Splenectomy

“How’s Zoe doing Honey?” Rory asked when he walked through the surgery door. He heard the steady beep, beep, beep of the respiratory monitor, a welcoming sound. When breathing stopped for more than a minute, an alarm went off. The dog was lying on her back, her four feet tied to the surgery table to keep her long body from tipping side to side. The shaved patch on her belly was colored brown from the betadine spritzer Honey added as the final prep.

“She’s good. Her breathing is stable,” Honey replied.

Rory nodded. “Open the surgery pack and table drape pack, then go tie Jen up. I’ll get started,” Rory said as he took his place on Zoe’s right side.

Rory placed four sterile towels to outline the surgery site on top of the belly, securing them to each other and the skin using sharp pincher clamps. The towels were secured onto the patient when the pincers were closed. The towels maintained a sterile barrier around the surgery site that wouldn't move.

Returning to the drape pack, Rory picked up the final curtain, a big folded piece of material. He waited for Jen to assume her place across the surgery table.

“Ready to place the drape?” He asked.

"Sure," Jen nodded and extended her gloved hands to his.

Sharing the material, they opened a large four by six-foot drape with a rectangular hole in the center, called a fenestration, through which the surgery is performed. Everything around them was clean, sterile actually, not even a single, contaminating bacteria in sight. Rory breathed a relaxed sigh. Besides maintaining sterility another effect of the drape is a visual one. Now the only thing in front of Rory was the surgical area placing him in a highly charged and very focused world. Right now, in this place that’s all there was for him.

“All set?” He asked.

Jen nodded, as Rory set a cutting blade onto his scalpel handle. She armed herself with white gauze sponges and they went to work. He had done this, many times. There is a midline on a dog’s underside. The less he strayed from the midline, the easier the surgery went. That’s why table positioning was critical. Zoe was on her back inside a V-shaped cradle. She was steady and straight, perfect positioning for a splenectomy.

Jen dabbed bleeders with gauze while Rory cut into the skin. He used Metzenbaum scissors to cut away some of the fatty, underlying connective tissue. Metzenbaum are perfect tissue scissors; they have blunt tips, so they don’t poke into things, and the blade is curved allowing for a smooth bite into slippery, moving, living tissue. He completed his arsenal with a pair of rat-toothed forceps. The teeth on these forceps, two on top one on the bottom, allow secure tissue pickup. Now Rory had the tools necessary to pick and cut his way through different tissues. And he had an assistant and an anesthesiologist/floor nurse to keep the patient asleep and hand him stuff when he needed it.

The cut through the skin exposed underlying subcutaneous tissue, the white stuff that keeps our skin connected to our body.

Rory scissored away the subcutaneous junk, mostly fat. Now with the skin cut open and the fatty tissue cleared away he could see the best place to enter into the animal's abdominal cavity.

“There’s the white line Rory,” Jen said pointing to the line running down the middle of the stomach from the xiphoid to the pubis.

“Yep, the linea,” he replied. He set the scissors down and picked up his scalpel blade. Using his rat-tooth forceps, he lifted the tissue.

“Why do you tent the linea?” She asked.

“I need to push the blade through the body wall with enough force to open a space for the scissors, but I don’t want to nick the bladder or spleen, or something else. I would need to repair it before I sew out. It's sloppy and unnecessary.”

Satisfied with his knife opening, he grabbed the scissors, pushing one end inside Zoe’s belly.

“Now watch how I slide the Metzenbaums along the white line, opening the belly with more of a push than a scissoring. That’s how sharp the scissors are.”

Jen didn’t have much sponging to do. There were few bleeders cut, as Rory did not stray from the white line. Finding the tumor was easy because it was so large. The hard part was to open the incision enough to pull the grapefruit-size thing from Zoe's belly. The mass was so big Rory had diagnosed the thing yesterday just by feeling the dog’s stomach.

His tugging on the tumor sent painful wake-up waves to the dog and Rory backed off.

“Turn her isoflurane up, Honey. She’s too light.” By dialing the gas level higher, Zoe went into a deeper anesthetic plane within ten breaths. Dropping both hands all the way inside the belly Rory began to ascertain the attachments the tumor had with other abdominal organs.

“Yep, this confirms it, it’s on the spleen. We’re going to have to remove the spleen too. That means we need more carmalts and more clamps. There are ten to twenty large blood vessels we need to ligate. First, we need to get the spleen, and the tumor exteriorized. You ready to manhandle this thing, Jen?”

She nodded. Her hands were ready, waiting on top of the drape. Rory worked his fingers deeper to cradle the mass. He lifted it gently and carefully lest he rip apart something important. Slowly working it back and forth he wrestled it from its nesting place.

“Wow it's immense,” Jen exclaimed, as Roy pulled the softball-size mass through the incision.

“Put your hands down here and cradle the thing, Jen. I have to work the spleen out too. Then we need to lay it out and ligate the vessels going to it.”

“So, the tumor isn’t attached to anything else besides the spleen?”

“Correct, Jen. There’s some omentum adhered to the cancer ball, but that rips away with no bleeding, see? Yep, the tumor is only attached to the spleen. In fact, part of it is growing from the spleen itself. We need to tie off lots of vessels, remove the sucker, then sew her back up.”

“Why do you need all the clamps?”

“It saves me half the work. When I ligate a vessel, I have to place two ties an inch apart. Then when I cut the artery between the two ties, there will be no bleeding. If there are twenty vessels, I need forty knots. But if I have twenty clamps, I only need to ligate the portion I leave inside Zoe not the half going into the spleen. When the tumor is removed and thrown away, hopefully, Honey will remember to retrieve the clamps.”

“Okay, I’m convinced. I like the clamp idea.”

“Hand me another reel of 2-0 Vicryl please Jen.”

“Did you look up the Australian import requirements, Doc?”

“You are serious, aren't you? Why do you want to go there?”

“Why do men want to go to the moon, Rory? This deal combines my love of dogs with my love to travel.”

“It’s the travel thing, Jen. Your big travel life has been a few months or so in Flagstaff, and then you come right back here.”

“What makes you think that? Why do you think I never spend time in Flagstaff?”

“You let Katie and I stay there when I brought her back from the Rez remember?”

“So?” She sounded irritated.

“The place looks spanking new. It’s not lived in at all. It’s like a hotel room.”

“Well, I’m feeling the travel urge now.” She was tired of talking.

Rory sensed it and focused on the surgery again. “You need to move the spleen over. I have to ligate this section. Oh good, only three more. Hand me some 2-0 Monocryl on a needle and get ready for closure.”

With the ligation finished they slid the mass into a container.

“Weigh this thing, please, Honey,” Rory asked.

“It’s twelve pounds!” she said setting it on the scale.

“Wow, that’s a lot for a sixty-pound dog. It's like a forty-pound tumor in a two-hundred-pound man.”