Vaginal vestibulotomy and wound treatment
Place: Rotterdam Zoo
Data provided by: Willem Schaftenaar
An uneventful first pregnancy (677 days) in a 29 years old Asian elephant ended in complete stagnation of the birth process. A 20x30 cm piece of fetal membrane tissue was found in the enclosure. Over 100 hours of strong labour activities did not result in progress of the parturition. Rectal palpation proved that the calf was in backwards position. Unfortunately ultrasonography equipment was not available. The presence of the amniotic sac was visible as a bulging below the anus. Labour activities stopped at that point. Total serum calcium level was 2.44 mmol/l (in 1993 this was still wrongly considered within normal ranges). The animal was chained and 50 IU of oxytocin s.c. to stimulate uterine contractions. The calf could easily be pushed backwards in between contractions (which nowadays is considered a sign of hypocalcemia!). No reactions of the calf were felt during these manipulations. The animal responded well to oxytocin. The uterine contractions and labor activities intensified during the next 30 min, but no progress was made.
Two hours after the dministration an i.v. infusion of 750 ml of Ca-Mg-borogluconate was administered, containing 12 g calciumborogluconate. Another 50 IU of oxytocin s.c. was given at the same time. As before, the induced labour activities did not result in progress of the parturition.
Again 2 hours alter, 50 IU oxytocin was given slowly IV, resulting in strong labour activities. One arm was brought into the vaginal vestibulum and the amniotic sac was cut using a vinger knife and a rubber rumen tube was advanced through the vestibulum and the tip of the tube was placed between the feet of the calf. Through this tube approximately 2 L of a lubricant was brought into the birth canal.
Local anesthesia was performed at 1700 hr by administering 5 injections of 20 ml lidocaine 2% + noradrenaline intra-and subcutaneously in the midline of the perineum, starting 5 cm ventrally of the anus, with an interval of 10 cm. Epidural anesthesia was not used, but new insides have proven that this is an important method to reduce movement of the tail and decreases pain perception in the perineal region.
The perineum was brushed with a povidone iodine soap (Betadine scrub, Dagra Pharma B.V., 1112 AX, NL). A 25 cm long incision was made in the midline, starting 5 cm below the anus. A rubber rumen tube that was inserted retrograde into the birth canal. The vestibulum wall was incised over this tube just below the anus. This incision was enlarged ventrally to a distance of 25 cm. The hind legs were not visible at that time and chains had to be fitted blindly. Parts of the thick amniotic sac had to be cut away for better attachment of the chains. No reaction from the calf was observed during these operations. The chains attached to the calf’s hind legs were initially passed through the distal part of the vulva in an attempt to pull the legs through the natural birth canal. Pulling the chains essentially horizontally caused too much irritation on the vulva, so this procedure was abandoned. The incision was then enlarged ventrally to 37 cm.
Pulling at the chains by 4 people resulted in advancement of the legs throught the surgical opening. The legs presented in horizontal position next to each other but when the tarsus were outside the opening, the calf got stuck in the maternal pelvic cavity.
Standing back to back, two persons pushed the calf as far as possible back into cranial direction of the birth canal. When accomplished, eight people, four on each hind leg, were allowed to pull on the chains: by pulling on one leg at the time and changing the direction during 45 min, the calf was rotated 90° and could finally be extracted.
During the extraction, it became evident that the umbilical cord was twisted twice around the hind legs, which had probably resulted in the death of the calf. It is well known from cattle and horse obestetry, that a dead fetus is often associated with dystocia, as the longitudinal rotation of a fetus is facilitated by movements of the fetus during its passage through the birth canal.
TREATMENT of the SURGICAL WOUND
The surgical wound was closed in 3 layers. The vestibulum wall was closed using atraumatic Dexon 0. A nonperforating continuous suture, tied after every fifth stitch was made. No subcutaneous tissue was available for suturing. The skin wound was flushed with 10% diluted povidone iodine. The endodermis was sutured using atraumatic Dexon 1
with the same type of stitch. The skin was closed with Mersilene 4 using 27 single stitches. The wound was sprayed with U.S.P. wound spray. Amoxicillin was given at 5 mg/kg i.m. SID for 4 days, when reatment was changed to enrofloxacin given at a dose of 1.33 mg/kg i.m. This treatment was continued until day 11 when the entire wound spontaneously opened.
The wound was sutured again under local anesthesia and xylazine sedation on four occasions at 8-12 wk intervals. The first attempt was made 8 wk after the vestibulotomy. The animal was given 480 mg zuclopentixol p.o. 1 hour prior to surgery. This seemed to chang her behavior in an undesired way; she became more alert and aggressive than was expected. Granulation tissue was removed and the wound was closed in two layers, using the same material used for the initial sutures. The wound opened again within a week. The wound was cleaned again completely and the mucosa
was separated from the underlying tissue. A nonperforating continuous stitch with thicker suture material, was used to close the wound; monofilamentous PDS-1 was used for the vestibulum, and braided PDS-1 for the submucosal/subcutaneous tissue. The skin was closed with a continuous mattress stitch with sheep’s Bühner tape using a modified Gerlach’s needle. Each skin perforation was made 2-3 cm from the incision and protected by 3 mm thick rubber rings (3 cm diameter). The animal remained hobbled on both hind legs during the following 10 days. During this period she received 500 mg acepromazine (Vetranquil granulate, Sanofi, 3144 EG, NL) p.o. b.i.d., 50 mg butorphanol p.o. b.i.d. and 20 g amoxicillin p.o. b.i.d. The wound opened partly after a few days. Twelve weeks later a third attempt was made to close the two remaining fistulas. Only the mucosa of these vestibulum fistulas (5 cm and 0.8 cm respectively) were closed in three layers, using PDS-1.
Again these wounds opened after a few days. One more attempt was made to close the remaining fistulas, which were healing per secundum. A modified balloon catheter was inserted into the urethra during this intervention. The orificium urethrae could be reached by hand, just at the edge of the horizontal part of the birth canal. The balloon was filled with 50 ml of water. Only the vestibulum mucosa was stitched to reduce infection of the wound by accumulation of purulent material in the subcutaneous space. During the following 2 days all urine was passed through the catheter. On the third day, the urine passed through the wound again. The catheter has never been recovered. No more attempts to suture the wound were made.
In the following 1.5 year the wound healed per sucundam to date two fistulas of 10 mm and 2 mm respectively.
Aspect of the wound immediately after closing the wall of the vaginal vestibulum
Aspect of the wound 11 days after first attempt to close the wound.
Immage of the sutured skin immediately after the second attempt to close the wound.
Separating the wall of the vaginal vestibulum from the skin before suturing the vestibulum for the 3rd time.
Immage of the wound 2 weeks after the second attempt to close the wound.
The use of Bühner tape and rubber tubes to prevent the skin sutures from cutting into the skin during the 3rd attempt to close the wound.
COMMENT of the AUTHOR
Closing the wound after a vaginal vestibulotomy does not seem to be rewarding. The wound healing capacity of the elephant skin is enormous. To my knowledge, in all reported cases the skin sutures did not hold and the skin wound finally closed per secundam (Miller et al. 2004). Closing the vaginal vestibulum might be worth attempting, as it may result in partial or complete healing of the vestibulum wound (Thitaram et al. 2006). Nevertheless, leaving the entire wound open will finally result in excellent healing per secundam. However, the epithelium of the vaginal vestibulum may fuse before the skin wound is closed. This condition requires minor surgical intervention, by separating the 2 layers and dissecting a small strip of the edges. See also the case report of the fetotomy.
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