The serious nature of spleen removal surgery is often overlooked. Perhaps the fact that dogs can function well without the organ is partly to blame. Or maybe, as posited by Harry W. Boothe, DVM, MS, DACVS, professor emeritus of soft-tissue surgery at Auburn University College of Veterinary Medicine, it’s because for many years it wasn’t unusual for veterinary schools to use the procedure in junior surgical laboratory settings as an exercise in knot tying and ligation placement.

Years of experience have taught Boothe to see the surgery a little differently. He says that while splenectomies are often straightforward and predictable, he has been a part of many surgeries that haven’t fit that neat and tidy mold— both peri- and postoperatively. “There are a lot of things we don’t understand about the spleen,” Boothe explained during a session at the Fetch dvm360® virtual conference in August, “not the least of which is the 

cause of cardiac arrhythmias being associated with splenic masses, splenic enlargement, and splenectomies.”

Boothe began with a quick refresher on splenic anatomy. The spleen, he said, is suspended by the greater omentum and attached to the greater curvature of the stomach by the gastrosplenic ligament. The splenic artery arises from the celiac artery, which is the first branch of the abdominal aorta and divides into multiple smaller hilar branches before entering the spleen.

“In addition to supplying the spleen, the splenic artery supplies the left pancreatic limb," Boothe said. That pancreatic limb that lies caudal and parallel to the stomach is a lot closer to the spleen than I think we often realize—or at least the blood supply is. And I think part of
my concern with some of the minimal ligation techniques is that, particularly with splenic hilar disease, we could be a lot closer to embarrassing blood supply to the left pancreatic limb then we realize.”

Boothe added that it is important to remember that although the splenic veins parallel the splenic artery, they enter the portal vein, not the caudal vena cava. “We can use them to access the portal venous system and to evaluate portal venous pressures,” he explained.

There are several reasons for removing a patient’s spleen, including lesions and trauma. Boothe focused first on splenic torsion, explaining that the condition occurs when the spleen rotates around its vascular pedicle, resulting in venous obstruction and subsequent splenomegaly.

True to the textbooks, Boothe has seen splenic torsion consistently in large- and giant-breed dogs with deep-chested conformations. “In my experience, it’s usually an isolated event, meaning it’s not necessarily associated with trauma or other situations." But, he said, “we always look for splenic torsion in association with gastric-dilatation volvulus.”

Boothe explained that there are 2 possible presentations for dogs with splenic torsion: acute and chronic. Abdominal pain and collapse are common acute presentations, while vomiting, anorexia, intermittent abdominal pain, abdominal distension, polyuria, and polydipsia characterize chronic cases. “I can recall a case with chronic presentation that did very poorly following splenectomy,” said Boothe. “I think time is some- what of the essence in dealing with presumed or documented splenic torsion.”

With regard to laboratory results, Boothe said hemoglobinuria may be noted on urinalysis in chronically presenting patients and that hematologic findings often include anemia, thrombocytopenia, and leukocytosis.

While abdominal radiography and ultrasonography are often part of getting to a diagnosis, Boothe said he could probably argue that you can't definitively diagnose splenic torsion based on radiographs alone. Abdominal ultrasound, however, particularly with Doppler flow capabilities, is an excellent diagnostic tool in splenic torsion cases. "Findings often include generalized splenomegaly, evidence of splenic infarction, a twisted splenic pedicle, and absence of blood flow through the splenic vessels on Doppler evaluation," Boothe explained. Still, he said, it's not uncommon for the definitive diagnosis to be made at the surgery table through exploratory laparotomy. 

Complete spleen removal is the treatment of choice for dogs with splenic torsion. Boothe said if you can perform surgery in a timely fashion, you will typically just see splenic engorgement with a twisted pedicle once your patient reaches the operating table. "But if it's been more of a chronic situation with a delay in getting to surgery," he continued, "there may be evidence of venous thrombosis and the possibility of necrosis." Necrosis tends to correspond with worse outcomes, he said.

Because Boothe knows that the patient’s splenic tissue may be friable, making simple attempts at exteriorization potentially insulting to the patient, he approaches the situation with what he calls a somewhat old-school plan that’s become his default. First, he confirms the location of the left pancreatic limb. Then, he uses 1 or 2 large-diameter sutures (eg, #1 polydioxanone) to ligate the entire splenic vascular pedicle before removing the spleen in its twisted state.

With the spleen out, Boothe slowly untwists the pedicle, 

examines it for hemorrhage, and places additional ligatures or uses a high-energy sealing device as needed. “Now, one could argue that high-energy sealing devices could be used to work through the pedicle in its twisted state and deal with it that way,” he said, “but I think that sometimes it’s easier and quicker to get the spleen out and then deal with the pedicle as a separate structure.”

Because delayed hemorrhage is a possible postoperative complication, Boothe is careful to ensure that the vascular pedicle isn’t bleeding before closing the patient’s abdomen and performing intraoperative peritoneal lavage to evacuate the hemorrhagic effusion.

Don’t miss a beat (particularly the irregular ones)

Remember those mysterious postoperative cardiac arrhythmias associated with splenectomies? Boothe does too, which is why he recommended that splenectomy patients recover for 2 to 3 days after surgery at a 24-hour care facility or in a setting with overnight monitoring—"not necessarily with continuous heart monitoring," he explained, "but just to make sure we’ve got good perfusion, good mentation, and good recovery from the procedure.”

Articles

Sometimes, splenectomies are straightforward and predictable. Other times, not so much. A veterinary surgeon shares tips for getting better outcomes in splenic torsion cases.

Let’s undo the twist: diagnosing and treating splenic torsion in dogs

Sometimes waiting to perform treatment is the best course of action when a patient presents with dental concerns, as noted in the August issue of dvm360® (“

The ABCs of veterinary dentistry: W is for waiting to treat

”). But other times waiting is simply not an option—the patient’s problem needs to be addressed immediately.

Dogs should have 42 permanent teeth, cats 30. If 1 or more teeth are not present clinically, it is time for detective work This involves examining intraoral radiographs to determine whether a tooth is present subgingivally and, if so, whether a pathologic process (periapical lucency) is at play that needs immediate care. Waiting to diagnose and treat can lead to progression of subgingival pathology in these patients (

When a patient presents with persistent primary teeth—primary (baby) and secondary (adult) teeth present clinically in the same alveolus—immediate extraction of the primary tooth is indicated. Persistent primary teeth may overcrowd the dental arch, moving the secondary teeth to abnormal locations and causing oral discomfort. Double sets of roots may also prevent normal development of the alveolus and periodontal support around each permanent tooth, leading to early tooth loss.

A persistent primary tooth should be extracted as soon as the permanent tooth is observed to erupt in the same alveolus. When extraction is performed early, the abnormally positioned permanent tooth ideally moves into normal position. Extraction must be done carefully to avoid accidental damage to the unerupted, permanent canine tooth that lies lingual to the mandibular teeth and rostral to the maxillary deciduous canines. Avoid placing the elevator along the lingual surface of the mandibular deciduous teeth. Instead, only elevate along the mesial surface (front), labial surface (toward the lip), and distal surface (caudally) of the mandibular deciduous teeth, and buccally and distally around the maxillary deciduous canines. Examination of intraoral radiographs before extraction is important to confirm that the tooth about to be extracted is a primary tooth (

Normally, deciduous canines exfoliate by 6 months of age. Occasionally, the crowns fracture secondary to chewing on hard objects. Waiting to extract a fractured deciduous tooth can lead to periapical infections and discomfort (

Discolored teeth are considered nonvital. Discoloration commonly occurs secondary to concussive or thermal trauma that results in internal bleeding and pulpal necrosis. Dull pain is reported by humans from pulpitis in discolored teeth. The treatment of choice for discolored teeth in dogs and cats is either root canal therapy to remove the nonvital pulp or extraction (

Once the pulp is exposed via fracture, oral bacteria infect the area, causing inflammation and pain. If left untreated, the pulp eventually will necrose, leaving an open portal for bacteria to populate the periapical tissues and cause pain. When diagnosed early and treated within 48 hours of the fracture, the tooth may be saved through vital pulp therapy. After 48 hours in the mature dog or cat, either root canal therapy or extraction is the treatment of choice.

When an adult maxillary cheek tooth is fractured with pulp exposure, the area below the eye often swells. When this occurs, administering antibiotics and anti-inflammatories usually results in temporary resolution. Within days to weeks, however, the swelling returns because it is secondary to complicated cheek teeth fractures with open pulp chambers. Successful treatment in these cases involves root canal therapy or extraction of the fractured tooth (

Once plaque and tartar result in gingival inflammation, it is time for professional dental scaling, irrigation, and polishing under general anesthesia. Treatment in these cases should not wait until the annual dental exam.

Tooth resorption that is exposed into the oral cavity

We still do not know the cause of external tooth resorption in dogs and cats, but we do know that once the resorption is exposed to the oral cavity, bacteria invades the pulp and causes inflammation and pain. Waiting, antibiotics, and anti-inflammatory medication are not indicated. Extraction is the treatment of choice.

The etiology of gingivostomatitis is believed to be multifactorial. This creates a challenge for any successful treatment other than full-mouth or selective extractions. In rare mild cases, stringent plaque control and a change in diet may be curative. Treating with repositol steroids or anti-microbials is wishful thinking with only short-lived improvement. In cases of refractory stomatitis despite extractions, CO2 laser ablation, with or without every-other-day oral prednisolone administration, shows promise in relieving inflammation (

Thanks to wellness plans that include dental evaluation, scaling, polishing, and full-mouth intraoral imaging, fees for needed dental care are less of an issue than they once were. Clients who understand the ramifications of dental disease and believe their dog or cat needs dental care will find a way to afford it. In-clinic and third-party payment plans are an option for most clients, and many pet insurance plans cover dental diseases as long as the pet was covered before the diagnosis was made.

Some clients are hesitant to proceed with recommendations because they fear general anesthesia will harm their pet. Thanks to Fear Free preanesthetic patient evaluation geared to the individual patient’s age and condition, patient-tailored preanesthetic and induction medication regimens, and close anesthesia monitoring during and after the procedure, anesthesia is considered safe with only rare adverse events.

Waiting in most of the cases outlined here is not wise and can lead to harm. When the moment of truth occurs during an oral exam, it is wise to be proactive in advocating for your patient. Your patient and client will thank you.

Dr. Jan Bellows owns All Pets Dental in Weston, Florida. He is a diplomate of the American Veterinary Dental College and the American Board of Veterinary Practitioners. He can be reached at dentalvet@aol.com.

When it comes to dental care, sometimes immediate action is a must for your patient’s health and comfort.

The ABCs of veterinary dentistry: When waiting is wishful thinking

Ambrose Animal Hospital has grown significantly over the past 12 years. What was 2 doctors and a staff of 11 is now 6 doctors and a staff of 45. Ambrose achieved this growth by practicing progressive medicine, hiring only top-quality staff, and being culturally sensitive. Ambrose believed staff diversity led to greater sense of community and tolerance among team members. Diverse races and sexual orientations were well represented among the hospital staff.

In the midst of the coronavirus disease 2019 pandemic, some of the clinic’s vendors started sending lunch for the front line veterinary workers. Curbside policies prevented the public from entering the hospital, and the staff was discouraged from going to restaurants on their lunch break. Having lunch sent in as well as the newly social distanced break room were much appreciated.

Not long after the lunch spreads started to be delivered, some staff members asked to speak with Ambrose. They explained to the owner that 2 of the restaurants that provided staff lunches advocated distasteful and objectionable policies. One espoused religious beliefs that resulted in homophobic statements, and the other displayed its pride in big game hunting via displays in their restaurants. The staff felt that their diverse workforce should not have to be exposed to services provided by a homophobic company, and a restaurant chain that advocates the killing of non-endangered big game was not consistent with the mission of the veterinary hospital. Ambrose thanked them for their input and verified that the information about the companies was correct.

As the practice owner, Ambrose was not comfortable patronizing any business whose policies offended or demeaned his clinic staff members. He proceeded to write a staff memo outlining his reasons for prohibiting staff from patronizing these restaurants during work hours. He was quite surprised when his memo was not as well received as he had expected.

Several staff members said that although they not approve of the restaurants’ policies, they did not feel their employer should be able to dictate their choice of restaurants. One noted that 2 of the clinic’s staff members ate only kosher food. They always brought their own lunch and did not object to their coworkers’ choice of foods. Another commented that neither restaurant was doing anything illegal.

Ambrose thought these comments were, quite literally, food for thought. He understood why some of his staff thought he was taking a cancel culture stance toward these objectionable restaurants and respected them for sharing their thoughts. He explained that he would never ask his employees not to patronize a business during 

 hours, but that as the practice owner he had the “boss's prerogative” to make the choice he did. He found the restaurants to be morally offensive and in good conscience could not allow their products on his premises. He understood there would be some whispering behind his back but chose to stick to his credo “to thine own self be true.”

Do you agree with Dr. Ambrose? Would you have made the same choice he did? We would like to know.Email your thoughts to dvm360news@mmhgroup.com.

Most veterinarians would never turn away someone whose pet is in dire need of veterinary care based on the owner’s lifestyle choices. The animal, of course, is always an innocent victim. As repulsive as the pet owner may be, it is still our job to care for animals in need. Ambrose would never refuse to care for an animal presented by a person who owned what he considered a morally offensive establishment. On the other hand, every individual—veterinarian or not—must decide when and whether they are going to take a stand based on their own moral imperatives.

Ambrose felt that the only way he could tell these 2 restaurant owners that he disapproved of their advocacies was to not purchase their products. He did nothing illegal, he did nothing violent; he simply spoke up with his pocketbook. He was well within his rights as a practice owner to make this decision, but he also had to expect that some staff disapproval would be a price he had to pay for taking a moral stance. Bravo!

Marc Rosenberg, VMD, is director of Voorhees Veterinary Center in Voorhees, New Jersey. Although many of the scenarios Rosenberg describes in his column are based on real-life events, the veterinary practices, doctors, and employees described are fictional.

Do practice owners have the right to tell employees what and where they can eat while they’re on the clock? 

Cancel culture at the veterinary clinic

This week on dvm360, we will be posting a wide variety of news content including:

A brand-new episode of The Vet Blast Podcast: On Episode 23, you’ll learn about workplace injuries and how to reduce your risk.

An article on the ABCs of veterinary dentistry and the importance of immediate action.

An article on why contract enforceability is so hard to predict.

This week on dvm360: New podcast episodes, dentistry and more

top 10 most dangerous jobs in the country

. Laura Catena, DVM, a small animal relief veterinarian and creator of The ArmOr Hand Glove, is all too familiar with the high injury risk associated with this profession.

“We are getting injured daily— bitten and scratched, “ she tells Dr. Christman in the latest episode of The Vet Blast Podcast.

For Catena, one serious cat bite nearly jeopardized her career in veterinary medicine. One day she says one of her cat patients bit her left hand. She went to the hospital and was sent home with antibiotics, but by the following morning, the infection had spread from her hand to the left side of her neck. Her joints had become septic, and she had to receive extensive surgery, along with 7 months of physical therapy to regain functionality in her left hand.

It was this harrowing event that prompted Catena to come up with a proactive solution to help prevent others from experiencing such serious work-related injuries: ArmORHand Protective Gloves. These innovative bite-proof gloves are machine washable and made with flexible, durable, and synthetic material. “It’s like another tool in our toolbox to protect us while providing the best care to our patients,” she says, adding that this product can also help to prevent life-threatening injuries among your elderly and immunocompromised clients.

Listen below to learn more about how to reduce work-related injuries, plus find out some surprising fun facts about Catena.

Podcasts

On this episode of The Vet Blast Podcast, Dr. Adam Christman talks with Laura Catena, DVM, about a life-changing work injury that led to a witty invention. 

Episode 23: Taking the bite...out of bites

Technicians don't always get the recognition that they deserve. These team members work hard each and every day to make a difference in the lives of pet owners and their pets. They are truly the backbone of the health care team, says Liz Hughston, MEd, RVT, CVT, LVT, VTS (SAIM) (ECC).

Although it's the last day of National Vet Tech Week, we are far from done celebrating all the  amazing veterinary technicians, veterinary assistants, client service representatives, hospital managers, and other team members out there. We appreciate all that you bring to this profession.

"You are important," says Stephen Cital, RVT, SRA, RLAT, VCC, CVPP, VTS-LAM. 

"People often don't think of us as frontline workers, but you know what, they're wrong, because we are."

Walter Brown, BS, RVTg, being able to build strong bonds with people and 

 pets is what he loves the most about being a technician. 

"Having that bond between man and animal and you being that person in the middle that takes care of these animals and educates these people on what these animals can't express to them, just brings a lot of joy to my life."

Cital encourages technicians to never let anyone put them in a box or undermine their role at their practice. "Nobody does or can do our job like the dedicated people I've met in this field," says Cital.

Here is a special greeting from technicians to their fellow technicians. Check out the video below. Happy Vet Tech Week 2020!

As the the week-long celebration comes to a close, technicians encourage their fellow technicians to never forget how valuable they are.