Roxy has a lipoma, a collection of fat cells that start multiplying and grow into a mass under the skin. Usually these tumors are not malignant, instead the problem occurs when the mass becomes too big too ignore. That's what happened with Roxy.
“Doc, Fran says we have to remove this mass,” Ray reported. “I thought we could ignore the thing, but Fran complains about it every time she looks at Roxie.”
Roxie, an eleven-year-old female spayed Bassett was presenting every month for issues. As a dog's body ages, more health problems come up, and it was that time in Roxie’s life for things to start falling apart. Today she came in with a very noticeable swelling behind her right shoulder.
Rory shaved the hair from the lump. Giving a vigorous cleaning with a sponge, he positioned a syringe having a needle on it over the mass, plunging it through the skin at the fattest point pulling the plunger back forcefully two or three times to pull a sample of the mass into his needle.
“I’m surprised she doesn’t feel anything,” Ray admitted when he saw Rory pull from the dog.
“There no nerves inside tumors because a tumor is a collection of similar cells, growing as a parasite just reproducing tumor cells, not nerves.” He carefully squirted a small amount of material on a glass slide and walked to the lab area to stain it, looking at the cellular architecture on the high power oil immersion objective to get maximum magnification.
“My aspiration cytology suggests the tumor is a mixed lipoma, most likely a fatty cell tumor with bands of pink connective tissue surrounding it, and it wouldn't hurt to leave it alone. You understand she’s pretty old, over ninety years old in human terms. You sure you want me to do this, Ray?”
“We’ve got to do what Fran wants; she wants it off, it's too ugly to look at every day." Rory understood Fran's point of view. The mass was growing behind the right front leg, causing a sway to her gait because of it. Now she abducted the leg, swinging it out wide when she walked another good reason to excise it.
“Very well, let’s get started.” Calling for Honey’s help he went through a pre-op checklist of the physical findings, looking at heart rate and character, femoral pulses, and other indicators of circulatory adequacy: gum color and capillary refill time.
Rory selected three pre-op drugs for the first level of anesthesia, the sedation, combining three drugs Dexdomitor, Morphine, and Ketamine to make into a dissociative cocktail to put Roxy into a sound slumber for about twenty minutes.
“Is that all you need to put her under for surgery, Doc? Just one shot?”
Cytology of a lipoma, a fatty cell tumor. The clear windows surrounded by blue are fat cells, which are the colorless areas outlined by the blue stained tissue. This lack of other cells makes the diagnosis easy and straightforward. I'll drop another slide in below of a cellular cancer that worries me more.
“I need more for this surgery, this mix just brings her down to a particular level, which is fine for many things, but we need to drop her deeper to remove this big mass. That's why I'm putting a catheter in her arm and placing a breathing tube in her face. That allows me to deepen the anesthesia with direct IV access as well as the option to start a gas inhalant through this plastic breathing tube. Doing these two things will give us a lot more safety and control over her depth of analgesia.”
Lifting her from the table, Rory set her on the floor and handed Ray the leash. “Keep her here until she gets sleepy. She might throw up from the morphine. That’s all normal but yell at us to clean it up. Honey or I will check back in a minute.”
Honey was in the surgery room to get it set up. He came up behind her. “Let’s see; I want a regular instrument pack, and the suture cassette, right. Don’t forget a drape pack, and let’s go with 2-0 Monocryl with a cutting needle for closure. I’ll use catgut from the reel to tie bleeders.”
“Doc, Roxy just barfed,” Ray called from the other room.
"I'll help," Honey left the surgery.
Lifting a sleepy Roxy on the table, Honey helped Rory shave the front leg, holding the leg to allow him to place a catheter.
"Let's push her induction, time to deepen her with Valium," he said, pushing a new liquid through the catheter. Because the catheter was accessing a mainline vessel the effect of the IV infusion was instantaneous, sending Roxy into a deep, profound unconscious sleep by the time Rory finished the injection.
With Honey holding the dog's mouth wide-open Rory investigated the back caverns of Roxy's throat. Using an endoscope, a long, stainless steel blade with a light at the tip to look in the back of the mouth allowed him to see exactly where to place the tube. He searched for the vocal cords. “It appears we need a 10.5 size ET tube, Rory decided, looking at the space inside the vee area outlined by the vocal cords. Picking up a 10.5 size medical grade plastic flexible pipe he threaded it down the dog's throat, directing anesthetic gas directly to her lungs.
"Ok, time to prep her surgery site," Rory said.
Rolling Roxy on her side Honey shaved hair from the area above the lump.
"Shave all around the lump, about eight inches," he decided.
Honey pulled the vacuum hose out of the cabinet to suck up all the loose hair. When done, they moved Roxy into the surgery room hooking her up to the gas machine, the breathing monitor, and the IV fluid drip.
“Don’t forget to hook up her heart monitor,” he reminded Honey. “I’m going to scrub up.”
Honey was finishing her prep job on Roxy when he returned. Each procedure begins with a clean, immaculate, sanitized surgery site. Preps include three scrubs of the site. First, a surgical soap to clean the skin, followed by a rubdown with copious amounts of alcohol. This sequence repeated twice more minimally; some animals are so dirty their prep requires more than three washes. Honey knew to keep scrubbing with the soap and alcohol until the white gauze sponges came back clean. Finally, a spritzer of brown Betadyne disinfectant applied to the site not only disinfected more, but the brown coloration showed Honey prepped the site correctly. Today he didn’t see the coloring.
“You forgot the betadyne, have you finished the scrub?” he asked her; she was busy fiddling with the anesthesia levels.
“Oh, I just forgot the spray.”
He nodded, waiting with sterile gloved hands held together in a praying position in front of him while she spray painted the site. Walking to the instrument table, he unwrapped the surgery and drape packs.
Honey knew these packs by heart because she was the one who put the packages together every day. The surgery instruments were steam sterilized in the autoclave to make them germ-free, stacks of clean gauze and surgery drapes were set on a steel tray, wrapped in two cloth coverings held together with autoclave tape. The tape has stripes on it that change color in high heat and tells us they have been processed and are ready for use.
“Are you going to need me to gown up too?”
“Oh yeah. More hands will help a lot.”
Opening the drape pack, he grabbed a sterile towel and placed it on the top edge of the site, continuing to isolate the area by laying three more cloth sheets along the right, bottom, and left sides of the mass, leaving five inches of space around the lump itself allowing him a square, clean surgical area.
Next he pulled the surgery drape from the pack, unfurled it and let it settle over the whole dog, pulling the front edge back so he could watch Roxy’s tongue and face during surgery. There is a square hole in the drape called a fenestration, which Rory adjusted over the mass as it settled down on top of the towels. He preferred this big drape for extended operations because it offered a large sterile area to work in, allowing him to relax his elbows on the cloth while his hands worked on tissue through the fenestrated rectangular opening sewn in the center of the drape.
“I’m ready to cut,” he yelled to Honey. “Are we set to go?”
“I am,” she replied, walking into the surgery room in her sterile gown, gloves, hat, and mask holding her gloved hands in a prayer-like position making sure she kept her elbows above her waist. A much higher level of contamination occurs below waist level in any place, not just animal hospitals. That's why you always see Doctors in medical shows holding their hands in the air to keep them as sterile as possible.
She stood on the other side of the surgery table, across from him. The surgeon decides what side is best for the procedure, and everything else follows. Today Rory was on the left and Honey across from him. She set her gloved, sterile hands on the sterile drape and waited for direction.
He was using the scalpel blade to make clean full thickness slices into the skin.
“Oh, you’ve almost cut through the skin completely around the mass,” she observed.
“Yeah, not many skin bleeders," he added making bold strong opening move is called for.
Healing is delayed if a timid surgeon works tentatively, hesitating here and there when expanding an incision; it leaves ragged edges that take longer to heal. This is when bold strong opening moves are called for, creating a deep clean-edged cut with smooth edges that heal quickly.
There were few skin bleeders, none spurting enough to make him stop progress and find a clamp.
“Oops, talked too soon.” The good luck changed when he began to cut tissue closer to the base of the mass, where it was closely attached to Roxy's body. Now a severed blood vessel squirted arterial blood a few inches into the air. Grabbing a mosquito hemostat, Rory sprung the jaws open, isolated the spurt, and clamped it.
“Do you want to ligate it, Doc?”
He shook his head.
“Not yet.” Not all oozers need to be ligated, or tied off because time and the pressure of the clamp offer adequate clotting opportunity.
With bleeding stopped he picked up Metzenbaum scissors, perfect for cutting into soft body parts. The blunt and curved end of the instrument makes it useful to get into tissue, separating and dissecting more than cutting, again causing minimal collateral damage, the goal of all surgeons.
“We’re going to find some bigger vessels underneath, have the ligatures ready,” he continued to work around the periphery but was about to dig under the mass. He knew he was sure to find bigger vessels here, the ones that supply life-giving nutrients to the tumor,
“What suture do you want?”
“Do you want it threaded to a needle?”
Rory's most often used suture material comes out of sterile plastic cassettes that dispense as much or as little thread as he needs. Once she pulled the desired length from the cassette, Honey threaded and double threaded the curved surgical needle as Rory continued to dissect the tumor. Double threading makes the suture material stay on the needle.
“Ok, here’s the first one,” he said, isolating a large blood vessel from the surrounding connective tissue by using mosquito hemostats to strip away unwanted stuff like fat and tissue pieces. Once he stripped it clean, he inserted the hemostat under the vessel. Opening the jaws he closed the hemostat on the ligature, pulling it towards him from underneath the artery. Setting the hemostats down he grabbed the needle holders, deftly forming a square knot finishing with four throws.
Finding three other big feeder vessels feeding the mass, he ligated and cut these too.
Soon it was approaching tumor lift–off time.
“Can you pull it towards you?” Rory needed her elevate the mass to allow him the ability to see further down, aiming to keep his Metzenbaum cutting through healthy tissue.
“How do you know where to cut, Doc?”
“Tumors are composed of only one type of cell, that’s what makes it a tumor. One cell somehow gets its genetic transfer process screwed up and just goes rogue. Usually, the rate of cell division is controlled by several factors. With cancer something causes those elements to go haywire and the cell goes wild dividing itself over and over again. Researchers are trying to find those things that screw up healthy controls.
Carcinogens alter this orderly process of cellular division and cause one cell to start dividing like crazy. These rapidly dividing cells are the tumor; it becomes a parasite living off the host. When I am dissecting, I dig out any tissue that looks different from the typical architecture. A cancerous mass is usually homogenous, meaning it’s made of only one cell type. That makes it easier to differentiate from the normal tissue it is growing off of.” He used a gauze sponge to wipe the bloody film from the site, which made it easy to see the difference in tissue types.
“Here look, see what I mean?” This part has a bunch of different elements, while this cancer looks like solid liver, or kidney, just a bunch of similar-looking cells."
“Why do you send in biopsies then, if you can pretty much see the tumor?”
“To ID the type of mass and to gauge its level of malignancy. Some tumors are much more deadly than others, and only the hisotpath guys can see individual organelles like dividing nuclear chromatin. Plus they tell me if they see any areas where I may have left some tumor inside."
Honey continued to pull the tumor gently and steadily up and away from Roxy's body as Rory cut it free of healthy tissue. It was an enormous mass, almost six pounds, and it left a huge hole.
“There, that’s the cut I was looking for, go ahead and lift the thing away.”
“Wow this is a big tumor,” Honey said.
“And we have a big hole to suture. Thread up two more two-oughts please.”
He grabbed a sponge to dab away the fresh blood. He was looking for spurters needing to be clamped and tied but could ignore the ever-present oozers, so long as they didn't pulse with the heartbeat.
Honey set the tumor aside and joined Rory in suturing the skin; both spent the next twenty minutes sharing skin suturing. Using an extra pair of needle holders and rat-toothed forceps she started on her left and Rory started on his left, both working toward the center. Roxy had a thick sub-dermal layer, and the edges of the skin melded together easily. The thickness offered an increased surface area and stopped the sides from sliding up or down, allowing the surgeons to safely space the sutures a little further apart.
“Look at the edges; they pucker outward. We call them dog ears,” Rory explained. “It is a common problem when trying to close a big circle into a straight line… there’s bound to pucker at each end,” he rambled on, much more at ease with all the thinking and deciding done.
“The solution is probably the simplest and most commonly used technique in cosmetic surgery. I pull a puckered end up like this with my rat-tooth tweezers, lifting the skin, and pulling it taut. Now I position my Metzenbaum scissors under the rat-tooth and snip off the pucker. Then I push the cut area back down, and it falls into place, like magic. It is an impressive and easy trick.”
Finally, they were finished, pulled our gloves off, cleaned the site with peroxide, and laid Roxy on a blanket on the recovery floor.
Rory carried the tumor down the hallway to show Ray. It looked almost like a heart with its size, texture, and color.