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Want to reach new levels of expertise when sterilizing cats and dogs? Here are some tips and tricks to help you increase efficiency while performing high-quality spays and neuters in your veterinary practice.

1. Simplify your surgical packs.

Every instrument you reach for during surgery should be easy to locate, so limit your pack instruments to those you use regularly. This could mean making separate packs for spay/neuter procedures or simply reevaluating which instruments you use during surgery.

Be sure your pack includes all the instruments you need. Nothing slows down a procedure like waiting for someone to open a separate pack for you or searching your surgical tray for an elusive instrument.

Finally, keep your instruments organized within your pack. Arranging instruments before surgery begins will ensure they are ready when you reach for them. If you're not sure where to start, there are resources that provide recommended pack lists.¹

2. Relax your patient's position.

Patient positioning can make a difference in your access to the reproductive tract. Placing the forelimbs down at the patient's sides, rather than stretched toward the head, may relax the suspensory ligaments by relaxing the epaxial muscles.

3. Plan before you cut.

A well-placed incision facilitates access to the reproductive tract while minimizing tissue handling and trauma. Evaluating the age and reproductive maturity of a dog, locating the umbilicus and pubic rim, and planning your incision save time not only when accessing the reproductive tract but also when closing.

Of the many factors that can help you determine where to make your incision, the most important is your surgical comfort level. If you generally have difficulty accessing the ovaries, move your incision more cranially. If you can access the ovaries but not the uterine bifurcation, consider moving your incision more caudally. Strategic placement of your incision will prevent unnecessary traction on the reproductive tract as well as time spent extending and then closing a larger incision.

Strategic placement of your incision will prevent unnecessary traction on the reproductive tract as well as time spent extending and then closing a larger incision.

Here are some general spay incision placement recommendations:

• Unless a flank procedure is being performed, all incisions should fall on the ventral midline between the umbilicus and the cranial brim of the pubis.
• The feline uterine body is typically more friable, with both traction and suture being able to cut through the tissue, so make the incision in cats more caudal on the ventral midline than in dogs.
• The ovaries and ovarian pedicles in adult dogs are typically more difficult to exteriorize than the uterine body, so make a more cranial incision in adults than you do in puppies.

Due to its immature nature, the reproductive tract in pediatric patients may be more caudal, flexible and disproportionately small compared with body size, so place your incision midway between the umbilicus and pubis.

4. Minimize incision size.

Many veterinarians are laser focused on the size of the incision. I have seen many students so intent on making a small incision that they end up struggling to access and exteriorize the tract. Conversely, a large incision allowing easy access to the entire tract requires a longer time to close. With proper placement, incision size can be minimized.

Smaller incisions mean decreased skin and subcutaneous tissue trauma as well as less time spent closing. Decreased surgical times have many benefits, including less time under anesthesia and hence less overall risk, decreased risk of surgical site infections, faster recovery, and lower costs with regard to both the facility and the welfare of the animal. More efficient surgeries may also result in an increase in the number of procedures that can be performed daily.

There is a happy medium between a small incision and an incision through which you can work efficiently. If you find that you regularly have to stop and increase your incision length, then consider making your initial incision 0.5 cm longer. Conversely, if you find that the tract is always smaller than anticipated and you spend a disproportionate amount of time closing the surgical site, consider decreasing your incision length. The need for incision adjustment should be the exception, not the rule.

5. Perform auto-ligation in cat spays.

You may be familiar with the popular technique of auto-ligation of feline ovarian pedicles.1 If you are not performing this technique on a routine basis, you may be spending more time than necessary on your cat spays.

A recent study found that use of the pedicle tie procedure decreased surgical time by two minutes compared with double-ligation of the ovarian pedicles with suture ligature, and lowered the risk of hemorrhage in the process.² This procedure is included as acceptable practice in the Association of Shelter Veterinarians'2016 Veterinary Medical Care Guidelines for Spay-Neuter Programs, an important reference for anyone routinely performing spay/neuter surgery.³ That study, coupled with my personal experience, prove that this procedure is safe, provides effective hemostasis and is effective for cats of all ages, including those that are pregnant and in estrus. It should be noted that this is not considered an acceptable practice in dog spays.

6. Let dogs join in on the auto-ligation fun.

Regardless of whether you perform the pedicle tie during feline spays, you are likely familiar with auto-ligation of feline testicular cords during neuters performed through scrotal incisions. While this has been common practice for years in cats, it is also safe and effective for neutering prepubescent dogs.¹

A recent publication described this method as simple with no intraoperative and very few postoperative complications.⁴ Additionally, it was found to be more efficient than a prescrotal approach with suture ligation for neutering adolescent dogs. In my experience, whether you perform a figure 8 tie or a simple cord tie, this method of neutering dogs under 6 months of age is very effective, does not lead to increased complications or self-trauma, and reduces surgical and anesthetic time.

7. Release the suspensory efficiently.

Releasing the suspensory ligament is often a point at which surgery can slow down or, depending on the level of anesthetic depth, stop altogether. This is because manipulation of the suspensory ligament is one of the most stimulating parts of the procedure. If an appropriate anesthetic depth is not achieved, manipulation of this ligament will result in the animal becoming light and responsive during surgery. Thus the more efficiently you can release the suspensory ligament with minimal manipulation, the faster you can continue the procedure.

The more efficiently you can release the suspensory ligament with minimal manipulation, the faster you can continue the procedure.

A recent study comparing manual disruption of the suspensory with sharp dissection demonstrated that cutting the suspensory ligament was about one minute faster than digital strumming.⁵ In this procedure, the suspensory is isolated and released by cutting with either scissors or a blade instead of stretching the tissue until release occurs. The same study found that sharp transection resulted in a smaller increase in heart rate during the procedure than manual disruption with no increase in intraoperative or postoperative complications. While one minute may not seem clinically relevant, two minutes earned back during each surgery, plus less time spent responding to an increased heart rate and potentially having to wait until a deeper anesthetic plane can be reached, make this a technique to consider.

8. Minimize your ligatures by maximizing security.

While many sutures may be necessary when learning surgery and suture handling fundamentals, once you master knot security you should minimize the number of ligatures needed. Decreasing the number of ligatures placed will increase your surgical efficiency, improve ligature security, and lower suture costs. Single ligation of each ovarian pedicle and the uterine body is generally sufficient to provide appropriate hemostasis via a modified Miller's knot. One exception to this would be spays on pregnant animals, in which additional ligatures (either a second encircling or transfixing ligature) are needed to secure the uterine arteries.

A review of ligation techniques and security found that surgeon's knots were less secure than other friction knots and that the Miller's, constrictor, and strangle knots were the most secure for vascular ligation.⁶ Many surgical teaching programs now focus on the modified Miller's knot.

9. Evaluate yourself.

There is no better way to understand where technical improvements can be made than by collecting and evaluating data. Videotaping yourself performing surgery and reviewing the footage will provide perspective on where time is being lost and where efficiency can be increased.

At the end of the day, increased efficiency during surgery will allow you to perform more surgeries, get to your medical cases faster and decrease anesthetic time and risk for your patients. Although many practices have historically been accepted as safe and efficient, there is a growing body of evidence allowing us to practice high-quality, high-volume, evidence-based surgery.

References

1. Bushby PA. Surgical techniques for spay/neuter. In: Miller L, Zawistowski S, eds. Shelter Medicine for Veterinarians and Staff, 2nd ed. Ames, IA: John Wiley & Sons; 2013:625-645.
2. Miller KP, Rekers W, Ellis K, et al. Pedicle ties provide a rapid and safe method for feline ovariohysterectomy. J Feline Med Surg 2016;18(2):160-164.
3. Association of Shelter Veterinarians' Veterinary Task Force to Advance Spay-Neuter, et al. The Association of Shelter Veterinarians' 2016 veterinary medical care guidelines for spay-neuter programs. J Am Vet Med Assoc 2016;249(2):165-188.
4. Miller KP, Rekers WL, DeTar LG, et al. Evaluation of sutureless scrotal castration for pediatric and juvenile dogs. J Am Vet Med Assoc 2018;253(12):1589-1593.
5. Shivley JM, Richardson JM, Woodruff KA, et al. Sharp transection of the suspensory ligament as an alternative to digital strumming during canine ovariohysterectomy. Vet Surg 2018;48(2):1-6.
6. Hazenfield KM, Smeak DD. In vitro holding security of six friction knots used as a first throw in the creation of a vascular ligation. J Am Vet Med Assoc 2014;245(5):571-577.

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“Shelter Snapshot” is a collaborative column between the Association of Shelter Veterinarians (ASV) and dvm360.com to help inform veterinarians and team members involved in veterinary shelter medicine and in related aspects of veterinary general practice. To learn more about the ASV and to find more information on these and other animal sheltering terms, visit sheltervet.org.

Dr. Uri Donnett received his DVM from the Iowa State University College of Veterinary Medicine in 2014 and completed a master of science in veterinary preventive medicine at Iowa State University as well. He then completed an internship and residency in shelter medicine at Mississippi State University and is currently the Maddie's Clinical Instructor in Shelter Medicine for the University of Wisconsin-Madison Shelter Medicine Program. His veterinary interests include teaching veterinary students shelter medicine and surgical skills, high-quality/high-volume spay/neuter, transport programs and epidemiology. He joined the ASV board in 2018 and serves on the membership and development committees.