Things That Make Me Cringe

I don’t really keep track of how many surgeries I do, though sometimes I think maybe I should start – just for the fun of it. If I had to guess I would say the non-elective surgery I do the most is a cystotomy. Either that or exploratories.

Cystotomy is literally cutting into the bladder. Cysto = bladder; tomy = surgical incision. There’s really only one reason I do this: to remove bladder stones.

Even just typing the term “bladder stones” makes my urinary tract cringe. The things I have felt and seen. . . *shudder*

Usually it goes like this: a dog or cat is having urinary issues, and when I have a look at the urine I see crystals. I recommend a radiograph to check for stones to go along with those crystals. Sometimes the crystals have not yet partied hard enough to form stones. Sometimes I wonder how the animal didn’t have problems before now.  If there are stones, I have a chat with the owner about the risks of leaving the stones in there and recommend surgery to remove them. Sometimes I can use a diet to dissolve them, but even still there are risks in the waiting.

Sometimes, an animal presents because it CAN’T urinate, thanks to a rogue stone making a go for the outside world and getting caught up in the urethra. (cringing again. . . ). In these cases, I will pass a catheter to relieve the immediate obstruction, and strongly recommend surgery as soon as possible to prevent reoccurrence.

Most cringe worthy case I’ve had? Cat came in blocked, which is actually not very often because of stones, and I passed a catheter to relieve the obstruction and empty the bladder. Before I passed the catheter, when I palpated his abdomen I felt a ginormous, very firm, melon that was his bladder. After getting a decent amount of urine out, I had my hand on his belly over his bladder, only now instead of being a firm melon, it was a giant sack of marbles. (I just experienced a bladder cramp thinking back on that.) That cat had surgery, it was the most stones I have ever removed from a cat, and he’s doing fine now.  . . but I will never forget that moment. *shudder*

When we go to surgery, it’s pretty easy to find our target: the bladder is usually all kinds of angry. Instead of being a thin walled little balloon I encounter during a spay surgery, I am greeted by a thick, red, ugly, thing. I try to find a spot in the bladder wall to make a hole – being sure to be far away from ureters (the tubes that bring urine from kidneys to bladder. They’re kind of important, don’t want to cut those). You don’t want too big of a hole, but you need to be able to get your bladder spoon in there and scoop out your stones. Yeah, bladder spoon. It’s a surgical tool that’s a bit of a scoop, with a scraping edge of it, so you can scrape the bladder walls for grit. Using it makes all of the sphincters in my urinary tract spasm.

Cystotomies come in wide variety : lots of little stones, lots of big stones, a few big stones with lots of little tiny gritty stones, one giant stone, smooth stones, crazy spiked jaggedy stones that make your bladder cry in sympathy for the bladder you removed them from. You always have a ‘before’ radiograph so you have an idea what you’re going in for. And you ALWAYS should take an ‘after’ radiograph to make sure you didn’t leave behind anything. The last thing you want, after the clients pay $1000+, is for the animal to come back next week with the same problem because you left one errant stone behind.

Random factoid about cystotomies: If you read an old surgery textbook, it will advise you to take the bladder up out of the abdominal cavity and flip it over to you make your incision on the dorsal (top) side of the bladder. The idea being that when the animal is standing, this side will be at a lower risk for urine leakage because gravity brings the urine to the bottom of the bladder. If you read current surgery textbooks, this idea has been abandoned and we make the incision on the ventral (bottom) side of the bladder. Why? Because the bladder is a balloon. It’s only as big as the volume of urine in it requires. There’s no air bubble. The pressure of urine against the ‘top’ it the same as the ‘bottom’. Silly old school surgical ideas. . .

When you’re confident you removed all your stones and grit, and you close up that bladder, you leak test it. Even if you buy into the old school dorsal side idea, you fill the bladder with sterile saline, give a squeeze, and make sure nothing bubbles out your incision. Then you place the bladder back down inside the abdomen, close the animal up, and take that post-op radiograph (making sure nobody touches your surgical instruments so they remain sterile just in case you have to go back in. If you don’t keep your instruments sterile, I guarantee your post-op rad will tell you to go back in.)

Bladders are pretty awesome about healing up. Once, when I was a student, I assisted on a cystotomy on a dog who had had a cystotomy 2 days prior, but still had stones left. . . and we could only barely figure out where the original incision was.

For all my complaints of cringing, I kind of enjoy cystotomies. They have a certain satisfaction to them – I enjoy surgeries that have before and after pictures where you can see that you fixed the problem. Maybe that’s why I like castrations so much? You can’t tell by looking that I’ve removed the uterus, but an empty scrotal sack is pretty telling.

Or maybe I just enjoy ripping out testicles. Just because.

Bob’s Adventures in Baking

Now that you’ve met Bob, he’d like some more of his adventures to be featured. He likes to look back at his younger days, when he had legs and could participate much more easily.

That summer of 2009, Bob helped me tackle my book of 500 cookie recipes. I think we got through maybe 20. I could go count, but I’m afraid to find out it was more like 4.

Our very first project together: Chocolate Raspberry Bars. I’m of the opinion you can’t go wrong with either chocolate or raspberries when it comes to desserts, so these seemed likely to be a success.

Reading up so he's ready to help out!

I took care of making the base, and baking the base. I also mixed the jam and liqueur and spread that over the base.

Bob’s job was the processing of the finely ground almonds, egg whites, sugar and almond exrtract.

Being careful not to fall into the tasty mix!

He felt that after such a good job, he deserved a sip treat or two.

Sampling the liqueur, bit of a lush he is. . .

Chocolate! Om nom nom!

After pouring Bob’s handy work over the jam, and sprinkling with almond flakes, the whole thing went back in the oven. When it came out, Bob was pretty pumped about the great job we did!

Field of deliciousness!

Before sharing these with anyone, as it was a new recipe for us both, we had to taste test. Happy to report they were absolutely delicious.

Have to test the finished product!

Here’s the recipe if you’d like to try ‘em yourself!

Preheat your oven to 325^oF

Line a 13×9 inch baking pan with aluminum foil.

Base: Sift  1 cup all purpose flour with 2 tabsp unsweetened cocoa powder and ¼ tsp salt into a medium bowl. In a separate bowl, beat ½ cup of softened butter, ½ cup of granulated sugar, and ½ tsp of vanilla at high speed until creamy. Mix in the dry ingredients. Firmly press the mixture into the prepared pan to form an even layer and prick all over with a fork. Bake for 15-20 minutes, or until firm to the touch.

Increase oven temperature to 375^oF.

Filling: Mix ½ cup raspberry preserves with 1tbsp raspberry liqueur in a small bowl and spread it evenly over the base. Sprinkle with 1cup of semisweet/dark chocolate chips.  Process 1.5 cups of finely ground almonds with 4 large egg whites, 1 cup white sugar, and ½ tsp of almond extract in a food processor or blender until well blended. Pour the mixture over the preserves and sprinkle with 2 tbsps of flaked almonds.

Bake for 20-25 minutes, or until lightly browned.

Using the edge of the aluminum foil as handles, lift the whole kit and caboodle onto a rack and let cool completely.

Remove the foil and cut into bars. Find people to share them with before you eat them all yourself.

If it Ain’t Baroque

The title of this post has very little to do with the topic, and a lot to do with my love of Disney movies . . . but I digress.

My least favourite surgery is pretty much the exact opposite of one of my most favourite: amputation. It’s not that I don’t want to be able to allow an animal to keep all 4 of its legs. . . but I really don’t like orthopaedics. Specifically, I dislike repairing fractures. I find it frustrating. It can be incredibly rewarding, but very rarely do the two feelings balance out in the favour of rewarding.

Now, we don’t do a lot of fracture repair at my clinic. It can be tricky, finicky business. We try to stick to simple fractures. Anything overly complicated we insist on referring to an actual board certified surgeon. I actually offer referral to all fractures, because the surgeons who do nothing but surgery and have all the fancy equipment are probably going to do a better job. However, sometimes we can offer an alternative to getting your pet off The Rock, and some people appreciate this. Some people need this.

A lot of the fracture repairs we do involve plating. A metal  plate with holes in it is screwed into the bone spanning across the fracture. I don’t do this. I will assist my boss when he does this, and that is where I draw the line. I have no interest in doing this. It seems so aggravating – picking the right plate, the right screws, getting the fracture reduced (aka putting the bone back together) and keeping it that way while you DRILL HOLES IN THE BONE (this would be on the list of things that give me the heebie jeebies). When I’m the one holding the broken bone in place for drilling, I’m afraid the drill is going to drill into me. I pick that over worrying about drilling the hole in the right spot.

Once the holes are made you screw in your screws, all the while hoping that you end up with a securely fastened plate that is holding the bone perfectly back together. Then you close it up and take a radiograph to make sure you screw placement is good. Are any too long? Too short? Do you have to mutter a bunch of curse words and go back in and replace some with different sizes?

Sounds like fun, eh? Yeah, not for me.

The other kind of repair we can do is to place a pin through the centre of the bone, and then put some wires around the spot where it’s broken to offer further support. This, I half don’t mind, actually. . . which is why recently, when my colleague had a cat with a simple spiral fracture in the femur and I said, “That just needs an IM pin and some cerclage wires, we can fix that here.” And she said, “You could do it! Would you do it?” I thought for a moment and shrugged and said, “Sure.”

And so December, 2011, I was lead surgeon on a fracture repair for the first time. We had a lot of fun doing it. The pin placement went really, really well. . . I got it placed, we did a quick close, and took a radiograph to double check the placement before putting the wires in. I don’t mind saying: IT WAS PERFECT. I couldn’t have possibly done it any better. I was super pumped.

Then we went back in to place the cerclage wires. I. Hate. Cerclage. Wires. By the time I had the wires placed, I wanted to stab someone in the eye with the wire cutters. Two became loose before I was done and had to be replaced. I couldn’t get the knots to lay flat. All the positive feelings from how well the IM pinning went disappeared. Poof. I was swearing, cussing, and threatening to poke wire cutters into people’s eyeballs.

There was still some satisfaction when I looked at the post-op radiographs . . . as long as I looked at the view where I couldn’t see the not flat knots. It is nice to know something was broken and not useable, and I made it better. Fingers crossed the cat does well. We’re feeling pretty confident – put 2 cat bones in a room, walk away, and when you come back you’ll have a whole cat! However, I am worried about those wire knots that aren’t flat . . . once her bones are well healed, we can take the wires out if they cause a problem, but that would probably be almost as much fun as putting them in there in the first place.

I guess you could say that under the right circumstances I enjoy fracture repair . . . I enjoy surgery as a general rule, and I like making broken animals better.  For the most part, though, it’s at the very bottom of the list for surgeries I want to do in my week.