HU M A N E A L L I A N C E

Ve t e r i n a r i a n T r a i n i n g P r o g r a m

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Veterinarian Training Program

Reference Guide

Sponsored by:

HUMANE ALLIANCE

Table of Contents

Training Team

Page 3

Clinic Map

Page 4

Program Syllabus

Page 5

Schedule

Page 6

Procedural Overview

Page 7

Tattooing

Page 9

Canine Ovariohysterectomy

Page 10

Canine Castration

Page 12

Feline Sterilization

Page 13

FAQs

Page 14

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Training Team

HUMANE ALLIANCE

Michelle Amtower, DVM

Anne Bayer, DVM

Karla Brestle, DVM

Veterinarian
Medical Director, Clinic
Veterinarian
dramtower@humanealliance.org drbayer@humanealliance.org drbrestle@humanealliance.org

Nellie Goetz, DVM

Stuart Hovis, DVM

Rob Seal

Medical Director, NSNRT

drgoetz@humanealliance.org

Veterinarian
drhovis@humanealliance.org

Training Program Manager

rob@humanealliance.org

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HUMANE ALLIANCE

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Clinic Map

HUMANE ALLIANCE

Program Syllabus

Our goal for our Veterinarian Training Program is to polish the individuals surgical skills, with
emphasis on sterilization procedures (the high-quality piece), and enhance their organizational
skills to make most efficient use of time (the high-volume piece).

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1. Pre-surgery
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Therefore, the Veterinarian Training syllabus may include but is not limited to the following:

Patient selection/review of the specifics of the physical exam that ensure identification of
appropriate low-risk surgical candidates.
Drug/anesthetic protocols.
Staff management.

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2. Surgery
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Recognition of surgical packs and the value in minimizing their contents.

Maintenance of sterile surgical technique in a high-volume situation .
Review of anatomy as it applies to the efficient and successful completion of
the sterilization procedure.
Review of instrument and tissue handling skills.
HVHQ specific surgical techniques:

Pedicle tie;

Overhand knot;

Incision placement.
Efficiency of motion/movement.
Body mechanics.

Identification of complications.
Management of complications.
Pain management.

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3. Post-surgery
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Schedule

HUMANE ALLIANCE

This schedule will serve as a guideline for your week of training at Humane Alliance. All times
should be considered approximate, since the nature of this business dictates that we may
have fluctuations in patient numbers that, in turn, may necessitate rearranging the schedule
(i.e. classroom topics in the afternoon instead of morning).
During inclement weather conditions, we will always do our very best to provide you with a
steady flow of patients, but when factors are beyond our control, we may have to end the
day early.
Demonstrations of each surgical procedure will be performed by your instructor before you
are expected to perform the procedure.
Please let your trainer know at the beginning of the week if you need to leave before
4:00pm on Thursday, so that we can adjust your schedule to best accommodate you.

Monday !

Time

Location

Topic

8:00 - 9:30 am

Classroom

Tour & Orientation

9:30 am - 12:30 pm

Prep/OR

Surgery

12:30 - 1:00 pm

Kitchen/Off-site

Lunch

1:00 - 4:00 pm

Prep/OR

Surgery

Tuesday - Thursday

Time

Location

Topic

8:45 - 9:30 am

Classroom

Discussion Topic

9:30 am - 12:30 pm

Prep/OR

Surgery

12:30 - 1:00 pm

Kitchen/Off-site

Lunch

1:00 - 4:00 pm

Prep/OR

Surgery

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Potential Classroom Topics:

Feral Cats
Surgery 101: Surgical Anatomy & Basics
Surgical Complications
Cryptorchidism & Uterine Anomalies

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HUMANE ALLIANCE

Procedural Overview

The surgical procedure itself should maintain a routine sequence of events to verify that each
patient is receiving the same standard of care. The surgeon should ensure that the technicians
follow a thorough protocol for surgical prep of the patients, including, but not limited to,
complete clip, debris removal, surgical scrub, and bladder expression in females.

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As the surgeon approaches the patient in the OR, a generally accepted practice would be to
double-check the status of the patient, including, but not limited to, the following:
1.
2.
3.
4.

The patient should be properly connected to the anesthesia machine

Oxygen and isoflurane levels should be appropriate
The monitoring equipment should be operational.
It should be confirmed that the patient is at the correct plane of anesthesia and the
veterinary surgeon must verify sex of the patient, especially with cats.
5. Finally, it should be noted that the patient is in proper position for the surgery and that the light
source is directed toward the incision site. At this point, the veterinary surgeon may proceed.

The patient is draped in with 3 or 4 quarter drapes, with or without a fenestrated drape. Any
combination of the above is considered acceptable, with the most important feature being that
there is an appropriate barrier to prevent contamination of the surgical site.

The incision placement will obviously vary with both the sex and the species of the patient. We
have also determined that varying the incision placement depending on the age of the patient
can improve the efficiency of the entire procedure. Incisions in adult female dogs are generally
placed approximately 1 inch caudal to the umbilicus (see Figure 1), while the incision in a
pediatric female dog would be placed approximately half-way between the umbilicus and
pubis (see Figure 2). When spaying an adult or pediatric cat, the incision is also placed
approximately half-way between the umbilicus and pubis.

Fig 1:
Adult dog incision placement

Fig 2:
Feline/pediatric dog incision placement

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Procedural Overview

HUMANE ALLIANCE

In dogs, there are several factors which will influence the craniality of your incision placement.
The older, larger, heavier, and deeper-chested a dog is, the more cranial the incision should be
centered.

Adult male dogs are neutered with either a pre-scrotal or scrotal incision. However, in pediatric
male dogs, the routine approach is scrotal. In fact, many spay/neuter veterinary surgeons will
actually perform a modified scrotal castration in adult dogs that have pendulous scrotums.
Dogs with this modified scrotal approach will go home with an open incision, and therefore must
go home with an additional set of discharge instructions.

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Suture size selection should follow these guidelines:

Procedure

Cat/Small Dog

Medium Dog

Large Dogs

Giant Dogs

(20 lbs or less)

(20 - 45 lbs or less)

(50 - 75 lbs)

(75 lbs+)

Pedicles

2-0

2-0 or 0

0 or 1

Linea Alba

2-0 or 3-0

2-0 or 0

0 or 1

Subcutaneous

3-0

2-0 (3-0 for males)

2-0 (3-0 for

males)

2-0 (3-0 for

males)

Subcuticular

3-0 or 4-0

2-0 (3-0 for males)

2-0 (3-0 for

males)

2-0 (3-0 for

males)

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The most important factor in proper surgical technique is that meticulous, careful tissue handling
is observed in any procedure. The following additional points will also be emphasized:

Five throws (2 square knots) on all sutures. This technique has been proven to decrease
the incidence of dehiscence, and must always be used.
Large bites on the linea alba: include at least 5 to 8 mm muscle tissue in the linea closure
in cats and up to 10 to 12 mm in large dogs. A cruciate suture pattern is used to
decrease tension and speed closure time.
No crushing sutures in closing - linea and subcutaneous tissue should be snugly and
completely closed but never crushed.
Dead space should be closed and the SQ should be anchored at least at both ends of
the linea incision. Linea and subcutaneous tissue are closed with PDS suture (see FAQ's for
discussion on suture material).
At least 3-layer closure-linea, SQ, and subcuticular plus skin glue. Staples are used if skin
edges are not apposed.
Skin edges should be properly apposed - never allow one side to flap over the other or
extend above the other. Skin glue should not be applied between the skin edges but on
the surface after apposing the edges.

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HUMANE ALLIANCE

Tattooing

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A tattoo is applied to all patients to ensure no future unnecessary anesthesia or surgery.

We perform a scoring procedure to accomplish the tattoo, by placing a small (~1cm) incision
in the dermis near the incision site, or near the umbilicus in the case of male cats, and applying
ink.

Tattoo Site

We prefer paste vs. liquid ink, in that it is neater and stays in place better, and green-colored
paste is more obvious, especially on animals with darkly pigmented skin.!

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HUMANE ALLIANCE

Canine Ovariohysterectomy

1. The overall size of an incision for a canine ovariohysterectomy will vary depending upon
various factors, the most obvious being the experience and/or comfort level of the surgeon.
Repetition over time will tend to naturally decrease the size of the incision to as little as 0.75
cm in some patients. A factor that may aid in efficiency is the use of the blade without the
scalpel handle; even a practice as minute as this saves time and creates less instrument
cleaning.

2. Once the skin has been excised, a small amount of subcutaneous adipose tissue is removed
to improve visualization of the linea. This technique decreases the time necessary to enter
the abdomen, but it also decreases both the time and difficulty of the closure. With this
approach, the layers of linea, subcutaneous and subcuticular tissues can be more
straightforwardly apposed.

3. The linea is incised by utilizing the thumb forceps to tent the linea. The scalpel blade is
positioned sharp side up to incise the linea and the incision is extended while using the
thumb forceps as a guide to safeguard the abdominal contents. Once entry is made to the
abdomen, the falciform ligament is dissected as necessary.

4. Due to the small size of the incision, it is typical practice to utilize a spay hook to locate and
exteriorize the first ovary. Learning to properly use a spay hook can occasionally be a
challenge in itself. As a rule, the thumb forceps are used to elevate and tense the body wall
and the spay hook is inserted with the hook toward the midline but held tightly against the
body wall. The spay hook is advanced to the dorsal most aspect of the abdomen and lift
between colon and bladder. The ovary retrieved first is surgeons preference,but we suggest
and teach removal of the right ovary first. The ovary is frequently higher on the right and
therefore, more obvious tension is felt when the spay hook is retracted.

5. After locating the ovary, the suspensory ligament is broken. This is accomplished by placing
tension on the ligament and applying digital pressure to tear. It is helpful to recognize the
groove created just below the border of the proper ligament. In rare cases you may need
to nick the suspensory ligament with a blade to facilitate its rupture. After breaking the
suspensory ligament, in order to isolate the ovary, create a window low in the broad
ligament side of the ovarian pedicle and place the appropriate size carmalt well below the
ovary. A second carmalt clamp can be placed above the first clamp if the surgeon prefers
more security. It is extremely important to allow enough room for a 4-5mm tissue tag above
the ligature when it is finished. This will prevent slippage of the ligature off the pedicle when
the final clamp is released. Place a clamp above the ovary for hemostasis and, while leaving
the tissue tag, cut the ovary away with scissors. Ligate, cut, or tear the broad ligament
(depending on vasculature). It is more efficient to tear away or ligate the broad ligament
before proceeding to ovarian pedicle ligature as it provides more room to ligate the
pedicle.
Select appropriate size suture and place Millers knot below carmalt. Double
ligation is not necessary if the first ligature is properly tied. Release the clamp on the pedicle;
the pedicle can be inspected for hemorrhage at this time.

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6. Follow the uterine horn to the bifurcation and repeat the steps above on the opposite ovary.
7. Proceed to the uterine body and exteriorize to allow for proper placement of ligature(s).
Place a Millers knot securely above the cervix but below the bifurcation, if possible. It is not
necessary to place the Miller's knot below the bifurcation, as research has shown no benefit
to ligating the uterine body in this manner. As long as the ovaries are completely removed,
there is no risk of a "stump pyometra", since that is a hormone-driven disease process. In fact,
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HUMANE ALLIANCE

Canine Ovariohysterectomy

it is prudent not to place excess tension on the uterus to achieve ligation at the bifurcation,
as it can contribute to post-op spay incontinence. Keep in mind that in pregnant patients
when the uterus is removed, a natural reflex will be contraction of the tissue. Thus, the knot
security should be closely checked. In some in heat or pregnant patients a modified
transfixing suture may also be necessary. In patients with extremely friable tissues, take care
not to cut through the uterus with the ligature. After ligating the uterine body, although it is
not necessary, you can place a clamp for additional crushing hemostasis; do not place the
clamp too close to the ligature as it may cause unnecessary distortion of tissue. Cut proximal
to clamp and remove uterine body. Check for oozing as the clamp is released and tension
on uterine body is decreased. Complete a visual sweep of the abdomen.

8. Perform closure of the linea making certain to bites of the external rectus (the holding layer
of the abdomen). Bites do not need to be full thickness. The surgeon should select an
appropriate suture size and close with cruciates. NO continuous patterns should be used in
the linea. The cruciate is more efficient because it allows for effective apposition without
relying on one pattern to hold the entire incision closed, is faster than simple interrupted, and
is a tension-relieving pattern.

9. Perform closure of the subcutaneous and subcuticular tissues. The runner from the linea is
used to place a simple continuous closure of the subcutaneous tissue to the opposite end of
the incision tacking down to the fascia as you go. Then, the subcuticular tissue is closed with
a horizontal continuous pattern, parallel to the incision, back to the last tag of the linea. The
runner is then tied off to the last tag which will bury the knot. The knot is buried to prevent
wicking and to ensure appropriate skin apposition. The closed incision then has glue applied
to the skin surface. The glue should be applied on, NOT in the incision. Glue in the incision
can act as a foreign body and delay healing. Rolling of the incision (inverting the incision)
can be helpful in to avoid issues with licking and wound contamination by creating a natural
bandage.

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HUMANE ALLIANCE

Canine Castration

CANINE CASTRATION (ADULT)

In the adult male, the closed technique is the preferred method because it is more efficient
(saves time not to close tunic), there is less foreign material (suture) in closure, and there is less
bleeding.

1. The testicle is exteriorized (to minimize incision size, expose from pole to pole vs. side to side)
by sharp excision of excess fibrous tissue.

2. Once exteriorized, a Millers knot is placed while leaving a 4-5mm tissue tag to ensure no
slippage. One ligature is usually sufficient. A modified transfixing ligature (pass needle
between the cord & vessel) can be used in place of or in addition to the Millers knot if
preferred. This method is repeated on the opposite testicle.

3. Closure can be accomplished on males with a simple continuous pattern in the

subcutaneous and subcuticular tissues by using the runner method as utilized in the OHE.
Glue is placed over the incision as with the OHE.

4. Another option for adult male castrations would be a scrotal approach. The testicles are
exteriorized through an incision in the median raphe of the scrotum, and ligated with a
modified Millers knot, or whatever the surgeon prefers. The incision is then apposed with one
simple interrupted suture in the subcutaneous tissues using 3-0 absorbable suture.

CANINE CASTRATION (PEDIATRIC)

1. In the pediatric male, one incision is placed over the scrotum along the median raphe. The
testicle is exteriorized and excess tissue is stripped away. Either the open or closed technique
work equally well in the pediatric male.

2. A figure 8 or overhand knot is placed and a tag left. This procedure is repeated on the
opposite testicle. The incision is closed with glue and the rolling technique is used to
prevent licking.

3. A modified scrotal approach is sometimes used, which is essentially the same procedure,
except the tunic is opened but the tunic is not removed from the pole until after the tied
cord/vessel is placed back into the tunic. The tunic is then stripped of excess tissue and tied
with a simple instrument tie. This technique is used on large breed puppies and other nonpendulous scrotums.

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HUMANE ALLIANCE

Feline Sterilization

FELINE OVARIOHYSTERECTOMY
The feline spay is performed in much the same way as the canine spay, with one notable
exception. We routinely use a method commonly referred to as the pedicle tie.

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1. An overhand instrument tie is performed on the ovarian pedicle, similar to the technique
many veterinarians use in neutering a male cat.
2. Upon isolation of the ovarian pedicle, the pedicle is feathered over the surgeons finger to
allow identification of the individual structures.

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3. The suspensory ligament is located and torn/cut. The ligament can be cut with scissors or
blade or torn with digital pressure or a hemostat.
4. A curved mosquito forcep is utilized to tie off the ovarian pedicle. The surgeon then slides the
knot off of the hemostat.

5. When ligating the ovarian body, the same techniques that were used in the female dog are
used in the female cat. The only notable exception is that close attention must be paid
when ligating a friable uterus in a post-partum or multi-parous cat, as the ligature can cut
through the uterine tissue easily if attention is not paid when tightening it. The Miller's knot is
specifically designed not to cut through tissue, as it is a 2-pass knot, and therefore distributes
pressure over a larger surface area. However, it can still cut through friable tissue, at which
point, suture of a larger size must be used to tie a new ligature.

FELINE CASTRATION
1. An incision is made centrally or over each testicle. Open or closed techniques both work
well.

2. An overhand knot or figure 8 knot can be used to ligate the cord, depending on the
surgeon's preference, and the thickness of the cord (figure 8 knots are more difficult to
perform on thick cords). This technique is repeated on the opposite side and the incisions are
left open.

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FAQs

HUMANE ALLIANCE
1. DO YOU PREFER CLIPPING OR PLUCKING FOR CAT CASTRATIONS?

We clip for all surgical procedures, including cat castrations. While plucking is an acceptable
form of hair removal, we choose to clip these patients to give us a broader hair-free surgical
field, which can decrease contamination, particularly in long-haired cats. Clipping is also a
faster way of preparing the surgical site for us than plucking is.

2. CAN I FOCUS ON CERTAIN PROCEDURES DURING MY TRAINING?

While we make every effort to provide the types of surgeries that you would like to perform,
ultimately, this is up to the discretion of your instructor and the types of animals that we have
come through the clinic. If your instructor feels that you need work in a certain area, he/she will
let you know and will work with you to also incorporate the cases that you would like to work on.
Keep in mind that some cases (such as cryptorchids) are not always available.

3. CAN I TAKE PICTURES/VIDEO OF PROCEDURES, EQUIPMENT, SETUP, ETC.?

Yes. Please first check our website under E-Learning to make sure that the video you need has
not already been posted there. We do ask that any pictures or videos taken at Humane Alliance
are used for your personal education only. We do not allow videos or pictures that include
patients to be posted on social media sites, and ask that permission be requested and credit be
given if the videos or pictures are to be used in presentations.

4. WHY DO YOU USE PDS SUTURE? WHY ON A REEL INSTEAD OF IN PACKETS?

Simply put, it is the best choice for the HQHVSN arena. Suture on a reel is much less expensive
than swaged-on suture (suture with the needle attached), and PDS has the balance of strength
and decreased reactivity that we need in an absorbable suture that is to be used on a large,
varied population of cats and dogs. Keep in mind that the body wall takes 2-4 weeks to heal
completely after surgery. When you look at the chart below of commonly used suture types, you
will see that PDS retains its strength longer than plain catgut, chromic catgut, and Monocryl TM.
Catgut's short duration of strength and high level of reactivity makes it unsuitable for use in the
HQHVSN setting (even on the pedicles, uterine stump, and testicular cords).

Suture

Strength Retention Profile

Absorption Time

Catgut (plain)

90% lost in 7-10 days

70 days

Chromic catgut

90% lost in 21-28 days

90 days

70% lost in 14 days

100 days

70% lost in 6 weeks

180 days

Monocryl
PDS

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HUMANE ALLIANCE

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FAQs

Although Monocryl TM has less reactivity in subcutaneous tissue than PDS, it's short duration of
strength retention makes it a less than ideal choice for anything but young, fast-healing patients.

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