Tension pneumoperitoneum due to spontaneous gastric perforation in cat

MetodievStoyanovBorislav Metodiev, DVM       Yavor Stoyanov, DVM

Bomed Veternary Clinic, Sofia

Pneumoperitoneum refers to accumulation of gas within abdominal cavity, resulting from a perforated hollow viscus, penetrating wounds or bacterial peritonitis. Emergency condition of massive pneumoperitoneum compromise cardiorespiratory function, known as pneumoperitoneum, has been reported in humans. In veterinary medicine, there are also a few similar cases.

This study reports a case of a cat that developed tension pneumoperitoneum secondary to gastric perforation. The cat was treated with emergency abdominocentesis, followed by laparotomy.Pneumoperitoneum

A 10 years old British shorthair spayed female cat Tara (2.8 kg) was presented with a remarkable abdominal distention. Three months ago, the cat was operated because of suspected alimentary lymphoma. A part of small intestine and caecum was removed. Histology confirmed large cell lymphoma. Tara was started on chlorambucil and prednisolone protocol. Regular control examinations showed only decreased appetite and one or two times weekly vomiting. The last examination was two days before pneumoperitoneum, and ultrasonography was unremarkable.

At the time of admission, the cat was in good condition except respiratory distress, with huge ballooned, tympanic abdomen. Abdominal US showed only gas. Emergency needle abdominocentesis was performed, and about 300 ml air was aspirated. Than was performed X-ray. The abdominal radiograph showed distended by air abdominal wall, compressed viscus, displaced to thoracic cavity diaphragm. There was no evidence for free fluid in abdominal cavity. Subcutaneously was small amount of air, leaked after the needle aspiration. Second abdominocentesis was performed, and about 400 ml air was aspirated. The aspirated gas had no odor or admixtures.

On the next day, the cat was rehydrated, and a laparotomy was performed. Mild peritonitis was found with a small almond of yellowish ascites. The small intestines were empty, in the large intestines there were some faeces. The site of previously enter anastomosis was perfect. There was no evidence of leaking from the gut or any visible evidence of recurrence of lymphoma. A 6-8 mm perforation was found at the gastric fundus. The stomach, liver margin and omentum were mildly adhered. Other portions of stomach wall looked visually and palpably normal. After blunt dissection of the adhered liver and omentum, the gastric perforation was closed with interrupted sutures. Materials from stomach wall for cytology and from free fluid for microbiology were taken. Abdominal cavity was flushed with 0.9% warm saline and closed in a routine manner. Cytology did not show atypical cells, or any suspect for alimentary lymphoma. Microbiology was unremarkable.

Reported common causes for pneumoperitoneum in small animals include abdominal surgery, gastrointestinal perforation and bacterial peritonitis. In cats pneumoperitoneum also has been reported as complication after endoscopic biopsy or gastrostomy tube replacement. Most of these cases have not shown severe abdominal distention, necessitating emergency decompression.

The exact cause of gastric perforation in this cat is unknown. We suspect local weakness of gastric wall due to iatrogenic factors. Chlorambucil or prednisolone, or combination of these two medicaments may cause damage of mucosa and weakness in the walls of GI tract.

Necessity of therapeutic emergency abdominocentesis due to spontaneous pneumoperitoneum in cats has been emphasized only in few previous reports.

 

Achieving primary closure on the proximal third of the tail after 4 cm mass removal in a dog

51559132_952390804967417_8511078558653743104_nFlorin Cristian Delureanu    

DVM, MRCVS

December 2019

Abstract

Defects located on the tail are challenging due to lack of skin. Second intention healing, skin grafts or random local flaps can be used as a treatment in this particular area. Primary closure can be used when small defects are present but risk of dehiscence and vascular compromise is very increased due to tension and tourniquet effect. In cats was described a perineal axial pattern flap used for covering a defect located on the proximal third of the tail. Also a “spiral closure technique” can be used to close small to medium size defects on the tail. The use of the advancement flap is usually the first choice in approaching the closure of defects if they can not be closed by undermining and suturing. This article illustrates the usage of advancement flap from the base of the tail for closing the surgical defect left after excision of a tumor located on the dorsal proximal third of the tail in a dog. No complications were noted after surgery and the tail maintained the normal function.

 

Case report

 

A 5 years old female neutered cross breed dog was admitted for assessment of a lump located on the tail. The owner was not sure for how long time the lump was in that place and how fast developed, was just recently observed on the tail.

On general examination no abnormalities were detected. A 4 cm mass was identified on the dorsal aspect of the mid proximal third of the tail. The mass had round shape, located under the skin and well attached to the coccygeus muscle. On palpation, local temperature was normal, elastic-firm consistency, without local pain. No other abnormalities were detected. Fine needle aspirate was recommended and performed before surgery.

Cytologic interpretation: marked pyogranulomatous inflammation, epithelial proliferation, neoplasia probable and evidence of mineralization.

 

 

 

Surgical approach and suture technique

 

Surgical site was aseptically prepared and the patient was placed on the table in ventral recumbency. Before starting the procedure, another evaluation of the mass in relation to the skin located on sacro-coccygeal area but also with the skin which surrounds the mass was done. Before incision, the skin mobility was checked. In physiological position a small skin fold was observed cranially to the lump (Fig.1).

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Figure 1. Preoperative appearance of the sacrococcygeal area after surgical site preparation. The tumor have a spheric shape, is located in the proximal third area of the tail-dorsal aspect and have a wide base of implantation. At the base of the tail a small fold can be observed

A circular incision was performed 3mm distance from the mass. No.10 scalpel blade was used to create the skin incision and the dissection until the muscle was done with Metzenbaum scissors.

 

A thin capsule that surrounds the mass was discovered at the junction between it and the coccygeal muscle. At that point the dissection was performed with the scalpel blade until the end. Care was taken to avoid the major vassels of the tail( Fig 2, Aand B)

Figure 2. Intraoperative view of the tail. (A) Right lateral side before tumor excision and (B) left lateral side after full excision hightlights the intact lateral coccygeal veins (yellow and black arrows).

 

 

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Fig 2

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Fig 2

 

 

 

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Figure 3. Transverse section at the level of caudal vertebrae illustrates distribution of the muscles

The tail movements are coordinated by 6 pairs of muscles (12 muscles in total) that are distributed concentrically over the coccygeal vertebrae (Fig.3).

 

 

 

The vascular supply of the tail is composed by 2 lateral caudal veins and arteries located

on lateral sides and the median caudal artery and vein. In this case both caudal lateral veins were preserved. Minimal bleeding was present and the small blood vassels were ligated with 3/0 PGA. Two parallel lines extended from the proximal border of

the defect to the base of the tail were  made in the skin deep to the muscle. Meticulous dissection of the skin was performed with Metzenbaum scissors until the fold located at the base of the tail. The flap was elevated and advanced distally to cover the defect

(Fig.4 A). The flap managed to cover ¾ of the defect without tension. Undermining of the skin  located on the distal border was attempted to obtain the mobility that can help to cover the ¼ of the defect but faild. To obtain the maximum coverage, walking sutures were used to further advance the flap. The first bite went deep into the dermis and the second bite in the tendinous portion of the m.  sacrocaudalis dorsalis  lateralis (sacrococcygeus dorsalis lateralis).Few walking sutures were placed so that the tension is equally distributed (Fig. 4B).

Figure 4. Undermining and elevation of the skin flap. (A) Stay sutured were placed on the flap corners (yellow arrows) to manipulate the skin; (B) Closer wiev of the first walking suture. First bite (blue arrow) is inserted deep in the dermis and the second bite is inserted in the tendons of m. sacrocaudalis dorsalis lateralis (black arrow).

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Fig 4

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Fig 4

 

 

 

 

 

 

 

 

 

 

 

 

Nor following this procedure the primary defect has not been fully covered. In the end, horizontal mattres pattern (“U” shape) was used on the edge of the flap and full coverage was achieved under moderate tension (Fig.5).

 

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Figure 5. Dorsal aspect of the tail after final closure

 

Usually after advancing a flap “dog      ears” will result at the base. In this particular    case minimal “dog ears” were present. For a    cosmetic appearance and to preserve the soft     tissue, central suture technique was performed     on the lateral sides of the skin flap due to crescent    shaped defect. There are many ways to close up a crescent shaped defect but in this particular case central suture technique was chosen to avoid “dog    ears” removal. First simple interrupted suture was placed     in the middle of the defect and after, another  sutures in the middle of the two defects obtained   and so on until complete closure.

 

The central closure technique distributes the “dog ears” all along the sutures line in small increments (Fig.6a, 6b). In the end, the final aspect of the tail in relaxing position was changed due to advancement flap. The tail gain a curved up position (Fig.6).

Figure 6. Central suture technique. (a) Left lateral view of the tail illustrates no “dog ear” present at the base of the flap due to suture technique. The black line show the curved shape of the tail after the final closure. (b) Illustration of closure of crescent shape defect1.

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Fig 6

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Fig 6

 

 

 

 

 

 

 

 

 

 

 

Postoperative care 

 

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Figure 7. Postoperative view after bandage application

For protection, a soft padded bandage was      used to cover the surgical site, this being made up of  square gauze applied on top, fixed in place with an elastic band; Stirrups were applied over the gauze and  extended proximally to the base of the tail and Vetrap  was used as a last layer (Fig.7).

 

The patient was sent home with booster collar to prevent self trauma and 3 days of robenacoxib, also in the surgery day a NSAID injection was administered with the same nonsteroidal anti-inflammatory drug. Until the first recheck (3 days post surgery) the bandage has fallen due to excessive tail movement in 24 hours but the owner apply another one at home; Four days after surgery the patient present for the first recheck, on inspection the tail was less curved in compare with the day the surgery was performed and no complications were present. The owner reports the patient was comfortable at home after surgery, and did not show any changes in behavior. The same bandage was applied in the same manner and this time did not slip until the second visit.                 The patient has presented for sutures removal in day 10 aftert surgery . No postoperative complications were present and the tail was less curved upwords. One last visit was 34 days after surgery. Due to the weight of the tail, continous tension was applied on the skin over time and the natural position was regain (the processes of mechanical creep and stress relaxation) (Fig.8). The owner reptorts the patient was comfortable in all this period and does not seem to be disturbed by surgery.

Figure 8. Ventral (A) and right lateral (B) aspect of the tail after sutures removal – 10 days post surgery; (C) Dorsal view of the tail 34 days after surgery.

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Fig 8

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Fig 8

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Fig 8

 

 

Histopthologic result and prognosis

 

The mass (Fig. 9) was put into a containter with formol and sent to the lab for histopathologic examination. Pilomatricoma partially ruptured and mineralized, associated with moderate granulomatous inflammation. This is a benign tumour of the hair follicle, slow growing, non-invasive, and generally rarely metastasizes (malignant variant exists but is rare). was the diagnosis and clear margins were achieved and the prognosis is was good. Poodles, Schnauzers and Kerry Blue and Bedlington terriers may be predisposed.

 

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Treatment of massive brain compression in two dogs

1575875879547blobDr. Vladislav Zlatinov

Central Vet Clinic

Sofia, Bulgaria

 

Introduction

 

This is case series of two dogs with similar advanced brain compression. The aetiology was different, but in both cases there was gradual epidural compression, indeed allowing survival of the patients. The final size of the brain compression lesions in both dogs was impressive and was related to the delayed diagnostic process. Both dogs were successfully treated and followed in next few months post op. Different surgical approaches and techniques were applied, according to the specific needs.

These cases present interest because such large lesions are rarely met in practice, and may be considered untreatable by some veterinary clinicians.

 

 

Case 1

 

Referring Vet: Dr. Evgeni Evtimov

Corresponding authors Dr. Aglika Jordanova (Clinical pathology), Dr. Vladislav Zlatinov (Surgery),Dr Nikola Penchev( Anesthesia)

 

 

Felix, a 7 months old Collie dog was presented for treatment of progressively deteriorating central nervous system dysfunction.

 

The male puppy lives in an apartment; vaccinations and deworming are current, fed on regular dry food diet. Had been with his owner for a month, came from a breeder.

 

The clinical signs had started 3 weeks ago, with unclear manifestation- decreased appetite, lethargy, intermittent fever, unstable walk. The overall body condition of the patient had been appreciated as underdeveloped, and the owner reported the dog is not growing.

Felix had been initially consulted by the referring vet, who had started primary diagnostic and treatment steps. Biochemistry profile, CBC and vector diseases fast serology tests had been done- being normal/ negative, not revealing the specific cause of the condition. Symptomatic antibiotic treatment had been started, without significant improvement. NSAIDs resulted in temporary alleviation of the symptoms – body temperature back to normal, the dog was brighter.

At this point the dog was referred to us to investigate the possible cause of the condition, suspected to be endocrinological.

The dog was found to be lethargic, walking with head positioned low, no pain during head lifting, does not resist opening the jaws, wobbly gait, with normal proprioception of all 4 limbs. body temp.39.0C. The CBC was WNL. Total T4 was normal (16nmol/l). Radiography of limbs and vertebrae showed normal physeal growth for the dog’s age; thus excluding congenital hypothyroidism.

 

Cerebrospinal fluid collection and computer tomography study of the head were suggested, as the symptoms were assessed as central neurological. During the period of owner contemplation, trial course with corticosteroids had been applied. Short-term clinical improvement had been noticed, followed by further decline in the dog’s condition. A bulge on the left side of the head became visible.  After gradual progression of neurological symptoms- dull behaviour, mild head tilt, inactivity, the dog deteriorated profoundly to the status of stupor- severely depressed mental status, barely reacting to stimuli.

 

CT study of the head was performed 14 days after the initial examination at Central Veterinary Clinic (with no anaesthesia needed), revealing dramatic findings. Extensively grown soft tissue “mass” (vs thick fluid accumulation) was found over and under (extra and intracranially) the left parietal and occipital skull calvaria. The outside lesion was more heterogeneous, lobular like, under the temporal fascia. The internal part was homogenous, with clear fluid density, well encapsulated, caudally extending over cerebellar tentorium. It was causing a significant mass effect with compression of the left parietal and occipital cerebellar brain lobes. Dramatic lateral ventricular compression and a falx shift to the right was present.The skull bone in the area was hypertrophied, with aggressive periosteal reaction, mostly extra- cranially. In the cranial left parietal bone, a small concave defect was noticed on 3d reconstruction images.

Fine needle aspiration was done puncturing the extra cranial lesion area. Pus-like  fluid was obtained, cytologically tested, confirming suppurative process.

 

All these findings suggested the main differential diagnosis- massive epidural empyema (abscess), compressing the brain parenchyma and causing profound neurological deficit. The probable cause was bite wound on the head (<=concave defect on the parietal bone).

 

Surgical decompression was suggested and accomplished as an urgent procedure because of the fast deterioration of the patient.

 

Lateral approach to the skull was applied. An abscess cavity with intensively neo-vascularised capsule was found, just under the temporal fascia, Topographically it was within the temporal muscle tissue. After partial capsule resection and copious lavage, the soft tissues were undermined and reflected to expose the lateral (parietal) skull area. Next, rectangular  rostrotentorial craniectomy was accomplished using maxilo-facial mini oscillating saw. Skull sutures and the concave defect (bite area?) were used as reference landmarks to orientate the cuts. The skull bone in the area had reached 1 cm thickness. A fluid filled epidural (over dura mater) cavity was found. It was filled by thick bright yellow purulent fluid. After microbiology and pathohistology sampling, the pus was aspirated and the residual cavity copiously lavaged. Prompt haemostasis was applied, with minimum haemostatic materials left in place.

A fenestrated drain tube was inserted into the empyema  cavity and under the soft tissues. The temporal fascia and the skin were closed routinely over the defect. The drain tube was connected to active vacuum suction system.

Intense post op care was applied in the next 12 hours- blood pressure monitoring and correction with vasopressors, fluid infusion, pain control, i.v. antibiotic therapy. The patient started to improve slowly but steadily- the mental status improved within 24 hours, and the dog was able to stand up on the second day after the surgery. On the fourth day it was stable enough to be discharged from the clinic (still with the active vacuum drainage). The last was removed on the 7th day.  Ultrasound examination rechecks was done on the 10th and 14th days, excluding new fluid accumulation.

 

The microbiology culture test result was negative, but no anaerobic isolation media was available. Just in case of not detected anaerobic infection- 3 weeks course with Clindamycin was prescribed.

The pathology report confirmed the the diagnosis of pyo-granulomatous inflammation with no neoplastic tissue present.

 

Eventually, Felix did full recovery with no infection relapses within the follow up period of 4 months.

 

Case 2

 

Referring Vet: Dr. Milena Pancheva

 

Dr. Vladislav Zlatinov (Surgery), Dr. Antoan Georgiev (Anaesthesia).

 

 

 

Beki, 4 years old female Dalmatian was referred for consultation, regarding the possible treatment  of a huge intra-cranial mass.

The dog had a long history of slowly progressing vestibular signs and eventually obvious ataxic walking  Unfortunately the owners had ignored the problem for several months (> 7 m), because of the mild clinical presentation in the beginning and the good overall condition of the patient. Recently the dog deteriorated- difficult to keep balance during walking and eating. Two seizures  and nocturnal hyper excitement activities were also demonstrated.The dog had already computer tomography study of the head, revealing huge cranial mass. An opinion about euthanasia was already suggested to the owners. Empirical therapy with steroids and antibiotics was already applied before the achievement of the correct diagnosis.

 

During our neurological examination we found: normal mental status and vision, normal cranial and limb segmental reflexes; the menace response reflexes were decreased; body posture revealed broad-based stance. The patient demonstrated obvious ataxia. It was defined as cerebellar one, presented by hypermetria and  swaying, mild intentional head tremors.

We analysed the CT study and found: large hyper-dense oval mass, starting from the region of the occipital bone and engaging the cerebellar tentorium. The mass was protruding extensively into the brain cavity, eccentrically to the right side. Bone lysis and infiltration was evident in the right occipital nuchal area and also cranial to the right nuchal crest. Severe cerebellar compression in cranio-ventral direction was evident. Less severe compression of the occipital cerebral lobes (without lateral vetntricular displacement) was also found.

Despite the large size of the mass, we suggested moderate malignancy of the lesion- smooth, encapsulated margins, homogenous density. Bone neoplasia (osteosarcoma and multilobular osteochondrosarcoma) or meningioma were the most probable diagnosis. Slow progression of mass, made the osteosarcoma less probable. The bone involvement is not typical for meningiomas. Multilobular tumors usually has similar imaging features as presented in the case. Their excision offer good opportunity for long-term tumor control, so a surgical decompression and mass removal was suggested and accomplished in Beki’s case.

 

We approached the skull caudo- laterally, undermining and retracting the overlaying temporal fascia and neck muscles. The tumor mass was found protruding from the bone through osteolysed right occipital and parietal bones.  Using speed burr we created large combined occipital and caudal-lateral craniotomy. Excessive bleeding from the right transverse sinus was anticipated but fortunately not found, because of possible gradual vein obliteration. Despite this, during gradual enlargement of the craniotomy, special precautions was taken not damage the ipsilateral left one.

After exposure the cranium, we attempted to determine the mass borders. The tumor was originating from the cranium bone not invading (just compressing) the nervous tissue. Because of the huge size, en block resection was far from possible, so slow “debulking” mass removal was started.  The brain meninga (dura mater) was not affected by the neoplasia, so tissue direction was amenable.

 

Diffuse, moderate but constant bleeding was met through the whole process of removal small partial tumour masses. Haemostatisis was achieved using Cellulose blood clot inducing products (Surgicel mesh) and intermittent gentle compression. Copious lavage was applied during the whole surgery.

 

To complete the mass removal was a laborious procedure, taking itself about an hour. Finally, immediately  after the decompression a visible brain tissue re-expansion was noticed. After prompt haemostatis (using bone wax and Surgicel materials), the residual craniotomy defect was covered with apposition of the soft tissues over it.

 

In the next 24 h post op period, the dog was was given opioid analgesia, anti-inflammatory doses of steroids and anti oedematous osmotic agent (Manitol).

Indeed, Beki started to recover surprisingly fast- eating on the 12 h post op (on the video). For about 48 h she showed exaggerated ataxia, with difficulties in walking, but the coordination started to improve fast. The patient was discharged from the clinic on the third day pos op, walking reasonably well. Harness supported leash walks were recommended.

No physiotherapy was applied in the recovery time, because the patient coordination improved to normal on the 10th days pos surgery.

 

Patohystology evaluation of the tumor was done. The results was Multi lobular bone tumor. This is a low malignant, well differentiated neoplasia. In short term it can be controlled successfully by surgical resection. Slow reoccurrence could be expected, also long term metaplasia to more aggressive osteosarcoma.

 

Recheck of the patient revealed condition undistinguishable from normal. The follow up period till now is 3 months.

 

 

 

 

Persistent right aortic arch

Presentation1Tsvetan Ivanov, Dimitar Ivanov, Vladi Kirilov – veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

 

  1. Introduction:

The persistent right aortic arch (PRAA) is vascular ring which is formed by the aortic arch on the right side, with ligamentum arteriosum dorsolaterally, and pulmonary artery on the left and ventrally. This ring compresses the esophagus and trachea, which leads to swallowing difficulty. This malformation is with genetic prevalence and represents  error in embryogenesis of the dog. In 95% of the cases of this vascular ring anomaly, a constricting band prevents solid foods from passing to the stomach which prevents the puppy from thriving well.  In the remaining 5% of cases, a bizarre anomaly of the vessels is present (double aortic arch and aberrant subclavian artery), which may be difficult to correct and may not have a good prognosis.pic 1

 

 

 

 

 

 

Signs of this condition usually become apparent shortly after weaning, when a puppy begins eating semi-solid or solid food.  While milk will slide down nicely, bulky foods will “jam up” in the esophagus, leading to a stretched structure and the inability to get food down, hence the symptom known as regurgitation. Regurgitation involves the puppy producing undigested food and mucus through the mouth with no effort; the pup tilts its head down and the food and mucus simply roll out.  By contrastvomiting is an active process, meaning there are abdominal contractions (heaving) and a retching noise when food and mucus are expelled out the mouth.

Often complication of the regurgitation is aspiration pneumonia (AP), which leads to poor prognosis for the patient.

The standart therapy is surgical and is with good prognosis if there is no signs of AP. Before the surgery CBC and blood chemistry is required – WBC is important to rule out infection and the level of blood sugar should be in the reference values. The surgery can be open thoracotomy or thoracoscopy – the goal is to ligate and resect the fibrous annulus.

 

  1. Patient report

The patient is 2 months old german shepherd dog with history of vomiting after eating, according to the owners, but there is no problems with water drinking. The dog have diarrhea but is in good overall condition. When the dog sleeps there is strange noises from his neck and there is visible peristaltic waves in the level of 1-st rib.

We perform CPV/CCV/Giardia and the result was negative. The CBC and blood chemistry shows no difference from the reference values.

pic 2

pic 2

Then we made x-ray of the chest: pic 2

 

 

 

 

 

 

 

 

Because of the typical sign of the chest, we performed and BaSO4 examination, and this was the result:pic 3

pic 3

pic 3

So our diagnosis is PRAA with no signs of AP. We performed surgery on the next day – it was open thoracotomy with ligation of the annulus.

Differentiation of the fibrous ring:

pic 4 pic 5 pic 6

 

 

 

 

 

 

 

 

 

 

 

 

It’s was administrated antibiotics, pain killers, sedatives and assisted feeding. We didn’t use thoracic tube after the surgery.

On the fourth day after the surgery, the dog was discharged. Three months after the surgery the owners still make assisted feeding, but the dog is not vomiting and is in good condition.

Wound management part 2: The approach of traumatic wounds

 

 

51559132_952390804967417_8511078558653743104_nFlorin Delureanu

DVM, MRCVS

March 2017

 

Introduction

From a general point of wiev, a traumatic injury is defined as a physical damage caused by an external factor. Even if we talk about a road traffic accident, a burn or projectile injuries, all of them represents a trauma for the body. Because the first part of this series described the physiologic process of healing and how can wounds be recognized according to the phase in which they are, the second part will highlight how wounds can be addressed.

Initial assessment of the patient

Due to various types of trauma, the patient should be treated according to the requirements. The patient can be unstable after a road traffic accident, after a fighting with another dog or can be bright, alert if superficial lesions are present (patients that develop wounds due to scratching). If the patient is not stable the plan must be focused first on stabilization by checking the major function (A- airway, B- breathing, C-cardiovascular, etc) followed by a good pain control and assess the life-threatening injuries. In an emergency situations is recommended to cover the wounds with sterile gauze or another type of sterile material to provide haemostasis and to protect against another contaminants that are considered already present in the wound.

Evaluation of the wound

When the patient became comfortable, a wound evaluation must be performed. There are some factors that can help the surgeon to take a decision regarding the local management. Therefore, the following should be considered:

  • the degree of contamination;
  • when the injury took place;
  • the degree of tissue ischaemia;
  • the amount of tissue loss;
  • type of wound (burn, snake bite, etc).

About the length of time between the production of the trauma and the presentation of the patient to the clinic and the degree of contamination, wounds are classified as clean, clean-contaminated, contaminated and infected (see details in part1).               Because every injury has as a result blood loss, the tissue exposed may have different aspect and can help with the prognosis. The first aspect of the wound may be misinterpreted due to colour and integrity of the surrounding tissues. Many times the skin is crushed due to a powerfull trauma and just small superficial wounds may be present. If at first presentation the skin looks normal and the small wounds have a clean aspect and the trauma happend in less than 4-6 hours not every time will be a good ideea to do a primary closure. Some wounds may have good viability but because the tissues are crushed can develop necrosis and some wounds may have an ischaemic aspect but if the surrounding tissues are not traumatised the evolution can be favorable. As a conclusion, not every time a primary closure will be a wright decision, sometimes wounds need 2-4 days to “settle” depending of the type of trauma.                The amount of tissue loss will guide the surgeon to use specific dressings according to depth and length if second intention healing will be elected.               Regarding wound type, some specific considerations must be taken. For example, bite wounds should be explored whereas for an early frostbite wound the patient must be rewarmed first.

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Fig1. Basic wound management in six simple steps (Atlas of Small Animal Wound Management and Reconstructive Surgery, 4th Edition Michael M. Pavletic, April 2018

As an approach, wounds can be managed by closure (primary closure, delay primary closure, secondary closure already described in part 1) or can be left for second intention healing.

Second intention healing occurs when a wound is left to heal by contraction and epithelialization. All wounds can be left to heal by second intention but this process may fail at a point or may end without providing a functional outcome. There are some reasons why not every time a complete healing by second intention (especially large wounds and in high motion area-joints, axillary, inguinal) is not recommended: the granulation tissue is very fragile and easly abraded; wound contraction, sometimes excessive, may impede normal function.

Some wounds may fail to completely reepithelialize. Open wound management is indicated in dirty, traumatized, contaminated wounds in which cleansing and debridement is necessary.

Wound preparation – cleansing

To prevent further contamination of the wound in the time of cleaning, all equipement must be sterile. Prior to application of topical treatments, the wound bed must be properly prepared. Initially the wound must be protected with a sterile lubricant (eg. K-Y sterile gel) or sterile gauze soaked in warm saline. After protection, the hair that surrounds the wound must be clipped. The hair represent one of the main foreign body that can imped wound healing in a clean wound. Next, lavage the wound with a proper solution under 7-8 psi to remove the surface contaminants and in the end dry the skin surrounding the wound. This may facilitate the adhesion of the dressing and also will prevent maceration of the skin if the wound is highly exudative.

  • Wound lavage: many lavage solutions are availabile. Most popular are
fig 2

Fig.2 Basic kit for wound lavage composed by seringe, 3 way-stop cock, 18G needle, intravenous tube and 500ml bag of sterile saline.

clorhexidine, betadine, Ringer’s and sterile saline. A study from human medicine compared tap water with sterile saline for wound irrigation and showed no difference in occurance of infection. Clorhexidine is availabile in many concentrations (4%, 2%, 0,5%) but for open wounds 0,05%  solution should be used. To obtain this concentration, 25ml of clorhexidine 2% must be mixed with 1liter bag of solution. Betadine may be a good option to use in wounds located on the face, particulary near eyes because clorhexidine have very toxic effect if will get in contact with the eyes. Betadine also must be diluted to a proper concentration (0,1%-1% solution). To obtain this solution, 1-10ml of 10% betadine must be mixed with 1 liter bag of solution. As a comparation, clorhexidine is not activated by anorganic matter while as betadine is inactivated by anorganic matter such as blood or exudate. Also a 0,01% clorhexidine gluconate with tris-EDTA solution was described for wound lavage. This combination help lyse Pseudomonas aeruginosa, Escherichia coli, and Proteus vulgaris. Recently polyhexanide/betaine (Prontosan), a solution or gel containing 0.1% of the antimicrobial agent polyhexanide and 0.1% of the surfactant betaine was described as a lavage solution in wounds with good results.

 

One of the key of this procedure is not necessarily the type of solution used, but the amount used. A copious lavage of 500-1000ml is recommended. The ideal pressure of 7-8 psi can be provided by different systems. The most cheapest way is to use an 18G needle, a 3 way stop cock, saline bag, 35-60ml seringe and an intravenous tube. Pressure cuff also can be attached to the solution bag and 300mm Hg pressure can be maintained to provide 7-8 psi in the time of lavage. If the pressure is too high, the healthy tissue can break; if the pressure is under 7-8 psi the surface contaminants may not be removed completely.

After cleansing, if the wound is not considered contaminated, primary closure is indicated. Most of traumatic wounds need also debridement.

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Fig. 3 Wet to dry bandage applied on a wound located on the ventral aspect of the metatarsal area in a cat as a nonselective form of debridement

Debridement: can be selective or nonselective. Usually chronic wounds needs debridement but also fresh wounds which present devitalized tissue. Surgical and mechanical debridement are considered nonselective forms. For surgical debridement different surgical instruments can be used (scalpel, scissors, etc.) and adherent bandages (wet-to-dry / dry-to-dry) are used for mechanical debridement.

 

Surgical debridement must be performed in layers, step by step until the necrotic/ devitalized tissue has been removed and blood can be visible from the wound edges or from the bed. An en block surgical debridement can be performed but this can be limited due to location and size. The wound margins should be closed with suture material or towel clamps can be applied for a temporary closure and after the entire wound is excised, including a margin of healthy tissue. Wound irrigation is also considered a nonselective debridement.There is no strong evidence that cleansing wounds increases healing or reduces infection, but it is almost universally recommended.

Three forms of selective debridement are described: enzymatic, autolytic, biosurgical/ biotherapeutic.

 

 

  • Enzymatic debridement – includes proteolytic enzymes that break down the necrotic
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Fig.4 An example of ointment with papain and urea used for enzymatic debridement

tissue. Papain, trypsin, chymotripsin, fibrinolysine, collagenase, urea are the most common enzymes used for enzymatic debridement. Castor oil, balsam of Peru, desoxyribonuclease are also described.

 

As an advantage, they will not damage healthy tissue. This type of debridement is used less and less nowadays in wound management because is less effective and needs a long period of time to have the proper effect. Surgical debridement may facilitate enzymatic debridement.

  • Autolytic debridement – is the most preferate selective debridement. Is less painfull in

compare with the other types. This method involves maintaining a moist environement on the wound so that natural enzymatic “phenomens” can take place. Hydrogels, hydrocolloids and foams are very common used to support autolytic debridement and will be described later as moisture retentive dressings. Due to their high osmolarity, honey and sugar can also be used also for autolytic debridement. They attract the fluid and will keep a moist environement.

 

  • Biosurgical debridement – refers to usage of maggots (Lucilia Sericata, Phaenicia

Sericata) and have and FDA approval since 2004. The maggots produce enzymes that dissolve the necrotic tissue and don’t interact with healthy tissue, that’s why the debridement is selective. They are applied in the wound as larva stage (4-7 days of life) and can be left in place 3-4 days. At the moment of application the larvae have 2-3 mm and in 4 days grow until 10-15mm. The optimal activity of the maggots depends on the wound pH. They don’t survive in an acidic environment. An 8.5 pH in the wound is preffered. Each maggot may consume up to 75mg of necrotic tissue every day. They cannot penetrate dry necrotic tissue or eschar therefore are not indicated for this situation.

 

 

Moisture retentive Dressings (MDR’s)

Transepidermal water loss represents the the amount of fluid lost by the normal skin. In humans with intact skin the transepidermal water loss is 4–9 g/m2/h. In partial and full-thickness wounds the water loss increase up to 90 g/m2/h. Dressings that have a low moisture vapor transmission value, less than 35 g/m2/h, are considered moisture retentive. In humans was found that the dressing with a water vapor transmission rate of 2028.3 ± 237.8 g/m2/24h was able to maintain an optimal moisture content for the proliferation and regular function of epidermal cells and fibroblasts in a three-dimensional culture model.                The process of wound healing can be accelerated by a moist environment. MDR’s retain water and hydrate the tissue and facilitate natural autolytic debridement. All wounds need to be covered with a specific dressing to maintain a proper moisture until full epithelialization otherwise the granulation tissue will get dry and eschar will occur. MDR’s are availabile on the market in various sizes, shapes, thicknesses, with or without adherent margins. They must be applied on top of the wound as a first layer and after can be covered with the second (absorbent layer) and third layer (protective layer).

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Fig.5 Lateral view of a polyurethanic foam. Noticed the convex shape that the foam acquired after beign moistened. Due to this particularity this dressing have a good contact with the wound bed.

Polyurethane foams: is a porous nonadherent dressing that can be used in moderate to high exudative wounds. It absorb several times it’s weight. Is recommended to be used in sterile wounds and regularly must be changed every 3-5 days. With time, the period in which the dressing must be kept in place will change according to the amount of exudate. Some articles described that can be used also over infected wound bed but must be changed every 24 hours.

 

Can or cannot have adhesive borders and does not transform in gel. It is contraindicated in wounds with low exudate and not recommended in areas with bony proeminence because is very soft and cannot protect the damaged area. In compare with hydrocolloids and alginates, foams are less effective for autolytic debridement.

Alginates (calcium alginate): have high absorbtive properties. It absorbs 20-30 times its weight in fluid. In contact with the exudate, alginates transforms in gel. Is derived from brown seaweed and is recommended in high exudative wounds. It promotes haemostasis and Ca2+ stimulates macrophages and fibroblast activity. Is not recommended to be used in low exudative wounds.

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Fig.6 Calcium alginate appearance. Left picture represents calcium alginate sheet applied on dorsal and ventral aspect of metatarsal area in a cat with a degloving injury after surgical debridement; Right picture represents the aspect of calcium alginate 24 hours later in the same patient; Note the transformation from dry fibers in gel and the proximal area in which the dressing was absorbed (yellow arrow).

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As a presentation form, alginates are used in flat sheets and can be applied even in narrow cavities. On the market alginates can be found in combination with silver, zinc or honey.

Hydrogels: are indicated in low exudative wounds. They donate fluid to wound but can also absorbe it. Can be found in two presentation forms-sheet and gel. Contains 60-95% water and the cooling effect may decrease pain. Is not indicated in high exudative wounds because maceration can occur. Overgranulation has been reported after usage of hydrogels in excess. In cavitary wounds the gel form is inficated due to better contact. Hydrogels can also be used to soak the dry necrotic tissue.

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Fig.7 Left picture describes hydrogel sheet used on the lateral aspect of digit IV in a dog with and abrasion wound. The wound had partial epithelialization and a small area with granulation tissue and the level of exudate was low. In the right picture gel shaped hydrogel is placed on Primapore.

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Various forms of hydrogels combinations are availabile: with hyaluronic acid, alginate, collagen, etc. Can be left in place 3-4 days in non-infected wounds. They are permeable to gas and water and have proven to be a less effective bacterial barrier than occlusive dressings.

 

 

 

 

 

Hydrocolloids: have in composition may constituents like sodium arboxymethylcellulose,

gelatin, pectin, and polyisobutylene. Gelatin, pectin, elastomers, alginates, silver, and other materials can be added to these substrates. In contact with exudate it transform in gel and maintain a moist environment. Hydrocolloids are indicated in wounds with low to moderate exudate.

Sheets, powder and paste are the form of presentation. In compare with alginates, foams and hydrogels, the contact face of hydrocolloids is adherent but just on the skin, not on the granulation bed. Regarding permeability, hydrocolloids are semi-permeable to water vapour and oxygen but not permeable to bacteria and other contaminants. Is not recommended in infected wounds. May cause overgranulation.

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Fig. 8 Different aspects of hydrocolloid dressing. (a) Fresh hydrocolloid applied on a mild exudative wound in a dog; the dressing have is brown and opaque. (b) View of the dressing 5 days after application on the dorsal metacarpal area in cat. Note the brown dark colour that hydrocolloid achieved. (c) Dressing removal in the same patient in the same day. Note the yellow, gelly and bright aspect due to granulation bed contact.

 

 

Miscellaneous dressings

Honey – called also natural dressing, they are composed by glucose, fructose, sucrose, maltose, amino acids, vitamins, minerals and enzimes. Honey is the most popular product used as a topical treatment for wounds; have an antimicrobial effect due to low pH (3-4.5 ), release of small amounts of hydrogen peroxide or the presence of methyglyoxal. Honey promotes autolytic debridement and reduce oedema due to high osmolarity. It was demonstrated that honey have effect against a multitude of bacteria including Pseudomonas spp., MRSA and E. coli. Composition of honey does vary according to the geographical source. Many types of honey are availabile, from raw honey to medical grade. Manuka honey (Leptospermum scoparium) that originates from New Zealand is the most common used in humans and animals for wound care. Medical grade Manuka honey is recommended despite raw honey because raw honey may contain bacteria and fungal contaminants including anaerobic spore‐forming organisms. Recently was developed a new type of honey was developed which is not manuka honey. SurgihoneyRO is an antimicrobial wound gel utilising bioengineered honey to deliver Reactive Oxigen and is superior to Manuka honey. It cames in a variety of form such as gels, sheets, in combination with alginates or simple gauze. Honey is recommended in wounds that needs debridement and is not recommended to be applied over the granulation tissue. Despite the multitude of benefits, the quality of the evidence is variable.

Silver dressings– should be used when infection is suspected. Has been shown that silver ions have an antibacterial effect in contact with the exudate. Because silver ions are activated by a moist environment, is not indicated to be used in wounds with moderate-to-low exudate. There are some evidence that suggest delay healing if silver dressings are used in acute wounds. Is available as gel, sheets, impregned in alginates, foams and hydrocolloids and can be left in contact with the wound up to 7 days. Silver is a broad-spectrum antimicrobial agent that is effective against bacteria, fungi, viruses, and yeast. It has also been proven to be active against MRSA and vancomycin-resistant enterococci (VRE) when used at an appropriate concentration. Silver destroy bacteria due to multiple mechanisms: disrupts bacterial cell walls, inactivates bacterial enzymes, and interferes with bacterial DNA synthesis. Therefore bacterial resistance has yet to be documented, although reports of isolated Escherichia coli and Pseudomonas aeruginosa have shown resistance to silver in vitro.  Despite the benefits, some articles concluded that is still a lack of evidence about usage of topical silver and silver dressings for treatment of infected or contaminated chronic wounds.

Collagen dressing: are available in different forms such as granules, powders, sheets, pastes, gels. The collagen from these products derived from bovine, porcine, equine, piscean or avian source. Collagen has been widely used in cosmetic surgery, as a healing aid for burn patients for reconstruction of bone. Is the main structural protein in the extracellular space. Is resistant against bacteria and in this way it helps to keep the wound sterile. Platelets interact with the collagen to make a hemostatic plug. Collagen based dressings need a secondary dressing layer to maintain a moist environment. Products that contain collagen promotes angiogenesis and stimulates fibroplasia. Recently, usage of Tilapia skin fish in veterinary medicine and blue shark skin in human medicine for burns were described with promising results.

Silicone dressings– are used mainly in humans to reduce the hypertrophic scar. The mechanism of action of silicone dressings is not fully understood. It is believed that silicone due to occlusive effect, decrease the oxygen of the tissue until anoxia, environment in which fibroblasts cannot have a normal function and undergo apoptosis. In humans has been shown to help reduce trauma and pain. Silicone dressings were tested in rabbits, rats and horses. Silicone dressings are nontraumatic and the contact surface is adherent but just on the skin surrounding, not to the granulation bed. A comparison between silicone dressing and silicone gel in a controlled trial for treatment of keloids and hypertrophic scar. Compared to the untreated controls, all of the measured parameters including scar size and induration were reduced in both silicone and nonsilicone-treated groups. In 2005, silicone dressing was used with good outcomes in horses with exuberant granulation tissue. In 2017, a review of silicone gel sheeting and silicone gel for the prevention of hypertrophic scars and keloids concluded that was statistical significance in the effectiveness of both of them but most of the trials had poor quality with high or uncertain risk of biases.

Borate glass nanofiber – was developed in 2010 by human engineers and is recognized to have regenerative properties on bones and soft tissues due to stimulation of angiogenesis and osteogenesis. Two borate glasse with (1605) or without (13-93B3) CuO and ZnO were studied along with the silicate-based glass, 45S5 for the potential effect on vascular endothelial growth factor. The study demonstrate that silicate glass is inferior to borate glass. Copper and zinc ions together with calcium, phosphorus, magnesium, etc., stimulate the proliferation of human endothelial and osteoblast-like cells, promote angiogenesis, and stimulate vascular endothelial

growth factor secretion. Osteogenesis is encouraged because the fibers convert to hydroxyapatite.

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Fig.9 Borate based glass nanofiber. Macroscopic aspect, “cotton-candy” like (left picture) and electron microscopy (right picture).

In 2017, borate glass nanofiber was evaluated for treatment of full thickness wounds in six dogs. The study had many criteria: wound cause and location, type and duration of previous wound management, time to granulation tissue formation, time to complete wound healing, subsequent procedures if applicable, outcome, and complications associated with treatment. With a “cotton candy” aspect and soft texture, the borate glass can be applied to any defect, even in deep wounds can be packed. Is not expensive and did not require hospitalization. A veterinary product was developed and is available (RediHeal) for cats, dogs and horses. Because promotes bone growth, the product can be packed also in the defect which result after dental extraction. After application, the fibers degrades at a controllable rate and release ions.

 

Wet-to-dry Vs MDR’s

 

·         Wet to dry bandages: first they overhydrate and after dessicate the wound bed. As

a result, cells involved in the healing process will lose their function. Because is a nonselective debridement form, when wet to dry bandages are removed normal cells (WBCs, macrophages, granulation tissue) are pulled off with the surface contaminants. The environmental bacteria can penetrate the gauze.

 

Because is adherent, in the time of removal will be not comfortable for the patients due to pain sensation. Small gauze fibers can remain in the wound bed, will act as a foreign body and will extend the inflammatory phase. They are not expensive but if are used as a sole treatment for wounds, the cost may increase semnificatively due to delay healing and daily replacement.

 

·         Moisture retentive dressings: during the inflammatory phase, support selective

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Fig.9 Characteritics of an ideal dressing

autolytic debridement and promote healing because will keep a moist environment. They are nonadherent and nonpermeable for bacteria  so the infection rate is lower in compare with wet to dry bandages. They also require replacement every 3-6 days (depends on the product and the wound appearance) therefore decrease the costs for total wound care. Because MDRs are occlusive or semioclusive in nature, they decrease the pH and oxygen tension in wound and, as a result, WBCs are attracted, angiogenesis and collagen formation are stimulated and inhibit bacteria. MDRs are comfortable  not painfull for the patient when are removed from the wound bed. Also they prevents dessication and necrosis.

There is no dressing that meets all the conditions and cannot be considered that one is better than the other. The aim is to use the correct dressing according to the needs of the wound. Therefore, the physiology of wound healing needs to be understood. As an example, even if gauze (wet-to-dry) have many negative consequences, it can be used for debridement as part of wound management and is very effective but contraindicated in the proliferative phase while calcium alginate (MDRs) is less effective and can dessicate the wound bed when is applied on dry wounds.

 

Regarding moisture, a simple general rule is considered: exudative wounds need dressing that will absorb the fluid and dry wounds need dressings that will deliver moisture. It is detrimential to assess the volume and the appearance of the exudate each time the bandage is changed. A wound with a favorable evolution will produce less and less exudate with a clear clear aspect.

Alternative therapies

 

            Wounds have different behavior and the evolution depends on many factors (localization, degree of contamination, size, etc.). In particular situations, wounds may not heal by second intention or they may decrease in size in the time of treatment but in some cases the proliferation may stop. If surgical closure cannot be achieved, alternative therapies may be considered. As an example, vaccum assisted closure (negative pressure therapy), laser therapy or platelet-rich plasma (PRP) should be considered.

Wound management part 1: the healing process and recognition of wound healing stages

51559132_952390804967417_8511078558653743104_nFlorin Delureanu

DVM, MRCVS

Romania

 

Section A

The physiology of the healing process

The most largest organ of the body is the skin. The skin acts like a barrier between the body and environement. Composed by 3 layers (epidermis, dermis, subcutis) and associated adnexa, the skin is a complex organ with many functions and properties: thermoregulation, motion and shape, environmental protection, storage (vitamins, electrolytes, fat, etc.), immunoregulation, sensory perception, secretion, excretion, etc.

Following trauma, the skin is the first organ to undergo changes. A wound represent a disruption in the continuity on anatomical structure with deterioration of the physiological function. There are several criteria for wound classification:

–                by the time that has passed since wound production: acute or chronic;

–                by the thickness of the skin layer that has been injured: full-thickness or partial thickness;

–                by the degree of contamination:

·                clean wounds – made under aseptic conditions (surgical wounds), in which it does not penetrate into the chest cavity, gastrointestinal, genitourinary tract;

·               clean contaminated wounds – in which the respiratory, gastrointestinal, or                            genitourinary tract is entered with minimal contamination;

·               contaminated wounds – wounds with a major break in sterile technique, open traumatic wounds less than 4-6 hours old with inflammatory process without purulent discharges;

·               infected wounds – traumatic wounds with purulent discharges or perforated viscera, more than 6 hours old.

 

After trauma, when the patient shows up in the clinic, it must be stabilized initially. If haemmorage is present, the wounds need to be bandaged with sterile gauze to stop bleeding, and emergency treatment should be initiated according to the patient’s needs. If it is not an emergency and the patient comes to the clinic with an older wound, after obtaining the complete anamnesis and examining the wound, formation of an initial plan of treatment is necessary. Thereby, depending on the type of wound, the approach differs. Four types of wound closure are described:

–                 primary closure, called also healing by first intention represents immediate closure of a fresh wound. This category includes recent traumatic wounds and surgical wounds.

  • delayed primary closure is indicated when the injured tissue have questionable viability or infection is suspected. The closure is delayed 3-5 days in which time the wound is assessed with proper dressings. Also delay closure offers time for proper drainage and the inflammation will decrease. Approximately 5 days after wounding fibroplasia, cytokines and macrophages will protect the wound against infection and closure can be performed. This type of closure is done before granulation tissue formation.

–                 secondary closure is performed after granulation tissue formation. Usually 5-10 days after injury; this type of closure is indicated when necrotic tissue persists and need to be debride many times, when inflammation is prolonged or when signs of infection are still present

.-                healing by second intention represents healing by granulation, contraction and re-epitelisation. This method is applicable for next types of wounds:

·                    moderate to large wounds in young animals that are located on trunk. Kittens and puppies have a fast rate of healing;

·                    wounds located in areas where the closure may create a “tourniquet effect“ (commonly on distal limbs). In this situation the circulation is compromised

;·                    infected wounds and those who presents questionable tissue viability;

·                    wounds that are closed under tension and dehiscence will occur.

How do wounds heal?

Tissue continuity is restored by the healing process. This biologic process begin immediately after injury or incision. Wound healing is a complex process that comprise three phases: inflammation and debridement, proliferation (repair), maturation and remodeling. All these three stages overlap and have a different duration.

Ø              Inflammatory and debridement phase.

After wounding, to avoid exsanguination hemostasis occur. Following the breakdown of blood vessels, endotheline is produced and along with other mediators (serotonin, bradykinin, catecholamines, histamine, prostaglandins) cause contraction of muscle within the vessel walls and hemorage is stopped by vasoconstriction. After 5-10 minutes, vasodilation occur. An increased blood flow to the wound bed and extravasated fluid in the wound will be present. Subsequent vasodilation, leukocyte migration starts (neutrophils and monocytes). At this point the wound will have the classic aspect of inflammation: swelling, elevated local temperature, erythema, pain. In early inflammatory phase the neutrophils predominate and in late inflammatory phase they decrease and monocytes predominate.

The main cells: –endothelial cells: neoangiogenesis-provides oxygen and nutrients to the tissue;

macrophages and neutrophils: debridement, phagocytosis of bacteria

and other pathogens.

 

  • Proliferative (repair) phase. About 4-6 days later, after wound debridement, the wound enters in repair phase. This stage lasts from day 5 until day 20 but can be longer and depends on many factors: wound size, location, age, health, etc. Four stages are included in the proliferative phase: angiogenesis, fibroplasia, contraction and epitelisation. The aspect of the wound will change in this phase from red to pink and the quantity of exudate will decrease. This phase is predominated by macrophages, fibroblasts, endothelial and epithelial cells. Due to platelet-derived groth factor (PDGF) and transforming growth factor (TGF-β), fibroblasts migrate in the wound from surrounding tissue. As a response to PDGF
    type III collagen is synthesized by fibroblasts. After 7-14 days, TGF-β increase synthesis of type I collagen. Collagen afford strength to connective tissue. There are more than 20 types of collagen. Type I collagen is present in unwounded dermins in 80% and type III collagen in 20%. Finally, due to TGF-β1, fibroblasts are transformed into myofibroblasts and wound contraction begin. Contraction increases with a speed of approximately 0.6 to 0.8 mm/day. As a response to epidermal growth factor (EGF) and TGF-α proliferation of epithelial cells begin. Epitelisation continue until complete epidermal thickness. The growth rate of the granulation tissue is 0.4 – 1mm/ day. The granulation tissue is very fragile in consistency and act as a barrier to infection.
  • Maturation and remodeling phase. In the last phase of wound healing remodelling and strengthening of collagen take place. Care must be taken at the beginning of this phase because the scar tissue new formed is very thin and fragile and need few weeks until will gain a proper strength. Due to a changing in collagen type (only 10% of type III collagen present in the scar tissue) rigidity rise and the matrix becomes more stiff. Though, the final scar tissue will not achieve the elasticity and strength of a normal tissue. The maximum strength will be approximately 70 % – 80%. Usually this phase starts 3 weeks after wounding and continue until 1 year.

Figure 1. Illustration of approximate time of wound healing stages. Inflammatory phase last between 0-6 days,

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Fig 1

repair phase 4-25 days and maturation and remodelling phase 21 days to months. Overlapping of healing stages is represented by the green triangles.

 

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Fig 2

  Figure 2. Illustration of cell distribution in the time of healing;

 

Conditions that delay or impede wound healing

 

Factors who are involved in this process are grouped into several categories:¨             Host factors: hypoproteinemia (malnutrition); age (wounds in elderly patients have a longer healing time compared to young patients); internal organ disfunctions (Cushing Syndrome- excess circulation of glucocorticoids, liver diseases – clotting factor deficiencies, diabetes mellitus, uraemia, hypothyroidism), obesity, immune disfunction, viral diseases (FeLV/FIV), cancer, coagulopathies, self trauma;¨             External factors: infection, foreign bodies (environmental – grass awns, soil; surgical  metal plates, drains), radiation therapy, long surgical time and hypoperfusion;¨             Medication: chemotherapy, glucocorticoids, NSAID, anticoagulants, cytotoxic solution used for lavage; ¨             Mechanical factors: motion, tension, pressure (from bandage).

 

 

Section B

 

In which stage of healing we are?

In order to choose an appropriate treatment method (closure or dressing) it is necessary to recognize the phases of wound healing. Some specific aspects should be considered: macroscopic appearance (infection, contamination, blood, inflammation), time elapsed from wound appearance, amount of exudate, wound size, tissue viability, wound margins. This section will illustrate wound details in different phases of healing.

Figure 3. Ventral view of abdomen of a cat during     Figure 4. Approximate 1 hour old wound located on

spay, midline approach; This is a surgical clean        the left front leg, between digit IV and digit V. Small

wound.                                                                                amount of  unclotted blood and early inflammation

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Fig 3

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Fig 4

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5. (a)Lateral view of digit V of  left hind in a 6 years old paraplegic female dog. Healthy

granulation tissue is present 9 days post dressings treatment. Mild exudate was present following the

removal of the bandage . (b)The same pacient 18 days after wounding; a nearby photograph was made to highlight the presence of epithelisation present at the wound edge (black arrows). The white color at the

center of the wound represents the reflection of the camera light. (c) Maturation phase- complete

epithelisation present in day 44 post dressing treatment.

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Fig 5

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Fig 5

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Fig 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 6. Dorsal view of the right paw of the hind limb in a cat;

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Fig 6

The deglowing wound shows necrotic tissue, foreign materials devitalised tissue and mild exudate; High local tempreture was present on palpation. The infected wound was debride surgically, treated with dressings and later a full thickness mesh graft was applied. The cat disappeared from home for 2 weeks.

 

 

Figure 7. Left latera view of a 4 years old male Yorkshire beign bitten by a dog; Second intention healing

from the beginning until the end was chosen. Granulation tissue is in the middle followed by epithelisation

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Fig 7

and obvious wound contraction after 4 weeks of treatment with dressings.

 

 

THE ABDOMEN IS ALWAYS A MAGIC BOX

41768527_2349628575051886_8602568388625039360_nDr Giulia Nadasan

Vet Point Vest

Arad,Romania

 

Patient: Ellie

Species: canine

Breed: mix German Shepherd

Age: 9 years

 

Anamnesis: the dog and it’s owner are very close to our vet practice, they ask for anual hematology and biochemistry exams, abdominal ultrasounds  x-rays just for prevention. In the 19th of September 2018 the owner called beacause her dog was not being herself, she was not eating for 24 h and she thinks the dog is in pain.

 

Clinical findings: when the dog got to our practice she was lethargic, with pale mucose membranes, tahicardic, dispneic and with an enlarged abodomen.

 

Blood samples were taken and the results were:

-mild anemia 4130000 mm3

-hemoglobine 9,9 g/dL

-hematocrit 27,2 %

-severe trombocitopenia 52.000 /mm3

-leucocitosis 22510/mm3

-limfopenia 8%

-extended clotting time

-TCR >2 sec

-CPK increased 955 U/L

-ASAT 289 U/L

-ALAT 70 U/L

-Ureea 124 mg/dL

 

We performed and ultrasound and there was free fluid in the abdomen and after the paracentesis we removed aprox. 300 ml of blood from the abdomen. We suspected an abdominal hemorrage.

 

Diferential diagnosis:

  • Intoxication with anticoagulant raticides
  • Trauma
  • Internal bleeding: organ hemorrage
  • Hemangiosarcoma

 

After a few hours of i.v fluids (aprox 2000 ml NaCl 0,9%) to reestablish blood volemia we decided to do a laparatomy.

Thoracid X-rays were free for pulmonary metastasis. At the ecocardiography the heart was free of any mass in the right atrium.

46485884_1961554200619042_5719984655369764864_n

** Note that we did not made that incision, this is how the spleen looked like

Splenomegaly with ruptured spleen was our main concern, we did a splenectomy and removed aprox 4L of free blood from the abdomen. The splenectomy was made with sutures and the attached omentum was removed in bloc. A thorough abdominal lavage was made and the instruments were changed to minimize the risk of metastatic seeding.

46482518_199968860887539_5583318005737062400_n

*After surgery

A sample of the spleen was sent to the histopathology lab. That night we performed a blood transfusion from a 60 kg Tossa Inu.

 

 

 

 

 

 

 

 

 

The next morning the dog was feeling great, she ate normal, she waig her tail and everything was great.

41990593_2047810025282302_2732172247677534208_n

*next day after surgery

 

After too weeks our suspected diagnosis was confirmed: Spleen’s red pulp hiperplasia and splenic haemangiosarcoma. The staging could be: T1 (primary site tumor), N1(regional lymph node involvement: mesenteric lymphadenitis 2 weeks after surgery), N0( no evidence of distant metastatis: clear lungs, heart, liver at ultrasound).

 

Final diagnosis: Visceral Hemangiosarcoma stage II

 

I also tested cardiac canine troponin I (a marker with high specificity for cardiac injury) at PraxisLab in Budapest to check for miocardial metastatic modifications but the result was normal ( <0,25) .

 

Treatment: it has been 2 months since the surgery and splenectomy was the treatment of choice at that time.

She received ONCOSUPORT (RX) and a shot of 3 ml of Theranekron (Tarantula cubensis extract) every 5 days.

We finally found Doxorubicine and we started the treatment with the following protocol:

-Doxorubicine 30 mg/m2 = 16 mg/38 kg every 2 weeks for 5 treatments. It does have a cardiotoxic effect but if the dog lives long enough I will continue as much as I can.

-Maropitant (Cerenia) 1mg/kg 2-3 days after chemotherapy.

46494473_323963678435767_3170791749807243264_n

*2 months after splenectomy

Other drugs that can be used with a antiangiogenic effects are : Masivet, Thalidomide, Palladia.

 

The prognosis with dogs with haemangiosarcoma treated with splenectomy only is really poor, 2-3 months surviving time after surgery. Even with chemiotherapy the surviving time of 12 months is only 10%. Median survival time with spelectomy and doxorubicine is 132 days.

Surgical removal of the luxated lens including the capsule (intracapsular lens extraction) in a bear

Belica_surgery118Dr Maria Savova

Veterinary Clinic NOVA

Sofia, Bulgaria

 

Violeta is a 37y.old brown bear form Belitsa Dancing bears park, Bulgaria.

She was suddenly blinded and had an urgent eye check.The ophthalmological examination revealed increased pressure (40mmHg) and displaced lens in the left eye.The cornea was mildly opaque and the lens was with senile cataract. No PLR. The retina was also degenerated resulting in marked tapetal hyper reflexivity.Belica_surgery30 Belica_surgery40

Lens subluxation (posterior) is partial detachment of the lens form the ciliary body, due to breakdown or weakness of the zonules.

We preformed surgical removal of the luxated lens including the capsule (intracapsular lens extraction).

In the “open sky” approach, the superior cornea was incised 120 – 160 degrees using a cornea knife. The lens and its capsule were removed together in one piece through the incision.Belica_surgery93 Belica_surgery100 Belica_surgery110

Hydrodissection was employed for the removal of lens. We left the eye without artificial lens (aphakic).

During the removal of the lens, prolapsed vitreous was determined and we removed it with scissors in the anterior chamber.

Following the irrigation of the anterior chamber, corneal incisions were closed by separate sutures using 8/0 polyglactine.

For the postoperative care, we applied systemic antibiotics for the first five days.Belica_surgery121 Belica_surgery126

7 days after surgery, the eye is calm; there is no secretion or swelling.

 

Now the bear is in preparation for hibernation and her eye will be examined in the spring.

OSTEOCHONDROSARCOMA- SURGERY

43715598_336141656947602_6782174039545741312_n(CASE REPORT)

DR LUCIAN FODOR HAPPY PET TIMISOARA-ROMANIA

Introduction:

Osteochondrosarcoma is an uncommon tumor that generally arises from the skulls of dogs (cranium, orbit, zygomatic arch, mandible, and maxilla) and can occasionally arise from the pelvis, ribs, and os penis. These tumors have a characteristic appearance on radiographs, CT, and MRI: generally the borders of the tumor are sharply demarcated with limited lysis of the adjacent bone, with a coarse granular density throughout. A popcorn-like appearance with stippled and heavily calcified or ossified regions has been described on survey radiographs.

Clinical signs are generally based on location and extent of the lesion; ranging from a palpable, fixed, and firm mass to pain on mouth opening for tumors involving the mandible and zygomatic arch, exophthalmos with infraorbital lesions, and neurologic abnormalities for tumors involving the cranium.

43950478_167475047490012_2226512029793910784_n

Fig 2

43514688_913495158846702_418217810473254912_n

Fig 1

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Fig 3

Cara, a one year unsterilized mallinois female bitch, from the age of 7 months beggin to develop in the fronto-parietal region a globular formation(fig.1-2-3)

 

.She came to our unity with neurological manifestations, ataxia, deviation, refusal to rise from the bottom, bilateral midriasis.

Blood analyzes where in optimal parameters. After performing the CT, a giant extra and intra-cerebral form was noticed, being the imaging feature of the osteocondrosarcoma. (Fig.4-5)

43759528_484990658670865_14835555774758912_n

Fig 4

43788744_241906113168260_7429289207186587648_n

Fig 5

After consulting with the owner we decided surgery.

It was performed a large, circular craniotomy with a safety margin of one cm. The formation did not adhere to dura mater, only compressing the brain. (Fig. 6-7-8-9)43828104_267060260621234_1089416852607598592_n 43727747_1873646689408833_5453387625761079296_n

T43828915_108324666763855_6959109323293196288_n 43750703_2206611569596014_4590836245717843968_nhe bone reconstruction was accomplished with Collapat, a substrate of bone based on hydroxyapatite and collagen. (Fig.10)

Concluzion:

Post operator evolution was good, 48 hours after the surgery the patient was recovered neurologically(Fig11). At six (Fig12)and 12 months post surgery,(Fig.13) Cara feels good, fully recovered.

 

 

The rhomboid flap

22264908_689114241295076_1764003733_nFlorin Cristian Delureanu

DVM, MRCVS

 

 

ABSTRACT

 

In plastic and reconstructive surgery flaps have an important place not only for the aesthetic results obtained but also because they can be used to cover an area without producing tension. The flap mechanism mainly consists of moving a piece of skin from the donor site and moving it to the recipient site (primary defect). The rhomboid flap have a big versatility because can be done anywhere on the surface of the body. Filling small and large wounds with tissue similar in texture, colour and thickness is the ideal objective of the flap. This article describes the surgical approach of two cases, one with an abscess and the other with a benign tumor located at the cutaneous level, both of which are approached by the use of the rhombic flap.

 

 

Introduction

A skin flap represent a partial detachment of a piece of skin and the adjacent subcutaneous tissue with its vascular supply intact. All skin flaps have a pivot point or base. Survival of the skin flap is made by blood circulation through its base during the procedure. From this point of view, it is important that the base of the flap be large enough to prevent necrosis.

Local flaps are based on two types of vascularization: the subdermal plexus or a vein and an artery (figure A; right side- island flap).

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine). Depending on the transfer method, local flaps are classified as follows: -advancement flaps: those who advance forward; -rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine).
Depending on the transfer method, local flaps are classified as follows:
-advancement flaps: those who advance forward;
-rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

 

 

The rhombic flap was invented by a human maxilofacila surgeon called Limberg Alexander Aleksandrovich in 1946. By name, the flap has rhomboid shape with two angles of 120 degrees and two angles of 60 degrees. Depending on the primary defect / lesion pattern which require coverage, the flap angles may change. It is often used in reconstructive surgery of the face in humans: eyelid, floor of nose, alar rim and chin defects with good cosmetic results. This skin flap also called Limberg flap is a transposition flap – the elevated skin will have both advancement and rotation movement when is applied over the primary defect.

 

How to design the rhombic flap

 

Whether it is a wound or a tumor, around a defect is drawn a diamond with angles of 120 degrees and 60 degrees as mentioned above. First, the short diagonal that joins the 120 degree angles (BD) must be measured and then extended in the desired direction. The extension (DE) to the outside must have the same length with the short diagonal (BD) and with the sides of the diamond. The next step is to extend another line wich is equal and parallel with the closest side of the diamond (EF). Finally the skin flap is obtained (ADEF).

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

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Figure 2. Transferring the flap to the primary defect. The direction of rotation of the flap is indicated by the purple arrow. After rotation in point A dog ear will occur (yellow elipse). During the rotation the flap describes a 120 degree movement. The higher the angle, the dog ears will be more prominent. The secondary defect will be closed following the transfer of point F to the initial position of the D point

 

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Figure 3. The final shape of the rhomboid flap. Point D reached point B, point E reached point C and point F reached point D. A is the only point which maintain the initial position.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The surgical defect created can be covered with the rhomboid flap from 4 sides (Picture 4).

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

 

 

 

 

 

 

 

 

 

Case 1

                  

History

 

Daisy, a six years old female cat of the Maine Coon breed presented with a sebaceous cyst, 2 cm diameter, round shape, locatad on the dorsal lombo-sacral area. The owner says that the cat have a decreased appetite. The pacient was rescued and adopted and was vaccinated just when was young. The cat lives with another 3 cats in the same house, all with the same vaccination status.

General Examination

At clinical examination, apart from the wound, dehydration 6%  and a small buccal ulcer behind the last molar on the right mandible were detected. The patient was initially treated with clindamycin and meloxicam for 7 days but no improvement observed. The cyst was infected, with bad smell, partially covered with agglutinated hair and inside soft tissue necrosis was present.

Figure 5. The initial appearance of the wound, 24 hours prior to surgery.

Figure 5. The initial appearance of the wound, 24 hours prior
to surgery.

After inspection, dead space was noticed under the skin around the wound. One day before the surgery we noticed fever (40,1°C) and dehydration 8%. CBC, serum biochemistry and FeLV/FIV test were performed. Neutropenia (0.15 x 109/L, normal range: 1.48 – 10.29) and hyperglobulinemia (57g/L, normal range: 28-51) and decreased ALKP (<10 U/L, normal range: 14-111). IDEXX Snap FeLV/FIV was negative. The cat was hospitalized 24 hours for fluid therapy and i.v. antibiotic (Cefuroxime-Zinacef). After stabilizing the patient the intervention was performed.

 

 

 

Descripting the surgical steps

 

The area was clipped and clorhexidine was used for local antisepsis. Sterile marker was used to draw the rhombic shape around the primary defect.

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

 

 

 

 

 

 

 

 

 

 

Due to the presence of dead spaces   under the skin, the round shape of the primary defect was converted to a rhomboid and the rhombic lines were positioned about 1 cm from the wound margin. In this way the tissue that was not healthy was removed. Identifying the area with the highest laxity is the next step. This was done by pinching the skin around the primary defect. After choosing the appropriate area, the flap that must be transferred was drawn.

The first side of the flap (the extended line outward of the defect) and the second side of the flap (line that is the same length as the first, to the adjacent side of the defect and makes an angle of 60 degrees at the flap apex) were cut and the flap was elevated after undermining

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 7. The picture illustrates the extension to outside of the short diagonal of the diamond

Figure 7. The picture illustrates the extension to outside of the
short diagonal of the diamond

 

 

 

 

 

 

 

 

 

Skin cuts were made perpendicular with No.10 scalpel blade and and the flap was mobilized with help of Metzenbaum scissors. The surrounding tissues are widely undermined to avoid any tension and the flap is rotated into the recipient site. After rotation, the flap is locked in place by fixing its corners by subcutaneous sutures. The donor site is closed as the flap moves over into the new location. Finally the skin was closed with 4/0 PDX in simple interrupted suture pattern.

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

 

 

 

 

 

 

 

 

 

 

 

 

A common unaesthetic appearance after transposed flap was the “dog ears” at the pivot point. In this situation, dog ear was corrected by excising one triangle along one side of its base.

Figure 13. The aspect of the flap at 48 hours after surgery

Figure 13. The aspect of the flap at 48 hours after surgery

Figure14. The aspect of the flap in the eighth day after surgery. The direction of the hair grow is change because of the rotation.

Figure14. The aspect of the flap in the eighth day after
surgery. The direction of the hair grow is change because of the rotation.

 Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction


Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction

 

 

 

 

 

 

 

 

 

 

 

 

Case 2

 

History

 

Coco, a mix breed male dog, three years old was brought to the clinic because a lump was identified on the skin. Owner reports that the mass was seen some days ago and does not believe it has increased significantly. Also says it makes itching and that the dog often scratch there and bleeds. This was the owner’s only concern.

 

General examination

 

No abnormalities were detected after clinical examination except the lump. With a cauliflower aspect, the lump had a small base of implantation and 1,2/1,4 cm in diameter. After palpation of the skin around, no pain or local temperature were identified. FNA and blood tests were recommended before surgery and histopathological examination after. The owner declined for financial reasons the FNA and blood test but accepted the histopathological examination. In this situation, a two centimeter safety margin clearance was decided.

 

Surgical approach

 

            Surgical steps along with flap drawing were described above except for asepsis. In this case  iodine povidone was used.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

 

 

 

 

 

 

 

 

 

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

 

 

 

 

 

 

 

 

Histopathological result

               Description: Cutaneous/ subcutaneous mass composed of  chistic masses well delimited by a cheratinized multilayered epithelium with epithelial cells with squamous differentiation oxifiles, mixed with abundant, granular and amorphous keratin; multifocal with the tendency of confluence, inflammatory infiltration with neutrophils, macrophages and epithelial cells is observed. Malignant neoplastic cells are not present in the examined sections.

 

               Interpretation: Benign follicular tumor – pilomatrixoma with associated granulomatous inflammatory process.

 

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

 

 

 

 

 

 

 

 

 

 

Common complication of the flap

 

  • Hematoma;
  • Bleeding;
  • Flap necrosis;
  • Secondary infection.

 

Short indications for proper surgical procedure

 

  • The sides of the rhomboid must have the same length;
  • The sides of the flap must must have the same length;
  • Depending on the shape of the primary lesion, the diamond angles may vary in degrees;
  • Any defect in rhombic shape shows 4 variants in which it can be covered.
  • The lowest laxity region should be chosen and as far as possible so as not to alter anatomical plans.