9.30 am - 12 noon
"The catheter just would not be pulled out," the young vet (YV) said at the end of the bladder stone removal surgery. I had stopped gas anaesthesia such that the 3-year-old male Miniature Schnauzer would wake up at the last stitch or within 3 minutes.
"How can that happen?" I could not believe this unprecedented situation from even occurring. "In all my past cases, the catheter just slips out too easily from the bladder when I pull it."
The dog winced as YV pulled again. The catheter was stuck. What should I do? I was the mentor. This was so unreal.
"I don't think I had stitched the catheter to the bladder," YV said.
"No," I said. "I saw you stitching and the wall of the catheter is thick and not so easily stitched up by mistake."
Still there was this problem. I could not pass the buck further.
What happened? Could not think why this occurred. As if there was something pulling the catheter back into the bladder. A vacuum suction?
The catheter was elastic. But it could only come out 1/4 of the length.
What to do now?
"Push the catheter back into the bladder," I advised.
The YV did it and pulled again. It was still stuck.
What could be done? There was a problem. We should not leave the catheter inside the bladder now as it was not needed. Besides it was stuck now.
"Think hard". How to solve this problem?
I went back to basic anatomy. Could the bladder sphincter be in spasm such that the catheter got clamped very tightly. Such that the catheter could not be pulled out. What to do if it was this situation?
"OK, I will give the dog anaesthesia gas again," I said to the YV. This was his case.
A young girl had sent the dog to a veterinarian who had diagnosed bladder stones but would not permit her to have the X-rays to be given to YV. I was the mentor for YV. As part of community education, I try to help young vets who are interested in surgery. The vet surgical reference books sometimes advised impractical long-incisions but in practice, such procedures may not be necessary.
After less than 2 minutes of anaesthesia, YV pulled out the catheter easily.
As to the cause of this problem, it could be that I had sucked out the residual saline and stones using a syringe. This could have created a vacuum preventing release of the catheter. A theory.
SURGERY
1. 10 days of antibiotics.
2. X-rays done.
3. Although X-rays were not given, I could feel crepitus (gas) inside the bladder and a lump of around 1 cm in diameter. The clinical signs of blood in the urine but no dysuria and the diagnosis of the vet taking the X-rays were sufficient.
4. Temperature 38.4C before surgery. Dog is normal. Blood tests preferred but add to the costs. Not done. OK for surgery.
5. "No blood in the urine," the owner said. On catheterisation, bloody urine flowed out of the bladder.
6. YV was apprehensive about the penis being in the way of the access to the bladder. How to incise the skin to get to the midline linea alba? I pulled away the penis while he incised the skin, separate the fascia and looked for the linea alba.
7. "Feel the pelvic rim", I said. "Make more than 10 cm long incision, otherwise it will be difficult to get the bladder out." YV did not encounter any bleeding in the fascia although he was careful and slow.
8. I pump 20 ml saline into the bladder. He got it out. Inflamed badly.
9. Incised 1 cm of bladder. Saline flushed out into bowl. Only a small piece of stone was flushed out.
10. "Use artery forceps to go 360 degrees inside bladder", I said. YV encountered scruncy sounds at 2 sides, apex and near exit of bladder. Spikey stones removed in pieces.
11. "Clamp bladder incision with forceps," I said. "I flush 20 ml saline".
12. Unclamp and let residual stones be flushed into bowl. Repeat.
13. Suture bladder. Lambert and Cushing. Flush saline into bladder. "No leak," I said. "Your suture is excellent."
"That's cool," the YV said.
Then the catheter got stuck inside the bladder. Back to the beginning of the story......
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