PRESENTATION
BROCHURE
Small animal surgery Rodolfo Brühl Day (Coordinator) María Elena Martínez Pablo Meyer José Rodríguez Gómez
Iatrogenesis Malpractice Postoperative haematomas and seromas Postoperative infections Fistulas Suture dehiscence Adhesions Dressings
Surgery atlas, a step-by-step guide
Errors and complications in surgery
Errors and complications in surgery
Small animal surgery
SMALL ANIMAL SURGERY
Small animal surgery Rodolfo Brühl Day (Coordinator) María Elena Martínez Pablo Meyer José Rodríguez Gómez
Iatrogenesis Malpractice Postoperative haematomas and seromas Postoperative infections Fistulas Wound dehiscence Adhesions Bandages
Surgery atlas, a step-by-step guide
Errors and complications in surgery P88770_ERRORS_surgery_COVER_SERVET.indd 3
18/12/17 12:30
AUTHORS: Rodolfo Brühl Day, María Elena Martínez,
Pablo Meyer, José Rodríguez, Tomás Guerrero.
FORMAT: 23 × 29.7 cm. NUMBER OF PAGES: 240. NUMBER OF IMAGES: 615. BINDING: hardcover.
eBook included
RETAIL PRICE
€83
This new book in the Small Animal Surgery collection has been designed as a review of the surgical errors and complications that may occur in daily practice when performing surgery on dogs and cats. It is intended for surgeons starting their professional careers and residents, as well as more experienced veterinary surgeons, since it must not be forgotten that error can occur at any time, no matter how much experience one may have. This book will guide veterinary clinicians in solving problems that may arise in surgery and in the postoperative period and help them anticipate these problems.
Errors and complications in surgery
Presentation of the book The purpose of this new book in the Small Animal Surgery series is to review surgical errors that occur in daily practice. Some are involuntary, while others are the result of a limited ability or inadequate training, lack of expertise, lack of the proper surgical technique or of the instruments necessary to perform a particular procedure. The lack of experience also plays an important role in obtaining a beneficial result for the patient. Referral cases can sometimes be demanding, so specialised surgeons in this area, with years of experience in training professionals and in private practice will explain each case, step by step, how it was diagnosed and, a posteriori, resolved through surgery. Coming face to face with the error of another professional can often turn into a serious ethical dilemma. This means not knowing how to confront the facts without condemning the work of a colleague. The purpose of this book is not to lift accusing fingers, but to review the errors and surgical complications that occur in the daily practice of small animal surgery. We hope it is a reference book that, despite not providing all of the solutions, will serve to point out evidence that will prompt us to continue paying attention, studying, researching, and providing, in addition, an ideal space to enhance the surgical skills and behaviour of the surgical team in the operating room. This book follows the direction of the other volumes of the series, from both a clinical and practical point of view. It is directed towards novice surgeons and residents, as well as more experienced surgeons because there is always room for error if it is not taken into consideration. Accidents can happen to anyone, to a greater or lesser extent. What hunter has not lost a hare at some point? That being said, amongst the described cases there are also cases that belong to us; the idea being that we should share without shame what went wrong, to prevent other colleagues from tripping over the same stone. That is called acquiring skill, becoming apt. All veterinary surgeons should train, accredit their training and prove it with facts. They should not do what they do not know, nor practice in a place that is inadequate. To err is human, to cover up is unforgivable, and to fail to learn is inexcusable. The important thing is to know how to recognise what happened and how to solve the problem or complication; the responsibility of having caused harm to a patient that was entrusted in our care is nontransferable. Those who only present successes do not show the full spectrum of their experience. In conclusion, it is important to encourage learning from one’s mistakes and to stress the importance of planning every tiny detail of a surgical procedure to make sure it is the success it deserves to be, in order to benefit the patient. Rodolfo Brßhl Day
Authors Rodolfo Brühl Day, DVM (coord.) Rodolfo Brühl Day graduated from the Faculty of Veterinary Sciences at the University of Buenos Aires (Argentina) in 1977. He graduated with honours (Magna cum Laude) and received an award for the best academic record. He completed a residency in small animal surgery at the Veterinary Medical Teaching Hospital of the University of California (Davis, USA) in 1984. In 1998 he became a Charter Diplomate in Small Animal Surgery of the Faculty of Veterinary Medicine, University of Buenos Aires. In addition, he is a specialist in University Teaching with an orientation towards Veterinary and Biological Sciences (2000) and a Diplomate of the Latin-American College of Veterinary Ophthalmologists (2002). He was recently appointed as a Small Animal Surgery Specialist by the Veterinary Professional Council of Argentina (2017). Throughout his extensive career, he has taught at various universities (Faculty of Veterinary Sciences, University of Buenos Aires; School of Veterinary Medicine, University of California; and Ross University, School of Veterinary Medicine, Saint Kitts, West Indies). Since 2008, he has been a professor of small animal surgery and the director of the Small Animal Medicine and Surgery Department at the School of Veterinary Medicine, St. George’s University (Grenada, West Indies). He is also a staff surgeon at the Small Animal Clinic of the same university. Dr Brühl Day has received numerous grants, awards and distinctions, and has contributed to a large number of publications such as books, journals and educational materials. He has also been a speaker at seminars and courses, and has continued his training with continuing professional development throughout his career.
María Elena Martínez, DVM María Elena Martínez graduated from the Faculty of Veterinary Sciences of the University of Buenos Aires (FCV-UBA), in 1991. She was a professor in the Small Animal Surgery and Anaesthesiology Department at the FCV-UBA from 1998 to 2006. In 2002 she obtained a Diploma in Small Animal Surgery from the University of Buenos Aires. She is a founding member of the Argentinian Association of Neurology (Neurovet Argentina), in charge of its surgery section, and head of the Neurosurgery Area as part of the Diploma programme in Neurology at the National University of La Pampa (Argentina). She is a member of Neurolatinvet (Latin American Association of Veterinary Neurology). She has gained wide experience in her specialty in foreign centres such as Gramercy Park Hospital (NY, USA) and Missouri University (USA), and has participated as a speaker in numerous congresses and specialisation programmes in Colombia, Chile, Peru and Bolivia.
Errors and complications in surgery
Pablo Meyer, DVM Pablo Meyer graduated from the Faculty of Veterinary Sciences of the University of Buenos Aires (UBA) in 1986. In 2003 he earned a Specialist Diploma in Small Animal Surgery from the UBA. From 2007 to 2009 he taught Skin Surgery and Reconstruction as part of the Specialist Programme in Small Animal Surgery at the UBA. Since 2010 he has taught Thoracic Surgery as part of the same programme. He is also a surgeon in the Surgery Service at the Veterinary Teaching Hospital of the Faculty of Veterinary Sciences at the University of Buenos Aires. He is also a professor of oncology and an academic speaker in Chile and Peru. Dr Meyer is the author of several papers and publications in specialised journals and has participated in conferences on oncology and surgery.
Collaborators José Rodríguez, DVM, PhD José Rodríguez Gómez graduated in veterinary medicine from the Complutense University of Madrid (Spain). He is the head of the Animal Pathology Department at the University of Zaragoza (Spain) and a veterinary surgeon at the Hospital Veterinario Valencia Sur (Valencia, Spain). He is one of the coauthors of the series Small Animal Surgery: Surgery Atlas, a Step-by-Step Guide and the video editor of this volume of the series.
Tomás Guerrero graduated in veterinary medicine from the National University of La Plata, Buenos Aires (Argentina) in 1993. In 2000 he began his small animal surgery specialisation at the University of Zurich (Switzerland), where he completed an internship and later a residency in small animal surgery. In 2003 he earned a PhD in veterinary medicine from the University of Zurich, with his thesis titled Advancement of the tibial tuberosity for the treatment of cranial cruciate-deficient canine stifle. Between 2005 and 2011, he worked as an assistant professor in the Surgery Area of the University of Zurich’s small animal hospital, and in 2006 he became a diplomate of the European College of Veterinary Surgeons (ECVS). In 2013, he received the Venia Legendi (habilitation) from the University of Zurich. Since 2011, he has been a professor of small animal surgery at St. George’s University’s School of Veterinary Medicine (Grenada, West Indies). He is an acknowledged member of AOVET, and is currently the chair of the AOVET Latin America Regional Board. Dr Guerrero has been a collaborator on previous works published by SERVET such as 3D Joint Anatomy in dogs Main joint pathologies and surgical approaches and Orthopaedic pathologies of the stifle joint.
hkeita/shutterstock.com
Tomás Guerrero, DVM, PhD, Dip. ECVS
Communication services Website Online visualisation of the sample chapter. Presentation brochure in PDF format. Author’s CV. Sample chapter compatible with iPad.
www.grupoasis.com/promo/errors_surgery
Small animal surgery Rodolfo Brühl Day (Coordinator) María Elena Martínez Pablo Meyer José Rodríguez Gómez
Iatrogenesis Malpractice Postoperative haematomas and seromas Postoperative infections Fistulas Wound dehiscence Adhesions Bandages
Surgery atlas, a step-by-step guide
Errors and complications in surgery P88770_ERRORS_surgery_COVER_SERVET.indd 3
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Table of contents 1. General information Definition of error Preoperative errors Intraoperative errors Postoperative errors
2. Errors in clinical and perioperative management Case 1 / Biopsy of a lung mass Case 2 / Bandage on the wrong limb Case 3 / Incorrectly secured limbs Case 4 / Inadequate splinting Case 5 / Removal of an ectopic cilium Case 6 / Testicular tumour Case 7 / Diaphragmatic rupture
3. Errors in surgery of the head, neck, thorax, and abdomen Case 8 / Chronic oronasal fistula repair Case 9 / Reconstructive neck surgery Case 10 / Postoperative evisceration Case 11 / Gastrectomy Case 12 / Incorrect gastropexy Caso 13 / Septic enteritis due to intestinal dehiscence Case 14 / Ruptured vessel. Partial hepatic lobectomy
Case 15 / Herniorrhaphy with transposition of the gluteus superficialis muscle Case 16 / Retained foreign body in the thoracic cavity Case 17 / Resection of an abdominal mass
4. Errors in urinary tract surgery Case 18 / Perineal urethrostomy Case 19 / Antepubic entero-neourethrostomy Case 20 / Perineal urethrostomy Case 21 / Prolapse of the urethral mucosa
5. Errors in surgery of the reproductive system Case 22 / Ureter ligation Case 23 / Adhesions following an ovariohysterectomy Case 24 / Intestinal obstruction due to adhesions following an ovariohysterectomy Case 25 / Ovarian remnant and pyometra Case 26 / Evisceration due to incorrect use of plastic cable ties Case 27 / Haematoma following an orchiectomy and scrotectomy Case 28 / Cystotomy and removal of an ectopic testis
6. Errors in trauma surgery Case 29 / Fixation of a comminuted fracture of the radius and ulna Case 30 / Fixation of a fractured tibia and fibula Case 31 / Fixation of an open femoral fracture Case 32 / Femoral head and neck excision Case 33 / Osteosynthesis with bone grafting in a fracture of the tibia and fibula
7. Errors in ocular surgery Case 34 / Resection of a fibroma Case 35 / Caudal auricular axial pattern flap
8. Errors in oncological surgery Case 36 / Resection of a palpebral neoplasm Case 37 / Z–Plasty
References
Errors and complications in surgery Discovering and revealing errors Discovering errors Revealing errors allows us to learn from them. It is an opportunity to improve. This fact improves and increases the communication with the owners and allows them to participate for their pet’s benefit. On the contrary, not revealing mistakes can lead to greater physical harm that can compromise the patient’s safety and, above all, can violate the commitment to service that the veterinary surgeon offers the owner.
As mentioned previously, there is fear in revealing errors given the judgements clinicians face regarding their professional practice. However, recognising a medical error is a sign of professionalism and transparency when the clinician or surgeon takes it seriously. It means they put the patient’s needs first and assume their part of the responsibility, and thus, it should not reflect negatively on the clinician. In any case, veterinary surgeons must disassociate themselves from an adverse outcome if all available resources were employed without obtaining the expected success.
Therefore, when faced with a situation in which an error is detected in clinical practice, the problem must first be identified and defined. Once this stage has been accomplished, efficient and routine identification should become part of the daily practice; the staff must exhibit a creative mentality and collaborate in order to apply preventive measures in the future.
Recognising an error is an act of responsibility, not recognising or hiding it is much more serious than the actual error itself.
A study of behaviour in novice veterinary surgeons (Mellanby and Herrtage, 2004) When an accident occurs, accept responsibility, apologise, and convince the owners that the lessons learned will reduce the likelihood of repeating the error.
When faced with the error, different attitudes may be adopted. Some are detailed below:
4
The reality in veterinary medicine is not as accurate as the reality reflected in periodic surveys conducted in human medicine. A study done with recent graduates in the United Kingdom showed that: ■
78 % reported having made an error that resulted in a negative consequence.
Hiding the error.
■
83 % of them worked with limited or no supervision.
■
Living with the error.
■
■
Searching for culprits.
Approximately 40 % did not discuss or inform the owner of the pet about the mistake.
■
Evading responsibility and blaming others.
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Facing the error and resolving it.
■
Asking forgiveness and making up for it.
■
Denying the error (egocentrism).
■
New veterinary clinicians have a very high risk of making mistakes as a result of failed team work, especially due to the lack of supervision by experienced staff.
Recognising it
Opportunity for improvement
■
Describing what happened.
■
It enables us to learn.
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It must be done directly and immediately.
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It is an opportunity to improve.
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Recognising the damage and apologising.
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Offering help.
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Explaining what will be and how it will be avoided in the future.
■
Indicative of honesty.
■
Transparency.
■
Putting the needs of the patient first.
■
Recognising the owner’s right to be informed.
Error
Hiding it
■
Fear of consequences.
■
Ignorance of the obligation to inform.
■
Not knowing how to do it.
■
Not “bothering” the owner.
Professionalism
Figure 1. When faced with an error, the professional may behave in different ways. The results obtained will depend on this.
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General information / Definition of error A study of behaviour in novice veterinary surgeons
Definition of malpractice
70
In order to get a clear understanding of the different behaviours associated with the incorrect (whether voluntary or not) practice of human or veterinary medicine, it is necessary to define the following terms:
60
■
Incompetence is the lack of competence or ability (skill or special aptitude) that highlights the technical incapacity to practice the profession due to ignorance, to an error in judgement (misdiagnosis), or to a poor execution of the action (by inability or clumsiness). This usually happens during different procedures, either surgical or others, that require certain training or preparation in order to be successful.
■
Recklessness is the exposure to a risk without having taken the proper precautions to prevent it and an unnecessarily hasty manner, without stopping to think of the consequences that might result from that action.
■
Negligence is the result of improper medical conduct, either through carelessness or a lack of foresight, while having the necessary knowledge. Damage is not caused intentionally, but the necessary precautions are also not taken. Of all of them, this is the most serious one, since the veterinary surgeons subject themselves to injuring a patient, just out of carelessness.
80
50 40 30 20 10 0 Veterinary surgeons having made an error during their first year of practice Veterinary surgeons who informed the owners
Definition of iatrogenesis Extrapolating from human medicine, iatrogenesis is a health condition or harm caused by the veterinary clinician, the therapeutic treatments, or the medications, which is always involuntary and causes a complication of the treatment.
There must always be room for discrepancy, since veterinary medicine is not an exact science (two plus two are not necessarily equal to four), because biological patterns vary by the minute. This has an impact on the veterinary surgeon’s decision making process regarding the diagnosis, prescription, and the treatment.
In light of the above, iatrogenesis may be caused by: ■
A medical error.
■
A misdiagnosis.
■
Medical negligence or inadequate procedures.
■
Mistakes when writing the prescription or a prescription that is difficult to understand.
■
An interaction between the prescribed medicines, or their negative or adverse effects.
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An excessive use of medication that leads to antimicrobial resistance.
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A hospital-acquired infection.
There is a distinction between the following behaviours and others that may take place in the consultation or operating room, and that are not considered iatrogenesis: ■
An unforeseen circumstance.
■
Malpractice.
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Pain.
■
Unethical medical experimentation.
■
The consequences of noncompliance or failure to administer the treatment by the person in charge.
Iatrogenesis is often used as a synonym of malpractice, although the latter refers only to harm arising from deficiencies in therapeutic procedures.
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■
■
Malpractice corresponds to the suffering resulting from the misconduct of veterinary professionals failing in their duty to do what is right, when an inexcusable error occurs due to neglect or lack of expertise. It is a specific offence under the penal codes of every country. The more socially advanced and developed countries also have penal codes that legislate animal welfare.
5
Unforeseen circumstance. An unforeseen circumstance is any event that could not have been foreseen, or that, although expected, was unavoidable.
Medical errors differ from malpractice in the sense that the former are considered honest mistakes or accidents, while the latter are the result of negligence, reprehensible ignorance, or criminal intent.
How then to define error? In the opinion of different specialists, it can be defined as an unintentional act, either by an action or omission, that is deemed inappropriate for the expected effect or result. There is a tendency to assume that error and iatrogenesis are synonymous; however, it is not the case, since most errors do not cause harm or damage, which is the main element that defines iatrogenesis. Nonetheless, we must bear in mind that a high percentage of iatrogenic manoeuvres derive from an error.
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Errors and complications in surgery a
b
Fig. 10. Correct alignment and functional support of the limb.
Analysis of the case Error or surgical complication?
38
The circular band between the metatarsals and phalanges separated the necrotic area from the “vital” area. This, together with the fact that the process had begun 48 hours after the end of the ovariohysterectomy, led the clinicians and surgeons to conclude that the necrotic process was due to excessive tension applied to the ropes that had secured the limbs during the operation, which had also lasted longer than expected. Such a simple mistake as tying the ropes used to secure the limbs for the ovariohysterectomy too tight determined the loss of the left paw in this case. If not properly treated, the complication may have led to the amputation of the limb.
Tying the rope used to secure a limb too tight is a possible cause of ischaemia that may lead to tissue necrosis.
Correct technique For patient immobilisation not to cause injury, the correct technique would be a double loop, as shown in Figure 11. In this case, a small error led to an almost two-month long traumatic postoperative period for both the patient and the owner, with irreversible physical consequences for the patient. The surgeon, as the head of the team, working on it and directing it, is responsible for monitoring all peri-, intra-, and postoperative situations. He or she must take into account even the smallest details. The surgical procedure does not end when placing the last suture or closing the dial of the vaporiser, but when the last suture is taken out after carefully checking all aspects of the postoperative care and when the patient is finally discharged.
Every detail of the procedure should be carefully reviewed, especially at the end, when tensions have eased, so that no insignificant details remain neglected and do not result in situations with serious consequences. The use of an Elizabethan collar is an essential element to prevent self-mutilation.
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Perioperative errors / Incorrectly secured limbs a
b
c
d
e
f
Fig. 11. Procedure to tie the knot to immobilise the patient’s limbs (a–e). Final result (f).
a
b
c 39
Fig. 12. Immobilisation with a running loop through a plastic seal (arrow). The use of this element is an alternative to the use of the noose.
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Errors and complications in surgery
Case 18 / Perineal urethrostomy
Rodolfo Brühl Day, Paul Meyer, Maria Elena Martinez
Prevalence Technical difficulty
■
■
Name Species Breed
Noirette feline Persian
Sex
castrated male
Age
7 years old
Clinical history
Clinical procedure
The patient was referred by a veterinary nephro-urologist following a consultation in which the animal showed difficulty in urinating (Fig. 1).
Given the severity of the case, a new operation was performed to try to correct the urethral stenosis (Fig. 2).
Noirette had been operated on two months earlier. A perineal urethrostomy had been performed, which had caused a stenosis of the new opening or stoma 15 days after surgery. Another operation had given the same result (a new stenosis). 120
Signalment
Error: Not knowing the correct technique for perineal urethrostomy in the cat. Consequences of the error: Stenosis of the urethrostomy.
The surgeon who had performed both operations argued that it was due to the presence of large amounts of grit obstructing the opening of the urethrostomy. He had prescribed a diet to control the renal disease; however, he had not requested a physicochemical analysis of the urine or sediment or a urine culture.
Fig. 1. Noirette at her arrival at the clinic.
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The decision to operate again was based on the presence of a larger distance between the anus and the stoma than normal when the perineal urethrostomy is performed with the correct technique. The patient was placed in sternal recumbency with the hindlimbs hanging from the operating table and the tail raised. In such procedures, the anus should be temporarily closed using a purse-string or tobacco-pouch suture. An elliptical incision was made around the small remaining stoma (Fig. 3). The tissues around the stoma were bluntly dissected in search of the penis (Fig. 4). When found, the dissection continued in a dorsal direction.
Fig. 2. The patient’s stoma before surgery.
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Urinary tract / Perineal urethrostomy At this point, the skin incision was extended in a dorsal direction to perform the regular technique. The previously practiced urethrostomy had been performed at the end of the penis, which explained the origin of the stenosis of the urethral opening (Fig. 5). As the skin is dissected in a dorsal direction and the penis is freed, the remaining skin in the dissected area should be held with a Babcock clamp without taking hold of the mucosa in order to move the penis laterally and gain access to the ischiocavernosus muscles (Fig. 6). Examination of the area revealed that neither the left nor the right ischiocavernosus muscles had been incised (Fig. 7). This was therefore done at their insertion close to the ischium to reduce bleeding (Fig. 8). This bleeding, while it does not endanger the patient’s life, can hinder exposure of the surgical site needed to continue with the procedure.
Fig. 3. Diamond-shaped incision around the stenosis.
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Fig. 4. Dissection of the scarred area.
Fig. 5. Extending the skin incision in a dorsal direction helps the surgeon achieve the
correct technique.
Fig. 6. Using a Babcock clamp enables the surgeon to displace the penis and,
Fig. 7. The left ischiocavernosus muscle (arrow) and the right ischiocavernosus
therefore, to gain access to the ischiocavernosus muscles.
muscle had not been incised in the previous procedure.
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Errors and complications in surgery The best way to minimise bleeding when separating the ischiocavernosus muscles from their origin is to elevate them off the bone by sliding the scalpel blade against the ischial arch.
Note the length of penis cranial to the previous urethrostomy site in Figure 8. Technically, the dissection should reach the bulbourethral glands, where the diameter of the urethra widens. The ventral adhesions of the penis to the ischium were then released to mobilise the penis in a more caudal position (Fig. 9). The urethra was incised lengthwise from the caudal end of the penis. In this case, the retractor penis muscle was not found. Figure 10 shows the borders of the incised urethra. The incision was made until an adequate diameter of the urethra was confirmed by introducing closed curved Halsted mosquito forceps, which should be able to enter up to the hinge without difficulty.
This indicates that the diameter of the urethra is acceptable to proceed with its suture and with the creation of the new stoma (Fig. 11). Suturing began with the placement of simple sutures using 4-0 or 5-0 monofilament nylon. The first three sutures were placed at 11,12, and 1 o’clock using the clock-face analogy (Fig. 12). The mucocutaneous suture should always be placed from the urethral mucosa towards the skin to ensure a proper opening of the urethra. Interrupted sutures were placed on either side of the urethra to create a drainboard. After the procedure, the exposed urethral mucosa suffers metaplasia and eventually becomes a more resistant epithelium. The end of the penis was amputated and sutured using a cruciate suture to prevent bleeding. After this, the rest of the skin was sutured. At the end of the operation, the drainboard should have a length of at least 1.5–2 cm (Fig. 13).
122
Fig. 8. The ischiocavernosus muscles are separated from their insertion.
Fig. 9. The penis can be moved in a more caudal position by releasing the ventral
adhesions of the penis to the ischium.
Fig. 10. Note the borders of the sectioned urethra (arrows).
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Fig. 11. An acceptable diameter of the urethra to start suturing and creating the new stoma is confirmed by introducing curved Halsted mosquito forceps up to the hinge.
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Urinary tract / Perineal urethrostomy Bulbourethral glands
Sutures at 11, 12, and 1 o’clock
B
A A B
Sectioned ischiocavernosus muscle
Urethral drain board
Fig. 12. The first three sutures are placed at 11, 12 and 1 o'clock according to the clock-face analogy. The site where the penis should be sectioned after creating a drainboard of an appropriate length is also shown.
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Fig. 13. Suture of the perineal urethrostomy.
Finally, patency of the urethral opening was checked before waking up the patient (Fig. 14).
Do not forget to remove the anal purse-string or tobaccopouch suture.
Fig. 14. Halsted mosquito forceps are passed through the urethral lumen once again before waking up the patient.
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Errors and complications in surgery
Case 36 / Resection of a palpebral neoplasm
José Rodríguez, Ángel Ortillés, Carolina Serrano, Rodolfo Brühl Day
Prevalence Technical difficulty
■
■
Error: Attributing the discomfort of the initial procedure to postoperative inflammation. The consequence of the error: Ocular pain. Corneal lesion. Ocular perforation.
Signalment Name Species Breed
Otto canine Schnauzer
Sex
male
Age
6 years old
Clinical history Otto was brought to the clinic seven days after undergoing surgery due to a neoplasm on the lower eyelid of his right eye. He had begun to show ocular discomfort and pain on the day after the operation and his problems had been initially attributed to postoperative inflammation of the eyelids. The patient was referred since he was not responding to the medical treatment and had intense blepharospasm and lacrimal hypersecretion (Fig. 1). 216
Clinical procedure Anaesthetic eye drops were used so the ocular surface could be examined more easily. The lower palpebral conjunctiva was slightly congestive and a large defect that stained with fluorescein was visible in the ventral and central part of the cornea (Fig. 2). Since the corneal defect was likely to be a consequence of the palpebral surgery, the inner aspect of the eyelid was closely inspected. A suture thread that was causing damage to the cornea was identified in the lower part of the eyelid (Fig. 3). In this case, it was only necessary to remove all the sutures and ensure there was no suture material left on the inside of the eyelid (Fig. 4).
Fig. 1. The patient had severe pain in the right eye.
Fig. 2. The examination of the eye’s surface reveals a
Fig. 3. A portion of suture thread that rubs the cornea
Fig. 4. The knots are cut and the suture threads are
large defect in the centroventral region of the cornea.
is located in the lower part of the eyelid.
removed with special care, especially those placed on the inside of the eyelid. One of the threads is in direct contact with the cornea.
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Monofilament suture material from the previous operation is observed during the external examination of the eyelid (arrow).
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Oncology / Resection of a palpebral neoplasm
The solution to the problem was simple since the corneal lesion was not deep. Once the suture thread was removed, the cornea healed quickly with a medical treatment consisting of: ■
Chloramphenicol eye drops, 1 drop every 8 hours.
■
Artificial tears, 1 drop as frequently as possible.
■
Cycloplegic eye drops, 1 drop every 12 hours.
The problem was solved by removing the suture material that was rubbing against the cornea and the patient responded well to the medical treatment. The corneal lesion healed in 10 days (Fig. 5). In this case there were no serious consequences, but in similar cases the corneal lesion may become deeper and lead to the formation of a descemetocoele. There may even be perforation of the eye, which requires complex reconstructive surgery of the cornea.
Analysis of the case Error or surgical complication? Otto’s corneal lesion was due to an error when suturing the lower eyelid after removing the neoplasm. Eyelid sutures should include the tarsal membrane, but never the conjunctiva to avoid contact between the suture material and the cornea. If the suture thread is passed through the conjunctiva, the friction against the cornea can cause pain and lead to important lesions including ocular perforation (Figs. 6 and 7).
Correct technique For a palpebral suture to be stable, it should include the tarsal membrane, which is a part of the conjunctiva. However, we should make every endeavour to avoid passing the suture thread through the conjunctiva. If this occurs, the suture material will come into contact with the surface of the eye, which can lead to very severe corneal lesions.
The resection of palpebral neoplasms is a common surgical procedure in small animal practice. In general, very good results are obtained because the eyelids have a rich blood supply, which allows the wound to heal quickly and with a minimal incidence of infection.
Watch this video Palpebral neoplasm. Resection with an electrosurgical pen
Fig. 5. Ten days later fluorescein staining was negative, and dexamethasone eye
drops were given in order to minimise scarring (1 drop/8 hours for 2 weeks).
Fig. 6. A surgical procedure on the nictitating membrane had been performed on this
Fig. 7. A sliding conjunctival flap from the upper part was performed in order to treat
patient. One of the suture threads was in contact with the cornea (blue arrow) and produced a descemetocoele (yellow arrow).
the corneal lesion.
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Errors and complications in surgery Free edge of the eyelid
Ocular side
A figure-8 suture is the most suitable type of suture for closing wounds that involve the eyelid margin as it achieves good apposition of the free margin of the eyelid.
Palpebral openings of the meibomian glands
Cutaneous side Fig. 8. Correct technique to suture the eyelid margin.
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Fig. 9. Figure-8 suture to close the eyelid margin.
Fig. 10. The figure-8 suture achieves good apposition of the free margin of the eyelid.
Fig. 11. Final appearance of the wound.
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The publishing strength of Grupo AsĂs Editorial Servet, a division of Grupo AsĂs, has become one of the reference publishing companies in the veterinary sector worldwide. More than 15 years of experience in the publishing of contents about veterinary medicine guarantees the quality of its work. With a wide national and international distribution, the books in its catalogue are present in many different countries and have been translated into nine languages to date: English, French, Portuguese, German, Italian, Turkish, Japanese, Russian and Chinese. Its identifying characteristic is a large multidisciplinary team formed by doctors and graduates in Veterinary Medicine and Fine Arts, and specialised designers with a great knowledge of the sector in which they work. Every book is subject to thorough technical and linguistic reviews and analyses, which allow the creation of works with a unique design and excellent contents. Servet works with the most renowned national and international authors to include the topics most demanded by veterinary surgeons in its catalogue. In addition to its own works, Servet also prepares books for companies and the main multinational companies in the sector are among its clients.
Servet (División de Grupo Asís Biomedia S.L.) Centro Empresarial El Trovador, planta 8, oficina I Plaza Antonio Beltrán Martínez, 1 • 50002 Zaragoza (España) Tel.: +34 976 461 480 • Fax: +34 976 423 000 • www.grupoasis.com