The tumour grows back a second time two months later. It
was excised. It recurs for the 3rd time. The dog could not
eat normally and had a painful mouth. The young lady owner
wanted another operation without the dog dying on the
operating table.
"It is highly risky to do anaesthesia on an old dog," I
warned her of the possibility of death again. "This old
dog had survived two general anaesthesias. His cheek
tumour is malignant as it keeps doubling in size every
week. Why don't you consider chemotherapy?"
The young lady did not want chemotherapy for her beloved
companion as it had side effects and was not guaranteed to
work. I told her that I needed to remove the cheek tumour
from outside by blunt dissection from the skin.
"Your dog may be paralysed," I said. "There will be a lot
of bleeding."
The lady said: "Why don't you operate from inside the
cheek to remove the cheek tumour as you had done before?"
"I need to cut away as much of the cancer cells as
possible. There may be a root of the tumour and I need to
access the root from the skin to dissect away the tumours.
If all cancerous cells can be removed from the skin
approach, it will be good for your dog. Provided he
survives the operation which will take a long time
compared to the previous two excisions"
The lady was worried about deaths on the operating table.
Every time an old dog is put under general anaesthesia,
the chances of dying are increased. Every time a vet
operates on such high-risk dogs, he or she is bound to
suffer fatalities and damage to his reputation.
The dog was given antibiotics and painkillers for the next
2 weeks. The lady did not turn up on the appointed day and
so I thought she decided to opt out of the surgery. Then
she turned up. She was a busy working girl.
PRE-SURGERY
Antibiotic and anti-inflammatory pred injection on day 1
and antibiotics after Day 1. On Day 2, tolfedine
pain-killer oral. No pain in the cheeks on Day 3. Surgery
on Day 4 after admission. An IV drip is very important in
case emergency drugs are needed.
ANAESTHESIA
Domitor 0.2 ml IV from the IV saline drip line. The dog
had a cyanotic tongue. It was not a good sign of health. I
had a premonition that he would die on the operating
table.
TEAM
Teamwork is essential in this high-risk anaesthestic case.
I had two experienced assistants who are old experienced
Myanmar vets with over 20 years of experience combined and
Dr Vanessa Lim to assist.
SURGERY TIPS
1. "I don't need the scalpel blade," I said to my
assistants. "An electro-surgery electrode needle incises
the skin."
2. "Dissection with scissors is not advised," I explained
to my assistants. "I will use the electrode to separate
this hard mass of tumour from under the skin. The tumour
has a capsule."
3. Bleeding. Electro-surgery reduces bleeding
considerably. There was a small bursting artery which was
clamped. I could not find the big vein or artery supplying
blood to the tumour nodules. There were 3 nodules inside
the cheek muscles.
4. "Where to incise?" I asked my assistants as part of my
mentoring process. "A horizontal cut or vertical curved
cut or both?" They had to think.
EMERGENCY RESUSCITATION
The surgery took more than 30 minutes. The shorter the
better survival rate for an old dog. "The dog has died,"
my second assistant pointed to the dilated pupil which now
showed a whitish cataract. A matted white. The isoflurane
gas was given at a minimum. Too little, the dog's cheek
muscles would twitch and so I had asked for an increase.
There was no twitching and surgical dissection proceeded
smoothly. Too smoothly.
Now the dog had stopped breathing. He had not died as my
first assistant in charge of anaesthesia had much
experience and had observed regular breathing. A dilated
pupil is common in the deepest surgical anaesthetic stage.
A big dilated pupil could also mean imminent death or
death. Whatever it was, I stopped the anaesthesia, blew
air into the trachea tube and started cardiac massage
immediately. Three cardiac massages and blow three times.
My second assistant flushed out the isoflurane gas by
pressing the red button and gave me the tube to connect
oxygen to the dog. "It is better to blow air in and
massage the heart," I advised. The dog was not breathing
normally. A stethoscope to check the heart beating showed
no sounds. My lst assistant injected Doxapram respiratory
stimulant 1.0 ml into the IV line. I continued cardiac
massage and air blowing into the tracheal tube. My 2nd
assistant injected 0.2 ml Antisedan which is the antidote
for Domitor.
It took more than 5 minutes but it seemed like eternity.
"There was no hope," I thought as I could not hear the
breathing sounds when I put my ears to the endotracheal
tube after several cardiac massages. At one time, my first
assistant would compress the heart from the top while I
put my hand on the lower part of the dog's chest. It was
touch and go. The dog started breathing.
My second assistant offered me the anaesthetic tube to
connect to the endotracheal tube as the surgery was only
95% complete. There was the stitching to be done.
"God may not give 2nd chances," I pointed above my head
and declined the anaesthetic connection to the gas
machine. The Antisedan had reversed the Domitor sedation
and the dog's head started to move. There was little time
to stitch up. Subcutaneous stitching in certain areas
could be done. Horizontal mattress stitches quickly closed
up the skin incision. The dog put up his head in around 3
minutes as if he had a long nap. He did not cry or whine.
Dr Vanessa Lin gave me the meloxicalm pain-killers. "It is
best not to inject any drug to this old dog as he might
just die after the pain-killer injection," I thanked her.
antibiotics for 10-14 days
before surgery as tumour is
badly infected
3 hard nodules in the cheek muscles.
Domitor 0.2 ml IV given
malignant tumours as they double in
size every week
the owner did not turn up for
appointment till 2 days later. Tumour is infected
electro-incision close to the skin.
Thoroughly remove remnants of cancer cells
3 cheek tumours excised leaving a big
hole in the cheek but there is the skin to close up the wound
a third nodule is not shown here.
Histopathology is being done
<1 hour after completion of surgery.
Dog is ok
A dog alive is what
the owner wanted. Nothing more. No excuses. The dog ate 2
days after surgery and should be going home soon. In
high-risk anaesthetic cases, it is best to have a team of
experienced assistants. The brain dies when it is deprived
of oxygen and in this case, a team definitely helped to
revive this old beloved companion for the young lady.
The anaesthetist is more important than the surgeon as
anaesthesia deaths are fatal. An experienced team is
advised in high anaesthetic cases. Intubation and IV drip
line are essential in such surgeries. If the surgery can
be completed in less than 15 minutes, old dogs seldom die
but in this case, the 3 tumours were large and time had to
be spent on bluntly dissecting them to prevent excessive
bleeding. Surgery took more than 30 minutes to complete.
It was through teamwork that the old dog did not die on
the operating table.
Every member of the team, like the F1 race, must focus on
his specialised role. For example, the anaesthetist must
focus on anaesthesia and not be distracted by looking at
the surgery on the unusual tumour. Cardiac massage and
flushing off the anaesthetic gas through blowing into the
trachea are immediate priorities. Emergency oxygen can be
given later. Emergency drugs can be given as soon as
possible. Monitoring systems are important but not as
important as the experienced person monitoring
anaesthesia.
TOA
PAYOH VETS
