lameness following intra-synovial
Definition Swelling of the limb or increased synovial
anesthesia can be attributed to excess pressure in the joint,
effusion of joints following diagnostic anesthesia that can
which is very rare. An acute, non-septic inflammatory
be associated with tissue inflammation and/or local
reaction (flare) within a joint that has been injected with a
hemorrhage. Lameness can be variable.
local anesthetic is also very rare; however, the difficulty is
to distinguish this reaction from a true sepsis in the joint. A
Risk Factors
flare may result from an individual immune response to
● Nerve blocks performed adjacent to vascular structures the anesthetic solution or the carrier in which the
● Multiple distal limb nerve blocks performed on the same anesthetic is prepared; whereas a true synovial sepsis
or consecutive days would be the result of the introduction of bacteria into the
● Poor horse compliance for diagnostic anesthetic joint. Rarely, acute severe lameness following local
procedures anesthetic techniques can indicate the conversion of an
● Horse with an underlying incomplete fracture incomplete or non-displaced fracture to a more catastrophic
situation. Race or endurance horses are the most likely CFUs when comparing chlorhexidine gluconate and
candidates for this scenario due to their known high risk povidone iodine solutions, with a similar decrease in
for, and prevalence of, stress fracture occurrence. surface bacteria with clipped and unclipped sites [35].
An in vitro study investigated the likelihood of hair and/
Prevention Post-injection swelling can be prevented in or skin particles being carried into the joint with clipped
most cases by placing the needles carefully and using the compared to unclipped hair. Surprisingly, this and
smallest possible needle size and smallest volume of local subsequent studies demonstrated that about 90% of
anesthetic for each nerve block. With a smaller needle, an injections through the skin over the fetlock joint resulted
inadvertent hole in a vessel should be smaller and the risk in tissue debris being carried into the joint via the
of tissue damage with horse movement should be reduced. needle [36–38]. Approximately 30% of injections resulted
Prevention of swelling following multiple diagnostic nerve in hair particles being carried through the skin. The study
blocks in one session is helped by hydrotherapy of the limb demonstrated fewer hair particles with aseptically prepared
followed by placement of a distal limb bandage. Infection and unclipped skin compared to clipped skin, except when
can be avoided by careful preparation of the area of the a spinal needle was used. Of the different needles compared
nerve block, either perineural or intra-synovial. An (16, 18, 20 and 22 g) the 20-g needle had the least amount
unopened, sterile bottle of local anesthetic solution should of hair carried into the joint [36]. A further study using
be used for intra-synovial anesthesia. In addition, avoiding similar methodology demonstrated that a 20-g and 22-g
diagnostic anesthesia when cellulitis cutaneous or spinal needle with the stylet in place and angled insertion
subcutaneous infection (mud rash) is present is of needles were the least likely to deposit hair when an
recommended. intra-synovial injection was made. This study also
The necessity to clip hair is debatable, except in cases of demonstrated a decreased risk of tissue contamination
draft or cob horses where removal of hair is necessary to with clipped versus unclipped hair [37]. Therefore, for
actually palpate the anatomy accurately and to assess the injections such as the navicular or bicipital bursa,
health of the skin prior to injections. In general, there is no scapulohumeral joint or sacroiliac region, clipping and the
evidence that a significant risk of infection is present with use of a 20-g or 22-g spinal needle with stylet is
intra-articular injections. There is no evidence to suggest recommended [37]. Another in vitro study examined
that intra-articular antimicrobial therapy is required each needle size, concluding that a 20-g needle – spinal or
time a joint is injected [31–34], therefore responsible regular – carried hair into the joint [38]. Based on the above
antimicrobial use policies should discourage this practice. studies, preparation for intra-articular injections does not
The best method of skin preparation for intra-synovial require clipping in many situations; however, aseptic
injection has been the subject of some research. In general, preparation is required. The smallest needle possible
the recommendation has been to perform aseptic should be utilized to minimize the risk of synovial
preparation of the skin over sites of intra-synovial injection structures becoming contaminated with hair. Despite the
with the use of sterile gloves, needles, syringes and local high incidence of hair and tissue debris within injected
anesthetic for the actual injection. The debate that occurs is joints, the incidence of post-injections sepsis remains low.
relative to clipping of hair over the injection site. Obviously,
if the hair coat is long and dirty then clipping would be Diagnosis and monitoring Although lameness is not a
required; however, with a short hair coat this may not be feature in most cases of post-injection swelling, some
the case. There is evidence that clipping of the hair is not horses will show increase in lameness, and in some cases,
required to decrease the bacterial population of the skin local infection at the injection site may develop.
based on culture swabs taken before and after aseptic Occasionally, a horse shows increased lameness the day
preparation of the skin with povidone-iodine scrub following diagnostic nerve blocks due to using the affected
followed by an alcohol wipe [31]. limb more than is normal, thus exacerbating the lameness.
Another study compared the use of four different For cases of reaction to the local anesthetic and hema-
preparatory methods for unclipped arthrocentesis sites toma formation, clinical evaluation of the lame limb fol-
with no significant difference noted between techniques in lowing nerve blocking reveals variable degrees of swelling
relation to the reduction of the skin bacterial flora measured often accompanied by an increase in skin temperature. In
by colony-forming units (CFUs). The study compared the most cases, the swelling is generalized and not painful to
use of povidone iodine scrub for 10 minutes, 5 minutes and palpation. Hematomas may be more focal in location. If
3 times 30 seconds with a one-step iodophor surgical digital palpation does not provide sufficient information to
solution [32]. A study of skin preparation for intravenous determine the cause of the swelling or the swelling is mod-
catheter placement found no difference in the decrease in erate to severe, then ultrasonography is useful. Ultrasound
can determine the extent of the swelling in relation to the Pathogenesis Paresis or paralysis of motor nerves may
neurovascular bundle and relevant synovial structures. If a result from diffusion of local anesthetic away from the
moderate to severe lameness is present with a suspicion of intended site or from inaccurate placement of the local
synovial sepsis, synviocentesis of the suspect joint is anesthetic solution. Local anesthetic solutions do not
required. discriminate between sensory and motor nerves, as their
mechanism of action blocks transmission of nerve
Treatment Treatment of post-injection swelling from impulses, regardless of nerve type [39]. The risk of motor
perineural blocks due to a hematoma or minor reaction to nerve paresis or paralysis following perineural anesthesia
the anesthetic agent is primarily symptomatic, with cold- is low for the majority of diagnostic nerve blocks performed,
hosing, bandaging and walking exercise. Treatment with due to the lack of motor nerves in the distal limb of the
antimicrobials is rarely required. horse. However, the risk increases when the more proximal
When severe lameness and joint effusion are present fol- limb blocks are performed due to the proximity of motor
lowing diagnostic anesthesia – either intrasynovial or peri- nerves which are essential to drive muscle function. Extra-
neural – synovial sepsis or a joint flare are the main synovial diffusion of local anesthetic solution after intra-
differential diagnoses. Unfortunately, both of these synovial blocks can occur and cause paresis or paralysis of
situations result in an elevation in synovial fluid total white nearby nerves, which if located proximal in the limb, will
blood cell and neutrophil counts, with an elevated total likely carry motor function.
protein content. Cytological analysis of the white blood
cells can help distinguish inflammation (healthy Forelimb
neutrophils) from sepsis (toxic neutrophils), but only a There are two synovial structures of the fore limb, the
positive gram stain or culture would be definitive for a scapulohumeral joint and the cubital joint, that are blocked
post-injection sepsis. In these rare and stressful cases, a regularly, in which diffusion or leakage of local anesthetic
considered clinical judgment is required regarding the out of the joints presents a visible manifestation of nerve
merits of synovial lavage of the affected structure and/or paresis. Leakage of local anesthetic from a scapulohumeral
treatment with intra-synovial or systemic antimicrobial joint injection can result in suprascapular nerve paresis as
medication. When the possibility of an underlying fracture a result of proximal diffusion of the local anesthetic dorsal
exists, based on the horse’s clinical history or occupation to the supraspinatus muscle [6], or diffusion of local
(racehorse), then radiographic assessment of the affected anesthetic into the muscle itself. Dysfunction of the m.
area of the limb is prudent, particularly if arthroscopic supraspinatus and m. infraspinatus occur, resulting in
lavage under general anesthesia is being considered as a lateral instability of the shoulder joint, the typical
treatment. “Sweeney” appearance. Leakage of local anesthetic from
intra-synovial injection of the cubital joint can result in
Expected outcome Most swelling that results from signs of radial nerve paresis [6], particularly if the caudal
diagnostic anesthesia resolves within 1–2 days. Rarely, a approach to the joint is used.
hematoma may require cold-hosing and bandaging for 3–5 The signs of radial nerve paresis could be the result of
days. In most cases, the swelling will dissipate in 1 day or at leakage of local anesthetic around the radial nerve, or leak-
most 2–3 days. The author experienced one case that age into the triceps muscle causing focal paresis of the mus-
developed an infection following a palmar digital nerve cle and an inability of the horse to fix the elbow in extension.
block that subsequently sloughed the lateral heel bulb after With radial nerve paresis, the m. extensor carpi radialis, m.
about 3 weeks, with no long-term untoward effects. If extensor digitorum communis, m. extensor digitorum later-
synovial sepsis does occur, then the outcome should be alis and/or m. ulnaris lateralis could all be affected leading
good to excellent, provided that treatment is initiated to difficulty in extension of the limb, in addition to an ina-
rapidly. bility to fix the elbow in extension. Unfortunately, both of
the above scenarios are inconvenient since they prevent
appropriate assessment of lameness post-nerve block and
MotorNerveParesis
necessitate repeating the block on another day. Fortunately,
Definition The loss of motor function to selected muscles this complication is usually well-tolerated by the horse and
following the injection of local anesthetic solution for the the effect dissipates within hours.
purpose of lameness diagnosis
Hindlimb
Risk factorsDiagnostic nerve blocks proximal to the Mild signs of motor nerve paresis are sometimes encoun-
antebrachium or the tarsus tered when the superficial and deep peroneal nerves are
anesthetized as part of a tibial and peroneal nerve block. The occur with resulting blocking of motor function to the m.
superficial and deep peroneal nerves supply motor branches suprascapularis or m. triceps brachii, as described above. In
to the extensor muscles of the hind limb, which can explain addition, although it is recommended to put larger volumes
the toe drag that is sometimes noted with the use of this of local anesthetic into these joints [6], injecting under
diagnostic technique [6]. pressure should be avoided.
In the hind limb, paresis of the sciatic nerve can occur Being forewarned of the potential complication, the sac-
following attempts to place local anesthetic either in or roiliac joint/regional block should be performed at a site in
adjacent to the sacroiliac joint(s). Paresis of the sciatic the practice that is close to a recovery box or the horse’s
(ischiatic) nerve and the distal branches (tibial and deep stable so that management of the complication becomes
peroneal nerves) affects a large proportion of muscles easier, should it occur. For the sacroiliac region, there is a
that stabilize the coxofemoral and stifle joint, resulting in perception that injection of the joint or region using a
a horse that is unable to fix the hind limb in sufficient cranial approach is less likely to result in diffusion of local
extension. The muscles affected are likely to be m. biceps anesthetic to the region of the sciatic nerve [42]. The
femoris, m. semitendinosus, and m. semimembranosis. The volume of local anesthetic should be limited to 5–10 ml or
distal branch of the sciatic nerve is the tibial nerve, there- less [7]. In addition, the use of lidocaine or mepivacaine is
fore disruption of conduction in the sciatic nerve could preferred over bupivacaine, since the effects will resolve
also affect the extensor muscles of the tarsus and the within 1–3 hours should a complication occur.
flexor muscles of the digit. If the sciatic nerve compro- Ultrasound guided injection is recommended for the
mise is unilateral, then the horse can remain standing; cranial and the caudal parasagittal or caudomedial
however, if this complication occurs on the right and left approaches, as the direction of the needle can be monitored
side simultaneously, then recumbency and distress may more closely until it disappears under the ilial wing [40,
ensue. 41]. Another strategy to avoid the dramatic complication of
Any of the methods described for injection of the sacro- a horse that is unable to stand is to block only one side of
iliac joint/region [7, 40, 41] may result in nerve paresis if the sacroiliac joint region at a time. While this strategy may
the needle is not accurately placed and/or if the volume seem to compromise complete assessment of the lameness,
used was too great; however, anecdotal reports of paresis if sciatic nerve paralysis occurs then the complication
appear to be greater when the caudal approaches are used should be more easily managed. A preferred approach for
compared to the cranial approaches. In vitro work [7, 41] some clinicians is to avoid using local anesthetic and to
confirmed that injections aimed at the SI joint frequently simply treat the SI area and monitor the response to
result in peri-joint injection with the injectates being therapy, rather than risk the complication of nerve
placed or diffusing into the surrounding anatomical struc- dysfunction.
tures such as the lumbosacral transverse joints, the interos-
seous ligaments, the sciatic nerves and associated gluteal Diagnosis Diagnosis of motor nerve paresis is usually
vessels, as well as the m. gluteus medius, m. multifidus and obvious as the gait deficits are not subtle. Usually, walking
m. soleus. The diffusion of injectate to the region of the sci- the horse a few strides provides adequate information to
atic nerves appears more common with the caudomedial determine the problem.
approach [41]. Therefore, a similar problem to diffusion of
local anesthetic away from the exact intended site occurs in Treatment Similar to the previous issues of unpredictable
the sacroiliac region as well as in the distal limbs, decreas- desensitization, the treatment is patiently waiting for the
ing the specificity of the test. effects of the local anesthetic to resolve. Motor paresis of
the suprascapular nerve is usually well tolerated by the
Prevention At the risk of sounding redundant, prevention horses. Motor paresis of the radial nerve is also well
of motor nerve paresis relies on excellent knowledge of tolerated in most cases, requiring the horse to be placed in
anatomical landmarks and careful technique when a stable for 1–2 hours until the effects have dissipated.
performing the “at risk” blocks. Accurate placement of Occasionally, placement of a light bandage with a caudal
local anesthetic within a synovial structure should make splint from the fetlock to the elbow is required to prevent
desensitization of motor nerves uncommon; however, this knuckling of the forelimb and to decrease anxiety in the
complication may still occur. When placing local anesthetic horse. The loss of motor function to the sciatic nerves
solution into the scapulohumeral or radiohumeral joint, following blocking of the sacroiliac region often results in
the retrieval of synovial fluid should indicate that the local some distress to the horse and the potential for panic,
anesthetic will be injected in the correct place. However, with some horses becoming recumbent. These horses are
diffusion of local anesthetic along the needle tract can still best placed in a padded recovery box and observed
carefully until they have settled and the local anesthetic the local anesthetic. Pain tolerance appears to be as variable
effect resolves. Anxious horses may be calmed with low between horses as between people. It is possible also that
doses of sedation as well as head and tail ropes, to certain areas of the skeleton are more sensitive than others,
minimize the risk of injury. In the unfortunate situation due to thinner skin or greater local sensory nerve endings.
in which bilateral sciatic nerve paresis occurs and the Certainly, if placement of a perineural block results in
horse becomes recumbent, then heavy sedation, placing direct contact with a nerve and acute pain to the horse,
the horse in a sling and/or general anesthesia. may be then subsequent attempts at diagnostic anesthesia will be
required for a number of hours, until the nerve function resented. These rare events can also result in injury to the
returns. veterinary surgeon or handler.
Expected outcome The expected outcome in the majority Prevention Using careful clinical examination skills to
of cases of motor nerve paresis is a return to the baseline narrow the differential diagnoses before diagnostic
degree of lameness, once the paresis/paralysis has resolved. anesthesia is performed can limit the number of nerve
For the rare situation in which a horse becomes distressed, blocks required. Working efficiently and precisely while
recumbent, or that requires a general anesthetic while the preparing for and performing diagnostic anesthetic
problem resolves, then there is a risk that injury may occur techniques may help to prevent poor compliance by the
when the horse tries to rise. The injury may be minor cuts horse. The use of small skin blebs of local anesthetic can be
or abrasions, or could be a catastrophic fracture. helpful in some cases, particularly for areas that require
larger needles (shoulder, bicipital bursa, coxofemoral joint)
or that require multiple needles (stifle joint, sacroiliac joint
PoorCompliancebythe Horse region) [6]. Sedation can also be beneficial in improving
Definition Behavior patterns of the horse or pony that compliance. Sometimes an anxiolytic drug, such as acetyl
compromise the ability of the veterinary surgeon to achieve promazine, can smooth the lameness examination and the
accurate and safe execution of the diagnostic nerve blocks. diagnostic nerve block procedures, particularly in a
These unpleasant behaviors include stamping, kicking, nervous or young horse.
barging, rearing and biting the handler. Often, there is a hesitation to employ sedation during
diagnostic anesthetic techniques; however, a recent paper
indicates that the use of low-dose xylazine hydrochloride
Risk Factors
(0.3 mg/kg IV) does not alter lameness significantly and
● Young horses should not affect interpretation of response to diagnostic
● Excitable horses or horses that have had long periods of anesthesia [43]. The study did note a decrease in vertical
box rest head movement related to fore limb lameness that was
● Frightened horses more apparent in the xylazine treated group as compared
● Horses poorly disciplined by their owners/handlers to the control horses, with no clear effect of xylazine on the
● Multiple or repeated nerve blocks required. hind limb lameness.
Sedation may not affect the response to the nerve block,
Pathogenesis Poor compliance by the horse is the most but it may affect the ability to have consistent assessment
common and frustrating complication of diagnostic of the gait if the horse has not revived completely from the
anesthesia. Predicting which horses will be compliant and sedation when examination in motion is repeated. The
will easily permit the performance of single or multiple aforementioned study found that the head height from the
nerve blocks is difficult. Young horses, horses that have floor remained lower in the xylazine group compared to
had long periods of box rest and are excitable, and horses controls, indicating the residual effect of the sedation [43].
that are poorly disciplined by their owners/handlers would Acetylpromazine as an anxiolytic agent can also be useful
be more likely to be non-compliant; however, compliance during lameness evaluation. Normal horses treated with
is not predictable. Some horses tolerate only one nerve acetylpromazine hydrochloride (0.01 mg/kg) had a
block, with others allowing repeated diagnostic anesthetic decrease in kinematic gait parameters without any altera-
techniques to be performed without any objection. tion to the regularity, symmetry or stability of their
Generally, the more nerve blocks required, the more likely gait [44]. Therefore, although the general recommendation
that the horse will become uncooperative with the is to perform diagnostic anesthesia without sedation, the
procedure. judicious use of sedation can make the procedure of diag-
The propensity to non-compliance is likely related to the nostic anesthesia less traumatic for all parties without
pain associated with needle placement and the injection of compromising the ability to reach a diagnosis.
Diagnosis Excessive movement, kicking or other

unpleasant actions from the horse
Treatment The use of a nose or skin twitch can decrease

movement of the horse and improve compliance. Holding
up a front limb can help, if the blocks are being performed
on a hind limb or the opposite fore limb. Sedation is
sometimes required to safely perform the desired nerve
blocks. Some clinicians favor the performance of diagnostic
anesthetic techniques in stocks to be useful in improving
compliance, although rapid escape from flying limbs can
be compromised by this solid structure. Despite all of the
above techniques, compliance can still be difficult to
achieve. In some instances, bribery can be successful with
strategies such as offering the horse hay, hard feed, a
molasses lick or mints. Recently, the use of clicker training
techniques has been advocated to help modify unpleasant
equine behaviors, so this technique could also be
considered.
Expected outcome Poor compliance with and tolerance for

nerve blocks can result in injury to the horse and the
veterinary surgeon. Unfortunately, it is usually the veterinary
surgeon that is injured. Most often this is from a kick, but Figure44.2 Dorsolateroplantaromedial oblique radiographic
injury could also occur from the horse striking out with a view of the right tarsus of a horse. Note the linear radiopaque
artifact partially overlying the fourth tarsal bone representing a
fore limb. The wearing of a helmet when blocking hind piece of a needle. The needle broke as the horse kicked
limbs has become a requirement or a strong recommendation when diagnostic anesthesia of the right tarsometatarsal joint
in some practices. Injuries to horses during diagnostic was being attempted. The needle fragment was removed under
anesthetic procedures are few and include kicking stocks or standing sedation and local anesthesia using radiographic and
ultrasonographic guidance. Source: Image courtesy of Dr. Luis M.
walls and inducing trauma at the site of needle placement Rubio-Martínez, Sussex Equine Hospital.)
due to movement and breaking needles.
Breakage of a needle while performing nerve blocks
occurs when the horse moves during the procedure needle can be assessed. For intra-articular needle frag-
(Figure 44.2). Larger needles are less likely to break, but ments, arthroscopic exploration of the joint would be
alternatively they are often more painful for the horse recommended.
when placed. Bent needles can result from any diagnostic Hopefully, the techniques discussed above can improve
nerve block if the horse is poorly compliant. Anecdotally, compliance to allow the required procedures to be under-
needle bending is most common when placing local anes- taken; however, this is not always the case. In some horses,
thetic into the femoropatellar joint via a cranial approach, compliance is not possible, in which case alternate meth-
the elbow using a caudolateral approach and the shoulder ods can be used to facilitate diagnosis, such as nuclear scin-
using the craniolateral approach. Movement of the horse tigraphy. The findings on nuclear scintigraphy can often
can sometimes be minimized if a small bleb of local anes- lead to a targeted approach with nerve blocks, minimizing
thetic is placed at the site of needle insertion prior to place- the number of blocks necessary to reach a diagnosis.
ment of the needle for the block. Survey radiography or ultrasonography can be employed
If a needle were to break, the first action to be taken but leaves the veterinary surgeon in the position of not
would be radiographs or ultrasonography of the area to truly being able to assess the clinical relevance of abnor-
locate the needle’s position. Removal of the broken needle malities that might be discovered, so this approach is
should be considered an urgent procedure to prevent discouraged.
migration of the needle within the tissue or joint. Practically, the difficult issue with poor compliance is
Intraoperative radiographic and ultrasound-guided frustration for the veterinary surgeon and the client, when
retrieval of a peri-articular needle is probably the most effi- a clear diagnosis cannot be reached due to poor compli-
cient approach, since the exact location and depth of the ance by the horse.
Failureto Blockthe Lameness or focal muscle pain to be detected prior to diagnostic

anesthesia being performed. Certain anatomical regions
Definition Following the performance of a complete series
that are not traditionally included in regional or intra-
of nerve blocks, the anatomical location of the lameness
synovial anesthesia include the deltoid tuberosity, the third
remains undiscovered.
trochanter and bursa and the tuber ischium. In cases of
fore limb lameness associated with a radiculopathy or
Risk Factors
syndesmosis of the first and second ribs [46], the diagnosis
● Conditions of the axial skeleton not desensitized with may be reached by exclusion of other possibilities. In non-
conventional nerve blocks neurological cases, prevention of this frustrating
● Muscular pain complication can be difficult, as no clear clinical signs are
● Non-painful conditions causing gait alteration present to indicate the source of lameness.
● Severe painful conditions
● Failure to employ a methodical approach to diagnostic Diagnosis Persistent lameness despite performing the full
anesthesia by the veterinary surgeon range of diagnostic nerve blocks
Pathogenesis Even with a careful and methodical

approach to diagnostic anesthesia, resolution of lameness otentialInfluenceof Diagnostic
P
with nerve blocks does not occur on the odd occasion. In
Anesthesiaon DiagnosticImages
these frustrating cases, consideration should be given to
muscular conditions; subchondral bone pain; spinal or
Radiography
neurological conditions; swing phase lameness; or
mechanical gait abnormalities that are not a result of On occasion, the placement of the local anesthetic, either
pain (such as fibrotic myopathy or peripheral perineural or intra-synovial, can result in some air being
neuropathy). In addition, some foot conditions such as a injected into the tissues. When examining radiographs on
foot abscess or severe laminitic pain may not resolve horses that have undergone nerve blocks within a few
completely. hours of the injections, beware of artefacts that may
Discussion of the pathogenesis of each of the above occur [47]. When using contrast material as part of a diag-
conditions is beyond the scope of this chapter; however, nostic nerve block (navicular bursa, DFTS to examine a
all of the above are conditions that may not be associated manica flexoria), it is easy to forget that the contrast mate-
with a specific dermatome or area of sensitization by a rial will be present in subsequent radiographs taken within
peripheral nerve. Neuropathic pain can result from cen- 3–4 hours of the nerve block.
tral potentiation of nociceptive input to the brain [45],
which can result in poor response to local or systemic
Ultrasonography
analgesic medication. The evidence for the presence of
neuropathic pain is primarily associated with chronic The deposition of local anesthetic and some gas into tis-
cases of laminitis and potentially chronic osteoarthritis. sue can lead to artefacts on ultrasonographic images.
There is no clear evidence to explain the poor response of Therefore, it is prudent to consider delaying ultrasound
some lameness associated with subchondral bone pain to examinations of soft tissues, in particular the proximal
local or intra-articular analgesic techniques; however, suspensory ligament region, for about 12–24 hours after
this phenomenon has been noted anecdotally by lame- the diagnostic anesthesia [48, 49]. Alternatively, if there is
ness diagnosticians [6]. Subchondral bone pain may not a high index of suspicion of a soft tissue injury, then ultra-
be desensitized by local intra-synovial or perinerual diag- sound examination can be performed first with subse-
nostic anesthesia if the nerve supply to the deeper bone quent diagnostic anesthesia to confirm the site of pain.
tissue originates more proximal in the diaphysis of the This would be a practical approach but could lead to an
same bone. unnecessary ultrasound examination and delay in reach-
ing a diagnosis, if the lameness did not block to the region
Prevention and management When confronted with a case scanned. For the fore limb proximal suspensory region,
that does not respond to any diagnostic anesthetic desensitization of the lateral palmar nerve at the level of
techniques, considering alternate anatomical locations and mid-accessory carpal bone (Castro block) [50] or along
causes of lameness is essential. Careful assessment of each the accessorio-metacarpal ligament, avoids the placement
case with a detailed clinical examination at rest and in of local anesthetic in the area that may require an ultra-
motion often allows cases with clear neurological deficits sound examination.
Potential Complications of iagnostic Imaging echniques 597
GammaScintigraphy this chapter. The reader is referred to the excellent texts

available in each of these speciality areas.
Following a series of diagnostic nerve blocks, there is a
The techniques that involve ionizing radiation require
concern that an artefact may occur in the gamma scinti-
careful monitoring of exposure of staff, in particular for
graphic study due to localized inflammation and/or as a
nuclear scintigraphy and computed tomography where the
result of needles potentially touching bone. With this in
doses of radiation can be substantial. The use of personal
mind, the general recommendation is to perform gamma
dose meters with regularly monitoring of exposure is usu-
scintigraphy 2 to 3 weeks following nerve blocks to avoid
ally part of local radiation regulations in place to ensure a
false positives. The evidence for this recommendation is
safe workplace. Local regulations may vary considerably,
scarce. There is evidence that the low and high palmar
but usually the wearing of protective gowns, gloves and
nerve blocks may increase radiopharmaceutical uptake in
thyroid shields is recommended.
the soft tissue as compared to the hard tissue phase of scin-
tigrams; however, there is no evidence that more distal
limb blocks have an effect on images beyond 2 days [51,
52]. There is evidence that peroneal nerve blocks can result
in increased radiopharmaceutical uptake in the region of Table44.3 Complications of diagnostic imaging techniques.
the block on bone phase images for up to 7 days, potentially
due to the needle for the deep peroneal nerve block imping- Radiography ● Injury to equipment – cassette and
ing on the bone [53]. In many cases, if the foot or lower machine
limb has been eliminated as a source of pain and the horse ● Injury to personnel
is becoming difficult to block, proceeding directly to ● Poor compliance
gamma scintigraphy may be prudent, since the distal limb
has been eliminated as a source of lameness.
Computed ● Injury to personnel
tomography
Poor compliance due to small space and
MagneticResonanceImaging
●
need for immobility
Diagnostic nerve blocks are unlikely to affect the quality of ● Poor access to area of interest
magnetic resonance images (MRI); however, prior nerve ● Radiation exposure
blocks of either perineural or intra-synovial structures in
the area examined can result in subcutaneous fluid, arte-
factual increase in synovial fluid distension, and poten- Nuclear ● Radiation exposure during injection,
tially needle tracts [54]. scintigraphy sedation, scanning, handling
● Injury to personnel – in particular
individual holding lead around limbs
otentialComplications
P ● Damage to the detector/camera
of DiagnosticImagingTechniques ● Brain or lung embolus from loss of
catheter bung
Fortunately, the main diagnostic imaging techniques used ● Poor uptake of the radionucleotide
to elucidate the actual cause of lameness, once it has been ● Poor compliance of the horse
localized, are relatively safe procedures; however, they are
not completely without risk. For all of the techniques – radi-
ography, ultrasonography, nuclear scintigraphy, magnetic Ultrasound ● Clipper rash
resonance imaging, computed tomography, endos- ● Skin reaction to ultrasound gel
copy – the most common complications involve horse ● Poor quality images due to thick skin
compliance, a lack of which can result in injury to the han-
dler, the equipment or the horse itself (Table 44.3). The
risks of the above complications occurring can vary with Magnetic ● Poor compliance leading movement
technique, physical plant arrangement, efficiency of per- resonance imaging artefact (standing MRI)
sonnel and the horse. The second-most common complica- ● Metal artefact from nail clinches
tion would be failure of the equipment. Obviously, there ● Foot size too big for magnet (standing
are multiple issues regarding obtaining good-quality diag- MRI)
nostic images, but that large topic is not within the remit of
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601
45
Complicationsof SynovialEndoscopicSurgery(Arthroscopy,Tenoscopy,
Bursoscopy)
Troy N. Trumble DVM, PhD1 and Michael C. Maher DVM, DACVS-LA2
1
University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota
2
Brandon Equine Medical Center, Brandon, Florida
Overview – Poor triangulation

– Inadequate limb position/limb manipulation
For the purposes of this chapter, synovial endoscopic sur- – Visualization
gery refers to all procedures that use a rigid endoscope to ○ Inadequate distention
evaluate and treat the intrasynovial environment of a joint ○ Hemarthrosis
(arthroscopy), tendon sheath (tenoscopy), or bursa (bur- ○ Synovial villi obstruction
soscopy). In the horse, synovial endoscopic surgery is the ○ Fogging
best surgical procedure for evaluating, diagnosing, and – Intrasynovial instrument breakage
treating intrasynovial lesions [1]. The surgery is performed – Free-floating fragments
through small incisions, helping to keep complications to a – Iatrogenic damage
minimum, but they can still happen. Previous reports have
● Postoperative complications
described the most common complications that occur
when performing equine synovial endoscopic surgery [2– – Early: myopathy/neuropathies
5]. Most of the information provided in this chapter is from ○ Inadequate removal/debridement
personal experience of the authors and/or their mentors. ○ Infection: subcutaneous or intra-synovial
Synovial endoscopic surgery is technically demanding. ○ Pain
Small technical errors during a synovial endoscopic surgery – Late: synovitis

are common for inexperienced and experienced surgeons ○ Cosmesis
alike, but the experienced surgeon often knows how to ○ OA/enthesophyte/dystrophic mineralization/
prevent these from turning into big technical mistakes that fibrotic capsule
will ultimately cause future problems for the horse. Many
mistakes can be dealt with quickly, provided the surgeon
honestly admits to themselves that they have erred. This ynovialEndoscopicSurgery
S
chapter will focus on complications that commonly occur Pre-Planning
because of mistakes in planning or technique and will try
to offer ways to help the surgeon navigate these issues as Preoperative planning is crucial for the success of any sur-
they arise. gery and is no different for synovial endoscopic surgery.
While the surgeon cannot foresee all issues that will occur
preoperatively, decisions made during that time can help
L minimize the morbidity of the horse, while increasing the
with SynovialEndoscopic speed of the surgery and chance for a successful outcome.
Many preoperative planning complications occur because
● Synovial endoscopic surgery pre-planning the surgeon was rushed and/or failed to come up with a
● Intraoperative complications basic plan. Lack of planning regarding the patient, instru-
– Equipment problems mentation, positioning of the limbs, or approach for multi-
602 Complications of Synovial ndoscopic Surgery (Arthroscopyn, enoscopyn, ursoscopy)
ple limbs can lead to complications. Minor complications that usually have minimal effects on the overall success of
such as improper flexion, inability to change distention the surgery. However, it is important to realize that some of
media or output, or failure to come up with a plan of action the problems from inadequate planning do not surface
for operating on multiple limbs can hinder surgery and until the surgery is completed, such as myopathies or
lengthen operating times. Trying to rush the horse to sur- extravasation of fluid that generally cause some degree of
gery is the main reason for inadequate planning, but an pain and anxiety to the horse that will need to be con-
inaccurate diagnosis (such as assuming a bony opacity is trolled. If any of these complications occur, the surgeon
intrasynovial when it is not) will also cause the surgeon to needs to be introspective and try to understand what could
be ill-prepared in the operating room. Even though the sur- have been done differently from the beginning to try to pre-
gical approach for many synovial endoscopic surgeries are vent the complications that occurred and then apply that to
similar, each procedure is slightly different with regard to any future cases.
the amount of surgery time, the amount of pain it will
cause, whether the surgery site can be protected during
recovery, etc. Most of the time, complications arise when IntraoperativeComplications
the surgeon has not even considered one of these aspects or
has downplayed it in spite of overwhelming reasons not to. EquipmentProblems
Arthroscopic surgery is often performed on multiple
Definition Inadequate functioning of one or more pieces
joints on multiple limbs during the same anesthetic period.
of equipment leading to suboptimal or inadequate
This is a unique issue compared to most surgeries being
visualization or completion of surgical procedure
performed on the horse and in many ways is ideal because
it minimizes multiple anesthetic episodes. However, the
Risk Factors
surgeon needs to come up with an adequate plan for these
multiple procedures. The surgeon must consider the effect ● Aging equipment
of the position of the horse on access to the lesions as well ● Poor maintenance
as visualization. For instance, placing the horse in lateral ● Poorly trained technical staff
recumbency for a bilateral lesion may place the arthroscope ● Surgeon’s poor knowledge of or unfamiliarity with the
upside down for one of the limbs, which can cause fogging equipment
if using fluid for distention with an older arthroscope. In
addition, the surgeon needs to consider where to start and Pathogenesis Endoscopic evaluation of synovial structures
whether they can complete all of the joints in a timely is dependent upon the proper functioning of multiple
fashion, as surgery can often take longer than anticipated. pieces of equipment. The endoscope, camera, light source,
Often, inexperienced surgeons will start with the “easiest” and fluid pump are all vital components for visualization
limb/lesion to get things going. However, it is usually best inside the synovial structure. Even with the best and
to go after the most significant lesions first, in case there newest technology, equipment can fail for a variety of
are anesthetic complications that cause the surgeon to reasons, and mixing older and newer equipment can cause
have to stop surgery before all of the lesions are removed. complications. If one component malfunctions, successful
By going after the worst lesions first, the horse may still completion of the surgery will be at risk. In addition,
have a chance to improve despite not having everything removal of fragments and debridement of lesions are
completed; a second surgery may not always be necessary performed using specialized instruments that can fit
if the worst lesions were dealt with up front. It is important through small incisions. If the instrument does not perform
to note that there is no one right answer for most of these as anticipated (i.e. cuts tissue), then there is risk for
decisions, but the surgeon must be prepared to make a iatrogenic damage to the intrasynovial structures.
decision regarding the general patient care and not be
afraid to change it should the course of the procedure Prevention Make sure that all items of equipment are
change. This also includes adjusting antimicrobial therapy compatible with each other, especially when new
if the surgery lasts longer than expected, or considering equipment is purchased. If equipment is recently
using nerve/joint blocks or other intra-articular therapies purchased, or if used infrequently, test run all equipment
if the lesion appears to be larger/deeper than expected, prior to using it in surgery. If equipment is used commonly,
such that the horse may be in pain during anesthesia or troubleshoot minor problems at the end of surgery to try to
postoperatively. prevent them from becoming bigger issues on the next
Most complications that occur from inadequate preop- case. Also, consider investing in back-up equipment for the
erative planning result in minor added surgical morbidity endoscope, camera, light source, fluid pump, and the most
commonly-used instruments (such as 4 × 10 mm Ferris–

Smith rongeurs). The back-up equipment should be
periodically tested and stored close to the operating room.
This would allow surgery to continue if a piece of
equipment fails. Perform routine maintenance and replace
equipment and instruments periodically to ensure expected
performance. This is especially important with instruments
as they can become dull quickly. Invest in a plan that will
quickly provide a temporary replacement while equipment
is being repaired.
Diagnosis Inability to use equipment as expected
Treatment Equipment will fail. The surgeon and at least

one technician should know how to troubleshoot problems
when they occur, either at the time of surgery, or after.
Common issues can occur with the endoscope, camera,
light source, or fluid pump. For instance, if there is no
image on the monitor the following need to be considered:
connections to and from the monitor are loose, camera
may not be plugged in properly, or the monitor is faulty
(need another monitor). If no image can be displayed, and
no back-up units are available, it is important to note that Figure45.1 Damage to the tip of a 30-degree rigid endoscope.
the surgeon can only view the synovial cavity with the Note multiple scratches around the periphery of the lens, as well
naked eye when using eyepiece arthroscopes and not as a cloudy area (arrow) in the lens that will create a blurry
visual area. Source: Courtesy of Jim Schumacher and Tom
videoarthroscopes [6]. If the image is fuzzy or out of focus, O’Brien.
the tip of the endoscope may be damaged (Figure 45.1;
need to buff out the tip if minor, or replace arthroscope if
major), or fogging may be occurring at the coupling debris in the joint or break, they should be removed from
between camera and endoscope (wipe scope and camera the joint and replaced. It is important to remove any pieces
with dry gauze). If the amount of light is insufficient, there of broken instrument from the joint, or flush as much
may be a loose connection, burned out bulb, or the intensity debris from the joint as possible.
is turned down too low. White balancing with a gauze can
also help to improve the light quality. Indications of a Expected outcome It is important to understand that
malfunctioning fluid pump would be things such as lots of trying to work through an equipment failure often leads
air bubbles in the joint (prime the tubing or replace it), or a to increased surgery time and inadequate removal of
lack of distention in the pressure monitored system (in pathology, since the visual field is usually compromised.
chronic joints maximum pressure may be achieved quickly This can lead to iatrogenic trauma to the tissues as well as
with pressure-sensitive pumps, so need to switch to a other equipment (such as the tip of the endoscope). Even
motorized pump that can deliver high flow rates). If a with the newest and best technology, equipment can fail.
pump completely fails, a pressurized cuff bag can be placed If the surgeon and surgical staff are aware of how to
around fluid bags with delivery to the joint via an troubleshoot any issues, then most failures can be dealt
intravenous drip set. with quickly with minimal impact on the surgery.
If the problem occurs during surgery, and the surgeon However, if the malfunctioning equipment cannot be
has a back-up piece of equipment, it should be readily fixed or replaced in a timely fashion, the surgeon must
available to replace the malfunctioning equipment. It is make the call as to whether or not they can finish the
important to ensure that back-ups are interchangeable surgery. The surgeon should have working knowledge
with the current system and that they are periodically about how to transition an arthroscopic surgery to an
checked to know they are functional. In addition, for arthrotomy if required to finish the surgery. In addition,
instruments that can no longer cut tissue, they should be they need to understand how that transition may affect
removed from the joint to prevent further problems and the prognosis [7]. In the authors’ experience, it is often
sharpened. If instruments start to leave small metallic best to wake up the horse and perform surgery again after
all of the equipment has been repaired or replaced and

tested prior to the next surgery.
It is expensive to update an endoscope, camera, light
source, monitor, etc. Therefore, pieces are often replaced
on an aging unit, making it even more critical to make sure
all pieces of the tower can work together. Instruments usu-
ally fail because of lack of maintenance (such as sharpen-
ing – Figures 45.2a and b) or improper use that causes
undue wear and tear on the instrument (Figure 45.3).
Trying to perform a procedure without the proper instru-
mentation or with dull, poorly maintained instruments,
will often lead to minor complications that can slow down
surgery and at times cause extra morbidity for the horse.
An example of this is trying to use dull Ferris–Smith ron-
geurs (Figure 45.2a) to debride frayed ligamentous tissue;
this would lead to greater damage since the rongeur will Figure45.3 Arthroscopic image of a 2 × 10 mm Ferris–Smith
pull the frayed end and not cut it (Figures 45.4a and b). rongeur. Note that the instrument has been improperly stressed
Another common mistake is not having the appropriate such that the jaws do not line up properly, which can make it
become dull quicker and lead to breakage of the pin that
forceps that can securely hold onto an osteochondral frag- connects the jaws. Source: Troy N. Trumble, Michael C. Maher.
ment after it has been loosened (Figure 45.5). Most of these
just lead to increased surgery time, but can also often lead
to further iatrogenic trauma (Figure 45.4b). ● Working on the ipsilateral side of a synovial cavity.
● Working in synovial structures that have limited space
PoorTriangulation (such as palmar carpus)
Definition Failure to apply the triangulation principle to Pathogenesis Triangulation is the fundamental principle
bring the operating instrument and surgical lesion into the used in equine endoscopic surgery of a synovial structure,
field of view to allow adequate treatment and therefore needs to be mastered in order to successfully
complete surgery. The principle involves bringing an
Risk Factors
operating instrument into the visual field of the endoscope.
● Incorrect portal placement. The instrument is introduced into the synovial structure
● Suboptimal anatomical knowledge through a separate portal from the endoscope, such that
● Surgeons’s inexperience or inadequate technical the tip of the instrument and the tip of the endoscope are
knowledge close to each other at the apex of the triangle [8, 9]. The
(a) (b)
Figure45.2 Arthroscopic images of a dull Ferris–Smith rongeur (a) and curette (b). Source: Troy N. Trumble and Michael C. Maher.
(a) (b)
Figure45.4 Arthroscopic image of the cranial medial femorotibial joint demonstrating fraying of the cranial ligament of the medial
meniscus (CLMM) prior to debridement (a), and after debridement with dull Ferris–Smith rongeurs (b). Notice that debridement of the
ligamentous tissue caused greater injury due to tearing the tissue when trying to pull it loose rather than cutting it. MFC = medial
femoral condyle. Source: Troy N. Trumble, Michael C. Maher.
angle of inclination of the lens on a rigid endoscope (0-, achieve triangulation. In addition, inadequate knowledge
25-, 30-, or 70-degrees) will influence how easy or hard it is of the field of view or associated blind spots associated
to achieve and maintain triangulation within a synovial with the angle of inclination of the endoscope chosen (0-,
cavity [9]. Separation of the instrument and endoscope 25-, 30-, or 70-degree endoscopes) can affect triangulation.
improve depth perception, meaning that the closer the The angle of inclination is the angle between the line of the
instrument is to the endoscope, the harder it is to determine long axis of the endoscope and a perpendicular line at the
the depth. surface of the lens (tip) of the endoscope. Increasing the
Inadequate knowledge or understanding of the anatomy angle from 0 to 70 degrees increases the field of view by
of the synovial structure can put the surgeon at risk of plac- rotating the endoscope, but also creates a blind spot in the
ing the portal for either the endoscope or instrument in a center with 70-degree endoscopes [9]. Knowledge about
suboptimal or inadequate position making it difficult to this field of view is very important with regards to triangu-
lation, as it is possible to change the viewing angle such
that the instrument can no longer be seen.
Finally, inadequate knowledge about the orientation of
the camera and endoscope with relationship to the surgeon
will create problems with triangulation. With any endo-
scope that has an angle of inclination greater than zero, the
light cable can be moved in any direction to help with visu-
alization, but the camera should only be held in one posi-
tion to maintain the surgeon’s perspective as they look at
the limb (in other words, when looking at a limb, the anat-
omy is in the same position as what is seen on the video
monitor: Figures 45.6a and b). If the orientation of the
camera is rotated or flipped, the image on the monitor will
change accordingly (Figure 45.6c). This will alter triangu-
lation and the movements will be the opposite of what one
would expect.
Figure45.5 Arthroscopic image of a large osteochondral
fragment in the dorsal pouch of the tarsocrural joint. Note that
the size of the fragment is too big for the instrument (4 × 10
Prevention Improve knowledge of anatomy for each
mm Ferris–Smith rongeurs). This risks breakage of the pin that
holds the jaws of the rongeur together, as well as losing the individual synovial structure. If examining a synovial
fragment in the joint. Source: Troy N. Trumble, Michael C. Maher structure that is unfamiliar, the surgeon should review the
anatomy prior to surgery; if possible, practicing the expected. This is simply corrected by looking at how the
approach on a cadaver is even better. Understand the surgeon is hanging onto the camera. The best practice is to
relationship of the positions of the camera and light source make sure the camera cord is in the same orientation as the
for each angle of inclination used in an individual’s practice surgeon’s visual field (think of the cable of the camera as
and how that relates to instrument position and movement the surgeon’s neck and the box as their head: Figure 45.6b),
(Figure 45.6a). It is best to practice this in cadavers or via as this will put the image in the correct orientation. If the
simulators (such as those available via Sawbones USA, camera cord is flipped up away from the surgeon’s hand
Vashon, WA). This becomes especially important if the (such that the cable is coming in from the top), then the
surgeon tends to use a 25- or 30-degree endoscope (used for camera will be upside down compared to the surgeon’s
most equine synovial structures) and then wants to use a visual perspective of the limb (Figure 45.6c). Usually by
70-degree endoscope to increase the field of view (such as rotating the camera, triangulation will be easily corrected
in a coxofemoral joint). Knowledge about the central blind
spot created with the 70-degree endoscope is important to Expected outcome Triangulation errors are easy to fix. If the
understand, especially with regards to instrument portal error is because of inexperience, the surgeon should practice
placement for best triangulation. more on cadavers or simulators. If the error is because of
While still learning triangulation principles, it is best to poor portal placement, this is easy to fix as long as the
try to make the instrument portal on the contralateral side surgeon recognizes and accepts their mistake. If the surgeon
of the synovial structure, if possible, as triangulation is does not know or acknowledge that their portals are in poor
harder the closer the instrument gets to the endoscope due locations, it is highly likely that the surgery will take longer
to a relative lack of depth perception [8, 9]. This usually and that iatrogenic damage to the synovial structure or
occurs when the arthroscopic and instrument portals are equipment will occur. Poor portal placement can make the
made on the ipsilateral side of a synovial structure, with difference between an easy and hard surgery. For instance,
the exception of big, or long structures (such as sheaths). in joints where the arthroscope needs to go across a trochlear
ridge, the portal placement is vital to achieve triangulation;
Diagnosis Inability to see an instrument that is placed in a poor portal placement will pin the arthroscope against the
joint ridge, making it very difficult to see the instrumentation. If
a particular surgery was harder than anticipated, the
Treatment It is important to recognize when triangulation surgeon should critically evaluate their portal placement to
is less than ideal. This is usually obvious for a surgeon with see how they can improve upon it in the future.
any endoscopic experience. Quick recognition can allow
the surgeon to re-assess the endoscopic and instrument
portal placements prior to creating iatrogenic damage to InadequateLimbPosition/LimbManipulation
either the synovial structure (inadequate visualization of
Definition Suboptimal limb positioning or manipulation
the instrument) or the equipment (trying to force the
leading to inadequate or suboptimal visualization and/or
endoscope or instrument around a corner). If a portal is not
surgical treatment
ideal, it is recommended to abandon that portal as quickly
as possible and make a new portal in a better position. The
Risk Factors
tradeoff is that distention of the synovial structure will be
harder to obtain, with greater chance for extravasation of ● Poor positioning of the horse on the table
fluid if the fluid flow needs to be increased. However, in the ● Poor positioning of the limbs. This includes inadequate
authors’ experience, this is usually a more tolerable flexion for the given procedure as well as rigid fixation of
complication because by changing portals to more ideal the limb such that it cannot be manipulated easily during
locations will help the surgeon to finish the procedure surgery (via surgeon, assistant, or technician via
quicker with less iatrogenic damage to the synovial manipulation of a hoist/rope)
structure or equipment. ● Using lateral or dorsal recumbency for a given procedure
With relatively new surgeons, the relationship of the when the other is better for either maintaining limb
positions of the camera and light source with regard to the position, or allowing limb manipulation
angle of inclination can be common causes for confusion ● Standing surgery
about triangulation. After assessing that the portal
placements are in the ideal locations, the easiest way to Pathogenesis Limb positioning is crucial for successful
know that this problem is occurring is to recognize that the creation of portals as well as minimizing morbidity while
instrument is moving in an opposite direction to what is under anesthesia. A portal might be created in the proper
(a) (b)
(c)
Figure45.6 (a) Photograph of an assembled 30-degree rigid endoscope that is connected to the camera (black box with black cord),
light cable (blue cord), and inserted through the endoscopic cannula with a fluid line attached (clear line with blue cap). (b)
Photograph of an image on the monitor with the camera oriented and light cable oriented as shown in image (a) (camera cable
oriented down) such that the words appear in the same visual field as the surgeon is positioned. (c) Photograph of an image on the
monitor with the camera-oriented upside down of the image shown in (a) (camera cable oriented up) while the light cable orientation
is maintained as shown in image (a). This orientation will flip the visual field 180 degrees from where the surgeon is positioned.
Therefore, position of the camera is important for proper triangulation and needs to be examined when normal movements within the
joint with an instrument feel like they are backward of what one would expect. Source: Troy N. Trumble, Michael C. Maher.
location, but if the limb is not positioned properly, then the contamination. On the other hand, standing surgery is
lesion may not be visualized [8]. This is often due to usually only successful if the limb can be maintained in a
inadequate understanding of the anatomy and/or lesion certain position. If the horse moves at an incorrect time,
location within a synovial structure. In addition, it is often there will be likely iatrogenic damage to the synovial
critical that a limb is manipulated while the arthroscope is structure, damage of equipment, contamination of the
in the synovial structure to allow visualization, access, surgical site, and/or injury to surgeon and staff.
fracture manipulation, etc. Most often, this is increased Some surgeons may not be comfortable performing dis-
flexion or extension; therefore, if a limb is fixed in any one tal limb arthroscopic surgery in either dorsal or lateral
position it will be difficult to manipulate it without possible recumbency. They should understand the tradeoffs of each
recumbency in relationship to limb manipulation. It can be Treatment It is important to recognize poor horse and limb
more difficult for the surgeon to manipulate the limb when positioning as early as possible after anesthesia, so that the
the horse is in dorsal recumbency, as they are reliant on position can be changed prior to scrubbing/draping. If the
their system for limb support or an assistant surgeon to arthroscope is inserted and the lesion cannot be identified as
perform and maintain adequate manipulation. In lateral expected, the surgeon should immediately assess the limb
recumbency, the surgeon can more directly control flexion position. This can be done using subtle flexion or extension.
or extension of the distal limb by placing the foot in their If that does not bring the lesion into view, the surgeon should
belly. However, the tradeoff is that in lateral recumbency, take radiographs to identify the position of the lesion relative
the limb will naturally move more throughout the to the portal (Figure 45.7). If the lesion is close, further
procedure than in dorsal recumbency, which can cause manipulation can be considered with the current portal. If
overlap of tissue at the incision, effectively closing down the lesion is still distant to the portal, the arthroscope should
fluid egress, allowing fluid to fill the subcutaneous space be removed and the limb position changed based on
(called extravasation of fluid). radiographic guidance and a new endoscopic portal made.
Prevention Having multiple options available in an Expected outcome If the horse is improperly positioned
operating room for limb positioning and manipulation is under anesthesia, major complications such as myopathies
ideal, in case one does not work as expected for a given can occur. The horse should be positioned on the table in as
case. For example, if a table adapter does not work due to stable a fashion as possible, while minimizing the potential
length of the limb, then the surgeon could transition to a for areas of impingement that can cause myopathies/
hoist or rope on the ceiling. If using a hoist or rope on the neuropathies; often this is related to improper padding, but
ceiling that cannot move front to back or side to side, then can also occur when there is proper padding but improper
the table should be adequately positioned under the hoist/ limb position. For instance, when in lateral recumbency,
rope to achieve the correct position/manipulation. The the down limb is not pulled forward. Another example
best way to prevent improper positioning is to have the would be fixating the patella to lock the entire hindlimb in
surgeon present once the horse has been placed on the extension for the entire surgery. Positioning is also
table. The surgeon should be meticulous about the important to consider for standing procedures to minimize
positioning of the horse on the pads as well as the position injury to the surgeon and horse, as well as potential damage
of the limbs. Even a knowledgable staff will not appreciate to the instrumentation.
or understand all of the intricacies of positioning, especially
when multiple joints are being examined. Once the horse
and limb are positioned, the surgeon and assistant/
technician should know how the limb can be manipulated
if need be to obtain either more or less flexion or extension,
and this manipulation should be tested prior to scrubbing.
The recumbency should be chosen not only based on the
location of the lesion/s, but also on the skill of the surgeon.
Often, for bilateral lesions, dorsal recumbency is easiest
based on ease of access and minimizing the need to have
the arthroscope positioned upside down (making it more
vulnerable to fogging, depending upon the system being
used). However, dorsal recumbency might be difficult for
the surgeon to obtain the proper amount of flexion of the
distal limb. In addition, if the surgeon does not have an
assistant, or if the hoist/rope cannot adequately manipulate
the limb as needed, then the surgeon should perform the
Figure45.7 Lateral intraoperative radiograph of a right stifle.
surgery in lateral recumbency. Standing surgery is only
The arthroscope (in its sheath – white arrow) is placed into the
recommended for horses with ideal temperament and with cranial medial femorotibial joint using a lateral approach.
surgeons highly skilled in endoscopic techniques. However, the subchondral cystic lesion (black arrows) cannot be
seen in the current visual field of the arthroscope because the
limb is in too much flexion. Radiographic guidance was then
Diagnosis The horse and/or limbs are positioned on the
used to identify the location of the cyst (via two 1.5-inch
table such that the lesion cannot be adequately identified, needles) and to insert a spinal needle to inject the cyst. Source:
with subtle limb repositioning being difficult to accomplish. Troy N. Trumble, Michael C. Maher.
The amount of flexion or extension of the limb is para- – Necessity to remove large fragment
mount for the success of most endoscopic procedures. – Use of gravity flow or pressure regulated pump
Limb position is easy to learn and fix prior to the start of – Use of suction with a mechanical resector
surgery, but is much harder to fix after the horse has been ● For too much distention:
draped and surgery started. If the surgeon is not sure – Endoscopic procedures which require a change in
whether the degree of flexion is adequate for a particular limb position (please see Section on Inadequate limb
surgery, radiographic guidance can be performed to adjust position/limb manipulation)
the limb prior to making portals. If the limb has to be – Use of high-flow fluid pump with no pressure
manipulated during surgery after a portal or two have been regulation
created, the surgeon should re-assess triangulation to make – Arthroscopic exam of deep synovial structures (such
sure that new portals do not need to be created. Prolonged as scapulohumeral or caudal femorotibial joints)
manipulation after portals have been created can lead to ● For air bubbles (Figure 45.8):
extravasation of fluid, since the tissue planes of the portal – Not priming the fluid line at the beginning of surgery
are stressed differently than when initially made. The sur- – Switching fluid line from one fluid bag to another
geon should also consider whether the position of the limb – Using vacuum with the mechanical resector
is one that can be maintained throughout patient prep and
surgery, or whether the limb should be relaxed and then Pathogenesis In order to perform endoscopy in synovial
manipulated immediately prior to performing surgery on structures, a distention medium is required. This distention
that particular synovial structure (an example is the exten- can be obtained using fluid (lactated ringer solution or
sion of the stifle for access to the femoropatellar joint, espe- saline) or gas (carbon dioxide) [6]. In equine surgery, fluid
cially when lesions are bilateral). If the limb is to be relaxed is the most commonly used, and will therefore be the focus
and replaced into the correct surgical position, the surgeon of this discussion. There are many different ways to deliver
must know that the surgical position can be easily achieved fluid into the synovial structures, including gravity flow,
after the horse has been draped. The easiest way to do this pressure bag with hand pump, pressure regulated, flow, or
is to drape the horse with the limbs in their proper surgical a combination of pressure and flow [6]. No one system is
positions and then relax the limb making sure all necessary perfect for all joints or all disease conditions. Therefore, the
areas remain sterile. surgeon may deal with too little distention such that lesions
cannot easily be assessed or manipulated, or too much
distention where fluids get trapped in the subcutaneous
Visualization tissues leading to potential collapse of the joint. For
example, minimal distention may occur when a joint
Endoscopic surgery is dependent upon the ability to ade-
capsule is fibrotic, which occurs in many chronic
quately see inside a synovial structure so that lesions can
conditions. A pressure regulated pump alone will not
be removed and debrided. There are multiple factors that
can affect how well the surgeon can see inside a synovial
structure. These will be broken down into 4 different sub-
categories: inadequate distention (too little or too much),
hemarthrosis, synovial villi obstruction, and fogging of the
camera.
Inadequate distention
Definition Insufficient or excessive synovial distention
leading to inadequate or suboptimal visualization, fluid
extravasation and/or presence of air bubbles that can limit
completion of the surgical procedure.
Risk Factors
● For too little distention:

– Performing arthroscopy on a joint with chronic osteo-
Figure45.8 Arthroscopic image demonstrating an obstructed
arthritis/capsulitis view of a Ferris–Smith rongeur by an air bubble (upper left).
– Large portal size/multiple portals Source: Troy N. Trumble, Michael C. Maher.
provide enough distention to move the synovial villi from is hard to get rid of if a bag of fluids is allowed to com-
the cartilage surfaces since the capsule is no longer pliable pletely empty without anyone noticing. Occasionally the
(Figure 45.9). Minimal distention may also occur when the surgeon will knock off the ingress line from the arthro-
ingress of fluids is inadequate. This can be due to too large scopic cannula and not notice that fluid is no longer enter-
of an arthroscopic portal such that fluid escapes from it, ing the synovial structure, allowing air to enter through the
low fluid flow, or partially closed fluid portals on cannula. In addition, use of the vacuum with a mechanical
arthroscopic sheath. Occasionally the surgeon will knock resector can create air bubbles in the synovial structure if
off the ingress line from the arthroscopic cannula and not the suction power is not well regulated.
notice that fluid is no longer entering the synovial structure.
If using suction with a mechanical resector, more fluid can D>Prevention Proper portal shape is important to ensure
be removed than is entering the joint. Conversely, too adequate ingress and egress of the distention medium. If
much distention can occur when high volume ingress is there is a problem with either, then visualization may be
used with inadequate egress. This can be due to improper affected. The skin and extra-articular tissue incision should
egress needle placement (not in synovial structure), be larger than the joint capsule incision. Use of a #11 blade
improper shape of the instrument portal, or excessive will assist with this, given its wedge shape. Large portal
angulation or manipulation of instruments within the formation should be avoided, especially for the endoscope
portal. Changes in limb position after portals have been portal, as this will lead to poor distention. Large fragments
made can also decrease proper egress. Too much distention should be removed last, so that the majority of the
often leads to fluid getting trapped in the subcutaneous arthroscopic procedure is performed before enlarging the
tissues (extravasation of fluid) that can cause the joint to portal to remove the fragment. Turn the fluids off when
collapse. removing a large fragment through the portal, to prevent
Air bubbles in the synovial cavity create a visual problem closing down the egress flow and pumping fluid into the
(Figure 45.8). It is important to understand that air is subcutaneous tissues.
present in the distention system at the beginning of surgery, Care should be used when instruments are inserted or
since the fluid lines need to be filled. After this, the most exited (with or without a fragment) through the portal. In
typical times that air gets into the synovial cavity is via the addition, instrument angles relative to the incision and
fluid line from an inadequate switching from one fluid bag excess manipulation can close down the egress flow
to another. This can range from a small amount of air that pumping fluid into the subcutaneous tissues. This can also
usually clears the joint quickly, to a large amount of air that occur when the limb is repositioned. Maintaining an egress
cannula in the portals during repositioning of the limb can
minimize movement of tissue planes that would lead to
extravasation of fluid into the subcutaneous tissues. Once
extravasation of fluid starts to occur, visualization of the
entire synovial structure becomes poor. The surgeon
should be able to recognize when the joint space is closing
down, based on clues such as difficulty in moving
instruments in the joint, re-inserting instruments, or
viewing the margins of the joint due to synovial villi that
are not hypertrophic or hyperplastic.
Air bubbles can be prevented by adequately priming the
line whenever air is in the system. In addition, technical
staff should be aware of when fluids are running low in a
bag and let the surgeon know prior to switching bags. The
fluids should be turned off allowing the surgeon to close
off the ingress portal and prime the line. If a mechanical
resector is being used, the surgeon should only
Figure45.9 Arthroscopic image in a dorsal pouch of a
metacarpophalangeal joint with chronic osteoarthritis and intermittently use suction or have the assistant pinch off
multiple linear score lines in the cartilage. The joint is being the suction hose when not needed.
maximally distended with a pressure-driven system. Note that
due to the fibrotic nature of this joint, the pressure-driven
Diagnosis Difficulty in visualizing the instruments due to
system cannot provide full distention. A volume-driven system
would be better for this type of joint. Source: Troy N. Trumble, lack of distention, air bubbles, or collapse of the joint from
Michael C. Maher. extravasation of fluid
Treatment Make sure ingress and egress are both If an air bubble gets into the synovial structure, it can be
adequate, paying particular attention when something difficult to remove. Small air bubbles tend to leave easily if
changes during the surgery (new portal, instrument, limb the ingress flow is increased. A large air bubble tends to
position, etc.). If distention is too low, increase fluid flow just move around if an instrument is used to try to pop it. A
rate, understanding that this will result in a greater needle can be placed into the synovial structure to pop a
pressure in the synovial cavity that can lead to extravasation large air bubble, or to make it smaller. In addition, as a last
of fluid into the subcutaneous tissue. The surgeon should resort, the limb position can be changed, taking advantage
be confident that with the increase flow, they can finish of the knowledge that air bubbles will rise to the top, and as
the surgery in a timely manner to reduce extravasation. It such can be manipulated toward a portal.
is ideal if the surgeon can have a combination of different
types of fluid systems (gravity flow, pressure bag with Expected Outcome Fluids are most often delivered via
hand pump, pressure and/or flow-regulated) readily pressure- or volume-driven systems. In general, use of one
available in the operating area, so that they can switch or the other will work well for the majority of surgeries, but
readily if need be. there are times in which they will create complications,
When making arthroscopic portals, especially when and the surgeon must recognize this promptly and switch
examining the joint completely (i.e. dorsal and palmar/ to another system, if possible. Not enough distention
plantar pouches), it is important for the surgeon to recog- makes it difficult to complete surgery in a timely manner,
nize when the arthroscope is placed in the subcutaneous as does extravasation of fluid, since fluid in the
tissues (Figure 45.10). If recognized, the fluids should be subcutaneous space will ultimately collapse the
shut off immediately and the arthroscope should be reposi- intrasynovial space making it difficult to see and move the
tioned. When switching between the arthroscopic portal endoscope and instruments. In humans, fluid extravasation
and an instrument portal, a switching stick (a long straight can lead to compartmentalization syndrome [10]; however,
instrument with blunt ends that has a thinner diameter this does not appear to be an issue in horses as most of the
than the arthroscopic cannula) can be placed in the instru- extravasated fluid will be resorbed, within 24 hours, with
ment portal incision and the arthroscopic cannula can minimal consequence. Air bubbles are usually a nuisance
then be placed around the stick to enter the joint, minimiz- during surgery that will cause a short delay.
ing incorrect placement of the arthroscope. If recognized
early, massaging the edematous soft tissue toward the skin Hemarthrosis
portals will decrease the focal swelling.
Definition
Presence of blood in the synovial cavity
Risk Factors
● Laceration of vessels upon portal creation

● Inflamed/septic synovial structures
● Synovectomy
● Aggressive debridement of subchondral bone
● Lateral recumbency
Pathogenesis The term “hemarthrosis” is used to indicate

bleeding from within the synovial structure, usually as a
part of the disease process, but for the purposes of this
chapter, it will be used to describe any visualization issue
that is due to active bleeding into the synovial structure.
This active bleeding usually comes from iatrogenic trauma
to vasculature during portal placement (commonly
Figure45.10 Arthroscopic image of fluid being pumped into happens with tarsocrural joint, digital tendon sheath, and
the extrasynovial subcutaneous tissues. This can cause a navicular bursa), or during debridement (especially
collapse of the synovial cavity such that it becomes difficult to inflamed synovium). An active hemorrhage into the
visualize structures, maneuver the arthroscope and instruments,
and even identify the instrument portal (blade is being inserted
synovial structure makes it very difficult to see anything
to open up the instrument portal). Source: Troy N. Trumble and (Figure 45.11). If debridement is continued before trying to
Michael C. Maher. control the hemorrhage, it is easy to cause iatrogenic
in various locations throughout the synovial structure.

Minimum contact with such synovium can create hemor-
rhage. Excessive subchondral bone debridement, espe-
cially when combined with low fluid flow, can also cause
hemarthrosis. If fluids are shut off after fragment removal
and subchondral bone debridement to take radiographs,
often the bone will bleed into the joint making it difficult to
see if surgery needs to be continued.
When the patient is operated on in lateral recumbency,
the limb position is close to the level of the heart level
which can increase bleeding. In lateral recumbency, it is
also difficult to identify portal locations on the side that is
facing down, leading to more chance of vessel laceration
(especially with digital tendon sheath and navicular
bursa).
Figure45.11 Arthroscopic image in a tarsocrural joint after
laceration of the saphenous vein upon creation of the
arthroscopic portal. It is not possible to see any structure within Prevention One of the simplest ways to prevent
the joint. Source: Troy N. Trumble and Michael C. Maher. hemarthrosis is to know the anatomy of the joint, paying
particular attention to the location of vasculature. This will
minimize poor portal placement that lacerates a vessel.
damage due to the limited visibility. Often, even after
lavage has been performed, it is still difficult to clearly see
Some hemarthrosis is to be expected with most endo-
into the synovial structure, even if the tip of the endoscope
scopic procedures, due to debridement of synovium and
is placed very close to a structure or instrument
subchondral bone. Appropriate ingress fluid pressure is
(Figure 45.12).
often sufficient to minimize hemorrhage, and keep it from
Within a synovial structure, the vasculature is located
obstructing one’s view. However, a tourniquet may be
within the synovial membrane, so even if they are not
applied when hemarthrosis is considered to be likely (i.e.
inflamed, debridement of the membrane will create some
inflamed or septic joint). The surgeon should continue
degree of hemorrhage. However, when significant inflam-
fluid egress while taking radiographs to prevent blood
mation is present in a synovial structure, the highly vascu-
build up on the debrided bed of subchondral bone.
lar synovium is usually hypertrophic and/or hyperplastic
Diagnosis Poor visibility due to the presence of
intrasynovial blood (Figures 45.11 and 45.12)
Treatment Ensure adequate ingress pressure to decrease

hemorrhage. Usually, once hemorrhage occurs, the ingress
fluid flow needs to be increased relative to the egress to
increase the intrasynovial pressure. Once hemorrhage has
decreased, egress of fluid is necessary to clear the synovial
cavity. The addition of ephedrine in the lavage fluids has
been suggested as a way to decrease hemorrhage [2, 3].
If a vessel is lacerated during portal creation, it can be
tied off. A tourniquet can be added during surgery if the
synovial structure is distal and the limb is in a position
such that a technician can get to the limb without contami-
nating the surgery site. If the hemorrhage cannot be ade-
quately controlled to complete the surgery, then the
Figure45.12 Arthroscopic image from the same joint shown in surgeon could wake the horse and try again in a few weeks,
Figure 45.10 after needle lavage and instrument portal creation. as a pressure bandage will stop the bleeding and the body
Note that the instrument and surrounding structures can now be will resolve most of the blood within a few days to weeks. It
partly identified, but the clarity is still less than ideal. In
addition, the arthroscope is placed very close to the instrument would be wise to use a tourniquet on the subsequent sur-
in order to see it. Source: Troy N. Trumble and Michael C. Maher. gery if possible.
Expected outcome With adequate knowledge of the must be capable of ensuring adequate synovial cavity
anatomy of the synovial structure for portal placement, distension so that the villi are pulled off from the margins
combined with adequate distension and lavage, as best as possible. In addition, the surgeon should be
hemarthrosis is often self-limiting. comfortable using instruments close to the tip of the
endoscope without damaging the scope. This is because
Synovial villi obstruction often the tip of the endoscope will need to be inserted
under the villi near the lesion.
Definition
Obstruction of the margins of the synovial structure by
Diagnosis Inability to visualize the margins of the synovial
synovial villi
structure due to overlap with the synovial villi
Risk Factors
Treatment If the margins of the synovial structure are
● Endoscopic surgery for any lesion located directly next to obscured due to synovial villi, the distention should be
the synovium (i.e. at joint margin). checked. If the distension is poor, the fluid ingress should be
● Chronic disease where the synovium is hypertrophied increased or the fluid egress decreased to create greater
and hyperplastic with less plasticity to the joint capsule. intrasynovial pressure, knowing that it may lead to
This is often the case in synovial structures where sur- extravasation of fluid (see Section on Inadequate distention
gery needs to be performed for a second or third time. above). Use the instrument to push villi away from the lesion
(toward the joint capsule), while carefully moving the
Pathogenesis The intrasynovial aspect of the synovial arthroscope into the cavity toward the lesion (Figure 45.13b).
membrane is made of villi, which are finger-like projections Then carefully release the synovium and bring the
that extend into the synovial structure. They are present to instrument into view. This can be thought of as the
provide a greater cellular surface area for the synovium as instrument lifting up an edge of the villi so that the scope
well as allowing greater reach into the joint to provide can drive under it, placing both the scope and instrument
nutrients and collect debris. During arthroscopy, they often under the villi. The surgeon must, however, be comfortable
look like seaweed moving around with the fluid flow. When working in a small space to minimize iatrogenic damage to
trauma such as an osteochondral fragment occurs within a the synovial structure and equipment (Figure 45.13c). The
synovial structure, there is initial local inflammation. This flexion or extension of the joint can be subtly changed to see
often leads to hypertrophy and hyperplasia of the synovial if that helps move the villi off of the lesion. However, this
membrane villi. Since many of the osteochondral fragments might make it harder to move around with the instrument.
are at the margins of the joint next to the synovium, it is If possible, the surgeon could temporarily switch to a gas
not uncommon for villi to cover the fragment making it distention medium, such as carbon dioxide. In a fluid
difficult to completely identify its margins (Figure 45.13a). medium, the villi will “float” around, whereas with a gas
This is common with dorsoproximal and palmaro-/ medium, the villi will be pushed to the periphery. However,
plantaroproximal first phalanx fragments, and distal this is dependent upon having the proper equipment and
radius, proximal intermediate and radiocarpal bone the surgeon should understand potential complications of
fragments. This can also occur at the lateral trochlear ridge using a gas medium [6]. If nothing else will work, a partial
of the talus and the femur. synovectomy can be performed to improve visualization.
Inadequate synovial cavity distension with ingress fluid This should only be performed to the extent necessary to
can obscure visualization with synovial villi. This occurs see and approach the lesion, as the synovium does not
mostly commonly in chronic cases where the synovial repair as quickly as it does in other species after
capsule is less pliable and a pressure-driven fluid delivery synovectomy [7]. In addition, a synovectomy will often
system is used (Figure 45.9). The joint reaches maximal cause hemarthrosis (see Section on Hemarthrosis above).
pressure quickly but does not separate the villi from the
bone requiring higher ingress flow. Excessive fluid egress Expected outcome With experience, synovial villi will
can also obscure visualization with synovial villi, since an usually become a temporary nuisance as the surgeon will
adequate pressure cannot be maintained. Adhesions of generally know when it may be a problem and how to work
synovial villi to the bone can also obscure vision. around it. Good triangulation skills are required to
minimize iatrogenic damage to the tissues and equipment.
Prevention It is not possible to know preoperatively every In addition, if the surgeon has the proper equipment and
synovial structure that will have visualization blocked by knowledge to use a gas medium for distention, the villi will
the synovial membrane. Therefore, if present, the surgeon not cause a problem with visualization.
(a) (b)
(c)
Figure45.13 (a) Arthroscopic image of hypertrophic and hyperplastic synovial villi obstructing the dorsal margin of the distal
intermediate carpal bone. (b) A blunt trocar is placed into the joint and is used to push the villi toward the synovial membrane, while
the arthroscope is directed closer to the lesion. (c) The blunt trocar is removed and a Ferris–Smith rongeur is inserted in the same
fashion and slowly positioned so that it can debride the lesion. Note how close the tip of the arthroscope is to the instrument. Source:
Troy N. Trumble and Michael C. Maher.
Fogging This is most common with older equipment in which a

Definition coupler is used to connect the endoscope to the camera.
Fogging creates a general haze to the endoscopic image. Most of the newer models minimize this [6]. The haze
makes it difficult to see inside the synovial structure. It can
Risk Factors happen at any stage of the surgery.
● Using older equipment
● Positioning of the arthroscope in a more dependent Prevention One of the simplest ways to prevent this is to
aspect (upside down so that fluid runs down the scope to upgrade the equipment so there is not a coupler that
the junction with the camera) connects the camera to the endoscope. If this is not possible,
● Bilateral lesion in lateral recumbency (arthroscope usu- one should minimize exposure of arthroscope and camera
ally needs to be held upside down for at least one lesion) connection to moisture. This is best accomplished by
minimizing having the arthroscope upside down as usually
Pathogenesis Fogging is due to condensation at the occurs with a bilateral lesion when in lateral recumbency.
junction of the camera and the arthroscope (Figure 45.14). Therefore, the surgeon should consider dorsal recumbency,
Intra-SynovialInstrumentBreakage
Definition Breakage of an instrument within a synovial
structure
Risk Factors
● Age of instrument
● Improper maintenance (dull)
● Too much force applied to instrument
● Improper instrument selection. Wrong instrument cho-
sen or improper size (usually too small)
● Use of motorized burrs (can damage the tip of the
arthroscope)
● Movement of the horse, especially with standing
Figure45.14 Arthroscopic image of the plantar pouch of a procedures
fetlock. The image quality is not clear and in focus because
condensation or “fogging” is occurring between the connection
of the camera and the arthroscope. Source: Troy N. Trumble and Pathogenesis There are many specialized instruments
Michael C. Maher. available for use in intrasynovial surgery. Selection of
instruments is critical for successful completion of surgery.
especially for bilateral or biaxial lesions. Other ways to However, just like in any surgery that requires the use of
minimize fogging are to use warm irrigation fluids or a instruments, breakage of the instrument in the surgical
camera bag or fluid shield (such as Dry Vu Fluid Shield, field will complicate the surgery. Breakage can occur for a
Cannuflow, Inc., Campbell, CA) that will minimize fluid variety of reasons, ranging from poor maintenance to
accumulation around the arthroscope–camera interface by overzealous use. The main problem with instrument
diverting most away. breakage in a synovial structure is that the surgeon must
stop working on the lesion and focus on removal of the
Diagnosis There is a consistent white haze of the broken instrument before it gets carried away by the
endoscopic image that cannot be improved by changing distention fluid. Occasionally, the instruments can also
the focus or amount of distention. leave behind fine metal debris that is difficult to flush out
of the joint (Figure 45.15).
Treatment Once recognized, the arthroscope should be
separated from the camera and both should be carefully
dried using a 4 × 4 or lap sponge. Anti-fogging solutions are
available (such as Fred™ Anti-Fog Solution, Covidien, LP,
Mansfield, MA) that can be applied to the endoscope–
camera interface, but they are rarely helpful [6]. After
reconnecting, the surgeon should assess the endoscope
position to see how they can minimize further exposure of
the endoscope–camera junction to the egressing fluids. If
further exposure cannot be prevented, warm irrigation
fluids could be used or the camera could be placed in a
sterile bag, or a fluid shield (such as Dry Vu Fluid Shield,
Cannuflow, Inc., Campbell, CA) could be used if available
to divert most fluid away.
Expected outcome In general, with most new equipment,

this is not a major complication. With older equipment, it
can mostly be averted by choosing the best limb position to Figure45.15 Arthroscopic image demonstrating small metallic
debris (arrow) that came off an instrument and is floating
minimize placing the endoscope in a dependent position. around the joint. Due to the sharp edges, it is difficult to flush
Most of the time, it can be controlled by periodic drying of this type of debris out of the joint. This type of debris can come
the endoscope–camera interface. from a curette, as that is shown in Figure 45.2b.
Older instruments will fatigue with repetitive usage and

at some stage will break. This breakage could simply ren-
der the instrument useless, leave a portion in the synovial
structure, or shed metallic debris into the cavity
(Figure 45.15). Instrument breakage often occurs when too
much force or torque is applied to an instrument
(Figure 45.3). This occurs most often when the wrong
instrument is chosen for the job, or when the surgeon tries
to remove too big a fragment for the instruments that are
available (Figure 45.5). When these large fragments are
grabbed by a Ferris–Smith rongeur, the pin that holds the
two jaws together is stressed and can break, leading to sep-
aration of the jaws and potentially losing the pin in the
synovial cavity.
When an instrument is chosen that is not designed for
the intended purpose, breakage is a common sequelae (i.e. Figure45.17 Arthroscopic image of a synovial resector within
the synovial cavity. The resector is too close to the tip of the
using a #11 blade in the synovial cavity instead of a beaver
arthroscope, and the cutting portion of the resector can clearly
or retractable blade: Figure 45.16). Instrument breakage be seen (white arrows). Before starting the resector, the surgeon
(especially the endoscope) may occur if the patient moves must rotate it 180 degrees such that only the sheath can be
while the instrument is within the synovial structure. seen to prevent damage to the tip of the arthroscope. Source:
Troy N. Trumble and Michael C. Maher.
Damage to the tip of the endoscope can occur if the cutting
portion of a mechanical resector faces the endoscope
(Figure 45.17). When the resector is cutting, often some maintenance, such as sharpening, should be periodically
small unpredictable movements can occur, and if the performed, but old or often used instruments that are worn
cutting surface were to bump into the tip of the endoscope, (such as the curette shown in Figure 45.2b) should be
it could damage it such that visualization will become dif- replaced. It is ideal to always have a back-up instrument for
ficult to impossible. the most often-used instruments.
Surgeons can minimize the force and torque placed on
Prevention Equipment should be periodically examined. an instrument. This is most often done by selecting the
This can be done by putting the working portion of the appropriate instrument (and size) for the job. For example,
instrument close to the lens of the arthroscope to determine fixed cutting instruments such as beaver blades should be
if there are signs of excessive wear (Figure 45.2). Proper used rather than disposable cutting instruments (such as
#11 blades). In addition, in general, the bigger the lesion or
fragment, the bigger the instrument required. Large frag-
ments should be divided into smaller fragments for
removal, when possible (Figure 45.18). Finally, caution
should be used with the motorized resector, such that the
cutting surface faces away from the tip of the endoscope
prior to use.
Diagnosis An instrument breaks during use, sheds

metallic debris into the synovial structure, or damages the
tip of the endoscope
Treatment The movement of the distention fluid will

make the broken instrument move away from the tip of
the endoscope as the endoscope approaches the broken
piece. Therefore, ingress fluids should be turned down or
Figure45.16 Arthroscopic image of a broken #11 blade in the off in an attempt to keep broken instruments within the
palmar aspect of a metacarpophalangeal joint. The white arrows
visual field. If the intrasynovial portion of the instrument
point out where the blade was broken and the black arrow
points out the apex that is cutting into the cartilage. Source: is out of view, it will often be found in the most dependent
Troy N. Trumble and Michael C. Maher. part of the joint due to gravity. This will also occur if using
should be chosen. Remove any debris manually, if possible,

without creating iatrogenic damage. At the time of
identification as well as at the end of surgery, the synovial
cavity should be flushed under high flow/pressure to force
as much of the debris out of the cavity as possible.
However, due to the often jagged edges of this debris, most
will get caught in the synovial membrane instead of
flushing out of the joint.
Expected outcome Usually no direct morbidity results from

broken instruments, unless they are left in the intrasynovial
cavity. Usually, the morbidity is indirect because surgery
time is increased to remove the broken instrument. Quick
action to remove the broken instrument is paramount for
minimal morbidity. When instruments shed metallic debris
Figure45.18 Arthroscopic image of a large free-floating into the synovial cavity, this is usually harder to remove as
fragment in a femoropatellar joint that is being divided into
the debris usually does not completely flush out. Most will
smaller fragments by gently tapping an osteotome into the
middle of it so that it can be removed in smaller pieces. Source: be trapped by the synovial villi causing a minor local
Troy N. Trumble and Michael C. Maher. reaction, but with no known sequelae beyond effusion. It is
best for the surgeon to have multiple different types of
a gas medium for distention. Radiographs can help locate well-maintained instrumentation that can be used for
radio-dense materials if a quick but thorough evaluation multiple different jobs. Simple examples of this would be a
of the synovial structure fails to identify the broken set of multiple Ferris–Smith rongeurs that have different-
instrument. Needles can be used to help identify the sized openings and angles, as well as multiple different-
location of a broken instrument, or to trap it in a certain sized and angled curettes. They should be sharp and should
location so that it can be removed. If necessary, an be regularly checked for defects. The surgeon should look
additional instrument portal can be made to remove an closely at their case load in a given area and determine
intrasynovial object (Figure 45.19). This is often best so what instruments are most crucial for the types of lesions
that the broken instrument can be directly approached they will encounter most often. In addition, even if they do
rather than trying to perilously grasp it at an odd angle not see certain types of lesions often, they should consider
using existing portals. If metallic debris is discovered in a what types of instruments could be used in multiple ways
joint (Figure 45.15), the inciting instrument needs to be (such as a mechanical resector) or that would be extremely
removed from the surgery table and a new instrument useful for a given scenario (such as beaver blades). Too
often, instrument breakage occurs when trying to use the
wrong instrumentation for the job because the practice
cannot, or will not, purchase some specialty instruments
that would prevent the surgeon from reaching for an
inadequate tool.
Free-FloatingFragments
Definition Fragments within a synovial structure that are
not attached to the parent bone or synovial membrane
Risk Factors
● Large fragment and/or multiple fragments

● Improper instrument used for size of fragment
● Poor portal location for securely grasping fragment
Figure45.19 Arthroscopic image of a new portal created in
● Large joint spaces with dependent locations that frag-
the metacarpophalangeal joint to specifically allow retrieval of
the broken #11 blade shown in Figure 45.17. Source: Troy N. ments can migrate to, such as the suprapatellar pouch in
Trumble and Michael C. Maher. the femoropatellar joint (Figure 45.20)
portal placement for retrieval of the fragment. In other

words, the angle of approach to the fragment is not ideal
for the instruments to be able to securely grasp the frag-
ment. The surgeon could also be too aggressive when loos-
ening up a fragment from the parent bone, such as using a
periosteal elevator to loosen an OCD on the distal interme-
diate ridge of the tibia, or could be overzealous with
debridement without concurrent removal of fragments.
Prevention Fragments should be gently loosened from the

bone or soft tissue. Final loosening can be performed after
the fragment is grasped by rotating or twisting the grasping
instrument. In general, the size of the instrument used to
grasp the fragment should increase as the size of the
fragment increases. It is also ideal to have specialty
instruments such as up-angle or down-angle rongeurs that
could allow adequate access to the fragment when the ideal
portal cannot be created, or rongeurs with teeth to provide
a more secure hold on the fragment. The surgeon should
wait to remove large fragments until the end of the surgery
(i.e. remove small fragments first). This will allow the
Figure45.20 Intraoperative radiograph of a right stifle after surgeon to make the instrument portal bigger without risk
removal of OCD fragments from the lateral trochlear ridge of of losing distention for the remainder of the surgery. Large
the stifle. The radiograph is positioned as it would be seen at
fragments can be divided into smaller pieces for removal by
the time of surgery, to point out that free-floating fragments will
drop to dependent locations (arrows), especially in large joints gently using an osteotome (Figure 45.18). In addition, the
such as the femoropatellar joint. Source: Troy N. Trumble and surgeon should ensure that the fragment can be securely
Michael C. Maher. grasped via the current instrument portal, and if not, then
a new instrument portal should be created. Finally,
Pathogenesis Fragments within a synovial structure may fragments will float to dependent portions of the synovial
be naturally free-floating as a result of being mechanically structure if too much bone is debrided without subsequent
separated from the parent bone. Usually small fragments removal.
become synovialized (synovial membrane “catches” the
fragment and slowly tries to digest it), so that they may
appear to be free-floating on a radiograph. The relative
position of these fragments will not change however, as the
limb position is changed, whereas free-floating fragments
will move. Usually larger fragments will be free-floating
and the surgeon should remember that they may change
position when the horse’s position is changed while
anesthetized. Therefore, radiographs are recommended
after the horse is positioned on the table.
From a technical standpoint, it is also common to cause
fragments that are naturally attached to the parent bone to
become free-floating fragments when trying to remove
them from the joint. This type of fragment will be the focus
of this section, as similar to broken instruments, this is a
major complication since the surgeon must immediately
focus on finding the fragment and figuring out how best to Figure45.21 Arthroscopic image of a fragment that is too
remove it. Often, this occurs when using too small of an large for the portal size. If the portal size is not enlarged, then
there is a high risk of losing at least a portion of this fragment
instrument to grasp a large fragment or trying to remove a
when trying to pull it out through the small portal. This will
large fragment through a small portal incision result in a free-floating fragment. Source: Troy N. Trumble and
(Figure 45.21). However, this could also occur from poor Michael C. Maher.
Diagnosis A fragment of bone is identified in the synovial

cavity and is mobile.
Treatment Most of the time, it is easy to recognize when

fragments become free-floating at the time that it occurs
and treatment should begin immediately. The movement
of the fluid will make the fragment move away from the tip
of the endoscope as the endoscope approaches the
fragment. Therefore, ingress fluids should be turned down
or off in an attempt to keep fragments within the visual
field. If the fragment is out of view, it will often be found in
the most dependent part of the joint due to gravity
(Figure 45.20). This will also occur if using a gas medium
for distention. Radiographs can help locate fragments, if a
quick but thorough evaluation of the synovial structure
fails to identify the fragment. If necessary, additional Figure45.23 Arthroscopic image of a large loose fragment
that was identified radiographically using a needle. The needle
endoscopic and instrument portals may need to be made to
was then used to help trap the fragment in place by pushing it
remove fragments, especially in joints with dorsal/cranial into the fragment, pinning it against the synovial membrane
and palmar/plantar/caudal pouches (Figure 45.22). until a new portal could be made to directly retrieve the
Needles can be used to help identify the location of a fragment. Source: Troy N. Trumble and Michael C. Maher.
fragment, or to trap it in a certain location so that it can be
removed (Figure 45.23) via creation of a portal that can try to break up the fragments into smaller pieces that can
directly grasp the fragment. If fragments are in a difficult then be sucked up by the suction attached to the resector.
location to reach, the mechanical resector can be used to Care must be taken with this approach to not create any
iatrogenic damage.
Expected outcome Usually no direct morbidity results from

free-floating fragments, unless they are left in the
intrasynovial cavity. Free-floating fragments, especially
small ones, will create score lines in the cartilage as they
are loaded between the cartilage surfaces. These score lines
often become full-thickness lesions (Figure 45.9). This is
why it is important to document that no further fragments
are present via intraoperative radiographs and to lavage the
synovial structure thoroughly before closing. Some free-
floating fragments may get trapped by the synovial villi
causing a minor local reaction, but with no known sequelae
beyond effusion. Usually, with free-floating fragments, the
morbidity is indirect because surgery time is increased to
remove the fragment/s. Therefore, quick action to remove
the fragment is paramount for minimal morbidity.
IatrogenicDamage
Definition Damage induced by the surgeon during the
course of surgery
Figure45.22 Intraoperative radiograph of a tarsus with the
arthroscope placed in the tarsocrural joint. The radiograph is
positioned as it would be seen at the time of surgery. Please Risk Factors
note that the fragment in the proximal intertarsal joint was
● Poor portal placement
there preoperatively, but the ones in the plantar pouch occurred
during surgery, thus requiring new portals to retrieve the ● Poor triangulation technique
fragments. Source: Troy N. Trumble and Michael C. Maher. ● Poor visualization
● Aggressive insertion of endoscope or instruments

● Horse movement during surgery (under general anes-
thesia or standing)
● Incorrect use of instrument (especially with motorized
resector)
● Using an inferior instrument for the job (such as using a
#11 blade instead of a beaver blade)
Pathogenesis Iatrogenic damage refers to that induced by

the surgeon during the course of surgery (Figures 45.24
and 45.25). This is most often described as damage to the
intrasynovial structures, but could also be extrapolated to
equipment damage (most often damage to the lens of the
endoscope from an instrument: Figure 45.1). Iatrogenic
damage can be created in the soft tissue or bone. For
instance, it can include laceration of an artery, overzealous Figure45.25 Arthroscopic image of needle insertion into a
synovectomy, score line/s to cartilage, debriding normal septic joint. Note that the needle was inserted too deeply and
lacerated the cartilage surface. Source: Troy N. Trumble and
structures (such as synovial fossa), and overzealous Michael C. Maher.
debridement of bone.
Inadequate knowledge of the anatomy in and surround-
ing the synovial structure can lead to poor portal place- see and maneuver, which could result in damage to intra-
ment, which can damage soft tissue structures such as synovial structures. A simple example would be a portal
vessels (especially with tarsocrural joints, digital tendon placed too abaxial in the tarsocrural joint for a distal inter-
sheaths, and navicular bursas). This would also make visu- mediate ridge lesion, leading to the arthroscope and/or
alization difficult (see Section on Hemarthrosis above). By instrument being leveraged on a trochlear ridge.
not correctly understanding intrasynovial anatomy, the Blind entry with poor distention can also cause iatro-
surgeon may misinterpret normal structures (i.e. manica genic damage. This can occur if the endoscopic portal is
flexoria) as lesions and debride them. not maximally distended, or if incorrectly aimed into the
Poor portal placement can also lead to iatrogenic damage synovial cavity. For example, in the carpal joints, the trocar
in a synovial structure. For example, if the portal place- should not be inserted perpendicular to the incision, as
ment makes triangulation difficult, the surgeon is then that will damage vital cartilage. Instead, it should be
often using the instruments in locations that are difficult to directed more medial or lateral. In addition, incisions may
be blindly created for instrument portals. This often occurs
when the horse is in lateral recumbency and the dependent
incision is created, putting neural and vascular structures
at risk of injury.
Common technical issues that lead to iatrogenic damage
include trying to do too much with an inadequate instru-
ment, or trying to debride or grab fragments that cannot be
seen, either due to visualization issues (see Section on
Visualization above), triangulation issues (see Section on
Triangulation above), or size. Instruments that are too small
for a job can slip off and create further damage, or break
unexpectedly (see Section on Intrasynovial Instrument
Breakage above). Instruments that are too big will often
debride more tissue than intended. Similarly, curettes that
are too dull will often slip because they will not dig into the
lesion as they should, or dull rongeurs will not cut appropri-
Figure45.24 Arthroscopic image of a tarsocrural joint after ately, creating more damage to the tissues (Figure 45.4). In
debridement of a distal intermediate ridge of the tibia OCD
addition, more aggressive instruments, such as a motorized
lesion. Note the full thickness iatrogenic lesion that was created
on the talus during debridement. Source: Troy N. Trumble and resector or radiofrequency equipment, can cause extensive
Michael C. Maher. damage quickly if not utilized properly.
Prevention Generally, less experienced surgeons are going such as this. Iatrogenic damage should be honestly assessed
to have more iatrogenic lesions than more experienced and reported to the client and the surgeon should make an
surgeons. Practice on cadaver limbs, when possible, will effort to learn from the case as to how to reduce future
help minimize some of this damage. This not only includes damage in similar cases. The best treatment is prevention
portal placement and triangulation, but also using more via knowledge and experience.
advanced instruments such as a motorized resectors or
radiofrequency probes. This will help with knowledge of Expected outcome Because the anatomy of the joints,
the anatomy such that portal placement stays away from sheaths and bursas are all different, it is important that the
neural and vascular structures, and adequate triangulation surgeon has been trained and has experience performing
is created to allow adequate visualization and free the surgeries in all areas. Being able to diagnose damage
movement of the endoscope and instruments. that occurs to the normal anatomy usually depends on the
The endoscopic sleeve should be inserted with a blunt anatomical structure that is injured. For instance, if a
trocar in the proper orientation. This can be facilitated by vessel is transected during portal placement (such as the
using a #11 scalpel blade to make a small cut into the syno- saphenous when making a portal for the tarsocrural joint),
vial capsule so that the sleeve/trocar can easily enter the it is easy to diagnose since bleeding will occur. However,
synovial structure and be directed toward a region where it when a nerve is transected inadvertently, immediate
will create the least damage upon entry (e.g. in the dorsal diagnosis is much more difficult. Iatrogenic damage inside
fetlock, aim entry toward the villonodular pad). When a synovial structure can, and should be, documented
making the instrument portal, a needle should be used first provided there is adequate visualization. Monitoring
to determine if that location will provide the best triangula- damage to the anatomy is only as good as the surgeon’s
tion and access to the lesion. Upon needle removal, a #11 understanding of that anatomy. How can damage be
scalpel blade can be used to make the portal into the syno- monitored if one is not aware that there is anything there to
vial cavity under endoscopic visualization to control depth damage? Conversely, iatrogenic damage is easy to monitor
and angle of blade insertion. If a portal is created that does and even inexperienced surgeons can usually tell the
not allow ideal access to the lesion, re-assess to determine difference between naturally-occurring lesions and
if another portal would be better to help minimize iatro- iatrogenic ones (Figures 45.24 and 45.25). Nonetheless, the
genic damage. surgeon should do their best to understand and document
In general, it is always best to have an instrument com- any damage that may have resulted to the normal anatomy
pletely in sight before cutting, debriding, or biting a frag- as a result of their surgery. Often, there is not much that
ment, as this will minimize any residual damage. When can be done to treat or solve damage to the normal anatomy.
debriding cartilage with a curette, damage to the adjacent The surgeon should document any damage present as best
bone can be avoided by curetting toward the synovium as possible; they should not try to act like it did not happen
rather than toward the bone (Figure 45.2b). Ideally, the or was part of the naturally-occurring disease process.
curette should also be aimed away from the endoscope to
minimize damage to the tip of the scope. When using a
mechanical resector, the cutting edge should always face PostoperativeComplications
away from, and be as far away from the endoscope as pos-
sible, as the movement created by this instrument is often Early:Myopathy/Neuropathies
erratic when first engaged and can easily bounce into the
Definition The inability to properly use a limb or limbs
lens of the endoscope.
due to muscle or neural problems, most often related to
limb position/manipulation while on the table
DiagnosisDamage identified to a synovial structure after
debridement that was not present prior to debridement.
Risk Factors
Treatment Once it is recognized that an iatrogenic lesion ● Poor positioning/limb manipulation or padding
is being created, the surgeon should immediately re-assess ● Hypotension while under general anesthesia
the situation and determine why the damage is occurring ● Prolonged anesthesia
and should take corrective measures to prevent any further
damage. The surgeon should identify, document, and Pathogenesis Myopathies can affect a group of muscles or
debride any created lesion accordingly, if necessary. Not all can be a general myopathy. It usually occurs due to
lesions will need to be treated in the same way, so it is hypotension, abnormal loading of a muscle group due to
impossible to state what exactly should be done in a review positioning, or time of anesthesia. Neuropathies, on the
other hand, typically occur when there is focal pressure typically responds favorably over a few days of treatment.
over a peripheral nerve due to poor positioning, padding, Focal neuropathy may be temporary, but can take up to
or limb manipulation. In general, either can occur from a 10–14 days to improve function. If the myopathy affects
lack of support for a limb. For example, when performing more muscle groups, the prognosis for normal use of the
femoropatellar arthroscopy, if the hindlimbs are extended limb is much worse. Similarly, if a neuropathy does not
without support, there is increased pressure placed on the respond in 2 weeks, the prognosis is worse.
quadriceps and/or femoral nerve. In addition, changing
limb position during surgery by either the horse moving Inadequate removal/debridement
while under anesthesia, or by the surgeon’s volition, can Definition
result in loss of padding and protection initially established Inadequate removal or debridement of bony fragments
when the horse was placed onto the surgery table. identified on postoperative radiographs
Prevention The best way to prevent myopathies/ Risk Factors

neuropathies is to not anesthetize the horse and perform
surgery standing. However, the surgeon must have ● Multiple intrasynovial fragments
adequate skill to complete surgery standing and the horse ● Arthroscopy of large volume synovial cavities where
must be a good candidate based on the lesion location and debrided fragments may be hard to flush out (i.e. femoro-
behavior. Otherwise, once the horse is under anesthesia, patellar joint)
the surgeon should be quick and decisive in surgery to get ● Poor preoperative planning regarding what radiographic
the horse off the table as fast as possible. The horse should changes are actual lesions versus artefact, as well as
be monitored for hypotension and treated as necessary those that are intracapsular versus extracapsular
while also ensuring adequate positioning, padding, and ● Loose fragments that appear to be located in the middle
limb support during surgery. If the limb is to be manipulated of the synovial cavity on preoperative radiographs and
during surgery, care should be taken to make sure that it do not move much with flexion or extension
does not affect the padding/protection that was initially ● Poor triangulation, such that the entire joint cannot be
established. In addition, if the horse moves while under adequately examined
anesthesia, its positioning should be re-evaluated once it ● Poor visualization, such that surgeon cannot tell if
stops moving. debridement is adequate, or if debris has been adequately
collected
Diagnosis Inflammation/damage to muscles or nerves ● Not taking intraoperative radiographs
that result in a horse being reluctant or unable to stand
from recovery, or painful on a limb(s) after standing, such Pathogenesis Even if intraoperative radiographs are taken,
that it is unable to appropriately support weight and/or postoperative radiographs can identify inadequate removal
advance that limb(s). or debridement of bony fragments. This could be related to
the lesion of interest, or could be due to bone debris that
Treatment For a focal myopathy, the affected muscle group was debrided from the lesion but was not appropriately
is firm and painful. Depending on the muscle group or flushed from the synovial cavity. The debris can occasionally
groups affected, this might affect recovery. The horse may be missed on intraoperative radiographs, especially if they
be reluctant to stand, cannot stand up, or can stand up, but focus on just the lesion of interest and do not show the
acts painful on the limb and will not bear weight. For a entire joint. An example of this would be collection of
neuropathy, depending on the peripheral nerve affected, fragments in the suprapatellar pouch of the femoropatellar
the horse will be unable to appropriately support weight after debridement of the lateral trochlear ridge of the femur
and/or advance that limb. Radiographs may need to be (Figure 45.20).
taken to rule out a fracture. The extent of treatment depends Inadequate knowledge of the anatomy can lead to inad-
on the severity of the myopathy/neuropathy. Briefly, anti- equate removal and debridement. This takes on many
inflammatory therapy should be initiated to decrease forms with regards to this complication. It can be as simple
swelling, pain, and anxiety [11]. If the condition affects as not knowing whether a fragment is intra- versus extra-
ability to support weight or advance the limb, treatment to capsular. If the fragment is extracapsular, the surgeon will
help stabilize the affected limb(s) should be initiated. not be able to debride it without extensive debridement,
and as such, it will still be present on the radiographs. If the
Expected outcome The outcome depends on the extent and portal placement is poor, triangulation will be poor. Poor
severity of the myopathy or neuropathy. Focal myopathy triangulation makes it difficult to fully assess and debride
the lesion of interest and/or assess debris. In the case of Expected outcome The presence of fragments identified in
multiple fragments, it can be difficult to identify all the postoperative period is usually not a favorable outcome
fragments within the synovial cavity, especially if some are for the horse, client, or surgeon, unless adequate
loose bodies. Based on the position of the limb during preoperative discussion was performed establishing the
surgery, the surgeon needs to understand where debris will expectations about what would and what would not be
settle. Some fragments are partially synovialized, which removed. Removal of the fragments is usually easy with
means that the synovium has trapped the fragment in the additional surgery, provided the client will allow the
villi and is starting to slowly digest the bone. These may surgeon to perform surgery a second time.
look like loose bodies but do not move on radiographs
when the limb is manipulated. They can be difficult to Infection: subcutaneous or intra-synovial
identify at surgery. Definition
Contamination of the subcutaneous tissues or synovial
Prevention Good preoperative planning with establishment cavity with enough bacteria to cause variable inflammation
of appropriate expectations of what will and what will not
be removed from the radiographs is the best way to prevent Risk Factors
this complication. This requires identification of all
fragments preoperatively to determine if they are ● Poor aseptic technique
intrasynovial, attached to bone, loose, or partially ● Lack of ability to protect incisions (surgery on highly
synovialized. Multiple radiographs are required with mobile proximal joints such as the stifle)
occasional manipulation of the limb, plus or minus ● Poor recovery/long surgery
ultrasound, or other advanced imaging (CT or MRI). ● Extravasation of fluid
Ultrasound can help identify the location of partially ● Introducing debris into the joint during surgery (such as
synovialized fragments so that a partial synovial resection draping material or hair: Figure 45.26)
(conservative) can be performed in the identified region to ● Bandage slips so rubs on incisions or horse chews on
remove a partially synovialized fragment. In addition, bandage/incisions
intraoperative radiographs of the entire synovial structure
should be performed to ensure that the lesion has been Pathogenesis There are numerous sources of contamination
adequately debrided and that debris has been adequately that can occur when performing synovial endoscopic
removed. If any are identified on intraoperative radiographs, surgery. For instance, this can occur due to poor aseptic
a needle or ultrasound could be used to identify the exact technique, introduction of foreign material during surgery
location of fragments if not easily visualized. Additional (Figure 45.26), from the incisions being exposed immediately
portals in dependent locations should be considered to postoperatively (such as the stifle), from the horse working
remove any remaining debris or fragments. This can be on its bandage, exposing the incisions, or directly biting
combined with lavage under high flow with a large egress
cannula.
Diagnosis The presence of fragments in the synovial cavity

identified via postoperative radiographs compared to
preoperative films.
Treatment The surgeon needs to discuss with the client

the significance of the remaining fragments. If the
fragments are from incomplete debridement of the lesion
or are large/multiple debris fragments, repeat arthroscopy
should be considered. Loose debris can create multiple
scores lines throughout the entire joint, which can
potentially speed up the development of osteoarthritis. If
the fragments are partially synovialized, discussion should
be directed toward how to control inflammation and
effusion. If the fragments are extracapsular, discussion Figure45.26 Arthroscopic image of hair debris (arrows) being
should be had regarding any potential treatment for introduced into the synovial cavity via a rongeur. Source: Troy N.
dystrophic mineralization. Trumble and Michael C. Maher.
incisions. Infection may be contained to the subcutaneous Expected outcome The most common bacterial isolates are
tissues, or can go into the synovial structure. If sepsis Staphylococcus species [2, 3, 14], suggesting skin
becomes established in a synovial structure, this can be life- contamination versus environmental. For septic synovial
threatening. However, the reported risk of septic joints after structures, early detection and treatment are paramount
arthroscopy appears to be <1–2% [4, 12, 13]. for successful management. However, the incidence of
septic arthritis post-elective arthroscopy in horses is low
Prevention Ensure aseptic technique and verify all surgical and the use of perioperative antimicrobial therapy has not
instruments are sterilized appropriately. Make sure all hair been shown to decrease the incidence postoperatively [4,
and other debris are adequately removed during prep. If 12, 13]. Subcutaneous infections rarely result in further
using adhesive drapes, make sure that small portions are complications. Most respond quickly with antimicrobial
not dragged into the joint while placing instruments. Keep therapy, suture removal and careful bandaging. Often, the
surgical portals covered, and minimize touching the main long-term complication is a scar at the incision site.
incisions in first few days postoperatively. Monitor the Rarely does a subcutaneous infection turn into a septic
surgical sites every day to every other day until suture synovial structure [2, 3].
removal. When possible, maintain and monitor the
bandage until suture removal while monitoring the horse Pain
for lameness. Change the type of bandage being used, or
Definition
add deterrents to the bandage so the horse cannot rub
Discomfort that results due to the endoscopic procedure
(Vasoline over top of duct tape) or chew on it (Cayenne
pepper on bandage or cradle around neck).
Risk Factors
Diagnosis Subcutaneous infection manifests as warm, ● Extensive debridement, especially to subchondral bone
painful swelling/edema at or immediately surrounding the ● Prolonged surgery, especially if positioning of the horse
incisions (± drainage) without increased effusion, whereas on the table is not ideal
a septic synovial cavity will have increased effusion and ● Complications as described in this chapter
lameness with an increased synovial fluid total nucleated
cell count (>30,000 cells/μL ± degenerative Pathogenesis Endoscopic surgery usually does not result
neutrophils [14]). in obvious postoperative pain. This does not mean it does
not exist or that the surgeon should not try to help minimize
Treatment Definitive diagnosis would be based on synovial it. In general, excessive debridement of subchondral bone
fluid analysis (± positive culture of bacteria). Keep in mind is reportedly painful in people, and as such is assumed to
that recent arthroscopy can artificially increase total be in the horse as well. Prolonged surgery, which may be
nucleated cell count, but values >30,000 cells/μL should be partly due to complications described in this chapter, can
treated as if the synovial structure is septic. Also, the cause pain from protracted time down.
presence of degenerative neutrophils is also highly
suggestive of sepsis [14]. It should be noted that adult Prevention In general, the surgeon should be able to predict
horses will rarely have a fever due to a septic joint, and that those cases where the horse may require more pain relief
clinical signs of septic arthritis post-arthroscopy have been pre-, peri-, or postoperatively to help prevent wind-up. Ways
reportedly delayed as long as several weeks [4]. Systemic to minimize wind-up include performing surgery as quickly
antibiotics or regional antibiotics should be considered and and efficiently as possible, as well as debride only what is
should be based on cytology/culture when possible. needed; do not be overzealous. Provide pre- or perioperative
Staphylococcus species are the most common type of pain relief by performing perineural or intrasynovial
bacteria in postoperative infections, so initially aim to treat analgesia. This will help minimize pain during surgery,
that [2, 3, 14]. If the infection is maintained in the while also helping reduce the amount of anesthetic required.
subcutaneous tissue, the surgeon could consider removing Administer intra-articular opioids or analgesics at the end of
the suture/s, especially if there is drainage present. If there the arthroscopic procedure so that it helps with recovery and
is even a possibility that the synovial structure is infected, the early postoperative period. Please note that with
then lavage of that structure should be performed as soon bupivacaine administered intra-articularly during suturing,
as possible, either via needles, or endoscopically. one author has noted several horses becoming agitated
Intrasynovial antimicrobials can also be used alone, or in approximately 4–6 hours after administration such that colic
combination with lavage. For more detailed treatment signs had to get ruled out in the early postoperative period.
regimens, please refer to the following reviews [14, 15]. Administer a preoperative epidural for hindlimb surgeries
likely to produce greater pain (especially associated with the effusive due to a low-grade inflammation still being
stifle – lateral trochlear ridge OCD or medial femoral condyle present. Some horses will maintain effusion even though
subchondral bone cysts) [3]. there is no evidence of residual or progressive disease. This
is often referred to as idiopathic and is presumed to be due
Diagnosis Postoperative pain can take on many different to pre-conditioning of the synovial membrane such that it
clinical signs, such as an unwillingness to rise in recovery continues to produce excess synovial fluid.
or to move after recovery, shaking/tremors, going off feed,
being agitated, circling, laying down, moaning, having an Prevention Completely debride the original lesion and try
elevated heart rate, and/or sweating; these signs need to be to avoid creating further iatrogenic lesions to the cartilage,
distinguished from colic and hypothermia created while bone or capsule. Administer anti-inflammatories in the
under anesthesia. postoperative period to help decrease inflammation. Prior
to a return to exercise, administer anti-inflammatories
Treatment The surgeon must recognize and treat any signs such as corticosteroids or hyaluronic acid intra-articularly.
of expected or unexpected pain as soon as possible. Once
identified, appropriate treatment should be administered Diagnosis Postoperative effusion that is the same or worse
to minimize pain. Treatment is usually as simple as than the preoperative baseline
administering non-steroidal anti-inflammatories, but may
require additional therapies; there is not one cure for all Treatment If the original lesion was not completely
horses and as such each scenario must be critically debrided, or if loose fragments are present in the synovial
evaluated. Increasing knowledge about pain in the horse structure such that the horse is still lame, another
and the options for pain relief are becoming available, and endoscopy is likely warranted (see Section on Inadequate
the reader is encouraged to read further for treatment removal/debridement). If the disease has progressed, or a
options [16]. new lesion is present, appropriate surgical and/or medical
therapy should be discussed. Anti-inflammatories can be
Expected outcome Minimal pain is expected with most administered systemically or locally to see if the effusion
arthroscopic surgeries, and in general, it can be easily will decrease. In idiopathic cases, where no known cause
managed if identified early. Therefore, it is best practice if can be identified, atropine can be administered intra-
all horses are closely examined for at least 12 hours articularly (4–20 mg), in an attempt to minimize synovial
postoperatively to identify any unexpected signs of pain so fluid production [17]. This should be used with caution as
that it can be treated quickly. it has been associated with colic.
Late:Synovitis Expected outcome Effusion should eventually reduce after

a successful synovial endoscopy. However, there will be
Definition Joint effusion that persists 2–6 weeks horses where it is maintained or worsens. These cases are
postoperatively usually frustrating for owners/trainers and veterinarians
alike, as persistent effusion can cause lameness as well as a
Risk Factors
cosmetic blemish due to the distention. Being diligent in
● Unresolved disease (such as incomplete removal of frag- trying to identify the cause, as well as being open to trying
ments from surgery) different treatment regimens, is usually necessary to help
● Chronicity of the disease prior to surgery decrease the effusion.
● Progressive disease
● Recommence of exercise too early Cosmesis
Definition
Pathogenesis If the lesion of interest was not completely
The outward appearance and radiographic appearance of
debrided or removed during the initial surgery, effusion
the synovial structure after surgery (i.e. radiographs “clean”
will remain due to the presence of continued inflammation
of any fragments)
from the debris in the joint. If the disease is chronic prior to
surgery, it may take longer for the effusion to dissipate, if Risk Factors
ever. The lesion that was debrided might progress over time
in spite of initial treatment, or a new lesion may develop ● Not establishing appropriate expectations prior to sur-
causing further debris, inflammation, and effusion. If the gery with the owner/trainer with regards to outward and
horse starts exercise too soon after surgery, the joint can get radiographic appearance postoperatively
● Infection and maintaining the best possible bandage for the given
● Inadequate removal of fragments such that effusion individual. In addition, minimize use of adhesives that rip
remains as well as radiographic evidence of fragments more hair from the leg. Show the owner/trainer how to put
(see Section on Inadequate removal/debridement) on the proper bandage that you want on the horse, as most
● Bandage that is poorly placed or maintained of the bandage changes will occur after the horse has left
● Large incision the hospital.
● Poor suturing technique, such that skin is everted or
inverted too much Diagnosis Outwardly different appearance of the synovial
● Suture sinus track creating firm nodule or draining tract structure compared to the other leg or legs, or the presence
● Poor portal placement or over-zealous debridement of of lesions or fragments on postoperative radiographs when
joint capsule leading to synovial herniation the intention of the surgery was to remove them
Treatment It is best to prevent cosmetic issues as much as

Pathogenesis The visual appearance of the synovial
possible, as they are difficult to treat once present. If
structure after surgery may be very important to one
effusion is present due to remaining lesions or fragments,
owner/trainer, while another may not care at all. Cosmesis
another surgery should be performed. It may also be treated
after surgery can take on a couple of different meanings. It
medically with anti-inflammatories if no lesions or
usually refers to the outward appearance of the synovial
fragments remain. Scar tissue may need to be debrided, but
structure including scars, swelling, hair color, herniation,
this will often result in further scar tissue. Change the type
and/or distention. The outward appearance can be affected
of bandage if the horse is not tolerating one type well. For
by infection, suture technique and the bandage. Infection
example, go from a combined bandage to a light wrap with
of the subcutaneous tissues or the synovial structure can
Elasticon, or vice versa. If they are trying to rub the bandage
cause chronic distention, swelling, or scarring due to the
down, put vertical strips of duct tape over the outside of the
pathology present, the need for further therapy and
bandage in the location they are most apt to rub and cover
bandaging. A large incision requires more care with suture
that with Vaseline. If they chew on their bandage, place a
techniques to minimize a visible scar, and also leads to a
spicy or bitter tasting product such as Cayenne pepper on
greater risk of a suture sinus tract from failure to remove
the bandage or place them in a cradle so they cannot bend
the entire suture. A poorly placed bandage can create rub
their neck to the bandage.
sores, swelling, or different color hair growth due to pulling
out hairs with the tape. In addition, bandages can be placed
Expected outcome The surgeon can do a great job with the
well, but the horse can rapidly change its position due to
surgery, but can ultimately lose the client based on cosmetic
excessive leg movement, rubbing it on the stall or with the
issues. In the authors’ experience, many of the cosmetic
other leg, or chewing at it.
issues can be dealt with prior to surgery by establishing
Cosmesis can also refer to the radiographic appearance
realistic expectations. If unexpected cosmetic issues
of the synovial structure after surgery. The surgeon may
appear, it is very difficult to make them better. Often the
have removed all of the pertinent aspects of the lesions
bandage can be a source of much of this, and can be
such that the horse can perform with no issues, but if the
frustrating to the surgeon, because it is usually because of
owner/trainer wanted the radiographs to be clean after
how the horse wears the bandage or how the owner/trainer
surgery, and they are not, this surgery may be considered a
changes the bandages after the horse leaves the hospital.
failure. In addition, inadequate removal of fragments may
continue the production of synovial fluid due to the debris
Osteoarthritis/enthesophytes/dystrophic
and inflammation that remains in the joint, causing a poor
mineralization/fibrotic capsule
visual appearance due to increased effusion.
Definition
Months to years after synovial endoscopic surgery, a horse
Prevention Establish expectations as best as possible
develops clinical and/or radiographic evidence of osteoar-
preoperatively with the owner/trainer so that they have a
thritis, enthesophytosis, dystrophic mineralization of soft
realistic understanding of what the surgeon can or cannot
tissue, or fibrosis of the joint capsule.
remove or change with surgery. Take intraoperative
radiographs to make sure all lesions were adequately
Risk Factors
debrided and fragments removed. If a complication occurs
during surgery or afterward (such as how well the horse ● Unresolved disease (such as incomplete removal of frag-
wears a bandage), describe the potential sequelae as clearly ments from surgery), especially those that create score
as possible. Protect incisions as well as possible by placing lines in the cartilage
References 627
● Chronicity of the disease at the time of surgery soon, which is often out of the surgeon’s control. Rarely do
● Progressive disease these horses have any issue related to the surgery in the
● Recommence of exercise too early short term, but they may speed up the development of any
● Postoperative infection post-traumatic osteoarthritis development by not letting
● Over-zealous debridement, especially at the joint cap- the inflammation decrease.
sule or soft tissue, leading to fibrosis or dystrophic
mineralization Prevention It is impossible to prevent most of these
● Multiple surgeries changes from occurring over years, but the best way to
prevent any of these changes over months is to perform
Pathogenesis In most instances, these complications surgery at the highest standard, minimizing the
could likely be predicted based on the disease present at the complications discussed in this chapter. Surgery should be
time of surgery, or the amount of debridement that was performed as early as possible after the disease has been
needed during surgery. After all, most injuries treated identified, to minimize the development and progression
using synovial endoscopic surgery are traumatic in nature. of degradative changes.
Occasionally, however, the cause can be related to a new
injury or is of unknown origin. Diagnosis Clinical and radiographic examination usually
Most of the time, it is possible to completely resolve the reveal synovial effusion and lameness of varying degrees
problem that the horse went to surgery for, since many with the development of osteophytes, enthesophytes, and/
arthroscopic surgeries are for removal of incongruent frag- or dystrophic mineralization that is different from the
ments that create inflammation and pain. However, some- original preoperative radiographs.
times the chronicity of the disease is such that the surgeon
can only help a little. These horses will progress. However, Treatment Treatment varies greatly on the amount of
there are other instances where the surgeon can contribute change and disease present. Sometimes, further surgery is
to progression of the disease by having many of the compli- required, but other times further surgery may only
cations mentioned in this chapter (such as creating iatro- aggravate the problem (such as further debridement of
genic damage, overzealous debridement, leaving fragments enthesophytes). Therefore, this is a case-by-case situation.
behind, etc.). Many fragments can extend to the joint cap- Anti-inflammatories or other medical therapies may be
sule connections. If the capsule is inadvertently debrided considered. In addition, rehabilitation exercises, or other
excessively, it is not uncommon to develop fibrosis of the sports medicine related treatment modalities (i.e.
capsule and enthesophytes, that when combined may limit therapeutic ultrasound, shockwave, acupuncture, etc.)
the range of motion of the joint. In addition, occasional may need to be considered.
debridement of soft tissue can lead to dystrophic mineraliza-
tion of the structure. Multiple surgeries will often result in Expected outcome Most horses that are operated on using
fibrosis of the capsule, at a minimum, due to the multiple synovial endoscopic surgery will recover with minimal
incisions over time. Postoperative infection can cause severe issues and perform as expected for years. However, there
inflammation in the synovial cavity leading to a degradative will be horses that develop new problems or worsen their
state. The longer this goes on, the worse the changes that old condition. Often it is hard to blame the original surgery,
will occur, and the harder it will be to help those horses but at the same time, it is hard to prove that the surgery did
Synovial endoscopic surgery has helped horses to recover not at least lead to some of the issues. In general, the more
quicker from injury and surgery, such that they can return complications that the surgeon experiences during the
to performance quicker than previous arthrotomy tech- surgery, the more the surgery itself will be blamed, fairly or
niques. However, there are some horses that return too unfairly.
References
1 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). 2 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
Introduction. In: Diagnostic and Surgical Arthroscopy in Problems and complications of diagnostic and surgical
the Horse, 4e (ed C.W. McIlwraith, A.J. Nixon, and I.M. arthroscopy. Introduction. In: Diagnostic and Surgical
Wright), 1–4. Elsevier. Arthroscopy in the Horse, 4e (ed C.W. McIlwraith, A.J.
Nixon, and I.M. Wright), 419–425. Elsevier.
3 Goodrich, L.R and McIlwraith, C.W. (2009). 10 Allum, R. (2002). Complications of arthroscopy of the
Complications associated with equine arthroscopy. Vet. knee. J. Bone. Jnt. Surg. – Series B. 84: 937–945.
Clin. N. Am. Equine Pract. 24: 573–589. 11 Bettschart-Wolfensberger, R. (2012). Recovery from
4 Olds, A.M., Stewart, A.A., Freeman, D.E. et al. (2006). anesthesia. In: Equine Surgery, 4e (ed J.A. Auer and J.A.
Evaluation of the rate of development of septic arthritis Stick), 246–253. Elsevier.
after elective arthroscopy in horses: 7 cases (1994–2003). 12 Stockle, S.D., Failing, K., Koene, M. et al. (2018).
J. Am. Vet. Med. Assoc. 229: 1949–1954. Postoperative complications in equine elective, clean
5 Wilson, D.G. (1989). Synovial hernia as a possible orthopaedic surgery with/without antibiotic prophylaxis.
complication of arthroscopic surgery in a horse. J. Am. Tierarztl Prax Ausg G Grosstiere Nutztiere. 46: 81–86.
Vet. Med. Assoc. 194: 1071–1072. 13 Borg, H. and Carmalt, J.L. (2013). Postoperative septic
arthritis after elective equine arthroscopy without
6 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015).
antimicrobial prophylaxis. Vet. Surg. 42: 262–266.
Instrumentation. Introduction. In: Diagnostic and
14 Morton, A.J. (2005). Diagnosis and treatment of septic
Surgical Arthroscopy in the Horse, 4e (ed C.W.
arthritis. Vet. Clin. N. Am. Equine Pract. 21: 627–649, vi.
McIlwraith, A.J. Nixon, and I.M. Wright), 5–27. Elsevier.
15 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. ed.
7 Frisbie, D.D. (2012). Surgical treatment of joint disease. (2015). Endoscopic surgery in the management of
In: Equine Surgery, 4e (ed J.A. Auer and J.A. Stick), contamination and infection of joints, tendon sheaths,
1123–1130. Elsevier. and bursae. In: Diagnostic and Surgical Arthroscopy in
8 McIlwraith, C.W., Nixon, A.J., and Wright, I.M. (2015). the Horse, 4th edition. 407–418. Elsevier.
General technique and diagnostic arthroscopy. In: 16 Guedes, A. (2017). Pain management in horses. Vet. Clin.
Diagnostic and Surgical Arthroscopy in the Horse, 4e (ed N. Am. Equine. Pract. 33: 181–211.
C.W. McIlwraith, A.J. Nixon, and I.M. Wright), 28–44. 17 Kirker-Head, C.A. and Feldmann, H. (2014).
Elsevier. Pharmacotheraphy of joint and tendon disease. In:
9 Phillips, B.B. (2013). General principles of arthroscopy. Equine Sports Medicine & Surgery Basic and Clinical
In: Campbell’s Operative Orthopaedics, 12e (ed S.T. Sciences of the Equine Athlete, 2e (ed K.W. Hinchcliff,
Canale and J.H. Beaty), 2364–2378. Philadelphia, PA: A.J. Kaneps, and R.J. Geor), 473–502. United Kingdom:
Elsevier. Saunders.
629
46
Complicationsof EquineOrthopedicSurgery
Kyla F. Ortved DVM, PhD, DACVS, DACVSMR and Dean W. Richardson DVM, DACVS
New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett, Square, Pennsylvania
Overview ○Incorrect screw length

○Incorrect screw positioning
○ Thermal injury
Complications are inevitable in any type of surgical inter-
vention. Unfortunately, the margin for error in equine – Complications of plate fixation
○ Inadequate metal
orthopedic surgery is incredibly low, which means small
○ Introgenic damage
mistakes can lead to big problems. Unlike human patients,
horses cannot be directed to have controlled rest following ● Osteosynthesis: Common complications in specific ana-
orthopedic repairs. Furthermore, delayed weight-bearing tomic sites
in any limb greatly increases the risk of supporting limb
– Condylar fractures
laminitis. The overarching goal of equine fracture repair is
○ Medial condylar fractures
immediate postoperative stability, because that affords
○ Lateral condylar fractures
optimal comfort and any horse that can stand has a chance
– Third carpal slab fractures
to heal. Accurate restoration of anatomy, i.e. perfect
– Sagittal fractures of the proximal phalanx
reduction, is another very important goal, because it has
– Ulnar fractures
the best chance of yielding a horse with adequate or even
– Pastern arthrodesis
normal athletic function. Complications of orthopedic
– Fetlock arthrodesis
surgery can only be minimized by limiting errors during
○ Technical errors
preparation/planning, intraoperative technique and
postoperative management. ● Osteosynthesis: Recovery and postoperative
complications
– Cast complications
L ○ Cast sores
with EquineOrthopedicSurgery ○ Cast-associated fractures
○ Broken casts
● Osteosynthesis: Preoperative patient preparation to – Complications secondary to cast immobilization

decrease risk and complications ○ Weakness of structural tissues
● Osteosynthesis: Intraoperative complications – Complications secondary to cast removal

– Complications of lag screw fixation – Tranfixation pin cast complications
○ Inadequate fracture reduction ○ Thermal injury
○ Failure to compress fractures even though the lag ○ Pin tract infection
screw tightens well ○ Pin loosening
○ Broken bits and taps ○ Fractures associated with transfixation pin casts
○ Broken screws – Postoperative lameness

○ Stripped screws – Supporting limb laminites
○ Stripped screw heads – Postoperative infection
630 Complications of quine rthopedic Surgery
steosynthesis:PreoperativePatient
O occurred during shipping. Intraoperative surprises are not
Preparationto DecreaseRisk usually a good thing. Avoiding complications means avoiding
and Complications mistakes so it is critical that radiographs are of good quality
and complete. It is folly to assume that a proximally propagat-
Proper planning is key to minimizing risk and complications ing fracture going to the edge of the image will necessarily
in equine orthopedic surgery. Regardless of the injury, time progress in the direction you predict. Imaging must ade-
should be given to accurately assess the patient through a quately extend above and below the injured site. The selec-
careful physical examination, administration of preopera- tion of views (obliques, tangentials, flexed) should be such
tive medications, and to meticulous surgical planning. that the surgeon is as confident as possible that he/she under-
Many orthopedic injuries are presented to the orthopedic stands the injury. Fracture lines that disappear radiographi-
surgeon as an emergency. Despite the seemingly urgent cally without exiting through a cortex, such as a spiraling
nature of the injury, thorough examination of the patient medial condylar fracture or many ostensibly simple P1 frac-
as a whole, with special attention to the orthopedic issue, tures, are ideal candidates for three-dimensional imaging.
should be performed well before surgery. Although it is Three-dimensional imaging is tremendously advanta-
easy for the surgeon to focus exclusively on the geous in most equine fractures, especially complex, com-
musculoskeletal system, the systemic health of the patient minuted fractures. The use of preoperative and/or
is also vital for a good operative outcome. For example, a intraoperative computed tomography (CT) should be
racehorse presenting with a condylar fracture that trained strongly considered in any hospital with a CT unit available
earlier in the day may require fluid replacement prior to (Figure 46.1). Currently, the availability of standing CT is
surgery, due to dehydration and exhaustion associated limited, thus requiring horses to be placed under general
with training and shipping. The majority of horses with anesthesia for placement into the CT gantry. As standing
orthopedic injuries can be safely stabilized for 24–48 hours CT become more widely available, this may aid in
prior to surgery. Rushing horses to surgery can lead to preoperative planning as fractures can be evaluated well
oversights in planning and can unnecessarily stress before surgery (Figure 46.1). This technology will also
animals, leading to difficult recoveries from anesthesia. decrease anesthesia time and allow for imaging of more
Preoperative assessment of the patient should include proximal fractures than currently feasible with traditional
packed cell volume and total protein measurements at a CTs. No matter what CT technology is used, modern
minimum in order to assess hydration. Complete blood hospital designs should attempt to integrate CT imaging
count, fibrinogen, and serum amyloid A can be performed, with the operating theater. An accurate analysis of
especially if there is any concern regarding underlying infec- preoperative images is essential to minimize intraoperative
tion. Serum biochemistry is useful to assess electrolyte levels problems. It can be very difficult to do an optimal repair if
and renal function in horses that have trained intensely, you have the horse in the wrong recumbency or make your
been shipped long distances prior to presentation, or in incision in a place that simply makes things more difficult.
horses with known comorbidities. Careful inspection of the Following initial assessment of the horse, stabilization of
injury site is important to determine if the fracture is open or the affected limb is often indicated. First aid should aim to
closed, as this will affect prognosis and will guide timing of decrease pain and allow some use of the limb without pro-
antimicrobial administration. Bandages and splints should moting further damage to the fracture site or neurovascular
be removed upon presentation if there is a concern that the structures [1]. One of the best ways to minimize complica-
fracture may be open or could have become open during tions in an orthopedic injury is to keep the fracture as simple
transport. Additionally, the horse should be assessed for con- as possible before your repair. The surest way to make any
current lacerations or lesions, as these can affect surgical fracture more difficult (and far more expensive) is to damage
approaches and prognosis considerably. overlying skin and soft tissue. Proper coaptation also can
Preoperative diagnostic imaging is vital to assess the ortho- minimize eburnation of fracture ends; sharp/jagged edges
pedic injury and to create an appropriate plan. Two- are much easier to anatomically reduce than those that have
dimensional imaging techniques, including plain radiography been rubbed smooth during transportation and preparation
and ultrasonography, are adequate for most orthopedic inju- for surgery. Horses with unstable fractures are often pan-
ries but more advanced imaging, especially computed tomog- icked and sedation should be administered to help prevent
raphy, is becoming (and certainly will become) the standard further injury. Sedation allows for a more thorough exami-
of care for complex fractures. Horses often present to the sur- nation of the horse and facilitates radiography and external
geon with previously obtained radiographs, but it is usually coaptation (bandages or splints). Typical α-2 agents (xyla-
prudent to take another set of radiographs following presen- zine, detomidine) are generally best. Use step-wise doses as
tation in case any changes in fracture configuration have needed to avoid ataxia in adults. In foals, however, higher
steosynthesis: Preoperative Patient Preparation to ecrease isk and Complications 631
(a) longitudinally unstable cannon bone fracture should be

bandaged ground to elbow with at least two longitudinal
splints, but routine condylar fractures need only a simple
well- (but not excessively) padded bandage. Simple
prefabricated splints, for example Kimzey LifeSaver
(Figure 46.2), that hold the fetlock in a longitudinally
aligned position, are perfect for unstable fetlock injuries
such as avulsed distal sesamoid ligaments, displaced
fractures of both sesamoids or extensive palmar metacarpal/
metatarsal soft tissue injury. Allowing excessive fetlock
“drop” can stretch the major blood vessels of the foot. If a
(b)
prefabricated splint is not available, a stave of thick-walled
PVC pipe can be positioned over the dorsal hoof up to the
proximal metacarpus/metatarsus and then the heel is
pulled up toward the splint using non-elastic tape.
Complete, unstable fractures in the lower limb should
always be further stabilized with a bandage and at least two
splints at right angles, e.g. caudal and lateral.
(c) Major fractures in between the fetlock and the elbow/
stifle should be lightly bandaged with strong splints
whenever possible. Appropriate width (curvature matching
the bandage) staves of PVC pipe (usually thick-walled
6-inch) are generally the most practical (strong, easily
cuttable, easy to find) splint material.
There are several common mistakes:
● Placing too heavy a bandage. This adds weight to the

limb and makes it more awkward for the horse to move.
Use just enough padding to allow a tightly wrapped
bandage not to act as a tourniquet. The outdated concept
that a Robert Jones Bandage needs to be 3–5 times the
diameter of the limb is not sound, especially when splints
Figure46.1 (a) Ceretom (Samsung Neurologica, Danvers, MA) are used. The mechanical value of a splint is diminished
portable 8-slice computed tomography (CT) scanner for
the farther it is placed away from the limb. If you use
preoperative and intraoperative use. (b) Dorsal, transverse and
sagittal plane CT images of a comminuted fracture of the middle splints, make the bandage light enough to ensure that
phalanx obtained preoperatively using the Ceretom portable CT the splints are closer to the limb.
scanner to aid in fracture repair planning. (c) 4DDI robotic cone ● Using elastic tape for attaching a splint will nearly always
beam CT unit used to obtain CT images of the hind
metatarsophalangeal joint in a sedated, standing horse. Source: result in the splint shifting/slipping. Both elastic adhe-
Kyla F. Ortved and Dean W. Richardson. sive (e.g. Elastikon®) or self-adhesive (Vetrap®) bandage
material are good for the bandage itself, but splints
doses encouraging recumbency should be strongly consid- should be securely attached with non-elastic material
ered. Shipping the foal heavily sedated in recumbency along such as duct tape or packing tape. If multiple staves are
with an attendant is optimal if it can be arranged. Adult placed around the limb, metal hose clamps can also
horses should be shipped in the tightest possible slot in a assist to help compress the splints against the padded
trailer or van so that the horse can balance/support itself by bandage and hold them in alignment.
leaning against the wall/partition. ● Incorrect length of a splint may lead to more harm than
Skin wounds should be cleaned with mild soap and good. If possible, it is still a good principle to stabilize a
water, and covered by a sterile bandage if possible. General joint above and a joint below the injury. The most com-
recommendations for bandaging/splinting of equine mon error for cannon bone, carpal, tarsal, radial and
fractures have been established [2] (Figure 46.2), based on tibial fractures, is not to have the splint reach the ground.
anatomical location but the specifics of the injury should If it does not reach the ground, motion and gravity will
be considered when selecting coaptation. For example, a tend to shift it down.
(a)
IV IV
III III
II
II
I I
(b) (c)
Figure46.2 (a) Diagram of a horse demonstrating important anatomic/biomechanical regions to consider when applying external
coaptation. The regions in the front limbs include: I) distal metacarpus to foot; II) distal radius to distal metacarpus; III) elbow joint to
distal radius; and IV) distal scapula to elbow joint. The regions in the hindlimbs include: I) distal metatarsus to foot; II) tarsus to distal
metatarsus; III) stifle joint to tarsus; and IV) pelvis to stifle. (b) A splinted bandage applied to the left front limb for stabilization of a
radial fracture. One splint is applied to the caudal/palmar aspect of the limb from the foot to the elbow and one splint is applied to
the lateral aspect of the limb extending from the foot up and over (touching) the scapular region. These two examples are using
wooden splints but staves of PVC piping are commonly used. (c) A Kimzey Leg Saver Splint (Kimzey Welding Works, Woodland, CA)
applied over a bandage to the front limb of a horse. Kimzey splints are useful for quick stabilization of distal fractures (region I) and
disruptions of the suspensory apparatus. Source: Kyla F. Ortved and Dean W. Richardson.
● Splinting the incorrect side of the lower limb can be Fractures of the radius and tibia are best stabilized with
avoided if you remember to apply at least one of your a long, lateral splint extending to the point of the hip or
splints to the convex or “open” side of the injury. That is, shoulder (Figure 46.2). Fractures in region 4, including the
if the horse’s digit is deviated laterally below the level of scapula, humerus and femur, should not be splinted or
the fetlock joint (valgus), place at least one splint on the casted, as these techniques simply increase the weight of
medial side and incorporate the foot. For severe carpal/ distal limb making displacement of the fracture far more
tarsal, radial and tibial fractures, always have the splint likely. Improper external coaptation can lead to significant
in contact with the shoulder/pelvis. complications by turning a non-displaced fracture into a
● An excessively heavy splint (e.g. a 2 × 4) will often make displaced fracture or a closed fracture into an open frac-
the limb more cumbersome and possibly serve to ture. Even in emergent situations, careful attention should
worsen the situation. Do your best to obtain appropri- be paid to external coaptation for stabilization and trans-
ate material. port to prevent further damage to the limb. The owner
● Another major error to avoid is failure to splint the car- should always be advised to ship an adult horse as “tightly”
pus of a horse with a fractured ulna. Splinting for radial as possible so that it can lean against both sides.
and tibial fractures will afford modest stability and only Broad-spectrum antimicrobial therapy should be started
slightly relieve anxiety, but a horse with a properly immediately in any horse with an open fracture or any
splinted ulnar fracture will immediately relax and be horse at risk of developing an open fracture. For example,
able to maneuver itself with some confidence. a complete tibial fracture may become open prior to surgery
Osteosynthesis: Intraoperative Complications 633
due to continual motion in an area with little soft tissue age to surrounding tissues, broken drills/bits, common
coverage over the fracture ends. The use of drugs with technical errors and inappropriate use of implants, will be
nephrotoxic properties, such as aminoglycosides, should discussed in the following section. Technical errors and
be carefully considered in horses at risk of dehydration, e.g. complications specific to anatomical sites will also be fur-
endurance horse at the end of a race. A non-steroidal anti- ther discussed in the following section.
inflammatory drug (NSAID) should also be administered
to decrease pain and swelling prior to surgery. Systemic
Complicationsof LagScrewFixation
analgesics, such as an opioid, can also be given to decrease
pain prior to surgery. Intravenous fluid therapy should be Inadequate fracture reduction
strongly considered in any horse with evidence of
Definition
dehydration or any horse that has experienced significant
Inadequate anatomical reconstruction of the fractured
blood loss associated with the injury. Any fluid or electrolyte
bone and bone surface
imbalances should be corrected prior to surgery to help
prevent anesthetic or post-anesthetic complications.
isk Factors
An important decision is always whether or not to take a
horse directly to surgery. In general, if the injury can be ● High degree of comminution
well stabilized and the horse is acceptably comfortable, ● Chronic fractures
performing the repair after extensive preparation will help ● Inappropriately stabilized fractures
avoid complications. Anesthesia (induction and recovery) ● Absence of arthroscopic or imaging guidance
is nearly always better after the horse is given several hours ● Inexperience
to learn how to adapt and protect a painful, less than per- ● Limited equipment
fectly functional limb. Proper scrutiny of preoperative
images allows more accurate planning. After being given a Pathogenesis Perfect reduction of a fracture is not always
thoroughly considered surgical plan, operating room possible, but it is always the intention of the surgeon.
personnel have time to ascertain that all necessary Anatomical reduction allows weight-sharing rather than
equipment/implants are available and sterile. weight-bearing by the implants. Bone touching bone allows
Complications are inevitable if the surgeon has to “make compressive forces to be sustained by the bone and bending
do” with what is available. It is nearly always a much wiser forces to be minimized, thereby increasing stability and
choice to have essential equipment shipped overnight than protecting the metal implants. Larger patients mean
to use marginal implants. Anesthesia staff have time to greater loads. Greater loads mean more risk of implant
consider the best induction technique, positioning and failure, so more accurate reduction becomes more
probable recovery methods. The right number of assistants important in larger patients. The same principle means
in surgery can usually be gathered over a matter of a few that more and larger implants become more essential as
more hours. The entire team can nearly always be more the quality of reduction diminishes.
rested and alert if a difficult case can be done during The critical goal in the repair of every articular fracture
normal hours. All of these factors should lead to fewer of any orthopedic surgeon should be to achieve perfect
complications and faster surgery times. reduction, as any defect in the articular surface will lead to
Either inadequate planning or unnecessarily rushing a osteoarthritis and degeneration of the joint. The larger the
horse to surgery inevitably decreases efficiency and execu- defect, the more severe the degeneration will be. The most
tion of surgery. Prolonged surgery times are associated common articular fractures faced by the equine surgeon
with increased risk of surgical site infection (SSI) [3, 4], include displaced lateral condylar fractures, carpal slab
increased incidence of myopathy and neuropathy, and fractures and mid-body sesamoid fractures. In these
decreased recovery scores [5]. fractures, accurate reduction must be accomplished in
order to achieve an athletic future.
Minor comminution or eburnation of edges that
steosynthesis:Intraoperative
O diminish perfect apposition of the fracture will in turn lead
Complications to a weaker fixation and higher load on the implants and
higher risk of failure.
Many general technical errors and intraoperative complica- Inadequate intraoperative imaging, including radio-
tions are possible that can affect stabilization and successful graphic and arthroscopic imaging, prevents adequate
outcome of any fracture. Common general errors, including assessment of the bone/articular surface and adequate
inadequate stability, inadequate reduction, iatrogenic dam- assessment of the degree of reconstruction achieved.
Prevention Arthroscopic-guided fracture reduction is the example, it is unnecessary to use anything larger than 4.5-
most accurate tool to ensure the articular surface is aligned mm screws in a simple condylar fracture but eburnation
and can be accomplished easily in the above fractures. A can result in more bending load on the screws, so more 4.5-
useful, generally applicable technique for repairing or 5.5-mm screws should be used in such cases. “Clean”
articular fractures with lag screws involves drilling the 3rd carpal slabs can be reliably repaired with 3.5-mm
glide hole through, but not past, the fracture line. This is screws but those with a large wedge fragment on their
most easily done if the glide hole is drilled before the proximal surface should be treated with 4.5-mm screws
fracture is reduced, because that allows the surgeon to because they are much stronger (2.7X). A narrow plate is
more reliably recognize when the fracture plane is reached. nearly always adequate in any size of horse with a simple
A smooth Steinmann pin is placed into the glide hole and ulnar fracture but if there is severe enough comminution, a
the drill guide is removed leaving the pin in place. The broad plate might be a better choice.
centering insert sleeve is slid over the pin and fully inserted
into the glide hole, which allows manipulation of the Diagnosis Intraoperative arthroscopy, when possible, can
fracture during manual reduction. The arthroscope, which reveal inadequate reduction of the articular surface.
is centered over the fracture line, is used to visualize when Inadequate reduction may also be noted intraoperatively
reduction is achieved (Figure 46.3). Bone clamps can then via direct visualization or by diagnostic imaging (e.g.
be used to maintain reduction while the thread hole is radiography, fluoroscopy, CT) intra- or postoperatively.
drilled and the lag screw is placed. No matter what specific Instability and arthritis associated with inadequate
technique is used, it is absolutely essential that an articular reduction of the fracture is usually associated with pain,
fracture is accurately reduced before the thread hole is loss of use of the limb and lameness.
drilled and tapped.
As mentioned above, larger or higher number of implants Treatment Further attempts, including additional
should be considered for cases with weaker fixations, such intraoperative imaging and arthroscopic examination, should
as in cases with fracture eburnation or comminution. For be made when fractures appear to be inadequately reduced.
(a)
(b)
Figure46.3 (a) Arthroscopic reduction of a displaced lateral condylar fracture using a centering sleeve and Steinman pin in the glide
hole. In this example, both glide holes were drilled before reducing the fracture. (b) Arthroscopic images of a displaced lateral
condylar fracture prior to, during, and following reduction. Source: Kyla F. Ortved and Dean W. Richardson.
Expected outcome Inadequate reduction of a fracture is the length of the threaded hole. Complete drilling through the
major cause of two important complications: instability entire thickness of the cis fragment must be ascertained
(any type of fracture) and osteoarthritis (articular fractures). before drilling the thread hole in the trans fragment.
Instability in any location, especially in the proximal limb,
can cause catastrophic failure of the limb. Inadequate Diagnosis Lack of compression or inadequate seating of
reduction in any joint will lead to osteoarthritis; however, the screw inside the plate hole or against the surface of the
high motion joints such as the fetlock joint are at particular bone is usually noted intraoperatively. Intraoperative
risk. imaging will also help to achieve diagnosis.
Failure to compress fractures even though the lag Treatment The long screw should be replaced with a
scre tightens ell shorter one. In cases of incomplete tapping, the screw can
be removed, the entire length of the thread hole tapped and
Definition
a screw of appropriate length replaced.
Inadequate interfragmentary compression across the frac-
In cases where threads have been created in the cis frag-
ture plane
ment, the glide hole should be extended through the entire
thickness of the cis fragment. Drilling and tapping in these
isk Factors
situations have to be done with extra care to decrease risk
● Technical error of over-enlarging the hole or stripping the threads.
● Inexperience
Expected outcome Failure to compress a fracture should be
Pathogenesis Lag screw fixation is commonly used in noted and resolved intraoperatively, in which routine
equine orthopedic surgery, as it has the ability to provide fracture healing can be expected. If failure to compress a
excellent compression across the fracture line. However, it fracture is not noted, instability can result causing
is possible for screws to feel as if they have been tightened postoperative pain and poor bone healing. Removal of the
well without actual fracture compression. The screw may screw and placement of lag screw that provides adequate
tighten very firmly and feel perfect, but the tightening is compression should be strongly considered in these cases.
occurring before the screw head compresses against the
near fragment. roken eits and taps
When a slightly long screw is placed in a hole that does
Definition
not exit the far cortex, the screw will reach the blind end of
Broken orthopedic equipment happens with some fre-
the hole before being inserted in its entire length. In this
quency. Broken bits and taps are a fairly common compli-
scenario, the head of the screw will not be in direct contact
cation and one that is difficult to completely avoid,
with the cis-cortex and will not provide compression across
especially in complex fractures in adult horses (screw
the fracture plane.
interference and dense bone).
When failing to completely tap a thread hole over its
entire length, the screw will reach the end of the threaded
isk Factors
portion but not the end of the drill hole. The absence of
threads in the far side will not allow the screw to advance ● Dense or sclerotic cortical bone
to its end. Similar to above, the head of the screw will not ● Horse movement, especially during standing
be in direct contact with the cis-cortex and will not provide procedures
compression across the fracture plane. ● Placing inappropriate stress on drill bits and taps
Incomplete drilling of the glide hole through the entire
thickness of the cis fragment leads to creation of threads in Pathogenesis Forcing/bending the bit, especially a dull bit
the cis fragment. This causes the screw to engage the cis in hard bone: internal fixation of fractures in standing
fragment, which prevents application interfragmentary horses has a greater potential for the horse to move and
compression. break a bit or tap (Figure 46.4).
“Missing” the far cortex in a long bone lag screw: even a
Prevention Always drill and tap all the way through the far slightly oblique positioning of a bit or a tap makes it easy
fragment. The tip of the tap should extend 2 mm beyond for the bit/tap to slide down the endosteal side of the cor-
the far cortex. In cases where the far cortex cannot be tex, bend and break.
completely drilled for some anatomical reason, the surgeon Tapping (especially power tapping) a hole in hard corti-
should be certain that that the screw stops short of the cal bone that does not extend all the way through the cor-
(a) (b)
Figure46.4 (a) Lateral-medial radiograph of the third metacarpus with a broken drill bit present. The drill bit broke during standing
surgery for a dorsal cortical fracture. (b) Lateral-medial radiograph of the third metacarpus with a broken tap. The tap broke when it
hit the non-drilled trans-cortex. The tap was left in the medullary cavity and a screw was placed routinely. Source: Kyla F. Ortved and
Dean W. Richardson.
tex: the tap will impact on the bottom of the hole and even horse, even though it may be more embarrassing for the
a slight additional twist will break a tap, especially 3.5-mm surgeon. Several instruments are useful to have on hand if
taps (Figure 46.4). the broken bit, tap or screw requires removal. A pair of
sterile, high-quality locking pliers can be extremely useful
Diagnosis Evident intraoperatively during the procedure to grasp a broken piece of bit or tap that is close to the bone
surface. A specialized screw extraction set is available
Prevention Use sharp bits and clean bits frequently. Clean (Screw Extraction Set, Synthes, West Chester PA)
even more frequently with smaller bits and when drilling (Figure 46.5), which include a bone gouge to expose broken
in hard bone. Use plenty of sterile fluids to cool and drill and tap ends, and pliers for grasping the ends
lubricate as you drill. (Figure 46.5). Broken drill bits and taps can generally be
In order to avoid having the bit or tap slide down the removed with pliers following removal of adjacent bone
endosteal surface, the surgeon should be very careful to using a gouge or hollow reamer.
“feel” for the hole before continuing with drilling or
tapping. Expected outcome Broken bits and taps can generally be
left in place without adverse consequences, other than
Treatment When a drill bit, tap or screw breaks, the being present on radiographs. There is a slight possibility
surgeon is faced with the decision to remove the broken that the metal will cause discomfort to the horse when it
piece or leave it in place. In major fracture repairs, broken returns to athleticism.
bits and taps can usually be left in place without adverse
consequences. A bit more effort may be made to retrieve roken Scre s
broken metal in horses intended to return to work, but it is Definition
very important to seriously consider how much trauma It is difficult to break a 5.5-mm screw but surprisingly easy
will be incurred by the removal. It is often the case that to break a 4.5, and very easy to strip the hex-head recess or
leaving the broken piece alone is the better option for the break a 3.5-mm screw.
(a) isk Factors
● Screw size (4.5-mm and especially 3.5-mm cortical

screws)
● Incompletely drilled hole
● Incompletely tapped holes
● Overtightening screws
● Failure to countersink in a highly contoured bone
Pathogenesis Although bone screws can be broken by

simple overtightening, it is most likely to happen when the
surgeon expects further tightening and becomes even more
vigorous. This is most likely to happen using a long screw
in a hole that has a bottom or in a hole that is complete but
(b) (c) was not tapped entirely. Failure to countersink a screw
entering a highly contoured bone surface (Figure 46.6) can
also cause breakage. Furthermore, screws that break
postoperatively due to cyclic fatigue or bending overload
are not essentially “complications” if adequate stability
persists (Figure 46.7).
Prevention The surgeon should ensure that holes are

completely tapped and countersink when appropriate. The
surgeon should avoid overtightening and the use of
(d) (e)
excessively long screws.
Provide adequate stability with implants and external
coaptation to avoid overloading screws.
Diagnosis Broken screws become obvious during surgery.
Treatment and expected outcome If instability is enough to

threaten comfort and healing, removing and replacing
screws will not generally be worthwhile. More strength, for
(f) (g) example an additional plate, a replaced plate or a heavier/
longer plate, may be the solution.
The specialized screw extraction set mentioned above
(Screw Extraction Set, Synthes, West Chester PA) is useful
for removing broken screws. The bone gouge can be used
to expose broken screw ends and pliers can be used for
grasping the ends of broken screws (Figure 46.5). The
set also includes other instruments to remove bone around
the broken screw and specialized instruments to grasp it. If
Figure46.5 (a) Synthes screw removal set containing the bone gouge is not enough to expose the screw, a hollow
instruments required for removing broken or damaged screws. (b) reamer (Figure 46.5) is centered on the broken screw and
If the screw breaks in the near cortex, a bone gauge can be used to
used in a counterclockwise direction to expose enough of
expose enough of the screw so that it can be grasped with (c)
forceps or pliers. (d) If the screw breaks far below the near cortex, a the threads that the screw can be grasped. If the screw
hollow reamer can be used in a counter-clockwise direction to cannot be extracted with pliers, an extraction bolt that
enlarge the hole and (e) expose several threads of the broken engages the screw threads when turned counterclockwise
screw. (f) An internally threaded extraction bolt is then used to
can be used (Figure 46.5). Once the screw is threaded in the
engage the exposed threads and (g) used to remove the screw with
counter-clockwise rotation. Source: Courtesy of Depuy Synthes, Inc., bolt, continued counterclockwise rotation backs the screw
Paoli, PA. Copyright 2009, Synthes, Inc. All rights reserved. out of the bone.
Stripped screws Stripped screw heads
Definition Definition
Stripping screw holes causes total breakage of the bone Damaging the screw head during tightening prevents
threads, leading to lack of bone purchase by the screw and engagement of the screwdriver in the head such that the
an inability to tighten the screw when fully inserted. screw cannot be removed or advanced.
isk Factors isk Factors

● Proportional small trans fragment in comparison with ● Overtightening
cis fragment ● Screw driver not sitting well inside the hex-recess
● Soft bone ● Small screws (3.5 mm)
● Measuring hole length after tapping ● Old screw driver
● Surgeon inexperience
Pathogenesis Damaging the screw head frequently occurs

Pathogenesis It is almost impossible to “overtighten” and
when tightening 3.5-mm screws into dense equine bone, as
strip screws in adult equine bone and even foal bone is rarely
the hex-recess of the 3.5-mm screw is shallow and relatively
so soft that screws cannot be properly tightened. However,
fragile. It is possible to strip a 5.5-mm screw head when the
using a screw that is too short will cause a total lack of
surgeon attempts to maximally tighten one. The more
engagement by the threads or the thread engagement will be
correctly designed 4.5-mm screw rarely strips but the screw
limited to a small proportion of the screw, which will place a
often will break before the hex-head strips.
high torque concentration on the threaded portion. The
When the screw driver is not inserted fully into the hex-
same situation will occur if the glide hole is too long.
recess, the hex-recess is abnormally loaded and the risk of
If the threads are damaged, the ability of the screw to
damage increases.
engage the bone is also limited and increases risk of
stripping the threads. Measuring hole lengths after tapping
damages the bone threads. Prevention Avoid a worn-out screwdriver with rounded
edges to its hex-insert. When removing screws, ensure that
Diagnosis Unable to adequately tighten the screw soft tissue or bone ingrowth is removed from the recess
before inserting the screwdriver. The screw driver should
Prevention The surgeon must be careful to drill the glide always be fully inserted into the hex-recess. Use caution
hole only to the fracture line or just beyond. This can be when tightening 3.5-mm screws. Use 4.5-mm screws
ascertained by using radiographic guidance during glide whenever possible.
hole preparation.
The hole lengths must be measured correctly prior to Diagnosis The lack of engagement of the screw driver and
tapping to avoid damaging threads. hex-insert becomes readily obvious intraoperatively.
Treatment If the reason is a short screw that does not Treatment Grasp the screw head with pliers to remove
engage the threads created, the screw should be replaced screw. If the screw cannot be removed with pliers, a conical
with a slightly longer screw. extraction screw on a T-handle can be inserted into the
The screw can be replaced with a larger diameter screw recess by rotating it counterclockwise while exerting
of the correct length (e.g. remove the 4.5-mm screw and pressure. Predrilling the screw recess can be done if there is
place a 5.5-mm screw), but this is (obviously) not possible difficulty engaging the extraction screw.
if you already have the largest screw in place. If a 5.5-screw
has been stripped, a cancellous 6.5 mm may be used in
Expected outcome Screws with stripped heads can usually
some cases. A larger screw can generally be inserted by
simply enlarging the glide hole to the appropriate size; the be removed with pliers or a conical extraction screw.
hole does not usually need to be tapped with a larger tap. In
Incorrect scre length
situations where no larger screw is available, an entirely
new hole should be drilled. Definition
Inappropriate screw length with the screw being either too
Expected outcome In most cases, a longer or larger screw short or too long, leading to instability or soft tissue
will resolve the problem. damage, respectively
(a) (b) (c)
(d) (e) (f)
(g) (h) (i)
Figure46.6 Depiction of counter-sinking a screw placed in the proximal phalanx for repair of a simple sagittal fracture. Adequate
counter-sinking in a highly contoured bone, such as the proximal aspect of P1, is required to reduce the risk of bending/breaking the
screw (a–f). Failure to counter-sink highly contoured bony surfaces will cause bending of the screw head (g–i). Source: Kyla F. Ortved
and Dean W. Richardson.
(a) (b)
Figure46.8 (a) A long screw was placed during repair of a

spiraling medial condylar fracture. Long screws can impinge on
soft tissue or bony structures causing lameness. (b) The screw
can be seen interfering with the medial splint bone in this
image. Source: Kyla F. Ortved and Dean W. Richardson.
Figure46.7 Two broken screws (arrow and circle) in an
imperfectly stable fetlock arthrodesis. Source: Kyla F. Ortved and
Dean W. Richardson. Prevention The screw holes should be accurately measured
prior to tapping. Intraoperative imaging should include a
view that accurately assesses its length, i.e. a radiographic
isk Factors
projection truly perpendicular to the direction of the screw.
● Screw holes that are difficult to measure due to inability
to apply measuring device directly to cortex Diagnosis Intraoperative imaging
● Technical error
Treatment and expected outcome Replacement of screws of
inappropriate length will correct the problem.
Pathogenesis The reason is an inaccurate measurement of
screw holes. Inappropriate screw length can cause Incorrect scre positioning
significant postoperative complications. Screws that are Definition
too short can lead to fracture instability, because the screw Drill paths or screws placed through a fracture line or an
is only engaging a few threads when it could be engaging articular surface are major technical errors that can lead to
many more. A lag screw is only as strong as its engaged catastrophic failure of the bone.
threads. Either an excessively long glide hole or an
unnecessarily short screw will be less than optimal. In isk Factors
horses, nearly every screw across any bone with a medullary ● Only two-dimensional imaging available
cavity should engage two cortices. Bicortical screws have ● Limited experience
inherently more strength than unicortical screws [6]. Some ● Suboptimal anatomical knowledge
human orthopedic literature promotes the use of
unicortical screws in locking plates but in horses, longer Pathogenesis This complication occurs as a result of
bicortical screws are always advised. Screws that are too misinterpretation of fracture planes, especially when only
long can cause damage to soft tissues, including tendons, two-dimensional imaging is available, and an expansive
ligaments, nerves and adjacent bones (Figure 46.8). This open approach is undesirable. The presence of complex
can lead to long-term pain and lameness, especially in fractures with several different fracture planes increases
implants that are not removed. the risk.
A screw placed through a fracture line can lead to cata-

strophic failure of the bone, either during recovery from
anesthesia or during the postoperative period. Screws
placed through a joint surface can be catastrophic if the
expected outcome was for the horse to be athletic.
Prevention Use three-dimensional imaging when

available. If three-dimensional imaging cannot be
performed, the surgeon should obtain enough radiographic
projections to allow an optimal assessment. Keep an
anatomical specimen in the operating room for visual aid.
Use intraoperative imaging when placing screws close to a
joint surface. An inviolatable rule is to have a minimum of
two orthogonal views that absolutely prove that the bit or
screw does not enter the joint.
When placing an implant that is necessarily very close to
a joint (e.g. short sagittal P1 fractures, tarsal slab fractures,
palmar/plantar condylar fractures), intraoperative imaging
should be done at multiple stages during the procedure. It
is often possible to correct a badly aimed drill bit before it
causes irreversible injury.
Treatment Always remove and replace poorly positioned Figure46.9 Thermal injury to bone is evidenced by osteolysis
screws immediately, otherwise a catastrophic consequence around the screws (“ring sequestra”) in the 2 most proximal
screws on this radiograph of a third metatarsus. Source: Kyla F.
may occur. Ortved and Dean W. Richardson.
Expected outcome The damage caused to an articular Diagnosis Pain, lameness, swelling or discharge at the
surface by an incorrectly placed screw may lead to screw placement are signs that may be associated with
development of arthritis, even after replacement of the osteonecrosis and occur in the postoperative period.
screw. Radiographic examination reveals presence of radiolucent
halos around the implants (Figure 46.9).
Thermal injury
Treatment Once thermal injury occurs, little can be done
Definition
to treat the subsequent osteonecrosis. Prevention is by far
Osteonecrosis of the bone around the screw that occurs in
the best tactic.
the postoperative period
Expected outcome Instability and infection can be caused

Risks Technical error
by osteonecrosis. This may necessitate removal of the
● Inexperience
implant and antimicrobial therapy.
Pathogenesis Equine bone is very dense and even

“normal” drilling and tapping generates considerable heat.
Failure to mitigate this heat results in adjacent bone death Complicationsof PlateFixation
and “halos” around screws that require considerable time In horses, plate fixation is the strongest and most versatile
to heal (Figure 46.9). technique for long bone fracture repair and arthrodeses.
All of the above noted problems with screws alone can be
Prevention Provide constant, high flow irrigation during seen when screws are used to attach plates. Complications
drilling. Always use sharp drill bits and clean the bits following plate fixation are more common because plates
frequently during drilling. You should never drill are being used in more difficult cases. Infection is more
completely through an adult long bone cortex without common because procedures are more invasive and involve
removing and cleaning the bit multiple times. more metal. Instability is more common because the initial
injury is more difficult to stabilize. Loss of stability leading having a fatal outcome. Ensuring that the fracture has been
to clinical failure is unquestionably seen as a complication, adequately stabilized during the first surgery is key.
but it does not always indicate a technical error. Internal
fixation of equine fractures is often treading on the preci- Iatrogenic damage
pice of failure.
Definition
Inadequate metal
Some iatrogenic damage to cartilage, bone, nerve, vessels,
and soft tissues (tendons, ligaments and muscle)
Definition
Inadequate metal will inevitably lead to instability and
isk Factors
likely failure. Attempting to repair fractures with
inadequate implants is a serious error with major conse- ● Inadequate knowledge of anatomy
quences (Figure 46.10). ● Limited surgeon experience
isk Factors Pathogenesis Some iatrogenic damage to cartilage, bone,

● Inexperience nerve, vessels, and soft tissues (tendons, ligaments and
● Lack of adequate implants muscle) may be inevitable in major equine fracture
repairs but greater knowledge of anatomy should result in
Pathogenesis Using inappropriately small screws, not fewer such lesions. The consequences of not knowing
using enough screws, using a plate with inadequate where a major nerve or blood vessel “lives” become
strength (thickness/width/design), or not using two plates progressively more important as the area of injury moves
when appropriate will lead to complications. You are up the limb. Damaging the radial nerve as it courses
guaranteed to have complications if you use a 5.5-mm plate through the muscular groove on the caudal aspect of the
on a foal’s metacarpus or a 4.5-narrow plate to repair an humerus is catastrophic compared to nerve damage in the
adult radius. metacarpus. Nicking the suprascapular nerve during the
repair of a supraglenoid tubercle fracture negates the
Prevention Most equine long bone fractures (clear value of the surgery. A severed blood vessel in the depths
exceptions being simple ulnar and non-displaced of the upper arm or thigh becomes a life-threatening
metacarpal/metatarsal fractures) should be treated with at complication.
least two plates. At least one plate should always be on the
tension surface of a bone if at all possible and plates should Prevention Be sure to review all relevant anatomy prior
be placed at right angles to maximize overall resistance to to surgery. Use intraoperative imaging as much as
bending and torsion. Using more than one plate means necessary.
there is risk of screw interference. The plates (especially
locking plates that diminish the options for screw Diagnosis Damage to an important vessel becomes
angulation) must be positioned to allow optimal screw obvious during surgery. Damage to nerves, especially in the
placement (Figure 46.10). upper limb with motor function, may only become evident
Have larger-sized implants, especially 5.5-mm screws, if during recovery or early postoperative period, with the
you are going to tackle demanding fracture repairs. Use patient showing difficulties moving or bearing weight on
locking plates for anything other than the simplest frac- the affected limb.
tures. They are stronger, provide more inherent stability
and should be considered standard technique for the inter- Treatment Treatment for iatrogenic damage to cartilage,
nal fixation of most major equine fractures. bone, nerve, vessels, and soft tissues should be aimed at
limiting any further damage and will be specific to the site
Diagnosis Unfortunately, the complications related to this of injury.
error become obvious during recovery or in the
postoperative period and in many cases be present as Expected outcome An uncontrolled bleeding from a
catastrophic failure of the fixation that may be visibly major vessel in the proximal limb, or complete damage to
obvious or confirmed with radiography. a nerve in the proximal limb (i.e. radial nerve) will
typically be associated with euthanasia of the animal.
Treatment and expected outcome Adding more implants Damage to cartilage and subchondral bone may lead to
postoperatively is less than ideal and many cases end up osteoarthritis.
(a) (b) (c)
(d) (e)
Figure46.10 Inadequate implants usually result in failure. (a) Any fracture disrupting the weightbearing axis of the bone should
never be treated with screws alone. (b) These plates are both too short and both end at the same place in the diaphysis, leading to
stress concentration and increased risk of fracture at this site. (c) A diaphyseal tibial fracture should be treated with two plates, as one
plate will not provide sufficient strength to overcome bending forces in equine long bones. (d–e) A short oblique fracture of tibial
diaphysis repaired with two LCP plates at 90-degree angles and interdigitating screws. Source: Kyla F. Ortved and Dean W. Richardson.
steosynthesis:CommonComplications
O Lateral condylar fractures
in SpecificAnatomicSites Fractures originating in the lateral condyle are common
injuries in racehorses. Most lateral condylar fractures tend
CondylarFractures to break the lateral cortex of the third metacarpal or meta-
tarsal bone, therefore are markedly less likely to suffer cat-
Medial condylar fractures astrophic failure. Complete fracture of hindlimb lateral
Although medial condylar fractures are usually non-dis- condylar fractures can occur during recovery, through
placed and often incomplete, they present significant chal- screw holes or occult transverse/oblique fractures
lenges for the equine surgeon. Medial condylar fractures, (Figure 46.11). Although catastrophic failure is less com-
originating in the parasagittal condyle of the third metatar- mon in lateral fractures, several technical errors are possi-
sal or metacarpal bone, often spiral up the length of the ble that can decrease prognosis [7]. The goals of lag screw
bone or split in the mid-diaphysis into a Y configuration. fixation in displaced and non-displaced lateral condylar
These fracture configurations make medial condylar frac- fractures are to adequately stabilize the fracture plane and
tures prone to catastrophic failure prior to surgery, during accurately re-align the articular surface. Accurate reduc-
recovery and even up until several weeks after surgery tion of the articular surface is key to preventing post-trau-
(Figure 46.11) [7]. Metatarsal fractures are at much higher matic osteoarthritis (PTOA).
risk. Appropriate implant selection and placement is key to Inaccurate positioning of the lag screws and inadequate
avoiding technical errors and complications. Preoperative compression of the fracture are the most common technical
determination of the fracture configuration, preferably errors (Figure 46.12) [8]. Intraoperative imaging, especially
with CT, can help determine if a plate or lag screws alone digital radiography or fluoroscopy, is essential for
will be used. consistently accurate screw placement, even for
Furthermore, a CT can aid in the positioning of lag screws experienced surgeons. Prior to screw placement, the
intended to follow a spiraling fracture proximally, in order to palpable landmarks should be identified including the
avoid inadvertent placement of a screw in a fracture line. If most dorsal aspect of the lateral condyle and the palmar/
CT is not available, an open approach can be used to ensure plantar eminence of P1. Following a stab incision down to
screws are placed perpendicular to the spiraling fracture the condylar (epicondylar) fossa, the surgeon should be
plane. Medial condylar fractures with a Y configuration able to feel the fossa with the scalpel. It is also possible to
should ideally be repaired with a bone plate to decrease the use radio-opaque markers such as sterile skin staples or
likelihood of the transverse/oblique fracture plane becom- needles to identify the location of the intended stab inci-
ing complete [8]. Placement of plates is generally on the lat- sion. Correct positioning of the drill is key to a well-placed
eral or dorsolateral aspect of the bone, because standing screw. Most horses have some degree of external rotation
plate removal is much easier after the fracture has healed. of the distal limb when placed in lateral recumbency;
Close attention should be paid to length of screws in the therefore, it is common to drill holes that aim too palmar or
proximal holes, in order to avoid engaging the medial splint plantar if the surgeon intuitively orients the drill perpen-
bone or the suspensory body. Recovery from anesthesia is dicular to the floor. Careful attention to the position of the
always a risky period for horses with medial condylar frac- limb and use of orthogonal radiographic/fluoroscopic
tures. A specialized recovery system such as a pool or sling is views help ensure the drill is correctly positioned in a dor-
recommended (Figure 46.11). If such a system is not availa- soplamar and lateromedial plane. Inadequate compression
ble, a full limb cast or full limb splint should be applied and can usually be avoided by being sure to drill and tap the
the recovery should be assisted. thread hole fully through the trans cortex.
Standing screw fixation of both medial and lateral con- Long screws are another easily avoidable technical error.
dylar fractures has become popular with many surgeons in Screws protruding through the trans cortex can lead to
an effort to eliminate catastrophic events during anesthetic chronic irritation of the collateral ligament of the meta-
recovery. Although anesthetic recovery disasters can be carpo- or metatarso-phalangeal joint. Accurate measuring
avoided, screw fixation alone of propagating medial condy- and intraoperative imaging decrease the likelihood of this
lar fractures, especially in the hind limb, will not prevent error. The number of screws placed depends on the length
disastrous dehiscence of the diaphyseal component. of the fracture. Screws should be placed 1–20 mm apart,
Furthermore, asepsis is inevitably inferior in the standing with the most proximal screw being placed at least 20 mm
patient and unexpected movement by the horse can result from the proximal extent of the fracture. Screws placed too
in bit/tap breakage. Intraoperative imaging should still be close to the proximal end of the fracture can enter the frac-
considered essential when doing the procedure in a stand- ture line or split the narrowing proximal spike. The great
ing patient. majority of lateral condylar fractures can be repaired well
steosynthesis: Common Complications in Specific Anatomic Sites 645
(a) with 2 screws. Lateral condylar fractures can be repaired

with 4.5-mm or 5.5-mm screws. Screws are rarely stripped
in the cannon bone but the option to put a 5.5-mm screw
into a stripped 4.5-mm screw hole is one advantage of start-
ing with 4.5-mm screws. Broken screws, bits or taps in the
condyle should be left in place with another screw placed
either palmar/plantar, dorsal, proximal or distal, depend-
ing on the position of the first hole (Figure 46.12).
In displaced lateral condylar fractures, perfect re-align-
ment of the articular surface is the most challenging aspect
of the repair. Malalignment of the articular surface leads to
post-traumatic osteoarthritis and can result in increased
(b)
bending and shear forces on the lag screws. Arthroscopically
guided reduction is unequivocally the most accurate way to
assess articular reduction (Figure 46.13) [9]. As discussed
above, a 3-mm pin placed through the centering insert in a
4.5-mm glide hole can be used to reduce the fracture using
variable fetlock flexion, extension, rotation and/or valgus/
varus stress. Large pointed bone reduction forceps help to
maintain reduction while the thread hole is drilled and
tapped. The reduction and compression of the fracture line
should be confirmed with the arthroscope. The arthro-
scope should be placed in the proximal dorsolateral joint to
(c) see enough curvature of the condyle that alignment can be
properly assessed.
Osteochondral fragmentation at the palmar/plantar sur-
face is common and any loose fragments should be
removed. Some fractures may require arthroscopic
debridement of the fracture line prior to reduction.
Additionally, an open approach over the proximal spike
can facilitate reduction in displaced fractures that are
difficult to realign. Arthroscopic evaluation of the palmar/
plantar joint pouch also allows assessment of articular
damage to the proximal sesamoid bones; a common con-
comitant lesion in lateral sesamoid fractures, even non-
displaced ones. Although there is no proof that there is a
difference in clinical outcome, microfracture treatment of
Figure46.11 (a) Radiographs demonstrating different
full thickness cartilage lesions can be performed.
configurations and complications of medial condylar fractures,
including a dorsopalmar radiograph of the left front limb Another “complication” of lateral condylar fractures that
showing a medial condylar fracture with a Y-component needs to be recognized before surgery is an axial sesamoid
mid-diaphysis (left), a dorsoplantar radiograph of the right hind fracture (Figure 46.13). These are avulsions by the inter-
limb showing a spiraling medial condylar fracture (middle), and
sesamoidean ligament and augur a very poor outcome,
a dorsopalmar radiograph of the right front limb showing
catastrophic failure 3 days following lag screw fixation. (b) even if they are repaired. Fetlock arthrodesis may be
Images from a horse with a third metatarsal bone with an considered in some horses with displaced lateral condylar
incomplete, non-displaced lateral condylar fracture. The fracture fractures and concurrent axial sesamoid fractures.
was repaired routinely with two 4.5-mm screws placed in a lag
fashion. The postoperative dorsoplantar radiograph showing
catastrophic failure of the third metatarsus that occurred during CarpalSlabFractures
recovery from anesthesia. Post-mortem specimen of the third
metatarsus with two lag screws placed distally and propagation Third carpal slab fractures are common in racehorses and
of the fracture proximal and transversely leading to failure. (c) A
can be challenging to repair [10]. Frontal slab fractures of
horse recovering from general anesthesia in a pool-raft recovery
system, following repair of a hindlimb fracture. Source: Kyla F. the third carpal bone are often markedly displaced, whereas
Ortved and Dean W. Richardson. sagittal slab fractures tend to be non-displaced. The major-
(a) (b) (c)
(d) (e) (f)
Figure46.12 (a) Inaccurate positioning of lag screws and inadequate compression of fracture sites are the most common technical
errors in lateral condylar fracture repair. In (a), the first condylar (epicondylar) screw hole was drilled too far dorsally, while the
epicondylar screw in (b) was placed into a short hole that was not drilled completely across, resulting in lack of compression across
the fracture line. (c) A broken screw that was not providing compression was left in place while another screw was placed just distal to
the broken screw. Other common positioning complications include placing screws (d) too dorsally, (e) too palmarly, or (f) directed too
distally. Such errors can be avoided by careful and consistent intraoperative imaging. Source: Kyla F. Ortved and Dean W. Richardson.
ity of these fractures benefit from lag screw fixation which removal with judicious debridement of the surrounding
is best done under arthroscopic guidance, although articular surface.
removal of fragments is possible if they are <10 mm The most common technical error in frontal slab frac-
thick [11]. Frontal plane fractures commonly have a tures, by far, is inaccurate screw placement. This may lead
wedge-shaped fragment on the proximal articular surface to poor reduction, rotation of the fragment out of align-
that can complicate reduction and articular realignment ment as the screw is tightened, or cracking through the
(Figure 46.14). Some fragments are trapped and compressed slab fragment (Figure 46.15) [12]. If a single screw is to be
during lag screw fixation; however, most fragments require placed, the screw should be centered in the fracture frag-
(a) (b)
(c)
Figure46.13 (a) Dorsoplantar radiograph, (b) frontal plane CT image, and (c) transverse CT image, showing a concurrent axial
fracture of the lateral proximal sesamoid bone with a lateral condylar fracture. Source: Kyla F. Ortved and Dean W. Richardson.
ment, ideally confirmed using radiographic or fluoro- #10 scalpel such that the blade can be seen with the
scopic guidance. Although needles alone can be used to arthroscope (Figure 46.16). The screw can also be visual-
select the site for drilling, it is technically easier to use nee- ized arthroscopically at, or just distal to, the dorsal joint
dles to find the center followed by a direct incision with a capsule attachment on the third carpal bone. If the screw
(a) (b) (c)
Figure46.14 Wedge-shaped fragments at the proximal margin of third carpal slab fractures are common. (a) Transverse and (b)
sagittal plane CT images clearly demonstrate the typical shape for these fragments seen arthroscopically in (c). Source: Kyla F. Ortved
and Dean W. Richardson.
Figure46.15 Small (3.5-mm) cortical screws placed too distally through the slab fragment provide inadequate resistance to bending,
especially if there is comminution. Larger screws should be used if there is any doubt about stability and the screws should be
carefully centered. Source: Kyla F. Ortved and Dean W. Richardson.
does not provide adequate reduction or the fragment operative imaging and using a 3.5-mm screw. The 3.5-mm
rotates as the screw is tightened, a second screw should be screw head is much smaller than the 4.5-mm screw head
placed. If the fragment breaks during screw placement, and still provides adequate strength and compression for
the surgeon will need to decide if repair of the smaller these relatively stable fractures.
fragments is possible or if removal of the entire slab frag-
ment is necessary. Minimal countersinking is recom-
SagittalFracturesof the ProximalPhalanx
mended to avoid weakening the fragment such that it
splits with final tightening. Sagittal fractures of the proximal phalanx are generally
Another common complication of dorsal (frontal) plane seen as relatively simple fractures, but technical difficul-
C3 slab fractures is having the screw exit the palmar medial ties are not uncommon (Figure 46.17). Due to thin corti-
side of the bone. It is critical to aim all screws in C3 toward cal bone in the diaphysis, stripping screws is easy to do
the center of the palmar aspect of the limb, i.e. not simply especially when placing a mistakenly short screw or
aim dorsal to palmar as you drill (Figure 46.16). excessively tightening a screw. A longer screw can be
The most common technical error of sagittal slab frac- attempted or a screw can be replaced with a larger screw.
ture repair is impingement of the screw head on the second In the event of a stripped 5.5-mm screw, the surgeon can
carpal bone. This can be avoided by using meticulous intra- redirect the drill to create a new thread hole. A partially
(a) (b)
(c)
Figure46.16 (a) Arthroscopic image showing the tip edge of a #10 scalpel blade entering the middle carpal joint through the joint
capsule reflection at the central dorsal aspect of the third carpal bone during a slab fracture repair. (b) A lateral-medial radiograph
with a scalpel to demonstrate positioning of the scalpel during surgery. (c) Transverse CT images of a frontal slab fracture of the third
carpal bone demonstrating inaccurate (middle image) and accurate (right image) placement of a screw. The drill should be aimed
toward the center of the palmar aspect of the limb (right image), not simply “front to back” (middle image) in order to avoid the C2–C3
articulation. Source: Kyla F. Ortved and Dean W. Richardson.
threaded 6.5-mm cancellous lag screw can be placed in

UlnarFractures
the stripped hole; however, these are very challenging to
remove if that were necessary. The most proximal screw Ulnar fractures are common traumatic injuries in horses
in P1 should be placed 5 mm below the sagittal grove to and generally considered very good candidates for internal
achieve ideal articular interfragmentary compression. fixation. Ulnar fractures are most commonly repaired with
Intraoperative imaging and arthroscopy can ensure that bone plates (DCP, LC-DCP, LCP) or tension-band wiring/
the screw is not placed too proximal where it would pen- pin and wiring. There are a few somewhat specific compli-
etrate the articular surface. Adequate preoperative imag- cations associated with ulnar fracture repair. Bone plates
ing is needed to determine the fracture configuration as must be precisely placed on the caudal surface of the ulna,
many sagittal fractures begin to course obliquely toward especially if locking screws are used. Screws inserted
the lateral or medial cortex in distal P1. Placing a screw through a caudolaterally positioned plate can penetrate the
too close to a visible or occult fracture line can be a seri- medial cortex of the radius distally, which can lead to a
ous error that can lead to catastrophic failure of the bone. stress riser in the radius and increase the risk of a radial
Comminuted P1 fractures are complex fractures that ben- fracture. Accurate screw placement is important in the
efit greatly from preoperative planning with CT. proximal fragment due to the concave medial cortex of the
Inaccurate screw placement can lead to serious postoper- olecranon [13]. Incorrectly placed screws will exit the
ative complications and failure of the repair [12]. medial cortex and not provide optimal fixation. Screw
(a) (b) (c)
Figure46.17 Some common errors in P1 screw placement. (a) This proximal screw was placed obliquely and dangerously close to
the sagittal groove. (b) The proximal screw is too far distal to the articular surface such that compression at the joint surface is not
optimal. The second screw stripped during placement and was replaced by a 6.5-mm cancellous screw. This is undesirable because
there would be no compression unless the glide hole was somehow enlarged to 6.5 mm. (c) The most proximal screw is too dorsal.
This also would not provide optimal compression of the fracture at the joint surface. Source: Kyla F. Ortved and Dean W. Richardson.
lengths should be correctly measured, especially at the triceps apparatus can create a stress concentrating effect
level of the trochlear notch, in order to avoid joint penetra- that can result in failure (Figure 46.18).
tion or engagement of the humeral condyle. Although
engagement of the caudal radius is common practice in
PasternArthrodesis
repair of ulnar fractures in adults, care must be taken to
avoid penetrating the lateral cortex of the radius, especially Arthrodesis of the proximal interphalangeal joint is most
when using locking screws where the angle of insertion is commonly performed due to osteoarthritis, comminuted
fixed [14, 15]. Although careful plate positioning can usu- fractures of P1 or P2, and subluxation or luxation of the
ally avoid this complication, a cortical screw can be angled joint. There are several surgical techniques described
away from the lateral cortex or a unicortical locking screw involving the use of transarticular screws alone or a com-
can be used instead. bination of a dorsally applied plate and transarticular
In foals younger than 6 months, engagement of the cau- screws. The latter is a superior technique in terms of sta-
dal cortex of the radius should be avoided in order to pre- bility. Although both techniques are relatively straight-
vent elbow incongruity. Tension-band wiring can be used forward, technical errors and complications can affect
in young foals to avoid interference with growth outcome. Drilling too close to the navicular bone, i.e.
(Figure 46.18). This technique is excellent for type I, II, and aiming the transarticular screws too distally is an easy
III fractures of the olecranon, but will not provide adequate mistake to make (Figure 46.19). Intraoperative imaging
stability in comminuted/unstable fractures. will help avoid this, but checking the glide hole exit site
If elbow joint incongruity develops secondary to attach- with the joint open also will help assure that the glide
ment of the ulna to the radial metaphysis, the plate should hole is complete and that the thread hole is entering the
be removed and an osteotomy of the ulna made 4–6 cm palmar/plantar process where it is unlikely to damage
distal to the joint. the more distal navicular region. Furthermore, the bio-
One of the most serious common complications of ulnar mechanics of the situation are superior with the lag
fractures is a catastrophic fracture at the proximal end of screws placed palmarly/plantarly; the natural weight-
the plate, especially during recovery. Although it may not bearing of the horse and a tensioned dorsal plate will
be possible to avoid every such incident, the most common tend to close the dorsal aspect of the joint. When a dorsal
cause of this complication is not placing the plate close midline plate is used, only one screw should be placed in
enough to the proximal end of the olecranon process. proximal P2 in order to avoid interference with the exten-
Ending the plate “short” of the top of the attachment of the sor process of P3.
(a)
(b)
Figure46.18 (a) An ulnar fracture repaired with single 4.5-mm screw placed in lag fashion across its obliquity combined with simple
tension-band wiring. This technique has the advantage of minimizing any possibility of joint penetration with a drill/screw or
engagement of the radius and subsequent elbow incongruity in younger horses (not applicable in this case). (b) Postoperative
radiograph of an ulnar fracture repair. The plate did not extend proximally enough, causing fracture displacement during recovery.
Source: Kyla F. Ortved and Dean W. Richardson.
If a locking dorsal plate is used, the plate should be mation and persistent lameness. Excessive bone formation
placed as close as possible to the bone surface in order to is likely associated with reduced stability of the fixation
minimize the moment arm bending of the distal screw. A and is more common in arthrodeses using transarticular
longer moment arm significantly increases the risk of this screws only [16, 17, 19]. A stronger fixation (5.5-mm tran-
screw breaking under the plate (Figure 46.19). sarticular screws and a dorsal locking plate) usually results
in a fusion with less bone proliferation (Figure 46.19).
Postoperative complications are generally associated
with incisional infections and casting. Due to little soft tis-
FetlockArthrodesis
sue coverage of the bone plate, incisional and implant
infection are not uncommon [16–18]. Additional reported Fetlock arthrodesis is a technically challenging surgery
long-term complications include excessive new bone for- with numerous potential complications. Arthrodesis of
(a) (c)
(b)
1 month 2 months 3 months 6 months
Figure46.19 Radiographs of several different pastern arthrodeses. (a) Radiograph of a screw-only pastern arthrodesis showing a
transarticular screw that was aimed too distal so that its tip is too close to the navicular bone. (b) Serial postoperative radiographs of
a pastern arthrodesis. The radiograph obtained 1 month postoperatively shows the distal end of the plate sitting too far off the dorsal
aspect of the second phalanx (red line), which increases the bending moment on the distal screw. Radiographs obtained at 2 months
postoperatively show that the distal screw has broken (yellow arrow). The decreased stability of the fixation leads to an excessive
bony callous demonstrated at 3 and 6 months postoperatively. (c) A lateral-medial and dorsopalmar radiograph of a pastern
arthrodesis obtained 5 years following surgery. There is minimal bony callous present due to the very stable fixation afforded by the
locking plate and 4 trans-articular screws. Source: Kyla F. Ortved and Dean W. Richardson.
this joint for management of suspensory apparatus break- cult than management of fetlock osteoarthritis [20].
downs in racehorses, including biaxial sesamoid fractures Disruption of the suspensory apparatus puts the surgical
and rupture of distal sesamoidean ligaments, is more diffi- implants at high risk because the plate cannot be placed on
steosynthesis: ecovery and Postoperative Complications 653
the tension side of the limb due to anatomical constraints. Technical errors
Although placing lag screws through the metacarpus into Precise midline positioning of the dorsally applied bone
the proximal sesamoid bones can be used to create tension plate is vital to successful repair (Figure 46.21). The plate is
if the sesamoids and distal sesamoid ligaments are intact, initially placed only to the proximal phalanx, so it is not
tension band technique (figure 8 wire/cable) is absolutely always obvious if it is malaligned. Even a slight angulation
essential for all cases with shattered sesamoids or disrup- error as it is applied to P1 will result in the proximal part of
tion of the distal sesamoidean ligaments (Figure 46.20). the plate not aligning to the dorsal cannon bone. An error
Additionally, horses with breakdown injuries are at in alignment also becomes a bigger problem with a longer
increased risk of vascular injury due to the excessive plate. If malalignment occurs, the surgeon can remove the
stretching of the palmar fetlock that occurs at time of plate and attempt to twist it, but this error can be easily
injury. Unfortunately, evidence of thrombosis and necrosis avoided if great care is taken before the second screw is
may not be present until several days following the injury. placed in P1 (Figure 46.21).
The most frequently used construct for fetlock arthrode- It is possible to perform the arthrodesis with the fetlock
sis includes a dorsal bone plate with a tension band on the too straight or too angled [12]. A dorsiflexed position
palmar/plantar aspect of the limb [21]. Use of an LCP is a results in excessive bending forces on the plate and screws,
superior choice over an LC-DCP or DCP, due to the whereas an overly straight fetlock may lead to subluxation
increased yield strength and higher stiffness of the LCP of the pastern (Figure 46.21). A plate bent approximately
construct demonstrated in equine fracture models [22]. 15 degrees will result in a desirable, slightly upright fet-
lock angle.
Inadvertent damage to the tension band wire/cable
during the surgical procedure is a major technical compli-
cation because it requires removal of the plate, replace-
ment of the tension band and re-application of the plate
(Figure 46.22). Adequate intraoperative imaging and
direct visual estimations during surgery should prevent
this complication, but self-discipline by the surgeon to
check throughout the procedure is required. With locking
plates, an intraoperative radiograph taken directly down
the center of the drill guide can tell the surgeon if the ten-
sion band is at risk from the plate screws. The transarticu-
lar screws should be placed cautiously as well because
they can accidentally damage the tension band
(Figure 46.22).
Pastern subluxation is a major complication of traumatic
disruption of the suspensory apparatus if the base of the
sesamoids and/or distal sesamoidean ligaments are fully
compromised (Figure 46.21). If the bases of the sesamoids
are unstable, a tension band cable of the palmar/plantar
pastern region must be placed [23] or the dorsal plate
should incorporate the middle phalanx.
steosynthesis:Recovery
O
and PostoperativeComplications
Figure46.20 Placing lag screws through the metacarpus into

CastComplications
the proximal sesamoid bones can be used to create tension on Cast sores
the palmar fetlock if the sesamoids and distal sesamoidean
ligaments are intact. In this horse with basal fractures of the Definition
medial and lateral proximal sesamoid bones, the surgeon did Damage to skin and soft tissues caused by pressure or rub-
not recognize the proximal position of the sesamoids. There is
no tension band and this fixation will nearly always fail. Source: bing of the cast that can lead to soft tissue inflammation,
Kyla F. Ortved and Dean W. Richardson. ischemia, necrosis and sloughing
(a)
(b) (c)
Figure46.21 Some errors with fetlock arthrodesis. (a) An LCP placed in the appropriate dorsal position for a fetlock arthrodesis
(“yes”) and an LCP that has deviated from the correct axial position (“no”). (b) Postoperative lateral-medial radiograph of a sub-optimal
fetlock arthrodesis. This plate was poorly positioned as shown in (a) with deviation off the correct axial position. The proximal part of
the plate had to be twisted in order to fit the plate on the metacarpus. The overall fixation was probably not as stable as desired and
the proximal screw in P1 has broken. (c) Subluxation of the proximal interphalangeal joint following fetlock arthrodesis in a horse
with loss of the distal sesamoidean ligamentous support. In order to avoid this complication, a tension band cable of the palmar/
plantar pastern region should be placed or the dorsal plate should incorporate the middle phalanx. Source: Kyla F. Ortved and Dean W.
Richardson.
isk Factors ● Unstable fixation

● Underprotection of cast ends ● Excessive ambulation of the patient
● Loose cast ● Limited experience placing casts
● Excessive padding ● Wrinkles in cast material
(a) (b) (c)
(d)
Figure46.22 Fluoroscopic images used to avoid drilling through the cable. (a) Plate holes surrounded by a yellow circle are safe to
drill through, as no cable can be seen crossing them. (b) A fluoroscopic image obtained exactly perpendicular to the centering sleeve
in the glide hole, which allows the surgeon to ensure that the drill will not interfere with the cable. (c) A similar fluoroscopic image
obtained exactly perpendicular to the centering sleeve in the glide hole showing that the cable would interfere if a screw was placed
in that hole. (d) Postoperative radiographs of a fetlock arthrodesis in which the tension cable broke due to interference from the
transarticular screw (top). The horse had to be re-anesthetized, plate removed, tension band replaced and re-plated (bottom). It is a
serious error to break the tension band. Source: Kyla F. Ortved and Dean W. Richardson.
Pathogenesis It is often necessary to place orthopedic Casts should be changed when indicated or when the
patients in casts for increased stability; however, casts in horse shows discomfort on the cast limb or the cast
horses are never without risk. There is a surprisingly high becomes damaged (cracked or bent).
complication rate with one study reporting that 49% of
horses with a cast had one or more complications [24], Diagnosis The presence of a cast sore is a cause of
with cast sores being the most common complication. discomfort to the patient and the horse typically shows
Cast sores occur as a consequence of excessive pressure lameness, and decreased use and weight-bearing of the
or movement that leads to trauma of underlying skin and cast limb. In some cases, swelling around the top of the
soft tissues over boney areas. Cast sores often occur at the cast, a foul smell, fever, and warm or discolored areas on
proximal ends of the cast, over the dorsal cannon bone, the cast are noted.
over joints and/or over bony protuberances (Figure 46.23).
Cast sores can be superficial or very deep involving tendon Treatment Cast sores on the dorsal cannon bone can be
sheaths and joints. mitigated (at least for a limited time) by the addition of a
heel wedge [12].
Prevention There does not appear to be “one” technique Transfixation pins can be used to minimize movement
that eliminates cast rub sores. This is undoubtedly within a cast if a horse has severe cast sores but cannot be
because there are so many variables involved with the managed without a cast.
application of a cast. Almost every clinician has a fixed
opinion about the thickness and specific type of cast Expected outcome Superficial cast sores tend to heal with
padding and the angles of the fetlock and interphalangeal local treatment. Deeper cast sores can be very problematic,
joints, that quantifying the interaction of so many especially if they enter joints, bursae or tendon sheaths,
variables is difficult. following which synovial sepsis can occur. Significant skin
Provide adequate but not excessive padding. Avoid exces- necrosis may require skin grafting in the future.
sive wrinkles or depressions in cast material during appli-
cation. Daily monitor for early, minor complications. It Cast-associated fractures
should be protocol to assess any horse in a cast daily in a
Definition
consistent manner. The horse should be walked around or
Bone fracture associated with casting is a serious but rare
briefly outside its stall. The opposite foot should be picked
complication.
up daily and any change in willingness noted. Odor, dis-
charge through the cast, attraction of flies and palpable
isk Factors
focal heat are all warning signs. Increased lameness and
visible cast sores at the proximal dorsal margin of the cast ● Cast ending in the diaphysis
are the most commonly perceived complications [24]. ● Full limb cast
(a) (b)
Figure46.23 (a) Cast sores on the mid-dorsal metacarpus and the palmar fetlock joint. (b) Saw-resistant tape placed over cast
padding to prevent soft tissue injury and/or infection during cast removal using an oscillating saw. Source: Kyla F. Ortved and Dean W.
Richardson.
Pathogenesis Casts that end in a diaphyseal location or ComplicationsSecondaryto Cast

near the end of a fracture are at particular risk [24] as stress Immobilization
is concentrated in this location, which is has a thinner
Weakness of structural tissues
cortex than metaphyseal bone.
Horses in full limb casts are also at risk, especially when Definition
rising or lying down, especially in the hind limbs where Cast immobilization of limbs causes disuse osteopenia,
awkward positioning of the cast limb can lead to coxofemo- cartilage loss, tendon/ligament laxity and decreased range
ral luxation, femoral neck fracture or peroneus tertius of motion of joints [25–28].
ruptures.
isk Factors
Prevention Ensure that casts do not end in the diaphyseal
region of a long bone. Avoid casts that end near a fracture ● Cast application
plane. Only use full limb casts when absolutely necessary. ● Age of the animal
● Prolonged use of a cast
Diagnosis The fracture becomes very obvious.
Pathogenesis Significant loss of bone mineral density has
Treatment and expected outcome In some cases, these are been demonstrated in experimentally casted limbs
catastrophic fractures that may require euthanasia of the following seven weeks of immobilization [25]. Osteopenia
patient. is also subjectively evident on radiographic evaluations of
casted limbs.
roken casts Studies have also demonstrated significant decreases in
Definition proteoglycan concentration in the articular cartilage of
Discontinuity of the integrity of the cast that may initially immobilized joints due to decreased compression and poor
appear as a bent cast and may progress to full thickness nourishment [27].
cracks. Tendon and ligament laxity increase with increased time
spent in a cast.
isk Factors
Prevention The above pathological changes are especially
● Use of inadequate cast material
pronounced in foals, such that a cast should be avoided
● Uneven cast application
unless absolutely necessary [12].
● Very active, fractious or nervous horses
Diagnosis Soft tissue laxity is commonly obvious after
Pathogenesis Casts themselves are susceptible to breaking,
removal of the cast. Osteopenia may be evident on
especially at the bottom of the cast and at the fetlock region
diagnostic imaging, although changes may not be too
where there are increased bending forces [24]. Single
obvious on plain radiographs.
overload or cyclic fatigue of casts can cause them to break.
Treatment Although the pathological changes above are
Prevention Use an adequate amount of cast material (5–6
largely reversible, studies have demonstrated that bone
layers) and assure even application of the cast layer.
density takes longer than 8 weeks to return to normal [25].
Reinforce the bottom and toe region of casts with acrylics
Following cast removal, foals will require gradually
such as polymethylmethacrylate (PMMA).
decreasing coaptation due to excessive soft tissue laxity.
Diagnosis Daily inspection of the cast reveals presence of Foals with any form of coaptation, including casts and
bends or crack in the cast. In some cases, these may be splints, often require nursing care to assist them to rise
associated with increased discomfort by the patient and every 2–3 hours.
decreased use of the cast.
Expected outcome Provided that exercise and confinement
Treatment Generally speaking, casts that break should be are adjusted to the patient, restoring of bone density and
replaced, as patched and repaired casts are significantly soft tissue strength occurs normally.
weaker.
ComplicationsSecondaryto CastRemoval
Expected outcome Favorable, provided that the fracture
fixation has remained stable and the cast is changed Definition Iatrogenic damage to the skin, soft tissues and
promptly. joints underlying the cast and caused by the cast saw
Pathogenesis Casts can often be removed or changed in distal MCIII/MTIII, and breakdown injuries of the fetlock
the standing sedated horse. General anesthesia may be joint that are not amenable to arthrodesis (Figure 46.24) [29].
required for cast changes fractious patients, those with Although pin-casts are an important part of our equine
fragile status of a fracture or a site that is difficult to orthopedic armamentarium, serious complications are
position. Care must be taken when using oscillating saws often associated with their use [30]. The most common
to cut through cast material as it can lead to soft tissue complications associated with the pins include pin tract
injury and/or infection, most commonly skin and possibly infection, ring sequestra, pin loosening, pin breakage and
underlying structures, including tendons and joints. catastrophic fracture through a pin hole [31].
Prevention Gigli wire protected by plastic tubing can be

Thermal injury
placed on either side of the cast under the cast material to
aid in removal. Use saw-resistant tape placed over the cast Definition
padding (Figure 46.23). A good handler and adequate Overheating of the bone around the pin during the
sedation are important, as some horses panic when the cast drilling
is split and partially removed.
isk Factors
Diagnosis If the cast is being replaced standing, horses
may resent when the iatrogenic damage to the skin and soft ● Use of large pins
tissues occurs. The iatrogenic damage becomes obvious ● Dense cortical bone
after removal of the cast and padding layer. ● Technical error
Treatment Local wound care. Articular lavage if a joint is

Pathogenesis Large pins are used in transfixation pin
inadvertently penetrated.
casts; therefore, significant thermal injury during drilling
Expected outcome Dependent on the extent of the injury can occur, thereby increasing pin-associated complications.
and the tissues involved Thermal injury to the bone around the pin leads to
osteonecrosis and loosening of the pins. The fixation will
become unstable secondary to pin loosening.
TransfixationPinCastComplications
Transfixation pin casts are most commonly used for com- Prevention Thermal damage can be reduced by using
minuted fractures of the proximal and middle phalanges, sharp bits, drilling sequentially larger holes, copious
(a) (b)
Figure46.24 (a) Radiograph of comminuted proximal phalangeal fracture repaired with lag screws and a transfixation pin cast. The
distal pin placed in the condyles is infected with mild bony lysis present on the radiograph. (b) A transfixation pin cast with two pins
placed in the metaphysis at 30-degree divergence in the frontal plane to decrease the risk of fracture. Source: Kyla F. Ortved and Dean
W. Richardson.
irrigation, frequent cleaning of drill bits, and slow isk factors

insertion of the threaded pin.
● Infection
● Thermal injury
Diagnosis Ring sequestra noted on radiographs
● Instability
Treatment Once thermal injury occurs, little can be done
Pathogenesis Pin loosening is a very frequent complication
to treat the subsequent osteonecrosis. Prevention is by far
of transfixation pin casts. Osteolysis around the pin due to
the best tactic. Loose pins should be removed as they are no
weight-bearing ± infection eventually leads to a pin that is
longer providing stability. A larger pin can sometimes be
no longer engaged in bone.
placed in the original hole; however, an entirely new hole
Local infection plus weight-bearing forces acting at the
is often required.
pin–bone interface can lead to bone lysis and pin loosening.
Thermal injury and osteonecrosis can also lead to pin
Expected outcome Loosening of pins and infection
loosening.
commonly occur secondary to thermal injury.
Pin tract infection

Diagnosis In more advanced cases, pins may shift and/or
Definition
be loose when palpated. Horses may show discomfort in
Infection of pin holes is an inevitability of transfixation pin the limb with the infected pin-cast. Radiographs may show
casts. increased radiolucency or sequestrum formation around
the pins involved.
isk Factors
Prevention Minimize thermal damage during insertion.
● Inherent to the use of tranfixation pins Minimize infection by covering pin ends with PMMA and
● Thermal injury keeping the cast clean. Administer antimicrobials when
indicated.
Pathogenesis Pin holes are susceptible to infection
because of their communication through the skin. Bacterial Treatment Loose pins tend to be uncomfortable for the
contamination extends from the skin surface along the patient, provide little support and may propagate deeper
surface of the pin leading to localized infection. infection so they generally should be removed/
replaced [32].
Diagnosis Sero-purulent discharge is commonly observed Loose pins can usually be removed standing.
from the pin–skin interface. Radiographs may show
increased radiolucency or sequestrum formation around Expected outcome Resolution once the pin is removed
the pins. In more advanced cases, pins may become loose
and some horses may show discomfort in the limb with the Fractures associated with transfixation pin casts
infected pin-cast. Definition
Fractures associated with a transfixation pin
Prevention Cover pins with polymethylmethacrylate
(PMMA) where they exit the cast and keep the cast covered Pathogenesis Fractures tend to occur through a pin hole,
with bandage material to minimize external contamination. especially when they are located in the diaphysis or when
they are close to the end of the cast. The diaphysis has
Treatment Removal of pins and lavage of pin holes thinner cortical bone than the metaphysis, therefore is at
generally resolves infections. higher risk of fracture. The combination of pins and the
end of the cast causes a significant stress riser at this level
Expected outcome Pin tract infections tend to resolve easily and should be avoided if possible.
following removal of the pin. Systemic and local
antimicrobials may be required in some cases. More Diagnosis Increased discomfort or lameness is common in
widespread osteomyelitis following infection of the pin horses, and misalignment of the limb proximal to the cast
holes is uncommon. may also be obvious. Radiographic examination confirms
presence of fracture.
Pin loosening
Definition Prevention The risk of fracture is reduced by placing pins
Pin becomes loose and not engaged in bone. as far as possible from the proximal extent of the cast and
within the metaphysis [12, 33]. Because there seems to be evaluated. Radiographs of the limb allow the surgeon to
greater risk of catastrophic fractures with pins placed more evaluate the repair for loss of reduction, implant failure or
proximally in the diaphysis, some surgeons place the distal fracture. Radiographic evidence of infection, including
pin through the most distal metacarpus/metatarsus [34]. If osteolysis around implants and periosteal reaction
this is done, great care should be taken to center the pins to unassociated with fracture repair, requires several weeks to
minimize pin exposure to the joint. However, even with develop, therefore sequential radiographs can be helpful.
careful placement, this technique does put the fetlock joint
at risk of contamination/infection (Figure 46.24). Treatment Instability should be addressed with the
It has been advised that transfixation pins should be addition of more implants or external coaptation. Infection
placed with 30-degree divergence in the frontal plane to should be treated as described below.
improve stability and decrease the risk of fracture
(Figure 46.24) [35]. Expected outcome Expected outcome depends on the
surgeon’s ability to treat the underlying cause of lameness. If
Treatment and expected outcome Fractures through pin instability and infection can be resolved or managed until
holes tend to be catastrophic the fracture heals or the joint fuses, outcome is favorable.
Complete loss of stability, uncontrollable infection, and
supporting limb lameness are all associated with poor
PostoperativeLameness outcomes.
Definition Decreased use or lower than expected use of
the affected limb in the postoperative period SupportingLimbLaminitis
isk Factors Definition Failure of the laminae of the contralateral limb
● Inadequate fixation materials and/or technique isk Factors

● Inexperience surgeon
● Surgical errors ● Heavy horse
● Prolonged non-weight-bearing lameness
Pathogenesis Postoperative lameness immediately ● Patient with previous laminitis episodes
following fracture repair is almost always indicative of
instability. If the fracture has been sufficiently stabilized Pathogenesis Although the exact pathophysiology of SLL
during surgery, the horse should be significantly more remains unknown, it seems likely that excessive and static
comfortable postoperatively and ideally should be almost weight-bearing impairs normal metabolic activity in
fully weight-bearing. lamellar tissues that result in mechanical failure [36, 37].
Instability, as discussed above, can be due to inadequate Horses that have not been fully weight-bearing in all 4
anatomical reduction, inadequate or inappropriate limbs for any period of time are at risk of supporting limb
implants, implant failure and/or infection. Fractures laminitis (SLL). Although the risk of SLL increases with
distant to the original site should be considered if the horse severity and duration of lameness, the development of SLL
develops a significant lameness that cannot be explained is unpredictable and can occur surprisingly quickly and
by the primary fracture. Nerve damage from the original suddenly [38]. An estimated incidence of SLL of greater
injury or the repair (e.g. radial nerve damage associated than 10% has been reported [39]. Because SLL has a high a
with a humeral fracture) should be considered if the horse high mortality rate (~50%) [40], even horses with successful
appears to be unable to bear weight on the limb but is not fracture repairs will be lost to this complication; therefore,
necessarily feeling pain. Pain and lameness associated with every effort must be made to avoid the development of SLL.
a surgical infection typically take days to weeks to manifest.
Prevention The single-most effective means of preventing
Diagnosis Due to the nature of fracture repair in large SLL is to make the horse as comfortable as possible on its
animals, not all fractures can be perfectly reduced or injured limb, i.e. perform a stabilizing surgery in an optimal
adequately stabilized with available implants. A certain manner. Although a plethora of preventative measures
degree of lameness can be acceptable in animals where have been advocated (sole support, frog pressure, heel
anatomical reduction was not achieved or where significant wedges, sand bedding and floor mats), clinical evidence
soft tissue damage occurred during the repair. Horses with suggests that none of these will reliably prevent SLL.
excessive postoperative lameness should be closely Mechanical support of the foot and decreased tension on
the deep digital flexor tendon (DDFT) have been dosage), preservation of blood supply and careful tissue
recommended for horses at risk of SLL [39]. Mechanical handling are essential elements of orthopedic surgery.
support of the foot can be achieved with impression material
used to fill the arch of the foot or application of a Lily Pad. Diagnosis Despite appropriate precautions being taken,
Horses can also be placed in deep, supportive bedding such orthopedic infections in horses undergoing major
as sand or cushioned stall mats. Raising the heels with a orthopedic procedures occur with a reported incidence of
wedge can be used to decrease DDFT tension and move the 10–28% [3, 4]. Timely recognition of clinical signs is key to
breakover point back toward the heel. Controlled exercise successful treatment of orthopedic infections. The most
or some physical therapy to improve circulation to the foot common clinical signs include fever, decrease in comfort,
have been recommended, but this option is clearly limited persistent swelling or increase in swelling, drainage/
in a horse with a painful primary injury [38]. discharge, failure of incision to heal normally and/or
development of pink, shiny, hairless area indicative of an
Diagnosis Horses will often begin to display lameness on abscess (Figure 46.25) [12]. Hematology can also be helpful
the contralateral limb. Increased digital pulses, clefting at in diagnosing orthopedic infections. Leukocytosis
the coronary band, and increased hoof wall temperature characterized by a mature neutrophilia,
may also be present. Lateral and dorsopalmar/dorsoplantar hyperfibrinogenemia and elevated serum amyloid A are
radiographs of the foot should be obtained to assess P3 for common findings. The acute phase proteins may be serially
rotation and/or sinking. monitored to evaluate response to treatment.
Diagnostic imaging is an important tool for diagnosing
Treatment As in all cases of laminitis, treatment is difficult
and monitoring orthopedic infections. In the acute phase,
and is entirely supportive. By far the most effective
radiographic changes are limited to soft tissue swelling,
treatment is increasing comfort on the injured limb such
which can be difficult to discern from normal surgical site
that more equitable load sharing is possible. Providing the
swelling. Osteolysis around implants and periosteal
horse with deep bedding, mechanical support of the foot
reaction unassociated with fracture healing become
through application of frog support and/or shoes, and
evident after several weeks (Figure 46.25) [41]. Osteolysis
analgesia should be undertaken. More aggressive treatment
extending into the cancellous bone and/or medullary
options may include placing the laminitic limb in a
cavity is often seen in chronic infections. Three-dimensional
transfixiation pin cast to unload the foot and/or maintaining
imaging such as CT and MRI can be useful to determine
the horse in a sling.
the extent of infection and diagnose infections that are
difficult to evaluate on plain radiographs. Ultrasonography
Expected outcome Development of SLL is usually a serious
is useful to demonstrate fluid around the bone and/or
setback and often leads to humane euthanasia. Prevention
implant. An accurate bacterial culture and sensitivity can
is key.
be extremely helpful to determine effective antimicrobial
choices. Draining tracts or incisional drainage can be
PostoperativeInfection cultured; however, these areas should be sterilely prepared
prior to sampling to avoid contamination. Ultrasound-
Definition Infection at the surgical site
guided aspiration is often more accurate for bacterial
cultures and is very useful for sampling deeper infections.
isk Factors
● Open fractures Treatment Treatment of orthopedic infections should

● Long surgical time include systemic and local antimicrobial therapy, as well as
● Concurrent soft tissue injury drainage and/or lavage when appropriate. Surgical sites
● Poor incisional closure with fluid present should be drained through the ventral
● Break in aseptic technique aspect of incision. The area should be sterilely prepared
● Number of implants prior to introducing a sterile instrument to facilitate
drainage. A ventral drain can also be placed if necessary.
Pathogenesis Infection is the most common and Local antimicrobial therapy has many advantages over
inarguably the most important postoperative complication systemic therapy, including the ability to achieve very high
in orthopedic surgery. concentrations of the drug, ability to use otherwise
prohibitively expensive antimicrobials, and avoidance of
Prevention Meticulous aseptic technique, appropriate adverse side effects from high doses of systemic antimicro-
antimicrobial prophylaxis (selected drugs, timing and bials. Several methods of local antimicrobial delivery exist.
(a) (b)
Figure46.25 (a) An inverted “T” incision 2 weeks following a pastern arthrodesis. Although most such incisions heal well, this one
has moderate purulent drainage. (b) Lateral-medial radiograph obtained 3 months following repair of a simple, sagittal P1 fracture.
The two distal screws are infected with obvious bony lysis around both screws. Typical periosteal reaction is seen dorsally. Source:
Kyla F. Ortved and Dean W. Richardson.
The application of antimicrobial impregnated polymethyl- tions well above the MIC for most bacteria [54, 55].
methacrylate (PMMA) around implants is common and Regional limb perfusion is performed with an Esmarch or
effective for long-term, localized delivery (Figure 46.26) [42– pneumatic tourniquet applied proximal to the site of infec-
44]. PMMA can be applied directly adjacent to implants, be tion (Figure 46.26). The antimicrobial is diluted in sterile
used for plate luting or can be formed into cylinders or saline to a total volume of 30–60 mL and injected via a but-
spheres and placed within the surgical site (Figure 46.26). terfly needle or catheter into a superficial vein. Adequate
PMMA can elute antimicrobials for months [45]; how- sedation is required to ensure that the horse stands still, as
ever, disadvantages include that it is not absorbable and movement is associated with decreased tourniquet effi-
heat labile antimicrobials cannot be used. Antimicrobial ciency. The tourniquet should be left in place for 20–30 min-
powder or liquid (1–2 g) can be added to every 10 g of utes. Application of a topical anti-inflammatory such as 1%
PMMA. The use of liquid antimicrobials requires the vol- diclofenac (Surpass, Boehringer Ingelheim Vetmedica Inc.,
ume of the liquid component of PMMA to be decreased by St. Joseph, MO) and a compression bandage over the site of
half the volume of the added antibiotic. Common antimi- venipuncture can help decrease subcutaneous inflamma-
crobials include amikacin, gentamicin, cephalosporins, tion and thrombophlebitis.
enrofloxacin and ampicillin. Plaster of Paris can also be Antimicrobial selection is ideally based on bacterial cul-
used if an absorbable material is preferred [46]. Newer ture and sensitivity. Antimicrobials should be soluble in
materials under investigation may (should) ultimately saline and should not cause vasculitis (e.g. enrofloxacin).
replace PMMA and include polylactide [47], collagen The most commonly used antimicrobials include amino-
sponges [48], polyanhydrides [49], calcium phosphate [50], glycosides, β-lactams, and cephalosporins. Recommended
chitosan, fibrin [51], and others. doses are variable, with some authors recommending
Regional limb perfusion (RLP) is an effective and rela- administration of one-third the daily systemic dose as the
tively simple way to deliver high concentrations of antimi- dose for RLP [12, 56]. Carbapenems (including imipenem
crobial to an area of infection [52, 53]. Several studies have and meropenem) and vancomycin have been used for
shown that RLP results in tissue antimicrobial concentra- regional limb perfusion in resistant infections; however,
References 663
(a) (b) (c)
Figure46.26 (a) Antibiotic-impregnated polymethylmethacrylate (PMMA) being applied around a bone plate following arthrodesis
of the metacarpophalangeal joint. (b) Antibiotic-impregnated PMMA formed into cylinders on a string. (c) Regional limb perfusion in
the right cephalic vein with a wide rubber tourniquet applied proximally. Source: Kyla F. Ortved and Dean W. Richardson.
these antimicrobials should be used judiciously and spar- Antimicrobials can be injected into the desired joint under
ingly as they are extremely important antimicrobials for aseptic conditions. Alternatively, an indwelling catheter
the treatment of resistant human infections. can be placed for continuous administration.
Intra-osseous (IO) perfusion can also be used to achieve Cancellous bone grafts have been used to accelerate frac-
high concentrations of antimicrobials at sites of infection. ture healing and promote healing in nonunions and infected
Commercial catheters (Cook Intraosseous Needle, Cook fractures. Autogenous cancellous bone has osteogenic,
Medical, Bloomington, IN) and cannulated screws can be osteo-inductive and osteo-conductive properiies and can be
used as indwelling ports for intra-osseous perfusion. easily harvested from the ilium, sternum and proximal tibia
Alternatively, the male end of a luer-tipped extension set of the horse [61]. Because cancellous bone contains osteo-
can be used. In adult equine bone, a 4.0-mm drill bit can be blasts that contribute to new bone growth (osteogenesis),
used to make a hole into the medullary cavity at the desired stimulates osteoprogenitor cells to differentiate into osteo-
location first. A tourniquet must be placed proximal to the blasts (osteo-induction), and provides a mechanical scaffold
injection site and should be maintained for 20–30 minutes. for new bone growth (osteo-conduction), a cancellous bone
Similar antimicrobials, as described for IV regional limb graft can help support unstable fractures and stimulate
perfusion, can be used. The most common adverse side healing, even when infection is present [62].
effect with IO perfusion is swelling over the injection site. Ultimately, orthopedic infections that do not respond to
Although no studies have evaluated the effect of IO perfu- treatment may require implant removal with debridement
sion on the equine medullary cavity, bone marrow fibrosis of soft tissue and bone. Many fractures can heal despite
and cancellous new bone formation have been reported in infection; therefore, delaying implant removal until frac-
goats [57]. There is at least one report of osteonecrosis in ture healing has occurred is ideal. Alternative methods of
an equine proximal phalanx after IO perfusion [58] and stabilization, such as a transfixation pin cast, may be
anecdotal experience has been that some horses experience required if implants need to be removed prematurely from
pain with IO perfusion. Studies comparing the diffusion of an unstable fracture.
perfusate in the distal limb following IV perfusion or IO
perfusion found no significant differences [59, 60]. Because Expected outcome At best, infection usually leads to
veins are more accessible and IV perfusion is less invasive, increased cost, need for implant removal, decreased
IV RLP is more commonly used than IO RLP. cosmetic outcome, and a poorer functional outcome. At
Intra-articular administration of antimicrobials is espe- worst, infection can lead to fracture instability, mechanical
cially useful for treating infected articular fractures. failure, delayed union/nonunion, and euthanasia.
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47
Complicationsof Surgeryof the EquineFoot

Britta S. Leise DVM, PhD, DACVS-LA
Louisiana State University, School of Veterinary Medicine, Baton Rouge, Louisiana
Overview The following conditions and associated complications

have been described for surgical treatments of the horse’s
Lameness, which is frequently associated with the foot, foot:
can limit athletic performance and threaten the life of the Surgical Debridement for Septic Ostetitis of the
horse. Some of these conditions require surgical interven- Distal Phalanx
tion to resolve or improve lameness. With surgical sites in Intraoperative complications
direct or close proximity to the environment, infection 1) Hemorrhage
can be a great concern and is one of the largest complica- Postoperative complications
tions associated with surgery of the equine foot. The com-
plex anatomy of the foot also places various structures at 1) Recurrence of sepsis
risk of damage, occurring from either the primary disease 2) Pathological fracture
or secondary to the surgical approach and techniques 3) Sepsis of the distal interphalangeal joint or navicular
used. This chapter will discuss both intraoperative and bursa
postoperative complications associated with surgery of 4) Tetanus
the equine foot. Keratoma Removal/Dorsal Hoof Wall Resection
Intraoperative complications
1) Hemorrhage
L
Postoperative complication
with Surgeryof the EquineFoot
1) Lameness
● Hemorrhage 2) Infection of the lamellae and/or distal phalanx
● Surgical site infection 3) Excessive granulation tissue at the hoof wall resection
● Persistent/recurring infection site
● Surgical site dehiscence and excessive production of 4) Recurrence
granulation tissue 5) Laminitis
● New, persistent or recurrent lameness Surgical Fixation of Distal Phalanx Fractures
● Pathological fracture of distal phalanx or navicular bone Intraoperative complications:
● Iatrogenic damage to related anatomical structure
1) Incomplete or inappropriate reduction
● Contraction, deformation or abnormal growth of the 2) Intraoperative hemorrhage
hoof
● Hoof abscess Postoperative complications:
● Laminitis 1) Infection (bone or abscess within the hoof capsule)
● Neuroma formation 2) Development of abnormal hoof shape
● Rupture of the deep digital flexor tendon 3) Implant failure
668 Complications of Surgery of the quine Foot
4) Delayed union or non-union can occur secondary to Postoperative complications:

infection and/or instability
1) Incomplete resolution or recurrence of infection
5) Osteoarthritis of the DIP joint
2) Infection of the distal interphalangeal joint
Surgical Fixation of Navicular Bone Fractures 3) Dehiscence of the surgical site
Intraoperative complications: 4) Tetanus
1) Splitting of the fragment during repair Palmar Digital Neurectomy

2) Poor reduction Intraoperative complications:
Postoperative complication: 1) Inadvertent transection of the palmar digital artery or

vein
1) Infection (bone or abscess within the hoof capsule) Postoperative complications:
2) Implant failure
3) Delayed union or non-union can occur secondary to 1) Recurrence of lameness
infection and/or instability 2) Neuroma formation
4) Residual lameness 3) Failure to alleviate lameness
4) Abscess or deep hoof infection
Arthroscopy of the Distal Interphalangeal Joint 5) Ruptured deep digital flexor tendon
Intraoperative complications: 6) Fracture of the navicular bone
1) Iatrogenic trauma to the joint, including articular General complications related to synovial endoscopy
damage, tearing of the joint capsule or extensor tendon (arthroscopy, tenoscopy, bursoscopy), fracture repair, and
2) Inadvertent entry into navicular bursa or distal digital neurectomy are discussed in Chapter 45: Complications of
flexor tendon sheath Synovial Endoscopic Surgery (Arthroscopy, Tenoscopy,
3) Incomplete removal of intra-articular fragments Bursoscopy); Chapter 46: Complications of Orthopedic
4) Damage to the palmar/plantar neurovascular bundle Surgery; and Chapter 60; Complications of Peripheral
5) Damage to the coronary band Nerve Surgery. The reader is referred to these chapters for
more information.
Postoperative complication:
1) Sepsis of the distal interphalangeal joint
2) Osteoarthritis Hemorrhage
3) Mineralization of the soft tissue
Definition Intraoperative or early postoperative bleeding
Navicular Bursoscopy resulting from iatrogenic trauma of major or minor vessels
Intraoperative complications: encountered during the surgical approach
1) Iatrogenic damage to the navicular bone and/or deep
digital flexor tendon isk Factors
2) Damage to the palmar/plantar neurovascular bundle ● Inherited conditions such as coagulation factor deficits
during portal placement may increase the risk of hemorrhage but are uncommon
3) Incomplete visualization of the navicular bursa in the horse.
4) Lack of ventral drainage and debridement of the distal ● Acquired coagulopathy or thrombocytopenia resulting
palmar/plantar aspect of the deep digital flexor tendon from disorders such as systemic sepsis/SIRS or dissemi-
in cases with penetrating injuries nated intravascular coagulopathy. These conditions would
Postoperative complication: unlikely accompany disorders requiring surgery of the
equine foot.
1) Sepsis of the navicular bursa ● The surgical approach and anatomy associated with the
2) Residual lameness condition requiring surgical treatment.
3) Reformation or formation of adhesions
Pathogenesis The majority of hemorrhage is a direct result
Debridement of Infected of Collateral Cartilages
of the surgical procedure and inadequate surgical
Intraoperative complications:
hemostasis. In humans, 75–90% of all intraoperative and
1) Inadvertent entry into the distal interphalangeal joint early postoperative bleeding results from the surgical
2) Hemorrhage technique [1]. Although the major blood supply to the foot
Surgical Site Infection 669
is relatively simple, composed primarily of the medial and loss intraoperatively [4], and/or a blood transfusion. The
lateral palmar digital artery and vein, there are numerous author is referred to Chapter 8: Complications of Blood
arterioles, venules and capillaries within the soft tissue Transfusion, for further information.
structures within the hoof. Access to the distal phalanx
often requires a surgical approach, through either the Expected outcome Substantial hemorrhage requiring
dorsal lamellae or digital cushion, resulting in significant blood transfusion or resulting in death is unlikely to occur.
hemorrhage that can obscure the surgical field. The Knowledge of the surgical anatomy and appropriate
location of small vessels tightly packed within the hoof prevention through the use of a tourniquet will greatly
capsule makes it difficult to control hemorrhage by minimize blood loss.
common methods such as ligation or electrocautery.
Prevention The use of a tourniquet is essential for

SurgicalSiteInfection
intraoperative visualization during debridement of the
affected area in cases of keratoma and septic distal phalanx or
Definition Surgical site infections (SSI) occur when
collateral cartilages. The use of a tourniquet can also be
bacteria are introduced at the time of surgery or in the
helpful to control hemorrhage within the joint during
immediate postoperative period. SSI can be minor involving
tenoscopy/arthroscopy, particularly during removal of
just the skin and subcutaneous tissues or more serious
extensor process fragments. However, there is an increased
involving the sensitive (lamellar and digital cushion)
risk of iatrogenic trauma to the neurovascular bundle (during
tissues of the hoof, bone or synovial structures of the foot.
a palmar/plantar surgical approach) when an Esmarch
bandage is applied, as it is more difficult to identify the
isk Factors
vasculature once exsanguination of the vessels has occurred.
Complete knowledge of the surgical anatomy and tech- ● Location: The equine foot is located in a contaminated
nique is important to avoid vascular structures during the environment with numerous aerobic gram-negative and
surgical approach and throughout the procedure. For anaerobic bacteria present on the hoof and skin
example, careful palpation of the neurovascular bundle surfaces
and understanding of the anatomy is important when ● Poor preparation of the foot prior to surgery
placing portals into the palmar/plantar aspect of the DIP ● Decreased host immunity
joint [2]. Adequate visualization of the neurovascular ● Presence of foreign material or devitalized tissue
bundle is also important when performing a palmar/ ● Increased surgical duration
plantar digital neurectomy; therefore, an appropriate size
incision is necessary to identify the nerve. More experience Pathogenesis High concentrations of environmental
will allow for smaller incisions. bacteria exist on the equine digit due to its proximity to dirt
and fecal material. This results in an increased risk of
Diagnosis Presence of blood in the surgical field surgical site infections. Infection of the surgical site, by
intraoperatively and bleeding through the bandage in the environmental contaminates, occur when bacteria is
early postoperative period are observed. In severe cases of introduced during preparation of the hoof for surgery or
hemorrhage, drop in mean arterial pressures from insufficient barrier protection in the postoperative
intraoperatively can occur. Decreases in total protein and period. In addition to fecal contaminates, the anaerobic
packed cell volume may also be noted in more severe cases environment of the hoof can allow for growth of the
of hemorrhage during the postoperative period. specific bacteria, Clostridium tetani. High mortality rates
are seen in unvaccinated horses with tetanus; furthermore,
Treatment If large enough to visualize, ligation of the hoof abscesses are one of the more common conditions
transected vessel will stop the hemorrhage. If the vessel related to tetanus in the adult horse and should be
cannot be visualized, placement of a pressure bandage can addressed to prevent this complication from occurring [5].
be used postoperatively to minimize hemorrhage. In severe
cases of hemorrhage, medical intervention may be Prevention Appropriate preparation of the hoof prior to
indicated. This could include administration of intravenous surgery is important to prevent surgical site infections.
fluids for volume expansion, aminocaproic acid for its Trimming of the foot, removal of the periople and pairing
antifibrinolytic effects by inhibiting plasminogen out of the sole can be helpful in eliminating environmental
activator [3], administration of Yunnan Baiyao, a Chinese contaminates and is recommended prior to disinfecting the
herbal drug that has been demonstrated to reduce blood hoof. Aseptic preparation with iodine and alcohol should
be performed on the entire hoof. While soaking of the foot Intraoperatively, adherence to Halsted’s principles,
overnight prior to surgical procedures is advocated by debridement of all infective and devitalized tissues, and
some, one report found an increase in bacterial minimizing surgical procedure time can all help decrease
recolonization when the hoof was soaked with povidone the risk of surgical site infection [12]. Application of a
iodine for 12 hours [6]. Therefore, a 4-minute disinfection sterile bandage with aseptic changes as needed
with iodine (either tincture or povidone) is recommended postoperatively are essential to limit the development of
for pre-surgical preparation of the equine foot [6]. surgical site infections until keratinized granulation tissue
Intraoperatively, appropriate draping/covering of the fills the hoof defect or skin incisions have healed (10–14
foot is important to prevent contamination during the days postoperatively). Sterile dressing covering the entire
surgical procedure. When performing surgical procedures surgical site should be maintained until arthroscopic
involving the hoof capsule, careful surgical debridement is portals are sealed and skin sutures removed. Placing
important. Initial hoof debridement using a Dremel tool to waterproof adhesive tape (duck tape) over the sterile
reach the sensitive lamellar tissue, followed by aseptic bandage to prevent wicking of water and bacteria into the
resection of the affected area with sterile instrumentation, bandage is recommended. In addition to bandaging, it is
can help limit contamination. important to keep the horse in a clean, dry stall during the
Perioperative antimicrobial therapy has been postoperative period.
demonstrated to reduce the occurrence of surgical site Horses that have not received tetanus prophylaxis should
infections [7]. However, the use of prophylaxic antibiotics be administered tetanus antitoxin. Horses not vaccinated
is controversial due to the continual development of within 6 months of injury should receive a tetanus toxoid
antibiotic resistance. This is prompting the judicious use of booster at the time of surgery.
systemic antimicrobials in our veterinary patients, and
studies suggest that perioperative antibiotics may not be Diagnosis Surgical site infections associated with surgery
indicated in all cases [8, 9]. of the foot may be diagnosed by the clinical signs of
Administration of antibiotics 1 hour prior to making the drainage at the site and/or lameness. A complete blood
incision, using appropriate spectrum of antimicrobials and count may reveal leukocytosis and hyperfibrinogenemia.
limiting use to no longer than 24 hours post-surgery is Infection of synovial structures will have an increased
recommend when prophylaxic antibiotic therapy is number of white blood cells and total protein in the
utilized. While broad-spectrum systemic antibiotics are synovial fluid obtained via arthrocentesis. Increase in
frequently administered perioperatively in horses synovial concentrations of lactate or increases in serum
undergoing surgery of the distal limb, they may not be amyloid A may also be suggestive of sepsis in a synovial
ideal for limiting local infections. Intravenous regional structure [3, 14]. Radiographs may reveal evidence of bone
limb perfusion performed intraoperatively will allow for infection demonstrated by lysis of the affected bone or lysis
high concentrations of antibiotics to accumulate in the soft surrounding implants. Culture of the affected tissue, bone,
tissue structure and bone of the foot. Performing this and/or synovial fluid would document infection and anti-
procedure at the time of surgery, particularly in fracture microbial sensitivities are necessary to determine
repair of the distal limb, can be helpful in preventing appropriate therapy.
surgical site infections. Additionally, use of an antibiotic in
the saline lavage fluid is frequently used intraoperatively Treatment Surgical site infections involving the lamellae,
during fracture repair to prevent surgical site infection digital cushion, soft tissue structures (tendons/ligaments),
associated with implants [10]. synovial structures and/or bones of the foot, require
Sealing of the hoof defect created for screw placement antimicrobial therapy. Systemic administration of broad-
during repair of distal phalanx or navicular bone fractures spectrum antimicrobials and intravenous regional limb
can prevent contamination. Use of antibiotic impregnated perfusions or intra-synovial administration of antibiotics
polymethylmethacrylate will seal the hoof wall defect. are recommended in these cases. Placement of
Placement of collagen sponges filled with amikacin have antimicrobial impregnated beads at the affected site may
been used at the surgical site to fill the hoof defect prior to also be used to treat surgical site infections. For synovial
patching with hoof acrylic [11]. In hoof defects that cannot infections, through-and-through lavage is a cornerstone of
be sealed, the use of topical antimicrobials may decrease therapy. While needle lavage or arthroscopy/bursoscopy
the risk of infection. For example, packing hoof defects can be utilized, endoscopic procedures allow for more
with betadine-soaked gauzes (with or without the addition aggressive treatment. Multiple lavages may be necessary
of crushed metronidazole tablets) may prevent the devel- and arthroscopy/bursoscopy are recommend for chronic
opment of infection. cases.
Persistent/Recurring Infection 671
Infection of the implant, evidence by lysis of the bone Detailed preoperative assessment is essential to determine
surrounding implant, is treated by removal. However, the extent of initial infection. Radiographs alone may not
depending on the severity of the infection and the status of be sufficient in exposing the affected area in its entirety. CT
healing and stabilization of the fracture in the face of or MRI can be useful in these cases and may be indicated if
infection, it may be preferred to treat the horse with sepsis persists (Figure 47.1).
antimicrobials over immediate removal to allow further Cytology and analysis of synovial fluid is important
healing to occur. when treating synovial sepsis, as it can help determine if
treatment protocols are resolving the infection. Accurate
Expected outcome Surgical site infection rates vary, assessment of the distal interphalangeal joint and navicular
depending on the type of procedure performed. Rates for bursa is important. Horses with septic distal phalanx ostei-
orthopedic complications associated for SSI range from 8% tis or infected collateral cartilages may also have involve-
in clean procedures and up to 52% in clean contaminated ment of these synovial structures. If contamination of
procedures [12]. The overall risk of synovial sepsis in the these structures exists, then aggressive therapy should be
horse post arthroscopy is low with reported rates of 1%. incorporated into the treatment regimen at the time of
Increased risk of synovial sepsis can occur after elective surgery.
arthroscopy is increased with large lesions [15], suggesting When treating septic otitis of the distal phalanx, thor-
that arthroscopy to remove large extensor process ough debridement is crucial. Adequate access is dependent
fragments would have increased risk of complications. upon amount of ventral (Figure 47.2) or dorsal exposure
Surgical repair of fractures within the hoof have an SSI risk created during the surgical approach. While larger defects
of 37.5% [16]. in the solar surface of the hoof can take longer to heal,
inappropriate window size can significantly limit the sur-
geon’s ability to debride the affected bone.
Navicular bursoscopy via a direct approach in cases of
Persistent/RecurringInfection
suspected sepsis/penetrating injures allows for lavage of
the bursa and is considered the current standard of care in
Definition Infection that does not resolve with appropriate
horses with penetrating injuries [19, 20]. In one study, 10
combined surgical and medical therapy
out of 16 horses with penetrating injuries returned to full
function after bursoscopy [21]. It was found that the bur-
isk Factors
soscopy technique was less invasive, allowed for similar
● Presence of bacteria resistant to commonly used postoperative management, and had better results than
antimicrobials with the traditional streetnail procedure [21]. It is impor-
● Presence of necrotic or poorly perfused tissue tant however, that the location of the penetrating injury in
● Systemic disease, such as equine pituitary pars the sole or frog of the hoof is paired out to provide ventral
intermedia dysfunction may impair neutrophil function, drainage. Additionally, while the distal aspect of the deep
thereby allowing persistent infections digital flexor tendon does not undergo surgical debride-
ment during bursoscopy, infection of the tendon can be
Pathogenesis Recurrence of sepsis can occur for several prevented or treated via intravenous regional limb perfu-
reasons. Incomplete debridement and resistant infections
can be predisposing causes [12]. Infections of synovial
structures can be difficult to resolve, particularly in chronic
cases, due to the presence of fibrin and synovial
proliferation. Implants allow for the production of biofilms
by bacteria, which create barriers to antimicrobial
therapy [17, 18]. Inappropriate postoperative management
of the surgical site by not maintaining a sterile bandage
and clean dry environment will result in the introduction
of new bacteria into the region and may be another cause
for incomplete resolution of disease.
Prevention Accurate diagnosis and a good surgical

Figure47.1 CT image of septic osteitis of the distal phalanx
technique are essential, during both initial management of demonstrating communication with the distal interphalangeal
the case and once persistent infection has been identified. joint (arrow). Source: Britta S. Leise.
coronary band when performing the trephination. Maggot

therapy has also been used to help assure complete debride-
ment of the devitalized tissue associated with the infected
collateral cartilage [23].
Culture and sensitivity of the affected tissue/bone can be
of benefit to assure appropriate antimicrobials are admin-
istered. While numerous bacteria are present in and around
the hoof, septic osteitis/synovitis can be life threatening to
the horse, making appropriate therapy a key to success;
therefore, knowledge of antimicrobial resistance early in
the course of treatment may help prevent recurrence of
sepsis.
Adequate preparation of the sole and hoof prior to sur-
gery can help prevent the introduction of new bacteria into
the surgical site.
Diagnosis Persistent infection may be diagnosed by the

continuation or worsening of clinical signs such as drainage
at the surgical site and/or lameness. A complete blood
count may reveal leukocytosis and hyperfibrinogenemia.
Infection of synovial structures will have an increased
number of white blood cells and total protein in the
synovial fluid obtained via arthrocentesis. Increase in
synovial concentration of lactate or increases in serum
amyloid A may also be suggestive of sepsis in a synovial
structure [13, 14]. Radiographs may reveal evidence of
Figure47.2 Defect in the solar surface of the hoof must be bone infection demonstrated by lysis of the affected bone
large enough to adequately debrided the affect portion of the
distal phalanx. Source: Britta S. Leise. or lysis surrounding implants (Figure 47.3). Culture of the
affected tissue, bone, and/or synovial fluid would indicate
that infection and anti-microbial sensitivities are necessary
to determine appropriate therapy.
sion of the affected limb. In cases where navicular bursos-
copy cannot be performed, navicular bursotomy in Treatment Treatment of persistent or recurring infection
combination with systemic and local antimicrobials have requires antimicrobial therapy, including systemic
been successful in resolving infection [22]. These cases are administration of broad-spectrum antimicrobials,
surgically treated with ventral debridement through the intravenous regional limb perfusion with antibiotics,
frog into the bursa followed by proximal needle placement intra-synovial administration of antibiotics in cases of
and lavage [22]. synovial sepsis, and/or placement of antimicrobial
Careful yet aggressive dissection for complete removal of impregnated beads at the affected site. Through-and-
infected collateral cartilage and surrounding tissue is nec- through lavage of infected synovial structures is always
essary to prevent persisting infection in these cases. indicated and repeated lavages or placement of an
Application of methylene blue dye aids dissection down orthopedic drain may be necessary, particularly in chronic
the draining tract to determine the complete location of the cases. Repeat surgical debridement may also be indicated.
affected tissues [23]. It is also important to control hemor- If the lesion has substantial necrotic issue or is difficult to
rhage for complete visualization to assure thorough dissec- access for debridement, medical maggots can be used [25]
tion of affected tissue. Application of a tourniquet is (Figure 47.4). Maintenance of a sterile bandage during
recommended in these cases. Adequate dissection of infec- the postoperative period is also important to prevent
tion that continues distally into the hoof capsule may re-infection.
require a large (19 mm) trephine hole into the hoof
wall [24]. Placement of this hole will allow for improved Expected outcome Persistent and resistant infections can
debridement of the affected cartilage and allows for ventral be difficult to treat. Chronic cases of synovial sepsis carry a
drainage. It is important, however, to avoid damage to the more guarded prognosis. Culture with antimicrobial
Surgical Site ehiscence and xcessivey xueerant ranulation issue Formation 673
urgicalSiteDehiscence
S
and Excessive/Exuberant
GranulationTissueFormation
Definition Wound margins of the surgical incision become

separated, resulting in failure of the surgical incision
(dehiscence). Excessive granulation tissue can occur at the
skin if the incision dehisces or if the surgical wound heals
by second intention.
isk Factors
● Presence of infection
● Poor blood supply or presence of necrotic tissue
● Tension
● Movement
Pathogenesis Sutures at the surgical site fail, resulting in

separation of the wound margins. This typically occurs at 7
days (range 3–10 days) postoperatively. Infection, poor
blood supply, tension and movement all play a role in
dehiscence [26]. Sutured wounds heal primarily by
epithelialization and wound contraction. However, wounds
that have dehisced, undergo second intention healing,
where formation of granulation tissue is necessary to close
Figure47.3 Type III fracture of the distal phalanx, 8 months the wound gap. Excessive or exuberant granulation tissue
post repair via lag screw fixation. Recurrent hoof abscesses had
been reported in this horse with intermittent lameness. Note is more likely to occur on the distal limb of horses, due to
lysis present surrounding the screw. Source: Britta S. Leise. reduced wound contraction and persistence of chronic
inflammation [27, 28]. Second intention healing is also
sensitivity is essential to assure the infection is being more likely to result in scar tissue formation.
treated appropriately. Additional medical and possible Hoof defects cannot be closed primarily and therefore
surgical revision in these cases results in increased expense must heal by second intention through the production of
and a decrease in prognosis. granulation tissue followed by epithelization and keratini-
zation of the tissue. During this process, it is possible for
excessive granulation tissue to form and require additional
treatment during the postoperative period. Excess granula-
tion tissue has been reported to occur in up to 31% of horses
receiving a hoof wall resection in one study [29].
Prevention Maintenance of a sterile bandage is necessary

to prevent infection and trauma that can lead to dehiscence.
Application of a foot cast can minimize movement,
allowing for improved healing and decreased risk of
dehiscence [19, 30, 31]. Appropriate antimicrobial therapy
will limit the risk of infection. Thorough debridement at
the initial surgery is essential to provide healthy tissue for
successful wound healing.
In regards to excessive granulation tissue formation at
the hoof wall resection site, one study reported 7 out of 8
horses undergoing complete hoof wall resection for
Figure47.4 Use of medical maggots to assist in the
debridement of necrotic tissue within a septic lesion in the hoof. keratoma removal had excessive granulation tissue forma-
Source: Britta S. Leise. tion [29]. Increased movement and decreased stability
occur with complete hoof wall resections potentially comprised tissue and treatment with appropriate
increasing this risk. Therefore, partial hoof wall resections antibiotics in cases of infection are also important to
may be beneficial in preventing the development of exces- assure healing of the surgical site.
sive granulation tissue (Figure 47.5).
Expected outcome It is important to determine the cause
Diagnosis Observation of a gap or presence of excessive for dehiscence or production of exuberant granulation
granulation tissue at the surgical site provides the diagnosis. tissue in order to move forward with appropriate treatment.
Histological assessment of granulation tissue can be Delayed primary closure or second-intention healing will
performed to rule out recurrent keratoma formation in the often result in successful outcomes.
hoof or neoplastic transformation of tissue at the surgical
site.
ew,PersistentorRecurrent
N
Treatment Dehiscence of skin closed primarily will Lameness
heal by second intention, but should be monitored for
the production of exuberant granulation tissue. Definition Gait deficits affecting performance and/or
Application of a foot or distal limb cast can minimize quality of life that persist or recur after surgical treatment
movement, allowing for improved healing and decreased
risk of dehiscence [19, 30, 31]. Excessive granulation isk Factors
tissue at the hoof wall resection site requires removal of
the granulation tissue to allow appropriate healing and ● Prolonged course of disease prior to initiation of treat-
keratinization to occur. Debridement of devitalized or ment can make complete resolution more difficult or
result in complications that result in new cause of lame-
ness (such as osteoarthritis or laminitis)
● Resistant or difficult to treat infections
● Poor fracture repair
Pathogenesis Persistent lameness often results from

incomplete resolution of the initial problem, which can
occur with difficult to treat infections, incomplete removal
of keratoma or presence of excessive granulation
tissue [32], and non-healing fractures. Residual lameness
associated with fracture fixation of the distal phalanx or
navicular bone occur with instability of the fracture or with
inappropriate alignment (step formation). Persistent
lameness after neurectomy can result from the presence of
accessory branches of the palmar digital nerve that were
not transected or from incomplete transection of the
nerve [33]. Horses with core or linear lesions of the deep
digital flexor tendons diagnosed on MRI prior to palmar
digital neurectomy frequently have residual or early
recurrent lameness [34]. Recurrent or new lameness can
result from complications associated with the primary
condition or from the surgical technique performed.
Causes for recurrent lameness include development of
osteoarthritis, laminitis, hoof abscess, intra-synovial
adhesions, neuroma formation, and re-innervation.
Prevention
Figure47.5 Partial hoof wall resection for the treatment of a Fracture repair
keratoma in the horse. Note how the partial resection provides
stability to the distal aspect of the foot. A shoe with clips on
To prevent lameness postoperatively, it is important to
either side of the resection was also placed to improve stability repair and stabilize the fracture in a timely manner. This
and comfort. Source: Britta S. Leise. will prevent movement of fragment(s), particularly at the
New, Persistent or Recurrent Lameness 675
articular surface, thereby lowering the risk of the vator (TPA) may help prevent the reformation of adhe-
development of osteoarthritis. Good surgical technique is sions postoperatively. Postoperatively, treatment of the
essential to prevent fracture instability and implant failure non-septic bursa for 2 weeks with hyaluronic acid or
and to appropriately reduce and stabilize the fracture. autologous conditioned serum may also help prevent the
Advanced imaging (CT scan and fluoroscopy) is considered reformation of adhesions. Early return to light exercise/
essential to appropriately reduce and stabilize the fracture movement is important to prevent the formation of adhe-
in many cases [16]. Use of an aiming device can help sions. Walking within 10 days of surgery is recommend,
improve accuracy, particularly if advance imaging is not with amount and frequency dependent upon surgical
available. findings.
Particularly for type III distal phalanx fractures, it is Early treatment of cases with sepsis is important when
important that the glide hole completely crosses the penetrating injuries occur. Removal of fibrin and lavage of
fracture plane to prevent incomplete or inappropriate the bursa will help prevent the formation of adhesions;
reduction. Fluoroscopy or intraoperative digital radiographs therefore, navicular bursoscopy should be performed as
should be utilized to verify placement [11]. Additionally, soon as possible in any suspect case. A direct approach to
the use of a 5.5-mm cortical screw placed in lag fashion the navicular bursa is recommended for these cases to
may be preferred over 4.5-mm cortical screws to improve minimize the introduction of infection into the distal
surgical reduction of type III fractures. The 5.5-mm cortical digital flexor tendon sheath [20].
screws were more effective in a cadaver model compared to
the 4.5-mm screw at reducing the distal fracture gap
Palmar digital neurectomy
expansion under load [35].
Patient selection is important in assuring successful out-
Other preventions to minimize lameness in cases
comes. Horses with core or linear lesions of the deep digital
involving fracture repair include treatment with
flexor tendon have been reported to have residual lameness
antimicrobials to prevent infection (see above for details),
post-neurectomy [34]. MRI evaluation prior to surgery can
postoperative immobilization via therapeutic shoe or cast,
help identify these cases. Prevention of lameness or other
and adequate rest from exercise to allow time for the
postoperative complications require knowledge of the sur-
damaged cartilage to heal; minimum of 2 months of stall
gical anatomy to assure the correct structure is transected.
rest followed by 2 months small paddock turnout [36]. No
Ligament of the ergot can be mistaken for the nerve by the
forced exercise is recommended until the fracture has
inexperience surgeon. Appropriate surgical dissection,
healed, which can take up to 6–10 months [36]. Treatment
without splitting fibers of the nerve, is important to assure
postoperatively with systemic chondroprotective agents,
complete transection of the palmar digital nerve. During
such as polysulfated glycosaminoglycans and hyaluronate
the procedure it is important to remove a large section of
sodium, may be beneficial to help prevent the development
the nerve to prolong regrowth. The pull through double
of osteoarthritis. Additional intra-articular therapies such
incision technique has been recommended by some to
as autologous conditioned serum, steroids, and hyaluro-
remove larger sections of nerves, thereby slowing regrowth
nate sodium can be also be used; however, the use of ster-
of the nerve and return of the lameness [39]. Immobilization
oids should be avoided during the early stages of the
postoperatively is important to prevent the development of
fracture healing period.
neuromas. Stall rest for a minimum of 4 weeks, with band-
ages applied, decreases swelling around the surgical site
and may be beneficial in preventing neuroma formation.
Navicular eursoscopy
Preventing swelling with the administration of non-steroi-
Case selection is important to prevent persistent lame-
dal anti-inflammatory medications may also help prevent
ness. Navicular bursoscopy only allows for access to the
the development of neuroma formation, which can be a
proximal one-third to one-half of the navicular bursa;
source of pain/lameness postoperatively.
therefore, lesions that occur distal to this cannot be ade-
quately debrided. MRI prior to navicular bursoscopy can
help determine prognosis preoperatively [37]. The modi- Diagnosis Lameness evaluation with local anesthetic
fied approach through the T-ligament allows for the great- blocks (perineural and/or intra-articular) may help to
est amount of visualization within the bursa and is localize the cause of the lameness. Radiographs can allow
recommended in cases where the goal is to treat prolifera- for the diagnosis of osteoarthritis (osteophyte formation,
tive bursitis, remove adhesions, and debride dorsal fibril- enthesopathy, joint space narrowing, subchondral
lated tendon lesions [20, 38]. Treatment of the non-septic sclerosis), laminitis (rotation or displacement of the distal
bursa at the time of surgery with tissue plasminogen acti- phalanx), and hoof abscesses (gas lines, lysis of the solar
margin of the distal phalanx). Radiographs can also be athologicalFractureof Distal

P
used to assess fracture healing, presence of malunions/ PhalanxorNavicularBone
nonunions, and step formations. Ultrasound and/or MRI
can be used to evaluate the soft tissues structures within Definition Development of a fracture due to pathology
the foot. Comparing postoperative images to images within the bone
obtained prior to surgical treatment is recommend.
isk Factors
Treatment Lameness associated with the development of
● Infection of the navicular bone or distal phalanx
osteoarthritis can be managed with the following intra-
● Horses with substantial amount of sclerosis or lysis of
articular treatments: steroids, hyaluronate sodium, and
the navicular bone
various regenerative medicine therapies (such as
● Horses with large cyst-like lesions within the navicular
autologous conditions serum, PRP, stem cells). NSAIDs or
bone
systemic chondroprotective agents (such as polysulfated
● Palmar/plantar digital neurectomy [39]
glycosaminoglycans, hyaluronate sodium, polyglycan or
pentosan) may be also be beneficial for horses that develop
osteoarthritis postoperatively. Pathogenesis
For horses having residual lameness due to implant fail- Associated with infection
ure or infection, treatment may require removal of the Lysis of the distal phalanx or navicular bone due to infec-
implant. However, removal of broken screws can be tion results in weakening of the bone, allowing for subse-
challenging and increases the risk of infection/abscess at quent fracture during normal weight-bearing
the surgical site. It is recommended to not counter-sink the
screw too deep on initial placement, as this can make it Associated with palmar/plantar neurectomy
difficult to remove the implant if considered necessary at a Fracture of the navicular bone is a rare complication [39]
later date. [11]. Horses that have residual lameness after a that can occur with significant bone resorption and
palmar digital neurectomy or have recurrence of lameness demineralization. Removal of sensation to the caudal
due to re-innervation, may have the procedure repeated. aspect of the foot allows for increased weight-bearing,
Conservative therapy for painful neuromas can also be thereby increasing the risk of fracture.
used and includes local injection of triamcinolone over the
surgical site [39]. Depending on the cause of the lameness, Prevention Severe sclerosis or large cyst lesions within the
a palmar/plantar digital neurectomy may be performed to navicular bone, demonstrated on radiographs or MRI, may
eliminate the lameness. Substantial improvement to be predisposed to fracture; therefore, palmar digital
palmar/plantar digital perineural block is recommend neurectomy may be contraindicated in these cases.
before considering this palliative therapy. Other
complications could occur with this procedure and horses Diagnosis Diagnosis of pathological fracture would be
may be at an increased risk depending on their primary made radiographically.
condition. Horses with laminitis should not have a palmar/
plantar digital neurectomy performed under any Treatment Fractures of the navicular bone not related to
circumstances. sepsis can be repaired via internal fixation. Conservative
management of navicular bone fracture and some fractures
Expected outcome Resolution of new, recurrent or of the distal phalanx includes a well-balanced trim of the
persistent lameness depends on the cause of the lameness, hoof and application of a bar shoe with clips. Heel wedges
which can be difficult to determine in some cases. Good may be indicated, depending on the horse’s hoof pastern
case selection is also important to have successful axis and palmar angles. Heel elevation also may decrease
outcomes, such as the use of navicular bursoscopy to treat the risk of adhesion formation of the deep digital flexor
lesions within the navicular bursa, where only lesions tendon to the navicular bone during the healing
located within the proximal half are accessible [20]. process [40]. Fractures or sequestered fragments of the
Prognosis for causes of post-surgical lameness is variable. distal phalanx related to ongoing septic osteitis require
For example, causes such as hoof abscess or osteoarthritis removal via a surgical approach, either through the solar or
can be treated or managed with the horse returning to dorsal surface of the hoof.
previous or slightly lower levels of athletic function;
however, horses that develop conditions such as laminitis Expected Outcome Removal of sequestrums off the solar
can have a guarded prognosis for life. margin of the distal phalanx has a fair to good prognosis.
Iatrogenic amage to elated Anatomical Structures 677
Up to 25% of the distal phalanx can be removed with return motorized synovial resector combined with sharp dissec-
to normal function [23]. Fractures of the navicular bone tion of the fragment is recommended [2]. Removal of dor-
can be challenging to repair; however, they have a prognosis sal or palmar/plantar abaxial articular fragments can result
to return to work of approximately 80% [40]. This prognosis in disruption of the collateral ligament of the DIP joint. If
would be decreased in cases with additional soft tissue damage to the ligament during removal is believed to occur,
damage and with fractures associated with significant lysis it is recommended to place a foot cast on the horse for
of the navicular bone. recovery to prevent luxation/subluxation of the distal
interphalangeal joint. Anatomical knowledge of the distal
interphalangeal joint and location for portal placement can
I atrogenicDamageto Related help prevent inadvertent entry into the navicular bursa or
the digital flexor tendon sheath. Fowlie and co-work-
AnatomicalStructures
ers [41] compared a conventional palmar approach versus
a lateral palmar approach to the DIP joint. They reported
Definition Inadvertent injury to surrounding structures
inadvertent penetration of the digital flexor tendon sheath
occurring during the surgical procedure
occurring in 60% of the conventional approaches versus 3%
of the lateral approaches. The navicular bursa was inad-
isk Factors
vertently entered in 5 out of 10 limbs via the conventional
● Novice surgeon approach versus 0 out of10 limbs via the lateral
● Inappropriate preoperative planning approach [41]. Therefore, performing the lateral palmar/
● Swelling or tissue injury, resulting in altered appearance plantar approach to the DIP joint may decrease the risk of
of normal anatomy entering the bursa or sheath.
● Inappropriate or lack of imaging used intraoperatively There is an increased risk of iatrogenic trauma to the
neurovascular bundle when Esmarch bandage and
Pathogenesis Numerous important anatomical structures tourniquet is used to control intraoperative bleeding.
are present in the equine digit and many are in close However, use of a tourniquet can be helpful to control
proximity to each other. This limits surgical approaches hemorrhage within the joint during surgery, particularly
and makes iatrogenic damage to related anatomical during removal of extensor process fragments. Careful
structures more likely to occur, even with experienced palpation of the neurovascular bundle and understanding
surgeons. of the anatomy is important when placing portals into the
palmar/plantar aspect of the DIP joint [2]. The navicular
Prevention Preoperative planning, using imaging such as bursoscopy portal should be placed palmar/plantar to the
radiology, CT or MR to define extent of the damage from the neurovascular bundle in both the direct and transthecal
primary condition, is important to have an understanding of approaches, to minimize damage to the nerve and prevent
the structures involved prior to surgery. Adequate laceration of the artery or vein [20]. Instrument portals
visualization of structures requiring absence of hemorrhage may be placed dorsal to the neurovascular bundle, but care
and appropriate surgical approach. during placement is recommended. Use of the transthecal
In regards to surgical debridement of infected collateral approach to the navicular bursa via entry through the
cartilages, careful dissection of the damaged cartilage and T-ligament at the distal aspect of the distal digital flexor
surrounding affected tissues is necessary to prevent tendon sheath is reported to result in significantly less
inadvertent entry into the distal interphalangeal joint. This trauma to the intrabursal structures [42] and therefore
can be aided by the application of methylene blue dye into should be used in cases without sepsis.
the draining tract to determine where the affected tissues
are located [23]. Placement of the foot in traction may also Diagnosis Diagnosis depends on the structure involved
help to place tension on the joint capsule, retracting it away and severity of the resultant damage. Radiographs,
from the area of dissection [23]. Control of hemorrhage is ultrasound, CT and MRI can all be utilized to determine
also important for visualization and appropriate dissection presence and/or extent of injury.
(see above).
When performing distal interphalangeal joint arthros- Treatment Inadvertent entry into a synovial structure
copy or navicular bursoscopy, appropriate distension of the should be addressed immediately and include lavage of the
joint prior to entry can help prevent iatrogenic damage to synovial structure and administration of intra-synovial
the articular cartilage. To improve visualization during antibiotics. Transection of large vessels should be ligated or
removal of an extensor process fragment, the use of a primarily repaired if possible.
Expected outcome Outcome depends on the structure(s) Treatment Therapeutic trimming/shoeing may be
involved and the extent of the iatrogenic damage. indicated, depending on the degree of abnormal shape.
Exercise once the horse has recovered from their primary
problem may allow for improved blood flow and changes
ontraction,Deformationor
C in hoof growth allowing for changes in foot size and shape.
AbnormalGrowthof the Hoof
Expected outcome Subtle alterations in foot shape or size
Definition Changes to the normal shape or size of the hoof should have minimal to no affect clinically; however,
due to altered hoof growth significant changes in foot shape and size could result in
lameness requiring therapeutic trimming/shoeing.
isk Factors
● Pain HoofAbscess
● Casting/immobilization
● Hoof wall resection Definition Accumulation of purulent debris, usually
● Damage to the coronary band associated with an infection within the hoof capsule
isk Factors
Pathogenesis Development of abnormal hoof shape can
occur with immobilization with shoe or cast, or with ● Septic osteitis of the distal phalanx
reduced weight-bearing [43]. Young foals with ● Puncture wound to the solar aspect of the hoof resulting
immobilization are more likely to develop hoof contracture in septic navicular bursitis
than adult horses [44]. Hoof growth occurs from the ● Presence of a keratoma
coronary band due to its vascular supply and source of ● Laminitis
epidermal cells. Damage to the coronary band, therefore, ● Internal fixation of distal phalanx or navicular bone
affects both hoof growth and shape. fracture
● Palmar/plantar digital neurectomy
Prevention Pain management, with non-steroidal anti-
inflammatories, is important to encourage normal weight- Pathogenesis Damage or infection of the lamellar tissue
bearing and prevent hoof deformities. While duration of results in an inflammatory response with migration of
immobilization did not play a role in the development of neutrophils and macrophages to fight infection and clean
abnormal hoof shape in one study, casting or therapeutic up debris. This leads to the production of purulent material
shoeing may alter weight-bearing, thereby, affecting hoof causing pressure within the enclosed hoof capsule resulting
shape. As there appears to be no advantage to prolonged in lameness. Abscess or deep hoof infection can occur and
immobilization, it is recommended to remove the cast or will be more severe after a palmar/plantar neurectomy, as
shoe at 6–8 weeks to reduce the risk of heel contraction [43]. lack of sensation of the solar region of the foot will result in
In cases of keratoma removal, partial hoof wall resection penetrating injuries and subsolar abscess to be unrecognized
should be performed when possible. Leaving a portion of until disease is advanced. Long-standing infection within
the hoof wall near the ground surface improves stability of the hoof capsule could result in septic osteitis of the distal
the foot, thereby decreasing pain during loading [29]. In phalanx.
cases of distal interphalangeal joint arthroscopy, particu-
larly when large fragments are removed from the joint, it is Prevention Application of an appropriate plug/seal in the
important that appropriate surgical techniques (including hoof capsule to prevent infection are important to prevent
accurate placement of portal sites) are used to prevent dam- hoof abscess in horses undergoing internal fixation for
age to the coronary band. Large fragments may require distal phalanx or navicular bone fractures.
removal in parts. This can be performed with an osteotome In horses undergoing palmar/plantar digital neurec-
to divide fragments into multiple parts or through the use of tomy, application of a shoe with a pad can prevent pene-
an arthroscopic burr (however, in one report this technique trating injury to the solar region, which may not be felt by
failed to create a clean dissection and resulted in residual the horse post-neurectomy. Frequent examination and
fragments becoming buried in the soft tissues) [2]. cleaning of the foot twice daily is important to identify
penetrating injuries or solar abscess as early as possible.
Diagnosis Diagnosis is made by appearance of the hoof Once identified, prompt and aggressive therapy should be
capsule with abnormal foot size or shape. administered.
Contractionn, eformation or Aenormal ro th of the oof 679
Diagnosis Presence of lameness, increased digital pulse in This includes treatment of the primary disease, alleviating
the affected foot, and hoof tester reaction over the affected pain, and providing mechanical support to both the
site are diagnostic clinical signs associated with hoof affected and support limbs. While not evaluated
abscesses. Radiographs may reveal the presence of gas experimentally, cryotherapy may be a useful preventative
within the hoof capsule and possible associated lesions, therapy in horses at increased risk of developing support
such as infection, keratoma, or laminitis. limb laminitis. Providing mechanical support to the
affected limb and preserving healthy lamellar attachments
Treatment Treatment of hoof abscesses require drainage during the surgical approach is also important in preventing
and foot soaks, followed by application of a foot bandage laminitis.
until resolved [23]. Removal of a plug placed at the time of
fracture repair may be indicated with or without implant
Diagnosis Diagnosis of laminitis is often made from the
removal. Intravenous regional perfusion with
presence of clinical signs, such as increased digital pulses,
antimicrobials may be indicated, particularly if infection is
increased temperature of the affected hooves, weight
suspected within the distal phalanx or navicular bone.
shifting, lameness, reluctance to lift feet, and positive
Expected outcome With appropriate treatment, prognosis response to hoof tester applied to the toe region of the foot.
for horses with hoof abscesses are good. Advanced subsolar Radiographic evidence of rotation or displacement of the
abscess that involve a substantial amount of the solar area distal phalanx would be definitive for laminitis, but may
can compromise the attachment of the distal phalanx. This not be present during the acute phase.
results in laminitis with collapse of the distal phalanx in
the hoof capsule, causing severe lameness and a poor Treatment There are numerous therapies employed once
prognosis. Hoof infections that lead to involvement of the laminitis develops that are beyond the scope of this chapter;
distal phalanx will require more aggressive therapy and however, anti-inflammatory/pain management and
have a fair to guarded prognosis. mechanical support are pillars in the treatment and
management of laminitis in the horse. Deep digital flexor
Laminitis tenotomy may be indicated for some cases of laminitis.
Complications associated with deep digital flexor tenotomy
Definition Inflammation of the epidermal and dermal can be found in Chapter 52: Complications of Tendon
lamellar tissues within the foot that can result in complete Surgery.
failure of the digital suspensory apparatus (separation of
the hoof capsule from the distal phalanx exhibited by
Expected outcome Laminitis can be a career-ending, life-
rotation or displacement of the bone)
threatening condition and should be treated as such. Mild
acute cases that quickly resolve clinically with minimal to
isk Factors
no radiographic changes have fair prognosis. However,
● Pain in the affected limb resulting in overuse/increased more commonly laminitis carries a guarded to poor
weight-bearing in the opposite supporting limb results in prognosis.
support limb laminitis.
● Substantial damage to the lamellar tissue related to the
NeuromaFormation
primary disease results in laminitis of the affected limb.
Definition Presence of painful scar tissue around the
Pathogenesis Laminitis has a complex pathogenesis that transected nerve
is beyond the scope of this chapter. However, mechanical
overload through increased weight-bearing forces on the isk Factors
supporting limb in horses with severe lameness will
frequently result in laminitis. Additionally, structural ● Local perineural injection prior to surgery
changes within the lamellar tissue, due to conditions such ● Postoperative inflammation or infection
as septic osteitis of the distal phalanx, severe hoof abscesses, ● Dehiscence of surgical site
and large ketatomas, can result in laminitis within the ● Excessive movement
affected limb. ● Repeat surgical procedure
Prevention Prevention of support limb laminitis is aimed Pathogenesis Neuroma formation occurs secondarily to
at improving and maintaining comfort in the affected foot. scar tissue formation around the resected nerve. Although
not common, neuromas can also form if iatrogentic trauma pain to the foot is removed and tendon pathology exists.
occurs to the neurovascular bundle during navicular Resolution of pain removes inhibition, resulting in
bursoscopy. Neuromas have been reported to occur in overstretching of the damaged tendon allowing for
approximately 35% of horses undergoing palmar/plantar rupture to occur. Rupture of the DDFT results in severe
digital neurectomy [33]. pain that is not relieved by the neurectomy. Once
ruptured, laxity of the deep digital flexor tendon,
Prevention Delaying surgery 5–7 days post-perineural subluxation of the distal interphalangeal joint, and
block may limit local inflammation at the surgical site altered foot growth occurs. Distal interphalangeal joint
and reduce the risk of neuroma formation. Meticulous subluxation results in hyperextension of the distal
dissection of the palmar/plantar digital nerve during interphalangeal joint secondary to removal of the
neurectomy and accurate portal placement during inhibitory forces (flexion) on the extensor tendons.
navicular bursoscopy is important to minimize surgical Chronic subluxation of the distal interphalangeal joint
trauma, which will also decrease the risk of neuroma will result in the development of osteoarthritis in this
formation. Postoperatively, immobilization with a joint. Rupture of the deep digital flexor tendon is often
minimum of 4 weeks of stall rest and bandaging decreases considered a life-threatening complication of the palmar
swelling around the surgical site and may be beneficial in digital neurectomy.
preventing neuroma formation. Additionally,
administration of non-steroidal anti-inflammatory Prevention Accurate assessment of the complete
medications may also help minimize swelling and pathological changes of the navicular region is very
subsequent neuroma formation. important. Radiographic presence of deep digital flexor
tendon mineralization can be suggestive of severe injury to
Diagnosis Pain on palpation of the surgical site, presence the tendon. MRI evaluation of the soft tissue structures and
of lameness assessment for the presence of adhesions is also
important [34]. If significant adhesions are present, there
Treatments Treatment of neuromas consist of limiting the is an increased risk for rupture of the deep digital flexor
inflammatory process and inhibiting further fibrosis tendon.
around the site early during the healing process by injecting
triamcinolone [39] or Sarapin locally over the surgical site.
Diagnosis Diagnosis of a ruptured deep digital flexor
Surgical resection of the neuroma may be indicated if
tendon is often made from appearance of the limb and pain
lameness and pain at the surgical site persist. However,
on palpation of the DDFT. Ultrasound or MRI can be used
surgical dissection is made more difficult by increased
to help diagnose rupture of the DDFT and is most beneficial
amount of scar tissue and repeat formation of neuroma is
when it is compared to pre-surgical images. Radiographs
possible [36]. Additionally, risk of neuroma formation has
can be used to diagnosis subluxation of the distal
been suggested to increase each time the procedure is
interphalangeal joint.
repeated.
Expected outcome Horses that develop a neuroma have a Treatment If rupture of the deep digital flexor tendon
fair prognosis. occurs, pain management with non-steroidal anti-
inflammatories is recommend as this is a very painful
condition that can be difficult to manage, despite lack of
Ruptureof the DeepDigitalFlexorTendon
sensation to the affected area. Application of a shoe with
(DDFT)
an extended heel is necessary if the deep digital flexor
Definition Complete breakdown/tearing of the DDFT tendon should rupture. This therapy is important to
minimize the risk of luxation/subluxation of the distal
isk Factors interphalangeal joint. Placement of a distal limb cast to
immobilize the tendon and allow for healing can also be
● Adhesions of the DDFT to navicular bursa and/or bone
attempted. However, this will require a minimum of 4–6
● Presence of large core lesion or mineralization within
weeks and re-injury post cast removal can occur.
the DDFT
Pathogenesis Rupture of the DDFT is an uncommon Expected outcome Horses that rupture their deep digital
sequala to palmar digital neurectomy when sensation of flexor tendon have a guarded to poor prognosis.
References 681
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683
48
Complicationsof SurgicalCorrectionof AngularLimbDeformities

Robert J. Hunt DVM, MS, DACVS and Amy M. Buck DVM, MS, DVM
Hagyard Equine Medical Institute, Lexington, Kentucky
Overview utilized instead of periosteal stripping; however, this will

not be covered in this discussion as there is no benefit to
Surgical intervention for correction of angular limb the procedure. Periosteal stripping is performed on the
deformity (ALD) is commonly performed with the primary relatively slow-developing (concave) side of the limb [4,
goal of improving function and cosmetics of the limb. Most 8–11], whereas transphyseal bridging techniques are used
angular limb deformities in foals, especially carpal valgus, to slow or arrest uniaxial longitudinal growth of the faster-
correct spontaneously and surgery is often performed in an developing side of the limb [4, 13–20]. Periosteal stripping
attempt to take advantage of the rapid growth potential of and transphyseal bridging techniques may be performed
the foal and to ensure correction of the deformity before medially or laterally at the distal metacarpus/metatarsal
this growth potential is lost [1–6]. During the past two physis, distal radial physis, and distal tibial physis [1, 3, 4,
decades, emphasis has changed toward addressing varus 6, 13–18].
deviation of the metacarpophalangeal region of foals and Three basic techniques are utilized for transphyseal
carpal varus in weanlings and yearlings. Surgeries for bridging, which include staples, screws and wires, and a
correction of ALD may be performed as early as 2 weeks of single transphyseal screw [1–6]. There are advantages and
age until 16 to 18 months of age [1, 2]. In general, disadvantages of each technique as well as complications
indications for surgery include lack of improvement or that are unique to each procedure [12–21]. It is important
worsening of an angular limb deformity in the face of to note that all of the surgical procedures have the potential
conservative measures [1, 2]. to blemish and severity of the blemish is influenced by the
Surgical techniques for management of angular limb technique, surgery site, and aftercare. Certain complications
deformity have evolved over the past three decades and are are associated with specific surgical techniques, whereas
based on the principles of growth enhancement or others are common among the different procedures.
retardation through physeal manipulation [7–12]. Complications may be encountered during the surgical
Unfortunately, complications occur as a result of these procedure itself or during the postoperative period [1, 4,
procedures and vary in severity from mild and self-limiting 8–10, 12–16, 19–21].
cosmetic problems, to debilitating issues resulting in While it is impossible to completely remove the potential
permanent lameness and loss of usefulness [1, 4, 6–10, for complications resulting from surgical manipulation of
13–22]. It is important for the surgeon to be knowledgable angular limb deformities in foals, it is possible to minimize
and well versed with the surgical techniques and the host them. Therefore, it is crucial to be aware of every aspect of
of complications that are associated, in order to prevent the the surgery, case selection, and postoperative management
complications or recognize them early and administer to reduce the occurrence of complications. Familiarity
appropriate treatment in a timely fashion. with the anatomical and physiological details of each
Surgical procedures utilized for correction of angular surgical procedure will reduce the risk of intraoperative
limb deformities include hemi-circumferential periosteal complications associated with incorrect technique, and
transection with periosteal elevation (periosteal stripping) proper postoperative management may prevent occurrence
and several techniques of transphyseal bridging. A of environmental complications. Furthermore, it is
technique of iodine injection above the physis has been essential to quickly identify surgical complications and
684 Complications of Surgical Correction of Angular ime eformities
effectively communicate with owners and farm personnel cosmetics improved significantly and were used extensively
in order to effectively manage them if they do arise. on the medial and lateral aspect of the distal radius, and
distal metacarpus and metatarsal growth plate [13, 4,
19–21]. A comparison with a screw and wire technique
L (discussed below) described the staples as having more
with SurgicalCorrectionof Angular problems with cosmetic blemishes than with the screw and
LimbDeformities wire technique [19, 20].
● Techniques to correct angular limb deformities TransphysealScrewand Wire

– Hemi-circumferential periosteal transection and ele-
vation (HCPT/PE) Screws and wires have been utilized for transphyseal bridg-
– Transphyseal stapling ing since the 1970s [4, 12, 15, 19, 20]. Self-tapping cortical
– Transphyseal screw and wire screws are placed above and below the physis, then a piece
– Single screw transphyseal bridging (SSTB) of stainless steel is placed in a “figure of 8” configuration
underneath the skin engaging the two cortical screws. The
● Intraoperative complications screw heads are tightened, which provides more tension on
– Incorrect placement of surgical implant or failure of the wires providing compression across the physis.
surgical implant
– Incorrect selection of surgical technique or implant
– Surgical site hemorrhage or transection of important SingleScrewTransphysealBridging(SSTB)
structures
Currently the most common procedure utilized for
● Postoperative complications transphyseal bridging to correct angular limb deviation in
– Failure to correct or overcorrection horses is single screw transphyseal bridging coursing from
– Comestic blemishes: hematoma, seroma, abscess for- the metaphysis to the epiphysis [1, 4, 15–18]. Although
mation, and bony exostosis complications are common, most are self-limiting.
echniquesto CorrectAngularLimb
T Intraoperative Complications
Deformities
IncorrectPlacementof SurgicalImplantor
As mentioned above, the following are the most utilizes Failureof SurgicalImplant
procedures to correct ALD [1, 2]. Full surgical methods are Definition Correct placement of the surgical implant is
beyond the scope of this book and can be found elsewhere. based on the technique used, age of the horse, and
anatomical location. Incorrect placement occurs when the
Hemi-CircumferentialPeriostealTransection implant fails to restrict physeal growth, resulting in a
and Elevation(HCPT/PE) failure to improve or only partially improve the angular
limb deformity. Additionally, failure of the implant can
Historically, HCPT/PE has been the most commonly per- occur when the implant breaks or is partially left in the
formed procedure for stimulation of longitudinal animal, ultimately resulting in a failure to improve the
growth [1–4, 7–10]. The technique revolves around deformity or blemish. This includes the staple itself or the
tunneling underneath the skin on the distal lateral radius tine of the staple breaking upon removal if uneven forces
and incising the periosteum in an inverted T fashion. are applied, stripping of the screw (either with screws and
wires or SSTB), unknowingly breaking the wire, having
the wire or staple dislodge or loosen, stripping of the
TransphysealStapling
hexagonal screw head when attempting to remove
The use of staples for transphyseal bridging in horses was (especially with the 3.5-mm screws), and failure to remove
initially described by Heinze [13], in which the staples the wire when the implant is removed [13–21].
were used across the distal medial radial physis for Furthermore, technical errors include improper
correction of carpal valgus deviation and this continues to positioning of the screw or improper length of the screw.
be the most common deformity corrected with a staple [13, Specifically, complications associated with staples,
14]. As the technique for staple placement evolved, resulting in failure of correction, include dislodging of the
staple from the bone in young foals, spreading of the staple when drilling, debris in the screw tract causing binding
tines, thus mitigating their effectiveness, or migration of and resistance to removal, or heat generation then cooling
the staple into the metaphyseal bone in older yearlings during and after screw placement with a power driver.
(Figure 48.1) [13, 14, 19, 20]. This later phenomenon may be observed while advancing
the screw and stopping with the screw partially placed,
Risk Factors then trying to advance or remove the screw and having
the screw break.
Failure to correct the deformity can result if the entry
● Poor surgical planning and technique
site of the screw is positioned too proximally (greater than
● Failure to identify correct placement on intraoperative
2 cm above the physis), because it is too difficult to angle
radiographs
the drill bit vertically enough to allow abaxial screw
● Using 4.5-mm screws in the distal radius
placement in near parallel alignment with the long axis of
(Figure 48.2) – most common technique and implant
the bone. The end result is the screw engaging the physis
combination to cause breakage
closer to the axial plane, thereby reducing the mechanical
advantage of uniaxial physeal bridging and failure of cor-
Pathogenesis Incorrect placement is primarily the failure rection of the angular deviation. Conversely, if the screw
of the surgeon to identify correct placement or to select is positioned too far distally on the metaphysis, there may
the correct surgical technique. Incorrect placement not be enough bone engaged to result in growth reduction
ultimately leads to a failure to restrict growth, allowing (Figure 48.3).
the limb to continue to grow at the wrong angle. In
regards to SSTB, difficult screw removal and possible Prevention Incorrect placement and breaking of surgical
screw breakage likely occur from asymmetrical bending implant are minimized with proper identification of
of the screw head if there is excessive tension on the anatomic landmarks and the utilization of intraoperative
screw. Screw breakage may also be caused by the screw radiographs to ensure proper placement. Prevention of
becoming bound within the bone, either through curving surgical implant breakage is also minimized with careful
attention to detail during implant removal; in regard to the
staples, even force is necessary when removing it. In regard
to a transphyseal screw, screw breakage is a common
complication and can often be prevented by backing the
screw out one-quarter to one-half turn upon final
tightening. This will help to prevent stress along the length
of the screw and screw head to facilitate removal.
Diagnosis Diagnosis can be made intraoperatively where

the implant can be subsequently removed and replaced in
the proper location. Postoperatively, incorrect placement is
identified when the deformity fails to correct with time;
postoperative radiographs can help assist with this
diagnosis.
Treatment Once identified, the implant can be removed

and replaced in the proper location. However, if the foal
has passed a period of growth, replacing the implant may
not be an option. For transphyseal screws, implant removal
is facilitated by repetitively tapping the screwdriver while
Figure48.1 Dorsopalmar radiographic images of both carpi of
backing the screw out, in addition to maintaining proper
a foal after bilateral transphyseal staple implantation for
correction of bilateral carpal valgus (right carpus on the left the linear alignment of the screwdriver with the screw to
image). The staple on the right carpus has dislodged from the reduce uneven torsional forces during removal. In the
bone and is now entrapped in the subcutaneous tissue. On the event of screw breakage, a commercially available extractor
left carpus, the tines of the staple have spread apart and
(Extractor Kit) may be utilized for removal of the shaft of
therefore are not engaging the physis properly. Both of these
complications will lead to a failure to correct the angular limb the screw (Figures 48.2 c, d) [17]. A complication of this
deformity. Source: Robert Hunt and Amy M. Buck. removal procedure is the creation of metallic fragments
(a) (b)
(c) (d)
Figure48.2 Examples of complications from single screw transphyseal bridging. (a) Dorsopalmar radiographic image of the right
carpus of a foal showing bending of the screw, which was subsequently broken when removal was attempted. (b) Dorsopalmar
radiographic image of the right carpus of a foal showing breakage of the screw head, which renders removal of the screw very
complicated. (c and d) Breaking of the screw head necessitates the use of an extractor kit, as illustrated on an intraoperative
dorsopalmar radiograph (c) and intraoperative surgical image. A common complication to the use of this extractor method is the
creation of metallic fragments along the screw tract, which emphasizes the importance for proper placement of the implant during
the initial surgery. Source: Robert Hunt and Amy M. Buck.
along the screw tract with the reamer if improperly utilized. In the event of a stripped screw head, curettage and/or
These metallic fragments and bone debris may be difficult drilling a channel around the screw head, to allow appli-
to remove, but may be reduced with copious lavage and cation of pliers to facilitate removal, will be necessary.
curettage of the tract. Although a commercially available extractor seta can be
Risk Factors
● Inadequate case selection

● Inexperience
● Failure to take intraoperative radiographs to assess the
placement of the surgical implant
● Failure to follow up at the farms
Pathogenesis A poor understanding of physeal growth

and development may lead to improper implant selection.
The improper implant will ultimately either restrict the
physis to a greater extent than originally desired, causing
an overcorrection or a failure of the implant to engage the
physis, thereby causing no growth restriction. Close follow
up is necessary to ensure that the limb is progressing well.
Inaccurate screw length, in which the screw may be too
short or too long, will result in this potential complication.
Articular penetration will occur with an excessively long
screw during transphyseal screw placement.
Postoperatively, the screw may pull out or disengage the
physis as the bone lengthens, which will stop retarding
growth.
Figure48.3 Dorsopalmar radiographic image of the right
metacarpophalangeal joint of a foal after attempted single Prevention Prevention of complications begins with
transphyseal screw placement. The screw has been inadvertently appropriate case selection and avoiding surgery on
placed at the level of the physis. The appropriate location for an individuals prone to complications. Gaining familiarity
SSTB in a fetlock is 1.5 cm proximal to the physis. Since the with surgical techniques to eliminate intraoperative errors
screw is not engaging the metaphysis, it will not sufficiently
restrict the growth plate, resulting in a persistent angular limb may mitigate many complications.
deformity. This illustrates the importance of taking Intraoperative imaging will allow to detect inadequate
intraoperative radiographs and how complications can be position and/or size of implants. If there is failure of
caught and corrected at the time of surgery. Source: Robert Hunt improvement in limb alignment after 4 weeks of screw
and Amy M. Buck.
placement, radiographs should be repeated to assess
implants position and size.
used, it is generally insufficient for removal of a screw It is vital to follow up cases to ensure that proper growth
with a stripped head. restriction is achieved or to identify when there is a lack of
growth restriction and the surgeon may intervene.
Expected outcome The outcome is dependent on Diagnosis Diagnosis can be made at follow-up evaluation
recognition of improper placement or breakage and when when a failure to correct the ALD is identified. If articular
this complication was identified. If encountered early, penetration has occurred and if not detected at surgery,
there may be time to appropriately address the ALD with lameness will result and remain unless the screw is
the proper placement of the surgical implant. If identified removed. If the screw is too short and not engaging enough
later, the period of growth may be missed and failure to epiphysis, the screw may be pulled into the metaphysis
correct the ALD may occur. with bony lengthening and not correct the deviation
(Figure 48.4).
IncorrectSelectionof SurgicalTechniqueor
Treatment Appropriate recognition is key to treating this
Implant
complication. Once identified, the implant can be removed
Definition Incorrect selection of surgical technique or and appropriate implant can be used if there is enough
implant occurs when there is improper selection of time within the growth cycle. Removing the implant is
technique or implant that results in the failure to correct or imperative if there is articular involvement; this is most
the overcorrection of the angular limb deformity. commonly seen with transphyseal screws.
dorsolateral distal carpal region due to fluid settling in the

distal portion of the sheath [4, 6, 8–10].
Poorly placed surgical incisions or lack of visualization
of vessels can lead to hemorrhage and a lack of anatomical
knowledge can lead to inadvertent incision of important
structures. The failure of the surgeon to identify anatomical
variations between patients can lead to transection of
important structures.
Prevention As the intraoperative complications associated

with HCPT/PT are largely a result of anatomy and surgical
technique, prevention of these problems is accomplished
through precise dissection and controlling hemorrhage
during surgery and appropriate bandaging after surgery. A
good knowledge of anatomy is essential to prevent
transection of an important structure.
Diagnosis Diagnosis can be made visually during surgery.
Treatment Appropriate hemostasis is required during

surgery to correct bleeding. Bleeding may be noted after
surgery and appropriate bandaging can be used to stop
bleeding. Treatment will vary if important structures are
transected (see Chapter 7: Complications Associated with
Hemorrhage).
Figure48.4 Dorsopalmar radiographic image of a
metacarpophalangeal joint of a foal after single transphyseal Expected outcome The prognosis is good if bleeding is
screw placement. The length of the screw is inappropriately
caught early, but may vary depending on what structures
short; it only engages about 40% of the epiphysis and will likely
not sufficiently restrict the growth. This will ultimately result in have been damaged during the surgery.
persistent angular limb deformity. Source: Robert Hunt and Amy
M. Buck.
Expected outcome Outcome depends on the timing and
location of the implant. Prognosis varies between good to Failureto CorrectorOvercorrection
poor cosmetic outcome.
Definition Absence or insufficient correction to the original
ALD or the limb has developed the opposite to ALD.
SurgicalSiteHemorrhageorTransection
of ImportantAnatomicalStructures
Risk Factors
Definition Iatrogenic bleeding or involvement of
● Failure to recognize correction of deformity leading to
structures such as tendons and/or tendon sheaths
the inadvertent delay of the surgery implant removal
● Case selection such that an individual was selected out-
Risk Factors
side a period of growth that would allow for correction
● Anatomical variation between surgical candidates
● Inadequate anatomical knowledge on part of the surgeon Pathogenesis A complication occasionally discussed is
● Poor surgical technique over-correction of the deviation following HCPT/PE; there
is no evidence to support this claim and it is well recognized
Pathogenesis As with any surgery, there are inherent risks that foals with severe ALD will over-correct without having
associated with bleeding and transection of important surgery [6–10]. Alternatively, lack of correction, or
structures. Intraoperative complications associated with recurrence of the deviation, are far more common
HCPT/PT include hemorrhage, inadvertent transection of occurrences with PE if the underlying factors precipitating
the lateral digital extensor tendon sheath, or the tendon the ALD are not addressed [1, 6].
itself [4, 8–10]. In the case of lateral digital extensor tendon With any implant, there is always a risk that overcorrec-
sheath involvement, the swelling is situated on the tion of the deviation associated with compression of the
physis will occur following failure to remove the implant in correct and the opposite ALD will be present if there is an
a timely manner. One of the most severe complications over-correction. Physitis is normally diagnosed based on an
associated with transphyseal bridging techniques is over- enlarged physis. It may sometimes be warm to the touch.
correction from leaving the implant too long or developing
physeal dysplasia after removal. This is mostly recognized Treatment To prevent further correction, a second implant
with SSTD. This may occur while the screw is in place too may be required on the opposite side of the limb; this may
long, allowing overcorrection or, more commonly, occurs not be sufficient for correction due to the amount of damage
after removal. There is often concomitant occurrence of of the growth plate. For physitis, anti-inflammatories and
physeal dysplasia and bridging of the physis at the region cold therapy are useful to decrease the inflammation and
of the implant removal. potentially the growth stemming from the physis.
Prevention Controlling and understanding postoperative Expected outcomes Cosmetic outcomes will vary,
management so that complications are recognized early depending on the age of the horse, surgical site, and
will allow more timely treatment if problems arise. It is original deformity. Long-term athletic performance will
important to monitor the patients after screw placement also vary with age of horse at surgery, surgical site, and the
and remove the screw prior to complete correction. It is original deformity.
especially important to follow the case after the screw has
been removed and monitor for evidence of physeal
dysplasia, such as heat or swelling at the level of the physis, CosmeticBlemishes
and overcorrection. If either is noted, it is important to
Definition Formation of hematoma, seroma, abscess
intervene immediately.
formation, and bony exostosis at the surgical site
Proper case selection is essential for a good outcome.
Errors include performing SSTB on the distal radius when
Risk Factors
the growth plates are particularly prone to physeal dyplasia,
usually between 10 and 13 months of age, and with yearlings ● Increased dead space when tunneling to implant site;
prone to physeal dysplasia. Individuals with very mild carpal especially for staple placement which utilizes a skin roll-
valgus deviation and rotational deviation with physeal dys- ing technique
plasia may be at an increased risk of over-correction after ● Poor surgical technique
implant removal. Yearlings which are offset in the knees and ● Surgical site infection
appear to have normal axial limb alignment when standing ● Prolonged correction time
but when tracking display carpal varus with base narrow ● Inappropriate bandaging
foot placement, often result in an undesirable pattern of ● Poor farm management
lower limb flight following SSTB of the lateral radius.
Performing SSTB of the distal metacarpus at less than 6 Pathogenesis Complications recognized after surgery
weeks of age may result in rapid correction of the deviation include swelling at the surgery site from hematoma or
and require removal while the foal is growing rapidly. It is seroma development. Blemishes associated with staples
common for the deviation to reoccur after the implant is are unique in that they begin with a local seroma directly
removed and not have enough residual growth to allow over the staple, with the end result being focal thickening
correction. If the surgery is performed after 3½ to 4 months of tissue over the staple [13, 14, 19, 20]. The most common
of age, there is typically an altered flight pattern of the limb complications associated with the screw and wire technique
with a tendency to rotate the ankle in a varus or valgus con- are cosmetic blemishes associated with tissue reaction or
figuration during the swing phase of the stride, even sepsis [15, 19–21]. Although complications of single screw
though the alignment is normal when in the stance phase. transphyseal bridging vary between surgical sites, those
Therefore, in general, the ideal time to perform SSTB of the common to all sites include surgical site blemish associated
distal metacarpus appears to be between 8 and 12 weeks of with soft tissue reaction [1, 15–17, 19–21]. This is very
age [15–17]. common at the distal metacarpus, which is complicated by
It must be emphasized how important proper case selec- relatively thin soft tissue coverage over the screw head and
tion and monitoring of the implant both before and after placing a bandage too tight over the screw head resulting in
placement is to achieve proper correction and prevent pressure necrosis (Figure 48.5). Interestingly, these
overcorrection. decubital-like areas often are not directly over the screw
head but usually are palmar to the screw head in the
Diagnosis Diagnosis is made 2–4 weeks after surgery at the metacarpus but dorsal to the screw head in the distal
farm. The ALD will still be present if there is a failure to radius.
(a) (b)
(c) (d)
Figure48.5 Cosmetic complications associated with the use of single transphyseal screws. (a) Soft tissue swelling associated with
the distomedial aspect of the left metacarpus. This can occur to overly loose bandages not putting enough pressure over the surgery
site, ultimately leading to seroma or hematoma formation. (b) Conversely, if the bandages are placed too tightly, pressure necrosis can
occur over the screw head; this is especially a concern over the distal metacarpus/metatarsus where the skin is thinner. (c) Another
example of pressure necrosis over the screw head in a canon bone. (d) Later stage example of pressure necrosis with severe amount
of necrotic tissue. Distal is toward the bottom in all images. Dorsal is to the left in (b) to (d). Source: Robert Hunt and Amy M. Buck.
If excessive soft tissue reaction, seroma or abscess forma-

tion occur at the surgical site of the distal metacarpus,
there is an increased risk of calcification over the screw
head, especially if the screw requires more than one month
for correction. Development of a bony exostosis at the site
of screw removal may likewise occur; this is common with
3.5-mm screws used at the distal metacarpus or metatar-
sus [15–21]. This may present a clinical problem if the cal-
lus is positioned along the palmar border of the lateral
metacarpus, in that there may be some interference with
the branch of the suspensory ligament (Figure 48.6).
Consequently, it is advisable to place the screw at the mid-
point of the lateral or medial surface of the metacarpus, in
order to attempt to avoid this complication.
In addition to postoperative swelling from hemorrhage
or seroma, abscess development may occur which requires
opening and flushing in order to obtain an adequate cos-
metic outcome (Figure 48.7).
With procedures that require postoperative bandages,
blemishes caused by tissue reaction or sepsis are most com-
Figure48.7 The arrow indicates an example of a seroma over
the medial physis of the right carpus associated with
transphyseal staple placement. This can lead to thickening over
the area, resulting in an unappealing blemish. Source: Robert
Hunt and Amy M. Buck.
monly caused by aggressive bandaging techniques leading

to tissue necrosis over the screw heads. Conversely, band-
aging the area too loosely or premature removal of the
bandage allowing fluid to accumulate beneath the incision
may lead to seroma and possible abscess
development [21].
Prevention As cosmetic blemishes are typically the result

of tissue necrosis, careful bandaging is often key in
preventing these complications. It is important to recognize
that most of the postoperative management is in the hands
of non-veterinary personnel and is carried out in a farm
setting out of the control of the attending veterinarian. It is,
therefore, crucial for the veterinarian to become familiar
with the staff providing the postoperative care so that
thorough instructions may be given and complied with.
Specifically, with the staple, the position of the incision,
as discussed previously, is important and correct position-
Figure48.6 Dorsopalmar radiographic image of the right ing greatly reduces the likelihood of a blemish occurring.
metacarpophalangeal joint of a foal after single transphyseal
screw placement showing formation of bony callus over the
Diagnosis and monitoring Blemishes are usually apparent on
head of the screw. This is more common with 3.5-mm screws in
the distal metacarpus/metatarsus. This may cause a problem if visual inspection and at the times of bandage changes. Some
the callus is palmar/plantar, because it could interfere with the of these complications may cause pain and foals may show
suspensory apparatus, making it advisable to place the screw at lameness. It is important that the managers closely evaluate
the midpoint on the lateral or medial surface. In order to remove
the surgical site when changing bandages, so these conditions
the screw covered by bone, use of chisel and hammer may be
necessary to get to the head of the screw and seat the may be caught early. If any swelling or heat develops, the site
screwdriver. Source: Robert Hunt and Amy M. Buck. should be evaluated immediately for infection.
Treatment If a callus develops over the screw head, the prognosis can be good. Prognosis for function is generally
screw head location should be identified radiographically, higher than complications associated with over- or under-
but it generally resides at the proximal dorsal border of the correcting the ALD.
callus rather than in the center. After lengthening the
incision, a small chisel and hammer may be utilized to
remove the callus and clear a tract to remove the screw. This
procedure may be utilized for removal of screws Conclusion
inadvertently not removed and discovered months after
implantation. In the event of a screw becoming bound While it is impossible to completely remove the potential
within the bone, reaming the entire length of the screw may for complications resulting from surgical manipulation of
be required before the extractor can successfully remove the angular limb deformities in foals, it is possible to mini-
screw. Head stripping may be prevented by establishing a mize them. Therefore, it is crucial to be aware of every
clear channel for unimpeded removal of the screw using a aspect of the surgery, case selection, and postoperative
curette. A small chisel may be required to remove enough management to reduce the occurrence of complications.
bone to establish a pathway for the screw head to travel. An Familiarity with the anatomical and physiological details
abscess should be treated in the routine fashion. of each surgical procedure will reduce the risk of intraop-
If a bony exostosis develops at the site of the screw erative complications associated with incorrect tech-
removal, the callus may be removed with a chisel, ron- nique. Furthermore, proper postoperative management
geurs, and curette, and results in favorable cosmetics and may prevent occurrence of environmental complications.
function. Finally, it is essential to quickly identify surgical compli-
cations and effectively communicate with owners and
Expected outcome Outcome is dependent on the severity farm personnel in order to effectively manage complica-
of the blemish, but if caught and managed early, the tions if they do arise.
References
1 Witte, S. and Hunt, R. (2009). A review of angular limb 8 Auer, L.A. and Martens, R.J. (1982). Periosteal transection
deformities. E.V.E. 8 (62): 378–387. and periosteal stripping for correction of angular limb
2 Bramlage, L.R. and Auer, J.A. (2006). Diagnosis, deformities in foals. Am. J. Vet. Res. 43: 1530–1534.
assessment, and treatment strategies for angular limb 9 Auer, L.A., Martens, R.J., and Williams, E.H. (1982).
deformities in the foal. Clin. Tech. Equine Pract. 5 (4): Periosteal transection for correction of angular limb
259–269. deformities in foals. J. Am. Vet. Med. Assoc. 181: 459–466.
3 Bramlage, L.R. and Embertson, R.M. (1990). Observations 10 Bertone, A.L., Turner, A.S., and Park, R.D. (1985).
on the evaluation and selection of foal limb deformities Periosteal transection and stripping for treatment of
for surgical treatment. Proc. Am. Assoc. Equine Pract. 36: angular limb deformities in foals: clinical observations. J.
273–279. Am. Vet. Med. Assoc. 187 (2): 145–152.
11 Baker, W.T., Slone, D.E., and Ramos, J.A. (2014).
4 Auer, J.A. (2012). Angular limb deformities. In: Equine
Improvement in bilateral carpal valgus deviation in 9
foals after unilateral distolateral radial periosteal
Louis, MO: Elsevier Saunders.
transection and elevation. Vet. Surg. 44: 547–550.
5 Santschi, E.M., Leibsle, S.R., Morehead, J.P. et al. (2006).
12 Slone, D.E., Roberts, C.T., and Hughes, F.E. (2000).
Carpal and fetlock conformation of the juvenile
Restricted exercise and transphyseal bridging for
Thoroughbred from birth to yearling auction age. Equine
correction of angular limb deformities. Proc. Am. Assoc.
Vet. J. 38: 604–609.
Equine Pract. 46: 126–127.
6 Greet, T.R.C. (2000). Managing flexural and angular limb 13 Heinze, C.D. (1969). Epiphyseal stapling – a surgical
deformities: The Newmarket perspective. A.A.E.P. Proc. technique for correcting angular limb deformities. Proc.
46: 130–136. Am. Assoc. Equine Pract. 15: 59–73.
7 Colles, C.M. (2008). How to aid the correction of angular 14 Carlson, R.L., Lohse, C.L., Eld, L.A. et al. (1972).
limb deformities in foals using physeal stimulation. Proc. Correction of angular limb deformities by physeal
Am. Assoc. Equine Pract. 54: 60–63. stapling. Mod. Vet. Pract. 53: 41–42.
References 693
15 Roberts, B.L., Railton, D., and Adkins, A.R. (2009). A 19 Turner, A.S. and Fretz, P.B. (1977). A comparison of
single screw technique compared to a two screw and wire surgical techniques and associated complications of
technique as a temporary transphyseal bridge for transphyseal bridging in foals. A.A.E.P. Proc. 23: 275–294.
correction of fetlock varus deformities. E.V.E. 21 (12): 20 Fretz, P.B. and Turner, A.S. (1978). Retrospective
666–670. comparison of two surgical techniques for correction of
16 Kay, A.T. and Hunt, R.J. (2009). Single screw transphyseal angular deformities in foals. J. Am. Vet. Med. Assoc. 172:
bridging of the distal metacarpus and metatarsus for 281–286.
correction of angular limb deformities in the foal. E.V.E. 21 Carlson, E.R., Bramlage, L.R., Stewart, A.A. et al. (2012).
21 (12): 671–672. Complications after two transphyseal bridging
17 Kay, A.T., Hunt, R.J., Thorpe, P.E. et al. (2005). Single techniques for treatment of angular limb deformities of
screw transphyseal bridging for the correction of angular the distal radius in 568 thoroughbred yearlings. E.V.J.
limb deviation. Proc. Am. Assoc. Equine Pract. 51: 44: 416–419.
305–308. 22 Baker, W.T., Slone, D.E., Lynch, T.M. et al. (2011). Racing
18 Witte, S., Thorpe, P.E., Hunt, R.J. et al. (2004). A lag- and sales performance after unilateral or bilateral single
screw technique for bridging of the medial aspect of the transphyseal screw insertion for varus angular limb
distal tibial physis in horses. J. Am. Vet. Med. Assoc. 225 deformities of the carpus in 53 thoroughbreds. Vet. Surg.
(10): 1581–1583. 40: 124–128.
694
49
Complicationsof SurgicalCorrectionof FlexuralLimbDeformities

Belinda Black BSc, BVMS, DVSc DACVS-LA1 and James R. Vasey BVSc, FANZCVSc2
1
Murray Veterinary Services, West Coolup, Western Australia
2
Goulburn, Valley Equine Hospital, Congupna, Victoria, Australia
Overview ○ Excessive laxity

○ Sudden collapse (hypotension)
Flexural limb deformities involve the soft tissues and cause – Complications regarding shoeing
○ Lameness
the joint to be held in an abnormally flexed or extended posi-
○ Thermal damage
tion in the sagittal plane. Congenital deformities are present
○ Contracted heels/club foot formation
at birth, whereas acquired flexural deformities develop most
usually in the months thereafter. They are named according – Complications to conservative management of rup-
to the joint(s) affected and may be present in multiple ture of the gastrocnemius
○ Abscessation
regions. Flexural deformities are treated with a variety of dif-
○ Acute hemorrhage (blood loss)
ferent therapies, depending on the severity and region
○ Concurrent illness
affected. These include conservative methods, such as band-
ages, splints and casts, oxytetracycline, and shoeing, or may ● Complications to Surgical treatments
be combined with a surgical procedure if conservative treat- – Desmotomy of the accessory ligament of the DDFT
ment is not achieving the desired outcome. It is not uncom- ○ Intraoperative hemorrhage
mon for a foal to have a front limb flexural deformity and a ○ Difficulty in transecting the ligament (tenoscopic
concurrent hyperextension involving the hind limbs, there- approach)

fore careful evaluation of the whole animal and particular ○ Impairment of ultrasound image with air (ultra-
decision making is warranted. sound guided approach)

○ Postoperative complication 1: Seroma formation/
swelling
L ○ Postoperative complication 2: Incision Dehiscence
with FlexuralLimbDeformities ○ Postoperative complication 3: Scarring or thicken-
ing of the surgical site

● Complications to conservative treatments ○ Postoperative complication 4: Incomplete
– Complications to external coaptation Correction or Recurrence
○ Pressure ulcers/sores – Tenotomy of the DDFT
○ Septic/aseptic pedal osteitis ○ Postoperative complication 1: Hemorrhage
○ Reluctance to ambulate/inability to stand ○ Postoperative complication 2: Dorsiflexion of the toe
– Complications to digital hyperextension deformities ○ Postoperative complication 3: Distal interphalan-
○ Secondary trauma to the palmar/plantar phalanx geal joint subluxation

○ Infection of the common digital extensor tendon ○ Postoperative complication 4: Synovial sinus
(CDET) sheath formation
– Complications to oxytetracycline administration ○ Postoperative complication 5: Surgical site infection
○ Renal problems ○ Postoperative complication 6: Enlargement of the
○ Injection site reaction tenotomy site
Complications to Conservative reatments 695
– Desmotomy of the accessory ligament of the SDFT

(superior check ligament desmotomy)
○ Hemorrhage
○ Incomplete transection
○ Postoperative complication 1: Seroma/swelling
○ Postoperative complication 2: Surgical site

infection
○ Postoperative complication 3: Carpal
hyperextension
○ Postoperative complication 4: Failure to resolve
– Tenotomy of SDFT
○ Postoperative complication 1: Scarring or thicken-
ing of the surgical site

○ Postoperative complication 2: Pain
– Tenotomy of flexor carpi ulnaris and ulnaris lateralis

○ Incomplete ossification
○ Neurovascular damage
○ Hemorrhage
○ Postoperative complication 1: Dehiscence
○ Postoperative complication 2: Failure to resolve
– Desmotomy of the suspensory ligament

Figure49.1 A superficial bandage sore over the dorsolateral
– Surgical transection of the peronius tertius muscle
aspect of the left metacarpal area caused by a splint applied to
– Lateral release incisions and reinforcement of the treat a distal limb flexural deformity. Source: Belinda Black and
medial patellar support structures; and/or sucloplasty Jim R. Vasey.
with U-shaped cartilage flap; or sucloplasty with
wedge osteotomy
Pressure ulcers/sores
○ Technical difficulties performing the medial
imbrication Definition
○ Questionable holding strength of imbricated tissue An area of localized soft tissue ischemic necrosis caused by
○ Postoperative complication 1: Seroma prolonged pressure higher than capillary pressure, which
○ Postoperative complication 2: Dehiscence usually occurs over a bony prominence [1]. This results in
○ Postoperative complication 3: Septic arthritis of the skin damage characterized by necrosis and ulceration,
femoropatellar joint where tissues are compressed between bony prominences
○ Postoperative complication 4: Re-luxation and the high-pressure areas of the bandages. The hair that
regrows in these areas is often white, which may seem
● Flexural deformities affecting multiple regions
inconsequential; however, it can be a source of frustration
to an owner.
omplicationsto Conservative
C
Risk Factors
Treatments
● Inadequate padding or loose padding
Complicationsto ExternalCoaptation ● Presence of a splint or cast (especially a dorsal active
tension-extension splint)
External coaptation such as bandaging, splints (including
● Neonates with concurrent illness
active tension-extension splints) and casts are more
efficacious when used for flexural deformities of the distal ● For horses wearing a cast: prolonged application, the
limb. These include the distal interphalangeal joint, number of casts applied, increasing age and weight of
metacarpo(or tarso) phalangeal joint, and sometimes, the horse
carpus. When treating foals with flexural limb deformities ● Slipping or rotation of the external coaptation
with external coaptation, the most common complications ● Excessive exercise (friction)
to prevent are slipping or rotation of the splints, white hair ● Moisture
formation, and bandage sores (Figure 49.1). ● Edema
696 Complications of Surgical Correction of Flexural ime eformities
Pathogenesis Skin sores are a known complication of foal suffering from neonatal iso-erythrolysis has decreased
casts and bandages, and increased total casting time oxygen carrying capacity to tissues including the skin, and
increases the risk of developing these sores (Figure 49.1). failure-of-passive-transfer of colostrum leaves patients
In a study of 398 horses, 197 (49%) developed some kind of predisposed to sepsis. Edematous tissue experiences
cast complication of which 45% were skin sores [4]. The compromised circulation since the interstitial tissues exert
reported rate of skin sores as a complication of casts is increased pressure on blood vessels, decreasing tissue
often high, between 70 and 81%; however, the rate has also oxygenation.
been reported to be as low as 11% for short-term casts (<11
days). Twenty horses (5%) in this study experienced cast Prevention Ensure the limb is dry prior to application, and
breakage and 3 horses (0.8%) developed a bone fracture maintain the horse in a confined, dry environment.
(third metatarsal, third metacarpal and tibia) between When placing splints under pressure, ensure the band-
7 and 27 days of application [4]. Less horses developed age is thick enough to protect the tissues from compres-
complications when a bandage cast was applied (34%), sion. Laminar application of the material prevents
than when a traditional cast was applied (52%). Casting the bunching and uneven pressure. Apply an appropriate
limb in a flexed position and application on geldings have amount and type (foam padding intended for casting
been identified as increasing the chances of complications instead of cotton padding) of material (excessive padding
in multiple studies [4, 6]. Commonly, cast sores affect only can lead to bunching and too little padding material can
superficial structures, but occasionally tendons and cause pressure or rubbing [2]). Frequently change custom-
synovial structures can be involved. made splints (at least every 12–48 hours) and casts every 4
Uneven or inadequate application of bandage material, days. Taping the splint in sections, rather than top to bot-
overtight application, or an over ambitious attempt to tom, and alternating the direction of the tape, can help pre-
apply a splint on a growing foal can increase the pressure vent rotation of the splint. “Donuts” of bandage material
exerted. Pressure can compress the soft tissues and occlude can be used to relieve the pressure from bony prominences,
capillaries, leading to ischemia and cell death, thereby but if these slip they can cause increased focal pressure.
resulting in necrosis and ulceration [1]. Presence of a splint During application and curing of the cast [3], the
or cast increases the risk, since the tissues are compressed clinician or assistant should ensure there is no inadvertent
between a bony prominence and a hard surface, hence digital pressure, as this can created divots.
pressure sores are often located over bony prominences or Ensuring a cast or bandage finishes at the recommended
areas being bandaged firmly for application of a splint. site (i.e. does not finish mid-cannon or mid-tibia/radius)
Dorsal active tension-extension splints generate pressure can help decrease the risk of limb fracture.
on the dorsal cannon bone, therefore bandage sores can be Applying acrylic to the base of the cast can prevent dam-
more common than with other splinting methods. age to the base and delay wearing through [4]. If clinically
Coffin and fetlock joints with flexural deformities may suitable, apply a bandage cast instead of a traditional cast, as
experience pressure sores over the heels, proximal sesamoid they tend to have fewer complications [4]. Ensure the top is
bones, proximo-dorsal cannon bone where a splint usually well sealed to prevent bedding entering the bandage/cast, as
ends, and accessory carpal bone if this is included in the foreign material can quickly contribute to creating sores.
bandage. Cases with carpal contracture in a palmar splint Being aware that increasing age, weight of the horse,
may experience pressure ulcers over the heels or the palmar time in a cast, and the number of casts applied have been
aspect of the antebrachium where the splint ends. identified as significant risk factors to cast complications,
Many factors, in addition to pressure, contribute to the and can help clinicians identify those cases at greatest risk.
formation of pressure sores in humans and many of these
also contribute to bandage sores in equines. These factors Diagnosis Clinical signs of a problem were evident prior to
include friction, moisture, malnutrition, anemia, edema cast removal in 77% and the most common signs were
and concurrent illness. Friction between the skin and the worsening lameness and visible cast sores [4]. The bandage/
bandage material can cause damage to the epithelium, cast and limb should be closely monitored and palpated
resulting in a breach in the barrier against infection. This daily for heat, (especially over areas such as the proximal
can result from a cast applied too loosely, muscle atrophy, sesamoids and areas of pressure), and the limb examined for
resolution of edema or compaction of padding material [2, evidence of swelling. Appraise the animal ambulating and
3]. Moisture from sweat, urine, and discharge, especially in address lameness early. If the horse becomes suddenly lame,
recumbent foals, can cause maceration of the skin, making the bandage/cast should be removed immediately as
it susceptible to pressure and friction. Nutritional factors, superficial sores can quickly progress to full thickness
especially in foals, can impact skin health. For example, a necrotizing wounds. Signs of irritation include biting or
rubbing the cast, while the existence of foul odor often

indicates a serious problem. A cast applied for a flexural
deformity should not exhibit an odor. Daily rectal
temperature should be performed, since a fever can indicate
an underlying problem.
Treatment Remove the bandage/cast and decrease

bacterial contamination while having little negative
influence on the cellular activity to provide optimal
conditions for healing. Commonly in equine practice,
wounds are cleaned with solutions that are relatively
cytotoxic [5]. Read packages to identify the pH: the closer
to neutral, the less cytotoxic the solution.
Decide if the wound is infected to determine if systemic
antibiotics are required. A bacterial culture and sensitivity
should be performed to determine appropriate antibiotic Figure49.2 A sloughed hoof as a result of an over tight
bandage. Source: Belinda Black and Jim R. Vasey.
therapy while continuing local wound treatment [5]. Cover
the wound with a dressing appropriate for the degree of
dorsal hoof wall to pass a wire, creating an extension of the
discharge. The type of bandaging will be determined by
distal limb (Figure 49.3). If the soft laminae are penetrated,
whether the flexural deformity has been resolved or not.
a septic process involving the distal phalanx may develop.
Create a new cast. Replacing the old one is likely to
compound the already present problem. Prevention Excessive tension on the toe wire can cause
damage to the hoof wall, so the clinician should take care
Expected outcome Bandage sores complicate flexural limb not to over-tighten. Prophylactic antibiotic treatment is
deformities because their presence does not justify the recommended if hemorrhage of the hoof wall is evident
cessation of the coaptation device, unless the deformity has after drilling for placement of the cerclage wire [7]. We
resolved. The pain from the wound can make the foal place equithane on the dorsal toe and subsequently drill
reluctant to bear weight, worsening the deformity; through this, avoiding penetration of the hoof (Figure 49.3).
therefore, the clinician must be able to apply a new splint
or cast that is comfortable. Judicious use of NSAIDs is
useful to encourage foals to use their splints. Even in the
event of cast sore development, this study found no
influence on the outcome or on the time of
hospitalization [6]. Our personal experience indicates that
cast sores involving synovial structures increase
hospitalization time, cost and may decrease prognosis.
Scaring in the form of a fibrotic lump on the dorsal cannon
bone region is experienced in 10% of cases wearing a dorsal
active tension-extension splint [7].
Avascular necrosis of the distal limb leading to sloughing
of the hoof has been reported after an owner applied an
overly tight bandage [8] (Figure 49.2).
Septic/aseptic pedal osteitis

Definition
Rarefying (to make less dense) osteitis of the pedal bone [9]
Risk factors Application of a dorsal active tension-

extension splint due to drilling through the hoof wall
Pathogenesis During the application of the dorsal active Figure49.3 An active tension-extension splint applied to a
tension-extension splint, a hole is drilled through the foal’s front limb. Source: Belinda Black and Jim R. Vasey.
Diagnosis Clinicians should monitor the foal carefully for and encourage circulation of the soft tissues. Examine the
lameness and foot sensitivity. The horse will be sensitive to animal and look for systemic disease.
hoof testers in the toe region.
Lameness and foot pain resulting from pedal osteitis is Treatment Treat any concurrent disease or cast sores,
evident as radiographic remodeling of the solar margin of provide appropriate analgesia and help foals to stand
the bone, although differentiating between a septic and regularly to nurse. Significant supportive therapy and
aseptic process is not always evident from radiographs nursing care is required for foals in full limb splints/casts,
alone [10]. The third phalanx can experience remodeling especially those with severe deformities.
of the solar margin or demineralization, resulting in focal
or generalized loss of radiopacity and widened vascular Expected outcome The outcome varies significantly
channels. Additionally, the palmar process may show cir- depending on the reason for decreased ambulation; however,
cular lucent regions. When differentiating septic pedal severe flexural deformities and foals with concurrent disease
osteitis from aseptic pedal osteitis, the former is typically tend to have a poorer prognosis.
more painful and tends to have a focal area of deminerali-
zation, although in chronic cases a radiopaque sequestrum Complicationsto DigitalHyperextension
surrounded by a lucent border is sometimes seen [10]. Deformities
Radiographic changes to the pedal bone can take weeks to
show, so repeat radiographs should be performed. Digital hyperextension deformities are relatively common
in newborn foals.
Treatment Aseptic pedal osteitis can resolve with treatment
of the flexural deformity itself, since the abnormal concussive Secondary trauma to the palmaryplantar phalanx
forces are removed; however, septic pedal osteitis responds Definition
best to surgical resection of the necrotic bone and devitalized During the weight-bearing stage, the palmar/plantar aspect
tissue under general anesthesia. The hoof should then be of the phalanges contacts the ground, causing trauma,
bandaged to protect the underlying soft tissue. Depending abrasions and necrosis of the skin.
on the case, an intravenous regional limb perfusion may be
useful. Risk Factors
● Premature foal
Expected outcome With appropriate treatment, the ● Dysmature foal
prognosis for this complication is excellent.
Prevention A heel extension will stop the toe from
Reluctance to ambulate/inability to stand elevating while preventing contact of the palmar aspect of
Definition the phalanges with the ground.
The animal’s movement/locomotion is abnormally
decreased or the animal may not be able to stand. Diagnosis Observing the foal walk will reveal the severity
of the laxity. In severe cases the toe, or most of the foot,
Risk Factors may be lifted from the ground [11]. Secondary trauma to
the heels resulting in abrasions and necrosis of the skin
● Full limb splints usually occurs quickly.
● Severe flexural deformity
● Cast/bandage sores Treatment Superficial wounds can heal by second
● Concurrent disease intension if treatment is instituted to elevate the limb from
the ground via strength exercises and a heel extension.
Prevention Ensure the focus is not only on the flexural
deformity and the whole animal is examined for concurrent Expected outcome Untreated wounds and untreated laxity
disease. can progress and result in damage and infection of deeper
structures. Foals with severe hyperextension can experience
Diagnosis Remove bandages, splints and casts if the trauma to the fetlock region, progressing to secondary
lameness is unexplainable and rule out pressure sores. infection of the digital flexor tendon sheath or the fetlock
Determine if the animal can stand/walk without the splints joint, significantly decreasing prognosis. Secondary
in case this is the cause. A period without the splints is degenerative joint disease of the fetlock joint can also
often necessary to allow the animal relief from the pain develop.
It should be noted that tenoplasty of the superficial and Complicationsto Oxytetracycline

deep digital flexure tendon as treatment for digital Administration
hyperextension deformities has been described [12], but is
Oxytetracycline is often used to help lengthen the
no longer recommended.
musculotendinous unit in animals affected with a flexural
limb deformity [11]. Oxytetracycline administration is
Infection of the common digital extensor tendon
contraindicated in foals with concurrent hyperextension in
(C ) sheath
the hind limbs, as the hyperextension often worsens.
Definition Complications of oxytetracycline can occur through the
Invasion and multiplication of microorganisms in the physical act of administration, the toxic effects of the drug,
CDET sheath, especially those causing local cellular or when unwanted elongation of the limb occurs.
injury [9] Rapid intravenous injection of oxytetracycline can result
in hypotension and sudden collapse and extravasation of
Risk Factors undiluted preparations can lead to severe tissue
irritation [14].
● Surgical management of ruptured common digital exten-
sor tendon(s) Renal problems
● Synoviocentesis of the CDET sheath
Definition
Acute renal failure (ARF) is characterized by an abrupt
Prevention Provide conservative treatment and avoid
decrease in glomerular filtration rate (GFR). Clinically,
surgical management.
blood urea and creatinine concentrations increase rapidly,
resulting in disturbances to fluid, electrolyte, and acid–
Diagnosis When diagnosing a surgical site infection, the base homeostasis [15]. Acute tubular nephrosis is
clinician should look for the usual cardinal signs; redness, characterized by tubule cell damage and cell death that
swelling, pain, heat, lameness (loss of function). The usually results from an acute ischemic or toxic event.
wound may have started to dehisce and will likely produce
a discharge. A fluid sample from the sheath should be
Risk Factors
collected (via synoviocentesis) and assessed for cytology,
cell count and culture. ● Concurrent renal insufficiency
● Using expired products
● Hypovolemia
Treatment Treatment should commence without haste.
● Sepsis
Comprehensive treatment explanation is beyond the scope
of this section; however, the following basic principles
should apply: Prevention When treating very young foals, clinicians
should wait for serum creatinine to return to normal levels
● Drainage of infected tissues should usually be performed before administering oxytetracycline. Clinicians should
with the aid of gravity. evaluate renal function including serum urea nitrogen and
● Devitalized and infected tissue should be debrided. creatinine concentration before treatment, especially in
● Synovial sites should be lavaged with a large volume of compromised patients [14]. Those with renal insufficiency
fluid. should not have tetracyclines administered, and it should
● Therapeutic antimicrobial therapy should be guided by be noted that the administration of expired tetracycline
the culture and sensitivity results. products could lead to acute tubular nephrosis [14].
● Sterile bandaging of the site helps prevent contamination Routinely diluting the dose in a 500–1,000 ml normal saline
and infection by opportunistic bacteria. bag and administering via a short-term catheter helps
provide hydration, whilst slowing administration and
Expected outcome Previous management recommendations decreasing the chance of collapse.
for a ruptured CDET within the tendon sheath, included
lavaging the sheath to improve cosmesis. The risk of Diagnosis Clinical signs for renal failure can include
complications, including infection, generally outweighs the dehydration, colic, teeth-grinding, polyuria, oligouria or
benefits of surgery. Surgical intervention, and aspiration of anuria. Monitor blood levels for increases in blood urea
synovial fluid, is now predominantly avoided due to the nitrogen (BUN) and creatinine concentration. Monitor
excellent conservative prognosis [13]. the patient’s urine production, noting however, that the
urine specific gravity of foals with azotemia is often pain, and yellow discoloration at the injection site can
normal (1.001–1.027). occur later. Damage to the recurrent laryngeal nerve is
unlikely, but possible, if the injection or damage was deep.
Treatment Fluid therapy is the mainstay of treatment for Upper airway endoscopy can be employed to help diagnose
acute renal failure. Deciding which type of fluid to laryngeal hemiplegia.
administer will depends on the patient’s serum potassium
concentration. If potassium is greater than 4.5 mEq/L, Treatment Treatment is supportive and can consist of heat
0.9% NaCl is recommended, unless the animal is packing the area and general wound management if the
hypernatremic, then 0.45% NaCl and 2.5% dextrose is skin necroses.
best [16]. A polyionic replacement fluid (lactated Ringer’s,
Plasmalyte, Normosol-R) can be used if the serum Expected outcome Generally, prognosis should be good. If
potassium level is normal [16]. Administer fluids at the recurrent laryngeal nerve is involved, there is a chance
maintenance rates plus the deficit over 12 hours. Care it may be permanent and athletic ability could be
should be taken with foals, since as little as 40 ml/kg of IV compromised.
fluids can cause pulmonary oedema. Drug treatments to
increase urine production or renal perfusion include xcessive laxity
frusemide, mannitol, and dopamine [16]; however, their
Definition
usefulness in the treatment of renal failure in foals is
Unwanted elongation of untargeted joints
controversial.
Risk Factors
Expected outcome Duration of renal failure before
initiation of treatment is the most important determinant ● Any current hyperextension of the limb
of prognosis. Rapid resolution of azotemia over the first 2 ● Bandaging of the limb to prevent or protect excoriations
to 3 days of treatment suggests a good prognosis. A
favorable prognosis shows a more gradual decline in serum Prevention Carefully consider or do not administer
creatinine concentration over 3 to 7 days, although it may oxytetracycline for treatment of a flexural deformity if
be weeks before there is complete resolution of azotemia. If hyperextension of another limb is evident.
serum creatinine concentration at initial examination is
greater than 10 mg/dL without change in the first 2 days of Diagnosis During physical examination, hyperextension
treatment, the prognosis is guarded. Patients remaining of the limb (usually the hind limbs) is evident. In severe
oliguric 24 to 48 hours after the start of intensive treatment cases, the heels and plantar aspect of the phalanges may
with an initial creatinine concentration of 15 mg/dL have a contact the ground.
grave prognosis [16].
Treatment Discontinue treatment with oxytetracycline.
Injection site reaction Restrict exercise and lightly bandage the area that is at risk
Definition of damage. A heel extension may be appropriate.
Extravasation of undiluted preparations can lead to severe
tissue irritation [14]. Expected outcome The expected prognosis is good.
Risk Factors Sudden collapse (hypotension)
● Injection off the needle (without a catheter) Definition

● Foal movement/inadequate foal restraint Rapid intravenous injection of oxytetracycline can result in
hypotension and sudden collapse.
Prevention Prevent extravasation. Obtain adequate foal
restraint and place a catheter prior to administration. Risk factors Rapid intravenous administration
Dilute the drug into 500–1,000 ml normal saline and
administer via the catheter. Flush the catheter before and Prevention Dilution of oxytetracycline with normal saline
after administration. and administration through an intravenous catheter
Diagnosis If the extravasation has just occurred there may Diagnosis Foal loses consciousness during administration
be swelling around the vein/catheter. Swelling, necrosis, of oxytetracycline and collapses if standing.
Treatment Discontinue treatment until the foal gains ● Toe extension longer than (approximately) 3 cm
consciousness. If administration is to be continued, the ● Hoof prick injury
rate of administration must be slowed.
Pathogenesis Lowering the heels stretches the flexor
Expected outcome The expected prognosis is good.
tendon unit and can cause pain if sufficient analgesia is not
provided. A toe extension that is too long will make
ComplicationsRegardingShoeing ambulation difficult due to the extensive break-over. Hoof
prick injury is more likely to occur when trying to apply a
Corrective trimming should always be performed to work
shoe to a small hoof as the young hoof is friable, small and
toward normal conformation. For mild cases of coffin joint
lacks holding strength.
flexural deformities (Stage 1), we lower the heels without
an extension to the toe. When treating moderate cases, we
Prevention Make changes to the heel level gradually by
lower the heels then apply a swan necked shoe (Figure 49.4).
either rasping only, or have an experienced farrier work
The abnormal concussive forces placed on the dorsal distal
with you if inexperienced. Do not make toe extensions
hoof wall causes widening of the white line, flaring of the
longer than 3 cm. Glue-on shoes are a great alternative to
hoof wall and tearing of the laminae, therefore the principle
nail-on shoes. The swan shoe (Figure 49.4) in conjunction
for applying the swan neck shoe is to shift some of the
with an acrylic attachment surrounding the hoof spreads
leverage stress from the solar toe area to the dorsal wall [17].
the forces over the wall and does not carry the risks
The swan shoe in conjunction with an acrylic attachment
associated with nailing.
surrounding the hoof spreads the forces over the wall and
does not carry the risks associated with nailing.
Diagnosis The horse may knuckle over and trip, be
unwilling to fully weight bear, or be unable to place the
Lameness
heels on the ground.
Definition
The state of being lame [9] (reluctance to bear weight)
Treatment Provide analgesics and walk the horse on a
Risk Factors hard surface daily. Physiotherapy in the form of manual
extension can also help.
● Overly lowering the heels
● Failure to provide analgesia
Expected outcome Good, if treated promptly. Failure to
resolve the problem will result in worsening of the flexural
deformity, as the animal will not want to load the flexor
tendons.
hermal damage
Nails on shoes are small and difficult to forge, the wall of
the young hoof is friable and lacks holding strength, and
the hoof is prone to hoof prick injury [17]; therefore, these
are not suitable options for very young foals. Glue-on shoes
are a great alternative, although the clinician should be
mindful of the rare chance of thermal damage caused by
the setting acrylic adhesive.
Definition Heat damage to tissues
Risk Factors
● Acrylic glue-on shoes

● Higher ambient temperature
Pathogenesis The acrylic undergoes an exothermic

Figure49.4 Swan-necked shoe. Source: Belinda Black and Jim reaction during curing. This could possibly damage delicate
R. Vasey. tissues if temperatures denaturize the proteins.
Prevention Some farriers wait until foals are 2 weeks old

before using acrylic extensions to help prevent this from
occurring [18]. The product may also be applied in layers to
reduce heat. Note that hotter ambient temperatures (e.g.
summer) will have the product set at a higher temperature [19].
Diagnosis Thermal damage is characterized by chronic

lameness in the affected limb. Radiographs of the foot may
reveal a sub-solar abscess type lesion or septic pedal osteitis
(Figure 49.5).
Treatment Treatment to remove devitalized tissue and

necrotic bone (Figure 49.5) necessitates aggressive surgical
debridement (Figures 49.6 and 49.7) and lavage, usually
performed under general anesthesia. The hoof should then
be bandaged, to protect the underlying soft tissues.
The degree of damage, and the structures involved, will
determine the prognosis. In most cases, the hoof will heal
once the affected bone is removed.
Contracted heels/club foot formation

Definition
Figure49.6 Devitalized tissue and necrotic bone are being
Contraction of the hoof or heels caused by mechanical
removed at the dorsal aspect of the sole and third phalanx with
constriction of a shoe or acrylic protection a curette. Source: Belinda Black and Jim R. Vasey.
Risk Factors
● Prolonged wearing of glue-on shoes without changing

sizes [17]
● Both heels included in a glue-on shoe
Pathogenesis The hoof is unable to freely flex and expand

in the rapidly growing foal due to constriction or tethering
by the shoe, therefore circumferential growth is impaired.
Figure49.5 Lateromedial radiographic image showing

radiolucency at the dorsodistal aspect of the third phalanx and
associated laminae and solar area. This foal had septic osteitis
of the apex of the third phalanx. Source: Belinda Black and Jim Figure49.7 A fragment of the third phalanx that was removed
R. Vasey. surgically. Source: Belinda Black and Jim R. Vasey.
Prevention Changing shoes every 12–14 days will prevent Only one of the three foals that survived to adulthood raced,
this [18]. suggesting that a negative influence on athletic ability may
be correlated with abscess formation [21]. Statistically
Diagnosis The hoof size may not be increasing, and the though, treatment complications or abscess formation did
hoof will become more upright with longer heels. not actually influence racing performance [21].
Treatment The shoes need to be removed, the heels

Acute hemorrhage (elood loss)
trimmed and encouraged to expand, analgesics
Definition
administered (if chronic), and the foal encouraged to walk
Acute blood loss due to vascular disruption of the femoral
and load the heels.
vein, artery, branches and muscle belly
Expected outcome The prognosis is good.
Risk factors Gastrocnemius rupture
Complicationsto ConservativeManagement Prevention No known prevention, as it occurs concurrently

of Ruptureof the Gastrocnemius with the original injury.
Rupture of the gastrocnemius is sometimes classified as a
flexural deformity. To enable a quick diagnosis, clinicians Diagnosis Increasing swelling of the soft tissue region
should be aware that a causal relationship between hip proximal to the tarsus, tachycardia, tachypnoea, pale
lock dystocia and assisted delivery exists [20]. The aim of mucous membranes, weak peripheral pulse, and decreasing
treatment is to immobilize the limb in a position that per- packed cell volume and total protein.
mits healing so fibrosis and subsequent stabilization at the
site of rupture are enhanced [20]. This is generally obtained Treatment Whole blood transfusion and supportive
with conservative management such as maintaining therapy
recumbency and application of splints or casts; however,
internal repair of the tendon with carbon fibre has been Expected outcome Acute hemorrhage is a component of
performed. over half (15 out of 28) of all gastrocnemius ruptures, as
evidenced by ultrasound examination [21]. In some (3 out
Abscessation of 28), it poses a life-threatening situation, causing clinical
Definition signs of compensation [21], while others may die as a result
Formation of an abscess at the gastrocnemius muscle of hypovolemic shock [2].
injury site
Concurrent illness
Risk Factors Definition
Illness existing at the same time (e.g. enterocolitis, hypoxic
● Concomitant illness ischaemic encephalopathy, sepsis)
● Necrotic debris, inflammation, oedema and hemorrhage
are all thought to predispose to infection Risk factors No determined factors
Diagnosis Ultrasound was used to identify the presence of
Prevention Concurrent disease is difficult to prevent as
an abscess and diagnosis was confirmed via ultrasound
many of the foals have the disease at the time of
guided aspiration and cytology [21].
presentation.
Prevention Broad-spectrum antibiotic coverage may help
prevent abscessation. Particular antibiotic therapy against Diagnosis Diagnosis will depend on the disease entity.
non-hemolytic E. coli, beta-haemolytic Strepptococcus spp. Approximately 60% of foals presenting with a gastrocnemius
and Salmonella spp. are indicated, since these microbes rupture will suffer from concurrent disease [21].
have been cultured from gastrocnemius abscesses [21].
Treatment Treatment will depend on the disease process.
Treatment Surgical debridement and establishment of
drainage Expected outcome Concurrent disease is significant, since
it decreases prognosis [20, 21] and complicates treatment.
Expected outcome In one study, 4 out of 28 foals (14%) Foals who present without concurrent disease are more
formed abscesses at the gastrocnemius muscle injury site. likely to begin training or start to race later in life [21].
Overall, a wide prognosis for survival ranges from 0–82%, Risk factors Tenoscopic approach
with up to 82% of those survivors achieving race
training [21–23]. Prevention After placement of the scope and instrument
portals, straighten the leg with the hoist [25].
Complicationsto SurgicalTreatments Diagnosis Palpation of the ligament with a probe will

reveal intact fibres.
Desmotomyof the AccessoryLigament
of the DDFT Treatment Straighten the limb with the hoist after
placement of the scope and instrument portals. Ensure all
This procedure is used to treat acquired flexural deformity fibres are severed by prising the deepest aspect of the
of the coffin joint, which usually occurs in foals from 1 to 4 transection.
months of age. For severe cases, where the hoof wall is
vertical to the ground or worse, or those refractory to Expected outcome Transection should be able to be
conservative management, a desmotomy of the accessory completed without difficulty.
ligament of the DDFT is our first surgical intervention.
This must always be performed with corrective shoeing Impairment of ultrasound image with air (ultrasound
and analgesia for maximum results. guided approach)
It can be completed by an open, tenoscopic, or ultra- Definition
sound-guided approach. Excessive acoustic shadowing caused by air
Subluxation of the proximal interphalangeal joint is rare
and is thought to represent a form of DDFT “contrac- Risk factors Placing the palmar/plantar forceps (closest to
ture” [24], hence desmotomy of the AL-DDFT has been per- the skin) before the dorsal forceps
formed as a treatment for this condition.
Prevention Place the most dorsal forceps before the
Intraoperative hemorrhage palmar/plantar ones [26]. Limit the amount of dissection
Definition (and therefore the amount of air introduced into the
The escape of blood from a ruptured vessel [9] incision) by the use of Desjardin forceps to facilitate
isolation and elevation of the AL-DDFT.
Risk factors Medial approach
Diagnosis Presence of an intensely echogenic line, which
Prevention A lateral approach avoids the large medial impedes the clinician’s ability to identify the structures
palmar artery and vein, and is easier to access the ligament being examined.
given its more lateral position. If the medial approach is
Treatment Removing the air artefact is not possible so the
performed, the neurovascular bundle should be identified
procedure should be converted to an open approach if
and reflected away from deeper structures.
visibility is impaired such that appropriate structures
Diagnosis Acute hemorrhage is readily observed cannot be identified.
intraoperatively, with blood filling the surgical field.
Expected outcome There should be no negative clinical
consequence, other than converting to the standard open
Treatment This can be resolved with direct, firm pressure
approach, and a state of frustration on behalf of the
to the area.
surgeon.
Expected outcome Completion of the procedure is
Postoperative complication 1: seroma formation/
generally without difficulty. A hematoma may develop;
swelling
however, this is of no serious consequence.
Definition
Difficulty in transecting the ligament (tenoscopic A collection of serum at the surgical site
approach)
Risk Factors
Definition
Intraoperative trouble during the transection phase of ● Excessive exercise
surgery ● Minimal bandaging
Complications to Surgical reatments 705
Prevention Immediately postoperatively place a bandage Risk Factors

with a 4-inch roll of gauze bandage over the incision,
● Inadequate bandaging
parallel with the limb, then applying a firm bandage over
● Uncontrolled exercise
the top. We recommend bandaging the limb for 3 weeks
● Lateral approach (visually more obvious)
postoperatively for the best cosmetic approach. Other
recommendations include bandaging from 10 days to 4 Prevention Pressure bandaging for 10 days to 4 weeks has
weeks to decrease swelling [25, 27]. been recommended to decrease swelling [25, 27] and
limiting exercise may decrease fibrosis in older foals [27]. A
Diagnosis Swelling of the limb may exist in the region of
conservative postoperative exercise regime (6 weeks stall
the surgical site with either the open or tenoscopic method.
rest with small amounts of hand walking, then 6 weeks
A soft fluid-filled structure under the incision represents a
stall rest with turnout in small paddock daily, then 3
seroma and may be evident after the tenoscopic approach.
months paddock turnout) has been recommended for the
Ultrasonographic examination of the fluid should appear
best cosmetic and functional outcome [31].
anechoic.
Diagnosis A firm area on palpation with or without a
Treatment Swelling of the medial incision has resolved
visible scar is identifiable on clinical examination.
with bandaging and time [25].
Treatment Once a scar is present it is difficult to resolve,
Expected outcome Overall, the tenoscopic technique is
evaluated as having a good cosmetic outcome [25]. therefore prevention is preferred.
Postoperative complication 2: incision dehiscence Expected outcome Scarring or thickening of the check
Definition ligament is considered normal by many clinicians and will
The splitting open of the surgical wound [9] affect approximately 50% cases [30, 32] when performed
with the standard open approach, and does not appear to
Risk Factors affect functional ability [32]; however, it is a cosmetic issue
as approximately 15% horses will develop scarring
● Excessive tension on sutures significant enough to reduce their future value [30]. One
● Infection study reported 4 out of 34 (12%) foals having moderate
● Movement of the limb (unrestrained exercise) wound swelling and persistent scarring [26], but the
ultrasound approach reported only 3% having significant
Prevention Small incisions and restricted exercise help
scarring [30]. The ultrasound approach reported nearly
prevent dehiscence.
half of cases having a thickened region, lump or swelling
Diagnosis Opening of the wound edges. Careful immediately after surgery, but appeared “acceptable to
examination of the wound (and animal overall) should be normal” at long-term follow up [31].
performed to ensure the site is not infected.
Postoperative complication 4: incomplete correction
Treatment Infected wounds need to be diagnosed and or recurrence
treated appropriately. A dehisced wound not due to Definition
infection should be allowed to heal by second intention. It Failure of the hoof to return to normal, or near-normal
is advisable to bandage the wound with interactive angles, or worsening of the symptoms following surgery
dressings or topical gels that stimulate healing (i.e.
Solcoseryl® or alginate dressings) [28]. Risk Factors
Expected outcome Incision dehiscence occurs rarely [29, ● Chronic cases

30]. Wounds will take longer to heal and may need to be ● Older animals (>6–8 months [31, 32])
bandaged for an additional amount of time. The scar is ● Failure to continue corrective shoeing
likely to be more obvious than with a primary closure, due
to the act of contraction during second intention healing. Prevention Do not delay surgical treatment if conservative
therapy is not effective. Diligent corrective shoeing (toe
Postoperative complication 3: scarring or thickening extension and heel rasping) is of paramount importance.
of the surgical site
Definition Diagnosis Measurement of the dorsal hoof angle will
A mark remaining after the healing of a wound [9] reveal an angle that fails to improve, or increases.
Treatment The procedure can be repeated (with an Expected outcome Laceration of the median palmar artery
emphasis on maintaining corrective shoeing), although did not change the outcome in the two horses it was
increased scar tissue/blemish is to be expected. Alternatively, reported in [35].
a DDF tenotomy can be employed for severe cases as a
salvage procedure. Postoperative complication 2: dorsiflexion of the toe
Definition
Expected outcome Long-term follow up has shown 68% of Excessive retraction of the tendon ends, to the level of the
horses to have a normal hoof wall angle, 27% steeper than proximal sesamoid bones
normal, and 5% unknown [30]. Overall, 6 out of 40 (15%)
Risk factors Mid-pastern approach [35]
horses in one study redeveloped contracture to the degree
that they could not be used for their intended purpose [30]. Prevention Perform tenotomy at the mid-metacarpal
Generally, favorable outcomes range from 54–97% [26, 31, region rather than the mid-pastern region.
32] for foals treated with an inferior check ligament
desmotomy, with the majority of papers reporting toward Diagnosis Upward rotation (tipping) of the toe during the
the higher percentages. Younger horses having surgery at loading phase of the stride
less than 6 to 8 months of age had a better cosmetic and
functional outcome [31–33], although excellent results Treatment Slight dorsiflexion of the toe is easily managed
(86% returned to previous use) have been demonstrated in with a heel extension shoe. Severe dorsiflexion following a
horses older than 2 years old [32]. mid-pastern approach complication can be permanent but
may be managed with an extended heel shoe.
Tenotomyof the DDFT Expected outcome The heel extension shoe should be worn
Tenotomy of the deep digital flexor tendon is reserved for for a minimum of 8–10 weeks after which time the tendon
cases with a refractory flexural deformity of the coffin joint ends develop fibrosis and become more stable, and the toe
or severe stage II cases. It is also selected for treatment of should not elevate. The extension can be worn for longer if
severe metacarpophalangeal flexural deformities, where it has not resolved in this time.
the DDFT is the affected structure. The surgical procedure
Postoperative complication 3: distal interphalangeal
can be performed at the mid-metacarpal or mid-pastern
joint sueluxation
region. The intrathecal approach now tends only to be used
Definition
to resect septic tendon, in cases of tenosynovitis [34] or
A rare occurrence, where partial dislocation of the distal
following a mid-metacarpal approach (for laminitis). To
interphalangeal joint becomes evident.
decrease complications and preserve the best athletic
outcome, an inferior check ligament desmotomy, rather
Risk factors Mid-pastern approach
than deep digital flexor tenotomy, should be performed,
since severe cases can still respond favourably [31]. Prevention Some clinicians do not recommend transecting
the DDFT in case of this complication [35]. This
Postoperative complication 1: hemorrhage complication is less likely to occur if the mid-metacarpal
Definition technique is employed, since in this region surrounding
Laceration of the median palmar artery resulting in connective tissue supports the DDFT. Place a heel extension
bleeding shoe prior to surgery, to prevent hyperextension, especially
if performing the mid-pastern approach.
Risk factors Medial approach
Diagnosis Lameness is likely to be evident. Subluxation
Prevention Use a mosquito hemostatic forceps to isolate can be ruled in or out with a lateral to medial radiograph.
the DDFT from the neurovascular bundle prior to
transection. Treatment Distal interphalangeal joint subluxation is
resolved with an extended heel reverse shoe with elevation
Diagnosis Acute bleeding during surgery of the heel [35].
Treatment The hemorrhage can be resolved with direct Expected outcome The heel extension shoe should be worn
pressure to the area [35] and completion of the surgery is for a minimum of 8–10 weeks. after which time the tendon
without difficulty. ends fibrose and become more stable.
Postoperative complication 4: synovial sinus Diagnosis When diagnosing a surgical site infection, the
formation clinician should look for the usual cardinal signs; redness,
Definition swelling, pain, heat, lameness (loss of function). The
An abnormal fistula permitting drainage of synovial fluid wound may have started to dehisce and will likely produce
a discharge. A fluid sample from the DFTS should be
Risk factors Mid-pastern approach collected (via synoviocentesis) and assessed for cytology, a
cell count and culture.
Prevention This complication is less likely to occur if the
mid-metacarpal, rather than the mid-pastern technique is Treatment Treatment should commence without haste.
employed, because the digital flexor tendon sheath is not Comprehensive treatment explanation is beyond the scope
entered. of this section; however, the following basic principles
should apply:
Diagnosis Drainage of fluid from the surgical site through
a fistula, and impaired healing of the incision ● Drainage of infected tissues should usually be performed
with the aid of gravity.
Treatment If the fistula is acute, and is not infected, it can ● Devitalized and infected tissue should be debrided.
be allowed to heal via second intention. It should be kept ● Synovial sites should be lavaged with a large volume of
bandaged to protect from ascending infection and bandage fluid.
changes should be performed in a sterile manner. ● Therapeutic antimicrobial therapy should be guided by
the culture and sensitivity results.
Expected outcome The duration of bandaging will be ● Sterile bandaging of the site helps prevent contamination
prolonged. If the fistula does not heal, and becomes and infection by opportunistic bacteria.
chronic, it may need to be surgically revisited and closed.
Expected outcome Studies report survival rates for septic
Postoperative complication 5: surgical site infection tenosynovitis (not exclusively surgical site infections) of
Definition between 73 and 100% [37–39]. However, of these, only
Surgical site infections are classified by the structures approximately 50% return to their previous level of
involved: performance [38–40]. The clinician and owner must also
● Superficial incisional: infection occurs within 30 days consider that the cost of treatment remains high and
after operation and involves only skin and subcutaneous hospitalization time is usually increased [36].
tissue of incision [36].
Postoperative complication 6: enlargement of the
● Deep incisional: within 30 days after operation and
tenotomy site
infection appears to be related to the operation and
Definition
involves deep soft tissues (fascial and muscle layers) [35].
● Organ/space: within 30 days after operation and infec- Enlargement of the tenotomy site
tion appears to be related to the operation and involves
Risk Factors
any part of the anatomy (organs and spaces) other than
the incision, which was opened or manipulated during ● Postoperative exercise
an operation [36]. ● Inappropriate bandaging
Prevention This is a difficult complication to prevent

Risk Factors
entirely, but careful exercise restriction and bandaging for
● Broach of sterile field during surgery a prolonged period can help.
● Mid-pastern approach usually involves DFTS
Diagnosis Formation of a firm swelling at the surgical site.
Prevention A mid-metacarpal approach will mean the This can worsen over time when the tendon ends heal.
DFTS will be avoided, and hence a synovial site infection
will also be avoided. Usual sterile preparation prior to Treatment There is no treatment, as surgical intervention
surgery and maintenance of a sterile field should be often results in greater fibrosis.
maintained. If the sterile field is broached, appropriate
measures should be taken reflecting the degree and type of Expected outcome The most common complication
contamination. occurring more than 7 months postoperatively is scarring,
which can be twice the diameter of the normal tendon [35]. During one case, a tourniquet was applied intraoperatively
Most clinicians accept some degree of fibrosis, especially at to successfully stem the flow of blood [8]. Positioning the
the mid-metacarpal region. It is possible that fibrosis may horse in dorsal recumbency for the tenoscopic technique
cause a subsequent flexural deformity when the tendon facilitates bilateral treatment and enables any hemorrhage
ends heal together. to be controlled with fluid pressure alone [41]. Hemorrhage
can alternatively be controlled with bipolar laparoscopic
cautery forceps or a hemostatic clip [44].
Desmotomyof the AccessoryLigament
of the SDFT(SuperiorCheckligament
Expected outcome In 2 out of 49 operations, intraoperative
Desmotomy)
hemorrhage made visualization difficult, prolonging
This procedure is recommended for congenital and surgery time [42]. Anectodal information suggests that
acquired cases of metacarpophalangeal flexural deformities cases experiencing hemorrhage suffer more swelling or
if conservative treatment has failed, or if the fetlock angle oedema of the surgical site than those that do not bleed
approaches 180 degrees (normal fetlock angle is 135 from the nutrient artery. One horse experiencing marked
degrees). The procedure can be completed by an open or distension of the carpal tendon sheath following
tenoscopic approach. hemorrhage during the tenoscopic approach, displayed
pain (pawing and sweating) and in the 12 hours following
Hemorrhage surgery later developed mild pitting oedema distal to the
Definition carpus. A support bandage resolved the oedema and
Damage to the nutrient artery of the SDFT can result in centesis of the tendon sheath, 7 days later, resolved the
leakage of blood. effusion [42].
Risk factors Blindly cutting the proximal extent of the Incomplete transection
ligament (the nutrient artery is located in this location) Definition
Transection of the accessory ligament is thought to be com-
Prevention We perform the modified open approach [40] plete, but intact fibers remain.
with some minor changes. Specifically, mosquito
hemostatic forceps are used to identify the nutrient artery Risk factors Hemorrhage (impairs view)
at the proximal extent of the superior check ligament.
Some surgeons complete the transection from distal to Prevention To prevent this during the open approach,
proximal in case of hemorrhage. We attempt to identify palpation can be used to identify any remaining fibers, and
and avoid this vessel and transect the accessory ligament once complete, the radial head of the deep digital flexor
using heavy curved mayo scissors from proximal to distal. muscle can be viewed beneath [43]. Tenoscopically,
Transection of the nutrient artery of the superior check creating the portal 6–8 cm proximal to the radial physis [44]
ligament can be prevented by careful palpation and discrete enables access to the proximal aspect of the ligament
fibre transection at the proximal extent. (changes made after revision of the original technique [41]).
Important technical considerations regarding the teno- Accessing the superior check ligament is facilitated if the
scopic approach include placing the horse in dorsal surgeon elevates the DDFT caudally. To access the proximal
recumbency as this can help control hemorrhage [41], and caudal limits of the superior check ligament, it helps to
although some hemorrhage was noticed during most initially place the limb in slight flexion then flex to 90
transections [42]. degrees during desmotomy whilst maintaining sheath
distension [41]. A suitable cutting instrument, such as
Diagnosis Hemorrhage becomes present during biopsy punch ronguer or radiofrequency probe, is required
transection of the proximal extent of the accessory ligament beyond the proximal reflection of the sheath as it becomes
of the SDFT. more robust [44].
Treatment Ligating the vessel(s) is difficult as the artery Diagnosis During the open approach, the ligament should
ends retract into the fascia [43]. If performing the open be palpated to ensure it is completely transected. Even to
approach, bleeding can make continuation of the surgery the inexperienced surgeon, remaining fibers will be easily
difficult. Direct pressure can slow bleeding and the felt and can then be transected. During the tenoscopic
transection can be continued blindly and the sheath approach, the limb should be flexed to ensure the proximal
sutured closed as soon as possible to cause tamponade [8]. and caudal margin is not missed.
Treatment The remaining ligament should be transected. 23 of 36 surgeries developing a swelling or seroma [45],
Exchanging the arthroscopy and instrument portals often with 3 of these progressing to dehiscence of the incision. If
improves visualization. performing the open approach, closing the sheath of the
flexor carpi radialis muscle and application of a
Expected outcome Intraoperative correction to complete compression bandage immediately following surgery for
the transection should have no consequences. If the horse 7 days was found to help prevent seroma formation [45]. It
is recovered and the ligament is not fully transected, it can was also noted that horses that removed their own bandages
be assumed that maximum elongation of the SDFT will not were likely to deveop a seroma and were then at increased
be achieved. risk of surgical site infection. Our experience remains that
invasion of the carpal canal is without consequence if the
Postoperative complication 1: seroma/swelling sheath and fascia are closed. Another study reported the
Definition development of surgical site seromas in only 4 out of 61
A collection of serum at the surgical site [9] horses (101 surgical procedures). These were treated and
resolved with medical therapy and drainage, and did not
Risk Factors impact the horses’ recovery [46]. In another study, drainage
from the incision was present in 2 out of 22 horses [42] and
● Opening the carpal canal has been associated with
carpal canal swelling with pain evident in 1 out of 22
slower healing and an increased risk of seroma
horses [42]. Overall, complications involving the tenoscopic
formation [45].
approach are less frequent (10%) [41, 42, 47].
● Bandage removal by the horse [45].
● Transection of the ligament’s nutrient artery [41].
Postoperative complication 2: surgical site infection
Definition
Prevention Closing the fascia is recommended [43, 45]. Surgical site infections are classified by the structures
We close the tendon sheath using 2-0 absorbable suture involved:
material in a continuous pattern. The fascia and
subcutaneous tissues are closed in simple continuous ● Superficial incisional: infection occurs within 30 days
pattern using 2-0 absorbable suture, while the skin is closed after operation and involves only the skin and
using horizontal mattress sutures. The limb is also subcutaneous tissue of the incision [35].
bandaged to apply pressure over the surgical site, and the ● Deep incisional: within 30 days after operation and
distal limb if needed. infection appears to be related to the operation and
involves deep soft tissues (fascial and muscle layers) [36].
Diagnosis Effusion of the carpal canal will be evident and ● Organ/space: within 30 days after operation and infection
there may be soft tissue swelling around it. The incision appears to be related to the operation and involves any
may leak fluid. part of the anatomy (organs and spaces) other than the
incision, which was opened or manipulated during an
Treatment In one study, four different protocols were used operation [36].
to treat the seromas. The first involved sterile needle
drainage only, the second involved opening the distal 2 or 3 Risk Factors
sutures with placement of a penrose drain, the third The open approach appears to have a higher infection rate
included opening the distal sutures only and the fourth than the tenoscopic approach [41]. Horses that remove
was aimed at prevention by placing a suction drain their own bandages are more likely to develop a seroma
intraoperatively, which was removed 6 to 7 days and are at increased risk of surgical site infection [45].
postoperatively. The best treatment was surmmized to be General risk factors for SSI in the horse include:
opening the distal sutures for drainage [45].
The surgical site should remain bandaged with a sterile ● Host-related factors [36]
pressure bandage. Bandaging can reduce the swelling and – Extremities of age
should continue until fluid leakage has ceased and the – Gender (female)
incision healed. The site should be carefully monitored for – Immunocompromise (corticosteroid administration)
development of a surgical site infection. – Weight (>300–325 kg)
– Distant sites of infection
Expected outcome Historically, the procedure has had a – Hypoxia, e.g. systemic and local
relatively high complication rate, with one study reporting – Foreign material, e.g. clay, dirt
● Surgery-related factors [36] Diagnosis The horse exhibits hyperextension of the carpal
– Emergency procedures joint following surgery.
– Patient and surgeon preparation: shaving vs. clipping
– Increased duration of surgery Treatment The hyperextension resolved without
– Inexperienced surgical skill treatment.
– Foreign material, e.g. suture and prostheses
Expected outcome Good. Moderate bilateral carpal
Prevention There are many general preoperative, hyperextension immediately post anesthesia was an
intraoperative and postoperative interventions that can be unusual complication reported by Kretzschmar et al.
implemented to decrease the likelihood of an SSI [36]. following tenoscopic desmotomy of the superior check
Specifically, for this procedure, the tenoscopic approach ligament for a flexural deformity in a Quarter horse. This
has decreased infection rates. complication resolved without treatment in the ensuing
weeks [42].
Diagnosis A diligent physical exam will often identify the
early signs of an SSI. An unexplained fever, pain, heat or
Postoperative complication 4: failure to resolve
swelling that is increasing or failing to resolve often
Definition
accompany an infection. Purulent discharge is an obvious
Failure of the fetlock angle to improve to less than 180
identifier, and a culture and sensitivity should be obtained.
degrees
Treatment Culture and sensitivity testing of the infected
Risk factors Severe (as opposed to mild or moderate)
site is extremely important in being able to select an
fetlock flexural deformities
appropriate antibiotic. In one study [45], the infected
carpal canals were treated with antibiotics following
Prevention Success of these cases also depends on the
culturing of the infection, iodine and saline irrigation,
correct procedure(s) being selected. It may be that a failure
hydrotherapy, and bandaging, while another used
to resolve resulted because the case was always going to
antibiotics and antiseptic dressings such as organic iodine
need multiple procedures, therefore careful case
or scarlet oil under the bandage [47].
investigation and procedure selection is needed to prevent
Expected outcome In a large study of 332 tenoscopically failure. Successful improvement often also requires
performed cases, just 1% (6 horses) of surgical coaptation as an adjunct to surgery. Without splint/casts or
procedures [47] became infected. All surgeries were diligent physiotherapy aftercare, the likelihood of failure is
performed by the same surgeon, in the same room and high. The fetlock angle must decrease by less than 180
received the same pre- and postoperative instructions. Five degrees so that loading of the flexor tendons can occur.
out of the six horses resolved with antimicrobials, which
were selected after culture and sensitivity testing, and one Diagnosis The angle of the fetlock has failed to improve or
was euthanized at the owners request after involvement of has improved but remains greater than 180 degrees.
the carpal canal was confirmed [48].
In a study investigating the open technique [45], 3 out of Treatment Repeat examination of the horse and limb
19 horses contracted an SSI. The site was cultured and might reveal other tendons or ligaments that are under
sentivity testing obtained, after which the horse was treated tension, an explanation as to why the horse has not
with antibiotics, drainage and lavage of the site. The improved, and perhaps what other procedures are
infections resolved; however, hospitalization was necessary.
significantly prolonged by the SSI.
Expected outcome In one study, superior check ligament
Postoperative complication 3: carpal hyperextension desmotomy was performed for Quarter horses that suffered
Definition severe fetlock flexural deformities [42]. Two of five horses
Bilateral or unilateral carpal hyperextension following des- failed to improve after receiving both an inferior and
motomy of the superior check ligament superior check ligament desmotomy as treatment for their
marked flexural deformities, resulting in one yearling
Risk factors Unknown being euthanized and the other receiving a bilateral mid-
cannon superficial digital flexor tenotomy. The remaining
PreventionThis is a rare complication and therefore no three horses showed improvement of the flexural
known prevention exists. deformities. Generally, severe metacarpophalangeal joint
flexural deformities are often difficult to successfully Risk factors The procedure itself [40]
correct [49], and horses may seem to respond to treatment
initially, only to later relapse [11]. Prevention Although pain may be an inherent factor of
the procedure, most textbooks advocate the use of
phenylbutazone only [40]. Comprehensive preoperative
Tenotomyof SDFT multi-modal analgesia (NSAIDs, opioids, local anesthesia)
Very severe cases of fetlock joint (which may or may not with good postoperative analgesia can lessen the pain and
include the coffin joint) flexural deformities may require should be employed for procedures that are known to be
an SDFT tenotomy. If surgical treatment is necessary, a painful.
diligent physical examination should be performed to
determine which structure (SDFT or DDFT) is involved. Diagnosis Using a pain score chart, facial pain scores or
Very severe cases may require various surgical treat- behavior descriptions can help identify pain.
ments., including superficial digital flexor tenotomy, deep
Treatment Administration of analgesics that match the
digital flexor tenotomy and cast application or osteotomy
degree of pain, taking into account the age and physical
and metacarpophalangeal joint arthrodesis [11, 50]. For
status of the patient.
complications pertaining to osteotomy and MCP arthro-
desis, please refer to Chapter 46: Complications of
Expected outcome With appropriate analgesics, the pain
Orthopedic Surgery.
should be controlled.
Tenotomy of the SDFT has few intraoperative complica-
tions and can be done with direct visualization, or blindly
through a stab incision. Inexperienced surgeons should Tenotomyof FlexorCarpiUlnarisand Ulnaris
start with direct visualization until they are familiar with Lateralis
the technique, then progress to the blind approach.
Congenital flexural deformity of the carpus is often bilateral.
Grade 1 is mild and less than 20 degrees deviation from nor-
Postoperative complication 1: scarring or thickening
mal. These cases may spontaneously resolve with gentle
of the surgical site
exercise, or a full limb bandage. Grade 2 carpal flexural
Definition
deformity deviates between 20 and 40 degrees from normal,
A mark remaining after the healing of the surgical
while grade 3 is the most severe (>40 degrees from nor-
wound [9]
mal) [52]. Severely affected foals often require assistance to
Risk factors Open approach (direct visualization) stand. By the time the foals are presented, they have already
received various forms of conservative treatment such as
Prevention Blind approach with stab incision (if controlled exercise, bandaging, splinting, casting, oxytetra-
experienced) may improve cosmesis. cycline and analgesic administration. A poor response to
conservative therapy usually means we will treat these cases
Diagnosis Observation and palpation of the limb will with a flexor carpi ulnaris and ulnaris lateralis tenotomy.
reveal a thickened, firm region in the vicinity of the surgical Transection of the palmar capsule of the middle and ante-
site. brachial joint used to be performed; however, we do not find
it a useful procedure so it will not be further discussed.
Treatment Prevention is the best approach, as there is no
treatment that makes a significant difference. Incomplete ossification
Definition
Expected outcome Performing this procedure usually
Failure of the carpal bones to completely form bone
means the other forms of treatment for fetlock flexural
limb deformity have failed, and therefore the prognosis is
Risk Factors
generally poor to guarded [51]. Superficial digital flexor
tenotomy compromises future athletic ability and the ● Premature
cosmetic result is generally poor [40]. ● Dysmature
● Twinning
Postoperative complication 2: pain
Definition Prevention This complication is unable to be prevented;
A feeling of distress, suffering or agony, caused by stimula- however, twins and premature foals should always be
tion of specialized nerve endings [9] radiographed prior to surgical intervention.
Diagnosis Radiographs are used to determine the Diagnosis Hemorrhage will become evident upon
ossification of the carpal bones. transection of the flexor carpi ulnaris tendon.
Treatment We personally recommend euthanasia, since Treatment Firm pressure to the area may be able to stop
these cases tend to have a poor prognosis. the bleeding; however, due to its location it can be visualized
and ligated.
Expected outcome Foals with incompletely ossified carpal
Expected outcome The procedure should be able to be
bones and severe carpal flexural deformities have a grave
completed without difficulty. Hemorrhage causing
prognosis [52].
technical problems is generally not encountered if the
above-mentioned vessel is avoided.
Neurovascular damage
Definition
Postoperative complication 1: dehiscence
Encountering the dorsal carpal branch of the collateral
Definition
ulna artery and the dorsal branch of the ulna nerve
The splitting open of the surgical wound [9]
Risk factors Extending the incision beyond the level of the
Risk factors (speculated) Excessive tension on sutures:
distal radial physis
● Movement of the limb (unrestrained exercise)
Prevention Keep the majority of the incision above the ● Older age patient [8]
level of the distal radial physis.
Prevention Incision dehiscence has been rarely
Diagnosis The dorsal branch of the ulna nerve wraps
encountered [54], so definitive preventative techniques
laterally around the ulnaris lateralis and the flexor carpi
have not been identified; however, the usual surgical
ulnaris. The dorsal carpal branch of the collateral ulna
principles such as preventing excessive tension on sutures
artery emerges laterally from between the splitting of the
then confined housing with limited exercise, should be
ulnaris lateralis, where it divides into its long and short
practiced.
tendon [53]. A distal incision will mean the surgeon will
encounter artery and nerve and may risk damage to these.
Diagnosis Opening of the wound edges becomes evident.
Treatment The artery and nerve should be left alone and

Treatment The dehisced wound was treated with local
the incision moved proximal where the transection of the
wound care, systemic antibiotics and sterile bandaging,
tendons can take place without risk of damage to these
resulting in an excellent cosmetic result [54].
structures.
Expected outcome Wounds will take longer to heal and
Expected outcome The incision may be longer than
may need to be bandaged for an additional amount of time.
described; however, this should be of no significant
There will possibly be supplemental scarring, particularly
consequence. If the artery is damaged or transected,
in older animals [8].
hemorrhage will occur and the vessel may need ligation.
An increase in postoperative swelling may be evident.
Postoperative complication 2: failure to resolve
Damage to the nerve has not been reported.
Definition
If the surgical procedure results in less than 50% improve-
Hemorrhage ment of limb extension, we class this as unsuccessful.
Definition
The escape of blood from a vessel [9] (in this situation the Risk factors Grade 3 classification
lateral palmar vein)
Prevention Knowing the prognosis is less than 50% for
Risk factors Careless transection of the tendons grade 3 carpal flexion allows the clinician to present
realistic options to the owner.
Prevention Exercise meticulous care in the transection of
the flexi carpi ulnaris tendon, avoiding the lateral palmar Diagnosis The angle between the radius and metacarpal
nerve and vein, beneath it. II, III, and IV is still significant.
Treatment If the response following surgery is involvement, experience more complications and have a
unsuccessful, a cast or splint can be applied and the case poorer prognosis. Lateral luxation of the the patellar in
managed with coaptive bandaging. equines is rare and medial luxation is very rare [57, 58], but
is the most common cause of stifle flexural deformity. It is
Expected outcome This issue was not encountered with generally evident in Miniature horses, although a lateral
grade 1 foals: 2 out of 92 (2.2%) grade 2 foals, and 6 of 10 release and imbrication has been performed on effected
(60%) grade 3 foals experience an unsuccessful result with Standardbreds, one of which later raced successfully [8].
surgery alone [52]. Grade 3 foals requiring this additional Lateral release of the patellar involves incising the insertion
treatment following surgery have been shown to have a of the biceps femoris, lateral femoro-patellar ligament ±
grave chance at a successful outcome (17%); however, it is the lateral patellar ligament. However, it is possible to
the concurrent disease that complicates results [52]. Many release the patellar by transecting the tensor fascia and
grade 3 foals are less than 2 weeks of age and frequently fibrous joint capsule while preserving the lateral
experience concurrent medical or orthopedic problems, femoropatellar ligament. If the trochlear groove is
giving them an overall poorer prognosis; therefore, these hypoplastic, leading to instability of the patella, then
patients should be carefully assessed before making a sulcoplasty with a U-shaped cartilage flap or a wedge
surgical decision. Foals requiring bilateral splints or casts osteotomy should be performed.
usually require intensive nursing and assistance to stand.
This leaves them at risk of developing the usual echnical difficulties performing the medial
complications from external coaptation in addition to imbrication
complications of other body systems. Definition
Excess tension present on the tissues being imbricated
Desmotomyof the SuspensoryLigament
Risk Factors
This procedure has historically been used for correcting
● Excessive synovial fluid
severe fetlock flexural deformities. It has fallen out of favor,
● Lateral release not performed
due to hyperextension of the fetlock joint and the risk of
ischemic necrosis to the distal limb. Subluxation of the
Prevention Remove excess femoropatellar joint fluid prior
proximal interphalangeal joint is also to be expected [11].
to imbrication. Do not perform medial imbrication alone,
without either a sulcoplasty or a lateral release of the
SurgicalTransectionof the PeroniusTertius patella.
Muscle
Flexural deformities of the tarsus are rare. One Quarter Diagnosis Imbrication may be difficult to achieve, such
horse foal with a tarsal angle of 70 degrees was treated that the tension on the tissues is great.
successfully with surgical transection of the peronius
tertius muscle and physical therapy [55]. No complications Treatment Excessive femoropatellar joint fluid may impair
were reported. Embertson [56] used the same surgical medial imbrication so drainage with a needle and syringe
procedure to treat a foal with a tarsal angle of between 70 can help decrease suture tension [59]. Sutures should be
and 90 degrees; however, there was no significant pre-placed then pulled at the same time and each tied
improvement following surgery, so the foal was euthanized tightly.
before physical therapy was undertaken.
Expected outcome This complication should be overcome
with removal of synovial fluid and manipulation of the
LateralReleaseIncisionsand Reinforcement
tissues. If this is still not possible, then a lateral release
of the MedialPatellarSupportStructures;
should be performed [59].
and/orSucloplastywith U-shapedCartilage
Flap;orSucloplastywith WedgeOsteotomy
Questionable holding strength of imbricated tissue
Complications for these two procedures overlap as they are Definition
perfomed in the same region and both procedures may be When imbricating the medial joint capsule there may be
employed. Congenital flexural deformity of the stifle needs concern regarding the holding strength of the tissue.
to be distinguished from developmental and traumatic
causes, as the latter generally need more aggressive surgical Risk factors Unknown
Prevention If the tissue appears friable and unable to Prevention To reduce the risk of the sutures pulling out,
withstand the suturing process, additional measures the tendon of the sartorius can be incorporated into the
should be undertaken. imbrication [60]. Ensure the medial imbrication is
performed with either a sulcoplasty or a lateral release of
Diagnosis When performing the medial imbrication, the the patella to prevent excessive tension of the lateral
suture may tear through the tissue, or the clinician may structures.
feel that there is excess tension on the sutures.
Diagnosis Separation of the sutures and exposure of the
Treatment The tendon of the satorius muscle, with the incision edges
parapatellar fascia, can be used as an anchor when suturing
to the joint capsule and medial patellar ligament [60]. A Treatment Treatment will depend on the reason for the
mesh implant has been used as an imbrication dehiscence. If the wound is infected then culture and
reinforcement, since the holding capacity of friable tissue sensitivities should be obtained, the animal administered
was a concern [59]. Medial imbrication should be performed appropriate antimicrobials, and the wound lavaged and
with either a sulcoplasty or lateral release; never alone. protected from further contamination (bandage/adhesive
protectant). Septic arthritis can develop, so steps should be
Expected outcome No implications to outcome were taken to prevent/treat this complication. Sterile lavage of
noted [59], although it should be noted that mesh implants the wound should still take place, even if not infected.
can provide a nidus for infection, as they are often non-
absorable, so strict sterile surgical technique is pertinent. Expected outcome Dehiscence of the wound is a serious
complication. In Leitch’s paper [61], medial imbrication
Postoperative complication 1: seroma was performed as the sole procedure in four cases. Two of
Definition these cases dehisced and developed septic arthritis,
A collection of serum at the surgical site [9] resulting in euthanasia. It was the results of these cases
that led to the development of the concurrent lateral
Risk factors Large amount of dissection (innate part of the release of the patella.
procedure)
Postoperative complication 3: septic arthritis of the
Prevention No specific recommendations have been femoropatellar joint
made; however, careful tissue handing and meticulous Definition
dissection should be employed so minimal dead space is The invasion of infectious microorganisms, resulting in
created. severe joint inflammation
DiagnosisThe surgical site may feel soft and fluid-filled Risk Factors
when palpated. The incision may leak fluid from the
seroma. ● Repeated surgical procedures
● Mesh implantation
Treatment Generally, no special treatment is required. ● Medial imbrication without lateral release
Expected Seromas usually resolve without

outcome Prevention Performing a lateral release of the patella
treatment [59]. Englebert [60] reports performing the prevents excessive tissue tension on the medial imbrication,
lateral release and medial imbrication through a single helping to prevent dehiscence and probable septic arthritis.
incision with no reported complications.
Diagnosis Symptoms usually include a hot, painful,
Postoperative complication 2: dehiscence swollen joint. The horse will likely become lame and may
have a fever. The incision may dehisce or may be discharging
Definition
fluid. A cell count and culture and sensitivity of the joint
The splitting open of the surgical wound [9]
fluid and wound should be obtained.
Risk factors
Treatment Treatment usually involves lavage of the joint
● Lack of lateral release of the patella [61] with appropriate systemic and intra-articular antibiotic
● Infection therapy.
References 715
Expected outcome The prognosis was grave [60]; however, Treatment There are no published reports of second-
the rate of septic arthritis has decreased since the lateral attempt surgical procedures, possibly due to the financial
release was initiated. burden.
Postoperative complication 4: resluxation Expected outcome One horse with a bilateral grade 3
patellar luxation initially responded well until an episode
Definition
of unrestricted exercise 2 weeks postoperatively. The horse
Patellar luxation that recurs following surgery later redeveloped a grade 3 luxation in one limb and had a
shortened stride with that limb [60]. One of four cases
Risk Factors re-luxated 4 weeks postoperatively and was euthanized [61].
● Uncontrolled exercise soon after surgery [60]

● Larger animal size may play a role lexuralDeformitiesAffecting
F
● Hypoplastic trochlea MultipleRegions
Flexural limb deformities, either congenital or acquired,

Prevention Hand recovery to minimize hindleg exertion,
affecting more than one region are not uncommon in foals
postoperative exercise restriction (stall rest >2 weeks), and
and present a clinical dilemma such that treatment of one
physiotherapy consisting of passive flexion and extension
does not worsen the other. All limbs should be evaluated
of the stifles 2 to 8 times daily [60].
throughout the treatment period to ensure undesirable
changes do not develop. If improvements are not being
Diagnosis Examination of the horse’s gait may reveal made quickly, other treatment options should be sought,
lameness, and manual manipulation of the patella should since flexural limb deformities are more refractory to treat-
reveal the grade of relaxation. ment, the longer they are present.
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718
50
Complicationsof SplintBoneFractures
Timothy B. Lescun BVSc (Hons), MS, PhD, DACVS
Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana
Overview nerves which course along the axial margin of the respec-
tive splint bones.
The splint bones (metacarpal/metatarsal 2 and 4) of the Fractures of the splint bones in the horse are relatively
horse are described as vestigial in nature and are not common and fall into two distinct etiologies: those that
involved in direct axial weight-bearing. However, they do occur as a result of external trauma and those that occur as
contain multiple ligamentous attachments that stabilize a result of overload injury. These fractures can also be
and integrate them into the functions of the metacarpal/ categorized according to their proximal to distal location,
metatarsal region. The soft tissue attachments of the splint whether they are open or closed fractures and whether
bones have been highlighted by Lischer [1] and are com- they involve the articular surface of the head of the splint
prehensively covered elsewhere [2]. The primary attach- bone. Conservative management of splint bone fractures is
ments are the short metacarpal/metatarsal interosseous warranted and may be preferable in some instances.
ligaments, which intimately attach the splint bone to the Surgical treatment options for splint bone fractures depend
third metacarpal/metatarsal bones along the majority of upon the location of the fracture, the presence of concurrent
their axial length. The splint bones also articulate with the pathology, whether the fracture is acute or chronic, and
carpus/tarsus and function in the stability of the carpomet- whether the fracture is open or closed. Complications of
acarpal or tarsometatarsal joints. The stabilization func- splint bone fractures are more common when external
tion is through the ligamentous insertions of joint capsules trauma is involved and particularly if the fracture is
and collateral ligaments and through a small articular sur- open [3].
face at the head of each splint bone that ultimately trans-
fers load to the third metacarpal/metatarsal bone by way of
the interosseous ligament attachments. The second meta- istof ComplicationsAssociated
L
carpal bone has the most substantial articulation at the car-
with SplintBoneFractures
pus, while the fourth metatarsal bone has the smallest
articulation of the splint bones with the tarsus.
Finally, the splint bones also function as an insertion
– Iatrogenic bone, vascular or nerve damage
point for fascial layers of the carpus/tarsus and metacarpus/
– Instability of the proximal fragment
metatarsus, including the superficial carpal/tarsal fascia
and the superficial and deep metacarpal/metatarsal fascia. ● Early postoperative complications
These layers invest intimately with the periosteum of the – Complete fracture of the third metacarpal or metatar-
splint bones. An additional important soft tissue attachment sal bone
of the splint bones, as it relates to distal fractures, is a thin – Local infection, osteomyelitis, bone sequestration and
ligament originating from the distal end of the splint bones, joint sepsis
which inserts diffusely at the level of the distal metacarpal/ ● Late postoperative complications
metatarsal condyles [1, 2]. Other relevant anatomical – Excessive callus formation
relationships with the splint bones include the medial and – Non-union
lateral palmar/plantar metacarpal/metatarsal vessels and – Suspensory desmitis
IntraoperativeComplications reduce the risk of hitting the third metacarpal/metatarsal

in such a way as to create a sharp defect. It seems more
IatrogenicBone,VascularorNerveDamage likely that an injury to the third metacarpal/metatarsal
bone during the initial traumatic event would be a more
Definition Damage caused by the surgeon to the third likely cause in cases of complete third metacarpal/
metacarpal/metatarsal bone, or the palmar/plantar metatarsal fracture following surgery. A common sense
metacarpal/metatarsal vessels or nerves during splint approach to minimizing any iatrogenic damage of
fracture treatment surrounding structures should be taken by the surgeon, as
it is well recognized that a defect in the bone can result in
Risk Factors stress concentration at the site and may predispose to
fracture [6, 7]. The surgeon should be familiar with the
● Proximal fracture location
locations of metacarpal/metatarsal vessels and nerves
● Chronic fractures
during surgery. Making a sufficiently long skin incision
and approach to the splint bone will ensure adequate
Pathogenesis The primary reason that either third
visualization and enable the surgeon to apply sufficient
metacarpal/metatarsal bone or neurovascular injury
retraction and surgical space to manipulate the splint
occurs during surgery is their immediate proximity to the
bones. Clear identification of the dorsal metatarsal artery
splint bones. Damage to the third metacarpal/metatarsal
on the lateral side of the hind limb is essential to avoid
bone may result in a stress concentration effect in this
damage to this vessel.
location of the bone and predispose it to complete
fracture during recovery from anesthesia or in the early
Diagnosis Iatrogenic damage to the third metacarpal/
postoperative period. There is a single report, published
metatarsal bone will be immediately evident upon
in German, that documents damage to the third
inspection of the location of the splint osteotomy. Nerve
metacarpal bone during lateral splint bone amputation
damage is not always detected at surgery but significant
using an oscillating saw [4]. The horse subsequently
hemorrhage from major vessels will be readily apparent
suffered a non-displaced fracture of the palmarolateral
unless a tourniquet or Esmarch bandage has been used
cortex of the third metacarpal bone following a fall and
intraoperatively.
developed ongoing lameness. Internal fixation was
performed of the proximal portion of the splint bone and
Treatment Iatrogenic damage to the third metacarpal/
the adjacent third metacarpal bone fracture to resolve the
metatarsal bone should be debrided with curettes to
lameness. There are also reports in the literature of
smooth the defect. The use of external coaptation during
horses suffering complete third metacarpal/metatarsal
recovery from anesthesia may also be indicated, depending
fractures following surgery for splint bone fractures [3,
on how concerned the surgeon is regarding the damage.
5]. However, it is not possible to determine from these
Significant hemorrhage should be controlled during
reports whether iatrogenic bone damage occurred
surgery.
intraoperatively or whether there was involvement of the
third metacarpal/metatarsal bone in the initial injury.
Expected outcome Superficial damage to the third
Iatrogenic injury to the neurovascular structures, while
metacarpal/metatarsal bone is expected to heal along the
not ideal, is not of major concern for the long-term
same time course as the fractured splint bone, provided
prognosis, but may result in a slightly prolonged surgery
complete fracture of the third metacarpal/metatarsal does
time controlling hemorrhage.
not occur during recovery from anesthesia. There is
sufficient collateral circulation in the limbs to compensate
Prevention The surgeon should actively protect the third for complete loss of one of the metacarpal/metatarsal
metacarpal or third metatarsal bone during splint bone vessels if complete ligation is required [8]. Biaxial ligation
cutting procedures. This can be achieved using a thin or thrombosis of metacarpal/metatarsal vessels is more
metallic guard placed between the splint bone and cannon likely to result in distal limb necrosis. While neurectomy of
bone, such as a scalpel handle or malleable ribbon retractor, the palmar/plantar nerves can also result in distal limb
at the site of the osteotomy. An oscillating saw allows for a necrosis in some cases [9], the effects of damage to the
more controlled cut than a chisel or gouge, but will generate palmar/plantar metacarpal/metatarsal nerves have not
thermal injury to the cut surface if sufficient cooling fluid been evaluated. Clinical experience suggests that damage
and time are not used to perform the cut. Utilizing a to one of these nerves is unlikely to have lasting negative
45-degree or lower proximal to distal angle of cut will also consequences.
720 Complications of Splint one Fractures
Instabilityof the ProximalFragment engages the remaining proximal fragment and the third
metacarpal/metatarsal bone with screws to replace the lost
Definition Excessive movement of the proximal portion of
lever arm that occurs when significant distal ligament
the splint bone following disruption of distal attachments
attachments of the splint bone are removed.
As a guide, careful evaluation of stability of the proximal
Risk Factors
fragment should be performed whenever more than two-
● Disruption of proximal ligamentous attachments thirds of the splint length is removed. This is least critical
● Fracture of the proximal third of the splint bone for the fourth metatarsal bone as its complete resection is
● Extensive resection of the proximal splint bone possible. Intra-articular fractures, which course into the
joint leaving a small triangular shaped proximal fragment
Pathogenesis The splint bone soft tissue attachments on the palmar/plantar aspect of the proximal splint bone,
described earlier, if disrupted, can result in displacement are the most difficult to stabilize and may be the most likely
of the proximal portion of the bone with the rotation to displace due to an absence of metacarpal/metatarsal
centered on the articulation with the carpus/tarsus. The interosseous ligament attachment. Interestingly, none of
length of attachment of the splint bones to the third the reports of conservatively managed proximal splint
metacarpal/metatarsal bone acts as a strong lever arm that bone fractures contain cases in which proximal fragment
resists the rotational forces of joint capsule, collateral displacement occurred [3, 5, 12, 13].
ligament and carpal/tarsal fascia in the proximal region of
the bone, as well as the load transfer from carpal/tarsal Diagnosis Gross instability of the proximal fragment is
bone articulation. A greater length of disruption of the diagnosed radiographically with proximal displacement
axial splint bone attachment to the third metacarpal/ and rotation combined with subluxation of the head of the
metatarsal bone from either injury, infection or extensive splint bone at the articulating surface with the carpus/
surgical resection will increase the likelihood of this tarsus. Instability without displacement may result in
complication. A complication with similar origins is excessive bone proliferation at the distal extent of the
instability of the proximal fragment without displacement proximal fragment, osteoarthritis of the carpometacarpal/
as a cause of ongoing lameness. Reports of proximal splint tarsometatarsal joint and lameness.
bone fracture in the horse contain only individual cases
where instability and displacement of the proximal Treatment Displacement of the proximal fragment of the
fragment occurred [3, 10, 11]. Jackson et al. described a splint bone is treated with internal fixation to the third
single open comminuted proximal splint fracture that was metacarpal/metatarsal bone using a bone plate and screws.
managed with resection of the distal bone segment and the This plate needs to be contoured over the step between the
distal aspect of the proximal segment of the splint bone in splint and cannon bone and so some surgeons prefer the
which displacement of the proximal fragment resulted in use of a reconstruction plate, designed for easier
ongoing lameness [3]. contouring [10]. Other options include 3.5 mm narrow
LCP, LC-DCP, DCP, or semi tubular plates. It is not
Prevention Fractures at risk of instability of the proximal recommended to use screw fixation of the splint directly to
fragment can be managed in one of two ways, in an effort the cannon bone alone as a method of acute stabilization,
to prevent this complication. First, if at the time of as this does not provide sufficient stability to maintain the
diagnosis there is no displacement evident radiographically, position of the proximal splint fragment and has previously
a conservative treatment approach is warranted, even in been reported to result in a poor outcome with implant and
fractures that are open or comminuted. Second, if surgical bone failure as possible further complications [10, 11].
removal of a large distal fragment with associated soft However, screw placement between the proximal fragment
tissue attachments is performed, the surgeon can assess and the cannon bone has been used in cases of suspected
proximal fragment stability at the time of surgery using instability with secondary excessive exostosis formation at
digital manipulation and apply a plate to stabilize the the distal aspect of the proximal splint [12]. A 4th metatarsal
proximal fragment and prevent further instability or bone can be removed completely if displacement of the
displacement. In a report by Peterson et al., 6 out of 11 of proximal fragment occurs [14].
the fractures stabilized using bone screws alone failed from
either bone failure around the screw or screw pullout. This Expected outcome Horses can return to their intended use
was in contrast to 11 fractures stabilized using plates in the if a displaced proximal fragment is corrected and stabilized.
same report, in which all fractures remained stable and Horses are likely to remain lame if the displaced position of
only 2 cases had partial screw pull out [10]. The plate the proximal fragment is not corrected. Removal of the 4th
metatarsal bone following displacement is expected to in the case of splint exostoses). Recovery from general
result in a good outcome, unless other complications occur anesthesia can place stress on bones that exceed their
such as sepsis or luxation of the tarsometatarsal joint [2, 3, loading limit and result in acute fracture of healthy bones
12, 14]. in rare cases [15]. The additional disruption of normal
attachments of the splint bone to the third metacarpal/
metatarsal bone as a result of the initial splint bone fracture
EarlyPostoperativeComplications and/or surgery to treat it, can result in stress concentration
at these sites of disruption. Iatrogenic damage to the third
CompleteFractureof MC3/MT3 metacarpal/metatarsal, as stated previously, can have a
similar effect. The presence of either a pre-existing cortical
Definition A complete fracture of the third metacarpal/
fracture or stress concentration effects from splint bone
metatarsal bone at a location close to the initial splint bone
disruption can result in a complete third metacarpal/
fracture
metatarsal fracture if the loading limit of the weakened
bone is exceeded. Recovery from general anesthesia or
Risk Factors
other high loading use of the limb with the fractured splint
● Traumatic fracture of the proximal or middle thirds of bone (such as kicking, jumping, bucking or running) can
the splint bone result in the load necessary to cause a complete third
● Recovery from general anesthesia metacarpal/metatarsal fracture. Undetected, non-displaced
cortical fracture of the third metacarpal/metatarsal can
Pathogenesis While the splint bones are not weight- occur in splint bone fractures that are the result of a high
bearing in function, they contribute to the distribution of energy injury (Figure 50.1).
stresses through the third metacarpal/metatarsal bones as While the risks may be low, there are two reports docu-
a result of their soft tissue attachments (bone attachment menting complete third metacarpal/metatarsal fracture
(a) (b)
Figure50.1 (a) Dorsal 45-degree lateral-plantaromedial oblique radiographic projection of the left proximal metatarsal region in a
horse showing an open comminuted fracture of the second metatarsal bone. The presence of multiple fracture lines in the splint bone
superimposed on the third metatarsal bone make examination of the third metatarsal bone cortices difficult. (b) Lateral-medial
radiographic projection of the left proximal metatarsal region shows the comminuted second metatarsal bone fracture with no visible
fracture line in the plantar cortex of the third metatarsal bone. This horse subsequently suffered a complete fracture of the third
metatarsal bone. Source: Timothy Lescun.
during recovery from anesthesia in two horses with splint in addition to the typical convalescence after splint bone
bone fracture undergoing surgical treatment [3, 5]. Three fracture of the proximal or middle third of the bone.
other horses, identified in these reports as having third
metacarpal/metatarsal fissures or damage identified con- Treatment A complete displaced third metacarpal/
current with a splint bone fracture, were treated conserva- metatarsal fracture should be treated using stabilization
tively. All three of these horses survived and were used as with internal fixation. In cases where the fracture is open,
intended. The number of splint bone fracture cases in these this reduces the prognosis for a successful outcome and
reports totaled 153, with 106 having a proximal or middle may warrant the use of transfixation casting to stabilize the
third splint location, where external trauma is typically fracture and manage the open wound,
involved in the etiology. The five reported cases were the
Expected outcome Significant soft tissue injury results
only ones recognized; however, there are likely to be splint
when a complete fracture of the third metacarpal/
bone fractures with third metacarpal/metatarsal involve-
metatarsal bone occurs during anesthetic recovery;
ment that also go unrecognized, even through the healing
primarily because the horse continues to use the limb
process. The author has observed a complete third metatar-
during attempts to stand. Humane euthanasia has been the
sal fracture 10 days following diagnosis of an open com-
result in the cases reported and in this author’s experience.
minuted proximal second metatarsal bone fracture. The
Non-displaced fractures, that are identified either initially
horse was excessively active despite being confined to a
or during the course of healing, are expected to have a good
stall and fractured following an episode of bucking in the
outcome provided displacement of the fracture is avoided.
stall. Complete third metatarsal bone fractures have also
been observed during anesthetic recovery following
segmental ostectomy of the fourth metatarsal bone in LocalInfection,Osteomyelitis,Bone
horses used for a bone healing augmentation study (J.F. Sequestrationand JointSepsis
Hawkins, personal communication).
Definition The presence and persistence of bacteria in
tissues associated with a splint bone fracture
Prevention Surgeons should only treat cases of splint bone
fracture in the acute phase of injury under general Risk Factors
anesthesia after consideration of all of the risk factors.
Following a 2–3-week period of conservative management ● Open fracture
and repeat radiographs, the veterinarian may identify cases ● Comminuted fracture (for bone sequestration)
in which third metacarpal/third metacarpal involvement is ● Proximal fracture involving the articular surface (for
present (Figure 50.2). In those cases, in which third joint sepsis)
metacarpal/metatarsal fracture is only identified at surgery, ● Immunocompromised patient
application of a full limb cast and assistance during
Pathogenesis The presence of an open wound and the lack
anesthetic recovery should be instituted. Strict stall rest,
of soft tissue covering the splint bone results in bacterial
support bandaging and even application of a full limb
contamination either from skin flora or the environment.
splint in horses that display more lameness than expected
Exposed bone is an attractive surface for bacterial adhesion
for the type of splint bone fracture present should be
and the establishment of local infection. The formation of
instituted in the acute phase of the injury.
a bacterial biofilm on the bone surface favors persistence of
infection through mechanisms protecting the bacteria
Diagnosis Diagnosis of a complete third metacarpal/ within the biofilm from local immunity and antimicrobial
metatarsal fracture is straightforward when they become penetration.
displaced. In the rare instance of a non-displaced fracture, The formation of a sequestrum is associated with a loss
a complete series of radiographs should be performed to of blood supply to a segment of bone and the presence of
identify the fracture. bacterial infection. Trauma to the splint bone sufficient to
result in a comminuted fracture can result in separation of
Monitoring Non-displaced fractures of the third bone fragments from their periosteal blood supply.
metacarpal/metatarsal bone should be monitored closely Extension of infection from an open wound in which a
for healing and occurrence of secondary complications fracture line communicates with the articular surface of
such as sequestration or osteomyelitis. Healing progress the splint bone can result in joint sepsis. In rare cases, a
will be parallel with the fractured splint bone; however, wound directly communicating with the joint at the head
return to exercise should be delayed for 1 or 2 months extra of the splint bone may occur and result in joint sepsis.
(a) (b) (c)
(d) (e)
Figure50.2 Dorsal 60-degree lateral-plantaromedial oblique radiographic projections of the proximal left metatarsus. (a) Initial
diagnosis of an acute comminuted fracture of the fourth metatarsal bone. (b) 2 weeks following diagnosis. (c) 4 weeks following
diagnosis. (d) 6 weeks following diagnosis. (e) 10 weeks following diagnosis. A lucent fracture line is evident in the plantarolateral
aspect of the third metatarsal bone by 2 weeks following diagnosis of the splint bone fracture that was not visible at the time of the
original injury. Source: Images courtesy of Jake Jensen.
Prevention Open fractures of the splint bone should be infection or prevent more serious complications such as
treated with wound debridement and lavage, including fulminant osteomyelitis and joint sepsis. Prophylactic use
removal of any loose bone fragments to prevent of local antimicrobials is also warranted when articular
sequestration. Exposed bone surfaces should be curetted communication of the splint bone fracture is present.
to remove adherent bacteria. The goal is to reduce the Direct injection of antimicrobials into the joint involved
number of bacteria within the wound environment to or the use of regional limb perfusion techniques have
prevent established infection. Systemic, broad-spectrum both been shown to achieve high synovial tissue
antimicrobial coverage is appropriate to treat local concentrations of antimicrobials [16, 17].
Diagnosis Local infection of an open splint bone fracture Treatment Treatment of local infection, osteomyelitis and
is characterized by purulent drainage, swelling, heat and bone sequestration is based on sound surgical principles
pain on palpation of the wound area. Lameness may be a of debridement of affected tissues combined with
feature but is not always present, particularly in chronic appropriate antimicrobial and anti-inflammatory therapy.
cases where splint bone stability may have returned. The presence of a local infection involving primarily the
Bacterial culture and sensitivity testing can be performed soft tissues surrounding the fracture may respond to
to identify specific bacterial species causing infection and medical therapy alone; however, osteomyelitis and bone
to direct appropriate antimicrobial therapy. The most sequestration are best managed surgically. Similarly, joint
commonly reported bacterial isolates from wounds sepsis requires either broad-spectrum antimicrobial
involving a splint bone fracture have been Escherichia coli, therapy directed toward the most likely bacterial species
Streptococcus sp. and Staphylococcus sp. [10, 12]. involved or a more targeted approach based on culture and
Radiographs of the splint bone fracture and the adjacent susceptibility results. Local antimicrobial delivery
third metacarpus/metatarsus are required to diagnose methods such as direct joint injection or regional limb
osteomyelitis with or without sequestrum formation. perfusion have the advantage over systemic therapy of
Radiographic changes include osteolysis of the affected achieving higher tissue and joint concentrations with less
bone with irregular margins and a surrounding zone of risk for systemic side effects. Joint lavage through needles
sclerosis in chronic cases. A sequestrum is visible can also be used to reduce bacterial numbers and
radiographically separated from the parent bone, typically inflammatory mediators within the synovial environment.
slightly more radiopaque than surrounding bone and One of the biggest challenges in treating splint bone
located within an involucrum formed by the parent bone fractures is the proximal fracture that is open, articular
(Figure 50.3). and potentially unstable. Internal fixation may be required
Ultrasonography may be useful in certain circumstances, if gross instability is present; however, delaying surgery
but typically is not necessary unless there is significant until local infection is resolved can reduce the risk of
involvement of soft tissues or a sequestrum cannot be complications such as implant associated infection or
identified radiographically, even though there is a high displacement of the proximal fragment if internal fixation
degree of suspicion of one being present. Joint sepsis can is not employed.
be hard to confirm through synovial fluid analysis, since
obtaining a sample from the joints involved can be Expected outcome The expected outcome in cases of local
challenging, particularly the tarsometatarsal joint, when infection, osteomyelitis or bone sequestration associated
open communication with the fracture and wound may be with an open splint bone fracture, can be good with
present. The presence of a communicating fracture line, appropriate treatment. However, open fractures can be
lameness of greater severity than expected for the diagnosed expected to take longer to heal and have a greater chance of
splint bone fracture, or early radiographic findings such as causing chronic lameness, independent of the presence of
lysis involving the associated joint, can be used to make a exuberant callus [3]. Excellent results were reported by
presumptive diagnosis of joint sepsis associated with an Jenson et al., who performed segmental ostectomy in
articular splint bone fracture. combination with wound debridement in 17 cases of splint
bone fracture [13]. Fifteen of those cases were open
Monitoring Monitoring infections of local soft tissues, fractures and 9 had sequestered bone fragments with
bone and joint involves periodic reassessment of the chronic draining tracts. All horses returned to their
findings used to diagnose these complications. The previous use and cosmetically were reported as good or
frequency of reassessment depends on the diagnostic excellent. Jackson et al. reported that the presence of a
technique. Clinical findings should be assessed daily, sequestrum associated with open splint bone fractures did
radiographs may be repeated at 2-week intervals if local alter the prognosis with all affected horses returning to
debridement is not performed, and intra- or their intended use [3], and Sherlock and Archer found that
postoperatively for cases in which surgical debridement sequestrum formation had no effect on outcome in open
is used to treat osteomyelitis or bone sequestration. proximal fourth metatarsal fractures [5]. Joint sepsis as a
Ultrasonography used to evaluate and monitor the soft result of fracture communication with the carpometacarpal
tissues may provide useful information on response to or tarsometatarsal joint, while uncommon, has a fair
treatment within 48–72 hours. While culture and prognosis for survival and a poor prognosis for return to
susceptibility testing are not commonly repeated, in function [5, 11, 14]. The reports document individual cases
cases that are unresponsive to therapy, repeating these of joint sepsis resulting from open proximal fractures that
tests may uncover bacterial antimicrobial resistance that were either chronically lame or euthanized as a result of
was not apparent initially. the infection.
(a) (b)
(c) (d)
Figure50.3 (a) Dorsal 45-degree lateral-palmaromedial oblique radiographic projection of the right metacarpus in a horse showing
a splint bone fracture with delayed healing and sequestrum formation. (b) The dorsopalmar radiographic projection shows a distinct
sequestrum of bone surrounded by a zone of lucency and abundant periosteal callus formation. (c) Intraoperative photograph of the
affected region of splint bone and sequestrum exposed. The horse had a draining tract at the time of presentation and was treated
surgically using a segmental ostectomy approach. (d) Intraoperative photograph of the affected region of the splint bone following
sequestrectomy and segmental ostectomy with local debridement and removal of overlying fibrous tissue. The area was packed with
antimicrobial impregnated calcium sulfate prior to wound closure. Source: Timothy Lescun.
LatePostoperativeComplications Risk Factors
● Open fractures
ExcessiveCallusFormation
● Fracture or splint bone instability
Definition The formation of proliferative new bone
associated with a splint bone fracture or at the distal end of Pathogenesis Callus formation at the fracture site of a
an amputated splint bone that is detrimental to the splint bone or at the distal end of an amputated splint bone
appearance and/or function of the limb is expected during the healing process and results from
periosteal tissue disruption. Bone forming cells within the following fracture healing is sufficient to reduce the size
periosteal lining are stimulated to produce new bone and importance of an excessive callus formation.
following separation from the underlying bone. Ongoing
instability and inflammation results in continued stimulus Treatment Conservative approaches to reducing excessive
for the formation of periosteal new bone. However, callus formation can be used, including local installation of
excessive callus formation that interferes with appearance corticosteroids, counter pressure bandaging, and stall
or function of the limb is not easily predicted from case to confinement. However, surgical treatment with removal of
case. It is intuitive that motion at the fracture or amputation excessive callus and the distal segment of splint bone has
site could result in excessive callus, but excessive motion frequently been used to address this undesired complication
will contribute to a non-union and the formation of fibrous of splint bone fractures. Removal of the overlying
callus only at the fracture site. Chronic inflammation, in periosteum and surrounding fibrous tissue is also
the form of osteomyelitis and/or sequestrum formation, recommended to minimize recurrence postoperatively.
can be risk factors for the formation of excessive callus There is a report of using screw fixation near the proximal
associated with a splint bone fracture. Open fractures are end of the proximal splint bone in cases where excessive
more likely to develop excessive callus; however, it is not callus had formed at the distal extent of an excised splint
clear if this is due to the greater likelihood of local infection following closed proximal fractures. These 2 horses were
or the greater energy and tissue disruption that may be reported sound at 1 year follow up but with no mention of
associated with open fractures. the subsequent size of the callus [12]. Stabilization using
plates and screws contoured to the amputated splint bone
Prevention Reducing the factors that contribute to excessive and cannon bone should more effectively stabilize the
callus formation, including infection, inflammation and splint bone and reduce the excessive callus formation when
instability, may reduce the likelihood of excessive callus. necessary in proximal fractures [10].
However, the initiating trauma often dictates how much
bone injury, periosteal separation and damage, and callus Expected outcome Over time, the callus can remodel and
formation will ensue. One approach to reducing excessive become less of a cosmetic concern. In cases where the
callus formation has been to perform amputation of the callus appears excessive, it is often not associated with
distal segment of fractured splint bone with complete lameness. Interestingly, while occasional cases of chronic
removal of any overlying periosteum and fibrous tissue. lameness have been reported with the formation of
There is some evidence that excessive callus formation may excessive callus, no correlation between radiographic
be less common in conservatively treated fractures [3, 5], or findings of excessive callus and outcome were found by
in fractures treated by segmental ostectomy where cosmetics Jackson et al., despite its presence in 37% of horses followed
were reported to be good to excellent [13]. radiographically [3]. Other studies have reported lameness
associated with excessive callus formation [5, 10, 12]. If
Diagnosis Excessive callus formation is relatively lameness is attributable to the callus and surgical removal
straightforward to diagnose. The visual appearance of the is performed, often close apposition or adhesion to the
limb can be used to make a presumptive diagnosis. suspensory ligament may be observed that links the callus
Radiographs are used to document the amount of callus formation and the presence of lameness [5]. A good
present, its location relative to adjacent structures, and outcome is expected in the majority of cases.
how organized it is. Deciding whether the callus is excessive
and causing a clinical problem can be more challenging
and may require more detailed imaging. Callus that Non-union
impinges on or is adhered to the suspensory ligament is
Definition Failure of complete bone healing following a
likely to cause lameness. Ultrasonography of the suspensory
splint bone fracture with cessation of ongoing fracture
ligament, the splint bone and its attachments can be used
healing activity
to document the proximity of bony callus to the suspensory
ligament and help to decide whether the callus is a likely
Risk Factors
cause of lameness. Magnetic resonance imaging can also
be used in more challenging cases to assess suspensory ● Fracture instability
ligament impingement. ● Infection
● Fracture of the distal third of the splint bone
Monitoring Visual and radiographic monitoring is
sufficient to follow the clinical progress of excessive callus. Pathogenesis Distal splint bone fractures are more likely
Often the remodeling process that occurs over the months to form an atrophic non-union, particularly when horses
are not allowed sufficient rest for healing following the can be with either removal of just the affected segment of
fracture. Continued excessive motion of the separated bone, removal of the entire distal splint bone, or
segments in a distal splint bone fracture overwhelms the debridement and stabilization if necessary. Non-union of
bone healing capacity, particularly in the thinnest segment the middle or proximal portion of the splint bone has
of the bone, leading to the formation of a fibrous union been reported in multiple studies following conservative
with little to no bone proliferation. Verschooten et al. treatment [3, 10, 13]. Jackson et al. reported that non-
reported 2 out of 24 distal splint bone fractures with long- union accounted for 3% of cases but did not influence
term follow up as having a non-union. These were not a long-term outcome [3]. Jenson et al. reported 2 out of 17
cause of pain or lameness [18]. Middle and proximal splint horses with closed non-healing fractures with excessive
bone fractures are more likely to form hypertrophic non- callus formation that were successfully treated using a
union, usually as a result of ongoing local infection. segmental ostectomy technique [13].
Prevention Prevention of non-union following splint bone

fracture is best achieved by appropriate initial management SuspensoryDesmitis
of splint fractures, including 4–6 weeks of rest while initial
Definition Inflammation of the suspensory ligament
bone healing progresses to reestablish stability at the
resulting from a splint bone fracture or associated with a
fracture site. Initial management of open fractures should
splint bone fracture
include local debridement and lavage of the fracture site to
prevent local infection from becoming established.
Risk Factors
Stabilization of unstable proximal fractures may be
necessary for bone healing to progress in some cases. ● Excessive callus on the axial aspect of the splint bone
● Lack of fitness for high-intensity exercise in racehorses
Diagnosis Radiographs taken 6–12 months following
fracture are used to diagnose a non-union. In distal Pathogenesis There are two distinct mechanisms by which
fractures, very little bone proliferation will be present at the suspensory desmitis can occur in cases of splint bone
bone ends and a variable-sized gap without bone bridging fracture. The first is as a concurrent injury in cases of distal
will be observed. In proximal and middle segment fractures, splint bone fracture. Hyperextension of the fetlock places a
proliferative bone may be present around each of the bone high degree of strain on the suspensory ligament and
ends as well as sclerosis adjacent to the fracture gap. Signs tension on the distal fibrous attachment of the splint bones.
of local bone infection may also be present, including areas Avulsion fracture of the distal splint bone, often at its
of irregular lucency and chronic draining tracts in the soft thinnest location, is likely to occur during fetlock
tissues. hyperextension. Tearing of the suspensory ligament is also
likely to occur at this point of the stride as an overload
Monitoring Distal splint bone non-unions do not require
injury. Speculation exists as to whether these two injuries
monitoring and are often an incidental finding. A non-
are related by more than fetlock hyperextension and
union of the middle and proximal bone segments will
independent overload injuries. It has been proposed that
require intervention and repeated radiographic monitoring
outward or abaxial pressure from the suspensory ligament
to ensure future healing.
on the splint bone, particularly if the suspensory ligament
Treatment Distal splint bone non-unions can be treated by is thickened following injury, may be an additional factor
removal of the distal segment of bone. Middle and proximal contributing to fracture [18–20]. Lack of fitness going into
segment non-unions can be treated similarly with removal high-intensity exercise demands may also contribute to
of the distal bone segment. Alternatively, a segmental distal splint bone fracture and concurrent suspensory
ostectomy may be performed to stimulate the healing ligament injury [21].
process following removal of all infected bone tissue and The second mechanism for suspensory desmitis is as a
the segment of non-union [13. result of impingement by or involvement of the suspensory
ligament at the fracture callus as it forms. Chronic inflam-
Expected outcome Distal splint bone non-unions are mation can result in ongoing involvement of the suspen-
rarely a cause of lameness and are expected to be sory ligament during healing, with fibrous attachment and
asymptomatic in the majority of cases. Surgical removal in some cases progression to ligament mineralization [13].
of the distal segment is expected to have an excellent This mechanism is considered a true complication of splint
outcome. Middle and proximal splint bone segment non- bone fracture, whereas the occurrence of suspensory
unions are expected to have a good outcome with desmitis concurrently with distal splint bone fractures is
resolution of the underlying cause of the non-union. This not.
Prevention Methods of reducing ongoing inflammation Treatment Treatment of primary suspensory desmitis,
associated with the healing process of a splint bone concurrent with a distal splint bone fracture, involves
fracture, such as appropriate debridement and wound sufficient rest from athletic activities to allow appropriate
management for open fractures, stall confinement and ligament healing. Additional treatments such as
bandaging, and appropriate use of anti-inflammatory extracorporeal shock wave therapy or the intra-lesional
and antimicrobial drugs, should be employed in an effort injection of platelet rich plasma may reduce the re-injury
to minimize excessive callus and ongoing local rate in these cases. Treatment of an impinging or adhered
inflammation. Removal or realignment of fracture fracture callus is effectively achieved through splint bone
fragments on the axial surface of the splint bone that amputation from a site proximal to the fracture. For a
have displaced toward the suspensory ligament may also proximal fracture, where amputation at that level may
be warranted in acute fractures. For middle and distal risk creating an unstable proximal fragment, surgical
fractures, a part of the justification of treating these reduction of the callus on the axial aspect of the splint
fractures with splint bone amputation has been as a bone with breakdown of adhesions may successful [22].
preventative measure against future suspensory Alternatively, horses with suspensory desmitis associated
impingement by the fracture callus. with a fracture callus may improve with extended rest
time to allow both the fracture callus to remodel and the
Diagnosis Suspensory desmitis associated with a splint suspensory ligament to heal. Intra-lesional corticosteroids
bone fracture is most easily diagnosed using ultrasonography. may be employed to reduce local inflammation and
A complete examination of the suspensory ligament is provide pain relief.
warranted whenever a splint bone fracture is diagnosed. In
one study, ultrasonography showed evidence of suspensory Expected outcome The major drawback of this
damage in 2 horses and in an additional 2 horses damage complication is the prolonged convalescence that it can
was identified at surgery (a total of 8% of the study create in some cases. Additional time following surgical
population) following proximal fourth metatarsal bone amputation is required for rehabilitation, particularly if
fracture [5]. In another study, ultrasonography identified there is ligament damage that remains to heal. Despite
suspensory desmitis in 16% of horses (12 distal, 2 middle, this, the expected outcome is good, although cases are
and 2 proximal) with splint bone fractures [3]. Sometimes reported in which chronic lameness was the long-term
adhesions or impingement of the suspensory ligament is outcome when suspensory desmitis was diagnosed. For
suspected from palpation but may require surgery to confirm horses with concurrent suspensory desmitis and distal
the extent of involvement of the suspensory ligament. splint bone fracture, the suspensory desmitis is expected
Radiography and ultrasonography can be utilized to assess to be the limiting factor in outcome for these cases. For
the axial aspect of the splint bone following a fracture, to distal splint bone fractures, early reports found that
specifically determine the likelihood of suspensory ligament between 50 and 70% of cases had concurrent suspensory
damage. desmitis [18, 29], while up to 74% of these cases returned
to their previous level of racing performance [19]. In the
Monitoring Repeat ultrasonographic examinations are study by Jackson et al., examining 100 splint bone
performed to monitor healing of concurrent suspensory fractures, there was a tendency for horses diagnosed with
desmitis. In cases of adhesion and impingement, whether suspensory desmitis to have a poorer outcome than those
treated conservatively or surgically, monitoring is best without suspensory desmitis. Five out of 16 horses
achieved through observation of lameness, palpation of the diagnosed with suspensory desmitis were either
splint callus or distal end of the amputated splint bone and chronically lame or euthanized due to the persistence of
the suspensory ligament. suspensory desmitis [3].
References
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importance of soft tissue attachments. Equine Vet. Educ. Saunders.
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and metatarsal bones. In: Equine Surgery, 4e (ed J.A. 1992–2001. Equine Vet. Educ. 19 (6): 329–335.
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730
51
Complicationsof Craniomaxillaryand MandibleFractures

Timothy B. Lescun BVSc (Hons), MS, PhD, DACVS
Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana
Overview emerging from the skull, while the vestibulocochlear nerve

lies just caudal to the facial nerve without being directly
The head is a frequent site of injury in the horse. The rostral within the pouch. The mandibular nerve runs dorsally and
jaw (mandible or maxilla), the orbit and the sinuses are the rostrally in the lateral compartment. The internal carotid
areas of the head where fractures occur commonly occur. (medial compartment), external carotid and maxillary
Fractures involving the caudal mandible, cranium and spe- arteries (lateral compartment) also lie immediately beneath
cific locations such as the paracondylar process, the basis- the mucosa of the guttural pouch [1, 2].
phenoid/basioccipital bone, hyoid apparatus and nuchal The hypsodont dentition of the horse allows it to
crest, are less common. Similar to other species, the horse masticate on abrasive forage. There is continual wear of the
has an excellent blood supply to the head which is advanta- teeth at a rate of approximately 2–3 mm per year, which is
geous for healing. Epistaxis is a common clinical finding balanced by the almost lifelong eruption of teeth that
associated with fractures involving the sinuses or bony occurs following their formation [1, 3]. This results in age-
orbit. In addition, fractures of the head are often open due related changes in the size and location of the teeth within
to sparse soft tissue coverage of bones, including within the the jaw and in their relationship to the sinus cavities of the
oral and nasal cavities. These factors contribute to compli- head. Tooth anchorage is important for interdental wiring
cations encountered when managing these fractures. techniques and so age and tooth stability are factors to be
Unique features of the equine head, which are relevant considered in these cases. Continual tooth eruption is also
to complications associated with these fractures, include important in the long-term management of horses with
the guttural pouches and the presence of hypsodont teeth jaw fractures that result in malocclusion of teeth.
which erupt throughout life. The guttural pouch is an Malocclusion or tooth loss requires a more regular dental
anatomical feature of the horse’s head which has clinical care schedule to avoid overgrowth of a tooth that does not
implications due to its location and close association with incur appropriate wear from an opposing tooth surface.
major nerves and vessels. The pouches are mucosa-lined Detailed anatomical descriptions of the equine head are
diverticula of the auditory tube. The stylohyoid bones available [1]; however, one relatively recent development
divide each pouch into medial and lateral compartments. in equine practice that has changed many clinicians’
Each pouch is closely associated with the pharynx and understanding and appreciation of regional anatomy, is the
upper esophagus ventrally, the ventral straight muscles of introduction of slice imaging modalities. Computed
the head and the opposite pouch medially, the parotid and tomography and magnetic resonance imaging, and the
mandibular glands, and the pterygoid muscles laterally, ability to perform digital segmentation of specific tissue
and the atlas and base of the skull dorsally [1]. Clinically densities and three-dimensional reconstructions for
important nerves, which lie immediately beneath the additional analysis and perspective, have improved many
mucosa within the medial compartment of the guttural aspects of both diagnosis and treatment of head injuries [4].
pouches, include the glossopharyngeal, vagus, accessory, Radiography continues to be used for imaging horses with
hypoglossal, and the sympathetic trunk continuation of suspected fractures of the head region; however, computed
the cranial cervical ganglion. The facial nerve lies adjacent tomography has been shown to be superior for a complete
to the caudodorsal aspect of the lateral compartment after assessment [5–7].
L
with Craniomaxillaryand Mandible
Fractures

– Dental malocclusion
– Hemorrhage
● Early postoperative complications
– Poor mastication
– Infection and bone sequestration
– Implant failure
– Poor cosmesis
I ntraoperativeand Technical
Figure51.1 Latero-lateral radiograph of the rostral aspect of
Complications the head of a horse with a bilateral fracture of the mandible
through the interdental space. The oblique orientation of the
DentalMalocclusion fracture is typical and note the sharp bone edges displaced into
the mouth and ventrally under the skin. There is malalignment
Definition A failure of corresponding mandibular and of the lower incisor teeth, despite the cheek teeth being in full
maxillary teeth to oppose each other at the occlusal surface occlusal contact. Source: Timothy Lescun.
resulting in abnormal or absent tooth wear
fracture healing in the short term or the horse’s ability to
Risk Factors masticate in the long term, but addressing the resulting
abnormal tooth wear will be required during dental floating
● Comminuted fractures procedures in the future.
● Bilateral fractures
● Tooth loss
Pathogenesis Fractures of the jaw are typically a result of

traumatic injury in the horse. High energy injuries, such as
a kick or collision, may result in bone comminution at the
fracture site. Good fracture reduction and dental alignment
is more challenging when there is missing or unstable bone
fragments associated with the fracture. Bilateral fractures
of the maxilla or mandible are inherently less stable than
unilateral fractures (Figure 51.1). Tooth loss due to the
injury results in a missing occlusal surface for proper tooth
wear in the future.
Prevention Efforts must be made by the surgeon to

re-establish bone and dental alignment at the time of
fracture repair. Many cases of simple fracture involving the
incisors are adequately aligned and stabilized using intra-
Figure51.2 Laterolateral radiograph of the rostral aspect of
oral wiring techniques. These techniques have been well
the head of the horse in Figure 51.1, 10 weeks following
described previously [8]. Additional fixation methods, fracture repair. Insufficient stabilization of the fracture was
such as intra-oral splints or even external skeletal fixators, achieved at the time of the initial surgery. There is
should be added to the repair if alignment or stability is malalignment of the incisor teeth and a wide fracture gap. The
fracture is stable at this time and healing well through
inadequate with intra-oral wiring alone (Figure 51.2) [8–
secondary callus formation and the malalignment is not a cause
10]. Minor malocclusion of teeth is unlikely to affect of clinical concern. Source: Timothy Lescun.
732 Complications of Craniomaxillary and andiele Fractures
Diagnosis The diagnosis of malocclusion is made at the of the sinuses [13] or the bony orbit, particularly the
time of surgery through a visual assessment of the dental zygomatic process of the temporal bone [14]. Hemorrhage
arcades and their contact through the normal range of as a complication during surgery can be the result of
motion of the jaw. In cases where malocclusion develops manipulation of fractured bone pieces in the vicinity of
postoperatively during the healing process due to a change major blood vessels and these risks will vary with fracture
in fixation stability and fracture alignment, a similar configuration.
approach to diagnosis is made through simple postoperative
monitoring of incisor alignment. Prevention A thorough understanding and appreciation
for the anatomical relationships that exist in the head
Treatment Malocclusion may be managed through regular region of the horse is the single-most important preventative
monitoring and dental floating to avoid excessive measure that can be taken by the surgeon prior to treating
overgrowth of teeth not sustaining normal amounts of fractures of the head. Isolation and protection of specific
wear. In cases where fracture fixation fails and malocclusion vessels may be necessary to avoid their damage. Local
is severe, revision surgery should be performed with application of phenylephrine to mucosal surfaces of the
additional fracture fixation methods to re-stabilize the sinus to cause vasoconstriction and minimize hemorrhage
dental arcade involved [8, 11]. Permanent loss of one or may be considered in cases where significant hemorrhage
more teeth requires ongoing management through regular has occurred; however, the application of local pressure is
dental floating. usually sufficient in most cases to control or prevent
significant blood loss. The preoperative planning for a case
where blood losses are expected to be significant should
Expected outcome Malocclusion can be successfully
include identification of a potential blood donor.
managed over the long term with routine dental care. Only
severe malocclusion is likely to result in significant
Diagnosis The diagnosis of hemorrhage is not the
detrimental effects on mastication. The primary concern of
challenge for the surgeon. The estimation of blood loss
owners is often a cosmetic appearance of the teeth.
amount and its effect on the patient is critical for
Fortunately, the horse’s lips will make mild malocclusion
appropriate case management. Monitoring of packed cell
difficult to discern. In a study of mandible and maxilla
volume does not reflect the amount of blood loss in real
fractures treated by both surgical and conservative
time due to the compensatory effects of volume
approaches, Martens et al. reported slight malocclusion in
redistribution and splenic contraction in the horse. A
11 out of 42 (26%) horses and serious deviation of the
reduction of total blood solids measured from a
mandible in 1 horse for which long-term follow-up
refractometer will give an earlier indication of significant
information was available [12]. Henninger et al. reported
blood loss; however, this has to be considered in the
malocclusion in 9 out of 63 (14%) horses for which
context of intravenous crystalloid fluid administration
follow-up information was available [11]. Three of the 9
rate and the potential for dilution effects.
were due to the development of brachygnathism following
bilateral fractures of the mandible in young foals.
Treatment Treatment of significant hemorrhage involves
two primary aims: stopping the blood loss and supporting
Hemorrhage the patient to avoid systemic compromise. The application
Definition Excessive bleeding or blood loss as a result of of counter-pressure is sufficient to control hemorrhage in
vascular damage before, during or after surgery for a the majority of cases. Occasionally, ongoing hemorrhage
fracture of the head from a bone such as the mandible may require the use of
bone wax or some other hemostatic agent to provide
Risk Factors pressure and facilitate clotting within the cancellous
structure of the bone. Gauze packing of a sinus cavity to
● Degree of initial trauma control local blood loss is rarely necessary beyond surgery,
● Location of fracture relative to major blood vessels unless there is significant sinus mucosal involvement in
the trauma and should be avoided if possible because it will
Pathogenesis Hemorrhage when treating sinus fractures contribute to the likelihood that sinus empyema will
is common due to the abundant vascularity of the sinus develop in the postoperative period. Patient support
mucosa and the inevitable trauma both from fracture and/ involves administration of either crystalloid or colloidal
or surgical manipulation. Hemorrhage presenting as fluids to maintain vascular volume and systemic blood
epistaxis is a common clinical sign associated with fracture pressure. Administration of whole blood is rarely needed
but provides oxygen carrying capacity, oncotic capacity and bone(s). Belsito and Fischer reported good results with
volume (refer to Chapter 7: Complications Associated with the use of external fixation techniques for mandibular
Hemorrhage). fractures and often combined this with intraoral
wiring [10]. Similarly, Kuemmerle et al. reported on the
Expected outcome Hemorrhage associated with orbital use of locking compression plating of complicated jaw
fractures was found to resolve in all cases and did not fractures and included intraoral wiring in most of these
persist beyond 2 days [14]. Hemorrhage into the paranasal cases [17]. Selection of fixation technique also depends
sinuses following facial fracture may predispose to the on fracture configuration, whether the fracture is open or
development of sinus empyema [13, 15]. However, closed, and the involvement of teeth or their proximity to
hemorrhage is typically not a determining factor of long- the fracture line or intended location of screws or pins.
term outcome in cases of fracture in the head region, unless Beard has provided a good review of fracture repair
it involves uncontrolled bleeding from a lacerated major techniques for jaw fractures in the horse [8]. An
vessel. assessment of the final fixation should be made at surgery
to ensure there is no impingement of implants that may
affect mastication.
Diagnosis Poor mastication, if observed following fracture
PoorMastication repair of the jaw, should alert the surgeon to evaluate the
stability and sensitivity of the jaw during manual
Definition Inability or difficulty in masticating food
manipulation. Radiographs may be necessary to diagnose
following repair of a jaw fracture
implant displacement or loosening, but generally physical
assessment of the jaw is sufficient to make a diagnosis of
Risk Factors
instability associated complications. Horses that are
● Unstable or comminuted fracture reluctant to eat in the early postoperative period may require
● Inadequate fixation more aggressive analgesic therapy to help distinguish
● Severe dental malocclusion between fracture instability and postoperative pain as the
cause if it is not apparent from other diagnostics.
Pathogenesis Horses often continue to eat following a jaw
fracture if there is minimal displacement or instability. Treatment Revision surgery is required to re-establish
However, unstable jaw and interdental space fractures fixation stability in cases where implant failure has
result in a horse that is less likely to masticate well prior to occurred. In cases where infection-associated implant
fracture repair due to pain, discomfort and malocclusion. loosening occurs early in the postoperative period and
Following fracture repair of an unstable jaw fracture, results in instability, an alternative approach to fixation
observation of poor mastication in the early postoperative may be required along with thorough debridement of the
period should alert the surgeon to the possibility that the infected implant holes. In some cases where the fixation
fixation is unstable. Insufficient fixation, failure of fixation has not completely failed but may have minor instability,
or implant impingement during chewing are all possible diet modification and additional analgesic therapy may
causes of poor mastication in the early postoperative period allow improvement in mastication without complete
if dental realignment is acceptable. revision surgery. Fortunately, fractures of the jaw regain
stability quickly, requiring as little as 6 weeks of fixation
Prevention Selection of an appropriate fixation for before complete implant removal may be possible.
unstable jaw fractures is the key to prevention of fixation
failure. While it has been shown that dynamic compression Expected outcome Poor mastication postoperatively is
plating of interdental space fractures provides superior infrequently encountered; however; when instability is
construct stiffness, other techniques which incorporated determined to be the cause, revision surgery with improved
intraoral wiring, such as external fixation and intraoral fixation is indicated. The long-term outcome is expected to
splinting, were similar to bilateral ventrolateral plating be good because of the rapid progression of healing that
for yield, failure and gap formation in a controlled study occurs in cases of jaw fracture [11, 12]. Involvement of the
comparing mandible fixation techniques [16]. The temporomandibular joint may result in longer-term
inclusion of intraoral wiring methods allows that part of problems, although this is an infrequent site of fracture in
the fixation to be located on the tension surface of the the jaw [17].
Infection/BoneSequestration with the fracture. Localized infection is typically resolved

with a combination of antimicrobial therapy and the body’s
Definition Development of septic osteitis, osteomyelitis or
own immune and healing response.
sinus empyema secondary to a fracture with or without
bone sequestration
Diagnosis A clinician’s suspicion of infection may be
raised by the occurrence of low-grade pyrexia, greater than
Risk Factors
expected local swelling or edema, tenderness to palpation,
● Open fracture or a drop in appetite. Clinical signs such as local purulent
● Heavy feed contamination (from the oral cavity) drainage and radiographic evidence of significant regions
● High energy injuries of bone lysis will confirm that septic osteitis/osteomyelitis
is present. Purulent nasal discharge is an indication of
Pathogenesis Fractures of the head are frequently open likely sinus empyema, although clinical signs such as a
externally due to the lack of soft tissue coverage of the change in odor from the face may be a precursor to
bones. The mandible is also closely associated with the oral discharge. Radiographs may be used to confirm a fluid line
cavity, particularly in the rostral portion, and the sinus and in the paranasal sinuses and endoscopic examination can
nasal mucosa are closely associated with the maxilla, be used to determine the location of origin of the discharge.
premaxilla, nasal, frontal, lacrimal and zygomatic bones. A non-healing wound or chronic draining tract associated
Commonly, fractures involving the oral mucosa, such as with a fracture also warrants radiographic examination.
avulsions of incisor teeth or interdental space fractures, Henninger et al. reported that draining tracts or soft tissue
become heavily contaminated with feed material as most infections were observed in 15% of rostral jaw fracture
horses continue to eat despite the injury. This behavior and cases in the short term and in 19% of cases following
the large lips of the horse, often result in a delay in owners hospital discharge [11]. These were due to implant
to recognize this type of fracture and to present the horse associated infections, bone sequestra or infected fracture
for evaluation and repair. Bone sequestration is the process sites. Bone sequestration is observed radiographically as a
whereby blood supply is lost to a portion of bone, typically distinct, separate and often more radio-dense piece of bone
involving open, comminuted fractures, an infectious within the fracture site. A bone sequestrum may also be
process and high energy injuries such as a kick. Facial diagnosed during repeat debridement of an infected
fractures of the head presenting with epistaxis can be fracture site without prior recognition of its presence. The
assumed to involve the nasal or sinus mucosa and therefore viability of some facial bone segments may be difficult to
be open to contamination (Figure 51.3). The accumulation discern radiographically (Figure 51.3).
of blood within paranasal sinus spaces provides a good
medium for development of infection. Sinus empyema Treatment The principles of treatment for septic
may be associated with comminuted orbital fractures, skull osteomyelitis, sinus empyema and bone sequestration
and sinus depression fractures, maxillary fractures and
tooth fractures [12–15, 18].
Prevention Thorough surgical debridement of the fracture

site(s) and broad-spectrum antimicrobial therapy should
be undertaken in an effort to prevent septic osteitis/
osteomyelitis. Lavage of the paranasal sinuses to remove
blood clots in the case of acute trauma is indicated as a
preventative measure for sinus empyema. Removal of bone
fragments that have tenuous soft tissue attachment (and
hence blood supply) should be performed during initial
debridement. This does not guarantee that bone
sequestration will not occur in the future, as some bone
fragments which look viable at initial surgery may still
become non-viable over time, particularly in the face of Figure51.3 Right-dorsal-left-ventral-oblique radiographic
severe local infection. In many cases of open fracture view of the skull in a horse that sustained trauma to the head. A
non-displaced fracture of the nasal bone is evident (arrowheads).
involving the jaw with heavy contamination, it is a realistic
This fracture became infected and developed a bone sequestrum
goal to prevent widespread septic osteitis/osteomyelitis of that was removed upon surgical debridement. Source: Timothy
the fracture site rather than prevent any infection associated Lescun.
apply to the head in the same way as any other location in Facial bone fractures have a similarly high rate of long-
the horse (Figure 51.4): surgical debridement of affected term success when focal sequestration or osteitis is
bone and removal of any non-viable sequestered bone, present [13, 15].
collection of infected bone material or sinus discharge for
microbial culture and sensitivity testing, and the initiation
ImplantFailure
of broad-spectrum systemic antimicrobial therapy. Lavage
of the paranasal sinuses is usually required at a minimum Definition Loss of stability, either acutely or insidiously, of
to remove purulent drainage and resolve sinus empyema if orthopedic implants used to stabilize fractures of the head
it develops. More aggressive approaches to treatment may
be required in some cases. Application of local antimicrobial Risk Factors
therapies such as impregnated beads can be beneficial
● Comminuted fractures
following debridement of infected bone. Non-absorbable
● Wire fixation used alone for jaw fractures
beads such as polymethylmethacrylate require removal,
whereas absorbable beads such as calcium sulfate tend to Pathogenesis Comminuted fracture of the jaw results in
elute antimicrobials more quickly and for a shorter period an absence of inherent fracture stability gained from
of time. The presence of anaerobic bacteria should be fragment interdigitation and greater loading of implants.
considered in these cases, particularly with fractures Biomechanically, the ideal location for implant placement
involving the mouth, and therapy should include drugs to stabilize fractures of the rostral jaw is the oral surface of
known to be effective against these organisms, such as both the maxilla and the mandible. This is the tension side
penicillin or metronidazole. of the bones during mastication [16]. As a result, when
plate fixation is employed, it is not applied in the ideal
Expected outcome Sequestrum removal and local location unlike for intraoral wiring techniques. Despite
debridement resolves chronic infections in the majority of this, dynamic compression plating on the ventrolateral
cases and a good outcome is expected. Henninger et al. surface of the mandible has been shown to provide greater
reported that 92% of horses with postoperative draining construct stiffness than other fixation methods [16].
tracts following rostral jaw fractures resolved following Implant failure for fracture cases of the head is most
treatment [11]. Martens et al. reported that 93% of horses commonly related to infection surrounding the implants
with a jaw fracture had a satisfactory or better outcome, and bone holding failure rather than cyclic loading and
and all of the unsuccessful outcomes had chronic signs of failure of the implant material. Comminuted facial
infection associated with the fracture [12]. Complications fractures can be challenging to realign due to a lack of
reported secondary to the use of external skeletal fixation surrounding soft tissue support, although very little
techniques for jaw fractures were chronic draining tracts at strength of fixation is required to retain the fragments in an
pin sites but all of these horses had a good outcome [10]. acceptable position.
(a) (b)
Figure51.4 (a) Photograph of the ventral aspect of the head of a horse with a chronic draining tract associated with an old fracture
of the mandible. (b) Intraoperative image showing the tract through the ventrolateral aspect of the mandibular bone cortex at the site
of the chronic tract after exposure through curettage and debridement of infected tissue. Source: Timothy Lescun.
Prevention There are two ways in which surgeons can Risk Factors
prevent implant failure in fractures of the head region. The
● Comminution
first is to use sufficient fixation stability for the particular
● High energy injuries
fracture present. The second is to ensure good bone holding
● Chronic infection
at the time of implantation and the adherence to aseptic
technique to the greatest extent possible.
Pathogenesis Sources of a cosmetic blemish following a
Diagnosis The diagnosis of implant failure is usually self- fracture repair of the head are numerous; however, the
evident upon examination of the horse and fracture. In primary reasons are excessive callus associated with jaw
some cases, subtle clinical signs such as reduced willingness fractures, depression of facial bones or excessive reaction
to eat, fever, localized swelling and pain, may be recognized along suture lines of the facial bones, orbital depression,
prior to gross instability of the implants. For facial fractures, facial deformity, or malalignment of the jaw. The cause of
implant failure may be accompanied by depression of the excessive bone reaction in any of these locations is
bone, displacement at the fracture site and sometimes fresh associated with either initial instability of repair with
epistaxis. Radiographs are indicated to both confirm the abundant secondary fracture healing despite fixation, or
diagnosis in some cases and to plan ongoing treatment. chronic sepsis associated with a fracture site resulting in
ongoing inflammation and fibrous tissue response.
Treatment The combination of several methods of fixation Depression of facial bones, the bony orbit and facial
can be advantageous in the head. The use of ventrolateral deformity occurs with either poor initial alignment or
plating or external skeletal fixation combined with intraoral additional trauma and fragment displacement during the
wiring or intraoral splinting is commonly employed for healing process. High energy injuries of the head can result
rostral jaw fractures [10, 17]. Treatment of implant failure in excessive bony reaction along the suture lines of the
requires a complete reassessment of the case. In select facial bones without any apparent instability. Presumably
cases that have already gained some inherent stability from some minor disruption and instability is present at these
the fracture healing process, simply removing the implants locations at the time of initial injury, which results in the
may be all that is required. More commonly, re-stabilization formation of new bone along the suture line. Comminuted
with an alternative method of fixation or using an fracture of the facial bones may initially appear well-
alternative location of implants is performed. Facial aligned and acceptable when there is soft tissue swelling
fractures can be repaired using stainless-steel wire, heavy associated with the fractured area, only to appear sunken
suture material or small reconstruction plates [13, 15, 18]. following healing and resolution of swelling.
Expected outcome Wire loosening or breakage in cases of Prevention Prevention of cosmetic blemishes associated
rostral jaw fracture repair occurs in approximately 7% of with fracture repair and fracture healing is based on
cases [11]; however, long-term outcome is expected to be adhering to the principles of treatment that control
good. For cases where external skeletal fixation is infection, provide adequate fixation stability, and encourage
employed, the use of casting tape for connection between bone healing. It is preferable to prevent rather than treat
pins was associated with high failure and so depression deformity of the facial and orbital bones.
polymethylmethacrylate connections are preferred and Owners should be warned of the possibility of a cosmetic
reduced fixation failure is expected [10]. Healing of facial blemish when depression fractures are treated and also
fractures is expected regardless of fixation method; their likelihood if owners refuse surgical treatment. While
however, the use of plate fixation may necessitate the cosmetic appearance is not important for some owners,
removal of screws or implants due to localized some depression fractures can impinge on the nasal
infection [18]. The use of stainless-steel wire or heavy passage or other vital structures of the head. Good owner
absorbable suture material have resulted in good outcomes education of the timeline for healing events, the expectation
in facial fractures with few complications [13, 15]. of callus formation and its eventual resolution can prevent
this “complication” from becoming an issue that comes to
the veterinarian’s attention.
Diagnosis Poor cosmesis as a complication is usually
PoorCosmesis
brought to the attention of the veterinarian by the owner
Definition Development or persistence of a cosmetic and so diagnosis is not difficult. Making an accurate
blemish following repair of a fracture of the head region assessment of the status of healing and the treatment
References 737
options available often requires a combination of imaging malalignment of the jaw and in some young horses with
modalities including radiography and endoscopy. the development of brachygnathism [11]. There are many
Computed tomography may be employed in severe cases of reconstructive procedures of the skin which can be
facial or orbital depression to assess the structures involved performed in the head region when necessary and the
and the current extent of healing which will determine surgeon is often only limited by imagination in ways to
what approach should be taken. improve the cosmetic appearance of a healed fracture of
the head.
Treatment Serious consideration should be given to the
relative risk and reward associated with treatment of facial Expected outcome Long-term cosmetic outcome is more
or orbital bone depression or deformity. Realignment of often than not good to excellent in cases of fracture of the
these bones through cutting and restabilization may seem head region in the horse, particularly considering the
logical but surgeons can contemplate other approaches for extent of damage that can accompany these injuries.
improving cosmesis, such as tissue filling techniques, if Outcome of cases which present for poor cosmetic
there is risk of damage to structures such as the globe or appearance is heavily dependent upon the severity of the
nasolacrimal duct. Most cases where excessive callus is blemish and the extent of involvement of underlying and
considered a cosmetic blemish, owners should be important structures. Many owners are willing to accept
encouraged to allow more time for fracture remodeling to less than perfect cosmetic appearance in favor of
occur. Skeletal tissue has the ability to re-establish its functionality and for those where cosmetic appearance is
normal shape but this remodeling process may be delayed important, given sufficient resources, a good outcome is
in cases of protracted healing such as with the presence of often possible, even in cases where a poor cosmetic
infection. Ongoing dental care may be required in cases of appearance is present.
References
1 Dyce, K.M., Sack, W.O., and Wensing, C.J.G. (2010). The 8 Beard, W.L. (2009). Fracture repair techniques for the
head and ventral neck of the horse. In: Textbook of equine mandible and maxilla. Equine Vet. Educ. 21 (7):
Veterinary Anatomy, 4e. 501–531. St. Louis, MO: 352–357.
Saunders-Elsevier. 9 Iacopetti, I., De Benedictis, G.M., Faughnan, M. et al.
2 Freeman, D.E. and Hardy, J. (2012). Guttural Pouch. In: (2009). Treatment of incisive bone fracture in a horse
Equine Surgery, 4e (ed J.A. Auer and J.A. Stick), 623–642. using an acrylic splint. Equine Vet. Educ. 21 (7):
St. Louis, MO: Elsevier. 346–351.
3 Dixon, P.M. and du Toit, N. (2010). Dental anatomy. In: 10 Belsito, K.A. and Fischer, A.T. (2001). External skeletal
Equine Dentistry, 3e (ed J. Easley, P.M. Dixon, and J. fixation in the management of equine mandibular
Schumacher), 51–76. Edinburgh; New York: fractures: 16 cases (1988-1998). Equine Vet. J. 33 (2):
Saunders. 176–183.
4 Kinns, J, and Pease, A. (2009). Computed tomography in 11 Henninger, R.W., Beard, W.L., Schneider., R.K. et al.
the evaluation of the equine head. Equine Vet. Educ. 21 (1999). Fractures of the rostral portion of the mandible
(6): 291–294. and maxilla in horses. J. Am. Vet. Med. Assoc. 214 (11):
5 Huggons, N.A., Bell, R.J.W., and Puchalski, S.M. (2011). 1648–1652.
Radiography and computed tomography in the diagnosis 12 Martens, A., Steenhaut, M., Boel, K. et al. (1999).
of nonneoplastic equine mandibular disease. Vet. Radiol. Conservative and surgical treatment of mandibular and
Ultrasound. 52 (1): 53–60. maxillary fractures in 54 horses. Vlaams Diergeneeskd
6 Lacombe, V.A., Sogaro-Robinson, C., and Reed, S.M. Tijdschr. 68 (1): 16–21.
(2010). Diagnostic utility of computed tomography 13 Schaaf, K.L., Kannegieter, N.J., and Lovell, D.K. (2008).
imaging in equine intracranial conditions. Equine Vet. J. Management of equine skull fractures using fixation with
42 (5): 393–399. polydioxanone sutures. Aust. Vet. J. 86 (12): 481–485.
7 Manso-Diaz, G., Garcia-Lopez, J.M., Maranda, L. et al. 14 Gerding, J.C., Clode, A., Gilger, B.C. et al. (2014). Equine
(2015). The role of head computed tomography in equine orbital fractures: a review of 18 cases (2006 - 2013). Vet.
practice. Equine Vet. Educ. 27 (3): 136–145. Ophthalmol. 17: 97–106.
15 Little, C.B., Hilbert, B.J., and McGill, C.A. (1985). A 17 Kuemmerle, J.M., Kummer, M., Auer, J.A. et al. (2009).
retrospective study of head fractures in 21 horses. Aust. Locking compression plate osteosynthesis of complicated
Vet. J. 62 (3): 89–91. mandibular fractures in six horses. Vet. Comp. Orthop.
16 Peavey, C.L., Edwards, R.B., Escarcega, A.J. et al. (2003). Traumatol. 22 (1): 54–58.
Fixation technique influences the monotonic properties 18 Dowling, B.A., Dart, A.J., and Trope, G. (2001). Surgical
of equine mandibular fracture constructs. Vet. Surg. V.S. repair of skull fractures in four horses using cuttable
32 (4): 350–358. bone plates. Aust. Vet. J. 79 (5): 324–327.
739
52
Complicationsof TendonSurgery
Roger K. W. Smith, MA, VetMB, PhD, DEO, FHEA, ECVDI LAassoc, DECVSMR, DECVS, FRCVS
The Royal Veterinary College, Hatfield, Hertfordshire, UK
Overview IntraoperativeComplications
Tendon surgery encompasses a wide range of surgical tech- InaccurateorIneffectiveIntra-tendinous

niques: from intra-tendinous injections and minimally Injection
invasive options such as tenoscopy and bursoscopy to open
Definition Injection of therapeutic material into the wrong
approaches for tenectomy, tenotomy and neurectomy. This
location
chapter will discuss the most common complications that
occur with these procedures, with suggestions for strategies
Risk Factors
to avoid them.
● Injection without image guidance
● Inaccurate lesion evaluation
L
with TendonSurgery Pathogenesis Intra-tendinous or intra-ligamentar
injections are a common therapeutic modality for over-
● Intraoperative complications strain (and in some cases, traumatic) tendon and ligament
– Inaccurate or ineffective intra-tendinous injection injuries. Case selection is important for these intra-
– Iatrogenic damage to tendons and adjacent vascular tendinous injections. The area of tendon damage needs to
structures be contained by an intact outer layer of tendon tissue or
● Early postoperative complications paratenon, so that the injected preparation is retained and
– Postoperative tendon hemorrhage the injected preparation is deposited accurately within the
– Tendon or synovial sepsis tendon lesion itself. Injection into normal (intact) tendon is
– Exacerbation of unrecognized tendon or ligament very hard, while there is usually minimal resistance to
damage injection into a core lesion. However, this loss of resistance
● Late postoperative complications is also encountered when the needle has been introduced
– Needle tracts following intra-tendinous injection through the entire thickness of the tendon, which is easy to
– Abnormal tissue formation after intra-tendinous do and hence is not a reliable indication of accurate
injections location within the core lesion. If the deep surface of the
– Postoperative neuroma formation tendon is penetrated, then injected solution tends to leak
– Adhesion formation through this opening. This is particularly common when
– Exacerbation of tendon or ligament pathology after injection of the collateral ligaments of the distal
neurectomy interphalangeal joint is attempted under ultrasound
– Tendon rupture following casting guidance alone. In a recent study, almost two-thirds of
– Fragmentation of the apex of the patella attempted injections entered the underlying distal
– Incisional breakdown, hematoma formation and syn- interphalangeal joint (unpublished data). Leakage of the
ovial fistulae associated with open approaches to ten- injected solution will also occur when mid-substance
don sheaths lesions are injected where the lesion communicates with
740 Complications of endon Surgery
the periphery of the tendon. This is less common in extra- ligament pathology offer a combination of diagnostic and
thecal lesions, but is more common in intra-thecal tendon therapeutic capabilities. Tendon and ligament lesions that
injuries. cause disruption of the border of the structure, result in
different consequences to that of extra-thecal injuries – the
Prevention Intra-tendinous injections should always be synovial environment prevents the debridement of
performed under imaging guidance to ensure accurate damaged tendon matrix and kills cells on the exposed
placement of the injected preparation into the tendon or surface of the damaged tendon or ligament [2].
ligament. This usually involves ultrasound, although MRI- Furthermore, the release of intact and cleaved matrix
guided injections are necessary for those sites where proteins [3] and bleeding [4] from the damaged tendon
ultrasound does not function well, such as for collateral drives inflammation in the synovial cavity, resulting in
ligaments of the distal interphalangeal joint [1]. The key effusion in the adjacent joint, tendon sheath, or bursa.
steps in the procedure are: Tenoscopy and bursoscopy offer both diagnostic and
● Using “in-plane” targeting where the needle is aligned therapeutic potential for managing such injuries, but are
with the transducer so that the entire length of the needle also challenging surgical techniques with a steep learning
can be imaged at the same time (Figure 52.1). curve. Hence embarking on these procedures without
● Avoiding advancing the needle too far prior to suitable training can be both frustrating for the surgeon
identification of the needle-tip on imaging, so as to avoid and result in inadvertent iatrogenic damage to the digital
penetrating the deep surface of the tendon or ligament. sheath wall and contained tendons. Common areas for this
● Using transverse as well as longitudinal imaging to to occur are when creating the arthroscope portal into the
ensure accurate location of the needle within the core digital sheath immediately distal to the proximal sesamoid
lesion. bones.
The area for appropriate arthroscope placement is not
Careful preoperative imaging can help in determining large and if the portal is not created sufficiently abaxially, it
any extension of the mid-substance lesion to the border of is possible to create the portal through the border of the
the tendon. Ultrasonographically, this requires the addition superficial digital flexor tendon (Figure 52.2). However, if
of oblique views and non-weight-bearing imaging where the portal is created too far abaxially, the entry site can
border lesions can become more apparent. damage the palmar/plantar digital nerves and vessels. At
this site, the neurovascular bundle is usually easily palpable
Diagnosis Often this complication goes unnoticed, and as a result is rarely traumatized. However, subsequent
especially if the injection was performed without image creation of the proximal instrument portals, not usually
guidance. Unexpected swelling adjacent to the tendon or made with reference to the palmar/plantar nerves but via
within an adjacent synovial cavity can be indications and with the introduction of needles viewed tenoscopically, can
ultrasound with reveal air outside the tendon or ligament. result in damage to neurovascular bundle as these are less
palpable.
Treatment and expected outcome No further therapy is
Inadvertent damage to the tendons within the tendon
necessary, but the initial treatment can be expected to be
sheath or bursa can occur from the arthroscope itself or
ineffectual.
when instruments (especially hook knives) are intro-
duced incorrectly (Figure 52.3). This has a higher risk
IatrogenicDamageto Tendonsand Adjacent when the fetlock canal is constricted and when surgery is
VascularStructures conducted in dorsal recumbency. Dorsal recumbency for
digital sheath tenoscopy allows greater flexibility to all
Definition Damage to structures near minimally invasive
areas of the digital sheath as well as, in this author’s opin-
portals during incisions and cannula placement
ion, resection of structures such as the manica flexoria,
but does increase the tension in the digital flexor
Risk Factors
tendons.
● Inexperience Bleeding is also common during desmotomy of the
● Inappropriate portal placement accessory ligament of the superficial digital flexor tendon
● Inadvertent use of surgical instruments when performed via the carpal sheath [5]. This arises
● Constricted palmar/plantar annular ligament because of the necessary dissection and transection of the
accessory ligament outside the sheath cavity and the easy
Pathogenesis Minimally invasive techniques for the transection of the artery running along the proximal bor-
evaluation and treatment of intra-synovial tendon and der of the ligament.
(a) (b)
(c) (d)
Figure52.1 Ultrasound guided injection of superficial digital flexor tendon lesions: (a) in plane targeting, using a longitudinally-
aligned needle from the palmar aspect of the limb. This allows easier movement of the needle along the lesion compared to a
transverse orientated needle, but when associated with a needle tract through the tendon results in a palmar contour swelling (b)
arrow); (c) transverse and (d) (longitudinal ultrasound images of the hypoechoic needle tracts that can develop post-intra-lesional
tendon injection. They are often associated with a Doppler positive signal in non-weight-bearing scans, but affect only a small part of
the tendon and do not appear to adversely affect outcome. However, given that they are often obvious on re-exams up to
approximately 6 months after injection, it is worth warning owners before intra-lesional injection of this possible complication.
Source: Roger K.W. Smith.
Neurectomy of the deep branch of the lateral plantar

nerve is frequently combined with a fasciotomy to reduce
pressure created by the thickened ligament on the nerves
within the “canal” formed by the third metatarsus dorsally,
lateral and medial splints abaxially, and the fascia plantarly.
This procedure necessitates transecting the fascia using
scissors or an fasciotome deep inside a small incision used
to perform the neurectomy. Consequently, it is relatively
easy to damage the underlying suspensory ligament and
this has been reported as a complication (Figure 52.4) [6].
Prevention Accurate placement of both arthroscope and

instrument portals is essential to minimize these risks.
This requires a detailed knowledge of the anatomy and
careful palpation before portals are created. The use of
needles to determine accurate location can be helpful.
During endoscopy, the arthroscope should be used gen-
Figure52.2 Non-weight-bearing transverse image showing a tly with the least number of passages through the fetlock
defect created through the superficial digital flexor tendon after canal as possible to minimize damage to the tendons. If
tenoscopy. This complication arises when the arthroscopic portal is
created too close to the superficial digital flexor tendon. Creating access through the fetlock canal is significantly restricted,
the portal as close to the neurovascular bundle as possible and transection of the palmar/plantar annular ligament is
feeling for the scalpel blade entering a “space” can help to recommended to help minimize the risk of iatrogenic
minimize this complication, although it may not adversely affect trauma to the digital flexor tendons.
the outcome of the case. Source: Roger K.W. Smith.
When performing tenoscopy of the digital sheath in
dorsal recumbency, it is recommended that the Esmarch
bandage is applied with the limb in full extension and with
the distal interphalangeal joint extended with the help of
an assistant to minimize tension in the deep digital flexor
tendon. This can also be achieved by placing the wires
through the hoof wall at the widest point of the foot rather
than, paradoxically, at the toe, for the same reasons.
Careful and slow dissection through the accessory
ligament of the superficial digital flexor tendon will enable
the surgeon to identify the nutrient artery and so dissect
around it rather than through it.
When performing a fasciotomy in the proximal
metatarsal region, keeping the scissors adjacent to the axial
surface of the lateral splint can minimize the risk. A special
fasciotome can also be used to minimize the risk of
iatrogenic damage to the suspensory ligament [7].
Alternatively, concurrent intraoperative ultrasonography
(Figure 52.4) can be used to ensure that the scissors or
fasciotome is lateral to the margin of the proximal
suspensory ligament.
Figure52.3 Iatrogenically created damage to the surface of the
deep digital flexor tendon (arrow) during tenoscopic resection of
Diagnosis Damage to the tendons is usually evident during
the manica flexoria (cut-end indicated by dashed arrow). Surface
damage can result in cell death within the tendon itself and/or the endoscopic examination. If an artery is damaged,
adhesion formation, although the latter is rare unless there is immediate bleeding externally and into the sheath will be
damage on an opposing surface. Therefore, every effort should be evident, but if an Esmarch bandage is used (as is most
made to minimize iatrogenic damage by gentle manipulation of
common for the digital sheath), it will not be evident until
the instruments and maximizing space within the fetlock canal if
restricted by desmotomy of the palmar/plantar annular ligament. the Esmarch tourniquet is removed and can be the cause of
Source: Roger K.W. Smith. bleeding through the bandage during recovery.
(a) (b)
Figure52.4 (a) Damage visible postoperatively in the suspensory ligament after a neurectomy and fasciotomy procedure. Source:
Reproduced from Dyson and Murray (2012) [6] with permission from Wiley. (b) Intraoperative transverse ultrasound image being used
to ensure that the Mayo scissors used to transect the fascia are located abaxial to the suspensory ligament to minimize this
complication. The use of a fasciotome, as it is smaller, tends to reduce but not eliminate the risk. Source: Roger K.W. Smith.
Damage to the proximal suspensory ligament can be Risk Factors

identified postoperatively using ultrasound where a defect
● Stage of the injury
can be seen on the lateral aspect of the ligament [6].
● Choice of injectable
Treatment Any iatrogenic damage to the tendons should ● Iatrogenic damage to adjacent vascular structures
be lightly debrided with a synovial resector. Bleeding ● Surgical transection or marked debridement of tendon
usually stops following increase in the intra-thecal pressure or ligament structures within the tendon sheath, bursa,
through increased flow of fluid (intraoperative) or pressure or joint
with a bandage (immediately postoperatively).
● Exercise
Expected outcome Damage to the intra-thecal tendons ● Insufficient bandaging
carries an increased risk of subsequent adhesion formation,
although damage to just the surface of the tendon, without Pathogenesis Most tendon- or ligament-related endoscopic
corresponding damage to the adjacent tendon sheath wall, procedures involve the distal limb and are performed with
appears to be remarkably well tolerated. Intraoperative an Esmarch bandage in place to minimize bleeding and
hemorrhage usually does not cause long-term problems, maximize visibility during the procedure. This is
although damage to nerves or postoperative hemorrhage particularly important during tendon surgery, because
can cause problems (see later). Iatrogenic damage to the tendons and ligaments have an abundant blood supply and
proximal suspensory ligament has not been associated are susceptible to bleeding. This hemorrhage can be intra-
with any adverse effects on outcome [6]. tendinous (for injected closed lesions) or intra-thecal.
Some injected agents can provoke intra-tendinous
hemorrhage, especially if injected very early after injury
and when using agents that may have anti-coagulative
properties such as polysulphated glycosaminoglycans [8].
PostoperativeTendonHemorrhage
Worsening of some lesions seen after platelet-rich plasma
Definition Hemorrhage within the tendon or ligament may be due to intra-tendinous or intra-ligamentar
after surgery or therapeutic injection hemorrhage (Figure 52.5).
(a) (b)
Figure52.5 Superficial digital flexor tendon lesion (a) arrowed, treated with intra-lesional platelet-rich plasma, showing significant
exacerbation of the pathology at an examination 6 weeks after injection (b). Source: Courtesy of Murray Shotter.
When the Esmarch bandage is removed after tenoscopy management, although these cases may be at greater risk
or bursoscopy, significant intrathecal hemorrhage can of adhesion formation and greater long-term lameness
occur. This can drive an inflammatory response and result problems (see below).
in postoperative lameness that can be so marked as to
resemble synovial sepsis.
Tendonorsynovialsepsis
Prevention The ideal prevention is to minimize damage to
Definition Infection of tendons, ligaments, or synovial
both tendons and adjacent vasculature, although this is
structures
often inadvertent or else a necessary aspect of the surgery
(such a tendon debridement). Cases which have had
Risk Factors
significant tendon debridement or transection should be
strictly box-rested postoperatively and caution should be ● Carpal sheath tenoscopy
exercised in discharging these cases too early from the ● Sterility of the procedure
hospital where transport can re-initiate hemorrhage. ● Intra-thecal hemorrhage
● Poor portal healing or contamination
Diagnosis Synoviocentesis is still warranted to ensure that
sepsis is not the cause, but samples will usually display just Pathogenesis Whenever injections or surgery is performed,
a hemorrhagic tap with a low, or marginally elevated, white there is always a risk of infection. However, both tendon
blood cell count. and synovial sepsis is an extremely rare complication
following tendon injection or endoscopic procedures.
Treatment Treatment is strict stall rest and pain relief, Tendon appears to be more resistant to infection than
usually with non-steroidal anti-inflammatory drugs, synovial cavities and most intra-thecal tendon pathology is
although additional pain relief strategies such as the use of approached surgically using endoscopy which involves the
opiates and epidural morphine can be very helpful for constant flushing of the synovial cavity. However, a recent
managing hindlimb cases. publication [9] has documented an increased risk for
carpal sheath tenoscopy compared to other endoscopic
Expected outcome Repeat endoscopy is rarely necessary as procedures (Odds ratio of 14:9). The reasons for this are
the level of lameness usually resolves rapidly with this unclear but may relate to greater soft tissue dissection
associated with performing a desmotomy of the accessory In recent years, there has been an increased interest in
ligament of the superficial digital flexor tendon, leading to the intra-tendinous injection of various “biological
intra-thecal hemorrhage, extravasation of fluid during the agents” such as stem cells and platelet-rich plasma.
procedure, or greater risk of portal contamination. “Flares,” a non-septic inflammatory reaction, not uncom-
An additional risk is at the time of suture removal, where monly seen after the injection of these biological agents
any subcutaneous portal hemorrhage can represent a site for into joints, is rare in tendons and any such reaction is
potential contamination, which can then extend back into more likely to be related to the introduction of infection,
the synovial cavity through the portal sites (Figure 52.6). although this is also very rare.
(a) (b) (c)
(d) (e)
Figure52.6 Arthroscopic portal complications. (a) Appearance of the proximal instrument portal 2 weeks after elective tenoscopy.
The portal had remained swollen and moist but the horse was sound at the walk until the day after suture removal when the digital
sheath swelled considerably and the horse became severely lame. Synoviocentesis revealed a septic sheath. (a) shows the appearance
of the portal, which had been enlarged at the time of surgery for manica removal, immediately prior to tenoscopic lavage. The pale
fibrinous material can be seen through the broken-down incision, which can also be seen in the ultrasonographic image (b) transverse
and (c) longitudinal images from the medial aspect of the limb overlying the portal. The ultrasound image shows the cavity
containing a fibrinous clot (solid arrows), the communication with the incision (dashed arrows), and the communication with the
sheath cavity (long dashed arrow), which allowed secondary infection of the clot post suture removal to infected the sheath cavity. *
indicates the fibrinous material within the sheath cavity. (d) shows the tenoscopic appearance of the fibrinous material (black arrow)
plugging the communication with the subcutaneous cavity containing the infected clot (shown in (e) after debridement of the cavity).
This shows the importance of sterility when removing sutures from tenoscopic portals, which are either swollen or discharging.
Source: Roger K.W. Smith.
Prevention Careful aseptic preparation of both intra- tendon damage is common. Sharp or blunt contusion can
tendinous injection sites and endoscopic portal sites is result in complete or partial transection of the tendon.
essential. Any draining of synovial fluid in the immediate Complete rupture results in specific conformational
postoperative period or unexpected swelling which could be changes in the limb under weight-bearing load [10], while
representative of hematoma formation under the skin partial transection does not. The recognition of the degree
portal, should indicate that more care should be taken when of tendon transection is important to avoid the progression
removing sutures, including prior ultrasonographic of partial transection to complete rupture. However, most
examination and aseptic preparation prior to suture removal. flexor tendon lacerations occur when the tendon is loaded
and so the location of the tendon damage is frequently at a
Diagnosis Synoviocentesis is necessary to confirm different site to the skin wound when the horse has reduced
synovial sepsis. Tendon sepsis is more difficult to confirm loading post-injury.
except when the affected area is within a synovial cavity, Partial lacerations may not only progress transversely to
where synovial sepsis will be inevitably concurrent. Extra- a full rupture. What is more common is for splits to extend
thecal tendon sepsis is characterized by rapid progression proximally through the body of the tendon as a result of
of ultrasound signs, usually with a sharp delineation unloading of tendon fibers in the lacerated part, while the
between normal tendon tissue and the infected area. intact portion retains its loading and hence shear forces
between the two parts are established which disrupt the
Monitoring The level of lameness is a valuable clinical tendon matrix. This can occur when the severity of the
parameter to monitor and synoviocentesis should be accompanying soft tissue damage may not have been fully
repeated should lameness remain marked. Judicious use of appreciated prior to undertaking the surgery. For digital
non-steroidal anti-inflammatories should be considered so flexor tendon partial transections, a horse restricted to
as not to mask worsening lameness that might indicate walking exercise only (e.g. under box-rest), the superficial
persistent infection. digital flexor tendon is loaded approximately twice what it
would be if the horse was standing evenly [11] and hence,
Treatment Synovial sepsis should be treated by endoscopic for a horse kept on box-rest, approximately 50% of the ten-
debridement and lavage, and infected tendons need radical don can be lacerated without risk of progression to full
debridement. rupture.
Expected outcome Successful management of synovial Prevention Post trauma, a full clinical and ultrasonographical
sepsis carries a good prognosis, although affected horses assessment of any tendons and ligaments that may have
can be expected to be at greater risk of adhesion formation. been injured should be made. Visual inspection of the
The prognosis after tendon infection depends on the extent wound alone is rarely sufficient except for the largest wounds
of the tendon infected but since such infections are rapidly because of the possibility of remote tendon damage, and so
progressive and radical surgical debridement is necessary a full ultrasound examination is indicated both at the site of
to eliminate the infection, the prognosis tends to be the skin wound and remotely to determine the degree of
guarded. tendon damage. For those injuries where 50% or more of the
tendon is damaged, external support of the relevant joint is
imperative. For superficial digital flexor tendon and
Exacerbationof UnrecognizedTendonor
suspensory lacerations, support to the fetlock joint can be
LigamentDamage
provided by the addition of a cast or splint. For deep digital
Definition Causing further damage to unrecognized flexor tendon lacerations or tenotomy, fitting a shoe with
injuries caudally extended branches and/or raised heels not only can
prevent progression to rupture but can also prevent or reduce
Risk factors Incomplete evaluation of injured and adjacent subluxation of the distal interphalangeal joint that occurs
tendons and ligaments with disruption of deep digital flexor tendon.
Pathogenesis While not specifically a complication of Diagnosis The diagnosis after surgery is appreciated
tendon surgery, surgery performed for other reasons can through the mechanical disruption as a consequence of
result in complications associated with unrecognized or full tendon or ligament rupture, such as fetlock collapse
poorly defined tendon and ligament damage. with superficial digital flexor tendon or suspensory rupture
Due to the minimal soft tissue cover to the palmar/plan- and joint instability with collateral ligament and deep
tar aspect of the distal limbs of the horse, percutaneous digital flexor tendon rupture.
Treatment and expected outcomeTreatment and prognosis Risk Factors

relate to the structure damaged and the extent of the
● Intra-tendinous injection of corticosteroid
damage. Mechanical instability often requires external
● Intra-tendinous injection of crude bone marrow
coaptation.
Pathogenesis The formation of cartilage or fat tissue

LatePostoperativeComplications during tendon healing has been attributed to the use of
corticosteroids [12]. Dysplastic mineralization is seen in
NeedleTractsFollowingIntra-Tendinous some tendons (most commonly the deep digital flexor
Injection tendon and the suspensory ligament branches [13]), as a
consequence of chronic pathology. However, it can also be
Definition Injury to tendons or ligaments with intra-thecal
a complication of intra-tendinous injections with
injection due to needle penetration
corticosteroids and neat bone marrow (Figure 52.7). The
accumulation of fat is rare in equine tendons (c.f. human
Risk Factors
tendons), while fibrocartilage repair is more common and
● Unknown but possible factors include: can occur spontaneously as a feature of “failed” healing.
Mineralization may be more common with depot steroid
● Oversized needles
preparations where the crystalline nature of the carrier has
● Injection under pressure causing back-flow of the
been suggested as the main cause for this mineralization/
injected solution up the needle tract while the needle is
ossification. Bone marrow injected directly after aspiration
in place
from the sternum was a popular early form of stem cell
Pathogenesis Unknown. These needle tracts are not treatment and a large number of horses were injected
inevitable but are common and there appears to be no without recorded mineralization. However, cancellous
ability to predict which injections will result in one bone is a recognized strategy for inducing bone formation
forming. The tract is usually significantly larger than the in fracture repair and so it would not be unexpected for
size of the needle that created it, suggesting that there is bone to be formed in injected tendons and ligaments. This
significant resorption of tendon tissue around the hole. has been observed in a single case by the author
(Figure 52.7).
Prevention There are no known strategies for the
prevention of needle tracts after intra-tendinous injection.
Prevention Avoid preparations which may induce
It is recommended that intra-tendinous injections are
mineralization (or other abnormal tissue).
delayed until the initial inflammatory phase has resolved
(normally about 7 days in a superficial digital flexor
Diagnosis The presence of fibrocartilage is characterized by
tendinopathy) and that injections are performed using as
the presence of a hypoechoic area not dissimilar to acute
small a needle gauge as appropriate. Immediate bandaging
pathology, but can be differentiated by the presence of a
after injection may help prevent leakage of the injected
sparse fascicular pattern. Dysplastic mineralization is readily
solution subcutaneously.
identifiable ultrasonographically as bright hyperechoic foci
Diagnosis When needle tracts form, they are usually which cast acoustic shadows. When present is sufficient
associated with a small amount of subcutaneous swelling amounts, it can also be seen radiographically, especially if
opposite the site of injection and an anechoic tract is visible reduced exposures are used.
ultrasonographically (Figure 52.1).
Treatment and expected outcome There is no treatment for
Treatment None necessary
fibrocartilaginous tissue within a healed tendon but its
Monitoring and expected outcomeThey usually fill in over importance lies not only in its association with poor-quality
several months and do not compromise the final outcome healing and hence a risk for re-injury, but also to avoid
of the case. misinterpreting the area as an acute lesion which might be
subjected to intra-tendinous injection, as this will be both
very difficult and cause further damage. Extracorporeal
AbnormalTissueFormationafterIntra-
shockwave therapy has been suggested to be effective at
TendinousInjections
resolving tendon mineralization in human tendons,
Definition Dysplastic tissue formation after intra-thecal although no treatment has yet been found to be effective
injections with equine tendon mineralization [13].
(a) (b) (d)
(c)
Figure52.7 Iatrogenically-induced tendon mineralization after intra-lesional treatment of superficial digital flexor tendinitis with
depot corticosteroids (a: arrow) and after implantation of bone marrow aspirate (b–d). (b) Transverse ultrasound image. (c)
Longitudinal ultrasound image. (d) Lateromedial radiograph showing the “rice grains” of mineralization (arrows). Tendon mineralization
can occur spontaneously as a sign of abnormal healing but may come at a higher risk after the use of depot corticosteroids and direct
bone marrow injection, which can contain all the components to induce ossification. Source: Roger K.W. Smith.
PostoperativeNeuromaFormation Prevention The surgeon should take care in locating both

the endoscopic and instrument portals to avoid damage to
Definition A neuroma is the result of damage to a
the adjacent digital nerves. The neurovascular bundle
peripheral nerve, which results in a focal swelling that is
should be palpated and can be retracted in one direction
exquisitely painful on palpation and can result in lameness.
prior to making the portal. Palpation of the neurovascular
bundle can be made more difficult when there is
Risk Factors subcutaneous fluid as a result of inaccurate attempts to
● Portals in close proximity to nerves distend the digital sheath prior to portal creation which
● Transthecal approach to the navicular bursa leaves fluid subcutaneously, or due to extravasation of fluid
during the surgery.
Pathogenesis For navicular bursoscopy via the transthecal

route [14], there is minimal flexibility at the site for the Diagnosis Damage to the nerves is usually not evident
introduction of the arthroscope and, contra-axially, the perioperatively and more commonly manifests as
instruments, and these portals are in close proximity to the persistently swollen portals which are very sensitive to
palmar digital nerves. Hence damage to these nerves and palpation. Ultrasonographic examination is indicated with
subsequent neuroma formation is more common with this any severely swollen portal or one that is persistently
procedure. Such iatrogenic damage to the digital nerves painful. This can reveal hematoma formation or less
results in swollen and focally painful portals, which can be evident hypoechoic regions indicating inflammation.
the cause of postoperative lameness. Neuroma formation or neuritis can be suspected if this
hypoechoic region is adjacent or involving the nerves synovium can cause persistent tendon pathology and pain
(Figure 52.8). Occasionally the nerve can be observed for the same reasons as naturally occurring tears outlined
ultrasonographically to be severed or swollen. above, but also carries a significant risk of adhesion
formation and this risk is likely to be even greater when
Treatment and expected outcome Neuromas can benefit there are two opposing surfaces damaged. While adhesion
from local and systemic anti-inflammatory treatment but formation does seal the tendon defect from the synovial
usually resolve gradually with rest over a number of weeks. environment and provides vasculature and a cell source to
enable healing, they have significant adverse functional
consequences, resulting in both mechanical and pain-
Adhesionformation
related lameness.
Definition Formation of aberrant scar tissue after surgery
or therapy Prevention Care should be taken when created tenoscopic
or bursoscopic portals to minimize iatrogenic damage to
Risk Factors the tendons or neurovascular bundle. This is particularly
important for the pastern portal sites for the transthecal
● Iatrogenic damage to tendons during endoscopy
approach to the navicular bursa, where palpation of the
● Prior damage to tendons or synovium
neurovascular bundle, and its digital manipulation dorsally
● Infection
or palmarly prior to creating the portal with a scalpel blade,
can minimize this risk.
Pathogenesis Movement of the instruments within a
Bleeding associated with tenoscopic transection of the
tendon sheath or bursa can cause damage to the surface of
accessory ligament of the superficial digital flexor tendon
the tendons, and this is particularly true when advancing
can be minimized by careful piece-meal transection of the
the arthroscope through the fetlock canal when there is
accessory ligament fibers at the proximal border using
relative constriction of the palmar/plantar annular
instruments such as suction-punch rongeurs, so that the
ligament. Such damage to the surface of tendons or the
artery can be identified and avoided. Techniques involved
thermocautery instruments [15] have also been used to
minimize hemorrhage, although a comparison between
the use of a radiofrequency probe and sharp transection
did not show any difference in the frequency of
hemorrhage [16].
Adhesion formation is best avoided by minimizing iatro-
genic trauma to the tendons during tendoscopy or bursos-
copy. This can be achieved through careful movement of
the arthroscope during the procedure and never forcing the
instrument. For the digital sheath, lateral recumbency
results in less tension in the deep digital flexor tendon,
although reduced flexibility in operating on either side of
the digital sheath. Performing a palmar annular ligament
desmotomy can increase the space within the fetlock canal
and is recommended when access is restricted. While mini-
mal adverse effects of a palmar annular ligament desmot-
omy have been reported, adhesions to the site of the
desmotomy have been observed (Figure 52.9).
Figure52.8 Neuroma formation post tenoscopy. This The risk of postoperative hemorrhage can be minimized
longitudinal ultrasound image over the palmar digital nerve and by restricting the degree of soft tissue trauma induced by
focal and painful swelling of the tenoscopic portal shows the
the surgery and by maintaining the horse on strict box-rest
digital nerve (dashed arrows) associated with the hypoechoic
area (solid arrows) at the site of the portal swelling. Such in the initial postoperative period. In addressing the former,
neuromas are rarer at the site of the arthroscopic portal because the author now advises more restricted synovial
the portal is created when the neurovascular bundle can be debridement in cases of non-septic tenosynovitis. The
palpated, than the instrument portals either proximal or distal
latter may be achieved by keeping the horse in the hospital
in the sheath where the digital nerve is not so easily palpated
intraoperatively, especially when an Esmarch bandage is used. for an extra day prior to discharge and the inevitable extra
Source: Roger K.W. Smith. movement this will entail. Those cases having under-
(a) (b)
Figure52.9 Adhesion formation after palmar annular ligament desmotomy. (a) Tenoscopic appearance. This complication was
identified in a horse that had previously undergone tenoscopic transection of the palmar annular ligament when no other
abnormalities had been detected. The horse subsequently became lame and was re-examined tenoscopically. Only this adhesion was
identified and was transected and the horse’s lameness resolved. (b) ultrasonographic appearance of adhesion formation of the
superficial digital flexor tendon to the sheath wall (dashed arrows) in a non-weight-bearing dynamic ultrasound examination. The
solid arrow shows the “gapping” that can occur between the superficial and deep digital flexor tendons when the limb is flexed. This
does not occur normally, but however can also occur with complete rupture or removal of the manica flexoria. Source: Roger K.W.
Smith.
navicular bursoscopy via the transthecal route, which of the adjacent joints. In the case of the digital sheath, the
necessitates transection of the “T”-ligament between the digital flexor tendon will move independent to the deep
digital flexor tendon sheath and navicular bursa, are digital flexor tendon and not move with respect to the
usually kept in the hospital for 2 days postoperatively as a overlying sheath wall or skin. Significant adhesions will
result. result in a gap developing between the two tendons with
Careful bandaging post endoscopy is essential to protect distal limb flexion (Figure 52.10).
the portal sites [17]. Any persistently discharging portals
should initiate more stringent treatment including Treatment Treatment should be instigated early if possible.
antibiotics and sterile bandaging until they are sealed to Controlled movement, especially using passive (non-
minimize the risk of ascending infection of the tendon weight-bearing) motion, can limit the restrictive nature of
sheath. Careful attention of the state of the portals when adhesions in the early stages. Equally intra-thecal
sutures are removed is advised. Scrubbing or disinfection medication with hyaluronate and/or corticosteroids can
of the sutures would be advised if the portal is swollen or limit adhesion formation [18], although corticosteroids
discharging. Ultrasound examination prior to suture should be used with caution when there is concurrent
removal is probably advisable if there is substantial swell- tendon damage, as they will slow or prevent tendon
ing of the portal site. healing.
However, once adhesions have formed, they can be chal-
Diagnosis The identification of adhesions, however, can lenging to resolve. Isolated single adhesions can be tran-
be challenging, both clinically and when using imaging. sected endoscopically, although many adhesions are more
Affected horses show lameness with, in acute cases, painful extensive and rapidly reform after transection.
foci in the region of the adhesion on palpation. One of the
best methods for confirming the presence of an adhesion is Expected outcome The prognosis with established
real-time ultrasound imaging during flexion and extension adhesions is guarded.
(a) (b)
Figure52.10 Sudden exacerbation (arrows) of proximal suspensory desmitis post-neurectomy in both transverse (a) and longitudinal
(b) ultrasound images. This horse had developed sudden proximal plantar metatarsal swelling and mild lameness about 8 months
after neurectomy of the deep branch of the lateral plantar nerve. Source: Roger K.W. Smith.
Exacerbationof TendonorLigament cases which have presented because of an exacerbation or

PathologyafterNeurectomy recurrence of the lameness (Schramme M.C.: personal
communication).
Definition Further trauma to tendons or ligaments after
Pain functions to limit loading. If this pain is removed
pain sensation has been removed secondary to neurectomy
by neurectomy and the pathological process is active
Risk factors Preceding tendon or ligament pathology
Pathogenesis Some tendon and ligament injuries are often

associated with persistent pain and lameness, in spite of
multiple attempts at treatment and prolonged periods of
rest. This is particularly common for deep digital flexor
tendinopathy in the forefoot and proximal suspensory
desmitis in the hindlimb. In these cases, neurectomy allows
resolution of the lameness purely by removing sensation
from the affected area.
Neurectomy of the deep branch of the lateral plantar
nerve for refractory proximal suspensory desmitis of the
hindlimb is now a common, and usually effective, treat-
ment [6] for the variation of conditions blocking out to this
region. There were no cases out of the 155 horses described
in the above study that suffered a sudden exacerbation of Figure52.11 Distal interphalangeal joint subluxation (solid
arrow) as a rare complication of deep digital flexor tendon
the suspensory pathology, although 1 of a further 39 cases rupture after palmar digital neurectomy. Note the extensive
described in the discussion did show these signs (giving a distal interphalangeal joint osteoarthritis and navicular bone
frequency of 1 in 194 cases or 0.5%). This author has, how- changes for which the neurectomy is likely to have been
ever, seen 2 cases of marked exacerbation of the suspen- performed. Note also that the toe is off the ground (dashed
arrow), which is indicative of deep digital flexor tendon rupture
sory desmitis following neurectomy, which presented with and evidence of dysplastic mineralization in the soft tissues
marked swelling in the proximal metatarsal region without possibly at the site of the neurectomy (dotted arrow). Source:
marked lameness (Figure 52.11). Others have described Roger K.W. Smith.
and/or has compromised the structural strength of a coaptation applied as a consequence of tendon surgery for
tendon or ligament, exacerbation of the pathology can traumatic injury or flexural deformity.
occur. This is well recognized for secondary rupture of
the deep digital flexor tendon following palmar digital Risk factor Casting
neurectomy (see Chapter 60: Complications of Peripheral
Pathogenesis Tendon homeostasis relies on regularly
Nerve Surgery). The deep digital flexor tendon provides
cyclical loading of the tissue at sub-injury levels; removal
significant palmar support to the distal interphalangeal
of load completely from a tendon for a prolonged period of
joint and so a consequence of deep digital flexor tendon
time results in the activation of catabolic enzymes and the
rupture (or transection) is palmar subluxation of the dis-
destruction of the tendon matrix. In addition, partial
tal interphalangeal joint.
transection also induces marked metabolic changes in the
Prevention It is important to ensure that the cases being tendon throughout its length [19]. Consequently, partially
neurectomized do not have substantial “active” tendon or lacerated tendons that have been protected from loading in
ligament pathology at the time of surgery. MRI evaluation a cast are more at risk of rupture if there is a sudden
of the deep digital flexor tendon is prudent prior to imposition of high load. Thus, immediately after the
performing a palmar digital neurectomy, as is ultrasound removal of a cast is a high-risk period for tendon rupture.
examination of the proximal suspensory ligament prior to This process can also occur in intact tendons that have had
neurectomy of the deep branch of the lateral plantar nerve. prolonged unloading as a result of acquired flexural
If marked pathology exists, a substantial period of rest deformities in adult horses. Therefore, following tenotomy/
should be given before (or after) surgery in an attempt to tenectomy and/or extensive adhesiolysis as a treatment for
maximize fibrous healing and/or the combination of the these acquired flexural deformities in adult horses, rupture
neurectomy procedure with intralesional treatment given of the remaining intact tendon can occur (Figure 52.12).
at the time of surgery.
Prevention When prolonged casting is used for the
treatment of tendon lacerations, protected loading
Diagnosis Severe exacerbation of the deep digital flexor
techniques for the damaged tendon should be considered
tendon after palmar digital neurectomy will result in distal
when the cast is removed. A Robert Jones bandage is
interphalangeal joint subluxation, which is most reliably
frequently applied after a cast is removed, but this is largely
identified using a lateromedial radiograph (Figure 52.11).
to prevent rebound oedema and provides insufficient
Such cases may not be very lame because of the effects of
support for the metacarpophalangeal/ metatarsophalangeal
the neurectomy, but can show toe elevation when weight-
joint in an adult horse [20]. A palmar splint or brace is an
bearing, characteristic of rupture of the deep digital flexor
effective alternative [20] and fitting a raised heel shoe can
tendon.
protect the deep digital flexor tendon. Similarly, joint
Severe exacerbation of the proximal suspensory ligament
support is necessary after multiple tenotomies for acquired
may again not be associated with a marked change in lame-
flexural deformities, although this may not eliminate the
ness because of the neurectomy, but can result in increased
risk entirely.
fetlock over-extension on weight-bearing.
Diagnosis and treatment As for Section on Exacerbation of
Treatment There are usually limited options for treatment unrecognized tendon or ligament damage
other than rest to allow the damage to repair. Subluxation
of the distal interphalangeal joint can be readily reduced by Expected outcome Complete rupture carries a poorer
using a raised heel shoe with caudal extension of the prognosis.
branches in the early stages, which can avoid significant
osteoarthritis and, with healing of the tendon, normal
Fragmentationof the Apexof the Patella
function can return.
Definition Abnormal fragmentation or bone formation of
Expected outcome Usually the severity of the exacerbation the apex of the patella after medial patellar ligament
indicates a guarded prognosis. desmotomy secondary to instability
Pathogenesis Surgical desmotomy of the medial patella

Tendonrupturefollowingcasting
ligament is an established technique for treating
Definition The risk of tendon rupture is increased when permanent upward fixation of the patella. This technique
the tendons have been protected from loading by external is relatively simple to perform using a bistoury knife in
(a) (b) (d)
(c)
(e)
Figure52.12 Tendon rupture after protected loading. (a) shows an acquired flexural deformity after chronic superficial digital flexor
tendinopathy. In order to get sufficient resolution of the deformity, in addition to removal of the fibrosed superficial digital flexor
tendon which had adhered to the accessory ligament of the deep digital flexor tendon, (b; arrow) desmotomy of the accessory
ligament of the deep digital flexor tendon was also performed. A distal limb cast was placed and the horse walked comfortably for 3
days postoperatively. There was then a sudden exacerbation of the lameness. The cast was removed 6 days postoperatively, which
revealed a good fetlock conformation (c). However, the toe elevated when the horse loaded the limb and ultrasound examination (d
and e) confirmed that the deep digital flexor tendon had ruptured in spite of being protected in a distal limb cast. (d) Transverse
ultrasound image from the mid-metacarpal region with arrow demonstrating the absence of the deep digital flexor tendon at the
rupture site (it was visible above and below this level). (e) Longitudinal ultrasound image from the same level showing the end of the
ruptured deep digital flexor tendon (arrow)). It is presumed that even the minimal loading of the deep digital flexor tendon inside the
cast had been sufficient to rupture the tendon, which had been weakened by stress protection from the fibrosed superficial digital
flexor tendon, adhered to the accessory ligament of the deep digital flexor tendon, as well as subsequent casting. Source: Roger K.W.
Smith.
the standing horse and hence became a popular treatment transection of one of its three retaining ligaments would
for both permanent and less severe forms of intermittent seem a logical explanation.
upward fixation, including horses demonstrating a variety
of delayed release of the patella when exercised. However, Prevention Although the frequency of observed apical
as a result of clinical observations in some operated patellar fragmentation is considered less frequent than
horses developing apical patellar fragmentation [21] described in the experimental study, it is logical to suggest
(Figure 52.13), an experimental study was performed on that medial patellar ligament desmotomy should only be
12 normal horses where the medial patellar ligament was performed for the most severely affected cases. In addition,
transected [22]. This resulted in 11 out of the 12 horses if performed, it should be followed by a period of rest to
developing changes on the apex of the patella. The allow the ligament to heal and the tracking of the patella to
mechanism is not fully understood but a change to the be re-established so as to minimize the risk of apical
tracking of the patella in the trochlear groove after fragmentation.
associated with an open approach to the digital sheath,

which included incisional breakdown and synovial fistulae.
In an attempt to minimize this risk, blind “semi-open”
approaches were advocated which involved a small incision
being made at the proximal end of the annular ligament and
scissors introduced to cut the annular ligament in a blind
fashion. However, this would also carry the risk of iatrogenic
damage to the manica flexoria. To avoid any entry into the
digital sheath, a mid-line approach through the midline
vinculum attachment between the palmar/plantar annular
ligament and the superficial digital flexor tendon has been
suggested. However, this also makes definition between the
annular ligament and the superficial digital flexor tendon
difficult to identify and consequently it is easy to continue
the desmotomy incision into the superficial digital flexor
tendon itself.
Open approaches to desmotomy of the accessory liga-
ments of the deep or superficial digital flexor tendons have
also been associated with complications. Such desmoto-
mies can be incomplete and hence fail to provide therapeu-
tic benefit. Desmotomy of the accessory ligament of the
deep digital flexor tendon is usually uncomplicated but can
give rise to excessive fibrosis at the surgery site, resulting in
Figure52.13 Fragmentation of the apex of the patella
(arrow) – a common complication post-medial patellar ligament a cosmetic blemish and occasionally adhesions to the adja-
desmotomy performed for the treatment of upward fixation of cent tendons with subsequent flexural deformities. Open
the patella. The horse from which this radiograph was obtained desmotomy of the accessory ligament of the superficial
was rested post-desmotomy but still developed an apical digital flexor tendon has been commonly associated with
fragment which was not present prior to surgery. Source: Roger
K.W. Smith. hematoma formation and wound dehiscence.
Prevention Tenoscopy has revolutionized tendon sheath

Diagnosis Latero-medial radiograph of the stifle and/or surgery because it avoids these complications and provides
ultrasonography of the apex of the patella will reveal bony better visualization of the structures within the tendon
fragmentation. Less severe pathology, such as cartilage sheaths. This has resulted in the identification of a number
fragmentation, may only be detectable arthroscopically. of conditions previously not recognized which has, in turn,
improved our diagnostic approach. It is now appreciated
Treatment Arthroscopic removal of the fragments is that a thickened palmar/plantar annular ligament does not
recommended, especially if joint effusion and lameness is necessarily indicate constriction and is frequently
evident. secondary to primary pathology within the digital sheath,
justifying that a tenoscopic evaluation prior to transection
Expected outcome This can still be favorable, especially of the annular ligament is essential. Furthermore,
after fragment removal. constriction of the annular ligament can be best assessed
by the resistance encountered when the arthroscope is
passed through the fetlock canal. Consequently, performing
IncisionalBreakdown,HematomaFormation
a tenoscopically-guided annular ligament desmotomy is
and SynovialFistulaeAssociatedwith Open
the best option for preventing complications related to an
Approachesto TendonSheaths
open approach.
Definition Secondary wound complications associated Minimally invasive techniques for accessory ligament
with open synovial surgical procedures desmotomies have been proposed as ways of avoiding com-
plications associated with the open approach. These can be
Pathogenesis Open transection of the palmar/plantar performed under ultrasound-guidance (accessory ligament
annular ligament is rarely performed now with the advent of of the deep digital flexor tendon [23]; or tenoscopically,
tenoscopy. This has also reduced the array of complications both accessory ligaments [5, 24]), although hemorrhage
References 755
during tenoscopic desmotomy of the accessory ligament of Treatment Conservative approaches to allow healing by
the superficial digital flexor tendon is not uncommon (see second intention are usually employed, although synovial
above). fistulae may require surgical closure to prevent secondary
infection. Secondary infection requires tenoscopic
Diagnosis Inspection of the surgical incision will readily debridement and lavage.
identify these complications. The leakage of straw-colored
fluid may be indicative of communication with the tendon Expected outcome The prognosis is favorable, except if the
sheath, although this can also be serous fluid from the tendon sheath becomes secondarily infected.,
subcutaneous tissues. Synoviocentesis is necessary to
confirm any secondary synovial sepsis, although this may
be challenging if the sheath is open and draining.
References
1 Lamb, M.M., Barrett, J.G., White, N.A. 2nd. et al. (2014). with intralesional polysulphated glycosaminoglycans.
Accuracy of low-field magnetic resonance imaging versus Equine Vet. Educ. 4 (6): 280–285.
radiography for guiding injection of equine distal 9 Hawthorn, A., Reardon, R., O’Meara, B. et al. (2016).
interphalangeal joint collateral ligaments. Vet. Radiol. Postoperative synovial sepsis following endoscopic
Ultrasound. 55 (2): 174–181. surgery: increased risk associated with the carpal sheath.
2 Garvican, E.R., Salavati, M., Smithm R.K.W. et al. (2016). Equine Vet. J. 48 (4): 430–433.
Exposure of a tendon extracellular matrix to synovial 10 Avella, C.S. and Smith, R.K.W. (2012). Diagnosis and
fluid triggers endogenous and engrafted cell death: a management of tendon and ligament disorders. In:
mechanism for failed healing of intrathecal tendon Equine Surgery (ed J.A. Auer and J.A. Stick), 1157–1179.
injuries. Connec.t Tissue Res. 58 (5): 438–446. St. Louis, MO: Elsevier.
3 Happonen, K.E., Heinegård, D., Saxne, T. et al. (2012). 11 Takahashi, T., Yoshihara, E., Mukai, K. et al. (2010). Use
Interactions of the complement system with molecules of of an implantable transducer to measure force in the
extracellular matrix: relevance for joint diseases. superficial digital flexor tendon in horses at walk, trot
Immunobiology. 217 (11): 1088–1096. and canter on a treadmill. Equine Vet. J. Suppl. (38):
4 Fiske-Jackson, A.R., Barker, W.H., Eliashar, E. et al. 496–501.
(2013). The use of intrathecal analgesia and contrast 12 Zhang, J., Keenan, C., and Wang, J.H. (2013). The effects
radiography as preoperative diagnostic methods for of dexamethasone on human patellar tendon stem cells:
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(1): 36–40. injury. J. Orthop. Res. 31: 105–110.
5 Southwood, L.L., Stashak, T.S., Kainer, R.A. et al. (1999). 13 O’Brien, E.J.O. and Smith, R.K.W. (2018). Mineralization
Desmotomy of the accessory ligament of the superficial can be an incidental ultrasonographic finding in equine
digital flexor tendon in the horse with use of a tenoscopic tendons and ligaments. Vet. Radiol. Ultrasound. 59 (5):
approach to the carpal sheath. Vet. Surg. 28 (2): 99–105. 613–623.
6 Dyson, S. and Murray, R. (2012). Management of 14 Haupt, J.L. and Caron, J.P. (2010). Navicular bursoscopy
hindlimb proximal suspensory desmopathy by in the horse: a comparative study. Vet. Surg. 39 (6):
neurectomy of the deep branch of the lateral plantar 742–747.
nerve and plantar fasciotomy: 155 horses (2003–2008). 15 David, F., Laverty, S., Marcoux, M. et al. (2011).
Equine Vet. J. 44 (3): 361–367. Electrosurgical tenoscopic desmotomy of the accessory
7 Sidhu, A.B.S., Rosanowski, S.M., Davis, A.M. et al. (2019). ligament of the superficial digital flexor muscle (proximal
Comparison of Metzenbaum scissors and Y-shaped check ligament) in horses. Vet. Surg. 40 (1): 46–53.
fasciotome for deep metatarsal fasciotomy for the 16 Nelson, B.B., Kawcak, C.E., Ehrhart, E.J. et al. (2015).
treatment of proximal suspensory ligament desmopathy radiofrequency probe and sharp transection for
in horses. Vet. Surg.48 (1): 57–63. tenoscopic-guided desmotomy of the accessory ligament
8 Smith, R.K.W. (1992). A case of superficial digital flexor of the superficial digital flexor tendon. Vet. Surg. 44 (6):
tendinitis: ultrasonographic examination and treatment 713–722.
17 McIlwraith, C. (2005). Tenoscopy. In: Diagnostic and 21 McIlwraith, C.W. (1990). Osteochondral fragmentation of
surgical arthroscopy. In: The Horse, 3e (ed: C.W. the distal aspect of the patella in horses. Equine Vet. J. 22
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764–773. 23 White, N.A. 2nd. (1995). Ultrasound-guided transection
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757
53
Complicationsof MuscleSurgery
Brad Nelson DVM, MS, PhD, DACVS-LA
College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO
Overview I ntraoperativeand Technical

Complications
Muscle is a highly vascular tissue with a large capillary net-
work surrounding individual muscle fibers. Despite high Hemorrhage
vascularity and the fast healing that occurs in most
See also Chapter 7: Complications Associated with
instances, muscle has a limited healing response to injury
Hemorrhage.
and surgical complications have the potential to restrict
muscle function or compromise the successful outcome of
Definition Hemorrhage is defined as escape of blood from
the procedure. When performing muscle surgery, it is
a vessel and occurs intraoperatively during dissection,
important to consider the degree of trauma, anticipated
though may go undetected until after the surgical procedure
amounts of hemorrhage or large amounts of dead space
is completed.
that may occur. Many of the complications that are
encountered can be prevented or minimized with sufficient
Risk factors Primary:
knowledge of regional anatomy and adhering to Halsted’s
principles of surgery: minimizing tissue trauma, meticulous ● Failure to recognize bleeding intraoperatively or bleed-
hemostasis, aseptic technique and obliteration of dead ing that is not recognized until after anesthetic recovery
space without excessive tension on tissues. ● Careless surgical technique or inappropriate use of
ligation methods
● Patient related factors (e.g. coagulopathy, infection or
L inflammation of tissues)
with MuscleSurgery Secondary:
● Devitalized tissue and foreign material remaining in the
wound
– Hemorrhage
● Infection
● Early postoperative complications ● Wound tension
– Infection
– Hematoma and Seroma Pathogenesis Primary hemorrhage occurs because of the
– Dehiscence surgical technique used, the lack of identifying bleeding
– Peripheral nerve injury vessels intraoperatively or may be related to intrinsic
patient factors (e.g. coagulopathy). Secondary hemorrhage
● Late postoperative complications occurs after surgery is completed and is usually related to
– Fibrosis the presence of foreign material, infection, or excessive
– Septic arthritis/tenosynovitis tension on the surgical site [1]. Direct (primary)
758 Complications of uscle Surgery
hemorrhage is usually related to the disruption of the large Treatment Intraoperative treatment includes suture
capillary network surrounding the muscle fibers within ligation or the use of electrosurgical or other vessel-sealing
the muscle. This leads to diffuse bleeding (seeping) rather devices (e.g. electrosurgical coagulation, LigaSure,
than bleeding from a single vessel [1]. Compared with hemoclips). With diffuse hemorrhage, digital pressure or
transection of vessels within muscle, disruption of larger topical hemostatic agents can be applied. Anastomosis of
vessels between muscle groups will cause more bleeding. large transected vessels can be considered, especially if
Postoperative hemorrhage (during or after anesthetic there is a lack of collateral circulation to the region due to
recovery) results from excessive tension on the tissues extensive soft tissue disruption.
overwhelming the sutures. The ligation method used to Postoperatively, directly observed bleeding vessels can be
maintain hemostasis intraoperatively might also fail (i.e. ligated with suture. Diffuse bleeding can be treated with
ligature failure or inappropriate use of vessel sealing compressive bandaging. Cold compressive therapy may
devices beyond specifications) promoting hemorrhage. also cause local vasoconstriction to reduce hemorrhage.
Infection or necrotic tissue remaining after surgery may Since blood is a favorable bacterial culture medium,
also locally induce hemorrhage through direct invasion or systemic antimicrobials should be considered if there is
secondarily by the release of local inflammatory cytokines, blood accumulation (e.g. hematoma) and strongly
which weakens soft tissues and vessels. recommended when there is communication with the
external environment (e.g. incisional discharge) or when
Prevention The best way to prevent hemorrhage is to use clean-contaminated, contaminated and infected
meticulous technique during dissection. The use of blunt procedures are performed.
over sharp dissection methods will minimize disruption of Bandages are initially changed every 24–48 hours,
the surrounding capillary network. Once hemorrhage depending upon the amount of hemorrhage. Too frequent
starts, maintaining hemostasis will prevent further blood bandage changes will counteract the benefit of the applied
loss and improve wound healing. Ligation methods to compression, causing persistent bleeding.
control hemorrhage require proper use within reported
specifications: monopolar and bipolar electrosurgical Expected outcome The typical amounts of hemorrhage
coagulation (vessels 2 mm and 3 mm, respectively), encountered during muscle surgery are not likely to
Ligasure [Covidien, Medtronic, Minneapolis MN] (vessels influence long-term outcomes and are usually acceptable.
7 mm), and suture ligation (all vessel diameters including Uncontrolled hemorrhage could lead to hematoma
>7 mm) [2]. formation or postoperative swelling that may delay wound
healing, promote dehiscence or lead to infection that can
Diagnosis Many surgical procedures involving muscle are reduce the successful outcome of the procedure. If severe
performed in relatively superficial locations. Thus, hemorrhage is encountered and not addressed, the horse’s
hemorrhage is usually observed directly. If deeper survival may be jeopardized.
dissection is performed, bleeding could be sequestered and
difficult to observe directly. Systemic derangements (e.g.
pale mucous membranes, tachycardia, declining packed
cell volume and total protein concentrations) indicate EarlyPostoperativeComplications
severe and clinically relevant amounts of blood loss,
though are rarely encountered in muscle surgery. Infection
Postoperatively, persistent hemorrhage may manifest as
Definition The inoculation and subsequent multiplication
soft tissue swelling underneath the incision (with or
of microorganisms at the site of surgery. Infection may
without drainage).
occur at the skin incision and/or within the deeper soft
tissues.
Monitoring If continued, hemorrhage postoperatively is
confined beneath the skin, and ultrasonography can reveal
Risk Factors
the amount of blood or increases in echogenicity that
would be consistent with organization into a hematoma. If ● Hematomas/seromas that become contaminated
hemorrhage drains through the incision, the amount ● Incisional dehiscence
observed in the bandage can be useful to determine if ● Poor aseptic preparation or technique
bleeding is hastening or declining. Systemic evaluation of ● Contamination of the surgery site
the patient is performed to ensure there are no clinically ● Poor anesthetic recovery compromising the integrity of
relevant consequences of the blood loss. incisional closure
Pathogenesis Intraoperatively, infection can result (2), and complete incisional dehiscence (2). Eight (40%)
following a break in aseptic technique exposing the surgical horses that developed a complication had an unsuccessful
site to bacteria. If hematomas/seromas develop, the outcome (relapse of crib-biting <1 year after surgery).
sequestered fluid can promote bacterial growth. Pressure Conversely, in horses without complications, 93% of proce-
building up underneath the incision from enlarging dures were successful. Though there was an association
hematomas/seromas will compromise the integrity of the between the development of complications and an unsuc-
closure and may lead to dehiscence and increased risk of cessful outcome, this was not significant in the multivaria-
infection. The surgical incision could also become infected ble analysis [3]. Because this surgical procedure leads to
due to contamination from the local environment if not the unavoidable creation of dead space, passive (Penrose)
covered with bandages or as a consequence of poor drains were placed along with compressive bandaging and
anesthetic recovery. If the infected tissues are sufficiently the authors also reported that meticulous dissection meth-
confined underneath the incision, then a capsule ods and hemostasis was maintained [3, 4]. Other drains
surrounding the infected tissue can develop forming an can be considered and this author prefers the use of a
abscess. closed suction drain (Figure 53.1) with pressure
The modified Forssell’s procedure is a technique used for bandaging.
the treatment of stereotypic crib-biting and has a reported Antebrachial fasciotomy is a rarely reported proce-
complication rate of 20–22% [3, 4]. In 4 out of 10 horses, dure [5, 6]. Incisional complications including infection
2 complications were directly associated with the surgical have been reported, though do not appear to compromise
procedure (incisional infection and incisional abscess) [4]. the success of the procedure [5, 6]. In these locations,
In another study, 20 out of 90 (22%) horses developed com- adherence to aseptic technique and compressive bandag-
plications and included: prolonged incisional drainage >2 ing are likely to prevent these complications from
weeks (7), incisional infection (6), hematoma (3), seroma developing.
Figure53.1 Placement of closed suction drains in a horse following the modified Forssell’s procedure for treatment of stereotypic
crib-biting. The left image shows the locations of the drains proximal and distal to the ventrally located incision. The right image
shows the elastic bandage material covering the incision with some compression that helps to reduce dead space and also shows how
the closed suction drains are secured to the horse. Because of the closed nature of this drain, the amount of fluid that accumulates
postoperatively can also be quantified and monitored. Source: Courtesy of Britta Leise.
Prevention The best way to prevent infection is to maintain After aseptic preparation and infusion of local anesthetic
an aseptic environment by using sterilized instrumentation subcutaneously at the planned site(s), an incision is made
and aseptic surgical techniques. Prophylactic antimicrobial through the skin and underlying soft tissue layers at the
therapy may prevent the development of infection if there is most ventral aspect of the fluid pocket, away from the
a breach in aseptic technique. Though prophylactic surgical incision. The ideal location for the incision can be
antimicrobial administration is not required for all surgical determined using ultrasound with or without placement of
procedures (clean surgeries), it is recommended when a needle to mark the location. The size of the incision is
moderate amounts of bleeding are anticipated. The presence made large enough to promote continued drainage and
of contaminated or infected tissues prior to surgery warrants blunt separation of the incisional tract using hemostatic
antimicrobial therapy. Using meticulous technique forceps will help prevent edematous subcutaneous tissues
intraoperatively will also prevent the accumulation of blood from obstructing drainage.
that could increase the risk of developing an infection. Following drainage, lavage of the cavity is performed
Postoperatively, effective bandaging and protection of the using 0.9% saline (dilute antiseptic solutions can be consid-
surgical site will decrease the risk of infection. ered, although are not necessary). If further tissue debride-
ment is needed, a bone curette can be inserted into the
Diagnosis Direct observation of purulent discharge exiting incision for mechanical debridement of the cavity lining or
the incision confirms the diagnosis, though the lack of can be filled with a hypertonic saline dressing for 24–48
visual exudate does not rule out infection. Preceding hours. A Penrose or other passive drain is placed to prevent
discharge, palpable swelling, heat and pain may be present premature closure of the incision and is usually retained
and can manifest as lameness. Adult horses with focal sites for at least 48 hours. Depending upon the degree of con-
of infection are typically afebrile. Ultrasonographic tamination, daily lavage is repeated until no further debris
evaluation of the region demonstrates fluid within the soft exits the cavity. After the drain is removed, the incisions
tissues. A fibrous capsule is identifiable once a mature heal by second intention.
abscess has formed. Although hyperechoic shadowing
within the fluid may support abscessation over hematoma/
seroma formation, distinguishing between these two Expected outcome With prompt recognition and treatment
entities can be difficult using ultrasound alone – especially of infection, the prognosis is usually acceptable. Delayed
in the early stages of infection. Fluid aspirates identifying identification or the development of infected synovial
increased neutrophilic inflammation with intracellular cavities risk decreasing the prognosis. This is mostly
bacteria confirm the diagnosis. Aerobic and anaerobic dependent upon how quickly the infection can be resolved
culture and susceptibility profiles of the fluid will determine without leading to secondary sequellae (persistent
the microorganisms involved. inflammation and fibrosis) that may restrict function.
Monitoring If there is adequate drainage, the amount of

discharge observed will indicate if the infection is persisting Hematomaand Seroma
or resolving, though premature closure of the drainage Definition Accumulation of blood or serous (transudate)
tract can indicate the formation of an abscess. fluid beneath the skin or within other soft tissues
Ultrasonography can also be used to monitor the amount
and character of fluid beneath the skin. Other physical and Risk factors Hematoma:
clinical examination parameters including lameness
evaluation (at a walk) are performed periodically to ● Incomplete hemostasis during surgery
monitor the horse’s comfort. ● Large amounts of dead space remaining after surgery
● Disruption of the surgical site during anesthetic recovery
Treatment The main goals of treatment are to remove any causing tissue tearing
nidus of infection and to promote drainage. Drainage can
● Coagulopathy
be accomplished using surgical incisions or through needle
aspiration, though this latter technique is reserved for very Seroma:
small volume fluid accumulation. Systemic broad-
● Large areas of dead space remain after surgery
spectrum antimicrobial therapy is recommended and is
ideally chosen based upon culture and sensitivity results, ● Disruption of the surgical site during anesthetic recovery
though commonly has to be selected empirically using causing tissue tearing
knowledge of commonly encountered organisms. ● Shearing forces between the skin and muscle
Pathogenesis Hematomas develop due to bleeding within occurred in 5 limbs in 4 horses (out of the 13 horses treated
a confined space. Inadequate hemostasis and incomplete bilaterally with surgery). Despite the high success rate,
closure of dead space promote their development. there was no comment on whether these complications
Overstretching of muscle from excessive tension on the affected the outcome and it should be remembered that
surgical site (i.e. during poor anesthetic recovery or this acquired form of reflex hypertonia can resolve sponta-
associated with suture placement) may cause suture failure neously [9, 11].
that generates dead space allowing for further blood
accumulation. Seromas occur from the accumulation of Prevention The best ways to prevent hematoma/seroma
serous fluid within a confined space and are composed of formation are to use meticulous surgical technique while
blood plasma/serum and inflammatory fluid from injured maintaining hemostasis and closing dead space. Drains
tissues. The fluid is generated as a consequence of should be considered in locations that are difficult to
inflammation or from shearing forces between the skin sufficiently close the dead space (Figure 53.1). Negative
and underlying musculature [7]. pressure wound therapy has been shown to decrease the
The size of the hematoma/seroma that forms is deter- development of seromas in humans [12]. Once a drain is
mined by the amount of fluid that is produced and elastic- placed, it remains until fluid production starts to decline
ity of skin and soft tissues in the region. Tight fascial (usually in 2–4 days). This time frame is also the same
compartments limit their size, while hematoma/seroma duration of the wound debridement phase of wound
formation in loose connective tissue areas can become healing. However, large areas of dead space or infection
quite large. Surgical procedures that generate dead space may require longer periods of drain use [13]. Since drains
(e.g. the modified Forssell’s procedure for the treatment of are foreign bodies, their presence will also stimulate the
crib-biting) and that are difficult to close are at increased development of fluid and signifies why drains require
risk of hematoma/seroma formation [3]. removal before wound drainage ceases. Conversely,
In a study of horses undergoing the modified Forsell’s premature removal of surgical drains leads to the
procedure to correct stereotypic crib-biting, 25% of the development of seromas in dogs [14].
complications encountered were due to hematoma/seroma
formation. All three horses with hematoma formation and Diagnosis A fluctuant soft tissue swelling is usually
one with seroma formation resumed crib-biting after palpable underneath the skin. However, if the hematoma/
surgery (procedure failed) [3]. However, the horses that seroma develops in deeper tissues, swelling underneath
developed hematoma/seromas also had a prolonged the skin may not be apparent. Large amounts of
duration of crib-biting (>3 years) prior to surgery and this accumulated fluid may increase pressure at the incision
factor was associated with lower success than those that and cause dehiscence with discharge. Ultrasound
had less crib-biting prior to surgery [3]. Thus, the decreased examination will reveal fluid accumulation and may give
success in horses that developed hematoma/seroma insight into the characteristics of the fluid. Hematomas can
complications may be confounded by a pre-surgical factor. have increased echogenicity compared with seromas, but
Fasciotomy procedures are performed to relieve pressure this is also dependent upon the organization and maturity
built up beneath the underlying fascia. The most common of the hematoma. The diagnosis is confirmed following
locations where this is performed include the plantar fascia percutaneous aspiration of the fluid or collecting draining
for treatment of proximal suspensory desmopathy and the fluid and analyzing its composition. Cytologic fluid analysis
antebrachial fascia for traumatic compartment and culture and sensitivity can be performed to distinguish
syndrome [5, 6, 8]. In a large case series of horses treated hematomas/seromas from infection. The time frame of
with plantar fasciotomy (and neurectomy of the deep development following surgery can suggest an etiology. If
branch of the lateral plantar nerve) there were minimal developing less than 24 hours after surgery, a hematoma is
complications, but did include seroma formation, damage more likely than a seroma, which usually progressively
to the proximal suspensory ligament and postoperative enlarges 2–4 days after surgery.
swelling and a subsequent case not included in this series
developed incisional dehiscence following seroma Treatment Treatment strategies for hematomas/seromas
formation [8]. Lateral digital extensor tenectomy/partial are dependent upon the amount and location of the
myectomy is performed for the treatment of reflex accumulated fluid. Once infection is ruled out, small
hypertonia (Stringhalt). Reported complications include hematomas or seromas can be treated conservatively with
infection, dehiscence, seroma formation, and septic monitoring, application of cold packs in the early
tenosynovitis of the enveloping tendon sheath [9, 10]. In postoperative period and with compressive bandaging. If
one study, seroma formation with incisional dehiscence the swelling is painful, compromises function in the region,
or is large, fluid removal through aspiration or open Pathogenesis Inadequate technique/suture selection will
drainage is warranted. Before percutaneous drainage is increase the risk of suture breakage, suture pulling through
selected as the only treatment, the potential for infection is the tissue or unraveling knots causing separation of the
strongly considered. While it is tempting to drain wound edges. Increased pressure beneath the wound from
hematomas and seromas, secondary infection can persist a hematoma or seroma, shearing forces deep to the incision,
within sutures or implants placed during surgery, leading or suturing of devitalized tissue will increase the risk of
to a nidus of infection that is difficult to remove without knot or suture failure, even when proper suturing technique
further surgical intervention and risking the success of the has been followed and appropriate suture material is
procedure. chosen. Infection leads to decreased tissue strength through
For percutaneous drainage, the skin is aseptically pre- increased inflammatory mediators that weaken the tissue
pared. A sterile needle is inserted into the fluid and aspi- and buildup of underlying fluid that puts pressure on the
rated using a syringe or suction. If aspiration is not effective, incision leading to suture pulling through the tissue
open drainage is recommended, as described above for (Figure 53.2) [18].
infection. Once the fluid is removed, compressive bandag-
ing and local application of cold packs will help reduce the Prevention Using appropriate suture materials and
hematoma or seroma from reforming in the resultant dead technique will prevent the development of dehiscence.
space. Because of the risk of infection, antimicrobial ther- Sutures should be placed in healthy and viable tissue
apy is considered. whenever possible. Tension-relieving patterns (e.g. vertical
mattress, near-far-far-near) or other skin mobilization
Expected outcome With appropriate treatment, outcomes methods (e.g. skin undermining, tension-relieving
are typically favorable after the development of hematomas incisions, plastic surgery techniques) are considered to
or seromas. However, their presence can increase the risk counteract tension at the closure site. Bandaging is used to
of infection or delay wound healing by alterations of the protect the incision from contamination and infection.
local blood supply and may negatively affect outcomes [3, Suture removal is performed after an adequate time for
16]. Depending upon their size, the time for reabsorption incisional healing has elapsed (usually 12–14 days) and the
of hematomas and seromas can take weeks to months. horse is kept on stall confinement until the incision is
Hematomas can organize into masses that do not resorb healed prior to allowing increased levels of activity. Some
and in humans have been successfully resolved following factors including the unpredictability of anesthetic
hyperthermia, shockwave therapy or surgical excision. [26, recovery cannot be prevented.
27]. Secondary infection of hematomas/seromas are more After semitendinosus tenotomy for treatment of fibrotic
likely to compromise the success of the surgical procedure myopathy, 2 out of 4 horses had skin dehiscence and
than if they resolve without infection. abscess formation. Both horses subsequently had a
successful outcome after the calcaneal insertion was
transected in the first horse and after abscess drainage in
Dehiscence the second [19].
Definition Dehiscence is the separation or disruption of

Diagnosis The diagnosis of skin dehiscence is with visual
wound edges following closure. It can refer to the skin observation of the separated wound edges. The dehiscence
incisions with or without involvement of deeper tissues. of deeper soft tissues without skin disruption usually
requires ultrasound examination.
Risk Factors
● Inadequate technique: ineffective selection of suture Monitoring Visual inspection of the wound edges is
material, size, or pattern or knot tying performed on a daily basis. This allows cleaning and
debridement of the wound that can be performed as
● Excessive tension on sutures: increased motion during or
necessary while the incision heals by second intention.
after anesthetic recovery, underlying pressure from a
Ultrasound is useful for the monitoring of deeper tissue
hematoma/seroma or shearing forces in tissues deep to
dehiscence and the secondary fluid accumulation that
the incision
builds up in the generated dead space.
● Suturing of devitalized or weakened tissue or tissue with
a compromised blood supply Treatment The underlying causes of dehiscence need to
● Premature suture removal be addressed (e.g. hematoma/seroma, infection). The
● Infection wound edges are cleaned daily with 0.9% saline or dilute
Figure53.2 Dehiscence of a pectoral wound closure caused by excessive tension on the sutures. The left image shows a partial skin
closure after primary closure failed. Initially, primary closure of the wound (using near-far-far-near sutures) resulted in successful
apposition of both skin edges. However, as the horse moved, the excessive tension on the sutures caused them to break. Tension-
relieving sutures (near-far-far-near, quilled horizontal mattress) were placed loosely to help reduce environmental contamination
while the wound healed by second intention. A large elastic stockinette (right image) was also placed on the horse’s thorax to help
retain a combined cotton bandage over the wound, which further protected the site from contamination. This large stockinette was
easily removed and replaced streamlining bandage changes. Source: Brad Nelson.
antiseptic solution. The skin can be cleaned with Expected outcome Dehiscence significantly delays wound
antiseptic soaps (e.g. betadine or chlorhexidine scrub) but healing, though outcomes are usually acceptable with
should not contact deeper soft tissues due to the resultant appropriate treatments. Second intention healing is more
cytotoxicity [20]. Primary closure of an acute dehiscence likely to have decreased cosmesis than primary closure.
can be considered by using large monofilament skin Deep soft tissue dehiscence is also likely to have a favorable
sutures with drain placement; although, the outcome, though secondary infection in these locations
contamination commonly encountered from the can compromise success.
environment usually warrants second intention healing.
Placement of multifilament sutures in the tissues deep to
skin should be avoided as they create a potential nidus of PeripheralNerveInjury
infection [21]. Definition Iatrogenic injury to the nerve during the
Local debridement of the incisional edges is performed surgical procedure. Peripheral nerve injury is also defined
as needed and bandaging of the region is recommended to by the degree of nerve damage. Neuropraxia is the (usually
prevent further contamination. The application of topical transient) disruption of nerve conduction without damage
antimicrobial ointments is not indicated, although can to axon, while disruption of the axon is termed axonotmesis.
provide a barrier to reduce further contamination. Once More extensive damage to the surrounding connective
granulation tissue is present and the local infection is tissue sheath including the endoneurium, perineurium
under control, bandage changes are less frequent. and/or epineurium are defined as neurotmesis.
Dehiscence beneath the skin can usually be monitored
without further treatment unless large amounts of fluid
Risk Factors
accumulate or infection is suspected, and then systemic
antimicrobial therapy is warranted with or without surgical ● Incomplete knowledge of surgical anatomy
drainage. ● Aggressive surgical technique
Pathogenesis After blunt or sharp trauma, pressure caused also be considered. The amount of muscle atrophy can
by the regional soft tissue swelling (e.g. hematoma/seroma) also be monitored but lags behind improvements in nerve
results in the dysfunction of normal nerve conduction. healing.
Bruising or inflammation causes injury to the myelin
sheath but does not damage the axon (neuropraxia) [22]. Treatment Nonsurgical management of nerve injury is
Axonotmesis involves injury to the axon, while neurotmesis targeted at reducing inflammation and swelling, while
is even further damage of the nerve and perineural tissues. providing supportive care to prevent excessive unilateral
With axonotmesis and neurotomesis, there is degeneration weight -bearing that promotes the development of
between the neuron cell body and the distal segments of laminitis. Treatment options to decrease inflammation
the nerve that innervate muscle. As the severity of the include the administration of non-steroidal anti-
injury increases, so does the time needed for the damaged inflammatory drugs (systemic or topical), dimethylsulfoxide
nerve to reinnervate and regain function [22]. (DMSO), corticosteroids and cold-water hydrotherapy.
Gabapentin can also be considered if there is neuropathic
Prevention The ways to prevent peripheral nerve injury pain [25]. Cold and active compressive therapy (Game
are to recognize the anatomy of the local nerve supply in Ready, Concord CA) may also help decrease inflammation
the regions where surgery is being performed. Also, blunt and swelling. If accessible, the limb is bandaged and
dissection is less likely to cause nerve injury than sharp splinting can be considered if the horse is unable to bear
dissection, though aggressive dissection techniques weight. Foot support on the contralateral limb is also
irrespective of method will not prevent iatrogenic considered. The horse is to remain in stall confinement to
damage [22]. Proper anesthetic positioning with adequate prevent further injury. Surgical treatment involves
padding is also important to prevent nerve injury – notably decompression of any structures impinging upon the nerve
the radial and femoral nerves. or, if the nerve has been transected, anastomosis can be
considered [26, 27].
Diagnosis Clinical signs, including gait evaluation, testing
of muscle reflexes and cutaneous sensation, can indicate Expected outcome Expected outcomes are variable, based
the nerve has been damaged. Examples of nerves at risk for upon the degree of nerve injury. If only minor neuronal
injury include the ulnar nerve in antebrachial fasciotomy inflammation (neuropraxia) occurs, it will likely resolve
and the common peroneal nerve during tumoral calcinosis within a few days and there are usually no lasting effects.
removal in the caudal stifle [5, 9, 23]. Horses with ulnar As the degree of nerve damage increases, so does the time
nerve damage may demonstrate a stiff gait (can be normal needed to recover from the injury [22]. Gait abnormalities
without concurrent median nerve injury) and hypalgesia resolve as normal nerve function returns. Muscle atrophy
of the lateral metacarpus/caudal antebrachium. Injury of similarly resolves with healing and re-innervation of the
the common peroneal nerve can result in extension of the damaged nerve. Persistent muscle atrophy may not
tarsus with flexion of the metacarpophalangeal joint and prevent a successful outcome, but is depended upon the
toe dragging. Horses commonly stand on the dorsum of degree of atrophy and the muscle groups affected [22].
their fetlock with hypalgesia over the craniolateral aspect Severe nerve injuries or those that do not respond in 12
of the tibia, tarsus and metatarsus [9, 24]. Muscle atrophy months are generally considered to have a poor
of the supplied muscles (ulnar nerve: superficial digital prognosis [22, 28].
flexor and flexor carpi ulnaris muscles; common peroneal
nerve: cranial tibial and long/lateral digital extensor
muscles) can take 2 weeks after injury to become apparent.
Muscle atrophy is less common with neuropraxia than
axonotmesis or neurotmesis. Nerve stimulation techniques
Fibrosis
(e.g. electromyography) may help to distinguish the degree
of nerve injury but require at least 7 days after injury to be Definition Fibrosis is the formation of scar tissue after soft
useful [22, 24]. tissue injury that occurs because the degree of muscle
tissue damage is incapable of full regeneration. The amount
Monitoring In general, supportive care and monitoring of fibrosis and the region affected will depend upon
of the horse’s overall comfort is the most important. whether it restricts movement and is clinically relevant to
Periodic gait evaluation can be performed though, the horse. While some fibrosis is expected and typically
depending upon the severity of injury, it may take weeks unavoidable during muscle surgery, strategies should be
to notice improvement. Nerve stimulation techniques can undertaken to minimize its development.
Risk Factors best ways to prevent the development of fibrosis. In

locations where this damage is unavoidable, incorporation
● Extensive tissue loss
of rehabilitation techniques (stretching exercises)
● Damage to deep tissues
postoperatively may help reduce the degree of functional
restriction [40, 41]. Using semitendinosis tenotomy on the
Pathogenesis Once muscle is damaged, myofibers contract medial aspect of the limb instead of resecting the fibrotic
while macrophages remove devitalized tissue and satellite muscle directly is likely to reduce further fibrosis. [19, 38].
cells (subpopulation of skeletal muscle stem cells) under Transforming growth factor β1 (TGF-β1) has been
the stimulation of growth factor cytokines differentiate implicated in the pathogenesis of fibrosis and counteracting
into myoblasts. When the myofibers contract, the resultant expression with decorin, relaxin, and antibodies against
space is filled with a hematoma [29–31]. With large TGF-β1 have been investigated in humans, though not in
remaining spaces, the ability for adjacent muscle to horses [30].
regenerate may be compromised, thus generating fibrotic
tissue. Also, damage to the cellular basement inhibits Diagnosis Fibrosis is usually detected by observing an
revascularization and re-innervation promoting the altered and restricted gait. Affected muscle tissue is firm
development of fibrosis. [30, 32]. Minor muscle injury not upon palpation. Moving the limb through passive range of
involving the basement membrane does have the capability motion can aid in its detection. Ultrasound can be useful by
to fully regenerate without compromising function [30]. demonstrating a focal and well-defined area of
Low intensity pulsed ultrasound in experimental rat stud- hyperechogenicity [42].
ies have shown a decrease in inflammatory cells that could
lead to fibrosis [33]. Therapeutic ultrasound has been used Monitoring Once fibrosis has formed, there is little that
to treat soft tissue injuries in horses [34, 35]. While heating can be done to reverse the process. Therefore, after surgery
effects on the superficial and deep digital flexor tendons has been performed in muscle regions susceptible to
after therapeutic ultrasound were observed, there was no fibrosis, periodic gait evaluation and placing the limb
effect on epaxial musculature [35]. Further investigation of through a passive range of motion can help detect the early
therapeutic ultrasound and its ability to reduce fibrosis is development of fibrosis.
warranted in horses. ESWT has been shown to reduce myofi-
broblast formation and decrease hypertrophic scar forma- Treatment Fibrotic tissue can be surgically resected in
tion in humans [36, 37]. In horses, ESWT reduces pain and attempts to provide more movement to the region.
is used for treatment of some orthopedic conditions (e.g. However, there is a high likelihood of recurrence.
osteoarthritis, desmitis), though studies to investigate its Rehabilitation techniques including physiotherapy and
ability to reduce muscle fibrosis are still required [34]. Low stretching exercises, therapeutic ultrasound, extracorporeal
level laser therapy has also been used for treatment of soft shockwave therapy (ESWT) and laser therapy, may help
tissue injuries [34]. Its purported benefit is also to stimulate reduce the degree of constriction [40, 41]. However, unless
tissue healing while reducing inflammation and pain. The rehabilitation methods are instituted early before the
benefits of these therapeutic methods are to reduce the for- fibrotic tissue is formed or the fibrosis is mild, these
mation of muscle fibrosis, but their ability to reverse muscle methods are unlikely to completely resolve the
fibrosis once it is formed is unknown. condition [43]. After muscle surgery in areas susceptible to
Horses with fibrotic (± ossifying) myopathy are treated fibrosis (semitendinosus or semimembranosus muscle for
with myotomy of the affected muscle or tenotomy of the treatment of fibrotic myopathy), rehabilitation stretching
semitendinosus muscle. Recurrence after myotomy of the exercises should be considered postoperatively. Surgical
semitendinosus muscle occurs in about 33% of cases and procedures that reduce the chance of fibrosis should also
can be attributed to fibrosis [38]. By using the be considered [19].
semitendinosus tenotomy procedure, the damaged muscle
is avoided, although it may not completely resolve the gait Expected outcome In most locations where muscle surgery
abnormality in severe injury or if the semimembranosus is performed, there is a low risk of fibrosis affecting the
muscle is affected [9, 19, 39]. Stretching rehabilitation outcome of the procedure. If it develops after
exercises are a great complement to these surgical tech- semitendinosus (or semimembranosus) muscle resection
niques and will likely help improve outcomes. or after lateral digital extensor myotenectomy, the outcome
is usually unfavorable as the horse continues to have an
PreventionAdhering to Halsted’s principles of surgery altered gait [38, 44]. Repeat surgeries can be performed to
and minimizing the damage to adjacent muscle are the resect the fibrotic tissue, but with a high likelihood of the
fibrosis reforming without incorporation of additional Tumoral calcinosis (calcinosis circumscripta) lesions
therapeutic strategies that attempt to prevent fibrous have a propensity to be adjacent to joint capsules, espe-
reattachment [38, 41]. Reattachment of transected muscles cially the caudal stifle. Surrounded by a thick capsule
through fibrosis following the modified Forssell’s procedure themselves, separation from the joint can be challenging
for treatment of stereotypic crib-biting and semitendinosus and therefore risks penetration of the synovial space. The
myectomy have been implicated in the failure of both location of the common peroneal nerve, popliteal artery
procedures [3, 38]. and vein and popliteal tendon are on the caudolateral
aspect of the limb [23]. Depending upon the amount of tis-
sue removed (i.e. size of the mass), bandaging may be
SepticArthritis/Tenosynovitis
important to prevent hematoma/seroma formation, dehis-
Also see Chapter 45: Complications of Synovial Endoscopic cence or septic arthritis due to inadvertent or unavoidable
Surgery (Arthroscopy, Tenoscopy, Bursoscopy). penetration into the joint [9].
Definition The inoculation and subsequent multiplication Prevention Knowledge of surgical anatomy and careful
of microorganisms within a synovial cavity leading to surgical technique will minimize the development of
synovitis and infection. sepsis. Prophylactic antimicrobial therapy is recommended
if there is risk of penetrating a synovial structure.
Risk Factors
Diagnosis Pain, joint swelling, and severe lameness are
● Incomplete knowledge of surgical anatomy
usually observed. If synovial fluid is draining, then the
● Unrecognized penetration of the synovial cavity without
degree of lameness is usually less severe than if confined to
proper antimicrobial prophylaxis
the synovial cavity, because of increased joint distension
and pressure. Adult horses are usually afebrile.
Pathogenesis A break in aseptic technique and inoculation
Synoviocentesis reveals elevated neutrophilic inflammation
of bacteria into the synovial cavity during dissection leads
and total protein concentrations; synovial fluid culture and
to persistent septic inflammation and synovitis causing
sensitivity can reveal the offending organism(s) [45].
effusion and lameness. Although synovial structures are
not expected to be involved during most muscle surgery
Monitoring Serial evaluation of the horse’s lameness and
procedures, there are a few exceptions. The lateral digital
synovial fluid can be useful to determine if treatments are
extensor tendon is encased within a synovial sheath. When
successful.
portions of the lateral digital extensor muscle and tendon
are removed for horses with reflex hypertonia (stringhalt),
Treatment Antimicrobial (combination of local and
the synovial sheath is penetrated. Also, a common location
systemic) and anti-inflammatory therapies are indicated.
for tumoral calcinosis (calcinosis circumscripta) is the
Joint lavage is performed either with needles or
caudal aspect of the stifle, which is adjacent to the
arthroscopically [45, 46].
femorotibial joints. The tendency for these lesions to attach
to the joint capsule and the deep dissection needed for their
Expected outcome With prompt recognition and treatment,
removal risks penetration into the femorotibial joint.
most cases will have a favorable outcome [45–47].
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54
Complicationsof RegenerativeMedicine
Ashlee E. Watts DVM, PhD, DACVS
Texas A&M University, College Station, Texas
Overview ImmuneReaction
Regenerative medicine has been used in the horse for a Definition Although rarely cited in the literature, the
few decades. To date, regenerative medicine experience most common complication of therapeutics used in
has been largely for tendon and ligament injury by ultra- regenerative medicine has been immune recognition of
sound guided intra-lesional injection. The second-most the regenerative medicine product and resultant
common use has been intra-articular injection for carti- inflammation and host immune responses against the
lage injury or osteoarthritis. Regenerative medicine regenerative product [4–6].
approaches have also been used for wound healing, lami- Immune recognition can be via innate immunity or adap-
nitis, eye conditions, lung conditions and almost any tive immunity or both. Adaptive immunity will worsen with
other disorder. The most common approaches have been repeated exposure. Immune reaction can induce signs or
platelet rich plasma (PRP), interleukin-1 receptor antago- inflammation and/or can result in destruction of the regen-
nist protein (IRAP) and autologous stem cells [1]. Many erative medicine product by the recipient immune system.
other regenerative medicine products including amnion, In other words, this complication could neutralize the activ-
allogeneic (non-self) stem cells and stem cell products, ity of an otherwise effective therapeutic or it could even
xenogeneic (other species) stem cells and stem cell prod- induce hypersensitivity reactions including anaphylaxis. It is
ucts, porcine urinary bladder matrix, growth factors, and important to remember that lack of clinically apparent infu-
antibodies have been used by equine veterinarians. Most sion-related toxicity does not equate to lack of
approaches are expected to provide broad effects such as allo-recognition.
trophic (pro-growth) and/or anti-inflammatory effects The synovial joint or tendon sheath is particularly
and a few are used for tissue replacement. A few prone to immune reactions, due to the confined localiza-
approaches are more targeted to the disease process itself, tion of the injected product and the enhanced immune
with specific and measurable mechanisms of action, like recognition and immune response by the synovial mem-
IRAP for blocking Il-1beta induced inflammation in the brane cells [5].
joint [2] and miRNA29a for blocking scar tissue accumu-
lation in tendon injury [3].
Risk Factors
● Repeated administration
L ● Intra-synovial administration
with RegenerativeMedicine ● Use of an allogeneic (same species, different individual)
product [7]
● Immune reaction ● Use of a xenogeneic (different species) product
● Worsened inflammation ● Use of an autologous (self-derived) product that is
● Ectopic tissue formation contaminated with non-self additives such as fetal
● Excessive fibrosis in tendon or ligament bovine serum, used during ex vivo production [5, 8]
770 Complications of egenerative edicine
Pathogenesis Other than entirely autologous (self) many autologous products can become contaminated with
products, many regenerative medicine therapeutics are xenogeneic proteins during the laboratory preparation
immunogenic due to the presence of xenogeneic (other steps [5, 8].
species) or allogeneic (non-self) cells, proteins, cytokines,
biomolecules, or antibodies [9]. This is often overlooked Diagnosis When immune reactions are mild, there may be
because many sources of allogeneic therapies and even no clinical signs noted during routine veterinary
xenogeneic therapies have been labeled as immune monitoring. Unfortunately, even when there are no clinical
privileged, leading users to believe that the recipient signs, immune reaction could be occurring, resulting in
immune system will not recognize the product as non- destruction of the regenerative therapeutic by the
self. Unfortunately, immune privilege does not equate to recipient’s immune system. Destruction of the regenerative
immune silence. Any equine product that is not self- therapeutic by the recipient immune system would reduce
derived is an allogeneic product, subject to innate or efficacy of the therapeutic [9].
adaptive immune recognition and unless the donor and After local administration, when immune reactions lead
recipient happen to be of the same MHC haplotype, the to clinical signs, they are usually recognized within 6–24
recipient is likely to recognize the product as foreign with hours of treatment. Clinical signs will depend on the site of
resultant immune reaction [9]. The immune reaction may therapeutic application. In joints, there will be the clinical
cause little observable harm other than destruction of the appearance of a joint flare with synovial effusion, peri-
therapeutic product or it may cause severe anaphylactic capsular swelling, edema and heat, abnormal synovial
reaction and death of the recipient. The degree of immune cytology and lameness. In tendon or ligament, there will be
reaction will depend the site of therapeutic administration, similar signs of localized swelling, edema and heat around
the immune distance between the host and recipient the injection site, swelling of the tendon or ligament itself,
haplotypes, the dose of the product used and whether it is lameness and possibly even enlargement of the core lesion
the first or subsequent exposure to the product. This itself. Joint flares can be distinguished from a joint sepsis
explains why an allogeneic product might appear to be by the percentage of neutrophils, which will be elevated
safe with minimal observed adverse events in one but not as high as a septic joint (>90%) and by the synovial
recipient, while another recipient of the same species will lactate, which will be elevated but not as high as a septic
develop severe immune reaction including joint (>8). When sepsis versus flare is not clear,
anaphylaxis [10]. microbiological testing should be utilized. Tendon and
Even autologous products can induce an immune ligament flares are more difficult to distinguish from a
response due to accumulation of xenogeneic biomolecules septic process, but in general, the rapid onset supports
during product development ex vivo [11]. An example of immune reaction versus sepsis. Immune recognition of
this would be the use of fetal bovine serum supplementation topical regenerative medicine therapeutics on wounds is
during culture expansion of mesenchymal stem cells. more difficult to recognize. Increased inflammatory
Contaminating biomolecules from fetal bovine serum exudate might indicate immune recognition.
within autologous cells will induce recipient immune When immune reactions are severe, clinical signs of
responses, which are likely to lead to immune targeting anaphylaxis could occur within moments of
and destruction of injected cells [5, 8]. administration [10].
Prevention To prevent immune recognition of regenerative Monitoring Monitor for systemic signs of inflammation
products, use only autologous products (e.g. such as lameness, fever, tachypnea, and tachycardia and
IRAP, PRP, etc.) that have not been contaminated with local signs such as swelling, heat, and pain on palpation of
non-self additives during production. When xenogeneic or the injected structure.
allogeneic products will be used, use only therapeutics
with thoroughly understood and validated immunologic Treatment Treat local reactions symptomatically with
properties that have been approved by the FDA, which anti-inflammatory medications, icing, wrapping and rest.
should ensure a thorough understanding of immunologic Treat systemic reactions symptomatically with epinephrine,
properties. There are currently no approved xenogeneic or anti-histamines, anti-inflammatory medications, airway
allogeneic veterinary regenerative products on the market, support and blood pressure support.
so until one is approved, allogeneic and xenogeneic
products should not be used. Use of entirely autologous Expected outcome Significant flares, especially in tendon
(self-derived without xenogenic (non-self) contamination) and ligament, can result in significant worsening of the
products would abolish this risk completely. Keep in mind, original problem with significant increases in lesion cross-
Ectopic Tissue Formation 771
sectional area and possibly even tendon or ligament all products remain sterile throughout the entire production
rupture. Presumably, this is due to worsened inflammation process and should not depend solely on filtration at the
and accumulation of degradative enzymes within the core final preparation step, which will not remove contaminating
lesion. The worst-case scenario could be as severe as tendon endotoxin.
or ligament rupture. Mild flares in tendon or ligament may
have minimal detectable long-term effects. Within the joint Diagnosis Usually worsened inflammation that is not due
it appears that even severe flares, although stressful for the to immune recognition is noted within the first 5–7 days
treating clinician and owner, have minimal negative effect after treatment. Clinical signs will depend on the site of
on the long-term outcome. Topical therapy flares may slow therapeutic application. In joints, there will be synovial
wound healing. It is important to realize that an immune effusion, peri-capsular swelling, edema and heat, abnormal
reaction could indicate that the regenerative medicine synovial cytology and/or lameness. In tendon or ligament,
therapeutic will have reduced potency (duration and there will be similar signs of localized swelling, edema and
degree of effect) due to destruction and or clearance of the heat around the injection site, swelling of the tendon or
product from the desired location. ligament itself, lameness and possibly enlargement of the
Anaphylaxis could result in patient death. core lesion itself. To distinguish inflammation from joint
sepsis, synovial fluid should be analyzed and microbiological
cultures submitted, as outlined above for immune
recognition.
WorsenedInflammation
Monitoring Monitor for lameness, swelling, heat, and pain
Worsened inflammation independent of
Definition
on palpation. Monitor the ultrasound appearance of tendon
immune recognition can occur when injected products
or ligament injury.
contain white blood cells, inflammatory cytokines,
chemokines or contaminants like endotoxin.
Treatment Treat symptomatically with anti-inflammatory
medications, icing, wrapping and rest
Risk Factors
● The presence of increased concentration of WBCs in the Expected outcome Cosmetic blemishes at the site of
regenerative medicine product might increase the risk injection have occurred in horses, presumably due to
for worsened inflammation [12]. worsened inflammation from the regenerative product
● Poor aseptic technique during sample collection can lead used [13]. If the inflammation is severe, it can lead to
to the presence of bacterial-derived products such as enlargement of tendon or ligament lesions and even
endotoxin in the regenerative medicine product. complete tendon or ligament rupture.
Pathogenesis When WBCs are the cause of worsened

inflammation it may be due to inflammatory enzymes, EctopicTissueFormation
chemokines and/or cytokines released by WBCs. When
endotoxin is the cause of worsened inflammation, it is Definition Ectopic tissue formation and or tumor
usually due to bacterial growth during some phase of formation are potential complications of stem cell
product preparation. An example where this may occur is transplantation.
in the preparation of autologous IL-1 receptor antagonist
protein. During the overnight incubation process, Risk factors Unknown. In theory, use of stem cells with
endotoxin could accumulate due to bacterial growth, greater potency (e.g. embryonic vs. adult-derived cells)
which would not be removed by filtration at the final might increase the risk.
preparation step.
Pathogenesis The exact mechanism is unknown but
Prevention Unfortunately, there is no consensus on the presumed to be due to differentiation ability and relatively
ideal concentration of WBCs in blood-derived regenerative unlimited growth potential of stem cells. This is because of
products. Practitioners are encouraged to understand the the multiple tissue type differentiation potential and the
expected concentrations of WBCs in the product they are somewhat unlimited growth potential of stem cells [14]. In
using and encouraged to measure the change in WBC people, a single report has documented tumor formation in
concentration when preparing autologous blood derived the spinal cord 8 years after stem cell transplantation.
products on their patients. Practitioners should ensure that There have been no reports of this complication in horses.
772 Complications of egenerative edicine
Prevention Unknown pathogenesis appears to be regulated by diverse processes

that are perturbed in damaged tendon [15]. Regenerative
Diagnosis Biopsy therapies that are meant to decrease the accumulation of
Monitoring Monitor for mass formation collagen type III may result in a healed tendon that is more
like a normal tendon compared to other regenerative
Expected outcome Unknown therapies that increase the accumulation of collagen type
III [3].
xcessiveFibrosisin Tendonor
E Prevention Use products that are known to reduce the
Ligament accumulation of collagen type III and that enhance the
accumulation of collagen type I, like miRNA29a, to prevent
Definition Tendons heal by accumulation of scar tissue. excessive fibrosis [3].
Some regenerative therapies may speed the accumulation
of scar tissue, which is less functional than healing by Diagnosis Excessive accumulation cannot be diagnosed
normal tendon tissue. with routine methods ante mortem. It is possible that the
T2 mapping of tendon MRI could distinguish between
Risk factors Unknown tendons with predominantly a single collagen type versus a
mix of collagen type and organization, but currently this is
Pathogenesis Type I collagen is the predominant collagen not in clinical use.
type in normal tendon. Tendons heal by accumulation of
type III collagen, which does not have the same Monitoring Unknown
interfasicular and biomechanical properties as type I
collagen. Excessive fibrosis can occur when regenerative Expected outcome A higher rate of re-injury to the tendon
medicine products enhance the healing process by will occur when there is excessive collagen type III
stimulating accumulation of collagen type 3. The accumulation.
References
1 Ortved, K.F. (2018). Regenerative medicine and compared to autologous cells in the equine model. Stem
rehabilitation for tendinous and ligamentous injuries in Cell Res. Ther. 8 (1): 42. Accessed December 5, 2018. doi:
sport horses. Vet. Clin. N. Am. Equine Pract. 34 (2): 10.1186/s13287-017-0503-8.
359–373. Accessed December 5, 2018. doi: 10.1016/j. 6 van Beers, M.M.C. and Bardor, M. (2012). Minimizing
cveq.2018.04.012. immunogenicity of biopharmaceuticals by controlling
2 Frisbie, D.D., Kawcak, C.E., Werpy, N.M. et al. (2007). critical quality attributes of proteins. Biotechnol. J. 7 (12):
Clinical, biochemical, and histologic effects of intra- 1473–1484. Accessed February 13, 2019. doi: 10.1002/
articular administration of autologous conditioned serum biot.201200065.
in horses with experimentally induced osteoarthritis. Am. 7 Thangakunam, B., Christopher, D.J., Mathews, V. et al.
J. Vet. Res. 68 (3): 290–296. doi: 10.2460/ajvr.68.3.290. (2015). Mesenchymal stromal stem cell therapy in
3 Watts, A..E, Millar, N.L., Platt, J. et al. (2017). advanced interstitial lung disease – anaphylaxis and
MicroRNA29a treatment improves early tendon injury. short-term follow-up. Lung India. 32 (5): 486–488.
Mol. Ther. 25 (10): 2415–2426. Accessed April 25, 2018. Accessed February 13, 2019. doi:
doi: 10.1016/j.ymthe.2017.07.015. 10.4103/0970-2113.164156.
4 Berglund, A.K., Fortier, L.A., Antczak, D.F. et al. (2017). 8 Riordan, N.H., Madrigal, M., Reneau, J. et al. (2015).
Immunoprivileged no more: Measuring the Scalable efficient expansion of mesenchymal stem cells in
immunogenicity of allogeneic adult mesenchymal stem xeno free media using commercially available reagents. J.
cells. Stem Cell Res. Ther. 8 (1): 288. Accessed December Transl. Med. 13: 232. Accessed February 13, 2019. doi:
5, 2018. doi: 10.1186/s13287-017-0742-8. 10.1186/s12967-015-0561-6.
5 Joswig, A., Mitchell, A., Cummings, K.J. et al. (2017). 9 Isakova, I.A., Lanclos, C., Bruhn, J. et al. (2014). Allo-
Repeated intra-articular injection of allogeneic reactivity of mesenchymal stem cells in rhesus macaques
mesenchymal stem cells causes an adverse response is dose and haplotype dependent and limits durable cell
References 773
engraftment in vivo. PLoS One. 9 (1): e87238. doi: 10.1371/ 13 Garrett, K.S., Bramlage, L.R., Spike-Pierce, D.L. et al.
journal.pone.0087238 [doi]. (2013). Injection of platelet- and leukocyte-rich plasma at
10 Ikeda, K., Ohto, H., Okuyama, Y. et al. (2018). Adverse the junction of the proximal sesamoid bone and the
events associated with infusion of hematopoietic stem suspensory ligament branch for treatment of yearling
cell products: a prospective and multicenter surveillance thoroughbreds with proximal sesamoid bone
study. Transfus. Med. Rev. June 1: S0887-7963(18)30023-3. inflammation and associated suspensory ligament branch
doi: 10.1016/j.tmrv.2018.05.005. Online ahead of desmitis. J. Am. Vet. Med. Assoc. 243 (1): 120–125. doi:
print. doi: 10.1016/j.tmrv.2018.05.005. Online ahead of 10.2460/javma.243.1.120 [doi].
print. 14 Dlouhy, B.J., Awe, O., Rao, R.C. et al. (2014). Autograft-
11 Martin, M.J., Muotri, A., Gage, F. et al. (2005). Human derived spinal cord mass following olfactory mucosal cell
embryonic stem cells express an immunogenic transplantation in a spinal cord injury patient: case
nonhuman sialic acid. Nat. Med. 11 (2): 228–232. report. J. Neurosurg. Spine. 21 (4): 618–622. Accessed May
Accessed February 13, 2019. doi: 10.1038/nm1181. 10, 2018. doi: 10.3171/2014.5.SPINE13992.
12 McCarrel, T.M., Mall, N.A., Lee, A.S. et al. (2014). 15 Millar, N.L., Gilchrist, D.S., Akbar, M. et al. (2015).
Considerations for the use of platelet-rich plasma in MicroRNA29a regulates IL-33-mediated tissue
orthopedics. Sports Med. 44 (8): 1025–1036. doi: 10.1007/ remodelling in tendon disease. Nat. Commun. 6: 6774.
s40279-014-0195-5 [doi]. doi: 10.1038/ncomms7774 [doi].
774
55
Complicationsof OsseousCyst-LikeLesions
Ashlee E. Watts DVM, PhD, DACVS
Texas A&M University, College Station, Texas

L
with OsseousCyst-LikeLesions
Osseous cyst-like lesions (OCLL) are areas of subchondral
bone loss that frequently communicate or have ● Damage to surrounding healthy structures
communicated with the adjacent synovial joint, and lack ● Fracture at Site on Trans-Cortical OCLL Debridement
an epithelial lining. They occur in several locations and can ● Fracture at the OCLL
be developmental, traumatic or infectious in origin. ● Gas emboli
Reviews on their etiology are found elsewhere. This chapter ● Enlargement of OCLL
will address complications due to surgical treatment of ● Inappropriate screw position
OCLL of developmental or traumatic origin. Several
different surgical techniques are used: trans-synovial cyst
debridement, trans-cortical cyst debridement, arthroscopic amageto SurroundingHealthy
D
cyst debridement with graft augmentation, trans-cyst bone
Structures
screw placement, intra-cyst corticosteroid injection, and
arthrodesis for selected joints. The widespread use of
Definition Damage to the surrounding healthy tissues,
varying surgical techniques is probably because of diverse
including the articular cartilage, or other soft tissue
etiologies, age groups and joints affected and possibly due
including the medial meniscus (stifles), either as a
to only moderate success of each surgical therapy. The
consequence of the surgical procedure. This damage may
potential complications specific to each of these techniques
occur and become evident either during the surgical
other than arthrodesis, which is covered in separate
procedure or in the postoperative period.
chapters of this book, will be discussed. Other techniques,
such as transplantation of osteochondral grafts and
Risk Factors
composites, are being developed but have not yet found
widespread clinical use. Therefore, they will not be ● Surgical technique (debridement of femoral OCLL)
discussed. ● Cysts morphology: large opening
A major complication that is not specific to the surgical ● Cyst positioning
technique selected is failure to resolve clinical signs of ● Poor imaging guidance
lameness and joint effusion referable to the OCLL. For
most surgical techniques, this complication is more likely Pathogenesis The main intraoperative complication when
to occur in older horses and when osteoarthritis of the the cyst is arthroscopically debrided and/or arthroscopically
affected joint or injury to the meniscus (stifle) or opposing grafted, is damage to surrounding healthy structures
articular cartilage surface is present at the time of surgery. including the articular cartilage or other soft tissue
When osteoarthritis is not present at the time of including the medial meniscus (stifles).
intervention, the prognosis is generally good following Prior to debridement, OCLLs tend to have a very small
surgical treatment for OCLL, when the intervention results defect in the articular cartilage that is often described as a
in resolution of articular communication with the OCLL. dimple. After surgical debridement, the OCLL opening
Fracture at Site on ranssCortical C eeridement 775
will be much large and there will be a clearer change in leading to development of soft tissue damage (i.e. meniscal
frictional forces between the meniscus and the opposing tear), osteoarthritis, and/or persistent lameness.
femoral surface. One group has proposed that meniscus
injury can be a long-term postoperative complication of
OCLL debridment [1]; however, development of severe ractureatSiteon Trans-Cortical
F
meniscal pathology after placement of a transcondylar
OCLLDebridement
screw without arthroscopic debridement has also been
reported [2]. It is possible that the OCLL itself causes
Definition Trans-cortical OCLL debridement is performed
meniscal injury, regardless of previous surgical debridement
by accessing the OCLL through the adjacent cortical bone.
or not.
The cortical defect may precipitate long bone fracture [4].
For metacarpo(tarso) condyle of the fetlock joint and for
the coffin joint, when OCLLs are more central or palmar/
Risk Factors
plantar, there may be increased risk of damage to adjacent
articular cartilage with arthroscopic approaches. ● Creating a large cortical defect to access an OCLL via the
Penetration of or damage to the subchondral bone plate adjacent cortex
can occur during arthroscopic debridement, trans-cortical ● Creating a cortical defect through diaphyseal bone ver-
debridement or during screw placement, especially with sus metaphyseal or epiphyseal bone of a long bone to
poor radiographic control. access an OCLL
● Creating a defect through both cortices
Prevention Perform careful preoperative imaging to select ● Creating a cortical defect and an opposing endosteal
cases without significant pre-existing OA or meniscal defect on the opposite cortex
pathology. Use careful arthroscopic technique as described
elsewhere [3] and avoid overly aggressive cyst debridement, Pathogenesis The cortical defect creates a stress-riser in
and especially avoid gross enlargement of cyst cloaca. bone. There is minimal change in torsional strength with
Use radiographic control to ensure accurate drilling for small defects, less than 10% of bone diameter. However, a
trans-cortical cyst debridement or trans-cyst screw 20% defect results in significantly reduced torsional
placement. strength, and defects between 20 and 60% reduce torsional
breaking strength linearly [5].
Diagnosis and monitoring Iatrogenic inadvertent damage
to healthy neighboring tissues may be obvious at the time Prevention Performing trans-cortical debridement in
of surgical procedure. Arthroscopic evaluation of the standing patients when possible avoids the torsional forces
damage in cases of cartilage or subchondral bone, as well and risk of ataxia and incoordination of general anesthesia
as use of other imaging techniques such as radiographic an recovery, which may increase risk of fracture at the
ultrasonography, usually provides further assessment of transcortical drill site.
the damage. Use of a three-dimensional imaging technique, Approach the OCLL through epiphyseal or metaphyseal
such as CT or MRI (not after screw placement), may also be bone as opposed to diaphyseal bone, where the smaller
considered in some cases if necessary. bone diameter of the diaphysis translates to a relatively
In other cases, damage will occur later in the postopera- larger hole and greater reduction in torsional strength with
tive period and may be associated with clinical signs of the same size defect.
increased lameness and synovial distention. To decrease the stress riser effect, drill with the smallest
drill hole required to allow adequate debridement and/or
Treatment Once damage to surrounding healthy structures application of intra-cyst therapies and utilize only one
has occurred, it can be managed by a more careful (slower) cortex and avoid the opposite cortex. The development of
program for rest and rehabilitation and additional of chondro- resorbable fillers such as calcium phosphate or polylactic
protectants, such as poly-sulfated glycosaminoglycans acid and polyglycolic acid [6] to fill the cortical hole may be
(Adequan), for a longer period postoperatively. useful in the future to reduce stress concentration at empty
If the horse resumes work or free exercise prior to bone defects.
resumption of joint inflammation and OCLL-associated
lameness, it may have an increased risk of failure. Diagnosis Fracture through the transcortical drill hole site
is usually associated with obvious fracture, severe lameness
Expected outcome Depending on the degree of damage, and patient stress. Clinical and radiographic examination
the effect on the long-term prognosis could be negative, confirm presence of fracture.
776 Complications of sseous Cysts ike esions
Expected outcome This complication is often catastrophic, clot [8]. Gas arthroscopy, or when air is accidentally
as the resultant fracture is often irreparable. pumped into the joint when fluid bags are empty and the
pump continues to run [9], can lead to embolization of gas
following access to the vascular system via exposed
Fractureatthe OCLL subchondral bone [10, 11]. Emboli to the heart or brain can
be fatal [12].
Definition Fracture of the epiphyseal bone around the
OCLL. Prevention Insufflate the joint with carbon dioxide, which
will dissolve in blood faster than any other medical gas or
Risk Factors room air if embolization occurs.
● Large OCLL
● Overly effective analgesia [7] Diagnosis and monitoring Venous embolism can be
detected by development of a water wheel murmur during
surgery [13], a drop in end-tidal carbon dioxide, a drop in
Pathogenesis Fracture of the bone around the OCLL after blood pressure, and/or development of ventricular
intra-cyst corticosteroid injection and extracorporeal tachycardia. Paradoxical embolism or arterial embolism
shockwave therapy has been reported in one horse [7]. The can occur in any organ with organ-related signs possible,
authors theorized that overly effective analgesia led to but greatest morbidity and mortality occur after coronary
overload of the bone around the OCLL and subsequent or cerebral ischemia.
fracture [7].
Treatment When there is gas embolization, the patient
Diagnosis and monitoring Fracture through the OCLL should receive the highest inspired oxygen content
would be associated with obvious severe lameness and possible, ideally 100%, and intravenous fluids to minimize
patient stress. Clinical and radiographic examination hemoconcentration and to increase venous pressure.
would confirm presence of fracture. Hyperbaric oxygen therapy, when available, could also be
used. If the site of gas embolization is known (e.g. in the
Expected outcome Catastrophic as the articular joint is heart), aspiration of gas with a multiluminal catheter could
destroyed. For some distal joints, arthrodesis may be an be performed. Finally, symptomatic therapy should be
option for salvage. instituted (e.g. benzodiapene or barbituates for seizures).
Expected outcome Can be catastrophic leading to patient

GasEmboli death or inability to recover from general anesthesia.
Definition Access of gas into the vascular system via

exposed subchondral bone may allow gas uptake to the Enlargementof OCLL
circulatory system. Gas within the circulatory system can
accumulate within a vessel, causing embolization and Definition The size of OCLL increases postoperatively.
occlusion of the blood supply and ischemia to the
downstream or distal tissue. Risk Factors
● Surgical technique
Risk Factors
● Unknown
● Gas arthroscopy
● Accidental air infusion at arthroscopy Pathogenesis It is unknown in many cases, but often
● Arthroscopic pump pressure >30 mm Hg assumed to be due to penetration of the sclerotic bone
around the OCLL combined with incomplete debridement
Pathogenesis If OCLL debridement is followed by graft of inflammatory cyst lining. OCLL debridement can lead to
augmentation (see Chapter 54: Complications of enlargement of the OCL.
Regenerative Medicine, for associated regenerative
medicine complications), it is often performed under gas Prevention Ensure adequate debridement of the cyst
arthroscopy to allow the use of clottable materials within lining and avoid penetration of or disruption to the
the OCCL such as stem cells or chondrocytes in fibrin subchondral bone plate.
eferences 777
Diagnosis and monitoringLameness and physical evaluation Prevention Intraoperative imaging should be used to
for signs of worsening joint effusion and radiographic ensure accurate placement of screw relatively parallel to
monitoring for OCLL size the joint surface and close to the articular opening (<50%
of the cyst length). When possible, perform surgery
Treatment If OCLL enlargement occurs along with standing to make surgical approach (as in the elbow) and
treatment failure (i.e. lack of intact subchondral bone plate orientation to limb and joints easier. When possible,
between OCLL and joint), re-treatment or treatment with a position patient so orientation of limb and joints is obvious
different modality could be considered. to surgeon.
Expected outcome OCLL enlargement can occur with no

Diagnosis and Monitoring Intraoperative or postoperative
effect on resultant lameness or prognosis if the subchondral
imaging should be used.
bone at the OCLL opening to the joint heals or remains
intact.
Treatment If postoperative imaging reveals inappropriate
screw position, returning to surgery to remove and/or
InappropriateScrewPosition replace implants should be considered.
Definition The main intraoperative complication when Expected outcome Penetration of the subchondral bone
placing a trans-cortical screw for an OCLL is poor screw and articular cartilage in the joint adjacent to the OCLL by
placement either through the subchondral bone, poorly the screw could be devastating, leading to severe lameness
positioned within the cyst or missing the cyst entirely. and rapid progression of osteoarthritis. However,
Poorly positioned screws within the cyst, either distant to penetration of the subchondral bone and articular cartilage
the articular surface (>50% of cyst length) or not parallel to in the joint adjacent to the OCLL by the screw, followed by
the articular surface, can result in inappropriate healing of removal and replacement in a more appropriate position
the cyst postoperatively [2, 14]. intraoperatively, may cause minimal long-term damage. To
minimize long-term damage to the joint, the patient may
Risk Factors
need a longer period of rest and confinement after surgery
● Poor use of radiographic control during screw placement or chondroprotectants, to allow healing of the subchondral
● Poor surgical technique bone and articular cartilage.
References
1 Wallis, T.W., Goodrich, L.R., McIlwraith, C.W. et al. 5 Edgerton, B.C., An, K.N., and Morrey, B.F. (1990).
(2008). Arthroscopic injection of corticosteroids into the Torsional strength reduction due to cortical defects in
fibrous tissue of subchondral cystic lesions of the medial bone. J. Orthop. Res. 8 (6): 851–855.
femoral condyle in horses: a retrospective study of 52 6 Alford, J.W., Bradley, M.P, Fadale, P.D. et al. (2007).
cases (2001–2006). Equine Vet. J. 40 (5): 461–467. doi: Resorbable fillers reduce stress risers from empty screw
EVJ07120 [pii]. holes. J. Trauma. 63 (3): 647–654. doi: 10.1097/01.
2 Santschi, E.M., Williams, J.M., Morgan, J.W. et al. (2015). ta.0000221042.09862.ae [doi].
Preliminary investigation of the treatment of equine 7 Moser, D.K., Schoonover, M.J., Sippel, K.M. et al. (2017).
medial femoral condylar subchondral cystic lesions with Catastrophic complication following injection and
a transcondylar screw. Vet. Surg. 44 (3): 281–288. doi: extracorporeal shock wave therapy of a medial femoral
10.1111/j.1532-950X.2014.12199.x [doi]. condyle subchondral cystic lesion in a 14-year-old
3 McIlwraith, C.W., Wright, I.A., Nixon, A.J. et al. (2006). Arabian mare. Open Vet. J. 7 (2): 111–116. Accessed May
Diagnositc and Surgical Arthroscopy in the Horse. 3rd 11, 2018. doi: 10.4314/ovj.v7i2.6.
edition. Elsevier Health Sciences. 8 Ortved, K.F., Nixon, A.J., Mohammed, H.O. et al. (2011).
4 Bertone, A.L., McIlwraith, C.W., Powers, B.E. et al. Treatment of subchondral cystic lesions of the medial
(1986). Subchondral osseous cystic lesions of the elbow of femoral condyle of mature horses with growth factor
horses: conservative versus surgical treatment. J. Am. Vet. enhanced chondrocyte grafts: a retrospective study of 49
Med. Assoc. 189 (5): 540–546. Accessed May 22, 2018. cases. Equine Vet J. 44 (5): 606–613.
778 Complications of sseous Cysts ike esions
9 Zmistowski, B., Austin, L, Ciccotti, M. et al. (2010). Fatal 12 Muth, C.M, and Shank, E.S. (2000). Gas embolism. N.
venous air embolism during shoulder arthroscopy: a case Engl. J. Med. 342 (7): 476–482. Accessed May 11, 2018.
report. J Bone Jnt. Sur. Am. 292 (11): 2125–2127. Accessed doi: 10.1056/NEJM200002173420706.
May 11, 2018. doi: 10.2106/JBJS.I.01704. 13 Pandey, V., Varghese, E., Rao, M. et al. (2013). Nonfatal
10 Habegger, R., Siebenmann, R., and Kieser, C. (1989). air embolism during shoulder arthroscopy. Am. J. Orthop.
Lethal air embolism during arthroscopy. A case report. J. 42 (6): 272–274. Accessed May 11, 2018.
Bone Jnt. Surg. Br. 71 (2): 314–316. Accessed May 11, 2018. 14 Roquet, I., Lane Easter, J., Coomer, R.P.C. et al. (2017).
11 Faure, E.A., Cook, R.I., and Miles, D. (1998). Air Treatment of subchondral lucencies in the medial
embolism during anesthesia for shoulder arthroscopy. proximal radius with a bone screw in 8 horses. Vet. Surg.
Anesthesiology. 89 (3): 805–806. Accessed May 11, 2018. 46 (4): 478–485. doi: 10.1111/vsu.12643 [doi].
779
56
Complicationsof EquineOphthalmicSurgery
Kate S. Freeman MEM, DVM, DACVO1 and Dennis E. Brooks DVM, PhD, DACVO2
1
Affiliate Faculty of Ophthalmology, Colorado State University, Fort Collins, Colorado
2
University of Florida, Gainesville, Florida
Overview respectively. Additionally, any complications from the

anesthesia or sedation used in any ophthalmic procedure
Veterinary ophthalmic surgery is a field that is growing, will not be included in this chapter. Please refer to
and novel techniques and devices are being implemented. Chapter 15: Complications of Sedative and Anesthesia
The field still lags behind physician ophthalmic surgery Medications, for that information.
but is improving. Equine ophthalmic surgery is not as
advanced as canine ophthalmic surgery and there are still
some areas where significant advances need to be made. istof ComplicationsAssociated
L
For example, laser and pneumatic retinopexy is frequently with EquineOphthalmicSurgery
performed in canine and feline ophthalmology but has not
been described in equine ophthalmology, so is not dis- ● Globe and Orbit
cussed in this chapter. Some of the delay in equine surgical – Enucleation/exenteration/evisceration
techniques has been due to hesitancy in anesthetizing ○ Perforation of the globe
horses due to greater anesthesia recovery risks than in ○ Hemorrhage including nasolacrimal duct hemorrhage
small animal ophthalmology. For this reason, equine oph- ○ Rejection or migration of an orbital prosthesis
thalmic surgeries are performed more commonly in aca- ○ Secreting tissue left behind in the orbit: infection,
demia where an entire anesthesia and recovery team is neoplasia, conjunctiva, third eyelid or glandular
available than in private practice, and the overall number ○ Corneal issues postevisceration
of surgeries performed by veterinary ophthalmologists is – Intravitreal ciliary body ablation

far fewer than in canine and feline ophthalmology. To com- ○ Lens or retinal damage
bat the anesthesia recovery risk, the equine surgical field ○ Uveitis
has adapted to perform more surgeries standing. While this ○ Endophthalmitis
provides an added challenge for the surgeon, it is far safer ○ Failure to control increased intraocular pressure
for the horse and the increasing willingness of surgeons to (IOP)

perform more standing surgeries is advancing the equine ● Orbitotomy/orbitectomy
ophthalmic surgery field. ○ Permanent nerve damage
Nearly all ophthalmologic surgical procedures have the ○ Delayed postoperative swelling due to infection or
potential postoperative complications of dehiscence, hem- mass regrowth

orrhage, swelling/inflammation, and infection, and there- ● Adnexal surgery
fore these will not be addressed in the individual section – Entropion procedures (temporary tacking and
unless these risks are higher or would be managed differ- Hotz-Celsus)
ently than a typical surgical case. In the typical case, these ○ Corneal issues
would be managed by repeated suturing, achieving ade- – Eyelid laceration repair

quate hemostasis, cold compresses/anti-inflammatory ○ Corneal issues
medications, and systemic broad-spectrum antibiotics, ○ Damage to the nasolacrimal system
780 Complications of quine phthalmic Surgery
– Eyelid mass procedures ● Intraocular surgery

○ Mass regrowth – Endolaser cyclophotocoagulation
○ Cisplatin reactions ○ Lens or iris damage
○ Muscular contractions with Electrochemotherapy ○ Uveitis and fibrin development
(ECT) ○ Postoperative ocular hypertension (POH)
○ Tissue swelling and discoloration post-photodynamic ○ Failure to adequately control the IOP
therapy – Laser ablation of uveal cyst or melanoma

○ Cryotherapy complications: corneal damage, lid ○ Failure to deflate the cyst or adequately damage the
swelling, and depigmentation tumor

○ Anaphylactic reaction post-immunotherapy ○ Corneal damage and iris depigmentation/fibrosis
– Subpalpebral lavage placement – Equine phacoemulsification

○ Endplate migration ○ Radial tear in the anterior lens capsule or tear in
– Conjunctivectomy/SCC removal posterior lens capsule

○ Mass regrowth ○ Iris, often corpora nigra, prolapse
– Nasolacrimal punctral stenosis surgery ○ Hypotony
○ Infection ○ Postoperative ocular hypertension (POH)
– Third eyelid removal ○ Corneal edema or ulceration
○ Mass regrowth/failure to remove the entire mass ○ Uveitis and/or pre-irisal fibrovascular membranes
○ Orbital fat prolapse (PIFM)

● Ocular surgery ○ Endophthalmitis
– Conjunctival pedicle, island graft, corneoconjunctival ○ Posterior capsular opacification (PCO)
transposition ○ Retinal detachment or folds
○ Buttonholing the conjunctiva or cornea or making ○ Glaucoma
the graft too thin – Pars plana vitrectomy

○ Suture problems leading to breaking down/retrac- ○ Fibrin and retinal detachment
tion/non-attachment of the graft ○ Cataract, chorioretinitis, and/or failure of the
– Corneal laceration repair procedure

○ Synechia formation
– Keratectomy and adjunctive treatments (Cryotherapy,

Strontium-90, CO2 Laser Ablation, Mitomycin C) for
Globeand Orbit
squamous cell carcinoma
ComplicationsAssociatedwith Enucleation/
○ Corneal issues
Exenteration/Evisceration
– Keratectomy for infection, foreign body, or eosino-
philic disease Eye removal in horses is indicated for a variety of blinding
○ Infection, fibrosis, and granulation tissue formation and painful ocular conditions, including advanced glau-
○ Microleaks or suture abscesses coma, corneal perforation with iris prolapse, intraocular
○ Graft issues including rejection and misalignment tumor, endophthalmitis and chronic uveitis, among others.
○ Inflammation (uveitis) and scarring (fibrosis) In animals with a complete orbit such as a horse, there are
– Thermal keratoplasty two enucleation techniques that can be performed: the
○ Perforation subconjunctival approach and the transpalpebral approach.
○ Infection Exenteration is performed in cases of orbital infection or
○ Fibrosis neoplasia. Evisceration is rarely performed, but can be per-
– Suprachoroidal cyclosporine implant formed as a cosmetic procedure in globes that are not
○ Surgical mistakes infected and non-neoplastic.
○ Implant extrusion, migration, or intraocular infection
– Cyclodestructive procedures: cyclophotocoagulation Perforation of the globe

or cyclocryoablation Definition Unintended perforation of the globe occurs
○ Retinal detachment when the fibrous capsule of the globe is breached during
○ Uveitis and hyphema enucleation/exenteration.
○ Corneal ulceration
○ Failure to control IOP Risk factors Buphthalmic globes make this more likely.
loee and reit 781
Pathogenesis Unintended perforation of the globe occurs Diagnosis Presence of abnormal bleeding during the
when careful surgical technique is not used. Globe perforation procedure
can happen with either subconjunctival or transpalpebral
enucleation techniques, although is less likely in exenterated Treatment The following techniques can be used to
globes. obliterate the hemorrhaging vessel:
Perforation is most concerning if it occurs in an infected ● Electrosurgical cautery
or neoplastic globe, thus globes with neoplastic and/or ● Suction
infectious involvement should be removed via extentera- ● Ligation of the vessels
tion and not enucleation. ● Ice
● Epinephrine
Prevention Careful presurgical planning and surgical ● Gel foam
technique ● Closing the orbit and bandaging the face to tamponade
the orbital blood
Diagnosis Unintended perforation of the globe is diagnosed ● Need for blood transfusion with severe hemorrhage
when the contents of the globe are noted outside of the globe
in the orbit. Rejection or migration of an orbital prosthesis
Definition Orbital or intrascleral prosthetic migration or
Treatment As long as there is no intraocular tumor or rejection by the body (Figures 56.1a and b)
intraocular infection, this complication can be managed in
enucleations with routine dilute (5% or less) povidone- Risk factors
iodine [1, 2] and sterile saline orbital flushing that is performed
● Any eye with a prosthetic device (Figure 56.2a)
prior to closure. If there is concern about potential infectious
● Orbital infection or marked inflammation
contamination of the orbit, a culture should be performed.
● Unsterile or poor surgical technique
● Persistent patency of the nasolacrimal duct
Expected outcome If there is no infection or tumor, and as
long as globe contents are adequately flushed from the orbit,
Pathogenesis If careful surgical technique and thorough
there is not likely to be any long-term significant concern.
flushing after globe, or globe contents removal is not used,
postoperative infection and rejection of the prosthetic
Hemorrhage including nasolacrimal duct hemorrhage
device may occur.
Definition Hemorrhage (excess bleeding) during the
If the prosthetic device is not adequately covered with a
surgical procedure
mattress suture pattern and orbital facial tissue layer,
migration or rejection is more likely.
Risk factors
An inappropriately-sized prosthetic device is more likely
● Surgical technique to be rejected or migrate.
● Infected or neoplastic processes
Prevention Careful surgical technique with adequate
flushing and an appropriately-sized and appropriately-placed
Pathogenesis Causes include laceration of the angularis
orbital prosthetic are all necessary steps for prevention. For
oculi vein, incomplete hemostasis during the procedure,
orbital prosthetic devices, it is important to completely encase
incomplete hemostasis of the optic nerve vessels, and
the prosthetic with a tissue layer deep to the skin [4].
persistent patency of the nasolacrimal duct.
It is recommended that the nasolacrimal duct be flushed
Hemorrhage is encountered more commonly in transpal-
with tincture of iodine to chemically cauterize the duct and
pebral enucleations than in subconjunctival. Hemorrhage
eliminate bacterial migration along the duct from the nose
can be more severe with exenteration or evisceration.
to the orbit.
Minor nasolacrimal duct hemorrhage (bleeding from ipsi-
lateral nostril) is not uncommon for up to a few days after Diagnosis Swelling or discharge from the surgical site that
enucleation [3]. can occur weeks to months later. Opening of the incision
Hemorrhage can range from mild to severe, depending or visible movement of the prosthetic may also occur.
on the level of inflammation present prior to performing
the procedure, and therefore it is more likely infected or Treatment If infection occurs, a course of oral antibiotics
neoplastic processes that may be associated with a greater may be sufficient. Generally, the prosthetic needs to be
blood supply. Hemorrhage is less likely in phthisical globes. removed if rejection occurs.
(a) (b)
Figure56.1 (a) Migration of orbital prosthetic. (b) Rejection of orbital prosthetic. Source: Kate S. Freeman and Dennis E. Brooks.
(a) (b)
Figure56.2 (a) Image of an orbital implant. (b) Orbital implant infection. Source: Kate S. Freeman and Dennis E. Brooks.
Expected outcome Once the prosthetic device is removed, ● Inadequate tissue dissection with lack of thorough
the outcome is generally good. removal of conjunctiva or gland of third eyelid
● Subconjunctival technique is more likely to result in
Secreting tissue left behind in the orbit: infection, remnants of conjunctiva or glandular tissue
neoplasia, conjunctiva, third eyelid or glandular
Definition Swelling and discharge postoperatively due to Pathogenesis If careful surgical technique and thorough
remnants of infection, neoplasia, conjunctiva or glandular flushing after globe removal is not used, conjunctiva, third
tissue in the orbit. Return of the underlying infectious or eyelid and glandular material, and tumor cells or infection
neoplastic process despite globe removal. can be left within the orbit. Extensive tumors, particularly
those with bony involvement, may be impossible to
Risk factors
completely remove, making it likely that tumor recurrence
● Eyes with underlying infectious or neoplastic disease will occur.
loee and reit 783
Prevention Careful presurgical planning, careful surgical medical management with calcinurin inhibitors and
technique with careful inspection of the orbit and remaining topical lubricating ointment and if severe, surgical
tissue prior to closure, as well as inspection of the removed management with either permanent lateral tarsorrhaphy
globe and adnexa, are all important. Additionally, in cases of or globe removal.
infection or neoplasia, extensive orbital tissue removal and
thorough flushing during surgery can prevent this. Expected outcome Variable, pending response to treatment;
likely long-term problems with ulceration, keratitis, and
Diagnosis Swelling or discharge from surgical site weeks KCS
to months later (Figure 56.2b)
ComplicationsAssociatedwith Intravitreal
Treatment If infection recurs, a course of oral antibiotics CiliaryBodyAblation
may be sufficient, although a second surgery with culturing
the wound and possible drain placement [5] may be needed Ciliary body ablation (CBA) can be performed in blind eyes
to treat a recurrent infection. If conjunctiva or third eyelid or with glaucoma with intravitreal injection of gentamicin in
glandular tissue is left behind, a second surgery to remove horses. This medication is often also injected with a steroid
the remnant tissue is needed. If tumor extension is extensive, to reduce secondary inflammation. The goal of this proce-
a second surgery (with histopathology) may help, although dure is to cause toxic damage to the ciliary body to reduce
radiation or chemotherapy may also be indicated. or eliminate aqueous humor production in globes blind
from glaucoma.
Expected outcome The outcome depends on the tissue type
Lens or retinal damage
left behind: if glandular/conjunctival tissue is appropriately
Definition Accidentally damaging the lens or the retina
removed at the second surgery, then the outcome is good.
If it is infectious in origin, it may also be managed medically with the needle during CBA
or surgically with a good outcome. If neoplastic, the
Risk factors
outcome is often poor due to extensive tumor growth.
● Poor animal restrain
Corneal issues postevisceration ● Buphthalmic eye
Definition Keratitis (corneal inflammation), corneal
Pathogenesis May be caused by an inexperienced surgeon
ulceration, and keratoconjunctivitis sicca (KCS) develop-
or an animal moving too much. Buphthalmic eye may
ment post-evisceration
change anatomy of the proper injection site.
Risk factors
Prevention Accurate initial needle placement 7 mm
● Prior decreased tear production posterior to the limbus and directed at 45 degrees toward the
● Recurrent ulceration optic nerve is a key method to avoid this [5, 7, 8]. Also, taking
into account any changes due to buphthalmos is important.
Pathogenesis Corneal ulceration is a very common late An ocular ultrasound can be helpful to guide the needle.
postoperative complication of evisceration [4], in part due
to damage to the corneal nerves as part of the procedure [6] Diagnosis Can be difficult to know for sure, but marked
and also in part due to buphthalmos. Corneal nerve damage uveitis may indicate lens damage.
is also likely the pathogenesis for KCS post-evisceration,
which is common in dogs and less common in horses. Treatment While the intraocular inflammation can be
addressed with topical and oral anti-inflammatory, it is best
Prevention Careful surgical technique minimizing the to not damage the lens in the first place.
corneal nerve damage and postoperative management
with a tarsorrhaphy can help. Expected outcome Variable pending response to treatment;
procedure may fail due to chronic inflammation and
Diagnosis Visible ulcer or keratitis or measurable KCS hyphema and require enucleation.
with a Schirmer tear test
Uveitis
Treatment An ulcer is managed with lubrication, topical Definition Inflammation within the anterior or posterior
antibiotic, and in some cases, tarsorrhaphy. KCS involves (or both) uvea
Risk factors Pathogenesis A late postoperative complication that

occurs in about 35% of CBA procedures in small animal
● Some uveitis is expected as part of the procedure
ophthalmology is where the intraocular pressure does not
● Poorly sedated animal with too much eye or head
decrease [9].
movement
In some cases, the cause is unknown. It may be inade-
Pathogenesis The introduction of a needle into the eye
quate drug penetration to the ciliary body if fibrous mem-
and the drug itself cause uveitis. In horses poorly sedated branes are blocking the distribution to the ciliary body.
or moving the head and/or eye too much, inaccurate needle Globes with advanced glaucoma may have little residual
placement can cause more uveitis. ciliary body tissue to be affected by ablation.
Prevention Some uveitis is unavoidable. Accurate initial Prevention Performing the procedure before marked uveitis
needle placement 7 mm posterior to the limbus and directed develops or after treatment for uveitis may help. Using a
at 45 degrees toward the optic nerve is a key method to avoid concurrent injectable steroid with the procedure may also help.
this [5, 7, 8].
Diagnosis Uncontrolled IOP with tonometry measurement
Diagnosis Continued hyperemia, pain, flare, and hypotony
all indicate persistent uveitis. Treatment Consider repeating the procedure
Treatment Topical and oral anti-inflammatory medications

ComplicationsAssociatedwith Orbitotomy/
Expected outcome Variable pending response to treatment; Orbitectomy
procedure may fail due to chronic inflammation and
Orbitotomy/orbitectomy is performed due to a retrobulbar
hyphema resulting in need for enucleation.
mass, or due to orbital fracture(s) from trauma (Figure 56.3).
Endophthalmitis Retrobulbar masses necessitating surgery can be due to
Definition Intraocular infection neoplasia, cyst, sialocele, granuloma, foreign body, or
abscess. The goal of this procedure is to preserve the globe
Risk factors Pre-existing corneal or intraocular infection and vision, while removing the diseased retrobulbar tissue
or the displaced bony fragments. Advanced imaging (CT/
Pathogenesis Intralenticular injection can cause
endophthalmitis, and unsterile technique is likely the culprit.
Prevention Maintaining sterile technique, aseptically

preparing the eye prior to the procedure, and ensuring the
animal is heavily sedated/anesthetized
Diagnosis Affected animals typically show marked

hypopyon and uveitis that generally does not resolve with
treatment. Organisms may sometimes be found through
aqueocentesis.
Treatment Topical and oral anti-inflammatory and antibiotic

medications
Expected outcome Variable, pending response to treatment;

most result in enucleation.
Failure to control increased intraocular pressure (IOP)

Definition Persistent IOP in the late postoperative period
Risk factors Animals with pre-existing significant uveitis Figure56.3 Dorsal orbital rim fracture. Source: Kate S.
may be at higher risk of failure. Freeman and Dennis E. Brooks.
Adnexal Surgery 785
MRI) is crucial in surgical planning for this procedure and Expected outcome Variable, pending response to treatment
may lead to cancellation of the procedure due to extent of
the mass in neoplastic cases.
AdnexalSurgery
Permanent nerve damage
Definition Iatrogenic nerve transection Complicationsof EntropionProcedures
(TemporaryTackingand Hotz-Celsus)
Risk factors Significant trauma or tissue swelling may
Entropion is a condition where the eyelid margin rolls in
make nerve identification difficult.
toward the cornea, leading to trichiasis where the periocu-
lar hairs touch the cornea (Figure 56.4). This can be due to
Pathogenesis Permanent nerve damage can occur if nerves
a congenital malformation or dehydration/illness in foals
are accidentally transected during surgery, resulting in
and may resolve with growth. For foal entropion, tempo-
possible permanent blindness as well as a variety of ocular
rary tacking with staples or sutures, and topical lubricating
movement/position or eyelid function abnormalities [10, 11].
ointment is performed. Permanent tissue removal surgery
is only needed if the entropion persists with age and is per-
Prevention Careful dissection with thorough understanding
manent. Other causes of entropion include orbital fat loss
of anatomy
(often age-related), blepharospastic entropion (eyelid
spasm due to corneal irritation/wound, surgery not indi-
Diagnosis Blindness or paralysis of ocular movement
cated), or cicatrical (scarring) entropion.
Treatment None
Corneal issues
Definition Undercorrection, overcorrection, or suture/
Expected outcome Likely irreversible nerve damage
staple corneal contact can cause corneal issues including
ulceration, vascularization, and fibrosis.
Delayed postoperative swelling due to infection or
mass regrowth
Risk factors Extensive entropion
Definition Swelling at the surgical site in the late
postoperative period
Pathogenesis The entropion is undercorrected by not
stapling/suturing the lids enough to roll the lid margin out
Risk factors
well enough.
● Animals with significant neoplasia invading bone
● Poor surgical technique Prevention Careful planning before any sedation to assess
for natural lid position and to ensure the appropriate lid
Pathogenesis Incomplete removal of the mass or mass amount is removed
regrowth is generally the most common complication
causing postoperative swelling with orbitotomy/orbitectomy
[10]. Infection either present before or occurring during
surgery can also cause swelling.
Prevention Advanced imaging preop can help with

surgical planning. Take as wide margins as possible and
consider scraping the periosteum in surgery.
Diagnosis The affected animals will show persistent

postoperative swelling with or without discharge. Imaging
of the orbit is indicated.
Treatment If the cause is infection, antibiotics may work

or a repeated procedure to clean the orbit. If it is neoplasia,
adjunctive treatments such as debulking the orbit and Figure56.4 Foal lower lid laxity and entropion. Source: Kate S.
radiation may help. Freeman and Dennis E. Brooks.
Diagnosis Visible trichiasis or recurrence of entropion

leading to corneal irritation if inadequate tissue removal
Treatment Repeat the procedure
Expected outcome If undercorrected, a repeated procedure

should fix the issue; overcorrection is difficult to fix and
may need an extensive blepharoplasty procedure. A contact
lens can be used to protect the cornea while the lid swelling
from the entropion surgery resolves.
Complicationsof EyelidLacerationRepair
Eyelid laceration repair is frequently performed after trau-
matic eyelid laceration. This is particularly important
when there is full thickness damage to the eyelid margin.
Corneal issues Figure56.5 Superior lid suture malposition causing corneal

ulcer. Source: Kate S. Freeman and Dennis E. Brooks.
Definition Damage to the cornea as a result of the repair
If too much tissue is removed, there is poor suture posi-
tioning, or there is inadequate tissue apposition, there will Expected outcome If poor lid positioning, then a repeated
be sutures, a lid notch, or hairs (trichiasis) in contact with procedure is needed. If too little tissue remains, then a
the cornea leading to exposure keratitis, cornel ulceration, blepharoplasty may be needed.
corneal vascularization, and/or fibrosis and pigmentation.
Damage to the nasolacrimal system [13]
Risk factors Definition Laceration of or damage to the nasolacrimal
system
● Extensive eyelid damage
● Poor suture material and/or technique
Risk factors Extensive eyelid damage will make a repair more
Pathogenesis If too much eyelid tissue is damaged, a well- difficult and will more likely involve the nasolacrimal system.
positioned repair can be difficult. Poor suture material
Pathogenesis This occurs when either the laceration itself
choice and poor suture technique can lead to suture corneal
contact. If the eyelid margins are not adequately apposed or the repair damages either the superior or inferior
with a figure-of-eight suture, this can lead to a notch defect. nasolacrimal puncta.
If there is inadequate tissue apposition, there will be sutures,
Prevention Careful planning before surgery and careful
a lid notch, or hairs (trichiasis) in contact with the cornea
leading to exposure keratitis, corneal ulceration, corneal surgical technique
vascularization, and/or fibrosis and pigmentation. A
significantly displaced margin may lead to incomplete blink Diagnosis Epiphora or visible nasolacrimal damage
or ectropion with secondary exposure keratopathy [12].
Treatment Surgical correction recreating a nasolacrimal
Upper eyelid injury is more potentially serious.
system can be performed with a dacryocystorhinostomy.
surgical technique. Additionally, if there is too little tissue Expected outcome If both puncta or the lacrimal sac are
remaining, a blepharoplasty surgery should be considered. damaged to the point of being non-functional, chronic
epiphora will develop, leading to chronic facial dermatitis.
Diagnosis Visible trichiasis, notch defect, or suture contact
causing ulcer or irritation (Figure 56.5) Complicationsof EyelidMassProcedures
Treatment Repeat the procedure, remove and replace the When dealing with an eyelid mass such as a squamous cell
offending sutures with suture corneal contact, or perform a carcinoma or sarcoid (Figure 56.6), complete surgical excision
blepharoplasty procedure. with clean margins is always preferred, particularly as eyelid
Adnexal Surgery 787
(a) (b)
Figure56.6 (a) Extensive SCC of the eyelids and periocular region OS. (b) Sarcoid periocular medial canthal region. Source: Kate S.
Freeman and Dennis E. Brooks.
(and orbital) SCC has the worst prognosis [14]. Often this will sarcoids treated multiple times [39, 40]. Intralesional radia-
require more than a simple wedge excision and will involve tion treatments have a very high success rate of non-recur-
some type of blepharoplasty such as an H-plasty. When the rence, nearing 100% [41]. The complications will differ,
mass is too extensive or involving too much lid tissue (i.e. both some based on the procedure performed, but general com-
upper and lower lids), surgical excision may not be an option plications are as follows.
(Figure 56.6a). For example, if a squamous cell carcinoma is
found to involve more than just the eyelid margin, such as Mass regrowth
involving the third eyelid, cornea, and potentially even reach- Definition Regrowth of the original eyelid mass
ing the retrobulbar space, conversion to an exenteration may
be needed if there is enough tissue for adequate skin clo- Risk factors Extensive eyelid mass covering greater than
sure [15, 16]. In other situations, a variety of options can be one-third of the eyelid margin or covering more than one
performed including chemotherapy, photodynamic therapy lid will not be successfully removed with a simple surgery.
(PDT), cryotherapy, immunotherapy with BGC [17–22], radi-
Pathogenesis Tumor cells extended beyond surgical
ofrequency hyperthermia, electrochemotherapy, carbon diox-
margins lead to mass regrowth. Some horses have a genetic
ide laser ablation, and radiation with either iridium192, gold198,
predisposition to SCC development.
tantalum, cesium137, and radon222 [23–30]. Mass regrowth is a
possibility with all of these procedures and thus will not be
discussed individually.
surgical technique with as large a margin as possible
The success rates for complete remission of these proce-
dures vary, with cisplatin achieving 80–88% non-recurrence Diagnosis Visible regrowth of mass
for SCC and 85% for sarcoids, and reported as more effective
than 5-FU [13, 31–33]. Implantable cisplatin (beads) may Treatment Blepharoplasty procedure to recreate a lid
take up to 19 treatments to achieve disease control, but this margin with extensive tissue removal or exenteration of
study reported 83% success rate with varying eyelid secondary adjuctive procedure
tumors [34]. PDT has been successful the first time in 78% of
cases and all of these resolved after a second procedure [35]. Expected outcome Variable, pending response to secondary
Cryotherapy has been reported to be successful in 67% of the procedure
cases [36], but may vary from that number in other reports.
The success rate with BCG depends on the type of sarcoid, Cisplatin reactions: leakage of cisplastin, slippage of
but for the responsive types, the success rate is around beads, or reaction to the bead
70–100%. [37, 37]. A 66% success rate with radiofrequency Definition Backflow of fluid out from the injection or
hyperthermia has been reported in smaller tumors that were slippage of the cisplatin beads. Tissue reaction to the
treated twice and a higher success rate (91%) is reported for cisplatin itself can also occur.
Ulcerated or large lesions. Anecdotally reactions

Risk factors Diagnosis Visible bead slippage or leakage of fluid leading to
may be more severe when treating sarcoids than SCC. necrosis or tissue damage. Local tissue reaction to cisplatin can
vary from transient edema to marked excoriations and necrosis.
Pathogenesis Shallow bead placement or usage of too
large a needle for the injection, or injection into ulcerated Treatment Wound management can be minor requiring
lesions, may be responsible. Some tissue reactions occur anti-inflammatory treatment for resolution [42]. The tissue
based on individual animal sensitivity. reaction can be so severe that performing another
procedure may not be possible and exenteration, possibly
Prevention Careful surgical technique with appropriately- with a skin graft, may be needed (Figure 56.8).
sized bead pockets and cruciate suture pre-placement
(Figure 56.7). Avoid injectable cisplatin with ulcerated lesions. Expected outcome Variable, pending extent of damage
(a) (b)
Figure56.7 (a) Cisplatin beads prior to injection. (b) Immediate postoperative cisplatin bead implantation. Source: Kate S. Freeman
and Dennis E. Brooks.
(a) (b)
Figure56.8 (a) Preoperative periocular sarcoid. (b) Week’s postoperative cisplatin bead implantation. Source: Kate S. Freeman and
Dennis E. Brooks.
Adnexal Surgery 789
Muscular contractions with Electrochemotherapy Treatment Eliminating any sun exposure, managing any
(ECT) wounds and waiting until the compounds have cleared the
body
Definition Electrochemotherapy is a procedure where cisplatin
is injected intra-lesionally followed by lesional electric pulses to
Expected outcome Will resolve when the compounds are
increase cell permeability to the chemotherapy. Muscular
cleared
contractions are the main complication.
Cryotherapy complications: corneal damage, lid
Risk factors If the tumor is near to a nerve plexus, it is
swelling, and depigmentation
possible to have more extensive muscular contractions.
Definition Iatrogenic side effects of cryotherapy on cornea
Pathogenesis The low frequency or high amplitude pulses and eye adnexa
cause the secondary muscle contractions [43].
Risk factors Larger lesions or lesions near the cornea
Prevention Some may be unavoidable, although caution increase the risk of side effects.
around nerve plexuses will help and increasing the
frequency or lowering the amplitude have been used in Pathogenesis Cryotherapy can be performed as an adjunctive
other species to reduce the contractions [43]. treatment, ideally after initial mass removal or mass
debulking [44–49]. Cryotherapy alone has been reported to
Diagnosis These are observed intraoperatively as a have a success rate of up to 75% [50].
temporary reaction to the treatment but are generally The cold of the cryotherapy probe causes intracellular
localized to the treated or nearby the treated area. damage to diseased and non-diseased tissues and therefore
ulceration, swelling, and depigmentation will occur in tis-
Treatment None needed, as is transient discomfort during sues affected by the probe. An intraoperative complication
the procedure is damage to the cornea, such as ulceration and fibrosis
from the cryo unit, generally from the spray nozzle. An
Expected outcome Will resolve with cessation of treatment early postoperative complication is lid swelling in the area
affected by the cryotherapy. An early and late postoperative
Tissue swelling and discoloration post- complication is depigmentation of the affected tissue.
photodynamic therapy
Prevention To avoid corneal damage, protecting the cornea
Definition Photodynamic therapy uses light and light-
with a plastic contact lens or a styrofoam corneal protector will
sensitive compounds to cause mass necrosis in the cases of
avoid accidental corneal damage. (Figure 56.9). Lid swelling is
equine SCC. PDT generally involves partial surgical
an unavoidable complication, but the severity may vary based
excision followed by injection with 2-[1-hexyloxyethyl]-2-
on individual sensitivity as well as extent and temperature of
devinylpyropheophorbide-a (HPPH) and subsequent
the cryotherapy used. It is critical to always perform a double or
irradiation with a 665-nm wavelength diode laser [36].
triple cycle of fast freeze, slow thaw each time, as there is no
There is tissue swelling and discoloration within a week of
effective ability to reduce this complication [51].
treatment in all cases [36].
Risk factorsContinued exposure to sunlight can worsen DiagnosisVisible swelling soon after treatment, with
these complications. depigmentation lasting weeks to years or permanently
Pathogenesis When the surrounding normal tissues are Treatment Oral anti-inflammatory medications may
affected, the light sensitive compounds can photosensitize reduce the swelling; managing a corneal ulcer with
these tissues, causing tissue swelling and discoloration appropriate antibiotic treatment should be performed.
when exposed to light.
Expected outcome The swelling will dissipate; corneal
Prevention Some may be unavoidable, although caution fibrosis and depigmentation may remain permanently.
when injecting the photosensitizing compounds is ideal;
additionally, avoiding sunlight after the procedure is key. Anaphylactic reaction post-immunotherapy
Definition Immunotherapy with Bacillus Calmette-Guerin
Diagnosis Visible swelling and discoloration generally (BCG) vaccine is injected every 2–4 weeks for up to 9
within a week of treatment treatments into the lesion to stimulate an immune response
(a) (b)
(c) (d)
Figure56.9 (a) Lower lid SCC pre-excision. (b) Debulking of lower lid SCC. (c) Cryotherapy probe to lower lid lesion post-debulking.
(d) Styrofoam corneal protector with spray nozzle cryo. Source: Kate S. Freeman and Dennis E. Brooks.
and to mass regression [13]. This complication is an Expected outcome Variable pending response to treatment
immediate immune-mediated postoperative complication
with BCG, that can worsen after each successive treatment. Complicationswith SubpalpebralLavage
Placement(SPL)
Risk factorsSome animals are more prone to overactive
SPLs are an integral procedure to manage any equine cor-
immune responses; multiple treatments may increase this
neal or intraocular disease, or surgery that requires frequent
likelihood.
topical treatment. They can be placed in the lower or the
upper lid, depending on surgeon preference, although there
Pathogenesis Excess stimulation of the immune system
are fewer complications with inferomedial placement [52]
leading to a possible anaphylactic reaction in unusual
(Figure 56.10). There are multiple complications with the
situations
device itself and initial placement such as breakage or block-
age of the line of the SPL, suture dehiscence of the skin
Prevention To reduce the risk of anaphylaxis, pretreatment
sutures attaching the line to the face, or hemorrhage and lid
with diphenhydramine and flunixin meglumine is
swelling at the time of placement, require fixing, replacing
recommended [13].
the line, or cold compressing [53].
Diagnosis Visible anaphylaxis Endplate migration

Definition The endplate of the SPL can migrate, particularly
Treatment Anti-inflammatory medications may reduce when placed in the superior lid, leading to corneal ulceration
the reaction. (Figure 56.11).
Adnexal Surgery 791
Diagnosis Increased blepharospasm will occur and an

ophthalmic exam with a slit lamp and fluorescein dye stain
will identify the ulcer.
Treatment The line needs to be tightened to ensure the

endplate is not rubbing on the cornea, or the SPL needs to
be replaced and placed in the lower lid. Manage the corneal
ulcer with topical antibiotics and oral pain medications.
Expected outcome Good, as long as the ulcer heals well

and is treated appropriately.
Complicationswith Conjunctivectomy/SCC
Removal
As with eyelid mass treatment, the best method is always
removal of the mass with 1–2 cm margins. Margins like
this are rarely if ever possible with the conjunctiva, so
adjunctive treatment is nearly always performed. The most
typical management for a conjunctival SCC is excision
with adjunctive cryotherapy. The aforementioned side
Figure56.10 Inferomedial SPL placement, corneal fibrosis effects of cryotherapy, such as corneal damage, apply simi-
post-SCC keratectomy and strontium-90. Source: Kate S. Freeman
and Dennis E. Brooks.
larly here and the procedure to protect the cornea with sty-
rofoam (Figure 56.9d) is the same prevention as for the lid
cryotherapy. The main other complications are mass
regrowth (discussed below) and intraoperative hemor-
rhage, which can be managed with epinephrine, phenyle-
phrine, and/or cautery.
Mass regrowth
Definition Regrowth of the original tumor after removal
Risk factors
● If the initial excision does not achieve adequate margins

or adjunctive treatment is either not performed or not
performed adequately, mass regrowth is more likely.,
● Horses with SCC have a genetic predisposition to SCC.
Figure56.11 Dorsal corneal ulcer from superior lid SPL Pathogenesis Tumor cells are left behind.
endplate slippage. Source: Kate S. Freeman and Dennis E. Brooks.
Prevention More aggressive excision and adjunctive
treatment
Risk factors A loose placement of the SPL and excess
rubbing by the horse make this more likely.
Diagnosis Visible mass regrowth
Pathogenesis Gravity and rubbing will cause the endplate Treatment Repeating the procedure or attempting a
to drop from its position in the conjunctival fornix to touch different adjunctive treatment with strontium-90 may be
the cornea. attempted; alternatively, an exenteration may be needed.
Prevention Lower lid placement of the SPL will reduce Expected outcome Generally poor if the SCC has already
this concern. returned; exenteration improves the outcome.
Complicationswith NasolacrimalPunctal superficial keratitis and nasal lid conformational changes.

StenosisSurgery While all of these complications have consequences, they
are very rare and yet unavoidable with this surgery; they
An imperforate nasal puncta is the most common nasolac-
should be discussed as possible outcomes with the client
rimal congenital defect in horses [54]. When this occurs,
prior to surgery.
there is absence of the nasal opening of the nasolacrimal
system. Treatment entails creating an opening and sutur-
Mass regrowth/failure to remove the entire mass
ing a catheter through the new puncta for a few weeks
Definition Regrowth of the original tumor
until the new opening heals.
Risk factors Extensive mass
Infection
Definition Infection of the nasolacrimal duct or cannaliculi
Pathogenesis If the initial excision does not achieve
adequate margins or adjunctive treatment is either not
Risk factors
performed or not performed adequately, mass regrowth is
● Surgical procedure itself more likely.
● Animal in a contaminated environment
Prevention A CT performed prior to surgery can help with
Pathogenesis Infection is more likely in this than in other surgical planning and understanding of the extent of the
procedures, because the proximal and distal openings of tumor. An adjunctive treatment post-excision can help
the catheter are exposed to normal bacterial flora on the prevent regrowth.
face near the medial canthus and within the nose. This
bacteria flora can colonize the catheter and lead to Diagnosis Visible mass regrowth or swelling near medial
infection, although this is generally more of a problem canthus
preoperatively than postoperatively.
Treatment Repeating the procedure or attempting a different
Prevention Treating prophylactically after the procedure adjunctive treatment may be attempted; alternatively, an
with either sterile saline flush or an ophthalmic antibiotic exenteration may be needed.
solution that will flow through the tube and keep it clean
will help. Expected outcome Generally poor if the SCC has already
returned; exenteration improves the outcome.
Diagnosis Purulent material from either end of the catheter
Orbital fat prolapse
Treatment Systemic antibiotics and flushing the nasolacrimal Definition Prolapse of the orbital fat from the opening
catheter with dilute povidone-iodine and sterile saline should made in the conjunctiva
be performed.
Risk factors Deep tumors that extend to the base of the
Expected outcome Generally good if appropriate treatment third eyelid
is instituted in a timely manner; the catheter may need to
be removed and replaced at another time if the infection Pathogenesis If the conjunctival edges are not sutured
does not clear with medical treatment. together, the orbital fat will have a window through which
to prolapse out through the conjunctiva.
Complicationswith ThirdEyelidRemoval
Prevention Suturing the conjunctival edges together after
Surgery
third eyelid removal will prevent this problem.
Neoplasias affecting the third eyelid, such as squamous
cell carcinoma, are common and require surgical treat- Diagnosis Visible fat prolapsed near the medial canthus
ment for management. Unless the lesion is small and just
affecting the leading edge of the third eyelid, complete Treatment Excising the fat and suturing the opening with
resection of the third eyelid is generally required. The the conjunctiva closed
most common complications with this procedure are dis-
cussed below. In addition to these, there are very rare Expected outcome Generally good if the conjunctival hole
complications including keratoconjunctivitis sicca (KCS), is closed appropriately.
Ocular Surgery 793
OcularSurgery Diagnosis Visible hole in the conjunctiva; white conjunctiva

over the lesion
Complicationswith ConjunctivalPedicle,Island
Graft,orCorneoconjunctivalTransposition(CCT) Treatment The hole should first be sutured, but if it does
not close well or leads to an inadequate amount of tissue to
A conjunctival pedicle graft or an island graft are indicated cover the diseased tissue, more tissue should be harvested
in cases of infected corneal ulcers or corneal perforations or additional tectonic support should be used (porcine
(Figure 56.12a). Depending on the extent of blood vessel small intestinal submucosa, A-cell, or amniotic
growth, an island graft may be chosen over a pedicle graft. membrane) [55].
A corneo-conjunctival transposition can be performed in
cases where there is loss of corneal tissue, but the wound is Expected outcome Generally good if the conjunctival hole
not infected. The benefit of this procedure over a conjunc- is closed appropriately; ischemic conjunctival grafts can
tival graft is replacing the cornea, allowing for a more heal the cornea but may also require additional surgery.
transparent visual axis.
Buttonholing the conjunctiva or cornea or making the Suture problems leading to breaking down/retraction/
graft too thin nonattachment of the graft
Definition Creating a hole in the conjunctiva as the tissue Definition Failure of graft to take
is dissected when creating a graft (Figure 56.12b)
Risk factors Pre-existing infection at the surgical site
Risk factorsMovement of horse in surgery, such as with a
standing procedure Pathogenesis Premature graft retraction/non-attachment
occurs due to a variety of causes, including severe bacterial
Pathogenesis When dissecting the conjunctival graft, the or fungal infection that has not been treated prior to
surgeon can accidentally make a hole in the conjunctiva. surgery, aqueous humor microleaks, incomplete epithelial
Using too sharp instruments or performing the procedure debridement, or too much Tenon’s capsule remaining,
too quickly or in the field without general anesthesia. Too causing tension [56, 56].
thin a graft can lead to disruption of the conjunctival blood Suture dehiscence or micro-absesses often leading to
supply, graft ischemia, graft thrombus, and graft failure. retraction of the graft where, with the graft pulling away
from the initial location where it was sutured.
Prevention This can be prevented by very careful dissection If Tenon’s capsule is not well dissected, the suture is
and removing all of the Tenon’s capsule but not making it the incorrect size or expired, the sutures are not well
too thin by using blunt ended microsurgical instruments placed, or there is marked infection that has not been
(Westcott or Stevens Tenotomy scissors for conjunctiva, 64 medically managed, then the animal will be at a higher risk
blade or Martinez for cornea). of this occurring.
(a) (b)
Figure56.12 (a) Seidel positive fungal ulcer needing conjunctival pedicle graft. (b) Buttonhole of conjunctival graft over stromal
abscess. Source: Kate S. Freeman and Dennis E. Brooks.
Prevention In addition to debriding the epithelium and should be managed with culturing, topical aggressive broad-
Tenon’s thoroughly and careful suture placement (no more spectrum antibiotics (i.e. gram-negative like ofloxacin and
than 2 mm apart using non-expired and appropriately- gram-positive like cefazolin, and possibly oral antibiotics
sized suture), it is recommended to treat with intensive and an oral NSAID), and may need to have the suture
medical management for at least 24 hours prior to surgery replaced. A repeated conjunctival graft or enucleation may
to reduce the bacterial or fungal load. be needed if infection does not resolve medically.
Diagnosis The graft will not be fully attached or in the Expected outcome Most infected sutures respond, but this
location it was initially placed; the edges will be rolled up and can depend on the cause of suture breakdown and degree
pulled away from the sutures (Figure 56.13a). The microleaks of graft retraction.
are visible with fluorescein staining using a Seidel’s test and
the abscesses should be off white/yellow colored around the
Complicationswith CornealLacerationRepair
sutures (Figures 56.13b and c). Dehiscence can also occur due
to infection, as is seen in Figure 56.13d. In cases of full thickness laceration of the cornea, often
with iris prolapse, or with full thickness corneal foreign
Treatment In cases of graft retraction/non-attachment, the body penetration, a laceration repair is needed. This
procedure may need to be repeated. The suture abscesses involves suturing the wound closed, with or without the
(a) (b)
(c) (d)
Figure56.13 (a) Retraction and thickening of graft due to aqueous humor microleaks. (b) Arrow showing microleaks around sutures.
(c) Suture abscess. (d) Dehiscence due to infection breaking down sutures. Source: Kate S. Freeman and Dennis E. Brooks.
Ocular Surgery 795
use of a conjunctival graft [56–59]. Similar to the conjunc-

tival graft, there can be suture problems leading to microle-
aks or infection breaking down the sutures; please refer to
the aforementioned discussion of these complications.
Additionally, a long-term complication from the initial
wound itself and not necessarily the surgery is persistent
uveitis, which can lead to cataract development, blindness,
and possibly a phthisical eye. The best method to address
this persistent uveitis is with oral banamine use and fre-
quent rechecks to determine when topical anti-inflamma-
tories can be started.
Synechia formation
Definition Anterior (iris to cornea) or posterior (iris to Figure56.14 Corneal SCC pretreatment. Source: Courtesy of
lens) synechia can occur where the iris attaches either to Kate S. Freeman and Dennis E. Brooks.
the cornea or to the lens.
formed under general anesthesia using a combination of
Risk factors Iris prolapse from a full thickness wound surgical excision/debulking (keratectomy) and cryother-
apy, strontium-90 [61–65], CO2 laser ablation, or mitomy-
Pathogenesis When there is a full thickness wound through cin C (MMC). Similar to eyelid SCC management, mass
the cornea, causing a perforation of the globe which is regrowth is a potential for all procedures and thus will not
normally under pressure, the aqueous rushes out and the be discussed individually. Cryotherapy offers somewhere
thin iris flows forward and naturally plugs the hole in the between 70 and 80% success at no regrowth [66]. One
cornea creating synechia. recent study found no regrowth in at least 4 out of 9 cases
of corneal SCC treated with keratectomy and strontium-90;
Prevention Once it has occurred, it is difficult to reverse; if the other 5 were lost to follow up [66]. Another showed an
there is a laceration without synechia, treating with a 83% success rate with adjunctive strontium-90 [67]. Limbal
topical dilator like atropine will reduce the changes of SCC is not as successfully treated with strontium and
synechia development intra- or postoperatively. Posterior recurrence is seen in 30% of the cases [67]. With CO2 laser,
synechia occur secondary to uveitis and miosis from the there was only recurrence in 15% of the cases after the first
perforating wound. attempt and in only 8.3% after a repeated attempt [68].
MMC was successfully able to prevent regrowth in 82.4% of
Diagnosis Tenting of the iris either forward touching the the cases [69].
cornea or slightly backwards touching the lens
Corneal issues
Treatment During surgery, it is possible to try to push the Definition Development of corneal edema, bullous
iris back into the globe and dilate it to draw it away from keratopathy, fibrosis, granulation tissue, ulcerative keratitis
the cornea; posterior synechia will sometimes break down and/or overall delayed healing of keratectomy sites
with dilation. (Figure 56.15)
Expected outcome Variable; if the iris is prolapsed prior to Risk factors Inherent to the surgical technique used
surgery, it is generally permanent. (stromtium-90 therapy, cryotherapy, laser, mitomycin C
[MMC])
ComplicationswithKeratectomyand
Pathogenesis The corneal edema is expected and due to
AdjunctiveTreatments(Cryotherapy,
both the keratectomy and cryotherapy if used. The delayed
Strontium-90,CO2laserablation,or
healing can occur due to all the procedures, but particularly
MitomycinC)forSquamousCellCarcinoma
due to strontium-90 and cryotherapy.
Management
Early postoperative complications of stromtium-90
Corneal squamous cell carcinoma is the most common include delayed ulcer healing, bullous keratopathy, and a
ocular tumor [60] and needs to be managed with dual higher risk of infection than after a keratectomy alone [70].
treatment modality (Figure 56.14). Ideally, this is per- The main postoperative complication with CO2 laser abla-
(a) (b)
Figure56.15 (a) Granulation tissue post-keratectomy + beta. (b) Fibrosis and vascularization post-keratectomy + beta. Source: Kate S.
tion is granulation tissue formation [69]. More serious Expected outcome Generally good if the cornea heals (albeit
postoperative complications that can occur with MMC are slowly) and an infection does not occur. Scarring is inevitable
due to the toxicity of MMC and include inflammatory reac- but the granulation tissue and bullae should resolve.
tions of the cornea, conjunctiva, and eyelids. This includes
ulcerative keratitis, conjunctivitis, and blepharitis. The Complicationswith Keratectomyfor Infection,
blepharitis can be ulcerative or nonulcerative and the con- ForeignBody,orEosinophilicDisease
junctival irritation can be so severe as to necrose [69]. The
corneal reaction can also be severe and can lead to descem- A keratectomy alone, without use of adjunctive treatment
etocele formation [69]. These major complications are such as SCC therapies or grafts, can be performed in cases
more common with MMC than the other techniques. of infected ulcers, corneal foreign bodies, immune medi-
ated keratitis, or eosinophilic keratitis. This procedure can
Prevention One method to reduce this granulation tissue be performed either standing or under general anesthesia
response is to place amnion over the keratectomy site after and it is often used without a graft in situations where the
the radiation [71]. The eyelids need protecting from the keratectomy removes less than 50% of the cornea.
MMC if possible and any non-diseased tissue should be well
Infection,fibrosis, and granulation tissue formation
protected from all adjunctive procedures as best as possible.
Definition Secondary bacterial or fungal infection in the
open corneal wound that can progress to melting. Fibrosis
Diagnosis Granulation tissue generally resolves over time
development or scarring after incision; a robust response
but can often look similar to SCC regrowth, so differentiation
can also include granulation tissue.
is important. Typically, the time frame is very helpful with
differentiation, as granulation tissue reaction happens soon
Risk factors
after surgery and SCC regrowth takes longer. One method to
reduce this granulation tissue response is to place amnion ● Wounds that are infected prior to the procedure are more
over the keratectomy site after the radiation [71]. likely to have post-keratectomy infection.
● Wounds that have been there a long time are more likely
Treatment If extensive to the point where bullae have to have more severe fibrosis and granulation tissue
developed, topical 5% sodium chloride can be used to development.
reduce the edema. It is ideal to have an SPL system in place
to allow for weeks of treatment with a topical antibiotic to Pathogenesis Bacteria or fungi in the stroma or conjunctiva
prevent an infection [70]. In addition, careful monitoring can enter the surgical site. The body responds to corneal
of the case and frequent rechecks are needed to ensure the wounding with production of fibroblasts and inflammatory
wound is healing appropriately. Anti-inflammatory mediators leading fibrosis and granulation tissue. Keratocyte
medications and amnion placement can be used to decrease transformation results in the inability of the stroma to
the granulation tissue response. remain clear.
Ocular Surgery 797
Prevention Performing the procedure aseptically and treating Expected outcome Generally good, as long as the leaks stop
postoperatively with topical broad-spectrum antibiotics. soon and abscesses resolve.
Performing surgery as soon as possible to minimize further
inflammation and use of an amnion graft at the time of Graft issues including rejection and
surgery may prevent some of the granulation reaction. misalignment [72]
Definition Marked inflammation and overall rejection of
Diagnosis Off-white to yellowish cellular infiltrates in the the graft and/or malposition of the graft
wound; sometimes there is visible melting; cytology and culture
Risk factors Poor surgical technique or marked infection
can confirm. Fibrosis will be grey/wispy and granulation tissue
prior to surgery can predispose to misalignment or rejection.
is raised and red/pink with vessels leading to it.
Pathogenesis Within 3–7 days of graft placement, the body
Treatment Topical broad-spectrum aggressive (q2 hour)
starts rejecting the tissue and there is marked inflammation
antibiotic use and oral anti-inflammatories. If the infection
(corneal vascularization, possibly, graft opacification and
cannot be medically managed, surgery with a conjunctival
intrastromal hemorrhage results) [73] (Figure 56.16).
graft can be performed. If there is no infection and the
ulcer has healed, a topical anti-inflammatory can be used. Prevention Use of anti-inflammatory medication can help
minimize rejection and careful surgical technique with
Expected outcome Variable, pending response to therapy adequately positioned and anesthetized horse can minimize
and based on level of infection or inflammation misalignment.
Complicationswith LamellarKeratoplasty(either Diagnosis Visible inflammation and malposition

DeeporPosterior)
These procedures are similar to a corneoconjunctival trans- Treatment Anti-inflammatory medications and sometimes
position, in that cornea is used to replace damaged cornea. a repeated procedure
In most of these cases, the cornea is damaged due to an
infection and therefore the first step is to cut out the infec- Expected outcome With medical management, this will
tion. Once the infection is removed, the deep lamellar generally improve over time, but it does lead to permanent
endothelial keratoplasty (DLEK) or posterior lamellar ker- scarring of the surgery site [73].
atoplasty (PLK) is performed using the donor cornea.
Inflammation (uveitis) and scarring (fibrosis)
Microleaks or suture abscesses Definition Corneal fibrosis at the surgical site, particularly
Definition Small leaks of aqueous humor around the in the posterior stroma, and anterior uveitis are expected
sutures or small suture abscesses complications of lamellar keratoplasty procedures.
Risk factors Suboptimal suture placement and/or suture

technique
Pathogenesis Suture placement with a DLEK or PLK is

challenging and if too close or too far apart, may lead to
incisional gaping often secondary to incisional tissue
swelling [5]. The gapes and abscesses can lead to microleaks
that may need another surgery to manage.
Prevention Adequately deep, appropriately-sized and

appropriately-spaced suturing using good suture material
will prevent these leaks.
Diagnosis Seidel’s test around the graft site will identify these.
Treatment Topical antibiotics and if the leaks do not stop

within a day, cyanoacrylate glue or additional sutures or Figure56.16 Corneal edema 3 days post-DLEK. Source: Kate S.
even a conjunctival graft may be needed. Freeman and Dennis E. Brooks.
Risk factors Surgical technique, particularly use of a Treatment The fibrin formation can be managed with
penetrating keratoplasty (PK) intracameral TPA. The uveitis is best managed with oral
flunixin meglumine. Once the graft has healed, a topical
Pathogenesis DLEK and PLK are chosen over a PK, as NSAID such as diclofenac can be considered; topical steroids
they result in less fibrosis [74]. are often risky in these cases. Some fibrosis is inevitable and
Fibrosis or scarring occurs whenever the stromal lamella no treatment is indicated.
are damaged, as with a DLEK or PLK. Keratocyte networks
and leukocyte migration tracks become opaque to cause Expected outcome Corneal fibrosis can vary from mild to
corneal haze. Uveitis occurs any time the anterior chamber more severe long-term (Figures 56.17a and b). The expected
is penetrated or secondary to corneal inflammation, and long-term damage varies based on the individual case, but
can lead to cataract formation, fibrin formation, synechia can be quite severe, as seen in Figure 56.17c.
development, and potentially glaucoma.
Complicationswith ThermalKeratoplasty
Prevention Use of anti-inflammatory medications can help
minimize rejection and careful surgical technique can minimize A thermal keratoplasty or corneal thermal cautery is used
this, but some rejection scarring will occur in all cases. to manage indolent/nonhealing corneal ulcers, also
known as spontaneous chronic corneal epithelial defects
Diagnosis Fibrosis appears as white/grey stromal opacity. in multiple species. This procedure has shown a 100%
Uveitis is seen as a flare in the anterior chamber, low success rate in a limited sample size of horses [75]
intraocular pressure, and miosis. (Figure 56.18).
(a) (b)
(c)
Figure56.17 (a) Corneal fibrosis and vascularization some weeks post-DLEK. (b) Chronic corneal fibrosis 14 years post PLK. (c)
Corneal fibrosis and melanosis and chronic uveitis damage: lens capsule melanosis, cataract, synechia post-PK. Source: Kate S.
Ocular Surgery 799
(a) (b)
(c)
Figure56.18 (a) SCCED/indolent ulcer pretreatment. (b) Thermal cautery unit performing procedure. (c) Corneal fluorescein stain
immediately post procedure. Source: Kate S. Freeman and Dennis E. Brooks.
Perforation Treatment If this were to occur, immediate sealing of the

Definition Full-thickness penetration of the cautery unit wound would be needed, either by cyanoacrylate glue,
through the cornea suturing, or a conjunctival graft.
Risk factors Poorly restrained horses Expected outcome Generally good (scarring will occur) as
long as managed appropriately and the wound is small.
Pathogenesis Horses that are not well sedated or whose
heads are moving during the procedure are at higher risk Infection
of this occurring. Definition Secondary bacterial or fungal infection in the
Usage of a new thermal cautery unit and a surgeon perform- open corneal wound that can progress to melting
ing the procedure without adequately bracing their hands will (Figure 56.19)
predispose to a higher risk of perforation. When the hot cautery
unit is touched, it melts too deep through the cornea. Risk factors Wounds that are infected prior to the procedure
Prevention The best way to prevent this complication is Pathogenesis Microbes in the environment can enter the
adequate sedation of the horse and careful surgical technique, open wounds caused by the cautery.
as well as using a medium or low heat cautery unit.
Prevention Performing the procedure aseptically and
Diagnosis Visible perforating wound through the cornea treating postoperatively with topical broad-spectrum
that is Seidel’s test positive. antibiotics
Prevention Fibrosis is expected from the procedure and

can be minimized by using fewer points of contact.
Diagnosis The initial appearance of the wound will

look a little like a golf ball, with small oblong stromal
defects surrounded by a rim of brown burned stroma.
These will regress, some to become grey wispy areas in
the stroma.
Treatment None indicated; topical steroids can be used once

the wound is healed, but they are not likely to significantly
alter the fibrosis.
Figure56.19 Melting corneal ulcer post-thermal cautery Expected outcome Some subtle fibrosis is permanent.
procedure. Source: Kate S. Freeman and Dennis E. Brooks.
Complicationswith Suprachoroidal
Diagnosis Off-white to yellowish cellular infiltrate in the
CyclosporineImplant
wound; sometimes there is visible melting; cytology and
culture can confirm. Equine recurrent uveitis (ERU) is the number one cause of
blindness in horses and is a devastating disease
Treatment Topical broad-spectrum aggressive (q2 hour) (Figure 56.21). There is not a perfect solution for managing
antibiotic use ERU and often a combination of medical and surgical
options is considered. The most typical surgical option per-
Expected outcome Generally good if fast response to
formed in the US is a suprachoroidal cyclosporine implant.
antibiotics; scarring will likely be worse than if there was
no infection.
Surgical mistakes
Definition Surgical mistakes can include too deep a
Fibrosis
dissection leading to choroidal prolapse and hemorrhage,
Definition Corneal scarring post-procedure (Figure 56.20)
damage to extraocular muscle insertions, or too small a
Risk factorsLarger wounds or wounds needing a repeat scleral window.
procedure will have more fibrosis.
Risk factors
Pathogenesis The cautery unit permanently scars the ● Standing surgery
subepithelial corneal stromal lamella. ● Surgeon inexperience
(a) (b)
Figure56.20 (a) Corneal fibrosis and edema immediately postoperatively. (b) Corneal fibrosis some weeks post-thermal. Source: Kate
S. Freeman and Dennis E. Brooks.
Ocular Surgery 801
Figure56.21 Fibrin and cataract in chronic ERU eye. Source: Figure56.22 Conjunctival and episcleral hemorrhage post-
Kate S. Freeman and Dennis E. Brooks. cyclosporine implant. Source: Kate S. Freeman and Dennis E. Brooks.
Pathogenesis Performing the surgery under sedation

instead of general anesthesia may increase the likelihood Risk factors Surgery that is performed in the field or in a
of surgical mistakes. non-sterile manner predisposes to infection.
If the tissue is dissected too deeply, choroidal prolapse
and subsequent hemorrhage (at the incision as well as Pathogenesis A nonsterile surgical field would allow
intravitreal) can occur. If the incision is not made in the bacteria to enter the surgery site and could lead to infection.
correct location or the correct size, extraocualar muscles Too shallow or too deep an implant placement could lead
can be damaged. to extrusion or migration.
Prevention Additionally, it is critical to make the scleral Prevention Performing the procedure under general anesthesia
incision 7 × 7 mm to have adequate space to place the with a sterile surgical field and using careful surgical technique
implant [78]. Having the horse fully anesthetized and using will decrease the risk of these complications
careful surgical technique will also avoid these complications.
Diagnosis Visible cyclosporine implant extruded out of
Diagnosis Visible dark protruding uveal tract and presence the incision or migrating and wandering within the eye
of abnormal bleeding during the procedure and (Figure 56.23). Endophthalmitis may be seen if infection is
postoperatively in the vitreous (Figure 56.22) present.
Treatment Gently return the prolapsed choroid to its Treatment A repeated surgery will be needed if the implant
origin and carefully close the incision. If too much choroid extrudes or migrates. If infection, aggressive antibiotic use is
has prolapsed, it is not ideal to place the implant in that needed and possibly enucleation if that fails.
location. If the incision is in the wrong location or the
wrong size, it is important to identify these errors during
Complicationswith Cyclodestructive
surgery and correct for them.
Procedures:Cyclophotocoagulationor
Cyclocryoablation
Expected outcome Long-term, the hemorrhage or simply
the level of vitreous inflammation from the procedure, Glaucoma management is difficult and when medical
could lead to progressive vitreal degeneration, but management fails, surgical procedures need to be consid-
fortunately this procedure has not been associated with ered. These include laser and cryo cyclo-destructive proce-
retinal detachment [5, 77]. dures. These can be performed through the sclera
(transscleral) or laser can be performed intraocularly (dis-
Implant extrusion, migration, or intraocular infection cussed in Section on Intraocular Suugery below).
Definition Movement of the implant either out the
incision, into the vitreous or anterior chamber, or an Retinal detachment
infection of the surgery site or intraocular infection, are all Definition Post-surgical separation of the neurosensory
possibilities. retina from the choroid
corneal edema if the endothelium is damaged or cataract

development if chronic [5].
Prevention Use of anti-inflammatory medication prior to

the procedure will help.
Diagnosis Flare, low intraocular pressure, and miotic

pupil are signs of uveitis.
Treatment The uveitis is managed medically with topical

steroids (as long as no corneal ulceration) and oral flunixin
meglumine. The uveitis can worsen the glaucoma and
therefore both topical and full dose systemic anti-inflammatory
treatment are indicated to lessen this likelihood.
Figure56.23 Migration/wandering implant visible in anterior
chamber. Source: Reproduced from Hermans and Ensink [76], by
Expected outcome Control often takes a long time but the
permission of Hippiatrika Verlag, Baden-Baden, Germany.
uveitis will generally improve over time. Some cases never
resolve or lead to significant damage and glaucoma, and
Risk factors Buphthalmic eyes can make site selection must be enucleated.
more difficult.
Corneal ulceration
Pathogenesis This generally occurs secondary to
Definition Development of reduced corneal wound
inaccurate site selection. Damage to the retina will occur if
leading to loss of the epithelium and ulceration
the laser is performed too far posteriorly. Too much lasering
or too much freezing can cause choroidal effusion and
Risk factors
retinal detachment.
● Buphthalmos
Prevention Having the horse fully anesthetized and using ● Edema
careful surgical technique will also avoid these complications.
Pathogenesis Corneal ulceration occurs due to a variety of
Diagnosis This complication may not be noticed until the causes, including exposure from the procedure, reduced
postoperative time and is generally noticed on indirect tear production from the anesthesia, persistent corneal
fundoscopy. edema, or reduced corneal sensation from the procedure [5].
Buphthalmos causes corneal nerve damage and will
Treatment If detachment is noticed and the retinal detachment increase the likelihood of ulcer development; edema may
can be adequately visualized through the cornea, laser also be present from endothelial cell dysfunction.
retinopexy may be indicated to prevent further detachment.
Prevention Adequate lubrication during the procedure
Expected outcome Most globes receiving these procedures may help reduce ulceration development.
are blind prior to surgery. If visual, vision will be affected in
areas of detachment, the extent of which depends on the Diagnosis Fluorescein dye test positive lesion
extent of detachment.
Treatment The ulceration is managed with prophylactic
Uveitis and hyphema topical antibiotics and lubricants.
Definition Inflammation (uveitis) and bleeding (hyphema)
development after the procedure Expected outcome The ulcer may or may not be a long-
term problem (depending on the initial cause).
Risk factors Uveitis prior to the procedure
Failure to control IOP
Pathogenesis An early postoperative complication is Definition Persistent postoperative IOP
anterior uveitis or hyphema development secondary to the
procedure [79]. The uveitis can then lead to permanent Risk factors Prior uveitis may make this more likely.
Intraocular Surgery 803
Pathogenesis As the procedure does not destroy all of the Expected outcome May not resolve with medications;
ciliary processes, it is not uncommon for the procedure to fail. enucleation is often considered.
Prevention Good technique performing the procedure is Uveitis and fibrin development
key to minimize this complication. Definition Postoperative uveitis and fibrin formation
Diagnosis Tonometry revealing elevated intraocular pressure Risk factors Prior uveitis may make this more likely.
Treatment Antiglaucoma medications and/or a repeated Pathogenesis In the immediate postoperative period, fibrin
procedure formation is a very typical occurrence as the procedure
induces uveitis [80]. Breakdown of the blood aqueous barrier
Expected Outcome May not resolve, even with a repeated
and the procedure itself lead to inflammatory cell buildup
procedure; enucleation is often considered.
from the uveal tract in the aqueous. Preoperative uveitis may
make this more likely.
IntraocularSurgery
Prevention The shorter the surgery time, the best for
Complicationswith Endolaser reducing uveitis.
Cyclophotocoagulation(ECP)
Diagnosis Visible flare, fibrin, and low intraocular
Endolaser cyclophotocoagulation is performed to manage pressure
glaucoma in horses. Glaucoma is most commonly second-
ary to uveitis (particularly equine recurrent uveitis) and Treatment The best method to reduce the sequela of this
can be very difficult to manage. Once medical manage- complication is aggressive anti-inflammatory treatment
ment fails, cyclophotocoagulation is often the best option and potentially intracameral TPA injection.
to attempt to save vision and lower intraocular pressures.
Expected outcome May not resolve with medications;
Lens or iris damage
enucleation is often considered
Definition Intraoperative damage to the lens or iris or
postoperative cataract formation
Postoperative ocular hypertension (POH)
Definition Raised intraocular pressure development
Risk factors
within approximately 3 hours after surgery
● Prior uveitis may make this more likely
● Inexperienced surgeon Risk factors Prior damage or compromise to iridocorneal
angle
Pathogenesis This can be due to laceration or perforation
of the anterior lens capsule or iris; cataract development is Pathogenesis In one study, POH occurred in 75% of the
possible [80]. Iris damage occurs as the laser tip could eyes that received ECP [80].
accidentally hit the base of iris during the Various reasons including physical blockage of the irido-
cyclophotocoagulation. corneal angle with large inflammatory molecules have
been proposed; a definitive answer is unknown.
Prevention The best method to prevent this from occurring
is to remove the lens via phacoemulsification during the Prevention Antiglaucoma medications may help reduce
same surgery and immediately prior to performing the the extent of the POH.
cyclophotocoagulation. Laser damage is best minimized by
very careful technique and surgeon expertise. Diagnosis Tonometry revealing raised intraocular pressure
Diagnosis Hyphema or uveitis from iris damage or visible Treatment Antiglaucoma medications, aqueocentesis, and
cataract time will help reduce the IOP in most cases.
Treatment Anti-inflammatory medications or possibly Expected outcome In all of these eyes, the pressure was
surgery (may need enucleation) if uveitis is not controllable reduced by day 4 without further medical or surgical
or glaucoma develops intervention [80].
Failure to adequately control the IP Diagnosis Visible cyst or tumor

Definition Persistently elevated IOP in the postoperative
period Treatment In these situations, if it is a cyst, aspiration can
be attempted but there is a large risk of infection and
Risk factors Prior uveitis may make this more likely. endophthalmitis and so is not recommended. Lasering iris
cysts is the medical standard of care. The blood supply of
Pathogenesis As the procedure does not destroy all of the uveal tumors can be disrupted to shrink the tumor with
ciliary processes, it is not uncommon for the procedure to laser. If it is a mass, sector iridectomy can be attempted
fail. with the complication of hemorrhage [84, 85] (Figures
56.24a and b), but enucleation is generally performed for
Prevention Good technique performing the procedure is larger tumors or melanomas extending into the
key to minimize this complication. vitreous [86].
Diagnosis Tonometry revealing elevated intraocular pressure Expected outcome A cyst lasering is most often successful;
if a tumor, uveitis or glaucoma may develop, necessitating
Treatment Antiglaucoma medications and/or a repeated enucleation.
procedure
Corneal damage and iris depigmentation/fibrosis
Expected outcome In cats, ECP has achieved greater than Definition Damage to the cornea and iris from the
90% success at maintaining vision and controlling IOP long procedure
term, as well as reducing antiglaucoma medications [81].
Additionally, success has been reported in canine cases as Multiple cysts may make it more likely to have
Risk factors
well, with about 80% success at lowering IOP and 70% of the more corneal and uveal damage.
cases remaining visual [82, 83]. Therefore, as ECP in normal
equine eyes confirms successful cyclo-destruction [80], and Pathogenesis The corneal damage will occur if the laser
the literature in other species supports ECP as having a good light is not adequately focused or is the incorrect size
success rate at IOP reduction and vision maintenance, then leading to a corneal burn, ulcer, or fibrosis.
by extrapolation, this may be a good solution for managing
equine glaucoma. Prevention This is prevented by using the smallest laser
setting (0.3 mm) and ensuring the light is adequately
focused on the uveal cyst.
Complicationsof LaserAblationof UvealCyst
orMelanoma
Diagnosis Tonometry revealing raised intraocular pressure
Laser ablation can be performed for a uveal cyst or mela-
noma through use of an argon laser or a diode laser via a Treatment No treatment
G-probe attachment or via an operating microscope
attachment. Expected outcome The fibrosis and depigmentation are
likely permanent (Figure 56.24c).
Failure to deflate the cyst or adequately damage the
tumor
Complicationsof EquinePhacoemulsification
Definition The cyst or melanoma does not respond
adequately to the laser procedure. Phacoemulsification or cataract surgery can be performed
in horses and is generally performed in horses that are
Risk factors Larger melanomas are less likely to respond. non-visual due to cataract development. The most com-
mon causes of cataracts in horses are congenital cataracts,
Pathogenesis When this occurs, it is sometimes due to traumatic cataracts, or uveitis-induced cataracts. Overall,
inadequate laser energy being applied. In other situations, cataract surgery success rate in the long term in horses is
the cyst or mass may simply not respond or be too large or much lower than it is in other species, including humans,
dense to respond to the treatment. dogs, cats, birds, marine mammals, and even fish. Success
rates range, but are often around 20–30% for successful
Prevention Performing the procedure before the melanoma vision long term [87, 88]. Reasons for this are discussed
becomes too large below.
(a) (b)
(c)
Figure56.24 (a) Uveal melanoma near corpora nigra. (b) Introcular hemorrhage postiridectomy. (c) Uveal fibrosis 1-year post laser of
a melanoma. Source: Kate S. Freeman and Dennis E. Brooks.
Radial tear in the anterior lens capsule or tear in Pathogenesis An anterior lens capsular tear occurs during
posterior lens capsule capsulorrhexis (removal of a circular region of anterior
Definition During the capsulorrhexis (removal of a circular lens capsule). When a significant radial tear develops, an
region of anterior lens capsule), a tear occurs in the anterior intraocular lens (IOL) may not be able to be placed due to
lens capsule. A tear in the posterior lens capsule can happen the risk of IOL prolapse out of the capsular bag. A posterior
during phacoemulsification. lens capsular tear in two studies was the most frequent
intraoperative complication of equine cataract surgery and
Hypermature cataract with anterior lens capsule
Risk factors it often results in lower success rates. [88, 89]. The tear can
wrinkling makes an anterior capsular tear more likely. be present prior to cataract surgery or it can occur during
phacoemulsification, often due to the phaco needle field. Posterior lens capsular tears can be prevented by
puncturing the very mobile and thin posterior lens capsule. careful surgical technique.
Although less common, it can also occur during irriga-
tion and aspiration if the aspiration is too vigorous. A pos- Diagnosis Visible tear during cataract surgery
terior lens capsular (PLC) tear can lead to lens cortical
material falling into the vitreous, which can cause long- Treatment No treatment, although not placing an IOL is
term low-level uveitis. Additionally, a PLC tear is signifi- often the best option to prevent further problems.
cant if an IOL is to be placed. Historically, equine cataract
surgery has not always placed IOLs and there has been Expected outcome This will be permanent and may not be
much debate about the appropriate IOL strength for a problem aside from no IOL placement in many cases. If
horses [90, 91]. Nonetheless, some recent studies have suc- lens fragments are left behind, this may lead to persistent
cessfully placed IOLs and achieved near emmetropia [91], uveitis and blindness (Figures 56.25a and b).
so IOL placement is ideal. If there is a significant PLC tear,
an IOL may not be able to be placed. Iris, often corpora nigra, prolapse
Definition Iris protruding through the corneal incision
Prevention To reduce the risk of a radial tear, Trypan Blue
can be used to better visualize the anterior lens capsule and Risk factors Incision too close to the corpora nigra or too
this procedure should only be performed by experts in the large
(a) (b)
(c)
Figure56.25 (a) Post-phaco lens fragment in anterior chamber. (b) Post-phaco lens fragment admixed with PCO. (c) Dyscoria with
incisional anterior synechia and corneal ulcer. Source: Kate S. Freeman and Dennis E. Brooks.
Pathogenesis This often occurs due to excess viscoelastic Postoperative ocular hypertension (POH)
injection that gets under the iris, pushing it anteriorly [92]. It Definition When the intraocular pressure is high after
can also occur if an incision is made too close to the corpora surgery
nigra. This can lead to intraocular hemorrhage if the iris is
not handled extremely carefully. The iris protrusion happens Risk factors This is more likely if the horse rubs the
frequently [87, 92] and it becomes more of a problem if there incision after surgery.
is hemorrhage or if the iris gets permanently incorporated
into the incision. Pathogenesis This often-transient pressure spike occurs
generally 3–4 hours after surgery, although it may occur or
Prevention One method to reduce the chance of iris incision last from 24–72 hours after surgery. One equine study
prolapse is to initiate the clear corneal incision further from found POH in a relatively small percentage (19%) of eyes
the corpora nigra, i.e. more limbal, and another method is to after cataract surgery [93].
use less viscoelastic [87, 92].
Prevention Unlike small animal medicine, where miotics
Diagnosis Visible tear during the suturing in cataract surgery such as latanoprost or carbachol may help decrease
POH [94], these are not used immediately postoperatively in
Treatment No treatment horses, as POH is much less of a concern and the side effects
of these medications are undesirable in the postoperative
Expected outcome This will be permanent anterior synechia period in horses [95].
(Figure 56.25c). Endophthalmitis can result if iris is trapped
in the incision. Diagnosis Tonometry is performed.
Hypotony Treatment Antiglaucoma medications or aqueocentesis

Definition When the intraocular pressure is too low may be needed.
Risk factors Expected outcome Generally good as long as addressed

soon and it resolves fast.
● This is more likely if the horse rubs the incision after
surgery Corneal edema or ulceration
● Persistent uveitis Definition Development of edema or a corneal ulcer
during or immediately after surgery
Pathogenesis This can occur if the limbal incision is not
adequately sealed and microleaks have developed. Risk factors
This surgical procedure exacerbates the uveitis present
preoperatively, which some globes cannot recover from, ● Longer phaco times increase the risk of edema
resulting in low IOP. ● Inadequate protection of the cornea during anesthesia
increases the risk of an ulcer
Prevention The best way to prevent this is to ensure enough Pathogenesis Corneal edema is common and has been
sutures have been placed, to place simple interrupted listed as one of the most common complications after equine
sutures, and to double check the incision for leakage (placing cataract surgery [93]; it often develops in the perilesional
a Weck cell at the suture line and gently indenting the globe area and may be exacerbated by phacoemulsification heat,
with the back end of a sterile cannula) prior to finishing the Trypan-blue use, or extended phacoemulsification time in
surgery. the eye. Corneal ulceration has also been listed as the most
common postoperative complication [89] and typically
Diagnosis To test for this, a Seidel’s test is performed. occurs immediately postoperatively or even intraoperatively,
secondary to decreased tear film/exposure and decreased
Treatment Re-suturing may be needed if the hypotony tear production from anesthesia.
does not resolve.
Prevention Performing the surgery as efficiently as possible
Expected outcomeGenerally good if suture microleaks are with a shorter phaco time and protecting the cornea well
addressed soon; poor outcome if uveitis cannot be with lubrication during surgery may help prevent these
controlled. complications.
Diagnosis Visible edema and fluorescein stain positive for Pathogenesis This is often due to Streptococcus spp. or
an ulcer. Staphylococcus spp. and is very severe [5, 100].
Treatment Treat the ulcer with cessation of topical anti- Prevention Unlike small animal medicine, where miotics
inflammatories and use of topical antibiotics. Corneal such as latanoprost or carbachol may help decrease
edema will respond temporarily to topical sodium chloride POH [94], these are not used immediately postoperatively
administration. in horses, as POH is much less of a concern and the side
effects of these medications are undesirable in the
Expected outcome Corneal edema often resolves within a postoperative period in horses [95].
few weeks after surgery, but it may be persistent if there is
extensive corneal endothelial cell damage [5]. As long as Diagnosis Hypopyon and marked intraocular inflammation
the animal is systemically healthy and the ulcer is that generally does not resolve with treatment (Figure 56.26b).
appropriately treated, a corneal ulcer should heal and not
pose a long-term complication. Treatment When this occurs, there is very little that can be
done to save the eye. Intracameral antibiotic injections
Uveitis and/or pre-iridal fibrovasular membranes (PIFM) combined with oral antibiotics and oral NSAIDs can be
Definition Inflammation in the anterior chamber and attempted, but are rarely successful.
development of a fibrous membrane across the pupil
Expected outcome Enucleation is generally needed.
Risk factors
Posterior capsular opacification (PCO)
● Longer phaco times
Definition Opacification with fibrosis of the posterior lens
● Hypermature cataract
capsule after surgery
● Uveitis prior to surgery
Pathogenesis Marked uveitis including fibrin development Risk factors Surgical treatment itself
[96–99] can occur post-cataract surgery, particularly in foals.
Pathogenesis Arguably the most common late postoperative
Prevention Unlike small animal medicine, where miotics such complication is posterior capsular opacification (PCO)
as latanoprost or carbachol may help decrease POH [94], these development [5, 88, 93, 99]. In one study, there was PCO
are not used immediately postoperatively in horses, as POH is development in all eyes (111) and it was severe in nearly half
much less of a concern and the side effects of these medications of them [87].
are undesirable in the postoperative period in horses [95]. PCO is somewhat unavoidable in all cataract surgery and
it can often progress rapidly in the postoperative period [87].
Diagnosis Tonometry is performed to reveal low IOP and PCO development is multifactorial, but one intraocular
flare is seen with a small pupil. method to minimize PCO is careful and extensive vacuum-
ing or aspiration of the lens capsule to remove as many lens
Treatment Mild-moderate uveitis is a typical complication epithelial cells as possible [100].
and is managed with SPL placement, allowing frequent (q2–4
h) topical and BID systemic anti-inflammatory medications Prevention The only way to prevent this is to remove the
as well as atropine to dilate the pupil and reduce the chance of entire posterior lens capsule.
synechia.
Diagnosis Slit lamp biomicroscopy or retroilluinated view
Expected outcome Signs of chronic uveitis may develop of the fibrosis on the posterior lens capsule (Figures 56.26c
(Figure 56.26a). and d)
Endophthalmitis Treatment None

Definition Intraocular inflammation usually caused by an
infection Expected outcome Depends on extent of PCO
Risk factors
Retinal detachment or folds
● Intraoperative breaks in sterility Definition The retina detaches or folds during or after
● Microleaks after surgery surgery.
(a) (b)
(c) (d)
Figure56.26 (a) Incisional fibrosis, PCO, and melanin on anterior lens capsule from chronic uveitis. (b) Endophthalmitis post-
phacoemulsification. (c) PCO post-phaco with PLC intact. (d) PCO post-phaco with hole in PLC. Source: Kate S. Freeman and Dennis E.
Brooks.
Risk factors Expected outcome Variable depending on the extent of

detachment; may have chronic uveitis and may be
● Inherent to surgical treatment
nonvisual (Figure 56.27).
● Drop of lens material into the vitreous
● Vitreous loss
Glaucoma
Pathogenesis These often start due to hypotony during Definition Intraocular pressure is high after surgery,
surgery and once the IOP returns, it will generally resolve [7], beyond the initial few hours of POH.
particularly in foals. In other cases, it can happen immediately
thereafter or months later and can be a permanent condition. Risk factors
● Horses that rub the incision after surgery

Prevention Maintaining a normotensive globe with
● Persistent preoperative uveitis predisposes
viscoelastic use during surgery may help.
DiagnosisIndirect ophthalmoscopy to visualize the Pathogenesis This is can occur either through direct
detachment blockage of the iridocorneal angle secondary to marked
inflammation or due to synechia leading to a pupillary block
Treatment Laser retinopexy may be done to prevent glaucoma. One of the authors has found that glaucoma is
progression of the detachment. more common in pseudophakic eyes than aphakic eyes.
Pathogenesis The hemorrhage and fibrin generally come

from the uveal tunic, most likely from the ciliary body itself.
Prevention Avoiding any manipulation of the retina during

surgery [102]. Intraoperative hemorrhage is often noted
intraoperatively, and in these cases the procedure should be
aborted and the wound closed [102]. This allowed for hemostasis
to be achieved and in the cases where this occurred, the
hemorrhage resolved without further inflammation.
Diagnosis Visible fibrin and/or detachment
Treatment Once the hemorrhage has been controlled, the

fibrin can be managed with intracameral TPA if needed.
Figure56.27 Retinal detachment post-phacoemulsification.
Source: Kate S. Freeman and Dennis E. Brooks. Expected outcome The detachment will remain and could
worsen, and the fibrin may resolve with time or medical
management.
Prevention The best prevention is aggressive anti-
inflammatory medications to reduce the uveitis as well as Cataract, chorioretinitis, and/or failure of the
mydriatics to prevent synechia. procedure
Definition Development of a cataract [102] or inflammation
Diagnosis Tonometry is performed. of the choroid and retina, which can lead to failure of the
procedure.
Treatment Once a high intraocular pressure is noted, medical
and/or surgical treatment of glaucoma should be initiated, Risk factors
including antiglaucoma medications or aqueocentesis may be
● Inherent to surgical treatment
needed.
● ERU causing cataract and/or chorioretinitis
Expected outcome If medical management fails, an end-
Pathogenesis Both cataract and chorioretinitis are
stage complication of cataract surgery is glaucoma that
common sequela of ERU, so they may be present prior to
ends in enucleation.
the procedure but could be worsened by the procedure.
In some cases, in the literature, the procedure-induced
Complicationswith ParsPlanaVitrectomy cataracts are described as mild cataract development rang-
ing from incipient to posterior capsular [102]. Nonetheless,
Pars plana vitrectomy is a procedure that is performed to in some of the eyes in the Frühauf study, progression of the
manage equine recurrent uveitis. This procedure involves chorioretinal scarring was noted [102].
inserting a vitrector probe through the pars plana ciliaris
and aspirating the vitreous contents including vitreous Prevention The main way to minimize the chorioretinitis
itself and any associated inflammatory material. This pro- and failure of procedure is to minimize any uveitis
cedure is most typically performed in horses outside of the associated with the procedure and treat aggressively with
United States, specifically in Europe [79, 101]. anti-inflammatory medications.
Fibrin and Retinal Detachment Diagnosis Direct and indirect ophthalmoscopy and tonometry
Definition Intravitreal fibrin and hemorrhage and fibrin to measure IOP
in the anterior chamber as well as retinal detachment, are
both possible complications of this procedure [5, 77]. Treatment Anti-inflammatory medications may help to
reduce the chorioretinitis and reduce the chance of failure
Risk factors of the procedure.
● Intraoperative hemorrhage Expected outcome In one study, stable vision and successful
● Manipulation of the retina during surgery control of the ERU was noted in 85% of the cases [7].
References 811
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815
57
Complicationsof DiagnosticProceduresof the NervousSystem

Laura Johnstone BVSc, MVSc, DACVIM (LAIM)
Cromwell, New Zealand
Overview – Decreased craniospinal pressure

– Increased craniospinal pressure
Complications of diagnostic procedures of the nervous sys- – Pneumocephalus and pneumorachis
tem are associated with handling and restraining an ataxic, ● Complications associated with injection of the cervical
unpredictable patient or relate to the procedure itself. This articular process joint
chapter will first discuss how to avoid injury to the horse – Iatrogenic infection of the joint
and personnel during a neurological workup, for which ● Complications associated with nerve or muscle biopsy
appropriate use of anesthesia is an important considera- – Swelling at the incision site
tion. Complications specific to individual diagnostic proce- – Non-diagnostic biopsy
dures will then be discussed. ● Complications associated with electrodiagnostics
L PatientorPersonnelInjury
with DiagnosticProcedures
Definition When examining or performing diagnostic
of the NervousSystem
procedures on a horse with neurological disease, the safety
of the handler, clinician and patient need to be considered.
● Patient or personnel injury
● Increased intracranial pressure
Risk factors Inexperience
● Complications associated with cerebrospinal centesis
– Blood contamination of CSF ● Inadequate physical or chemical restrain
– Inability to obtain sufficient CSF ● Enhanced ataxia associated with sedation
– Aspiration of air ● Recumbency associated with general anesthesia
– Changes in craniospinal pressure
– Damage to the spinal cord Prevention An experienced handler, sound footing,
– Violent reactions protective padding in stalls, horse helmets and appropriate
● Complications associated with cervical myelography use of stocks all reduce the risk of injury. Although it is
– Seizures important that the neurological examination is performed
– Exaggeration of ataxia without the confounding influence of sedation, ancillary
– Non-specific hyperthermia diagnostic procedures can be performed under sedation or
– Misplacement of the spinal needle general anesthesia, providing an effective means of
– Non-neurologic complications restraint to allow diagnostic procedures to be performed
● Complications associated with myeloscopy and safely. However, anesthesia of the neurological horse has
epiduroscopy its own inherent complications. These include enhanced
– Injury to the spinal cord or subarachnoid blood ataxia, recumbency and the impact on intracranial pressure
vessels (ICP). The latter is discussed in the following section.
816 Complications of iagnostic Procedures of the Nervous System
Sedation inevitably enhances ataxia and it is prudent to Increased ICP can result from underlying intracranial
consider that ataxic horses have an increased risk of fall- disease such as a space occupying lesion or parenchymal
ing, and therefore potentiating spinal trauma. Careful dos- edema resulting from trauma or infection. In addition,
ing, using combinations of drugs and the use of local factors associated with anesthesia can contribute to an
anesthesia, ensure that the enhancement of ataxia is mini- increase in ICP. Hypoventilation can occur during sedation
mized. Various combinations of alpha-2 adrenoceptor ago- or general anesthesia and result in hypercapnia-induced
nists and opioids are commonly-used sedation protocols. cerebral vasodilation and subsequent increased ICP [3].
For the ataxic horse, romifidine should be considered The head-down position also increases ICP by impeding
because at equipotent doses it induces a lesser degree of venous outflow from the intracranial compartment [3].
ataxia and lowering of the head when compared with xyla- Use of ketamine in patients with traumatic brain injury is
zine or detomidine [1]. However, romifidine’s longer dura- controversial. The traditional mantra was that ketamine
tion of action may be a disadvantage for short procedures increased ICP and was therefore contraindicated; however,
due to residual enhancement of ataxia. recent studies refute this and some studies indicate that it
The addition of an opioid enhances sedation but it decreases ICP [5]. In addition, by increasing cerebral
should be noted that butorphanol will enhance any ataxia perfusion [5], ketamine might prevent cytotoxic edema
caused by alpha-2 adrenoceptor agonists, while morphine caused by inadequate cerebral oxygenation.
does not [2]. The use of phenothiazines in neurological
patients has been discouraged because of the belief that the Prevention Avoiding a lowered head position [4] and
seizure threshold is lowered. However, this has been diffi- hypoventilation might prevent increases in ICP.
cult to confirm in clinical situations [3] and when used in
combination with an alpha-2 adrenoceptor agonist, their Diagnosis Monitoring ICP, as described elsewhere [4, 6],
anxiolytic effect can reduce the dose of alpha-2 adrenocep- ensures that cerebral blood flow is not compromised.
tor agonist required and thus minimize the enhancement Bradycardia and systemic hypotension occur with acute
of ataxia. elevations of ICP via the Cushing’s reflex, while continued
Recumbency during general anesthesia might result in elevation in ICP and reduction in cerebral blood flow
the inability to stand unassisted or injury from attempting increases sympathetic discharge and might result in
to stand during recovery, the consequences of which cardiac arrhythmias. Other clinical signs associated with
depend on the facilities available to assist recovery. increased ICP include depressed or somnolent mental
status, abnormal pupillary size and paresis.
Treatment Treatment aims to compensate for the decrease

IncreasedIntracranialPressure in cerebral blood flow by optimizing the delivery of oxygen
and substrates to brain tissue by oxygen therapy and
Definition Increased pressure within the cranium optimizing mean arterial blood pressure. Increased
intracranial pressure can be treated directly with
Risk factors hyperosmolar agents, including hypertonic saline or
● Underlying intracranial disease mannitol, elevating the head and, if under general
● Hypoventilation anesthesia, hyperventilation.
● Lowered head position
Pathogenesis The intracranial cavity is enclosed by bony omplicationsAssociated

C
structures and its contents are fixed in total volume. with CerebrospinalFluidCentesis
Therefore, three components are important regarding the
intracranial pressure (ICP): brain, CSF and blood. If arterial Cerebrospinal fluid (CSF) can be obtained via atlanto-
blood pressure remains constant, an increase in ICP occipital, lumbosacral [7], or cervical centesis [8]. Minor
decreases cerebral perfusion pressure. If cerebral vascular complications include blood contamination of the CSF,
resistance is maintained, a decrease in cerebral perfusion failure to obtain sufficient CSF, and aspiration of air into
pressure causes a decrease in cerebral blood flow and the collecting syringe. Serious complications from CSF
therefore might compromise cerebral oxygen delivery. centesis are rare. They include changes in craniospinal
Direct measurement of ICP in 6 normal horses ranged volume and thus craniospinal pressure, damage to the
from –3 to 7 mmHg, which is similar to the human spinal cord, and violent reactions. Although difficult to
reference range of 0 to 15 mmHg [4]. assess in horses, headache and nausea are common
Complications Associated ith Cereerospinal Fluid Centesis 817
complaints by humans following CSF centesis and resolve new needle and collecting syringe.
with analgesic therapy.
Expected outcome The negative outcome of blood
contamination is that it complicates cytological and
BloodContaminationof the CSF
immunological interpretation. Epidural hematomas have
Definition Blood contamination is the most common been reported [11]. However, none occurred as a
complication of lumbosacral CSF centesis. It is defined as complication of centesis and the author is unaware of
blood within the CSF secondary to centesis of the vertebral anecdotal reports or of any other clinical signs associated
canal and is problematic as it complicates cytological and with bleeding.
immunological interpretation [9].
Risk factors Inabilityto ObtainSufficientFluid

from LumbosacralCentesis
● Lumbosacral centesis
● Inadequate restraint Definition Inability to obtain sufficient fluid from
● Poor technique lumbosacral centesis despite appropriate placement within
the subarachnoid space
Pathogenesis Iatrogenic blood contamination is likely due
Risk factors
to damage to the epidural vein, meningeal vessels or spinal
cord vessels, or the vessels in the muscles previously ● Reduced CSF pressure
traversed. Hemorrhage at the site of collection is less ● Use of stylet-less needles
common during atlanto-occipital centesis compared with
lumbosacral centesis, but can occur at either site [7]. Frank Pathogenesis This minor complication arises despite
blood obtained during lumbosacral centesis indicates that appropriate needle placement and is probably related to
the tip of the needle is probably in one of the ventral reduced CSF pressure or occlusion of the needle by the
vertebral sinuses, off-center and too deep. trabeculations of the arachnoid mater. A dry tap has also
been reported due to an extradural thoracolumbar
Diagnosis Iatrogenic blood contamination is unevenly hemangiosarcoma [7].
mixed in the CSF and clears as successive aliquots are
removed. Frank blood indicates misplacement of the Prevention/treatment Flow of CSF may be encouraged by
needle in one of the ventral vertebral sinuses. These elevating the horse’s head, compressing the jugular veins,
findings are distinct from discoloration that is evenly mixed rotating the spinal needle 90 degrees or gentle aspiration. A
with CSF, which is unlikely iatrogenic. stylet can be used to clear the needle if it is suspected to be
clogged by tissue.
Prevention Techniques that reduce the chance of
traumatizing blood vessels during collection include
Aspirationof Air
maintaining the needle along the median plane, ensuring
that the stylet is always engaged in the hub of the needle Definition Aspiration of air into the collection syringe
during advancement, resting the hand that is holding the during CSF centesis
needle firmly on the horse’s dorsum, breaking the seal on
the collecting syringe prior to attaching to the needle and Risk factors Technical error
applying gentle suction. In addition, minimizing the
number of needle redirections during the procedure can Pathogenesis Aspiration of air into the collection syringe
minimize blood contamination and can be obtained occasionally occurs during lumbosacral centesis and is the
through experience and ultrasound guidance [8]. result of the syringe being too loosely attached to the needle
hub or air entering the needle when the stylet is removed.
Treatment If blood contamination occurs, collecting the
CSF in 2–3 mL aliquots will allow the least contaminated Prevention It is prudent to place a finger over the needle
sample to be used for analysis. Furthermore, blood hub to minimize the entrance of air.
contamination can be accounted for by calculating the IgG
index or Albumin quotient [10]. When frank blood is Diagnosis, treatment and expected outcome Anecdotally, in
encountered, it is best to withdraw completely and use a horses, no clinical signs have been attributed to aspiration
of air following CSF centesis. In humans, pneumorachis Diagnosis Invasive intracranial pressure monitoring [4] or
can occur secondary to many conditions, including measuring CSF opening pressure would be required to
pneumothorax and traumatic brain injury. In most cases, correlate adverse reactions to changes in craniospinal
there are no spinal cord symptoms and the condition pressure. Therefore, diagnosis is based on clinical signs.
typically resolves by addressing the underlying cause [12]. MRI could be used to diagnose herniation of the cerebellum
However, transient apnea, unconsciousness, hypotension or brainstem.
and bradycardia were reported in a human with
pneumocephalus following dural puncture [13], while Treatment and expected outcome Brainstem or cerebellar
other cases report clinical signs consistent with spinal cord herniation carries a grave prognosis. In contrast, 85% of
compression requiring decompressive surgery [12]. humans that have postdural puncture headaches respond
to conservative management [17]. This includes bed rest,
maintenance of hydration, intracranial vasoconstrictors
Changesin CraniospinalPressure such as caffeine, and gabapentin.
Definition The alteration of craniospinal pressure
secondary to centesis, causing clinical signs
SpinalCordTrauma
Risk factors Definition Damage to the spinal cord caused by spinal
needle misplacement
● Elevated intracranial pressure
● Removal of excessive volumes of CSF
Risk factors
Pathogenesis Craniospinal pressure is the pressure within ● Location of centesis

the cranium and spinal canal and is directly proportional to ● Poor technique
the volume of CSF fluid within the craniospinal space. The ● Inadequate restraint
intracranial cavity is open through the foramen magnum
into the spinal subarachnoid space. Theoretically, the Pathogenesis At the location of the lumbosacral space, the
sudden release of pressure during CSF collection, terminal spinal cord has transitioned into the cauda equina
particularly from a horse with elevated intracranial and passage of the needle through this structure does not
pressure, could result in fatal herniation of the cerebellum cause subsequent neurologic deficits. In contrast,
through the foramen magnum with resulting medullar or penetration of the spinal cord at the atlanto-occipital site is
cerebellar signs and death. Extrapolating from humans, in typically fatal and therefore careful technique is required.
less extreme cases, a decrease in craniospinal pressure
might result in headache, nausea, vertigo, tinnitus or neck Prevention Proper technique for atlanto-occipital centesis
pain. avoids spinal cord trauma. The wrist of the hand advancing
Up to one-third of human patients receiving lumbar the needle should brace against the neck to stabilize the
dural puncture report experiencing a headache that needle and prevent excessive insertion. The first finger of
typically occurs within 5 days of the procedure and is the other hand should be placed on the hub of the stylet to
orthostatic [14]. Although the mechanisms of post-dural ensure the stylet remains correctly in place as
puncture headache is uncertain, there are two theories. In disengagement of the stylet can result in damage or
the first, CSF loss decreases CSF pressure and thereby collection of a portion of neural tissue [7]. The mean depth
reduces the cushioning effect of intracranial fluid and at which CSF is obtained is 6.5 cm (2.6”) [7]. However,
places traction on intracranial structures. The second once inserted 2.5 cm (1”), the stylet should be removed at
theory is that a sudden drop in CSF pressure results in millimeter intervals to check for CSF flow before advancing.
intracranial vasodilation. Although the procedure has been described standing [15]
it is not advised, as the head and neck need to be
Prevention Centesis of CSF is contraindicated in horses immobilized and therefore general anesthesia is essential.
with increased ICP. However, standing healthy horses Ultrasound guidance has been described for
tolerate removal of more than 100 mL of CSF without lumbosacral [18], atlanto-occipital [19] and cervical
exhibiting adverse effects [15] and a general rule that can centesis [8] as a means of reducing the risk of spinal cord
be applied is 0.2 ml CSF/kg BW [16]. This volume should trauma. However, it should be noted that ultrasound
provide ample fluid for analysis without compromising guided atlanto-occipital puncture required the needle to be
craniospinal pressure. inserted less perpendicular to the dura mater in order to
Complications Associated ith Cervical yelography 819
optimize visualization of the needle compared with the recommended that subsequent CSF collection be
traditional technique [19]. This increases the risk of performed under general anesthesia.
pushing the dura mater ventrally rather than passing
through this layer and if not recognized sonographically
could also result in spinal cord trauma. The cervical omplicationsAssociated
C
approach minimizes the risk of spinal cord trauma by with CervicalMyelography
using ultrasound guidance and by the ventrolateral to
dorsomedial approach, as any upward movement of the A recent, multi-institute, retrospective study reported
horse’s head will cause the needle to pull out [8]. adverse reactions in 95 out of 278 (34%) horses undergoing
myelography [21], indicating that complications are
Diagnosis The development of neurological deficits that common. Most adverse reactions are mild and self-limiting.
are consistent with caudal brainstem and upper cervical However, a small percentage might require euthanasia [21].
lesions after atlanto-occipital puncture suggest iatrogenic Even so, myelography is essential when surgical
trauma. Neuroanatomy in this region includes caudal intervention is anticipated. The myelographical technique
brainstem nuclei, ascending and descending spinal tracts, has been described elsewhere [22] and complications
and the ascending reticular activating system. Therefore, associated with general anesthesia and atlanto-occiptial
neurological signs might include lower motor neuron centesis have been described earlier in this chapter.
deficits of multiple cranial nerve nuclei, decreased Seizures, exaggeration of ataxia and non-specific
mentation, upper motor neuron paresis of all limbs and hyperthermia are common complications of myelography
death. MRI in dogs with iatrogenic needle trauma to the and although the pathophysiology behind these clinical
caudal brainstem revealed conspicuous T2-W hyperintense signs is poorly understood, neurotoxicity of the contrast
linear lesions on midsagittal images, compatible with medium is a common theory. Changes in craniospinal
hemorrhage [20]. pressure might also contribute to some myelographical
complications.
Treatment and expected outcome Conservative management
may be attempted. However, if neurological signs are
severe the prognosis is grave. Seizures
Definition Seizures are the clinical manifestations of rapid
ViolentReactions excessive electric discharge from the cerebral cortex,
resulting in involuntary alterations of motor activity,
Definition During lumbosacral centesis, it is typical that a
consciousness, autonomical functions, or sensation, and
horse may twitch their tail, flex the pelvic limbs slightly, or
can be partial or generalized.
contract the axial muscles momentarily when the needle
penetrates the dura. Rarely, a horse will respond violently.
Risk factors
These responses can include kicking, rearing and jumping
but more importantly are sudden and entirely ● Use of metrizamide as a contrast medium
unpredictable. To the author’s knowledge, violent reactions ● Large total volume of contrast material
have not been reported in association with standing ● Shorter duration of time from injection of contrast to
cervical centesis. anesthetic recovery [23]
● An association between recognition of contrast material
Risk factors None known surrounding the brain and seizures is not known
Pathogenesis The cause is unknown but is assumed to be Pathogenesis The incidence of focal or generalized
an anomalous sensation resulting from contact of the seizures associated with myelography has decreased with
needle with nerve roots or the cauda equina. the change in contrast medium from metrizamide to
iohexol [24]. However, it remains a common complication
Prevention To avoid injury as a sequela of these reactions, and was reported to occur in 6 out of 278 horses during the
it is prudent to assess the environment prior to performing time between injection of contrast and recovery and in 9
CSF collection, ensuring the clinician has an escape path out of 278 post-myelography, an incidence similar to that
and having a competent, experienced handler. Adequate reported in dogs [23].
sedation and use of a twitch might reduce the risk of a The cause of myelogram-associated seizures is not
violent reaction. In the event of a violent reaction, it is known. However, changes in craniospinal volume, the
neurotoxicity of the contrast medium, and aseptic or septic Non-SpecificHyperthermia

meningitis are likely candidates.
Definition Rectal temperature >101.5oF (38.5oC) during
the period from recovery after anesthesia to 1 week after
Prevention Use of short-term corticosteroids to reduce
myelography [21]
contrast medium reactions is controversial in humans due
to their questionable efficacy [25], but anecdotally appear
Pathogenesis Non-specific hyperthermia was reported to
to have some benefit in horses.
occur in 25 out of 278 cases and was not attenuated by
administration of pre- or intramyelography anti-
Diagnosis Generalized seizures involve the entire cerebral inflammatory or osmotic agents [21]. Neck pain and
cortex and result in generalized tonic-clonic muscle activity stiffness and changes in mentation are reported to occur
over the whole body, with loss of consciousness. Partial concurrently, suggesting aseptic meningitis or
seizures are limited to a discrete area of the cerebral cortex meningoencephalitis as the cause.
and in the horse often manifest as facial or limb twitching, Development of aseptic meningitis or meningoencephali-
compulsive running in a circle, or self-mutilation. tis after intrathecal administration of nonionic contrast
medium has been reported in humans [27] and dogs [28].
Treatment and expected outcome Myelogram-associated The pathophysiology is unknown but is thought to relate to
seizures typically resolve without treatment. changes in intrathecal osmolarity, direct toxicity, or an
immune-mediated process. In people, additional reactions to
iohexol are reported including headaches, nausea, vomiting
Exaggerationof Ataxia and dizziness [29], and idiosyncratic reactions [30]. The latter
Definition Affected horses displaying a higher degree of resemble anaphylactic reactions but do not require prior sen-
ataxia after recovering from myelography. sitization and do not consistently occur in the same patient.
Prevention As with myelogram-induced seizures, the

Risk factors
benefit of prophylactic short-term corticosteroids is
● Contrast medium reaction unclear.
● Trauma during general anesthesia
Diagnosis Careful examination is required to rule out
Pathogenesis It is not uncommon for horses to display a gastrointestinal or respiratory complications of general
higher grade of ataxia post-myelography [21, 26]. In anesthesia.
addition to the factors potentially contributing to seizure
activity, injury to the spinal cord secondary to manipulation Treatment and expected outcome In the absence of
of the head and neck or falling during induction or recovery complications, horses respond to conservative treatment
could also contribute. including flunixin meglumine (1.1 mg/kg IV) and
supportive care.
Prevention If severe compression is suspected from survey
radiographs, minimizing manipulations of the vertebral Misplacementof the Needle
column is indicated, with care taken to avoid overextension
or overflexion. Definition Misplacement of the needle resulting in
contrast material being injected into the epidural space,
Diagnosis and treatment Repeat neurological evaluation is subdural space, the cranial nuchal bursa or intramedullary.
required to determine the neuroanatomical location of the
additional ataxia and further imaging may be required if Risk factors
trauma is suspected. However, conservative treatment is ● Inexperience
generally sufficient. As with myelogram-induced seizures, ● Blind approach
the benefits of prophylactic or therapeutic short-term
corticosteroids are unclear. Pathogenesis Injection of contrast medium intramedullary
results in direct spinal cord damage.
Expected outcome Worsening of neurological signs is
transient and with exception of horses with severe ataxia Prevention Ultrasound-guided atlanto-occipital puncture
(grade 4), it is rare that outcome is affected [26]. for myelopgraphy in the horse has been described [19] and
Complications Associated ith yeloscopy and piduroscopy 821
promoted as a technique that reduces complications associated with tracheal trauma that results from
associated with misplacement of the needle. manipulation of the head and neck while the horse is
intubated [21] or lateral recumbency causing compression
Diagnosis Correct placement of the needle within the atelectasis.
atlanto-occipital space should result in a steady flow of
CSF from the needle and injection of contrast should lack Prevention Standing myelography of the horse was first
resistance. If misplaced, the presence of contrast outside reported in 1986 [33] and promoted as a method that avoids
the subarachnoid space will be obvious on survey complications associated with general anesthesia, while
radiographs. Intramedullary injection of contrast medium, reportedly allowing good-quality myelographical images to
although not reported in horses, has been reported in a be obtained. However, 4 out of 6 horses experienced
woman during a C1–C2 myelogram and manifested as generalized seizure activity at the time of contrast medium
intense neck pain initiated at the time of injection, which injection. Metrizamide was used in this study and has since
occasionally radiated into the face, arm and the leg [31]. been replaced with non-inoic contrast mediums, iohexol
Extrapolation of neurological signs in humans should be and iopamidol. A subsequent study in 2007 reported no
done cautiously as humans are injected laterally at C1–C2. significant complications when performing standing
Intramedullary injection of contrast medium during myelography in 8 horses by lumbosacral injection of
cervical myelography has been reported in a dog. Thirty-six iohexol [34]. However, concerns remain, including the
hours after the procedure, the dog was non-ambulatory ability of the horse to stand squarely and quietly for the
with spontaneous positional nystagmus, a left-sided head duration of the procedure, the ability to obtain a diagnostic
tilt and obtundation. A discrete, linear, intra-axial lesion study in only 5 out of 8 horses, the limited ability to obtain
was observed with MRI [20]. flexed views of the caudal cervical spine, and the large
volume of iohexol injected (0.2 mg/kg) [34].
Treatment In the case of suspected intramedullary
misplacement, conservative management including rest Diagnosis, treatment and expected outcome These vary
and anti-inflammatories can be attempted. according to the type and severity of each complication.
The reader is referred to relevant chapters and other
literature describing treatment of those conditions.
Expected outcome Except for intramedullary
misplacement, the most common consequence of needle
misplacement is reduced diagnostic utility of the study.
The outcome of iatrogenic intramedullary contrast omplicationsAssociated
C
injection would depend on the site and extent of damage with Myeloscopyand Epiduroscopy
and as a worst-case scenario would be fatal. In humans, the
outcome ranges from complete recovery, to permanent Myeloscopy and epiduroscopy of the cervical vertebral
hypoalgesia or paresis, to death [20] and persistent canal [35, 36] and epiduroscopy of the lumbosacral
neurological deficits can result after even small amounts of vertebral canal [37] have been described and their
contrast injected intramedullary [31]. diagnostic use justified by their ability to localize the site
and characterize the nature of spinal cord injury with
greater accuracy than myelography [38]. Myeloscopy is
Non-NeurologicComplications considered superior to epiduroscopy at assessing spinal
Definition Non-neurological complications reported in cord compression, because the view in this fluid-filled
horses undergoing myelography include pneumonia, space is more likely to allow identification of narrowing of
colitis, colic, and musculoskeletal trauma [21]. the vertebral canal. However, epiduroscopy has fewer risks,
as the dura is not opened, avoiding direct contact with the
Risk factors spinal cord, entrance of air into the subarachoid space, and
CSF loss.
● General anesthesia
Head and neck manipulation
Injuryto the SpinalCordorthe Subarachnoid
●
BloodVessels
Pathogenesis Although these complications are likely
secondary to general anesthesia, the incidence of DefinitionIatrogenic trauma to the spinal cord or
pneumonia is higher in horses undergoing myelography surrounding blood vessels during myeloscopy or
than anesthesia for other procedures [32]. This may be epiduroscopy
Risk factors Pathogenesis During myeloscopy, CSF is lost from the

dural incision, either during the procedure or leaking
● Inexperience
through the sutured incision post-myeloscopy. If
● Inadequate relevant anatomical knowledge
uncompensated, the reduction in CSF volume will cause a
● Myeloscopy > epiduroscopy
decrease in craniospinal pressure.
Pathogenesis Iatrogenic trauma occurs at the time of
insertion or manipulation of the endoscope. Myeloscopy Prevention Preplacement of simple interrupted sutures
has greater risk than epiduroscopy, as trauma is most likely allows the incision in the dura to be sealed after insertion
to occur during introduction of the endoscope into the of the endoscope in the subarachnoid space. Tilting the
subarachnoid space. In humans, spinal subarachnoid operating table by 20 degrees so that the horse’s head is
hematomas are a rare but serious complication that often elevated above the caudal aspect of the horse (reverse
lead to permanent neurological deficits and can be Trendelenburg position) decreases the pressure of CSF in
fatal [39]. the cerebello-medullary cistern prior to incising the dura.
Lowering the operating table to a horizontal position once
Diagnosis Although there are no reports of subarachnoid the dura is closed allows visual check for CSF leakage.
hematomas in the equine literature, cervical extradural Feeding the horse from an elevated hay net for 14 days
hematomas of unknown etiology have been reported in a post-surgery encourages the horse to maintain the poll
case series of 4 horses [11]. Each showed grade 3–4/5 region as the highest point of the body and thus fluid
ataxia, paresis, and neck pain, which in 3 horses pressure at the site of the surgical approach remains low.
necessitated euthanasia. The remaining horse showed As discussed previously, horses can tolerate loss of more
gradual improvement, but 5 years after diagnosis remained than 100 ml of CSF [15]. Nonetheless it is prudent to
mildly ataxic. Diagnosis of epidural spinal hematomas in prevent excess loss.
human medicine is based on CT or MRI [11].
Diagnosis, treatment and expected outcome In humans,
Prevention During the development of this technique, chronic CSF loss manifests as orthostatic headaches,
minimally invasive approaches were abandoned due to nausea, neck pain or stiffness. In the worst-case scenario,
spinal cord and subarachnoid blood vessel damage [36]. herniation of the brainstem can occur [40]. Eighty-five
An open approach, using a 15-cm-long skin incision, was percent of humans that have postdural puncture headaches
deemed necessary to allow exact placement of the incision respond to conservative management [17]. This includes
in the dura and arachnoid mater, and gentle, controlled bed rest, maintenance of hydration, intracranial
insertion of the endoscope into the vertebral canal [36]. vasoconstrictors such as caffeine, and gabapentin.
Even so, subarachnoid hemorrhage occurred in 1 out of 3
horses in which the latter myeloscopical technique was
IncreasedCraniospinalPressure
used [35].
Definition Changes in craniospinal pressure are induced
Treatment and expected outcomeFor the horse mentioned by injection of fluids into the epidural space.
previously with subarachnoid hemorrhage following
myeloscopy utilizing an open approach [35], mild Risk factors
impairment of the endoscopic view occurred during the
procedure, and postoperatively this horse experienced ● Epiduroscopy
transient ataxia and diffuse muscle fasciculations that ● Rapid injection of fluids into the epidural space
resolved after 7 days. However, evidence from human
medicine suggests that the consequence of spinal Pathogenesis During epiduroscopy injection, of fluid is
subarachnoid hematomas might be serious. necessary to allow manipulation of the endoscope and a
clear visual field. Theoretically, rapid injection of fluids
into the epidural space can increase epidural pressure and
DecreasedCraniospinalPressure thus craniospinal pressure and subsequently result in the
Definition Craniospinal pressure decreases with the loss “Cushing Reflex,” which leads to hypertension, bradycardia
of CSF. and apnea [35].
Risk factors Myeloscopy Prevention Slow injection of fluids is recommended.

Complications Associated ith Nerve and uscle iopsy 823
Diagnosis and monitoring Changes in craniospinal pressure omplicationsAssociatedwith Nerve

C
can be monitored indirectly via blood pressure and heart rate. and MuscleBiopsy
Treatment If an increase in blood pressure and a decrease Antemortem diagnosis of Equine Motor Neuron Disease
in heart rate are observed, the rate of fluid injection into (EMND) is based on either histopathological evidence of
the epidural space should be reduced. degeneration of myelinated axons in a nerve biopsy or
neurogenic atrophy of predominantly type 1 muscle fibers
Expected outcome No long-term consequences were in the sacrocaudalis dorsalis medialis muscle. More broadly,
reported for three horses that had an increased mean these procedures might be justified to determine the cause
arterial pressure and heart rate during epiduroscopy [35]. of muscle atrophy.
Biopsy of the ventral branch of the spinal accessory
Pneumocephalusand Pneumorachis nerve has been described [43]. This nerve is accessible and
biopsy causes no disfigurement of the sternocephalicus
Definition Entrance of air within the subarachnoid space muscle or any interference with muscle function. Biopsy of
the sacrocaudalis dorsalis medialis muscle is the preferred
Risk factors muscle for diagnosis of EMND and the technique is
● Dural incision described [44].
● Insufficient seal around the endoscope during
myeloscopy
Swellingatthe IncisionSite
Pathogenesis In addition to CSF escaping the subarachnoid Definition Swelling at the incision site is a common but
space, myeloscopy might allow air to enter this space. minor complication.
Prevention Ensuring an adequate seal around the Risk factors

endoscope by use of preplaced sutures minimizes this risk
● Break in aseptic technique
during myeloscopy.
● Dead space
Diagnosis, treatment and expected outcome Refer to previous

Prevention Adhering to aseptic technique and ensuring that
discussions on pneumocephalus and pneumorachis during
dead space is minimized might prevent this complication.
CSF collection.
Treatment and expected outcome No specific treatment is
required and swelling typically resolves in 7–10 days [43].
C In rare cases, the swelling may become moderate/severe
with CervicalArticularProcess and/or develop into an infection, in which case treatment
JointInjection with anti-inflammatory and antimicrobials drugs may be
indicated.
Injecting corticosteroids into the cervical articular process
joint can aid in the diagnosis of cervical arthrosis. The
Non-DiagnosticBiopsy
technique for ultrasound-guided injection is described
elsewhere [41]. Definition Obtaining a non-diagnostic biopsy is the main
complication with nerve and muscle biopsies.
Definition Potential complications with this procedure
include mild, transient discomfort from needle placement Risk factors
and iatrogenic infection of the joint.
● Trauma to the muscle sample
● Insufficient size of sample
Risk factors Inexperience: studies indicate that this
● Incorrect muscle sampled
technique has 72% accuracy and that gained experience
● Spoiling during shipping
was the only significant determinant of accuracy [42].
PreventionAseptic, careful ultrasound-guided technique Prevention Artifacts are created by injecting lidocaine into
is recommended. the muscle belly, pulling the muscle with forceps while
trying to dissect the muscle, and crushing the muscle especially if samples are being frozen rather than formalin
sample. The area often contains a significant layer of fixed. Shipping times should also be considered for fresh
subcutaneous fat, so the biopsy needs to be deep enough to muscle tissue that will be frozen.
ensure collection of muscle tissue. Ideally, a ½-inch cube is
required for analysis but as muscle contracts after
transection, the biopsy needs to be 1 inch long prior to omplicationsAssociated
C
transecting. When obtaining a biopsy for diagnosis of with Electrodiagnostics
EMND, knowledge of anatomy is important. If the biopsy
is taken too cranially, the biceps femoris or the superficial Electrodiagnostics are minimally invasive procedures that
gluteal muscle will be biopsied, neither of which are help in the localization, diagnosis and prognosis of dis-
diagnostic for EMND. Shipping methods need to be eases of the lower motor unit. Complications mainly arise
considered and obtaining instructions from the laboratory from general anesthesia, when required, rather than the
where the sample will be submitted is recommended, procedure itself.
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58
Complicationsof AnteriorCervicalFusion
Barrie DonLeo Grant DVM, MS, DACVS, MRCVS
Equine Consultant, Bonsall, California
Overview ● Incorrect labeling of survey radiographs and myelogram

● Not getting the entire neck imaged at the time of
There are a number of potential complications associated surgery
with the anterior cervical fusion technique that are unique
to the procedure. Other complications such as infection Pathogenesis The equine neck is a complicated structure,
and seroma will be discussed with emphasis on prevention and other than C2 with its distinctive spine, the other
and mitigation. As with most surgical interventions, proper vertebra can be mistaken for the wrong level with palpation
planning, well trained personal, and functioning equip- and imaging.
ment significantly reduce the number and severity of the
complications. Prevention This possibility can be avoided by reviewing
the myelogram with the clinician in charge and confirming
that the level(s) that are to be fused are the same as the
L interpretation of the myelogram. This interpretation
with AnteriorCervicalFusion should have been in a written report, with the owner/agent
signing off on the proposed plan.
● Intraoperative and preoperative planning: fusing the After the patient has been induced and placed in the cer-
incorrect site vical brace, a preliminary skin preparation should be done.
● Inraoperative: insecure implant This should include the lateral aspect of the cervical area
● Neuropathy distal enough so that the placement of the 14-gauge nee-
– Horners syndrome dles can be performed in a clean environment. The needles
– Recurrent laryngeal neuropathy should be placed in an alternating pattern with two needles
● Hematoma/seroma at C3/C4, one needle at C4/C5, two needles at C5/C6, and
● Infection one needle at C6/C7. I recommend 14-gauge needles as
● Traumatic recovery/fracture they are more easily seen on intraoperative films than
● Fractures in the rehabilitation stage 18-gauge needles. At the sites with two needles, they
should be inserted in a crossing pattern. It is important
I ntraoperativeand Preoperative when using a small digital screen that will not allow obser-
Planning:Fusingthe IncorrectSite vation of the entire neck, that the first image obtained
should include both C2 with its distinctive spine and C3/
C4. Additional images should be done in an overlapping
Definition Fusing of the incorrect cervical site is the most
pattern. This is especially important if a C-arm will be used
troubling complication intraoperatively.
for the intraoperative monitoring. The surgeon should
Risk factors vocally state the level to the entire operating room staff
every time an intraoperative image is obtained. It is a natu-
● Poor communication between clinician in charge and ral temptation to concentrate more on the positioning and
the surgeon depth of the drills or Kerf cleaner rather than to look at the
Intraoperative: Insecure Implant 827
entire image and confirm that the correct site is being

prepared.
Treatment The correction of the incorrect level depends

on the timing of the discovery. If only the spine has been
removed, then the longus colli muscles need to re-apposed
with a double layer of suture, with the first level being a
continuous horizontal mattress and the second to be a
simple continuous. If the implant was been inserted and
the surgical area is still open, then the implant should be
packed with the harvested graft and the muscle closed as
previously described. Then checking with the anesthesia
team and involving them in the decision to continue to the
correct level; or call it a day, recover the patient and come
back 7–10 days later.
Figure58.1 Radiograph showing the central Kerf Cut Cylinder
backing out of the drill hole. The arrow indicates the original
Expected outcome It should go without saying that as soon
depth of the hole. Source: Barrie DonLeo Grant.
as the surgeon is in a position to do so, the owner/agent
and the referring veterinarian need to be informed. This
has happened to the author on two occasions and in both
cases a second procedure was performed at my expense.
Both horses recovered and were able to improve
neurologically and one was a champion show horse and
the other a winner of a minor stake. Both owners and their
connections were appreciative of our candor and credibility
and a fortunate outcome was realized.
Intraoperative:InsecureImplant
Definition The Kerf Cut Cylinder does not lock tight upon
placement.
Risk factors If the implant does not lock tightly into place,
Figure58.2 Radiograph showing the caudal Kerf Cut Cylinder
it is predisposed to premature loosening and failure backing out of the drill hole. The arrow indicates the original
(Figures 58.1 and 58.2). depth of the hole. Source: Barrie DonLeo Grant.
Pathogenesis The cylinder threads can have bone debris

with a small curette. Next, make sure that the isthmus is
embedded within them that will stop the cylinder from
low enough that it will prevent the implant from going
locking into place.
deep enough as its most superficial surface is bottoming
out of the implanter. Removing more of the isthmus is all
Prevention
that is needed. If the implant will still not engage, then a
● Make sure the cylinder is clean prior to implantation. fully threaded implant can be used. One should always
● Make sure the hole is drilled deep enough to accept the have a fully threaded implant in the pack, if only as
entire cylinder. insurance that it will not be needed. The fully threaded
implants are self-tapping and if the surgeon is not paying
Diagnosis Intraoperative imaging attention with intraoperative monitoring it is possible to
thread the implant into the spinal canal. If this occurs,
Treatment It is disappointing to have the implant site then reversing the implant to the proper level is advised.
prepared and the implant threaded into place to not have it Anesthesia should be notified because enough trauma to
lock tight. When this occurs, make sure the Kerf is cleaned the cord may cause cessation of normal respiration.
828 Complications of Anterior Cervical Fusion
One might be tempted to insert small pins in a cruciate is adequate muscle contraction to assist in stabilization of
pattern through the holes of the implant into the surround- the implant site.
ing bone and cap the pins with bone cement. Based on one
case, it is possible for enough migration to occur to lacerate Expected outcome A postoperative radiograph should be
the esophagus or have the pins perforate the spinal canal obtained immediately after the patient recovers, so that the
(Figures 58.3 and 58.4). position of the implant can be monitored every other day
Ideally, small titanium interlocking plates are available for a week. There may be some ventral migration but most
to place over the implant and graft to assist in stabilization. often the migration is only 3 to 4 mm and will stabilize. As
The failure of the implant to lock is not uncommon and long as the trachea is not compressed and the animal is
has been treated with the firm application of the graft and comfortable with only minimal NSAID medication, a good
secure closure of the longus colli with at least #1 absorbable outcome can be expected.
suture. Having a smooth recovery is most beneficial. There If there is increased discomfort, and severe migration of
the implant with compromise of the trachea diameter, then
reoperation and replacement of the implant with a fully
threaded implant and augmentation with an interlocking
plate may be necessary.
Neuropathy
Definition There is a neuropathy of the vago-sympathetic

nerve trunk and or recurrent laryngeal nerve secondary to
the surgical approach.
Risk factors
● Retraction of the nerve bundles

● Pressure on the carotid artery
Figure58.3 Radiograph showing the treaded profile of the
“Seattle Slew” implant, as well as cross pins through the implant Pathogenesis The surgical exposure of the ventral aspect
into the bone and covered with polymethylmethacrylate. Source: of the cervical vertebra requires retraction of the vago-
Barrie DonLeo Grant. sympathetic nerve trunk and the recurrent laryngeal nerve.
These two nerve bundles are in close contact with the
carotid artery. Prolonged and incorrect pressure on the
carotid artery and nerves with retraction can result in
immediate dysfunction of these nerves. The neuropathy(s)
are not usually recognized until the recovery period.
Prevention Avoiding excessive and prolonged retraction

on the neurovascular bundle is the primary prevention.
Placing a thick moistened towel, lap sponge or soft plas-
tic strip between the retractors and the neurovascular bun-
dle is highly recommended. Some surgeons do not use
Deaver retractors for the initial retraction, instead substi-
tuting fingers and hands. This method has a lower inci-
dence of surgical associated Horners/Laryngeal
dysfunction (Brett Wood: personal communication).
Preoperative endoscopic exam should be performed on
all patients. If there is a unilateral laryngeal paralysis, then
Figure58.4 Necropsy image of vertebra showing Kerf Cut
Cylinder with a cross pin going through the cylinder into bone
that is the side that the neurovascular bundle should be
and penetrating the spinal canal. Source: Courtesy of Barrie retracted. Traditionally, the author uses a right-sided
DonLeo Grant. approach to get a better exposure without the presence of
Hematoma/Seroma 829
the esophagus. If the left arytenoid is paralyzed then plac- side that was paralyzed before surgery so that the paralysis
ing a nasogastric tube into the esophagus will greatly aid the on the operated side may improve with time, especially if
dissection on the left side. Since insisting on preoperative the damage is only neuropraxia and not axonotmesis or
endoscopic examination, the author has had to perform neurotmesis.
only one emergency tracheostomy in the last 20 years. If a unilateral laryngeal paralysis does occur, then a laryn-
geal prosthesis (tie-back) surgery will be needed if the
patient is to perform in a sport that requires a normal laryn-
HornersSyndrome
geal function. The need for this surgery is often not recog-
Treatment If only the sympathetic nerve has been nized until the patient is back in intense training; if the
compromised, then the classical signs of Horners become neurological improvement is adequate to permit training
immediately obvious, with the eyelid ptosis and distinct and competing at speed safely. Usually the paralysis is on
sweating of the anterior cervical area and to the midline of the right side and this requires some adaption for the sur-
the skull. Other than the appearance being a constant geon who are usually trained for a left-sided condition.
concern for the owner/agent, the patient usually has no
problem with recovery. Fusion will proceed normally.
Infrequently there may be a delay in onset, and this is
Hematoma/Seroma
thought to be the result of seroma and hematoma causing
increased pressure on the nerves. The continued use of
Definition A collection of blood or serum in a pocket of
NSAIDs to reduce the pressure is indicated. The use of
dead space left by the surgical approach
ultrasound to assess the size of the hematoma/seroma is
helpful. I do not recommend the aspiration of the
Risk factor
hematoma/seroma, unless it is actually an abscess, as the
fluid returns by the next day and repeated aspiration greatly ● Incision length
increases the likelihood of infection. (See Section on ● Incision depth
Infections (sepsis) below). Over time (which can be as short ● Vascular supply
as 14 days or as long as 8 to 12 months), the clinical signs ● Movement of region after surgery
subside. When these clinical signs are noted, an endoscopic
exam should be performed as most cases will also show a Pathogenesis Any surgical procedure with an incision in
paralysis of the arytenoid cartilage from a concurrent excess of 2 to 3 cm through multiple muscle layers without
recurrent laryngeal nerve paresis. the use of a tourniquet will be at increased risk of seroma
formation. The diagnosis of a seroma is usually not difficult
as there is an increase in size of the surgical area that
RecurrentLaryngealNeuropathy
obscures the normal appearane of the jugular furrow.
When the recurrent laryngeal nerve is compromised dur- Postoperative radiographs should be obtained to rule out a
ing the surgical exposure, it can be life-threatening if the fracture of the implant site. The radiograph will also
opposite nerve is also compromised. The marked dyspnea provide necessary information about the size of the seroma
is usually not observed until the tracheal tube has been and if the tracheal lumen is being compromised. Diagnostic
removed. Each hospital has their own protocol on the ultrasound will also provide information about the nature
removal of the trachea tube. Some do not remove it until of the fluid and a more accurate method to measure the
the patient is standing and some remove it as soon as the size. It is a great temptation, especially for the
patient is swallowing. A bilateral laryngeal paresis needs ultrasonographer, to drain the seroma. This should be
an immediate tracheostomy and so the removal of the tube avoided as the seroma returns within a few hours and will
when the patient is standing makes an emergency do so for the several weeks. Repeated aspiration greatly
tracheostomy much more difficult. The patient is desperate increases the possibility of suppuration.
to get an airway reestablished and can become very violent, If left alone, even the largest seromas resolve over a 4- to
endangering the person attempting to block the skin, make 6-week period; however, if the seroma becomes infected
an incision and open the trachea. If the patient is still then open drainage needs to be instigated.
recumbent, the procedure is considerably easier and safer
to perform. Prevention A 2-layer closure with good apposition of the
longus colli muscles is the most important aspect of
Expected outcome While the paralysis may improve with preventing seromas. In addition, an adequate length of an
time and NSAIDs, a laryngeal prosthesis is needed on the incision will reduce the pressure of the retractors on the
tissues at the surgery site. Currently, minimally invasive the fluid should be examined for CBC and cytology.
procedures have been popularized as being less painful and Continued use of antibiotics is recommended and will
returning the patient to normal as quickly as possible. This depend on the results of the culture and sensitivity.
procedure by its nature is invasive. Adequate exposure to Immediate removal of the implant is not recommended, as
encourage good visualization and reduction of excessive the infection may only involve the large muscle and trachea
retraction on the muscles and carotid sheath should have area and not the implant site, as the 2-layered closure of the
the highest priority. longus colli muscle over the implant and graft may protect
this area from invasion with organisms.
Prevention Any surgery with a large incision and

Infection prolonged exposure (as compared to arthroscopy) often
performed on younger horses in a surgery room that most
DefinitionBacterial reproduction in a wound leading to
often is used for colic surgeries is predisposed to a surgical
trauma and discomfort of the patient
infection. A complete cleaning of the surgery room and
overhead lights and lift tracks is necessary. The use of
Risk factors
preparation fluids and sponges that have been freshly
● Incision length autoclaved and are not from a common container is
● Incision depth mandatory. Antibiotics should be administered
● Movement of region after surgery preoperatively and continued for at least 3 days following
● Seroma or hematoma formation surgery. No horse should be operated on that has had a
current or recent respiratory infection. Many patients with
Pathogenesis A surgical infection is the bane of all this condition are young horses with poor vaccination
surgeons, especially if an implant is involved. Recognizing histories, have been shipped long distances and then had a
infection of the implant or the surgical site requires myelogram performed soon after arrival at the hospital. All
obtaining all the usual parameters. The temperature may these factors increase the level of stress and predispose to
not be elevated initially because the postoperative NSAIDs serious respiratory conditions.
depress the febrile response. Initially, a CBC may only Even chronic abscesses in the long term can be mobi-
show a slight increase in WBC with a left shift. An increase lized during the combined stress of shipping, myelogram
is SAA may only be from the trauma of the surgery. The and then surgery. A bacteremia then results and the
patients certainly show an increase in discomfort with a intervertebral disc is a favorite site for infection by
rigid neck, inability to eat off the ground and an increase in facultative anaerobes.
incisional swelling. A fracture at the implant site with an
instability will also result in increased swelling and Treatment The relatively poor circulation of the
discomfort. Postoperative radiographs are necessary to intervertebral disc makes treatment with antibiotics
distinguish between the two. A fracture associated with the challenging. If the patient fails to respond to the initial
implant site usually shows a change in position and drainage and use of the correct antibiotics, a decision to
orientation compared to the immediate postoperative remove the implant needs to be made. If the pain and
radiograph that needs to be obtained before the patient is discomfort is unrelenting and the neurological status is
moved off the surgical table. Fracture lines may not be seen deteriorating, then the decision becomes much clearer. At
immediately. There is usually an increase in the distance surgery, the implant, suppurative tissue and disc material
between the ventral spine and the trachea. This can be should all be cultured. Radical debridement should be
from the hematoma associated with the fracture trauma performed so the entire implant site is bleeding. Bone
but can also be from the infection process. cement that has been mixed with antibiotics such as a
The use of diagnostic ultrasound will help separate a cephalosporin should be firmly pressed into place to
hematoma from an encapsulated abscess. If the radiographs provide some antibiotic coverage and to provide stability.
are normal and the SAA, fibrinogen, and WBC are all The author has only had to do this once during 40 years.
increased, then an ultrasound guided aspiration is The organism was a Klebsiella that had been transferred
necessary. The sonographer and support team should be from the small animal hospital when mutual instruments
prepared to obtain a sample for culture and sensitivity and were used. The patient had done well for the immediate
at the same time try to drain and flush the abscess and then postoperative 4 days and then became febrile with increased
deposit Amikacin (250–500 mg) before withdrawing the discomfort that was not reduced with the use of NSAIDs.
14-gauge catheter. Along with the culture and sensitivity, He became recumbent and unable to rise.
raumatic ecoveryyFracture 831
A myelogram showed the generalized narrowing of the agents that favor a smoother longer recovery. Reducing the
entire contrast column, which is characteristic of a menin- pain with another small dose of NSAIDs (author prefers
gitis. He was treated as described but his recovery required flunixin) and having the patient on a soft mattress versus a
the use of a sling to allow him to rise and be stable enough firm recovery floor is recommended. Small amounts of
to eat. He was allowed to sleep on a soft mattress during the sedation to keep the patient lying in a recumbent position for
night for 4-hour periods. He would then get restless (the 45 minutes is the goal. I try to avoid Xylazine, especially in
sling was left in place) and he would be assisted once again patients that are Grade 3/5, as they become more ataxic. The
for a period of time. This intense nursing and rehabilitation use of very small doses of Sedivet and/or Detomidine
lasted for a month before he was able to walk unassisted initially is preferred. If the blood pressure is normal, then
without falling and be able to lie and stand on his own. In small doses of acepromazine about 20 minutes into the
the next 8 months he slowly recovered and was used on a recovery period will enhance a smooth recovery without
limited basis as a stallion on a genetic trial program. increasing the amount of ataxia. There has recently been
published a protocol using proforol (Steffey) for prolonging
the recovery period and delaying and reducing the number
of violent recoveries. Any attempt to stand should be delayed
TraumaticRecovery/Fracture until nystagmus is absent and the patient is alert with normal
eye signs and can contract the tongue. Placing the patient on
Definition Fracture of one or more vertebra following
a soft mattress for the shoulders, thorax and hips will greatly
recovery from anesthesia
increase this quiet time. We also recommend catharizing the
bladder to drain excess urine as this will reduce the stimulus
Risk factors
for an early attempt at rising and will also help with providing
● Age of patient (bone quality) a dry non slippery surface for traction.
● Age of patient (poor recovery) The author prefers assisting with a head rope and tail
● Implant size rope. The assistance of a tail rope is greatly enhanced if the
● Anesthetic recovery rope is attached to a rapid pulley system used for manning
the sails. The author also tries to maintain contact with the
Pathogenesis Fractures of the cervical vertebra were most patient (usually by sleeping on the neck with a hand on the
commonly associated with older patients who seemed to maxillary artery) as most patients are reassured with human
have softer bone and had a Bagby Basket hammered into contact.
place to act as a dowel. In addition, a traumatic recovery If the patient is more than Grade 3/5 then a sling recov-
was often associated with the actual fracture as the patient ery is recommended. The success of a patient recovering to
vaulted head first into the recovery room wall or fell laterally a standing position using a sling is greatly enhanced if the
with some force. The cardinal signs of a fracture would be patient is trained to the sling during the period following a
the inability of the patient to become sternal, even with myelogram to the surgery. Ideally this period should be at
assistance. Radiographs should be taken in the recovery least 5 days, although the author has performed surgery 48
room and compared to the immediate postoperative image. hours after the myelogram when time constraints of the
Many times, fracture lines are not visible but the implant surgical team demand it.
has changed orientation and this is due to loss of stability of Repeated anesthesia and recoveries seem to be a learning
the implant site. experience for horses. This is a major reason why the
I have not tried to take these patients back to surgery and author would only do a cervical fusion at the time of the
try to stabilize the vertebra with an interlocking plate. The myelogram on a horse that was already recumbent.
necropsy most often shows severe hemorrhage around and Everyone learns from the recovery from a myelogram,
through the cord that most likely would not respond, even especially the patient. Doing another anesthesia 4 to 5 days
if the fracture was stabilized. after the myelogram allows the surgical team to plan the
surgery, prepare for added specialized instruments and
Prevention There a number of improvements that have most importantly to allow the attending veterinarian to
reduced the incidence of fractures over the years. The two have a full discussion with the owner/agent as to the extent
most important are changes in anesthesia protocols that favor of the surgery (multiple levels), chances of complete
a longer smoother recovery and the use of a threaded implant. recovery, and what the owner’s expectations really are. Two
short anesthesia periods are better than one longer surgery,
Recovery protocol While the more recent inhaled anesthetic especially with the contrast agent gravitating to the cerebra
agents are used for more speedy recoveries the author prefers hemispheres with the dorsal positioning.
force with a violent recovery and the quality of bone at the

implant site is not as healthy (more osteoporotic). In addi-
tion, they are more likely to have the C6/C7 site involved.
Diagnosis The inability to become sternal (especially if the

surgical site was C6/C7) is a common clinical finding. A
rapid increase in sweating, ventral deformity and increase
in bruxism and restlessness are also common clinical
findings. Sedation and NSAIDs are indicated to allow for
imaging of the surgical site. Any change in the alignment
of the implant with the vertebral column as compared to
the immediate postoperative image would be premia facia
evidence, even though no fracture lines are noted.
Treatment If the patient has had a violent/traumatic

Figure58.5 Radiograph showing the straight profile of the recovery and is now recumbent and unable to become
“Bagby Basket” implant. Source: Barrie DonLeo Grant.
sternal and radiographs show a change in the orientation
of the implant, then the prognosis is very unfavorable.
Fracturesin the RehabilitationStage The author has not had an opportunity to attempt to sta-
bilize the implant site with interlocking plates, mainly
Fractures at the implant site are most often associated with when explaining to the owner that another lengthy surgery
a traumatic event during recovery. Vaulting into the recov- is required to try to stabilize with interlocking plates (which
ery wall head first or severe head tossing laterally are the would require a more extensive dissection and the drilling
usual mode. Falling over backward and hitting the poll of more holes into already damaged bone) and very little
usually results in a fracture of the basisphenoid-occipital chance of a successful outcome, then euthanasia is
bone. requested and complied with.
Fractures of the implant site have been reduced since the However, if the patient is standing and only has some
change from the original Bagby Basket (Figure 58.5) to the discomfort with minimal implant displacement then the
Seattle Slew implant (Figure 58.3) with the threaded treatment consists of encouraging a trauma-free recovery
implant and tapping of the implant site. Older patients are period of 60 days in which the fusion will occur and a suc-
more likely to suffer a catastrophic fracture than younger cessful outcome can be obtained. Bi-weekly radiographs
patients, as they are generally larger and thus create more taken in the stall to monitor progress are recommended.
833
59
Complicationsof Surgeryfor Impingementof DorsalSpinousProcesses

Luis M. Rubio-Martinez DVM, DVSc, PhD, DACVS, DECVS, DACVSMR, MRCVS

L
with Surgeryfor Impingement
Impinging and overriding of the dorsal spinous processes of DorsalSpinousProcesses
(DSPs) (commonly referred to as “kissing spines”) are
frequently recognized causes of back pain in horses [1]. ● Ostectomy of the DSP
It mostly affects the caudal thoracic spine (T10–T18), but – Intraoperative hemorrhage
can also involve the cranial thoracic and/or lumbar ver- – Sub-optimal surgical visibility
tebrae [2, 3]. Thoroughbreds and older horses are more – Wound complications
commonly affected [2, 3]. The decision for surgery needs – Dystrophic mineralization or new bone formation at
to be carefully evaluated with each case, as a wide spec- the surgical site
trum of scintigraphic and radiographic changes affecting – Rotation of the dorsal spinous process contiguous to
the thoracolumbar DSPs are present, both in clinically the resected site
normal horses and horses with signs of back pain [2]. – Iatrogenic vertebral fractures
Kissing spines may be present in association with other – Sub-optimal cosmetic outcome
vertebral lesions or limb lameness [1]. ● Desmotomy of the interspinous ligament
The strong supraspinous ligament runs along the sum- – Intraoperative hemorrhage
mits of the DSPs and the space between the DSPs is occu- – Difficult access to interspinous space
pied by the interspinous ligament. The DSP shape, size – Instrument breakage
and inclination vary along the spine. The first 14 thoracic – Wound complications and sub-optimal cosmetic
vertebrae DSPs have a backward inclination, vertebra outcome
T15 is normally anticlinal, and the more caudally-located
vertebrae have DSPs with a forward inclination. It is
therefore important to preoperatively ascertain at what
level of the spine the pathology is located, as that will Ostectomyof the DSP
have an impact on the surgical approach. The DSPs are in
close apposition with the multifidus dorsi, spinalis tho- During this procedure, the summits of the DSPs involved
racic and longissimus dorsi muscles, which will be either in the impinging lesions are removed. Formerly, a more
elevated from the DSPs or partially transected during extensive resection of the affected DSPs in an alternate
surgery. manner was performed; however, the procedure has been
Two surgical treatments are available: resection of the modified, and lately a less invasive approach with partial
summit of the involved DSPs and desmotomy of the inter- removal of the area of the summit that is directly involved
spinous ligament. in the impingement is preferred.
834 Complications of Surgery for Impingement of orsal Spinous Processes
IntraoperativeHemorrhage DSP and widening of the interspinous processes is accom-

plished. The authors reported a subjective reduction of
Definition Bleeding at the surgical site that leads to
intraoperative hemorrhage but the degree of hemorrhage
reduced visibility, prolonged surgery and/or bleeding that
was still enough to significantly reduce visibility by
is difficult to control
obstructing the endoscope working channels and required
substantial time to achieve hemostasis [9]. In this case,
Risks factors
application of techniques such as electrosurgery were of
● Resection in the cranial thoracic/withers area little value as it was difficult to identify the source of
● Excessive dissection ventrally or laterally into epaxial bleeding [9].
muscle bellies
● Deep dissection planes with difficult access Prevention Use of less invasive techniques is
● Surgery under general anesthesia, questionable with recommended, as decreased dissection during less
minimal invasive surgery (i.e. wedge ostectomy vs. total extensive ostectomy procedures seem to have decreased
ostectomy, is performed) the degree of intraoperative hemorrhage, both in
standing [10] and under general anesthesia surgery [11].
Pathogenesis Intraoperative hemorrhage during this Standing surgery may be preferred, especially if involving
procedure is not associated with transection of specific the cranial thoracic spine.
isolated vessels, but usually from blood vessels within the
tissues disrupted during the procedure. Hemorrhage occurs Diagnosis This is readily visible during the procedure.
during the dissection of the muscles from the DSPs, as
dissection is extended in a ventral direction. It is recommended Treatment In the standing position, hemorrhage is minor
that dissection is limited to the area immediately adjacent to and typically stops spontaneously without intervention [10]
bone surfaces of the DSPs. Even though hemorrhage has (and personal observation by the author). When surgery is
always been reported to occur during this surgery, it has not performed under general anesthesia, packing with gauze,
been identified as significant by most authors [4, 5]. diathermy, electrocoagulation or ligature can assist in
The degree of bleeding seems more severe when surgery limiting hemorrhage [4]. Epinephrine can be applied
is performed on the long, thick DSPs located in the withers, topically to decrease bleeding via vasoconstriction [9, 11];
in comparison with surgery performed in more caudally- however, the use of phenylephrine may be preferred as the
located smaller DSPs [6]. This is likely related to the lesser latter lacks the potent cardiovascular effects of epinephrine.
degree of dissection required around DSPs in more caudal In the rare event of severe blood loss and hypovolemia,
locations. monitoring the amount of lost blood and cardiovascular
It has been suggested that blood pressure at the surgical parameters is advised, with administration of appropriate
site or venous congestion in the area are lower when horses treatment of major hemorrhage (see Chapter 8:
are standing versus laterally recumbent [6], and therefore Complications of Blood Transfusion).
intraoperative hemorrhage is less likely in the standing
position. Moderate-to-severe hemorrhage that is difficult Expected outcome Bleeding is virtually always minor and
to be control has been reported during DSP resection in the easily controlled, without consequences. Although not
withers area under general anesthesia [7]. Performing supported by strong evidence for this particular surgery,
standing surgery for resection of DSPs associated with fis- increased bleeding may increase risk of formation of
tulous withers subjectively decreased the amount of hem- postoperative seroma and/or infection.
orrhage compared to lateral recumbency under general
anesthesia [6]. Under standing sedation and local anesthe-
sia, the degree of hemorrhage reported including the with- Sub-OptimalSurgicalVisibility
ers area was low and was not identified as a complication
Definition Difficult/limited visualization of the relevant
making surgery difficult [6, 8]. The degree of bleeding
anatomical structures during surgery, which may lead to
under general anesthesia has not been reported to impede
increased surgical time and increased difficulty to complete
or hinder surgical progress when DSP surgery is performed
the surgical procedure
over the caudal thoracic and cranial lumbar areas.
A minimally invasive endoscopic resection technique
Risks factors
has been described in horses using the Destandau
Endospine developed for paraspinal endoscopic surgery in ● Lateral recumbency (questionable)
humans [9]. With this technique, partial ostectomy of the ● Cranial thoracic spine
stectomy of the SP 835
● Extensive dissection causing increased intraoperative Expected Limited visibility usually causes
outcome
bleeding prolonged surgery time and, in some cases, sub-optimal
● Use of total DSP vs. wedge ostectomy technique surgical outcome, such as incomplete or excessive
ostectomy. However, appropriate surgical methods and
Pathogenesis When surgery is performed on lateral radiological guidance normally lead to a successful
recumbency, it has been reported that dissection and procedure.
visibility around the DSP and especially on the side closest
to the surgical table is limited and that visibility of either WoundComplications
side of the DSP is better when surgery is performed in the
standing position [6]. Use of wound retractors can be used Definition Any untoward deviation from normal healing
to improve visibility [4, 11]. A recent report performing a of the surgical wound causing a prolonged healing time. In
less invasive partial ostectomy and using Gelpi retractors this section, wound complications will include swelling,
under general anesthesia in lateral recumbency reported sensitivity, seroma formation, dehiscence and/or surgical
good visibility and an increase in interspinous space site infection.
associated with lateral recumbency in comparison with the
standing position on the basis of radiographic images, Risk factors
which may aid surgical access and therefore decrease tissue
● Paramedian approach
trauma and dissection [11].
● Drain placement
Authors performing standing surgery have reported
good visibility on both sides of the DSPs, which was consid-
ered superior to under general anesthesia [6, 10]. They Pathogenesis Wound complications, including mild swelling,
have claimed that use of a wound retractor is unnecessary mild sensitivity or mild serous discharge from the surgical
during the standing position [10]; however, the author of site, have been reported in most of the published studies using
this chapters uses a wound retractor routinely during a midline approach, including more extensive and minimally
standing DSP ostectomy. invasive resection techniques, standing surgery and general
Intraoperative bleeding will obscure the surgical field. As anesthesia surgery [4, 9–11]. Specific incidences of these
discussed above, intraoperative bleeding is higher in more complications are not reported in most of the studies, but in a
invasive surgery such as in cranial thoracic spine, or when recent report of horses undergoing minimally invasive DSP
more extensive dissection into the muscle bellies is used. wedge resection under general anesthesia, the incidence was
Some authors have reported that pooling of blood in the 20% from a total of 25 cases [11]. Overall, all the studies
surgical field may be more common during the standing considered these complications as minor that resolved rapidly
position and potentially obscures visibility [11]; however, within 7–14 days without specific treatment.
this complication has not been reported in studies on Significant postoperative swelling and seroma formation
standing spine surgery and is not the case in the author’s at the surgical site were more common when a paramedian
experience. approach was followed [4]. This may be associated with
larger soft tissue disruption through the epaxial muscles
with the paramedian approach. The endoscopic technique
Prevention Use of minimally invasive surgical technique,
with Destandau Endospine used a paramedian approach
limited dissection and tissue disruption to the most axial
but was not associated with swelling and seroma formation
location, and use of adequate tissue retractors if required.
at the surgical site, which may be related to the limited-
Performing surgery on standing patients provides good
sized incisions and dead space [9].
visibility on both sides of the DSPs.
An early report on DSP ostectomy in horses with kissing
spines reported incidences of wound infection of 22% and
Diagnosis This is readily obvious during the surgical dehiscence and proud flesh of 14%, in a total of 50 cases
procedure. undergoing ostectomy under general anesthesia [5].
Placement of a drain at the surgical site may be the reason
Treatment Perform sufficient but avoid excessive for the increased rate of wound complications reported by
dissection and use of soft tissue retractors if required. If Lauk and Kreling, as the incidence of wound infection and/
limited visibility is associated with intraoperative or dehiscence is much lower in other reports using similar
hemorrhage, use above-mentioned measures. Use of ostectomy technique but without the use of wound drains [4,
intraoperative radiographic guidance is recommended to 5, 12–14]. In a study on 215 horses undergoing extensive
confirm adequate ostectomy. alternate ostectomy under general anesthesia, wound
infection occurred in 3.5% of cases and none of them had pain. Mild sensitivity, swelling or moisture at the surgical
long-term complications [4]. The use of Destandau site during the first few days postoperatively may be
Endospine was associated with 1 wound infection out of 10 considered within normal limits. Signs that increase in
cases [9]. Recent studies using less extensive techniques severity or persist should alert for possible complications.
report no incidence of incisional infections, but only mild Diagnostic imaging techniques (ultrasound and/or
serous discharge in a low number of cases [10, 11]. radiographic examination) may provide information about
Some authors have identified a higher risk of wound presence of seromas and bone involvement.
complications as the number of DSPs summits resected
increased and when surgery was performed under general Treatment Appropriate wound care, including culture and
anesthesia compared with standing sedation and local sensitivity of drainage, appropriate antimicrobials therapy,
anesthesia (15]; however, this has not been identified by selective removal of skin sutures to allow drainage. Because
others and wound complication rates are low, both under of dorsal location of the surgical site, identification and
general and standing surgery [4, 5, 11]. drainage of seromas may be difficult in some cases. Use of
The effect of different wound dressings, such as gauze ultrasound and/or radiography may aid localizing infection.
stent bandages [4, 11] or adhesive wound dressings [10], Resection of excessive granulation tissue is recommended
cannot be concluded from the literature. Production of if present.
excessive granulation tissue at the wound site has only
been reported sporadically and in association with wound Expected outcome Most of the cases reported developed
infection [5]. mild wound complications that healed without specific
In most studies, an oscillating saw has become the instru- treatment, other than wound care, and achieved a good
ment of choice to resect DSPs [4, 5, 10, 11]; however, other cosmetic outcome. However, other cases may develop more
instrumentation such as osteotome and hammer or Gigli extensive or non-responding infections that may require
wire have been used [5, 6]. The incidence of wound compli- prolonged treatment and convalescence [5]. To date,
cations was similar in the oscillating saw and osteotome/ studies have not reported the occurrence of these
hammer groups [5], and the incidence of wound complica- complicated wound infections; however, the author has
tions in horses treated with the oscillating saw in more seen one case that developed a multi-resistant wound
recent studies is very low [4]. Beveling of the adjacent DSPs, infection that required a prolonged treatment and
when performing extensive resection of alternate affected convalescence. This case had a successful outcome and
DSPs, was suggested as a factor to decrease postoperative returned to previous use without complications.
wound complications by reducing the wound pressure and Development of small depressions or bumps at the site of
sharp points [4]. However, that has not been substantiated surgery in the long term has been observed by some
and is not applicable to the newer techniques of resecting a authors [10, 11]; however, these have not necessarily been
smaller portion of all the affected DSPs [10, 11]. associated with previous postoperative wound infection or
long-term clinical signs of back pain or loss of perfor-
Prevention mance [10, 11] (and personal observation by the author).
The actual incidence and clinical relevance of this are
● Use midline approach preferentially over paramedian unknown.
approach
● Minimize dissection
● Shorten surgery time DystrophicMineralizationorNewBone
● Avoid use of drains FormationatSurgicalSite
● Follow Halsted’s surgical principles:
– maintain asepsis Definition Postoperative new bone formation or dystrophic
– minimize dissection mineralization on the surface of the resected DSPs stumps
– use of sharp instrumentation or neighboring DSPs
– cool down oscillating with sterile isotonic fluid while
being used Risk factorsPotentially more traumatic surgical techniques
– minimize tissue trauma or trauma in the postoperative period
– maintain hemostasis
Pathogenesis Dystrophic mineralization or new bone
Diagnosis and monitoring
Monitor surgical wound for signs formation around the resected DSPs is common and is
indicative of wound complications: swelling, discharge, likely the result of inflammation and surgical trauma
stectomy of the SP 837
leading to deposition of mineralization around the stumps

of the resected DSPs summits. This mineralization is
frequently observed without association with clinical signs
of back pain [4, 5, 9, 10] (and personal observation by the
author). However, it has also been observed in some horses
with recurrence of back pain [10] and the new bone
production can grow to impinge the adjacent DSP and
cause pain [14]. New bone formation or dystrophic
mineralization can also develop on the contiguous non-
resected DSPs. This was observed within the first 4 weeks
after surgery by Lauk and Kreling and was not associated
with recurrence of back pain or with early resuming of
riding exercise [5]. On the other hand, Walmsley et al. did
not observe new bone formation on non-resected DSPs in
any of the 70 horses radiographed 8–9 weeks postoperatively
and suggested that dystrophic mineralization may be Figure59.1 Dystrophic mineralization on a horse 24 months
after surgery without recurrence of clinal signs of back pain.
reduced by beveling neighboring DSPs and thereby Source: Courtesy of the University of Liverpool Equine Hospital.
reducing wound pressure at the site [4].
The author has observed dystrophic mineralization in
Rotationof the DorsalSpinousProcess
horses l2 years after surgery when using minimal wedge
Contiguousto the ResectedSite
resection technique with cooled saw blade and without
recurrence of clinical signs of back pain. Lack of controlled Definition Cranial or caudal rotation of the DSP located
postoperative studies assessing the surgical site with radi- immediately cranial or caudal to the first or last treated
ography precludes making conclusions about incidence DSP, respectively
and clinical relevance of these radiographic findings.
Risk factors Unknown, but likely extensive dissection and
Prevention Use of Halstead principles when performing resection
surgery. Use sharp instruments to transect the summits
and cool down and irrigate cutting instruments during the Pathogenesis Caudal rotation has been reported to affect
procedure to minimize heating of the bones. DSP 16 and 17 after subtotal ostectomy involving the
immediately cranial interspinous space and leading to
contact with the DSP immediately caudal [10]. The author
Diagnosis and monitoring Radiographic evaluation in the
has also observed cranial rotation of DSP 12 in a horse after
postoperative period will help identify dystrophic
cranial ostectomy in the space DSP 120–13 (Figure 59.2).
mineralization.
The reasons for the rotation of the DSP may be related to
the one-sided loss of stabilizing tension normally exerted
Treatment The clinical relevance of the presence of on the spinous process by the epaxial musculature and
dystrophic mineralization should be thoroughly intact cranial and caudal interspinous ligaments. Elevation
investigated individually, as it is frequently identified as an of the epaxial musculature from the sides of the DSPs, as
incidental finding. If clinical signs of back pain have well as the loss of tension from the interspinous ligament,
returned, thorough investigation is warranted before may lead to cranio-caudal instability of the DSP because of
considering medication or resection of the impinging bone loss of counteracting forces from the cranial and caudal
proliferation. interspinous ligaments. It may be also related to how
extensively in a ventral direction the interspinous space is
Expected outcome The dystrophic mineralization is widened and how much of the interspinous ligament is
expected to remain or remodel with time. As an example, destroyed during the surgical procedure.
refer to Figure 59.1, which illustrates dystrophic
mineralization on a horse 24 months after surgery without Prevention Assess the degree of impingement of the
recurrence of clinical signs of back pain. However, spaces and limit ostectomy to the affected area.
postoperative radiographs of the back of horses after DSPs
ostectomy has not been routinely performed or investigated Diagnosis and monitoring DSP rotation can be observed on
in a standard manner. routine latero-lateral radiographs. It is uncertain when the
Figure59.2 Cranial rotation of the DSP 12 in a horse after

wedge ostectomy of the DSPs 13-17. This radiograph was
obtained 16 hours after surgery. Source: Courtesy of the
University of Liverpool Equine Hospital.
Figure59.3 Postoperative radiograph of a horse undergoing

wedge resection of the DSP. Note the separate elongated
rotation will be most obvious, but the author has recognized radiopaque area consistent with remaining bone fragment
DSP rotation on radiographs obtained within 16–24 hours remaining after inadvertent transection of the cranial edge of
after surgery (personal observation by the author). In some the DSP. (Courtesy of the University of Liverpool Equine
cases, rotation of DSP may already be evident on Hospital.)
radiographs obtained intraoperatively at the end of surgery
before closing (P. Brink DVM DECVS, personal
communication).
Pathogenesis This complication has not been reported
with high frequency, although some authors have indicated
Treatment The consequence of DSP rotation is uncertain
fractures or splitting of the DSP vertebra to occur when
and may depend on the degree of impingement developed
osteotome and hammer are used to perform the
at the space. Revisiting the surgical site and performing
ostectomy [5, 10] (Singer, personal communication). The
either interspinous ligament desmotomy (see below) or
author has noted that when using the osteotome to separate
partial ostectomy of the rotated DSP can be performed
two closely apposed DSPs, the osteotome may go
without complications when the degree of impingement is
inadvertently into the DSP and transect a thin edge of the
considered significant.
DSP, which may be left in place if attention to detail is not
paid (Figure 59.3). In some other cases, the fracture plane
Expected outcome There is only one author [10] who has
may extend into the spinal canal or vertebral body, which
reported this complication and the author of this chapter
can have fatal consequences (Singer, Personal
has also observed this. The outcome should not be affected
communication).
by the repeated surgery, although risk of surgical site
infection may be partially increased.
Prevention Performing the ostectomy with a controlled
oscillating saw is commonly preferred, as this allows a
IatrogenicVertebralFractures more controlled osteotomy and has not been associated
with low risk of iatrogenic fracture of the vertebra.
Definition Inadvertent fracture of the DSP, lamina,
Intraoperative radiography is recommended as
transverse processes and/or vertebral body as a consequence
guidance and to assess for presence of bone fragments
of the surgical technique to perform ostectomy
in the area that will allow fragment retrieval before
closing.
Risk factors
● Insufficient preoperative preparation Diagnosis Fracturing of the DSP may be obvious during
● Lack of knowledge of the inclination of the SP in that surgery and radiography will allow confirmation and
location further evaluation. In cases with severe fractures involving
● Lack of attention to detail the spinal canal, clinical signs associated with spinal
● Use of osteotomy and hammer trauma may become apparent.
esmotomy of the Interspinous igament 839
Treatment It is uncertain if removal of fragments of bone esmotomyof the Interspinous

D
in the surgical site is required. The author has observed Ligament
some cases with some small fragments remaining in situ
without reported complications. Revisit surgery can be This surgical treatment for DSP impingement has been
performed if removal of the fragment is decided. developed recently and there is a limited number of publi-
cations [17]. The recognized complications with this proce-
Expected outcome The potential risk for sequestrum dure are reviewed to follow.
formation is low as, in the author’s experience, small
bone fragments contain strong soft tissue attachments,
which assure good blood supply. There is a risk for IntraoperativeHemorrhage
potential interference with spine biomechanics in the Definition Hemorrhage or bleeding during surgery that
area. leads to a decreased visibility, prolonged surgery and/or
bleeding that is difficult to control
Sub-OptimalCosmeticOutcome
Risk factors Unknown, but may be related to surgical
Definition Long-term unsatisfactory appearance of the technique.
back, including lumps, depressions or white hairs
Pathogenesis It is presumed to occur because of disruption
Risk factors Unknown, but potentially related to surgical of vessels in the area of approach. However, although
technique hemorrhage can occur, it is reported as mild [17]. Some
authors have found that bleeding is more common in more
Pathogenesis Focal raised areas or lumps, small painful areas (R. Coomer, MAVET MB DECVS, personal
depressions (Figure 59.4) and/or white hairs have been communication). Further dissection into the epaxial
reported at the surgical sites in a low proportion of horses, muscle bodies may be related to a higher risk of bleeding
with an incidence of 8.2% in one report [11]. The exact from within the muscle tissue.
pathogenesis for those complications has not been fully
described. It is likely that lumps develop as a consequence Prevention Minimize dissection and stay as close to the
of local inflammation and fibrosis at the surgical site. spine as possible.
Small depressions may be related to focal wasting of
epaxial muscles as a consequence of transection of muscle Diagnosis and monitoringBleeding is observed from or
fibers and potentially more prevalent in cases where the hematomas are formed subcutaneously at the surgical sites.
incisions are made further away from midline (author’s
opinion and R. Coomer’s MAVET MB DECVS, personal Treatment In the description of the surgical technique,
communication). Muscle waste secondary to transection the authors advocated closing of the skin incisions with
of motor nerve fibers in the epaxial muscles has also been suture despite continued bleeding (17]; however, they now
hypothesized [16]. recommend achieving hemostasis before skin closure (R.
Coomer MAVET MB DECVS, personal communication).
Prevention Use Halsted’s surgical principles, and limit Temporary packing of the surgical site with sterile gauze
dissections, especially into the bodies of the epaxial while continuing the surgery in the other sites tend to stop
muscles. bleeding. Use of hemostasis techniques with use of
hemostatic forceps or placement of subcutaneous ligatures
Diagnosis Clinical examination in the long-term at bleeding sites may be helpful.
postoperative period
Expected outcome The author of this chapter has found
Treatment Not required unless associated with problems. limited bleeding at the surgical sites, easily controllable
White hairs can be dyed. intraoperatively with conventional hemostasis techniques,
and without consequences to the normal healing of the
Expected outcome Horses reported to have developed this wound. Continued bleeding at the surgical site may lead to
suboptimal consequence are still able to return to athletic hematoma and seroma formation, which could have
use without complications and owners are still satisfied negative consequences on healing of the surgical site;
with the outcome [10, 11] (and personal observation by the however, this has not been reported and is not the
author). experience of the author.
instrument [17]. The author inserts spinal needles from

the proposed paramedial instrument location in a
ventromedial orientation to locate the interspinous space
at a more ventral location. The author finds performing
desmotomy of the interspinous ligament difficult in
cases with obliteration and/or over-riding of the
interspinous spaces and favors wedge ostectomy in these
cases.
Mayo scissors were first described to transect the inters-
pinous ligament, and incomplete transection of the inters-
pinous ligament was reported in 5 out of 30 cases [17]. The
author has occasionally used a robust mounted scalpel;
however, the risk of instrument breakage must be weighted
as the instrument may be subjected to important torque
and bending forces. The developer of the surgical tech-
Figure59.4 Focal depressions at the surgical sites after wedge nique still favors sharp short Mayo scissors in these cases
resection ostectomy of impinging dorsal spinous processes.
and reports good success rates (R. Coomer MAVET MB
Source: Courtesy of the Sussex Equine Hospital.
DECVS, personal communication).
DifficultAccessto InterspinousSpace
Diagnosis Surgeon unable to advance instrument into
Definition Difficulties advancing the instrument into the interspinous space
interspinous space, which may prevent the transection of
the interspinous ligament in its entirety Treatment Refer to the previous section on Prevention and
if still not possible, consider wedge ostectomy.
Risk factors
Expected outcome Incomplete transection of the
● Technical error: suboptimal knowledge or review of the
interspinous ligament at the site of impingement could be
anatomy
associated with suboptimal outcome; however, successful
● Complete obliteration of interspinous space or over-rid-
outcome was described in horses with incomplete transection
ing of DSPs
of the ligament [17]. Alternatively, wedge ostectomy is
another surgical technique available to treat these cases.
Pathogenesis Technical failure: the inclination of the DSPs
changes in direction and angle along the vertebral spine
and therefore this needs to be taken into account when the InstrumentBreakage
site is approached surgically. Cases with complete
Definition Breakage of a round osteotome in a tight space
obliteration of interspinous spaces and cases with overriding
(R. Coomer MAVET MB DECVS, personal communication)
of the DSPs can make it difficult to access the space.
Risk factors
Prevention Proper identification of affected interspinous
spaces and inclination of associated DSPs on preoperative ● Poor surgical technique
radiographs is essential. Use of markers on the skin, such ● Use of weak instruments
as staples before surgery, digital palpation and/or use of
ultrasound examination at the dorsal midline, can be Pathogenesis Inadequate identification of the interspinous
useful to identify the interspinous space [17]. An space may lead to instrument mal-positioning, with
instrumental approach to obliterated interspinous spaces subsequent increased load on the instrument. Applying
can be difficult, especially in cases with overriding DSPs. excessive torque to the instrument against the inflexible
In these cases, the orientation of the DSP overlap should DSP within the narrow interspinous space will also
be established preoperatively to assist instrument increase risk of instrument breakage.
placement and triangulation [17]. Advancement of a There is always an amount of torque and bending forces
stylet from a 3.5-inch 18-g needle into the interspinous applied to instruments when completing this procedure.
space has been used to assist triangulation with the Reuse of instruments with prolonged life that have
References 841
accumulated cyclic damage will increase risk of instru-

ment failure.
Prevention Adequate identification of the relevant

interspinous space and orientation of the over-riding
processes if present. Use of adequate instruments. The
short Mayo scissors are expected to be less flexible and
therefore stiffer and stronger than longer ones and
therefore the risk of breakage is low (R. Coomer MAVET
MB DECVS, personal communication).
Diagnosis Instrument breakage is obvious intraoperatively.
Treatment Retrieval of the broken piece of the instrument

is required. Whenever possible, this can be performed
through the surgical site incision, that may require Figure59.5 Presence of white hairs at the surgical sites after
desmotomy of interspinous ligaments. Source: Courtesy of
enlargement in some cases. Dissection through the tissues Richard Coomer.
should be kept as limited as possible. In cases where the
broken piece is not visible and is located deep within the that lasted for 48 hours was observed in most horses, and
tissues, radiographic or ultrasonographic guidance may be raised focal areas at the surgical sites were described in 20%
required. Presence of gas from the surgical approach may of the cases and disappeared after ridden exercise
limit usefulness of ultrasound. resumed [17]. White hairs were also reported in some cases
(Figure 59.5). The author has had similar experiences. To
Expected outcome After retrieval of the broken instrument
avoid focal wasting of epaxial muscles at incision sites, the
piece, normal healing of the site usually occurs, unless surgical approach should be performed as close as possible
excessive dissection was necessary or instrument breakage to the spine to avoid transection of muscle fibers that may
was associated with DSP breakage. be involved in the pathogenesis of this complication.
Application of minimally invasive techniques, adequate
WoundComplicationsand Suboptimal knowledge of anatomy, and adherence to Halsted’s princi-
CosmeticOutcome ples are recommended to minimize wound complications
and suboptimal outcome. Close monitoring and generally
There is only one peer-reviewed publication on this surgi- recommended techniques on surgical site complications
cal technique to date, and therefore estimation of repre- should be applied once complications are identified.
sentative incidences is limited. Mild incisional tenderness
References
1 Zimmerman, M., Dyson, S., and Murray, R. (2012). Close, the spinous processes in the equine thoracolumbar
impinging and overriding spinous processes in the region. Vet. Radiol. Ultrasound. 52 (6): 661–671.
thoracolumbar spine: the relationship between 4 Walmsley, J.P., Pettersson, H., Winberg, F. et al. (2002).
radiological and scintigraphic findings and clinical signs. Impingement of the dorsal spinous processes in two
Equine Vet. J. 44 (2): 178–184. hundred and fifteen horses: case selection, surgical
2 Erichsen, C., Eksell, P., Holm, K.R. et al. (2004). technique and results. Equine Vet. J. 34 (1): 23–28.
Relationship between scintigraphic and radiographic 5 Lauk, H.D. and Kreling, I. (1975). Behandlung des
evaluations of spinous processes in the thoracolumbar Kissing spines-Syndroms beim pferd – 50 Falle Teil 2:
spine in riding horses without clinical signs of back Ergebnisse. Pferdeheilkunde. 14: 123–130.
problems. Equine Vet. J. 36 (6): 458–465. 6 Perkins, J.D., Schumacher, J., Kelly, G. et al. (2005).
3 Zimmerman, M., Dyson, S., and Murray, R. (2011). Subtotal ostectomy of dorsal spinous processes performed
Comparison of radiographic and scintigraphic findings of in nine standing horses. Vet. Surg. 34 (6): 625–629.
7 Cohen, N.D., Carter, G.K., and McMullan, W.C. (1992). 13 von Salis, B. and Huskamp, B. (1978). Vorlaeufige
Fistulous withers in horses: 24 cases (1984-1990). J. Am. Erfahrungen mir der konservativen und chirurgischen
Vet. Med. Assoc. 201 (1): 121–124. Behandlung der Wirbelsaeulenerkrankung der Pferde.
8 Hawkins, J.F. and Fessler, J.F. (2000). Treatment of Prakt Tierarzt. 4: 281–284.
supraspinous bursitis by use of debridement in standing 14 Jeffcott, L.B. and Hickman, J. (1975). The treatment of
horses: 10 cases (1968–1999). J. Am. Vet. Med. Assoc. 217 hroses with chronic back pain hy resecting the summits
(1): 74–78. of the impinging dorsal spinous processes. Equine Vet. J.
9 Desbrosse, F.G., Perrin, R., Launois, T. et al. (2007). 7: 115–117.
Endoscopic resection of dorsal spinous processes and 15 Owen, K.R., Milner, P.I., Talbot, A. et al. (eds.) (2012). A
interspinous ligament in ten horses. Vet. Surg. 36 (2): comparison of partial ostectomy of the dorsal spinous
149–155. processes in the horse; standing sedation versus general
10 Brink, P. (2014). Subtotal ostectomy of impinging dorsal anaesthesia (28 cases). 21st Annual Scientific Meeting
spinous processes in 23 standing horses. Vet. Surg. 43 (1): European College of Veterinary Surgeons. 5–7 July.
95–98. Barcelona.
11 Jacklin, B.D., Minshall, G.J., and Wright, I.M. (2014). A 1 6 Derham, A.M., O’Leary, J.M., Connolly, S.E. et al. (1997).
new technique for subtotal (cranial wedge) ostectomy in Performance comparison of 159 Thoroughbred racehorses
the treatment of impinging/overriding spinous processes: and matched cohorts before and after desmotomy of the
description of technique and outcome of 25 cases. Equine interspinous ligament. Vet. J. (London). 249: 16–23.
Vet. J. 46 (3): 339–344. 17 Coomer, R.P., McKane, S.A., Smith, N. et al. (2012). A
12 Jeffcott, L.B. (1993). Rueckenprobleme des Athleten Pferd controlled study evaluating a novel surgical treatment for
2. Moegliche Differentialdiagnosen und kissing spines in standing sedated horses. Vet. Surg. 41
Therapiemethoden. Pferdeheilkunde. 9: 223–237. (7): 890–897.
843
60
Complicationsof PeripheralNerveSurgery
Yvonne A. Elce DVM, DACVS
Langford Vets Equine Hospital, Langford, Bristol, UK
Overview with success [2, 3]. The pain-free duration does vary among
the studies and so may hold promise for temporary pain
Surgery of the peripheral nerves is a relatively common relief in horses. The topical alcohol caused primary demy-
procedure in horses and, unlike other species, usually elination and some axon degeneration but preserved nerve
involves the removal of a portion of a nerve rather than alignment. Regeneration occurs within a variable time
the reconstruction and microsurgery that is often per- span.
formed in humans. This difference has unfortunately led Continued research efforts mainly based in the human
to a paucity of evidence on the best method to perform field, but certainly also in equine laryngeal neuropathies,
the surgery and limited information on complications. may yield valuable information for restoration of nerves
Several studies have been performed and that evidence and neural function in horses that have suffered trauma to
shall be reviewed along with the relevant anatomy, patho- a peripheral nerve. Studies relating to providing scaffolds
physiology and known complications. The most common for nerve growth may provide treatments for severed
procedure involving peripheral nerves is the palmar digi- nerves [4]. Other studies may lead to either replacement
tal (or less commonly the plantar digital) neurectomy, fol- therapies for injured or severed nerves or help maintain
lowed by the neurectomy of the deep branch of the lateral function in their absence [5]. Obliquely, some of these
plantar nerve for proximal suspensory desmitis (com- studies may help develop methods of preventing neural
monly combined with a fasciotomy). However, other regrowth when it is unwanted.
peripheral nerve surgeries are performed, such as surgery
to alleviate cribbing behavior, various surgical procedures
for head shaking, neuromuscular pedicle graft for laryn- istof ComplicationsAssociated
L
geal hemiplegia, repair of nerves after traumatic disrup- with PeripheralNerveSurgery
tion, and external neurolysis of the suprascapular nerve.
However, there is even less evidence-based information ● Anatomy and pathophysiology
regarding the complications of these less-common proce- ● Neurectomy procedures
dures and so discussion of these surgeries will be ● Palmar or plantar digital neurectomy
limited. – Intraoperative complications
There has been some preliminary work on alternatives to – Early postoperative complications
surgical denervation. Potential methods may avoid the ○ Infection
complications of neuroma formation but not the damage ○ Neuroma formation
to the denervated and pathological tissues due to contin- ○ Continued lameness
ued work. A recent article examined the use of either alco- – Late postoperative complications
hol or formaldehyde placed topically on a surgically ○ Reinnervation
exposed nerve as a method of temporary neurectomy [1]. ○ Complications due to lack of innervation to
Perineural injection of alcohol has been used in human tissues
medicine for treatment of painful conditions or spasticity ○ Poor client satisfaction
844 Complications of Peripheral Nerve Surgery
– Evidence based medicine for complications of PDN out of both the proximal and distal stumps, with only the
○ Summary of PDN surgery proximal Schwann cells bringing the regrowing axons
– Neurectomy of the deep branch of the lateral plantar along with them.
nerve This migration across the gap is guided by macrophages
○ Infection that fill the gap after transection. These macrophages are
○ Continued lameness part of the normal inflammatory response and they react to
– Evidence-based medicine for complications of neurec- hypoxia in the local area by producing vascular endothelial
tomy of the DBLPN growth factor and causing the polarized ingrowth of small
○ Neural repair surgeries capillaries. The Schwann cells are able to use the capillaries
as tracks across the bridge to reconnect the two nerve end-
ings [6]. The ability of a nerve to regrow and bridge a gap
Anatomyand Pathophysiology has been reported to be approximately 1 mm per day but
this is a complex process and growth rates may vary
Knowledge of anatomy is obviously crucial for any surgeon depending on local conditions (inflammation, nature of
to be able to accurately perform surgery. What is most rele- surrounding tissue, growth factors, etc.). The healing pro-
vant to complications of peripheral nerve surgery in horses cess can go astray with misdirected axonal sprouting and
is that the nerves run in neurovascular bundles with an Schwann cell proliferation, resulting in a neuroma or aber-
artery and a vein. This is classically demonstrated with the rant branching. Methods of either preventing or improving
position of the palmar digital nerve, which runs immedi- this process are not well established and indeed the healing
ately palmar to the digital vein and artery. The close apposi- pathways have only recently been elucidated [6]. More
tion of vessels with peripheral nerves requires the surgeon to research is required into how nerves heal in horses and
be familiar with the anatomy of that particular area and be whether there are biological or mechanical methods of pre-
able to distinguish between a vessel and a nerve under a vari- venting the healing and re-innervation when it is not
ety of different surgical conditions. Anatomical variations of desired, or enhancing it when necessary.
the course of vessels and nerves are well recognized and may Complications of peripheral nerve surgery can be divided
be implicated in some of the complications that are seen. into those that occur intraoperatively, immediately postop-
What is potentially just as relevant to the complications eratively, and then late in the postoperative period. A com-
seen with peripheral nerve surgery is the healing process plication in this instance is any undesirable outcome,
after a nerve has been transected. This information is which is an important distinction as one main complica-
mainly derived from studies in other animals, such as labo- tion of a palmar digital neurectomy is, in effect, successful
ratory mice and rats [6–8]. Once a nerve end has been tran- healing and re-innervation. In most other situations, this
sected, dividing the nerve into a proximal and distal stump, would be considered an excellent outcome after accidental
a chain of events is initiated to bridge that divide and re- nerve transection but in the horse can be considered as an
innervate the distally located tissues. After transection has undesirable outcome or complication of neurectomy.
occurred, the axons within the proximal and distal stumps Contrary to that is the successful re-innervation of the cri-
undergo Wallerian degeneration when they are separated coarytenoideus dorsalis by a neuromuscular pedicle graft.
from their cell bodies. For regrowth, these axons need to Division of complications into two categories may there-
regrow to bridge the gap. In both the proximal and distal fore be useful – those that involve a neurectomy procedure
stumps, the Schwann cells undergo differentiation to a and those that are trying to preserve or return neural func-
more progenitor-like cell. These Schwann cells migrate tion (Tables 60.1 and 60.2).
Table60.1 List of complications related to a neurectomy.
Intraoperative Postoperative(early) Postoperative(late)
Transection of blood vessels Incisional infection Reinnervation

Incorrect identification of nerve Continued innervation and pain Neuroma formation
Incomplete transection (missing aberrant Painful neuritis or neuroma formation Injury to denervated tissues (rupture of DDFT,
branches) abscesses, etc.)
Anesthesia complications Injury to denervated tissues
Palmar or Plantar igital Neurectomy 845
Table60.2 List of complications related to restoration of nerves.
Intraoperative Postoperative(early) Postoperative(late)
Technical difficulties with surgical procedure Neuroma formation Failure of reinnervation

Anesthetic recovery
Muscle atrophy
Neuropathic pain
NeurectomyProcedures excised. Gentle exploration of the area around the most

proximal portion of the main palmar digital nerve is
The two most common neurectomy procedures in the warranted. Mention of these smaller branches is
horse are the palmar or plantar digital neurectomy (PDN) unfortunately absent from many surgical textbooks, so it is
and the neurectomy of the deep branch of the lateral plan- difficult for the more junior surgeon to gain knowledge of
tar nerve (DBLPN) for proximal suspensory desmitis. Less these smaller branches in the pastern region, except
commonly, a neurectomy of the ventral branch of the spi- through experience [9].
nal accessory nerve is performed for treatment of cribbing The existence of aberrant or small branches does not
behavior. appear to be as common during neurectomy of the deep
branch of the lateral plantar nerve, although small varia-
tions in position are certainly encountered. The mistaken
almarorPlantarDigital
P transection of a blood vessel is another potential intraop-
Neurectomy erative complication during neurectomy, most commonly
in the palmar digital neurectomy due to the close apposi-
IntraoperativeComplications tion of the palmar digital artery and vein. With the horse in
the standing position, the identification is facilitated by the
Definition Intraoperative complications of neurectomy presence of blood in the vessels, although if a tourniquet is
procedure include inadvertent transection of blood vessels, used or if the procedure is performed under general anes-
missing aberrant or small branches of the nerve and thus thesia in dorsal recumbency, then the vessels can have little
retaining some innervation, incorrect identification of the blood flow and thus be more difficult to distinguish. The
nerve, and complications related to performing the position of the neurovascular bundle in the pastern region
procedure under general anesthesia. is an aid in correct identification, as the vein is located
more dorsally, then the artery and finally the nerve more
Risk factors
palmarly.
● Lack of anatomical knowledge and variability Additionally, the nerve is consistently located deep to the
● Risks associated with general anesthesia ligament of the ergot, which functions as a good anatomi-
cal landmark. The ligament should not be mistaken for the
Prevention Prevention of these complications requires the nerve; it is more superficial and when manipulated, the
surgeon to be familiar with the anatomy of this particular ergot can be seen to move. If all three structures in the neu-
surgical field and also to be familiar with the concept that rovascular bundle deep to the ligament are visualized, the
aberrant branches are relatively common when performing surgeon can be fairly certain of cutting the nerve. If less
a palmar digital neurectomy (Tim Lescun, Diplomate. dissection is performed, the nerve can be differentiated
ACVS: personal communication). Incomplete knowledge from the vessels by feel. The use of the tip of a finger and
of anatomy will contribute toward these complications fingernail can palpate the fibers running within a nerve
occurring intraoperatively. An effort should be made compared to the hollow tube of a vessel. If there is any
during surgery, whether standing or under general doubt, a small needle can be placed into the structure to
anesthesia, to search for small branches and to excise those ensure blood does not exit.
small branches in addition to the main nerve. Commonly, As a final step, the surgeon can place a hemostatic for-
these small branches are found more proximally (toward ceps proximal to the proposed transection site to inspect
the proximal aspect of the pastern) and so may contribute the cut end of the structure and place a ligature if a hollow
to continued sensation after surgery if they are not fully tube of a vessel has been inadvertently severed. The nerve
must then also be found in a more palmar location and uniaxial transection is likely of little consequence. Biaxial
excised. However, this practice does not allow the “guillo- transection of vessels, particularly the arteries, would be
tine effect” of a sharp transection under traction with recoil expected to lead to diminished circulation to the foot, as
of the proximal end to be performed (this technique is the digital arteries are the main source of blood supply to
addressed later as a method to prevent regrowth). Certainly, the distal foot. The level of the biaxial transection would be
there are other fibrous structures that can be excised important to the relative presence of collateral circulation.
instead of the nerve (ligament of the ergot) and small Horses with biaxial transection of the arteries should be
branches should not be mistaken for the major palmar dig- carefully monitored in the days following surgery for
ital nerve which is commonly of similar size to the digital coolness and problems with the structures of the hoof. No
vein and artery. data exists to guide the prognosis and horses with naturally
Knowledge of anatomy is crucial to eliminating these occurring lacerations that sever biaxial vessels in this
errors. The tendon sheath may also be penetrated if dissec- location often have sufficient other damage to warrant
tion is continued too far in the palmar direction; however, euthanasia.
the sheath does not require closure and has not been
reported to cause any complications [10]. Current recom-
mendations are to perform the surgery in either dorsal EarlyPostoperativeComplications
recumbency under general anesthesia or standing with
Postoperative complications following a neurectomy pro-
local anesthetic placed proximal to the incisions.
cedure in the initial few weeks after surgery include inci-
Performing the surgery under the former procedure and
sional infections, neuritis or early neuroma formation,
flipping to the opposite lateral recumbency is not recom-
continued innervation, and injury to the soft tissues
mended, as sudden death has been reported (Patrick Burns,
affected by the neurectomy.
Diplomate ACVA: personal communication). When the
horse is in dorsal recumbency, attaching the limbs to a
Infection
diagonally placed horizontal bar will allow access to both
Definition A bacterial, or less commonly, a fungal
medial and lateral sides of each limb and maintain shorter
colonization and proliferation in the surgical site
anesthesia times.
Risk factors
Diagnosis Although realization of vessel transection can
be obvious because of acute onset of intraoperative ● Lack of sterile technique or preparation of the surgical site
hemorrhage or the obvious hollow tubular structure of the ● Contamination after surgery
severed end, non-identification of aberrant branches is not ● Duration of procedure (less likely as neurectomy proce-
obvious and this may not be recognized until persistent dures commonly do not exceed on hour)
sensation is observed in the postoperative period.
Pathogenesis The incidence of incisional infection is
Treatment Inadvertant transection of blood vessels should similar to other elective surgical procedures in the horse
be treated by placement of a ligature proximally and (0–7%) [10–12].
distally if possible. This is particularly advisable if the
artery is transected. The nerve should then be located and Prevention The surgical procedure should be short, sterile,
transected. and with minimal soft tissue damage and therefore
If aberrant branches are not transected and sensation is prophylactic antibiotics are unlikely to make a significant
retained in the postoperative period, the horse should be difference in the incidence of incisional infection. Without
reassessed for lameness after a few weeks to allow the skin clear evidence to the contrary, the surgery would not merit
incisions to heal. If skin sensation remains but the lame- antibiotic prophylaxis given current guidelines, unless
ness is eliminated, then the aberrant branches do not there are complicating factors such as additional surgical
require treatment. If lameness continues then regional procedures, advanced age, concurrent equine metabolic
nerve blocks should be used to verify that the lameness syndrome, or other risk factors for incisional infection
responds appropriately. If so, the surgery can be repeated present. As the incisions are relatively close to the ground
and aberrant branches (often more dorsally located) should and potentially contaminated bedding, careful bandaging
be identified and resected. is recommended after surgery.
Expected outcome While there is no published consequence Diagnosis Infected surgical sites are typically associated
to the severance of an artery or vein, it is apparent that with local swelling and pain and in some cases purulent
discharge from the incisions. Ultrasound of the site may Prevention There is no clearly proven method of reducing
reveal pockets of fluid and distinguish them from neuroma neuroma formation. Based on the pathophysiology of
formation. Culture and sensitivity of drainage is healing, methods to seal the end of the proximal nerve
recommended to guide therapy. stump and physically prevent any regrowth or decreasing
inflammation in the area during healing may be useful.
Treatment Drainage of the infected incision site and daily However, more research is required in this area to take an
bandaging and wound care should be performed. Broad- evidence-based approach. Both the coagulation of the
spectrum antimicrobials can be administered if drainage is proximal stump after transection with a CO2 laser to seal the
not sufficient to resolve the infection or if there is concern end and the guillotine method under tension to cause
about deeper structures being affected. proximal retraction of the stump into less inflamed tissue,
have been proposed to decrease neuroma formation [10, 13,
Expected outcome Generally, not a large problem in this area 15, 16]. Evidence for one method over another is relatively
unless involvement of the tendon sheath has occurred slim, but currently the guillotine method or CO2 laser would
[10–12]. It is unknown if inflammation and infection of the be preferred over other methods for neuroma prevention.
incision leads to a difference in the complications of neuroma
formation or early re-innervation. Diagnosis After surgery, neuromas can be detected as
extremely sensitive areas close to the proximal portion of the
Neuroma formation incision upon palpation and commonly a small nodule can
Definition Inflammation and disorganized regrowth of be palpated under the skin (Figure 60.1). Additionally, some
the severed nerve stump that is commonly associated with horses will stamp their feet or show evidence of hyperalgesia
pain or allodynia. Pain on palpation can be difficult to quantify
and is very subjective. One study showed that all horses had
Risk Factors Unknown at this time, may be related to pain on palpation of the incision after PDN up to 30 days
increased inflammation or trauma at the time of surgery after surgery [16]. Therefore, the diagnosis of neuroma
should be based not only on pain but also palpation of a
Pathogenesis Formation of neuritis or neuroma formation nodule forming at the end of the nerve stump or an
has been reported in horses following a PDN with rates ultrasonographic evaluation of the nerve stump showing it
ranging from 0–7% [10–13]. A neuroma is formed by to be disorganized. Ultrasound evaluation of nerves is a
disorganized axonal sprouting and Schwann cell proliferation useful and undervalued method in large animals, although
at the end of the nerve [14]. They almost always form to it has been shown to be useful in guiding nerve block [17].
some degree and can be found at the time of a second PDN,
but some appear to become persistently painful (Figure 60.1). Treatment Treatment of neuromas once they are diagnosed
can be initially medical and eventually surgical if they fail to
respond to medical management. Use of anti-inflammatory
treatments such as icing the area, restricted exercise,
bandaging to reduce any swelling, and systemic anti-
inflammatories may be administered. In addition, if there are
no signs of infection, then a small amount of triamcinolone
(~3 mg) may be injected and infiltrated around the nerve
ending [10]. This has been useful in our experience in the
patients with early neuroma formation (in the first few weeks
after surgery) and may partially prevent the formation of a
neuroma and reduce painful neuritis. However, it has been
less successful with more chronic cases. Surgical excision of
the neuromas can be performed if medical treatment is
unsuccessful. Based on the available literature, either sealing
the proximal end with the CO2 laser or performing a guillotine
transection under tension, would be recommend for excision
of the neuroma to try and minimize recurrence.
Figure60.1 A non-painful neuroma found during a second

Expected outcome As the incidence of neuroma formation
neurectomy in the middle of the regrown palmar digital nerve.
Proximal is to the right. Source: Yvonne A. Elce. is low, the outcome is difficult to predict. Currently it is
recommended to try medical treatment followed by one study does give the amount of lameness present imme-
surgical excision if that fails. The incidence of recurrence diately after surgery as 8% [11]. The author has also had the
after surgical excision is unknown, but likely to be similar experience that, despite apparent excision of the main pal-
to that experienced whenever a nerve is severed mar digital nerve, the lameness persists after surgery.
(0–7%) [10–13]. Owners should be counselled that the result is not always
as expected in a small percentage of horses. Repeated
Continued lameness examination to determine the source of continued lame-
Definition Persistent postoperative lameness from the ness is warranted.
intended denervated area Vigorous exercise soon after a neurectomy procedure
may predispose to rupture of the already pathological
Risk factors structures and has been reported in horses after PDN with
rupture of the deep digital flexor tendon (DDFT). This may
● Anatomical variation leading to insufficient excision of
also occur in the later periods after neurectomy and will be
nerves and branches
discussed in the following section on late complications.
● Inadequate preoperative identification of lameness
● Rupture of soft tissue structures within the foot, particu-
Expected outcome The occurrence of lameness in the
larly with insertional deep digital flexor tendon tears
postoperative period is likely to have a poor outcome [11].
Careful identification of where the lameness is originating
Pathogenesis Continued lameness from the foot despite a
may help guide treatment.
neurectomy can occur. Continued focal areas of skin
sensation have been reported after PDN in the horse as a
fairly common event (Tim Lescun: personal communication). LatePostoperativeComplications
However, this does not always correlate to continued
Complications occurring after a neurectomy include pain-
lameness. Skin sensation may be provided by small aberrant
ful neuroma formation, re-innervation, and damage to the
branches.
tissues desensitized by the neurectomy.
Unsevered nerve fibres will obviously maintain sensitiv-
ity from the intended denerved site. Whether there are
Reinnervation
other sources of pain, even with an effective neurectomy
Definition Regained sensation from the denerved area by
(such as nervous innervation in the tendon), is unknown.
regrowth of the transected nerves
Prevention Confirmation of complete lameness resolution
Risk factors
with high palmar digital nerve block prior to surgery is
always necessary, as otherwise a persistent lameness after ● Unknown
PDN should be expected. MRI examination prior to surgery ● Potentially removal of a shorter section of nerve
to determine cause of foot lameness and identification of
structures affected is also recommended. During surgery, Pathogenesis The more common complication is rapid
careful isolation and identification of the palmar digital regrowth of the nerves and therefore a return of the
nerve and variable branches must be performed. lameness. The current studies present a range of numbers
for horses remaining lame-free 1 year after surgery as from
Diagnosis Obvious during lameness examination 74 to 88% [10–13]. Cutaneous sensation has been shown to
return in less than a year with a variety of different methods
Treatment Horses with skin sensation after surgery should studied [16]. The numbers of horses remaining sound after
be treated with continued rest and anti-inflammatory that time drops off considerably in most studies, likely due
medications and after 3–4 weeks should have passed a short to nerve regeneration. The median length of lameness
lameness examination to determine if the surgery has resolution after PDN in one study was 20 months, although
successfully desensitized the painful tissues. The presence of other studies vary considerably [11].
incisional infection or neuritis/neuroma formation causing
pain on palpation should be investigated and treated if Prevention In order to try and prevent this complication,
present. techniques that restrict the regrowth of the nerve may be
Continued lameness immediately after surgery is a dis- used during surgery, although more evidence on the best
appointing result. Many studies give the percentage of methods is lacking. Coagulation of the proximal stump of
horses that are lame at 1 year after surgery as 74–88%, but the nerve with a CO2 laser may help prevent regrowth, and
removal of a longer portion of the nerve may prolong the scar tissue and blood vessels. It is recommended that a
period of time before re-innervation. Removal of a longer complete lameness examination and imaging be performed
piece of nerve during a PDN has been described by using two prior to a subsequent surgery, in order to ensure the
small incisions proximally and distally and removing the lameness is still originating from the heel region and that
length of the nerve between them, or removing as much as pathology of those tissues has not advanced considerably.
possible through one centrally located incision by retracting
the nerve out of the incision proximally and distally prior to Expected outcome The outcome after a second neurectomy
transection. It is unknown how much of an effect removal of is likely similar to the initial surgical procedure but
a longer portion of nerve will have, although it should evidence in this area is lacking [10–13].
theoretically create a longer time before the nerve regrows
and re-innervates the foot. It is unknown if the relatively poor Complications due to lack of innervation to tissues
outcome after neurectomy of the ventral branch of the spinal Definition Damage or progression to anatomical structures
accessory nerve is related to quick re-innervation, an within the denervated area
incomplete denervation, or the complexity of the abnormal
behavior. Certainly, the same principles to prevent regrowth Risk factors
can be applied in this surgery as in the PDN [18].
● Large core lesions or insertional tears of the deep digital
Diagnosis Clinical examination of the area will reveal flexor tendon
presence of skin sensitivity or increased sensitivity when ● Lack of sensation to the denervated tissue removing pro-
hoof testers are applied. Lameness examination will show tective mechanisms preventing overloading of those
that the lameness has returned and subsequent nerve structures
blocks should isolate the lameness to the foot region for a ● Inappropriate shoeing and hoof care after surgery
second time.
Pathogenesis Rupture of the DDFT with potential
Treatment Once lameness has recurred, a subsequent subluxation of the coffin joint, sloughing of the hoof, pedal
neurectomy can be performed in order to remove the osteitis, pedal bone fracture, and navicular bone fracture
regrown nerve (Figure 60.2). As some scar tissue may be have all been reported after PDN surgery [11, 12]. These
present, it is recommended that the subsequent surgeries complications can be related to pathological structures
be provided through a single larger incision so that the being exacerbated by increased exercise once pain is
nerve can be successfully identified and separated from removed or to the fact that the horse cannot feel the area
and minor injuries go unnoticed. Denervation can cause
atrophy of the muscular structures and potentially weaken
an already pathological structure [19].
Diagnosis Depending on the anatomical structure, further

degeneration of the affected tissues can be obvious during
clinical examination (i.e. change in conformation such as
subluxation of the distal interphalangeal joint with
proximal displacement of the toe when the limb is loaded)
or a sudden onset of mechanical lameness. Examination of
the foot should be performed daily. Trauma to the hoof
should be readily identified during daily examinations by
the owner. Radiographs can be used in case of recurrence
of lameness to identify any potential fractures or deeper
infection that has not been noted. Rupture of the DDFT
can commonly be diagnosed by the classic toe flipping up
during weight-bearing and subluxation of the coffin joint
Figure60.2 Two segments of nerve that have been removed can occur (Figure 60.3).
during a second neurectomy. A non-painful neuroma was found
in one nerve and a thickened, less organized structure is
Prevention Prior and after surgery, a thorough discussion
apparent in the second nerve. A longer incision is recommended
to improve the exposure necessary to completely dissect out the about surgery and postoperative care needs of the horse in
regrown nerve during the second PDN. Source: Yvonne A. Elce. general and the horse’s feet, shoeing, level of exercise and
(a) (b)
Figure60.3 Lateromedial radiographic images of the front digits of a horse showing unilateral subluxation of the distal
interphalangeal joint after rupture of the deep digital flexor tendon (DDFT). Mineralization can be seen in the DDFT in the region of
the pastern, indicative of prior pathology. Complete rupture of the insertion of the DDFT occurred subsequent to a palmar digital
neurectomy. (a) Affected foot. (b) Normal contralateral foot. Source: Yvonne A. Elce.
ground surfaces after surgery, is crucial. Hooves need daily Arthrodesis of the coffin joint can be performed after sub-
inspection to promptly identify and treat hoof abscesses or luxation as a salvage procedure [20, 21].
trauma.
The use of MRI prior to PDN, to identify risk factors and Expected outcome Trauma to the deeper structures of the
ensure that large core lesions or lesions affecting the inser- foot after neurectomy has a poor outcome, although a large
tion of the DDFT are not present, may be useful. These diag- enough number of horses have not been studied to
nostics are not always possible and communication with the determine if healing can be successful. The structures
client about risks is crucial. MRI prior to PDN surgery has affected were likely pathological and the cause of lameness
been performed in one study and, while some DDFT lesions prior to surgery. The horses are often euthanized rather
were diagnosed, the PDN did not necessarily cause complete than continuing salvage treatment in the face of a probably
rupture [11]. Emphasis was placed on appropriate shoeing poor prognosis [20, 21].
after PDN to protect the hoof and soft tissue structures by
maintaining appropriate foot alignment. More research into
Poor client satisfaction
which horses are suitable candidates for PDN with known
Definition Suboptimal outcome in the owner’s opinion
MRI findings would be appropriate to help case selection.
Risk factors
Treatment Treatment of superficial trauma and infection
is straightforward. Treatment of trauma or fracture to ● Poor client communication and understanding
deeper structures can take the form of appropriate ● Unrealistic expectations
therapeutic shoeing and reduction in exercise.
Once DDFT rupture is diagnosed, the options for treat- Pathogenesis When discussing complications of
ment is limited. Radiographs should be taken to determine neurectomy surgery, the client satisfaction should be
the degree of coffin joint subluxation of any concurrent discussed. As detailed above, there are many potential
fractures. If possible, an MRI may give information on the complications after PDN surgery and these should be
extent and exact location of the rupture. Many cases are clearly outlined with the owner prior to surgery. In one
euthanized as the prognosis for healing is very poor, likely study, 22% of owners were not satisfied with the outcome
due to the rupture commonly involving the insertion of the of the surgery [12]. It is very important that risks and
DDFT. Cast application is a possibility if the rupture is in possible outcomes are discussed clearly with the client and
the body of the tendon and if the coffin joint is stable. expectations are realistic.
Prevention Expectations as to the length of lameness-free Neurectomyof the DeepBranchof the Lateral
time should be discussed, with emphasis on individual PlantarNerve
variation in anatomy and speed to healing. Additionally,
There are fewer studies and fewer complications reported
with neurectomy, the owner should be aware that some
with the neurectomy of the lateral branch of the deep plan-
organizations do not allow horses that have undergone a
tar nerve as a treatment for proximal suspensory desmitis
neurectomy to compete.
in the horse. It is unknown or uncommon to diagnose neu-
ritis or early neuroma formation potentially as the surgical
Evidence-BasedMedicinefor Complications site is deeper in the soft tissues and palpation of the surgi-
of PDN cal site is unlikely to induce a painful response. The more
common complications are those of surgical site infection
The majority of the articles relating to peripheral nerve com-
or continued lameness after surgery. The majority of infor-
plications are those concerning the PDN. There are no rand-
mation is based on a single larger study and thus evidence
omized controlled experimental studies concerning
is lacking.
peripheral nerve surgery in the horse, except one on PDN
that was only reported in a Proceedings of the AAEP. This
Infection
study performed a different technique on each of the 4 legs
Bacterial (and less likely fungal) colonization and prolifer-
of 6 horses [16]. Obviously, this was a small number of
ation at the surgical site after surgery.
horses, but the study did look at the rates of neuroma forma-
tion and found that the guillotine method followed by CO2
Risk factors
laser transection and coagulation of the proximal stump had
lower histological scores for neuroma formation than peri- ● Duration of surgery (>1–1.5 hours)
neural capping and simple laser transection. All horses in ● Trauma to the soft tissue during surgery
this study had a return of cutaneous sensation at less than a ● Inadequate sterile preparation of patient or surgeon
year, indicative of nerve regeneration. One small retrospec- ● Intraoperative break in sterile technique
tive study examined the effect of the use of the CO2 laser on ● Difficult area to maintain bandaging after surgery – expo-
the nerve endings, with one horse rupturing its DDFT after sure to trauma or contamination
surgery, but no other complications were reported [15].
However, the number of horses was small and the fol- Pathogenesis Surgical site infection can be divided into
low-up period was short, so it is difficult to draw any firm superficial and deep surgical site infections. The most
conclusions [15]. Multiple other retrospective studies have common would appear to the superficial incisional infections.
been performed with a focus on the complications after Although not reported in the literature, communications
one or two surgical techniques. The number of horses var- between surgeons at conferences would indicate that deep
ies in these studies, as does the specificity of the diagnosis surgical infection extending into the tarsal sheath is possible.
of the underlying disease, so it is difficult to draw compari- Most of the listed risk factors above relate to general risks for
sons between them [10–13]. What is of particular note is surgical site infections.
that with one exception (that had the fewest number of
cases) complications were common, with the majority con- Prevention Aseptic technique and Halsted’s principles
cerning neuroma formation (5, 6, and 7%) and recurrence should be maintained during surgery to minimize tissue
of lameness (20, 22, and 28%) 1 year postoperatively) [10– trauma. Postoperatively, adequate protection with
13]. Importantly, some of the reported complications can bandages is also recommended.
be fatal (7%), such as those concerning rupture of the
DDFT, infection, or fracture of the bones in the foot [10]. Diagnosis Diagnosis is uncomplicated for superficial
These articles tend to favor the use of the guillotine tech- infections with clinical signs including swelling, incisional
nique to remove varying lengths of the palmar digital drainage or breakdown, pain on palpation or mild
nerve, although unfortunately the evidence is weak. lameness. Continued lameness or swelling that extends
above the hock should be investigated with ultrasound or
Summary of P N surgery synoviocentesis, to ensure deeper structures have not been
It is clear that, while PDN surgery can be useful at prolong- affected. Culture and sensitivity of any incisional drainage
ing the comfortable and useful lives of horses affected with or synoviocentesis should be performed to guide therapy.
heel pain, there are complications that require good com-
munication with the owners and careful follow-up of the Treatment Treatment should consist of incisional care
patients themselves. with cleaning and bandaging, as well as ensuring adequate
drainage. Broad-spectrum antimicrobial therapy is Treatment The treatment of continued lameness depends
indicated, particularly if lameness is present. on the cause and so various treatments may be used. If the
lameness continues to be attributable to the proximal
Expected outcome While there is little evidence for the suspensory region, then additional diagnostic imaging may
expected outcome, treatment of superficial incisional be useful. Alternative techniques may be explored, such as
infections is commonly successful. What effect the infection microfracture or injection of a variety of biological agents
may have on the outcome of the surgery is unknown. (e.g. IRAP, PRP, stem cells). There have been reports of
Certainly, the cosmetic appearance of the limb will be success using biological therapy, which have not been
diminished, as it is likely that there will be residual scarring published in peer reviewed journals and thus the results
and thickening around the surgical site. must be interpreted with caution but use of biological
theories in one form or another may offer potential
continued treatment options after diagnostic examination
Continued lameness
and imaging reconfirms that the lameness is still coming
Definition Persistent lameness in the postoperative period
from the proximal suspensory region.
Risk factors
Expected outcome There is little evidence regarding the
● Additional sites of lameness treatment of continued lameness after surgical excision of
● Straight hock conformation the deep branch of the lateral plantar nerve [22]. Even in
● Fetlock laxity horses with only proximal suspensory desmitis, the return
to full athletic soundness is reported at 77% [22]. However,
Pathogenesis The cause of the lameness may be varied and in horses with additional sites of lameness or identified
thus originate from different etiologies. After neurectomy of the increased issues with the suspensory (straight hock
deep branch of the lateral plantar nerve, some atrophy of the confirmation or fetlock laxity), the return to exercise may
muscle in the proximal suspensory ligament has been noted be as low as 44% [22]. The prognosis is poor for a full return
which may weaken the overall strength of the structure [19]. to exercise in light of a failure to respond to the appropriate
Vigorous exercise soon after a neurectomy procedure may therapy.
predispose to rupture of the already pathological structures.
The persistence of lameness after neurectomy may be
Evidence-BasedMedicinefor Complications
attributable to a variety of reasons, including adhesions between
of Neurectomyof the DBLPN
soft tissue structures, endosteal bone pain or additional
innervation of the area [22]. There are few studies available to base decisions on for the
neurectomy of the DBLPN, other than those to guide case
Prevention Good case selection is important to avoid risk selection and prognosis, which ranges from 44 to 77%. [22].
factors (dropped fetlocks and straight hocks). If a large core There are no studies comparing varying techniques to tran-
lesion is present, then performing a neurectomy of the sect the nerve or varying complications when combined
DBLPN is not recommended due to the increased risk of with a fasciotomy or not. It may be that neuroma formation
rupture after muscle atrophy [19]. The cause of lameness rates will be similar to those found in PDN studies ranging
should be accurately identified through lameness from 5 to 7% [10–12]. Recent studies have looked at differ-
examination and diagnostic imaging. Client communication ent methods to perform the fasciotomy, but not at rates of
about probably outcome after surgery is also important, potential adhesions before and after or relation to
particularly if there is concurrent lameness or risk factors outcome [23].
for a poor outcome present.
Neural repair surgeries
Diagnosis The diagnosis of continued lameness requires a There are far less nerve preservation or nerve repair surger-
lameness examination and diagnostic imaging and cannot ies performed in horses than in other species. The neuro-
be simply attributed to failure of the surgery. This can muscular pedicle graft for innervation of the
occur after the appropriate rest and rehabilitation period cricoarytenoideus dorsalis muscle is performed by few sur-
and an examination and work-up is necessary to determine geons and repair of nerves lacerated during trauma is rela-
if the lameness is continuing to originate from the proximal tively uncommon. External neurolysis for decompression
suspensory area or another cause. Additional causes of of the suprascapular nerve is described, but is also an
lameness may be involved that can be treated or affect the uncommon procedure. The number of complications
expected outcome. therefore is unknown in the current literature. When
References 853
nerves are severed during lacerations, attempts can be

made to repair them using anastomotic techniques [14].
The complications during surgical repair of nerves in the
horse are unknown, but certainly neuroma formation and
failure of the anastomosis and re-innervation would be
among the most common. Careful handling of severed
nerve endings and decreasing the surrounding infection
and inflammation would be recommended (Figure 60.4).
Self-trauma to denervated areas must be monitored for,
and prevented, and medications given to relieve any neuri-
tis. The use of non-steroidal anti-inflammatories or drugs
to combat neuropathic pain such as gabapentin would be
recommended.
Figure60.4 A facial laceration that has severed the facial nerve
resulting in paralysis. Attempts to anastomose the nerve endings
can be made at the time of repair. Source: Yvonne A. Elce.
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Effects of Functional Electrical Stimulation on 15 Haugland, L.M., Collier, M.A., Panciera, R.J. et al. (1992).
denervated laryngeal muscle in a large animal model. The effect of CO2 laser neurectomy on neuroma
Artif. Organs. 39: 876–885. formation and axonal regeneration Vet. Surg. 21: 351–354.
6 Cattin, A.L., Burden, J.J., Emmenis, L.V. et al. (2015). 16 Dabareiner, R.M., White, N.A., and Sullins, K.E. (1997).
Macrophage-induced blood vessels guide schwann Comparison of current techniques for palmar digital
cell-mediated regeneration of peripheral nerves. Cell. 162: neurectomy in horses. Proc. Am. Assoc. Equine Pract. 43:
1127–1139. 231–232.
7 Christie, K.J. and Zochodne, D. (2013). Neuroscience 17 O’Neill, H.D., Garcia-Pereira, F.L., and Mohankumar, P.S.
forefront review: peripheral axon regrowth: new (2014). Ultrasound guided injection of the maxillary
molecular approaches. Neuroscience. 240: 310–324. nerve in the horse Equine Vet. J. 46: 180–184.
8 Lowery, L.A. and Vactor, D.V. (2009). The trip of the tip: 18 Baia, P., Burba, D.J., Riggs, L.M. et al. (2015). Long-term
understanding the growth cone machinery Nature. Rev. outcome after laser assisted modified Forssell’s in
Mollcellbiol. 10: 332–343. cribbing horses Vet. Surg. 44: 156–161.
19 Pauwels, F.E., Schumacher, J., Mayhew, I.G. et al. (2009). horses using three parallel 5.5-mm cortical screws. Vet.
Neurectomy of the deep branch of the lateral plantar Surg. 22: 122–128.
nerve can cause neurogenic atrophy of the muscle fibres 22 Dyson, S. and Murray, R. (2012). Management of
in the proximal part of the suspensory ligament (M hindlimb proximal suspensory desmopathy by
interosseous III). Equine Vet. J. 41: 508–510. neurectomy of the deep branch of the lateral plantar
20 Busschers, E. and Richardson, D.W. (2006). nerve and plantar fasciotomy: 155 horses (2003–2008).
Arthroscopically assisted arthrodesis of the distal Equine Vet. J. 44: 361–367.
interphalangeal joint with transarticular screws inserted 23 Sidhu, A.B.S., Rosanowski, S.M., Davis, A. et al. (2019).
through a dorsal hoof wall approach in a horse. J. Am. Comparison of Metzenbaum scissors and Y-shaped
Vet. Med. Assoc. 288: 909–913. fasciotome for deep metatarsal fasciotomy for the
21 Schneider, R.K., Bramlage, L.R., and Hardy, J. (1993). treatment of proximal suspensory ligament desmopathy
Arthrodesis of the distal interphalangeal joint in two in horses. Vet. Surg. 48: 57–63.
855
Index
a third eyelid removal 792 surgical techniques 683

abdominal approaches aesthetic blockade 393–394 transphyseal screw and wire 684
dehiscence 285–286 air embolism, endoscopy transphyseal stapling 684
hernia 285–288 complications 27–28 anterior cervical fusion 826
incisional drainage 280–281 airway fire 409–410 fractures in the rehabilitation
incisional edema 279–280 airway obstruction 155, 164 stage 832
incisional infection 281–282 alcohol‐based hand rubs (AHR) 176 hematoma/seroma 829–830
repeat laparotomy 282–285 allergic reactions, blood transfusion infection 830–831
abdominal muscle rupture 387–388 complications 65–66 insecure implant 827–828
abdominal testis 514–516 allogeneic transfusion 348 intraoperative and preoperative
aberrations, in body temperature alpha‐2 adrenergic agonists planning 826–827
144–145 111–112, 114 neuropathy 828–829
abnormal tissue formation after intra‐ aminocaproic acid 60 traumatic recovery/fracture 831
tendinous injections 747–748 anaphylactoid reaction 110–111 antimicrobial prophylaxis 179–180
abrasion injury 386–387 anesthesia arthrodesis
abscessation 703 brainstem 127–128 fetlock 651–653
acid‐citrate dextrose (ACD) 348 loco‐regional (see loco‐regional pastern 650–651
acute kidney injury 573–574 anesthesia complications) aspiration pneumonia 260–261, 268
acute renal failure (ARF) 699 negative effect 111–113 ataxia 135
adenosine monophosphate prosthetic laryngoplasty 439 ATP. see adenosine triphosphate
(AMP) 156 anesthesia‐related (ATP)
adenosine triphosphate (ATP) 156, complications 301
348 anesthetic recovery 145–146 b
adhesion formation 749–751 anesthetic time 169 bacterial contamination 46
adhesion injury 386–387 angular limb deformity (ALD) balloon‐tipped catheters,
adjacent structures, damage to correct placement, of surgical complications 478
217–218 implant 684–687 aberrant branches 475–477
adnexal surgery HCPT/PE 684 arterial penetration 477–478
conjunctivectomy/SCC intraoperative complications blindness 479–480
removal 791 incorrect selection, of surgical catheter dislodgement 478–479
entropion procedures 785–786 implant 687–688 errors identification of affected
eyelid laceration repair 786 surgical site hemorrhage 688 artery 474–475
eyelid mass procedures 786–790 postoperative complications failure of surgery to prevent
nasolacrimal punctral stenosis correct/overcorrection 688–689 hemorrhage 480–481
surgery 792 cosmetic blemishes 689–692 iatrogenic damage to nearby
subpalpebral lavage placement single screw transphyseal structures 474
790–791 bridging 684 incisional infection 478
856 Index
basic SSI risk index 171–173 cartilage/bone breakage 429–430 intra‐luminal and peri‐cervical
Beldon technique, of urethroplasty cast‐associated fractures 656–657 adhesions 560–561
556–558 cast immobilization 657 live foal 562
bilateral ovariectomy 539 castration of entire stallions 498 poor surgical access 559–560
bispectral index (BIS) 137 hemicastration 513–514 re‐injury 561–562
bladder calculi 574–575 hemorrhage 500–503 septic peritonitis 561
blood glucose hydrocele 509–510 cervical myelography
abnormalities 146 improper care after 514 exaggeration of ataxia 820
concentration 355–356 penile damage 508–509 needle misplacement 820–821
blood lactate concentration 356 preoperative and operative non‐neurologic complications 821
blood loss 703 considerations 498–499 non‐specific hyperthermia 820
blood transfusion complications pyrexia 506 seizures 819–820
allergic and febrile retention of masculine behavior cesarean section 542–543
reactions 65–66 510–513 abdominal incision 546
immune reactions 64–65 scrotal infection and excessive anesthetic complications 546
nonimmune reactions 67 edema 505–506 death of the mare or foal 547–548
RBC storage lesion 68 septic funiculitis 506–507 decreased fertility 546–547
transfusion‐related acute lung septic peritonitis 508 retained fetal membranes, metritis,
injury (TRALI) 66–67 signs of colic 510 laminitis 544–545
transfusion‐transmitted tetanus 507–508 septic peritonitis 545
infections 67–68 visceral prolapse/evisceration signs of abdominal pain 545
Bolz technique 528–529 503–505 uterine adhesions 544
bone breakage 429–430 cast sores 653–656 uterine hemorrhage 543–544
bone graft complications catecholamines 136 cheek teeth dentistry
donor site catheter associated complications cheek tooth repulsion 242–247
fracture 82–83 50–51 lateral buccotomy
morbidity associated with catheterization 18 technique 250–251
incision at 81–82 CBA. see ciliary body ablation (CBA) oral extraction 247–250
early postoperative 81–84 CCT. see corneoconjunctival reducing overgrowths
intraoperative 80–81 transposition (CCT) (odontoplasty) of cheek
late postoperative 84–85 central and peripheral neuropathies teeth 240–242
pneumothorax/hemothorax cardiovascular system 162–163 widening of cheek teeth
83–84 peripheral nerve damage diastemata 240
reduced viability of 80–81 161–162 cheek teeth diastemata, widening
suboptimal integration of 84–85 respiratory system 163–165 of 240
bone sequestration 722–725 spinal cord malacia 159–161 cheek tooth repulsion
bradyarrythmias 109–110 cerebrospinal fluid (CSF) adjacent structures 243
broad‐spectrum antimicrobial aspiration of air 817–818 delayed healing of
therapy 632–633 blood contamination of 817 alveolus 243–245
broken casts 657 craniospinal pressure 818 infraorbital nerve 242–243
Brown technique, of urethroplasty lumbosacral centesis 817 oronasal fistula 246–247
552, 555 spinal cord trauma 818–819 orosinus (oromaxillary) fistula
violent reactions 819 245–246
c cervical articular process joint 823 persistent postoperative
carbon dioxide laser 100–101 cervical cerclage 562 sinusitis 247
cardiac arrhythmias 139–140 cervical laceration 558 chondrotoxicity 122–123
cardiorespiratory depression 154 cervical cerclage 562 ciliary body ablation (CBA) 783–784
cardiovascular system 162–163 concurrent abnormality 558–559 circumferential incisions 527
carpal hyperextension 710 endometritis 561 citrate‐phosphate‐dextrose with
carpal slab fractures 645–648 good seal after repairing 560 adenine (CPD‐A) 348
Index 857
cleanliness of the surgical excessive local edema and pain desflurane 156
procedure 178 90–91 desmotomy
Clostridial myonecrosis, parenteral excessive tissue necrosis 91–93 DDFT 704–706
drug administration 11–12 intraoperative 88–90 difficult access to interspinous
Clostridium difficile 340–341 cryosurgical equipment and space
Clostridium perfringens 340–341 technique 88–89 840–841
Clostridium perfringens enterotoxin “run‐off” of cryogen 89–90 instrument breakage 841–842
(CPE) 341 late postoperative 93 intraoperative hemorrhage 840
club foot formation 702–703 tumor recurrence 93 SDFT 708–711
coagulating devices 399 cryptorchid castration 399–400 wound complications and
colloids 163 cryptorchidectomy suboptimal cosmetic
colpotomy 532–533 abdominal testis 514–516 outcome 842
computerized pattern scanners 100 conventional inguinal diaphragmatic hernia 303
concurrent illness 703 approach 517–518 diarrhea
condylar fractures 644–645 laparoscopic surgery 518 definition 339
conjugated estrogens 61 vaginal ring 516–517 diagnosis 341–342
conjunctivectomy/SCC removal 791 crystalloid fluid infused expected outcome 342
continued lameness 849, 853 glucose/dextrose containing fluids pathogenesis 340–341
continuous rate infusion (CRI) 337 43–44 prevention 341
contracted heels 702–703 other electrolyte imbalances risk factors 339–340
corneal squamous cell carcinoma 41–42 treatment 342
795–796 potassium imbalance 40–41 difficult exteriorization of the
corneoconjunctival transposition sodium bicarbonate 42–43 ovary 533–534
(CCT) 793–794 sodium imbalance 39–40 digital hyperextension deformities
corporeal anastomosis 530 CSF. see cerebrospinal fluid (CSF) 698–699
corpus spongiosum penis (CSP) 523, cyclocryoablation 801–803 disease recurrence 422–423
529, 530 cyclophotocoagulation 801–803 distal interphalangeal joint
cosmesis 625–626 subluxation 706
cosmetic blemishes 689–692 d Di‐tri‐octahedral (DTO) 341
CPD‐A. see citrate‐phosphate‐dextrose damage to a viscus 537–538 dorsal displacement of the soft palate
with adenine (CPD‐A) DBLPN. see deep branch of the lateral (DDSP) 427, 463–465
craniomaxillary and mandible plantar nerve (DBLPN) dorsal recumbancy 392–393
fractures 731 DDFT. See deep digital flexor tendon dorsal spinous processes (DSPs)
early postoperative complications (DDFT) desmotomy
implant failure 735–736 death of the mare/foal 547–548 difficult access to interspinous
infection/bone sequestration decreased gastrointestinal motility space 840–841
734–735 146–148 instrument breakage 841–842
poor mastication 733 deep branch of the lateral plantar intraoperative hemorrhage 840
intraoperative and technical nerve (DBLPN) 846 wound complications and
complications deep digital flexor tendon suboptimal cosmetic
dental malocclusion (DDFT) 680 outcome 842
731–732 desmotomy 704–706 ostectomy 833
hemorrhage 732–733 tenotomy 706–708 dystrophic mineralization/new
late postoperative complications dehiscence 70–75, 285–286 bone formation 836–837
736–737 infection without 75 iatrogenic vertebral fractures
creatine phosphate (CP) 156 partial phallectomy 524–525 838–839
cryoablation 87 of sutured internal intraoperative hemorrhage 834
cryosurgery lamina 528–529 rotation of the DSP 837–838
early postoperative 90–93 dental malocclusion 731–732 sub‐optimal cosmetic outcome
bleeding after cryosurgery 90 desensitization 585–586 838, 840
858 Index
dorsal spinous processes (cont’d) enteral fluid therapy exacerbation

sub‐optimal surgical visibility administration setup 48–49 of tendon/ligament pathology after
834–835 fluid volume used 49–50 neurectomy 751–752
wound complications 835–836 type of fluid 50 of unrecognized tendon/ligament
dorsiflexion of the toe 706 withholding of enteral damage 746–747
drug‐induced alpha‐1 adrenergic nutrition 53 excessive callus formation 725–726
blockade 136 enteropexy 307 excessive granulation tissue
DSPs. See dorsal spinous processes enterotomy/enterectomy 348–350 (EGT) 204
(DSPs) enthesophytes 626–627 damage to important structures
dysphagia, acute 448–450 epidural analgesia during excision of 209–210
dysphagia/pharyngeal incompetence ataxia/recumbency 124–125 formation
434–435 spinal canal, infection 125–127 definition 204–205
dystrophic mineralization 626–627 epidural block failure 374–375 diagnosis and monitoring 207
dystrophic mineralization/new bone epidural sedation 393 excessive hemorrhage after EGT
formation 836–837 epiduroscopy. see myeloscopy excision 209
epiglottic entrapment (EE) expected outcome 208–209
e long‐term complications 463–465 pathogenesis 204–206
ectopic tissue formation 771–772 preoperative complications 462 prevention 206–207
edema 462–463 short‐term complications 462–463 treatment 207–208
electrolyte imbalances 41–42 epiglottitis 462–463 excessive granulation tissue (EGT)
EMND. see Equine Motor Neuron epinephrine reversal 136 forming after grafting 228
Disease (EMND) epiploic foramen entrapment excessive intra‐abdominal
empyema, guttural pouch surgery (EFE) 296 contamination 292–293
complications epistaxis 730 excessive laxit 700
failure to resolve 469–470 mucosal trauma 25–26 external coaptation 695–698
parotid gland/duct trauma 471 nasogastric intubation extracellular fluid compartment
peripheral nerve injury 470 complications (ECF) 36
endolaser cyclophotocoagulation 29–30 extravasation 575–576
(ECP) 803–804 Equine Motor Neuron Disease eyelid mass procedures 786–790
endometritis 561 (EMND) 823, 824
endoscopic laser surgery erythromycin lactobionate 339 f
interoperative esophageal fistula formation 258 facial deformities 424
airway fire 409–410 esophageal mucosa, perforation of failed laryngeal tie forward (LTF)
granulation tissue formation 442–445 432–433
410–412 esophageal surgery febrile nonhemolytic transfusion
hemorrhage 406 aspiration pneumonia and reaction (FNHTR) 65–66
iatrogenic tissue pleuropneumonia 260–261 fetal membranes 544–545
damage 407–408 esophageal fistula formation 258 fetlock arthrodesis 651–653
smoke (laser plume) laminitis 262–263 fibrotic capsule 626–627
accumulation and laryngeal hemiplegia and Horner’s fistula 383–384
toxicity 408–409 syndrome 261–262 flexor carpi ulnaris 711–713
laser surgery 105–106 mucosal dehiscence and ulceration flexural limb deformities 694–695
methods 404–406 256–257 affecting multiple regions 715
endoscopy periesophageal infection 257–258 conservative treatments
air embolism 27–28 stricture 258–260 digital hyperextension
epistaxis/mucosal trauma 25–26 water, electrolyte and metabolic deformities
equipment damage 26 disturbances 255–256 698–699
insufflation‐related complications esophageal trauma 31–32 external coaptation 695–698
26–27 etiopathogenesis 416–417 gastrocnemius 703–704
endotoxemia 357–359 evisceration 535–536 oxytetracycline 699–701
Index 859
shoeing 701–703 associated with a transfixation pin general measures for

surgical treatments 659–660 prevention 155
desmotomy 704–706, 708–711 in rehabilitation stage 832 hypotension 137–139
medial patellar support structures fractures, craniomaxillary and hypoventilation 140–142
713–715 mandible 731 hypoxemia 142–144
peronius tertius muscle 713 early postoperative complications morbidity and mortality of 154
tenotomy 706–708, 711–713 implant failure 735–736 musculoskeletal/nervous system
fluid deficit 37 infection/bone additional actions 158–160
fluid overload, using crystalloid sequestration 734–735 myopathy 156–158
solutions 36–38 poor mastication 733 pathogenesis in general 155–156
fluid therapy intraoperative and technical risk factors in general 154–155
administration of colloid therapy complications unanticipated movement 136–137
47–48 dental malocclusion 731–732 glomerular filtration rate (GFR) 699
administration of parenteral hemorrhage 732–733 glucose/dextrose containing fluids
nutrition solutions 50–53 late postoperative complications 43–44
crystalloid fluid infused 39–44 736–737 graft displacement/removal
enteral fluid therapy 48–50 fragmentation of apex of patella definition 225
fluid overload using crystalloid definition 752 diagnosis 226
solutions 36–38 diagnosis 754 expected outcome 226
intravascular plasma administration expected outcome 754 monitoring 226
44–47 pathogenesis 752–754 pathogenesis 225
withholding of enteral prevention 753 prevention 226
nutrition 53 treatment 754 treatment 226–227
fogging 614–615 free‐floating fragments 617–619 graft failure
foot surgery definition 224
abnormal hoof 678 g diagnosis 225
hoof abscess 678–679 gallium aluminum arsenide (GAA) expected outcome 225
laminitis 679 diode laser 101–103 monitoring 225
neuroma formation 679–680 gamma scintigraphy 597 pathogenesis 224
rupture of the deep digital flexor gas‐cooled coaxial fibers 103 prevention 224–225
tendon 680 gas emboli 776 treatment 225
distal phalanx/navicular bone gastric impaction 265 granulation tissue formation 410–
676–677 gastric ulceration 269 412, 423–424
hemorrhage 668–669 gastrocnemius 703–704 granulosa‐cell tumor 537
iatrogenic damage 677–678 gastrosplenic ligament greater palatine artery
new, persistent or recurrent trauma 276–277 damage 236
lameness general anesthesia 154 laceration 239–240, 250
674–676 aberrations in body temperature guttural pouch surgery
persistent/recurring infection 144–145 empyema
671–673 cardiac arrhythmias 139–140 failure to resolve 469–470
surgical site dehiscence and central and peripheral neuropathies parotid gland/duct trauma 471
excessive/exuberant cardiovascular system 162–163 peripheral nerve injury 470
granulation tissue peripheral nerve mycosis
formation 673–674 damage 161–162 balloon‐tipped
surgical site infections respiratory system 163–165 catheters 473–481
669–671 spinal cord malacia 159–161 ligation procedures failure 473
treatments 667–668 complications associated with transarterial embolization
forelimb 592 recovery from 155 techniques 481–483
formalin 60 definition 169 temporohyoid osteoarthropathy
fractures (middle ear disease)
860 Index
guttural pouch surgery (cont’d) splenic surgery 275–276 immunological reactions 44–46
hemorrhage 484 tenotomy 706 implant failure 735–736
hypoglossal nerve 484–485 treatment 199, 216–217, 223, 489, impotency 529–530
iatrogenic fractures 485–486 492 inaccurate/ineffective intra‐tendinous
peripheral nerve injury 484–485 urinary surgery 571–572 injection 739–741
stylohyoid bone regrowth 485 uterine 543–544 inadequate distention 609–611
tympany hemothorax 83–84, 495–496 inadequate fracture reduction
failure to resolve 472–473 hernia 286–288 633–635
peripheral nerve injury 471 recurrence 384–386 inadequate limb position/limb
hernia repair manipulation 606–609
h inadvertent enterotomy 379–380 inadequate removal/debridement
hand hygiene 176, 178 intraoperative 379–380 622–623
hemarthrosis 611–613 methods 378–379 incisional breakdown 754–755
hematoma 489, 829–830 postoperative incisional dehiscence and delayed
formation 754–755 abdominal muscle rupture healing 218–219
hemicastration 513–514 387–388 incisional drainage 280–281
hemi‐circumferential periosteal adhesion/abrasion‐related incisional edema 279–280
transection and elevation 386–387 incisional infection 281–282
(HCPT/PE) 684 hernia recurrence 384–386 equine nasal passages and
hemoperitoneum 346–348 mesh infection 381–383 paranasal sinuses 420
hemorrhage 541–542, 732–733 seroma 380 laryngeal tie‐forward
definition 198, 216, 222, 488, surgical site infection (SSI) 381 (LTF) 430–431
491–492 suture sinus/fistula 383–384 incisor and gingival
desmotomy 708 hernioplasty techniques 378 damage 237–238
diagnosis 199, 216, 223, 489, 492 herniorrhaphy techniques 378 incisor dentistry
endoscopic laser surgery hindlimb 592–593 incisor extraction 238–239
complications 406 hoof abscess 678–679 orthodontic treatment of overjet
equine nasal passages and Horner’s syndrome 262, 829 and overbite 235–238
paranasal sinuses 416–417 hydrocele 509–510 incisor extraction 238–239
expected outcome 199, 217, 223, hypertonic saline 163 incomplete resolution 422–423
489 hyponatremia 39–40 incomplete septal resection
foot surgery 668–669 hypotension 137–139 419–420
intraoperative 57–61 hypoventilation 140–142 incomplete surgical
intraoperative colic patient hypoxemia 142–144, 164 excision 212–214
intra‐abdominal 298 incontinence 576–577
from large colon mesentery i incorrect screw
296–297 iatrogenic bone, vascular or nerve length 638–640
from small intestinal mesentery damage 719 positioning 640–641
294–296 iatrogenic damage to tendons and increased urine output 146
monitoring 199, 216, 223 adjacent vascular structures infection 830–831, 847–848,
muscle surgery 757–758 740, 743 852–853
outcomes 492 iatrogenic tissue damage 407–408 after thoracic surgery 496–497
partial phallectomy 522–524 iatrogenic vascular injuries 299–300 bone sequestration 734–735
pathogenesis 198, 216, 222, 488, iatrogenic vertebral fractures osteosynthesis, recovery and
492 838–839 postoperative
postoperative 61–2 ICP. see intracranial pressure (ICP) complications 661–663
prevention 198–199, 216, 222–223, ileus 114–115 tracheal surgery 489
488–489, 492 alpha‐2 adrenergic agonists 114 urinary surgery 577
prosthetic laryngoplasty 439–442 opioids 113–115 inferior alveolar nerve block 128,
severe 534–535 immune reaction 64–65, 769–771 234–236
Index 861
infra‐orbital and mental nerve intestinal ischemia at the intravitreal ciliary body ablation
blocks 234 anastomosis 300–301 783–784
infraorbital nerve 242–243 intestinal rotation 301–302 IOL. see intraocular lens (IOL)
injectable techniques 155 intra‐abdominal hemorrhage 298 IRAP. see interleukin‐1 receptor
injection site reaction 700 intraoperative injury to small antagonist protein (IRAP)
inotropes 163 intestinal mesentery 298–299 isoflurane 156
insecure implant 827–828 partial thickness tears 293–294 isotonic crystalloid fluids 162–163
instrument breakage 841–842 ruptured viscus 291–292
insufficient donor skin 223–224 rupture of the portal vein 296 j
insufflation‐related complications intraoperative hemorrhage 57–60, joint sepsis 722–725
26–27 834, 840
interleukin‐1 receptor antagonist adjunctive systemic k
protein (IRAP) 769 treatment 60–61 Kaneps technique of urethroplasty
interspinous space, difficult access blood transfusion 60 553, 555–556
to 840–841 fluid therapy 60 keratectomy 796–798
intestinal rotation 301–302 intra‐osseous (IO) perfusion 663 ketamine 112–113
intra‐abdominal adhesions 537 intra‐synovial
intra‐arterial, intravascular anesthesia 588–590 l
injection 18 instrument breakage 615–617 laceration, bone 429–430
intracranial pressure (ICP) 815, 816 parenteral drug administration 12 lag screw fixation
intramuscular, parenteral drug intravascular foreign bodies 21–22 broken bits and taps 635–636
administration 10 intravascular injection broken screws 636–637
intraocular lens (IOL) 805–806 anatomic considerations 16 inadequate fracture reduction
intraocular surgery catheter placement/dislodgement/ 633–635
ECP 803–804 patency 18–19 lag screw tightens well 635
equine intra‐arterial injection 18 stripping screw 638
phacoemulsification 804–810 intravascular foreign bodies 21–22 lameness 660, 701
laser ablation of uveal cyst or perivascular swelling and diagnostic anesthesia
melanoma 804, 805 inflammation 16–18 failure to block 596
pars plana vitrectomy 810 thrombophlebitis 19–21 inaccurate needle placement
intraoperative colic patient vascular air embolism/bleeding 583–585
anesthesia‐related 22–23 intra‐synovial
complications 301 intravascular plasma administration anesthesia 588–590
enteropexy 307 immunological reactions 44–46 motor nerve paresis 592–594
excessive intra‐abdominal non‐immunogenic perineural local
contamination 292–293 complications 46 anesthesia 586–588
failure to correct the serum hepatitis 46–47 poor compliance by the horse
lesion 303–305 intravenous catheter‐associated 594–595
failure to identify the lesion complications post‐injection swelling 590–592
302–303 definition 342 unpredictable desensitization
failure to remove an intra‐ diagnosis 344–345 585–586
abdominal surgical expected outcome 346 diagnostic images
item 306–307 pathophysiology 343 gamma scintigraphy 597
hemorrhage from large colon prevention 343–344 magnetic resonance
mesentery 296–297 risk factors 342–343 imaging 597
hemorrhage from small intestinal treatment 345–346 radiography 596
mesentery 294–296 intravenous regional anesthesia techniques 597
iatrogenic vascular injuries (IVRA) 128–130 ultrasonography 596
299–300 tourniquet failure 128–129 laminitis 262–263, 359–361,
instrument failure 305–306 tourniquet ischemia 129–130 544–545, 679
862 Index
laparoscopy 5, 391, 518 gallium aluminum arsenide diode maxillary nerve block 234–236
access 394–395 laser 101–103 McKinnon technique of
aesthetic blockade 393–394 in horses 104–106 urethroplasty 556–558
cryptorchid castration 399–400 neodymium yttrium aluminum MC3/MT3, complete fracture of
dorsal recumbancy 392–393 garnet (Nd:YAG) 721–722
epidural sedation 393 laser 101–103 medication errors, parenteral drug
insufflation 395 patient complications administration 13–14
ligating loops 397–398 endoscopic 105–106 melena 268–269
ligation 397 general surgery 104–105 mesh infection 381–383
nephrosplenic space ablation physics and tissue mesorectum 374
400–401 interaction 95–100 metabolic aberrations 51–53
ovariectomy 400 safety 103–104 metabolic complications 355–357
standing positioning 392 tarsal arthrodesis metastatic spread 215–216
surgical laser 398–399 complications 106 methicillin‐resistant Staphylococcus
surgical stapling devices 398 in veterinary surgery 100–103 aureus (MRSA) 190
thermal injuries 396–397 lateral buccotomy methicillin‐resistant Staphylococcus
thorascopy 401 technique 250–251 pseudintermedius (MRSP) 190
ultrasonic cutting and coagulating Lidocaine 113, 338 metoclopramide HCl 338
devices 399 Ligate Divide Stapler (LDSTM) 295 metritis 544–545
urinary surgery 401 ligature loop failure 76–77 middle ear disease 484–485
vessel sealing 399 local antimicrobial therapy 661 MODS. see multiple organ dysfunction
laryngeal hemiplegia 262, 263 local infection 722–725 syndrome (MODS)
laryngeal, perforation of 442–445 local muscle reaction 10–11 Monin technique, of
laryngeal tie forward (LTF) local nerve blocks 234 urethroplasty 554–555
early postoperative complications loco‐regional anesthesia motor nerve paresis 592–594
incisional infection 430–431 allergic reactions 123–124 mucosal dehiscence 256–257
seroma 430 brainstem anesthesia 127–128 mucosal trauma 25–26
failed 432–433 chondrotoxicity 122–123 multidrug resistance 190
intraoperative complications epidural analgesia multidrug resistant
bleeding 428–429 ataxia/recumbency 124–125 Acinetobacter 190
cartilage/bone breakage or spinal canal, infection 125–127 multidrug resistant Enterococcus
laceration 429–430 inferior alveolar nerve block 128 spp. 190
late postoperative complications intra‐oral technique 128 multiple organ dysfunction syndrome
failed laryngeal tie forward intravenous regional anesthesia (MODS) 357
432–433 (IVRA) 128–130 muscle surgery
fracture stylohyoid bone myotoxicity 121–122 early postoperative complications
postoperatively 431–432 nerve injury 120–121 dehiscence 762–763
unilateral breakage of the pruritus 126–127 hematoma and seroma
suture 431 retrobulbar blocks 127–128 760–762
vocal cord collapse 431 self‐inflicted lingual trauma 128 infection 758–760
larynx surgery tourniquet failure 128–129 peripheral nerve injury 763–764
epiglottic entrapment 461–465 tourniquet ischemia 129–130 intraoperative and technical
laser ventriculo‐cordectomy vascular puncture 118–120 complications 757–758
455–459 Loop syndrome 267, 268 late postoperative complications
partial arytenoidectomy 459–461 LPS‐binding proteins (LPS‐BP) 357 fibrosis 764–766
prosthetic laryngoplasty 438–455 lung and diaphragmatic injury septic arthritis/
laser energy 99 492–494 tenosynovitis 766
laser surgery muscular contractions with
carbon dioxide laser 100–101 m electrochemotherapy
equipment complications 106–107 magnetic resonance imaging 597 (ECT) 789
Index 863
musculoskeletal/nervous system esophageal/pharyngeal trauma non‐union 726–727

additional actions 158–160 31–32 nutritional supplementation 4
myopathy 156–158 sinusitis 34
mycosis, guttural pouch surgery tube fragmentation 32–33 o
complications tube misplacement 30–31 Obel grade for laminitis 360
balloon‐tipped catheters 473–481 nasogastric tubes 32 OCLL. see osseous cyst‐like lesions
ligation procedures failure 473 nasolacrimal punctral stenosis (OCLL)
transarterial embolization surgery 792 ocular surgery
techniques 481–483 nasopharyngeal, perforation of conjunctival pedicle graft
myeloscopy 442–445 793–794
craniospinal pressure 822–823 National Nosocomial Infection corneal laceration repair 794–795
pneumocephalus and Surveillance (NNIS) 171, 172 corneal squamous cell carcinoma
pneumorachis 823 navicular bursoscopy 671, 675 795–796
spinal cord or the subarachnoid necrosis, of skin beneath cyclodestructive procedures
blood vessels 821–822 bolsters 529 801–803
myopathy 156–158, 621–625 needle breakage 442 keratectomy 796–798
myotoxicity 121–122 needle tracts following intra‐ suprachoroidal cyclosporine
tendinous injection 747 implant 800–802
n neodymium yttrium aluminum garnet thermal keratoplasty 798–800
nasal passages and paranasal sinuses (Nd:YAG) laser 101–103 odontoplasty 240–242
surgery neostigmine methylsulfate 339 ophthalmic surgery
clinical diagnosis of sinus nephrosplenic space adnexal surgery
disease 415 ablation 400–401 conjunctivectomy/SCC
early postoperative complications nerve injury 120–121 removal 791
incisional infection 420 nervous system, diagnostic entropion procedures 785–786
sinus packing complications procedures of eyelid laceration repair 786
421–422 cerebrospinal fluid eyelid mass procedures 786–790
suture periostitis 420–421 centesis 816–819 nasolacrimal punctral stenosis
intraoperative/technical cervical articular process joint 823 surgery 792
complications cervical myelography 819–821 subpalpebral lavage placement
hemorrhage 416–417 electrodiagnostics 824 790–791
incomplete septal resection increased intracranial third eyelid removal 792
419–420 pressure 816 enucleation/exenteration/
trauma 417–419 myeloscopy and epiduroscopy evisceration
late postoperative complications 821–823 corneal issues
airway narrowing due to nerve or muscle biopsy 823–824 postevisceration 783
adhesions 423–424 patient or personnel hemorrhage including
disease recurrence 422–423 injury 815–816 nasolacrimal duct
etiopathogenesis 416–417 neural repair surgeries 853–854 hemorrhage 781
facial deformities 424 neurectomy of the deep branch of the infection, neoplasia, conjunctiva
granulation tissue lateral plantar nerve 852–853 or glandular tissue in orbit
formation 423–424 neuroendocrine, surgical 782–783
incomplete resolution 422–423 complications 4–5 perforation of the
respiratory noise 424–425 neuroma formation 679–680, globe 780–781
pertinent anatomy for surgery 848–849 rejection or migration of an
413–415 neuropathy 621–625, 828–829 orbital prosthesis 781–782
nasogastric intubation complications non‐healing alveoli 249 intraocular surgery
administration of fluid into non‐immunogenic complications 46 ECP 803–804
lungs 33–34 non‐steroidal antiinflammatory drugs equine phacoemulsification
epistaxis 29–30 (NSAIDs) 573, 574 804–810
864 Index
ophthalmic surgery (cont’d) orthopedic surgery 154, 629 abdominal incision 546
laser ablation of uveal cyst or osseous cyst‐like lesions (OCLL) anesthetic complications 546
melanoma 804, 805 damage to surrounding healthy death of the mare or
pars plana vitrectomy 810 structures 774–775 foal 547–548
intravitreal ciliary body ablation enlargement of 776–777 decreased fertility 546–547
783–784 fracture 776 retained fetal membranes,
ocular surgery gas emboli 776 metritis, laminitis 544–545
conjunctival pedicle graft inappropriate screw position 777 septic peritonitis 545
793–794 trans‐cortical OCLL debridement signs of abdominal pain 545
corneal laceration 775–776 uterine adhesions 544
repair 794–795 ostectomy 833 uterine hemorrhage 543–544
corneal squamous cell carcinoma dystrophic mineralization/new ovariectomy
795–796 bone formation 836–837 damage to a viscus or the
cyclodestructive procedures iatrogenic vertebral fractures cervix 537–538
801–803 838–839 difficult exteriorization 533–534
keratectomy 796–798 intraoperative hemorrhage 834 evisceration 535–536
suprachoroidal cyclosporine rotation of the DSP 837–838 failure of bilateral 539
implant 800–802 sub‐optimal cosmetic outcome general anesthesia 538–539
thermal keratoplasty 798–800 838, 840 incisional complications 537
orbitotomy/orbitectomy 784–785 sub‐optimal surgical visibility intra‐abdominal adhesions 537
opioids 113–115 834–835 laparoscopic 539–540
oral and salivary gland surgery 233 wound complications 835–836 metastasis of ovarian
cheek teeth dentistry osteoarthritis 626–627 neoplasia 537
cheek tooth repulsion 242–247 osteomyelitis 722–725 neuropraxia 538–539
lateral buccotomy technique osteosynthesis poor selection of approach
250–251 intraoperative complications 532–533
oral extraction 247–250 lag screw fixation 633–641 septic peritonitis 536–537
reducing overgrowths plate fixation 641–643 severe hemorrhage 534–535
(odontoplasty) of cheek teeth preoperative patient preparation signs of colic 537
240–242 630–633 total and partial ovariohysterectomy
widening of cheek teeth recovery and postoperative hemorrhage 541–542
diastemata 240 complications infection at the uterine
incisor dentistry cast complications 653–657 stump 542
incisor extraction 238–239 cast immobilization 657 infertility after 542
orthodontic treatment of overjet cast removal 657–658 poor surgical access 540
and overbite 235–238 infection 661–663 septic peritonitis 540–541
inferior alveolar and maxillary lameness 660 signs of colic 542
nerve blocks 234–236 supporting limb ovariectomy 400
local nerve blocks 234 laminitis 660–661 damage to a viscus or the cervix
parotid salivary gland ablation transfixation pin casts 658–660 537–538
251–252 specific anatomic sites difficult exteriorization 533–534
“wolf tooth” (triadan 05) extraction carpal slab fractures 645–648 evisceration 535–536
239–240 condylar fractures 644–645 failure of bilateral 539
oral extraction 247–250 fetlock arthrodesis 651–653 general anesthesia 538–539
oronasal fistula 246–247 pastern arthrodesis 650–651 incisional complications 537
orosinus (oromaxillary) fistula sagittal fractures of the proximal intra‐abdominal adhesions 537
245–246 phalanx 648–649 laparoscopic 539–540
orthodontic prostheses 237 ulnar fractures 649–650 metastasis of ovarian
orthodontic treatment of overjet and ovarian and uterine surgery neoplasia 537
overbite 235–238 cesarean section 542–543 neuropraxia 538–539
Index 865
poor selection of intra‐synovial administration 12 palmar/plantar digital neurectomy

approach 532–533 local muscle reaction 10–11 early postoperative
septic peritonitis 536–537 medication errors 13–14 complications 847–849
severe hemorrhage 534–535 post‐injection synovitis and evidence‐based medicine for
signs of colic 537 lameness 12–13 complications of neurectomy
oxygen supplementation 164–165 parenteral nutrition solutions of the DBLPN 853–854
oxytetracycline 699–701 catheter associated complications evidence‐based medicine for
50–51 complications of PDN 852
p metabolic aberrations 51–53 intraoperative complications
pain 624–625 withholding of enteral feeding 53 846–847
composite pain score 312, 313 Parker‐Kerr procedure 305 late postoperative
definition 312 parotid salivary gland ablation complications 849–852
diagnosis 312, 313, 315–319 251–252 neurectomy of the deep branch of
expected outcome 319–320 partial phallectomy the lateral plantar nerve
numeric rating scale 312 dehiscence 524–525 852–853
pathogenesis 314 hemorrhage 522–524 peritonitis, septic
prevention 314–315 recurrence of neoplasia 525–527 cesarean section 545
risk factors 312, 314 urinary obstruction 525 ovariectomy 536–537
treatment 319 partial thickness tears 293–294 perivascular swelling 16–18
pain/dehiscence at the donor site pastern arthrodesis 650–651 peronius tertius muscle 713
definition 227 PCO. see posterior capsular persistent postoperative sinusitis 247
diagnosis 228 opacification (PCO) phacoemulsification
expected outcome 228 PDN. see palmar/plantar digital corneal edema or ulceration
monitoring 228 neurectomy (PDN) 807–808
pathogenesis 227 penile and preputial surgery endophthalmitis 808
prevention 227–228 Bolz technique 528–529 glaucoma 809–810
treatment 228 partial phallectomy 522–527 Iris, often corpora nigra, prolapse
palmar digital neurectomy 675–676 priapism 529–530 806–807
palmar/plantar digital neurectomy segmental posthetomy 527–528 PCO 808, 809
(PDN) penile damage 508–509 postoperative ocular hypertension
early postoperative complications perforation 269 (POH) 807
847–849 periesophageal infection 257 radial tear in anterior lens capsule/
evidence‐based medicine for perineal injury 563–564 tear in posterior lens capsule
complications of neurectomy concurrent genital 805–806
of the DBLPN 853–854 abnormality 564 retinal detachment or
evidence‐based medicine for dehiscence 564–569 folds 808–810
complications of PDN 852 perineural local anesthesia 586–588 uveitis and/or PIFM 808
intraoperative perioperative preventive measures pharynx surgery 427
complications 846–847 181–186 laryngeal tie forward 427–433
late postoperative complications periorbital hematoma and infection laser palatoplasty 435–436
849–852 235–236 staphylectomy 433–435
neurectomy of the deep branch of peripheral nerve injury 161–162 sternothyroideus
the lateral plantar guttural pouch empyema 470, 471 myotenectomy 435
nerve 852–853 guttural pouch tympany 471 pheochromocytoma 303
parenteral drug administration temporohyoid osteoarthropathy photodynamic therapy 789–790
complications 484–485 PIFM. see pre‐iridal fibrovasular
anatomical and procedural peripheral nerve surgery 844–845 membranes (PIFM)
considerations 10 anatomy and pathophysiology pin tract infection 659
Clostridial myonecrosis 11–12 845–846 plasma or serum triglyceride
intramuscular administration 10 neurectomy procedures 846 concentration 356
866 Index
plate fixation 641–642 incisional complications 325–332 prosthetic laryngoplasty

iatrogenic damage 642–643 intravenous catheter‐associated early postoperative complications
inadequate metal 642 complications 342–346 acute dysphagia and coughing
platelet rich plasma (PRP) 769 laminitis 359–361 448–450
PLC. see posterior lens capsular metabolic complications 355–357 seroma formation 445–446
(PLC) tear monitoring sheet 310, 311 sudden major loss of abduction
pleuropneumonia 260–261 pain/colic 312–320 447–448
pneumothorax 83–84, 277–278, postoperative intraperitoneal wound infection 446
494–495 adhesions 352–355 intraoperative complications
urinary surgery 572–573 postoperative reflux and esophageal mucosa, perforation
POH. see postoperative ocular postoperative ileus 332–339 of
hypertension (POH) pyrexia 320–325 442–445
POI. see postoperative ileus (POI) septic peritonitis 351–353 general anesthesia 439
polymethylmethacrylate postoperative hemorrhage 61–62 hemorrhage 439–442
(PMMA) 662 postoperative ileus (POI) laryngeal, perforation
polytetrafluoroethylene (PTFE) 342 definition 332 of 442–445
poor client satisfaction 851–852 diagnosis 336–337 nasopharyngeal, perforation of
poor cosmesis 736–737 pathogenesis 334–335 442–445
poor cosmetics prevention 335–336 needle breakage 442
functional outcome risk factors 332–333 late postoperative complications
definition 230 treatment 337–339 chronic coughing and
diagnosis/monitoring 231 postoperative intraperitoneal dysphagia 452–455
pathogenesis 230–231 adhesions 352–355 gradual loss of abduction
prevention 231 postoperative morbidity 2 450–452
treatment and expected outcome postoperative neuroma formation proximal fragment instability
231–232 748–749 720–721
functional result postoperative ocular hypertension proximal phalanx, sagittal fractures
definition 219 (POH) 807 of 648–649
diagnosis 219 postoperative pain and nursing PRP. see platelet rich plasma (PRP)
expected outcome 220 problems 237 pruritus 126–127
monitoring 219–220 postoperative reflux (POR) pulmonary edema 164, 165
pathogenesis 219 definition 332 pure protein or calorie malnutrition
prevention 219 diagnosis 336–337 (PPCM) 4
treatment 220 pathogenesis 334–335 pyometra 562–563
poor knot‐tying technique 71 prevention 335–336 septic peritonitis 563
poor mastication 733 risk factors 332–333 pyrexia 506
POR. see postoperative reflux (POR) treatment 337–339 definition 320
posterior capsular opacification (PCO) postoperative tendon hemorrhage diagnosis 322–324
808, 809 743–744 expected outcome 325
posterior lens capsular (PLC) potassium imbalance 40–41 pathogenesis 320–321
tear 806 Pouret procedure 551, 554 prevention 321–322
postoperative antimicrobials pre‐iridal fibrovasular membranes risk factors 320
180–181 (PIFM) 808 treatment 324–325
postoperative colic patient preparation time (PT) 169
diarrhea 339–342 preputial cavity 528 r
endotoxemia/SIRS and shock priapism 529–530 radiography 596
357–359 pro‐calcitonin (PCT) 187 reconstructive surgery 196
enterotomy/enterectomy procedure finish time (PFT) 169 failure to close the wound with
complications 348–350 procedure start time (PST) 169 196–198
hemoperitoneum 346–348 prolonged anesthesia time 155 hemorrhage 198–199
Index 867
wound dehiscence definition 510 laryngeal tie forward 430

definition 199 diagnosis and prosthetic laryngoplasty 445–446
diagnosis 202 monitoring 511–513 Serum Amyloid A (SAA) 187
expected outcome 202 outcome 513 serum hepatitis 46–47
pathogenesis 199–200 pathogenesis 510–511 severe hemorrhage 534–535
prevention 199–202 prevention 511 sevoflurane 156
treatment 202 treatment 513 Shires technique 555–556
recovery time (RT) 169 retrobulbar blocks 127–128 shock 357–359
rectovestibular laceration 564–569 rib fractures, in horses 491 sinus packing complications
rectum and anus surgery ruptured viscus 291–292 421–422
early postoperative complications SIRS. see systemic inflammatory
375–376 s response syndrome (SIRS)
intraoperative complications salbutamol 165 skin grafting 222
dehiscence 377 Salmonellosis 340 intraoperative/technical
hind limb weakness, paresis or scrotal infection and excessive edema early postoperative 224–228
paralysis 376–377 505–506 hemorrhage 222–223
inadequate surgical closure of the SDFT. See superior check ligament insufficient donor skin
perineum 376 desmotomy (SDFT) 223–224
intraoperative/technical sedative and anesthesia late postoperative 229–232
complications 374–375 medication 135 skin mobilization procedures 201
recurrence of neoplasia during anesthetic skin neoplasia 212
definition 213 recovery 145–146 early postoperative
diagnosis 215 blood glucose abnormalities 146 incisional dehiscence and delayed
expected outcome 215 decreased gastrointestinal motility healing 218–219
monitoring 215 146–148 poor cosmetic or functional result
partial phallectomy 525–527 during general anesthesia 219–220
pathogenesis 213 aberrations in body temperature intraoperative/technical
prevention 214 144–145 damage to adjacent structures
treatment 215 cardiac arrhythmias 139–140 217–218
recurrent/chronic colic 267–268 hypotension 137–139 haemorrhage 216–217
recurrent laryngeal neuropathy hypoventilation 140–142 incomplete surgical excision
(RNL) 438, 829 hypoxemia 142–144 212–214
regenerative medicine unanticipated metastatic spread 215–216
ectopic tissue formation 771–772 movement 136–137 recurrence of
excessive fibrosis in tendon or increased urine output 146 neoplasia 213–215
ligament 772 during standing sedation 135–136 SLL. See supporting limb laminitis
immune reaction 769–771 segmental posthetomy 527–528 (SLL)
worsened inflammation 771 self‐inflicted lingual trauma 128 smoke (laser plume) 408–409
regional limb perfusion (RLP) 662 self‐mutilation (biting/rubbing) sodium bicarbonate 42–43
reinnervation 849–850 229–230 sodium imbalance 39–40
renal problems 699–700 sepsis 357 soft palate damage 249–250
repeat laparotomy septic funiculitis 506–507 spinal cord malacia 159–161
diagnosis 283 septic peritonitis 266–267, 351–353, splenic adhesions 274–275
outcome 285 508 splenic surgery
pathogenesis 282–283 cervical laceration 561 gastrosplenic ligament trauma
prevention/treatment 284 cesarean section 545 276–277
rescue cardioplegia 129 ovariectomy 536–537 pneumothorax 277–278
respiratory noise 424–425 pyometra 563 splenic adhesions 274–275
respiratory system 163–165 seroma 489, 709, 829–830 splenic trauma 272–274
retention, of masculine behavior hernia repair complications 380 splenic trauma 272–274
868 Index
splint bone fractures 718 desmotomy 708–711 intraoperative

early postoperative complications tenotomy 711 equipment problems 602–604
complete fracture of MC3/MT3 supporting limb laminitis (SLL) free‐floating fragments
721–722 660–661 617–619
local infection, osteomyelitis, suprachoroidal cyclosporine implant iatrogenic damage 619–621
bone sequestration and joint 800–802 inadequate limb position/limb
sepsis 722–725 Surgical Care Improvement Project manipulation 606–609
intraoperative complications (SCIP) 179 intra‐synovial instrument
iatrogenic bone, vascular or nerve Surgical Safety Checklist (SSC) 3 breakage 615–617
damage 719 surgical site infections (SSIs) 168, poor triangulation 604–606
instability of the proximal 381, 669–671 visualization 609–615
fragment 720–721 definition 325 postoperative
late postoperative complications definition and myopathy/
excessive callus formation classification 169–173 neuropathies 621–625
725–726 diagnosis 328–330 synovitis 625–627
non‐union 726–727 epidemiology preoperative planning 601–602
suspensory desmitis 727–728 basic SSI risk index 171–173 synovial fistulae 754–755
SSIs. see surgical site infections (SSIs) infection rates and risk factors synovial sinus formation 707
standing positioning 392 173–174 synovial villi obstruction 613
standing sedation 135–136 expected outcome 332 synovitis 625–627
staphylectomy 433–435 management 189–190 systemic analgesic drugs
sternothyroideus partial multidrug resistance 190 intraoperative complications
myectomy 435 pathogenesis 326–328 anaphylactoid reaction
stomach surgery prevention 328 110–111
aspiration pneumonia 268 overall preventive anesthesia, negative
failure to thrive and recurrent/ measures 175–179 effect 111–113
chronic colic 267–268 perioperative preventive bradyarrythmias 109–110
gastric impaction 265 measures postop complications
gastric outflow obstruction 266 181–186 ileus 114–115
gastric ulceration and post‐op 181, 185 opioids 113–114
perforation 269 pre‐operative preventive systemic inflammatory response
melena 268–269 measures 179–181 syndrome (SIRS) 357–359
septic peritonitis 266–267 understanding the occurrence of
strangulation 302–303 174–175 t
stricture 258–260 recognition 185, 187–189 tarsal arthrodesis complications 106
stylohyoid bone postoperatively risk factors 325–326 temporohyoid osteoarthropathy
431–432 treatment 330–332 hemorrhage 484
subcutaneous emphysema 490 surgical stapling devices 398 hypoglossal nerve 484–485
sub‐epiglottic granuloma 462–463 surgical wound 169 iatrogenic fractures 485–486
sub‐optimal cosmetic outcome 838, surveillance of SSI 181, 185 peripheral nerve injury 484–485
840, 842 suspensory desmitis 727–728 stylohyoid bone re‐growth 485
sub‐optimal surgical visibility suture periostitis 420–421 tendon rupture following casting
834–835 suture‐related complications 752–753
subpalpebral lavage placement dehiscence 70–75 tendon surgery 739
790–791 infection without 75 early postoperative complications
sudden collapse 700–701 ligature loop failure 76–77 exacerbation of unrecognized
sudden major loss, of reactions 75–76 tendon/ligament damage
abduction 447–448 suture sinus 383–384 746–747
superior check ligament desmotomy suture, unilateral breakage of 431 postoperative tendon hemorrhage
(SDFT) synovial endoscopic surgery 601 743–744
Index 869
tendon or synovial late postoperative complications ultrasonography 596

sepsis 744–746 496–497 unanticipated movement 136–137
intraoperative complications thoracoscopy 491 undermining skin 201
iatrogenic damage to tendons and thorascopy 401 urethra 528
adjacent vascular structures thrombophlebitis 342–346 urethroplasty
740, 743 intravascular injection 19–21 Beldon technique 556–558
inaccurate or ineffective intra‐ tongue trauma 234–235 Brown technique 555
tendinous injection 739–741 total and partial ovariohysterectomy Kaneps technique 555–556
late postoperative complications hemorrhage 541–542 McKinnon technique 556–558
abnormal tissue formation after infection at the uterine stump 542 Monin technique 554–555
intra‐tendinous injections infertility after 542 Shires technique 555–556
747–748 poor surgical access 540 urinary obstruction, partial
adhesion formation 749–751 septic peritonitis 540–541 phallectomy 525
exacerbation of tendon/ligament signs of colic 542 urinary surgery 401
pathology after neurectomy tourniquet failure 128–129 intraoperative
751–752 tourniquet ischemia 129–130 acute kidney injury 573–574
fragmentation of the apex of the tracheal surgery bladder calculi 574–575
patella 752–754 hematoma and seroma 489 hemorrhage 571–572
incisional breakdown, hematoma hemorrhage 488–489 pneumothorax 572–573
formation and synovial fistulae infection 489 postoperative 571
754–755 subcutaneous emphysema 490 incontinence 576–577
needle tracts following intra‐ tracheostomy 165 infection 577
tendinous injection 747 tranexamic acid 61 stricture/fistula 578–579
postoperative neuroma formation trans‐cortical OCLL debridement suture choice and
748–749 775–776 placement 579
tendon rupture following transfixation pin casts 658–660 urine scalding 578
casting 752–753 transfusion‐related acute lung injury uroabdomen/extravasation
tendon/synovial sepsis 744–746 (TRALI) 66–67 575–576
tenotomy transphyseal bridging 683 urine pooling. See vesicovaginal reflux
DDFT 706–708 trauma 169 urine scalding 578
SDFT 711 to buccal branches of the facial uroabdomen, urinary
tension‐reducing suturing nerve 235–236 surgery 575–576
techniques 201 equine nasal passages and urovagina. See vesicovaginal reflux
testicular surgery paranasal sinuses 417–419 uterine adhesions 544
castration of entire traumatic recovery/fracture 831 uterine hemorrhage 543–544
stallions 498–514 triangulation 604–606
with cryptorchidectomy 514–518 tube fragmentation 32–33 v
tetanus 507–508 tube misplacement 30–31 vaginal ring 516–517
thermal damage 701–702 tumoral calcinosis 766 vascular air embolism/bleeding,
thermal injury 396–397, 641, 658–659 tumor recurrence 93 intravascular injection 22–23
thermal keratoplasty 798–800 tympany, guttural pouch surgery vascular puncture 118–120
thermal relaxation time 100 complications vesicovaginal reflux
third‐degree perineal failure to resolve 472–473 Brown technique, of
laceration 563–564 peripheral nerve injury 471 urethroplasty 555
third eyelid removal 792 failure of surgery to restore fertility
thoracic surgery u 551–554
early postoperative complications ulceration 256–257 McKinnon and Beldon technique,
494–496 ulnar fractures 649–650 of urethroplasty 556–558
intraoperative and technical ulnaris lateralis 711–713 Monin technique of urethroplasty
complications 491–494 ultrasonic cutting 399 554–555
870 Index
vesicovaginal reflux (cont’d) widening of cheek teeth definition 199

Pouret procedure 551, 554 diastemata 240 diagnosis 202
Shires and Kaneps technique, of wolf teeth fracture 239 expected outcome 202
urethroplasty 555–556 “wolf tooth” (triadan 05) extraction pathogenesis 199–200
vessel sealing 399 239–240 prevention 199–202
violent reaction/nerve trauma during worsened inflammation 771 treatment 202
needle placement 234 wound class definitions 169–170 wound infection 446
vocal cord collapse 431 wound closure definitions 169–170 wound protection and hygienic
wound complications 835–836, 842 care 181
w wound contamination definitions
weakness, of structural tissues 657 169–170 y
white blood cell scans 188 wound dehiscence Yunnan baiyao 61
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COMPLICATIONS­IN EQUINE­SURGERY

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Library of Congress Cataloging•in•Publication Data

Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India

2 Complications of Parenteral Administration of Drugs 10

3 Complications of Intravascular Injection and Catheterization 16

5 Complications of Nasogastric Intubation 29

6 Complications of Fluid Therapy 36

7 Complications Associated with Hemorrhage 57

8 Complications of Blood Transfusion 64

9 Complications Associated with Sutures 70

10 Complications of Bone Graft Harvesting, Handling, and Implantation 79

12 Complications of Laser Surgery 95

13 Complications of Systemic Analgesic Drugs 109

14 Complications of Loco-Regional Anesthesia 118

15 Complications of Sedative and Anesthesia Medications 135

16 Complications During Recovery from General Anesthesia 154

17 Complications Associated with Surgical Site Infections 168

18 Complications of Reconstructive Surgery 196

19 Complications of Excessive Granulation Tissue 204

20 Complications of Skin Neoplasia 212

21 Complications of Skin Grafting 222

22 Complications of Oral and Salivary Gland Surgery 233

23 Complications of Esophageal Surgery 254

24 Complications of Stomach Surgery 265

25 Complications of Splenic Surgery 272

26 Complications of Abdominal Approaches 279

27 Complications of the Intraoperative Colic Patient 291

28 Complications of the Postoperative Colic Patient 310

29 Complications of Surgery of the Rectum and Anus 374

30 Complications of Abdominal Surgery: Incisional Hernia 378

31 Complications of Equine Laparoscopy 391

32 Complications of Endoscopic Laser Surgery 404

34 Complications of Pharynx Surgery 427

35 Complications of Larynx Surgery 438

36 Complications of Surgery for Diseases of the Guttural Pouch 468

37 Complications of Equine Tracheal Surgery 488

38 Complications of Equine Thoracic Surgery 491

39 Complications of Testicular Surgery 498

40 Complications of Penile and Preputial Surgery 522

41 Complications of Ovarian and Uterine Surgery 532

42 Complications of Vulvar, Vestibular, Vaginal, and Cervical Surgery 550

43 Complications of Urinary Surgery 571

44 Complications of Diagnostic Tests for Lameness 583

45 Complications of Synovial Endoscopic Surgery (Arthroscopy, Tenoscopy, Bursoscopy) 601

46 Complications of Equine Orthopedic Surgery 629

47 Complications of Surgery of the Equine Foot 667

48 Complications of Surgical Correction of Angular Limb Deformities 683

49 Complications of Surgical Correction of Flexural Limb Deformities 694

50 Complications of Splint Bone Fractures 718

51 Complications of Craniomaxillary and Mandible Fractures 730

52 Complications of Tendon Surgery 739

53 Complications of Muscle Surgery 757

54 Complications of Regenerative Medicine 769

55 Complications of Osseous Cyst-Like Lesions 774

56 Complications of Equine Ophthalmic Surgery 779

57 Complications of Diagnostic Procedures of the Nervous System 815

58 Complications of Anterior Cervical Fusion 826

59 Complications of Surgery for Impingement of Dorsal Spinous Processes 833

60 Complications of Peripheral Nerve Surgery 843

COMPLICATIONSIN EQUINESURGERY

Complicationsof ParenteralAdministrationof Drugs

Complicationsof IntravascularInjectionand Catheterization

AnatomicConsiderations Definition Perivascular swelling is localized swelling that

Overview Risk Factors

Diagnosis Development of respiratory distress immediately Sinusitis

hypovolemia and endotoxemia, and therefore Na-HCO3 is ComplicationsDue to Glucose-/Dextrose-

titrated properly and separately from the amount of other omplicationsAssociated

Complicationsof BoneGraftHarvesting,Handling,and Implantation

ReducedViabilityof the Graft

Figure10.1 Loosely arranged cancellous bone graft in

Table10.1 Summary of bone graft donor sites

DonorSite Advantages Disadvantages

FractureatDonorSite Pathogenesis Fracture of the humerus or tibia following

Table11.1 Complications related to cryosurgery

Intraoperative Earlypostoperative Latepostoperative

IntraoperativeComplications freezing and a “slow spontaneous” thawing. Tissue

"Run-off "of Cryogen

EarlyPostoperativeComplications ExcessiveLocalEdemaand Pain