Irish Veterinary Specialists

Veterinary positions Available.
Some contacts of mine in a couple of Cork City small animal practices asked me to put out a mention of some job availabilities. Bother practices are based in Cork city and have experienced senior vets present and generally progressive. One is looking for a relatively experienced vet that wants to progress with the practice. The other is happy for an experienced or relatively new vet.
Both seem like good places to work and there is no on call on either as far as i know.
If anyone is interested then send me a message and ill pass you on the contact details.

Closing Wedge and TTA course with Duggan Veterinary supplies.

Spent a fantastic Friday and Saturday in Duggan’s new purpose built facility, teaching and demonstrating closing wedge and TTA techniques with a skilled group of vets.

The set up was perfect and the mix of lectures and lab work was balanced to give everyone an excellent chance of progressing on to these surgeries.

Even managed to catch up with a few old classmates and some of my former students so socially that was a plus.

Along the way I think we discussed almost ever issue with cruciate disease and complications that exist!!

I have lectured and demonstrated in many countries and I can happily say this was up there with the best of them.

Well here is the continued success of these courses as they are truly a great credit to the veterinary profession in Ireland.

Jerry

Exploratory laparotomy talk November 4th, 8pm Zoom. I am going to try and get the mix right in this talk. I may skip fast through some of the things we are likely to know well, concentrate on things that may be more relevant for us in practice. Use a bucket load of case pictures and videos and hope i wont over run too much !!!
I definitely feel and hope this will be useful for all practitioner.

https://us06web.zoom.us/webinar/register/WN_d9hGIYhHR9-tdXIonBY59A

Missing the roof of his mouth!!!!

His owners thought it was strange that he drank like a pigeon, water poured out of his nose and he sneezed dog food out of his nose after every meal.

So when we had a look we could see this little fella had no roof to his mouth.
There was a massive hole. So anytime anything went into his mouth it went straight up into the nose.

What was amazing was how well this fella was doing.

So I has to transplant a flap of tissue with its own blood supply across and build a new roof to the mouth and the soft palate behind it to stop food going down the the wrong tube.

Bish Bash Bosh new mouth rebuilt. No in fairness I had the easy part of the deal, his owners had to stop a puppy chewing on anything harder then “Bunty the fluffy teddy bear “ until this had healed.

Now he has a totally normal top of the mouth and life is going well. The picture above are chronological and the last few are about four weeks following the surgery.

Pretty impressive!!!!

Where has my intestine gone??????
They are never going to let these pictueres stay up on face book but here we go any way. If you have weak stomach then look away!!!

dodgie pictures are in the comments !

This fella had a broken pelvis years ago and recovered well with magical cat healing ability that we as vets know and love. The only problen is the fracture healing lead to a narrow pelvic ca**l and theis lead to periods of constipation. As time progtressed the constipation got worse and it became clear that the muscles of the large intestine were no longer able to expel the faeces.
If I got it earlier enough I can opertate and open up the pelvic ca**l and sometimes that is enough. It is a pretty cool proceeure and I have a fancy technique that makes it much easier but not for this case.
In this case we needed to remove the large intestine as well as opeing up the pelvis. Its call a sub total colectomy. For most cats the faeces become softer and most it allows them to have a normal life without the extremely painfull impaction and constantat e***as and veterinary treatments.
Cats with chronic constipation were medical management stops working require surgical intervention. The surgery of choice is a subtotal colectomy, basically removing most of the colon. YUCK !!!!
There are two types depending on if we keep ileocaecocolic valve or dont. The ijunction normally stops colonic contents getting into the small intestine; so getting rid of it can lead to bacterial overgrowth in the small intestine, with messy consiquences and diarrhoea. If I have to I remove it but if I can keep the juntion I will as there are potential side affect that we just can predict. If I can do a subtotal easliy it is my preference but somttimes it is not and for most patient this is a last chance surgery so I will do what is necessary.
The most commonly reported complication in the long term is recurrence of constipation one study cited a 25percent rate (that’s why I opened upo the pelvic in this case too). But most of these are ealiy maanages medically at that stage so its still a win.
I don’t use an e***a prior to surgery as this converts the content to a poo soup that can leak out and mess the surgica site, nobody wahts a leaky poo soup , especially during surgery.
The colon has the most bcteria in it and it heals the worst out of the whole intestines so careful technique and managemen are essential as a contimation leads to peritonititis and most don’t recover.
Most of them get diarrrhoea for some level for about eight weeks but then it resolves. This case did super well, no longer has constipation and no longer poops on the kitchn table and cooker, I know!!! What but turns out he was in such pain that when he could get it out he woud get it out where ever he could, poor lad.
Any way solution this one is now cured happy and amazd how easily it is to poo now. Got to be a good reslt the only is saving a fortune in e***as, lacutloase , parafin and ready meals ( as she can use the kitchen again)

We turned a greyhound into a pin cushion!!!!!

External fixator tibia

This lady smashed her leg just running and playing like an Olympic gymnast.

With fractures like this we have a choice.

Open up the area expose the bone and place a large plate across the fracture. This is a big time consuming procedure, is painful even with an epidural and it removes the local enzymes that promote healing that have been produced by the body in response to the fracture.

Another option is to align the joint above and below the fracture, no need to reduce the fracture perfectly like a jigsaw and to stabilise this with an external frame and pins through the bone.

This has the advantages of being quicker, maintaining the healing soup of enzymes and chemicals around the fracture, maintaining the blood supply.

Guess which one we did!!!

If you look at the immediately post operative images where you can see the fracture gap and the six weeks post operative images where you can see the new healing bone has filled the gap.

No in fairness she bruised her owner up a bit over that time using the metal enshrouded leg like a mace!!!
Basically we had to put pads over the pins to protect her owner as she was like a Tasmanian devil on speed and happy juice with a combine harvester leg!!!

But he didn’t mind as she did so well.

No the pins are out and she is back to living her best life.

Gallbladder Mucocele

Over the last two weeks we had a number fo gallbladder mucoceles. I thought I would put in a bit of information about the condition and what we did as well as a number of disgusting surgival pictures below (attached in the comments).

Normal bile is liquid and has minimal but with a mucocele well it turns into mostly mucus mostly solid mucus. A mucocele bile is thick and goopy and cant flow through bile duct. The gall bladder gets bigger and bigger and eventually ruptures, which leads to death.
When we see signs on ultrasound in a sick, jaundiced patient, surgery to remove the diseased gall bladder should be performed as soon as possible.
Mucocoele development starts with delayed gall bladder contraction, which allows bile acids to accumulate. Altered fat metabolism is also associated with reduced gall bladder contraction, resulting in an accumulation of bile acid. With that accumulation, the lining of the gall bladder feels inflamed and responds by making more mucus and more mucus-producing glands. Pretty soon the bile is just a big wad of congealed mucus and it will not flow.
Removing a dog’s gall bladder is a big involved surgery with risks and is best performed by a specialist.
Basically you want to remove it before it ruptures. Sometimes it has already ruptured and we need to clean out and flush the abdomen.
Dogs can do without the gall bladder in general so if the dog recovers from surgery the prognosis is excellent.

see the pictures of the surgery in the comments, and dont worry this case did really really well.

Gatric Torsion talk For thursday night, hopefully it will interest, educate and maybe make you guys laugh.

link to talk https://zoom.us/webinar/register/WN_h74Vx977TYuZ9KwFAbpjWQ

Dont Crack my chest !! Scary big world decisions.

Graphic pictures and video of recovery in the comments below.

This big lad was having difficult breathing and started coughing up blood. His vets did a big work up and identified masses in the chest. They tried to get a sample of what it was but didn’t manage to get a good result.

When we saw him he was in great form, you would never think he had a problem. Also he was one of the sweetest lads ever seen in the practice.
We decided to get a CT of the chest and abdomen to see if it had spread and to see if surgery was possible.

The results were good but bad at the same time. No spread to the other organs but the amount of mass in the chest meant we would have to be very aggressive and he could die on the table. So many hard choices.

We had a long chat with his owner who was terrified and of the options, as we all would be. If he did nothing then his friend was going to die if we tried the surgery he could still die on the table or if we were a bit luck on the histology we would give him some more time.

I was happy that we could technically do the surgery but so much rested on what we saw surgically and how his body responded to the changes in his metabolism we would cause by removing so much lung tissue.

His owner made a brave decision and allowed us to proceed. Following a weekend of being spoiled and going on all his favourite walks he came in to us.

Some specialist anaesthesia friends of mine from UCD (Dr Vilhelmiina Huuskonen), and from Dick White referrals in Britian (Valentina Andreoni) help come up with the best anaesthetic regimn to make him as comfortable as possible. We really have to thank them as he was so so stable and pain free.

Surgery went well, we cracked open the chest removed the lungs that were affected. Cleaned everything and and wired everything together.

He woke up as if nothing had happened , just look at the video in the comments. I got to ring a very very relieved owner. The next mornig he was dragging the nurses outside to have a walk and you would not believe that he had major chest surgery.

This guy was a legend.

Well he is now off home to recouperate and wait for the results of the histology.

Just look at the pictures of him at home and you know he is going to recover well.

The safe pictures are above but the more surgical bloody picutures are in the comments if you are brave enough.

Fishing For Spaniels?
This cute little lady is full of trouble and sticks her head anywhere. They took their eyes off her for a second and she had leaped all over a poor lad fishing next to the river. He didn’t mind but when she tried to eat all his bait (worms and maggots) he got worried.
Wasn’t there a hook in there and where had all the fishing line gone with weights.

Quick pop down to the vets, plonked on the X rays table and there we have it a bloody hook and bits of fishing weights in the oesophagus stomach and small intestine. Something else looked wrong but they could not put their eye on exactly what that was.

They tried to remove the hook with the endoscope but for the life of them they couldn’t find it and the stomach anatomy looked weird.

She came to us and we prepared to operate. We would have to go into the chest, assess if there is any damage to the lungs and remove the hook without damaging the blood vessels and nerves.

The reason the X ray looked funky was somehow the stomach was in the chest!! That didn’t make any sense.

We went in between the ribs and right there in the chest was her stomach, moving back and forth as she took breaths. Sticking out just next to the aorta was this huge hook that had lacerated a massive hole in the oesophagus and the diaphragm!!

That was the first diaphragm tear I have seen caused by a fishhook.

The fishing line was attached and stretched into the stomach and intestines.

The hook and most of the line was removed, the oesophagus and diaphragm had to be reconstructed. The lungs were checked for perforation. And she was stitched up.

A few hours later she was up and begging for more food. It really shows how well the nerve blocks and meticulous surgical technique lead to minimal discomfort.

I have put the video of her after and some operative pictures and videos in the comments below.

New KIT!!!!
Hard to believe how much kit, plates drills and saws we need.
just got another deliver today to stock up from Veterinary Orthopaedics.
I really love the battery powered saws and drills, allow me to have more versatility in surgery and save space. Really nifty pieces of kit.
Even the plates allow me multiple options for screw placement and allow me to use locking or non locking screws interchangeably.

FRACTURED SPINE!!!!!!
Our little hero got hit by a car and had the scariest injury, the one that has us all in fear…. A fractured spine!!!!!
His emergency care by his vet was perfect, they treated his shock, gave super amounts of hallucinogenic painkillers and tried to identify any other life threatening injuries while being monumentally careful of his spine.

He arrived down to me, scared, worried and willing family in tow. Well they drove, I mean he is a dog and just had a spinal fracture. Come on !

After an assessment I could identify that his neurological examination correlated the location of the injury to the area of the fracture. He could feel his toes and I could not find any other significant injuries.

Great news, we can fix that.

So we needed to assess if in fact if surgery was necessary. We did a CT to try and get a gauge if the area was unstable.
It was helpful but it was on those goldilocks situations, stable enough that it might be ok, unstable enough that a problem could be catastrophic.

We elected to leap in there, place screws around the area and link them with special medical cement. I would have liked a plate but the location T13 made my options to place the screws a little limited and the ribs get in the way.

The post operative images showed the implants were correctly placed and post operative assessment showed his neurological status was no worse.

Now it is up to him, I’m pretty sure he will recover.
You should have seen the little troublemaker dragging us outside for his walk and physio. His front legs couldn’t wait for us.

The next step before he can go home and rehab/ cause mischief there is can he urinate by himself.
Once he started that off he went. Should have seen his face when the family arrived. He pretty much jumped into the car, well with back legs not working it was a challenge but he was up for it.

See the x rays above the still images if the CT, I have put the video of the CT on the comments.
Also our nurses make a fantastic hind limb support /sling with leads and bandages, so good I have put an image of that too for people to try if they ever need it.

Weeks Radiographs and images.

Here is a selection of the last whiles cases, see if you can guess the cases an what was done.
We have a buzzard that flew into a window and made an arse of its wing.
A spaniel with a jigsaw for an elbow after a car crash.
A obtunded Tibetan terrier after running into a window.
Dislocated elbow, ouchy! Cattle grate!!!
Humeral osteosarcoma.
Dislocated hip!!!
Brachycephalic breathing surgery.

Cut his TONGUE OFF!!!!!
This little fella has a terrible fall and nearly sliced his tongue off. Given that he was very attached to it and had some super memories of armpit licking, toe cleaning and general sticking it where he shouldn’t, he made a compelling argument as to why we should fight to save it.

We felt a life in the cat shadows destined for showers and baths rather than good old cat cleaning was a terrible fate for our little hero. Also he sounded terrible funny with half a tongue!!
So here are some images of it sutured together, we had to fold it back on its self so the tip ended up a bit backwards.

The most impressive thing is how well it has healed and how it remodelled itself back normally.
Any way he is happily running around the neighbourhood licking anything that sits still for a second!!!!!

Fitting or Drunk.
This little fella started to behave strangely. It was like he had his own dealer and after meals he would hang around behind the couch getting high. Especially when he got his hands on take away or human food. Then waking him up was worse then a teenager on Sunday afternoon following a night in the parent’s drinks cabinet!

His owners were concerned, especially if they couldn’t get to the bottom of this he might progress to knocking over people on the streets for his fix or doing a bit of nightly breaking and entry just to get his next pork chop.

His vets were on the ball. They worked out from his examination and his signs that it was unlikely to be a brain issue but it was likely a liver shunt. No wasting time with a brain CT, no neurological assessments when this is actually a medical issue.

Yup I know!! We have seen a few of these before but I couldn’t help putting it up as the CT images are so cool and the video is awesome, if you can handle innards and blood and blood vessels.

Shunts are terrible, the blood that absorbs all your food skips the liver and the poisons and toxins are not made safe and filtered by the liver, they just dump into the system and make things go haywire. It can cause fatal fits, kidney failure developmental failures and death. They earlier they are diagnosed and fixed the better chance of a normal long life.

So we did a CT and you can see the 3D reconstruction of the blood vessels and can see this huge vessel acting the maggot and sneaking in a short cut into the caudal venal cava. They are not usually that big.

The trick then is to know exactly which blood vessel is which inside the abdomen and find the sneaky shunting vessel. If you close the wrong one it can be fatal. this one was in a completely different one to the last one we posted.
I have put the video of the vessel and the surgical picture in the comments so you can skip it if you have just had your breakfast.

Anyway we closed the vessel and stitched him up and he is doing super well. No more hallucinating no more craving for takeaway and no more risk to the neighbour’s valuables. Another blood test, bile acid stim, in three months and hopefully that’s the end of it.

It’s a win all around

TPLO complications.

After the last post I put up about the TPLO plates, I had a lot of questions about TPLO so I though I would put up a number of TPLO complication that came into me to fix over the last while.

None of these are mine, but cases that were sent in because they were not doing well, or images sent in to me to assess what the problem is.

I am just putting them up to show that if not done with skill and experience you can turn lameness into a catastrophic fracture, permanent lameness or amputation. It’s a great surgery but not a forgiving procedure and mostly complications are due to surgeon errors.

No 1
The first image is a case that had not done well post surgery. You can see this has a screw in the joint. That has damaged the joint surfaces and could lead to significant permanent irreparable changes if not changed immediately. It should not happen and if should have been noticed immediately post op and gone straight back into surgery. This can also chew up the meniscus and leave a hole in the joint!!!!! This should never happen.

No 2
The second image is exactly the same as the above, just more obviously in the joint. TPLO is not forgiving and if you are inexperienced you can really damage a dog.

No 3
The next image is where the surgeon left the cranial tibial segment too narrow, where the straight patellar ligament attaches it need to be substantial otherwise it fracture and pulls off and can lead to severe problems even amputation. There is also a gap in the cranial aspect of the osteotomy that is leading to instability. This case is also infected which is delaying the healing, you can se the affect it has on the bone and the effusion and fluid in the joint. This is very serious and if not managed properly this case could lose the leg. Again the errors are surgeon related.

No 4
The next one was never rotated. So during the procedure it slipped back in to the original position and the surgeon didn’t notice!!! Not good.

No 5
The next one has the K wire in the wrong place, it is distal to the attachment of the straight patellar ligament and leads to a weakness and stress riser at that point. This is a terrible error and there is a huge risk that the tibial crest segment will fracture off. Also leaving the K wire which is too large anyway in place provides not benefit. This is unforgivable.

No 6
The next one is just unlucky. Technically the surgery looks good but the dog chased a cat in the garden. The surgically looks technically great!! The vets didn’t give detailed discharge instruction for crate rest and lead only exercise, the dog was very comfortable and the owners didn’t restrict him. So it’s not just the surgery that can have issues, once you have done the surgery you need to protect it until the bone healing (usually 6 weeks).

No 7
The last one has a cut that is too distal leading to a weakness at the narrowest point cranially!! These can look ok superficially but have huge risks of fracture.

No Bottom!!!!

This cute little fella was born without a bottom. It’s Called Atresia Ani, not very common and quite a few Dodgy little causes. His owners would do anything for him and this was found but the vets at vaccination. They went to take his temperature and found an undercarriage like they have never seen before.

These type of abnormalities are usually noted when they are starting to be weaned and eating more solid food.

They had a CT taken in the hope that they would identify what type it was and whether he had other internal abnormalities but unluckily the imager was having a lazy day, a trying to do as little as possible day, a sure I can get away with a rubbish report day and wrote a pointless report. Basically they said in a couple of line he had no bum!!!!! Complete waste !!!!

Any way he came to me and I was able to see he had no p***s but had a common opening between a deformed small passage to the re**um and the urethra. You can see it in the pictures.
Luckily I had been involved in a study of these a few years ago where we came up with a new way to repair them and this little fella was perfect candidate.

I managed to make a flap using the abnormal re**al tissue, make a new a**s (bum ) in the usual place, reconstruct the sphincter muscles, suture it in place while separating I from the urethra and then made a new urethral exit.

Lots and lots and lots of sutures in a very small area.

Little fella had to spend two week in a cone to prevent any undercarriage licking. We couldn’t have wound breakdown. It would have been catastrophic!!

He looked like he had a baboons arse for a few days but eventually it healed, he remained continent and had now he is back to normal life with his mum and sisters.

He happily growing up with normal plumbing now and nobody should have to look at his bum for the rest of his life. Unless he needs a temperature taken!!!

Atresia ani is an uncommonly reported congenital malformation of the feline lower gastrointestinal tract, having several anatomic variations:
• type I atresia, where the re**um terminates as a blind pouch just cranial to the a**l membrane
• type II, where the re**al pouch terminates further cranially to the membrane overlying the a**s
• type III where the terminal re**um and a**s are normal but there is re**al atresia into the pelvic ca**l
• type IV in females, where a fistula connecting the urogenital tract and the anore**um may accompany atresia ani
All feline cases reported in the literature were associated with urethrore**al or rectovaginal fistulas. An intact but sometimes poorly developed external a**l sphincter may also accompany these anomalies.

Neurological assessment Talk

Thanks to the Mid Western Veterinary Clinical Society that invited me to speak over zoom last night about neurological assessments in practice.

I really enjoyed it and it was very professionally prepared.

I have to admit it was different not having the feedback and faces looking at you while you talk but hopefully it worked and it was useful for the vets and nurses in attendance.

I have put a couple of slides from it up in the pictures to give a taste of the topic.

While I would prefer to talk in person ( allows me to see how bad my jokes really are) this is definitely an option.

Tibial Plateau levelling Osteotomy (TPLO ) surgery.

I just finished a TPLO in a large Labrador last week and I could not help but think how the surgery and the implants have changes so much over the last 20 years.

The first plates were casted plates (unusual) and had to be bent and manipulated into the exact shape for each dog. This was very difficult and took huge skill to get the time down so the surgery could be completed. It was a patented surgery and I had to get to the states to do a course and be registered to do the procedure. (see first image)

These were then superseded by an arrow head plate and others that were pre contoured and not made in cast, it still needed to be bent and manipulated but not as much and this saved us some time. In fairness I liked that arrow plate and it was once of my favourite for at least six or seven years. (See image 2 and 3)

More recently we have been bombarded by multiple locking plates that are stiffer and don’t need to be contoured. Some are good some are mediocre.

My favourite is the one I have used here in these radiographs, it’s from a company called Veterinary Orthopaedics. It has a lovely curve on it that fits to the shape of most legs and small holes for temporary wires in difficult cases. All in all the modern locking plate saves me at least 20 minutes and allows me to make a much smaller approach. They also make a selection of plates from a broad one, which I have used on a 100kg mastiff to tiny ones I have used on a Chihuahua. (See images with multiple pates and radiographs)

It just goes to show that we don’t stand still and what is ok yesterday might not be good enough tomorrow.

Here is a couple of pictures of some of the older plates and ones we never or should never uses any more and then a few of the plates I use now with a picture of the radiographs from my recent case.

If you look at the radiographs you can see i used two different types of screw. the narrower one with tighter threads are locking screws. they lock into the pate and make the whole construct more robust and allows it to take more load.